9/11-related Ptsd Among Highly Exposed Populations a Systematic Review 15 Years After the Attack

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Psychol Med. Author manuscript; available in PMC 2018 Mar 1.

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ix/xi-related PTSD amid highly exposed populations: a systematic review xv years afterward the assault

A. Lowell,^{i, 2} B. Suarez-Jimenez,^{1, ii} Fifty. Helpman,^{one, 2} X. Zhu,^{1, 2} A. Durosky,² A. Hilburn,² F. Schneier,^{1, 2} R. Gross,^{3, 4, five} and Y. Neria^{ane, ii, iii, *}

A. Lowell

¹Section of Psychiatry, Columbia University Medical Center, New York, NY, USA

²New York Land Psychiatric Plant, New York, NY, United states

B. Suarez-Jimenez

ⁱDepartment of Psychiatry, Columbia University Medical Center, New York, NY, USA

²New York State Psychiatric Establish, New York, NY, U.s.a.

L. Helpman

¹Department of Psychiatry, Columbia University Medical Center, New York, NY, USA

²New York State Psychiatric Found, New York, NY, U.s.

Ten. Zhu

^aneDepartment of Psychiatry, Columbia University Medical Eye, New York, NY, Us

ⁱⁱNew York State Psychiatric Constitute, New York, NY, USA

A. Durosky

²New York State Psychiatric Constitute, New York, NY, United states of america

A. Hilburn

²New York State Psychiatric Establish, New York, NY, U.s.a.

F. Schneier

^oneSection of Psychiatry, Columbia University Medical Middle, New York, NY, USA

²New York Country Psychiatric Institute, New York, NY, USA

R. Gross

ⁱⁱⁱSection of Epidemiology, Columbia Academy Medical Center, New York, NY, USA

⁴Department of Epidemiology and Preventive Medicine, Sackler Schoolhouse of Medicine, Tel Aviv University, Tel Aviv, Israel

⁵Sectionalisation of Psychiatry, Chaim Sheba Medical Center, Tel Hashomer, Israel

Y. Neria

^oneSection of Psychiatry, Columbia Academy Medical Center, New York, NY, Usa

²New York State Psychiatric Found, New York, NY, USA

^threeDepartment of Epidemiology, Columbia University Medical Eye, New York, NY, USA

Abstruse

Background

The 11 September 2001 (9/11) attacks were unprecedented in magnitude and mental health impact. While a large body of enquiry has emerged since the attacks, published reviews are few, and are limited by an emphasis on cantankerous-sectional enquiry, short fourth dimension frame, and exclusion of treatment studies. Additionally, to date, there has been no systematic review of available longitudinal information equally a unique data set. Consequently, knowledge regarding long-term trajectories of nine/eleven-related mail service-traumatic stress disorder (PTSD) amongst highly exposed populations, and whether available handling approaches effectively address PTSD within the context of mass, man-fabricated disaster, remains limited.

Methods

The present review aimed to address these gaps using a systematic review of peer-reviewed reports from October 2001 to May 2016. Eligible reports were of longitudinal studies of PTSD among highly exposed populations. We identified twenty reports of 9/xi-related PTSD, including 13 longitudinal prevalence studies and seven treatment studies.

Results

Findings advise a substantial brunt of 9/xi-related PTSD amid those highly exposed to the assail, associated with a range of sociodemographic and back-ground factors, and characteristics of peri-outcome exposure. While almost longitudinal studies evidence declining rates of prevalence of PTSD, studies of rescue/recovery workers have documented an increase over time. Treatment studies were few, and generally limited by methodological shortcomings, but support exposure-based therapies.

Conclusion

Future directions for research, treatment, and healthcare policy are discussed.

Keywords: September 11, 2001, ix/11; post-traumatic stress disorder (PTSD); trauma exposure severity; treatment of PTSD

Introduction

The events of xi September 2001 (nine/eleven) claimed the lives of close to 3000 people and injured 6000 more, including hundreds of firefighters and many law enforcement officers and military machine personnel, with the economic price of amercement measured in the 10s of billions of dollars by some estimates (Kunreuther et al. 2003). Although the acute effects of 9/11 attacks across emotional, social, and political spectrums were exceedingly deep and widespread (Comer & Kendall, 2007), the focus of this review is on the long-term trajectory of postal service-traumatic stress disorder (PTSD) and outcomes of PTSD treatments in 'highly exposed' populations (i.east. populations with directly trauma exposure), for whom the gamble of PTSD was the highest (Galea et al. 2005; Neria et al. 2008, 2011). We focused on longitudinal studies, a ready of findings nevertheless to be systematically reviewed since the attacks of 9/eleven. Moreover, our review is the start to review treatment studies of 9/11-related PTSD across all highly exposed populations.

PTSD is a disabling, maladaptive reaction to traumatic stress with significant functional damage and comorbidity (Kessler et al. 1995, 2005; Breslau et al. 1998). Hence, it is unsurprising that PTSD is the most normally studied disorder following major disasters (Norris et al. 2002, 2008; Galea et al. 2005). The attacks of 9/11 were no exception; previous reviews (Pfefferbaum et al. 2004; Bills et al. 2008; Neria et al. 2008, 2011; Pfefferbaum et al. 2013; Wilson, 2015) and 1 meta-analysis (Liu et al. 2014) have tracked a relatively big book of epidemiological literature on ix/xi-related PTSD, and have drawn conclusions regarding rates of PTSD across multiple afflicted populations. Such information have critically informed debates regarding the need to develop coordinated efforts for intervention and prevention efforts (Breslau & McNally, 2008). A fundamental limitation of these reviews, still, is that the range of PTSD rates was extremely wide across populations and time periods, and has consequently been difficult to interpret. Wilson (2015), for example, reviewed prevalence rates of PTSD among first responders post-obit mass homo-made violence events ranging from 1.3% to 22%, while Bills et al. (2008) reviewed rates of PTSD ranging from 8% to 22.5% among first responders following 9/11. Our own previous review examining prevalence rates of 9/11-related PTSD reflects this challenge likewise, with reported rates ranging from 1.v% to 42% across various high-exposure populations (Neria et al. 2011). Although some have suggested x% equally an approximate prevalence rate for PTSD among first responders involved in ix/11 (Wilson, 2015), observed heterogeneity has prevented general agreement on PTSD rates over time, and there has been niggling consensus regarding other loftier-exposure populations.

A prime number contributor to this wide variability in prevalence rates of PTSD is data from cross-exclusive studies conducted at different time points and among different populations. For example, reported rates of PTSD in the yr post-obit 9/eleven include 1.v% in a customs sample (Galea et al. 2003), 29.6% in a sample of children and adolescents (Pfeffer et al. 2007), and eight% in a sample of New York City (NYC) transit workers (Tapp et al. 2005). In subsequent years, prevalence rates of PTSD were reported at iii.eight% in a community sample (Adams & Boscarino, 2006), xv% in a sample of World Trade Centre evacuees (DiGrande et al. 2011), and 12.4% in a sample of rescue and recovery workers (Perrin et al. 2007).

Cross-exclusive studies are by definition limited past information collected at a single time betoken, and therefore cannot inform PTSD prevalence charge per unit alter and development over time. This is particularly problematic in the case of PTSD, as the trajectory of PTSD varies across populations (due east.g. come across Debchoudhury et al. 2011), and PTSD is known to sometimes develop after a considerable delay (Andrews et al. 2007). Furthermore, cross-exclusive studies cannot found temporal sequence and accept limited potential for inference of predictors of PTSD among characteristics of the traumatic exposure and other potential co-factors (Galea & Maxwell, 2009). Combining findings from cross-sectional studies that span disparate time points and sample populations does not mitigate these problem and over-reliance on an assumed heterogeneity between samples leads to a danger of distorting actual trends (Susser et al. 2006; Garcia-Vera et al. 2016). Such challenges potentially prevent valid estimation of bear on likewise as development of appropriate interventions following a large-calibration disaster. For example, in a meta-assay of 9/11-related PTSD, Liu et al. (2014) concluded that prevalence rates of PTSD were lower for showtime responders based on a pooling of data from cross-sectional and longitudinal studies. Nevertheless, this statement is not supported by increasing rates for this population over time, a trend reflected past longitudinal studies focusing on this population (Berninger et al. 2010a, b; Bowler et al. 2012). Other reviews of 9/11 have similarly failed to sufficiently distinguish between longitudinal and cross-sectional findings, despite recognition by some of the inherent advantages of longitudinal data (Pfefferbaum et al. 2004; Bills et al. 2008; Neria et al. 2008, 2011; Pfefferbaum et al. 2013; Wilson, 2015).

An additional limitation of extant reviews of 9/11 PTSD literature is that virtually eschew treatment studies, with the exception of a review conducted on treatment of starting time responders just (Haugen et al. 2012). Handling studies naturally complement longitudinal epidemiological efforts by demonstrating how interventions may interact with affliction trajectory, thus providing a more than comprehensive picture. Moreover, with the contempo increase in natural disaster and terror attacks worldwide, long-term longitudinal data, which include intervention, may serve equally guidelines for treatment similar traumatic experiences in the USA and away.

The electric current investigation aimed to accost inherent limitations of previous reviews every bit new longitudinal information accept emerged regarding course of nine/xi-related PTSD and treatment amongst high-risk populations, including information collected through organized registries such every bit the World Trade Eye Health Registry (WTC-Hr) and the Globe Trade Center Health Program (WTC-HP). The goal of this review is to systematically survey 9/eleven research in the 15 years since the attacks, focusing on evidence regarding class of PTSD, take a chance factors, and handling of PTSD among 9/eleven exposed populations, emphasizing findings unique to longitudinal investigations.

Methods

For the present review, we performed a search of peer-reviewed literature published from October 2001 to May 2016 and included published studies on longitudinal course of PTSD related to the events of 11 September, factors apropos run a risk and resilience, and treatment. Nosotros used two search engines: EBSCOhost Inquiry Databases and Medline/PubMed. Manufactures were tagged for review if they included (a) the terms 9 11, 9/11, September 11, September 11th, or World Trade Middle entered as search terms in the text body, title, or subject field heading of an article, and (b) PTSD, in the same fields, using the terms PTSD, trauma, and posttraumatic stress. The initial search generated 3477 manufactures through EBSCOhost and 2017 through Medline/PubMed. Nosotros likewise cross-referenced previous reviews and meta-analyses concerning 9/11-related PTSD and/or treatment (Pfefferbaum et al. 2004; Bills et al. 2008; Neria et al. 2008, 2011; Haugen et al. 2012; Pfefferbaum et al. 2013; Liu et al. 2014; Wilson, 2015). Reports were excluded if they did not highlight highly exposed populations, defined as those living or working in close proximity to the 9/11 attacks, also as first responders, rescue, recovery, and make clean-up workers who attended the World Trade Center on 9/11 or directly afterward. We further excluded secondary analyses, review manufactures, editorials, commentaries, case reports, and studies that lacked full assessment of PTSD and/or prevalence rates or that focused primarily on physical illnesses associated with 9/xi rather than mental health, as well equally those that contained cross-sectional information but. Our final list consists of 20 peer-reviewed manufactures, classified as longitudinal studies (north = 13) and treatment studies (n = 7). Survey methods included face-to-face interviews, in-person questionnaires, telephone interviews, online questionnaires, or mailed questionnaires depending on the study. Standardized PTSD instruments included the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-Iv) (SCID; First et al. 1995), Clinician-Administered PTSD Calibration (CAPS; Blake et al. 1995), and the PTSD Symptom Checklist (PCL; Blanchard et al. 1996). With ane exception (Cukor et al. 2011), nigh of the epidemiological studies included in this review utilized measures that do not constitute clinician-administered assessments of PTSD. For this reason, the term 'probable' was used when referring to estimates of PTSD prevalence for well-nigh studies. A meta-analysis was not conducted due to the high caste of variability in methods nowadays beyond studies reviewed.

In this review, we have reported time points of data drove mail service-ix/11, sample size at each time signal, PTSD assessment instruments, and estimated prevalence of probable PTSD in Table i. Correlates of PTSD were reported in Table two. Results of multivariate analyses were reported in favor of bivariate results if both were reported in the report of origin. But correlates that showed a statistically significant relationship with PTSD (p < 0.05) were reported. Continuous variables (e.g. age, arrival time at scene of nine/xi) were listed in abbreviated fashion for some studies in the interest of clarity. In such instances, only the effect size, odds ratio, or other reported statistic of greatest magnitude was reported.

Table one

Prevalence of PTSD/likely PTSD in highly exposed populations by Fourth dimension Postal service-9/11

Source	Sample population	Sampling method and type	PTSD musical instrument	Boilerplate time frame post-9/11 and population at each time indicate (north)	Estimated prevalence of PTSD/probable PTSD (%)
Adams & Boscarino (2006)	NYC residents	Random, CATI	NWS	1 year (2323)	4.7
				2 years (1681)	3.eight
Berninger et al. (2010a)	Firefighters	Systematic, IPQ	PCL (DSM–Four criteria and non-weighted cut-off score ix out of fourteen possible items)	1 year (8679)	9.8
				2 years (1161)	9.9
				iii years (2820)	eleven.vii
				four years (4166)	10.6
Berninger et al. (2010b)	Firefighters	Systematic, IPQ	PCL (DSM–IV criteria and non-weighted cutting-off score of ix out of xiv possible items)	0–6 months (5656)	8.6
				3–four years (5656)	11.one
Bowler et al. (2012)	Police responders	Convenience, CATI, FTFI	PCL (DSM-Four criteria)	two–3 years (2940)	vii.8
				5–6 years (2940)	sixteen.five
Brackbill et al. (2009)	RR, LMR, LMO, Atomic number 82	Mixed, CATI	PCL (cut-off score 44)	2–3 years (40 032)	14.3
				R/R (20 294)	12.1
				LMR (5852)	13.2
				LMO (14 718)	16.9
				PB (2087)	xix.iii
				5–6 years (40 032)	19.one
				R/R (20 294)	19.five
				LMR (5852)	16.three
				LMO (xiv 718)	19.1
				PB (2087)	23.two
Cone et al. (2015)	Police responders	Convenience, FTFI	PCL (cut-off score 44)	2–3 years (2204)	xiii.6
				v–8 years (2204)	11.9
				ten–eleven years (2204)	11.0
Cukor et al. (2011)	Utility workers	Convenience, FTFI, IPQ	CAPS and PCL (DSM-Iv criteria)	ane–2 years (2960)	nine.5a
				3–4 years (2626)	4.viii
				six–vii years (1983)	2.iv
Debchoudhury et al. (2011)	Affiliated and lay volunteer disaster workers	Convenience, CATI, CAPI	PCL (cut-off score 44)	iii–4 years (4974)	10.8
				Affiliated (3702)	7.five
				Lay (1272)	20.2
				5–6 years (4974)	xv.9
				Affiliated (3702)	11.2
				Lay (1272)	29.6
Neria et al. (2010)	Principal intendance patients	Systematic, IPQ	PCL (cut-off score 44)	1 twelvemonth (455)	9.6
				four years (455)	4.1
Pfeffer et al. (2007)	BC, NBC	Convenience, FTFI – child and parent	1000-SADS	4 months to 2.6 years (79)b	17
				BC (45)	29.6
				NBC (34)	2.ix
				Timepoint 2 (79)	~ 4
				BC (45)	~ 5
				NBC (34)	<3
Pietrzak et al. (2014)	PR, NR	Convenience, IPQ	PCL (cut-off score 44)	1–5 years (ten 835)	18.three
				PR (4035)	8.5
				NR (6800)	24.i
				iv–7 years (x 835)	18.vii
				PR (4035)	9.3
				NR (6800)	24.2
				half-dozen–9 years (10 835)	17.eight
				PR (4035)	nine.eight
				NR (6800)	22.v
Silvery et al. (2005a)	Usa residents: DE, LME, NLE	Random, OQ	At two weeks, ASD assessed with SASRQ (DSM–Four criteria); at 1 year, PCL (DSM–IV criteria)	2 weeks (1906)	11.9
				DE (57)	9.3
				LME (1225)	12.8
				NLE (624)	10.4
				1 year (1906)	iv.5
				DE (57)	11.2
				LME (1225)	4.7
				NLE (624)	3.four
Zvolensky et al. (2015)	Rescue and recovery workers: PR, NR	Convenience, IPQ	PCL	ane–ix years (18 896)c	14.3
				PR (8466)	11.7
				NR (10 430)	16.4
				3.5–11.5 years (18 896)	15.3
				PR (8466)	13
				NR (10 430)	17.two

Table ii

Prevalence and correlates of probable PTSD in highly exposed populations by time post-9/xi

Source	Sample population	Significant correlates of PTSD/probable PTSD past time mail service-nine/eleven and type of analysisa
		Correlate	Fourth dimension one	Time 2	Time 3	Time 4
Adams & Boscarino (2006)	NYC residents	Multivariate (adjusted OR)	1 yr	ii yrs
		Younger age	3.79	N.S.
		Middle age	N.S.	x.86
		Female gender	two.78	Due north.Southward.
		Latino ethnicity	Northward.S.	2.48
		Greater 9/11 exposure	2.71	N.Due south.
		Non-9/11 trauma	5.94	half dozen.64
		Multiple negative life events	2.23	nine.98
		Low social support	1.85	N.S.
		Depression self-esteem	4.68	three.54
Berninger et al. (2010a)	Firefighters	Bivariate (unadjusted OR)	i yr	ii yrs	three yrs	4 yrs
		Difficulty functioning at habitation	17	20.half-dozen	26.7	22.half-dozen
		Difficulty performance at work	12.1	23.0	18.4	20.one
		Multivariate (adjusted OR)
		Earliest arrival at WTC	3.four	ane.five	2.v	3.3
		Longer duration, WTC site	1.six	ane.half-dozen	two.one	1.7
		9/11-related disability retirement	1.5	2.6	ane.eight	Northward.Due south.
		Number of deaths in firehouse	one.one	1.i	N.S.	N.Due south.
		Increment in booze use	2.8	three.2	2.4	2.two
		Emotional support	one.five	NA	NA	NA
		Decrease in exercise habits	2.3	NA	2.3	2.6
		Utilise of counseling services	two.9	4.0	iv.3	three.5
		Religious amalgamation	N.South.	North.S.	N.S.	i.8
Berninger et al. (2010b)	Firefighters	Multivariate (adjusted OR)b
		Middle historic period	1.0
		Older age	0.6
		Above loftier school education	1.two
		Not living with a partner	1.06
		Earliest arrival at WTC	iv.8
		Longer elapsing, WTC site	2.0
		Higher rank	1.1
		Number deaths in firehouse	2.3
		9/xi supervising responsibilities	2.2
		Previous disaster experience	1.4
Bowler et al. (2012)	Police responders	Multivariate (β)b
		Female gender	5.37
		Older historic period	0.07
		Written report response, phone	8.33
		Greater 9/eleven exposure	2.17
		Current smoker	1.91
		Task lost mail service-9/11	4.45
		Less social integration	−2.28
		Interaction (variable × time)
		Male person gender	−0.91
		Report response, mail or web	−ane.33
		Job lost mail-nine/11	one.76
		Being disabled	1.44
Brackbill et al. (2009)	Rescue/recovery workers, lower Manhattan residents and office workers, passersby	Multivariate (adjusted OR)c		5–half-dozen yrs
		Pre-issue low		1.8
		Greater dust cloud exposure		two.0
		Greater WTC exposure		two.2
		Sustained injury 9/11		2.3
		Loss/decease of other nine/eleven		30.9
		Mail-event job loss		4.6
		Fewest social supports		vi.9
Cone et al. (2015)	Police force responders	Multivariate (adjusted OR)d		5–8 yrs	10–11 yrs
		Lower social support		4.5	2.6
		Unable to work due to health		8.0	three.7
		Life threatened post-ix/11		1.9	three.iii
		Unmet mental health needs		10.8	9.5
		Recent life stressors		3.two	3.2
		Sustained injuries during ix/11		2.7	Due north.S.
Cukor et al. (2011)	Utility workers	Multinomial (adapted OR)			6–7 yrs
		Trauma history			two.27
		Major depressive disorder			2.eighty
		Occupational exposure to nine/11			1.31
Neria et al. (2010)	Main care patients	Multinomial (OR)b	10.18
		Low pre-9/xi
		Depression post-9/11
Pfeffer et al. (2007)	Bereaved and non-bereaved children	Bereavemente
		Hypothalamic-pituitaryadrenal axis dysregulation
		Cortisol suppression
Pietrzak et al. (2014)	Police force and non-traditional responders	Multinomial (adjusted OR)b,f
		Police responders
		Previous psychiatric disorder
		Greater stressors pre-9/11
		Greater nine/xi exposure
		nine/11-related medical conditions
		Non-traditional responders
		Hispanic ethnicity
		Previous psychiatric disorder
		More stressors pre-9/11
		Greater ix/11 exposure
		ix/11-related medical conditions
Silver et al. (2005a)	U.s. residents with straight and indirect exposure	Bivariate (adjusted OR)b	2 weeks	i yr
		Proximity to WTC	0.42	N.S.
		Pre-nine/11 mental health problems	1.72	1.82
		Female person gender	1.56	Northward.S.
		Age	0.98	N.S.
		Astute stress at time betoken ane	NA	2.44
		Lower education	N.S.	0.33
		Lower income	N.Southward.	0.89
Zvolensky et al. (2015)	Constabulary and non-traditional responders	Bivariate (r)	1–9 yrs	3.5–eleven.5 yrs
		Age	−0.02	0.sixteen
		Gender	0.16	0.26
		Hispanic ethnicity	0.22	−0.14
		African–American ethnicity	−0.11	0.04
		Exposure to grit cloud	0.09	0.14
		Know someone injured	0.twenty	0.07
		Traumatic loss	0.13	0.79
		Depression	0.78	0.72
		Disability	0.70	0.41
		Life stress postal service-9/xi	NA	0.29

Results

Prevalence and course of PTSD

Traditional and non-traditional first responders

8 of the 13 epidemiological reports reviewed concerned first responders and rescue and recovery workers, representing the greatest concentration of longitudinal studies of high-exposure populations afflicted by ix/xi (come across Fig. 1). Prevalence rates for probable PTSD varied among these eight studies depending on when data were collected, as well as by responder type (see Table 1). Studies of traditional first responders (e.g. police force, firefighters) inside the first 4 years found petty change in rates of probable PTSD, remaining steady at between approximately eight% and 12% (Brackbill et al. 2009; Berninger et al. 2010a, b). For most longitudinal studies that included later time periods, notable increases were present at v–6 years mail service-ix/11 relative to earlier time points, with estimated prevalence of likely PTSD at this later time point increasing from 4.8% to 7.8% to the higher rate of 7.4–xvi.5% (Brackbill et al. 2009; Bowler et al. 2012; Cone et al. 2015). An exception was Pietrzak et al. (2014), who plant an increase of <1% from approximately years 3 to 6 post-9/11 amidst constabulary responders (8.5% and 9.3%, respectively). We institute only ii studies that tracked longitudinal data beyond time points subsequently than 6 years. Both establish rates of PTSD of approximately 10% at year six mail-9/11 and niggling change between twelvemonth 6 and years 8–x among police responders (Pietrzak et al. 2014; Cone et al. 2015).

Prevalence of estimated PTSD of starting time responders/rescue recovery workers by written report. Multiple articles using the aforementioned data set are listed only once. Zvolensky et al. (2015) was excluded due to lack of information regarding specific time points. Studies that used a range of time points (eastward.grand. data collected at 2–three years post-ix/11) include notation at the both upper and lower ranges.

Three longitudinal studies directly compared probable PTSD prevalence in traditional (e.g. policemen and firefighters) 5. not-traditional (e.one thousand. volunteer) responders. They establish markedly higher prevalence of probable PTSD amongst non-traditional responders. The studies, withal, differed somewhat with regard to course of PTSD. Zvolensky et al. (2015), who used variable starting time and follow-up time points, institute an average increment in probable PTSD prevalence from 11.7% to 13.0% for traditional responders as compared with an increase from xvi.4% to 17.2% among not-traditional responders as measured subsequently an interval of approximately two.5 years following visit i. Debchoudhury et al. (2011) examined changes from years 3 to iv post-ix/11 to years five–half dozen post-9/eleven, finding increase in likely prevalence from 20.two% to 29.6% among lay volunteers, and from seven.5% to 11.2% amidst affiliated volunteers (i.e. those affiliated with the Cerise Cross or other like relief organization). Pietrzak et al. (2014) found that prevalence of probable PTSD decreased among not-traditional responders across years 3 and 8 post-9/xi from 24.1% to 22.5%, but increased from 8.v% to 9.eight% amongst traditional responders over the same time interval.

Other populations

Five longitudinal epidemiological studies concerned other populations directly exposed to the attacks. These studies establish decreasing prevalence of probable PTSD over time (see Fig. two). Adams & Boscarino (2006) found a decrease from v% to 3.8% from i to 2 years post-9/xi in a sample of NYC residents. Cukor et al. (2011), who examined rates of PTSD in utility workers who assisted in cleanup, but not rescue and recovery, plant decreasing rates of PTSD from years i to ii through years six–7 post-9/11. Specific results of this written report varied by the rating instrument for PTSD, but indicated a steady turn down over time. A written report of main care patients reported reductions in rates of probable PTSD from approximately 10% to 4% from years 1 to 4 mail-ix/xi (Neria et al. 2010). Pfeffer et al. (2007), who conducted the just longitudinal written report with children directly exposed to the events of 9/11, establish that the prevalence of probable PTSD declined from 30% at 4 months post-9/11 to about v% at 2 years. Silver et al. (2005a) establish increasing rates of trauma symptoms in those directly exposed in NYC and Washington, DC. They found a 9.3% prevalence of probable acute stress disorder among those highly exposed ii weeks following ix/xi, and an 11.2% prevalence of probable PTSD afterwards 1 twelvemonth. An boosted report, which included both start responders and other NYC residents, found increasing rates of probable PTSD from xiv.3% at 2–3 post-ix/11 to 19.1% 5–6 years post-9/11 and showed increasing rates for all responder and non-responder populations over time (Brackbill et al. 2009). With the exception of studies focusing on rescue and recovery workers, no longitudinal study reported data following yr 4 post-9/eleven (come across Table 1).

Prevalence of estimated PTSD for not-commencement responders/rescue recovery workers by written report. Silver et al. (2005a) estimated astute stress disorder, rather than PTSD, for the outset time bespeak. Studies that used a range of time points (e.g. data collected at two–3 years post-9/11) include notation at the both upper and lower ranges.

PTSD correlates

As tin can be seen in Tabular array 2, the principal take chances cistron for PTSD across most studies was trauma exposure, with greater severity and amount of trauma exposure associated with college likelihood of PTSD (Adams & Boscarino, 2006; Brackbill et al. 2009; Berninger et al. 2010a; Bowler et al. 2012; Pietrzak et al. 2014; Zvolensky et al. 2015). Other notable hazard factors included bereavement/traumatic loss (Pfeffer et al. 2007; Brackbill et al. 2009; Berninger et al. 2010a), female gender (Silver et al. 2005a; Adams & Boscarino, 2006; Bowler et al. 2012; Zvolensky et al. 2015), and Hispanic or Latino ethnicity (Adams & Boscarino, 2006; Bowler et al. 2012; Pietrzak et al. 2014; Zvolensky et al. 2015). Previous trauma exposure or other history of psychopathology, low social support, and recent life stressors or ongoing stress post-9/11 was establish to contribute to chronicity of PTSD (Silver et al. 2005a; Adams & Boscarino, 2006; Pfeffer et al. 2007; Neria et al. 2010; Cukor et al. 2011; Bowler et al. 2012; Pietrzak et al. 2014; Cone et al. 2015; Zvolensky et al. 2015). Notably, a repeat finding among longitudinal studies of beginning responders and rescue and recovery workers, whether traditional or non-traditional, was concrete impairment and/or task loss related to 9/xi as a correlate of PTSD (Brackbill et al. 2009; Berninger et al. 2010a, b; Bowler et al. 2012; Pietrzak et al. 2014; Cone et al. 2015; Zvolensky et al. 2015).

Treatment studies

We identified seven studies examining efficacy and/or effectiveness of diverse treatment approaches to PTSD related to ix/11 (see Table 3). Two treatment studies were conducted with children and adolescents under the auspices of the Child and Adolescent Treatment Services (CATS) Consortium, aiming to deliver evidence-based, trauma-focused treatment to New York youth and written report the implementation processes of these services (CATS Consortium, 2007). In 1 report involving 306 children, brief cognitive–behavioral therapy (CBT) or trauma-specific CBT was provided based on level of symptom severity, with significant clinical comeback in both groups (CATS Consortium, 2010). In a similar study, both trauma-specific CBT and Tell-Me-A-Story Narrative Trauma Therapy (TEMAS-NTT) were shown to be effective in a sample of 131 children, with TEMAS-NTT possibly showing some advantages for younger children and Hispanic children (Costantino et al. 2014). Although conclusions suggested the utility of treatment approaches established within existing school environs (CATS Consortium, 2007), findings regarding efficacy are limited generally past lack of control group and randomization.

Tabular array iii

Treatment of PTSD in highly exposed 9/11 populations

Source and written report blueprint	Sample	Fourth dimension frame of data drove post-9/11	PTSD instrument	Treatment weather condition	Outcomes	Average reduction in scoresa
CATS Consortium (2010) (quasi-experimental)	NYC youths anile 5–21 (n = 306)	1–4 years	PTSD-RI (trauma-specific CBT >25, brief CBT skills <25)	Trauma-specific CBT, brief CBT skills training (assignment depending on symptom severity)	Both groups showed comeback	Trauma-specific CBT: 14.88 CBT skills training: 7.93
Costantino et al. (2014) (quasi-experimental)	Hispanic/Latino NYC public schoolchildren (n = 131)	2–4 years	PTSD-RI (cut-off score 25)	TF-CBT v. TEMAS-NTT	TF-CBT and TEMAS-NTT effective in reducing PTSD, low, and anxiety. TEMAS-NTT possibly better for younger children	TF-CBT: 15.82 TEMAS-NTT: 19.89
Difede et al. (2006) (experimental)	NYC residents (n = 17)	Non reported	CAPS	Virtual reality 5. waitlist command	VR is constructive, may be especially effective for those who did non succeed with imaginal exposure	VR = ane.53 (reported result size) Waitlist = N.S.
Difede et al. (2007) (experimental)	Disaster relief workers (due north = 31)	vii months to three years	CAPS (cut-off score 30), PCL	Exposure-based CBT v. TAU	CBT effective in reducing symptoms; drop-out charge per unit relatively high	CBT = 24.86 (CAPS), 14.28 (PCL) TAU = ii.43 (CAPS), 5.38 (PCL)
Levitt et al. (2007) (quasi-experimental)	NYC residents with directly or indirect exposure (due north = 59)	i year	MPSS-SR	CBT (STAIR/MPE)	Significant reduction of PTSD and depression, improved functioning	36
Schneier et al. (2012) (experimental)	NYC residents (north = 37)	3–8 years	CAPS (cut-off score 50), PCL	PE + SSRI 5. PE + placebo	Combined treatment more efficacious	PE + SSRI: 42.2 PE + placebo: 37.5
Silver et al. (2005b) (quasi-experimental)	NYC residents with directly or indirect exposure (n = 65)	ii–48 weeks	IES-R (cutting-off score 45)	EMDR (early: 2–ten weeks post-9/11; late: 30–48 weeks post-ix/11)	Meaning reduction in anxiety, depression, and PTSD symptoms	22.8

Among studies of highly exposed adults, simply 3 were randomized controlled trials, and all three had relatively small samples. In the sole treatment written report focusing on rescue and recovery workers, Difede et al. (2007) found that symptoms significantly improved for patients who received exposure-based treatment as compared with treatment-as-usual (n = 31). The authors noted a relatively high drop-out rate (forty%) compared with other studies using exposure therapies. Schneier et al. (2012) studied 37 patients with 9/11-related PTSD, finding that prolonged exposure (PE) therapy combined with the selective serotonin reuptake inhibitor (SSRI) paroxetine was more efficacious than PE plus placebo. Finally, in a pilot study of 17 participants investigating the efficacy of virtual reality (VR) exposure therapy v. look-list control, Difede et al. (2006) found bear witness that VR may exist an effective tool for exposure, particularly for patients who previously experienced difficulty with imaginal procedures. Two other treatment studies did non use a command group. In an open trial of center motility desensitization and reprocessing therapy, improvement was noted in a sample of 65 patients (Argent et al. 2005b). In a second open trial, a flexibly applied modified manualized CBT approach resulted in improvement in a study involving 59 patients (Levitt et al. 2007).

Discussion

The goal of this review was to clarify the longitudinal prevalence, grade, and correlates of PTSD in loftier-exposure populations during the fifteen years since 9/11. Although previous reviews of PTSD related to man-made disasters have noted the importance of longitudinal data and its scarcity (Pfefferbaum et al. 2004; Bills et al. 2008; Neria et al. 2008, 2011; Wilson, 2015; Garcia-Vera et al. 2016), this is the first systematic review of longitudinal studies of nine/eleven-related PTSD and probable PTSD. We also reviewed treatment studies, which serve to elucidate the course of PTSD in the context of clinical intendance and the efficacy and effectiveness of interventions for 9/eleven-related PTSD. We accept purposefully focused on longitudinal studies, to the exclusion of cantankerous-sectional examinations, so every bit not to be encumbered by concerns generated past combining disparate data, and disruptive causal inference, that limit previous reviews (Susser et al. 2006; Galea & Maxwell, 2009; Garcia-Vera et al. 2016).

A number of conclusions may be drawn from our review. Overall prevalence of PTSD following 9/11 appears to be relatively loftier in the period directly post-obit the attacks, particularly for those with the greatest levels of traumatic exposure. These rates announced to reject over fourth dimension for the bulk. The exception is get-go responders and rescue/recovery workers, who appear to accept had lower PTSD prevalence than other populations in the first 3 years following ix/11, only show substantial increment in prevalence after that indicate. Conclusions regarding longer term prevalence are limited, every bit only 2 studies considered time points for this population afterward than six years, but available studies suggest that rates of PTSD may pinnacle at five or 6 years mail service-nine/11. A similar tendency was plant for non-traditional responders, except that prevalence of PTSD among not-traditional responders is markedly higher than for traditional responders. Initially, lower just increasing rates of PTSD among traditional responders may event from resistance to help-seeking behavior and under-reporting, and possibly due to the nature of training and preparedness. These possibilities have been discussed in prior literature addressing trauma in get-go responders, with no clear satisfactory conclusion reached (Pietrzak et al. 2014). More nuanced longitudinal information are needed to better explore the extent and nature of exposure and its relationship to PTSD prevalence, also as stigma and other factors that may touch on epidemiological inquiry. The higher prevalence of PTSD among non-traditional responders might be explained by greater vulnerability due to lower levels of preparation and support, but more research is likewise needed to better understand this miracle.

Take a chance factors reviewed hither are consistent with before reviews (Neria et al. 2008) that identified exposure intensity every bit a principal risk cistron. An important finding drawn from the longitudinal studies concerning first responders was that ix/11-related injury and job loss are important factors in chronicity of PTSD. This finding is consequent with results of a cantankerous-sectional written report conducted 10 years post-9/eleven, which found health-related unemployment to be the greatest predictor of chronic PTSD (Caramanica et al. 2014). Risk factors for chronic PTSD are not well understood, just some prove suggests that constant, negative reminders of the trauma, such as physical pain, may exist a comorbid expression of the disorder and/or assist maintain it (Brennstuhl et al. 2015).

Our findings regarding prevalence and failing form of probable PTSD are consistent with information collected across multiple disaster types (Neria et al. 2008) and specifically in regard to terrorist attacks (Garcia-Vera et al. 2016). Nevertheless, prior findings regarding starting time responders and rescue and recovery workers in the context of natural and human being-made disasters are mixed, with significant disparities in reported PTSD prevalence and class across studies. Presented theories across contexts alternatively advise enhanced resilience among first responders due to greater preparedness and professional grooming, higher risk for PTSD due to increased exposure, or both (Neria et al. 2008; McCaslin et al. 2009). Nonetheless, there appears to be understanding on a prevalence rate of approximately ten% for PTSD among rescue and recovery workers, and suggestion that rates of PTSD typically refuse (Neria et al. 2008; Berger et al. 2012). This estimate is consistent with a contempo cross-sectional findings among commencement responders conducted an average of 12 years later 9/eleven (Bromet et al. 2016), although others, which combine first responders with other populations, indicate higher rates (Caramanica et al. 2014). While it remains across the scope of the current endeavor to fully uncrease the factors that touch observed rates of PTSD across studies of commencement responders and rescue and recovery workers beyond disasters, lack of clarity is probable exacerbated past a tendency to pool results of cantankerous-sectional and longitudinal studies, too equally those involving disparate populations (e.m. traditional v. non-traditional responders).

The overall lack of longitudinal studies fifteen years post-9/eleven is disappointing. We identified 45 epidemio-logical manufactures concerning PTSD in those highly exposed to 9/xi in the process of conducting the literature review for the present study. Of these, merely xiii, less than one-third, take been identified as longitudinal in design. Furthermore, a drawback of the available longitudinal data is that the bulk of these studies were collected on just 1 highly exposed subpopulation. Offset responders and rescue and recovery workers are certainly an important group that deserves resource and attention, but i that has come to be disproportionately represented in the ix/11 literature to the exclusion of other groups. Children and adolescents, for case, were the discipline of only one longitudinal study, limited by small sample size and limited to 2 years post-9/eleven, despite possible unique vulnerabilities in this population, every bit well equally additional areas of concern including impact on developmental trajectory and take a chance for afterward psychopathology. Similarly, we found only three studies that considered NYC residents (Argent et al. 2005a; Adams & Boscarino, 2006; Brackbill et al. 2009) and no studies that focused exclusively on highly exposed NYC residents. Bachelor longitudinal studies are also limited by length of follow-up, as only a very few to date extend across 6 years. In addition, though a pocket-size number of manufactures brand reference to resilient groups or possible factors that may affect resilience (Berninger et al. 2010b; Bowler et al. 2012; Pietrzak et al. 2014), such as social support, to our knowledge little data are available because factors affecting resilience. While run a risk factors remain an of import expanse of focus, resiliency data represents an important counterpoint to such data.

Equally noted, we found very few treatment studies, and of these, most used small samples, many utilized a quasi-experimental blueprint rather than a randomized controlled trial, and none conducted follow-up analyses. It remains particularly surprising that no treatment written report was adult to treat PTSD in first responders specifically, especially considering the efforts made to create registries and develop resources for get-go responders, which limits knowledge regarding effective interventions in first responders following mass-scale terrorist events. Others have besides commented on this unfortunate dearth (Foa et al. 2005; Bills et al. 2008; Haugen et al. 2012). The minor number of treatment studies found parallels the lack of adequate quantity of longitudinal investigations.

Despite these limitations, available treatment studies broadly demonstrate the effectiveness of mental wellness treatment for traumatized individuals within the context of a national disaster. Exposure-based approaches to PTSD were further validated (Silver et al. 2005b; Difede et al. 2007; Levitt et al. 2007), including approaches utilizing VR technology (Difede et al. 2006) and deliveries in conjunction with SSRI medication (Schneier et al. 2012). The few available studies on psychotherapy with children and adolescents support school- and community-based initiatives (CATS Consortium, 2010; Costantino et al. 2014). These findings are consequent with previous efforts suggesting the utility of exposure-based approaches for the treatment of PTSD following disasters (Lopes et al. 2014). Unfortunately, every bit with the 9/11 literature, information are limited given the very small number of treatment studies of those exposed to disasters, whether natural or human being-made, including with first responders or rescue/recovery workers, that utilize randomized controlled trials (RCT; Haugen et al. 2012; Lopes et al. 2014). The lack of RCTs in the area of disaster literature is a recognized problem, as without such efforts information technology remains unknown whether the efficacy of exposure therapy established in other contexts truly translates to those exposed to disaster-related trauma. The logistical difficulties of organizing an RCT in the aftermath of disasters is undoubtedly considerable, equally has been noted elsewhere (Difede & Cukor, 2009). Nevertheless, that the prevalence of probable PTSD has continued so many years subsequently nine/11 suggests that such efforts are worthwhile, even if they are not implemented in the immediate aftermath of a disaster.

In summary, despite the relatively pocket-sized amount of available longitudinal enquiry, these data may shed unique light on class of PTSD following nine/11 in populations highly exposed to 9/11, peculiarly traditional and non-traditional responders. Our review highlights the importance of longitudinal studies when disaster strikes, as such design is less vulnerable to the variability concerns mutual to cross-sectional investigations that span disparate time points and populations. Our review farther underscores the importance of greater investment in not just using large registries for data tracking following large-scale disasters, but too connecting victim to treatment and measuring the outcome of interventions. The overwhelming focus on cantankerous-sectional investigations, to the exclusion of longitudinal and treatment studies, suggests that such are perhaps easier or more affordable for investigators to complete; this likelihood implies the need for greater, more comprehensive, and more organized funding and direction of research efforts in the event of grand-scale disasters such as ix/11.

Although we cannot make a definitive statement absent directly statistical comparison, we believe the data presented hither are less highly variable than the typical range ubiquitous among cross-sectional data from trauma-related studies of 9/11 and other disasters. Nonetheless, a limitation of this review is that methodology was not consistent across the private studies, with regard to sampling methods, sample size, measurement of PTSD, adjustment for loss to follow-upwards in the longitudinal studies, and use of controls. This likely contributed to variability and suggests caution in interpretation of composite estimates. The extent of overlap between populations across epidemiological and treatment studies is besides unknown. The use of cocky-written report information and other limited assessment techniques past the majority of studies limits conclusions that may be drawn regarding actual rates of PTSD. In detail, some apparent symptoms of PTSD may overlap with respiratory or other medical atmospheric condition for some respondents. Sex differences in rates of PTSD were not discussed here for reason of inconsistent reporting in previous studies, and variability of the significance of sex every bit a correlate of PTSD was also a cistron; however, sex differences in rates of PTSD is a known phenomenon that would probable benefit from further consideration in the context of exposure to man-fabricated disasters. Another limitation is that virtually studies used retrospective assessment of exposure and risk factors. This makes the information on exposure and related factors susceptible to retrieve bias. An additional limitation is that generalizability from high-exposure populations to other populations is limited. Futurity research should put greater emphasis on longitudinal studies, include treatment outcomes, and collect data on biomarkers, rather than focus solely on epidemiological information. Although prevalence, class, and take chances factors are all of interest in PTSD research, enhanced knowledge of the role of biological factors and of effective components of PTSD treatment may serve to exponentially benefit those exposed to large-scale traumatic events.

Acknowledgments

Dr Suarez-Jimenez's work was supported by a NIMH T32 MH015144 grant. Dr Neria's piece of work was supported by the New York State Psychiatric Institute, and NIMH RO1 MHO72833 grant.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5805615/

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