Posttraumatic Stress Disorder Among Adults in Communities With Mass Violence Incidents.

Importance: Mass violence incidents (MVIs) are prevalent in the US and can have profound and long-lasting psychological consequences on direct survivors, but their outcomes among the broader communities where the MVI occurred are unknown. Objective: To investigate the prevalence of and factors associated with past-year and current posttraumatic stress disorder (PTSD) among adults in communities that experienced an MVI. Design, Setting, and Participants: This cross-sectional survey was completed between February and September 2020 with a household probability sample of adults from 6 communities that had experienced an MVI between 2015 and 2019: Dayton, Ohio; El Paso, Texas; Parkland, Florida; Pittsburgh, Pennsylvania; San Bernadino, California; and Virginia Beach, Virginia. Address-based sampling was used to identify randomly selected households, mail invitations, and select 1 adult per household to complete a self-administered paper or online survey. Data analysis was performed from September to November 2023. Main Outcomes and Measures: The primary outcome was presumptive diagnostic-level past-year PTSD and current (past month) PTSD determined using American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) PTSD criteria. Results: A total of 6867 adults aged 18 years or older accessed the website with a description of the study and consent materials. Of these, 5991 (87.2%) agreed to participate and completed the survey, 343 (6.3%) partially completed the survey, and 443 (6.5%) did not meet eligibility criteria or refused to participate. Most of the 5991 respondents were female (3825 individuals [53.5%]) and had a mean (SD) age of 45.56 (17.58) years. A total of 1261 of 5931 individuals (21.0%) reported high exposure to the MVI (either they or a close friend and/or family member was on site during the shooting). Nearly one-quarter (23.7%; 1417 of 5977 participants reporting PTSD) met presumptive DSM-5 diagnostic criteria for past-year PTSD, with 8.9% (530 participants) meeting the criteria for current PTSD. Regression analyses found that being female (odds ratio, 2.32; 95% CI, 2.01-2.68) and having a history of both physical or sexual assault and other potentially traumatic events (odds ratio, 9.68; 95% CI, 7.48-12.52) were associated with the greatest risk of past-year PTSD. Conclusions and Relevance: In this survey study of 5991 participants, presumptive PTSD was quite prevalent long after the MVI among adults in communities that have experienced an MVI, suggesting that MVIs have persistent and pervasive public health impacts on communities, particularly among those with prior exposure to physical or sexual assault and other potentially traumatic events. Focusing exclusively on direct exposure to MVIs is not sufficient. Incorporating these findings into screening should improve efforts to identify the individuals most in need of prevention or mental health service after MVIs.

Medical maximization: The effect of personality on triage decision-making.

Mass Casualty Incidents (MCIs) rapidly overwhelm the ability of local medical resources to deliver comprehensive and definitive medical care and they have been occurring more frequently in recent decades and affect countries of all socioeconomic backgrounds (Hart et al., 2018). As such, it is important to understand how individuals make such decisions in these events and what factors can hinder or help the process. In this study we focused on the critical role of maximization within MCI triage. Triaging an MCI requires juggling the demand and supply of resources, time, and focus, likely leading to various decisions involving compromise/sacrifice. In a vignette study, hosted on Amazon Mturk (n = 235, Mean age = 38.05, 51.49% self-identified as male), which involved triaging over 100 patients we found that trait differences maximization impacted the willingness to use a "black tag". Furthermore, maximization also impacted how much information an individual needed about the patient before being willing to use a black tag. Overall, this research demonstrates the importance of understanding factors that create individual differences in how people make decisions during MCI events, especially those decisions that involve the use of potentially lifesaving treatments.

Mental Health Outcomes of Arab and Jewish Populations in Israel a Month after the Mass Trauma Events of October 7, 2023: A Cross-Sectional Survey of a Representative Sample.

On October 7, 2023, a war erupted in Israel following a mass terror attack including mass shootings, violent events, civilian abductions, and numerous fatalities, ranking as the third most deadliest terror attack. This cross-sectional, population-based study evaluated the impact on the mental health and utilization of mental health services in the Arab and Jewish populations. Conducted through a virtual platform, the study compared demographic factors, exposure to war-related events, anxiety, and post-traumatic stress symptoms among 517 participants in a representative sample of the adult population in Israel (79.1% Jewish, 20.9% Arab). Jews reported higher exposure to war-related events, but a majority expressed a lack of interest in mental help. In contrast, more Arabs desired mental help but faced barriers like stigma and scarce resources. Arabs showed a greater preference for group therapy and medical treatment. Trust in official bodies was consistently higher among Jews. Both populations exhibited similar levels (12-15.4%) of probable post-traumatic stress disorder (PTSD). This study equips clinicians, researchers and policymakers with real-time insights into improving mental health support for the culturally diverse needs of Jewish and Arab communities following exposure to mass trauma.

Prevalence and risk factors of depression in U.S. adults post mass shootings: evidence from population-based surveys of multiple communities.

OBJECTIVES: Mass violence incidents (MVIs) involving firearms, commonly referred to as "mass shootings" have become increasingly frequent in the United States. These shootings often result in immediate casualties and have far-reaching psychological impacts on survivors, witnesses, and the broader community. This study aimed to assess the prevalence and risk factors of depression within affected communities. STUDY DESIGN: Population-based cross-sectional study. METHODS: Data were collected from six communities affected by MVIs involving firearms that occurred between 2015 and 2020. Participants were randomly selected through address-based sampling, and depression was assessed using Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) diagnostic-level major depressive episode (MDE). RESULTS: Overall, the MDE prevalence was 17·2% since the MVI, 15·4% in the past year, and 8·2% in the past month. Significant risk factors for MDE since MVIs include high exposure to the incident (adjusted relative risk [aRR] = 1·32, 95% confidence interval [CI]: 19-1·60), being aged 18-29 years (aRR = 2·52, 95% CI: 1·61-3·95), being a woman (aRR = 1·58, 95% CI: 1·27-1·96), having low social support (aRR = 1·80, 95% CI: 1·46-2·22), and experiencing past sexual or physical trauma (aRR = 2·20, 1·52-3·19). CONCLUSION: Our study reveals a high burden of depression within communities affected by MVIs involving firearm use. Persons with high exposure to the MVIs and certain demographic groups had greater risks for MDE. These findings highlight the long-term mental health burden in communities affected by MVIs and underscore the necessity of providing mental health services in its aftermath.

Role of media and the media hypes in the aftermath of mass casualty incidents a qualitative thematic content analysis.

Objective: To explore the role of media during mass casualty events and its impact on people. METHODS: The qualitative thematic content analysis was conducted at Jinnah Sindh Medical University, Karachi, from 2018 to 2020 and comprised of semi-structured in-depth interviews and focus group discussions involving participants from the health sector and policymakers at the provincial level. The Frontline Workers such as the ambulance drivers and the first-aid-givers were also included. Data was subjected to conventional content analysis to generate themes. RESULTS: There were 5 in-depth interviews and 4 focus group discussions in the study. Qualitative analysis revealed that the media has a great deal to do in times of a disaster. The media is the strongest weapon and largely impacts people's mind and behaviour, but it has been playing with their emotions and creating unrest among them. Conclusion: There is a need for the policymakers to set guidelines and define the role of the media in times of a disaster.

Understanding the psychological impacts of responding to a terrorist incident.

Background: Responding to a mass casualty event can cause significant distress, even for highly trained medical and emergency services personnel. Objective: The purpose of the study was to understand more about first responders' perspectives about their participation in major incident responses, specifically how and which individual and system factors contributed to their preparedness or may have enabled or hindered their response. The aim of the work was to improve preparedness and response for future incidents. Methods: This study reports a detailed analysis of qualitative interview data from frontline staff who responded to a large mass casualty terrorist incident in the UK in 2017. Data highlighted the psychological distress caused by responding to terrorist events and thus became the focus of further, detailed analysis. Results: Participants (n = 21) articulated in their own words the psychological distress experienced by many of the first responders to the event. Participants reported that they were not prepared to deal with psychological impact associated with this mass casualty terrorist incident and their role in the response, and that follow-up support was inconsistent. Multiple factors were identified as potentially increasing psychological distress. Social support provided by peers and organizational debriefs were identified as two most common support mechanisms. Organizational support was identified as inconsistent. Conclusions: This research contributes to the literature the voices of first responders to UK terrorist incidents, building on existing findings while further contributing unique contextual perspectives. This research reinforces the importance of psychosocial support for those who respond to these tragic incidents, and offers a number of recommendations for organizational preparedness for future events. Abbreviations: A&E: Accident and Emergency; EPRR: Emergency Preparedness, Resilience and Response; ERD: Emergency Response Department; HEPE: Health Emergency Preparedness Exercise; PHE: Public Health England; PHE REGG: Public Health England Research Ethics and Governance Group; MCI: Mass Casualty Incident; NHS: National Health Service.

Antecedentes: Responder a un evento con presencia masiva de víctimas puede causar una angustia psicológica significativa, aún para el personal médico y de emergencias altamente entrenados.Objetivo: El propósito del estudio fue tener una mayor comprensión acerca de la perspectiva de los primeros respondedores sobre su participación en la respuesta a incidentes mayores, específicamente cómo y qué factores individuales y del sistema contribuyeron a su preparación o que pudieron haber habilitado u obstaculizado su respuesta. El objetivo del trabajo fue de mejorar la preparación y respuesta para futuros incidentes.Métodos: Este estudio reporta un análisis detallado de los datos de entrevistas cualitativas realizadas al personal de primera línea que respondieron a un gran incidente terrorista con víctimas masivas en el Reino Unido durante el 2017. Los datos destacaron la angustia psicológica causada por responder a eventos terroristas y, por lo tanto, se convirtieron en el foco de un análisis más detallado.Resultados: Los participantes (n = 21) articularon en sus propias palabras la angustia psicológica experimentada por muchos de los primeros en responder al evento. Los participantes reportaron que no se encontraban preparados para lidiar con el impacto psicológico asociado con este incidente terrorista con víctimas masivas y su rol en la respuesta, y que el soporte durante el seguimiento fue inconsistente. Se identificaron múltiples factores con pueden incrementar la angustia psicológica. El apoyo social proporcionado por los pares y el 'debriefing' organizacional fueron identificados como los dos mecanismos de apoyo más comunes. El apoyo organizacional se identificó como inconsistente.Conclusiones: Esta investigación contribuye a la literatura las voces de los primeros respondedores a los incidentes terroristas del Reino Unido, basándose en los hallazgos existentes y, al mismo tiempo, aporta perspectivas contextuales únicas. Esta investigación refuerza la importancia del apoyo psicosocial para quienes responden a estos trágicos incidentes, y ofrece una serie de recomendaciones para la preparación organizacional para eventos futuros.

Crisis Standards of Care.

Nursing considerations during states of emergency.

Validation of a new method for saliva cortisol testing to assess stress in first responders.

BACKGROUND: Acute or chronic stress can lead to physical and mental disorders. Measuring cortisol can objectify the degree of stress. Cortisol is traditionally measured in serum, but recently the relevant fraction of free cortisol can be reliably measured in saliva, using the very sensitive liquid chromatography tandem mass spectrometry (LC-MS/MS) method. The use of saliva is non-invasive and allows easy serial testing around stressful events. The main objective of this study is to investigate whether serial saliva cortisol determinations using the LC-MS/MS method can be used to assess the stress response that first responders may experience during moments of acute professional deployment in their daily work. METHODS: Healthy first responders (police officers, firefighters, rapid response team, ambulance personnel, first aid and emergency medical personnel) were recruited to participate in a Euregional high-reliability simulation training ('Be Aware'-scenario training, 19 April 2018). At three time points, simultaneous venous blood samples and saliva samples were obtained. These time points were 1 hour before, immediately after and 10 hours after the simulation training. The correlation between changes in saliva cortisol measured by LC-MS/MS and serum cortisol at all three time points was determined. Results were compared with spectators not directly participating in the simulation. RESULTS: 70 subjects participated in the simulation. There was a strong correlation between the changes in saliva and blood cortisol at the three time points. A significant increase in blood and saliva cortisol was shown 1 hour after the experienced stress moments. The levels had almost completely returned to baseline in all healthy volunteers 10 hours later. Cortisol in spectators was unaffected. CONCLUSION: Serial saliva cortisol measurements using LC-MS/MS is a reliable and fast non-invasive functional stress assay, which can be easily collected in daily practice and used for investigation and monitoring of stress response in front line responders.

Mental Illness, Mass Shootings, and the Future of Psychiatric Research into American Gun Violence.

ABSTRACT: This article outlines a four-part strategy for future research in mental health and complementary disciplines that will broaden understanding of mass shootings and multi-victim gun homicides. First, researchers must abandon the starting assumption that acts of mass violence are driven primarily by diagnosable psychopathology in isolated "lone wolf" individuals. The destructive motivations must be situated, instead, within larger social structures and cultural scripts. Second, mental health professionals and scholars must carefully scrutinize any apparent correlation of violence with mental illness for evidence of racial bias in the official systems that define, measure, and record psychiatric diagnoses, as well as those that enforce laws and impose criminal justice sanctions. Third, to better understand the role of firearm access in the occurrence and lethality of mass shootings, research should be guided by an overarching framework that incorporates social, cultural, legal, and political, but also psychological, aspects of private gun ownership in the United States. Fourth, effective policies and interventions to reduce the incidence of mass shootings over time-and to prevent serious acts of violence more generally-will require an expanded body of well-funded interdisciplinary research that is informed and implemented through the sustained engagement of researchers with affected communities and other stakeholders in gun violence prevention. Emerging evidence that the coronavirus pandemic has produced a sharp increase both in civilian gun sales and in the social and psychological determinants of injurious behavior adds special urgency to this agenda.

Stress induced by the COVID-19 health situation in a cohort of 111 subjects present in the Bataclan concert hall during the November 2015 terrorist attacks in Paris.

Background: The management of the psychological consequences of the COVID-19 pandemic is all the more difficult when subjects suffer from a prior psychiatric illness. BV13 is a 54-month prospective longitudinal cohort study of 111 subjects who were present in the Bataclan concert hall during the November 2015 terrorist attack in Paris. Objectives: Our first objective was to investigate the association between stress related to the COVID-19 pandemic and PTSD symptoms, notably with respect to two positive risk factors: trait mindfulness and social support. The second was to explore how PTSD severity mediated the relationship between trait mindfulness and COVID-19-induced stress. Method: The primary endpoint was evaluated using the COVID-19 Peritraumatic Distress Index (CPDI). PTSD symptoms were evaluated using the PTSD Check List Scale (PCL-5) during the sanitary crisis and two years before. Social support was assessed with a Likert scale that measured perceived support from family, friends and the workplace. Trait mindfulness was measured with the 14-item Freiburg Mindfulness Inventory (FMI). Results: 54 months after the attack, a univariate analysis identified a significant positive correlation between COVID-19 stress (CPDI) and PCL-5 (r=0.77, p<0.01) scores, on the one hand, and significant negative correlations with FMI (r=-0.59, p<0.01), and social support (r=-0.28, p<0.01) scores, on the other hand. In the multivariate model, CPDI scores were closely associated with PCL-5 scores (p<0.01) after adjustment for FMI and social support scores. CPDI and FMI scores were significantly associated (p=0.05), but not CPDI and social support scores (p=0.89). The PTSD score was a strong mediator of the relationship between trait mindfulness (FMI) and COVID-19 stress (CPDI) scores. Conclusion: PTSD symptoms diminished the beneficial impact of trait mindfulness on stress related to COVID-19. Our finding highlights that subjects with previous experience of trauma need specific treatment for PTSD symptoms during the COVID-19 crisis.

Antecedentes: El manejo de las consecuencias psicológicas de la pandemia del COVID-19 es aún más difícil cuando los sujetos padecen de una enfermedad psiquiátrica previa. BV13 es un estudio de cohorte longitudinal prospectivo de 54 meses de 111 sujetos que estuvieron presentes en la sala de conciertos Bataclan durante el ataque terrorista de Noviembre del 2015 en Paris.Objetivos: Nuestro primer objetivo fue el de investigar la asociación entre estrés relacionado con la pandemia de COVID-19 y síntomas de TEPT, en particular con respecto a dos factores de riesgo positivos: rasgos de atención plena (Mindfulness) y apoyo social. El segundo fue de explorar cómo la severidad del TEPT mediaba la relación entre los rasgos de atención plena y el estrés inducido por COVID-19.Método: El criterio de evaluación principal se evaluó usando el Índice de Malestar Peri traumático COVID-19 (CPDI en sus siglas en ingles). Los síntomas de TEPT se evaluaron usando la Escala de lista de chequeo para TEPT (PCL-5) durante la crisis sanitaria y dos años antes. El apoyo social fue evaluado con una escala de Lickert que medía el apoyo percibido por la familia, los amigos y el lugar de trabajo. Los rasgos de atención plena se midieron con el Inventario de Mente plena de Friburgo (FMI en sus siglas en ingles).Resultados: 54 meses después del ataque, un análisis univariado identifico una correlación positiva significativa entre los puntajes de estrés por COVID-19 (CPDI) y el PCL-5 (r= 0.77, p<0.01), por una parte, y una correlación negativa significativa con los puntajes de FMI (r= −0.59, p<0.01) y apoyo social (r= −0.28, p<0.01), por otro lado. En el modelo multivariado, los puntajes de CPDI se asociaron estrechamente con los puntajes del PCL-5 (p<0.01) después del ajuste por FMI y puntajes de apoyo social. Los puntajes de CPDI y FMI se asociaron significativamente (p=.05), pero no los puntajes CPDI y apoyo social (p=.89). El puntaje de TEPT fue un fuerte mediador de la relación entre rasgos de atención plena (FMI) y los puntajes de estrés por COVID-19 (CPDI).Conclusión: Los síntomas de TEPT disminuyeron el impacto beneficioso de los rasgos de atención plena en el estrés relacionado con COVID-19. Nuestros hallazgos enfatizan que los sujetos con experiencias previas de trauma necesitan un tratamiento específico para los síntomas de TEPT durante la crisis COVID-19.

UK healthcare staff experiences and perceptions of a mass casualty terrorist incident response: a mixed-methods study.

INTRODUCTION: System learning from major incidents is a crucial element of improving preparedness for response to any future incidents. Sharing good practice and limitations stimulates further actions to improve preparedness and prevents duplicating mistakes. METHODS: This convergent parallel mixed methods study comprises data from responses to an online survey and individual interviews with healthcare staff who took part in the responses to three terrorist incidents in the UK in 2017 (Westminster Bridge attack, Manchester Arena Bombing and London Bridge attack) to understand limitations in the response and share good practices. RESULTS: The dedication of NHS staff, staff availability and effective team work were the most frequently mentioned enabling factors in the response. Effective coordination between teams and a functional major incident plan facilitated an effective response. Rapid access to blood products, by positioning the blood bank in the ED, treating children and parents together and sharing resources between trauma centres were recognised as very effective innovative practices. Recent health emergency preparedness exercises (HEPEs) were valued for preparing both Trusts and individual staff for the response. Challenges included communication between ambulance services and hospitals, difficulties with patient identification and tracking and managing the return to 'normal' work patterns post event. Lack of immediately available clinical protocols to deal with blast injuries was the most commonly mentioned clinical issue. The need for psychosocial support for responding and supporting staff was identified. DISCUSSION: Between-agencies communication and information sharing appear as the most common recurring problems in mass casualty incidents (MCIs). Recent HEPEs, which allowed teams, interdisciplinary groups, and different agencies to practice responding to similar simulated incidents, were important and informed actions during the real response. Immediate and delayed psychosocial support should be in place for healthcare staff responding to MCIs.

Baseline well-being, perceptions of critical incidents, and openness to debriefing in community hospital emergency department clinical staff before COVID-19, a cross-sectional study.

BACKGROUND: Emergency department personnel routinely bear witness to traumatic experiences and critical incidents that can affect their own well-being. Peer support through debriefing has demonstrated positive impacts on clinicians' well-being following critical incidents. This study explored community hospital emergency department staff's perceptions of critical incidents, assessed openness to debriefing and measured baseline well-being. Our analysis provides a baseline of provider well-being immediately prior to the local onset of COVID-19. The potential need for additional resources to support frontline providers during the pandemic can be evaluated. METHOD: We conducted a cross-sectional study for 4-weeks prior to the first COVID-19 case in Connecticut using a survey offered to an interprofessional group of emergency department clinical staff. The main outcome measures were the Hospital Anxiety and Depression Scale (HADS) and the Professional Quality of Life (ProQOL) scale. Pearson's chi-square test was used to identify significant differences in perceptions of critical incidents and debriefings between professional categories. One-way ANOVA and Tukey's test were used to analyze significant differences in well-being between professional categories. RESULTS: Thirty-nine clinical personnel from St. Vincent's Emergency Department responded to the survey. Events frequently selected as critical incidents were caring for critically ill children (89.7%), mass casualty events (84.6%), and death of a patient (69.2%). Critical incidents were commonly reported (81.6%) as occurring once per week. Additionally, 76.2% of participants reported wanting to discuss a critical incident with their team. Across all respondents, 45.7% scored borderline or abnormal for anxiety, 55.9% scored moderate for burnout, and 55.8% scored moderate to high for secondary traumatic stress. CONCLUSIONS: At baseline, providers reported caring for critically ill children, mass casualty events, and death of a patient as critical incidents, which typically occurred once per week. Death of a patient occurs at increased frequency during the protracted mass casualty experience of COVID-19 and threatens provider well-being. Receptiveness to post-event debriefing is high but the method is still underutilized. With nearly half of staff scoring borderline or abnormal for anxiety, burnout, and secondary traumatic stress at baseline, peer support measures should be implemented to protect frontline providers' well-being during and after the pandemic.

Using search engine data to gauge public interest in mental health, politics and violence in the context of mass shootings.

Despite significant potential for providing insight to private perceptions and behaviors, search engine data has yet to be utilized as a means of gauging the U.S. public's interest and understanding of mental health in the context of gun violence and politics. An analysis of Google Trends revealed that Mental health searches increased in volume starting in the beginning of the current decade. Notably, both "mental health" and "gun(s)" were searched with greater frequency the week after the mass shooting events occurred. Related searches after the event also observed a significant increase in interest in mental health and gun regulation, legal reform, mass shootings, and gun(s). Results suggest that the American public's perception of mental illness increasingly incorporates associations with themes of violence and politics, which becomes more apparent surrounding mass shooting events. Future studies are needed to determine implications for stigmatization of vulnerable groups, and possible relations to media coverage.

Using clinical based vignettes to further develop a mass gathering event triage tool.

BACKGROUND: Previously published triage tools for use at mass gathering events (MGE) lack real-world validation. Non-health care professionals, such as first aiders, first responders, and advanced responders often undertake a triage role at MGEs. This research aimed to determine consistency in the decision-making of a MGE triage tool. METHOD: Volunteer members of St John Ambulance Australia were recruited. Surveys included participant demographics and real-world clinical vignettes. Participants determined a triage category based on the vignettes and supplied triage tool. Demographics were analysed using descriptive statistics and responses to vignettes were analysed using Fleiss Kappa [p-bar]. RESULTS: There were 110 participants, the majority male (60%), having completed a Bachelor or higher degree (53.6%), and were non-health care professionals (70%). Of the vignettes, there was a slightly better than moderate agreement (items: 18, p-bar: 0.55). There was an excellent level of agreeance for the resuscitation category (items: 3, b-par 0.69), and moderate level of agreeance for the urgent (items: 10, b-par 0.52) and minor (items: 5, b-par 0.52) categories. CONCLUSIONS: This research demonstrated similar findings to that of emergency department triage tool validation. Multi-country, multi-site, multi-type, real-world testing at MGEs is the next step to progress the development of this tool.

Physicians on the Frontlines: Understanding the Lived Experience of Physicians Working in Communities That Experienced a Mass Casualty Shooting.

This qualitative study describes the lived experience of physicians who work in communities that have experienced a public mass shooting. Semi-structured interviews were conducted with seventeen physicians involved in eight separate mass casualty shooting incidents in the United States. Four major themes emerged from constant comparative analysis: (1) The psychological toll on physicians: "I wonder if I'm broken"; (2) the importance of and need for mass casualty shooting preparedness: "[We need to] recognize this as a public health concern and train physicians to manage it"; (3) massive media attention: "The media onslaught was unbelievable"; and (4) commitment to advocacy for a public health approach to firearm violence: "I want to do whatever I can to prevent some of these terrible events."