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Article   |    
Health Services Utilization in Jerusalem Under Terrorism
Itzhak Levav, M.D., M.Sc.; Ilya Novikov, Ph.D.; Alexander Grinshpoon, M.D., M.H.A.; Joseph Rosenblum, M.D.; Alexander Ponizovsky, M.D., Ph.D.
Am J Psychiatry 2006;163:1355-1361. doi:10.1176/appi.ajp.163.8.1355
Abstract

Objective: The authors explored the effects of an escalation of terrorism on the help-seeking behavior of the general population in Jerusalem, a city that offers an adequate supply of medical and psychiatric services. Method: Time-series analyses were applied to examine the utilization of health services (primary medical care and ambulance calls) and mental health services (clinics, hospitals, and telephone hotlines) by Jerusalem residents before and during part of the current intifada. The authors assessed seasonality, general linear trends (from factors such as health education and increased access), short-term intifada impact (reflecting reactions that peaked at the third month and ended 1 year thereafter), and long-term impact (starting at the intifada outbreak and reflecting a more stable population behavior). Results: Adult psychiatric outpatient visits did not change except for the elderly in ongoing care who had both short- and long-term increases. The proportion of recorded ICD-10 diagnoses reflecting intifada-related reactions remained generally stable. Short-term effects included an increase in psychiatric readmissions. First contacts to substance abuse clinics remained unchanged. While long-term effects included a decrease in new psychiatric hospitalizations, the rate of monthly general practitioner visitors and the number of monthly ambulance and hotline calls increased. Conclusions: Except for the elderly and previously hospitalized persons, Jerusalem residents did not increase their use of psychiatric services but did increase their use of some other health services. These results suggest that this terrorism-affected population did not perceive their mental and social suffering as requiring specialized intervention.

Abstract Teaser
Figures in this Article

Jerusalem has been subjected to numerous terrorist attacks over the last 60 years, even before modern Israel reached independence (1948). From 1967 through September 2003, there were 486 attacks, with 510 persons killed and 2,636 injured (1, 2). During the present armed intifada (Arabic for insurrection), terrorism has escalated steeply, often including the suicide/homicide bomber modality targeting civilians (3). To illustrate, while five large-scale terrorist attacks occurred in Jerusalem between 1995–1997, and four civilians were killed in isolated attacks in 1998, since the beginning of the intifada in late September 2000 through December 2002 the number of attacks rose to 21. These later attacks caused 146 deaths, both of adults and children, untold number of wounded persons, and considerable property damage (2). Including the surrounding areas of Jerusalem, the number of terrorist episodes during this period reached 68, with 182 dead and 1,160 wounded.

Terrorist attacks leave in their wake personal and community sequelae of different duration and intensity (4–17). The psychological and psychopathological effects of terrorism on urban populations (e.g., Northern Ireland [8, 9] and Algeria [10]) have been raised anew in the literature following the 2001 events in the United States. The effects may be examined with regard to their psychiatric impact (14), the population-level behavior (17), and the human suffering that falls outside the psychopathological domain (11). In the United States, the reactions are a matter of ongoing research, with results (12–16, 18) suggesting that the psychiatric impact of the September 11 events may be similar to findings made in other disasters (19) in that exposure is a risk factor for anxiety, depression, and posttraumatic stress disorder (PTSD).

Prior to the current intifada, several studies were conducted in Israel on the effects of the Iraqi missile attacks during the 1991 Gulf War. The results indicated early elevated cardiovascular mortality (20) as well as worsened self-appraisal of physical health status, increased smoking, diminished physical activity, changed diet habits, and increased psychological distress (21). One study explored reactions among the elderly and found an increased vulnerability among Holocaust survivors (22). Nakar et al. (23) studied general practitioner burden in a highly exposed area and found a decreased total rate of visits. In addition, a laboratory study exploring the Gulf War impact on anxiety and cortisol and growth hormone levels showed that biological measures were within normal limits, presumably as a result of adaptation (24).

How does terrorism affect psychiatric services utilization by the general population? American reports suggest that psychiatric services were used sparingly after September 11 (15, 25–32) but that there were increases in prescriptions of anxiolytic drugs by non-psychiatrists (27) as well as by existing users (28). A similar pattern of changes in service utilization had been noted in Northern Ireland, where terrorism has been long-lasting (8). Despite reporting relatively elevated rates of traumatic stress-related symptoms, a low proportion (5.3%) of Israelis sought professional help according to a national telephone survey conducted during the current intifada (6).

Thus, the New York, Northern Ireland, and Israel studies suggest that under the stress of terrorism there are changes in some, but not all, health behaviors. In the study reported here we examined a comprehensive mosaic of routinely collected mental health and general health service indicators to ascertain intifada-related health utilization demands of specialized and nonspecialized services among Jerusalem residents.

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Data Sources

Governmental and nongovernmental service organizations provided monthly data on general health and mental health services indicators, covering the Jerusalem Jewish population (N=261,400) (Table 1).

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Psychiatric Services

Citywide, free, and easily accessible governmental psychiatric clinics that offer care for all types of psychiatric disorders provided information on the number of contacts by gender, age group (18–64 or 65 years and older), diagnoses, and administrative status (new contacts, renewed contacts after a 6-month break, and ongoing care). We also obtained data on the number of new patients who contacted these clinics before and during the current intifada and their respective diagnoses, as well as data on the number of adults that sought help for the first time in the city’s two clinics for substance abuse disorders.

The National Psychiatric Case Registry, which records all admissions to and discharges from inpatient services, provided the number of first and repeat hospitalizations of Jerusalem residents.

The national emergency (personal crisis) hotline submitted the number of telephone calls originating in Jerusalem.

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General Health Services

Two of the four national health maintenance organizations, estimated to cover over 40% of our target population, provided information on the monthly rate of adult visitors to their primary care physicians.

Magen David Adom (local Red Cross) provided the number of home visits for ambulances equipped to handle cardio- and cerebrovascular emergencies, dispatched by the duty officer according to the problem described during the telephone call.

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Statistical Analysis

Time series analysis was applied given the temporal nature of the data (33). We used an autoregression approach, a variant of a linear regression permitting autocorrelation of residuals. All health indicators were examined monthly. The period of observation was divided into two time intervals: the 21 months preceding the current intifada (Jan. 1, 1999–Sept. 30, 2000) and the 27 months after the intifada onset (Oct. 1, 2000–Dec. 31, 2002). The models included 1) a periodic seasonal component to account for the seasonality in the use of health services; 2) a general linear trend, since there is a steady increasing trend in service utilization resulting from widespread health education and greater access, among other factors; and 3) two intifada-related components, short- and long-term impact. Short-term impact included effects that resulted from an initial reaction to the intifada outbreak, defined as including a peak at the third month and ending about 1 year thereafter. Long-term impact included effects that followed a linear trend starting at the intifada outbreak that may represent a more stable behavior of a population living under continuous threat.

The full model we applied included all components regardless of their statistical significance. While preserving the general linear trend, we also performed a backward elimination of components to reach a parsimonious model in which all remaining components were statistically significant (p<0.05).

To eliminate the seasonal component we performed median smoothing. Smoothed values were calculated for the period June 1999 to June 2002. A smoothed value at a specific point was defined as the median of a 12-month period starting 5 months before that point and ending 6 months thereafter. With regard to clinic diagnoses, we compared the proportions of patients for each of the eight diagnostic groups between the periods before and following the intifada outbreak using chi-square statistics. The correction for multiple comparisons was performed using the step-down Bonferroni procedure (SAS procedure Multitest). All analyses were performed with SAS 8.12, using the SAS ETS AUTOREG procedure (34).

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Psychiatric Services Utilization

Following the intifada outbreak, adult psychiatric outpatient visits (new, renewed, or ongoing) did not increase (Figure 1, smoothed line). In contrast, the number of visits by the elderly (i.e., those 65 and older) increased on three of six short- and long-term impact parameters: increases in visits among ongoing cases (short- and long-term) and short-term increases in new contact visits (Table 2).

The diagnoses of new cases at the psychiatric clinics did not significantly change during the two study periods with regard to the following categories: organic, mood (affective), personality, and unspecified disorders. There was a decrease with regard to behavioral syndromes associated with physiological disturbances and an increase in psychoactive substance use (p<0.01), schizophrenia (p<0.01), and neurotic stress-related and somatoform disorders (p<0.03). However, when Bonferroni correction for multiple comparisons was applied, no significant changes remained.

Similarly, we found no changes over time in the number of first contacts at the city’s two substance abuse clinics (1998: N=168; 1999: N=161; 2000: N=171; 2001: N=164; 2002: N=160; 2003: N=128).

There were no short-term changes in the number of first admissions to psychiatric hospitals but there was a significant long-term decrease (Table 2). There was a significant short-term increase in the number of psychiatric readmissions but a long-term (albeit nonsignificant) decrease. There was also a long-term increase in the number of hotline calls (Table 2).

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General Health Services Utilization

Following the intifada outbreak, the rate of monthly general practitioner visits reported by the two health insurers increased for both men and women (Table 2 and Figure 2, smoothed line; data are shown for both genders combined). There were also short- and long-term increases in the number of monthly ambulance calls (Figure 3).

Our inquiry focused on a single behavioral dimension, health service use, among the general population in response to terrorism. Analogously, Stecklov and Goldstein (17) focused on driving behavior during part of the period we covered. Neither that study nor ours targeted people that survived the attacks or were bereaved by the loss of a significant other.

Our results show that, with few exceptions, the Jerusalem residents did not seek increased help from psychiatric services during the study period. Thus there was no increased influx of adult patients to governmental psychiatric clinics, except for elderly patients, a subgroup that may be vulnerable to terrorism-related stress due to earlier life exposure to the Holocaust and past wars (22). Last, the changes in the relative proportion of diagnoses over time among new patients failed to remain significant following statistical correction. These almost general negative findings are reinforced by the reduction in the long-term first psychiatric hospitalizations, or, stating it more conservatively, by the nonreversal of a negligible descending trend that characterizes first inpatient admissions in the country (35). The readmission of patients who had been previously hospitalized showed mixed results, a short-term increase (a possible effect of stress on this vulnerable group [36]) but no long-term changes, perhaps an effect of adaptation. Consistent with studies in the United States (37) and in Israel (6), emergency personal crisis telephone hotline service use increased. This is not surprising, since this service is easily accessible from home, it operates around the clock, it is free, and it is anonymous. It is important to note in order to better judge the results that Jerusalem did not lose more residents during the period studied compared with previous years (www.jils.org.il/shnaton), although life in the city was more dangerous.

This report has some limitations. Information was collected and recorded by agencies outside our immediate supervision, except those from the government (35). Also, data from the university clinic specializing in stress reactions following all types of traumatic events were not collected nor were data from private practice psychologists funded by the National Insurance Institute. Those settings, which charge a fee for their services, mostly or solely provide care for survivors of the attacks and their families as well as for bereaved families that may be referred by the National Insurance Institute rehabilitation officers upon need. Recall here that our focus was the general Jerusalem population and not persons directly involved in the attacks.

The two health insurers that provided data on visits to primary care physicians cover slightly over 40% of the Jewish city residents. We are confident, however, that the populations covered are not biased, since the insured belong to a heterogeneous population in terms of socioeconomic status, degree of religious observance, and residence, and their doctors’ clinics are spread across the city, including the neighborhoods in which the attacks occurred. Obviously, our study is neither covering later periods of the current intifada nor the time when terrorism will cease and peace and reason will prevail. Thus, we cannot claim that the mental health help-seeking pattern will remain as we found it here.

This study has several strengths. Methodologically, it relies on a composite mosaic built by using multiple sources of information that kept their system of data collection unchanged over the years under examination. Note here that, in contrast with the community surveys conducted in New York City (32) and Israel (6), purported to provide unbiased population rates, our data sources were not affected by the relatively low response rates obtained in those studies nor by respondent recall. With regard to the analysis, we utilized time-series analyses, controlling for long-term effects and seasonal fluctuations. Boscarino et al. (25), who did not use time-series analysis, found a small, yet significant increase in 1-month services utilization in Manhattan after September 11, 2001, but their finding may be questioned by lower services utilization in the month of August, when many New Yorkers (including service providers) are on vacation. Rosenheck and Fontana (31) studied six 6-month periods of services utilization and applied analysis of variance to assess the impact of the September 11 attacks in New York on Veteran Affairs mental health services utilization. Their study likely contains too few data points to distinguish between short-term and long-term effects and to ensure that identified effects (or the lack thereof) are not the result of a general trend. The importance of adjusting for a general linear trend, which reflects inherent dynamics of service utilization, is obvious since changes due to the greater use of the services by an increasingly health-educated population may be mistakenly attributed to the stress of terrorism.

The field of public mental health faces a certain paradox. Community-based surveys on terrorism highlight adverse psychopathological effects (4, 6, 12–16). Yet, our data and previous service-based inquiries (15, 23–27, 29) reveal a much less worrisome picture. Of late, Druss and Marcus reached a similar conclusion (28). We acknowledge that treatment gaps measured by true prevalence studies and services utilization rates are no novelty (38), but under the shadow of terrorism, the treatment gap with regard to psychiatric services looms very large. Indeed, a relatively small gap would have been expected, given that the social stigma of terrorism-induced mental disorder is conceivably less than that surrounding most other disorders, and that terrorism-induced psychopathology is likely to have a relatively sudden (19) and thus noticeable onset to the person and others compared with the insidious beginning of most mental disorders. In addition, one would expect that the public mental health information continuously available through the media during the current intifada, and the encouragement to seek consultation if needed, may have led to a lowering of the threshold for utilization of specialized services.

For the apparent paradox we offer two preliminary explanations. First, most trauma-exposed persons may consider their suffering as a normal psychological reaction and do not believe that psychiatric services are the adequate address to obtain the necessary relief. As noted, “In the aftermath of terrorist attacks, many Americans may have regarded their distress as a ‘normal’ reaction…than as a disorder needing [psychiatric] care” (28). As in regular times, people that may react with varied symptoms of terrorism-induced stress seem to turn to their general practitioner for help or to other sources (28). To better ascertain this we would have required the general practitioner diagnoses, assuming that they were reliable, but this is not yet feasible.

Second, some epidemiological studies may overstate the extent of trauma-related psychopathology (4, 6, 12–16); up to 14.3% of those living in proximity to the World Trade Center in Manhattan surveyed in October 2001 met criteria for PTSD or depression (32). In contrast to these results, Northern Ireland psychiatrists stated: “because someone experiences or witnesses an act of violence does not mean that…[he or she] will inevitably develop psychiatric morbidity” (10).

The time may be approaching to re-evaluate psychiatric predictions of the effects of terrorism and to make better empirical attempts to explain this paradox. In particular, research is needed on determinants of help-seeking both among trauma survivors and the general population indirectly affected. The pathway from the perception of distress to the utilization of psychiatric services involves attribution of lack of normalcy to the distress and, obviously, available effective care. These perceptions need to be studied in detail. Meanwhile, access to mental health care should be facilitated by buttressing the mental health component in primary health care in emergencies, as recommended by the World Health Organization (38, 39) and clearly showed in this inquiry. This strategy is most effective when the specialized mental health agents are community-based and collaborate with the general practitioners and nurses in dealing with the diverse trauma-related reactions, provided they avoid “medicalizing [complaints] without justification” (40).

+Presented in part at the 157th annual meeting of the American Psychiatric Association, New York, May 1–6, 2004. Received March 9, 2004; revisions received Oct. 18 and Dec. 15, 2004; accepted Jan. 10, 2005. From Mental Health Services, Ministry of Health, Jerusalem; the Gertner Institute of Epidemiology and Health Policy, Tel Hashomer, Ramat Gan, Israel; and Meuhedet Health Services, Israel. Address correspondence and reprint requests to Dr. Levav, Mental Health Services, Ministry of Health, 2 Ben Tabai St., Jerusalem 91010, Israel; Itzhak.Levav@moh.health.gov.il (e-mail).The authors thank Mr. E. Kedem (Maccabi Health Fund), Mr. I. Gilat (ERAN National Telephone Hotline), Mr. Z. Shmulovich (Maguen David Adom), Mr. V. Goryachy (Psychiatric Outpatient Clinics), and Dr. D. Shye (Ministry of Health) for providing the datasets. The authors also thank Drs. M. van Ommeren and S. Saxena (World Health Organization) for their suggestions and Drs. L. Eisenberg (Harvard University) and R. Kohn (Brown University) for their review of an earlier draft of this article.

1.Human Rights Watch web site: www.hrs.org/reports/2002/isr-pa
 
2.Israel Ministry of Foreign Affairs web site: www.mfa.gov.il/mfa/home.asp. Accessibility verified October 2004
 
3.Salib E: Suicide terrorism: a case of folie a plusieurs? Br J Psychiatry 2003; 182:475–476
 
4.North CS, Nixon SJ, Shariat S, Mallonee S, McMillen JC, Spitznagel EL, Smith EM: Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA 1999; 282:755–762
 
5.Ochberg FM: Victims of terrorism. J Clin Psychiatry 1980; 41:73–74
 
6.Bleich A, Gelkopf M, Solomon Z: Exposure to terrorism, stress-related mental health symptoms, and coping behaviors among a nationally representative sample in Israel. JAMA 2003; 290:612–620
 
7.Dohrenwend BP: The role of adversity and stress in psychopathology: some evidence and its implications for theory and research. J Health Soc Behav 2000; 41:1–19
 
8.Curran PS: Psychiatric aspects of terrorist violence: Northern Ireland 1969–1988. Br J Psychiatry 1988; 153:470–475
 
9.Curran PS, Miller PW: Psychiatric implications of chronic civilian strife or war: Northern Ireland. Adv Psych Treatment 2001; 7:73–80
 
10.de Jong JTVM, Komproe IH, Van Ommeren M, El Masri M, Araya M, Khaled van de Put W, Somasundaram D: Lifetime events and posttraumatic stress disorder in four post-conflict settings. JAMA 2001; 286:555–562
 
11.Summerfield D: War and mental health: a brief overview. Lancet 2000; 321:232–235
 
12.Schlenger WE, Caddell JM, Ebert L, Jordan BK, Rourke KM, Wilson D, Thalji L, Dennis JM, Fairbank JA, Kulka RA: Psychological reactions to terrorist attacks: findings from the National Study of Americans’ Reactions to September 11. JAMA 2002; 288:581–588
 
13.Silver RC, Holman EA, McIntosh DN, Poulin M, Gil-Rivas V: Nationwide longitudinal study of psychological responses to September 11. JAMA 2002; 288:1235–1244
 
14.Galea S, Ahern J, Resnick H, Kilpatrick, Bucuvalas M, Gold J, Vlahov D: Psychological sequelae of the September 11 terrorist attacks in New York City. N Engl J Med 2002; 346:982–987
 
15.DeLisi LE, Maurizio A, Yost M, Papparozzi CF, Fulchino C, Katz CL, Altesman J, Biel M, Lee J, Stevens P: A survey of New Yorkers after the Sept 11, 2001, terrorist attacks. Am J Psychiatry 2003; 160:780–783
 
16.Schuster MA, Stein BD, Jaycox L, Collins RL, Marshall GN, Elliot MN, Zhou AJ, Kanouse DE, Morrison JL, Berry SH: A national survey of stress reactions after the September 11, 2001 terrorist attacks. N Engl J Med 2001; 345:1507–1512
 
17.Stecklov G, Goldstein JR: Terror attacks influence driving behavior in Israel. Proc Natl Acad Sci USA 2004; 101:14551–14556
 
18.Simeon D, Greenberg J, Knutelska M, Schmeidler J, Hollander E: Peritraumatic reactions associated with the World Trade Center disaster Am J Psychiatry 2003; 160:1702–1705
 
19.Norris FH, Friedman MJ, Watson PJ, Byrne CM, Diaz E, Kaniasty K. 60,000 disaster victims speak, part I: an empirical review of the empirical literature, 1981–2001. Psychiatry 2002; 65:207–239
 
20.Kark JD, Goldman S, Epstein L: Iraqi missile attacks on Israel: the association of mortality with a life-threatening stressor. JAMA 1995; 273:1208–1210
 
21.Soskolne V, Baras M, Palti H, Epstein L: Exposure to missile attacks: the impact of the Persian Gulf War on physical health behaviors and psychological distress in high and low risk areas in Israel. Soc Sci Med 1996; 42:1039–1047
 
22.Solomon Z, Prager E: Elderly Israeli Holocaust survivors during the Persian Gulf War: a study of psychological distress. Am J Psychiatry 1992; 149:1707–1710
 
23.Nakar S, Kahan E, Nir T, Weingarten MA: The influence of SCUD missile attacks on the utilization of ambulatory services in a family practice. Med Confl Surviv 1996; 12:149–153
 
24.Weizman R, Laor N, Barber Y, Selman A, Schujovizky A, Wolmer L, Laron Z, Gil-Ad I: Impact of the Gulf War on the anxiety, cortisol, and growth hormone levels of Israeli civilians. Am J Psychiatry 1994; 151:71–75
 
25.Boscarino JA, Galea S, Ahern J, Resnik H, Vlahov D: Utilization of mental health services following the September 11th terrorists attacks in Manhattan, New York City. Int J Emerg Ment Health 2002; 4:143–145
 
26.Boscarino JA, Galea S, Ahern J, Resnick H, Vlahov D: Psychiatric medication use among Manhattan residents following the World Trade Center disaster. J Trauma Stress 2003; 16:301–306
 
27.McCarter L, Goldman W: Use of psychotropics in two employee groups directly affected by the events of September 11. Psychiatr Serv 2002; 53:1366–1368
 
28.Druss BG, Marcus SC: Use of psychotropic medications before and after Sept 11, 2001. Am J Psychiatry 2004; 161:1377–1383
 
29.Hoge CW, Pavlin JA, Milliken CS: Psychological sequelae of September 11. N Engl J Med 2002; 347:443–445
 
30.Rosenheck R: Reactions to the events of September 11. N Engl J Med 2002; 346:629–630
 
31.Rosenheck R, Fontana A: Use of mental health services by veterans with PTSD after the terrorist attacks of September 11. Am J Psychiatry 2003; 160:1684–1690
 
32.Galea S, Boscarino J, Resnick H, Vlahov, D: Mental health in New York City after the September 11 terrorist attacks: results from two population surveys, in Mental Health United States 2002. Rockville, Md, Substance Abuse and Mental Health Services Administration, 2004, pp 89–97
 
33.Harvey A. The Econometric Analysis of Time Series, second ed. Cambridge, Mass, MIT Press, 1990
 
34.SAS ETS User’s Guide Version 7 and 8, vol 1. Cary, NC, SAS Publishing, 2000
 
35.Mental Health Services, Department of Information and Evaluation: Mental Health in Israel: Statistical Annual 2002. Jerusalem, Ministry of Health, 2002
 
36.Franklin CL, Young D, Zimmerman M: Psychiatric patients’ vulnerability in the wake of September 11th terrorist attacks. J Nerv Ment Dis 2002; 190:833–888
 
37.Wunsch-Hitzig R, Plapinger J, Draper J, del Campo E: Calls for help after September 11: a community mental health hot line. J Urban Health 2002; 79:417–428
 
38.Kohn R, Saxena S, Saraceno B, Levav I: Treatment gap in mental health care. Bull World Health Org 2004; 82:858–866
 
39.Weiss MG, Saraceno B, Saxena S, van Ommeren M: Mental health in the aftermath of disasters: Consensus and controversy. J Nerv Ment Dis 2003; 191:611–615
 
40.Mental Health in Emergencies: Mental and Social Aspects of Populations Exposed to Extreme Stressors. Geneva, World Health Organization, 2003
 
 
Figure 1. First-Time Visits to Psychiatric Clinics by Adult Jerusalem Residents Before and During the Current Intifadaa

aDashed vertical lines present months with the most salient terrorist attacks. Observed represents raw data. Predicted represents data predicted by the full model. Smoothed represents values smoothed over 1-year period.

 
Figure 2. Visits to Primary Care Practitioners by Adult Jerusalem Residents Before and During the Current Intifadaa

aDashed vertical lines present months with the most salient terrorist attacks. Observed represents raw data. Predicted represents data predicted by the full model. Smoothed represents values smoothed over 1-year period.

 
Figure 3. Ambulance Calls to Households for Jerusalem Residents Before and During the Current Intifadaa

aDashed vertical lines present months with the most salient terrorist attacks. Observed represents raw data. Predicted represents data predicted by the full model. Smoothed represents values smoothed over 1-year period.

Figure 1. First-Time Visits to Psychiatric Clinics by Adult Jerusalem Residents Before and During the Current Intifadaa

aDashed vertical lines present months with the most salient terrorist attacks. Observed represents raw data. Predicted represents data predicted by the full model. Smoothed represents values smoothed over 1-year period.

Figure 2. Visits to Primary Care Practitioners by Adult Jerusalem Residents Before and During the Current Intifadaa

aDashed vertical lines present months with the most salient terrorist attacks. Observed represents raw data. Predicted represents data predicted by the full model. Smoothed represents values smoothed over 1-year period.

Figure 3. Ambulance Calls to Households for Jerusalem Residents Before and During the Current Intifadaa

aDashed vertical lines present months with the most salient terrorist attacks. Observed represents raw data. Predicted represents data predicted by the full model. Smoothed represents values smoothed over 1-year period.

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References

1.Human Rights Watch web site: www.hrs.org/reports/2002/isr-pa
 
2.Israel Ministry of Foreign Affairs web site: www.mfa.gov.il/mfa/home.asp. Accessibility verified October 2004
 
3.Salib E: Suicide terrorism: a case of folie a plusieurs? Br J Psychiatry 2003; 182:475–476
 
4.North CS, Nixon SJ, Shariat S, Mallonee S, McMillen JC, Spitznagel EL, Smith EM: Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA 1999; 282:755–762
 
5.Ochberg FM: Victims of terrorism. J Clin Psychiatry 1980; 41:73–74
 
6.Bleich A, Gelkopf M, Solomon Z: Exposure to terrorism, stress-related mental health symptoms, and coping behaviors among a nationally representative sample in Israel. JAMA 2003; 290:612–620
 
7.Dohrenwend BP: The role of adversity and stress in psychopathology: some evidence and its implications for theory and research. J Health Soc Behav 2000; 41:1–19
 
8.Curran PS: Psychiatric aspects of terrorist violence: Northern Ireland 1969–1988. Br J Psychiatry 1988; 153:470–475
 
9.Curran PS, Miller PW: Psychiatric implications of chronic civilian strife or war: Northern Ireland. Adv Psych Treatment 2001; 7:73–80
 
10.de Jong JTVM, Komproe IH, Van Ommeren M, El Masri M, Araya M, Khaled van de Put W, Somasundaram D: Lifetime events and posttraumatic stress disorder in four post-conflict settings. JAMA 2001; 286:555–562
 
11.Summerfield D: War and mental health: a brief overview. Lancet 2000; 321:232–235
 
12.Schlenger WE, Caddell JM, Ebert L, Jordan BK, Rourke KM, Wilson D, Thalji L, Dennis JM, Fairbank JA, Kulka RA: Psychological reactions to terrorist attacks: findings from the National Study of Americans’ Reactions to September 11. JAMA 2002; 288:581–588
 
13.Silver RC, Holman EA, McIntosh DN, Poulin M, Gil-Rivas V: Nationwide longitudinal study of psychological responses to September 11. JAMA 2002; 288:1235–1244
 
14.Galea S, Ahern J, Resnick H, Kilpatrick, Bucuvalas M, Gold J, Vlahov D: Psychological sequelae of the September 11 terrorist attacks in New York City. N Engl J Med 2002; 346:982–987
 
15.DeLisi LE, Maurizio A, Yost M, Papparozzi CF, Fulchino C, Katz CL, Altesman J, Biel M, Lee J, Stevens P: A survey of New Yorkers after the Sept 11, 2001, terrorist attacks. Am J Psychiatry 2003; 160:780–783
 
16.Schuster MA, Stein BD, Jaycox L, Collins RL, Marshall GN, Elliot MN, Zhou AJ, Kanouse DE, Morrison JL, Berry SH: A national survey of stress reactions after the September 11, 2001 terrorist attacks. N Engl J Med 2001; 345:1507–1512
 
17.Stecklov G, Goldstein JR: Terror attacks influence driving behavior in Israel. Proc Natl Acad Sci USA 2004; 101:14551–14556
 
18.Simeon D, Greenberg J, Knutelska M, Schmeidler J, Hollander E: Peritraumatic reactions associated with the World Trade Center disaster Am J Psychiatry 2003; 160:1702–1705
 
19.Norris FH, Friedman MJ, Watson PJ, Byrne CM, Diaz E, Kaniasty K. 60,000 disaster victims speak, part I: an empirical review of the empirical literature, 1981–2001. Psychiatry 2002; 65:207–239
 
20.Kark JD, Goldman S, Epstein L: Iraqi missile attacks on Israel: the association of mortality with a life-threatening stressor. JAMA 1995; 273:1208–1210
 
21.Soskolne V, Baras M, Palti H, Epstein L: Exposure to missile attacks: the impact of the Persian Gulf War on physical health behaviors and psychological distress in high and low risk areas in Israel. Soc Sci Med 1996; 42:1039–1047
 
22.Solomon Z, Prager E: Elderly Israeli Holocaust survivors during the Persian Gulf War: a study of psychological distress. Am J Psychiatry 1992; 149:1707–1710
 
23.Nakar S, Kahan E, Nir T, Weingarten MA: The influence of SCUD missile attacks on the utilization of ambulatory services in a family practice. Med Confl Surviv 1996; 12:149–153
 
24.Weizman R, Laor N, Barber Y, Selman A, Schujovizky A, Wolmer L, Laron Z, Gil-Ad I: Impact of the Gulf War on the anxiety, cortisol, and growth hormone levels of Israeli civilians. Am J Psychiatry 1994; 151:71–75
 
25.Boscarino JA, Galea S, Ahern J, Resnik H, Vlahov D: Utilization of mental health services following the September 11th terrorists attacks in Manhattan, New York City. Int J Emerg Ment Health 2002; 4:143–145
 
26.Boscarino JA, Galea S, Ahern J, Resnick H, Vlahov D: Psychiatric medication use among Manhattan residents following the World Trade Center disaster. J Trauma Stress 2003; 16:301–306
 
27.McCarter L, Goldman W: Use of psychotropics in two employee groups directly affected by the events of September 11. Psychiatr Serv 2002; 53:1366–1368
 
28.Druss BG, Marcus SC: Use of psychotropic medications before and after Sept 11, 2001. Am J Psychiatry 2004; 161:1377–1383
 
29.Hoge CW, Pavlin JA, Milliken CS: Psychological sequelae of September 11. N Engl J Med 2002; 347:443–445
 
30.Rosenheck R: Reactions to the events of September 11. N Engl J Med 2002; 346:629–630
 
31.Rosenheck R, Fontana A: Use of mental health services by veterans with PTSD after the terrorist attacks of September 11. Am J Psychiatry 2003; 160:1684–1690
 
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