Correspondence

Reactions to the Events of September 11

N Engl J Med 2002; 346:629-630February 21, 2002

Article

To the Editor:

Schuster et al. (Nov. 15 issue)1 report an increased incidence of distress after the events of September 11 and advise clinicians to be prepared to assist people with trauma-related symptoms. Using national workload data from the Department of Veterans Affairs, I compared the average number of daily outpatient visits during the 19 working days before and after September 11 in different clinical subgroups and geographic locations (excluding weekends, holidays, and September 11 itself).

Veterans Affairs facilities in New York City had small, nonsignificant (P>0.05) increases in the number of daily visits for general medical care (6.1 percent) and mental health care (5.0 percent), and more specifically for post-traumatic stress disorder (4.3 percent) and substance abuse (5.4 percent). Data from previous years show that these increases were smaller than those for the same period in 2000 (which had an 11.7 percent increase in mental health visits and a 21 percent increase in medical visits) but greater than those observed in 1999 (which had an 11.5 percent decrease in mental health visits and a 0 percent change in medical visits). The small increases in the use of services in 2001 thus differ little from those of previous years and probably reflect the fact that patients, clinicians, or both were returning from August vacations. The 5.0 percent increase in the use of mental health services in New York was slightly smaller than the increases in Washington, D.C. (10.9 percent), other large northeastern cities (15.3 percent), Oklahoma City (6.9 percent), and other large U.S. cities (10.1 percent).

Although the events of September 11 were profoundly traumatic for those directly involved and clearly distressing for others, they are not necessarily medically significant. I found no substantial short-term change in the use of services, even among more vulnerable patients with mental illness or post-traumatic stress disorder. Although we should acknowledge our natural emotional reactions to tragic events, we should not overly medicalize them without justification.

Robert Rosenheck, M.D.
Veterans Affairs Northeast Program Evaluation Center, West Haven, CT 06516
robert.rosenheck@yale.edu

1 References

1. 1

   Schuster MA, Stein BD, Jaycox LH, et al. A national survey of stress reactions after the September 11, 2001, terrorist attacks. N Engl J Med 2001;345:1507-1512
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We appreciate Dr. Rosenheck's data on the important issue of the use of health services in the 19 days after the September 11 terrorist attacks. We look forward to future research on the use of health services (as well as on the unmet need for treatment) over longer periods and in settings other than the Veterans Affairs system.

Our study found that many people across the United States had stress reactions during the days after the attacks. It is important for clinicians and others to be aware that such reactions are common and may even occur in people who are far from a disaster. Clinicians can reassure people that their stress symptoms are typical and that they will often resolve without any intervention. Such information is incorporated into most post-trauma mental health interventions.1,2 Clinicians can also inform their patients about effective coping strategies and give additional attention to those with persistent or particularly severe symptoms. Our study found that most people were using coping strategies that are considered healthy,2,3 such as talking with others, turning to religion, participating in group activities, and volunteering.

Many people's reactions will dissipate over time and without treatment, although ongoing threats, attacks, and unrelated catastrophes may prolong the process for some. We anticipate that a subgroup of people might have a harder time recovering, because they were directly exposed to the attacks or because of their personal characteristics (e.g., a history of mental health problems).

Mark A. Schuster, M.D., Ph.D.
Bradley D. Stein, M.D., M.P.H.
Lisa H. Jaycox, Ph.D.
RAND, Santa Monica, CA 90407-2138
schuster@rand.org

3 References

1. 1

   Foa EB, Davidson JRT, Frances A, eds. The expert consensus guideline series: treatment of posttraumatic stress disorder. J Clin Psychiatry 1999;60:Suppl 16-Suppl 16
   

2. 2

   Forster P. Nature and treatment of acute stress reactions. In: Austin LS, ed. Responding to disaster: a guide for mental health professionals. Washington, D.C.: American Psychiatric Press, 1992:25-51.
   

3. 3

   Norris FH. 50,000 Disaster victims speak: an empirical review of the empirical literature, 1981–2001. Bethesda, Md.: National Institutes of Health, September 2001.
   

Citing Articles (4)

Citing Articles

1. 1

   Victoria A. Franz, Carol R. Glass, Diane B. Arnkoff, Mary Ann Dutton. (2009) The impact of the September 11th terrorist attacks on psychiatric patients: A review. Clinical Psychology Review 29:4, 339-347
   CrossRef

2. 2

   Janet W. Rich-Edwards, Ken P. Kleinman, Emily F. Strong, Emily Oken, Matthew W. Gillman. (2005) Preterm Delivery in Boston Before and After September 11th, 2001. Epidemiology 16:3, 323-327
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3. 3

   Karen G Raphael, Benjamin H Natelson, Malvin N Janal, Sangeetha Nayak. (2002) A community-based survey of fibromyalgia-like pain complaints following the World Trade Center terrorist attacks. Pain 100:1-2, 131-139
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4. 4

   J. A. Salerno, C. Nagy. (2002) Guest Editorial: Terrorism and Aging. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 57:9, M552-M554
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