Impact of 9/11-related chronic conditions and PTSD comorbidity on early retirement and job loss among World Trade Center disaster rescue and recovery workers

World Trade Center psychological exposures and trauma related disorders: PTSD and adjustment disorders

The relationship between exposure to the World Trade Center (WTC) disaster and elevated rates of trauma related psychiatric illnesses in 9/11 responders and survivors has been well documented. This paper is part of a series to promote the practice of evidence-based medicine when managing persons with WTC-related conditions and focuses on "Trauma and Stressor Related Disorders," a diagnostic category that includes posttraumatic stress disorder (PTSD) and adjustment disorder. It offers background on 9/11-related trauma exposure, a summary of research findings from this cohort, and is followed by brief diagnostic and treatment information from selected clinical practice guidelines.

Substance use and related disorders among persons exposed to the 9/11 terrorist attacks: Essentials for screening and intervention

A growing body of research supports the association between direct exposure to the September 11, 2001, terrorist attacks, increased rates of alcohol and substance use and elevated risk of subsequent diagnosis with trauma-related and substance use disorders. Posttraumatic stress disorder (PTSD) is the most diagnosed psychiatric illness in individuals who witnessed the 9/11 attacks or participated in disaster response efforts, and substance use disorders (SUDs) are highly comorbid with PTSD. The presence of both conditions poses challenges for clinical management and highlights the importance of screening and offering intervention to this at-risk population. This paper provides background on substance use, SUDs, and co-occurring PTSD in trauma exposed populations, describes best practices for identifying harmful substance use, the role of psychotherapy and medication for addiction treatment (MAT), and recommendations for management of co-occurring SUD and PTSD.

A qualitative study of equine-assisted therapy for Israeli military and police veterans with PTSD-impact on self-regulation, bonding and hope

Equine-assisted therapy (EAT) is an increasingly popular form of treatment for people suffering from post-traumatic stress disorder (PTSD) who, for one reason or another, find psychotherapy and other traditional treatment approaches unsuitable or unhelpful. However, the concomitant growth of research in the field is yet to engage with key factors relating to EAT; specifically, there are few studies considering the phenomenological perspective of patients, and the embodied knowledge deriving from the lived experience of PTSD patients who participated in EAT-based intervention programmes. Based on a qualitative-phenomenological study, interviews were conducted with 12 PTSD patients who had completed an EAT-based intervention programme. From these, three main themes characterising the meanings they gave to participation in an EAT-based treatment programme were identified: the ability to relax (self-regulation); establishing a relationship (bonding) and transformation and hope for the future. The findings of this study point to a process whereby participation in an EAT-based treatment programme facilitates the ability to cope with PTSD symptoms in a way that bridges the patient's emotional, social and spiritual-existential dimensions. The findings suggest that EAT can contribute to the healing process of veterans suffering from PTSD.

COVID-19 vs. terrorism: Contribution of the COR theory to the process of coping with invisible threats

Two years have passed since the outbreak of the COVID-19 pandemic. The entire world is still struggling with the virus and its mutations, and governments have been imposing various restrictions, including social distancing and quarantine. This paper leans on the Conservation of Resources (COR) theoretical model in comparing the impact of COVID-19 with that of an ongoing threat of terror attacks, allowing us to understand the similarities and differences between them. Such exploration could result in an understanding that may guide devising psycho-social interventions to minimize the negative psychological consequences of a continuous life-threatening situation. By applying the extensive available literature on the aftermath of terrorist attacks to the little-known long-run consequences of the COVID-19 pandemic, this paper comes up with several guidelines such as increasing online social support and enhancing adaptive coping with stress, that are applicable on the individual, community, and societal levels.

Effects of 9/11-related injury on retirement patterns among World Trade Center Health Registry enrollees

BACKGROUND

Many survivors of the 9/11/2001 terrorist attacks in New York City sustained injuries. The aim of this study was to understand how 9/11-related injuries affected retirement patterns of World Trade Center Health Registry enrollees.

METHODS

The study included enrollees who participated in the 2017 Health & Quality of Life Survey, focused on 9/11-related injuries and quality of life, and the 2017-2018 Health & Employment Survey, focused on retirement and employment (N = 3535). Using Cox proportional hazards and logistic regression modeling, we calculated the risk of retiring at earlier ages and the odds of retirees working again, controlling for relevant covariates.

RESULTS

Results showed that 9/11-related injuries did affect retirement patterns. Injured enrollees were at greater risk of retiring at younger age compared to non-injured enrollees. Compared to more severely injured retirees, non-injured and less severely injured retirees were significantly more likely to work again postretirement. Our results suggested that being injured on 9/11 was associated with retirement, meaning that if the injury had not occurred, the individual may have continued working longer.

CONCLUSIONS

The need to retire earlier than planned could be addressed with employer and societal changes. Employers should consider making accommodations for those impacted by 9/11 a priority, as it is imperative for those who were injured on 9/11 to have the ability to work to support their physical, mental, and financial well-being.

Chronic and Traumatic Stress Among Emergency Medical Services Personnel

Abstract. Background: Emergency medical services (EMS) personnel are frequently confronted with multiple stressful and potentially traumatic events as well as adverse working conditions. Objective: This narrative review provides an overview of the impact of adverse mission experiences and working conditions on the mental and physical health of EMS personnel. Methods: We summarize the empirical findings on prevalence rates as well as individual vulnerability factors and resilience. Results: EMS personnel show the highest prevalence rates of stress-related health problems among first responders. The article outlines prevention and intervention approaches that contribute to maintaining and improving the mental and physical health of EMS personnel. Conclusion: In the future, further evidence-based intervention measures should be developed to adequately support this professional group.

Occupational post-traumatic stress disorder: an updated systematic review

BACKGROUND

Although numerous studies on occupational post-traumatic stress disorder (PTSD) have been conducted prior to the 1950-2010 seminal systematic review by Skogstad et al., the prevalence, risk factors, and impact of this disorder following traumatic events in occupational settings remain unclear. This study aims to address this knowledge gap by reviewing the literature published after 2010.

METHODS

We reviewed literature from databases such as PubMed and Google Scholar using PRISMA guidelines to identify studies that address occupational PTSD and examined the status (prevalence or incidence), the risk factors, and the health effects of PTSD among workers.

RESULTS

In total, 123 articles were identified, and finally, 31 (25.2%) articles were selected after excluding duplicates. Various occupational traumatic physical events were reported such as natural or manmade disaster, explosion, accident, handling refugee corpses, or bullying at work. Risk of PTSD was closely associated with working conditions, severity of injury, history of mental disorder, occurrence of psychiatric symptoms at the time of the event, personality, interpersonal relationships, etc. Workers with PTSD were likely to experience a deterioration of physical and psychological health and impairment of social and occupational functioning.

CONCLUSIONS

Our review suggests that many workers remain highly vulnerable to occupational PTSD and its consequences.

Implementation of a Standardized Screening Protocol to Improve Post-traumatic Stress Disorder Surveillance in First Responders

OBJECTIVE

The purpose of this quality improvement project was to implement a standardized screening protocol to identify post-traumatic stress disorder (PTSD) in first responders during employment physicals in a primary care setting.

METHODS

A pre-/post-intervention project design was used, utilizing the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (PCL-5) screening tool. Outcome measures included screening completion, positive screening rate, and referral rate.

RESULTS

A total of 331 first responders presented for employment physicals. In the post-intervention cohort, 96% (152/158) of first responders were screened. From pre- to post-intervention, first responders who screened positive increased from less than 1% (1/173) to 4.6% (7/152). Of those screening positive, a total of five of seven (71%) patients were referred for mental health evaluation.

CONCLUSIONS

A standardized screening protocol using a validated self-assessment tool improved PTSD surveillance in first responders and triggered referral.

Post-traumatic stress disorder and asthma risk: A nationwide longitudinal study

BACKGROUND

Increasing evidence suggests that post-traumatic stress disorder (PTSD) interferes with the immunological system and is correlated with cardiovascular disease, respiratory disease, and chronic pain conditions. However, the association between PTSD and asthma remains unknown.

METHODS

A total of 5518 patients with PTSD and 22,072 age- and sex-matched healthy individuals were enrolled between 2001 and 2009 and followed until the end of 2011. Individuals who developed asthma during the follow-up period were identified.

RESULTS

During the follow-up period, the patients with PTSD had an increased risk of asthma (hazard ratio [HR] = 2.27), particularly those belonging to the youngest age group (HR = 4.01). The findings were consistent in subsequent sensitivity analyses after the exclusion of the first year of surveillance or allergic disorders.

DISCUSSION

This study showed a significant link between PTSD and asthma after adjusting for demographic data and related comorbidities. The risk of developing asthma in patients with PTSD was consistently higher than that in the controls during the study period. Additional studies are necessary to clarify the underlying mechanisms involved in this association between PTSD and asthma.

Impact of Health on Early Retirement and Post-Retirement Income Loss among Survivors of the 11 September 2001 World Trade Center Disaster

The health consequences of the 9/11 World Trade Center (WTC) terrorist attacks are well documented, but few studies have assessed the disaster’s impact on employment among individuals exposed to the disaster. We examined the association between 9/11-related health conditions and early retirement among residents and workers who resided and/or worked near the WTC site on 9/11, and the association between such conditions and post-retirement income loss. The study included 6377 residents and/or area workers who completed the WTC Health Registry longitudinal health surveys in 2003–2004 and 2006–2007, and the 2017–2018 Health and Employment Survey. Logistic regression models were used to examine the associations. We found that 9/11-related health conditions were significantly associated with the likelihood of early retirement. Residents and/or area workers with more physical health conditions, especially when comorbid with posttraumatic stress disorder (PTSD), were more likely to retire before age 60 than those with no conditions. For retirees, having PTSD or PTSD comorbid with any number of physical conditions increased the odds of reporting substantial post-retirement income loss. Disaster-related outcomes can negatively impact aging individuals in the form of early retirement and income loss. Long-term effects of major disasters must continue to be studied.

Persistent mental and physical health impact of exposure to the September 11, 2001 World Trade Center terrorist attacks

BACKGROUND

Asthma, gastroesophageal reflux disease (GERD), posttraumatic stress disorder (PTSD) and depression have each been linked to exposure to the September 11, 2001 World Trade Center (WTC) terrorist attacks (9/11). We described the prevalence and patterns of these conditions and associated health-related quality of life (HRQOL) fifteen years after the attacks.

METHODS

We studied 36,897 participants in the WTC Health Registry, a cohort of exposed rescue/recovery workers and community members, who completed baseline (2003-2004) and follow-up (2015-16) questionnaires. Lower respiratory symptoms (LRS; cough, dyspnea, or wheeze), gastroesophageal reflux symptoms (GERS) and self-reported clinician-diagnosed asthma and GERD history were obtained from surveys. PTSD was defined as a score > 44 on the PTSD checklist, and depression as a score > 10 on the Patient Health Questionnaire (PHQ). Poor HRQOL was defined as reporting limited usual daily activities for > 14 days during the month preceding the survey.

RESULTS

In 2015-16, 47.8% of participants had ≥1 of the conditions studied. Among participants without pre-existing asthma, 15.4% reported asthma diagnosed after 9/11; of these, 76.5% had LRS at follow up. Among those without pre-9/11 GERD, 22.3% reported being diagnosed with GERD after 9/11; 72.2% had GERS at follow-up. The prevalence of PTSD was 14.2%, and of depression was 15.3%. HRQOL declined as the number of comorbidities increased, and was particularly low among participants with mental health conditions. Over one quarter of participants with PTSD or depression reported unmet need for mental health care in the preceding year.

CONCLUSIONS

Nearly half of participants reported having developed at least one of the physical or mental health conditions studied by 2015-2016; comorbidity among conditions was common. Poor HRQOL and unmet need for health were frequently reported, particularly among those with post-9/11 PTSD or depression. Comprehensive physical and mental health care are essential for survivors of complex environmental disasters, and continued efforts to connect 9/11-exposed persons to needed resources are critical.

Posttraumatic stress disorder in the short and medium term following the World Trade Center attack among Asian Americans

This study investigated patterns of probable posttraumatic stress disorder (PTSD) and their predictors among 2,431 Asian American and 31,455 non-Hispanic White World Trade Center (WTC) Registry participants 2-3 years and 5-6 years after the WTC attack. Participants were divided into four PTSD pattern groups: resilient, remitted, delayed onset, and chronic. Asians had a lower proportion in the resilient group (76.5% vs. 79.8%), a higher proportion in the chronic (8.6% vs. 7.4%) and remitted (5.9% vs. 3.4%) groups, and a similar proportion in the delayed onset group (about 9%) compared to Whites. In multinomial logistic regression analyses, disaster exposure, immigrant status, lower income, pre-attack depression/anxiety, and lower respiratory symptoms were associated with increased odds of chronic and delayed onset PTSD (vs. resilience) among both races. Education and employment were protective against chronic and delayed onset PTSD among Whites only. These results can inform targeted outreach efforts to enhance prevention and treatment for Asians affected by future events.

Effect of Evidence-Based Supported Employment vs Transitional Work on Achieving Steady Work Among Veterans With Posttraumatic Stress Disorder: A Randomized Clinical Trial

IMPORTANCE

Posttraumatic stress disorder (PTSD) often interferes with a person's ability to obtain or sustain employment, which leads to premature exit from the labor force and reduced income.

OBJECTIVE

To determine whether individual placement and support (IPS)-supported employment is more effective than stepwise vocational rehabilitation involving transitional work assignments at helping veterans with PTSD attain steady, competitive employment.

DESIGN, SETTING, AND PARTICIPANTS

The Veterans Individual Placement and Support Toward Advancing Recovery (VIP-STAR) study was a prospective, multisite, randomized clinical trial that included 541 unemployed veterans with PTSD at 12 Veterans Affairs medical centers. Data were collected from December 23, 2013, to May 3, 2017. Intent-to-treat analysis was performed.

INTERVENTIONS

Individual placement and support is a supported employment intervention that rapidly engages people with disabilities in community job development to obtain work based on their individual job preferences. Transitional work is a stepwise vocational rehabilitation intervention that assigns people temporarily to noncompetitive jobs as preparation for competitive employment in the community.

MAIN OUTCOMES AND MEASURES

A priori hypotheses were that, compared with those in transitional work, more participants in the IPS group would become steady workers (primary) and earn more income from competitive jobs (secondary) over 18 months. Steady worker was defined as holding a competitive job for at least 50% of the 18-month follow-up period.

RESULTS

A total of 541 participants (n = 271 IPS; n = 270 transitional work) were randomized. Mean (SD) age was 42.2 (11) years; 99 (18.3%) were women, 274 (50.6%) were white, 225 (41.6%) were African American, and 90 (16.6%) were of Hispanic, Spanish, or Latino ethnicity. More participants in the IPS group achieved steady employment than in the transitional work group (105 [38.7%] vs 63 [23.3%]; odds ratio, 2.14; 95% CI, 1.46-3.14). A higher proportion of IPS participants attained any competitive job (186 [68.6%] vs 154 [57.0%]; P = .005) and had higher cumulative earnings from competitive jobs (median [interquartile range] $7290 [$23 174] in IPS vs $1886 [$17 167] in transitional work; P = .004).

CONCLUSIONS AND RELEVANCE

This multisite trial demonstrated significantly greater effectiveness of IPS-supported employment over stepwise transitional work vocational rehabilitation for veterans living with chronic PTSD. The results provide supporting evidence for increasing access to IPS for veterans living with PTSD.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01817712.

Comorbidity amplifies the effects of post-9/11 posttraumatic stress disorder trajectories on health-related quality of life

PURPOSE

The present study aims to examine the impact of physical and mental health comorbidities on the association between post-9/11 posttraumatic stress disorder (PTSD) trajectories over 10 years and health-related quality of life (HRQOL) among 9/11-exposed persons.

METHODS

30,002 responding adult World Trade Center Health Registry enrollees reporting no pre-9/11 PTSD were studied. PTSD trajectories (chronic, delayed, remitted, no PTSD) were defined based on a 17-item PTSD Checklist-Specific to 9/11 across three waves of survey data. Three indicators of poor HRQOL were defined based on CDC HRQOL-4 measures. We computed age-adjusted prevalence of physical and mental health comorbidity (depression/anxiety) by PTSD trajectory and used modified Poisson regression to assess the effect of PTSD trajectory on poor HRQOL prevalence, accounting for comorbidity.

RESULTS

Age-adjusted prevalence of overall comorbid conditions was 95.8 and 61.4% among the chronic and no-PTSD groups, respectively. Associations between 9/11-related PTSD trajectories and poor HRQOL were significant and became greater when comorbidity was included. Adjusted prevalence ratios were elevated for fair/poor health status (APR 7.3, 95% CI 6.5, 8.2), ≥ 14 unhealthy days (4.7; 95% CI 4.4, 5.1), and ≥ 14 activity limitation days during the last 30 days (9.6; 95% CI 8.1, 11.4) in the chronic PTSD group with physical and mental health comorbidity compared to those without PTSD and comorbidity; similar associations were observed for delayed PTSD.

CONCLUSIONS

Ten years post-9/11 physical and mental health comorbidities have a substantial impact on the PTSD trajectories and HRQOL association. The need for early identification and treatment of PTSD and comorbidity should be emphasized to potentially improve HRQOL.

Quality of Life of Persons Injured on 9/11: Qualitative Analysis from the World Trade Center Health Registry

Introduction: A number of studies published by the World Trade Center Health Registry (Registry) document the prevalence of injuries sustained by victims of the World Trade Center Disaster (WTCD) on 9/11. Injury occurrence during or in the immediate aftermath of this event has been shown to be a risk factor for long-term adverse physical and mental health status. More recent reports of ongoing physical health and mental health problems and overall poor quality of life among survivors led us to undertake this qualitative study to explore the long-term impact of having both disaster-related injuries and peri-event traumatic exposure on quality of life in disaster survivors. 

Methods: Semi-structured, in-depth individual telephone interviews were conducted with 33 Registry enrollees who reported being injured on 9/11/01. Topics included: extent and circumstance of the injury(ies), description of medical treatment for injury, current health and functional status, and lifestyle changes resulting from the WTCD. The interviews were recorded, transcribed, and inductively open-coded for thematic analysis.

Results: Six themes emerged with respect to long term recovery and quality of life: concurrent experience of injury with exposure to peri-event traumatic exposure (e.g., witnessing death or destruction, perceived life threat, etc.); sub-optimal quality and timeliness of short- and long-term medical care for the injury reported and mental health care; poor ongoing health status, functional limitations, and disabilities; adverse impact on lifestyle; lack of social support; and adverse economic impact. Many study participants, especially those reporting more serious injuries, also reported self-imposed social isolation, an inability to participate in or take enjoyment from previously enjoyable leisure and social activities and greatly diminished overall quality of life.

Discussion: This study provided unique insight into the long-term impact of disasters on survivors. Long after physical injuries have healed, some injured disaster survivors report having serious health and mental health problems, economic problems due to loss of livelihood, limited sources of social support, and profound social isolation. Strategies for addressing the long-term health problems of disaster survivors are needed in order to support recovery.