Health problems presented in general practice by survivors before and after a fireworks disaster: Associations with mental health care

Abstract

Objective. To study the health problems presented to general practitioners by disaster survivors who received specialized ambulatory mental health care. Design. (Longitudinal) case-control study based on general practitioners’ electronic medical records. Setting. General practice and a mental health institution (MHI) in Enschede, the Netherlands. Subjects. A total of 728 adult disaster survivors who were registered in 30 study practices and had attended a specialized mental health institution (MHI group), and 728 practice-matched controls. Main outcome measures. Attendance rates in general practice before and after the disaster; health problems presented to the GP, classified according to the International Classification of Primary Care. Results. Disaster survivors in the MHI group reported higher GP attendance rates pre- and post-disaster and more health problems than controls. In the year post-disaster, the MHI group reported an increase in psychological, medically unexplained physical symptoms (MUPS), gastrointestinal and musculoskeletal problems, compared with the year pre-disaster. Controls, survivors themselves, showed also an increase in psychological problems in the year post-disaster compared with the year pre-disaster. Conclusion. General practitioners should be aware of an increase in consultations and health problems among patients who also receive mental health care following a disaster. The services of GP and mental health care professionals should be integrated when supporting disaster victims. Information on severity of exposure to disasters should be included in disaster databases.

• Disasters
• general practitioner
• mental health services
• longitudinal studies

Disasters can strike at any time and place and can affect health in many ways. Research on the long-term health consequences of disasters has demonstrated increased physical symptoms and mental health problems [1–6]. It is also known that disaster victims report increased use of medical and mental health services following disasters [7–11]. However, studies on utilization are often limited to patients visiting just one health care provider. To our knowledge, no publications have focused on patients visiting both their general practitioners (GPs) and mental health services, following disasters. Knowledge of the health problems presented in general practice by this specific group is important for a better understanding of the development of health problems in survivors with psychological problems. Furthermore, studies of long-term health problems following disasters in which prior data had been collected in a similar way and were available for study are rare [12].

The aim of this study was to explore health care utilization and health problems presented to GPs by all adult disaster survivors who were also receiving mental health care in an ambulatory mental health institution (MHI) and to compare their health problems with those of survivors not receiving this care.

This study was based on the disaster that took place on 13 May 2000 in the city of Enschede, a city of approximately 150,000 inhabitants in the east of the Netherlands. A firework depot exploded and destroyed a large part of a multicultural neighbourhood. As a result, 22 people were killed, about 1000 were injured and 1200 lost their homes [13].

Material and methods

Subjects and procedures

During a 2-year period, from 13 May 2000 (the day of the disaster) to 12 May 2002, all survivors receiving mental health care in a local MHI were registered (MHI patients). This MHI had specially been set up for survivors of the ‘Enschede fireworks disaster’. Various types of treatment were offered (e.g. cognitive behavioural therapy, eye movement desensitization and reprocessing, prevention, support, crisis intervention). This was the first time in the Netherlands that a specialized MHI had been set up exclusively for victims of disasters.

After the disaster, a longitudinal monitoring study was started using the electronic medical records of local GPs with whom the victims were registered (obligatory in the Netherlands to be registered with just one GP). Forty GPs participated (three-quarters of the GPs in the area) and together they cared for 89% of all victims (n = 8250). All data on health problems from one year pre-disaster until two years post-disaster were extracted from the electronic medical records in an anonymized format [14]. For this study, the MHI database and the GP database were integrated. A search through 980 MHI patients (of 17 years and older) in GP records identified 728 (74%) who were registered with participating GPs throughout the study period (MHI group). Thus 8.8% (728/8250) of known survivors registered in study practices attended the MHI.

A control group of disaster survivors (n = 728) was constructed from the patients registered with the GPs in the same period, but who did not visit the MHI. This group was matched for gender, age, ethnicity, and loss of housing due to the explosion, because these variables were considered likely to influence morbidity. The involvement of survivors in the disaster was checked against an officially maintained register of survivors (n = 12,956) in which all MHI patients appeared to be included. Data collection was performed in accordance with the privacy protection procedures of the Dutch Data Protection Authority [14].

Measures

The electronic registration system in general practice distinguishes four phases of the consultation process, i.e. the patient's symptoms, examination, diagnosis (or evaluation), and treatment (or plan). For this study, symptoms and diagnoses were used and classified according to the International Classification of Primary Care (ICPC). The ICPC has been used extensively as an epidemiologic tool for the description of general practice in countries all over the world [15–17].

Clusters of ICPC codes were generated according to the type of health problem (e.g. psychological, respiratory, musculoskeletal). Two additional clusters were constructed: medically unexplained physical symptoms (MUPS) and chronic diseases [14]. MUPS are somatic symptoms (tiredness, headache, nausea, abdominal pain) recorded without a diagnosis made by the GP. The clusters MUPS and chronic diseases are not exclusive; a patient could be reported with symptoms in one or more clusters [14]. A list containing the ICPC codes and clusters can be obtained from the authors.

Statistical analyses

Three time periods were constructed:

1. one year pre-disaster (13 May 1999–12 May 2000);

2. first year post-disaster (13 May 2000–12 May 2001);

3. second year post-disaster (13 May 2001–12 May 2002).

The prevalence rates of the seven most frequently reported clusters were calculated. For comparisons of reported health problems in MHI and control groups, chi-squared analyses were used. T-tests were used to examine differences in attendance rates in the general practices. Logistic regression was performed to examine increased health problems.

For comparison within groups, McNemar tests (two related samples) were conducted to study differences in health problems and paired t-tests to study differences in attendance rates.

Results

Attendance rates in general practice

The demographic characteristics of the MHI-group are summarized in Table I. During the 2 years post-disaster, annual GP attendance rates increased in the MHI group, compared with the year pre-disaster (Table II). The control group (also disaster survivors) did not attend their GPs more often in the first and second years after the disaster. The MHI group showed a higher mean rate of GP attendance than controls in the year pre-disaster.

Table I.  Demographic characteristics of survivors who attended a specialized mental health institution (MHI) and non-attenders (control group).

	MHI (n = 728)	Controls (n = 728)
Mean age (SD) in years	39.6 (13.7)	39.8 (14.0)
Male/female	347 (48%)/381 (52%)	346 (48%)/382 (52%)
Lost home	242 (33%)	242 (33%)
Dutch origin	449 (62%)	449 (62%)

Table II.  Mean number of GP contacts pre- and post-disaster of patients who attended a specialized mental health institution (MHI) and non-attenders (control group).

	MHI		Controls
Time	Mean	SD	Mean	SD	p-value^1
One year pre-disaster	6.3	7.0	4.6	5.8	0.000^1
First year post-disaster	8.6^2	8.4	4.8	5.7	0.000^1
Second year post-disaster	8.2^2	8.4	4.8	6.3	0.000^1

¹Significant difference between groups within periods; ²significant difference from one year pre-disaster within groups (p < 0.001).

Health problems in general practice

The health problems presented to the GP differed between MHI and control groups (Table III). In the pre-disaster year, the MHI group presented more somatic problems (MUPS, chronic, musculoskeletal) and more psychological problems than the control group. During the first year post-disaster, the MHI group reported increased somatic (MUPS, musculoskeletal, gastrointestinal) and psychological problems. They reported a greater increase in the first year post-disaster of psychological, MUPS, and gastrointestinal problems than those reported by controls. They did not show any changes in respiratory problems in the first year post-disaster, whereas the control group reported a decrease. Two years after the disaster, the MHI group showed a greater increase in psychological problems, compared with the situation pre-disaster and compared with the control group.

Table III.  The seven most prevalent health problems (in clusters), per 100, presented to the general practitioner pre- and post-disaster in MHI and control groups.

	MHI (n = 728)						Controls (n = 728)
Cluster of symptoms and diseases	One year Pre-disaster		First year post-disaster		Second year post-disaster		One year Pre-disaster		First year post-disaster		Second year post-disaster
	%	n	%	n	%	n	%	n	%	n	%	n
MUPS	53.7^2	391	61.7^1,2	449	59.5^1,2	433	44.5^2	234	41.6^2	303	45.1^2	328
Chronic	37.8^2	275	36.1^2	263	45.6^1,2	332	28.2^2	205	28.3^2	206	33.0^2	240
Psychological	24.6^2	179	70.7^1,2	515	57.7^1,2	420	15.1^2	110	35.4^1,2	258	23.6^1,2	172
Musculoskeletal	32.6^2	237	39.0^1,2	284	34.5^2	251	23.5^2	171	24.7^2	180	26.6^2	194
Gastrointestinal	19.0	138	24.0^1,2	175	19.8	144	15.8	115	14.7^2	107	15.0	109
Respiratory	19.8	144	20.1^2	146	22.4^2	163	18.3	133	12.6^1,2	92	15.8^2	115
Skin	19.2	140	18.8	137	20.9^2	152	15.0	109	14.1	103	12.9^2	94

*MHI = mental health institution; MUPS = medically unexplained physical symptoms; ¹statistically significant differences from 1 year pre-disaster within groups (χ²; p < 0.01); ²statistically significant differences between groups within periods (χ²; p < 0.01).

Discussion

Statement of principal findings

This longitudinal (case-control) study measured health problems presented in general practice by two groups of disaster survivors according to their use of mental health care services. Those receiving mental health care services reported higher annual GP attendance rates than the control group of survivors, both before and after the disaster. In the year pre-disaster, the MHI group presented relatively more health problems to their GPs than the controls. Therefore, the results show that patients seeking mental health care following the disaster were already vulnerable prior to it. Furthermore, more psychological, MUPS, gastrointestinal and musculoskeletal problems were presented by these patients post-disaster than pre-disaster. The control group contained disaster survivors who, as an effect of the disaster, also presented more psychological problems in the 2 years post-disaster than in the year pre-disaster. However, controls did not show an increase in GP attendance rate after the disaster. Over all periods, the MHI group presented more health problems than controls.

The increased prevalence of psychological problems in the MHI group post-disaster may be partly a consequence of discussing treatment at the MHI with their GP resulting in an increased likelihood of coding psychological problems in the registration system. In addition, it is possible that counselling at the MHI might have led them more readily to accept their symptoms as having psychological origins and influence the way in which these were presented to the GP. It remains unclear whether MHI patients present more health problems and use more health care services as a result of greater exposure to the disaster. Detailed information on the extent of exposure to the more horrifying events was not available. However, both groups were matched on loss of housing and are similar in this respect.

Our finding that the MHI group had higher levels of GP attendance in the years following the disaster is consistent with previous research. Disasters are associated with psychological problems [1–3], [6] and psychological problems are related to frequent attendance [11], [18–21]. The MHI group presented more physical health problems as well as psychological problems before and after the disaster compared with controls. Previous studies following disasters have found that patients with psychiatric disorders (e.g. PTSD) have more somatic complaints than others [5], [22–25]. Our study has shown that control group survivors reported increased psychological problems but no increase in GP attendance rates post-disaster.

Strengths and weaknesses of the study

This is the first study to examine health problems presented in general practice by a traumatized population receiving mental health care from a separate agency. We relied in our study on physician-diagnosed symptoms to assess health problems. Although this approach reduces the problems associated with self-reporting (recall bias), it does not exclude GP reporting bias. Independent research has shown that most of the self-reported symptoms after a disaster have also been reported to a GP [26]. The use of electronic registration systems as an alternative to self-reported symptoms minimizes the recording burden for victims, which may be particularly important for information regarding stressful events. Our study was unique in having pre-disaster data and it has added important knowledge on the evolution of health problems and health care utilization among victims. At least some of the differences between MHI and control groups post-disaster can be explained by differences existing pre-disaster.

We were not able to include data on the trauma history of victims and the degree of direct exposure to the disaster. Former research showed that direct exposure is predictive of post-disaster symptoms [6]. Identifying an individual's trauma exposure history is also important because of the serious psychosocial impairment associated with PTSD that can develop over time [27]. In future disaster management plans we would recommend that any official registration procedure might include information on these points.

The control group consisted of survivors who did not seek help for their psychological problems at the MHI. Although the majority of survivors are believed to have contacted the MHI for professional mental health care, some who may have sought help elsewhere (e.g. from religious groups, private psychiatrists, or occupational health counselling services) are not considered in this analysis though we have no reason to think this would bias the comparison between MHI and control groups.

Significance of the study

This study shows that patients attending the MHI were already vulnerable prior to the disaster. Further research should focus on the risk factors associated with increased health problems post-disaster for patients visiting both GPs and mental health care professionals. General practitioners need to be alert to increased attendance for both somatic and psychological health problems in persons receiving mental health care as a service specifically provided for assisting victims of disasters. General practitioners and specialized MHI are both important supports for disaster victims and their services should optimally be provided in collaboration and not independently.

Key Points

There is little knowledge about the health problems presented to general practitioners by survivors of disaster, especially in relation to mental health care.

• Survivors who have chosen to receive mental health care post-disaster were already more vulnerable pre-disaster.

• Survivors who have chosen to receive mental health care post-disaster showed increased psychological and somatic problems to their GPs in the year post-disaster.

The authors gratefully acknowledge the support of the staff of the Mediant institute for mental health in Enschede and all participating general practitioners and psychotherapists. They would like to thank Dr Douglas Fleming of the Birmingham Research Unit of the Royal College of General Practitioners for valuable comments on an earlier version of this article. This research project has received a grant from the Ministry of Public Health, Welfare and Sports in the Netherlands.