PTSD, Binge Drinking Persist a Decade After 9/11 Attacks

Pauline Anderson

September 07, 2016

Posttraumatic stress disorder (PTSD) and binge drinking persist among survivors of the September 11, 2001, terrorist attacks on the World Trade Center (WTC) 10 years after the event, new research shows.

The analysis showed that the incidence of PTSD and frequent binge drinking was higher for people who were in either of the WTC towers in comparison with people on the street who witnessed the attacks as well as those in neighboring buildings that were damaged. The odds of experiencing PTSD were also higher among those in the towers who sustained an injury.

These and other findings "suggest that different experiences may impact people differently and substantiate the importance of continued mental health and substance use screening and treatment after a disaster," write the authors, led by Lisa M. Gargano, PhD, MPH, Division of Epidemiology, New York City Department of Health and Mental Hygiene, World Trade Center Health Registry.

This study and others that examined long-term mental and physical health effects of 9/11 were published online in the September issue of the American Journal of Industrial Medicine.

Longitudinal Study

The 9/11 attack was one of the most significant terrorist events in history, resulting in almost 3000 deaths, substantial economic loss, and environmental damage.

An estimated 62,092 occupants of buildings, including 17,400 in the WTC towers, survived the attack. About 87% of these individuals survived by evacuating in a timely fashion.

The Registry is a cohort study of 71,431 people directly exposed to the events of 9/11. It was designed to monitor the physical and mental health effects of 9/11 for at least 20 years.

Registry enrollees include rescue/recovery workers, volunteers, area residents and workers, passers-by, and school children and staff. The Wave 1 (W1) baseline survey, carried out in 2003-2004, included 68,802 adult enrollees; Wave 2 (W2; 2006-2007) included 46,602 respondents; and Wave 3 (W3; 2011-12) included 43,134 respondents.

The current study sample included 7695 adults who were not rescue or recovery workers and who completed the three surveys. They were in the WTC towers, in another damaged or destroyed building, or on a street below on the morning of September 11, 2001.

Of these individuals, 25.3% were in one of the WTC towers, 32.2% were in other buildings, and 42.5% were on the street. There were no differences in the age distribution between these groups, although for those in the twin towers, a greater proportion were men, non-Hispanic whites, and persons with a household income of more than $75,000 in 2010.

Compared with those on the street, the odds of sustaining an injury on 9/11 were more than three times higher for WTC tower survivors (adjusted odds ratio [AOR], 3.4; 95% confidence interval [CI], 2.9 - 4.0) but only 1.4 times higher for those in other buildings (AOR, 1.4; 95% CI, 1.2 - 1.7).

The odds of witnessing three or more horrific events, including, for example, an airplane hitting a tower, people running away from a cloud of dust and debris, and people falling or jumping from a tower, were higher for those in other buildings (AOR, 1.8; 95% CI, 1.6 - 2.0) than for WTC survivors.

WTC survivors were 60% more likely to have experienced a 9/11-related job loss compared with those on the street.

Need for Long-term Screening

Those in other buildings were 150% more likely to have worked in the employ of a company or business that sustained fatalities compared with people on the street. According to the authors, this may be because companies in the towers had offices in surrounding buildings, or employees on their way to work in the towers sought shelter in these other buildings.

To measure PTSD, researchers used the PTSD Checklist, Stressor-Specific Version, a 17-item scale that inquired about 9/11-related psychological symptoms during the 30 days before W3. Participants with a score of 44 or greater were considered to have probably experienced PTSD.

The analysis found that a similar proportion of participants had PTSD for the first time at Wave 3 (4.5% in survivors from the WTC towers and other buildings, and 4.1% in those on the street).

Compared with those not in buildings, being in either WTC tower was significantly associated with PTSD (AOR, 1.3; 95% CI, 1.0 - 1.7). Those in the WTC towers were 50% more likely than those on the street to engage in frequent binge drinking, defined as having five or more drinks for men, and four or more drinks for women, on a single occasion.

The odds of PTSD among those who sustained an injury were highest among WTC tower survivors (AOR, 3.2; 95% CI, 2.5 - 4.2). Among those in other buildings, having witnessed three or more horrific events placed one at higher odds of PTSD (AOR, 2.7; 95% CI, 2.1 - 3.6) compared with those in other buildings who did not witness such events.

Witnessing three or more horrific events also was associated with higher odds of frequent binge drinking in all groups. Being caught in the dust cloud created by the terrorist attacks was associated with 1.5 increased odds of frequent binge drinking among survivors from both WTC towers and those on the street.

Understanding the effects of traumatic exposure on alcohol use among those most directly exposed can help identify factors that increase the risk for alcohol misuse following a disaster and can better inform disaster policy response, write the authors.

"This finding also demonstrates that alcohol screening and counseling in the aftermath of a large-scale traumatic event should occur over time regardless of psychological status," the investigators write.

Policy Implications

The researchers also looked at infrastructure barriers, including the number and spacing of floors, the configuration of stairways and exits, and conditions hindering exits, as well as behavioral barriers, such as crowding, panic, perception of danger, and communications problems.

They found that among those who evacuated from the towers, individuals who reported infrastructural and behavioral barriers were significantly more likely to have PTSD. Although not statistically significant, there was also a trend for them to be frequent binge drinkers.

The authors conclude that the findings of this and other research provide potential avenues for policy planning to reduce the burden of disaster-related psychopathology.

"Long-term studies using structured diagnostic assessments are needed to assess the burden of disease, help plan treatment and monitor the progress of those affected," the authors write.

A limitation of the study was that it relied on self-reports of PTSD and binge drinking. Also, the data on barriers were collected 5 to 6 years after 9/11 and may be subject to recall error.

Another article in the the same issue of the American Journal of Industrial Medicine examined employment adjustment after the 9/11 disaster among 7365 rescue and recovery workers. That study found that both early retirement and health-related job loss occurring 5 to 10 years after the event were positively associated with 9/11-related chronic health conditions. The association was even stronger when these chronic conditions were comorbid with probable PTSD.

Another study of more than 29,000 9/11-exposed people who were followed for 9 years found that an early diagnosis of asthma and PTSD were each associated with subsequent development of gastroesophageal reflux symptoms (GERS) and the persistence of GERS that was present at baseline.

Other studies in the special issue examined the incidence of cancer and metabolic syndrome.

The study was supported by the National Institute for Occupational Safety and Health of the Centers for Disease Control and Prevention (CDC), the Agency for Toxic Substances and Disease Registry, which included support from the National Center for Environmental Health, and the New York City Department of Health and Mental Hygiene. The authors have disclosed no relevant financial relationships.

Am J Ind Med. 2016;59:742-751. Abstract


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