Editor's note

Stress reactions run from Acute Stress Reactions and Adjustment Disorders to Post-traumatic Stress Disorder (PTSD). The first two, in many instances, may be thought of as time limited in their impact and respond to many different types of psychosocial interventions. The primary purpose of intervening in these disorders is to facilitate more effecting coping with the stressor, reduce functional impairment, and return the individual to his previous level of active functioning in the community. PTSD has been shown to respond to both trauma-focused cognitive-behavioral psychotherapies and to pharmacological agents, particularly the SSRIs, though other pharmacologic interventions may impact some of the disturbed affect, anxiety, and lability, and to psychosocial interventions. As with many other disorders, there is a treatment resistant group that remain significantly impaired despite treatment, and long-term management of symptoms becomes the primary goal.

Introduction: differences in classification of stress disorders

The adjustment disorders, acute stress disorder, and post-traumatic stress disorder (DSM-IV) all share the common feature of occurring as a response to an adverse environmental event or cluster of events. The distinction appears clear cut; post-traumatic stress disorders follow extreme stressors that are operationally defined, whereas adjustment disorders may follow any kind of stressor of a less serious degree.

Adjustment disorders are defined as “clinically significant emotional or behavioral symptoms in response to an identifiable psychosocial stressor or stressors” (DSM-IV), and must develop within 3 months of the stressor (DSM-IV).

Introduction

The impact of the World Trade Center terrorist attacks has no historical peacetime precedent in the USA in terms of loss of human life, magnitude of physical destruction, adverse economic consequences, and psychological distress and disorder. In this chapter, we review the literature on mental health consequences of disaster, review research findings on the mental health consequences of the 9/11 attacks, describe the large-scale response undertaken by the New York State Office of Mental Health (NYSOMH) to address the mental health needs, and, finally, summarize lessons learned and their public health implications for mental health and homeland security policy.

Historical perspective: long-term mental health impact

Disaster experts have consistently documented the persistence of mental health needs long after the disastrous event itself. The 1995 bombing of the Alfred P. Murrah building in Oklahoma City was perhaps the best-documented mass violence disaster in terms of its impact on mental disorders before the attacks of September 11, 2001. Surveys conducted in the Oklahoma City metropolitan area found that 62% of persons reported experiencing at least one of the following as a direct response to the bombing: increased alcohol use (approximately double their prior amount), increased psychological distress (approximately double their prior level), post-traumatic stress disorder (PTSD) symptoms, and intrusive thoughts related to the bombing (Smith et al., 1999). The psychological effects were prominent and persisted more than a year after the disaster. Two years after the disaster, children who were geographically distant from the disaster site and did not directly experience an interpersonal loss still reported PTSD symptoms and functional impairment associated with increased media exposure and indirect loss (Pfefferbaum et al., 2000).

Introduction

The events of 9/11 continue to have profound consequences for the sense of physical safety and psychological well-being of Americans. In particular, as epidemiological research revealed the full magnitude of the mental health consequences of the 9/11 attacks (Galea et al., 2002), there was an unprecedented level of outreach aimed at insuring that those in need of mental health services are identified and treated (Felton, 2002). As part of this campaign, members of the general public were encouraged to examine their own distress levels and, if needed, to seek assessment and treatment.

These campaigns, and the public response to them, represent a sea change in attitudes toward mental health in our culture. The public discussion of the mental health consequences of 9/11 has been relatively free of stigmatizing and shaming attitudes that are often associated with mental health disorders. As noted by Jack Rosenthal, the Pulitzer Prize winning president of the New York Times Foundation, in the wake of 9/11, the word “victim” no longer held its pejorative connotation (J. Rosenthal, personal communication, 2001).

Of course, even with this reduction in stigma, many needing psychological help as a result of the events of 9/11 will still feel resistant to seek help. A survey by DeLisi and colleagues reported that only 27% of those with severe post-9/11 psychological symptoms were obtaining treatment (DeLisi et al., 2003). Nevertheless, even conservative estimates predict that over 100,000 persons could be expected to seek help for 9/11-related psychological trauma in the New York area alone (Herman et al., 2002).

This is a great and exciting book; a volume filled with stories of endeavor, achievement, appraisal and learning; stories of heroism, challenge and hope. It will become a handbook for all who would research the impact of disaster and terrorism on mental health and well-being. It is a courageous contribution to the science of this field in giving testimony to the research that was done to assess need, to study reactions over time, and to provide and evaluate the best possible care. It is also courageous in that the research is presented openly, with its challenges, its successes, its imperfections, and with critical appraisal provided by “outside” experts. It is all the more powerful for this. It is the most comprehensive drawing together of the wide range of initiatives that followed a specific incident, initiatives that were implemented in the times of chaos and uncertainty. It was instigated by researchers and clinicians who were, at the time, themselves also experiencing the multiple, acute and subsequent stressors of the attack and its aftermath. It is a further contribution in terms of the universal wish to make meaning of what has happened. As mental health professionals and scientists, this surely, is one of our ways of making meaning.

A number of themes thread their way through this book: The enormity, unexpectedness and uniqueness of what happened; not only was America assaulted, but the world saw, and felt what happened.

Public health models after large-scale disaster always consider the problem of “surge capacity” – that is, how effectively will a community be able to absorb a sudden increase in a particular need for medical intervention. Before the 9/11 disaster, models of such an event – the complete collapse of two of the world's tallest skyscrapers along with the destruction of surrounding buildings would literally have focused on surge capacity for medical treatment, for basic needs (food, clothing, shelter for persons displaced from contaminated dwellings) and social services after dwellings. The totally unexpected public health problem, was the need to address surge capacity for mental health problems and disorders. These chapters document only a few of the programs developed in response.

All epidemiological studies of the mental health consequences of the 9/11 attacks found significant rates of new-onset 9/11 related posttraumatic stress disorder (PTSD) in those directly and indirectly exposed in New York, and, surprisingly, also in persons across the US. Several groups have replicated this finding independently over time (Neria et al., this volume; Galea et al., this volume; Hoven et al., this volume; Cohen-Silver et al., this volume). Because the population base is so large, small percentages translate into large absolute numbers (e.g., a rate of 0.9% in the New York area _ 142,000 persons).

INTRODUCTION

From the first chaotic days after the attacks of September 11, 2001, the co-directors of the Consortium – Marylene Cloitre, PhD, Spencer Eth, MD, Randall Marshall, MD, and Rachel Yehuda, PhD – shared a collective sense of alarm that the need for mental health services in our community would greatly exceed capacity to provide evidence-based treatment for trauma-related problems and disorders. Because federal programs almost exclusively emphasize the public health objective of restoring the general population to a semblance of normal functioning, we worried that there would not be adequate programs devoted to helping persons developing serious psychiatric disorder as a result of the attacks. Subsequent epidemiological studies (reviewed in this volume) confirmed our impression, but by the time these data were available – many months after 9/11 – we were already well underway with the project of providing intensive training to a group of clinicians at each of our centers, who could then serve as expert treatment providers, and, more importantly, clinician experts available to the community for educational programs. In sum, the Consortium was a rapidly implemented large-scale project with the overall objective of disseminating evidence-based treatments for trauma-related disorders to the greater New York community.

During the first year alone, approximately 920 patients were evaluated and treated at all sites. Treatment was provided in English, Spanish, Hebrew, German, Korean, and several Chinese dialects. Some sites developed intensive trainings for clinicians, and other focused on clinical work or other kinds of educational programs (e.g. intensive training and supervision for a small group of community clinicians).