Terrorism, trauma, and mass casualty triage: how might we solve the latest mind-body problem?

The global war on terrorism has led to increased concern about the ability of the U.S. healthcare system to respond to casualties from a chemical, biological, or radiological agent attack. Relatively little attention, however, has focused on the potential, in the immediate aftermath of such an attack, for large numbers of casualties presenting to triage points with acute health anxiety and idiopathic physical symptoms. This sort of "mass idiopathic illness" is not a certain outcome of chemical, biological, or radiological attack. However, in the event that this phenomenon occurs, it could result in surges in demand for medical evaluations that may disrupt triage systems and endanger lives. Conversely, if continuous primary care is not available for such patients after initial triage, many may suffer with unrecognized physical and emotional injuries and illness. This report is the result of an expert planning initiative seeking to facilitate triage protocols that will address the possibility of mass idiopathic illness and bolster healthcare system surge capacity. The report reviews key triage assumptions and gaps in knowledge and offers a four-stage triage model for further discussion and research. Optimal triage approaches offer flexibility and should be based on empirical studies, critical incident modeling, lessons from simulation exercises, and case studies. In addition to staging, the proposed triage and longitudinal care model relies on early recognition of symptoms, development of a registry, and use of non-physician care management to facilitate later longitudinal followup and collaboration between primary care and psychiatry for the significant minority of patients who develop persistent idiopathic symptoms associated with reduced functional status.

The impact of disasters and their aftermath on mental health.

Hurricanes Katrina and Rita were the latest disasters involving trauma to individuals and displacement of significant populations. As a consequence, those of us in health care fields often are affected both as professionals with critical skills and as individuals with families under intense stress. This Commentary, which appears in the January 2006 issue of The Journal of Clinical Psychiatry (2006;67:7-14), provides first-hand insight into the "at-the-front" realities faced by primary care professionals as disasters evolve, as well as the preparations we can make with our families and the key priorities to be addressed in our professional roles with individuals, affected groups of people, and response systems. While it is rare for us to dually publish material, we deem the importance of this information to merit joint publication in The Journal of Clinical Psychiatry and The Companion.-Larry Culpepper, M.D.

An outcome evaluation of the SOS Suicide Prevention Program.

OBJECTIVES: We examined the effectiveness of the Signs of Suicide (SOS) prevention program in reducing suicidal behavior. METHODS: Twenty-one hundred students in 5 high schools in Columbus, Ga, and Hartford, Conn, were randomly assigned to intervention and control groups. Self-administered questionnaires were completed by students in both groups approximately 3 months after program implementation. RESULTS: Significantly lower rates of suicide attempts and greater knowledge and more adaptive attitudes about depression and suicide were observed among students in the intervention group. The modest changes in knowledge and attitudes partially explained the beneficial effects of the program. CONCLUSIONS: SOS is the first school-based suicide prevention program to demonstrate significant reductions in self-reported suicide attempts.

A call to collaboration: the federal commitment to suicide prevention.

The federal government, largely through the U.S. Department of Health and Human Services (HHS), sponsors an array of science-based suicide prevention initiatives. This article details the prevention-related agendas and collaborative efforts of five operating divisions within the Department of Health and Human Services: the Substance Abuse and Mental Health Services Administration, National Institutes of Health, Centers for Disease Control and Prevention, Indian Health Service, and Health Resources and Services Administration. The article highlights HHS's activities and their link to the National Strategy for Suicide Prevention, the plan which will guide the nation's suicide prevention efforts for the next decade.

Disaster mental health services following the 1995 Oklahoma City bombing: modifying approaches to address terrorism.

How did the 1995 Oklahoma City bombing differ from prior disasters and what implications did it have for disaster mental health services and service delivery? The federal disaster mental health approach in this country developed largely out of experiences with natural disasters. The 1995 Oklahoma City bombing differed in several important ways, including the large number of human casualties, higher rates of psychopathology, and an extended period of concern due to the criminal investigation and trials, which suggested the need to consider modifications in the program. Outreach was extensive, but psychiatric morbidity of direct victims was greater than that of victims of natural disasters, emphasizing the need for attention to the triage and referral process. Other concerns that warrant consideration include practices related to record keeping and program evaluation.