The postdisaster prevalence of major depression relative to PTSD in survivors of the 9/11 attacks on the World Trade Center selected from affected workplaces.

BACKGROUND: Studies of survivors of the September 11, 2001 attacks on the World Trade Center in New York City suggest that postdisaster depressive disorders may be at least as prevalent, or even more prevalent, than posttraumatic stress disorder (PTSD), unlike findings from most other disaster studies. The relative prevalence and incidence of major depressive disorder (MDD) and PTSD were examined after the 9/11 attacks relative to trauma exposures. METHODS: This study used full diagnostic assessment methods and careful categorization of exposure groups based on DSM-IV-TR criteria for PTSD to examine 373 employees of 9/11-affected New York City workplaces. RESULTS: Postdisaster new MDD episode (26%) in the entire sample was significantly more prevalent (p<.001) than 9/11-related PTSD (14%). Limiting the comparison to participants with 9/11 trauma exposures, the prevalence of postdisaster new MDD episode and 9/11-related PTSD did not differ (p=.446). The only 9/11 trauma exposure group with a significant difference in relative prevalence of MDD and PTSD were those with a 9/11 trauma-exposed close associate, for whom postdisaster new MDD episode (45%) was more prevalent (p=.046) than 9/11-related PTSD (31%). CONCLUSIONS: Because of the conditional definition of PTSD requiring trauma exposure that is not part of MDD criteria, prevalence comparisons of these two disorders must be limited to groups with qualifying trauma exposures to be meaningful. Findings from this study suggest distinct mechanisms underlying these two disorders that differentially relate to direct exposure to trauma vs. the magnitude of the disaster and personal connectedness to disaster and community-wide effects.

Examining a comprehensive model of disaster-related posttraumatic stress disorder in systematically studied survivors of 10 disasters.

OBJECTIVES: Using a comprehensive disaster model, we examined predictors of posttraumatic stress disorder (PTSD) in combined data from 10 different disasters. METHODS: The combined sample included data from 811 directly exposed survivors of 10 disasters between 1987 and 1995. We used consistent methods across all 10 disaster samples, including full diagnostic assessment. RESULTS: In multivariate analyses, predictors of PTSD were female gender, younger age, Hispanic ethnicity, less education, ever-married status, predisaster psychopathology, disaster injury, and witnessing injury or death; exposure through death or injury to friends or family members and witnessing the disaster aftermath did not confer additional PTSD risk. Intentionally caused disasters associated with PTSD in bivariate analysis did not independently predict PTSD in multivariate analysis. Avoidance and numbing symptoms represented a PTSD marker. CONCLUSIONS: Despite confirming some previous research findings, we found no associations between PTSD and disaster typology. Prospective research is needed to determine whether early avoidance and numbing symptoms identify individuals likely to develop PTSD later. Our findings may help identify at-risk populations for treatment research.

Perceived impact of the disclosure of a schizophrenia diagnosis.

Stigma against those with schizophrenia has demonstrated deleterious effects. However, less is known about the experience of individuals who disclose this diagnosis and how such disclosures differ by social situations. This study examines diagnosis disclosure in different contexts. A convenience sample of 258 adults with schizophrenia recruited via the internet and e-mail lists completed an online survey. Subjects were more open about their diagnosis with doctors, parents and friends than with employers or police. Those who report very good current mental health or who had fewer types of relationships were more open overall. Although reactions to disclosure varied, many report worse treatment by police and better treatment by parents after disclosure. Many also experienced worse treatment for medical problems after disclosing their schizophrenia diagnosis. These results support targeted anti-stigma interventions. It also suggests that stigma must be understood through individual experience in specific contexts rather than as a unitary experience.

Epidemiological trends in psychosis-related Emergency Department visits in the United States, 1992-2001.

Mental health visits represented an increasing fraction of all Emergency Department (ED) visits in the U.S. between 1992 and 2001. This study used the National Hospital Ambulatory Medical Care Survey, a 4-staged probability sample of ED visits from geographically diverse hospitals around the U.S., to assess the contribution of all psychosis-related visits to this overall trend. Unlike other mental-health-related ED visits, the rate of psychosis-related visits did not increase. This lack of change is notable in the context of dramatic changes in both healthcare financing and antipsychotic prescribing practices during this period. There was an unexpected decrease in Medicare-funded psychosis-related ED visits at a time of increasing Medicare enrollment overall. An important demographic trend over this decade was the increasing urbanization of psychosis-related ED visits coincident with a relative decrement in such visits within rural areas.

Digital Technology Use Among Individuals with Schizophrenia: Results of an Online Survey.

BACKGROUND: Despite growing interest in the use of digital technology by individuals with schizophrenia, little is known about how these individual relate to, own, and use technology in their daily life and in the context of their symptoms. OBJECTIVE: The goal of this study is to better characterize technology use in those with schizophrenia. METHODS: A Web-based survey of individuals' use of and attitudes toward technology for those 18 years and older self-identifying as having schizophrenia, schizoaffective disorder, or schizophrenia spectrum disorders was conducted. Consumer input was sought in the design of the survey. RESULTS: In total, 457 individuals responded to this Web-based survey. Ninety percent owned more than one device (personal computer, landline telephone, tablet, public computer, mobile phone without applications or Internet, or smartphone), with many reporting high utilization of multiple devices, and 61% having 2 devices. The respondents reported that Web-based technology helped with support from family and friends, as well as in gathering information. Many respondents used Web-based technology to help identify coping strategies (24% very often or often) including music to help block or manage voices (42%), while others used technology to set alarms/reminders for medication management (28%). Younger respondents in particular anticipated the role of technology growing over time with respect to their recovery. CONCLUSIONS: Survey respondents reported that technology access was common, with utilization involving coping, reminders for medications and appointments, and connection. Overall, attitudes were largely positive. Overuse was a concern for 30% of respondents. The study is limited in its generalizability as the population was highly engaged in mental health treatment (87%), self-identified as living with the disorder, and had awareness of their illness. This survey demonstrates high engagement for a subset of technology-oriented individuals living with schizophrenia. It is not known what percent of individuals with schizophrenia are represented by these technology-oriented survey respondents.

Research on psychiatric outcomes and interventions subsequent to disasters: a review of the literature.

Tragic events such as those of September 11, 2001, underscore the increasingly prominent role that psychiatrists play in aiding survivors, emergency workers, and broader communities to cope with disaster. The present review was undertaken to identify whether there exists a scientific basis for the practice of psychiatry in the aftermath of disasters. Most of the extensive literature over the past 30 years suggests that disasters have psychopathological consequences as well as medical and social ones. Pre-existing mood and anxiety disorders, although surprisingly not psychotic illness, appear to be risk factors for further psychopathology after a disaster. Thus, both acute psychopharmacological and psychotherapeutic interventions at disaster sites may prevent long-term sequelae, although their efficacy remains uncertain. Future controlled treatment trials are needed to determine the optimal treatment strategy.

Mental health as an advocacy priority in the lesbian, gay, bisexual, and transgender communities.

This column reviews the evolution of lesbian, gay, bisexual, and transgender (LGBT) mental health advocacy in relation to modern mental health advocacy efforts. In addition to developments in organized psychiatry (e.g., American Psychiatric Association's LGBT caucus), grassroots LGBT community initiatives are playing an important role (e.g., Trevor Project providing crisis intervention/suicide prevention services to LGBT youth, face-to-face mental health services in LGBT community centers). Studies have found that LGBT individuals are at increased risk for mental health problems (e.g., depression, anxiety, substance misuse, suicidal ideation, self-harm). Mental health advocacy in the LGBT community has been slowed by the long-standing association of the concept of homosexuality with psychopathology in mainstream psychiatry (e.g., homosexuality was only removed from the DSM in 1973, ego dystonic homosexuality still appears in the ICD-10). However, positive developments in LGBT mental health advocacy have been fostered by the proposed minority stress model (i.e., that elevated risk of mental illness in LGBT individuals is a consequence of a hostile stressful environment). A particularly encouraging initiative is the It Gets Better Project, in which thousands of videos, some by prominent individuals, have been posted online to send a message of hope to LGBT youth facing harassment and low self-esteem.

Advocacy for people with borderline personality disorder.

Although many of the largest and best known consumer and family mental health advocacy organizations do not restrict themselves to a single diagnosis, over the last few decades an increasing number of disease-specific mental health advocacy organizations have emerged. This column describes the development of a movement advocating for consumers and families affected by borderline personality disorder (BPD) as an example of two trends in the mental health advocacy field: closer ties between advocacy and professional groups and specialization to better address the different needs created by different diagnoses.

A review and retrospective analysis of mental health services provided after the September 11 attacks.

OBJECTIVE: Various mental health services were provided in New York City in the response to the September 11 attacks. This article describes these services and the subsequent research in disaster psychiatry to identify recommended practices for future disasters. METHOD: A PubMed search identified 198 articles since the 9/11 attacks that included "New York City," and either "9/11" or "disaster," and either "psychiatry" or "mental health." The abstracts of all of these articles were reviewed to identify articles that described clinical services and those articles were then reviewed in detail. Additional reports on 9/11-related services were identified through book chapters. RESULTS: Acute services included debriefings and other single-time outreach interventions. Postacute phase interventions included community outreach with the goal of addressing normative psychological sequelae, multisession interventions based on evidence-based treatments, and hospital-based psychiatric services provided in the context of general health screenings for response workers. CONCLUSIONS: Many programs integrated medical and nonmedical services. The professional literature in the decade since this disaster has shifted recommended practices away from psychological debriefings in the acute phase to the implementation of psychological first aid (PFA). Many of the acute 9/11-related services actually closely resembled PFA. In the postacute phase, resources need to be made available for more resource-intensive psychiatric treatment for the fraction of survivors who develop psychiatric illness.

The challenge of gun control for mental health advocates.

Mass shootings, such as the 2012 Newtown massacre, have repeatedly led to political discourse about limiting access to guns for individuals with serious mental illness. Although the political climate after such tragic events poses a considerable challenge to mental health advocates who wish to minimize unsympathetic portrayals of those with mental illness, such media attention may be a rare opportunity to focus attention on risks of victimization of those with serious mental illness and barriers to obtaining psychiatric care. Current federal gun control laws may discourage individuals from seeking psychiatric treatment and describe individuals with mental illness using anachronistic, imprecise, and gratuitously stigmatizing language. This article lays out potential talking points that may be useful after future gun violence.

Wellness and recovery programs: a model of self-advocacy for people living with mental illness.

People living with mental illnesses, their family members, and advocacy groups have long encouraged the mental health system to adopt a greater focus on wellness and recovery. A superficial interpretation of wellness and recovery may cause some clinicians to devalue the possibility and importance of wellness and recovery for the people they serve, and this may inhibit or disrupt the development of a working therapeutic relationship. This column reviews definitions of wellness and recovery and their applicability to serious mental illnesses and provides an overview of several programs that promote wellness and recovery. In addition to peer-led courses, ongoing peer support and a range of applications for mobile devices can help consumers lead a self-directed and affirming life that facilitates symptom management and reduction and maximizes wellness. By understanding wellness and recovery and how people living with mental illnesses achieve these goals, psychiatrists may build rapport with their patients and improve outcomes. By familiarizing oneself with new resources available to people with serious mental illness, mental health clinicians may be able to suggest supports that extend far beyond the time constraints of our current treatment model.

Telemedicine as a potential medium for teaching the advanced trauma life support (ATLS) course.

OBJECTIVES: The advanced trauma life support (ATLS) course has become the international standard for teaching trauma resuscitation skills. The 2 to 2.5 days course is usually offered as an on-site teaching experience. The present project assesses the potential for applying telemedicine technology to teaching ATLS by distance learning. DESIGN: Two groups of equally trained first-year family practice residents were randomly assigned to a standard on-site ATLS course or one delivered by telemedicine. The 2 courses were compared by evaluating post-ATLS multiple-choice question test performance, instructor evaluation of student skill station performance, overall pass rate, participant rating of each component of the course, and overall feedback on the educational quality of the course (rating scale 1-4). RESULTS: The mean scores for the 2 groups (with the standard ATLS and with the telemedicine, respectively) were not statistically significantly different: post-ATLS multiple-choice question-89.69% vs 85.89%; pass rate for the course was the same for both models; instructor overall evaluation of student skill station performance-3.12 vs 3.00; and participant overall feedback on all components of the course-3.67 vs 3.91. CONCLUSIONS: Our results suggest that telemedicine technology could be successfully applied to teaching ATLS courses.

NAMI in our own voice and NAMI smarts for advocacy: self-narrative as advocacy tool.

In his first Advocacy column for the Journal of Psychiatric Practice, the author discusses the importance and relevance of advocacy for all mental health professionals and researchers in whatever setting they work. Advocacy efforts can and have influenced a range of issues that are important to hospital-based and community psychiatrists, private practitioners, and researchers. The author then discusses the importance of personal self-narrative as a tool for decreasing stigma and increasing understanding of serious mental illness, with a focus on two programs developed by the National Alliance on Mental Illness: NAMI In Our Own Voice and NAMI Smarts for Advocacy.

Trauma exposure and posttraumatic stress disorder among employees of New York City companies affected by the September 11, 2001 attacks on the World Trade Center.

OBJECTIVE: Several studies have provided prevalence estimates of posttraumatic stress disorder (PTSD) related to the September 11, 2001 (9/11) attacks in broadly affected populations, although without sufficiently addressing qualifying exposures required for assessing PTSD and estimating its prevalence. A premise that people throughout the New York City area were exposed to the attacks on the World Trade Center (WTC) towers and are thus at risk for developing PTSD has important implications for both prevalence estimates and service provision. This premise has not, however, been tested with respect to DSM-IV-TR criteria for PTSD. This study examined associations between geographic distance from the 9/11 attacks on the WTC and reported 9/11 trauma exposures, and the role of specific trauma exposures in the development of PTSD. METHODS: Approximately 3 years after the attacks, 379 surviving employees (102 with direct exposures, including 65 in the towers, and 277 with varied exposures) recruited from 8 affected organizations were interviewed using the Diagnostic Interview Schedule/Disaster Supplement and reassessed at 6 years. The estimated closest geographic distance from the WTC towers during the attacks and specific disaster exposures were compared with the development of 9/11-related PTSD as defined by the Diagnostic and Statistical Manual, Fourth Edition, Text Revision. RESULTS: The direct exposure zone was largely concentrated within a radius of 0.1 mi and completely contained within 0.75 mi of the towers. PTSD symptom criteria at any time after the disaster were met by 35% of people directly exposed to danger, 20% of those exposed only through witnessed experiences, and 35% of those exposed only through a close associate's direct exposure. Outside these exposure groups, few possible sources of exposure were evident among the few who were symptomatic, most of whom had preexisting psychiatric illness. CONCLUSIONS: Exposures deserve careful consideration among widely affected populations after large terrorist attacks when conducting clinical assessments, estimating the magnitude of population PTSD burdens, and projecting needs for specific mental health interventions.

Services provided by volunteer psychiatrists after 9/11 at the New York City family assistance center: September 12-November 20, 2001.

OBJECTIVE: To characterize the experience of volunteer disaster psychiatrists who provided pro bono psychiatric services to 9/11 survivors in New York City, from September 12, 2001 to November 20, 2001. METHOD: Disaster Psychiatry Outreach (DPO) is a non-profit organization founded in 1998 to provide volunteer psychiatric care to people affected by disasters and to promote education and research in support of this mission. Data for this study were collected from one-page clinical encounter forms completed by 268 DPO psychiatrists for 2 months after 9/11 concerning 848 patients served by the DPO 9/11 response program at the New York City Family Assistance Center. RESULTS: In this endeavor, 268 psychiatrist volunteers evaluated 848 individuals and provided appropriate interventions. The most commonly recorded clinical impressions indicated stress-related and adjustment disorders, but other conditions such as bereavement, major depression, and substance abuse/dependence were also observed. Free samples were available for one sedative and one anxiolytic agent; not surprisingly, these were the most commonly prescribed medications. Nearly half of those evaluated received psychotropic medications. CONCLUSIONS: In the acute aftermath of the attacks of September 11, 2001, volunteer psychiatrists were able to provide services in a disaster response setting, in which they were co-located with other disaster responders. These services included psychiatric assessment, provision of medication, psychological first aid, and referrals for ongoing care. Although systematic diagnoses could not be confirmed, the fact that most patients were perceived to have a psychiatric diagnosis and a substantial proportion received psychotropic medication suggests potential specific roles for psychiatrists that are unique and different from roles of other mental health professionals in the early post-disaster setting. In addition to further characterizing post-disaster mental health needs and patterns of service provision, future research should focus on the short- and long-term effects of psychiatric interventions, such as providing acute psychotropic medication services and assessing the effectiveness of traditional acute post-disaster interventions including crisis counseling and psychological first aid.