Psychiatric Symptoms Tied to 9/11 Resolving, But Long-Term Impact Still Unclear

In the first days after last September 11 the health care community turned its attention to psychological injuries as “mental health experts” made dire predictions of a massive mental health impact resulting from the deadly terrorist attacks.

Over the past year studies have concluded that the number of PTSD and depression cases significantly increased, especially among those who live and work in New York City. Yet experts in disaster psychiatry are questioning both the studies’ methods and their conclusions.

At least five studies have been published attempting to gauge the mental health impact of the terrorist attacks. Regardless of the methods used or population studied, the researchers have generally reached the same conclusions.

The first report, by RAND senior researcher and UCLA pediatrics professor Mark A. Schuster, M.D., appeared in the November 15, 2001, New England Journal of Medicine (NEJM). That study, a random-digit dialing survey done three to five days after the attacks, surveyed 560 adults throughout the United States. It concluded that “Americans across the country, including children, had substantial symptoms of stress.”

Schuster and his co-authors warned that even clinicians who practice far from the areas attacked should prepare for an influx of patients “with trauma-related symptoms of stress.”

The RAND study was followed by a series of reports from researchers at the New York Academy of Medicine (NYAM). In the first of three reports, which appeared in the March 28 NEJM, they reported that “13 percent of Manhattan residents suffered from posttraumatic stress disorder (PTSD) and/or depression after the September 11 attacks.”

Lead author Sandro Galea, M.D., an epidemiologist, called the finding “not surprising” given the scope of the disaster.

The three NYAM studies, all based on a random-digit dialing survey of about 1,000 Manhattan residents, were conducted from four to eight weeks after the disaster. Each participant answered questions designed to elicit signs or symptoms of PTSD, depression, anxiety attacks, and use of tobacco, alcohol, and marijuana.

In measuring PTSD prevalence, the NYAM group used a modified version of the Diagnostic Interview Schedule for PTSD. The study required symptoms to be present for “two weeks or longer”—less than the one-month duration required by DSM-IV-TR criteria. Galea concluded that 7.5 percent of those interviewed reported “symptoms consistent with PTSD related to the attacks.”

That percentage, the report said, translated into more than 67,000 Manhattan residents “suffering from PTSD.” In addition, 9.7 percent reported symptoms consistent with current depression, and 13.6 percent “met the criteria for either PTSD or depression, while 3.7 percent met the criteria for both disorders.”

The second NYAM report, which appeared in the June 1 American Journal of Epidemiology, examined changes in alcohol, tobacco, and marijuana use. It found that nearly 29 percent of those interviewed increased their intake of these three substances. In addition, researchers correlated that result with the PTSD findings, concluding that “those who smoked more cigarettes and marijuana were dramatically more likely to experience PTSD,” according to David Vlahov, Ph.D., director of NYAM’s Center for Urban Epidemiologic Studies, the second report’s lead author.

The third NYAM report detailed the effects of the disaster on children in New York City (Original article: see box below).

The NYAM team has followed up the initial studies with data collected at four months from the same areas of Manhattan along with other New York City boroughs. Those data, pending publication, show that the rates of PTSD and depression had decreased by about 66 percent and 60 percent, respectively, since the initial survey.

“What that’s telling us,” Vlahov told Psychiatric News, “is that there is a trajectory of recovery.”

The academy is also conducting a 12-month survey as well as further analysis of data from beyond the five New York boroughs at six months.

The most recent report on the prevalence of PTSD following the events of 9/11 appeared in the August 7 Journal of the American Medical Association. This study, with William Schlenger, Ph.D., at the Duke University Medical Center and Research Triangle Institute as lead author, used a Web-based epidemiological survey, administered to a representative cross-sectional sample of the U.S. population. Oversampling was done in the New York and Washington D.C., areas. In total, 2,273 adults participated. The PTSD Checklist and the Brief Symptom Inventory were administered to each subject four to eight weeks after 9/11.

Far Fewer Cases in D.C.

Schlenger, a psychiatric epidemiologist, and his group estimated that “the prevalence of probable PTSD was significantly higher in the New York City area (11.2 percent) than in Washington, D.C. (2.7 percent), other major metropolitan areas (3.6 percent), and the rest of the country (4.0 percent).” These rates translate into about 530,000 cases of PTSD in metropolitan New York beyond what would otherwise be expected.

In addition, the group concluded that “a broader measure of clinically significant psychological distress suggests that overall distress levels across the country” were normal. They found that direct exposure to the attacks and the amount of time spent watching television coverage of the events were both associated with “PTSD symptom levels.” This study again noted significant reports of distress among children of those adults participating.

What Did They Measure?

“Most people,” Carol North, M.D., told Psychiatric News, “don’t get a psychiatric disorder after a disaster. But symptoms are numerous—most people have at least some symptoms, and we know that those symptoms fade over time, and people, on average, start to feel better.”

North, a professor of psychiatry at Washington University in St. Louis, has done extensive studies of the victims of the bombing of the Murrah Federal Building in Oklahoma City in 1995.

“There are a lot of issues, though, relating to how these studies are different from each other, and I think that we may be looking at different things,” North suggested.

In a JAMA editorial that accompanied Schlenger’s report, North and Betty Pfefferbaum, M.D., J.D., professor of psychiatry at the University of Oklahoma School of Medicine, summarized their concerns.

“Acknowledgement of symptoms does not necessarily indicate psychopathology,” they wrote. Terminology may be part of the problem.

“I think that different people may be using the term [PTSD] differently,” North told Psychiatric News. According to DSM criteria for diagnosis of PTSD, she said, either a person was exposed to a trauma or wasn’t. “So that implies that at some point we have to draw the line as to what ‘exposures’ qualify.” It is very difficult to do this in the case of the World Trade Center and Pentagon attacks, she said, given the extensive, real-time coverage by media.

“But even the criteria are not 100 percent water tight,” North said. PTSD and acute stress disorder (ASD) are based on an individual’s subjective report, attributing the signs or symptoms they are feeling to a specific event, which may or may not be true.

It is not clear, North added, whether the reports are actually picking up what would more appropriately be termed ASD. However, even ASD, is controversial—some believe that it is actually a normal response to a stressor, she observed. “And if it’s normal,” she asked, “how can it be a disorder?”

Randall Marshall, M.D., director of trauma services at the New York State Psychiatric Institute, agreed. “In PTSD, you know, there’s always been sort of this fuzzy boundary between a really normative reaction to a horrific trauma and the development of actual PTSD. It’s not at all clear where you draw that line, and I’m not sure it ever will be.”

One Year Later

So, just what is the state of the collective mind, one year after September 11?

“All of these studies, regardless of methods, survey questions, and results,” Marshall concluded, “have said that there was an increase in symptoms that are suggestive of PTSD in the New York area following 9/11.” In the months following the attacks, symptoms decreased, which is what both Marshall and North expected.

Marshall and North view the Schlenger study as the most rigorous to date and applaud its use of the terminology “symptoms suggestive of probable PTSD.” While the NYAM studies proclaim higher rates of both PTSD and depression, Marhsall and North questioned whether the NYAM subjects would meet DSM diagnostic criteria.

These studies are nonetheless useful, North said, as a first peek at what is going on in the population following a disaster.

“Knowing that there were more symptoms in New York than in D.C. and other places suggests that there may be higher rates of disorders now in New York, which suggests that more mental health resources are going to be needed,” North said. ▪