Faculty Bibliography

AIM: To conduct a comprehensive analysis of the conflicting evidence on substance use and misuse following mass traumas such as terrorist incidents. METHODS: We reviewed and synthesized evidence from 31 population-based studies using Bayesian meta-analysis and meta-regression. RESULTS: The majority of the studied were conducted in the aftermath of the terrorist attacks of 11 September 2001. Controlling for exposure, type of incident and time since the event occurred, 7.3% [95% credible interval (CrI) 1.1-32.5%] of a population can be expected to report increased alcohol consumption in the first 2 years following a terrorist event. There is, however, a 20% probability that the prevalence will be as high as 14%. The unadjusted prevalence of increased cigarette smoking following a terrorist event is 6.8% (95% Cr I 2.6-16.5%). Unadjusted reports of mixed drug use (including narcotics and prescription medications) was 16.3% (95% Cr I 1.3-72.5%). CONCLUSIONS: These results underscore the potentially pervasive behavioral health effects of mass terrorism, and suggest that public health interventions may usefully consider substance use as an area of focus after such events.

OBJECTIVE: To develop, implement, and assess a web-based simulation training program for emergency medical services (EMS) personnel on recognition and treatment of ocular injuries resulting from weapons of mass destruction (WMD) attacks. DESIGN: The training program consisted of six modules: WMD knowledge and event detection, ocular anatomy, ocular first aid (ie, flushing, cupping, and patching), and three WMD simulations (ie, sarin gas release, anthrax release, and radioactive dispersal device). Pretest, post-test, and 1-month follow-up test and a program evaluation were used to measure knowledge gain and retention and to assess the effectiveness of the program. SETTING: New York State EMS. PARTICIPANTS: Four hundred and sixty-four individuals participated in the training program and all waves of the testing (86 percent retention rate). MAIN OUTCOME VARIABLES: The effectiveness of the training intervention was measured using pretest and post-test questionnaires and analyzed using dependent t-tests. RESULTS: Assessment scores for overall knowledge increased from the pretest (mean = 15.7, standard deviation [SD] = 2.1) to the post-test (mean = 17.8, SD = 1.3), p < 0.001, and from pretest (mean = 15.7, SD = 2.1) to 1-month follow-up test (mean = 16.6, SD = 2.0), p < 0.001. Ninety-two percent of respondents indicated that the program reinforced understanding of WMDs. CONCLUSIONS: This training method provides an effective and low-cost approach to educate and evaluate EMS personnel on emergency treatment of eye trauma associated with the use of WMD. Online training should also be supplemented with hands-on practice and refresher trainings.

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.