Utilization of mental health services following the September 11th terrorist attacks in Manhattan,New York City

To assess mental health utilization in Manhattan following the September 11th terrorist attacks, a random-digit-dial telephone survey was conducted 5 to 8 weeks afterwards, among 988 randomly selected adult householders over 17 years old (females = 52%; whites = 72%; mean age = 42). 16.9% (95% confidence interval [CI] = 14.4-19.5) of residents reported using mental health services 30 days before the attacks and 19.4% (95% CI = 16.7-22.2) reported using these services 30 days afterwards (pre/post NcMemar's chi2 = 8.0, df = 1, p = 0.005, odds ratio[OR] = 2.0). 10.0% (95% CI = 7.9-12.0) increased mental health utilization 30 days after the attacks, compared to 30 days before and 5.3% (95% CI = 3.7-6.9) decreased utilization. Risk factors associated with increased mental health utilization in multivariate analyses included: being 45-64 years of age (vs. 65+; OR = 8.3, p = 0.011) female gender (OR = 2.3, p = 0.004), experiencing 4+ lifetime traumatic events (vs. none; OR = 3.5, p = 0.002), experiencing 2+ stressful life events in the past 12 months (vs. none; OR = 3.3, p < 0.001), and experiencing an acute panic attack during the disaster (OR = 3.3, p < 0.001). Neither current post-traumatic stress disorder (PTSD) nor current depression was predictive of increased post-disaster utilization when panic attack was included in the multivariate analysis. While we did find a statistically significant increase in pre- vs. post-disaster utilization among the general population in Manhattan this increase was not substantial, except among specific subgroups, including those who had a perievent panic attack, among those exposed to previous stressors, among women, and among those less than 65 years old.     

Predictors of peritraumatic reactions and PTSD following the September 11th terrorist attacks

In this study the authors characterize peritraumatic reactions of residents of New York City during and immediately following the September 11th terrorist attacks, identify predictors of those reactions, and identify predictors of PTSD 4 months later. A cross-sectional sample of New York residents (n = 2,001) responded to questions about sociodemographics, historical factors, event-related exposure; acute cognitive, emotional, and physiological reactions to the September 11th terrorist attacks; and current (past month) PTSD symptoms. Factor analyses of peritraumatic reactions yielded three related, but distinct, peritraumatic response patterns - dissociation, emotional reactions, and panic/physiological arousal. Several demographic, historical, and exposure-related variables predicted one or more peritraumatic reaction patterns. After controlling for demographic, historical, and exposure factors, each of the peritraumatic reactions factors, one historical factor and one event-related exposure factor remained as significant predictors of PTSD. These results support a growing literature concerning the predictive value of peritraumatic reactions in relation to PTSD. Implications for preventive efforts and suggestions for future research are discussed.     

A national longitudinal study of the psychological consequences of the September 11, 2001 terrorist attacks: reactions, impairment, and help-seeking

This article examines the evolution of psychological and behavioral reactions following the September 2001 terrorist attacks in a nationally representative sample, and describes where people turned for support, information, and counseling. From November 9 to November 28, 2001, we resurveyed 395 (71%) of the original 560 adults 19 years or older within the United States who participated in our national random-digit-dialing telephone survey conducted on September 14 to September 16, 2001, about their terrorism-related psychological distress and behavior. Sixteen percent of adults had persistent distress, reporting one or more substantial distress symptoms in both September and November. Adults with persistent distress reported accomplishing less at work (65%); avoiding public gathering places (24%); and using alcohol, medications, or other drugs to relax, sleep, or feel better because of worries about terrorism (38%). Seventy-five percent talked with family and friends; however, 43% reported sometimes feeling unable to share their terrorism-related thoughts and feelings with others because it made others uncomfortable. Few reported receiving counseling or information about psychological distress from general medical providers (11%). These findings suggest that a significant number of adults across the country were continuing to experience terrorism-related distress and disruption of their daily lives approximately 2 months after September 11; many turned to family and friends for support, but at times many felt uncomfortable doing so, and few used clinicians as a source of information or support. Clinicians and policymakers should consider how the healthcare system and other community organizations might provide a coordinated community-wide response for individuals needing information and counseling following terrorist events.     

Elementary school children's responses 3 months after the September 11 terrorist attacks: a study in Washington, DC

This study examined the responses of elementary school children in Washington, DC, to the September 11 terrorist attacks. Parents (primarily mothers) of children in kindergarten through Grade 6 and children in Grades 4 to 6, including 47 matched parent-child pairs, completed questionnaires regarding exposure, stress reactions, and constructive actions taken 3 months after the attacks. Parent reports and, to an even greater extent, children's self-reports revealed high levels of negative reactions to the attacks on behalf of the children. These reactions were best understood in the context of their exposure to the attacks, primarily through television news, and the reactions of and coping assistance provided by their parents. Implications for school personnel, health care professionals, and intervention efforts are discussed.     

Post-trauma symptoms following indirect exposure to the September 11th terrorist attacks: The predictive role of dispositional coping

Few data prospectively address the role of coping in the development of PTSD. In the present study, 308 undergraduates were assessed for coping prior to the 9/11 WTC attack and for PTSD symptomatology at one and three-months post-9/11. Multiple regression analyses indicated that emotion-focused coping was predictive of increased symptomatology at Month 1 and Month 3, whereas problem-focused and avoidance-focused coping were not. Specifically, analyses predicting PTSD symptom factors (Intrusions, Avoidance, Dysphoria, and Hyperarousal) indicated that greater emotion-focused coping predicted increased Dysphoria symptoms at both time points and, among females, increased levels of Hyperarousal symptoms at Month 1. The role of coping style in the development of PTSD symptomatology and its clinical implications are discussed.     

Psychiatric patients' vulnerability in the wake of the September 11th terrorist attacks

The September 11, 2001 (9/11) terrorist attacks led to speculation about the vulnerability of psychiatric patients to psychological distress following such events. This study examined the impact of national terrorist attacks on psychiatric and medical outpatients living approximately 150 to 200 miles from the attack sites (N = 308). Two to 3 weeks following 9/11, patients were given questionnaires assessing background information, healthcare service utilization, and posttraumatic stress disorder (PTSD) symptoms. Psychiatric patients (33%) were significantly more likely than medical patients (13%) to report distressing symptoms meeting criteria for PTSD (except for the duration criterion) despite no differences in learning about the attacks or personal involvement with the victims. Patients meeting PTSD criteria were more likely to schedule an appointment to speak with their physician about their reactions. Psychiatric patients not directly impacted by the 9/11 terrorist attacks are at increased risk for experiencing distressing symptoms following national terrorist attacks.     

Compassion fatigue following the September 11 terrorist attacks: a study of secondary trauma among New York City social workers

Experience suggests that individuals working in the caring and psychotherapeutic professions are among those to provide mental health services to disaster victims suffering from psychological trauma following catastrophic events. Yet, few studies have focused on the emotional exhaustion from working with such clients, referred to as compassion fatigue (CF) in this study, and how CF differs from other occupational hazards, such as secondary trauma (ST) and job burnout. In the present study, we used recently validated scales to predict ST and job burnout related to providing services to those affected by the World Trade Center (WTC) attacks. Our study data were based on a random survey of 236 social workers living in New York City (NYC), over 80% of which reported being involved in post-WTC disaster counseling efforts. Our analyses indicated that controlling for demographic factors, years of counseling, and personal trauma history, ST was positively associated with WTC recovery involvement (p <. 001) and negatively associated with having a supportive work environment (p < . 01). In contrast, job burnout was negatively associated with having a supportive work environment (p < .01), but not associated with WTC involvement or WTC counseling efforts. We discuss these results in light of future conceptual and empirical research needs.     

Prevalence and predictors of posttraumatic stress symptoms in utility workers deployed to the World Trade Center following the attacks of September 11, 2001

Background: Recent attention has begun to be focused on the effects of disaster recovery work on nonrescue workers. The goal of this study was to assess the prevalence and predictors of posttraumatic stress disorder (PTSD) and related symptoms in a population of utility workers deployed to the World Trade Center (WTC) site in the aftermath of 9/11. Methods: Utility workers deployed to the WTC site were screened at their place of employment between 10 and 34 months following the WTC attacks, utilizing both structured interviews and self‐report measures. PTSD symptoms were assessed by the CAPS and the PCL; co‐morbid disorders were also assessed. 2,960 individuals with complete CAPS and PCL data were included in the analyses. Results: Eight percent of participants had symptoms consistent with full PTSD, 9.3% with subthreshold PTSD, 6% with MDD, 3.5% with GAD, and 2.5% with panic disorder. Although risk factors included psychiatric and trauma history, 51% of individuals with probable PTSD had neither; subjective perception of threat to one's life was the best predictor of probable PTSD. Extent of exposure predicted 89% of PTSD cases in those without a psychiatric or trauma history, but only 67% of cases among those with both. Conclusions: Nonrescue workers deployed to a disaster site are at risk for PTSD and depression. Extent of exposure affected the most vulnerable workers differently than the least vulnerable ones. These results suggest that the relationship among predictors of PTSD may be different for different vulnerability groups, and underscore the importance of screening, education, and prevention programs for disaster workers. Depression and Anxiety 28:210–217, 2011. © 2010 Wiley‐Liss, Inc.     

Psychiatric emergencies after the terrorist attacks of September 11, 2001

OBJECTIVE: Population surveys suggest that the events of September 11, 2001, resulted in psychiatric emergencies in U.S. communities. This study tested the extent of such emergencies in San Francisco. METHOD:S: Interrupted time-series designs were applied to counts of emergency calls to the police during the 424-day period beginning January 1, 2001, and of voluntary and coerced admissions to psychiatric emergency services during the 1620-day period beginning July 1, 1997. RESULTS: The number of men and women who were coerced into treatment increased significantly on Thursday, September 13, but the number of voluntary admissions was as expected. The number of telephone calls from citizens that police dispatchers judged to be mental health related increased significantly on Wednesday, September 12, and remained elevated through September 13. Several additional analyses were conducted to test the stability of the findings, and the results were essentially unchanged. CONCLUSIONS: The events of September 11 may not have induced emergent mental illness in U.S. communities at relatively great distance from the attacks. However, it is possible that persons with severe mental illness were either more evident to or less tolerated by the community.     

Television images and psychological symptoms after the September 11 terrorist attacks

Exposure to graphic television images may exacerbate psychological symptoms in disaster situations. We tested the hypotheses that (1) more frequent viewing of television images of the September 11 terrorist attacks was associated with posttraumatic stress disorder (PTSD) and depression, and that (2) direct exposure to disaster events had an interactive effect with media viewing. We recruited 1,008 adult residents of the borough of Manhattan in New York City through a random-digit-dial telephone survey conducted between October 16 and November 15, 2001. Respondents who repeatedly saw "people falling or jumping from the towers of the World Trade Center" had higher prevalence of PTSD (17.4%) and depression (14.7%) than those who did not (6.2% and 5.3%, respectively). Among respondents who were directly affected by the attacks (e.g., had a friend killed), those who watched this television image frequently were more likely to have PTSD and depression than those who did not. Among respondents not directly affected by the attacks, prevalence of PTSD and depression was not associated with frequency of television image viewing. Specific disaster-related television images were associated with PTSD and depression among persons who were directly exposed to a disaster. Future research should address causal directionality of this association.     

Use of mental health services by veterans with PTSD after the terrorist attacks of September 11

OBJECTIVE: Community surveys have demonstrated significant psychological distress since the terrorist attacks of Sept. 11, 2001. Since people with posttraumatic stress disorder (PTSD) and other mental illnesses are especially vulnerable to stressful events, the authors examined the use of PTSD treatment services and other mental health services at Department of Veterans Affairs (VA) medical centers in New York City and elsewhere after the attacks. METHOD: Analysis of variance was used to compare changes in average daily service use in the 6 months before and the 6 months after September 11, with changes in service use across the same months in the 2 previous years. Chi-square tests were used to examine differences from previous years in the proportion of new patients (i.e., who had not received treatment in the previous 6 months) entering treatment after September 11. RESULTS: There was no significant increase in the use of VA services for the treatment of PTSD or other mental disorders or in visits to psychiatric or nonpsychiatric clinics in New York City after September 11 and no significant change in the pattern of service use from previous years. Nor was there a significant increase in PTSD treatment in the greater New York area, Washington, D.C., or Oklahoma City or in the proportion of new patients. CONCLUSIONS: No increase was observed in the use of mental health services among VA patients with PTSD or other mental illnesses in response to the terrorist attacks of September 11.     

Outreach and peer-delivered mental health services in New York City following September 11, 2001

OBJECTIVE: Following the tragedy of September 11, 2001, the Federal Emergency Management Agency (FEMA) funded Project Liberty, an umbrella program operating from multiple sites throughout New York City to provide free crisis counseling and other assistance. One particular Project Liberty site provided peer support services for individuals with pre-existing psychiatric disabilities. This article reports on the outreach efforts undertaken by Project Liberty's Peer Initiative. METHODS: As part of a broader qualitative study, face to face interviews were conducted with Project Liberty Peer Initiative staff and service recipients. CONCLUSIONS: Outreach was found to be a key strategy used to identify and connect with psychiatrically disabled individuals in need after disasters. Implications for the use of similar outreach strategies in future disaster planning and service delivery are described.     

Fear of terrorism in New York after the September 11 terrorist attacks: implications for emergency mental health and preparedness

To examine the public's response to future terrorist attacks, we surveyed 1,001 New Yorkers in the community one year after the September 11 attacks. Overall, New Yorkers were very concerned about future terrorist attacks and also concerned about attacks involving biological or nuclear weapons. In addition, while most New Yorkers reported that if a biological or nuclear attack occurred they would evaluate available information before evacuating, a significant number reported they would immediately evacuate, regardless of police or public health communications to the contrary. The level of public concern was significantly higher on all measures among New York City and Long Island residents (downstate) compared to the rest of the state. A model predicting higher fear of terrorism indicated that downstate residents, women, those 45 to 64 years old, African Americans and Hispanics, those with less education/income, and those more likely to flee, were more fearful of future attacks. In addition, making disaster preparations and carefully evaluating emergency information also predicted a higher level of fear as well. A second model predicting who would flee suggested that those more likely to evaluate available information were less likely to immediately evacuate, while those with a higher fear of future attacks were more likely to flee the area. Given these findings and the possibility of future attacks, mental health professionals need to be more involved in preparedness efforts, especially related to the psychological impact of attacks involving weapons of mass destruction.     

Anxiety sensitivity and panic attacks: a 1-year longitudinal study

The hypothesis that anxiety sensitivity (AS) is a risk factor for panic genesis has obtained compelling support, but the clinical/practical importance of AS in panic genesis has been questioned. In addition, the association between panic experience and AS increase has not been clearly demonstrated. Through this 1-year longitudinal study among college students, the authors replicated the vulnerability effect of AS on panic onset. By measuring AS according to its hierarchical structure, the authors found an AS subfactor--AS-Mental Incapacitation Concerns--to be a significant predictor of panic onset. The authors also demonstrate that AS is not only statistically significant but also clinically/pragmatically important for the onset of panic. The association between panic and increased AS was confirmed in this study, although it remains for future research to conclude whether this association should be attributed to a "scar effect" of panic. Theoretical and methodological issues regarding tests of the scar effect hypothesis are discussed.