Remembering 9/11 and What We’ve Learned About Its Impact on Mental Health

Yuval Neria, PhD, was in Israel on 9/11 but he recalls the day with utter clarity. He had just flown from New York to Israel, his home, after finishing a postdoc at Columbia. But many people in his family were in still in the region.

Neria had studied war trauma and PTSD before 9/11, and after watching the events unfold on television and worrying about his family, he felt compelled to return to New York City and to focus his research on understanding the mental health impacts of the 9/11 trauma not only on first responders but New Yorkers in general.

9/11 changed Americans’ perceptions about their sense of security, the threat of terrorism, and their place in the world, and the attack’s impact on the mental health of New Yorkers was unprecedented. Hundreds of thousands of New Yorkers were affected because they were in Lower Manhattan at the time, knew people who died, or witnessed the towers fall from a distance and experienced the attack’s aftereffects on the city.

Neria returned to New York to take a position in Columbia’s Department of Psychiatry, where he is now professor of medical psychology and director of the PTSD Research Program.

We spoke with Neria about the legacy of 9/11 on the treatment of PTSD and trauma-related mental health issues.

What was different about 9/11 in terms of mental health responses?

Among people, particularly parents, who experienced the loss of a child on 9/11, I thought that there might be something very different about their response. Because of the enormity of the event, its unprecedent nature, its live transmission on TV, and because most bodies were not found, which could prevent a sense of closure for the bereaved.

We found that many bereaved family members developed unique kinds of emotional responses that should be addressed differently in treatment. By studying hundreds of 9/11 family members, we noticed a complicated phenotype of bereavement that is different from depression and different from PTSD.

When people lose intimates unexpectedly, in particular from malicious acts of violence, they are at high risk for chronic grief reactions. The reactions to loss by traumatic means is different from reactions to natural loss from disease or age, which can be very painful by itself.  

Until 9/11, those differences had not really been identified in the literature, and the 9/11 research, including our research, was an opportunity to do that and eventually an opportunity to tailor more targeted therapies to this problem.

Some of your research focused on immigrant and low-income groups. Were they more affected?

In the general population of New York City, we saw rates of mental health problems that arose right after 9/11 attacks really diminished over time.

In my own research, I wanted to examine whether such decrease in 9/11-related mental health problems was also true among high-risk groups. I wanted to understand the impact of 9/11 among the most vulnerable communities in New York City, namely minorities, immigrants, low-income, and undocumented, especially in Washington Heights and the Bronx, who are often forgotten and whose needs are ignored.

In these groups, I found that 9/11-related mental health problems did not decrease over time as rapidly and strongly as in the general population. In fact, in addition to the bereaved and first responders, large sub-groups in NYC, immigrant and undocumented persons are at particularly increased risk for PTSD and depression.

I think the research helped us identify, for the first time in the context of large-scale national trauma, that the emotional impact of 9/11 was long term, wide range, and debilitating among sizable urban, disadvantaged groups. The research also highlighted the unique contribution of previous trauma exposure and previous medical and mental health problems to the occurrence and course of current 9/11-related difficulties.

Because mental health resources, particularly those which are tailored to the specific needs of these groups, are very sparse, our 9/11 research may also inform needs of disadvantaged groups during COVID and social unrest. Colleagues at CUIMC have pioneered research of such groups and how to develop culturally sensitive approaches to address their mental health needs.

Many people are exposed to disasters via social media and TV. Interestingly, current COVID studies have shown that hyperexposure to social media is correlated with high anxiety and depression. Our own 9/11 research had unpacked this linkage by showing that exposure to trauma via the media is particularly harmful among those with a history of trauma and with previous mental health problems.

Did 9/11 change the way people are treated after traumatic events?

For years before 9/11, people deployed psychological debriefing for teams in the military, firefighters, or police. The idea was to bring together everyone in the team, regardless of their symptoms, and provide almost a group catharsis, in which everyone in the room shares their traumatic experience.

A number of studies found that this is not helpful and, in fact, in some people debriefing could make their mental health problems even bigger and more acute.

The debate about debriefing was happening before 9/11 but heated up because 9/11 affected so many people, particularly first responders, police, firefighters, and the military. That’s when practices started to change. The event made people more aware of the importance of providing different types of help for different needs.

Most people who experience trauma don't develop mental health problems. You don't need to give them some sort of preventative measure or treatment whatsoever. Yet, for those who are more symptomatic, anxious, or struggling with immense guilt, we need to develop ways to track their symptoms, and if they do not recover by themselves within the first several weeks, they will need timely trauma-informed treatments and perhaps medications provided by trained mental health professionals.

For those patients, a host of specific treatments, both psychotherapy and medication therapies, were developed since 9/11, and Columbia Psychiatry was certainly a major leader in this important effort. In particular, my lab has developed a host of brain imaging approaches to improve understanding of PTSD as a unique brain disorder, characterized by a host of brain signatures, and how to specifically address them in treatment.    

Are people still dealing with the mental health impacts of 9/11?

My lab conducted a review about five years ago of studies that looked at the long-term trajectories of PTSD in people exposed to 9/11. Most studies showed declining rates, though studies of rescue and recovery workers documented an increase over time, to almost 20% five to six years after the event.

But none of the studies assessed subjects over the really long term, 10 or 15 years. We Americans probably have less patience and resources to do such studies, and that's a bit unfortunate.

How does 9/11 compare with COVID?

COVID is very different from any threat of natural disaster, technological disaster, or terrorist event. The COVID threat is very diffused; there is no one epicenter. You can be infected anywhere, and the threat goes up and down. The sense of fear and psychological responses is very, very different.

Nevertheless, what we understood from 9/11 is that the effect of extreme stress is not limited to only one condition like PTSD. With COVID, like 9/11, you see effects on sleep habits, you may see an increase in consumption of alcohol and drugs, you can see both depression and PTSD, and, of course, you can see grief among those who lost loved ones.

So, what we understand is that people may deserve a more holistic kind of approach toward their needs.

Will the 20th anniversary reignite mental health issues in some?

With anniversaries of wars or disasters, it’s usually very difficult for those who suffered the most: the bereaved, the people with PTSD, the first responders whose lives were changed forever.

Exposure to trauma alters memory processes.  Though we are not great at remembering positive events in our lives—those are taken for granted—negative events are better remembered, in much greater detail, and their influence in our brains is greater.

PTSD is unique by being a memory disorder. It’s about hyperremembering, to a great detail, events that happened years ago. Our memory is stuck in a certain day, and in a certain space, and it comes with its own reminders that are linked to strong emotions. An anniversary is a powerful reminder, because it brings us back to the richness of such memories coupled with strong emotions, such as pain, guilt, and fear.

On the other hand, because of the presence of COVID in our current lives, with its own set of memories and emotions, I’m not sure the 20th anniversary will have the same impact. The COVID pandemic is a large-scale global event, which left a lot of damage in NYC: It has been stressful to all, traumatizing to many, and has cost so many lives already.

Yet my key observation about 9/11, 20 years ago, and now COVID is that as a nation, as a collective group of people, we have been changed quite a bit. We don’t enjoy anymore a sense of seclusion and invincibility, and as a nation America has transformed to become more hypervigilant and easily startled. Time will tell whether 9/11 and COVID changed our lives forever.