Best practices for managing depression and suicide risk in World Trade Center responders and survivors.

A growing body of research supports the association between exposure to the World Trade Center attacks and increased risk of subsequent depression, particularly among individuals who directly witnessed the attacks or participated in the rescue and recovery efforts. Depressive disorders, often comorbid with PTSD and substance use disorders, present an ongoing and substantial health burden for 9/11 responders and survivors. These conditions are associated with an increased risk of suicide mortality, highlighting the importance of screening for depression and suicidal ideation in this population. This paper, part of a series for primary care and other clinicians, offers a brief overview of research on depression in WTC-exposed populations, summarizes critical elements for identifying and managing depression, and offers best practices for suicide prevention.

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.

The World Trade Center Health Program: an introduction to best practices.

More than 20 years have elapsed since the September 11, 2001 (9/11) terrorist attacks on the World Trade Center (WTC), Pentagon and at Shanksville, PA. Many persons continue to suffer a variety of physical and mental health conditions following their exposures to a mixture of incompletely characterized toxicants and psychological stressors at the terrorist attack sites. Primary care and specialized clinicians should ask patients who may have been present at any of the 9/11 sites about their 9/11 exposures, especially patients with cancer, respiratory symptoms, chronic rhinosinusitis, gastroesophageal reflux disease, psychiatric symptoms, and substance use disorders. Clinicians, especially those in the NY metropolitan area, should know how to evaluate, diagnose, and treat patients with conditions that could be associated with exposure to the 9/11 attacks and its aftermath. As such, this issue of Archives contains a series of updates to clinical best practices relevant to medical conditions whose treatment is covered by the WTC Health Program. This first paper in the 14-part series describes the purpose of this series, defines the WTC Health Program and its beneficiaries, and explains how relevant Clinical Practice Guidelines were identified. This paper also reminds readers that because physical and mental health conditions are often intertwined, a coordinated approach to care usually works best and referral to health centers affiliated with the WTC Health Program may be necessary, since all such Centers offer multidisciplinary care.

Prevalence and correlates of suicidal ideation in World Trade Center responders: Results from a population-based health monitoring cohort.

BACKGROUND: Suicidal ideation (SI) is an early risk factor for suicide among disaster responders. To date, however, no known study has examined the prevalence, and pre-, peri-, and post-disaster risk correlates of SI in World Trade Center (WTC) responders, one of the largest disaster response populations in U.S. METHODS: The prevalence, and pre-, peri- and post-event correlates of SI were assessed in a population-based health monitoring cohort of 14,314 police responders and 16,389 non-traditional responders (e.g., construction workers) who engaged in response, recovery, and clean-up efforts following the 9/11/2001 terrorist attacks on the WTC. Multivariable analyses were conducted to identify correlates and individual psychiatric symptoms associated with SI in each group. RESULTS: A total 12.5% of non-traditional and 2.2% of police WTC responders reported SI. Depression, functional impairment, alcohol use problems, and lower family support while working at the WTC site were associated with SI in both groups of responders. Symptom-level analyses revealed that three symptoms accounted for approximately half of the variance in SI for both groups-feeling bad about oneself, or that one has let down oneself or family; feeling down, depressed, or hopeless; and sense of foreshortened future (44.7% in non-traditional and 71% in police). LIMITATIONS: Use of self-report measures and potentially limited generalizability. CONCLUSIONS: SI is prevalent in WTC disaster responders, particularly non-traditional responders. Post-9/11 psychiatric symptoms reflecting guilt, shame, hopelessness, and associated functional impairment are most strongly linked to SI, suggesting that interventions targeting these factors may help mitigate suicide risk in this population.

Mental health stigma and barriers to care in World Trade Center responders: Results from a large, population-based health monitoring cohort.

BACKGROUND: Nearly 20 years after the terrorist attacks of September 11, 2001, multiple studies have documented the adverse mental consequences among World Trade Center (WTC) rescue, recovery, and clean-up workers. However, scarce research has examined mental health stigma and barriers to care in WTC-exposed individuals, and no known study has examined whether rates of endorsement may differ between police and "nontraditional" responders, the latter comprising a heterogeneous group of workers and volunteers. OBJECTIVE: To identify the prevalence and correlates of mental health stigma and barriers to care in WTC responders. METHODS: Mental health stigma and barriers to care and their correlates were examined in 6,777 police and 6,272 nontraditional WTC responders. RESULTS: Nontraditional responders endorsed more stigma or barriers to care concerns than police responders. Within a subsample who screened positive for a psychiatric disorder, police were more likely than nontraditional responders to endorse "concerns that negative job consequences might result" (17.9% vs. 9.1%), while nontraditional responders were more likely to endorse "I don't know where to go to find counseling services" (18.4% vs.6.6%). Within this subsample, mental health service need and more severe WTC-related posttraumatic stress disorder symptoms were associated with increased likelihood of endorsing stigma or barriers; pre-9/11 psychiatric history and non-Hispanic Black race/ethnicity were associated with lower likelihood of endorsing stigma or barriers. CONCLUSIONS: Results of this study underscore the burden of mental health stigma and barriers to care in WTC responders, and highlight the need for targeted interventions to address these concerns and promote mental healthcare utilization in this population.