Mental health of those directly exposed to the World Trade Center disaster: unmet mental health care need, mental health treatment service use, and quality of life

Colorectal cancer screening: results from the World Trade Center Health Registry cohort

PURPOSE

Little is known about colorectal cancer screening in 9/11 World Trade Center (WTC)-exposed populations. We utilized survey data from the WTC Health Registry (WTCHR) to examine associations between enrollees' characteristics and colorectal cancer (CRC) screening.

METHODS

We studied 22,061 enrollees aged 50-75 who completed the WTCHR follow-up survey in 2015-2016. Those with a history of CRC were excluded. Screening was defined as a self-reported, routine colonoscopy or sigmoidoscopy during the 12-month period prior to the survey. Multivariable log binomial regression identified factors associated with screening in the 12 months preceding the survey. We also stratified by age group.

RESULTS

Of 22,061 enrollees, 23% were screened, with largely similar rates across age groups. Higher screening percentages were seen in selected groups including non-Hispanic Black enrollees (26.4%), males (24.3%), those married/living with a partner (24.1%), those with a higher household income (≥ $150 k, 25.4%), those who received services from the WTC Health Program (25.6%), and those with greater perceived social support (24.4%). On multivariable analyses, non-Hispanic Black enrollees [adjusted relative risk (aRR) = 1.30, 95% confidence interval (CI) 1.19-1.42] were significantly more likely to report screening, even after stratifying by age group. Hispanic enrollees, those with a higher household income, those with increased perceived social support, and those with diagnosed medical conditions under 70 years old were also associated with screening.

CONCLUSION

We found that non-Hispanic Black compared with non-Hispanic White enrollees were more likely to obtain screening for CRC. Continued efforts to promote health and wellness of WTC-exposed population is essential.

Predicting Unmet Healthcare Needs in Post-Disaster: A Machine Learning Approach

Unmet healthcare needs in the aftermath of disasters can significantly impede recovery efforts and exacerbate health disparities among the affected communities. This study aims to assess and predict such needs, develop an accurate predictive model, and identify the key influencing factors. Data from the 2017 Long-term Survey on the Change of Life of Disaster Victims in South Korea were analyzed using machine learning techniques, including logistic regression, C5.0 tree-based model, and random forest. The features were selected based on Andersen's health behavior model and disaster-related factors. Among 1659 participants, 31.5% experienced unmet healthcare needs after a disaster. The random forest algorithm exhibited the best performance in terms of precision, accuracy, Under the Receiver Operating Characteristic (AUC-ROC), and F-1 scores. Subjective health status, disaster-related diseases or injuries, and residential area have emerged as crucial factors predicting unmet healthcare needs. These findings emphasize the vulnerability of disaster-affected populations and highlight the value of machine learning in post-disaster management policies for decision-making.

Impact of natural disaster on oral health: A scoping review

Natural disasters may affect oral health as a result of serious damage to social function and public health. However, no article has systematically summarized the impact of natural disasters on oral health. This review aimed to map the existing literature on the impact of natural disasters on oral health. Targeted literature was searched using PubMed, Web of Science, Cochrane Library, and CINAHL databases with the keywords "disaster" and "oral health." Eligibility criteria were established based on the Participant-Concept-Context model, and eligible studies were identified based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 flow diagram. Eight eligible studies related to earthquakes were included in this review. Of these, 7 studies were related to the 2011 Great East Japan Earthquake. Oral health status of victims of disaster was analyzed by assessing the following parameters: questionnaire surveys; examination for fungal infection; and analyses of the teeth, periodontal, and oral hygiene condition. Six studies suggested that natural disasters had a negative impact on oral health. Two studies could not determine the impact of natural disasters on oral health. Only 1 study analyzed the impact of disasters on oral health based on pre- and postdisaster surveys. This scoping review found that there was insufficient evidence to suggest a relationship between natural disasters and oral health and that there are biases in geographical areas and types of natural disasters in this research field. Further research is needed to promote evidence-based support by dental professionals during different disaster phases.

Posttraumatic stress disorder and functional impairment among World Trade Center Health Registry enrollees 14-15 years after the September 11, 2001, terrorist attacks

The September 11, 2001, terrorist attacks on the World Trade Center (WTC) in New York City (9/11) had health-related consequences, including posttraumatic stress disorder (PTSD). PTSD is associated with functional impairment, which varies by symptom severity and other factors. This study aimed to identify predictors of functional impairment in individuals with low versus high PTSD symptom severity levels. WTC Health Registry enrollees exposed to 9/11 were surveyed four times between 2003 and 2015; cumulated data for individuals who endorsed at least one symptom on the PTSD Checklist-Civilian Version (PCL-C) at Wave 4 (2015-2016) were included (N = 30,287) and examined cross-sectionally. Individuals were classified based on PCL-C scores as having low/no (2-29) or high levels of PTSD symptom severity (≥ 44). Functional impairment was defined as subsequent difficulties in daily living. Among low/no PTSD severity participants, adjusted odds ratios (aORs) for the associations between functional impairment and poor self-rated health (vs. good), low social support (vs. high), and no physical activity (vs. active) were 1.23-1.92. In the same group, low versus high household income was associated with more functional impairment, aOR = 1.34, 95% CI [1.13, 1.59]. Among participants with high-level PTSD symptoms, women, aOR = 1.70, 95% CI [1.31, 2.20], and Hispanic enrollees, aOR = 1.76, 95% CI [1.31, 2.36], were more likely to report an absence of impairment. Self-rated health, social support, and physical activity emerged as important predictors of PTSD-related functional impairment across PTSD symptom severity levels, supporting clinical interventions targeting these factors.

Trajectories of psychological distress among individuals exposed to the 9/11 World Trade Center disaster

BACKGROUND

Individuals present in lower Manhattan during the 9/11 World Trade Center (WTC) disaster suffered from significant physical and psychological trauma. Studies of longitudinal psychological distress among those exposed to trauma have been limited to relatively short durations of follow-up among smaller samples.

METHODS

The current study longitudinally assessed heterogeneity in trajectories of psychological distress among WTC Health Registry enrollees - a prospective cohort health study of responders, students, employees, passersby, and residents in the affected area (N = 30 839) - throughout a 15-year period following the WTC disaster. Rescue/recovery status and exposure to traumatic events of 9/11, as well as sociodemographic factors and health status, were assessed as risk factors for trajectories of psychological distress.

RESULTS

Five psychological distress trajectory groups were found: none-stable, low-stable, moderate-increasing, moderate-decreasing, and high-stable. Of the study sample, 78.2% were classified as belonging to the none-stable or low-stable groups. Female sex, being younger at the time of 9/11, lower education and income were associated with a higher probability of being in a greater distress trajectory group relative to the none-stable group. Greater exposure to traumatic events of 9/11 was associated with a higher probability of a greater distress trajectory, and community members (passerby, residents, and employees) were more likely to be in greater distress trajectory groups - especially in the moderate-increasing [odds ratios (OR) 2.31 (1.97-2.72)] and high-stable groups [OR 2.37 (1.81-3.09)] - compared to the none-stable group.

CONCLUSIONS

The current study illustrated the heterogeneity in psychological distress trajectories following the 9/11 WTC disaster, and identified potential avenues for intervention in future disasters.

Self-Efficacy and Mental Health Help-Seeking Behavior of World Trade Center Health Registry Enrollees, 2015-2016

The September 11th World Trade Center (WTC) disaster resulted in an elevated prevalence of Post-Traumatic Stress Disorder (PTSD) among those directly exposed, yet lower than expected rates of mental health treatment seeking and high levels of reported perceived unmet mental healthcare need were observed in this population in the years following. Self-efficacy, an individual's self-perception of their ability to succeed in specific situations or accomplish a task or goal, may in part explain this discrepancy; however, little is known about its interplay with the help-seeking behaviors of disaster-exposed populations. We used WTC Health Registry data (n = 11,851) to describe the relationship between self-efficacy and three outcomes related to help-seeking behavior: (1) seeking mental health treatment, (2) perceived unmet mental health care needs, and (3) satisfaction with mental health treatment. Multinomial logistic regression models were used to estimate adjusted odds ratios (AORs) and 95% confidence intervals (CI). We found a dose-response relationship between self-efficacy score and mental health help-seeking: for every one unit increase in self-efficacy score, we observed a 6% increase in the odds of having treatment 4 to 12 months ago (OR = 1.06, CI: 1.03-1.09), a 7% increase in the odds of having had treatment 1 to 2 years ago (OR = 1.07, CI: 1.04, 1.09), and a 10% increase in the odds of having sought treatment 2 or more years ago (OR = 1.10, CI: 1.08, 1.12) compared to those who had sought treatment more recently. An understanding of individual self-efficacy may help improve post-disaster mental health treatment in order to provide more tailored and helpful care.

Testing alternative models and predictive utility of the Death Anxiety Inventory-Revised: A COVID-19 related longitudinal population based study

The beginning of the COVID-19 pandemic had a profound effect on all aspects of daily life and triggered a swell of anxiety across the world. Some suggest this emotional response to the pandemic can be explained through death anxiety (DA), a transdiagnostic dimension associated with numerous psychological disorders. However, it remains unclear as to whether DA is a unidimensional or multidimensional construct. The primary aim of this study was to examine the underlying structure of the Death Anxiety Inventory-Revised (DAI-R; Tomás-Sábado et al., 2005) and assess its associations with mental health and demographic variables during the COVID-19 pandemic. To achieve these aims, we utilized data from Waves 1 (N = 2205: collected between March 23 and March 28, 2020) and 2 (N = 1406: collected between April 22 and May 1, 2020) of the COVID-19 Psychological Research Consortium (C19PRC), a multi-wave nationally representative study. Results showed that a 4-factor model provided the best fit to the data compared to a unidimensional and 4-factor second-order model. Further analyses showed that DA at Wave 1 was positively associated with somatic symptoms, paranoia, depression, anxiety, and traumatic stress symptoms at Wave 2, supporting previous research that suggests that the fear of death is predictive of psychopathology. Significantly, the factor labelled 'Thoughts about Death' at Wave 1 was the strongest predictor of the five main psychological variables at Wave 2, after statistically controlling for the other latent variables. These findings highlight the transdiagnostic nature of DA and support this important diagnostic construct becoming a measure of mental health more generally within the population. It is hoped that this research will shine a light on those suffering from DA and become a catalyst for increased therapeutic intervention, funding, and research in this area.

Associations of Embeddedness and Posttraumatic Stress Disorder among 9/11 Survivors

Following exposures to traumatic events on 9/11, survivors have reported heightened levels of posttraumatic stress disorder (PTSD). Multiple factors contribute to both the exacerbation and amelioration of PTSD symptoms, including social integration and support. This cross-sectional study aimed to understand and identify associations of embeddedness and psychosocial risk factors by PTSD status for survivors and first responders of 9/11. Results indicate that those with chronic PTSD had the lowest prevalence of both social and emotional embeddedness and many who reported no PTSD symptoms following 9/11 reported moderate levels of social and emotional embeddedness. Overall, our findings suggest those individuals who reported little to no PTSD also reported the most social/emotional embeddedness; whereas those individuals who report greater or chronic PTSD report the least social/emotional embeddedness. As such, it may be beneficial for clinicians across multiple care disciplines and contexts to consider and address the social lives and needs of those individuals experiencing symptoms of PTSD to ensure their emotional and physical needs are truly being met.

Mental health in Lebanon: Tomorrow's silent epidemic

Lebanon is a middle-income country that has been recently crippled by several tragedies including the economic collapse, COVID-19, and the fourth of August Beirut port explosion, the world's most powerful non-nuclear explosion of the twenty-first century. Recent data on mental health from Lebanon is summarised, and other topics such as the psychological impact of cumulative adversities and the role of international support in Lebanon are examined. Data from Lebanon shows severe levels of distress among the people, in a country with minimal resources. Given current adversities in Lebanon, recent data in the country, and the literature on adversity and mental health outcomes of man-made disasters, Lebanon is most likely going to face an epidemic in poor mental health. A call is made for the wider scientific community and international organizations to support the mental health field in the country and help prevent further negative mental health outcomes. Understanding how to better navigate mental health in places with extreme adversity and emergencies can be beneficial to other communities which might face similar challenges.

Psychological outcomes for young adults after disastrous events: A mixed-methods scoping review

RATIONALE

Young adulthood (18 to 34) is a time of transitional change where individuals can be highly susceptible to mental health concerns. Despite similar vulnerabilities to their adolescent counterparts, the psychological outcomes for young adults following disasters are not well understood.

OBJECTIVE

This scoping review aimed to explore the literature on the psychological outcomes for young adults after disaster events.

METHODS

A systematic search of the literature was conducted in seven electronic databases, including PsycINFO, Medline, CINAHL, PILOTS, EMBASE, Scopus, and ProQuest dissertations and theses global. In total, 91 reports from 15 countries were included.

RESULTS

Findings suggested that young adults experience a range of psychological consequences after disasters, including posttraumatic stress symptoms, depression, anxiety, and other psychological outcomes, such as general/non-specific psychological distress. Pre-disaster, peri-disaster, and post-disaster factors were also found to influence the degree of psychological outcomes experienced by young adults, including prior psychological functioning and disaster exposure, among a host of other factors.

CONCLUSION

Future research is recommended to better understand young adults' psychological outcomes, experiences, and service needs following disasters.

World Trade Center Exposure and Posttraumatic Growth: Assessing Positive Psychological Change 15 Years after 9/11

We evaluated the presence of posttraumatic growth (PTG) among survivors of the 9/11 terrorist attack and how indicators of psychosocial well-being, direct 9/11-related exposure, and posttraumatic stress symptoms (PTSS) relate to PTG. PTG was examined among 4934 participants using the Posttraumatic Growth Inventory (PTGI). A confirmatory factor analysis (CFA) was conducted to determine if the original factor structure of the PTGI fits our data and principal component analysis (PCA) to identify the appropriate factor structure. Multivariable linear regression models were used to examine the association between PTG and indicators of psychosocial well-being, 9/11-related exposure, and PTSS, controlling for covariates. CFA identified a two-factor structure of the PTGI as a better fit than the original five-factor model. Participants who experienced very high 9/11-related exposure level (ß = 7.72; 95% CI: 5.75-9.70), higher PTSS at waves 1 (ß = 0.13; 95% CI: 0.08-0.18) and 2 (ß = 0.09; 95% CI: 0.05-0.14), high social integration (ß = 5.71; 95% CI: 4.47, 6.96), greater social support (ß = 0.49; 95% CI: 0.37, 0.61), and higher self-efficacy (ß = 1.26; 95% CI: 1.04, 1.48) had higher PTGI scores. Our findings suggest PTG is present, 15 years following the 9/11 terrorist attack. Very high-level 9/11 exposure, PTSS, and indicators of psychosocial well-being were associated with PTG.

Change in binge drinking behavior after Hurricane Sandy among persons exposed to the 9/11 World Trade Center disaster

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4.7% participants were new binge drinkers after Hurricane Sandy.

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Persons with high Sandy exposure were more likely to be new/consistent binge drinkers.

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Among persons without 9/11 PTSD, Sandy PTSD was associated with new binge drinking.

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High Sandy exposure, and Sandy PTSD were associated with higher binge intensity after Sandy.

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Response to future disasters should address alcohol use and PTSD simultaneously.

The objective of this study was to examine changes in drinking behavior after Hurricane Sandy among 3199 World Trade Center Health Registry (Registry) enrollees before (2011–12) and after Hurricane Sandy (2015–16). A composite Sandy exposure scale (none, low, medium and high) included Sandy traumatic experiences, financial and other factors. Probable Sandy-related posttraumatic stress disorder (PTSD) was defined as scoring ≥44 on PTSD Checklist, and binge drinking as consuming ≥5 alcoholic drinks for men or ≥4 for women on one occasion in the past 30 days. Some of the enrollees reported binge drinking post Sandy as new binge drinkers (4.7%) or consistent binge drinkers pre- and post-Sandy (19%). Compared with non-binge drinkers pre- and post-Sandy (66.9%), the adjusted odds ratios (aOR) for being new binge drinkers and consistent binge drinkers among high Sandy exposure enrollees were 2.1 (95%CI 1.1–4.1) and 2.5 (95%CI: 1.7–3.6), respectively. High Sandy traumatic experience alone was associated with consistent binge drinking (aOR: 1.9, 95%CI: 1.4–2.6). Among enrollees without 9/11 PTSD, those with Sandy PTSD were more likely to become new binge drinkers (aOR: 4.4, 95%CI: 1.4–13.9), while Sandy PTSD was not associated with any binge drinking behavior changes among those with 9/11 PTSD. Sandy exposure, Sandy traumatic experience, and Sandy PTSD were all associated with higher binge drinking intensity. Future natural disaster response should plan for treatment to address alcohol use and PTSD simultaneously.

Mental Healthcare Needs in World Trade Center Responders: Results from a Large, Population-Based Health Monitoring Cohort

Nearly two decades after the 9/11 attacks on the World Trade Center (WTC), the prevalence of mental disorders remains elevated among traditional (e.g., police) and non-traditional (e.g., construction workers) responders who were involved in the WTC rescue, recovery, and clean-up efforts. To date, however, scarce research has examined factors associated with perceived need for mental health care, which is critical to promoting engagement in mental health treatment in this population. Data were analyzed from 16,170 WTC responders, including 8881 police responders and 7289 non-traditional responders, who completed their first annual health monitoring visit with the WTC Health Program an average of 6.5 years after September 11, 2001. Predisposing, enabling, and need-based factors associated with perceived need for mental health care were examined using multivariable logistic regression analyses. Nearly half (48.7%) of non-traditional responders and a fifth (20.6%) of police responders reported a need for mental health care. The most common perceived needs were for psychotropic medication, individual psychotherapy, and stress management counseling. Predisposing (e.g., female gender) and need-based factors (e.g., WTC-related posttraumatic stress disorder) predicted perceived need for mental health care in both groups. Among non-traditional responders, Hispanic ethnicity and current suicidal ideation were additionally associated with this outcome. Non-traditional WTC responders are substantially more likely than police WTC responders to perceive a need for mental health treatment. Characterization of factors associated with perceived need for treatment can help inform population-based outreach and monitoring efforts designed to promote engagement in mental health treatment in WTC responders.

Probable Posttraumatic Stress Disorder and Lower Respiratory Symptoms Among Rescue/Recovery Workers and Community Members After the 9/11 World Trade Center Attacks-A Longitudinal Mediation Analysis

OBJECTIVE

Posttraumatic stress disorder (PTSD) and lower respiratory symptoms (LRS) often coexist among survivors of the September 11, 2001 (9/11) World Trade Center (WTC) attacks. Research in police and nontraditional responders suggests that PTSD mediates the relationship between 9/11 physical exposures and LRS, but not vice versa. We replicated these findings in WTC rescue/recovery workers (R/R workers), extended them to exposed community members, and explored the interplay between both physical and psychological 9/11 exposures, probable PTSD, and LRS over a 10-year follow-up.

METHODS

Participants were 12,398 R/R workers and 12,745 community members assessed in three WTC Health Registry surveys (2003-2004, 2006-2007, and 2011-2012). LRS and 9/11 exposures were self-reported. Probable PTSD was defined as a PTSD Checklist score ≥44.

RESULTS

Probable PTSD predicted LRS (R/R workers: β = 0.88-0.98, p < .001; community members: β = 0.67-0.86, p < .001) and LRS predicted PTSD (R/R workers: β = 0.83-0.91, p < .001; community members: β = 0.68-0.75, p < .001) at follow-ups, adjusting for prior symptoms and covariates. In both R/R workers and community members, probable PTSD mediated the relationship between 9/11 physical exposures (dust cloud, long duration of work) and LRS (indirect effects, p = .001-.006), and LRS mediated the physical exposure-PTSD relationship (indirect effects, p = .001-.006). In R/R workers, probable PTSD mediated the psychological exposure (losing friends or loved ones, witnessing horrific events)-LRS relationship (indirect effect, p < .001), but LRS did not mediate the psychological exposure-PTSD relationship (indirect effect, p = .332). In community members, high 9/11 psychological exposure predicted both probable PTSD and LRS at follow-ups; probable PTSD mediated the psychological exposure-LRS relationship (indirect effect, p < .001), and LRS mediated the psychological exposure-PTSD relationship (indirect effect, p = .001).

CONCLUSIONS

Probable PTSD and LRS each mediated the other, with subtle differences between R/R workers and community members. A diagnosis of either should trigger assessment for the other; treatment should be carefully coordinated.

Unmet Mental Health Care Needs among Asian Americans 10⁻11 Years After Exposure to the World Trade Center Attack

This study investigated the prevalence of unmet mental health care needs (UMHCN) and their associated factors among 2344 Asian Americans directly exposed to the World Trade Center (WTC) attack 10-11 years afterwards. Given the pervasive underutilization of mental health services among Asians, their subjective evaluation of unmet needs could provide more nuanced information on disparities of service. We used the WTC Health Registry data and found that 12% of Asian Americans indicated UMHCN: 69% attributing it to attitudinal barriers, 36% to cost barriers, and 29% to access barriers. Among all the factors significantly related to UMHCN in the logistic model, disruption of health insurance in the past year had the largest odds ratio (OR = 2.37, 95% confidence interval: 1.61-3.48), though similar to functional impairment due to mental disorders. Post-9/11 mental health diagnosis, probable mental disorder and ≥14 poor mental health days in the past month were also associated with greater odds of UMHCN, while greater social support was associated with lower odds. Results suggest that continued outreach efforts to provide mental health education to Asian communities to increase knowledge about mental illness and treatment options, reduce stigmatization of mental illness, and offer free mental health services are crucial to address UMHCN.

Conducting a study to assess the long-term impacts of injury after 9/11: participation, recall, and description

Background

The World Trade Center (WTC) attacks on September 11, 2001 (9/11) resulted in over 2700 fatalities and thousands injured. Injury on 9/11 has been identified as a risk factor for physical and mental health conditions, but the reasons for this are not well understood. In a population exposed to 9/11 and since followed, an in-depth study on the impacts of injury on 9/11 was conducted to identify factors that contribute to long-term functional issues. This report sought to examine factors influencing participation, participant recall of injury status over time, and determinants of injury severity.

Methods

Enrollees from the World Trade Center Health Registry who completed all surveys between 2003 and 2016 and initially reported being injured (N = 2699) as well as a sample of non-injured (N = 2598) were considered to be eligible for the Health and Quality of Life 15 Years after 9/11 (HQoL) Study. Predictors of study non-participation and inconsistent recall of injury over time (i.e., discrepant reports) were identified through fitting log binomial models.

Results

Participation rates were high overall (76.1%) and did not vary by initially reported injury status, although younger (vs. older), non-White (vs. White), and less educated (vs. more educated) enrollees were less likely to participate in the HQoL Study. Discrepant reporting of 9/11 injury status was much more common among enrollees who initially reported being injured on 9/11 (49.6%) compared with those who did not (7.3%). However, those who incurred more severe injuries on 9/11 were less likely to have discrepant reporting over time compared with those with more minor injuries (broken bone vs. sprain: risk ratio = 0.33, 95% Confidence Interval: 0.19, 0.57). Among those who consistently reported that they were injured on 9/11, most injuries occurred as a result of descending down stairs (31.5%) or by tripping and falling (19.9%); although being hit by a falling object was most often associated with high severity injuries (63.2%) compared with other modes of injury.

Conclusions

These findings highlight the methodological issues involved in conducting a study on the long-term impact of injury more than a decade after the initial incident and may be relevant to future investigators. Factors affecting participation rates, such as demographic characteristics, and those related to discrepant reporting over time, such as injury severity, may affect both the internal and external validity of studies examining the long-term impact of injury.

Characterizing Mental Health Treatment Utilization among Individuals Exposed to the 2001 World Trade Center Terrorist Attacks 14⁻15 Years Post-Disaster

Following the World Trade Center (WTC) attacks in New York City (NYC) on 11 September 2001 (9/11), thousands in NYC experienced significant stress reactions and disorders, presenting an immediate need for counseling and treatment. While other studies documented post-9/11 mental health treatment utilization, none have data more than two years post-disaster. We used data from 35,629 enrollees of the WTC Health Registry, a longitudinal cohort study of those exposed to the WTC attacks, to examine predictors of counseling after 9/11, the types of practitioners seen, and the perceived helpfulness of therapy up to 15 years post-disaster. Among enrollees, 37.7% reported receiving counseling at some time after 9/11. Predictors of seeking counseling included race/ethnicity, age at 9/11, education level, exposure to the WTC attacks, other traumatic experiences, mental health symptomology, and pre-9/11 counseling. Whites and Hispanics, those who were children on 9/11, and those with high levels of exposure to the WTC attacks sought counseling soonest after 9/11. Among those who sought counseling, Blacks, Asians, and those with lower education and income were less likely to see mental health specialists and more likely to see general practitioners or religious advisors. Finally, among those who sought recent counseling, women, Blacks, those aged ≥65 years, and those with very high WTC exposures were more likely to rate their recent counseling as very helpful. This study used data up to 15 years post-disaster to document mental health treatment utilization patterns, trends, and disparities that have implications for future preparedness plans and needs assessments.

Posttraumatic Stress Trajectories in World Trade Center Tower Survivors: Hyperarousal and Emotional Numbing Predict Symptom Change

There is a paucity of knowledge concerning the underlying symptomatology of heterogeneous posttraumatic stress symptom (PTSS) trajectories following mass trauma, such as a terrorist attack. This study examined longitudinal PTSS trajectories using latent growth mixture modeling in 2,355 World Trade Center (WTC) tower survivors surveyed by the WTC Health Registry an average of 2.5, 5.5, and 10.5 years after the September 11, 2001 terrorist attacks. Covariates included sociodemographic characteristics, WTC-related exposure, and other traumas/stressors. Four curvilinear PTSS trajectories were identified: low symptom (74.9%), recovering (8.0%), worsening (6.7%), and chronic (10.4%). The majority of WTC survivors (85.3%) maintained stable symptom trajectories over time, with PTSS changes occurring less often. Although WTC-related exposure was associated with initial PTSS severity, exposure was not associated with chronicity or change of PTSS over time. Male gender and a higher number of post-WTC disaster life-stressors were associated with worsening symptom severity over time. Individuals with more severe hyperarousal symptoms at Wave 1, particularly of anxious arousal, were more likely to have PTSS that worsened over time, adjusted odds ratio (aOR) = 1.55. Less severe emotional numbing symptoms, particularly of dysphoria, at Wave 1, were marginally significantly associated with subsequent PTSS recovery, aOR = 0.75. Interventions that target hyperarousal and emotional numbing symptoms may mitigate a worsening of symptoms and facilitate posttraumatic recovery following future mass traumas, such as terrorist attacks. Further clinical implications are discussed.

PTSD and comorbid depression: Social support and self-efficacy in World Trade Center tower survivors 14-15 years after 9/11

OBJECTIVE

Following the World Trade Center (WTC) terrorist attack in New York City, prevalence rates of posttraumatic stress disorder (PTSD) and depression remain elevated. Although social support and self-efficacy have been associated with PTSD, little is known about their differential effect on PTSD and depressive comorbidity.

METHOD

WTC tower survivors (n = 1,304) were assessed at Wave 1 (2003-2004), Wave 2 (2006-2007), Wave 3 (2011-2012), and Wave 4 (2015-2016).

RESULTS

At Wave 4, 13.0% of participants had probable PTSD, a decrease from 16.5% at Wave 1. In addition, 4.1% (54) were identified as having PTSD alone, 6.8% (89) had depression alone, and 8.9% (116) had comorbid PTSD and depression. Of those with PTSD, 68.2% also had comorbid depression. WTC tower survivors with PTSD and comorbid depression reported greater PTSD symptom severity and were more likely to have had greater exposure to the events of 9/11 (adjusted odds ratio [aOR] = 1.14) and lower self-efficacy (aOR = 0.85) than those with depression alone. Less perceived social support predicted only depression and not PTSD, whereas less perceived self-efficacy equally predicted having PTSD or depression (aOR = 0.76).

CONCLUSIONS

Findings indicate that self-efficacy may be more important to the severity and chronicity of PTSD symptoms than social support. Multivariate comparisons suggest that PTSD with comorbid depression is a presentation of trauma-dependent psychopathologies, as opposed to depression alone following trauma, which was independent of trauma exposure and may be secondary to the traumatic event and posttraumatic response. Implications for assessment and treatment are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Association between unmet healthcare needs and health-related quality of life: a longitudinal study

Background

As life expectancy has increased overall, health-related quality of life is now more important than ever. This is especially relevant in countries such as South Korea that are concerned about unmet healthcare needs and health-related quality of life (HRQoL). Thus, we investigated the relationship between unmet healthcare needs and HRQoL in the general population.

Methods

We used data from the 2011 to 2013 Korea Health Panel Survey, which included data from 8150 baseline participants of 19 years of age or older. We measured HRQoL using the EQ-5D and EQ-VAS indices. In addition, we used generalized estimating equations to perform a longitudinal regression analysis.

Results

Approximately 13.1% of the participants (n = 1068) experienced unmet healthcare needs. Individuals with unmet healthcare needs due to economic hardship tended to have lower values than those without unmet healthcare needs for EQ-5D and EQ-VAS indices (EQ-5D: -2.688, P < 0.0001; EQ-VAS: -5.256, P < 0.0001). Additionally, when stratified by gender, both male and female subjects who had unmet healthcare needs and low economic status had a drastic decrease in HRQoL regardless of the reasons for their unmet healthcare needs.

Conclusions

Unmet healthcare needs influences HRQoL, which was more pronounced in economically vulnerable groups. Thus, interventions to address HRQoL problems should focus on implementing a guarantee of healthcare services for economically vulnerable groups.

Longitudinal determinants of depression among World Trade Center Health Registry enrollees, 14-15 years after the 9/11 attacks

BACKGROUND

Exposure to the September 11, 2001 (9/11) terrorist attacks has been found to be associated with posttraumatic stress disorder (PTSD) and comorbid PTSD and depression up to 10-11 years post-disaster. However, little is known about the longitudinal predictors of mental health conditions over time.

METHODS

We examined longitudinal determinants of depression within strata of PTSD among 21,258 enrollees of the World Trade Center Health Registry who completed four questionnaires over 14 years of follow-up (Wave 1 in 2003-04; Wave 2 in 2005-06; Wave 3 in 2011-12; and Wave 4 in 2015-16). PTSD status was measured using the PTSD checklist on all four waves and defined as a score of ≥ 44; depression was assessed using the 8-item Patient Health Questionnaire at Waves 3 and 4 and defined as a score of ≥ 10.

RESULTS

Across Waves 3 and 4, 18.6% experienced depression, and it was more common among those who ever had PTSD (56.1%) compared with those who had not (5.6%). Across PTSD strata, predictors of depression included low income, unemployment, low social integration and support, post-9/11 traumatic life events, and chronic physical illness. These factors also decreased the likelihood of recovering from depression.

LIMITATIONS

Depression symptoms were not measured at Waves 1 and 2; data was self-reported.

CONCLUSIONS

These findings highlight the substantial burden of depression in a trauma-exposed population 14-15 years post-disaster, especially among those with PTSD. Similar life stressors predicted the course of depression among those with and without PTSD which may inform public health and clinical interventions.

Re-experiencing 9/11-Related PTSD Symptoms Following Exposure to Hurricane Sandy

Background

Understanding Pre-Existing Posttraumatic Stress Disorder (PTSD) symptoms and risk of PTSD following Hurricane Sandy (Sandy) has important implications for PTSD screening of persons exposed to multiple traumas. This study assessed the association between Sandy exposure and a subset of PTSD symptoms related to re-experiencing trauma from the events of the September 11, 2001 (9/11).

Methods

We studied 4,220 respondents from a random 8,870 person sample of adult World Trade Center Health Registry enrollees who completed a post-Sandy survey between March 28 and November 7, 2013. The symptom cluster of re-experiencing 9/11 was defined using 3 out of 5 questions in the intrusion domain of the PTSD Checklist. Multivariable logistic regression, adjusting for socio-demographics, social support and any post-9/11 life threatening events prior to Sandy, was performed separately in those symptomatic and non-symptomatic of re-experiencing 9/11 prior to Sandy.

Results

A total of 688 enrollees (16.3%) reported re-experiencing 9/11 symptoms after Sandy (58.8% in those symptomatic prior to Sandy, and 8.7% in those non-symptomatic). A significant association between Sandy exposure and re-experiencing 9/11 was observed only among those non symptomatic prior to Sandy (adjusted odds ratio (AOR)=1.7, 95% confidence interval=1.2-2.3 for moderate Sandy exposure; AOR=2.8, 2.0-4.0 for high Sandy exposure).

Conclusions

Individuals with a history of trauma should be considered for early screening and counseling for mental health after a subsequent traumatic event, regardless of PTSD status, especially in 9/11 exposed populations.

Psychological Distress in Parents and School-Functioning of Adolescents: Results from the World Trade Center Registry

Poor school-functioning can be indicative of parent and adolescent mental health and adolescent behavior problems. This study examined 472 adolescents enrolled in the World Trade Center (WTC) Health Registry, with a two-step path analysis, using regression-based models, to unravel the relationships between parent and adolescent mental health, adolescent behavior problems, and adolescent unmet healthcare need (UHCN) on the outcome school-functioning. WTC exposure was associated with UHCN and parental mental health was a significant mediator. There was no evidence that family WTC exposure was associated with UHCN independent of its effect on parental mental health. For the second path, after accounting for the effects of adolescent mental health, behavioral problems, and UHCN, there remained a significant association between parental mental health and school-functioning. Interventions for poor school-functioning should have multiple components which address UHCN, mental health, and behavioral problems, as efforts to address any of these alone may not be sufficient.

Screening for trauma-related symptoms via a smartphone app: The validity of Smart Assessment on your Mobile in referred police officers

To facilitate easily accessible screening for trauma-related symptoms, a web-based application called Smart Assessment on your Mobile (SAM) was developed. In this study, we examined whether SAM was able to accurately identify posttraumatic stress disorder (PTSD) and depression in adults. Eighty-nine referred police officers completed SAM, containing the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 (PCL-5) and the Depression Anxiety and Stress Scale (DASS-21), on their own device prior to a diagnostic interview where the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and Structured Clinical Interview for DSM-IV (SCID-I/P) were administered. Results showed a substantial agreement between SAM and the diagnostic interview in the assessment of PTSD and depression. An optimal trade-off between sensitivity (89%) and specificity (68%) levels was found at a cut-off score of 31 on the PTSD Checklist for DSM-5 (area under the curve = 0.845, 95% CI [0.765, 0.925], diagnostic odds ratio = 15.97). This is one of the first studies to support the validity and reliability of a mobile screener following trauma. SAM may facilitate screening for trauma-related symptoms on a large scale and could be a first step in a stepped-care model for trauma survivors to help identify individuals who need further diagnostics and care.

Intensity of Binge Drinking a Decade After the September 11th Terror Attacks Among Exposed Individuals

INTRODUCTION

The 9/11 terrorist attacks on the World Trade Center resulted in elevated post-traumatic stress disorder (PTSD) and alcohol use among exposed individuals. The relationship among traumatic exposure, PTSD, and excessive drinking is well documented; however, little is known about these relationships in the long term. This study examines factors increasing binge drinking risk among exposed individuals a decade post-9/11.

METHODS

In 2015-2016, data were analyzed from 28,592 World Trade Center Health Registry enrollees aged ≥18 years who completed the Wave 3 (2011-2012) survey. Women comprised 38.9% of participants. Binge drinking in the last 30 days was categorized as low (men, five to seven drinks; women, four to six drinks) or high intensity (men, eight or more drinks; women, seven or more drinks). Probable 9/11-related PTSD was defined as scoring ≥44 on the PTSD Checklist. Exposures to 9/11 (e.g., witnessing horror, sustaining an injury) were categorized as none/low (zero to two) or high (three or more).

RESULTS

Binge drinking was reported by 24.7% of participants, of whom 36.9% reported high-intensity binge drinking. Compared with non-binge drinkers, the odds of low- and high-intensity binge drinking were greater among enrollees who were male, aged 18-34 years, non-Hispanic white, had income >$75,000, were rescue/recovery workers, had high 9/11 exposure, or 9/11-related PTSD.

CONCLUSIONS

The observed associations among traumatic exposure, PTSD, and excessive drinking underscore the need for improved therapies addressing excessive drinking and PTSD concurrently, inclusion of repeated post-event screening for excessive drinking, and evidence-based population-level interventions to reduce alcohol consumption.

Parent Physical and Mental Health Comorbidity and Adolescent Behavior

The objectives of this study were to ascertain behavioral outcomes 10-11 years after 9/11 in adolescents ages 11-18 years (0-8 years old at the time of 9/11) enrolled in the World Trade Center Health Registry (Registry), and relate these outcomes to their 9/11-exposures and to parent health. Behavioral difficulties among adolescents were assessed using the adolescent-reported Strengths and Difficulties Questionnaire (SDQ). Parental post-traumatic stress disorder (PTSD) was assessed using a 9/11-specific PTSD Checklist-Civilian Version, a cut-off score of 44 or greater was considered probable PTSD. Multivariable logistic regression was used to estimate associations of 9/11-exposure and parental health with abnormal/borderline SDQ scores, adjusting for demographic variables that were significantly associated with the SDQ score in bivariate analyses. Of the 449 adolescents, 12.5% (n=56) had abnormal/borderline SDQ scores. In the multivariable model, adolescents with severe/ moderate 9/11-exposures were 2.4 times more likely to have abnormal/borderline SDQ scores compared to adolescents with mild 9/11-exposures (95% Confidence Interval (CI): 1.1-6.4). Adolescents who had a parent with 9/11-related PTSD and at least one comorbid chronic condition were 4.2 times more likely to have abnormal/borderline SDQ scores compared to adolescents with a parent who had no reported chronic health conditions. Adolescents whose parent reported 14 or more poor mental health days in the preceding 30 days were 3.4 times more likely to have abnormal/borderline SDQ scores (95% CI: 1.2-9.5) The finding that parents' health appears to influence adolescent behavior problems 10-11 years following a disaster may have implications for healthcare practitioners and disaster response planners.

Asthma control in adolescents 10 to 11 y after exposure to the World Trade Center disaster

BACKGROUND

Little is known about asthma control in adolescents who were exposed to the World Trade Center (WTC) attacks of 11 September 2001 and diagnosed with asthma after 9/11. This report examines asthma and asthma control 10-11 y after 9/11 among exposed adolescents.

METHODS

The WTC Health Registry adolescent Wave 3 survey (2011-2012) collected data on asthma diagnosed by a physician after 11 September 2001, extent of asthma control based on modified National Asthma Education and Prevention Program criteria, probable mental health conditions, and behavior problems. Parents reported healthcare needs and 9/11-exposures. Logistic regression was used to evaluate associations between asthma and level of asthma control and 9/11-exposure, mental health and behavioral problems, and unmet healthcare needs.

RESULTS

Poorly/very poorly controlled asthma was significantly associated with a household income of ≤$75,000 (adjusted odds ratio (AOR): 3.0; 95% confidence interval (CI): 1.1-8.8), having unmet healthcare needs (AOR: 6.2; 95% CI: 1.4-27.1), and screening positive for at least one mental health condition (AOR: 5.0; 95% CI: 1.4-17.7), but not with behavioral problems. The impact of having at least one mental health condition on the level of asthma control was substantially greater in females than in males.

CONCLUSIONS

Comprehensive care of post-9/11 asthma in adolescents should include management of mental health-related comorbidities.

Quality of Life of Persons Injured on 9/11: Qualitative Analysis from the World Trade Center Health Registry

Introduction: A number of studies published by the World Trade Center Health Registry (Registry) document the prevalence of injuries sustained by victims of the World Trade Center Disaster (WTCD) on 9/11. Injury occurrence during or in the immediate aftermath of this event has been shown to be a risk factor for long-term adverse physical and mental health status. More recent reports of ongoing physical health and mental health problems and overall poor quality of life among survivors led us to undertake this qualitative study to explore the long-term impact of having both disaster-related injuries and peri-event traumatic exposure on quality of life in disaster survivors. 

Methods: Semi-structured, in-depth individual telephone interviews were conducted with 33 Registry enrollees who reported being injured on 9/11/01. Topics included: extent and circumstance of the injury(ies), description of medical treatment for injury, current health and functional status, and lifestyle changes resulting from the WTCD. The interviews were recorded, transcribed, and inductively open-coded for thematic analysis.

Results: Six themes emerged with respect to long term recovery and quality of life: concurrent experience of injury with exposure to peri-event traumatic exposure (e.g., witnessing death or destruction, perceived life threat, etc.); sub-optimal quality and timeliness of short- and long-term medical care for the injury reported and mental health care; poor ongoing health status, functional limitations, and disabilities; adverse impact on lifestyle; lack of social support; and adverse economic impact. Many study participants, especially those reporting more serious injuries, also reported self-imposed social isolation, an inability to participate in or take enjoyment from previously enjoyable leisure and social activities and greatly diminished overall quality of life.

Discussion: This study provided unique insight into the long-term impact of disasters on survivors. Long after physical injuries have healed, some injured disaster survivors report having serious health and mental health problems, economic problems due to loss of livelihood, limited sources of social support, and profound social isolation. Strategies for addressing the long-term health problems of disaster survivors are needed in order to support recovery.

Risk factors for and consequences of persistent lower respiratory symptoms among World Trade Center Health Registrants 10 years after the disaster

OBJECTIVES

The prevalence of persistent lower respiratory symptoms (LRS) among rescue/recovery workers, local area workers, residents and passers-by in the World Trade Center Health Registry (WTCHR) was analysed to identify associated factors and to measure its effect on quality of life (QoL) 10 years after 9/11/2001.

METHODS

This cross-sectional study included 18 913 adults who completed 3 WTCHR surveys (2003-2004 (Wave 1 (W1)), 2006-2007 (Wave 2 (W2)) and 2011-2012 (Wave 3 (W3)). LRS were defined as self-reported cough, wheeze, dyspnoea or inhaler use in the 30 days before survey. The prevalence of three LRS outcomes: LRS at W1; LRS at W1 and W2; and LRS at W1, W2 and W3 (persistent LRS) was compared with no LRS on WTC exposure and probable mental health conditions determined by standard screening tests. Diminished physical and mental health QoL measures were examined as potential LRS outcomes, using multivariable logistic and Poisson regression.

RESULTS

Of the 4 outcomes, persistent LRS was reported by 14.7%. Adjusted ORs for disaster exposure, probable post-traumatic stress disorder (PTSD) at W2, lacking college education and obesity were incrementally higher moving from LRS at W1, LRS at W1 and W2 to persistent LRS. Half of those with persistent LRS were comorbid for probable PTSD, depression or generalised anxiety disorder. Enrollees with persistent LRS were 3 times more likely to report poor physical health and ∼ 50% more likely to report poor mental health than the no LRS group.

CONCLUSIONS

LRS, accompanied by mental health conditions and decreased QoL, have persisted for at least 10 years after 9/11/2001. Affected adults require continuing surveillance and treatment.

A PTSD symptoms trajectory mediates between exposure levels and emotional support in police responders to 9/11: a growth curve analysis

BACKGROUND

Exposure to the terrorist attack on the World Trade Center (WTC) on 9/11/2001 resulted in continuing stress experience manifested as Posttraumatic Stress Disorder (PTSD) Symptoms in a minority of the police responders. The WTC Health Registry has followed up a large number of individuals, including police officers, at three waves of data collection from 2003 to 2011. This analysis examines the relationship between initial exposure levels, long-term PTSD symptoms, and subsequent emotional support among police responders.

METHODS

The study population included police responders who had reported their 9/11 exposure levels at Wave 1 (2003/4), provided three waves of data on PTSD symptoms using the 17-item PCL scale, and rated their received emotional support at Wave 3 (N = 2,204, 1,908 men, 296 women, mean age: 38 years at exposure). A second-order growth curve reflected a PTSD symptom trajectory which was embedded in a structural equation model, with exposure level specified as an exogenous predictor, and emotional support specified as an endogenous outcome.

RESULTS

Exposure had a main effect on mean symptom levels (intercept) across three waves but it made no difference in changes in symptoms (slope), and no difference in emotional support. The symptom trajectory, on the other hand, had an effect on emotional support. Its intercept and slope were both related to support, indicating that changes in symptoms affected later emotional support.

CONCLUSIONS

Initial trauma exposure levels can have a long-term effect on mean symptom levels. Emotional support is lower in police responders when PTSD symptoms persist over seven years, but becomes higher when reduction in symptoms occurs.

Exposure to the World Trade Center Disaster and 9/11-Related Post-Traumatic Stress Disorder and Household Disaster Preparedness

Objective

In a population with prior exposure to the World Trade Center disaster, this study sought to determine the subsequent level of preparedness for a new disaster and how preparedness varied with population characteristics that are both disaster-related and non-disaster-related.

Methods

The sample included 4496 World Trade Center Health Registry enrollees who completed the Wave 3 (2011-2012) and Hurricane Sandy (2013) surveys. Participants were considered prepared if they reported possessing at least 7 of 8 standard preparedness items. Logistic regression was used to determine associations between preparedness and demographic and medical factors, 9/11-related post-traumatic stress disorder (PTSD) assessed at Wave 3, 9/11 exposure, and social support.

Results

Over one-third (37.5%) of participants were prepared with 18.8% possessing all 8 items. The item most often missing was an evacuation plan (69.8%). Higher levels of social support were associated with being prepared. High levels of 9/11 exposure were associated with being prepared in both the PTSD and non-PTSD subgroups.

Conclusions

Our findings indicate that prior 9/11 exposure favorably impacted Hurricane Sandy preparedness. Future preparedness messaging should target people with low social support networks. Communications should include information on evacuation zones and where to find information about how to evacuate. (Disaster Med Public Health Preparedness. 2015;9:625–633)

Posttraumatic Stress Disorder after Hurricane Sandy among Persons Exposed to the 9/11 Disaster

BACKGROUND

Traumatic exposure during a hurricane is associated with adverse mental health conditions post-event. The World Trade Center Health Registry provided a sampling pool for a rapid survey of persons directly affected by Hurricane Sandy in the New York City (NYC) metropolitan area in late October 2012. This study evaluated the relationship between Sandy experiences and Sandy-related posttraumatic stress disorder (PTSD) among individuals previously exposed to the September 11, 2001 (9/11) disaster.

METHODS

A total of 4,558 surveys were completed from April 10-November 7, 2013. After exclusions for missing data, the final sample included 2,214 (53.5%) respondents from FEMA-defined inundation zones and 1,923 (46.5%) from non-inundation zones. Sandy exposures included witnessing terrible events, Sandy-related injury, fearing for own life or safety of others, evacuation, living in a home that was flooded or damaged, property loss, and financial loss. Sandy-related PTSD was defined as a score of ≥44 on a Sandy-specific PTSD Checklist.

RESULTS

PTSD prevalence was higher in the inundation zones (11.3%) and lower in the non-inundation zones (4.4%). The highest prevalence of Sandy-related PTSD was among individuals in the inundation zone who sustained an injury (31.2%), reported a history of 9/11-related PTSD (28.8%), or had low social support prior to the event (28.6%). In the inundation zones, significantly elevated adjusted odds of Sandy-related PTSD were observed among persons with a prior history of 9/11-related PTSD, low social support, and those who experienced a greater number of Sandy traumatic events.

CONCLUSIONS

Sandy-related stress symptoms indicative of PTSD affected a significant proportion of persons who lived in flooded areas of the NYC metropolitan area. Prior 9/11-related PTSD increased the likelihood of Sandy-related PTSD, while social support was protective. Public health preparation for events similar to Sandy should incorporate outreach and linkages to care for persons with prior disaster-related trauma.

Chronic probable PTSD in police responders in the world trade center health registry ten to eleven years after 9/11

BACKGROUND

Police enrolled in the World Trade Center Health Registry (WTCHR) demonstrated increased probable posttraumatic stress disorder (PTSD) after the terrorist attack of 9/11/2001.

METHODS

Police enrollees without pre-9/11 PTSD were studied. Probable PTSD was assessed by Posttraumatic Stress Check List (PCL). Risk factors for chronic, new onset or resolved PTSD were assessed using multinomial logistic regression.

RESULTS

Half of police with probable PTSD in 2003-2007 continued to have probable PTSD in 2011-2012. Women had higher prevalence of PTSD than men (15.5% vs. 10.3%, P = 0.008). Risk factors for chronic PTSD included decreased social support, unemployment, 2+ life stressors in last 12 months, 2+ life-threatening events since 9/11, 2+ injuries during the 9/11 attacks, and unmet mental health needs.

CONCLUSION

Police responders to the WTC attacks continue to bear a high mental health burden. Improved early access to mental health treatment for police exposed to disasters may be needed.

The role of epidemiology in disaster response policy development

PURPOSE

Disasters expose the general population and responders to a range of potential contaminants and stressors which may harm physical and mental health. This article addresses the role of epidemiology in informing policies after a disaster to mitigate ongoing exposures, provide care and compensation, and improve preparedness for future disasters.

METHODS

The World Trade Center disaster response is used as a case study. We examine how epidemiologic evidence was used to shape postdisaster policy and identify important gaps in early research.

RESULTS

In the wake of World Trade Center attacks, epidemiologic research played a key role in identifying and characterizing affected populations, assessing environmental exposures, quantifying physical and mental health impacts, and producing evidence to ascribe causation. However, most studies suffered from methodological challenges, including delays, selection biases, poor exposure measurement, and nonstandardized outcomes. Gaps included measuring unmet health needs and financing coverage, as well as coordination across longitudinal cohorts of studies for rare conditions with long latency, such as cancer.

CONCLUSIONS

Epidemiologists can increase their impact on evidence-based policymaking by ensuring core mechanisms are in place before a disaster to mount monitoring of responders and other affected populations, improve early exposure assessment efforts, identify critical gaps in scientific knowledge, and coordinate communication of scientific findings to policymakers and the public.

Posttraumatic stress and other health consequences of catastrophic avalanches: A 16-year follow-up of survivors

To date, no study has investigated the effects of avalanches on survivor's health beyond the first years. The aim of this study was to examine long-term health status 16 years after exposure to avalanches using a matched cohort design. Mental health, sleep quality and somatic symptoms among avalanche survivors (n=286) and non-exposed controls (n=357) were examined. Results showed that 16% of survivors currently experience avalanche-specific PTSD symptoms (PDS score>14). In addition, survivors presented with increased risk of PTSD hyperarousal symptoms (>85th percentile) (aRR=1.83; 98.3% CI [1.23-2.74]); sleep-related problems (PSQI score>5) (aRR=1.34; 95% CI [1.05-1.70]); PTSD-related sleep disturbances (PSQI-A score≥4) (aRR=1.86; 95% CI [1.30-2.67]); musculoskeletal and nervous system problems (aRR 1.43; 99% CI 1.06-1.93) and gastrointestinal problems (aRR 2.16; 99% CI 1.21-3.86) compared to the unexposed group. Results highlight the need for treatment for long-term PTSD symptoms and sleep disruption in disaster communities.

Perceptions of distress and positive consequences following exposure to a major disaster amongst a well-studied cohort

OBJECTIVES

Research on the impact of natural disasters on health and well-being faces several methodological challenges, including: sampling issues; exposure assessment; and outcome measurement. The present study used a comprehensive measure of disaster exposure to assess relationships between exposure to the Canterbury (New Zealand) Earthquakes of 2010-2011 and both: (a) self-reported distress and (b) positive outcomes; and also investigated gender differences in reports.

METHODS

Data were gathered from the Christchurch Health and Development Study, a 35-year longitudinal study. The study examined data from 495 individuals exposed to the Canterbury Earthquakes for who complete data on exposure and reactions to the earthquakes at age 35 were available.

RESULTS

Participants with higher levels of exposure to the earthquakes reported significantly (p<0.0001) higher levels of distress due to fear, death and injury, and disruption caused by the earthquakes. Higher levels of exposure to the earthquakes were also associated with significantly (p<0.0001) higher levels of reporting positive consequences following the earthquakes. Women reported significantly (p<0.0001) greater distress than men and significantly (p<0.001) greater positive consequences.

CONCLUSIONS

Higher levels of exposure to disaster were associated with higher levels of distress, but also with higher levels of self-reported positive outcomes, with females reporting higher levels of both positive and negative outcomes. The findings highlight the need for comprehensive assessment of disaster exposure, to consider gender and other group differences in reactions to disaster exposure, and for studies of disasters to examine both positive and negative consequences.

Comorbidity of 9/11-related PTSD and depression in the World Trade Center Health Registry 10-11 years postdisaster

Many studies report elevated prevalence of posttraumatic stress disorder (PTSD) and depression among persons exposed to the September 11, 2001 (9/11) disaster compared to those unexposed; few have evaluated long-term PTSD with comorbid depression. We examined prevalence and risk factors for probable PTSD, probable depression, and both conditions 10-11 years post-9/11 among 29,486 World Trade Center Health Registry enrollees who completed surveys at Wave 1 (2003-2004), Wave 2 (2006-2007), and Wave 3 (2011-2012). Enrollees reporting physician diagnosed pre-9/11 PTSD or depression were excluded. PTSD was defined as scoring ≥ 44 on the PTSD Checklist and depression as scoring ≥ 10 on the 8-item Patient Health Questionnaire. We examined 4 groups: comorbid PTSD and depression, PTSD only, depression only, and neither. Among enrollees, 15.2% reported symptoms indicative of PTSD at Wave 3, 14.9% of depression, and 10.1% of both. Comorbid PTSD and depression was associated with high 9/11 exposures, low social integration, health-related unemployment, and experiencing ≥ 1 traumatic life event post-9/11. Comorbid persons experienced poorer outcomes on all PTSD-related impairment measures, life satisfaction, overall health, and unmet mental health care need compared to those with only a single condition. These findings highlight the importance of ongoing screening and treatment for both conditions, particularly among those at risk for mental health comorbidity.

Posttraumatic stress disorder and new-onset diabetes among adult survivors of the World Trade Center disaster

OBJECTIVE

To explore the temporal relationship between 9/11-related posttraumatic stress disorder (PTSD) and new-onset diabetes in World Trade Center (WTC) survivors up to 11 years after the attack in 2001.

METHODS

Three waves of surveys (conducted from 2003 to 2012) from the WTC Health Registry cohort collected data on physical and mental health status, sociodemographic characteristics, and 9/11-related exposures. Diabetes was defined as self-reported, physician-diagnosed diabetes reported after enrollment. After excluding prevalent cases, there were 36,899 eligible adult enrollees. Logistic regression and generalized multilevel growth models were used to assess the association between PTSD measured at enrollment and subsequent diabetes.

RESULTS

We identified 2143 cases of diabetes. After adjustment, we observed a significant association between PTSD and diabetes in the logistic model [adjusted odds ratio (AOR) 1.28, 95% confidence interval (CI) 1.14-1.44]. Results from the growth model were similar (AOR 1.37, 95% CI 1.23-1.52).

CONCLUSION

This exploratory study found that PTSD, a common 9/11-related health outcome, was a risk factor for self-reported diabetes. Clinicians treating survivors of both the WTC attacks and other disasters should be aware that diabetes may be a long-term consequence.

Frequent binge drinking five to six years after exposure to 9/11: findings from the World Trade Center Health Registry

BACKGROUND

Exposure to 9/11 may have considerable long-term impact on health behaviors, including increased alcohol consumption. We examined the association between frequent binge drinking, posttraumatic stress disorder (PTSD), and number of 9/11-specific experiences among World Trade Center Health Registry (Registry) enrollees five-to-six years after 9/11.

METHODS

Participants included 41,284 lower Manhattan residents, workers, passers-by, and rescue/recovery workers aged 18 or older without a pre-9/11 PTSD diagnosis who completed Wave 1 (2003-2004) and Wave 2 (2006-2007) interviews. Frequent binge drinking was defined as consuming five or more drinks on five or more occasions in the prior 30 days at Wave 2. Probable PTSD was defined as scoring 44 or greater on the PTSD Checklist. 9/11 exposure was measured as the sum of 12 experiences and grouped as none/low (0-1), medium (2-3), high (4-5) and very high (6+).

RESULTS

Frequent binge drinking was significantly associated with increasing 9/11 exposure and PTSD. Those with very high and high exposures had a higher prevalence of frequent binge drinking (13.7% and 9.8%, respectively) than those with medium and low exposures (7.5% and 4.4%, respectively). Upon stratification, very high and high exposures were associated with frequent binge drinking in both the PTSD and no PTSD subgroups.

CONCLUSIONS

Our findings suggest that 9/11 exposure had an impact on frequent binge drinking five-to-six years later among Registry enrollees. Understanding the effects of traumatic exposure on alcohol use is important to identify risk factors for post-disaster alcohol misuse, inform policy, and improve post-disaster psychological and alcohol screening and counseling.

Unmet mental health care need 10-11 years after the 9/11 terrorist attacks: 2011-2012 results from the World Trade Center Health Registry

BACKGROUND

There is little current information about the unmet mental health care need (UMHCN) and reasons for it among those exposed to the World Trade Center (WTC) terrorist attacks. The purpose of this study was to assess the level of UMHCN among symptomatic individuals enrolled in the WTC Health Registry (WTCHR) in 2011-2012, and to analyze the relationship between UMHCN due to attitudinal, cost, and access factors and mental health symptom severity, mental health care utilization, health insurance availability, and social support.

METHODS

The WTCHR is a prospective cohort study of individuals with reported exposure to the 2001 WTC attacks. This study used data from 9,803 adults who completed the 2003-2004 (Wave 1) and 2011-2012 (Wave 3) surveys and had posttraumatic stress disorder (PTSD) or depression in 2011-2012. We estimated logistic regression models relating perceived attitudinal, cost and access barriers to symptom severity, health care utilization, a lack of health insurance, and social support after adjusting for sociodemographic characteristics.

RESULTS

Slightly more than one-third (34.2%) of study participants reported an UMHCN. Symptom severity was a strong predictor of UMHCN due to attitudinal and perceived cost and access reasons. Attitudinal UMHCN was common among those not using mental health services, particularly those with relatively severe mental health symptoms. Cost-related UMHCN was significantly associated with a lack of health insurance but not service usage. Access-related barriers were significantly more common among those who did not use any mental health services. A higher level of social support served as an important buffer against cost and access UMHCN.

CONCLUSIONS

A significant proportion of individuals exposed to the WTC attacks with depression or PTSD 10 years later reported an UMHCN, and individuals with more severe and disabling conditions, those who lacked health insurance, and those with low levels of social support were particularly vulnerable.

Implications of the World Trade Center Health Program (WTCHP) for the public health response to the Great East Japan Earthquake

The attacks on the World Trade Center (WTC) on September 11, 2001 resulted in a serious burden of physical and mental illness for the 50,000 rescue workers that responded to 9/11 as well as the 400,000 residents and workers in the surrounding areas of New York City. The Zadroga Act of 2010 established the WTC Health Program (WTCHP) to provide monitoring and treatment of WTC exposure-related conditions and health surveillance for the responder and survivor populations. Several reports have highlighted the applicability of insights gained from the WTCHP to the public health response to the Great East Japan Earthquake. Optimal exposure monitoring processes and attention to the welfare of vulnerable exposed sub-groups are critical aspects of the response to both incidents. The ongoing mental health care concerns of 9/11 patients accentuate the need for accessible and appropriately skilled mental health care in Fukushima. Active efforts to demonstrate transparency and to promote community involvement in the public health response will be highly important in establishing successful long-term monitoring and treatment programs for the exposed populations in Fukushima.