Abstract
This study assessed the role financial and environmental factors have in determining psychiatric consequences following non-lethal motor vehicle accidents (MVA). Participants were grouped into urban (n=100) and kibbutz (n=100) cohorts, and interviewed using the Impact of Events Scale, Symptoms Checklist, Somatoform Disorder questionnaires, and patient adjustment score. Patient socioeconomic state, education, job, leisure time, and litigation process were evaluated. Subjects’ medical and mental state was also obtained. Only 1 patient from the kibbutz group claimed compensation compared to 88 in the urban cohort. Kibbutz patients developed less psychiatric morbidity, fewer somatic complaints, revealed better adjustment, and took significantly less time off work compared to urban victims. The kibbutz lacks the need for financial reimbursement because of its effective supportive system. We suggest that financial concerns as well as environmental factors might play a pivotal role determining psychiatric morbidity and course, adjustment disturbances, and physical symptoms following MVAs.

Introduction
Motor vehicle accidents (MVAs) are common traumatic events and a major cause of morbidity and mortality in people under the age of 30 in the western world (Mayou, Bryant, & Duthie, 1993; Ursano, Fullerton, Epstein, & Crowley, 1999), and a total of 3.5 million individuals in the United States alone (Blanchard, Hickling, Taylor, & Loos, 1995). The ensuing effects of MVAs may be chronic disabling and even catastrophic, and the cost of patient care and rehabilitation is considered an economic burden (Mayou et al., 1993; Ursano et al., 1999, Blanchard et al., 1995; Corns, 1992). In addition to the potentially severe physical injury, MVAs are associated with development of psychiatric morbidity - in itself an issue of great interest and clinical relevance (Mayou et al., 1993; Blanchard et al., 1995; Blaszczynski et al., 1998).
Previous studies have shown that victims of MVAs, even those suffering from non-disabling impairment (e.g., neither significant physical injury nor concussion) may exhibit significant psychiatric morbidity (Blanchard et al., 1996; Hickling, Blanchard, Silverman, & Schwarz, 1992; Mayou, Tyndel, & Bryant, 1996; Mayou & Bryant, 2001; Mayou & Bryant 2002), such as, psychological symptoms, adjustment disturbances (e.g. psychosocial and functional), and somatic symptoms; pain being the most common.
Despite the abundance of studies attempting to define and characterize the clinical presentation of MVA victims, no consistent profile has emerged thus far (Blanchard et al. 1995; Hickling et al., 1992; Mayou et al., 1996; Bryant, Mayou, & Lloyd-Bostock, 1997; Blanchard et al., 1995; Bryant & Harvey, 1995; Malt, 1988). For example, the incidence of post-traumatic stress disorder (PTSD) following MVAs is estimated between 1% and 100% (Blanchard et al., 1995). Such variability in the nature and severity of psychiatric consequences may be due, in part, to methodological differences among the studies (Blaszczynski et al., 1998). Nonetheless, it is agreed that acute distress, mood and anxiety disorders, PTSD, travel anxiety, drug dependence, and psychosomatic complaints are among the most commonly observed psychiatric manifestations in MVA victims (Mayou et al., 1993; Blanchard et al., 1995; Blaszczynski et al., 1998).
Several environmental factors contribute to the psychiatric morbidity and course of MVA victims. Of these, compensation is considered pivotal, given the potential impact of litigation on both motivation and magnification of symptoms (Blaszczynski et al., 1998; Mayou et al., 1996; Mayou & Bryant, 2002).
In 1961 Miller first introduced the topic of “accident neurosis” stating that it is not a result of the accident per se but rather due to the possibility of compensation and the hope for financial gain (Miller, 1961). In Milers view, this condition is not encountered where the possibility of financial reimbursement does not exist or when a settlement with the insurance company has been finalized (Miller, 1961; Blanchard et al., 1998). However, the majority of subsequent researches on this topic, including empirical studies and reviews, disagree with Millers sweeping conclusions (Bryant et al., 1997; Blanchard et al., 1998; Mayou, 1996; Weighill, 1983).
For the lack of comparative studies that isolate environmental factors that may affect the course and outcome of post-MVA psychiatric morbidity, except few studies(Mayou et al., 1993; Blaszczynski et al., 1998; Blanchard et al., 1998; Mayou, 1996), we designed a cross-sectional study comparing MVA victims from an urban-setting with kibbutz residents from Northern Israel. it is well known the kibbutz (before process of privatization) differs from the urban setting in that it is void of personal gain following any litigation process (as all profits are divided equally amongst its residents) and that it contains a multi-disciplinary supportive system. Hence, comparison between these two populations was performed as a platform to assess the contribution of environmental factors to the degree of psychiatric morbidity and course, adjustment disturbances and physical somatoform disturbances following MVAs.

Methods
Participants
All subjects included in this study were randomly recruited from their primary-care clinic at which documentation of the accident had been performed. Referral was executed by the primary-care physician, after which written informed consent was obtained. Inclusion criteria included: 1. patients’ age between 18 and 65 years old; 2. Glasgow Coma Scale score above 13 at the time of the accident; 3. the ability to clearly comprehend all interview questions without the aid of an interpreter; 4. hospitalization, if at all, lasted less than 24 hours following the accident; 5. brain concussion, if at all, lasted less than 15 minutes; and 6. no severe physical injury occurred. Subsequently, a total of 200 volunteers (108 men and 92 women), who had undergone a non-serious MVA within the previous three years were included in this study. Patients meeting the criteria were asked to fill out structured questionnaires. Participants were grouped into urban (n=100) and kibbutz (n=100) cohorts. Subdivision into three categories was performed according to the period of time that had passed since the accident had occurred, namely 1-6 months, 6-24 months, and 24-36 months post-MVA.

Study Procedures
Study participants were evaluated during an interview that lasted up to 1 hour. The occurrence of PTSD following the accident was assessed using the Horowitz Impact of Events Scale (IES) as previously described (Horowitz, Wilner, & Alvarez, 1979). Analysis of subjects’ general psychiatric morbidity - specifically somatization, anxiety, depression, hostility, and phobic anxiety was performed using the Derogatis Symptoms Checklist (SCL-90). The respondents indicated their adjustment to work, leisure, personal and interpersonal relations, and economic status, before and after the accident on a 65-mm visual-analogue scale. This data was calculated as a percentage for comparison between groups. For assessment of the patients’ physical state following the accident, both subjects and their attending primary care physician or nurse were asked to fill out a Somatoform Disorder Questionnaire. Subjects indicated what specific physical symptoms (related to the accident) they suffered from (out of 19, 18, or 17 possibilities for pregnant women, non-pregnant women, and men, respectively) on a scale ranging from 0 (non-existent) to 4 (severe). The somatization index (range: 0 to 4) derived was calculated by dividing the total score by the number of relevant questions. The physician or nurse indicated the number of visits following the accident and up to the interview as well as an equivalent period of time prior to the MVA. Included in this analysis were all visits to the clinic, and not solely those that were judged by the physician to be related to the accident. In addition, the amount and type of treatment (related to the accident) that the subject had received following the MVA were assessed. While filling out the IES, SCL-90, adjustment and somatization forms, responders were asked to describe their current physical and mental state (related to the accident), i.e., around the time the interview was carried out. In addition, questions were asked about the respondents’ life prior to and after the accident, their socioeconomic situation, education, job, leisure time and insurance. Finally, subjects were asked to disclose information regarding any litigation process underway as a consequence of the accident.

Statistical Analysis
Data analysis was performed using the SPSS package. The relationships between categorical variables were examined using the ?2 test. Continuous variables were analyzed using the Student’s t-Test. Non-parametric variables were analyzed using either the Mann-Whitney test, or the Kruskal-Wallis test when comparing more than two groups. For related samples we utilized the Wilcoxon Signed Ranks test. Statistical significance was accepted for p<0.05.

Results
Characteristics of the Study Populations
Subjects’ age ranged from 18 to 65 years, with a mean age of 44.38 (SD=12.52) among kibbutz victims and 41.19 (SD=12.97) among urban victims (t=1.77, df=178, p=0.08). Likewise, sex distribution was similar between the kibbutz (56 male and 44 female patients) and urban (52 male and 48 women patients) populations (?2=0.32, df=1, p=0.57). Both groups displayed similarity regarding education level (kibbutz: 12.92 years (SD=1.79); urban: 12.78 years (SD=3.28), t=0.39, df=198, p=0.69). The number of subjects who were housewives was 1 and 8 in the kibbutz and urban populations, respectively. The number of subjects who were students was 13 and 7 in the kibbutz and urban populations, respectively. Thus, a significant difference between the numbers of working subjects in these groups (91% and 80%, respectively, ?2=11.06, df=2, p=0.004) was observed.
In the kibbutz group 63 patients were car drivers, 31 were passengers, 2 were pedestrians, and 4 were motorcyclists. The dispersion in the urban group was 66 patients were car drivers, 27 was passengers, 4 were pedestrians, 1 was a bus passenger, and 2 were motorcyclists (?2=2.68, df=4, p=0.61).
Only 1 patient from a kibbutz claimed compensation as opposed to 88 in the urban group. Of the 91 kibbutz patients who had worked prior to the accident, 89 of 91 patients (97.80%) returned to work within a one-month of the accident compared to 53 out of 80 patients (66.25%) in the urban study group (?2=30.1, df=1, p<0.0001). Of those returning to work in the kibbutz population, 73% (65 out of 89 patients) did not lose a single workday, as opposed to 37.8% of their urban counterparts (20 out of 53 patients), ?2=17.22, df=1, p<0.0001.

Level of Distress
Table 1 summarizes the level of distress (IES analysis) in both study groups indicating a significantly lower level of post-traumatic anxiety in the kibbutz population. Subdivision according to the time that has passed since the accident revealed two discrete disease patterns as shown in Table 2. A lower distress level amongst kibbutz patients was demonstrated throughout all different time intervals when compared to the urban population. Moreover, time did prove to be a factor among the urban participants as the subgroups farthest away from the time of accident exhibited significantly lower distress levels. 





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