Faculty Bibliography

To illustrate how spatial modeling methods may provide insight about the relation between proximity to mass trauma and substance use, we examined the role of proximity to a terrorist event in determining risk of substance use related diagnoses. Previous analyses that have assessed changes in substance use following mass traumas such as terrorist attacks have produced conflicting results. We used Bayesian hierarchical modeling methods to assess whether distance from the World Trade Center (WTC) site in the aftermath of the September 11, 2001 terrorist attacks was associated with risk of substance use related diagnoses. In analyses controlling for age, gender, median household income, and employment-related exposure to the terrorist attacks, we found that each two mile increment in distance away from the WTC site was associated with 18% more substance use related diagnoses in the population we studied; this relation between distance from the WTC and substance use related disorder was the opposite of the relations observed one year before the same attacks in the same area. By accounting for spatial relationships that may influence the population risk of substance use health disorder, this approach helps explain some of the conflicting observations in the extant literature. These methods hold promise for the characterization of disease risk where spatial patterning of exposures and outcomes may matter.

Emergency physicians are likely to be first-line responders in any local or regional terrorist event. In addition to preparing for the potential physical conditions and injuries that are associated with terrorism, they should be aware of the behavioral and mental health implications as well. It is helpful to be familiar with the characteristics that predict who may be at increased risk for mental illness after such events and how they may be identified in an Emergency Department setting. Although most people in the general population with behavioral conditions stemming from a terrorist event can be expected to recover spontaneously within several months, other individuals are at increased risk of developing more debilitating mental health conditions that have been associated with post-terrorist and disaster environments. Screening tools are available to help emergency practitioners identify them and refer patients for more formal psychiatric evaluation and potential interventions to facilitate and speed the recovery process.

Data from existing administrative databases and ongoing surveys or surveillance methods may prove indispensable after mass traumas as a way of providing information that may be useful to emergency planners and practitioners. The analytic approach, however, may affect exposure prevalence estimates and measures of association. We compare Bayesian hierarchical modeling methods to standard survey analytic techniques for survey data collected in the aftermath of a terrorist attack. Estimates for the prevalence of exposure to the terrorist attacks of September 11, 2001, varied by the method chosen. Bayesian hierarchical modeling returned the lowest estimate for exposure prevalence with a credible interval spanning nearly 3 times the range of the confidence intervals (CIs) associated with both unadjusted and survey procedures. Bayesian hierarchical modeling also returned a smaller point estimate for measures of association, although in this instance the credible interval was tighter than that obtained through survey procedures. Bayesian approaches allow a consideration of preexisting assumptions about survey data, and may offer potential advantages, particularly in the uncertain environment of postterrorism and disaster settings. Additional comparative analyses of existing data are necessary to guide our ability to use these techniques in future incidents.

INTRODUCTION: While several population-based studies have documented behavioral health disturbances following terrorist attacks, a number of mental health service utilization analyses present conflicting conclusions. PURPOSE: The purpose of this study was to determine if mental health service utilization increased following a terrorist attack by assessing changes in psychoactive drug prescription rates. METHODS: The rate of selective serotonin reuptake inhibitor (SSRI) prescriptions was measured among New York State Medicaid enrollees before and after the terrorist attacks of 11 September 2001. The association between geographic proximity to the events and changes in the rate of SSRI prescriptions around 11 September 2001 was assessed. RESULTS: From September to December 2001, among individuals residing within three miles of the World Trade Center site, there was an 18.2% increase in the SSRI prescription rate compared to the previous eight-month period (p = 0.0011). While there was a 9.3% increase for non-New York City residents, this change was not statistically significant (p = 0.74). CONCLUSIONS: There was a quantifiable increase in the dispensing of psychoactive drugs following the terrorist attacks of 11 September 2001, and this effect varied by geographic proximity to the events. These findings build on the growing body of knowledge on the pervasive effects of disasters and terrorist events for population health, and demonstrate the need to include mental and behavioral health as key components of surge capacity and public health response to mass traumas.

STUDY OBJECTIVE: We assess emergency department (ED) utilization by a population whose health care encounters can be tracked and quantified for behavioral and mental health conditions in the aftermath of the terrorist attacks of September 11, 2001. METHODS: We assessed presentations to EDs by using Medicaid analytic extract files for adult New York State residents for 2000 and 2001. We created 4 mutually exclusive geographic areas that were progressively more distant from the World Trade Center and divided data into 4 periods. All persons in the files were categorized by their zip code of residence. We coded primary ED diagnoses for posttraumatic stress disorder, substance abuse, psychogenic illness, severe psychiatric illness, depression, sleep disorders, eating disorders, stress-related disorders, and adjustment disorders. RESULTS: There was a 10.1% relative temporal increase in the rate of ED behavioral and mental health diagnoses after the September 11, 2001, terrorist attacks for adult Medicaid enrollees residing within a 3-mile radius of the World Trade Center site. Other geographic areas experienced relative declines. In population-based comparisons, Medicaid recipients who lived within 3 miles of the World Trade Center after the September 11, 2001, terrorist attacks had a 20% increased risk of an ED mental health diagnosis (prevalence density ratio 1.2; 95% confidence interval 1.1 to 1.3) compared to those who were non-New York City residents. CONCLUSION: The complex role that EDs may play in responding to terrorism and disasters is becoming increasingly apparent. To the best of our knowledge, this is the first report of a quantifiable increase in ED utilization for mental health services by persons exposed to a terrorist attack in the United States.

BACKGROUND: Numerous studies have suggested that emergency medical services (EMS) providers are ill-prepared in the areas of training and equipment for response to events due to weapons of mass destruction (WMD) and other public health emergencies (epidemics, etc.). METHODS: A nationally representative sample of basic and paramedic EMS providers in the United States was surveyed to assess whether they had received training in WMD and/or public health emergencies as part of their initial provider training and as continuing medical education within the past 24 months. Providers also were surveyed as to whether their primary EMS agency had the necessary specialty equipment to respond to these specific events. RESULTS: More than half of EMS providers had some training in WMD response. Hands-on training was associated with EMS provider comfort in responding to chemical, biological, and/or radiological events and public health emergencies (odds ratio (OR) = 3.2, 95% confidence interval (CI) 3.1, 3.3). Only 18.1% of providers surveyed indicated that their agencies had the necessary equipment to respond to a WMD event. Emergency medical service providers who only received WMD training reported higher comfort levels than those who had equipment, but no training. CONCLUSIONS: Lack of training and education as well as the lack of necessary equipment to respond to WMD events is associated with decreased comfort among emergency medical services providers in responding to chemical, biological, and/or radiological incidents. Better training and access to appropriate equipment may increase provider comfort in responding to these types of incidents.