Correspondence
Psychological Sequelae of September 11
N Engl J Med 2002; 347:443-445August 8, 2002
- Article
To the Editor:
Studies of health care use after the September 11 terrorist attacks would complement surveys such as the one by Galea et al. (March 28 issue).1 We used the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) data base to conduct behavioral health surveillance among military health system beneficiaries in the Washington, D.C., area after the September 11 attack on the Pentagon. This data base includes the electronic records of all outpatient health care visits at military treatment facilities.2
Diagnostic groups for depression, anxiety, acute and post-traumatic stress disorders, substance-use disorders, and other behavioral health problems were defined according to the codes of the International Classification of Diseases, 9th Revision.3 We used ESSENCE to determine the weekly number of outpatient visits to behavioral health clinics at military treatment facilities within 50 miles of Washington, D.C., for each of these diagnostic groups from the week of September 11, 2001, through February 9, 2002. We compared these numbers with the weekly number of visits for the same 22-week period during the previous 2 years. Results are reported for adults and for children younger than 18 years of age (Table 1Table 1
Change in Number of Weekly Visits for Mental and Behavioral Health Problems among Military Beneficiaries after September 11, 2001.). Although there was no significant increase in the total number of visits to behavioral health clinics, there were significant increases in the number of visits for anxiety disorders and acute stress reactions in children and for adjustment reactions in adults.3 ReferencesCharles W. Hoge, M.D.
Julie A. Pavlin, M.D., M.P.H.
Walter Reed Army Institute of Research, Washington, DC 20307
charles.hoge@na. amedd. army. mil Charles S. Milliken, M.D.
Walter Reed Army Medical Center, Washington, DC 203071
Galea S ,Ahern J ,Resnick H , et al. Psychological sequelae of the September 11 terrorist attacks in New York City. N Engl J Med 2002;346:982-987
Full Text | Web of Science | Medline2
Pavlin JA, Kelley PW, Mostashari F, et al. Innovative surveillance methods for monitoring dangerous pathogens. In: Institute of Medicine. Biological threats and terrorism: assessing the science of response capabilities. Washington, D.C.: National Academy of Sciences, 2002:185-96.
3
Hoge CW, Engel CC Jr, Lesikar SE, Orman DT. Health care utilization for mental disorders among military personnel. In: American Psychiatric Association 53rd Institute on Psychiatric Services Meeting, Orlando, Fla., October 10–14, 2001. abstract.
To the Editor:
Most news polling is both rigorous and timely, and it can help inform the research reported in the Journal. Last November 15, Schuster et al. reported that “Americans . . . had substantial symptoms of stress” on the basis of national data collected three to five days after September 11.1 Between the time the data were collected and the time they were reported, however, any number of media polls found sharp declines in self-reported symptoms of stress, as compared with the levels immediately after September 11.
About a month after the attacks, for example, ABC News–Washington Post polls found a 15-point drop in the number of Americans expressing a “great deal” of worry about another major terrorist attack. By six months after the attacks, this value had become a 26-point decline.2,3 In more direct measures of personal stress, by mid-October, data from the Pew Research Center showed a 42-point drop in the number of respondents reporting depression, a 28-point decline in the number reporting difficulty concentrating, and a 21-point drop in the number reporting sleeplessness.4,5
In a recent issue of the Journal, Galea et al. reported a prevalence of post-traumatic stress disorder of 7.5 percent among Manhattan residents living south of 110th Street, according to data gathered between October 16 and November 15, 2001. This report also does not refer to the data that indicate declines over time in the rates of self-reported stress. Instead, the authors note that the duration of symptoms “remains to be seen.”
More recent local data, although less rich, point in the same direction as the national trend identified in news polls. In early March the Marist Institute for Public Opinion found a 15-point decline since October in the number of New York City residents who reported being worried about their personal safety and an 18-point decline in the number who were worried about another attack.6
A follow-up study by Galea and colleagues, presented May 18 at the American Association for Public Opinion Research, reinforces the suggestion that the reports would have benefited from the use of information from more current news polls. In data collected in January and February 2002, three months after the initial work, Galea and colleagues reported that the current rates of post-traumatic stress disorder and major depression related to the World Trade Center attacks had “both receded to less than half their levels at the one-month measurement.”7
7 ReferencesGary Langer
ABC News, New York, NY 10023
gary.e. langer@abc. com 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 | Medline2
ABC News. A sober response to anthrax scare. October 15, 2001. (Accessed July 19, 2002, at http://abcnews.go.com/sections/us/pollvault/pollvault.html.)
3
ABC News. Six months later: support for Bush and the war amid a sense of pride and purpose. March 11, 2002. (Accessed July 19, 2002, at http://abcnews.go.com/sections/us/pollvault/pollvault.html.)
4
Pew Research Center. September 11 shock slow to recede — 42% still depressed. October 14, 2001. (Accessed July 19, 2002, at http://www.people-press.org.)
5
Pew Research Center. Public remains steady in face of anthrax scare. October 15, 2001. (Accessed July 19, 2002, at http://www.people-press.org.)
6
Marist Institute for Public Opinion. World Trade Center six months later. March 8, 2002. (Accessed July 19, 2002, at http://www.maristpoll.marist.edu.)
7
Bucuvalas MJ, Galea S, Morgan M. Psychological impacts of September 11 on New York City residents. Presented at the 57th annual conference of the American Association for Public Opinion Research, St. Pete Beach, Fla., May 16–19, 2002.
Author/Editor Response
The authors reply:
To the Editor: Hoge et al. present important data from the military mental health surveillance system in the Washington, D.C., area that complement emerging data from New York City. In separate analyses of our survey of Manhattan residents, we found that there was no substantial increase in the use of mental health services in the first month after September 11. In our survey, 16.9 percent (95 percent confidence interval, 14.4 to 19.5 percent) of respondents reported visiting a mental health professional in the 30 days before September 11, and 19.4 percent (95 percent confidence interval, 16.7 to 22.2 percent) reported visiting a mental health professional in the 30 days after September 11.1 The data reported by Hoge et al. similarly show the absence of a substantial increase in the use of mental health services in the first five months after September 11. Taken together, these analyses suggest that existing therapeutic relationships or informal sources of support were the primary mental health resource for most people in the first few months after September 11.
Langer highlights the declining levels of worry about potential terrorist attacks documented in news polls. Although we concur that the decline in worry may be reassuring, we remain cautious about drawing any inferences about substantial long-term mental health psychopathology from these data. Preliminary data from our follow-up work suggest a decrease in the prevalence of current (within 30 days) post-traumatic stress disorder and depression symptoms in the population of New York City 4 to 5 months after the attacks. This finding is consistent with peer-reviewed evidence from longitudinal studies after traumatic events.2,3 Other work suggests that a substantial proportion of persons who experience traumatic events may have long-term psychological consequences.4 Further longitudinal, population-based studies using standardized measures are needed to determine the course of psychopathology among residents of New York City, particularly in the context of ongoing threats of further attacks and repeated media reminders of the events of September 11.
4 ReferencesSandro Galea, M.D., M.P.H.
New York Academy of Medicine, New York, NY 10029
sgalea@nyam.org Heidi Resnick, Ph.D.
Medical University of South Carolina, Charleston, SC 29425David Vlahov, Ph.D.
New York Academy of Medicine, New York, NY 100291
Boscarino JA ,Galea S ,Ahern J ,Resnick H ,Vlahov D . Mental health utilization in Manhattan following the September 11th terrorist attacks. Am J Epidemiol 2002;155:Suppl:353-353 abstract.2
Shalev AY ,Freedman S ,Peri T , et al. Prospective study of posttraumatic stress disorder and depression following trauma. Am J Psychiatry 1998;155:630-637
Web of Science | Medline3
Rothbaum BO ,Foa EB ,Riggs DS ,Murdock T ,Walsh W . A prospective examination of post-traumatic stress disorder in rape victims. J Trauma Stress 1992;5:455-475
CrossRef | Web of Science4
Kessler RC ,Sonnega A ,Bromet E ,Hughes M ,Nelson CB . Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995;52:1048-1060
Web of Science | Medline
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