More than a dozen major studies have been published so far looking at the mental health effects of the terrorist attacks of September 11. Experts in disaster and trauma mental health— including psychiatrists, psychologists, psychiatric nurses, social workers, and counselors with various degrees—have come together over the last few months with a common question: What does this growing body of research tell us that can help us be more prepared for the mental health fallout from what many feel is an inevitable "next time"?
Meetings have taken place throughout the country, examining what the mental health field has learned from 9/11. At the New York Academy of Medicine (NYAM) on September 9, some 440 people attended a day-long conference that highlighted the academy’s own research on the aftereffects of 9/11 (Psychiatric News, September 6), as well as presentations from other researchers.
"I am very hopeful that the deliberations of today will yield a better understanding of what we’ve learned from the past year and help us to better plan for what we need to do to move forward," said Thomas R. Frieden, M.D., M.P.H., commissioner of the New York City Department of Health, at the outset of the NYAM conference. "Terror presents a new and unique challenge to the public’s health."
Frieden suggested that there are many lessons for the health care community in the aftermath of 9/11. Preparedness is a continuous process that must be interdisciplinary, he said, and it must consider mental health as an integral part. In New York City, Frieden explained, the lessons learned from the post-9/11 research are guiding reorganization of the city’s disaster response and emergency-preparedness plans.
Previewing the studies to be presented at the conference, he told attendees, "We now know that some of the most important and devastating impacts of 9/11 are the mental health and chemical dependency effects."
Twenty-eight speakers presented and discussed current 9/11 outcomes research at the NYAM conference. Many of the studies were published in the September issue of the academy’s journal, the Journal of Urban Health.
Several of the studies detailed findings of large numbers of cases of posttraumatic stress disorder (PTSD) and depression in the months following 9/11. In fact, they seem to bear out the numbers predicted by needs-assessment studies commissioned by Frieden’s department in the early days following the World Trade Center disaster (see story on page 25).
Disaster psychiatry experts Carol North, M.D., a professor of psychiatry at Washington University School of Medicine in St. Louis, and Betty Pfefferbaum, M.D., J.D., a professor of psychiatry at the University of Oklahoma School of Medicine, detailed their findings from the terrorist bombing of the Alfred P. Murrah Federal Building in Oklahoma City in 1995.
North described the methods they used in Oklahoma City, utilizing the Diagnostic Interview Schedule plus Disaster Supplement. They were able to document actual cases of PTSD, depression, and anxiety following that bombing.
"That work provides a road map for work to be done in New York City," North told the crowd. She told Psychiatric News, however, that such a study would be time consuming, labor intensive, and expensive—especially given the enormity of the impact of the World Trade Center disaster, both in sheer numbers of individuals affected and the geographic area involved.
On behalf of NYAM, David Vlahov, Ph.D., director of its Center for Urban Epidemiological Studies, presented an update on NYAM’s research on the incidence of PTSD, depression, and substance use in the New York metropolitan area following 9/11.
Vlahov reported longitudinal data expanding the initial NYAM study from four to eight weeks after 9/11 (Psychiatric News, September 6) to six to nine months after 9/11. Follow-up at one year was under way at the time of the conference.
"Approximately one-third of the residents of New York City were directly affected by the events of September 11," Vlahov said, summarizing results from the NYAM studies. "Since 9/11, more than 1 million people in New York City have had symptoms consistent with at least subthreshold PTSD. Symptom prevalence has declined over time, but by six to nine months there remained an estimated 90,000 persons with probable PTSD in New York City."
Such large numbers of apparent cases in the New York metropolitan area seemed to startle many in attendance, and some questioned the NYAM research methods.
Yet the estimates of new cases of PTSD and/or depression reported by the NYAM researchers are not significantly different from those given in other published studies. Regardless of methodological differences, each of the studies reported significant percentages of the population of New York having PTSD, probable PTSD, or subthreshold PTSD,
In a question-and-answer period following the presentations, Howard Telson, M.D., a clinical associate professor of psychiatry at New York University School of Medicine, asked Vlahov about differences between the methods employed by NYAM and those used by North. Vlahov deferred the question to North, who noted that because of the differing methods used in the two studies, a comparison was not possible. "We measured different things," she said, "using different methods."
"What about methodology?," Telson said to Psychiatric News. "Many of these studies did not use any assessment tool that would allow a conclusion that the subjects met diagnostic criteria, yet researchers were touting hundreds of thousands of cases of new PTSD following September 11. What happened to the basics of the construct?"
Sally Satel, M.D., a staff psychiatrist at the Oasis Drug Treatment Centers in Washington, D.C., and the W.H. Brady Jr. Fellow at the American Enterprise Institute, was also uncomfortable with the conclusions.
"I was dismayed by the tendency of many of the researchers to talk about PTSD as if they had made actual diagnoses," Satel told Psychiatric News. "Their methods were too limited to allow them to make diagnoses."
Vlahov later told Psychiatric News that in reviewing the literature and speaking with colleagues, they softened the language in the latest study to "probable PTSD" or "indicative of subthreshold PTSD" rather than simply using the more definite terminology, PTSD.
Telson is still worried, however. "You have government officials announcing that they are changing policy and planning, based on the conclusions of this body of work, yet the conclusions in many of these studies are based on assumptions and ill-defined terminology. Therefore, you have to wonder how effective the research is for disaster preparedness and planning."
In the next issue of Psychiatric News, disaster and trauma mental health researchers take a critical look at variations in study design and data collection and at how those differences may inherently influence results, potentially skewing the reported mental health effects of the terrorist attacks of 9/11. Also in the next issue will appear the Web address of some of the major post-9/11 studies published to date. ▪