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Looking at Trauma – Long interview

Dr. Sandro Galea, a National Institute of Mental Health grantee, talks about disasters and mental health research.

Watch on YouTube.


Brief version

We know that after events like the September 11 attacks, we see an increase in mental illness across the board. The most commonly studied mental illness after these events are post-traumatic stress disorder and depression. But we know from many other studies that other disorders like anxiety and the use of alcohol and drugs can also go up after these events.

Post-traumatic stress is the sentinel disorder that has been most studied after traumatic events because we know that it is linked to a traumatic event experience. But increasingly we understand that the whole picture of mental illness in the population changes and increases when a large-scale event happens. So the –– when a –– when a traumatic event happens, there are several implications. The most immediate one is that people died after September 11 –– 3000 people died. Then there are injuries and the injuries can vary. September 11th really had relatively few injuries compared to the scope of people who died.

And then we have mental illnesses as well as some physical illnesses that can show up in the short-term and go on over time. So mental illness manifests in the first few months after these events, particularly in people who are directly affected by these events, and it can go on for years after a traumatic event like September 11th.

The physical illnesses may depend on the exposure to things like dust or exposure to other factors like debris, and can result in things like asthma or potentially in the long-term even physical illnesses like cancer, although that is really difficult to evaluate. And we also know now that the physical illness and the mental illness are not separate. People who have for example more post-traumatic stress disorder are more likely to have symptoms of asthma. And the picture is that those who are affected by these traumatic events go on to have adverse health defects across the board, for mental illness to physical illness.

So after the September 11th terrorist attacks, we and a number of other groups did several studies funded by the IMH, looking at the health impact on New Yorkers and residents of New York and the tri-state area. We found that in the first few months after the attacks, about 7 to 9 percent of people had symptoms of post-traumatic stress disorder and depression, and that the symptoms resolved in a large proportion of people after the first six months to a year, but that a proportion of people continued to have symptoms in the long-term. And the proportion was small in a city as large as New York stands to represent really tens-of-thousands of people.

There have been other studies that have been done in the American population at large and –– and shown that there is a proportion –– a small proportion of people in the general population –– mostly people who are linked to the attacks in some ways –– who also had symptoms consistent with post-traumatic stress and depression.

So the September 11th terrorist attacks were the first large-scale event in the United States that resulted in a large number of systematic studies –– trying to understand its consequences. We had worked before then around events like Hurricane Andrew. But, what the September 11th attacks allowed us to do was to launch a number of studies that I think have changed dramatically how we think of the mental health consequences of trauma at the individual level, but at the –– also at the population level. And we found that when these events happen, we are perturbing the population prevalence of mental illness. We are resulting in an increase of tens and hundreds-of-thousands of people with particular psychopathology who otherwise would not have come to attention –– who otherwise would not have had the functional limitation that comes with that psychopathology.

Now, subsequent to the September 11th attacks, we have done work in many other countries in the world and also large-scale work around for example Hurricane Katrina. And these studies have I think confirmed a lot of the results we have found after September 11th –– confirmed that there is a large proportion of people –– particularly those who are directly exposed to these events, who go on to have psychopathology –– particularly post-traumatic stress disorder, anxiety disorders, substance abuse disorders and depression. And that those disorders are associated with functioning –– functional limitations with loss of functioning, and in a certain proportion can go on to persist for a long time. So there are a number of studies that have been done, which I think give us very useful clues about what should be done both to prepare for an event like September 11th, but also to know what to do to deal with it after it happens. So starting from the preparation, we know that those who are most affected by these events are those who are exposed to them. In some respects it's hard to control that because these events are happening just erratically and they are hard to predict.

But we also know that people who are isolated –– socially isolated –– are at great risk of mental illness after these events. We know that people who are exposed to stressors, including financial stressors for example, stressors around family life –– including stressors associated with getting housing –– are the people who are most likely to have mental illness and to continue having mental illness for many years after these events.

So I think we have a good picture of the groups that we need to prepare for. We need to be ready to help those who are socially isolated and to put in place systems to help alleviate some of the ongoing stressors that really will compound the effect of these traumatic events.

So for example there's something now called Psychological First Aid, which essentially consists of supportive care for the groups who are most affected and providing them with help to deal with the life-stressors that are exacerbating the effects of the trauma.

Now, we also have studies around what treatments work better or not. We've learned in the past decade that rapid-debriefing after these events is not effective and in fact they may be harmful.

We also have, through several studies, particularly some studies that have been done after the bombings of buses and trains in England that one can stage a public mental health intervention where people are actually screened and observed for a few months. And the people who continue to have symptoms of mental illness can then be offered one of the several effective treatments for some of these disorders including both pharmacotherapy therapy as well as psychotherapy.

I think we are –– as a scientific community –– much better prepared to understand what are going to be the drivers of psychopathology after mass traumas like September 11th. I think we have a bit of a gulf between science and policies. I don't think it's an unusual gulf. I think we chronically have this challenge of translating science to policy. And I'm not sure that we are –– as a collective system –– as well prepared for these large-scale events as we can be. The reality is that our surge capacity or our capacity to deal with large numbers of patients within the mental health system. Any mental health system is very limited. And if there is a large-scale event, with widespread consequences –– particularly one that goes on for a long time or had deep economic impacts, which are going to exacerbate the psychopathology we see after these events, we are almost certainly going to be overwhelmed. I think these are difficult questions. I think it's difficult to properly implement the kind of preparedness that one would like to see, but history has taught us these events happen –– they happen regularly –– they will happen again, and I think it behooves us to be as prepared as we possibly can be with that in mind.

I think a traumatic event in some respects is a traumatic event, and I often use the analogy with my students of falling from a height. If you fall from a height, you are –– you have the risk of breaking your leg and in some respects if you fall from a height by yourself or if you fall from a height with 20 other people, you still have the same risk of breaking your leg. But having said that, it's not so easy to measure it sometimes in the context of large-scale traumatic events –– after an event like September 11th or Hurricane Katrina or other hurricanes. The number of people who are exposed to traumatic events can be large and their experience can vary and vary quite a bit, even for people who are really within feet of each other when an event happens.

So it's difficult to compare the traumas that are recorded after large-scale events with individual traumas. And we know that the intensity of the traumatic event matters a lot for the likelihood of having psychopathology after these events.

So it is important to measure carefully the individual exposure, which ultimately goes into our models that predicts the risk of psychopathology.