BACKGROUND: Following the tragic events of September 11, the Pentagon Post Disaster Health Assessmen

1
Evaluation of the Mental Health Impact of 9/11
Results from the Pentagon Post Disaster Health
Assessmant Survey
Nikki N. Jordan1, Charles Hoge2, Steve Tobler1,
James Wells1, George Dydek1, Walter Egerton1
1 U.S. Army Center for Health Promotion and
Preventive Medicine
ABSTRACT
2 Walter Reed Army Institute of Research
METHODS
RESULTS
BACKGROUND Following the tragic events of
September 11, the Pentagon Post Disaster Health
Assessment (PPDHA) survey was designed to
identify healthcare needs/concerns among Pentagon
personnel and assure that appropriate
care/information was provided. Fundamental in
this assessment was the evaluation of the mental
health impact due to the attack.

• The PPDHA was deployed through web-based and
  scanable paper options.
• Participation was voluntary and encouraged via
  email, ads, and TriService outreach.
• Surveys were routinely reviewed following
  submission to ensure that respondents who
  requested further information/contact received
  timely and appropriate care.
• The PPDHA mental health questions focused on four
  main symptom domains considered to be most
  important following a terrorist attack
• Acute and posttraumatic stress symptoms
• Depression
• Anxiety/panic attacks
• Alcohol abuse
• Questions were derived from standardized
  instruments widely used in primary care settings
  (SF8, SF12, and SF36) and/or stem questions from
  the Diagnostic and Statistical Manual for Mental
  Disorders, 4th edition.
• High risk groups were formulated for each of the
  symptom domains, and validation of risk groups
  was assessed based on reported mental health
  functioning, use of counseling services and
  anticipated risk factors.
• Basic descriptive analysis and binary logistic
  regression were performed to determine
  statistically significant differences in
  distributions of respondents across mental health
  outcome(s) of interest

• A total of 4,739 people completed surveys,
  representing 24.5 of the 19,450 Pentagon
  personnel contacted.
• Respondents on average were 43 years of age, and
  predominantly male, civilian, and affiliated
  with either the Army or the Air Force.
  Approximately 24 of respondents were located in
  the damaged area of the building during the
  attack. Table 1
• Approximately 40 of respondents were determined
  to be at risk for one or more of the symptom
  domains of interest Generalized anxiety (27),
  Panic attacks (23), Depression (18), PTSD (8),
  and Alcohol abuse (2.5). Table 2

• Approximately 21 of respondents reported their
  functioning as being at least somewhat impaired,
  among which a much higher proportion fell into
  the high-risk groupings. Table 3
• There was a highly significant statistical
  association between level of functional
  impairment and formulated risk groups.
  Respondents considered at high risk for any of
  the symptom domains had significantly reduced
  daily functioning compared to those who were not
  in the high risk groups. Table 4
• Respondents found to be at high-risk for the
  mental health outcomes examined were also more
  likely to seek counseling following the attack
  and/or to request consultation from a PPDHA team
  member. Table 5
• Significant risk factors included Female gender,
  civilian status, location, injury due to the
  attack, knowing someone dead/seriously injured,
  /witnessing someones death/serious injury,
  history of prior psychiatric treatment and prior
  childhood trauma. Increasing age and presence of
  2 or more confidants were observed to be
  protective. Table 6

METHODS Although a number of standardized
instruments exist for mental health domains, most
are lengthy and could not be used as a rapid
health assessment. Instead, a short screening
instrument consisting of 17 questions that
covered the most important mental health symptom
domains, mental health functioning and possible
predictive risk factors was developed. High-risk
groups for Post Traumatic Stress Disorder (PTSD),
depression, panic attacks, generalized anxiety,
and alcohol abuse were assessed, and validation
of risk groups was assessed across functional
levels. RESULTS Overall, 1,837 (40) of
respondents met the screening criteria for being
at high risk for any of the symptom domains of
interest PTSD (8), depression (18), panic
(23), generalized anxiety (27), and/or alcohol
abuse (3). Mental health risk groups were found
to strongly correlate with reduced daily
functioning and use of counseling services. In
addition, risk factors known to be associated
with mental health problems following traumatic
events were found to be strongly predictive of
the high-risk categories identified.
TABLE 1 Demographics/ Number Percentage of
Location (N 4,739) Respondents
Age ?30 436 9.3 30-39 1319 28.0 40-49 1734 36.8
50-59 1063 22.6 ?60 156 3.3 Missing 31 Mean
Age42.8?9.6 Gender Female 1812 38.4 Male 2909 6
1.6 Missing 18 Service Army 1608 34.6 Navy 550
11.8 Air Force 1181 25.4 Marines 81 1.7 DoD 846
18.2 Other 382 8.2 Missing 91 Status Military
2043 43.6 Civilian 2639 55.4 Missing 57 Locati
on Not at Pentagon (PNT) 1006 21.3 At/Near
Pentagon 3717 78.7
Mental Health Outcomes
Crude Adjusted p-value OR (95 CI) OR (95
CI) (Adjusted) (N4552) (N4345)
TABLE 6 Risk Factor Analysis (Any mental health
risk group)
Gender (FM) 3.30 (2.91-3.73) 2.79
(2.42-3.22) ?0.01Status (CivilianMilitary) 2.43
(2.14-2.75) 2.02 (1.73-2.36) ?0.01 Location (At
PNT Not) 1.69 (1.45-1.96) 1.55
(1.31-1.83) lt0.01 Injured (YN) 3.13
(2.24-4.36) 2.23 (1.52-3.36) ?0.01Trapped
(YN) 2.67 (1.83-3.91) 1.37 (0.87-2.17) 0.18Know
dead/seriously injured (YN) 1.61
(1.43-1.82) 1.46 (1.27-1.67) ?0.01Witness
death/serious injury (YN) 1.64 (1.37-1.96) 1.64
(1.33-2.02) ?0.01History of prior MH treatment
(YN) 2.47 (2.11-2.90) 1.86 (1.56-2.22)
?0.01History of prior trauma 0.01 Never 1.00 1
.00 Only as a child 1.48 (1.11-1.97) 1.43
(1.05-1.95) 0.02 Only as an adult 0.88
(0.75-1.03) 0.97 (0.81-1.15) 0.70 Both as a
child and as an adult 1.18 (0.96-1.45) 1.34
(1.06-1.68) 0.01Confidants (Several-Many
?2) 0.58(0.51-0.66) 0.52 (0.45-0.60)
?0.01Age ?30 1.00 1.00 ?0.01 30-39 0.70
(0.56-0.88) 0.74 (0.58-0.95) 0.02 40-49 0.66
(0.53 0.82) 0.59 (0.46-0.75) ?0.01 50-59 0.83
(0.66-1.04) 0.55 (0.42-0.72) ?0.01 ?60 0.56
(0.39- 0.85) 0.42 (0.27-0.65) ?0.01
CONCLUSION These data suggest that the approach
used within the survey had validity, and that the
short mental health questionnaire could serve as
a prototype for the rapid public health
assessment of the mental health impact of future
traumatic events.
BACKGROUND

• The Pentagon Post Disaster Health Assessment
  (PPDHA) was initiated with the following
  objectives
• To assist medical assets in providing optimum
  early care
• To understand and document the extent of
  injuries, illnesses, and exposures
• To provide Pentagon employees with information on
  attacks effects on themselves and their
  coworkers
• To provide engineers with useful data
• As evidenced from prior terrorist events, mental
  health problems affect a much higher proportion
  of disaster victims than do physical problems
  therefore, it was imperative that this assessment
  evaluate the mental health impact due to the
  attack.

LIMITATIONS

• The short length of the survey precluded making
  actual clinical mental health diagnoses
  therefore, only high risk groups based on symptom
  domains could be evaluated .
• The low response rate coupled with a lack of
  centralized Pentagon personnel data made it
  impossible to determine how representative the
  sample was to the actual Pentagon population.

CONCLUSION
Rapid and effective evaluation of the mental
health impact due to traumatic events is
essential in expediting/allocating appropriate
behavioral health resources. Ideally these
assessments would be administered to a systematic
sample of the population so that the results
could be better generalized to the actual
population, and follow-up inquiries using full
scale measures of key mental disorder categories
would be performed. Although the PPDHA is
limited in this regard, results from its short
mental health screening tool suggest that it has
validity and could serve as a prototype for such
assessments. Furthermore, the high prevalence of
mental health outcomes observed among respondents
also suggests a need for continued surveillance.
Efforts are on-going to examine health care
utilization among active duty PPDHA respondents
to further test the validity of the survey and to
address observed limitations. However, further
study is needed to adequately measure the full
impact of the attack.
Panic Attacks High-Risk Group

• U.S. Army Center for Health Promotion and
  Preventive Medicine (USACHPPM)
• North Atlantic Regional Medical Command (NARMC)
• Walter Reed Army Institute of Research (WRAIR)
• TRICARE Management Activity
• Service Surgeon Generals
• Uniformed Services University of the Health
  Sciences (USUHS)
• Freedom of Information Act Office (FOIA)
• Defense Manpower Data Center (DMDC)
• Assistant Secretary of Defense for Health Affairs
• Undersecretary of Defense for Personnel and
  Readiness

Acknowledgements