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EDITORIALS |
Sub-Department of Clinical Health Psychology, University College London, UK
Correspondence: Dr Matthew G. Whalley, Sub-Department of Clinical Health Psychology, University College London, Gower Street, London WC1E 6BT, UK. Email: m.whalley{at}ucl.ac.uk
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ABSTRACT |
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INTRODUCTION |
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MENTAL HEALTH OF THE GENERAL POPULATION |
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Schuster et al (2001) demonstrated that the proportion of people experiencing substantial stress was negatively associated with distance from the attacks of 11 September. Therefore, for comparison purposes it is easiest to consider studies that have sampled from the city where the incident happened or from the surrounding area (details of these studies are presented as a data supplement to the online version of this editorial). Despite using a variety of different instruments, these studies reveal a close relationship between the time post-incident and the prevalence of ‘substantial stress’. Rates are extremely high in the first few days after the incident but are already in decline in the first 2 weeks and by 6–8 weeks have fallen by two-thirds. Thus for the majority of individuals significant stress symptoms are temporary and are unlikely to have lasting mental health implications Vázquez et al, 2006). However, a significant minority will continue to have symptoms. Over 6 months after the 11 September attacks, 5.3% of New York City residents continued to meet criteria for subsyndromal post-traumatic stress disorder (Galea et al, 2003), a condition associated with substantial functional impairment.
The data on rates of probable acute stress disorder or post-traumatic stress disorder (PTSD) show a similar pattern. Rates of PTSD in the general population attributable to single attacks may be as high as 11–13% in the first 6 weeks but decline sharply with time, with most studies indicating rates below 3% 2 months after the incident.
When considering these studies it is important to bear in mind that stress symptoms measured in the immediate aftermath of an attack are not necessarily ‘post-traumatic’. One of the hallmarks of PTSD is a sense of extreme threat that endures despite the danger having passed, something that can rarely be assumed about a terrorist attack. Thus, symptom reporting following the Madrid train bombings was particularly high in regular train passengers (Vázquez et al, 2006). Transient symptoms should in most cases therefore be regarded as a general and not necessarily inappropriate stress response, partly reflecting involvement and concern with one’s own safety as well as with the safety of the community, family and friends. Symptom reporting will also be associated with actual losses of people, possessions and employment (Galea et al, 2002; DeLisi et al, 2003).
It should also be remembered that community samples will contain a proportion of people who may have particular reasons to feel threatened by the events. The data suggest that those reporting more symptoms will include members of minority groups (Schuster et al, 2001; Galea et al, 2002; Rubin et al, 2005), people with previous experience of adversity (Galea et al, 2002, 2003) and people who have developed psychiatric disorders in response to past stresses (DeLisi et al, 2003). For these groups the typically intense levels of media coverage and general concern around terrorist attacks may increase general levels of stress by acting as a potent reminder of feared outcomes or of thematically similar experiences from the past. More research is needed into the long-term outcomes for these at-risk groups.
Children
There are fewer studies of children’s responses to terrorism. Henry
et al (2004) found no
significant difference from parental reports in general levels of anxiety and
depression in children from Chicago in the 100 days before and after the 11
September attacks. A number of studies have explicitly assessed
children’s reactions to terrorist events. Close to 1 year after the
bombing of the Alfred P. Murrah Federal Building in Oklahoma City, about 5% of
elementary schoolchildren reported clinically significant levels of symptoms
of PTSD (Gurwitch et al,
2002). A year later, almost 20% of middle schoolchildren living
100 miles from the city reported current bomb-related symptoms that impaired
their functioning at home or at school
(Pfefferbaum et al,
2000).
Four days after 11 September 2001, 35% of a national sample of American parents reported that their child had at least one of five stress symptoms (Schuster et al, 2001). Six weeks later more than 60% of parents in the New York City metropolitan area reported that their child was upset (Schlenger et al, 2002) or had moderate post-traumatic stress reactions (Fairbrother et al, 2003). Without more normative data it is difficult to assess the significance of these reports. However, two studies have carried out diagnostic assessments in community samples of children after 11 September. One month later, 8% of Seattle children were estimated to have diagnosable levels of PTSD symptoms (Lengua et al, 2005). In New York City itself, 6 months later Hoven et al (2005) reported that 28.6% of children had at least one probable anxiety/depressive disorder, the most common being agoraphobia (14.8%), separation anxiety (12.3%) and PTSD (10.6%).
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MENTAL HEALTH OF DIRECT VICTIMS |
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TOPABSTRACTINTRODUCTIONMENTAL HEALTH OF THE...MENTAL HEALTH OF DIRECT...RECEIPT OF MENTAL HEALTH...CONCLUSIONSACKNOWLEDGMENTSREFERENCES |
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years after the Paris
attacks the rate of PTSD among direct victims was 25%, and 2 years after the
Pentagon attack on 11 September over 20% of employees who were present and
responded to the survey were found to have PTSD. These figures emphasise that
many reactions are intense and long-lasting and cannot be dismissed as normal,
transient responses to traumatic events. Studies of emergency workers have usually found considerably lower levels of psychopathology than in direct victims. Retrospective reports by body handlers describing their reactions at the time of the Oklahoma City bombing and 1 year later indicated negligible levels of PTSD and depression (Tucker et al, 2002), and North et al (2002) reported a PTSD rate of 13% among firefighters 3 years after the bombing. Two months after the Madrid bombings Miguel-Tobal et al (2005) found a rate of 1.2% for PTSD and 2% for depression among emergency personnel. Six months after the 11 September attack on the World Trade Center, 14.3% of those involved in the rescue effort in New York City had probable PTSD (Galea et al, 2003), but there appeared to be only a small excess of PTSD symptoms in handlers working in canine search and rescue teams who were deployed following 11 September, compared with non-deployed controls (Alvarez & Hunt, 2005).
Studies of emergency workers are hard to compare because response rates varied, and in all of them there was considerable scope for response biases to operate. Although it is not likely that these groups will respond with high levels of disorder, it is important to consider that actual levels of exposure to the attack site, and to scenes of severe injury and grotesque death, are likely to vary enormously, even among individuals attending the same incident. For example, in a study of firefighters who worked in the aftermath of the 1995 Oklahoma bombing, North et al (2002) found that time working on the site and time spent in the ‘pit’, a particularly perilous area of the building, were associated with increased PTSD prevalence. The involvement of trauma and occupational health advisors may be of great importance in ensuring that organisations recognise the potentially toxic effects of high or prolonged levels of exposure and provide appropriate levels of protection and support.
Children
Again there have been fewer systematic studies of child victims. Elbedour
et al (1999) found that 50% of the daughters and 23.1% of the sons of
those killed in the Hebron massacre were suffering from probable PTSD.
Children were more likely to experience post-traumatic symptoms following the
Oklahoma City bombing if they had been bereaved
(Pfefferbaum et al,
1999). Other commentators have drawn attention to a significant
risk of psychological disorder in children who are direct victims, suffer
bereavement or other losses, or have to witness repeated reminders of the
attacks, including parental distress
(Fairbrother et al,
2003; Hoven et al,
2005). Distress and disorder may manifest themselves in different
ways depending on the child’s developmental stage, and it is likely that
children’s distress is systematically underestimated by adults
(Gurwitch et al, 2002;
Koplewicz et al,
2004).
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RECEIPT OF MENTAL HEALTH SERVICES |
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TOPABSTRACTINTRODUCTIONMENTAL HEALTH OF THE...MENTAL HEALTH OF DIRECT...RECEIPT OF MENTAL HEALTH...CONCLUSIONSACKNOWLEDGMENTSREFERENCES |
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CONCLUSIONS |
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TOPABSTRACTINTRODUCTIONMENTAL HEALTH OF THE...MENTAL HEALTH OF DIRECT...RECEIPT OF MENTAL HEALTH...CONCLUSIONSACKNOWLEDGMENTSREFERENCES |
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These findings have important implications for health services. Whereas some direct victims are likely to be in contact with providers of psychological services, in New York City following 11 September only around a quarter to a third of adults and children with significant post-traumatic stress symptoms received any treatment at all. Survivors with no previous contact with services were least likely to benefit from what was available. This was despite the strenuous efforts of those involved in Project Liberty, an unprecedented exercise involving over 100 mental health agencies delivering free public education and crisis counselling. If this level of unmet need is replicated elsewhere, it suggests that a targeted, active outreach programme will need to be a major feature of the response, for example using a ‘screen and treat’ approach. An important future task is to demonstrate that an outreach programme can be effective in identifying individuals with significant symptoms or functional impairment, in facilitating access to evidence-based treatment and in achieving the kind of positive health outcomes typically obtained in treatment trials for PTSD.
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ACKNOWLEDGMENTS |
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TOPABSTRACTINTRODUCTIONMENTAL HEALTH OF THE...MENTAL HEALTH OF DIRECT...RECEIPT OF MENTAL HEALTH...CONCLUSIONSACKNOWLEDGMENTSREFERENCES |
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMENTAL HEALTH OF THE...MENTAL HEALTH OF DIRECT...RECEIPT OF MENTAL HEALTH...CONCLUSIONSACKNOWLEDGMENTSREFERENCES |
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Received for publication May 12, 2006. Revision received August 23, 2006. Accepted for publication September 1, 2006.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| Psychiatric Bulletin | Advances in Psychiatric Treatment | All RCPsych Journals |
