TERRORISM, MENTAL HEALTH, AND SEPTEMBER 11

LESSONS LEARNED ABOUT PROVIDING MENTAL HEALTH SERVICES TO A TRAUMATIZED POPULATION

GERRY FAIRBROTHER
AND

SANDRO GALEA

A CENTURY FOUNDATION REPORT

THE CENTURY FOUNDATION
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This report is part of The Century Foundation’s Homeland Security Project, a broader study aimed at informing the public and the policymaking community about the complex challenges related to preventing and responding to domestic terrorism. The report was produced with the support of The New York Times Company Foundation. More information on the Homeland Security Project is available at www.homelandsec.org.

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CONTENTS

Executive Summary Introduction Who Was Affected by the September 11 Attacks? Reactions by New Yorkers and the Nation as a Whole Reactions in New York City Immediately after the Attacks Persistence of Symptoms over Time Mental Health Counseling Services for New York City Unmet Need for Mental Health Services Conclusions and Lessons Learned Notes About the Authors About The Century Foundation

5 6 8 11 12 21 27 31 39 40 43 44

The terrorist attacks shook the nation. as well as others in the New York City area and throughout the nation.000.000.Terrorism. or possessions—were more likely to develop post-traumatic stress disorder (PTSD) than others in the general population. The individuals for whom symptoms persisted were likely to be those whose lives were directly touched by the attacks. though of course this figure draws on a much larger pool of area residents. it is particularly important to take stock of the stresses these terrorist acts exerted on the population and of the effectiveness of the mental health response.S. Symptoms cleared up over a six-month period for most individuals but persisted in a smaller group. those involved in the rescue. Mental Health. those who lost family members. The number of New Yorkers with PTSD among the population not directly affected is almost as large: 360. as well as those who lost jobs. suffered symptoms of trauma. Calculations put the number of New Yorkers with PTSD in the directly affected group at 460. is entering an age of terrorism. People who were directly affected by the attacks— those who were in the towers of the World Trade Center complex and survived the attacks. Those directly affected. ◆ ◆ ◆ . Those attacks may not be the last terrorist action on U. The substantial incidence of PTSD in those not directly affected is one of the surprising findings of the investigations of the effects of the September 11 attacks. along with other nations. homes. soil. If the United States. and September 11 5 EXECUTIVE SUMMARY A number of important conclusions and lessons emerged from the experiences of New Yorkers and the nation in coping with the events of September 11.

extensive publicity notwithstanding. Still. the evidence indicates that this would be an effective model for both identifying people in need of mental health services and working with the mental health system to deliver treatment to others. but. Other nations—Israel. They could then refer severe cases to a mental health professional and treat the milder cases. but the United States had been spared a large-scale attack up until that point. This was especially true for symptomatic children. A significant proportion of New Yorkers had not heard of Project Liberty and the mental health services it offered.6 ◆ Gerry Fairbrother and Sandro Galea Large proportions of symptomatic individuals—both children and adults—failed to receive mental health services. Funding under Federal Emergency Management Agency is not currently available for this purpose. It may be advisable for primary care physicians to screen for mental health disorders routinely after a disaster or terrorist attack. and Sri Lanka—have experienced bombings and suicide attacks. Funding. despite the availability of these services. and procedures would need to be in place to make broad-based screening by primary care physicians possible. the United Kingdom. the need was not met. who generally saw a primary care physician even though they did not see a mental health professional. All changed on that . A high percentage of children saw a primary care physician in the six months following the attacks. training. ◆ ◆ ◆ ◆ INTRODUCTION The terrorist attacks of September 11 were unprecedented in scope and horror in the United States. The nature of their symptoms suggested a need for mental health services.

the north tower fell. these are people who suffered injury. As the United States learned. The mental health community in New York City was taken by surprise at the magnitude of the disaster. in contrast to other tragic events. Because the September 11 attacks may not be the last terrorist assault on U. soil. or material loss or who lost family members or close friends. assessment of how mental health services are used following a catastrophe needs to include the population at large as well as those directly affected. the south tower collapsed.M. Seventeen minutes later a second plane hit the south tower. fear. The response of the community at large—the “indirect” victims—has received less attention. Suddenly. it is important to assess the mental health effects on all whose lives are disrupted. sometimes called the “direct victims. the psychological damage is broader and the victims more numerous. or a collective loss of well-being. with some research devoted to the effect on rescue workers. However. trauma. At 10:05 A. and September 11 7 September morning in 2001.Terrorism. together with their families.M. have focused on the psychological effect of the trauma on these direct victims. the feeling of security and safety was gone.S. This paper will explore the effect of September 11 on the mental health of both New Yorkers and the nation as .” In the case of the September 11 attacks.M. Likewise. an airplane slammed into the north tower of the World Trade Center. Some experts recognize this and refer to both the individual trauma to those people who experience personal. it is important to take stock of what was learned and determine what modifications need to be made to prepare to respond to possible future attacks. because the psychological damage from terrorist attacks spreads beyond the direct victims and their families. with terrorism. property. physical. for many Americans.1 Those who experience the trauma in person are. at 10:28 A. Mental Health. acts of terrorism are not only intended to bring destruction to a specific target but also to reverberate widely among the population. 2001. Thus. At 8:46 A. or material losses and the collective trauma experienced by the community at large in the form of heightened distress. Most studies of disasters or traumatic events before September 11.

Further. the actual services put in place. while the aftershocks of the disaster were still being felt. Finally.. But at whom or what were the September 11 attacks directed? New York City and Washington. Officials in both cities had to evaluate the scope and range of needs and provide services on the fly. D. The monitoring efforts were not as thorough in Washington. Subsequent attacks plausibly could be anywhere. and the use of those services.8 Gerry Fairbrother and Sandro Galea a whole and will examine the persistence of symptoms over time. in a very real way. while only 17 percent watched coverage for fewer than four hours.2 Many of the lessons about providing mental health services to a traumatized population can be learned from the response in the two cities that were hit. and the pall of smoke from the ruins was visible to many others throughout the area for days. Broadcasts of the attacks gripped the nation. D. but. Homes and businesses . WHO WAS AFFECTED BY THE SEPTEMBER 11 ATTACKS? Unlike natural disasters—such as tornadoes. it will report on lessons to be drawn from the experiences of professionals responding to the crisis and new policies that may need to be put in place to ensure a betterfunctioning response capability. In all likelihood.C. In New York a substantial proportion of the population witnessed the attacks firsthand.C. or tsunamis—terrorist attacks deliberately take aim at a specific target. Most information in fact comes from New York because surveys monitoring demands for such services were begun immediately there. About half of the population nationwide watched eight or more hours of television reporting on the attacks in the days following September 11 (see Figure 1). it will explore the organization of funding for mental health services. hurricanes. Next. were the targets of the attacks. these attacks were directed at the United States and its major institutions as a whole. the findings in New York apply to Washington as well. television coverage was immediate and graphic and brought horrific images of planes crashing into buildings into homes all over America.

affecting the livelihoods of thousands of New Yorkers. no. Public transportation was disrupted throughout the city. Schoolchildren could not be reunited with their parents for much of the day. The economic repercussions in terms of lost jobs.” New England Journal of Medicine 345. 2001): 1507–12.. the attacks reached the rest of New Yorkers. and thousands had to walk long distances to reach their homes. 2001. telephone and cell phone service was spotty. Terrorist Attacks. FIGURE 1. Mental Health. Large numbers of people fled for safety. Most New Yorkers reported that they saw televised pictures of the disaster more than daily during the first week after the attacks. slowed sales. 20 (November 15. In the days and weeks that followed.Terrorism. those who were further removed got an eyewitness account. Schuster et al. fearing injury or death (see Figure 2. TELEVISION BROUGHT THE SEPTEMBER 11 ATTACKS TO THE NATION Television watching hours about the attacks on September 11: 8–12 hours 31% 13 or more hours 18% 1–3 hours 15% Up to 1 hour 2% 4–7 hours 34% Source: Mark A. Through the medium of television. More than 96 percent of the respondents saw . Those who had been in proximity to the destruction or had seen the smoke could relive the day over and over through graphic television coverage. “A National Survey of Stress Reactions after the September 11. and cancelled activities took hold in the weeks and months afterward. and September 11 9 in the vicinity of the World Trade Center were damaged or destroyed. page 10). Schools and offices in the downtown district were evacuated.

The . with half seeing these twenty-five times or more. New York City. MANY NEW YORKERS WERE EXPOSED TO THE ATTACKS 50 40 38 Percent exposed 30 20 16 10 11 11 6 0 Witnessed the events Feared injury or death Friend or relative killed 3 Involved in Lost job Lost rescue because of possessions attacks Source: Sandro Galea et al. However.. approximately 60 percent of the respondents saw it before the networks stopped showing it. The concentric circles in Figure 3 show ever-increasing levels of “exposure” to the attacks. “Posttraumatic Stress Disorder in Manhattan. no.10 Gerry Fairbrother and Sandro Galea the image of an airplane hitting the World Trade Center. The networks were showing this footage initially but stopped early on because of the horror. Perhaps the most horrifying sight of all was that of people falling or jumping from windows. There are reasonably distinct groups of people who experienced different levels of exposure to the attacks. and half of these saw it more than thirty-six times.” Journal of Urban Health 79. half of these seeing the video segment two times or more. Scenes of buildings collapsing and people running away were seen by approximately 95 percent of the respondents. ranging from those who lost a family member to those who observed events only through television. FIGURE 2. after the September 11th Terrorist Attacks. 3 (September 2002): 340–53.

REACTIONS BY NEW YORKERS AND THE NATION AS A WHOLE The terrorist attacks—along with the frightening prospect of future ones— shook the nation. and September 11 11 central—and smallest—circle represents those most directly affected: those who witnessed the attacks. Mental Health. These individuals might be expected to suffer the most psychological distress. LEVEL OF EXPOSURE TO THE ATTACKS Rest of United States Rest of New York City Directly affected Psychiatric literature shows that the effects of trauma are felt most strongly by direct victims and to a lesser degree by indirect or community victims. who lost family or friends in the attacks. FIGURE 3. with New Yorkers suffering especially and those New Yorkers who were directly affected the most likely to exhibit symptoms of distress. As will be shown. The next sections of this paper explore the effects of the September 11 attacks on each of the three groups. shock waves from the impact of the planes hitting the towers were felt nationwide. or who were involved in the rescue effort. A survey taken five to eight days after the attacks showed that people throughout the nation reported stress symptoms: 90 percent of . and the outer ring represents the 290 million people in the nation as a whole.Terrorism. The next ring represents the 8 million adults and children living in New York City.

and feeling irritable or having angry outbursts (see Figure 4). no matter what the actual distance from the site of the attacks. repeated disturbing memories of the attacks. Some reports put levels of post-traumatic stress disorder (PTSD) up to three times as high among New Yorkers as among people in other parts of the nation. Reactions included feeling upset when something prompted recall of the attacks. psychological stress reactions were more intense in New York City than in other parts of the nation.3 However. the more likely one was to show signs of psychological distress. as expected. REACTIONS IN NEW YORK CITY IMMEDIATELY AFTER THE ATTACKS A number of studies have examined the psychological impact of September 11 on individuals in the greater New York City area.12 Gerry Fairbrother and Sandro Galea adults had one or more symptom to some degree. and 44 percent reported one or more symptoms categorized as substantial. according to their parents. The earliest study was conducted approximately one month after the attacks and focused on people living in the lower part of Manhattan (defined liberally as Manhattan below 110th Street).5 . Figure 5 shows that 61 percent of those living within one hundred miles of the World Trade Center exhibited substantial stress reactions. This area was selected to provide a rapid needs assessment of the residents most likely to be affected. Children as well as adults were affected: 35 percent of children experienced one or more substantial symptoms of stress. In the study a random sample of 988 residents were contacted by telephone five to eight weeks after the attacks and asked a series of questions about their experiences the day of the attacks and the subsequent effects on their psychological and economic well-being.4 Other studies showed that the closer one lived to New York City. having trouble concentrating. Almost half of the adults said that their child had been worrying about his or her safety or the safety of a loved one. compared to 36 percent of those living more than one thousand miles away. having trouble sleeping.

Terrorist Attacks. 2001): 1507–12. no. . Schuster et al. FIGURE 5. “A National Survey of Stress Reactions after the September 11. 20 (November 15.” New England Journal of Medicine 345. no. “A National Survey of Stress Reactions after the September 11. 20 (November 15. ADULTS AND CHILDREN NATIONWIDE EXPERIENCED SYMPTOMS OF STRESS Adults Very upset when reminded Repeated memories. 2001): 1507–12..” New England Journal of Medicine 345. 2001. 2001. and September 11 13 FIGURE 4. Terrorist Attacks.Terrorism. THOSE LIVING CLOSEST TO THE WORLD TRADE CENTER EXHIBITED THE GREATEST STRESS REACTIONS 70 Percentage of adults exhibiting stress reactions 60 50 40 30 20 10 0 61 48 36 ≤ 100 miles 101–1000 miles > 1000 miles Source: Mark A.. or dreams Difficulty concentrating Trouble sleeping Feeling irritable/angry One or more substantial symptoms 11 9 44 18 12 10 10 6 37 0 5 10 15 20 25 30 35 40 45 50 10 14 30 Children Avoiding the subject Trouble concentrating Trouble sleeping Feeling irritable/angry Having nightmares One or more substantial symptoms Percent Source: Mark A. Mental Health. thoughts. Schuster et al.

flashbacks. all reexperiencing symptoms and all content-specific avoidance symptoms had to be related to the September . and arousal. individuals must have symptoms in three additional areas: reexperiencing. In the case of the September 11 terrorist attacks. ASSESSING POST-TRAUMATIC STRESS DISORDER RELATED TO SEPTEMBER 11 To receive a diagnosis of PTSD related to a particular event. BOX 1. and intrusive memories. Avoidance (group C) symptoms include avoidance of thoughts and feelings about the event. Reexperiencing (group B) symptoms include such reactions as dreams or nightmares. in watching the attacks unfold and in the uncertainty about other possible attacks at the same time. which are called in the psychiatric literature group B. many research teams have suggested that all residents of New York City may have met the criteria for exposure to a terrorist attack. to receive a diagnosis of PTSD.14 Gerry Fairbrother and Sandro Galea POST-TRAUMATIC STRESS DISORDER AND MAJOR DEPRESSION This study and others that would follow focused on two major psychological reactions to the attacks: post-traumatic stress disorder and major depression. C. These are the so-called group A criteria. and two symptoms from group D. and avoidance of reminders.* To measure PTSD attributable to September 11. avoidance. and being jumpy or easily startled. Individuals can have any or all of the symptoms. and D criteria. given the pervasive nature of the attack and its media coverage that day and in the days immediately afterward. Arousal (group D) symptoms include insomnia. having difficulty concentrating. three symptoms from group C. but a diagnosis of PTSD requires one symptom from group B. the individual needs both to have been exposed to a traumatic event and to have felt a sense of helplessness or horror. The authors used the standard psychiatric method of assessing PTSD (see Box 1). detatchment. In addition to meeting the “A” criteria. In addition there was a pervasive sense of helplessness and horror citywide.

D.S. 14. 9.: American Psychiatric Association. 4th ed. (Washington.Terrorism. Manderscheid and Marilyn J.7 percent experienced major depression since September 11.6 Overall. with considerable overlap between the two.4% Depression only 5. A separate subset of avoidance symptoms and all the arousal symptoms need not be linked directly to the attacks except by time frame (occurrence within thirty days subsequent to the attacks). Henderson (Washington. or both.C. pp. Ronald W. and September 11 15 11 attacks. PTSD AND DEPRESSION AFTER SEPTEMBER 11 Overall. United States.6% PTSD and depression 4.C. 83–91. D. Participants were thus required to report at least one reexperiencing symptom specific to the attacks and at least three avoidance symptoms (content-specific where relevant or in the appropriate time frame) for a diagnosis of PTSD resulting from September 11. 2003).5 percent met criteria for PTSD specifically related to the attacks.3% Source: Sandro Galea et al. major depression. 2000). “Mental Health in New York City after the September 11 Terrorist Attacks: Results from Two Population Surveys.3 percent of New Yorkers in the targeted area had either PTSD.. Moreover. 2002. Mental Health.: U. * Diagnostic and Statistical Manual of Mental Disorders. .3 percent of respondents had symptoms consistent with diagnoses of PTSD or depression PTSD only 4. Government Printing Office.” in Mental Health. 14. ed. Following the September 11 attacks. 7. as shown in Figure 6.7 FIGURE 6.8 percent of these New Yorkers (Manhattanites living below 110th Street) met the criteria for PTSD generally. 8.

9 Studies after September 11. 2001. and a sense of foreshortened future (21. approximately 12 percent had three or more avoidance symptoms and thus met the criteria for group C. work.10 Furthermore.8 percent of respondents reported at least one symptom of PTSD. and approximately 27 percent had two or more arousal symptoms and thus met the criteria for group D. and education.8 Still other researchers stress the importance of recognizing significant distress that does not reach levels that qualify for a PTSD diagnosis following a disaster. Researchers have shown that traumarelated distress symptoms that do not meet the criteria for PTSD can impair functioning and significantly interfere with an individual’s daily life in areas such as social and family functioning. Significantly. PSYCHOLOGICAL DISTRESS THAT DOES NOT REACH THE LEVEL OF PTSD Clinical PTSD and clinical-level depression are not the only indicators of distress. .12 Figure 7 shows the proportion of New Yorkers who experienced one or more of the psychological reactions that together constitute PTSD approximately one month after the attacks. at 20 percent. The most commonly reported symptoms were intrusive memories (27. almost 35 percent had at least one reexperiencing symptom and thus met the criteria for group B. exaggerated startle response (23.4 percent). however. insomnia (24.5 percent).2 percent). Sandro Galea and colleagues reported that 57.11 echoing reports from nonrandom interviews that more than half of the respondents reported significant symptoms.16 Gerry Fairbrother and Sandro Galea Among the respondents who lived in the vicinity of the World Trade Center (south of Canal Street) the prevalence of PTSD was much higher. have reported that two to three times this many people had serious PTSD symptoms but did not meet the clinical definition of the disorder.6 percent). Symptoms may not reach the level of clinical disorder but may be significant nonetheless.

and 3.8 percent) of the respondents reported an increase in use of cigarettes.Terrorism.7 percent reported an increase in smoking. and . People who smoked cigarettes or marijuana more frequently were more likely to experience post-traumatic stress disorder than those who did not. “Posttraumatic Stress Disorder in Manhattan. MANY NEW YORKERS HAD ONE OR MORE INDIVIDUAL PTSD SYMPTOMS Meets reexperiencing criteria (group B) Intrusive memories Dreams or nightmares Flashbacks Upset by reminders Physiologic reactivity Meets avoidance criteria (group C) Avoids thoughts or feelings Avoids reminders Psychogenic amnesia Loss of interest Detachment or estrangement Restricted range of affect Sense of shortened future Meets arousal criteria (group D) Insomnia Irritability or anger Difficulty concentrating Hypervigilance Jumpy/easily startled 0 10 20 30 40 Percent Source: Sandro Galea et al. page 18). SUBSTANCE USE AFTER SEPTEMBER 11 Studies also noted a jump in substance use in the month after the September 11 attacks. alcohol. no. 3 (September 2002): 340–53. Mental Health. after the September 11th Terrorist Attacks.6 percent) New Yorkers registered an increase in alcohol consumption. 9.” Journal of Urban Health 79. and September 11 17 FIGURE 7. or marijuana.2 percent acknowledged an increase in marijuana use (see Figure 8.13 Almost one in three (28. In addition.. Most common was greater alcohol consumption—almost one in four (24. New York City.

most New York City children (91 percent) were in school or day care at the time.” American Journal of Epidemiology 155. thus. while only 14 percent were told by a parent and 22 percent heard first from another source. most children (64 percent) learned of them that way.. and Marijuana among Manhattan. Teachers and principals in other schools throughout the city needed to make decisions about whether to inform the students and. FIGURE 8. REACTIONS OF CHILDREN The attacks began just before nine o’clock in the morning.18 Gerry Fairbrother and Sandro Galea depression was more common among those who stepped up their cigarette smoking. “Increased Use of Cigarettes. Children in schools in the immediate vicinity of the World Trade Center needed to evacuate their buildings and were well aware of the tragedy unfolding. the greater frequency of use of different substances was associated with PTSD and depression. Not surprisingly. how much to disclose. or even whether to close the school. if so.6 3. Alcohol. 11 (June 1. Thus. Residents after the September 11th Terrorist Attacks. as shown in Figure 9.8 Source: David Vlahov et al.2 Marijuana Overall 28. no.7 Cigarettes Alcohol 24. alcohol consumption. ABOUT 1 IN 4 NEW YORKERS REPORTED INCREASING ALCOHOL CONSUMPTION AFTER SEPTEMBER 11 50 40 Percent 30 20 10 0 9. New York. . and marijuana use than among those who did not. 2002): 988–96. Many teachers made the decision to inform their students of the attacks. then. whether to tune into the television news.

was associated with severe or very severe post-traumatic stress reactions. Gerry Fairbrother and colleagues reported that 18 percent of children in the New York City area had severe or very severe post-traumatic stress reactions. page 20). Mental Health. the vast majority of children exhibited at least some symptoms of stress in the first several months following the attacks. MOST CHILDREN WERE IN SCHOOL OR DAY CARE AT TIME OF ATTACKS AND LEARNED ABOUT THEM FROM A TEACHER 100 90 80 70 60 64 91 Percent 50 40 30 20 10 0 9 Were at home Were at at time of attack school/day care at time of attack 14 Learned from Learned from Learned from parent teacher other source 22 Source: World Trade Center Survey. As with adults. experienced psychological distress after September 11. January and February 2002. and September 11 19 FIGURE 9.15 Thus.Terrorism. For children. having a parent with PTSD or seeing a parent cry was associated with severe or very severe post-traumatic . Children. like adults.14 and 66 percent had “moderate” reactions (see Figure 10. either through proximity to the site or through seeing graphic footage on television (particularly the image of people jumping from windows). level of exposure to the attacks. conducted by the New York Academy of Medicine.

Specifically. FIGURE 10.16 This study is important because the assessments were done face to face with the school children. This study was not able to determine the precise nature of the relationship: perhaps both children and their parents were directly exposed to the attack. the researchers discovered (see Figure 11) that 11 percent of the children met the criteria for PTSD. not just PTSD.20 Gerry Fairbrother and Sandro Galea stress reactions. January and February 2002. conducted by the New York Academy of Medicine. Six months after the September 11 attacks. it assessed a variety of mental health problems. Even though the cause is not clear. or perhaps—as prior studies have shown—psychological stress in one family member affects the entire family. APPROXIMATELY 18 PERCENT OF NEW YORK CITY CHILDREN HAD SEVERE OR VERY SEVERE POST-TRAUMATIC STRESS REACTIONS FOLLOWING THE SEPTEMBER 11 ATTACKS Severe 15% Moderate 66% Doubtful or mild 16% Very severe 3% Source: World Trade Center Survey. other disorders were more common than PTSD and depression. while 8 percent met criteria for major depression. Christina Hoven and colleagues assessed reactions of New York City public schoolchildren in grades four through twelve. As well. Indeed. the fact that stress occurs in multiple family members may indicate the need to focus on the family in recovery efforts. whereas the previous studies relied on parental reports of their children’s symptoms in a telephone interview. The mental health problem experienced by most children was agoraphobia at 15 .

these authors found that even higher proportions of children described experiencing a specific PTSD symptom.. one in four schoolchildren (27 percent) who met criteria for one or more of the psychiatric disorders assessed also revealed problems in day-to-day functioning. and September 11 21 percent. PERSISTENCE OF SYMPTOMS OVER TIME Findings about immediate effects of the attacks indicate the level of mental health services needed and how quickly they need to be in place. May 6. GRADES 4–12 35 30 29 25 Percent 20 15 10 5 0 8 11 10 12 9 15 Source: Christina W. Mental Health. 2002.” prepared by Applied Research and Consulting. the Columbia University Mailman School of Public Health. Hoven et al. “Effects of the World Trade Center Attack on NYC Public School Students: Initial Report of the Board of Education. and the New York State Psychiatric Institute. Most compelling. Moreover. PREVALENCE OF MENTAL HEALTH PROBLEMS (PROBABLE) FOLLOWING WTC ATTACK AMONG NYC PUBLIC SCHOOL STUDENTS. FIGURE 11.Terrorism. followed by separation anxiety at 12 percent and generalized anxiety disorder at 10 percent. LLC. such as often thinking about the event (76 percent). Research an At Pa d lea ni im st c pa o ne ire d dis fu o nc rd tio er ni ng de Ma pr jo es r sio n Se p an ara xi tio et n y Ag or ap ho bi a G en an era xi liz et ed y PT SD .

The authors followed trends in three groups: those who were directly affected by the September 11 attacks. it shows the degree to which PTSD specifically related to the attacks resolved or persisted in the overall population. While this methodology does not allow one to observe the progression of symptoms in the same group of people. They reported on trends in PTSD prevalence and PTSD symptoms that did not reach the level of the full-blown (called subsyndromal PTSD). Understanding how long symptoms persist and who has persistent symptoms also is important. . as symptoms began to resolve toward a less severe but still clinically important state. a substantial number of the latter also met criteria for attack-related PTSD. there was an increase in subsyndromal PTSD among those directly affected in the sixth month.18 The prevalence of symptoms was consistently higher among persons who were directly affected by the September 11 attacks than among those not directly affected.17 The authors included only recent symptoms related specifically to the September 11 attacks. four-month. Specifically. There was rapid decline in the proportion of people with either full-blown PTSD or subsyndromal PTSD between the first and the fourth month (see Figure 12).6 percent.22 Gerry Fairbrother and Sandro Galea pointing out who is most likely to develop psychological distress has implications for the best ways to target services. IN NEW YORK CITY Surveys assessing PTSD in the New York City population taken at one-month. and six-months intervals after September 11 show the trends over time. and the total population. Findings about persistence of symptoms give some guideposts regarding how long mental health services need to be in place and may offer signals about targeting as well. approximately one-third of those who met the criteria for PTSD had not been directly affected by the attacks. All three surveys were conducted over the telephone with randomly selected samples of New Yorkers. six months after September 11. people not directly affected by the attacks. which includes the previous two groups. and by the sixth month its prevalence had diminished to only 0. Still. However. The decline continued for full-blown PTSD.

Most prior research and most counseling interventions had focused on those directly affected by a calamity. the actual number of cases of PTSD in the population at large became substantial. PREVALENCE OF PROBABLE PTSD AND SUBSYNDROMAL PTSD IN MANHATTAN SOUTH OF 110TH STREET DURING THE FIRST NINE MONTHS AFTER THE SEPTEMBER 11 TERRORIST ATTACKS* 30 PTSD in directly affected Overall PTSD PTSD in not directly affected 20 20 30 Subsyndromal PTSD in directly affected Overall subsyndromal PTSD Subsyndromal PTSD in not directly affected 25 25 Percent 15 15 10 10 5 5 0 Oct.. Jan. all prevalences refer to current (previous 30-day) symptomatology. These studies show that. Mar.Terrorism. and for this reason the effects in the general population were not well known.–Feb. studies of the September 11 attacks examined the effects in both those directly affected and in the community at large. In contrast. All symptoms linked to the September 11 attacks where possible. 6 (September 15.–Nov. Mar. no.–Nov. “Trends of Probable Post-Traumatic Stress Disorder in New York City after the September 11 Terrorist Attacks. 2003): 514–24. * 0 Jan. THE GENERAL POPULATION WAS AFFECTED AS WELL One of the surprises to emerge from the studies of the effects of the September 11 attacks was the large number of people in the population at large with PTSD. and September 11 23 FIGURE 12.–Jun. Oct.–Jun. although the prevalence of PTSD is higher for the directly affected group than for the general population (12.0 versus 3.7 percent).” American Journal of Epidemiology 158.–Feb. Mental Health. Vertical bars represent standard error. In the first six . Source: Sandro Galea et al.

500.000 people in the not directly affected group did so as well (see Box 2).* * Sandro Galea and Heidi Resnick.24 Gerry Fairbrother and Sandro Galea months approximately 460. Findings from various studies suggest that the prevalence of PTSD in the first six months after September 11 was about: 6. BOX 2. . In absolute terms. While this calculation is meant to be illustrative and not a definite assessment of the number of people who had stress disorder. it demonstrates that the new burden of psychopathology in the aftermath of a terrorist incident in a densely populated urban area may be as high among persons who are not directly affected by the disaster as it is among those who are.0 percent overall in the area 12.3 percent of the region’s inhabitants could be considered directly affected by the attacks. We estimate that 28. “Posttraumatic Stress Disorder in the General Population after Mass Terrorist Incidents: Considerations about the Nature of Exposure. 2 (February 2005): 107–15. ◆ ◆ ◆ Calculations then show that the net burden of PTSD in the directly affected group would be expected to be approximately 460.000.7 percent in the not directly affected group. but 360. THE BURDEN OF PTSD WAS GREAT AMONG THE GENERAL POPULATION AS WELL In the New York metropolitan area. this means that approximately 3.0 percent in the directly affected group.000 and in the not directly affected group.000 adults (2000 Census).820.” CNS Spectrums 10. and 3.500 were not.000 people in the group directly affected by the attacks developed PTSD.500 people were directly affected and 9. about 360. there are approximately 13. no.679.

despite the higher rates of distress initially among New Yorkers. nearly two-thirds of the sample (64.C. Soon after September 11. adults with persistent distress reported accomplishing less at work (65 percent). and elsewhere. New York.20 Significantly. The residents of the Washington. fearfulness also subsided in the months following September 11. and fear of harm to their families was expressed by 40.6 percent. found that 16 percent of the U.Terrorism.22 Nationally.” and 59. Mental Health. page 26). fears of future terrorism were still present at least sometimes for 37. this proportion had dropped to 5. Two months after the attacks. medications. or using alcohol. sleep.S. but still substantial numbers of people remained frightened (see Figure 13. population outside of New York City reported symptoms of posttraumatic stress related to the September 11 attacks two months later. by November rates of persistent distress were similar across the country.8 percent four months after that.5 percent. D. in large communities and small. surveying immediately afterward and at two and six months after the attacks. These may have been responsible for keeping fears alive throughout the nation during the subsequent months. For example.6 percent) admitted to fears of future terrorism “at least sometimes. researchers comparing psychological distress in New York City with other areas reported that. Six months after attacks. area were subsequently horrified by a series of sniper attacks that claimed the lives of ten individuals. avoiding public gathering places (24 percent). and September 11 25 IN THE NATION Examinations of trends in the nation as a whole also show rapid resolution of symptoms within the first six months for most of the population but persistence of problems in a smaller group of people.. or other drugs to relax. .19 Researchers who followed a national probability sample of adults.23 The persistence of fear needs to be viewed in the context of the new threats that followed in rapid succession the attacks on the World Trade Center. or feel better (38 percent) in the face of ongoing worries about terrorism.21 Adults across the nation who were continuing to experience terrorismrelated distress approximately two months later also reported disruption of their daily lives.C. D. a series of anthrax-laced letters were discovered in Washington.5 percent reported fear of harm to their families as a result of terrorism..

It is unknown why this is. panic reactions. Hispanics were more likely to receive a diagnosis of PTSD than were individuals of other races or ethnicities. but the finding has been consistent across a number of studies. While prior stress. and losing possessions during the attacks.5 Source: Roxane Cohen Silver et al. living below Canal Street (close to the World Trade Center site in Manhattan). geographic residence and loss of possessions were not. having experienced a panic attack during or soon after the event. PREDICTORS OF PTSD AND DEPRESSION INITIALLY AND OVER TIME Evidence is mounting that individuals for whom PTSD and depression symptoms persist over time were more vulnerable in the first place because of other traumatic life experiences. 10 (September 11. Researchers in New York and elsewhere (Israel. In addition. for example.6 Two months after attack Six months after attack 59. no. In the short term after September 11.” Journal of the American Medical Association 288. “Nationwide Longitudinal Study of Psychological Responses to September 11.26 Gerry Fairbrother and Sandro Galea FIGURE 13.6 64. In addition. and Hispanic ethnicity also were predictive of depression. the predictors for developing PTSD were having had two or more stressful life events in the previous twelve months.5 40. 2002): 1235–44. circumstances that were not .. for example)24 have examined the characteristics associated with short-term and persistent PTSD and depression and have found important differences between them. FEARS SUBSIDED BUT PERSISTED FOR SOME 70 60 50 Percent 40 30 20 10 0 Fear of future terrorism Fear of harm to family 37.

being divorced.Terrorism. were having low income. Characteristics associated with persistent PTSD. Mental Health. and being unemployed after September 11. In sum. Predictors of persistent depression over the follow-up period included having low income. experiencing panic attacks on or since September 11. experiencing other traumatic or stressful events before or after September 11. experiencing trauma or stressful events during the follow-up period. or widowed. were significant predictors of depression. loss of a friend or relative. On the day of the attacks. and September 11 27 related to PTSD. feeling afraid of injury or death on September 11. living below 14th Street in Manhattan. Public mental health response systems were conditioned after September 11 to focus on persons who were most at risk of developing psychopathology. separated. MENTAL HEALTH COUNSELING SERVICES FOR NEW YORK CITY Providing services to the large numbers of traumatized individuals was made possible through support from the Federal Emergency Management Agency (FEMA). being divorced. the predictors of persistent PTSD and depression included fewer demographic characteristics than the predictors of onset of PTSD in the immediate aftermath of the attacks and encompassed instead a range of subsequent trauma and stressful experiences. or loss of a job. living below 14th Street in Manhattan. The differences are critical. including low social support. 2001. or widowed. on the other hand. the changing profile of those showing symptoms of distress suggests that public health workers need to be sensitive to who is most vulnerable at any given period of time as well as flexible enough to provide appropriate mental health services even as the nature of the demand shifts. making them eligible . However. separated. President Bush declared the five boroughs of New York City a federal disaster area. and experiencing panic attacks after September 11.

the psychiatrists. and referrals to other services. eligible for FEMA programs.30 . brief supportive services. the state Office of Mental Health subsequently requested that FEMA permit funds to be used for an expanded array of services to include evidence-based cognitive-behavioral interventions (such as interventions that are based on changing pathologic thoughts and behaviors) for traumarelated disorders. Because of the heightened need and evidence of longer-term problems.000 persons in New York and the surrounding counties would experience post-traumatic stress disorder resulting from exposure to the attacks and that more than 129. social workers. psychologists. on September 28. FEMA mental health services are delivered through the Crisis Counseling Assistance and Training Program. designed to handle the short-term mental health needs of communities affected by disasters.000 would seek treatment for it during 2002.28 Based in part on these estimates. too. the president expanded the disaster area to include ten surrounding counties where many New York City rescue workers and commuters lived.27 Meanwhile.2 million from FEMA for crisis counseling during the year following the attacks. New York State’s Office of Mental Health applied for and received $155. officials organized to apply for and use federal disaster relief funds. making these locales. Preliminary estimates of the need for mental health services indicated that approximately 520. public education. Then.25 FUNDING AND ORGANIZATION OF SERVICES The mental health community in New York City was taken by surprise on September 11 and was unprepared to respond to a disaster of such magnitude. and other mental health professionals mobilized and began offering services and training other clinicians to provide trauma-related services.29 FEMA crisis counseling funds traditionally are limited to short-term counseling.26 In the days and weeks following.28 Gerry Fairbrother and Sandro Galea for FEMA assistance.

and television. and trouble sleeping.35 . radio. These individuals experienced about twice as many traumatic symptoms as did those not referred. Project Liberty was operational in New York City and surrounding counties by mid-October. Project Liberty had offered crisis counseling services to more than thirty-six thousand individuals. approximately 9 percent of the people who came to Project Liberty were referred to the mental health system for further treatment.32 Publicity surrounding Project Liberty was substantial. and September 11 29 PROJECT LIBERTY The massive program mounted with these funds was called Project Liberty.2 million New Yorkers would receive Project Liberty services. 1.” also was intended to reduce stigma and to gain broader acceptance for its services. including sadness. as shown in Figure 14 (page 30). In addition to those receiving crisis counseling services. The individuals served reported a range of reactions. Most of them had just one session. Mental Health. anxiety or fear. irritability or anger.31 The Project Liberty slogan used in advertising. large numbers of New Yorkers (more than fifty-four thousand) received group education sessions through Project Liberty. Its originators thought that unifying the services under a special name was needed for easy identification. for a total exceeding forty thousand service encounters. “Feel Free to Feel Better. just four to six weeks after the attacks. Ultimately. some had more than one.34 Virtually all of these services (86 percent) were delivered within the community. They sought to distinguish the health services provided as part of the recovery effort from traditional mental health treatment to avoid the stigma sometimes associated with mental illnesses.33 PROJECT LIBERTY SERVICES USED By the end of the first six months (through March 2002). A Project Liberty hotline and Web site were made available as well. with advertisements on buses. with more than one hundred mental health service agencies providing free public education and crisis counseling services.Terrorism.

no. only 24 percent of New Yorkers had heard of Project Liberty by January 2002. THERE WERE MORE THAN FORTY THOUSAND CRISIS SERVICE ENCOUNTERS IN THE FIRST SIX MONTHS OF PROJECT LIBERTY 50 40 30 20 10 0 39 33 24 22 Percent 20 16 13 /a ng er bi lit y es s ty Source: Chip J.36 With steady publicity. Better-educated and higher-income individuals were more likely than others to have heard of the Project Liberty. however. 3 (September 2002): 429–33. but in spite of this disadvantaged New Yorkers were more likely to use the program. Two-thirds (66 percent) of the people who had heard of it had a good impression of the program. despite intense publicity. New Yorkers of racial or ethnic minority groups with less than a high school education were more apt to say they were “likely to call Project Liberty” than other groups.” Journal of Urban Health 79. “Project Liberty: A Public Health Response to New Yorkers’ Mental Health Needs Arising from the World Trade Center Terrorist Attacks. three months after its initiation. Felton.30 Gerry Fairbrother and Sandro Galea FIGURE 14. co Di nc ffic en ul tra ty tin g th ou Int gh rus ts/ ive Iso im la ag tio es n/ w ith dr aw al Irr ita D sle iffic ep ult in y g dn Sa An xi e . by the oneyear anniversary of the attacks 50 percent of New Yorkers had heard of Project Liberty. HOW MANY NEW YORKERS HAD HEARD OF PROJECT LIBERTY? However. As shown in Figure 15.

10 (October 2003): 1404–6. UNMET NEED FOR MENTAL HEALTH SERVICES Despite the high levels of reported psychological distress and despite the widespread availability of services. the stigma associated with mental health services. It is important to understand the reasons for low levels of service utilization. no.. a lack of awareness of the Project Liberty offerings. and September 11 31 FIGURE 15. ETHNIC MINORITIES AND THOSE WITH LOWER EDUCATIONAL ATTAINMENT WERE MORE WILLING TO USE THE PROJECT LIBERTY SERVICES 70 Percentage willing to use services 60 50 40 30 20 10 0 9 23 32 23 19 19 13 40 63 te Source: Sasha Rudenstine et al. in order better to design outreach and screen in the event of a future terrorism crisis.” Psychiatric Services 54. Such reasons include but are not limited to the belief that other people may have greater need for help. “Awareness and Perceptions of a Communitywide Mental Health Program in New York City after September 11. Am ri er can ica n Hi sp an ic L hi ess gh th sc an ho o Hi gh l sc ho So ol m e co lle Fi ge ni sh ed co lle ge gr ad So ua me te w or k hi W As ia n Af . the match between counseling and those who appeared to need it was surprisingly low for both adults and children. or misplaced concern about paying for the (free) services. Mental Health.Terrorism.37 This was a troubling finding. particularly for symptomatic individuals.

. as shown in Figure 16.39 FIGURE 16. even though more than half (53 percent) of this group reported at least one symptom of PTSD or depression. this was not the case: only 36 percent of those with PTSD or depression visited a professional for a mental health problem during the six-month period. a full 64 percent of those showing signs of disturbance did not receive any mental health services at the time. EVEN AMONG THE DIRECTLY AFFECTED Percentage receiving counseling 100 80 60 40 20 0 Probable PTSD or depression Directly affected All other respondents Source: Jennifer Stuber et al. even though persons with a probable diagnosis of PTSD or depression were more likely to seek professional care than were other respondents. This finding is all the more surprising in light of the knowledge that 70 percent of respondents with PTSD also reported diminished functioning. not just those with a diagnosis of PTSD. 2004. New York Academy of Medicine.38 Thus. However. approximately 9 percent of the New York City population overall had received counseling from a mental health professional. “Was There Unmet Need for Mental Health Services after the September 11 Terrorist Attacks on the World Trade Center?” unpublished manuscript. ONLY A SMALL PROPORTION OF NEW YORKERS RECEIVED MENTAL HEALTH SERVICES. One might expect that a large proportion of those individuals with symptoms would have sought out the available services. Moreover. 85 percent of people who were directly affected by the attacks did not receive any mental health services in the six months after September 11. .32 Gerry Fairbrother and Sandro Galea UNMET NEED AMONG ADULTS By six months after the September 11 attacks. Services through Project Liberty were available for anyone who desired them.

44 . In contrast schoolchildren are in a supervised setting where problems can be observed and referrals to care made. Even more startling. there was very little use of mental health services after the attacks among people who were not already seeking care prior to September 11.Terrorism. while the other half experienced more moderate symptoms (see Figure 17. and they could have a variety of reasons for not availing themselves of needed services. On the other hand. page 34). and September 11 33 These findings were echoed by other researchers. It is reasonable for children who are not highly symptomatic to be in counseling. who found that a surprisingly small proportion of individuals with severe symptoms obtained treatment. only 27 percent of the children with severe or very severe post-traumatic stress reactions after the attacks received counseling services. As seen in Figure 18 (page 34).40 A full year after the attacks. most of it in the schools (44 percent) or through a mental health professional (36 percent). By January 2002. the fact that symptomatic children were not in counseling is cause for concern. Crisis counseling services were available to anyone who felt a need for them.43 and that proportion had not changed by the four-month mark. Almost 90 percent of people with probable PTSD or depression who received counseling after the attacks already had done so beforehand. 10 percent of children citywide had received some sort of counseling. the numbers of symptomatic people who had received counseling services were still low. and only 14 percent with behavior problems did. Mental Health. the striking finding concerning low service demand among symptomatic adults also held true for children. Adults generally must seek their own care services out.42 Further. About half of the children who received services had severe or very severe post-traumatic stress reactions symptoms. four months after the attacks. fewer than one-quarter of the children living in proximity to the World Trade Center (below 110th Street) received counseling immediately after the attacks.41 UNMET NEED AMONG CHILDREN Even more surprisingly.

PERCENTAGE OF CHILDREN WITH SEVERE STRESS REACTIONS AND BEHAVIOR PATTERNS RECEIVING ANY TYPE OF MENTAL HEALTH SERVICES Percentage receiving counseling 100 80 60 40 20 0 27 14 Severe/very severe post-traumatic stress reactions Behavior problems Source: World Trade Center Survey. COUNSELING SERVICES FOR CHILDREN AFTER SEPTEMBER 11 Post-Traumatic Stress Reaction: Mild or doubtful 3% No counseling 90% 10% Counseling 47% Severe/very severe Moderate 50% Source: World Trade Center Survey. January and February 2002. these data strongly indicate there may be extensive unmet need among children most seriously affected by the September 11 attacks. conducted by the New York Academy of Medicine.34 Gerry Fairbrother and Sandro Galea FIGURE 17.45 These findings of disparity between the need for mental health services and . conducted by the New York Academy of Medicine. January and February 2002. Although children with severe or very severe post-traumatic stress reactions were more likely to receive mental health services than children with less severe reactions. FIGURE 18.

The overriding reason. relates to “altruistic concerns”— a belief that other people might need the services more. “Was There Unmet Need for Mental Health Services after the September 11 Terrorist Attacks on the World Trade Center?” unpublished manuscript. REASONS FOR NOT SEEKING SERVICES 60 50 40 PTSD or depression Directly affected All others Percent 30 20 10 0 Lack of knowledge Time constraints Altruistic concerns Stigma-related Financial concerns Source: Jennifer Stuber et al. FIGURE 19. either inside or outside the schools. which showed that only 34 percent of those with probable PTSD and impaired functioning in the months after September 11 attacks received counseling. look first at the reasons given by the individuals themselves in response to survey questions.46 WHY WAS SERVICE UTILIZATION LOW AMONG PEOPLE WHO PRESUMABLY NEEDED HELP? The failure broadly even of those with elevated symptoms of stress to get help that was readily available is puzzling. . To understand why. This result strongly suggests a need for an alternate route to services beyond self-referral. It is important to note that even individuals with PTSD and those who were directly affected by the terrorist assault expressed the view that others might need services more and indicated this as their reason for not seeking assistance.Terrorism. New York Academy of Medicine. Mental Health. as shown in Figure 19. 2004.. and September 11 35 their delivery echo results from an assessment of New York City schoolchildren.

Since Project Liberty services were provided at no charge. Good work was done in local areas.36 Gerry Fairbrother and Sandro Galea Other reasons cited for not seeking services were financial and time constraints. worry about others’ perceptions if one were to access these services continued to be a deterrent. proved to be a daunting task. in training community responders to recognize people in distress and to direct them to the appropriate services. people with PTSD or depression may not feel well enough to navigate the system on their own behalf. A final set of reasons for not seeking services is related to the stigma associated with receiving mental health services. gives pause. and this may have been adequate for some. These revelations are especially sobering given the extensive publicity surrounding Project Liberty. but these were not cited by as many people generally or as many showing symptoms. . IS THERE A ROLE FOR PRIMARY CARE PHYSICIANS AFTER A DISASTER? The finding that most people who used services were already connected with mental health services. It is ironic that the disorder’s very symptoms make seeking care difficult. in spite of the extensive Project Liberty outreach that aimed in part to allay such stigmatization. Second. those indirectly affected are harder to identify when symptoms ripple throughout the population. families. combined with indications of high unmet need. especially among those who were not directly affected but still needed services. First. While those directly affected are fairly readily identified and approached. It has been demonstrated that mental health pathology is stigmatized in many communities. those that cited cost as a barrier may not have been aware of their free nature. ignorance about features of the program might be a larger culprit than the figure indicates. friends. Reaching large numbers of people. It is possible that. religious groups—to help cope. by groups like Safe Horizons. individuals used informal networks—spouses. Professionals in the field offer other reasons why social services were underutilized in the aftermath of the September 11 attacks. Although a smaller proportion of people cited lack of knowledge about where to go to get help.

FIGURE 20. 2005. but the corresponding figure for children is a matter of public record. these discoveries point strongly to the need to use other means to identify symptomatic individuals in the general population and to connect them with services. Physicians are logical candidates. New York Academy of Medicine. Mental Health. This may mean relying on other professionals with whom people regularly come in contact.Terrorism. and Sandro Galea. In the six months after the attacks. and September 11 37 Taken together. . Jennifer Stuber. a high proportion of children—80 percent or more—saw a doctor. overwhelmingly (approximately 90 percent) saw their primary physician. but far fewer of them saw a mental health professional. a little more than half of the children with severe or very severe post-traumatic stress reactions saw a mental health specialist. and only about one-third of those with behavioral problems did (see Figure 20). Most adults and children have at least one doctor visit during the course of a year. “Do Primary Care Physicians Need to Screen for Mental Health Needs in This Age of Terrorism?” unpublished manuscript. too. CHILDREN’S PRIMARY CARE VISITS COMPARED WITH MENTAL HEALTH VISITS Primary care provider Mental health provider 100 93 80 80 87 89 Percent 60 53 40 34 20 18 0 All children Children with PTSD 14 Children with Children in families two or more prior directly affected by the attacks traumatic events Source: Gerry Fairbrother. Specifically.48 Symptomatic children.47 It is not known how many adults saw a doctor in the months after September 11.

PEDIATRICIANS REPORT NEEDING ADDITIONAL MENTAL HEALTH TRAINING TO HELP THEIR PATIENTS 100 80 77 Percent 60 40 20 0 12 PTSD Depression Bereavement Screening for Treating counseling mental health mental health problems problems 51 34 44 Source: Danielle Laraque et al. Additional training for physicians would be necessary in order for this to happen. Diagnosing PTSD constituted a more serious problem. for example. It may also be the case that children with psychological distress develop physical symptoms as well. the large proportion of children seeing a primary care doctor suggests that such physicians can play a major role after a disaster.38 Gerry Fairbrother and Sandro Galea It may be natural for parents to turn to their children’s customary physician in times of stress. A survey of pediatricians in the New York City area asked about their skills in diagnosing PTSD and depression and in providing bereavement counseling. for primary care physicians to screen patients routinely after a terrorist attack for mental health responses. “Reactions and Needs of Tristate-Area Pediatricians after the Events of September 11th: Implications for Children’s Mental Health Services. . It may be important. for adults and children alike. no. FIGURE 21. No matter what the reason..” Pediatrics 113. 5 (May 2004): 1357–66. Most of these physicians thought they could diagnose depression: only about 12 percent felt lacking in the skills needed. with about half of the physicians saying that they lacked the skills to make this determination (see Figure 21).

It would be essential as well to create a model for interaction between primary care physicians and mental health professionals. and distress reverberated throughout the nation as well. A second major finding was that the mental health services. but it is reasonable to assume that other physicians would respond similarly. a significant portion of the general population in New York City developed terrorism-related post-traumatic stress disorder. indicating the need for a nationwide public health response to a terrorist attack. A few such programs exist now. In addition to training. and many (44 percent) said they would like additional training in treating problems. As currently constituted. who regularly see the vast majority of the population. treat the mild cases. 2001. Indeed. were not delivered to many who could have been helped by them. funding would need to be available. and September 11 39 More than three out of four said they would like additional training in screening for mental health problems. While those closest to and most directly affected by the attacks were most likely to develop symptoms of psychological stress. changed the landscape in ways that went well beyond the physical.Terrorism. can and . This survey involved only pediatricians. One of the surprising lessons involved the breadth of the impact. FEMA assistance does not go to primary care physicians. Combined with a new understanding of broad mental health needs. despite being widely available and funded through FEMA. Mental Health. this demonstrates that a different approach to outreach and screening needs to be part of the process. mental health problems were by no means limited to that group. Primary care doctors. whereby the primary care physician would check for symptoms of distress. and refer the severe cases to a specialist. But such physicians may need to screen routinely for mental health problems in all patients they see after a terrorist attack. CONCLUSIONS AND LESSONS LEARNED The terrorist attacks on September 11.

.. Galea et al. Lynn E. 2002): 988–96. Galea et al. “Psychological Reactions to Terrorist Attacks: Findings from the National Study of Americans’ Reactions to September 11. “A National Survey of Stress Reactions after the September 11.” American Journal of Psychiatry 158. William E. 9 (September 2001): 1467–73.” Journal of the American Medical Association 288. D. 12. 5 (August 7. Stein et al. 4. 2. no. 13.. Schuster et al. 11. 2002): 633–36. 1981–2001. no..” American Journal of Psychiatry 160. 5 (August 7. Schlenger et al. Manderscheid and Marilyn J. Ibid. Sandro Galea et al. DeLisi et al. Marshall et al.” 11.” American Journal of Epidemiology 155. “Psychological Sequelae of the September 11 Terrorist Attacks in New York City.C. Randall D. “60. New York. Henderson (Washington. 6. pp. “Mental Health in New York City.. no... Ronald W. ed. An Empirical Review of the Empirical Literature.. “Posttraumatic Stress Disorder in Manhattan. no.” in Mental Health. 2002. United States. and Suicidality in Subthreshold PTSD. Carol S.” Journal of Urban Health 79. “Mental Health in New York City. NOTES 1. David Vlahov et al. Terrorist Attacks. 10. 2002): 581–88. Fran H. Impairment. “A Survey of New Yorkers after the Sept. and Marijuana among Manhattan.... Norris et al. “Research on the Mental Health Effects of Terrorism. “Full and Partial Posttraumatic Stress Disorder: Findings from a Community Survey.” New England Journal of Medicine 345. Residents after the September 11th Terrorist Attacks. “Increased Use of Cigarettes.” Psychiatry 65. 8 (August 1997): 1114–19. 2002): 982–87. Sandro Galea et al. 5.40 Gerry Fairbrother and Sandro Galea should be mobilized to identify those who are suffering after a terrorist incident. no. Government Printing Office. Alcohol. New York City. Terrorist Attacks. Ibid. no. Murray B. no. after the September 11th Terrorist Attacks. 2001. 3. 4 (April 2003): 780–83.000 Disaster Victims Speak: Part I. 2001): 1507–12.” Journal of the American Medical Association 288.” New England Journal of Medicine 346. no. Mark A. 11 (June 1.. 7.. Sandro Galea et al. 2003). “Mental Health in New York City after the September 11 Terrorist Attacks: Results from Two Population Surveys.” 8. 2001. 13 (March 28.: U. no. 9. “Comorbidity. no. North and Betty Pfefferbaum. 3 (Fall 2002): 207–39.” American Journal of Psychiatry 154. 20 (November 15.S.. This proposed initiative would require funding and policy changes to facilitate testing and to help upgrade the skills of general practitioners concerning the field of mental health. 3 (September 2002): 340–53. 83–91.

Terrorism. and September 11 41 14. which extends the same services for an additional nine months. no. “A National Longitudinal Study of the Psychological Consequences of the September 11. no. Christina W. 6 (September 15.” Psychiatry 67. “Acute Stress Reactions in Adults.” Journal of the American Medical Association 288. 27. 2 (Summer 2004): 105–17. Stein et al..” 21. .” prepared by Applied Research and Consulting. Gerry Fairbrother et al.. Chip Felton. “Effects of the World Trade Center Attack on NYC Public School Students: Initial Report to the Board of Education. Terrorist Attacks: Reactions.. 16. The Crisis Counseling Assistance and Training Program has two components: the Immediate Service Program. 2001. ed. “Mental Health Needs in New York State Following the September 11th Attacks. 201–15. 20.” Ambulatory Pediatrics 3. Daniel Herman. 2004). Impairment.. Silver et al. Marshall.” 22. Mental Health.5 million for the subsequent nine months. Silver et al. and the Regular Services Program. 19. “The Professional Response to the Aftermath of September 11. 2001. 17. 3 (September 2002): 322–31. 25.. “Nationwide Longitudinal Study of Psychological Responses to September 11. Arieh Y. which has a precise clinical definition. Ibid. Terrorist Attacks. and the New York State Psychiatric Institute. 2003): 514–24. Roxane Cohen Silver et al. Yuval Neria. Hoven et al.” Biological Psychiatry 51. Shalev. which covers the first ninety days following a disaster. Eun Jung Suh.. Early Intervention for Trauma and Traumatic Loss (New York: Guilford Press. “Trends of Probable Post-Traumatic Stress Disorder in New York City after the September 11 Terrorist Attacks. Sandro Galea et al. 18.” Journal of Urban Health 79. and Help-Seeking. LLC (New York). The assessment tool used to identify post-traumatic stress reactions is similar but not identical to the assessment procedure for PTSD. Litz.. 10 (September 11. and Ezra Susser. “Nationwide Longitudinal Study of Psychological Responses to September 11. and Randall D.. in New York City: Lessons Learned from Treating Victims of the World Trade Center Attacks. Ibid.7 million for the first ninety days and $132. 2002.” 24. 2002): 532–43. 28. no. no. Ibid. Bradley D. the Columbia University Mailman School of Public Health. 26. pp. “Posttraumatic Stress Reactions in New York City Children after the September 11. 2002): 1235–44. Stein et al. 7 (April 1. no. 2001. “Nationwide Longitudinal Study of Psychological Responses to September 11. The FEMA funding initially received included $22.. 23.” American Journal of Epidemiology 158. May 6. 15.” in Brett T. 6 (November-December 2003): 304–11. no. “A National Longitudinal Study of the Psychological Consequences.

“Effects of the World Trade Center Attack on NYC Public School Students.. Ibid. “Project Liberty.. Jennifer Stuber et al. 2001. “Unmet Need for Counseling Services by Children in New York City after the September 11th Attacks on the World Trade Center: Implications for Pediatricians.. 11. 40. Gerry Fairbrother et al.. 44. DeLisi et al. and Sandro Galea. Terrorist Attacks. 38. no. Quality. “Was There Unmet Need for Mental Health Services after the September 11 Terrorist Attacks on the World Trade Center?” unpublished manuscript. Utilization. “Project Liberty. Felton. Jennifer Stuber. 34.. “Lessons Learned since September 11th 2001 Concerning the Mental Health Impact of Terrorism.. “Survey of New Yorkers after the Sept..” 47. “Unmet Need for Counseling Services. 5 (May 2004): 1367–74. “Awareness and Perceptions of a Communitywide Mental Health Program in New York City after September 11.” Journal of Urban Health 79. Stuber et al.” Psychiatric Services 54. “Lessons Learned since September 11th. 7 (July 2002): 815–22. “Health Care for Children and Youth in the United States: 2001 Annual Report on Access. Fairbrother et al. Felton.. no. 48.42 Gerry Fairbrother and Sandro Galea 29. 6 (November-December 2002): 419–37.. Chip J. “Project Liberty: A Public Health Response to New Yorkers’ Mental Health Needs Arising from the World Trade Center Terrorist Attacks. Anne Elixhauser et al. 11. “Unmet Need for Counseling Services.” Pediatrics 113. Stuber et al. . DeLisi et al. no. Ibid. Chip J. Terrorist Attacks”. Hoven et al. Fairbrother et al. 46. 2005. no..” 45.” 36. Gerry Fairbrother. 31. 30.” Psychiatric Services 53. “Was There Unmet Need for Mental Health Services?” 39.” 35. Felton.. New York Academy of Medicine.” 33.. Jennifer Stuber et al. 32.” Psychiatry 67. “Do Primary Care Physicians Need to Screen for Mental Health Needs in This Age of Terrorism?” unpublished manuscript. 2004. Ibid. New York Academy of Medicine. no.” Ambulatory Pediatrics 2. 10 (October 2003): 1404–6.” 43. 2 (Summer 2004): 147–52. 37. and Expenditures. Felton. “Survey of New Yorkers after the Sept. 3 (September 2002): 429–33. Felton. Sasha Rudenstine et al. Appropriate Response Strategies and Future Preparedness.” 41. 2001. “Was There Unmet Need for Mental Health Services?” 42. “Determinants of Counseling for Children in Manhattan after the September 11 Attacks. Ibid. no.

Galea is board certified in family medicine and emergency medicine and has worked as a clinician in remote rural communities in northern Canada and in the Mudug Region of Somalia. She received her Ph. where she holds joint appointments in epidemiology and biostatistics as well as health policy and clinical effectiveness. Mental Health. Dr. from Johns Hopkins University. the Harvard University School of Public Health. and the use and consequences of illicit drugs. He did his graduate training at the University of Toronto Medical School. Dr. Previously. and September 11 43 ABOUT THE AUTHORS Gerry Fairbrother is a professor of pediatrics at the University of Cincinnati/Cincinnati Children’s Hospital Medical Center. He is interested in the epidemiology of mental health and substance abuse with a particular focus on social and economic determinants in urban settings. and the Columbia University Mailman School of Public Health.Terrorism. depression. His recent work has focused on post-traumatic stress disorder. Fairbrother has examined the effects of September 11 on children in New York City as well as the adequacy of procedures to identify and serve the mental health needs of children after a terrorist attack. she was senior scientist at the New York Academy of Medicine and research director of the Academy’s Child Health Forum. . Sandro Galea is a medical epidemiologist and associate director at the Center for Urban Epidemiologic Studies at the New York Academy of Medicine. She also has written extensively about the impact of changes in the health care delivery system on children.D.

President . Kaden James A. M. Sorensen Kathleen M. Hamilton Matina S. and domestic political issues. BOARD OF TRUSTEES OF THE CENTURY FOUNDATION Richard C. it was founded in 1919 and endowed by Edward A. Jr. Not-for-profit and nonpartisan. Leone. Chairman Joseph A. Alexander Morgan Capron Hodding Carter III Edward E. Berle Alan Brinkley. Leone Jessica Tuchman Mathews Alicia H. foreign affairs. Schlesinger. Horner Lewis B.D. Jr. Brewster C.44 Gerry Fairbrother and Sandro Galea ABOUT THE CENTURY FOUNDATION The Century Foundation sponsors and supervises timely analyses of economic policy. Denny Christopher Edley. A. Sullivan Shirley Williams William Julius Wilson H. Theodore C. Munnell P. Brandt Ayers Peter A. Harvey I. Jr. Califano. Leach Richard C. Charles V. David. Sloane. Filene. Jr. Michael Pitfield John Podesta Richard Ravitch Alan Sagner Arthur M.

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