Sept. 11 MH Studies Teach Lessons for Future Disasters

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 disaster response.”

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 individuals.”

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 Medicine article.

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 at:<www.ehponline.org/members/2008/11164/11164.pdf>.▪