The spectrum of human reactions to terrorist attacks with weapons of mass destruction: early management considerations

Residents of a community who are intentionally exposed to a hazardous biological, chemical, or radiological agent (including medical first-responders and other civil defense personnel who live in that community) will exhibit a spectrum of psychological reactions that will impact the management of the incident. These reactions will range from a variety of behaviors of normal people under abnormal circumstances that either will help or hinder efforts to contain the threatening agent, deliver medical care, and reduce the morbidity, mortality, and costs associated with the disaster, to the development of new, or exacerbation of preexisting, mental disorders. Anticipating the decisions that people will make and actions they will take as the crisis develops is hindered by the limited number of previous disasters that bear crucial similarities to a terrorist attack with a weapon of mass destruction. Such actions, therefore, could serve as models to predict community reactions. One result of a study that attempted to fill in these gaps suggested that medical first-responders and their spouses/significant others may require separately crafted information and advice to reduce the potential for disharmony within the family that could affect job performance during the crisis. For those persons who exhibit emotional lability or cognitive deficits, evaluation of their psychiatric signs and symptoms may be more difficult than imagined, especially with exposure to nerve agents. Appreciation of these difficulties, and possession of the skill to sort through them, will be required of those assigned to triage stations. The allocation and utilization of mental health resources as the incident unfolds will be the responsibility of local consequence managers; these managers should be aware of the results of a recently-held workshop that attempted to reach consensus among experts in disaster mental health, based on the peer-reviewed literature, on the efficacy and safety of various approaches to early psychological interventions for victims of mass trauma and disasters. Thus, psychological factors are likely to be significant in the management of a terrorist incident that involves an agent of mass destruction. Emergency medical workers with managerial responsibilities, whether limited in scope or community-wide, should be aware of these factors, and should train to handle them through effective risk communication as part of their planning and preparation.     

Unusual but potential agents of terrorists

Emergency personnel are tasked with the daunting job of being the first to evaluate and manage victims of a terrorist attack. Numerous potential chemical agents could be used by terrorists. The challenge for first responders and local hospital emergency personnel is to prepare for a terrorist event that might use one or more of these agents. As part of that preparation, emergency physicians should have a basic understanding of potential chemical terrorist agents. It is beyond the scope of this article to review all potential terrorist agents. Rather, four potential agents have been chosen for review: sodium monofluoroacetate, trichothecene mycotoxins, vomiting agents, and saxitoxin.     

Integration of disaster mental health services with emergency medicine

Despite limited resources, emergency medical settings will be called upon to play many roles in the context of disasters and terrorist attacks that are related to preparedness, surveillance, mental health services delivery, and staff care. Such settings are a central capture site for those individuals likely to be at highest risk for developing mental health and functional problems. Because much of the potential harm to survivors of disaster or terrorism (and their families) will be related to their mental health and role functioning, preparedness requires the active integration of behavioral health into emergency medicine in every component of disaster response. There are many challenges of doing this including: (1) finding ways to integrate activities of the medical care, emergency response, and public health systems; (2) determining whether an incident has actually occurred; (3) making differential diagnoses and managing other aspects of initial medical needs; and (4) coping with the risks associated with system overload and failure. Delivery of direct mental health care must include: (1) survivor and family education; (2) identification and referral of those requiring immediate care and follow-up; (3) group education and support services; and (4) individual counseling. In order for effective response to occur, the integration of psychosocial care into disaster response must occur prior to the disaster itself, and will depend on effective collaboration between medical and mental health care providers. At workplaces, emergency medical care centers must ensure that staff and their families are properly trained and supported with regard to their disaster functions and encouraged to develop personal/family disaster plans.     

Effects of seasonality and daylight savings time on emergency department visits for mental health disorders

ObjectivesEmergency Department (ED) utilization accounts for a large portion of healthcare services in the US. Disturbance of circadian rhythms may affect mental and behavioral health (MBH) conditions, which could result in increased ED visits and subsequent hospitalizations, thus potentially inducing staffing shortages and increasing ED wait time. Predicting the burden of ED admissions helps to better plan care at the EDs and provides significant benefits. This study investigates if increased ED visits for MBH conditions are associated with seasonality and changes in daylight savings time.MethodsUsing ED encounter data from a large academic medical center, we have examined univariate and multivariate associations between ED visits for MBH conditions and the annual time periods during which MBH conditions are more elevated due to changes in the seasons. We hypothesize that ED visits for MBH conditions increase within the 2-week period following the daylight savings time changes.ResultsIncreased MBH ED visits were observed in certain seasons. This was especially true for non-bipolar depressive illness. We saw no significant changes in MBH visits as associated with changes in the daylight savings time.ConclusionsData do not provide conclusive evidence of a uniform seasonal increase in ED visits for MBH conditions. Variation in ED MBH visits may be due to secular trends, such as socioeconomic factors. Future research should explore contemporaneous associations between time-driven events and MBH ED visits. It will allow for greater understanding of challenges regarding psychiatric patients and opportunities for improvement.     

Exploring the scope of the Emergency Department mental health nurse practitioner role

The mental health nurse practitioner (MHNP) role in the Emergency Department is focused on assessing and intervening to assist people in mental distress. The skills and expertise associated with this role are also compatible with the provision of short-term outpatient care. This scoping study investigated the potential for a MHNP outpatient service for patients presenting through the Emergency Department with a range of undifferentiated mental health concerns. The specific aim of this study was to explore the feasibility, structure, and potential outcome measures that may be used to evaluate a MHNP outpatient service. Data for the study were gathered via an extensive literature review and two separate focus group interviews. A series of semistructured interviews conducted with key informants were also undertaken to incorporate a range of clinical, academic, health manager, consumer, and carer perspectives. Findings from the study including prospective benefits and barriers associated with the implementation of this new service are highlighted and discussed. These findings indicate that a structured and formalized MHNP outpatient service has the potential to address a current deficit in the health-care system by providing timely, accessible, primary prevention, and early intervention mental health care that better meets the needs of the public and is consistent with the Australian National Mental Health Plan (2003-2008). A MHNP outpatient service also provides an important opportunity to explore, expand, and more clearly define the unique and valuable contribution of advanced mental health nursing practice to contemporary health care.     

The effects of marital dissolution and marital quality on health and health service use among women.

BACKGROUND: Little is known about the impact of marital dissolution and/or marital harmony on health service use. OBJECTIVES: To examine the ways in which marital dissolution and/or marital quality influence health and health service use. RESEARCH DESIGN: The Americans' Changing Lives (ACL) survey was designed to provide a longitudinal study of successful aging. The ACL contains a nationally representative sample of people over age 24, with an oversampling of individuals age 60 and above. SUBJECTS: Nine hundred and twenty seven female subjects who were married at baseline (1986); 101 (10.9%) of those were no longer married at follow up (1989). MEASURES: Health status and health service use at follow up. RESULTS: Marital dissolution, alone and together with marital quality, was associated with worsened mental and physical health and increased mental health service use. Marital harmony was associated with better sleep and fewer depressive symptoms and physician visits. Widowhood was associated with worsened health, but not with greater health service use. Separated women and women divorced from a discordant marriage were not more depressed but used more mental health services. Women separated from a marriage they had rated as harmonious increased their alcohol consumption. CONCLUSIONS: Marital dissolution increases the risk for mental and physical health problems, some of which emerge only among women who had harmonious marriages. Marital harmony appears protective against physician visits. Widows should be encouraged to seek help for their health difficulties. Separated women should be counseled that they are at heightened risk for increased alcohol consumption. Divorced and separated women appear to seek help for emotional problems, over and above depressive symptoms.     

Psychiatric Comorbidities and BMI: An Exploratory Analysis

Years of research and clinical practice have demonstrated that individuals with certain mental health conditions are at an increased risk of obesity. However, no identified research has examined associations between multiple comorbid psychiatric disorders and body mass index (BMI). This study uses a secondary analysis to examine associations between a large number of combinations of various mental health conditions and BMI. Surprisingly, the results of this study indicate that the most comorbid psychiatric disorders are not associated with an increased risk of elevated BMI. However, bipolar disorder, agoraphobia, attention-deficit hyperactivity disorder, and panic disorder had the greatest number of comorbid disorder associations linked with elevated BMI. The effect sizes ranged from a significant but relatively small Cohen's d of 0.3 to a more notable effect size of 0.7. The results of this study indicate that practitioners should be especially vigilant in helping their patients to avoid weight gain when they have one of the four identified disorders in combination with at least one other disorder. Future research is needed to understand the mechanisms underlying this increased risk and evaluate targeted interventions that would be the most effective for people with these diagnoses.     

Identification and treatment of mental and substance use conditions: health plans strategies

BACKGROUND: Mental health and substance use conditions are under-recognized and under-treated. Private health plans may be able to affect the extent of screening and, thus, identification of enrollees who need treatment. OBJECTIVES: The goals of this study were to determine strategies used by health plans to identify mental health and substance use conditions; and describe the characteristics of health plans associated with use of these strategies. METHODS: In 2003, we conducted a nationally representative survey of private health plans regarding behavioral health services. A total of 368 health plans (83% response rate) provided information about their managed care products: health maintenance organization (HMO), point-of-service (POS), or preferred provider organization (PPO) products (812 in total). MEASURES: We asked whether plans verify primary care providers' screening for mental health or substance use conditions, screen outside of primary care, and distribute practice guidelines. We characterized each product in terms of "carve-out" to a specialty behavioral health vendor, tax status, and region and market area population. RESULTS: Thirty-four percent of products verify primary care providers' screening for mental health, but only 8% verify alcohol or drug screening. Outside of primary care, 31% conduct screening through the mail, phone, or internet. Depression guidelines are distributed to primary care providers by 78% of managed care products: alcohol or drug guidelines are distributed by 33%. In multivariate analyses, specialty contracting was positively associated, and PPO product type was negatively associated with these strategies. CONCLUSIONS: Most health plans use multiple strategies to improve identification of behavioral health conditions, but use of such strategies was greater for mental health than for substance use conditions.     

Assessing prevalence of emotional and behavioral problems in suspended middle school students.

Schools are seeing an influx of disruptive behaviors related to an increase in emotional and behavioral issues. In the adolescent population, emotional and behavioral problems are manifested in a variety of forms and often result in some form of discipline within the school setting. Although discipline punishes the unwanted behavior, it does nothing to address the reason for the behavior. This study examined the prevalence of emotional and behavioral problems among middle school students who have been suspended. Students who are suspended are the very children at risk for social, emotional, and mental health problems. Results from the study indicate significance in some of the 14 subcategories of the Student Behavior Survey tool, lending support toward the conclusion that emotional and behavioral problems may be associated with suspensions. Advocating for assessment of emotional and behavioral needs should be considered for students with discipline problems that lead to suspension.     

Perinatal depression and infant mental health

A mother's mental health during pregnancy and the first year postpartum is of the utmost importance to the cognitive, social, and emotional development of her child. Perinatal depression is associated with increased risk for wide-ranging adverse child development effects that can affect infant and early childhood mental health. Although effective treatments for perinatal depression exist, it is currently unclear if treatment of maternal depression alone is sufficient to ameliorate the negative effects of maternal depression on child outcomes. Interventions focused on the mother-infant relationship and dyadic interaction may be required to address the potential effect of maternal depression on the child. This paper provides an overview of maternal perinatal depression, the risk it poses for infant/early-childhood mental health, strategies for intervention that include mitigating depression and decreasing risk to the child, and implications for psychiatric nurses who work with perinatal women. Early identification and treatment of perinatal depression are critical to ensure optimal infant development and the child's future mental health.     

Psychiatric emergencies in the elderly

Psychiatric disorders are best managed by interdisciplinary teams of psychiatrists, psychiatric nurses, social workers, and psychologists. Some Emergency Departments have access to such psychiatric services either in the hospital or in associated clinics or community mental health centers. Unfortunately, many are not staffed with mental health professionals or such expertise is available only on a limited basis, particularly on evenings and weekends. Therefore, one or more members of the Emergency Department staff should have specialized psychiatric training and experience. We have reviewed the format for conducting a psychiatric history and mental status examination and have discussed the most common emergency psychiatric disorders of the elderly and their management in the Emergency Department. In order to assess and treat elderly psychiatric patients properly, emergency personnel must be aware of the medical disorders associated with psychiatric illness and must be prepared to initiate treatment quickly and appropriately. For most patients, emergency intervention is the first step in ensuring that a correct diagnosis is made and that ongoing psychiatric treatment is arranged through timely consultation and referral.     

What are the experiences of Emergency Department nurses in caring for clients with a mental illness in the Emergency Department?

Background

Australian Emergency Departments are experiencing increased numbers of clients with a mental illness and Emergency Departments are becoming increasingly utilised as the first point of contact and portal into the mental health care system. Therefore nurses working within the Emergency Departments find themselves having to care for clients with a mental illness as part of their daily work. The aim of this study was to gain an understanding of the experiences of Emergency Department nurses caring for clients with a mental illness in the Emergency Department.

Methods

An interpretive phenomenological study was undertaken using semi structured interviews to enable the lived experiences of Emergency Department nurses to be discovered and articulated. Six Registered Nurses working within an Emergency Department were interviewed, and these participants were asked to tell the story of their experiences in their own words.

Results

Results are based on data collected from six participant interviews. Three major themes emerged related to caring for clients with a mental illness in the Emergency Department: (i) Time as a causative factor, (ii) environment and the influence of surroundings and (iii) understanding the client's personal journey.

Conclusions

Data obtained from participants in this study confirm what has been reported in the literature, that is, that there has been an increase in presentations of clients with a mental illness to the Emergency Department, and the results of this study highlight that time constraints specific to the Emergency Department impact both the client with the mental illness and the Emergency Department nurse caring for these clients. In addition, narratives from Emergency Department nurses purport that the environment within the Emergency Department is not conducive to the provision of optimal care to this client group who have unique care needs and require a specialised management focus. Furthermore, the participants expressed that they had difficulty conceptualising the role of the Emergency Department in the client's personal journey. The concept of recovery in mental health comes into conflict with the culture within the Emergency Department that views recovery as a restoration or return to health rather than the unique journey of the client living with a mental illness.     

Persistent paranoid delusions following the September 11 terrorist attacks in a man with no pre-existing mental illness

The effects of modern day terrorism on mental health are not well understood. Described here is a 51-year-old male with no pre-existing mental illness who developed paranoid delusions related to the September 11, 2001, terrorist attacks shortly after they occurred. After about two years of treatment with quetiapine the patient was no longer delusional about terrorism but experienced extensive paranoid delusions about commonly encountered persons, requiring treatment which continues to the current time. Clinicians should be aware of the possible impact of terrorist activities on the mental health of vulnerable individuals.     

"Not always smooth sailing": mental health issues associated with the transition from high school to college

Students who transition from high school to college are often excited by the new phase of their lives. However, they are exposed to circumstances and expectations which place them at risk for psychiatric disorders or that may exacerbate pre-existing problems. In this paper, we discuss risk factors and other issues associated with students transitioning to college or university life, identify challenges for health professionals, and suggest possible strategies to improve the mental health of young adults on college campuses. Academic staff and health care providers need to be aware of how best to engage and assist students during an important phase of their life. Processes and care pathways also need to be easily understood, user friendly, and appropriately resourced. It is anticipated that staff, students, and industry health care providers will benefit from a greater awareness of some of the mental health issues that may occur in higher education.     

Attention,Externalizing, and Internalizing Problems of Youth Exposed to Parental Incarceration

Few studies have examined the effects of parental incarceration (PI) on outcomes above and beyond other risk and adverse childhood experiences (ACEs). The objectives of this study were to (1) the associations between PI and mental health problems (attention, externalizing, internalizing, and total behavioral problems) and (2) the mediating role of current socioeconomic status and cumulative ACEs. An observational and cross-sectional design was employed. Analyses included hierarchical multivariable linear regression modeling. The analytic sample included 613 adolescents (11–17?years). On average, youth exposed to PI experienced three times as many ACEs compared with youth unexposed. Youth exposed to PI were more likely to have behavioral problems than their unexposed peers. The main effect for all models was attenuated by current economic hardship as well as exposure to increasing numbers of ACEs. Exposure to PI can be viewed as a marker of accumulative risk for intervention since youth impacted by PI are more likely to experience behavioral difficulties and associated adverse childhood experiences. Due to the associated adversity that impact youth exposed to PI, mental health providers need to be able to identify and screen for symptoms associated with trauma.     

Epidemiologic trends and costs of fragmentation

The data that were reviewed in this article documented that in health systems, which manage behavioral health disorders independently from general medical disorders, the estimated 10% to 30% of patients with behavioral health service needs can expect (1) poor access or barriers to medical or mental health care; (2) when services are available, most provided will not meet minimum standards for expected outcome change; and (3) as a consequence of (1) and (2), medical and behavioral disorders will be more persistent with increased complications, will be associated with greater disability, and will lead to higher total health care and disability costs than will treatment of patients who do not have behavioral health disorders. This article proposes that these health system deficiencies will persist unless behavioral health services become an integral part of medical care (ie, integrated). By doing so, it creates a win-win situation for virtually all parties involved. Complex patients will receive coordinated general medical and behavioral health care that leads to improved outcomes. Clinicians and the hospitals that support integrated programs will be less encumbered by cross-disciplinary roadblocks as they deliver services that augment patient outcomes. Health plans (insurers) will be able to decrease administrative and claims costs because the complex patients who generate more than 80% of service use will have less complicated claims adjudication and better clinical outcomes. As a result, purchaser premiums, whether government programs, employers, or individuals, will decrease and the impact on national budgets will improve. Ongoing research will be important to assure that application of the best clinical and administrative practices are used to achieve these outcomes.     

Improving the health and well-being of adolescent boys

Adolescent men are at risk of having significant unmet health care needs. Like adolescent girls, they have complex health care needs and are more likely than younger children to be to be uninsured. They are less likely than women and other age groups to seek medical attention from traditional sources of care. Because of inadequate youth-oriented services, as well as teens' developmental stage, they have a tendency to receive care that is brief and problem oriented [20]. Such care is not likely to address complex problems that may be related to risk behaviors. Adolescent boys are also more concerned with the skills of the provider offering services than with the system in which the provider functions. Opportunities for outreach to adolescent men exist within many institutions. Nurses as advocates, educators, counselors, and providers of preventive health care have a creative opportunity for enhancing services to the teenage boy. The school is a natural place to begin as adolescents spend a significant part of each day there. Family planning and STI clinics are a source of care that are not well used by adolescent males, but when they do attend it is an opportunity to identify problems, provide counseling and referrals, and offer continuity. These health care institutions are not often welcoming or comfortable for the male youth. Use of these clinics will be enhanced by providers demonstrating increased acceptance of the adolescent when he attends as well as actively requesting that he attend with his partner. The most unusual but sorely needed outreach must be made to incarcerated and delinquent adolescent male. Residential facilities for delinquent youth need to be encouraged to provide a multidisciplinary comprehensive medical, mental health, and social services model. This approach will not only benefit the adolescent but the youth's community as well. Emergency rooms represent another crucial, missed opportunity to connect with young men. With some forethought and follow-up, emergency departments must become connected to appropriate and accessible adolescent primary care resources in the community. Finally, adolescent men are an underinsured population. Nurses can be important advocates of available state insurance funds, sliding scale or free services to youth, and must be a voice in youth policy-making.     

Improving competence in emergency mental health triage

The Emergency Department is an important contact point for people with mental health problems (Tobin et al. 1999, p. 2). The Barwon Health Emergency Department is no exception. Approximately 1000 clients per year, or 2.6% of the 38,000 people seen annually in the Barwon Health, Geelong Hospital Emergency Department present with a primary mental health complaint or associated issue. The triage scale used in the Emergency Department contained little guidance for the triage of clients with mental health problems. A triage scale specifically designed to highlight mental health emergencies was implemented and its impact on practice was assessed. Improvements in communication, nurses' confidence in triaging clients with mental health problems and time to intervention by mental health staff were made. This article describes the implementation and evaluation of a mental health triage scale and changes to practice that resulted.     

The psychosocial effects of combat: the frequently unseen injury

The psychosocial issues related to deployment and combat duty are complex. Deployment may result in psychiatric casualties that are either the result of inadequate coping with the stressors of deployment or acute stress reactions caused by the trauma of battle, that is, combat stress reactions. Combat duty is associated with traumatic events, deprivation, and exposure to war atrocities that may result in acute, delayed or chronic psychosocial issues during and afer returning from deployment. Although protective and mediating factors ar in place, 11% to 17% of combat veterans are at risk for mental disorders in 3 to 4 months after return from combat duty. Combat veterans include service members directly involved in combat as well as those providing support to combatants, that is, nurses. All combat veterans are at risk for experiencing the negative effects of deployment. Frequent deployments of active duty, reserve, and National Guard members have become commonplace. This translates into a disruption of live for anyone associated with the military, as well as an increased focus on the psychosocial impact of combat across the nation. Modern warfare has resulted in multiple changes in policy that govern military operations. Initiatives that focus on the stabilization of service members and their families may impact mental health outcomes of service members returning from combat duty. An initiative toward decreasing the stigma of receiving mental health care is warranted. Mental health issues must be addressed before and during deployment to ensure optimum individual and unit functioning. Early identification and treatment of mental health problems may decrease the psychosocial impact of combat and thus prevent progression to more chronic and severe psychopathology such as depression and PTSD.