The longitudinal course of PTSD among disaster workers deployed to the World Trade Center following the attacks of September 11th

World Trade Center responders in their own words: predicting PTSD symptom trajectories with AI-based language analyses of interviews

BACKGROUND

Oral histories from 9/11 responders to the World Trade Center (WTC) attacks provide rich narratives about distress and resilience. Artificial Intelligence (AI) models promise to detect psychopathology in natural language, but they have been evaluated primarily in non-clinical settings using social media. This study sought to test the ability of AI-based language assessments to predict PTSD symptom trajectories among responders.

METHODS

Participants were 124 responders whose health was monitored at the Stony Brook WTC Health and Wellness Program who completed oral history interviews about their initial WTC experiences. PTSD symptom severity was measured longitudinally using the PTSD Checklist (PCL) for up to 7 years post-interview. AI-based indicators were computed for depression, anxiety, neuroticism, and extraversion along with dictionary-based measures of linguistic and interpersonal style. Linear regression and multilevel models estimated associations of AI indicators with concurrent and subsequent PTSD symptom severity (significance adjusted by false discovery rate).

RESULTS

Cross-sectionally, greater depressive language (β = 0.32; p = 0.049) and first-person singular usage (β = 0.31; p = 0.049) were associated with increased symptom severity. Longitudinally, anxious language predicted future worsening in PCL scores (β = 0.30; p = 0.049), whereas first-person plural usage (β = -0.36; p = 0.014) and longer words usage (β = -0.35; p = 0.014) predicted improvement.

CONCLUSIONS

This is the first study to demonstrate the value of AI in understanding PTSD in a vulnerable population. Future studies should extend this application to other trauma exposures and to other demographic groups, especially under-represented minorities.

50 Years After Political Protest Violence, Posttraumatic Growth is Associated with PTSD and Anxiety but not Depression or Sleep Difficulties

Rates of, and relationships between, posttraumatic stress disorder (PTSD), depression, anxiety, and posttraumatic growth (PTG) decades after a single-incident trauma remain unclear. During a two-month period surrounding the 50th anniversary of the political protest violence at Kent State University on May 4, 1970, 132 individuals completed measures of PTG, PTSD, depression, anxiety, and sleep difficulties. Participants were, on average, 19 years old (SD = 3.01) on May 4, 1970, and 44% were present at the protests. 17% met cutoff scores consistent with PTG, 6% for PTSD, 8% for anxiety, 11% for depression and 20% for sleep difficulties. PTG was significantly and positively correlated with PTSD (r = .32, 95% CI: 0.17-0.44) and anxiety (r = .23, 95% CI: 0.08-0.38) but not depression or sleep difficulties after controlling for additional trauma exposure since May 4, 1970. All relationships were best explained by linear rather than curvilinear relationships and were not moderated by proximity to the events of May 4, 1970. Results indicate that clinicians working with survivors of trauma decades later may be able to capitalize on the adaptive functions of PTG to foster positive treatment outcomes.

The long-term impacts of the Canterbury earthquakes on the mental health of the Christchurch Health and Development Study cohort

OBJECTIVE

Long-term studies following disasters are rare. It is important to quantify long-term effects of disasters to determine impacts on populations over time. We therefore aim to report the long-term associations between exposure to the Canterbury earthquakes and common mental disorders, taking into account potential confounding factors.

METHODS

The Christchurch Health and Development Study is a 40-year longitudinal study of a birth cohort of New Zealand children (635 males and 630 females). The Christchurch Health and Development Study includes 884 participants with data on earthquake exposure and mental health outcomes at ages 34 and 40 years. Rates of Diagnostic and Statistical Manual of Mental Disorders (4th ed.) disorders were measured categorically and using an expanded definition that included sub-syndromal symptoms. The current impact of the earthquakes is reported using 12-month prevalence data 7 years after the earthquakes. The cumulative impact of the earthquakes over the 7 years since onset is also reported.

RESULTS

There was a linear trend towards increasing rates of disorder with increasing exposure to the earthquakes. After adjusting for covariates, the 12-month prevalence of anxiety disorder symptoms was significantly increased (p = 0.003). The earthquakes were also associated with cumulative increases in symptoms of post-traumatic stress disorder (p < 0.001), anxiety disorder (p = 0.016), nicotine dependence (p = 0.012), and the total number of disorders (p = 0.039).

CONCLUSION

The Canterbury earthquakes were associated with persistent increases in Anxiety Disorder symptoms 7 years after their onset. The earthquakes were also associated with cumulative increases in symptoms of common psychiatric disorders. The magnitude of these effects is small, may no longer be clinically significant and has decreased over time.

Surviving the storm: A pragmatic non-randomised examination of a brief intervention for disaster-affected health and social care providers

Disasters affect the well-being of individuals, families and communities. Health and social care providers are essential in response and recovery efforts and are among the most vulnerable to negative physical and mental health impacts of a disaster. Few evidence-based interventions are available to address the psychological needs of providers. The aim of this study was to examine the psychological distress of health and social care providers before and after participating in the brief group intervention, Resilience and Coping for the Healthcare Community (RCHC) and its expanded version, RCHC+. We conducted a pragmatic non-randomised cluster trial with 762 health and social care providers in south Texas and Puerto Rico post-Hurricanes Harvey and Maria. Participants completed surveys assessing post-traumatic stress (PTSD), anxiety, burnout and secondary traumatic stress (STS) prior to intervention delivery and at two time points post-intervention. We calculated the frequency of symptom cut-off scores at baseline, then estimated multilevel ordinal models to examine changes in symptoms across time. Prior to participation in the RCHC (approximately 12 months after the hurricanes), providers reported high levels of PTSD, anxiety and STS symptoms. After participation, providers in both intervention conditions reported a significant reduction in PTSD symptoms from baseline that was sustained over both time points. The likelihood of a reduction in symptoms of anxiety and STS from baseline was sustained at both time points for participants in the RCHC+ condition. These findings indicate that both the RCHC and RCHC+ interventions may reduce psychological distress for health and social care providers and could be an important part of advance planning to support provider's mental health during and after a disaster. Further examination of the RCHC in other disaster contexts could provide additional insight into the responsiveness of the intervention to reducing psychological distress symptoms.

The 50th anniversary of May 4, 1970 is associated with elevations of distress but no increase in mental health symptoms

Anniversaries of traumatic events are associated with increased symptoms of posttraumatic stress disorder (PTSD), depression, and anxiety, especially in individuals with prior mental health symptoms. However, research has largely focussed on 1-year anniversaries, and it is unclear whether symptom exacerbation persists for more distal, or milestone, anniversaries. Symptoms typically decrease over time after traumatic events, but major anniversaries may be associated with increases in mental health symptoms. During and 3 months after the 50th anniversary of the political protest violence at Kent State University on May 4, 1970, 115 individuals completed measures of PTSD, depression, anxiety, and anniversary-related stress. Participants reported greater stress (t(97) = 4.04 p ≤ .001) during the 50th anniversary compared to 3 months later, but there were no differences in total PTSD (t(114) = .65, p = .52) or depression/anxiety symptoms (all p's > .05). Even in higher-risk individuals (those who previously received mental health services), symptoms did not differ during versus after the anniversary. In general, long-term anniversaries may contribute to transient increases in distress but do not induce major changes in mental health symptoms.

The Relationship between 9/11 Exposure, Systemic Autoimmune Disease, and Post-Traumatic Stress Disorder: A Mediational Analysis

The relationship between 9/11 exposure, systemic autoimmune disease (SAD) and mental health remains poorly understood. This report builds on a prior analysis of World Trade Center Health Registry data to determine whether 9/11 exposure is associated with higher risk of SAD, and if so, whether post-traumatic stress disorder (PTSD) is a mediating factor and whether the association varies by responder/community member status. The final analytic sample comprised 41,656 enrollees with 123 cases of SAD diagnosed post 9/11 through November 2017. SAD diagnosis was ascertained from survey responses and confirmed by medical record review or physician survey. Logistic regression models were constructed to determine the relationship between 9/11 exposure and PTSD and SAD. Causal mediation analysis was used to determine the mediational effect of PTSD. Each analysis was stratified by 9/11 responder/community member status. Rheumatoid arthritis (n = 75) was the most frequent SAD, followed by Sjögren’s syndrome (n = 23), systemic lupus erythematosus (n = 20), myositis (n = 9), mixed connective tissue disease (n = 7), and scleroderma (n = 4). In the pooled cohort, those with 9/11-related PTSD had 1.85 times the odds (95% CI: 1.21–2.78) of SAD. Among responders, those with dust cloud exposure had almost twice the odds of SAD, while among community members, those with 9/11-related PTSD had 2.5 times the odds of SAD (95% CI: 1.39, 4.39). PTSD was not a significant mediator. Although emerging evidence suggests 9/11 exposure may be associated with SAD, more research is needed, particularly using pooled data sources from other 9/11-exposed cohorts, to fully characterize this relationship.

Understanding the Role of Persistent Organic Pollutants and Stress in the Association between Proximity to the World Trade Center Disaster and Birth Outcomes

Fetal growth is affected by exposure to both prenatal stress and environmental contaminants. The attacks on the World Trade Center (WTC) resulted in exposure to chemicals and psychological stress amongst New York City residents. We measured prenatal maternal stress and exposure to persistent organic pollutants (polybrominated diphenyl ethers, polychlorinated biphenyls, and polychlorinated dibenzo-p-dioxins (PCDDs)) in 108 participants from a Columbia University WTC birth cohort. Principal component (PC) analyses were conducted to characterize the mixture of exposure to the three groups of chemicals. We evaluated the associations between geographical exposures (proximity to the WTC disaster) and both chemical exposures (PCs) and stress (demoralization). We then evaluated the effect these exposures (PCs and stress) had on previously reported associations between geographical WTC exposure and birth outcomes (birth weight and birth length) in this study population to understand their individual roles in the observed associations. Geographical exposure via proximity to the WTC was associated with the PC reflecting higher PCDD exposure (PC3) (β = 0.60, 95% CI: 0.03, 1.18 for living/working within 2 miles of the WTC; and β = 0.73, 95% CI = 0.08, 1.38 for living within 2 miles of WTC). Previously reported reductions in birth weight and length associated with WTC proximity (β = −215.2, 95% CI: −416.2, −14.3 and β = −1.47, 95% CI: −2.6, −0.34, respectively) were attenuated and no longer significant for birth weight (β = −156.4, 95% CI: −358.2, 45.4) after adjusting for PC3, suggesting that PCDDs may act as partial mediators in this previously observed association. The results of this study can help focus future research on the long-term health effects of these prenatally exposed populations.

What work-related exposures are associated with post-traumatic stress disorder? A systematic review with meta-analysis

OBJECTIVES

Although there is evidence that work-related exposures cause post-traumatic stress disorder (PTSD), there are few quantitative studies assessing the degree to which these factors contribute to PTSD. This systematic review with meta-analysis identified work-related exposures associated with PTSD, and quantified their contribution to this disorder.

METHODS

We searched Medline, PsycINFO, Embase, PILOTS and Web of Science (2005-10 September 2019) for longitudinal studies on work-related exposures and PTSD. We described included articles, and conducted meta-analyses for exposures with sufficient homogeneous information. We performed subgroup analyses for risk of bias, study design and PTSD ascertainment. We assessed evidence quality using Grades of Recommendations, Assessment, Development and Evaluation, and estimated population attributable fractions.

RESULTS

After screening 8590 records, we selected 33 studies (n=5 719 236). From what was moderate quality evidence at best, we identified various work-related exposures that were associated with PTSD, mainly involving individuals in the military and first responder (eg, police or fire brigade) occupations. These exposures included the number of army deployments (OR: 1.15 (95% CI 1.14 to 1.16)), combat exposure (OR 1.89 (95% CI 1.46 to 2.45)), army deployment (OR 1.79 (95% CI 1.45 to 2.21)) and confrontation with death (OR 1.63 (95% CI 1.41 to 1.90)). Effects were robust across subgroups and exposures attributed modestly (7%-34%) to PTSD. We identified additional exposures in other occupations, including life threats, being present during an attack, and hearing about a colleague's trauma.

CONCLUSIONS

We identified various work-related exposures associated with PTSD and quantified their contribution. While exposure assessment, PTSD ascertainment and inconsistency may have biased our findings, our data are of importance for development of preventive interventions and occupational health guidelines.

Received Social Support and Post-Traumatic Stress Symptoms in New Zealand and Philippine Emergency Responders

Introduction: Emergency responders are at risk of post-traumatic stress symptoms (PTSS). This study investigates the relationship between the different components of received social support (RSS) and PTSS in these occupations.

Method: This cross-sectional study involved emergency responders from New Zealand and the Philippines (n=223). Participants answered an online questionnaire measuring social support and PTSS.

Results: High amount of total received support was significantly associated with lower levels of PTSS. Analyses of RSS components revealed that co-worker, emotional, and tangible support exhibited salutary main effects on PTSS. Furthermore, high amounts of RSS from supervisors were found to be associated with low levels of PTSS only among participants who reported low trauma exposure.

Discussion: Findings were congruent with the main effects model of RSS. Results also underscored the importance of investigating varied manifestations of social support as they may differentially influence the strength of effects of receiving social support by emergency responders.

Development and Evaluation of a Screening Scale for Indirect Trauma Caused by Media Exposure to Social Disasters

As a result of mass media development, disaster-related information, such as the severity of damage, can be easily shared; thus, the issue of consequent indirect trauma has become as important as that of direct trauma. This study developed a scale to measure the degree of indirect trauma caused by media exposure to social disasters and then verified this scale’s reliability and validity. Initial items were developed through a literature review; 39 items were selected by examining their content validity and conducting a pretest. To verify the scale’s validity and reliability, exploratory factor analyses were conducted, and Cronbach’s alpha coefficients were calculated. The explanatory power of the screening scale developed through this study was 62.2%. The scale was ultimately composed of three factors comprising 24 items. Through exploratory factor analyses, factors were identified as “psychological, physical, and behavioral responses to social disasters” (factor 1), “moral resentment due to social disasters” (factor 2), and “a sense of threat to life due to social disasters” (factor 3). Regarding internal reliability, Cronbach’s alpha values ranged between 0.85 and 0.96. Future studies with expanded participant populations are suggested, which could further verify the scale’s validity and reliability and complement its shortcomings.

Assessment of Factors Associated With Long-term Posttraumatic Stress Symptoms Among 56 388 First Responders After the 2011 Great East Japan Earthquake

IMPORTANCE

First responders are at risk for developing symptoms of posttraumatic stress disorder (PTSD). Little is known about the risk factors for developing PTSD during a years-long period after complex mass disasters.

OBJECTIVE

To explore the long-term course of PTSD symptoms and to identify risk factors and their relative association with PTSD among first responders dispatched to the 2011 Japanese earthquake, tsunami, and nuclear disaster.

DESIGN, SETTING, AND PARTICIPANTS

This 6-year, large, prospective cohort study was part of a continuous longitudinal study of Japan Ground Self-Defense Force first responders. The data were collected at 1, 6, 12, 24, 36, 48, 60, and 72 months after mission completion from 2011 to 2017. Of approximately 70 000 eligible participants, 56 388 were enrolled in this study. Data were analyzed from 2017 to 2020.

EXPOSURES

Stress exposures owing to personal or professional disaster experience (eg, duties with body recovery or radiation exposure risk) and working conditions (eg, deployment length, postdeployment overtime work).

MAIN OUTCOMES AND MEASURES

The Impact of Event Scale-Revised score assessed PTSD symptoms; scores of at least 25 were defined as probable PTSD. Cox proportional hazards regression models assessed the risk factors for incidence of probable PTSD.

RESULTS

Among the 56 388 participants, 97.1% were men, and the median age at enrollment was 34 (range, 18-63) years. A probable PTSD rate was 2.7% at 1 month and showed a downward trend in the first year and a subsequent plateau. The cumulative incidence of probable PTSD was 6.75%. The severity of PTSD symptoms demonstrated a high degree of rank-order stability over time. Rather than professional disaster experience, sociodemographic factors and working conditions were independently associated with the incidence of probable PTSD: personal experience of the disaster (hazard ratio [HR], 1.96; 95% CI, 1.72-2.24), deployment length of at least 3 months (HR vs <1 month, 1.75; 95% CI, 1.52-2.02), increased age (HR for ≥46 vs ≤25 years, 2.28; 95% CI, 1.79-2.92), and postdeployment overtime work of at least 3 months (HR vs little to none, 1.61; 95% CI, 1.39-1.87).

CONCLUSIONS AND RELEVANCE

Given these findings, in the future, first responders' PTSD symptoms might be mitigated by shortening deployment length, avoiding postdeployment overtime work, and paying special attention to the needs of personnel with personal experience of the disaster or older age. Efforts to alleviate responders' initial symptoms will be required.

Occupational post-traumatic stress disorder: an updated systematic review

BACKGROUND

Although numerous studies on occupational post-traumatic stress disorder (PTSD) have been conducted prior to the 1950-2010 seminal systematic review by Skogstad et al., the prevalence, risk factors, and impact of this disorder following traumatic events in occupational settings remain unclear. This study aims to address this knowledge gap by reviewing the literature published after 2010.

METHODS

We reviewed literature from databases such as PubMed and Google Scholar using PRISMA guidelines to identify studies that address occupational PTSD and examined the status (prevalence or incidence), the risk factors, and the health effects of PTSD among workers.

RESULTS

In total, 123 articles were identified, and finally, 31 (25.2%) articles were selected after excluding duplicates. Various occupational traumatic physical events were reported such as natural or manmade disaster, explosion, accident, handling refugee corpses, or bullying at work. Risk of PTSD was closely associated with working conditions, severity of injury, history of mental disorder, occurrence of psychiatric symptoms at the time of the event, personality, interpersonal relationships, etc. Workers with PTSD were likely to experience a deterioration of physical and psychological health and impairment of social and occupational functioning.

CONCLUSIONS

Our review suggests that many workers remain highly vulnerable to occupational PTSD and its consequences.

Posttraumatic stress symptom courses in U.S. military veterans: A seven-year, nationally representative, prospective cohort study

The current study examined the nature and correlates of seven-year posttraumatic stress disorder (PTSD) symptom courses in a nationally representative, prospective cohort of U.S. military veterans. Data were analyzed from 2,307 trauma-exposed veterans who completed at least one follow-up assessment over a 7-year period, a subsample of n = 3,157 veterans who participated in the first wave of the National Health and Resilience in Veterans Study. Latent growth mixture modeling (LGMM) was used to identify PTSD symptom courses over four survey waves conducted in 2011, 2013, 2015, and 2018. Sociodemographic, health, and psychosocial variables were examined as potential correlates of symptomatic trajectories. PTSD symptoms were best characterized by three courses: No/Low (89.2%), Moderate Symptom (7.6%), and High Symptom (3.2%). Relative to the No/Low Symptom course, symptomatic courses were positively associated with a greater number of lifetime traumatic events, higher scores on measures of physical health difficulties and lifetime psychiatric history (relative risk ratio [RRR] range = 1.19-2.74), and were negatively associated with time since index trauma, household income, and social connectedness (RRR range = 0.14-0.97). Veterans in the Moderate Symptom course additionally had lower scores on a measure of protective psychosocial characteristics (RRR = 0.78) and were more likely to have received mental health treatment (RRR = 1.62), while those in the High PTSD Symptom course were more likely to be exposed to combat and to more traumas since Wave 1 (RRR range = 1.23-4.63). Three PTSD symptom courses in U.S. veterans were identified, with more than 10% of veterans exhibiting a moderate or high symptom course. Prevention and treatment efforts targeting modifiable correlates, such as social connectedness, may help mitigate symptomatic PTSD symptom courses in this population.

Posttraumatic stress disorder symptoms and sleep in the daily lives of World Trade Center responders

Sleep disturbances are common in posttraumatic stress disorder (PTSD) and can have major impacts on workplace performance and functioning. Although effects between PTSD and sleep broadly have been documented, little work has tested their day-to-day temporal relationship particularly in those exposed to occupational trauma. The present study examined daily, bidirectional associations between PTSD symptoms and self-reported sleep duration and quality in World Trade Center (WTC) responders oversampled for PTSD. WTC responders (N = 202; 19.3% with current PTSD diagnosis) were recruited from the Long Island site of the WTC health program. Participants were administered the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; SCID; First, Spitzer, Gibbon, & Williams, 1997) and completed daily assessments of PTSD symptoms, sleep duration and sleep quality for 7 days. PTSD symptoms on a given day were prospectively associated with shorter sleep duration (β = -.13) and worse sleep quality (β = -.18) later that night. Reverse effects were also significant but smaller, with reduced sleep duration (not quality) predicting increased PTSD the next day (β = -.04). Effects of PTSD on sleep duration and quality were driven by numbing symptoms, whereas effects of sleep duration on PTSD were largely based on intrusion symptoms. PTSD symptoms and sleep have bidirectional associations that occur on a daily basis, representing potential targets to disrupt maintenance of each. Improving PTSD numbing symptoms may improve sleep, and increasing sleep duration may improve intrusion symptoms in individuals with exposure to work-related traumatic events. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Posttraumatic stress disorder in the short and medium term following the World Trade Center attack among Asian Americans

This study investigated patterns of probable posttraumatic stress disorder (PTSD) and their predictors among 2,431 Asian American and 31,455 non-Hispanic White World Trade Center (WTC) Registry participants 2-3 years and 5-6 years after the WTC attack. Participants were divided into four PTSD pattern groups: resilient, remitted, delayed onset, and chronic. Asians had a lower proportion in the resilient group (76.5% vs. 79.8%), a higher proportion in the chronic (8.6% vs. 7.4%) and remitted (5.9% vs. 3.4%) groups, and a similar proportion in the delayed onset group (about 9%) compared to Whites. In multinomial logistic regression analyses, disaster exposure, immigrant status, lower income, pre-attack depression/anxiety, and lower respiratory symptoms were associated with increased odds of chronic and delayed onset PTSD (vs. resilience) among both races. Education and employment were protective against chronic and delayed onset PTSD among Whites only. These results can inform targeted outreach efforts to enhance prevention and treatment for Asians affected by future events.

Posttraumatic Stress Disorder, Functional Impairment, and Subjective Distress in World Trade Center Disaster Workers

Posttraumatic stress disorder (PTSD) is associated with functional deficits, poor physical health, and diminished quality of life. Limited research has examined PTSD symptom clusters and their associations with functioning and distress among disaster recovery workers, a population at high risk for PTSD due to potential for repeated trauma. The purpose of this study was to investigate associations between overall PTSD severity, as well as PTSD symptom clusters, and social and occupational functioning and subjective distress in World Trade Center (WTC) disaster workers after the terrorist attacks on September 11, 2001 (9/11). Disaster workers deployed to the site of the attacks completed assessments at three time points over approximately 5 years post-9/11. Our sample consisted of participants who met criteria for PTSD or subthreshold PTSD at baseline (n = 514), 1-year (n = 289), and 2-year follow-up (n = 179). Adjusted linear regression indicated that Clinician Administered PTSD Scale (CAPS)-rated PTSD severity was positively associated with subjective distress, and deficits in social and occupational functioning, over time, CAPS Criterion F items; βs = .20 to .62, ps < .001. The reexperiencing and avoidance/numbing symptom clusters were associated with increased subjective distress, the avoidance/numbing and hyperarousal clusters were associated with deficits in social functioning, and the reexperiencing and hyperarousal clusters were associated with worse occupational functioning. These associations were consistent across the study period. Findings point to the importance of targeting PTSD symptom clusters associated with specific areas of functional impairment, with the goal of improving global outcomes.

9/11-related PTSD among highly exposed populations: a systematic review 15 years after the attack

BACKGROUND

The 11 September 2001 (9/11) attacks were unprecedented in magnitude and mental health impact. While a large body of research has emerged since the attacks, published reviews are few, and are limited by an emphasis on cross-sectional research, short time frame, and exclusion of treatment studies. Additionally, to date, there has been no systematic review of available longitudinal information as a unique data set. Consequently, knowledge regarding long-term trajectories of 9/11-related post-traumatic stress disorder (PTSD) among highly exposed populations, and whether available treatment approaches effectively address PTSD within the context of mass, man-made disaster, remains limited.

METHODS

The present review aimed to address these gaps using a systematic review of peer-reviewed reports from October 2001 to May 2016. Eligible reports were of longitudinal studies of PTSD among highly exposed populations. We identified 20 reports of 9/11-related PTSD, including 13 longitudinal prevalence studies and seven treatment studies.

RESULTS

Findings suggest a substantial burden of 9/11-related PTSD among those highly exposed to the attack, associated with a range of sociodemographic and back-ground factors, and characteristics of peri-event exposure. While most longitudinal studies show declining rates of prevalence of PTSD, studies of rescue/recovery workers have documented an increase over time. Treatment studies were few, and generally limited by methodological shortcomings, but support exposure-based therapies.

CONCLUSION

Future directions for research, treatment, and healthcare policy are discussed.

Brain-Derived Neurotropic Factor Val66Met Polymorphism and Posttraumatic Stress Disorder among Survivors of the 1998 Dongting Lake Flood in China

OBJECTIVE

This study mainly aimed to explore the association between brain-derived neurotropic factor (BDNF) Val66Met polymorphism and posttraumatic stress disorder (PTSD) among flood survivors in China.

METHODS

Individuals who experienced the 1998 Dongting Lake flood in Southeast Huarong, China, were enrolled in this study. Qualified health personnel carried out face-to-face interviews with participants. PTSD was identified using PTSD Checklist-Civilian version (PCL-C). Blood samples were collected from the participants to extract DNA for genotyping.

RESULTS

A total of 175 participants were enrolled in this study. The prevalence of PTSD among flood survivors at 17-year follow-up was 16.0% (28/175). Individuals with PTSD were more likely to be female, experience at least three flood-related stressors, experience at least three postflood stressors, and carry the Met than those without PTSD. Compared with Val/Val homozygotes, Met carriers had higher scores of PCL-C (mean ± standard error: 23.60 ± 7.23 versus 27.19 ± 9.48, P < 0.05). Multivariable logistic regression analysis indicated that Met carriers (aOR = 4.76, 95% CI = 1.02-22.15, P < 0.05) were more likely to develop PTSD than Val/Val homozygotes.

CONCLUSIONS

Met carriers for BDNF rs6265 are at higher risk of developing PTSD and also exhibit more severe PTSD symptoms than Val/Val homozygotes among flood survivors in China.

A Consensus-Driven Agenda for Emergency Medicine Firearm Injury Prevention Research

STUDY OBJECTIVE

To identify critical emergency medicine-focused firearm injury research questions and develop an evidence-based research agenda.

METHODS

National content experts were recruited to a technical advisory group for the American College of Emergency Physicians Research Committee. Nominal group technique was used to identify research questions by consensus. The technical advisory group decided to focus on 5 widely accepted categorizations of firearm injury. Subgroups conducted literature reviews on each topic and developed preliminary lists of emergency medicine-relevant research questions. In-person meetings and conference calls were held to iteratively refine the extensive list of research questions, following nominal group technique guidelines. Feedback from external stakeholders was reviewed and integrated.

RESULTS

Fifty-nine final emergency medicine-relevant research questions were identified, including questions that cut across all firearm injury topics and questions specific to self-directed violence (suicide and attempted suicide), intimate partner violence, peer (nonpartner) violence, mass violence, and unintentional ("accidental") injury. Some questions could be addressed through research conducted in emergency departments; others would require work in other settings.

CONCLUSION

The technical advisory group identified key emergency medicine-relevant firearm injury research questions. Emergency medicine-specific data are limited for most of these questions. Funders and researchers should consider increasing their attention to firearm injury prevention and control, particularly to the questions identified here and in other recently developed research agendas.

Why Does Disaster Recovery Work Influence Mental Health?: Pathways through Physical Health and Household Income

Disaster recovery work increases risk for mental health problems, yet the mechanisms underlying this association are unclear. We explored links from recovery work to post-traumatic stress (PTS), major depression (MD), and generalized anxiety disorder (GAD) symptoms through physical health symptoms and household income in the aftermath of the Deepwater Horizon oil spill. As part of the NIEHS GuLF STUDY, participants (N = 10,141) reported on cleanup work activities, spill-related physical health symptoms, and household income at baseline, and mental health symptoms an average of 14.69 weeks (SD = 16.79) thereafter. Cleanup work participation was associated with higher physical health symptoms, which in turn were associated with higher PTS, MD, and GAD symptoms. Similar pattern of results were found in models including workers only and investigating the influence of longer work duration and higher work-related oil exposure on mental health symptoms. In addition, longer worker duration and higher work-related oil exposure were associated with higher household income, which in turn was associated with lower MD and GAD symptoms. These findings suggest that physical health symptoms contribute to workers' risk for mental health symptoms, while higher household income, potentially from more extensive work, might mitigate risk.

A Systematic Review of the Literature on Posttraumatic Stress Disorder in Victims of Terrorist Attacks

This article was aimed at systematically reviewing the literature on posttraumatic stress disorder (PTSD) among victims of terrorist attacks. Electronic and hand searches of the literature identified 35 studies addressing PTSD prevalence based on validated diagnostic interviews. Overall, in the year after terrorist attacks, 33% to 39% of direct victims developed PTSD, whereas the percentage of indirect victims with PTSD was lower (4% in the affected community, 5%-6% among emergency, rescue, and recovery workers, and 17%-29% among relatives and friends of the injured or killed victims), but nonetheless above the prevalence in the general population. With the passing of time, a significant reduction of PTSD can be expected in the affected community and in the emergency and rescue personnel, but not in the injured victims, in the relatives and friends of the injured or killed victims, and in nontraditional, more vulnerable disaster workers. The implications of these results for the psychological treatment of terrorism victims are discussed.

DSM-IV post-traumatic stress disorder among World Trade Center responders 11-13 years after the disaster of 11 September 2001 (9/11)

BACKGROUND

Post-traumatic symptomatology is one of the signature effects of the pernicious exposures endured by responders to the World Trade Center (WTC) disaster of 11 September 2001 (9/11), but the long-term extent of diagnosed Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) post-traumatic stress disorder (PTSD) and its impact on quality of life are unknown. This study examines the extent of DSM-IV PTSD 11-13 years after the disaster in WTC responders, its symptom profiles and trajectories, and associations of active, remitted and partial PTSD with exposures, physical health and psychosocial well-being.

METHOD

Master's-level psychologists administered sections of the Structured Clinical Interview for DSM-IV and the Range of Impaired Functioning Tool to 3231 responders monitored at the Stony Brook University World Trade Center Health Program. The PTSD Checklist (PCL) and current medical symptoms were obtained at each visit.

RESULTS

In all, 9.7% had current, 7.9% remitted, and 5.9% partial WTC-PTSD. Among those with active PTSD, avoidance and hyperarousal symptoms were most commonly, and flashbacks least commonly, reported. Trajectories of symptom severity across monitoring visits showed a modestly increasing slope for active and decelerating slope for remitted PTSD. WTC exposures, especially death and human remains, were strongly associated with PTSD. After adjusting for exposure and critical risk factors, including hazardous drinking and co-morbid depression, PTSD was strongly associated with health and well-being, especially dissatisfaction with life.

CONCLUSIONS

This is the first study to demonstrate the extent and correlates of long-term DSM-IV PTSD among responders. Although most proved resilient, there remains a sizable subgroup in need of continued treatment in the second decade after 9/11.

Examining Minority Attrition Among Women in Longitudinal Trauma Research

Research suggests that racial and ethnic minorities are more likely to attrit from longitudinal trauma studies than non-Hispanic Whites. Yet, little is known about how the loss of minority participants influences longitudinal findings as well as internal and external validity of study findings. Thus, the present study examined the effects of race/ethnicity on attrition in a longitudinal trauma study of women (minority = 223, non-Hispanic White or majority = 459) exposed to a campus shooting. Survival analyses were used to compare the attrition rates of minority participants to majority participants and assess the extent to which race/ethnicity, among other variables, predicted attrition. Minority participants were more likely to attrit than majority participants, hazard ratio (HR) = 0.69, 95% CI [0.48, 0.99], even after adjusting for study variables. A main effect was also found for age, HR = 1.06, 95% CI [1.01, 1.12]. Race/ethnicity did not interact with other study variables to influence attrition. The findings underscored the importance of assessing the effects of attrition on longitudinal findings and external validity.

Healthy start: description of a safety net for perinatal support during disaster recovery

Publicly funded programs and safety net organizations have key roles during post disaster recovery to care for vulnerable populations, including pregnant women with low resources. The objective of this study was to compare the health of prenatal women who accessed the New Orleans Healthy Start program to those women who only used traditional prenatal care (PNC) during long-term recovery from the Hurricane Katrina disaster. During 2010-2012, this descriptive, cross-sectional study recruited 402 prenatal women (24-40 weeks) from prenatal clinics and classes. All women were enrolled in PNC, with 282 experiencing only traditional PNC, while 120 women added Healthy Start participation to their usual PNC. Measures were obtained to determine, past hurricane experience, hurricane recovery, perceptions of prenatal care, mental health, and birth outcomes. Women accessing Healthy Start-New Orleans were more socially "at risk" (younger, lower income, not living with a partner, African American), lived through more hurricane trauma, and had a higher incidence of depression (40 %) and post-traumatic stress disorder (PTSD) (15 %) than women in traditional PNC (29 % depression; 6.1 % PTSD). Women using Healthy Start reported more mental health counseling and prenatal education than did women in only traditional PNC. Birth outcomes were similar in the two groups. The Healthy Start participants with less resources and more mental health difficulties after disaster, represented a more vulnerable population in need of additional support. This study underscores the necessity for community and governmental programs to develop disaster response plans that address needs of vulnerable populations during prolonged recovery.

World Trade Center disaster and sensitization to subsequent life stress: A longitudinal study of disaster responders

PURPOSE

The current study examined the role of World Trade Center (WTC) disaster exposure (hours spent working on the site, dust cloud exposure, and losing friend/loved one) in exacerbating the effects of post-disaster life stress on posttraumatic stress disorder (PTSD) symptoms and overall functioning among WTC responders.

METHOD

Participants were 18,896 responders (8466 police officers and 10,430 non-traditional responders) participating in the WTC Health Program who completed an initial examination between July, 2002 and April, 2010 and were reassessed an average of two years later.

RESULTS

Among police responders, there was a significant interaction, such that the effect of post-disaster life stress on later PTSD symptoms and overall functioning was stronger among police responders who had greater WTC disaster exposure (β's=.029 and .054, respectively, for PTSD symptoms and overall functioning). This moderating effect was absent in non-traditional responders. Across both groups, post-disaster life stress also consistently was related to the dependent variables in a more robust manner than WTC exposure.

DISCUSSION

The present findings suggest that WTC exposure may compound post-disaster life stress, thereby resulting in a more chronic course of PTSD symptoms and reduced functioning among police responders.

Trajectories of Scores on a Screening Instrument for PTSD Among World Trade Center Rescue, Recovery, and Clean-Up Workers

The longitudinal course of posttraumatic stress disorder (PTSD) over 8-9 years was examined among 16,488 rescue and recovery workers who responded to the events of September 11, 2001 (9/11) at the World Trade Center (WTC; New York, NY), and were enrolled in the World Trade Center Health Registry. Latent class growth analysis identified 5 groups of rescue and recovery workers with similar score trajectories at 3 administrations of the PTSD Checklist (PCL): low-stable (53.3%), moderate- stable (28.7%), moderate-increasing (6.4%), high-decreasing (7.7%), and high-stable (4.0%). Relative to the low-stable group, membership in higher risk groups was associated with 9/11-related exposures including duration of WTC work, with adjusted odds ratios ranging from 1.3 to 2.0, witnessing of horrific events (range = 1.3 to 2.1), being injured (range = 1.4 to 2.3), perceiving threat to life or safety (range = 2.2 to 5.2), bereavement (range = 1.6 to 4.8), and job loss due to 9/11 (range = 2.4 to 15.8). Within groups, higher PCL scores were associated with adverse social circumstances including lower social support, with B coefficients ranging from 0.2 to 0.6, divorce, separation, or widowhood (range = 0.4-0.7), and unemployment (range = 0.4-0.5). Given baseline, exposure-related, and contextual influences that affect divergent PTSD trajectories, screening for both PTSD and adverse circumstances should occur immediately, and at regular intervals postdisaster.

Leadership Opportunities for Mental Health Nurses in the Field of Disaster Preparation, Response, and Recovery

Disasters occur internationally and are nondiscriminatory. The loss resulting from the destruction associated with disasters leads to the development of various levels of psychological trauma in survivors. Health teams provide assistance to survivors before, during and after disasters, and mental health nurses make an important contribution to these teams. However, the leadership role of mental health nurses in disaster situations has not been extensively explored in the literature. This article discusses aspects of mental health nursing leadership in preparation for, response to and recovery from disasters. In particular, recommendations are made to enhance the leadership of mental health nurses in the context of disasters.

Post-disaster stressful life events and WTC-related posttraumatic stress, depressive symptoms, and overall functioning among responders to the World Trade Center disaster

BACKGROUND

The current study examined contributions of post-disaster stressful life events in relation to the maintenance of WTC-related posttraumatic stress, depressive symptoms, and overall functioning among rescue, recovery, and clean-up workers who responded to the September 11, 2001 World Trade Center (WTC) terrorist attacks.

METHODS

Participants were 18,896 WTC responders, including 8466 police officers and 10,430 non-traditional responders (85.8% male; 86.4% Caucasian; M(age) = 39.5, SD = 8.8) participating in the WTC Health Program who completed an initial examination between July, 2002 and April, 2010 and who were reassessed, on average, 2.5 years later.

RESULTS

Path analyses were conducted to evaluate contributions of life events to the maintenance of WTC-related posttraumatic stress, depressive symptoms, and overall functioning. These analyses were stratified by police and non-traditional responder groups and adjusted for age, sex, time from 9/11 to initial visit, WTC exposures (three WTC contextual exposures: co-worker, friend, or a relative died in the disaster; co-worker, friend, or a relative injured in the disaster; and responder was exposed to the dust cloud on 9/11), and interval from initial to first follow-up visit. In both groups, WTC-related posttraumatic stress, depressive symptoms, and overall functioning were stable over the follow-up period. WTC exposures were related to these three outcomes at the initial assessment. WTC-related posttraumatic stress, depressive symptoms, and overall functioning, at the initial assessment each predicted the occurrence of post-disaster stressful life events, as measured by Disaster Supplement of the Diagnostic Interview Schedule. Post-disaster stressful life events, in turn, were associated with subsequent mental health, indicating partial mediation of the stability of observed mental health.

CONCLUSIONS

The present findings suggest a dynamic interplay between exposure, post-disaster stressful life events, and WTC-related posttraumatic stress, depressive symptoms, and overall functioning among WTC disaster responders.

Trajectories of PTSD risk and resilience in World Trade Center responders: an 8-year prospective cohort study

BACKGROUND

Longitudinal symptoms of post-traumatic stress disorder (PTSD) are often characterized by heterogeneous trajectories, which may have unique pre-, peri- and post-trauma risk and protective factors. To date, however, no study has evaluated the nature and determinants of predominant trajectories of PTSD symptoms in World Trade Center (WTC) responders.

METHOD

A total of 10835 WTC responders, including 4035 professional police responders and 6800 non-traditional responders (e.g. construction workers) who participated in the WTC Health Program (WTC-HP), were evaluated an average of 3, 6 and 8 years after the WTC attacks.

RESULTS

Among police responders, longitudinal PTSD symptoms were best characterized by four classes, with the majority (77.8%) in a resistant/resilient trajectory and the remainder exhibiting chronic (5.3%), recovering (8.4%) or delayed-onset (8.5%) symptom trajectories. Among non-traditional responders, a six-class solution was optimal, with fewer responders in a resistant/resilient trajectory (58.0%) and the remainder exhibiting recovering (12.3%), severe chronic (9.5%), subsyndromal increasing (7.3%), delayed-onset (6.7%) and moderate chronic (6.2%) trajectories. Prior psychiatric history, Hispanic ethnicity, severity of WTC exposure and WTC-related medical conditions were most strongly associated with symptomatic trajectories of PTSD symptoms in both groups of responders, whereas greater education and family and work support while working at the WTC site were protective against several of these trajectories.

CONCLUSIONS

Trajectories of PTSD symptoms in WTC responders are heterogeneous and associated uniquely with pre-, peri- and post-trauma risk and protective factors. Police responders were more likely than non-traditional responders to exhibit a resistant/resilient trajectory. These results underscore the importance of prevention, screening and treatment efforts that target high-risk disaster responders, particularly those with prior psychiatric history, high levels of trauma exposure and work-related medical morbidities.

Delayed Treatment Seeking Following the April 16th Shootings at Virginia Tech: Impact on a First Responder

This case study discusses the treatment of an emergency responder to the 2007 shooting on Virginia Tech’s campus where 33 students and faculty members were killed. After a thorough assessment, prolonged exposure (PE) was used to treat the emergency worker, referred to as Jack, for posttraumatic stress disorder (PTSD). Assessment measures administered at the conclusion of treatment, 1 month post-treatment, and 6 months post-treatment suggest that the treatment gains were maintained following the culmination of treatment. The primary aim of this article is to provide support for the effectiveness of PE among emergency responders who develop PTSD. In addition, this case presentation is particularly important given the prevalence of mass shootings in the United States. Several complicating factors, including a delay in treatment seeking, arose over the course of treatment and are discussed.

Comorbid persistent lower respiratory symptoms and posttraumatic stress disorder 5-6 years post-9/11 in responders enrolled in the World Trade Center Health Registry

BACKGROUND

Co-occurrence of lower respiratory symptoms (LRS) and posttraumatic stress disorder (PTSD) has been increasingly recognized among responders and survivors of the World Trade Center (WTC) disaster. Information is limited on the degree which comorbidity intensifies symptoms and compromises quality of life across exposed groups.

METHODS

Among responders who completed the first and second Registry surveys, measures of respiratory illness, psychological distress, and diminished quality of life were compared between responders comorbid for LRS and PTSD and responders with only LRS or PTSD.

RESULTS

Of 14,388 responders, 40% of those with LRS and 57% of those with PTSD were comorbid. When demographic and WTC exposure-related factors were controlled, comorbid responders compared to those with LRS alone were twice as likely to have frequent dyspnea and to have sought care for dyspnea. Compared to responders with PTSD alone, comorbid responders were 2.1 times more likely to report intense re-experiencing of the disaster, 2.5 times more likely to express feelings of significant non-specific psychological distress, and 1.4 times more likely to have received mental health care. Comorbid responders were approximately three times more likely to report only fair or poor general health and more than twice as likely to report being unable to perform usual activities for ≥14 of 30 days before interview.

CONCLUSIONS

Outcomes in comorbid responders were similar to or more severe than in comorbid survivors. Health care and disaster relief providers must suspect comorbid illness when evaluating responders' respiratory or mental illnesses and consider treatment for both.

Continued distress among abandoned dogs in Fukushima

In Fukushima, Japan, a prolonged refugee situation caused by a major nuclear incident after the earthquake of March 11, 2011 has led to the unintentional abandonment of many pets. We received stray or abandoned dogs from rescue centers in Fukushima Prefecture. During re-socialization training and health care, we accessed the behavioral characteristics and the urine cortisol level of each dog and compared them with those of other abandoned dogs not involved in this earthquake. The dogs from Fukushima showed significantly lower aggression toward unfamiliar people, trainability, and attachment to their caretakers; also, urine cortisol levels in the dogs from Fukushima were 5–10-fold higher than those in abandoned dogs from another area of Japan. These results suggested that the dogs from Fukushima suffered through an extremely stressful crisis.