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Objective: The study compared delay of treatment for posttraumatic stress disorder (PTSD), major depressive disorder, and alcohol use disorder among post-9/11 veterans versus pre-9/11 veterans and civilians., Methods: The 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), a nationally representative survey of U.S. noninstitutionalized adults, was used. Participants included 13,528 civilians, 1,130 pre-9/11 veterans, and 258 post-9/11 veterans with lifetime diagnoses of PTSD, major depression, or alcohol use disorder. Cox proportional hazard models, controlling for relevant demographic characteristics, were used to estimate differences in treatment delay (i.e., time between diagnosis and treatment)., Results: Post-9/11 veterans were less likely to delay treatment for PTSD and depression than pre-9/11 veterans (adjusted hazard ratios [AHRs]=0.69 and 0.74, respectively) and civilians (AHRs=0.60 and 0.67, respectively). No differences in treatment delay were observed between post-9/11 veterans and pre-9/11 veterans or civilians for alcohol use disorder. In an exploratory analysis, post-9/11 veterans with past-year military health care coverage (e.g., Veterans Health Administration) had shorter delays for depression treatment compared with post-9/11 veterans without military coverage, pre-9/11 veterans regardless of health care coverage, and civilians, although past-year coverage did not predict treatment delay for PTSD or alcohol use disorder., Conclusions: Post-9/11 veterans were less likely to delay treatment for some common psychiatric conditions compared with pre-9/11 veterans or civilians, which may reflect efforts to engage recent veterans in mental health care. All groups exhibited low initiation of treatment for alcohol use disorder, highlighting the need for further engagement efforts.

Objective: The authors describe use of mental health services among children and adolescents after the September 11, 2001, attack on the World Trade Center., Methods: Six months after the attack, sixth- through 12th-graders (N=6,986) who were representative of the student population were asked about their use of mental health services to talk about the attack as well as their exposure to the attack, symptoms of posttraumatic stress and major depressive disorders, and any conversations about the attack with a parent, teacher, or religious leader., Results: Eighteen percent had used mental health services. Using in-school services was associated with conversation with a teacher about the attack. Using services outside school was associated with direct exposure to the attack, previous trauma exposure, probable psychiatric diagnosis, and conversation with a teacher or religious leader about the attack., Conclusions: Teachers and religious leaders can function as gatekeepers to identify children in need following a disaster.

Objective: This study assessed patient and clinician agreement about treatment type and its association with treatment helpfulness among World Trade Center rescue and recovery workers., Methods: A total of 187 outpatients and 280 clinicians completed a survey, which gathered information on patient characteristics, treatment types, and treatment helpfulness. Kappa statistics and sensitivity and specificity analyses were used, and the association between patient-clinician agreement and reported treatment benefit was determined., Results: Patient-clinician agreement was highest for group therapy, medication management, eye movement desensitization and reprocessing, and couples therapy. Agreement about medication management, individual psychotherapy, and workers' compensation evaluation was associated with higher reported treatment benefits., Conclusions: Findings support the hypothesis that agreement regarding treatment type is associated with higher reported benefit and extend findings of previous studies to a linguistically diverse, naturalistic sample exposed to a disaster trauma. Results also highlight the need for better understanding of eclectic therapies offered in real-world clinical practice.

Objective: In the aftermath of the September 11, 2001, attacks on the World Trade Center, the public mental health system in New York City mounted the largest mental health disaster response in history, called Project Liberty. The successes and challenges of Project Liberty are evaluated., Methods: The development of Project Liberty is summarized and analyzed from the perspective of the New York State and New York City officials and scientists who led the disaster response. Lessons learned that have implications for mental health support in future disaster responses are offered., Results: A high level of interagency collaboration, engagement of nongovernmental organizations to provide services, media education efforts, and ongoing program evaluation all contributed to the program's successes. Mental health professionals' limited experiences with trauma, options for funding treatment, duration of clinical program, and existing needs assessments methodologies all proved challenging., Conclusions: Project Liberty was a massive and invaluable resource during the years of rebuilding in New York City in the wake of the attacks. Challenges faced have led to lessons of generalizable import for other mental health responses to large-scale events.

Objective: Case finding is an important challenge in mental health programs responding to large-scale disasters. Most people who experience psychological symptoms after such events return to normal functioning within a few months. Yet a significant minority continues to experience enduring symptoms. This study demonstrated the use of signal detection analyses of community survey data to identify subgroups of children who were at highest risk of posttraumatic stress disorder (PTSD) after the September 11 attacks., Methods: This study reanalyzed results of a needs assessment survey conducted six months after the World Trade Center attacks on September 11, 2001, with a representative sample of 7,832 New York City public school students in grades 4 to 12. Receiver operating characteristic (ROC) analyses conducted on half the sample resulted in a decision tree for classifying children into groups at varying levels of risk of PTSD. These decision rules were subsequently retested on the second half of the sample., Results: We could reliably classify children into groups with varying probabilities of screening positive on a PTSD screen. Nearly two-thirds of children in grades 4 to 12 who screened positive for probable PTSD were concentrated among 4th graders (35%) and among children who had a friend or family member directly exposed to the attacks (28%)., Conclusions: Signal detection analysis of community needs assessment surveys can identify community subgroups most likely to screen positive for mental health problems after a disaster or terrorist attack. This information can help target screening and outreach efforts to community segments that have the highest need for services.

Objectives: This study determined the likelihood and predictors of Project Liberty counseling recipients' reporting their return to satisfactory life functioning 16 to 26 months after the September 11, 2001, attacks., Methods: Using anonymous brief paper-and-pencil questionnaires or structured telephone interviews, 452 respondents provided retrospective ratings of their functioning in five life domains during the month before the World Trade Center attacks and the month immediately before the assessment. Information on demographic characteristics and exposure to risk during the World Trade Center attacks also was obtained and used in logistic regression models. The 153 respondents who were interviewed by telephone also rated helpfulness of various coping strategies., Results: In the five domains, 77 to 87 percent of the sample reported good to excellent functioning in the month before the attacks; 55 to 68 percent reported returning to at least the same level of daily functioning after the attacks. African Americans were two to four times more likely than respondents of all other races to report a return to good or excellent functioning after the attack in four domains. Compared with respondents who did not lose their job as a result of the attacks, those who did lose their job were less likely to return to good preattack functioning in two domains. Project Liberty counseling reportedly helped 90 percent of respondents return to predisaster levels of functioning., Conclusions: Responses to future terrorist attacks should consider demographic characteristics and the impact of the attack because they can affect return to preattack functioning. Counselors should support activities that facilitate positive responses and ameliorate negative psychological responses.

Objective: The authors surveyed a sample of Project Liberty crisis counseling recipients approximately 1.5 years after the terrorist attacks on September 11, 2001, to determine the proportion of respondents who screened positive for complicated grief, a recently identified condition marked by symptoms of continuing separation distress and accompanying bereavement-related traumatic distress., Methods: A total of 149 service recipients drawn from eight high-volume providers responded to a telephone survey that included questions to screen for complicated grief., Results: Approximately half of the recipients knew someone who had been killed in the attacks. Of those recipients, 44 percent screened positive for complicated grief. Individuals who lost a family member were more likely than those who lost an acquaintance to screen positive for complicated grief. Positive screens were associated with functional impairment independent of the presence of symptoms consistent with full or subthreshold major depression or posttraumatic stress disorder (PTSD). Thirty-two percent of those who screened positive for complicated grief did not meet even subthreshold criteria for major depression or PTSD., Conclusions: Results affirmed the importance of complicated grief as a unique condition and indicated the need to attend to the psychological consequences of bereavement in disaster-related mental health services.

Objectives: Project Liberty was the first federally funded crisis counseling program to offer evidence-informed treatments to crisis counseling recipients in need of more intensive clinical intervention. The Adult Enhanced Services Referral Tool was developed as a screening instrument for making and monitoring referrals to enhanced services. This study aimed to examine how well the tool functioned for identifying persons who would perceive a need for professional treatment., Methods: A one-page tool was created that assessed demographic characteristics, risk categories, and psychological reactions to the focal event, September 11, 2001. Psychosocial reactions were assessed by the 12-item SPRINT-E, which is an expanded version of the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT). The SPRINT-E was embedded in the Adult Enhanced Services Referral Tool. Data were collected from 788 clients who received crisis counseling between June and October 2003., Results: The SPRINT-E is a unidimensional measure of distress and dysfunction. Internal consistency was excellent for the total sample (alpha=.93) and subsamples. Among the 543 clients offered referral, 71 percent accepted. Among those offered referral, the number of intense reactions (score of 4, quite a bit, or 5, very much) was by far the strongest predictor of referral acceptance., Conclusions: The SPRINT-E was successfully integrated into the crisis counseling program and provided an apparently successful, empirical basis for referral from counseling to professional treatment. Results of the brief psychological assessment provided a stronger basis for referral to treatment than membership in a risk category (for example, family member of deceased) alone.

Objective: Satisfaction with 11 aspects of service quality and four domains of effectiveness was assessed for counseling services offered through Project Liberty after the September 11, 2001, attacks on the World Trade Center., Methods: A total of 607 Project Liberty service recipients completed anonymous questionnaires, telephone interviews, or both. The 11 aspects of quality were counselor respect for client, willingness to listen, cultural sensitivity, speaking the same language as the client, amount of counseling time, convenience of meeting time and location, information received, whether the service would be used again, whether the service would be recommended to friends or family, and overall quality of service. The four effectiveness domains were daily responsibilities, relationships, physical health, and community involvement., Results: At least 89 percent of service recipients rated Project Liberty as either good or excellent across 11 service quality dimensions and four effectiveness domains. The counselor's respect for clients and his or her cultural sensitivity were rated particularly favorably., Conclusions: These ratings suggest that, from the viewpoint of these recipients of counseling services, Project Liberty counselors were largely successful in providing accessible, acceptable, and useful services after the World Trade Center disaster. Such evaluations can be conducted in a cost-effective manner and integrated with evidence-based practice to ultimately ensure that recipients of counseling receive the most efficient and effective interventions.

Objective: This study aimed to determine a pattern in the frequency with which individuals who manifested distress reactions resembling diagnostic syndromes of posttraumatic stress disorder (PTSD) and major depressive disorder accessed services provided by Project Liberty., Methods: Hierarchical cluster analysis was applied to 31 reactions to stress (event reactions) shown by 465,428 recipients of Project Liberty counseling, to determine how well event reactions mapped onto traditional diagnostic criteria. Service recipients were tracked when they first sought Project Liberty counseling during the 27 months after the attacks. Those who reported three or more reactions associated with these clusters were characterized as having possible diagnosable conditions., Results: Strong consistent clusters corresponding to traumatic stress and depressive symptoms emerged, with 26 percent, 16 percent, and 8 percent of service recipients rated as having possible PTSD, major depressive disorder, or both, respectively. Taken together, this group constituted over 40 percent of service recipients served by Project Liberty almost every month throughout the 27 months of its existence., Conclusions: Event reactions, as reported by Project Liberty crisis counselors, many of whom were nonclinicians, mapped coherently onto diagnostic syndromes, suggesting that a checklist of such reactions may be useful to disaster counselors as a cost-effective screening and planning instrument. The steady entry over time into Project Liberty counseling by a substantial number of individuals experiencing high levels of distress underscores the need for providing long-term access to mental health services postdisaster.

Clinical vignettes from the World Trade Center Worker and Volunteer Mental Health Monitoring and Treatment Program at the Mount Sinai Medical Center in New York City are presented. The hospital-based program pairs mental health screenings with federally funded occupational medical screenings to identify persons with mental health problems related to their rescue and recovery roles. The program also provides on-site mental health treatment. The cases illustrate the diverse mental health needs of the rescue and recovery workers, some of whom initially sought treatment years after September 11, 2001. The cases show that in addition to symptoms of posttraumatic stress disorder, workers experienced survivor guilt, distressing memories of childhood trauma, shame associated with intense feelings, substance abuse relapse, psychosis, and problems with family relationships.

Objective: This study examined outcomes associated with clinicians' fidelity to key elements of a cognitive-behavioral treatment intervention developed for Project Liberty's enhanced services counseling program., Methods: In telephone interviews 60 individuals reported how often their clinicians provided six components considered central to the intervention by the intervention developers. Respondents received services at sites where some (25 to 50 percent) or all clinicians had received training in the intervention., Results: Compared with respondents who received services where only some clinicians had received training (N=19), those who received services where all clinicians had received training (N=41) were significantly more likely to report that their clinicians applied techniques central to the intervention (p<.01). Additionally, those who received services from sites where all clinicians were trained were significantly more likely to report that they had been given homework (p<.05)., Conclusions: Brief questions to service recipients are a useful and cost-effective way to monitor intervention fidelity.

Objective: Project Liberty provided brief crisis counseling to 753,015 residents of New York City and surrounding counties after the attacks on the World Trade Center. Most regained predisaster functioning after counseling. For those who did not, Project Liberty provided enhanced services by specially trained, licensed mental health professionals. Individuals receiving crisis counseling and enhanced services responded to confidential telephone interviews about 18 and 24 months, respectively, after the attacks. Impairment was compared between groups to determine whether enhanced services recipients reported improved functioning and fewer symptoms of depression, posttraumatic stress, and complicated grief., Methods: Crisis counseling recipients (N=153) were interviewed once and enhanced services recipients (N=76) were interviewed twice about symptomatology and daily functioning., Results: The samples did not differ in age or gender. Significantly greater proportions of enhanced services recipients reported knowing someone who died as a result of the attacks, having been involved in rescue efforts, or having lost their job because of the attacks. Compared with crisis counseling respondents, enhanced services recipients at their first interview reported significantly more symptoms of depression, grief, and traumatic stress and significantly poorer daily functioning in five life areas. At follow-up, enhanced services respondents reported significant improvement in three of five functioning domains, significantly fewer symptoms of depression and grief, and marginally less traumatic stress., Conclusions: Recipients of enhanced services were more impaired than people who received only crisis counseling. On the basis of reports from service recipients, meaningful improvements in functioning and symptoms may be associated with the receipt of enhanced services.

Objective: This study examined news coverage of mental health resources after the attacks of September 11, 2001, in order to inform mental health disaster planning and response., Methods: Keyword searches resulted in a random sample of stories reported in the United States between September 11 and 25, 2001. A total of 10,428 stories combining attack and mental health terms were gathered, and a sample of 438 articles that mentioned mental health formed the basis of this content analysis., Results: Of the 438 reports in the nationwide sample, 35 (8 percent) identified at least one risk factor for developing emotional problems after the attacks, 204 (47 percent) described at least one coping mechanism, 25 (6 percent) provided contact information for support, and 97 (22 percent) cited expert sources., Conclusions: This exploratory study suggests a need to evaluate and improve the dissemination of mental health information to help the public cope in the aftermath of disasters.

Objectives: This study examined service utilization and event reaction patterns among children who used crisis counseling services provided under Project Liberty for 27 months after the September 11, 2001, terrorist attacks on the World Trade Center., Methods: The authors analyzed logs of 681,318 service encounters submitted by Project Liberty counselors, paying particular attention to demographic characteristics and reported event reactions., Results: Nine percent of service recipients reached by community-based Project Liberty providers were children, whereas census data for the 15 counties and boroughs served by Project Liberty indicated that children constituted 25 percent of the population. Service use as a function of race or ethnicity and of gender was consistent with census data. Similar to findings for adults, the most common emotional event reactions reported for children were experiencing sadness and tearfulness, being anxious and fearful, having difficulty concentrating, experiencing irritability and anger, having intrusive thoughts or images, and having difficulty sleeping. Behavioral event reactions listed on service logs suggested that older children (12 to 17 years) were more likely to use drugs whereas elementary school-age children were more likely to display signs of anxiety, isolation and withdrawal, and difficulties with concentration and memory., Conclusions: Sensitivity to differences in the event reaction patterns shown by younger and older children may be useful in refining treatments to help reduce the psychological impact of children's trauma after terrorist incidents.

Objective: The authors examined alternative methods for obtaining feedback from people receiving anonymous mental health services via Project Liberty, an initiative that provided free counseling to residents of the New York City area after the 2001 attacks on the World Trade Center., Methods: Counselors offered all English-speaking and Spanish-speaking adults who used Project Liberty crisis counseling services the opportunity to evaluate Project Liberty via a telephone interview (eight sites) or a brief questionnaire (four sites)., Results: A total of 107 service recipients provided feedback via a brief 32-item questionnaire, and 153 gave feedback via a 45-minute telephone interview. Although the overall participation rates were modest (less than 20 percent), nearly three-quarters of those who volunteered to participate in the telephone interview (for which they received $20) did so. Neither gender nor racial or ethnic group was associated with a greater likelihood of participating in one method over another., Conclusions: Responses to items on the brief questionnaire and in the telephone interview were similar, and offering multiple response methods increased participation rates. Although telephone interviews were more costly than the questionnaire to administer, they provided important additional information about ongoing symptoms and problems that individuals experienced after the attacks. The modest response rates obtained in the evaluation indicate that future evaluations of postdisaster services need to use methodstomaximizeresponse rates and provider adherence to administrative tasks that are critical to the evaluation.

Objective: The authors examined temporal changes in the rates at which people sought access to Project Liberty services after the attacks of September 11, 2001, according to risk category (family of missing or deceased, persons directly affected, uniformed personnel, other rescue or recovery workers, schoolchildren, displaced employed and unemployed workers, persons with disabilities, and the general population)., Methods: First visits to individual counseling services, as determined from logs of 465,428 service encounters, were proportioned among risk categories and plotted across 27 months., Results: Individuals who lost family members accounted for 40 percent of visits in the first month but dropped to 5 percent or fewer visits by five months. Uniformed personnel used disproportionately larger percentages of services after the first year. Occupationally displaced and unemployed workers sought counseling at relatively steady rates., Conclusions: Postdisaster counseling should be made available for extended periods, with shifting emphases to meet the changing needs of high-risk groups.

Objective: After the September 11, 2001, terrorist attacks on the World Trade Center, the New York State Office of Mental Health (NYOMH) initiated a three-phase multifaceted, multilingual media campaign that advertised the availability of counseling services. This study evaluated the association between patterns of spending within this campaign and the volume of calls received and referred to a counseling program., Methods: Spending on television, radio, print, and other advertising was examined, as was the corresponding volume of calls to the NetLife hotline seeking referrals to counseling services., Results: From September 2001 to December 2002, $9.38 million was spent on Project Liberty media campaigns. Call volumes increased during months when total monthly expenditures peaked. Initially, flyers, billboards, and other material items accounted for most monthly expenses. Over time, spending for television and radio advertisements increased, whereas other advertising declined. Temporal patterns show that in periods after an increase in media spending, call volumes increased independently of other sentinel events such as the one-year anniversary of the attacks., Conclusions: Sustained advertising through multiple media outlets appeared to be effective in encouraging individuals to seek mental health services.

Objective: Theories of perceived risk state that when people feel threatened, they will react more strongly than they would otherwise. This study tested the hypothesis that evaluations for involuntary psychiatric hospitalizations that were initiated by law enforcement personnel in Florida increased in the weeks after the attacks of September 11, 2001., Methods: The authors applied interrupted time-series designs to determine whether there was a relationship between the number of involuntary psychiatric examinations initiated by law enforcement officials and the attacks of September 11, 2001. They examined the number of psychiatric evaluations of men and women who were considered to be mentally ill and harmful to others by law enforcement personnel in Florida during seven-day periods ("areal" weeks) that began with Tuesday, July 6, 1999, and ended with Monday, December 31, 2001 (because September 11, 2001, fell on a Tuesday)., Results: Over the 130 weeks of the study, law enforcement officials initiated examinations of an average of 25.96 men and 13.47 women per areal week. Law enforcement officials initiated examinations of approximately 14 more women than expected in the areal week that began with September 11, 2001. During the three areal weeks that began with September 18, 2001, a total of 34 more men than expected were presented for evaluation. These findings cannot be attributed to trends, seasonality, other cycles, or the tendency of the examination time series to remain elevated or depressed after high or low values in the series., Conclusions: Perceived general risk in a community may increase the likelihood that law enforcement personnel and the persons who summon them perceive persons with mental illness as imminently harmful. The public health response to any future terror attacks should include efforts to alert psychiatric service providers to the possibility of lower community tolerance for mental illness in the aftermath of an attack.

Research has demonstrated an association between direct exposure to traumatic events and the exacerbation of mental illness. This report describes the case of a man who had a preexisting mental illness with psychotic symptoms and no history of psychiatric hospitalization who was evacuated from the World Trade Center area after the terrorist attack of September 11, 2001. He did not receive any intensive, specialized treatment during the ensuing months as his mental state deteriorated, and he eventually required psychiatric hospitalization for a full-blown psychotic episode. Given the continuing threat of terrorist attacks, recognition of preexisting psychiatric conditions and early, specialized interventions for those at risk are essential in providing effective treatment and preventing decompensation.

This study assessed relationships between exposure to the September 11, 2001, terrorist attack, current posttraumatic stress disorder (PTSD), current major depression, and current safety perceptions in a sample of 212 Pentagon staff members 13 months after the attack. Forty-eight respondents (23 percent) had possible PTSD; eight (4 percent) had probable major depression. Respondents who were directly exposed to the attack were more likely to have PTSD and major depression and were less likely to have a perception of safety at work and in usual activities and travel only. In contrast, respondents with PTSD reported a lower perception of safety at home, at work, and in usual activities and travel.