The challenge of preparation for a chemical, biological, radiological or nuclear terrorist attack.
Terrorism is not a new phenomenon, but, in the contemporary scene, it has established itself in a manner which commands the most serious attention of the authorities. Until relatively recently, the major threat has been through the medium of conventional weaponry and explosives. Their obvious convenience of use and accessibility guarantees that such methods will continue to represent a serious threat. However, over the last few years, terrorists have displayed an enthusiasm for higher levels of carnage, destruction and publicity. This trend leads inexorably to the conclusion that chemical, biological, radiological and nuclear (CBRN) methods will be pursued by terrorist organisations, particularly those which are well organised, are based on immutable ideological principles, and have significant financial backing. Whilst it is important that the authorities and the general public do not risk over-reacting to such a threat (otherwise, they will do the work of the terrorists for them), it would be equally ill-advised to seek comfort in denial. The reality of a CBRN event has to be accepted and, as a consequence, the authorities need to consider (and take seriously) how individuals and the community are likely to react thereto and to identify (and rehearse in a realistic climate) what steps would need to be taken to ameliorate the effects of such an event. (+info)
Value of debriefing during simulated crisis management: oral versus video-assisted oral feedback.
BACKGROUND: The debriefing process during simulation-based education has been poorly studied despite its educational importance. Videotape feedback is an adjunct that may enhance the impact of the debriefing and in turn maximize learning. The purpose of this study was to investigate the value of the debriefing process during simulation and to compare the educational efficacy of two types of feedback, oral feedback and videotape-assisted oral feedback, against control (no debriefing). METHODS: Forty-two anesthesia residents were enrolled in the study. After completing a pretest scenario, participants were randomly assigned to receive no debriefing, oral feedback, or videotape-assisted oral feedback. The debriefing focused on nontechnical skills performance guided by crisis resource management principles. Participants were then required to manage a posttest scenario. The videotapes of all performances were later reviewed by two blinded independent assessors who rated participants' nontechnical skills using a validated scoring system. RESULTS: Participants' nontechnical skills did not improve in the control group, whereas the provision of oral feedback, either assisted or not assisted with videotape review, resulted in significant improvement (P < 0.005). There was no difference in improvement between oral and video-assisted oral feedback groups. CONCLUSIONS: Exposure to a simulated crisis without constructive debriefing by instructors offers little benefit to trainees. The addition of video review did not offer any advantage over oral feedback alone. Valuable simulation training can therefore be achieved even when video technology is not available. (+info)
Emotional or educational debriefing after psychological trauma. Randomised controlled trial.
BACKGROUND: Recent studies show that individual single-session psychological debriefing does not prevent and can even aggravate symptoms of post-traumatic stress disorder (PTSD). AIMS: We studied the effect of emotional ventilation debriefing and educational debriefing v. no debriefing on symptoms of PTSD, anxiety and depression. METHOD: We randomised 236 adult survivors of a recent traumatic event to either emotional ventilation debriefing, educational debriefing or no debriefing (control) and followed up at 2 weeks, 6 weeks and 6 months. RESULTS: Psychiatric symptoms decreased in all three groups over time, without significant differences between the groups in symptoms of PTSD (P=0.33). Participants in the emotional debriefing group with high baseline hyperarousal score had significantly more PTSD symptoms at 6 weeks than control participants (P=0.005). CONCLUSIONS: Our study did not provide evidence for the usefulness of individual psychological debriefing in reducing symptoms of PTSD, anxiety and depression after psychological trauma. (+info)
Interventions for adolescent depression in primary care.
BACKGROUND: Depression in adolescents is underrecognized and undertreated despite its poor long-term outcomes, including risk for suicide. Primary care settings may be critical venues for the identification of depression, but there is little information about the usefulness of primary care interventions. OBJECTIVE: We sought to examine the evidence for the treatment of depression in primary care settings, focusing on evidence concerning psychosocial, educational, and/or supportive intervention strategies. METHODS: Available data on brief psychosocial treatments for adolescent depression in primary settings were reviewed. Given the paucity of direct studies, we also drew on related literature to summarize available evidence whether brief, psychosocial support from a member of the primary care team, with or without medication, might improve depression outcomes. RESULTS: We identified 37 studies relevant to treating adolescent depression in primary care settings. Only 4 studies directly examined the impact of primary care-delivered psychosocial interventions for adolescent depression, but they suggest that such interventions can be effective. Indirect evidence from other psychosocial/behavioral interventions, including anticipatory guidance and efforts to enhance treatment adherence, and adult depression studies also show benefits of primary care-delivered interventions as well as the impact of provider training to enhance psychosocial skills. CONCLUSIONS: There is potential for successful treatment of adolescent depression in primary care, in view of evidence that brief, psychosocial support, with or without medication, has been shown to improve a range of outcomes, including adolescent depression itself. Given the great public health problem posed by adolescent depression, the likelihood that most depressed adolescents will not receive specialty services, and new guidelines for managing adolescent depression in primary care, clinicians may usefully consider initiation of supportive interventions in their primary care practices. (+info)
Crisis resolution/home treatment teams and psychiatric admission rates in England.
BACKGROUND: Introduction of crisis resolution/home treatment teams has been associated with a reduction in hospital admissions in trials. Between 2001 and 2004 there was a rapid expansion in the numbers of these teams in England. AIMS: To examine whether national implementation of these teams was associated with comparable reductions in admissions. METHOD: Observational study using routine data covering working age adult patients in 229 of the 303 local health areas in England from 1998/9 to 2003/4. RESULTS: Admissions fell generally throughout the period, particularly for younger working age adults. Introduction of crisis resolution teams was associated with greater reductions for older working age women (35-64 years); teams always on call were associated with additional reductions for older men and younger women. By the end of the study admissions had fallen by 10% more in the 34 areas with crisis resolution teams in place since 2001, and by 23% more in the 12 of these on call around the clock than in the 130 areas without such teams by 2003/4. Reductions in bed use were smaller. Introduction of assertive outreach teams was not associated with overall reductions in admissions. CONCLUSIONS: Introduction of crisis resolution teams has been associated with reductions in admissions. (+info)
Mental health for persons with intellectual disability in the post-deinstitutionalization era: experiences from British Columbia.
The delivery of mental health services to persons with Intellectual Disability (ID) in British Columbia (BC), Canada, is worth documenting because BC is one of the few jurisdictions in the world to completely close its institutions for people with ID. This paper documents the delivery of mental health care in BC for this population and contrasts the dream versus the reality of community living for people with dual diagnosis (mental illness coupled with an intellectual disability). (+info)
Post-trauma support in the workplace: the current status and practice of critical incident stress management (CISM) and psychological debriefing (PD) within organizations in the UK.
Employers' duties of care under both common and statute law include the need to take reasonable care of the health and safety of the workforce. This includes both the moral and legal duties to consider the psychological needs of personnel following exposure to traumatic events related to the workplace. While this has been recognized within many high-risk occupations such the police, fire and rescue services and the military, there is also evidence that post-trauma support in the workplace is increasingly commonly provided not only among health and social services agencies, but within many private sector organizations. Over the past decade, however, there has been considerable controversy over the provision of early psychological support to personnel in the form of critical incident stress management (CISM) processes. In particular, one aspect of CISM, the use of psychological debriefing (PD) has come under scrutiny and criticism as two studies indicated that PD was ineffective and had the potential to do harm. Inevitably, this has provoked much uncertainty and confusion among some organizations as what should be the most appropriate support. It has also led to misconceptions and misunderstandings as to the aims and purpose of PD, together with inaccuracies of terminology, for example describing PD as 'counselling'. Despite the controversy, both CISM and PD continue to be provided on a widespread basis, often utilizing a framework of voluntary peer group support. This paper intends to (i) present a review of the current status of CISM practices, including the use of PD within various organizations in the UK and (ii) provide a clear framework and understanding of the main issues and to clarify conceptual misunderstandings. The history, principles and background of the use of post-trauma support in the workplace, charting trends over the past two decades, previous research, problems with the evidence base and current thinking and practice in the field are reviewed. The relevance and implications of the National Institute for Clinical Excellence Guidelines on the Assessment and Management of Post Traumatic Stress Disorder, which make recommendations for early interventions for post-traumatic stress disorder are discussed. Reference is made to the use of CISM and PD within both statutory and voluntary organizations in an international context. (+info)
An investigation of factors associated with psychiatric hospital admission despite the presence of crisis resolution teams.
BACKGROUND: Crisis resolution teams (CRTs) provide a community alternative to psychiatric hospital admission for patients presenting in crisis. Little is known about the characteristics of patients admitted despite the availability of such teams. METHODS: Data were drawn from three investigations of the outcomes of CRTs in inner London. A literature review was used to identify candidate explanatory variables that may be associated with admission despite the availability of intensive home treatment. The main outcome variable was admission to hospital within 8 weeks of the initial crisis. Associations between this outcome and the candidate explanatory variables were tested using first univariate and then multivariate analysis. RESULTS: Patients who were uncooperative with initial assessment (OR 10.25 95% CI-4.20-24.97), at risk of self-neglect (OR 2.93 1.42-6.05), had a history of compulsory admission (OR 2.64 1.07-6.55), assessed outside usual office hours (OR 2.34 1.11-4.94) and/or were assessed in hospital casualty departments (OR 3.12 1.55-6.26), were more likely to be admitted. Other than age, no socio-demographic features or diagnostic variables were significantly associated with risk of admission. CONCLUSION: With the introduction of CRTs, inpatient wards face a significant challenge, as patients who cooperate little with treatment, neglect themselves, or have previously been compulsorily detained are especially likely to be admitted. The increased risk of admission associated with casualty department assessment may be remediable. (+info)