Disaster workers who responded to the terror attacks of September 11, 2001,
showed a general increase in mental health symptoms, although findings varied
by the type of study and the subjects selected, according to a review of 25
published papers. Their counterparts in future disasters may profit from
improved training and better research, however (see HHS Criticized for
Progress on Responder Health Programs).
"[M]ost studies noted substantial rates of PTSD and major depressive
disorder symptoms," wrote Craig Katz, M.D., of the departments of
psychiatry and community and preventive medicine at New York's Mount Sinai
School of Medicine, and colleagues in the Mount Sinai Journal of
Medicine. "Among the majority of studies, exposure to events at the
[World Trade Center] was associated with greater rates of overall mental
health symptomatology" than in the general population.
"This is a timely report that points the way to protecting people who
help others," said Joseph Napoli, M.D., a Fort Lee, N.J. psychiatrist
and coauthor of the 2005 instructional guide Resiliency in the Face of
Disaster and Terrorism. "Resiliency is the key, both physically and
psychologically. That can be enhanced by proper personnel selection, training,
and mock disaster exercises for the men and women on the front lines of
A study of 10,132 workers by Mt. Sinai's Vansh Sharma, M.D., and colleagues
(including Katz), published too recently to be included in the review,
reported that 10 to 61 months after the attack on the World Trade Center, 11.1
percent of disaster workers met criteria for probable PTSD, 8.8 percent for
probable depression, 5.0 percent for probable panic disorder, and 62 percent
for substantial stress reaction.
"PTSD prevalence was comparable to that seen in returning Afghanistan
war veterans and much higher than the general U.S. population," they
wrote in the May 20 online journal Environmental Health.
Katz and colleagues identified 484 articles published between September
2001 and January 2008 that contained data on mental health exposures and
outcomes related to the attacks and their aftermaths (mostly from the New York
site, but also from the Pentagon site in Arlington, Va., the Shanksville, Pa.
site, and the Staten Island, N.Y., site that was the major collection/sorting
area for debris from the World Trade Center).
Twenty-five of those articles met the full inclusion criteria set by the
researchers and together contained data on 87,341 disaster workers."
Workers" included police, fire, and utility workers, and Red
Cross staff and volunteers, among others.
Comparing the studies was difficult because each used a variety of
screening and diagnostic tools to detect and evaluate symptoms, said the
authors. Some studies were limited to a single occupational group (such as
police or Red Cross workers), while others looked at only one diagnostic
category (such as depression or PTSD).
Most of the articles reviewed found that first responders exposed to the
September 11 events were more likely to suffer from PTSD than were unexposed
peers. Studies of depressive symptoms or anxiety often varied, with some
showing an increase among exposed workers while others did not.
Six studies reported on mental health screening, referral, or treatment
programs begun after September 11, said the authors. "September 11th
workers generally were reluctant to utilize screening and referral mental
health services," they wrote, attributing this reluctance to social
stigma among the occupational groups studied.
Acceptance of mental health screening services was associated in one study
with current PTSD, depressive symptoms, or previous mental health treatment.
However, another study reported that use of mental health services among 3,015
Red Cross workers found that those seeking mental health services before
September 11 were 80 percent less likely to use them afterward, while those
who had not sought them were 50 percent more likely to do so afterwards.
"Future research in this area should study a broader cross-section of
first responders from various organizations, occupations, and disaster sites
and take regard of various psychiatric outcomes," wrote Katz, and
colleagues in their review. Such research should include qualitative
evaluation of the "experience and manifestations" of psychological
distress following disasters.
In the future, health officials should establish mental health registries
soon after disaster strikes both to establish a base for further study and to
adapt responses quickly to help workers, said the authors. Workers' exposure
should be monitored while they are on the job. Better follow-up is also needed
to see if workers referred for treatment actually receive it. As things stand
now, according to Katz and colleagues, "it is difficult to formulate
conclusions about best practices for providing care and treatment to these
Lastly, they said, "a more mentally healthy and robust disaster
workforce," well-trained and well-organized for the tasks they will
encounter, may increase resilience and lessen the chances of
psychopathological outcomes among those who respond to disasters.
In addition, planning and training exercises to improve management of
disasters are critical, said Dori Reissman, M.D., director of the U.S.
National Institute for Occupational Safety and Health, and colleague John
Howard, M.D., in a separate but related Mount Sinai Journal of
An abstract of "Mental Health of Workers and Volunteers
Responding to Events of 9/11: Review of the Literature" is posted at:<www3.interscience.wiley.com/journal/119339124/abstract>.
"Enduring Mental Health Morbidity and Social Function
Impairment in World Trade Center Rescue, Recovery and Cleanup Workers: The
Psychological Dimension of an Environmental Health Disaster" is posted