The Anniversary of 9/11 Research Roundup

In this Research Roundup, we explore new studies examining the impacts of 9/11 trauma, as well as related injuries and psychiatric comorbidities.

Physical-Psychiatric Comorbidities Related to 9/11 Childhood Trauma

There is extensive research on the concurrent psychiatric and physical illnesses adults exposed to 9/11 endure; however, studies on the long-term physical-psychiatric comorbidities experienced by youth traumatized by 9/11 remain limited.

In a recent study, investigators examined individuals directly exposed to 9/11 as children (N = 844 high exposure, N = 104 low exposure) and compared them with a matched unexposed, control group (N = 491). Approximately 14 years after their trauma, investigators evaluated these individuals for physical and mental health conditions using health questionnaires and psychiatric assessments, either parent- or self-reported. Those with high exposure to 9/11 were significantly more likely to have experienced symptoms of a psychiatric disorder in the past year and a lifetime physical health condition when compared with individuals who were not exposed to 9/11. Additionally, those exposed to 9/11 had a higher prevalence of physical-psychiatric comorbidities, with a 3.5-fold increased prevalence compared with the unexposed group.

“This underscores how exposure to traumatic events during childhood heightens the risk of long-term concurrent mental and physical health issues. Our findings also highlight the importance of early and ongoing interventions to prevent future comorbidities and promote better quality of life throughout the lifespan,” wrote the study authors.

Reference

Amsel L, Cycowicz YM, Rodriguez-Moreno, DV, et al. The long-term physical-psychiatric comorbidities related to childhood exposure to 9/11 trauma. Int J Environ Res Public Health. 2024;21(8):988.

Dementia in World Trade Center Attack Responders Aged 65 or Younger

In a new prospective study, investigators sought to assess the incidence of dementia before age 65 years in World Trade Center (WTC) responders. They also sought to compare incidence of dementia among responders with severe exposures to debris vs responders not exposed to building debris who wore personalized protective equipment (PPE).

Investigators conducted a prospective cohort study from November 1, 2014, to January 1, 2023, in an academic medical monitoring program available to WTC responders who reside on Long Island, New York. Responders aged 60 years or younger who did not have dementia at the time of their first cognitive assessment were followed up every 18 months for up to 5 years on average. Exposure severity was determined based on responses to a detailed questionnaire of WTC exposures and exposure-related activities, including exposures to fine particulate dust and potentially neurotoxic debris, duration of work, and the use of PPE. Exposure level was divided into 5 categories: (1) low, (2) mild, (3) moderate, (4) high, and (5) severe.

Approximately 5010 responders out of 9891 were eligible for inclusion in the study (median [IQR] age, 53 [48-57] years; 4573 [91.3%] male). Increasing WTC exposure severity was associated with incremental increases in the incidence rate of dementia per 1000 person-years (low, 2.95 [95% CI, 1.07-11.18]; mild, 12.16 [95% CI, 10.09-14.79]; moderate, 16.53 [95% CI, 13.30-20.81]; high, 30.09 [95% CI, 21.35-43.79]; and severe, 42.37 [95% CI, 24.86-78.24]). Adjusting for social, demographic, and relevant medical factors, each unit increase in exposure severity was associated with increased incidence of dementia (adjusted hazard ratio, 1.42 [95% CI, 1.18-1.71]; P < .001; mean risk difference, 9.74 [95% CI, 2.94-32.32] per 1000 person-years; P < .001).

More severe exposure to dust or debris was significantly associated with a higher risk of dementia before age 65. This study also suggests that the use of PPE might help prevent the onset of dementia before age 65 years among individuals exposed to an uncontrolled building collapse like that of 9/11.

Reference

Clouston SAP, Mann FD, Meliker J, et al. Incidence of dementia before age 65 years among World Trade Center attack responders. JAMA Netw Open. 2024;7(6):e2416504.

Reducing Alcohol Abuse and Promoting Treatment Among Post-9/11 Veterans

A new ongoing randomized controlled trial seeks to examine the efficacy of a novel intervention for veterans who are not seeking treatment and struggle with hazardous drinking and potential cooccurring behavioral health problems, particularly for young adult veterans who served after the September 11 attacks on the United States in 2001. These individuals may have an increased risk of hazardous drinking, posttraumatic stress disorder (PTSD), and depression.

Investigators hope to overcome the significant barriers to behavioral health treatment for these veterans and reaching them through brief mobile phone-based interventions. They believe this may help reduce drinking and promote treatment engagement.

Investigators will evaluate 800 post-9/11 young adult veterans aged 18 to 40 years with potentially hazardous drinking and who have not recently received any behavioral health treatment. Veteran participants will be randomly assigned to either the personalized intervention or a control with resources for care. The intervention, which contains a personalized normative feedback module, will focus on the correction of misperceived norms of peer alcohol use. It uses empirically informed approaches to increase the user’s motivation to address their alcohol use and cooccurring behavioral health problems. Investigators will assess past 30-day drinking, alcohol-related consequences, and treatment-seeking behaviors at baseline and 3, 6, 9, and 12 months following intervention. Potential moderators of outcomes will be explored, including sex, barriers to care, PTSD, depression, and severity of alcohol use disorder symptoms.

The investigators expect to be finished with recruitment within 6 months. Data collection will take 12 months for each enrolled participant. Analyses will begin within 3 months of the final data collection point (12 months follow-up).

Reference

Pedersen ER, Davis JP, Hummer JF, et al. Reducing alcohol misuse and promoting treatment initiation among veterans through a brief internet-based intervention: protocol for a randomized controlled trial. JMIR Res Protoc. 2024;13:e59993.

Alcohol Use Patterns and Cognitive Diagnoses in Post-9/11 Veterans

A recent study aimed to investigate the association between alcohol use patterns and cognitive diagnoses in post-9/11 veterans with traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD).

Using electronic health record data, 193,663 veterans from deployments in support of post-9/11/2001 military operations (80.1 % male; 71.2 % white) were classified into 3 alcohol use trajectory groups based on self-reported Alcohol Use Disorders Identification Test-C (AUDIT-C) scores: (1) consistently low, (2) initially high transitioning to low, and (3) initially moderate transitioning to high. Investigators used Cox proportional hazards models to examine the association between alcohol use, TBI, PTSD, and the risk of cognitive diagnosis, while adjusting for demographic factors and comorbidities. The median age of veteran at service entry was 20 years and 31 years at service exit. Of the 193,663 veterans, 17.5 % had a history of TBI, 42 % had a PTSD diagnosis, and 2.9 % had a cognitive diagnosis.

Veterans with initially high transitioning to low (HR = 1.21, 95 % CI: 1.11–1.31) and initially moderate transitioning to high (HR = 1.42, 95 % CI: 1.33–1.51) alcohol use patterns had a significantly greater risk of cognitive diagnosis compared with those with consistently low alcohol use when accounting for TBI, PTSD, and comorbidities. TBI (HR = 5.40, 95 % CI: 5.06–5.76) and PTSD (HR = 2.42, 95 % CI: 2.25–2.61) were also independently associated with an elevated risk of cognitive diagnosis.

Veterans with higher levels of alcohol consumption, even if they decrease drinking over time, may have an increased risk of cognitive diagnosis if they have a TBI and/or PTSD. Mental health clinicians should consider long-term alcohol use patterns in their clinical assessments and interventions to best identify which patients are at greater risk for experiencing cognitive difficulties.

Reference

May AC, Hendrickson RC, Pagulayan KF, Schindler AG. An observational cohort study of alcohol use and cognitive difficulties among post-9/11 veterans with and without TBI and PTSD. Drug Alcohol Depend. 2024;263:112419.

New Therapies for World Trade Center Survivors With Persistent PTSD Symptoms

A recent study compared Internet-based, therapist-assisted psychotherapy for posttraumatic stress disorder (PTSD) with an active control intervention in World Trade Center (WTC) survivors and recovery workers with PTSD symptoms related to the WTC (n = 105; 75% syndromal PTSD). Participants were randomized to integrative testimonial therapy (ITT) that was focused on WTC-related trauma, or modified present-centered therapy (I-MPCT). Each comprised of 11 assigned written narratives. The primary outcome was baseline-to-posttreatment change in PTSD symptoms on the PTSD Checklist for DSM-5 (PCL-5). Secondary measures included PTSD symptom clusters, depressive/anxiety symptoms, functioning, and quality of life.

A significant main effect of time was observed for the primary outcome (average large effect size improvement, d = 1.49). Significant and moderate-to-large main effects of time were also observed for all PTSD symptom clusters, depressive symptoms, quality of life, and mental health-related functioning (d range=0.62-1.33). Treatment and treatment-by-time interactions were not significant. In planned secondary analyses incorporating 3-month follow-up measures, ITT was associated with significantly greater reductions than I-MPCT in PTSD avoidance and negative alterations in cognitions and mood, anxiety, and mental health-related functioning.

Both therapies significantly lowered PTSD symptoms, suggesting they may benefit hard-to-reach individuals with chronic WTC-related PTSD symptoms.

Reference

Feder A, Kowalchyk ML, Brinkman HR, et al. Randomized controlled trial of two internet-based written therapies for world trade center workers and survivors with persistent PTSD symptoms. Psychiatry Res. 2024;336:115885.

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