In part 2 of a 2-part series, we look at the mental health risks affecting 9/11 rescuers, the lessons learned that apply to health care workers during the current pandemic, as well as continued barriers to care.
As the United States memorializes the 20th anniversary of 9/11 in the midst of another national disaster, some may hasten to compare the human toll wrought by the attacks at the World Trade Center, the Pentagon, and aboard Flight 93 to the ongoing COVID-19 pandemic as experienced by first responders today.
Vastly dissimilar in their scope and element, it’s difficult to compare the mental health outcomes of a disaster from a single point in time with those of a global, long-term crisis. However, years of research on the aftermath of 9/11 and its effects on first responders point to lessons learned and potential interventions that could alleviate or prevent similar suffering resulting from COVID-19.
Numerous studies have substantiated the staggering mental health impacts of 9/11 on first responders, emergency workers, and those exposed to the catastrophe, while these effects continue to reverberate 20 years later and will likely persist into the future.
Meanwhile, during the past 20 months, amid the surges and lulls of the COVID-19 pandemic, urgent calls have been made to bolster the nation’s mental health care system to accommodate the rising rates of mental illness induced and exacerbated by the pandemic.
Throughout the early months of the pandemic, rising rates of illness and death were expected and inevitable to a point, as the nation had yet to develop life-saving vaccinations.
But now, in September 2021 when the majority of deaths are preventable through vaccination or public health measures, “for an individual health care worker already struggling with making sense of what happened last year, the additional fractiousness and the anger and the frustration compiles on those symptoms,” said Jonathan DePierro, PhD, an assistant professor in the psychiatry department at the Icahn School of Medicine at Mount Sinai, New York, in an interview with The American Journal of Managed Care® (AJMC®).
This fact—that hospitalizations and deaths could be largely prevented—“gives a sense, at least for some, of ‘Why am I doing this? I'm exhausted. I don't want to see this anymore,’” DePierro explained.
Using Lessons From the Past to Address 2020's Trauma, Stress
In the United States, New York City was the epicenter of the COVID-19 pandemic in March 2020. In addition to stringent social distancing measures, the city faced thousands of new COVID-19 cases each day, while health workers provided comfort to those dying alone in intensive care units, all the while working to protect their own families from infection.
As a mental health provider, DePierro explained how he felt a sense of responsibility to determine what would be most helpful for these workers and serve them as effectively as possible.
“It was really clear and upsetting to know as a clinician and a researcher that post-traumatic stress disorder (PTSD) was going to develop,” DePierro said of this time period. “Depression was going to develop. Anxiety disorders were going to develop due to the acute nature and prolonged nature of the trauma: health care workers seeing immense loss of life, families not being at the bedside when their loved one is passing away, resources being depleted, the exhaustion, the lack of sleep, the breaking up of social supports.”
Recognizing the risk of detrimental mental health outcomes among its workforce, experts at Mount Sinai established The Center for Stress, Resilience, and Personal Growth, where DePierro is clinical director. The center, which was designed to address the acute and long-term mental health needs of Mount Sinai’s staff, has already completed 135 workshops with employees since its inception in June 2020.
Based on research on the science of resilience—including laboratory and brain imaging studies and interviews conducted with individuals who have experienced extreme stress (ie, Vietnam war prisoners of war)—the workshops’ curriculum focuses on 5 themes: realistic optimism, the importance of social support, self-care, meaning and purpose, and facing fears. The workshops have also been integrated into residency and fellowship training programs.
Interventions like these should be the norm, not the exception, DePierro stressed. “I would love to see consortia being put together to advance best practices around responding to the mental health needs of essential workers…the essential worker status, actually—we know from other studies—conveys an enhanced risk of mental health distress.”
What’s needed, according to DePierro, is a concerted effort to address the holistic needs of essential workers, as a group, in addition to national attention directed at the scope of the pandemic’s mental health impact.
This could include education in evidence-based tools that workers can pull from on-the-job, when faced with distress.
Prior to his role at the Center for Stress, Resilience and Personal Growth, DePierro worked at the federally funded World Trade Center Health Program. This program allows researchers to track changes in the physical and mental health of 9/11 responders over time.
Among 9/11 responders were construction or utility workers, DePierro noted, “who went down to the pile and encountered body parts.” These individuals had no on-the-job training in disaster response or recognizing the signs of distress in themselves or in colleagues. When attempting to address that distress, these individuals had no frame of reference, DePierro said.
Studies conducted by the program have revealed a significant proportion of 9/11 responders suffer from chronic PTSD, or recurrent, persistent depression or anxiety, or recurrent alcohol misuse. “In short, they continue to experience the mental health impact of 9/11 still, 20 years after,” DePierro said.
But some long-term mental impacts could have been mitigated. Early intervention is key when it comes to managing and preventing these mental health disorders.
“Delays of care prolong suffering. So, when we identify people who are in distress, providing timely care can really be life altering and prevent someone having PTSD for 20 years,” DePierro said. “Untreated PTSD, untreated depression, crystallizes in the body in the brain, and it makes it even harder to treat down the road.”
By proactively planning for these outcomes via on-the-job training, workers will be more likely to stay in the workforce as they will be less likely to develop PTSD, individuals’ mental health will improve in their personal lives, and costs will likely decrease.
Resolving Barriers to Mental Health Care
Unfortunately, receiving timely mental health care can be largely influenced by changing political climates, stigma associated with seeking care, and a lack of resources for those who may not be able to identify symptoms of trauma.
As an example, DePierro points to the overwhelming sense of national unity and outpouring of support for first responders post-9/11, while decades before, some Vietnam war veterans were met with animosity from the public upon their return—due to the contentious nature of the war—and never sought out treatment.
Compounding the issue, at that time “we didn't know PTSD existed as a real entity, as a diagnosis,” DePierro said. “Many Vietnam veterans came back, were not warmly welcomed and suffered for decades before highly efficacious treatment services became available on a widespread basis.”
In some areas of the United States in 2021, fractiousness similar to that seen post-Vietnam War and in contrast to the national sentiment of unity displayed post-9/11, spells challenges for health workers, potentially exacerbating mental health consequences.
“There are some individuals and some clusters of individuals who still have doubts about the COVID-19 virus, as an entity, have significant doubts about the vaccine as helpful/harmful,” DePierro said. “There's strong political tensions and even significant violence that we see.”
After 9/11, a federally funded program was developed to support the health of survivors and responders, but in 2020 and 2021, “that scale of response in terms of infrastructure to support the wellbeing of folks in the United States and globally has not been put in place so much yet.”
Lack of access to care, due to cost or stigma can pose a major obstacle to recovery as treatment delays lead to prolonged suffering.
“We want people to know, here are the signs of distress, here are the resources available. And if there aren't, we need to make some effort as a country to provide those resources. Because it pays off down the road in terms of quality of life, contributing to the workforce, not having to pay into disability, and so on,” DePierro said.
Overall, recovery is the goal, and a light does exist at the end of the tunnel for those who experience trauma. Alongside the distress witnessed in 9/11 and COVID-19 responders, “we see growth as well,” noted DePierro. Many individuals have come through the pandemic—even after developing PTSD or depression—with new perspectives on priorities, having forged new relationships or picked up new skills and abilities.
“The distress and the growth go together,” DePierro stressed. “I want people to know that there is another side to this, that it is going to end, that there should be resources made available, and that growth is possible. It might be realized down the road, but we're seeing—especially in responders to the pandemic—who, even quite distressed, saying that they grew as people from this adversity. That is possible and should be fostered.”