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A 3-Year National Study Following the September 11th Attacks

E. Alison Holman, FNP, PhD; Roxane Cohen Silver, PhD; Michael Poulin, PhD; Judith Andersen, PhD; Virginia Gil-Rivas, PhD; Daniel N. McIntosh, PhD

Arch Gen Psychiatry. 2008;65(1):73-80.

Context  The terrorist attacks of 9/11 (September 11, 2001) present an unusual opportunity to examine prospectively the physical health impact of extreme stress in a national sample.

Objective  To examine the degree to which acute stress reactions to the 9/11 terrorist attacks predict cardiovascular outcomes in a national probability sample over the subsequent 3 years.

Design, Setting, and Participants  A national probability sample of 2729 adults (78.1% participation rate), 95.0% of whom had completed a health survey before 9/11 (final health sample, 2592), completed a Web-based assessment of acute stress responses approximately 9 to 14 days after the terrorist attacks. Follow-up health surveys reassessed physician-diagnosed cardiovascular ailments 1 (n = 1923, 84.3% participation rate), 2 (n = 1576, 74.2% participation rate), and 3 (n = 1950, 78.9% participation rate) years following the attacks.

Main Outcome Measures  Reports of physician-diagnosed cardiovascular ailments over the 3 years following the attacks.

Results  Acute stress responses to the 9/11 attacks were associated with a 53% increased incidence of cardiovascular ailments over the 3 subsequent years, even after adjusting for pre-9/11 cardiovascular and mental health status, degree of exposure to the attacks, cardiovascular risk factors (ie, smoking, body mass index, and number of endocrine ailments), total number of physical health ailments, somatization, and demographics. Individuals reporting high levels of acute stress immediately following the attacks reported an increased incidence of physician-diagnosed hypertension (rate ratios, 2.15 at 1 year and 1.75 at 2 years) and heart problems (rate ratios, 2.98 at 1 year and 3.12 at 2 years) over 2 years. Among individuals reporting ongoing worry about terrorism post-9/11, high 9/11-related acute stress symptoms predicted increased risk of physician-diagnosed heart problems 2 to 3 years following the attacks (rate ratios, 4.67 at 2 years and 3.22 at 3 years).

Conclusion  Using health data collected before 9/11 as a baseline, acute stress response to the terrorist attacks predicted increased reports of physician-diagnosed cardiovascular ailments over 3 years following the attacks.

Author Affiliations: Program in Nursing Science (Dr Holman) and Departments of Psychology and Social Behavior and Medicine (Dr Silver), University of California, Irvine; Center for Behavioral and Decision Sciences in Medicine, University of Michigan, Ann Arbor (Dr Poulin); Department of Veterans Affairs Medical Center, Syracuse, New York (Dr Andersen); and Departments of Psychology, University of North Carolina, Charlotte (Dr Gil-Rivas), and University of Denver, Denver, Colorado (Dr McIntosh).

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