Map of Study Area Relative to World Trade Center Manhattan residents living closest to the World Trade Center, south of Canal Street, were three times more likely than residents from Canal to 110th Street to suffer symptoms of posttraumatic stress disorder.

A survey of New York City residents in the wake of the September 11, 2001, terrorist attacks found high levels of both depression and posttraumatic stress disorder (PTSD) among respondents and documented an increase in substance abuse. The survey, conducted by NIDA-funded researchers Dr. David Vlahov and his colleagues at the New York Academy of Medicine 5 to 8 weeks after the terrorist attacks, quantifies the relationships among stress, depression, and substance abuse. The results provide insight into public health service delivery needs as well as clues to effective treatment strategies to help individuals cope with traumatic events.

Stress has long been recognized as one of the most powerful triggers for drug craving and relapse to drug abuse. Research has shown that survivors of disasters are prone to stress-related problems such as PTSD and depression. People who experience major trauma and those with PTSD or depression may self-medicate with drugs or alcohol to relax, cope with stress, or relieve symptoms. "This study is one of the first to capture data on the effects of traumatic events on substance abuse patterns," says Dr. Jacques Normand of NIDA's Center on AIDS and Other Medical Consequences of Drug Abuse. "The increase in substance abuse found here was of significant magnitude. This study reminds counselors and treatment providers to be alert to increased use of alcohol, tobacco, and marijuana in the wake of such events."

Survey respondents reported post-attack rates of depression and PTSD that were approximately twice the baseline levels previously documented in a 1999 benchmark national study. Some 9.7 percent had symptoms of depression, and 7.5 percent qualified for a diagnosis of PTSD compared to baseline levels of 4.9 percent for depression and 3.6 percent for PTSD.

In looking at rates of new substance use among respondents, the researchers found that, of respondents who did not use these substances during the week before September 11, 3.3 percent started smoking cigarettes after September 11; 19.3 percent started drinking alcohol; and 2.5 percent began using marijuana. Overall, the percentages of respondents who smoked, consumed alcohol, and used marijuana increased 9.7 percent, 24.6 percent, and 3.2 percent, respectively, after the attacks.

Almost 29 percent of respondents reported that they were smoking more cigarettes and/or marijuana and/or drinking more alcohol. Among those who were already using these substances before September 11, 41.2 percent smoked more cigarettes and 41.7 percent drank more alcohol after the attacks. Among smokers, 8.2 percent smoked at least one additional pack of cigarettes a week; 20.8 percent of drinkers had at least one additional drink a day.

"The survey results are significant for the sheer numbers of people revealed to be affected by the disaster, the scope of the problem on a citywide scale, and challenges to the delivery of services," says Dr. Vlahov. He estimates that of the approximately 911,000 people in the area of New York under study, 67,000 had PTSD and approximately 87,000 had depression at the time of the study. Likewise, he estimates that 265,000 people increased their use of any of the substances in question: 89,000 smoked more cigarettes, 226,000 consumed more alcohol, and 29,000 used more marijuana. "This survey demonstrated that whole populations are affected by such disasters," says Dr. Vlahov. "The increases in use of cigarettes, alcohol, and marijuana across the population are large, making this a broad public health issue."

While the initial survey goal was to perform a public health assessment to document the scope of the problems and to help authorities apply for appropriate aid, Dr. Vlahov says that other questions also drove the research. "From a scientific perspective, we knew that attention typically focuses on victims, rescue workers, and their families. But here was an event that affected everyone in a major way. We asked, how do people cope with the stress of a disaster? Do they turn to cigarettes, alcohol, or marijuana? What are the implications for public health planning and delivery?"

Association Between Respondents' 9/11 Experiences and Current Posttraumatic Stress Disorder and Depression Characteristics Number of Respondents PTSDa Depressiona Odds Ratio (95% C.I.)   Odds Ratio   (95% C.I.) Had symptoms of a panic attack during or soon after the events of 9/11/01 124 7.6 (4.2-13.7) 2.6 (1.3-4.9) Lost possessions 36 5.6 (2.5-12.4) NSb Lost job because of the attacks 64 NSb 2.8 (1.2-6.3) Friend or relative killed 108 NSb 2.3 (1.1-4.6) Two or more life stressors in the previous 12 months 183 5.5 (2.6-11.6) 3.4 (1.8-6.6) Low social support in previous 6 months 358 NSb 2.4 (1.2-4.8) Residence south of Canal Street 50 2.9 (1.3-6.8) NSb Hispanic ethnicity 114 2.6 (1.3-5.5) 3.2 (1.7-6.3) a Current PTSD and depression defined as symptoms consistent with the diagnosis within 30 days before the interview. b Not a significant association. Certain characteristics of survey respondents were found to significantly elevate the odds that they would report symptoms consistent with a diagnosis of PTSD or depression. For example, respondents who reported symptoms of a panic attack during or soon after the terrorist attacks were 7.6 times more likely to suffer from PTSD and 2.6 times more likely to suffer depression than respondents who did not report panic attack symptoms.

Survey Methodology

Researchers randomly selected 1,008 adults living south of 110th Street in Manhattan, the area closest to the World Trade Center, to take part in the telephone survey. A 35-minute questionnaire was used to assess respondents' exposure to the September 11 events, psychological symptoms after the attacks, changes in substance abuse patterns, and other factors such as demographics, levels of social support, and previous life stressors. Surveyors referred respondents for counseling services as appropriate. The overall cooperation rate for the survey was 64.3 percent; 52 percent of respondents were women, and 71.6 percent were white. The mean age of respondents was 42 years.

Surveyors used a series of questions based on accepted psychological tests to diagnose both depression and PTSD. To determine levels of pre- and post-September 11 substance abuse, surveyors asked respondents to estimate how many times they had used cigarettes, alcohol, and marijuana during the week before September 11, and then asked about the number of times they had used each substance during the week before the survey was conducted.

Analyses revealed that those who were most directly exposed to events were more likely to suffer PTSD; those who experienced loss -- of jobs, possessions, friends or family members -- were more likely to suffer from depression. Dr. Vlahov says that the key demographic, event experience, and other characteristics most closely related to diagnosis of either PTSD or depression provide important clues to immediate crisis intervention: "Clinicians can learn that getting a history of an individual's exposure to events can help focus or target issues and clarify how he or she may be reacting."

The survey data revealed associations between specific psychological diagnoses and drug use patterns. Survey respondents diagnosed with PTSD were approximately five times as likely as other respondents to increase their use of cigarettes or marijuana. Survey respondents who were diagnosed with depression were much more likely to increase use of all three substances than were those who were not depressed. Again, Dr. Vlahov suggests that these data may be important to clinicians. "Increased use of cigarettes, alcohol, and marijuana may be an indicator of underlying psychological response issues. Clinicians should look for links between PTSD, depression, and increased use of cigarettes, alcohol, or marijuana."

Followup studies will assess outcomes at 4 months, 6 to 8 months, and 12 months after the attacks. "We need a better understanding of the extent to which substance abuse complicates psychological problems," says Dr. Vlahov. "Longitudinal studies will help us determine whether increased use of substances leads to dependence, and to identify predictors of drug dependence that will help us guide intervention planning."

Sources

Galea, S.; Ahern, J.; Resnick, H.; Kilpatrick, D.; Bucuvalas, M.; Gold, J.; and Vlahov, D. Psychological sequelae of the September 11 terrorist attacks in New York City. New England Journal of Medicine 346(13):982-987, 2002. [Abstract]

Vlahov, D., et al. Increased use of cigarettes, alcohol, and marijuana among Manhattan, New York, residents after the September 11th terrorist attacks. American Journal of Epidemiology 155(11):988-996, 2002. [Abstract]

For More Information

Help for those struggling with stress and substance abuse issues is available in two recent NIDA publications:

• "Stress and Substance Abuse: A Special Report" is a research summary that can be downloaded from NIDA's Web site. Go to www.drugabuse.gov/stressanddrugabuse.html.
• Community Drug Alert Bulletin: Stress and Substance Abuse is available from the National Clearinghouse for Alcohol and Drug Information (NCADI). Order publication #PHD914 by phone (800-729-6686; 800-487-4889 for the deaf) or at the NCADI Web site, ncadi.samhsa.gov.

Volume 17, Number 4 (November 2002)