Mental health needs in New York state following the September 11th attacks

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.

The Impact of Community Disaster Trauma: A Focus on Emerging Research of PTSD and Other Mental Health Outcomes

This paper reviews community residents' mental health following exposure to a community disaster trauma, with a focus on post-traumatic stress disorder (PTSD) and other mental health outcomes, such as emotional disorders, behavioral problems including addictive disorders, and personality as a maladaptive trait. This review concludes with recommendations to advance the field of community disaster research by exploring how natural and man-made disasters impact community residents across multiple domains. Moreover, this study suggests that residents impacted by community disaster trauma are frequently appropriate targets for mental health assessments or services in a community setting.

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.

The World Trade Center attack: mental health needs and treatment implications

On 11 September 2001, the United States suffered the worst terrorist attacks in its history. In New York City, approximately 3000 persons were killed at the World Trade Center, while many thousands fled for their lives. Millions of other city residents observed the burning towers and breathed the acrid smoke that blanketed the city. Compounding the massive physical destruction and loss of life, the psychological impact of these terrifying events on the populace was profound – there were significant increases in mental distress and symptoms of disorder.

Unresolved Bereavement and Other Mental Health Problems in Parents of the Sewol Ferry Accident after 18 Months

OBJECTIVE

This study examined the overall mental health consequences of the bereaved parents after the Sewol ferry accident.

METHODS

Eighty-four bereaved parents participated in the study. Self-report scales assessing the severity of psychiatric symptoms and other related psychosomatic problems were used at 18 months following the accident. Univariate descriptive statistics and regression analyses were performed to report the prevalence, severity, and correlates of psychiatric symptoms.

RESULTS

94% of the participants appeared to suffer from complicated grief based on scores on the Inventory of Complicated Grief (ICG). Half of the participants were categorized as having severe depression and 70.2% reported clinically significant post-traumatic symptoms according to scores on the Patient Health Questionnaire-9 (PHQ-9) and PTSD Check List-5 (PCL-5). No significant differences by gender were observed in the severity of psychiatric symptoms. A higher educational level was associated with more severe psychiatric symptoms in fathers.

CONCLUSION

The loss of a child due to a disaster caused by human error may continue to have a substantial impact on parental mental health at 18 months after the event. A longitudinal study following parents' mental health state would be necessary to investigate the long-term effects of the traumatic experience in the future.

Disaster Mental Health Epidemiology: Methodological Review and Interpretation of Research Findings

Worldwide, disasters are increasing in frequency and severity. Mental health consequences of disasters are extensive, and knowledge of anticipated mental health effects is needed for effective disaster response. Difficulties inherent in conducting disaster research have limited the understanding of research findings. This article presents and interprets disaster mental health research findings in the context of research methods. A brief history of the disaster mental health research field is provided, and the presentation of findings is ordered into topical areas of disaster mental health consequences and timing and prediction of mental health outcomes. Results of different studies varied greatly by several main characteristics of research methods, especially methods of psychiatric assessment, sampling and exposure group determination, and consideration of confounding variables. In conclusion, many complexities in conducting disaster mental health research have limited the understanding and interpretation of available knowledge needed to inform efforts to plan and carry out effective mental health responses to disasters. Thoughtful interpretation of findings in the context of research design and methods is vital to accurate understanding of the types, prevalence, and predictors of anticipated mental health effects of disasters. A wealth of knowledge from disaster mental health research has accumulated in recent decades, but more research is still needed to resolve inconsistent findings through methodological refinements.

Anxiety, Depressed Mood, Self-Esteem, and Traumatic Stress Symptoms among Distant Witnesses of the 9/11 Terrorist Attacks: Transitory Responses and Psychological Resilience

Posttraumatic stress related to the September 11, 2001 terrorist attacks and general psychological distress were examined in six cohorts of college students (N=5,412) enrolled at an American public university between Spring 2000 and Fall 2002 some 2,500 miles from New York. Consistent with data from Schuster et al.'s (2001) national survey, which used a very low threshold criterion, our findings revealed that 44% of women and 32% of men experienced at least one symptom of posttraumatic stress 6-17 days after the attacks. In contrast to these results, depression levels showed only small differences, and self-esteem and trait anxiety showed no changes. Findings indicate that 9/11-related stress responses among distant witnesses were very mild, transitory and focused in scope, suggesting resilience with respect to broader psychological and psychopathological reactions. Findings are discussed with respect to the role of physical and psychological proximity on the reactions to traumatic events in the general population.

Post-Traumatic Stress Reactions Following the March 11, 2004 Terrorist Attacks in a Madrid Community Sample: A Cautionary Note about the Measurement of Psychological Trauma

Posttraumatic stress reactions related to the Madrid March 11, 2004, terrorist attacks were examined in a sample of Madrid residents (N = 503) 18-25 days after the attacks, using multiple diagnostic criteria and different cut-off scores. Based on the symptoms covered by the Posttraumatic Stress Disorder Checklist-Civilian (PCL-C; Weathers, Litz, Herman, Huska, & Keane, 1993), rates of probable posttraumatic stress disorder (PTSD) ranged from 3.4% to 13.3%. Taking into account additional criteria from the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 200; i.e., the impact of initial reaction and problems in daily functioning as a consequence of the traumatic event), only 1.9% of respondents reported probable PTSD. These results suggest that inferences about the impact of traumatic events on the general population are strongly influenced by the definition of traumatic response. Our findings also revealed that the magnitude of posttraumatic reactions is associated with several risk factors, including living close to the attacked locations, physical proximity to the attacks when they occurred, perception of one's life being at risk, intensity of initial emotional reactions, and being a daily user of the attacked train lines. The use of different cut-off scores did not affect the pattern of risk to develop traumatic stress. The implications of these results for public health policies related to terrorist attacks are discussed.

Policy and administrative issues for large-scale clinical interventions following disasters

OBJECTIVE

Large, programmatic mental health intervention programs for children and adolescents following disasters have become increasingly common; however, little has been written about the key goals and challenges involved.

METHODS

Using available data and the authors' experiences, this article reviews the factors involved in planning and implementing large-scale treatment programs following disasters.

RESULTS

These issues include funding, administration, choice of clinical targets, workforce selection, choice of treatment modalities, training, outcome monitoring, and consumer uptake. Ten factors are suggested for choosing among treatment modalities: 1) reach (providing access to the greatest number), 2) retention of patients, 3) privacy, 4) parental involvement, 5) familiarity of the modality to clinicians, 6) intensity (intervention type matches symptom acuity and impairment of patient), 7) burden to the clinician (in terms of time, travel, and inconvenience), 8) cost, 9) technology needs, and 10) effect size. Traditionally, after every new disaster, local leaders who have never done so before have had to be recruited to design, administer, and implement programs.

CONCLUSION

As expertise in all of these areas represents a gap for most local professionals in disaster-affected areas, we propose that a central, nongovernmental agency with national or international scope be created that can consult flexibly with local leaders following disasters on both overarching and specific issues. We propose recommendations and point out areas in greatest need of innovation.

Analyzing Postdisaster Surveillance Data: The Effect of the Statistical Method

Data from existing administrative databases and ongoing surveys or surveillance methods may prove indispensable after mass traumas as a way of providing information that may be useful to emergency planners and practitioners. The analytic approach, however, may affect exposure prevalence estimates and measures of association. We compare Bayesian hierarchical modeling methods to standard survey analytic techniques for survey data collected in the aftermath of a terrorist attack. Estimates for the prevalence of exposure to the terrorist attacks of September 11, 2001, varied by the method chosen. Bayesian hierarchical modeling returned the lowest estimate for exposure prevalence with a credible interval spanning nearly 3 times the range of the confidence intervals (CIs) associated with both unadjusted and survey procedures. Bayesian hierarchical modeling also returned a smaller point estimate for measures of association, although in this instance the credible interval was tighter than that obtained through survey procedures. Bayesian approaches allow a consideration of preexisting assumptions about survey data, and may offer potential advantages, particularly in the uncertain environment of postterrorism and disaster settings. Additional comparative analyses of existing data are necessary to guide our ability to use these techniques in future incidents. (Disaster Med Public Health Preparedness. 2008;2:119–126)

The Impact of Disasters on Populations With Health and Health Care Disparities

Context:A disaster is indiscriminate in whom it affects. Limited research has shown that the poor and medically underserved, especially in rural areas, bear an inequitable amount of the burden.

Objective:To review the literature on the combined effects of a disaster and living in an area with existing health or health care disparities on a community's health, access to health resources, and quality of life.

Methods:We performed a systematic literature review using the following search terms: disaster, health disparities, health care disparities, medically underserved, and rural. Our inclusion criteria were peer-reviewed, US studies that discussed the delayed or persistent health effects of disasters in medically underserved areas.

Results:There has been extensive research published on disasters, health disparities, health care disparities, and medically underserved populations individually, but not collectively.

Conclusions:The current literature does not capture the strain of health and health care disparities before and after a disaster in medically underserved communities. Future disaster studies and policies should account for differences in health profiles and access to care before and after a disaster.

(Disaster Med Public Health Preparedness. 2010;4:30-38)

Alcohol use in Polish 9/11 responders: implications for cross-cultural treatment

More than 35,000 individuals are estimated to have responded to the World Trade Center (WTC) site following the terrorist attacks of September 11, 2001. The federally funded WTC Medical Monitoring and Treatment Program (WTCMMTP) provides medical monitoring and occupational medicine treatment as well as counseling regarding entitlements and benefits to the workers and volunteers who participated in the WTC response. A major component of the WTCMMTP is the WTC Mental Health Program (WTCMHP), which offers annual mental health assessments and ongoing treatment for those found to have 9/11 associated mental health problems. In the program's 9.5 years of evaluating and treating mental health problems in thousands of Ground Zero responders, diversity in multiple domains (e.g., gender, family, profession and employment status, state of physical health, cultural identity, and immigration status) has been a hallmark of the population served by the program. To illustrate the types of issues that arise in treating this diverse patient population, the authors first present a representative case involving a Polish asbestos worker with an alcohol use disorder. They then discuss how accepted alcohol treatment modalities can and often must be modified in providing psychiatric treatment to Polish responders, in particular, and to foreign-born patients in general. Treatment modalities discussed include cognitive and behavioral therapy, relapse prevention strategies, psychodynamic therapy, motivational approaches, family therapy, group peer support, and pharmacotherapy. Implications for the practice of addiction psychiatry, cultural psychiatry, and disaster psychiatry are discussed.

PTSD in Children Younger Than the Age of 13: Toward Developmentally Sensitive Assessment and Management

Assessment of posttraumatic stress disorder (PTSD) is more difficult compared to other disorders for multiple reasons that are listed and explained. Multiple causes of low sensitivity for making the PTSD diagnosis in children are discussed. Diagnostic validity and comorbidity issues in particular are highlighted. For the diagnostic criteria, wording changes to five of the items have been proposed, but the most substantial proposed change is lowering the criterion C requirement from three to one symptom. Early studies suggest the course is more chronic. Parenting effects are reviewed and caution is urged before drawing premature conclusions about the directionality of effects. Advice for interviewing respondents is organized into seven practical suggestions. Treatment implications from the above are discussed.

Complicated grief associated with hurricane Katrina

BACKGROUND

Although losses are important consequences of disasters, few epidemiological studies of disasters have assessed complicated grief (CG) and none assessed CG associated with losses other than death of loved one.

METHODS

Data come from the baseline survey of the Hurricane Katrina Community Advisory Group, a representative sample of 3,088 residents of the areas directly affected by Hurricane Katrina. A brief screen for CG was included containing four items consistent with the proposed DSM-V criteria for a diagnosis of bereavement-related adjustment disorder.

RESULTS

Fifty-eight and half percent of respondents reported a significant hurricane-related loss: Most-severe losses were 29.0% tangible, 9.5% interpersonal, 8.1% intangible, 4.2% work/financial, and 3.7% death of loved one. Twenty-six point one percent respondents with significant loss had possible CG and 7.0% moderate-to-severe CG. Death of loved one was associated with the highest conditional probability of moderate-to-severe CG (18.5%, compared to 1.1-10.5% conditional probabilities for other losses), but accounted for only 16.5% of moderate-to-severe CG due to its comparatively low prevalence. Most moderate-to-severe CG was due to tangible (52.9%) or interpersonal (24.0%) losses. Significant predictors of CG were mostly unique to either bereavement (racial-ethnic minority status, social support) or other losses (prehurricane history of psychopathology, social competence.).

CONCLUSIONS

Nonbereavement losses accounted for the vast majority of hurricane-related possible CG despite risk of CG being much higher in response to bereavement than to other losses. This result argues for expansion of research on CG beyond bereavement and alerts clinicians to the need to address postdisaster grief associated with a wide range of losses.

Disaster mental health training programmes in New York City following September 11, 2001

The need for mental health resources to provide care to the community following large-scale disasters is well documented. In the aftermath of the World Trade Center (WTC) disaster on September 11, 2001, many local agencies and organizations responded by providing informal mental health services, including disaster mental health training for practitioners. The quality of these programmes has not been assessed, however. The National Center for Disaster Preparedness at Columbia University's School of Public Health reviewed disaster mental health training programmes administered by community-based organizations, professional associations, hospitals, and government agencies after September 11. Results indicate that the quality and the effectiveness of programmes are difficult to assess. A wide range of curricula and a widespread lack of recordkeeping and credentialing of trainers were noted. Most of the training programmes provided are no longer available. Recommendations for improving the quality of disaster mental health training programmes are provided.

Prevalence and risk factors for posttraumatic stress disorder: a cross-sectional study among survivors of the Wenchuan 2008 earthquake in China

BACKGROUND

The impact of the May 2008 Wenchuan earthquake, measuring a massive 8.0 on the surface wave magnitude scale, on public health in China has been significant and multifaceted. In light of extant data on prevalence and risk factors for posttraumatic stress disorder (PTSD) after other natural diasters, we collected data from the Wenchuan earthquake survivors to estimate the prevalence of PTSD and to characterize a range of PTSD risk factors.

METHODS

A cross-sectional multicluster sample survey of 446 respondents (201 from the Qiang ethnic-minority group, 245 the majority Han Chinese group) was conducted in August 2008 in Beichuan county, Sichuan province, a region that was severely affected by the earthquake. In total, 240 households were represented, with a mean of 2.2 respondents per household. Data were collected from structured interviews and the Harvard Trauma Questionnaire (HTQ) and DSM-IV criteria were used to diagnose PTSD.

RESULTS

The prevalence of PTSD was 45.5% (203/446). Low household income, being from an ethnic minority, living in a shelter or temporary house, death in family, and household damage were factors significantly related to increased odds of PTSD.

CONCLUSIONS

PTSD is common after a major disaster. Postdisaster mental health recovery programs that include early identification, ongoing monitoring, preventive and intervention programs, and sustained psychosocial support are needed for the highest-risk population, namely, the bereaved, people without incomes and those with serious household damage. These populations may also benefit from governmental and nongovernmental programs that provide social and economic support, as suggested by earlier studies.

Health consequences of the September 11 World Trade Center attacks: a review

In the aftermath of the September 11 World Trade Center (WTC) attack, a large number of people sustained potential exposures to smoke, dust, particulate matter, and a variety of toxins, including asbestos, pulverized concrete, glass fibers, polycyclic aromatic hydrocarbons (PAHs), and polychlorinated furans and dioxins. Additionally, many had exposure to psychological traumatogens. The most common effects seen to date are respiratory and mental health consequences. The long-term consequences of exposures are not yet known, and there remains concern about the potential for late-emerging diseases such as cancers. This article reviews WTC-related health effects, the spectrum of exposures and how they were documented, and discusses future preventive efforts.

A changed America? The effects of September 11th on depressive symptoms and alcohol consumption

In the weeks following the terrorist attacks of September 11, 2001, social commentators argued that America had profoundly "changed." In light of these arguments and the literature on disasters, we examine the immediate and longer-term mental health consequences of September 11th using a national sample of full-time American workers. We model the effects of temporal proximity to the attacks on depressive symptoms and alcohol consumption, while controlling for demographic characteristics. Our data revealed a significant increase in the number of depressive symptoms reported during the 4 weeks after the attacks. In the subsequent weeks, levels of depressive symptoms returned to pre-September 11th levels. Contrary to expectations, there was some indication of decreased alcohol consumption after September 11th, although these effects were modest. These analyses provide little support for popular assertions that September 11th resulted in lasting and measurable impacts on Americans' well-being.

Emotional and behavioral consequences of bioterrorism: planning a public health response

Millions of dollars have been spent improving the public health system's bioterrorism response capabilities. Yet relatively little attention has been paid to precisely how the public will respond to bioterrorism and how emotional and behavioral responses might complicate an otherwise successful response. This article synthesizes the available evidence about the likely emotional and behavioral consequences of bioterrorism to suggest what decision makers can do now to improve that response. It examines the emotional and behavioral impact of previous "bioterrorism-like" events and summarizes interviews with experts who have responded to such events or conducted research on the effects of community-wide disasters. The article concludes by reflecting on the evidence and experts' perspectives to suggest actions to be taken now and future policy and research priorities.

Approaching disaster mental health research after the 9/11 World Trade Center terrorist attacks

The article describes the author's experiences with disaster research in the post-9/11 period, first in application of prior research findings to the new situation and later in consultation on the design and development of new research specific to 9/11. The article begins by reviewing the important role of the science of disaster mental health, which was reinforced by the many requests for information from prior research for application to the post-9/11 situation. Next, the article summarizes enduring principles of disaster research application that apply across disaster sites, including 9/11. Addressing unique aspects of the post-9/11 setting, novel considerations for the disaster mental health field are introduced with a new model for conceptualization of subpopulations based on exposure level. Experience in developing research in the post-9/11 setting encountered a number of issues, suggesting need for new policy recommendations that may facilitate research in future disaster settings.

Reactions and needs of tristate-area pediatricians after the events of September 11th: implications for children's mental health services

OBJECTIVE

The terrorist attacks of September 11, 2001, caused mass destruction in Lower Manhattan, the Pentagon, and rural Pennsylvania and resulted in the death of >3000 people. Children were prominent among those affected. Given the wide impact of the attacks, we hypothesized that primary care professionals would see the broad population of affected children but would feel ill-prepared to respond to children's mental health needs.

METHODS

One year after the September 11th disaster, a hyperlink to a web-based 42-item survey was sent to all New York, Connecticut, and New Jersey American Academy of Pediatrics members with e-mail addresses (N = 4330), and a paper version of the survey was sent via postal mail to a random sample of those without e-mail (N = 1320). The survey requested demographic data, personal and practice experience of 9/11, perceived knowledge and skills regarding mental health, and perceived barriers to accessing mental health services for their patients. Both groups were contacted a total of 3 times at 2-week intervals, resulting in 1396 completed surveys from providers who were actively seeing patients.

RESULTS

Twenty-nine percent of respondents stated that they were seeing affected patients, and 32.6% reported seeing children who were exposed to at least 1 9/11 event. Sixty-four percent of the respondents identified behavioral problems in directly affected children: 41.6% identified acute stress disorder, and 26.3% identified posttraumatic stress disorder (PTSD). However, a majority of these professionals indicated that they either lacked or were uncertain (50.8% PTSD, 51.7% acute stress disorder) of their skills to identify children with mental health problems and that they were "not" or only "somewhat" knowledgeable (76.8% PTSD) in these areas. The majority agreed that child health professionals should be trained to screen for these 2 disorders. Generalists as compared with specialists were more likely to report seeing patients who were affected by 9/11. Gender, race/ethnicity, and geographic location were associated with reported effects of 9/11 on respondents' practice and perceived skills and knowledge related to the psychological effects of community disasters.

CONCLUSIONS

Pediatric practitioners in the tristate area reported that children/families sought care for an array of mental health-related concerns. Generalists in the areas affected and those who identified gaps in knowledge or skills in responding to the psychological effects of community disasters should be targeted for additional education.

Unmet need for counseling services by children in New York City after the September 11th attacks on the World Trade Center: implications for pediatricians

OBJECTIVE

The objectives of this study were to describe the prevalence of counseling services, contrasted with the need after the terrorist attacks of September 11, 2001, the types of counseling received, and the predictors of receipt of counseling services.

METHODS

A cross-sectional, random-digit-dial survey was conducted in New York City (NYC) of parents (N = 434) of children who were 4 to 17 years of age 4 months after the September 11th terrorist attacks on the World Trade Center.

RESULTS

Overall, 10% of NYC children received some type of counseling after the September 11th attacks, according to parental report. Among these, 44% received counseling in schools, 36% received counseling from medical or professional providers, and 20% received counseling from other sources. However, only 27% of the children who had severe/very severe posttraumatic stress reactions (PTSR) after the attacks received counseling services. In a multivariate model, receipt of counseling before the September 11th attacks (odds ratio: 4.44) and having severe/very severe PTSR (odds ratio: 3.59) were the most important predictors of use of counseling services after the September 11th attacks. Minority status and having a parent who experienced the loss of a friend or a relative were also associated with receipt of services.

CONCLUSIONS

There was substantial disparity between apparent need (as indicated by severe/very severe PTSR) for and receipt of mental health services for children after the September 11th attacks. There is need for intensified efforts to identify, refer, and treat children in need, especially for children who are not already in a therapeutic relationship. An enhanced role for pediatricians is indicated.

Estimating capacity requirements for mental health services after a disaster has occurred: a call for new data

OBJECTIVES

We sought to estimate the extended mental health service capacity requirements of persons affected by the September 11, 2001, terrorist attacks.

METHODS

We developed a formula to estimate the extended mental health service capacity requirements following disaster situations and assessed availability of the information required by the formula.

RESULTS

Sparse data exist on current services and supports used by people with mental health problems outside of the formal mental health specialty sector. There also are few systematically collected data on mental health sequelae of disasters.

CONCLUSIONS

We recommend research-based surveys to understand service usage in non-mental health settings and suggest that federal guidelines be established to promote uniform data collection of a core set of items in studies carried out after disasters.

Mental health service use 1-year after the World Trade Center disaster: implications for mental health care

The objective of this study was to assess prevalence and predictors of mental health service use in New York City (NYC) after the World Trade Center disaster (WTCD). One year after the attacks, we conducted a community survey by telephone of 2368 adults living in NYC on September 11, 2001. In the past year, 19.99% (95% confidence interval [CI]=18.2-21.77) of New Yorkers had mental health visits and 8.1% (95% CI=7.04-9.16) used psychotropic medications. In addition, 12.88% (95% CI=11.51-14.25) reported one or more visits were related to the WTCD. Compared to the year before, 8.57% (95% CI=7.36-9.79) had increased post-disaster visits and 5.28% (95% CI=4.32-6.25) had new post-disaster treatment episodes. Psychotropic medication use related to the WTCD was 4.51% (95% CI=3.75-5.26). Increased post-disaster medication use, compared to the year before, was 4.11% (95% CI=3.35-4.86) and new medication episodes occurred among 3.01% (95% CI=2.34-3.69). In multivariate logistic analyses, mental health visits were associated with younger age, peri-event panic attack, posttraumatic stress disorder (PTSD) and depression. In addition, WTCD-related visits had a positive "dose-response" association with WTCD event exposures (P<0.0001). WTCD-related visits also were positively associated with peri-event panic, anxiety, lower self-esteem, PTSD, and depression. All three medication measures were positively related to PTSD and depression, and negatively associated with African American status. WTCD-related medication use also was positively related to younger age, female gender, WTCD event exposures, negative life events, anxiety and lower self-esteem. Finally, while the percentage of New Yorkers seeking post-disaster treatment did not increase substantially, the volume of visits among patients apparently increased. We conclude that exposure to WTCD events was related to post-disaster PTSD and depression, as well as WTCD-related mental health service use. African Americans were consistently less likely to use post-disaster medications. Although the WTCD did have an impact on treatment-seeking among current patients, it did not substantially increase mental health treatment among the general population.

The World Trade Center attack: mental health needs and treatment implications

On 11 September 2001, the United States suffered the worst terrorist attacks in its history. In New York City, approximately 3000 persons were killed at the World Trade Center, while many thousands fled for their lives. Millions of other city residents observed the burning towers and breathed the acrid smoke that blanketed the city. Compounding the massive physical destruction and loss of life, the psychological impact of these terrifying events on the populace was profound - there were significant increases in mental distress and symptoms of disorder.

Implications of the World Trade Center attack for the public health and health care infrastructures

The September 11, 2001, attack on the World Trade Center had profound effects on the well-being of New York City. The authors describe and assess the strengths and weaknesses of the city's response to the public health, environmental/ occupational health, and mental health dimensions of the attack in the first 6 months after the event. They also examine the impact on the city's health care and social service system. The authors suggest lessons that can inform the development of a post-September 11th agenda for strengthening urban health infrastructures.

Adherence to HIV medications in a cohort of men who have sex with men: impact of September 11th

Adherence to highly active antiretroviral therapy (HAART) regimens remains a challenge for people living with human immunodeficiency virus (HIV). Severe traumas like that of September 11, 2001, can exacerbate the difficulties already associated with adherence. A community-based sample of 68 HIV-seropositive men who have sex with men (MSM) living in New York City who were on protease inhibitor HAART regimens completed quantitative assessments to examine adherence in the aftermath of September 11th. Data were drawn from a larger study of drug use and HIV medication adherence. Assessments conducted from September 24, 2001 to October 24, 2001 were compared to assessments taken 2-4 months prior to September 11th. Repeated measures analyses of variance were used to analyze the number of missed and suboptimal doses (doses taken outside the prescribed time by +/-4 hours) reported in the 2 weeks prior to each respective assessment. The results indicated a significant increase in the number of missed doses and the number of suboptimal doses immediately after the events of September 11th. Differences in adherence were not influenced, however, by sociodemographic characteristics. These results suggest that the events of September 11th had an impact on adherence to HIV medications among MSM in New York City and provide further support for the notion that the events of September 11th may have adversely impacted the lives of seropositive individuals. Attention should be paid by clinicians working with HIV-positive individuals on how this event has been incorporated into lives of individuals already burdened by a chronic and demanding disease.

The public costs of mental health response: lessons from the New York City post-9/11 needs assessment

There is evidence of increased rates of psychiatric disorder in New York City in the period following September 11th. Public mental health services need to develop plans to respond to these higher rates of disorder. This article describes what we know and do not know with respect to the costs of such response. We examine evidence on the demand for mental health services, the nature of services to be provided, the characteristics of providers, and the likely sources of payment for care in the context of the attacks of September 11th in New York City.