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PREFACE
Our nation’s agenda for homeland security lacks a
critical component—attention to mental health. A central purpose
of terrorism is to destabilize people and create psychological trauma.
Yet, as the nation pours money and resources into developing security personnel
and teams of first responders, we are neglecting the primary care providers
working on the front-lines to aid individuals and families in distress
and to help them develop psychological resilience.
Funded by the Robert Wood Johnson Foundation, America’s
HealthTogether (AHT) has formed a groundbreaking partnership with twenty
of the nation’s leading medical, nurse practitioner, mental health,
and public health organizations to fill this gap.
Through focus groups, surveys, conversations with national
and international experts, and a careful review of research on disaster
mental health, AHT and its partners have been investigating the changing
health and mental health needs of individuals and the capacity of our health
care system to meet these new needs. In an expansion of previous research,
AHT has been talking to primary care providers on the front-lines and asking
them what they are witnessing—and they are responding that
they are not prepared. Core findings include:
- September 11th changed our nation’s
emotional and psychological landscape.
September 11th and subsequent terror alerts are amplifying the psychological
distress and mental health needs of Americans. The response is strongest
among communities with physical proximity to the events of that day or
other previous disasters. Individuals with pre-existing chronic illnesses,
whether physical or mental, are also at greater risk. This places new
demands on our primary care providers.
- Primary care providers fear they will be unable
to handle the changing health and mental health needs of patients.
Now, more than ever, individuals are seeking physical and mental care
from their primary care providers. Primary care providers are universally
apprehensive about their capacity to handle fallout from real and perceived
acts of terrorism. Our frayed system of mental health care has long overburdened
primary care providers, and now providers more urgently need the time,
information, and resources to work effectively at the intersection of
primary care and mental health care.
- Primary care providers are calling for more support
and education in addressing mental health issues.
No one individual or organization is identified as a trusted and credible
leader in addressing the mental health aspects of the war on terrorism.
Primary care providers nationwide seek such a leader who can provide them
with the information and resources they need to address the mental health
needs of patients. Our primary care providers want to make collaboration
with mental health providers a central element of the homeland security
agenda.
Building on what it has learned from national research,
AHT is working with its partner organizations to develop education and
training materials that will increase the capacity of primary care providers
to meet the mental health needs of patients and bolster the psychological
resilience of individuals, families, and communities. AHT and its partners
are also working to expand the focus of health care on the homeland security
agenda and ensure that it includes primary care and mental health. This
report details the findings and recommendations for change.
BACKGROUND AND CONTEXT
In a New York Times editorial on February 23, 2003, Thomas
Friedman writes:
“The right response [to terrorism], after a
point, is not to demand more and more security—but to learn to live
with more and more anxiety … The question is not whether there will
be more attacks … The question is whether we can survive them and
still maintain an open society.”
Friedman aptly points to a large gap in our nation’s
response to the terrorist attacks of September 11th—a gap in attention
to the mental health needs of individuals and families. As the nation institutes
color-coded alert systems, more thorough airport checks, and detailed emergency
exit plans, we are forgetting that the foundation of a true sense of security
is a strong sense of psychological resilience. True security, in other
words, means living with fear, not living in fear.
At the center of our national response to 9/11, then, should
be a focus on addressing the mental health needs of Americans. Since September
11th, feelings of uncertainty and anxiety have subtly but powerfully pervaded
the lives of communities, families, and individuals nationwide. A pediatrician
in New York speaks about a seven-year-old girl who says, “I don’t
want to sleep, because I don’t know how long we are going to be able
to live. I really don’t want to spend any time sleeping.” This
heightened anxiety is neither isolated to areas that felt the direct impact
of 9/11 nor just to patients. A doctor in Detroit says,
“[A]ll of a sudden you see this abundance of
chest pain or neck pain or irritable bowel syndrome in patients with no
medical reason to have this problem. What is it from? Where did this come
from? It came from what we just experienced in this country. We all experience
these things, whether it’s a patient or us.”
As Americans confront new feelings of anxiety, they deserve
good mental health care. This follows directly from the U.S. Surgeon General’s
1999 Report on Mental Health. This report reaches three main conclusions:
1. Mental health is fundamental to health.
2. Mental health should flow in the mainstream of health care.
3. We should mend the destructive split between mental and physical health
care.
In concert with the Surgeon General’s report, primary
care providers around the country are calling for more support in addressing
the mental health needs of their patients. Individuals and families are
turning to their primary care providers for help in confronting new feelings
of anxiety, but these providers require adequate time, training, and resources
to provide mental health care. Now, primary care providers are alarmed
about their capacity to handle the mental health issues emerging from terrorism.
A health care professional in Pittsburgh puts it poignantly when she says,
“I’m very frightened about the possibilities
of what can happen … the more you know, the scarier it is. Most
health care workers are worried and anxious … I think we are more
worried than our patients.”
To fill the gap in attention to mental health care, America’s
HealthTogether has formed a partnership with the nation’s leading
medical, nurse practitioner, mental health, and public health organizations.
With the support of the Robert Wood Johnson Foundation, this partnership
seeks to shape the mental health component of the war on terrorism. The
partnership began by investigating the needs of primary care providers
as they meet the mental health challenges of terrorism, and will subsequently
convert that information into educational tools and resources for primary
care providers and recommendations for policymakers.
Unlike previous research focusing solely on the concerns
of patients, AHT and its partners have been reaching out to health care
professionals nationwide to ask them what they are observing, and what
they need. This is what AHT has found:
- The mental health needs of Americans nationwide
have increased since September 11th.
Health care professionals report that 9/11 exacerbated the psychological
distress of many Americans and triggered the onset for others. In a study
sponsored by the National Institutes of Health, researchers find that
the events of 9/11 set off a complex chain of events that led to feelings
of decreased safety and a diminished sense of control. In a national survey
conducted three days after the attacks, Schuster et al. (2001) demonstrate
that almost half of all Americans reported higher levels of stress. In
addition, providers working in areas that experienced previous disasters,
or with populations with a prior history of chronic illness, report that
9/11 often exacerbated existing concerns.
- Mental health issues associated with terrorism
are persistent.
The mental health effects of 9/11 will be reinforced as people experience
Code Orange terror alerts, impending war, a struggling economy, and public
tragedies—such as the loss of the space shuttle Columbia and local
natural disasters. In a longitudinal study of the psychological responses
to 9/11, Silver et al. (2002) find that mean levels of global distress
remained high between two and six months after the attacks. In empirical
studies of the psychological aftermath of a violent 1991 disaster in Texas,
North et al. (2002a) show that three years after the event, only half
of individuals with early and late onset post-traumatic stress disorder
(PTSD) had recovered. A review of research on disaster mental health finds
that among the 160 samples studied, peak symptoms appear most often in
the first year after the event, but often persist for months and years
beyond. The fallout from 9/11 will clearly be a part of our nation’s
mental health landscape for years to come.
- Primary care providers are the nation’s
de facto mental health care system.
Even before September 11th, the American Psychological Association estimated
that 75% of all primary care visits could be attributed to psychosocial
problems and that primary care providers manage and treat between 65%
and 85% of all mental health problems. Now, as individuals search for
care and support in a time of heightened anxiety, they are depending on
their primary care providers more than ever.
- The mental health fallout from September 11th
highlighted untenable gaps in our nation’s mental health care system.
As primary care providers confront the changing mental health needs of
Americans, they note that September 11th exposed existing holes not only
in our emergency health care response system, but also in our longer-term
mental health care system. In its interim report to the President in November
2002, the New Freedom Commission on Mental Health writes, “America’s
mental health service delivery system is in shambles.” September
11th only exacerbated this situation. As a pediatrician from Peekskill,
NY puts it, “It’s not 9/11 that caused this [crisis in mental
health care]. Nine-eleven blew the top off it. It’s always been
there.” Working in a new environment fraught with the uncertainty
of potential disaster, primary care providers realize that we can no longer
wait to fix our system of mental health care.
- Primary care providers are concerned that
they cannot meet the mental health needs of Americans.
Our medical, nursing, and mental health experts, the people we depend
on for help, are worried about their abilities to handle the fallout of
future disasters. Sixty-one percent of health care professionals responding
to a preliminary national survey sponsored by the AHT partnership report
being moderately to very apprehensive about future terrorist attacks.
The ravages of too little time, not enough information, and inadequate
insurance plans have been taking their toll. In addition, providers’
concerns about the system are converging with personal concerns about
disaster—producing a powerful, unexplored dynamic. A nurse practitioner
in Chicago explains, “We have been sheltered in this country, but
now [the possibility of disaster] is here and everywhere. You never know
where it’s going to strike again. That makes us [primary care providers]
feel very vulnerable.” In Albuquerque, providers bluntly state,
“We don’t feel we can respond,” and “I’m
unprepared. I would like more information.”
- Primary care providers want to make increased
collaboration between primary care and mental health care a central part
of homeland preparedness.
Primary care providers want more support in meeting the mental health
needs of Americans in a post-September 11th world—they want better,
coordinated information and assistance. Ninety-five percent of AHT preliminary
survey respondents believe that the inclusion of mental health services
into primary care improves the quality of care for patients. The combination
of good physical and mental health shelters a secure future, a vision
that providers strongly support. As primary care and mental health care
providers around the country respond to 9/11, they continually point to
the need for more interdisciplinary, collaborative work. Fifty-nine percent
of preliminary survey respondents believe the events of 9/11 have made
the need to integrate primary and mental health care services more urgent.
In focus groups conducted around the country, primary care providers continually
stress the difficulty of “doing emotional work when you are trained
to do physical work.”
The subsequent sections of this report elaborate the findings
enumerated above, and suggest recommendations for the future.
(More to come….)
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