The burden of full and subsyndromal posttraumatic stress disorder among police involved in the World Trade Center rescue and recovery effort

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Abstract

Background

This study examined the prevalence, correlates, and perceived mental healthcare needs associated with subsyndromal PTSD in police involved in the World Trade Center (WTC) rescue and recovery effort.

Methods

A total of 8466 police completed an interview/survey as part of the WTC Medical monitoring and Treatment Program an average of four years after 9/11/2001.

Results

The past month prevalence of full and subsyndromal WTC-related PTSD was 5.4% and 15.4%, respectively. Loss of someone or knowing someone injured on 9/11 (odds ratios [ORs] = 1.56–1.86), pre-9/11 stressors (ORs = 1.30–1.50), family support (ORs = 0.83–0.94), and union membership (ORs = 0.50–0.52) were associated with both full and subsyndromal PTSD. Exposure to the dust cloud (OR = 1.36), performing search and rescue work (OR = 1.29), and work support (OR = 0.89) were additionally associated with subsyndromal PTSD. Rates of comorbid depression, panic disorder, and alcohol use problems (ORs = 3.82–41.74), and somatic symptoms and functional difficulties (ORs = 1.30–1.95) were highest among police with full PTSD, with intermediate rates among police with subsyndromal PTSD (ORs = 2.93–7.02; and ORs = 1.18–1.60, respectively). Police with full and subsyndromal PTSD were significantly more likely than controls to report needing mental healthcare (41.1% and 19.8%, respectively, versus 6.8% in trauma controls).

Conclusions

These results underscore the importance of a more inclusive and dimensional conceptualization of PTSD, particularly in professions such as police, as operational definitions and conventional screening cut-points may underestimate the psychological burden for this population. Accordingly, psychiatric clinicians should assess for disaster-related subsyndromal PTSD symptoms in disaster response personnel.

Introduction

Police were among the largest occupational groups to respond to the September 11, 2001 terrorist attack on the World Trade Center (WTC). In addition to being exposed to the horrors of the 9/11 attacks, police played an integral role in rescue and recovery efforts that often involved long hours of arduous work, dangerous working conditions, and exposure to environmental hazards and human remains. Despite their being exposed to high levels of WTC-related traumas, studies have shown that police involved in the WTC rescue and recovery effort manifested considerable resilience to developing PTSD and related psychiatric conditions compared to other disaster workers (Bowler et al., 2010, Perrin et al., 2007). For example, a study by Perrin et al. (2007) examined the prevalence and correlates of WTC-related PTSD in a large, occupationally diverse sample of WTC rescue and recovery workers, and found that police had the lowest rates of PTSD (6.2%) compared to other workers, including firefighters, construction and sanitation workers, and unaffiliated volunteers (7.2–21.2%). Low rates of disaster-related PTSD in police may be explained by police screening procedures resulting in selection of a more resilient workforce; extensive training, preparation, or experience; and possible underreporting of PTSD and related symptoms out of concern that they might be judged as unable to perform their work responsibilities (Greene et al., 2007, Perrin et al., 2007).

Although police may have lower rates of PTSD compared to other occupations, some studies have suggested they may be more likely to experience subsyndromal or partial PTSD (i.e., symptoms below threshold for a diagnosis of PTSD (Carlier et al., 1997, Maia et al., 2007)). Subsyndromal PTSD, which is often ignored in clinical settings, has been found to be chronic (Cukor et al., 2010, Jeon et al., 2007, Pietrzak et al., 2011), and associated with elevated rates of other psychiatric disorders such as major depressive disorder, generalized anxiety disorder, and panic disorder, as well as suicidality, and functional difficulties in a broad range of trauma-exposed individuals (Breslau et al., 2004, Cukor et al., 2010, Jeon et al., 2007, Maia et al., 2007, Marshall et al., 2001, Pietrzak et al., 2011, Schnurr et al., 2000). Despite the importance of examining disaster-related subsyndromal PTSD in police exposed to mass disaster, no study of which we are aware has examined its prevalence and correlates among police involved in the WTC rescue and recovery effort. Characterization of the prevalence and correlates of WTC-related subsyndromal PTSD may help to identify an additional proportion of this population who may be at-risk or in need of treatment. This information may also help inform disaster preparation, training, and intervention efforts.

The purpose of the current study was to examine the prevalence, correlates, and risk factors associated with full and subsyndromal WTC-related PTSD among police involved in the WTC rescue and recovery effort. Based on earlier research (Bowler et al., 2010, Carlier and Gersons, 1995, Carlier et al., 1997, Maia et al., 2007, Perrin et al., 2007, Stellman et al., 2008), we hypothesized that: (1) the prevalence of subsyndromal PTSD would be higher than that of full PTSD; (2) risk factors for WTC-related full and subsyndromal PTSD would be similar, and would include exposure severity, especially traumatic losses during 9/11, demographic characteristics (lower age and education; Hispanic ethnicity), increased life stressors, and fewer sources of social support; and (3) police responders with full and subsyndromal PTSD would be more likely than police responders without these conditions to report need for mental health treatment.

Section snippets

Participants

Participants were 8466 police who completed an initial evaluation as part of the World Trade Center-Medical Monitoring and Treatment Program (WTC-MMTP). The sample was comprised predominantly (>85%) of New York City police officers; and also included Port Authority police, police from New York City and non-New York City sheriff's offices, and other non-New York City police departments. Initial evaluations were conducted between July 16, 2002 and September 11, 2008, an average of 3.9 (SD = 1.8;

Prevalence of full and subsyndromal PTSD

A total of 455 (5.4%) police met criteria for full PTSD and 1300 (15.4%) for subsyndromal PTSD. Rates of full PTSD and subsyndromal PTSD among male police were 5.3% and 15.3%, respectively; rates among female police were 6.0% and 15.7%. The remaining 6711 (79.2%) respondents were trauma controls who were involved in WTC rescue and recovery work but did not meet screening criteria for full or subsyndromal PTSD.

Demographic, WTC exposure, and psychosocial characteristics

As shown in Table 1, compared to trauma controls, police with full PTSD were more

Discussion

This study examined the prevalence, correlates, and perceived mental healthcare needs associated with full and subsyndromal WTC-related PTSD in a large sample of police involved in the WTC rescue and recovery effort. Past month prevalence rates of full and subsyndromal PTSD were 5.4% and 15.4%, respectively. As expected, the prevalence of full PTSD observed in this study was comparable to, albeit slightly lower, than that found in previous studies of police responders involved in the WTC rescue

Conclusions

Taken together, these findings suggest that current screening and diagnostic criteria for disaster-related PTSD may be too restrictive in identifying the full complement of police who have clinically significant psychiatric and functional difficulties, and who may need mental health services after responding to a mass disaster. They further underscore the importance of screening, monitoring, and treating disaster responders with subsyndromal PTSD. Additional research is needed to examine

Conflict of interest

RHP is a consultant to CogState, Ltd. for work unrelated to this project. BJL has served as a consultant for and has received royalties from Baxter Pharmaceuticals for work unrelated to this project. None of the other authors have any conflicts of interest.

Contributors

RHP, CBS, EJB, and SMS managed the literature searches and wrote the initial draft of the manuscript. CBS undertook the statistical analysis. CLK, DBR, FO, VS, MC, DH, RH, SML, BJL, JMM, JMS, IGU, and PJL collected the data, contributed to the conceptualization and design of the study, and provided critical comments and revisions of the manuscript.

Role of the funding source

This work was supported by the Centers for Disease Control and Prevention, National Institute of Occupational Safety and Health (contract 200-2002-0038 and grant 5U1O 0H008232), the American Red Cross Liberty Fund, The September 11th Recovery Program, The Bear Stearns Charitable Foundation, The September 11th Fund, The Robin Hood Foundation The findings and conclusions of this report are those of the authors and do not necessarily represent the views of the National Institute for Occupational

Acknowledgment

The authors thank the staff of the World Trade Center Worker and Volunteer Medical Screening, Medical Monitoring and Treatment programs; the labor, community, and volunteer organization stake-holders; and the WTC rescue and recovery workers, who gave of themselves so readily in response to the WTC attacks and to whom the WTC Programs are dedicated.

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