Chapter 6 Mental Health Needs (Section 1 Supplement)

PTSD and Depression among Manhattan Residents Post September 11th

(The following section is excerpted from an article entitled "Psychological Sequelae of the September 11 Terrorist Attacks in New York City" written by S. Galea, J. Ahern, H. Resnick, D. Kilpatrick, M. Bucuvalas, J. Gold, and D. Vlahov, published in the New England Journal of Medicine, Vol. 346, No. 13 on March 28, 2002.)

Following the attacks on the World Trade Center on September 11, 2001, researchers from the New York Academy of Medicine, the Columbia University Mailman School of Public Health, the Medical University of South Carolina, and Bellevue Hospital Center in New York collaborated on a study to assess the degree of acute posttraumatic stress disorder (PTSD) and depression experienced among residents of Manhattan. The goal of the study was to "determine the prevalence of psychopathic disorders and to identify primary predictors of the conditions."

Fifty-two percent of the randomly selected respondents were women and almost 70 percent were white. The mean age was forty-two plus or minus fifteen years. Of the sample, a little more than 5 percent had lived in the vicinity of the World Trade Center at the time of the attack. Overall, 13.6 percent of all respondents reported symptoms that met the criteria of PTSD or depression and 3.7 percent of all respondents met the criteria of both conditions. Compared to the national yearly average of 3.6 percent for PTSD and a thirty-day average prior to the attacks of 4.9 percent for depression, the prevalence of PTSD and depression in Manhattan was approximately twice the baseline average.

Of the 1,008 adults who lived between Canal Street in Lower Manhattan and 110th Street in Upper Manhattan and were randomly selected and interviewed, the survey determined that 7.5 percent reported symptoms of PTSD and 9.7 percent reported symptoms of current depression (occurring within thirty days of the survey). Twenty percent of the adults living south of Canal Street in the vicinity of the World Trade Center at the time of the attack reported PTSD.

Telephone surveys in both English and Spanish were used to collect data from the Manhattan residents between October 16 and November 15, 2001.

• Inquiries were made about the location of the respondent's residence in the city and his/her location at the time of the attack.

• Questions about social support were included in the survey: Were people there to provide love and emotional support? . . . If someone was bed ridden, for example, were people available to offer assistance? . . . Were people there to offer advice?

• Surveyors asked about other stressful events in subjects' lives that would contribute to depression or PTSD.

• Surveyors asked questions about their personal experience of the attacks on September 11, 2001: Did they observe the planes crash? . . . Were they injured? . . . Were friends or loved ones or acquaintances killed or injured? . . . Had they lost their home, their possessions, or their job because of the attack? . . . Had they been involved in the rescue efforts?

In a multivariate analysis, researchers found that the significant predictors for PTSD were:

• Hispanic ethnicity.

• Two or more other stressors in the respondent's life in the previous twelve months.

• A residence south of Canal Street.

• Loss of possessions in the attack.

• Experience of panic symptoms in the aftermath of the attack.

In a multivariate analysis, researchers found significant predictors for depression were:

• Hispanic ethnicity.

• Two or more stressors occurring in the twelve months prior to the attack.

• A low level of social support.

• The death of a friend or relative in the attack.

• Loss of a job as a result of the attack.

The higher rates of PTSD and depression among respondents of Hispanic ethnicity was not examined specifically in this research, although studies that have addressed membership in minority groups and psychological reactions after a disaster suggest that sociocultural influences are a factor in individual response to disasters.

Social support is also important for the maintenance of mental health after a disaster. Low levels of social support are directly tied to PTSD and depression. Furthermore, there is an association between those individuals who experience initial panic symptoms following a disaster and the onset of PTSD, and there is an indication that early intervention to address the trauma experience can decrease the likelihood of PTSD in the months that follow.

Researchers estimate that symptoms of PTSD usually subside after three months, but that up to one-third of cases may require a longer period of recovery. Given the ongoing perceived threat of further terrorist attacks in Manhattan, the large numbers of people without jobs as a result of the attacks (estimated at 100,000), and the disruption of services, they anticipate that PTSD and depression could be long lasting among Manhattan residents.

Other studies have been conducted on the psychopathology of community members following disasters and terrorist attacks. There is a general indication that persons directly affected by disaster have high rates of post-event psychiatric disorders:

• A survey in Los Angeles following the 1992 riots found a prevalence of 4.1 percent for PTSD.

• The prevalence for depression following a severe Mid-Western flood was 9.5 percent.

DISASTERS AND AN INCREASE IN DOMESTIC VIOLENCE
In a recent summary of research into increases in domestic violence following disasters, the National Center for Post Traumatic Stress Disorder (NCPTSD) cited a comprehensive examination of intimate violence in the aftermath of the 1993 Midwestern flood. During the nine months period following the flood, a sample of 205 married and cohabiting women who had suffered serious water damage in their homes were surveyed:

• Fourteen percent reported at least one act of physical aggression from their partners.

• Twenty-six percent reported emotional abuse.

• Seventy percent reported verbal abuse.

• Eighty-six percent reported partner anger (Mechanic, Griffin, and Resick 2001).

By comparison, studies of previous year prevalence of domestic violence under normal conditions suggest incidence rates of between 1 percent and 12 percent (NCPTSD 2001).

• Another study that looked at increases in reports of domestic violence surveyed persons directly exposed to the Oklahoma City Bombing in the Federal Building. They reported troubled interpersonal relationships ranging from 17 percent among noninjured persons to 42 percent among persons whose injuries required hospitalization (Shariat et al. 1999).

Mechanic, Griffin, and Resick also found in their analysis of increases in domestic violence following the 1993 flood that the presence of domestic violence in women's lives greatly increased their symptoms of PTSD and depression.

• Thirty-nine percent of the women who experienced post-flood abuse developed PTSD compared to seventeen percent who did not experience post-flood abuse. Fifty-seven percent of women who experienced post-flood abuse developed major depression compared to 28 percent of nonabused women.

Although the research is not extensive, it appears that the relationship between increases in domestic violence and the onslaught of PTSD and depression following a disaster or terrorist attack is significant. Services that address anger management and family safety should be integrated into the community mental health response following devastation of this nature.