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Psychosomatic Medicine 68:698-705 (2006)
© 2006 American Psychosomatic Society

APS PRESIDENTIAL ADDRESS

Presidential Address: Psychosomatic Medicine and Biodefense Preparedness—A New Role for the American Psychosomatic Society

Steven E. Locke, MD

From the Department of Psychiatry, Beth Israel Deaconess Medical Center, the Department of Psychiatry, Harvard Medical School, and the Department of Health Sciences and Technology, MIT, Boston, Massachusetts.

Address correspondence and reprint requests to Steven E. Locke, MD, 10 Deer Run, Wayland, MA 01778. E-mail: slocke{at}hms.harvard.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 BACKGROUND AND SIGNIFICANCE
 CONCLUSION
 APPENDIX
 NOTES
 REFERENCES
 
Biodefense preparations in the United States have focused mostly on improving biosurveillance and hospital surge capacity in the event of an outbreak or a weapons of mass destruction (WMD) event. However, what if an invisible bioweapon or dirty bomb was released in a major population center, or if avian flu took hold with sustained human to human transmission? Suddenly, we need to combine efforts from psychosomatic medicine and general medicine with public health practice to triage nonexposed patients with somatic symptoms from those with medical sequelae resulting from hazardous exposures. This would better enable the limited acute care resources to be directed to those most in need of urgent medical care. Furthermore, psychosomatic medicine experts are potentially important players in biodefense planning related to risk communication and health education strategies in a WMD scenario or outbreak in which individuals must make informed choices about their need for immediate medical attention.

Key Words: public health • biodefense • terrorism • bioterrorism • outbreak • pandemic

Abbreviations: WMD = weapons of mass destruction; APS = American Psychosomatic Society; PDBPR = Psychosocial Dimensions of Biodefense Preparedness and Response; CDC = Centers for Disease Control and Prevention; DHHS = Department of Health and Human Services; SAMHSA = Substance Abuse and Mental Health Services Administration; DOD = Department of Defense; SARS = severe acute respiratory syndrome.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
BACKGROUND AND SIGNIFICANCE
 CONCLUSION
 APPENDIX
 NOTES
 REFERENCES
 
The annual Presidential Address offers a unique opportunity to reflect on one's career and the thread that runs through the work over many years. I have been blessed with many opportunities to pursue my scientific curiosity, and for that I am very grateful to many people, especially my wife and family who have supported this exploration. Generally, my interests have been influenced by trends at the interface of science and the larger culture. My career began with an exploration of psychoneuroimmunology (1) in the 1970s and 1980s at a time when there was growing public interest in holistic health and alternative medicine. During the 1990s, my interests shifted to the use of clinical computing to integrate behavioral medicine into primary care (2). Recently, for reasons described subsequently, I have become interested in the interface of psychosomatic medicine, clinical computing, and public health preparedness. This article describes the emergence of that interest and attempts to elucidate the important contribution of psychosomatic medicine to public health preparedness for threats such as terrorism, disasters, or outbreaks such as severe acute respiratory syndrome (SARS) or avian influenza.

To begin, here is a characterization of the social environment at the time I joined the leadership of the American Psychosomatic Society (APS). I was nominated as President of APS in the fall of 2001. We had just been through the terrible events of 9/11 and the anthrax mail attacks were dominating the news. As a country, we were frightened and angry. The government was warning us not to open suspicious-looking envelopes from people we did not know and many of us were afraid to open our mail altogether. The stock market was plummeting. In this troubled climate, I wondered how someone with my background and experience could be of help. One day, I went to open the family's mail wearing latex gloves troubled by my surrender to fear. At that moment, I thought to myself: if someone with my education, knowledge, and experience, living far away from a primary terrorist target, is acting like this, what must other people be experiencing? In fact, thousands of people sought prescriptions for the antibiotic ciprofloxacin, driven by fear of exposure to anthrax through the mail (3), creating shortages of the drug and, with inappropriate use, increased the risk of drug resistance.

The following fall, 2002, the National Capital Region was gripped by fear as a result of the serial sniper shootings. Faced with yet another new terror, the nation was transfixed as law enforcement and public health authorities struggled to deliver effective public educational messages through the media regarding our potential exposure to risk of harm, a process known as risk communication. For Christmas, Santa brought us an Orange Alert, and the retail and travel industries suffered as we avoided travel and shunned public places. People lost jobs. Secretary Ridge told us to buy duct tape and plastic sheeting. One of my older patients, a widowed schoolteacher living alone, anxiously asked me if I thought that she should buy duct tape and plastic to be prepared. She lived in a suburb, far from any likely sources of threat of chemical weapons and more likely to be at risk of a toxic plume from a chemical spill from a nearby highway, something most of us never consider. As the stock market continued to fall, I realized that unless we could respond more effectively to future threats of terror, disasters, or outbreaks, mismanaged risk communication efforts would cause continued erosion of my retirement funds. In fact, one of the frequent complaints I have heard from my "boomer generation" patients is their discouragement at having to work 10 years beyond their planned retirement date as a result of the economic downturn of 2000 to 2002.

This was the climate in which I inherited leadership of this society. With the encouragement and support of the Executive Committee of APS, in 2002, we created the APS Task Force on the Biopsychosocial Impact of Terrorism and Disasters. An informal survey of our members revealed both interest in this field and considerable relevant experience among our members. The Task Force was initially chaired by APS members Frederick Stoddard and Robert Ursano and is now chaired by Cheryl Koopman. The Task Force has contributed to the program at the annual meeting of APS by organizing a symposium, and each year, a roundtable lunch workshop has been held on the biopsychosocial impact of terrorism, disasters, and outbreaks (see www.psychosomatic.org).

My leadership role in APS offered me an opportunity to establish relationships with other professional organizations and leaders interested in psychological aspects of public health preparedness. These collaborations led to exposure to the visionary leadership of several key mental health experts at the Centers for Disease Control and Prevention (CDC), the Department of Health and Human Services (DHHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Department of Defense (DOD). These leaders have increased awareness among public health officials of the urgent need to take psychosocial factors into consideration during emergency preparedness planning. Dori Reissman, Ann Norwood, Robert DeMartino, Charles Engel, and Robert Ursano, among others, deserve special recognition for their leadership. Michael McDonald and Dori Reissman also contributed through their help in coauthoring the summary report on which this talk is based (4).

In the fall of 2002, I joined the Surge Capacity and Risk Communication Workgroups of the Massachusetts Department of Public Health's Bioterrorism Preparedness and Response Advisory Committee. Up to that point, most of Massachusetts' planning efforts had focused on increasing the surge capacity of hospitals in the event a terrorist attack created an urgent need for additional inpatient bed capacity to handle an expected surge in demand after a weapon of mass destruction (WMD) event. However, as a specialist in psychosomatic medicine, I had a different set of concerns. I believed that a frightening WMD scenario, especially one involving invisible agents such as chemical, radiologic, or biologic weapons, would lead many anxious but nonexposed individuals to develop somatic symptoms that they would likely misattribute to acute manifestations of direct exposure to an invisible agent (e.g., a neurotoxin, dirty bomb, or a weaponized virus).

Terrorists seek to create widespread fear, uncertainty, and loss of faith in institutional response capacity (5,6). Generally, the terrorist's primary goal is the social disruption that occurs as a result of psychological terror rather than physical damage done to the relatively few persons who are directly injured or killed by terrorist activities. Previous terrorist attacks in Tokyo, Oklahoma City, Israel, and New York City produced psychiatric casualties that vastly outnumbered medical casualties (7–11). Furthermore, although most incidents of bioterrorism are later determined to be hoaxes, the psychological impact can be considerable nevertheless.

Review of the relevant literature and conversations with experts indicate that psychological terror poses a significant risk to public health preparedness because inadequate attention has been paid to the importance of psychosomatic factors in biodefense. Past reviews of the impact of several terror incidents reveal that, on average, there have been at least four times the number of people with psychiatric sequelae than medical after mysterious or frightening public health emergency events (7,10,12). For example, during the 1991 Gulf War, residents of Tel Aviv experienced a frightening attack by Iraqi SCUD missiles that were purported to be armed with chemical weapons. The Israeli civilian population had been prepared by prior distribution of gas masks and instructions for personal defense against a chemical or biologic weapon attack. Although the missiles contained only conventional explosives, there were numerous casualties, leading to 1059 war-related emergency room visits. Among the casualties were 233 (22%) who sought care for direct injuries as a result of missiles or debris and 826 (78%) who sustained indirect injuries arising from behaviors in response to the attack or psychiatric casualties. These included 544 persons with acute anxiety, 230 who injected themselves inappropriately with atropine, and 40 were injured while running for safety. There were a total of 11 deaths, of which seven were the result of faulty use of gas masks (10). Furthermore, Meisel and colleagues reported that the rate of myocardial infarctions was significantly higher during the SCUD missile attacks than during five control periods and reverted to normal after the initial phase of the Gulf War was over (13).

The number of people who perceive themselves to be at high risk of exposure to a WMD or infectious agent even when, in fact, they are not, may be orders of magnitude greater than those actually deemed to be at risk of such exposure. This occurred during the mail-related anthrax attacks of 2001. During that time, there were only 22 cases of anthrax (including five deaths) (14), yet approximately 35,000 people received medication to protect themselves, and it is estimated that well over a million people perceived themselves to be at high risk (15). The news media at the time reported that pharmacies nationwide were experiencing a run on ciprofloxacin—media reports which, by the way, only made matters worse (3).

Our current healthcare delivery system will be severely challenged if we are faced with large numbers of people presenting at healthcare facilities with multiple stress-induced somatic and psychiatric complaints that mimic or confound the medical consequences of actual toxic or infectious agent exposure. A wide variety of physical (or somatic) symptoms and associated worry about them occur commonly when individuals experience anxiety, depression, or acute stress. The physical symptoms of acute stress reactions, acute stress disorder, generalized anxiety disorder, and panic disorder are the most common presenting symptoms in general medical settings. They include such common symptoms as dizziness, fatigue, muscle tension, insomnia, palpitations, dyspnea, and sweating. These somatic complaints create a diagnostic challenge for medical personnel in emergency triage situations.

We must address these psychosomatic dimensions in our planning efforts. Otherwise, our nation's healthcare system will remain inadequately prepared to effectively and efficiently manage and treat large numbers of patients who perceive themselves to be at risk. Without proper attention to the psychosocial and psychosomatic aspects of large-scale terrorist attacks or infectious disease outbreaks, including avian flu, our lack of preparedness could quickly result in a patient surge that overwhelms local healthcare infrastructure and triggers rampant mistrust in authorities. Significant disruptions of social order could occur, potentially resulting in long-term damage to our economy, culture, and the health of the public.

Questions have arisen about our capacity to respond to the psychosocial dimensions of terrorist events and large-scale public health emergencies. The threats are real. The aftermath of September 11, 2001, the mail-related anthrax bioterrorist attacks, the serial sniper incidents in the National Capital Region (Washington, DC, and environs) in 2002, the epidemic of SARS in 2003, the Gulf Coast hurricanes in 2005, and now we confront the current concerns about the threat of pandemic avian flu. The question is, "Can we cope?" Knowledgeable experts have questioned the adequacy of our healthcare infrastructure to respond to surges in demand for health and risk information and medical evaluation in response to the use of weapons of mass destruction or infectious disease epidemics. Little attention has been focused on the potential for large numbers of citizens to respond to threatening events by perceiving themselves to be exposed and thus placed at high risk of bad health outcomes in the future. These scenarios may also generate an overwhelming number of psychiatric casualties, people who present with unexplained symptoms and impaired function that mimic conditions associated with the attacks or the epidemic spread of disease. The surge in demand created under such scenarios threatens to inundate emergency triage and primary care systems. Failure to manage a surge effectively will render healthcare systems ineffective to care for those individuals who require urgent medical treatment. The inability to marshal specialized infection control strategies may, in turn, create unnecessary exposure to pathogens, chemical hazards, or exacerbate secondary mass psychosocial reactions and further delay necessary diagnosis and treatment. Additional concern arises when considering the likelihood that without effective self-triage at home or in the community, large numbers of people who have no exposure to an infectious agent will seek care in a facility where sick, contagious people are being evaluated and treated. This scenario is one of the most difficult challenges facing those planning the public health response to pandemic flu.

With these concerns in mind, the APS Task Force set out to collaborate with other stakeholder organizations and panels of invited experts to explore the state of scientific knowledge about unexplained medical symptoms, amplified health concerns, and mental disorders that may occur after chemical, biologic, or radiologic terrorist attacks and outbreaks. Our aim was to summarize the scientific knowledge necessary to make critical triage assumptions, identify important gaps in the scientific knowledge base, make recommendations on how to proceed to resolve such gaps, and propose a psychiatric triage model (4). The ultimate goal has been to develop and pilot-test evidence-based, algorithmic protocols for accurate and efficient identification, triage, and management of health risks and psychiatric casualties that could pose a threat to our public health emergency response capability (12,16,17).

Our efforts have been unavoidably limited by the current level of scientific uncertainty about the effectiveness of any single triage approach to manage a diverse variety of potential threats and outbreaks (16). Therefore, the work was undertaken with thoughtful consideration and integration of the best scientific evidence, the best attainable critical incident modeling, and reflection of crucial lessons derived from analysis of past exercises and relevant experiences.

In the spring of 2003, with the support of APS leadership, Michael McDonald and I, with assistance from Dori Reissman, Robert DeMartino, Victor Weedn, Glen Nowak, and Ann Norwood, developed the Psychosocial Dimensions of Biodefense Preparedness and Response (PDBPR) Initiative. We convened expert panel meetings during the spring and fall of 2003 (see Appendix). Dori B. Reissman of the CDC provided federal steering, meeting facilitation, project guidance and oversight. We held two meetings, hosted by Georgetown Medical Center and organized by Veritas Health Solutions (S.E.L., principal) and Global Health Initiatives (M.D.M., principal), with support from APS, CDC, SAMHSA, and the National Institute of Mental Health (NIMH).

During the first meeting at Georgetown in June 2003, four expert panels were created: 1) scientific basis for assessment of multiple unexplained physical symptoms (Charles Engel and Arthur Barsky, cochairs); 2) risk communication (Glen Nowak, chair); 3) management of contact (or social) distance (Stephen Prior, chair); and 4) technology solutions (Victor Weedn, chair). Each of these panels produced a written report, one of which has been published (17) and another that has been submitted for publication (12). After the scientific underpinnings were elucidated, a fifth panel, "first-line medical triage" (Kurt Kroenke, chair), was created in November 2003, and their report was completed January 31, 2004 (16). The final PDBPR Initiative report (4) was submitted to the CDC in May 2004.


   BACKGROUND AND SIGNIFICANCE
TOP
 ABSTRACT
 INTRODUCTION
 BACKGROUND AND SIGNIFICANCE
CONCLUSION
 APPENDIX
 NOTES
 REFERENCES
 
The PDBPR Initiative is concerned primarily with individual perceptions of high personal risk and possible associated somatic symptoms that may drive individual health-seeking behaviors, mass psychosocial behavior, and psychiatric sequelae in the immediate aftermath of an attack, a disaster, or an outbreak. For example, many individuals directly exposed to a traumatic event may develop acute but transient forms of psychosocial distress, including acute stress reactions and panic attacks (18,19). Graphic representation of a disaster or dangerous health event (e.g., bioterrorist attack or infectious disease outbreak) in the media can often amplify psychosocial distress over a very large population. A significant minority of those directly (i.e., to the hazard) or indirectly (i.e., psychologically, through the broadcast and print media) exposed may experience persistent psychiatric or psychosomatic problems as a result of real or perceived trauma and loss (5,8,9,20–24). Of particular importance is a phenomenon called "multiple idiopathic physical symptoms" (MIPS) that has been noted after disasters, criminal assault, and warfare (25–28). (In the literature, MIPS is sometimes referred to as multiple undiagnosed physical symptoms, or MUPS, and these terms may be considered to be synonymous.) In addition to MIPS, emergent and maladaptive reactions may occur involving groups of people (i.e., collective psychosocial reactions) in the aftermath of terrorism and large-scale public health emergency events. One example is mass psychogenic illness, also called mass sociogenic illness, or mass hysteria (29–32). Such illness is characterized by the acute and rapid spread of medically unexplained physical symptoms, including dizziness, shortness of breath, nausea, and/or palpitations (see Table 1). These symptoms occur throughout a group of individuals, often through direct line of sight, in the absence of any substantiated toxic or microbiologic exposure.


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  		TABLE 1. Frequency of Symptom Reporting Among Patients With Mass Psychogenic Illness

 

Other mass reactions may be provoked by efforts to control the spread of disease such as travel restrictions or quarantine (33) or may be the result of stigma (34).

Even in the absence of disaster, terrorist attack, or other large-scale public health event, a wide range of medically unexplained physical and psychiatric symptoms are prevalent in both healthy and medically ill populations. The symptoms are associated with psychosocial stress, health-related anxiety, and depression, all of which are known to increase healthcare utilization (35–39). Currently, the healthcare triage process places a premium on identification of life-threatening physical injuries and illnesses. Emotional disturbances, mental disorders, or psychosocial impairments are often not adequately incorporated into triage procedures in general medical settings (12). The societal magnitude of large numbers of patients with psychiatrically based concerns like these far outweighs the relatively small numbers of actual medical or surgical casualties resulting from attacks.

In addition, insidious and indirect psychiatric or behavioral health effects may occur long after the acute phase of a terrorist attack is over. Terrorism and outbreaks can alter our way of life and lead to economic disruption (40). For example, bioterrorist-induced infectious disease outbreaks (e.g., smallpox), or even naturally occurring outbreaks (e.g., SARS, pandemic avian flu), can lead to changes in social behavior with disruptive economic consequences: worried people may avoid restaurants, theaters, or shopping malls or reduce their travel (11,41). Such behaviors have, in fact, led to job loss and increased unemployment (11,42). This is of particular concern because job loss and unemployment are known to be associated with poorer mental and physical health, including increased drinking, depression, suicide, and measurable declines in physical functioning (43–47). Clearly, there is also a need to recognize the magnitude of psychosocial sequelae that coexist with medical mortality and morbidity and that can lead to secondary economic hardship and its own set of harmful consequences.

Most psychosocial morbidity or comorbidity remains unrecognized in primary care settings (48,49), making it likely that psychiatric comorbidity will be underdiagnosed and undertreated after traumatic events like terrorist attacks, leading to poor life adjustment. WMD events or infectious disease outbreaks that involve large numbers of potentially exposed individuals when coupled with widespread public health anxiety are likely to create a surge in demand that could tax the response capability in affected areas. Training triage personnel to use brief validated psychiatric screening instruments to identify existing mental disorders or at-risk individuals that have been subjected to overwhelming stressors could lead to improvements in diagnosis and management under conditions of incapacitating surge. Biologic attacks with infectious agents (e.g., smallpox) or community spread of highly lethal novel infectious agents (e.g., SARS or possibly avian flu) are particularly dangerous because of the inherent uncertainties about self-protective measures and behaviors that could increase the spread of disease. Flocking to hospitals and healthcare settings for reassurance could be a grave mistake if nonexposed or noninfected persons come in contact with contagious patients, thereby enlarging the magnitude of the disease epidemic and confounding the epidemiologic investigation.

Unfortunately, important gaps in relevant scientific knowledge limit the ability to create a single triage strategy. These factors include uncertainty about the base rates of conditions associated with terrorist attacks, questionable applicability of existing screening instruments, challenges of deploying new technology-based solutions, and limited knowledge about which psychiatric triage approaches are most effective. These issues have been thoroughly reviewed by Engel et al. (12). However, implementing new, even if imperfect, systems is better than hoping that the current system will not become taxed beyond its capability to deliver quality health care (17). We must deliver information and learning tools to enable the average person to self-assess their own risk of exposure, illness, and risks and benefits of interventional options. These tools could be validated by exploiting naturally occurring disease epidemics (e.g., influenza, SARS) and scheduled biodefense exercise simulations by using historical data from prior events to test and iteratively improve the system before we have to rely on it during a large-scale terrorist event or disease outbreak. Triage tools can be further tested in simulation drills that use standardized patients trained to simulate a variety of signs and symptoms characteristic of chemical, biologic, and radiologic weapons as well as acute stress reactions and anxiety disorders. The ability of the self-assessment and other decision support tools could be tested by determining their sensitivity and specificity in making correct diagnoses in the simulations. Finally, tools need to be developed that are suitable for automated, computer-assisted, remote self-assessment (e.g., by telephone, Internet, or portable computing device such as a PDA). Such tools can facilitate triage in the community by engaging trained volunteers at alternate care sites or in an emergency medical setting (e.g., hospital).

In recognizing that in the United States, at least to date, the major threat of terrorism involves psychologic, social, and economic disruption, we need to develop systems to do the following: a) help clarify risks and choices among those who fear exposure; b) appropriately refer those who manifest psychosocial problems for mental health care; and c) appropriately refer those with hazardous exposures for medical care. Currently, no estab-lished validated tools exist to manage this challenge. By harnessing the power of information technology, self-assessment tools, scientifically informed risk communication and health education, and computer-assisted triage, we should be able to address the needs of the key target groups within a relatively short period of time. Proposed systems must be able to screen, prioritize, and manage the surge in healthcare needs and to provide appropriate information about exposure risk and health effects and resource allocation in the event of terrorist attacks or infectious disease outbreaks. By virtue of the expert panel process, we developed in the PDBPR Initiative, we proposed a preliminary five-stage triage model using automated, interactive crisis health risk self-assessment tools for consideration. The model includes preclinical telescreening to determine the likelihood of toxic exposure, rapid physical assessment, and brief psychiatric screening to promote appropriate referrals to integrated systems of care for medical problems and psychiatric comorbidity (12) (see Fig. 1).


Figure 19
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  		Figure 1. Flow diagram for screening patients during a weapons of mass destruction event, disaster, outbreak, or pandemic.

 

Inherent in any triage model is the recognition of the central role that effective risk communication and health education must play to guide and manage healthcare resource demands (50–53). There must be detailed consideration of appropriate and timely systems of response as well as strategies to mitigate the stigma associated with seeking appropriate medical attention. We must try to prevent reluctant infected patients from causing uncontrolled disease transmission. We have to openly acknowledge that any triage system will be vulnerable to unanticipated events.

Managing contact distance (or social distancing) is another essential element of effective and comprehensive triage. This term is one of an emerging lexicon that considers the full range of interventions associated with management of infectious diseases transmitted from person-to-person through close contact (e.g., breathing airborne infectious particles exhaled by another) to prevent spread of disease (e.g., SARS, pandemic flu). The PDBPR Initiative considered specific implementation strategies for communicable diseases requiring movement restrictions like quarantine and isolation (54). These strategies need to anticipate obstacles if they are to successfully promote appropriate public adherence to social distancing (quarantine) measures without resorting to onerous enforcement methods. This is another area in which behavioral and social science expertise has been helping to inform public policy in biodefense preparedness planning (55).


   CONCLUSION
TOP
 ABSTRACT
 INTRODUCTION
 BACKGROUND AND SIGNIFICANCE
 CONCLUSION
APPENDIX
 NOTES
 REFERENCES
 
There is an immediate need to develop and test systems of response to increase the likelihood that those in greatest need of urgent medical care will have access to it after a WMD event or infectious disease outbreak. The APS-sponsored PDBPR Initiative, with support from federal agencies and input from a panel of experts, has proposed that by harnessing the power of information technology, evidence-based self-assessment tools, scientifically informed risk communication, and computer-assisted triage, the needs of at-risk or exposed populations during a WMD event or infectious disease outbreak or pandemic could be addressed effectively and efficiently. We have proposed systems that will facilitate screening, triage, and patient management after mysterious exposures or disease epidemics. APS has initiated an urgent call for a federally supported public/private research and development effort to design, build, and test state-of-the-art systems for public health preparedness and response. Such systems offer the potential to increase the efficient and appropriate resource allocation for health care and population-based behavioral management in the face of public health emergencies. Failure to address the psychosocial dimensions of biodefense leaves hospitals, medical systems, and clinicians extremely vulnerable to the threat of being catastrophically overwhelmed in the face of a large-scale health emergency.

The report on which this work is based was commissioned by the Centers for Disease Control and Prevention under contract 200-2003-M-02417, with meeting and logistical support funded in part by the National Institute of Mental Health contract #263MD403004, the Substance Abuse and Mental Health Services Administration, the American Psychosomatic Society, Global Health Initiatives, Inc., and Veritas Health Solutions. The author thanks Michael McDonald and Dori Reissman for their assistance as coorganizers of the meetings that served as the basis for this report and as coauthors with Dr. Locke of the report summarizing the findings of those meetings. Ambassador Cynthia Schneider provided support and assistance at the Life Sciences and Society Initiative of Georgetown University by hosting the meetings. Ashley Boeri provided valuable administrative assistance during the expert panel meetings at Georgetown.


   APPENDIX
TOP
 ABSTRACT
 INTRODUCTION
 BACKGROUND AND SIGNIFICANCE
 CONCLUSION
 APPENDIX
NOTES
 REFERENCES
 
Psychosocial Dimensions of Biodefense Preparedness and Response Initiative

Expert Panel Members

Adil Alaoui, Donna Barbisch, DrHA, MPH, CRNA, Arthur Barsky, MD, John Barson, MD, Andrew Baum, PhD, James Carter, PhD, Fred A. Cecere, MD, Claude Chemtob, PhD, Briant Coleman, Niel Constantine, PhD, Bruce Cuthbert, PhD, Adam Darkins, MB ChB, MPH, MD, Robert DeMartino, MD, Leonard Derogatis, PhD, Cleto DiGIovanni, MD, Daniel Dodgen, PhD, Charles Engel, MD, MPH, LTC, MC, Baruch Fischoff, PhD, Robert Friedman, MD, Brenda Gearhart, PhD, David Goldbloom, MD, FRCPC, Dan Hanfling, MD, FACEP, Jeffery Jackson, MD, Gerard A. Jacobs, PhD, Stacy Kaltman, PhD, Wayne J. Katon, MD, Marcia Kovach, LICSW, Kurt Kroenke, MD, Ilan Kutz, MD, Steven Locke, MD, Rocky Lopes, PhD, Dan Lucey, Kenneth Mandl, MD, Michael McDonald, DrPH, Richard Newell, MPH, MD, Col. Ann Norwood, MD, Glen Nowak, MD, Michael Pietrzak, MD, FACEP, Stephen Prior, PhD, Dori Reissman, MD, MPH, Elspeth Ritchie, MD, LTC, MC, Lisa Rotz, MD, Dan Rutz, MPH, Cynthia Schneider, PhD, Merritt "Chip" Schreiber, PhD, Robert Smith, MD, Myra Socher, MS, NREMT-P, James Stanton, MSW, Alan Steinberg, PhD, Frederick Stoddard, MD, Ellen Stover, PhD, Michael Stoto, PhD, Gary Strong, PhD, Peter Szolovits, PhD, Terri Tanielian, MA, Lydia Temoshok, PhD, Farris Tuma, ScD, Robert Ursano, MD, Eugen Vasilescu, Ivan Walks, MD, Victor Weedn, MD, JD, and Raymond Weinstein, MD.


   NOTES
TOP
 ABSTRACT
 INTRODUCTION
 BACKGROUND AND SIGNIFICANCE
 CONCLUSION
 APPENDIX
 NOTES
REFERENCES
 
Dr. Locke is Past-President, American Psychosomatic Society, and President, Veritas Health Solutions. He is the principal in Veritas Health Solutions, LLC, a healthcare consulting company that markets behavioral informatics consulting services to public and private organizations and businesses in the healthcare industry.

Received for publication September 13, 2004; revision received July 14, 2006.

DOI:10.1097/01.psy.0000238218.45165.e0


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 BACKGROUND AND SIGNIFICANCE
 CONCLUSION
 APPENDIX
 NOTES
 REFERENCES
 

  1. Locke SE, Colligan D. The Healer Within: The New Medicine of Mind and Body. New York: EP Dutton; 1986.
  2. Locke SE, Kowaloff HB, Hoff RG, Safran C, Popovsky MA, Cotton DJ, Finkelstein DM, Page PL, Slack WV. Computer-based interview for screening blood donors for risk of HIV transmission. JAMA 1992;268:1301–5.[Abstract/Free Full Text]
  3. Cipro prescriptions go through roof. CBS News, October 26, 2001. Available at: www.cbsnews.com/stories/2001/10/22/archive/main315371.shtml. Accessed April 30, 2006.
  4. Locke SE, McDonald MD, Reissman DB. The Psychosocial Dimensions of Biodefense Preparedness and Response: A Call for Strategic Systems. Atlanta: US Centers for Disease Control and Prevention; 2004. Available at: www.psychosomatic.org/ed_res/index.htm.
  5. Ursano RJ, Fullerton CS, Norwood AE. Terrorism and Disaster: Individual and Community Health Interventions. Cambridge, UK: Cambridge University Press; 2003.
  6. Butler AS, Panzer AM, Goldfrank LR. Preparing for the Psychological Consequences of Terrorism: A Public Health Strategy. Washington, DC: National Academies Press; 2003.
  7. Ohbu S, Yamashina A, Takasu N, Yamaguchi T, Murai T, Nakano K, Matsui Y, Mikami R, Sakurai K, Hinohara S. Sarin poisoning on Tokyo subway. South Med J 1997;90:587–93.[Medline]
  8. North C, Nixon S, Shariat S, Mallonee S, McMillen J, Spitzanagel E, Smith E. Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA 1999;282:755–62.[Abstract/Free Full Text]
  9. Galea S, Vlahov D, Resnick H, Ahern J, Susser E, Gold J, Bucuvalas M, Kilpatrick D. Trends of probable post-traumatic stress disorder in New York City after the September 11 terrorist attacks. Am J Epidemiol 2003;158:514–24.[Abstract/Free Full Text]
  10. Bleich A, Dycian A, Koslowsky M, Solomon Z, Wiener M. Psychiatric implications of missile attacks on a civilian population. Israeli lessons from the Persian Gulf War. JAMA 1992;268:613–5.[Abstract/Free Full Text]
  11. Hall MJ, Norwood AE, Ursano RJ, Fullerton CS. The psychological impacts of bioterrorism. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 2003;1:139–44.
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