Rethinking Disaster Mental Health Response in a Post-9/11 World

Abstract

This In Review features 2 articles that examine different aspects of mental health interventions in disaster settings. The article by Dr Anand Pandya1 describes mental health interventions provided in New York City after the September 11, 2001 (9/11), terrorist attacks on the World Trade Center. The article by Dr Betty Pfefferbaum and me2 addresses principles of disaster mental health interventions for children. Both articles1·2 consider fundamental conceptual issues about disaster mental health that have crystallized in the decade since the 9/11 terrorist attacks.Because the 9/11 terrorist attacks constituted a disaster of unprecedented scope and magnitude, this disaster created a watershed in the conceptualization of disaster mental health.3·4 It stimulated more thorough examination of different categories of trauma exposures and their relation to posttraumatic stress disorder (PTSD) and also presented the problem of how to most effectively assess PTSD in circumstances of large-scale chaos and catastrophe. In the post-9/11 setting, disaster responders faced complexities never before encountered in the delivery of services; authorities charted new territory in their efforts to assess and respond to mental health needs of broadly affected populations. Dr Pandya's review1 details the efforts of providers to meet the profound mental health consequences and the many creative solutions they applied in overcoming the difficulties they encountered in delivery of interventions.These 2 articles1,2 articulate 4 overarching principles for the provision of disaster mental health interventions: trauma exposure is of central importance in conceptualizing mental health outcomes within affected populations; valid and accurate measurement of mental health outcomes are essential for informing interventions; psychiatric disorders must be distinguished from normative distress; and different types of interventions are needed for psychiatric illness than for normative emotional distress. Attention to all 4 of these principles is needed in the approach to provision of appropriate and adequate postdisaster mental health interventions.The first of these disaster mental health intervention principles - conceptualization of disaster exposures - is essential for successful application of the other 3 principles. Before the history-changing 9/11 terrorist attacks, categorizing the disaster exposures of survivors was relatively straightforward: people were either in the disaster and thus directly exposed, or they were elsewhere and hence not exposed. Among exposed survivor groups, those with the highest exposure levels are generally expected to suffer the most severe mental health sequelae.5 The disaster exposure issue is pivotal for assessing the diagnosis of disaster-related PTSD, which, by definition, cannot occur in the absence of a qualifying exposure to disaster trauma.4It follows that the second principle of disaster mental health intervention - measurement of outcomes (specifically, the diagnosis of PTSD) - requires application of the first principle. PTSD is generally the most prevalent diagnosis after disaster, so consistently that it is considered a signature psychiatric diagnosis of disaster. Because PTSD cannot be diagnosed without a qualifying trauma exposure, the selfreport symptom scales that are popular for assessment of PTSD - largely because they are relatively easy to administer - are inadequate for accurate diagnosis of PTSD in individuals as well as for PTSD prevalence estimates in populations. Symptoms measured outside the construct of psychiatric diagnosis in disaster survivors largely represent measures of emotional distress. Many studies examining the mental health effects of the 9/11 attacks used symptom scales to measure PTSD and estimate its population prevalence. However, a study6 using full diagnostic assessment methods found that 35% of the people most highly exposed (that is, those in the World Trade Center towers and within 1 block of the site during the attacks) developed PTSD in the first 2 to 4 years after the attacks. …