Sept. 11—Anticipated Mental Health Consequences and What Can We Do Now

By Arline Kaplan ©2001 (All Rights Reserved)

The terrorist attacks on the New York World Trade Center and the Pentagon and the crashes of the four hijacked airliners leave the nation with devastating human losses, disruptive economic repercussions and demoralizing fears. As of press time,

• 556 remains have been identified at the World Trade Center and approximately 3,908 people are believed still missing, including the 157 people on the two hijacked planes.
• 343 firefighters are missing or have been confirmed dead and, as a result, more than 1,000 children have lost a parent.
• 125 Pentagon workers are dead or missing, and 64 passengers on American Airlines Flight 77 are dead.
• 44 people are confirmed dead after the crash of the hijacked plan in Pennsylvania.
• New York City’s comptroller estimates the World Trade Center disaster will cost New Yorkers an estimated $105 billion over the next two years, including $34 billion in property damage.
• U.S. Defense Department officials estimate it could take more than $750 million and three years to the repair the damage done in the attack on the Pentagon.
• One in five Americans knows someone who was killed, injured or still missing from the attacks or has a friend or relative who does, according to a Pew Research Center survey. The survey also found that eight out of 10 women and six out of 10 men interviewed felt depressed. People described recurrent, unwelcome images of the event replaying in their heads; many felt hypervigilant.
  

While immediate mental health support is being offered to those experiencing evident psychological trauma, questions remain as to the long-term mental health consequences of this national tragedy, how best to address the needs and how to adequately prepare for future disasters of a similar magnitude.

"Applying emergency emotional first aid in the short-run only to abandon people in their long-term need is short-sighted," Carol North, M.D., recently told a Senate committee investigating the psychological trauma and suffering linked to the Sept. 11 disaster. North, professor of psychiatry at Washington University School of Medicine in St. Louis, Mo., and a researcher on the psychological trauma of disasters, warned the Senate Committee on Health, Education, Labor and Pensions that "existing mental health infrastructures may be overwhelmed in the coming months."

North explained that when disasters occur, a ripple effect of subsequent psychiatric disorders result:

"Those injured and those who fled for their lives from the burning World Trade Center towers and the Pentagon already have suffered physical and emotional distress, but they also will suffer the most frequent and severe mental health consequences. Ripple effects will extend to people who were evacuated from nearby buildings and others who witnessed the disaster unfolding from a distance, including those watching the towers collapse from the New Jersey shoreline. Others deeply affected are the thousands of bereaved who lost their loved ones, the rescue and recovery workers who risked their lives and also lost valued colleagues, and people affected by the plane crash in Pennsylvania…potentially overlooked populations at risk may include medical personnel, disaster workers and media professionals."

Lessons from Oklahoma City

To help predict the scope of future mental health problems, North reported on the aftermath of the 1995 bombing at the Alfred P. Murrah Building in Oklahoma in which 168 were killed and 675 wounded. One out of three people in the path of the bomb blast developed posttraumatic stress disorder (PTSD) and another 10% had some other psychiatric disorder, most often major depression. Two years after the Oklahoma City bombing, 16% of children 100 miles away reported significant PTSD symptoms related to it.

Research informs clinicians that people developing psychiatric problems after disasters can be identified early on by certain characteristics and symptom patterns, North said.

"Intensity of exposure in terms of injuries and loss of close family members predicts psychiatric illness. People so traumatized by the disaster that they are emotionally numbed and can cope only by avoiding all reminders of it are at particularly high risk. Pre-existing psychiatric disorders, especially, prior episodes of depression and trauma-related disorders, also predispose people to post-disaster psychiatric illness."

North warned that to "identify needs, we may need to knock on doors and visit employers, in order to find and encourage those who are reluctant to talk and seek treatment."

In an interview, Oklahoma City psychiatrist, Theresa Garton, M.D., shared some lessons learned from the Murrah disaster that may be applicable to Sept. 11. Garton had been working at a community mental health center and building her own private practice. In the days following the bombing of the federal building, she cared for her own patients, volunteered at a hotline established by a local television station, attended debriefing trainings arranged by the National Organization for Victim Assistance (NOVA), and went to centers established for the families of the bombing victims.
After the bombing, some people in the community began to feel vulnerable and unsafe. Others who did not lose family or friends were angry about the damage to the city itself. Once the media attention waned and the first rush of concern died away, some of the victims of the bomb blast who still needed help began to feel abandoned.

Garton said after the bombing, some of her own patients started remembering their own unrelated past traumas. A 60-year-old woman, who knew people killed in the bomb blast, remembered being abused as a child. Veterans reported that their previously well-controlled PTSD symptoms were becoming disabling. "I saw current patients decompensate," Garton said. She also had patients who thought certain life issues resurfaced after the bombing..
Her counsel to fellow clinicians "Don’t feel like you are not helping if you are not on the frontlines. People need you right where you are."

The Oklahoma City bombing also produced some beneficial effects, according to Garton. She talked of patients who re-evaluated their priorities, recovered quickly and valued their families more. In the community as a whole, she saw people express more genuine concern for each other.

"We would be at the store," she said, "and people in line would ask ´How are you?’ and they would really want to know. They really cared."

Asked about her own reactions, Garton said there were times she felt inadequate in the face of such an overwhelming need, with "no guidebook to follow." She also found herself feeling less separate from her patients, since they had a shared experience. And she found herself making more time for family and friends.

Predictions for New York

Spencer Eth, M.D., medical director of Behavioral Health Services at Saint Vincent Catholic Medical Centers in New York, said in an interview that he expects "huge increases in the prevalence of traumatic grief, depression, posttraumatic stress disorder and substance abuse in the New York City metropolitan area at the least. This is an unprecedented disaster, and its psychiatric toll will be enormous."

"The fact that this [disaster] was televised, meant that almost everybody in the United States if not the world was exposed to the sight of people dying. That alone is unusual," he said.

Eth believes the disaster revealed huge gaps in the mental health system.

"There are large numbers of people in New York as elsewhere in the United States who have no mental health coverage. How are they going to get treated?" he said. He also pointed to a sizeable number of undocumented aliens who are missing in the World Trade Center wreckage, and asked what kind of help would be available for their relatives.

"There are inadequate resources for the severely and persistently mentally ill, who are at higher risk for decompensation in the aftermath of this crisis," he said.

In testimony before the Senate health committee, Eth noted that Saint Vincent’s was collaborating with the Greater New York Hospital Association, American Psychiatric Association as well as managed care and pharmaceutical companies to facilitate the delivery of comprehensive psychiatric care to the most severely affected.

Asked by the Senate Health Committee for recommendations about what government could do, Eth urged government support to enable mental health professions to deliver "a large-scale training initiative and to disseminate educational materials to therapists, teachers, parents, corporate human resources departments and the general public."

"I made a recommendation that the SAMHSA [Substance Abuse, Mental Health Services Administration] program for child PTSD centers be expanded," he said. "It is an existing program that could be quickly and easily expanded. I also mentioned that that the mental health response should be a professional response…traumatic grief, posttraumatic stress disorder, major depression and substance abuse are serious psychiatric disorders."

Psychiatrists and senators at that Senate Health Committee hearing also submitted recommendations. Among them are

• Allocate more funds to support organized and rigorous scientific research on the psychological impacts of this tragedy, particularly traumatic grief.
• Establish a plan and program in every school for teachers and parents on how to respond to a disaster.
• Provide preventive interventions, such as specialized after school programs for children who have experienced prior trauma, whose parents are impaired by mental conditions, or who have been directly exposed to or impacted by the terrorist attack.
• Expand training of clergy, teachers, employers and family members so they can provide support to those who are in distress, identify individuals needing treatment, and direct them to appropriate mental health services.
• Institute a training program for therapists in specific techniques that are most useful in helping individuals during and after disasters.
• Provide additional mental health support for fire fighters, police, emergency medical technicians and others who initially responded during the attack.
• Provide forums for people to gather, share their experiences, mourn their losses, and begin to process and make meaning of events.
• Recognize that most posttraumatic disorders begin almost immediately after the disasters, so start interventions early.
• Pass the Mental Health Equitable Treatment Act.
• Provide mental health care to victims of the World Trade Center tragedy who have no or limited insurance by possibly enrolling them in Medicaid and State Children’s Health Insurance Program (SCHIP) without the usual restrictions.

Some help is already being provided by the national government. Health and Human Services Secretary Tommy Thompson provided emergency grants to support community mental health centers in the New York City area and established a national hotline to assist callers in coping with the attack. Recently, he announced the award of grants totaling $6.8 million to help eight states as well as the District of Columbia support crisis mental health services and to supplement existing mental health and substance abuse systems in the areas affected by Sept, 11. The grants are part of a total of $28 million in funding to be made available to SAMHSA under the emergency response supplementation appropriation. The $6.8 million will be allocated as follows: Connecticut, $1.1 million; District of Columbia, $987,000; Maryland, $250,000; Massachusetts, $50,000; New Jersey, $1.05 million; New York, $2.2 million; Pennsylvania, $650,000; Rhode Island, $50,000; and Virginia, $465,000.

The nine mental health-focused grants will support state mental health needs assessments to enable affected states to identify gaps in mental health service capacity that cannot be filled existing regular and emergency funding mechanisms. The 14 substance abuse prevention and treatment grants will supplement current hotline crisis counseling capacities and enhance current resilience-building, family-strengthening and substance abuse prevention activities in affected communities.

Viewers, Your Help is Needed: I am a freelance medical journalist. Most of the articles posted on this website were originally written for healthcare professionals, but I believe patients/consumers may find value in the articles as well. Many of us who have long-lasting or life-threatening health problems become experts on them. For that reason, I have kept the rights to electronically post these articles. I plan to post even more and develop new ones specifically for this site. It is my intention to keep this site free from the influence of advertisers and just offer you high-quality, well-researched information. Your financial support is needed to continue this user-sponsored service.

I welcome your comments, suggestions and financial help. You can send voluntary contributions to, or contact me at:

HealthRising
Arline Kaplan
P.O. Box 3644
Costa Mesa, CA 92628

(Web & PT 1101)