Trajectories of PTSD risk and resilience in World Trade Center responders: an 8-year prospective cohort study.

BACKGROUND: Longitudinal symptoms of post-traumatic stress disorder (PTSD) are often characterized by heterogeneous trajectories, which may have unique pre-, peri- and post-trauma risk and protective factors. To date, however, no study has evaluated the nature and determinants of predominant trajectories of PTSD symptoms in World Trade Center (WTC) responders. METHOD: A total of 10835 WTC responders, including 4035 professional police responders and 6800 non-traditional responders (e.g. construction workers) who participated in the WTC Health Program (WTC-HP), were evaluated an average of 3, 6 and 8 years after the WTC attacks. RESULTS: Among police responders, longitudinal PTSD symptoms were best characterized by four classes, with the majority (77.8%) in a resistant/resilient trajectory and the remainder exhibiting chronic (5.3%), recovering (8.4%) or delayed-onset (8.5%) symptom trajectories. Among non-traditional responders, a six-class solution was optimal, with fewer responders in a resistant/resilient trajectory (58.0%) and the remainder exhibiting recovering (12.3%), severe chronic (9.5%), subsyndromal increasing (7.3%), delayed-onset (6.7%) and moderate chronic (6.2%) trajectories. Prior psychiatric history, Hispanic ethnicity, severity of WTC exposure and WTC-related medical conditions were most strongly associated with symptomatic trajectories of PTSD symptoms in both groups of responders, whereas greater education and family and work support while working at the WTC site were protective against several of these trajectories. CONCLUSIONS: Trajectories of PTSD symptoms in WTC responders are heterogeneous and associated uniquely with pre-, peri- and post-trauma risk and protective factors. Police responders were more likely than non-traditional responders to exhibit a resistant/resilient trajectory. These results underscore the importance of prevention, screening and treatment efforts that target high-risk disaster responders, particularly those with prior psychiatric history, high levels of trauma exposure and work-related medical morbidities.

Dimensional structure and course of post-traumatic stress symptomatology in World Trade Center responders.

BACKGROUND: Post-traumatic stress disorder (PTSD) in response to the World Trade Center (WTC) disaster of 11 September 2001 (9/11) is one of the most prevalent and persistent health conditions among both professional (e.g. police) and non-traditional (e.g. construction worker) WTC responders, even several years after 9/11. However, little is known about the dimensionality and natural course of WTC-related PTSD symptomatology in these populations. METHOD: Data were analysed from 10 835 WTC responders, including 4035 police and 6800 non-traditional responders who were evaluated as part of the WTC Health Program, a clinic network in the New York area established by the National Institute for Occupational Safety and Health. Confirmatory factor analyses (CFAs) were used to evaluate structural models of PTSD symptom dimensionality; and autoregressive cross-lagged (ARCL) panel regressions were used to examine the prospective interrelationships among PTSD symptom clusters at 3, 6 and 8 years after 9/11. RESULTS: CFAs suggested that five stable symptom clusters best represent PTSD symptom dimensionality in both police and non-traditional WTC responders. This five-factor model was also invariant over time with respect to factor loadings and structural parameters, thereby demonstrating its longitudinal stability. ARCL panel regression analyses revealed that hyperarousal symptoms had a prominent role in predicting other symptom clusters of PTSD, with anxious arousal symptoms primarily driving re-experiencing symptoms, and dysphoric arousal symptoms primarily driving emotional numbing symptoms over time. CONCLUSIONS: Results of this study suggest that disaster-related PTSD symptomatology in WTC responders is best represented by five symptom dimensions. Anxious arousal symptoms, which are characterized by hypervigilance and exaggerated startle, may primarily drive re-experiencing symptoms, while dysphoric arousal symptoms, which are characterized by sleep disturbance, irritability/anger and concentration difficulties, may primarily drive emotional numbing symptoms over time. These results underscore the importance of assessment, monitoring and early intervention of hyperarousal symptoms in WTC and other disaster responders.

The consistency of combat exposure reporting and course of PTSD in Vietnam War veterans.

Self-reports of traumatic events are often used in clinical and epidemiologic studies. Nevertheless, research suggests combat exposure reports may be biased by posttraumatic stress disorder (PTSD) symptom severity, leading to an inflated dose-response relation between combat exposure and PTSD. The authors examined the consistency in combat exposure reports and their relation to PTSD symptoms in Vietnam Veteran American Legionnaires who responded to two mailed surveys (1984, 1998; N = 1,462). Combat exposure reports were highly reliable (test-retest correlation = 0.87). However, changes in exposure reporting were related to changes in PTSD symptoms, specifically reexperiencing symptoms. The effect size of the dose-response relation attributable to changes in reporting was smaller for continuous than categorical measures. Findings are discussed in relation to recent controversies over veterans' combat exposure reports.

Perspectives on women's occupational health.

This commentary provides a brief history of the development of the field of women's occupational health and safety. It discusses the broadening of the field from one with a reproductive health focus to one that considers women in their many roles and varied stages of life. Much of this widening of focus was contemporaneous with the growth of the women's movement. The paper emphasizes that the work burden borne by employed women in general includes responsibilities for homemaking and caregiving in addition to paid employment. Possible implications of these multiple roles are discussed, as are the major social, physical, biological, and chemical hazards encountered in traditional female employment. A research agenda for overcoming some of the research and policy barriers to a complete understand of women's occupational health burden and to development of preventive policies is proposed.

The impact of medicare funding on the use of mammography among older women: implications for improving access to screening.

BACKGROUND: In 1991, a policy change extended finan cial coverage for biennial mammography to holders of Medicare part B. The impact of this decision on mammography use was examined by comparing mammography use among Medicare-eligible and ineligible women in the years before (1990) and after (1993) the policy change, using National Health Interview Survey (NHIS) data, controlling for socioeconomic indicators and for having a usual source of medical care. METHODS: The Medicare-eligible group consists of 2,419 women ages 65-69 years and women ages 60-64 years who are Medicare-eligible. The Medicare-ineligible group consists of 1,872 women ages 60-64 years. The analysis used logistic regressions and compared women who had undergone mammography in the prior 2 years and controlled for race, ethnicity, socioeconomic status, insurance status, and usual source of care. RESULTS: Medicare reimbursement of mammography appears to have increased the number of Medicare-eligible women who had had a mammogram in the 2 years prior to the survey. However, the analyses suggested that disparities in mammography use due to access to primary care and socioeconomic status persisted after the change in Medicare coverage. Analyses indicated that having additional insurance was the only significant predictor of having a usual source of care among the Medicare population. CONCLUSIONS: This analysis suggests that simply removing financial barriers to mammography for older women (such as the 1998 elimination of a deductible payment for mammograms provided under Medicare) may have limited effectiveness. The strong relationship between having a usual source of care and mammography suggests that disparities in mammography use may reflect inequalities in access to health care in general.

Women workers: the social construction of a special population.

This paper presents data on the employment characteristics of women workers in the United States, together with a discussion of the biases that exist in current employment recording systems. These biases lead to an undercounting of women workers and an underestimation of risks related to both domestic and paid employment. The paper delves into the inappropriateness of considering women workers as a "special" category of workers. Also covered are the occupational health and safety hazards that women face on the job, with associated morbidity and mortality, and the relationships between women's work and women's health. This analysis presents ideas about research and policy needs in the area of women's occupational health.

Cancer and the workplace.

The study of occupationally related cancers has played an important role in the control of cancer in general. The very nature of the workplace allows for studies that can help establish a relationship between an environmental exposure and cancer. Once carcinogens are identified, strategies can be developed to prevent disease. The article reviews procedures for identifying, evaluating, and categorizing human carcinogens; provides an overview of the basic epidemiologic strategies that have been used to study cancer and the workplace; and outlines the clinical evaluation of occupational exposures.

Social factors: women and cancer.

Numerous factors in the social environment may affect the incidence and mortality from cancer in women. Women's work roles, possible exposure to workplace hazards, social class, social roles, social stress, access to health care, and health behaviors are among the factors that act together to help determine a woman's health and well-being.

Where women work and the hazards they may face on the job.

This article discusses historical and social reasons for the emergence of women's occupational cancer as a current area of research interest. It develops background information on relationships between social and occupational factors that must be considered if research on women, work, and cancer is to be well designed. These factors include specific occupational titles and tasks and the socioeconomic status and roles of women being studied. In addition, detailed demographic data on the industrial and occupational distribution of female workers are provided as one basis for setting priorities for women's occupational cancer studies. These demographic data are supplemented by analysis of specific potential exposures to carcinogens and other hazardous substances. By comparing lists of known and suspected carcinogens published by the International Agency for Research on Cancer to the industries and uses listed by the Hazardous Substances Data Base of the National Library of Medicine, a new target list of industries of significance to female workers was derived. Its implications are discussed herein.

The impact of the physical environment on the psychological well-being of office workers.

This paper examines the relationship between the physical office environment and the psychological well-being of office workers. The results indicate that adverse environmental conditions, especially poor air quality, noise, ergonomic conditions, and lack of privacy, may effect worker satisfaction and mental health. The data also provide substantial evidence that worker assessments of the physical environment are distinct from their assessments of general working conditions, such as work load, decision-making latitude and relationships with other people at work. Stated another way, people who reported problems with the physical environment could not simply be characterized as dissatisfied workers exhibiting a tendency to 'complain' about every aspect of their working conditions. Taken together, these findings lend support to the position that the stress people experience at work may be due to a combination of factors, including the physical conditions under which they labor. Both theoretical and practical considerations arise from these data, including the need for work site based health promotion and stress reduction programs to consider both the physical and psychological design of jobs.

Post-traumatic stress disorder among American Legionnaires in relation to combat experience in Vietnam: associated and contributing factors.

The relationship between combat stress, DSM-III-defined post-traumatic stress disorder (PTSD), and a variety of behavioral factors was examined in a large nonclinical population. A total of 2858 randomly selected American Legion members who had served in Southeast Asia completed a questionnaire which elicited information on military service, personal health, and a variety of mental health outcomes. The data confirm the utility of the PTSD diagnosis as a distinct clinical entity. The frequency of PTSD and the extent of symptoms developed varied with the severity of criteria used for determining the extent of traumatic exposure. The PTSD rate ranged from 1.8 to 15.0% of the total sample, depending on whether "exposure" to combat was defined relatively narrowly or broadly. A distinct linear dose-response relationship between combat stress and a quantitative measure of PTSD intensity was observed. The frequency of PTSD diagnosis was not affected by the presence of either physical or mental health problems which predated military service. A strong, stable relationship was found between combat stress and PTSD intensity for cohorts with differing intervals since the experience of combat trauma, which persisted up to 20 years after discharge from the military. The data thus support a broader approach to defining traumatic events which recognizes individual differences in response to combat, as well as the existence of other behavioral outcomes as residual effects of combat. Implications of these findings and the importance of treating veterans with varying presentations of PTSD are discussed.

Utilization, attitudes, and experiences of Vietnam Era veterans with Veterans Administration health facilities: the American Legion experience.

A random sample of American Legion members in six states who had served in the Armed Forces during the Vietnam Era was conducted through a mailed questionnaire, in order to determine patterns of usage of Veterans Administration health facilities, as well as attitudes toward the VA and experiences at these facilities. Of the 6810 male respondents, 42.0% had served in Southeast Asia. These subjects were categorized according to their level of combat in South Vietnam. Thirty-six percent of those who had served in Southeast Asia had used VA health facilities, compared to only 18% of men who served elsewhere. Among Southeast Asia veterans, combat level was an important predictor of extent of usage of VA facilities for problems of both physical and mental health. Combat level was also associated with lack of basic and major medical insurance. While men with lower incomes tended to make greater use of VA mental health facilities, nearly one-fourth of mental health users had family incomes above $30,000. Despite their greater usage of the VA, men with higher combat levels expressed lower feelings of security about this agency, and rated its staff less helpful and of lower quality than did men who experienced lower levels of combat. On the other hand, higher combat veterans thought themselves better informed about VA services. Men who had gone to the VA for mental health assistance reported a disturbingly low frequency of having been asked basic questions that relate to possible diagnosis of post-traumatic stress disorder (PTSD), questions related to combat, which may be one of its etiologic factors, or other questions relating to their military history. Because combat level in Vietnam veterans is a major determinant of both attitudes toward and utilization of VA health facilities, the VA as well as other health agencies which deal with Vietnam veterans should be especially sensitive to this factor, and should take it into consideration when evaluating veterans' physical and mental health.

Social and behavioral consequences of the Vietnam experience among American Legionnaires.

One aspect of a cross-sectional questionnaire study of a sample of Vietnam veterans belonging to The American Legion was devoted to analysis of social and behavioral consequences of service in Southeast Asia. Members of the study population were stratified by whether they served in Southeast Asia and, within the Southeast Asia group, by varying degrees of exposure to combat and to herbicides. Using validated scales for behavioral affect and for the exposure measures for combat and herbicides, a wide range of adverse effects was observed. Men who faced high levels of combat intensity were found to be at greater risk for divorce and for generally being less happy and satisfied with their lives, their marriages, their role as fathers, and as sexual human beings. Although in this population they have reached comparatively high levels of education, they earn significantly less money than peers of their same age and educational attainment. Vietnam veterans returning from combat were found to exhibit higher levels of behavioral disturbances, with mean scores for depression, anxiety, irritation, feelings of helplessness, and physical signs of depression significantly worse than noncombat peers. The lifestyle of combat veterans also continues to place them at greater risk for poor health. They smoke, drink, and use prescription drugs at rates significantly greater than the other veterans in this study. Combat veterans have had a significantly poorer rate of reduction and cessation of smoking and drinking than others in this population. Evidence is also presented which shows that for some of the behavioral outcomes measured, a negative interactive effect of concurrent exposure to herbicides is present.

Combat and herbicide exposures in Vietnam among a sample of American Legionnaires.

A cross-sectional survey of 6810 randomly selected members of The American Legion in six states who served in the U.S. Armed Forces during the Vietnam Era was conducted by a mailed questionnaire. Combat stress was evaluated by a previously validated eight-item scale. Exposure to Agent Orange and other herbicides was estimated via exposure probability index previously developed by the authors which uses an algorithm based on the combined Air Force and Joint Services HERBS files of spray data. Two-fifths of the men had served in Southeast Asia, generally at the same time during which the major proportion of herbicides were used; the remaining subjects served elsewhere. Both combat and Agent Orange exposure exhibited distinct, meaningful distributions among Vietnam veterans with service in Southeast Asia and were also correlated with each other (r = 0.24). Our analysis demonstrates conclusively that mere presence in Vietnam cannot be used as a proxy for exposure to Agent Orange. Categorization of Vietnam veterans according to herbicide exposure can be successfully accomplished, based on an existing detailed herbicide application data base. This analysis, together with the consistent dose-related results obtained in this series of papers on health and behavioral effects, demonstrates the utility of questionnaire-derived herbicide and combat exposure measures for epidemiologic study of Vietnam veterans.

Health and reproductive outcomes among American Legionnaires in relation to combat and herbicide exposure in Vietnam.

History of diagnosed illnesses, medical symptoms, and reproductive outcomes and their relation to combat intensity and herbicide exposure were studied, via a mailed questionnaire, among 6810 American Legionnaires who served during the Vietnam War (42% in Southeast Asia, 58% elsewhere). Heart disease, venereal disease, and benign fatty tumors were reported significantly more often by Vietnam veterans than by controls. Combat intensity was significantly dosage-related to history of high blood pressure, ulcers, arthritis and rheumatism, genito-urinary problems, nervous system disease, major injury, hepatitis, and benign fatty tumors. Agent Orange exposure was significantly dosage-related to history of benign fatty tumors, adult acne, skin rash with blisters, and increased sensitivity of eyes to light. Rates of the latter two conditions and of change in skin color were especially elevated in men whose military occupations involved direct handling of herbicides. Five "symptom complex" scales were constructed via factor analysis to measure degrees of feeling faint, fatigue or physical depression, body aches, colds, and skin irritation. Means of all five scales were significantly higher in Vietnam veterans compared to controls, and in herbicide handlers compared to nonhandlers. Both combat and Agent Orange exposure were significant, independent predictors of each of the five scales. Neither combat nor Agent Orange exposure was associated with difficulty in conception, time to conception of first child, or to birthweight or sex ratio of offspring, but maternal smoking was strongly related to reduced birthweight. The percentage of spouses' pregnancies which resulted in miscarriages was significantly higher for Vietnam veterans than controls (7.6% vs 5.5%, P less than 0.001). Logistic regression analysis showed that Agent Orange exposure and maternal smoking were both independently and significantly associated with miscarriage rates in a dose-related manner.

The spread of chemotherapeutic agents at work: assessment through simulation.

An innovative simulation technique employing a saline-soluble fluorescent dye for evaluating the potential contamination by cancer chemotherapeutic agents of the work area and of personnel during normal mixing and administration procedures has been developed. The technique involves replication of routine mixing and administration procedures within a sampling frame laminated with a nonfluorescent surface. The user also wears protective clothing and gloves which are later examined for contamination by the fluorescent dye, as are the vials and syringe. Typical results are presented here. Observations made during technique development demonstrate that under many routine procedures the work surface, hands, and clothing, particularly the inner sleeves and chest covering, are contaminated by the dye. The usefulness of the technique and the implications of these data are discussed and practical suggestions for preventing similar exposure from cancer chemotherapeutic agents during actual use are given.