Heike Thiel de Bocanegra,1,4 Sophia Moskalenko,2 and Elizabeth J. Kramer3. This study assessed the impact of the World Trade Center (WTC) attacks on ...
C 2006) Journal of Immigrant and Minority Health, Vol. 8, No. 3, July 2006 ( DOI: 10.1007/s10903-006-9323-0
PTSD, Depression, Prescription Drug Use, and Health Care Utilization of Chinese Workers Affected by the WTC Attacks Heike Thiel de Bocanegra,1,4 Sophia Moskalenko,2 and Elizabeth J. Kramer3
This study assessed the impact of the World Trade Center (WTC) attacks on emotional problems, prescription drug usage, and utilization of medical and mental health services within the Chinese community in lower Manhattan. We administered a survey to 148 randomly selected Chinese workers affected by the WTC attacks in March 2003. Although nearly half of the respondents had elevated PTSD and/or elevated depression scores, only a few (4.4%) had talked to a counselor. However, nearly all (86%) reported having visited a physician at least once since September 11, 2001. Individuals with elevated PTSD scores were significantly more likely to have gone to a physician after 9/11. They were also more likely to have received prescription drugs and to indicate an interest in counseling after 9/11 than individuals with low PTSD scores. The findings highlight the role of the primary care physician as gatekeeper for mental health symptoms after a disaster. They further suggest that primary care physicians should use screening tools for depression and posttraumatic stress after a major disaster and that they should be sensitive to potential emotional problems that are associated with somatic complaints. KEY WORDS: posttraumatic stress disorder; depression; World Trade Center; immigrants; displaced workers; disaster/terrorism; prescription drug use; Asian-American.
INTRODUCTION
or threatened death or serious injury, or a threat to the physical integrity of self or others” and the person’s response “involved intense fear, helplessness or horror” (1). PTSD often overlaps with other mental health problems such as depression, other anxiety disorders, somatization, dissociation, and, in some cases, psychotic symptoms (2). PTSD may be categorized as acute, if duration is less than 3 months, or chronic, if symptoms persist longer than 3 months. The onset of PTSD is considered delayed if symptoms begin at least 6 months following the stressor event. PTSD has been found to persist for decades and sometimes for a lifetime (3, 4). After the Lockerbie plane disaster, over 50% of those who had filed for psychological damages continued to have PTSD 3 years after the crash (5). In an assessment involving veterans of Operation Desert Storm, all those with symptoms of PTSD at 1 or 6 months continued to have them 2 years later,
Posttraumatic stress disorder (PTSD) occurs in response to exposure to a stressor event in which “the person experienced, witnessed, or was confronted with an event or events that involved actual
1 At
the time of the study, Dr. Thiel de Bocanegra was VicePresident for Research and Evaluation at Safe Horizon. 2 Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania. 3 Department of Psychiatry, New York University School of Medicine, New York. 4 Correspondence should be directed to Heike Thiel de Bocanegra, PhD, MPH, Bixby Center for Reproductive Health Research and Policy, University of California, San Francisco, c/o California Department of Health Services, Office of Family Planning, 1615 Capitol Avenue, P.O. Box 997413, MS 8400, Sacramento, California 95899-7413; e-mail: thielh@obgyn.ucsf.edu.
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204 with the number of symptoms increasing—an indication that it may take a significant amount of time for symptoms to appear (6). Immigrants and refugees may be at greater risk of experiencing PTSD due to vulnerability of their status, the forms of violence to which they may have been exposed in the past, and other sociocultural conditions. The immediate and long-term impact of the September 11th, 2001 attacks on the World Trade Center in New York City has been extensive. Physical proximity during and after the event (living or working close to the disaster site) is one of the major factors that increase the likelihood of PTSD. In January 2002, the Centers for Disease Control’s National Institute for Occupational Safety and Health evaluated the physical and mental health of workers who were employed in buildings in the vicinity of the World Trade Center (WTC). Workers employed near the WTC site were found to have significantly higher rates of physical and mental health symptoms several months after the attack than workers employed more than 5 miles away from the site (3).
Substance Use and Prescription Drug Use After a Terrorist Attack One of the observed behavioral responses in the aftermath of a traumatic event is the increased use of tobacco, alcohol, and drugs. In a study of responses to terrorist attacks in Israel, the use of tranquilizers, alcohol, and cigarettes was associated with posttraumatic stress symptoms (7). Five to 8 weeks following the WTC attacks, more than a quarter of Manhattan residents (29%) reported an increased use of alcohol (24.6%), cigarettes (9.7%), or marijuana (3.2%). Individuals whose smoking of either cigarettes or marijuana increased were more likely to experience PTSD than were those who did not (24.2% v. 5.6% for cigarettes; 36.0% v. 6.6% for marijuana). Respondents who reported an increased use of any of the three substances were more likely to have depression (22.1% v. 8.2% for cigarettes; 15.5% v. 8.3% for alcohol; 22.3% v. 9.4% for marijuana smoking) (8). The prevalence of psychiatric medication use significantly increased from 8.9% 30 days before the disaster to 11.6% 30 days after. However, 92% of those who used medications following the disaster had already used them prior to it and only 3% reported starting the use of psychiatric medication after the disaster. New users tended to be those with
de Bocanegra, Moskalenko, and Kramer panic attacks (44.1%) and those with both panic attacks and PTSD (69.2%) (8).
Mental Health Service Utilization Individuals who develop emotional problems after major traumatic events tend to seek support mainly from friends or relatives, rather than from social service and health agencies. A study of the partners of firefighters in the Oklahoma City bombing found that most sought support from friends or relatives, with fewer than 10% seeking professional help (9). When individuals do seek care, they are more likely to go to a primary care physician rather than to a mental health specialist. Veterans diagnosed with PTSD were far more likely to report use of primary care clinics (a median of 18 clinic visits) than of mental health services (a median of seven clinic visits) (10). The intersection between elevated mental health problems, low service use, and elevated prescription drug use was found in a study of Chinese workers who lost their jobs because of the WTC attack. Eight months after the attack, the prevalence of PTSD and depression among Chinese displaced workers was extremely elevated despite community and family support and low self-reported substance use. A high proportion of the sample met criteria for PTSD (21%) and moderate to severe depression (33%) (11). However, these elevated mental health symptoms did not cause an increase in mental health service use. Only 5% of the sample reported having consulted professional counselors. Interestingly, 21% of the sample reported starting or increasing use of prescription drugs as a result of the September 11 attacks (11). The survey did not solicit further details such as the types of medications or the conditions for which they were being used. We therefore conducted a follow-up assessment of 148 Chinese clients in March 2003. The aim was to explore in greater detail the nature and extent of WTC-related prescription drug usage and utilization of medical and mental health services.
METHODS Study Participants Participants in this study included 148 Chinese immigrants who had lost their jobs as a result of
Chinese Workers Affected by the WTC Attacks the WTC attacks and who had received 9/11 emergency relief services from Safe Horizon, the nation’s largest not-for-profit victim services agency. Potential participants were randomly selected from Safe Horizon’s central database of clients seen at the agency’s assistance centers in Chinatown. This database includes 5,000 Chinese-origin displaced workers who immigrated to the United States. A Safe Horizon research assistant contacted clients by phone and invited them to participate in a study on the impact of the World Trade Center attack on the Chinese community. If clients were interested, an appointment was scheduled at the Chinese American Planning Council, a well-known and wellrespected community based agency (11). The sample consisted of 65 individuals who had participated in the initial assessment in May 2002 (Cohort A) and 83 clients who were interviewed for the first time (Cohort B). As Cohort A had a large proportion of female participants (77%), efforts were made to achieve a more balanced gender distribution in the second survey. Priority was given to calling individuals with male Chinese names. We also increased the possibility of recruiting males by scheduling interviews on Saturdays. These efforts led to a larger proportion of males in Cohort B (31%). The two cohorts did not differ significantly on any other demographic or outcome variables. Procedures Interviews were conducted in March 2003, 18 months after the WTC attack. At the interviews, clients received a detailed explanation about the research project and were asked to sign the consent form. Interviews were held at the Chinese-American Planning Council (CPC) in Manhattan’s Chinatown, and were conducted by trilingual CPC case managers who had received training in interviewing and debriefing techniques and what to do if a participant displayed emotional distress during the interview. Interviews were conducted in Cantonese (90%) or Mandarin (10%), and lasted between 30 and 60 min. Participants received a $20 stipend for their time. The study was approved by Safe Horizon’s Ethics Committee prior to data collection.
205 and depression, respectively. All instruments were translated into and back-translated from Chinese in an earlier assessment (11). The semistructured interview assessed demographic information; exposure to prior (non-September 11th) traumatic events; exposure to the WTC attack; concerns generated by the terrorist attack; changes in behaviors as a result of 9/11; medical and mental health services utilization, and prescription drug use. The type and severity of prior traumatic events was assessed by the Life Events Scale used in the Clinician Administered PTSD survey (12). Posttraumatic stress symptoms were measured with the PTSD Checklist—Civilian version (PCL-C), developed by the National Center for PTSD (12). Participants were asked to rate symptoms that they had experienced in the past month. The PCL-C is a self-report rating scale based on the ClinicianAdministered PTSD Scale (CAPS) (13). It is used as a screening device for PTSD in community settings and contains 17 items that correspond to DSM-III criteria for PTSD (14). The Beck Depression Inventory (BDI) was used to assess depression (15). The 22 items are self-rated from 0 to 3 in terms of intensity within the past week. The Chinese translations of both scales had good internal reliability in this sample (BDI α = .90; PCLC α = .93). Respondents’ scores on the two scales were significantly correlated with each other (r = .59, p < .01).
Statistical Analyses We conducted reliability calculations to assess the internal consistency of the scales. We conducted descriptive data analyses (frequencies, cross tabulations) to describe the variables and variable associations, using SAS 10.0. The open-ended questions were categorized. Furthermore, we conducted statistical comparisons (χ2 and t-tests) of individuals with elevated PTSD or depression scores to those with low scores to explore whether mental health status influenced individuals’ health seeking behavior.
RESULTS
Instruments
Description of the Sample
The interview schedule consisted of a semistructured interview and two scales to measure PTSD
Participants were between 23 and 72 years old at the time of the interview, with a mean age of 51
206 (SD = 9.8). They were between 12 and 66 years old when they arrived to the U.S. (mean = 35 years, SD = 10.7). Some had arrived only shortly before the WTC attack. Forty-nine respondents (33%) came from the city of Canton and 14 (9.5%) had emigrated from Hong Kong. The rest came from the provinces/metropolitan areas of Fu-Jian, Gongzhou, Shanghai, Shen-Zen, or were Chinese immigrants from Indonesia, Malaysia, Taiwan, or Vietnam. Twothirds of the interviewees (69%) were female. The average length of schooling was 8.1 years (0–17 years, SD = 3.1). All participants had partially or completely lost their jobs due to the World Trade Center attack. Seventy-one percent (n = 105) had worked in a garment factory prior to 9/11 and 14% (n = 20) in the restaurant industry.
Mental Health Needs and Service Utilization All participants completed the BDI and the PCL-C, which yielded scores representing posttraumatic stress symptoms. Means replacement was used in cases where there were one or two missing items. Cases with three or more missing values were deleted, resulting in 139 valid cases for the PCLC and 148 valid cases for the BDI. Depression scores ranged from 0 to 35 (Mean 9.3, SD = 8.2). Twenty-two respondents (15%) had scores that fell in the moderate to severe depression range (score of 17 or higher). The summary scores for the PCL ranged from 1 to 51 (out of a possible high of 66), with a mean score of 16.4 (SD = 12.0). Nearly half the respondents (n = 58; 42%) had elevated PTSD scores (17 or higher on PCL-C). Summary scores were computed for each of three symptom clusters: Re-experiencing, avoidance/numbing, and hyper-vigilance. The majority of respondents (78%) met the diagnostic criterion for the re-experiencing cluster, 42% met the criterion for hyper-vigilance, and 24% for the criterion for avoidance/numbing. A clinical diagnosis of PTSD requires that scores meet or exceed cutoff criteria for all three clusters. Nearly a fifth of the sample (19%) met these criteria. Despite the high levels of posttraumatic stress symptoms and depression in this sample, only a few respondents (4.4%) had talked to a counselor in the 18-months since the WTC attack. The perceived need for counseling also was low, with only 9% indicating that they would like to receive counseling (only three of the 13 persons who wanted counseling had already received it).
de Bocanegra, Moskalenko, and Kramer Medical Care Visits Nearly all participants (86%) reported having visited a physician at least once since the World Trade Center attack. The average number of visits was 6.8 (min = 1, max = 60, SD = 8.1). In nearly two-thirds of the cases (62%) participants had gone to the same provider for all visits. Primary care providers were consulted most frequently (89%), followed by OB/GYN (31%), and other types of specialists (21%) including cardiologists, otolaryngologists, and dermatologists (multiple responses were possible). Fifteen percent of the sample indicated that they had gone to a Chinese doctor (a practitioner of non-Western medicine). Half of this group reported that they had gone to both a Chinese and a Western doctor. Four persons (3%) indicated they had visited a neurologist or psychotherapist. The most frequent reasons for the medical visits were annual physical examinations (68%) and chronic disease management (35%). Only five respondents (4%) indicated they had used the emergency room. In an open-ended question of why they went to a health care provider, several respondents attributed their medical problems (breathing problems, allergies, skin problems) to the September 11th attack and its aftermath. One study participant with 60 medical care visits after 9/11 indicated that symptoms began after 9/11. Mental health problems such as nightmares or depressive feelings were the primary reasons for medical visits in only eight cases. Only two of those eight individuals reported having talked to a counselor in addition to their medical provider.
Prescription Drug Use and PTSD Scores Of the 96 participants who responded whether or not they received a prescription from their medical provider, 58 (60%) said that they did. Most did not remember the names of the medications, but 35 respondents could indicate the purpose of the medication. Of this group, nine stated that it was for chronic health conditions such as diabetes, and hypertension (26%). Other frequently mentioned causes were pain (n = 8, 23%), mainly headaches. Two people indicated that they were taking medication for lungrelated problems, two for heartburn, and another two indicated the use of medication for potential emotional reasons (“makes me more relaxed, and less sensitive,” “used to relax the body and help
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sleeping”). Nineteen of 54 participants (35%) who responded to the question whether their medication usage has changed since 9/11 indicated that they had increased their prescription drug use. Of the 23 respondents who indicated why they went to the doctor, eight (35%) volunteered that the health problem started or was intensified due to the WTC attack. These WTC-attributed health problems included arthritis, body ache, thyroid problems, skin problems, and heartburn. Those who received prescription drugs after 9/11 were significantly more likely to have elevated PTSD scores (mean = 20.1, SD = 14.46) than those who had already taken medication prior to 9/11 (mean = 15.9, SD = 9.1; t = 1.222, F = 6.197, p < .016). Respondents who reported an increase in their medication usage had significantly higher PTSD scores (mean = 19.4, SD = 15.0) than those who did not report a change (mean = 16.5, SD = 10.5, F = 4.2226 (45), p < .05). We conducted statistical comparisons (χ2 and t-tests) of individuals with elevated PTSD or depression scores to those with low PTSD scores to explore whether the mental health status influenced individuals’ health seeking behavior. Results are reported in Table I below. Individuals with elevated PTSD scores were significantly more likely to have gone to a physician after 9/11 but less likely to have visited the same physician if they had multiple visits. They were significantly more likely to report that other people
commented that they had changed after 9/11. They were more likely to be interested in receiving counseling, although this trend did not reach statistical significance (p = 0.07). The group of individuals with elevated PTSD symptoms and those with low PTSD symptoms did not differ on any other variable such as reason for the visit or number of times they went to the doctor.
DISCUSSION Eighteen months after the WTC attacks, nearly a fifth in this group of Chinese displaced workers met criteria for PTSD diagnosis (19%), a percentage that is typically found immediately after a disaster (16). In addition to geographic proximity and exposure to the event, the average age of the respondents (51 years) may have affected this finding. Chen et al. observed in the Chinatown community that individuals in their 40s and 50s had relatively higher emotional distress after the WTC attack than both younger and older groups (17). This age group may also be more likely to seek care from an internist for chronic disease management. The proportion of Chinese respondents who went to a medical doctor in an 18-month period (86%) and especially who went for an annual physical exam (68%) is unexpectedly high. One possible explanation is that many displaced workers signed up for the September 11th Health Insurance Program which provided health
Table I. Health Care Behavior of Respondents With High PTSD or Depression Scores and Low PTSD or Depression Scores (N = 139) PTSD/depression scores (%) Health care variable
Low (n = 81)
Elevated (n = 58)
Significance level (χ2 , t test)
Went to physician after 9/11 Times went to doctora Went to same physician Saw an internist Reason of visit: annual physical exam Reason of visit: disease management Reason of visit: feeling sad/depressed Received prescription first time after 9/11 Changed way medication is taken Increase in prescription drugs Has somebody to talk to Talked to counselor Would like to receive counseling Others commented that changed
80 6.3 (6.6) 88 90 68 30 6 55 42 12 93 4 5 15
92 7.6 (7.6) 79 82 67 43 7 59 30 21 91 7 14 51
P = 0.045 ns ns ns ns ns ns ns ns ns ns ns P = 0.07 P < 0.001
a Expressed
in mean and SD.
208 insurance to victims of the 9/11 attack for 1 year. They may have used this temporary insurance for preventive visits and chronic disease management. We checked the date clients were found eligible for insurance coverage with the date they reported having gone to the doctor. The complete information was only available for a small proportion of the sample, thus limiting the findings. There was no significant difference in health care seeking behavior (such as going for an annual physical exam, going to a primary care doctor, and reason for visit) between those who went to a physician before they were found eligible and those who went after they were found eligible. Nevertheless it may be that health insurance coverage after a disaster could facilitate the identification and prompt treatment of physical and emotional problems in the affected population. Respondents with elevated PTSD or depression scores were more likely to have gone to a medical provider. This is consistent with studies that found PTSD to be associated with a higher rate of general medical complaints (18, 19). Furthermore, Asian American patients may prefer to seek help from their primary care providers rather than mental health specialists because of the shame and stigma they associate with receiving mental health services. The study participants’ linguistic isolation (all of them preferred to speak Cantonese or Mandarin) and the dearth of qualified, bilingual, bicultural mental health providers may have been another barrier to mental health services (20, 21). A physical problem is often seen as a more legitimate reason to seek help (22). For example, because being anxious is viewed as a sign of being weak or incompetent, many Asian patients with anxiety disorders (including PTSD) tend to present with physical complaints. Asian American patients expect the physician to be an expert and an authority, and to make them feel better immediately. If they do not receive instant relief from the medication that is prescribed they are likely to “doctor shop” (23). This could explain why individuals with high PTSD or depression scores were more likely to have seen different providers than individuals with low PTSD or depression scores. The cross-sectional design and the lack of preWTC posttraumatic stress prevalence data limit our ability to draw causal inferences. Were Chinese more likely to develop PTSD because they did not seek services or did the lack of seeking services exacerbate PTSD symptoms? What was the prevalence of PTSD in this community prior to the attacks? As all of the study participants experienced economic set-
de Bocanegra, Moskalenko, and Kramer backs due to the World Trade Center Attack, it may have been that some of the emotional problems were affected by a combination of the financial distress with the disaster exposure We do not have comparative data from a group that was only exposed to a job loss or to the World Trade Center disaster. Immigration concerns, such as fear of deportation or inability to bring a loved one to the United States, also may have intensified the emotional reactions. As the surveys were administered in a community setting, we did not review the actual prescriptions or inspect medication bottles so it was not possible to ascertain whether the medications are being used for the purpose for which they were prescribed. Most respondents did not recall the names of the prescription drugs, and only a subgroup could indicate precisely what the medication was for. We also did not ask whether participants used any herbs that were provided by friends or relatives. Herbs such as ginseng and ma huang, for example, can exacerbate anxiety (22). The impact of medication use for the direct or self-treatment of emotional problems is therefore inconclusive. The strong correlation between depression and posttraumatic stress symptoms with medical care visits raises the question of how aware physicians are of the association between physical symptoms and emotional problems, and whether they identified the emotional problems or explored underlying mental health reasons for somatic complaints. We did not assess to what extent physicians used this opportunity to identify and treat PTSD and depression symptomatology. Studies have documented that primary care providers fail to recognize major depression in approximately half of their adult patients who have the disorder. It has been proposed that routine screening for depression could result in improved recognition and earlier treatment of depression, and clinical trials have shown that the use of depression screening tests in primary care settings can increase clinician detection of depression. Three of the major screening instruments with high sensitivities and specificities depending upon the cutoff point have been translated into Chinese and used in various major studies. They are the Beck Depression Inventory (BDI), the Zung Self-Rating Depression Scale (SDS), and the Center for Epidemiologic Studies Depression Scale (CES-D) (24–26). The 9-item depression scale of the Patient Health Questionnaire (PHQ-9) was developed specifically for use in primary care settings (27). The items correspond to the signs and symptoms of
Chinese Workers Affected by the WTC Attacks depression in the DSM-IV, with a question about functional impairment from the symptoms. This allows it to serve as both a screening tool and a monitor of severity. The instrument has been and is being used in studies of Chinese-speaking individuals, but different cutoff points for this population may have to be established (Chen MT: Personal communication, 04/12/04). Recently, the PHQ-2 has been developed as a screening tool, and it has been found to have high construct and criterion validity (28). Researchers also have begun to develop brief PTSD screening tools for use in primary care settings, although it may take some time until these instruments are available in Chinese (29). The United States Preventive Services Taskforce (2002) recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and followup. (30) Given the high likelihood of developing posttraumatic stress and depression after a major disaster, and the gatekeeper role of the primary care physician, we recommend that primary care physicians screen for these conditions in the aftermath of a population-based traumatic event, and, if they are unable to screen systematically, that they maintain a high index of suspicion about these problems and intervene where appropriate. In addition, they learn how to integrate this information in their care delivery, and be informed about the culturally sensitive mental health programs to which they can refer patients. The development of creative and culturally sensitive screening and referral mechanisms for emotional sequelae seems to be of particular importance in communities that may not come forward for mental health services.
ACKNOWLEDGMENTS This study was prepared with financial support from the Solomon Asch Center for Study of Ethnopolitical Conflict, with support from The Andrew W. Mellon Foundation.
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