Rebecca P. Smith

Trends in US emergency department visits for suicide attempts, 1992-2001.

This article describes trends in suicide attempt visits to emergency departments in the United States (US). Data were obtained from the National Hospital Ambulatory Medical Care Survey using mental-health-related ICD-9-CM, E and V codes, and mental-health reasons for visit. From 1992 to 2001, mental-health-related visits increased 27.5% from 17.1 to 23.6 per 1000 (p < .001). Emergency Department (ED) visits for suicide attempt and self injury increased by 47%, from 0.8 to 1.5 visits per 1000 US population (p(trend) = .04). Suicide-attempt-related visits increased significantly among males over the decade and among females from 1992/1993 to 1998/1999. Suicide attempt visits increased in non-Hispanic whites, patients under 15 years or those between 50-69 years of age, and the privately insured. Hospitalization rates for suicide attempt-related ED visits declined from 49% to 32% between 1992 and 2001 (p = .04). Suicide attempt-related visits increased significantly in urban areas, but in rural areas suicide attempt visits stayed relatively constant, despite significant rural decreases in mental-health related visits overall. Ten-year regional increases in suicide attempt-related visits were significant for the West and Northeast only. US emergency departments have witnessed increasing rates of ED visits for suicide attempts during a decade of significant reciprocal decreases in postattempt hospitalization. Emergency departments are increasingly important sites for identifying, assessing and treating individuals with suicidal behavior.

Trauma Exposure and Posttraumatic Stress Disorder Among Employees of New York City Companies Affected by the September 11, 2001 Attacks on the World Trade Center

OBJECTIVE Several studies have provided prevalence estimates of posttraumatic stress disorder (PTSD) related to the September 11, 2001 (9/11) attacks in broadly affected populations, although without sufficiently addressing qualifying exposures required for assessing PTSD and estimating its prevalence. A premise that people throughout the New York City area were exposed to the attacks on the World Trade Center (WTC) towers and are thus at risk for developing PTSD has important implications for both prevalence estimates and service provision. This premise has not, however, been tested with respect to DSM-IV-TR criteria for PTSD. This study examined associations between geographic distance from the 9/11 attacks on the WTC and reported 9/11 trauma exposures, and the role of specific trauma exposures in the development of PTSD. METHODS Approximately 3 years after the attacks, 379 surviving employees (102 with direct exposures, including 65 in the towers, and 277 with varied exposures) recruited from 8 affected organizations were interviewed using the Diagnostic Interview Schedule/Disaster Supplement and reassessed at 6 years. The estimated closest geographic distance from the WTC towers during the attacks and specific disaster exposures were compared with the development of 9/11-related PTSD as defined by the Diagnostic and Statistical Manual, Fourth Edition, Text Revision. RESULTS The direct exposure zone was largely concentrated within a radius of 0.1 mi and completely contained within 0.75 mi of the towers. PTSD symptom criteria at any time after the disaster were met by 35% of people directly exposed to danger, 20% of those exposed only through witnessed experiences, and 35% of those exposed only through a close associates direct exposure. Outside these exposure groups, few possible sources of exposure were evident among the few who were symptomatic, most of whom had preexisting psychiatric illness. CONCLUSIONS Exposures deserve careful consideration among widely affected populations after large terrorist attacks when conducting clinical assessments, estimating the magnitude of population PTSD burdens, and projecting needs for specific mental health interventions.

Epidemiological trends in psychosis-related Emergency Department visits in the United States, 1992―2001

Mental health visits represented an increasing fraction of all Emergency Department (ED) visits in the U.S. between 1992 and 2001. This study used the National Hospital Ambulatory Medical Care Survey, a 4-staged probability sample of ED visits from geographically diverse hospitals around the U.S., to assess the contribution of all psychosis-related visits to this overall trend. Unlike other mental-health-related ED visits, the rate of psychosis-related visits did not increase. This lack of change is notable in the context of dramatic changes in both healthcare financing and antipsychotic prescribing practices during this period. There was an unexpected decrease in Medicare-funded psychosis-related ED visits at a time of increasing Medicare enrollment overall. An important demographic trend over this decade was the increasing urbanization of psychosis-related ED visits coincident with a relative decrement in such visits within rural areas.

Services Provided by Volunteer Psychiatrists after 9/11 at the New York City Family Assistance Center: September 12--November 20, 2001

Objective To characterize the experience of volunteer disaster psychiatrists who provided pro bono psychiatric services to 9/11 survivors in New York City, from September 12, 2001 to November 20, 2001. Method Disaster Psychiatry Outreach (DPO) is a non-profit organization founded in 1998 to provide volunteer psychiatric care to people affected by disasters and to promote education and research in support of this mission. Data for this study were collected from one-page clinical encounter forms completed by 268 DPO psychiatrists for 2 months after 9/11 concerning 848 patients served by the DPO 9/11 response program at the New York City Family Assistance Center. Results In this endeavor, 268 psychiatrist volunteers evaluated 848 individuals and provided appropriate interventions. The most commonly recorded clinical impressions indicated stress-related and adjustment disorders, but other conditions such as bereavement, major depression, and substance abuse/dependence were also observed. Free samples were available for one sedative and one anxiolytic agent; not surprisingly, these were the most commonly prescribed medications. Nearly half of those evaluated received psychotropic medications. Conclusions In the acute aftermath of the attacks of September 11, 2001, volunteer psychiatrists were able to provide services in a disaster response setting, in which they were co-located with other disaster responders. These services included psychiatric assessment, provision of medication, psychological first aid, and referrals for ongoing care. Although systematic diagnoses could not be confirmed, the fact that most patients were perceived to have a psychiatric diagnosis and a substantial proportion received psychotropic medication suggests potential specific roles for psychiatrists that are unique and different from roles of other mental health professionals in the early post-disaster setting. In addition to further characterizing post-disaster mental health needs and patterns of service provision, future research should focus on the short- and long-term effects of psychiatric interventions, such as providing acute psychotropic medication services and assessing the effectiveness of traditional acute post-disaster interventions including crisis counseling and psychological first aid. (Journal of Psychiatric Practice 2010;16:193–199).

The postdisaster prevalence of major depression relative to PTSD in survivors of the 9/11 attacks on the world trade center selected from affected workplaces

BACKGROUND Studies of survivors of the September 11, 2001 attacks on the World Trade Center in New York City suggest that postdisaster depressive disorders may be at least as prevalent, or even more prevalent, than posttraumatic stress disorder (PTSD), unlike findings from most other disaster studies. The relative prevalence and incidence of major depressive disorder (MDD) and PTSD were examined after the 9/11 attacks relative to trauma exposures. METHODS This study used full diagnostic assessment methods and careful categorization of exposure groups based on DSM-IV-TR criteria for PTSD to examine 373 employees of 9/11-affected New York City workplaces. RESULTS Postdisaster new MDD episode (26%) in the entire sample was significantly more prevalent (p<.001) than 9/11-related PTSD (14%). Limiting the comparison to participants with 9/11 trauma exposures, the prevalence of postdisaster new MDD episode and 9/11-related PTSD did not differ (p=.446). The only 9/11 trauma exposure group with a significant difference in relative prevalence of MDD and PTSD were those with a 9/11 trauma-exposed close associate, for whom postdisaster new MDD episode (45%) was more prevalent (p=.046) than 9/11-related PTSD (31%). CONCLUSIONS Because of the conditional definition of PTSD requiring trauma exposure that is not part of MDD criteria, prevalence comparisons of these two disorders must be limited to groups with qualifying trauma exposures to be meaningful. Findings from this study suggest distinct mechanisms underlying these two disorders that differentially relate to direct exposure to trauma vs. the magnitude of the disaster and personal connectedness to disaster and community-wide effects.

Expression of Ethnic Prejudice in Focus Groups from Agencies Affected by the 9/11 Attacks on the World Trade Center

Members of Muslim and Arab-American communities were publicly targeted as suspects and perpetrators of this terrorism. One to two years after the attacks, 145 participants from 6 affected agencies in New York City participated in 22 focus groups to discuss post-disaster psychosocial issues. Ethnic prejudice was reflected in 2% of the comments emerging from these discussions, representing three major subthemes: (1) observations of prejudice toward self or others, (2) personal fear-based or prejudicial attitudes and opinions, and (3) defense of Muslims. The discussion involving prejudice that emerged in these focus groups parallels the upsurge in prejudice reported by other sources after 9/11.

Experience of the September 11 Terrorist Attacks by Airline Flight Staff

The purpose of this exploratory study was to investigate the 9/11-related experiences, observations, and perceptions of airline flight staff highly connected to the terrorist attacks and the effects of the attacks on their work. A focus group of seven flight staff was conducted in January 2004. Spoken passages (N = 115) were categorized into themes, with excellent interrater reliability. Item count frequencies were tabulated for each theme. Five themes emerged: disaster experience, emotional response, perceived danger, interpersonal response, and workplace response. The flight staff characterized their daily work as front-line duty fraught with danger, uncertainty, and vivid reminders.

9/11: Mental Health in the Wake of Terrorist Attacks: The World Trade Center Worker/Volunteer Mental Health Screening Program

Does terrorism have a unique and significant emotional and behavioral impact among adults and children? In what way does the impact of terrorism exceed the individual level and affect communities and specific professional groups, and test different leadership styles? How were professional communities of mental health clinicians, policy makers, and researchers mobilized to respond to the emerging needs post-disaster? What are the lessons learned from the work conducted after 9/11, and the implications for future disaster mental health work and preparedness efforts? Yuval Neria and his team are uniquely placed to answer these questions having been involved in modifying ongoing trials and setting up new ones in New York to address these issues straight after the attacks. No psychiatrist, mental health professional or policy-maker should be without this book.

Textbook of Disaster Psychiatry: Neurobiology of disaster exposure: fear, anxiety, trauma, and resilience

This chapter reviews the findings of human and animal studies which have characterized normal function in the sympathetic nervous system (SNS) and the hypothalamic-pituitary-adrenal (HPA) axis, and then briefly describes post-traumatic stress disorder (PTSD)-associated abnormalities seen in each system. Neurobiological models of the structure, function and neurochemistry of the brain have evolved significantly as a result of recent input from findings of neuroimaging studies. In recent years several neurochemicals have been associated with resilience. In humans, neuroimaging studies of PTSD have primarily focused on the amygdala, the hippocampus, medial prefrontal cortex, and anterior cingulate cortex. Multidisciplinary studies that use neurochemical, neuroimaging, genetic, and psychosocial approaches may in the future clarify the complex relationships between genotype, phenotype, and psychobiological responses to stress. Pharmacological intervention aimed at treating early severe symptoms which are known to be predictive of later PTSD, such as excessive arousal, is one possible avenue of study.