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|Impact of
      September 11, 2001 Events onSubstance
      Abuse and Mental Health in the New York Area

# 1.  Introduction

## 1.1	Background

How a person's behavior changes following a major traumatic event, such as a natural disaster or a terrorist attack, has been examined in a number of studies.  These include the 1995 Oklahoma City bombing that killed 168 people (North et al., 1999); Hurricane Andrew, which killed 60 people and led to the evacuation of 2 million from their south Florida homes in 1992 (Perilla, Norris, & Lavizzo, 2002); and the 1994 Northridge earthquake near Los Angeles, which killed 57 people, injured 9,000, and displaced 20,000 from their homes (McMillen, North, & Smith, 2000).  Research efforts have primarily centered on examining the development of posttraumatic stress disorder (PTSD) among individuals who have been directly impacted by a major traumatic event.  PTSD may develop in the weeks and months following a traumatic event and is primarily diagnosed on the basis of reliving the traumatic episode, avoiding situations or people that may be reminders of the event, and developing arousal symptoms (e.g., difficulty sleeping, exaggerated startle response, and hypervigilance).  Findings from a recently released study show a higher than expected prevalence of PTSD and depression among Manhattan residents 6 to 8 weeks following the September 11, 2001 terrorist attacks on the Pentagon and New York's World Trade Center (National Institute on Drug Abuse [NIDA], 2002).

However, PTSD may not be the only problem to appear in reaction to a traumatic event. Substance use and other mental health problems may have increased since the September 11 attacks. Recent research has suggested that PTSD rarely occurs in isolation, with the most frequent comorbid diagnoses being depression and substance use disorders (McFarlane, 1998; North et al., 1999).  Individuals may experience increased stress, which in turn may lead to self-medication with various licit and illicit drugs.  Chronic stress can have such effects as impaired memory, increased craving, relapse to substance abuse, depression, anxiety, and sleep difficulties.

The September 11 attacks may have broad and far-reaching implications.  Some people feel additional stress because of the loss of life and the possibility of future attacks, which may increase the incidence of PTSD and negative coping behaviors, such as substance abuse. Health care providers and government officials may experience these consequences as an increased need for mental health and substance abuse services.  Increased sales of anti-anxiety drugs, antidepressants, and sleep aids were reported following the Oklahoma City bombing (North et al., 1999).  A recent survey of offices responsible for substance abuse services in the 50 States and the Nation's 10 largest cities found that 23 States and 6 cities reported an increase in the demand for alcohol and drug treatment services since September 11 (National Center on Addiction and Substance Abuse at Columbia University, 2002).  A random telephone survey of 988 Manhattan residents, conducted in late October and early November 2001 following the attacks, found that about one in every four respondents (28.8 percent) had increased alcohol, cigarette, or marijuana use since the attacks (Vlahov et al., 2002).  A second study conducted 1 to 2 months following the attacks found the prevalence of probable PTSD was significantly higher in the New York City metropolitan area than in Washington, DC, other major metropolitan areas, and the rest of the country.  However, overall distress levels across the country were within normal ranges (Schlenger et al., 2002).

However, the findings of these studies of the impact of September 11 events are limited by reliance on the recall of individuals about their behaviors before and after the events.  To understand the consequences of significant, unexpected events, it is important to have information about behaviors both before and after the event.  Fortunately, the National Household Survey on Drug Abuse (NHSDA) can provide this kind of information on substance use, mental health problems, treatment for mental health and substance abuse problems, and other relevant behaviors for New York City (NYC) and the New York Consolidated Metropolitan Statistical Area (NY CMSA).

The NHSDA, which is supported by the Substance Abuse and Mental Health Services Administration (SAMHSA), is the primary source of information on the prevalence and incidence of substance use and abuse in the United States.  A version of the survey is fielded every year, and the survey collects information during the entire calendar year.  In 1999, the NHSDA was expanded to include a sample of respondents from every State.  The eight largest States, including New York, have the largest sampleson average about 3,600 respondents each year.

Because of this design, the NHSDA can shed new light on how substance use and mental health may have been affected by the terrorist attacks on September�11.  This disaster occurred near the end of the third quarter of data collection in the NHSDA.  By that date, the survey had completed approximately 2,600 interviews in the NY CMSA.  The results from those interviews can be compared with information obtained from interviews conducted during the fourth quarter. Before the events occurred, the project planned to interview 800 persons in the NY CMSA during the fourth quarter.  The fourth quarter sample was increased to 1,400 respondents after September 11 to support comparisons with the findings from the first part of the year.  It is also possible to compare information from the 2001 NHSDA with information collected in the 2000 NHSDA.  Among other things, this comparison provides a basis for adjusting the 2001 data for seasonal effects.

## 1.2	Summary of the NHSDA Methodology

Conducted by the Federal government since 1971, the NHSDA collects data by administering questionnaires to a representative sample of the population through face-to-face interviews at their place of residence.  This section briefly describes the survey methodology.  A more complete description is provided in ***Appendix A***.

The NHSDA collects information from residents of households, noninstitutional group quarters (e.g., shelters, rooming houses, dormitories), and civilians living on military bases. Persons excluded from the survey include homeless people who do not use shelters, active military personnel, and residents of institutional group quarters, such as jails and hospitals.

Since 1999, the NHSDA has been carried out using a computer-assisted interviewing (CAI) methodology.  The survey uses a combination of computer-assisted personal interviewing (CAPI) conducted by the interviewer and audio computer-assisted self-interviewing (ACASI). Use of ACASI is designed to increase the privacy of the interview and seems to increase the level of honesty in the reporting of illicit drug use and other sensitive behaviors.

Both the 2000 and 2001 samples employed a 50-State design with an independent, multistage area probability sample for each of the States and the District of Columbia.  The eight States with the largest populations (which together account for 48 percent of the total U.S. population aged 12 or older) were designated as large sample States (California, Florida, Illinois, Michigan, New York, Ohio, Pennsylvania, and Texas).  For these States, the design provided a sample large enough to support direct State estimates.  For the remaining 42 States and the District of Columbia, smaller, but adequate, samples were selected to support State estimates using small area estimation (SAE) techniques.  The design also oversamples youth and young adults so that each State's sample is approximately equally distributed among three major age categories: 12-17 years, 18-25 years, and 26 years or older.  To enhance the precision of trend measurements, half the first-stage sampling units, or area segments, in each survey are included in the subsequent survey.  However, all households included in the sample each year are new.

The geographic areas discussed in the report include NYC, the NY CMSA, and the combined CMSAs of Los Angeles, Detroit, and Chicago, hereafter referred to as the C-CMSA.  ***Figure 1*** is a map showing the New York areas included in the study.  In the 2001 NHSDA, the NYC sample size was 1,688.  The NY CMSA sample, which includes NYC, was 4,113.  The C-CMSA sample was 6,132.  ***Table 1*** shows the distribution of the sample by quarter and year.  ***Table 2*** provides a distribution of the sample by age and by area for the years 2000 and 2001. For details on the NYC sample, the NY CMSA sample, and the C-CMSA sample, see ***Appendix B.***





### **Figure 1	New York City and the New York Consolidated Metropolitan Statistical Area (CMSA)**

**D**





|Table 1 Sample Sizes for New York City and Selected Geographic Areas, by Quarter: 2000 and 2001                                                                                                                                                                                                 
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
|
|
|2000                                                                                                                                                                                                                                                                                            
|Quarter 1                                                                                                                                                                                                                                                                                       
|Quarter 2                                                                                                                                                                                                                                                                                       
|Quarter 3                                                                                                                                                                                                                                                                                       
|Quarter 4                                                                                                                                                                                                                                                                                       
|Total                                                                                                                                                                                                                                                                                           
|2001                                                                                                                                                                                                                                                                                            
|Quarter 1                                                                                                                                                                                                                                                                                       
|Quarter 2                                                                                                                                                                                                                                                                                       
|Quarter 3                                                                                                                                                                                                                                                                                       
|Quarter 4                                                                                                                                                                                                                                                                                       
|Total                                                                                                                                                                                                                                                                                           
|NYC = New York City.
		NY CMSA = New York Consolidated Metropolitan Statistical Area.
		C-CMSA = Combined Consolidated Metropolitan Statistical Areas of Los Angeles, Detroit, and Chicago.
		Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 2000 and 2001.





|Table 2	Sample Sizes for New York City and Selected Geographic Areas, by Age Group and Time Period:  2000 and 2001                                                                                                                                                                              
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
|
|
|2000                                                                                                                                                                                                                                                                                            
|Quarters 1-3                                                                                                                                                                                                                                                                                    
|                                                                                                                                                                                                                                                                                                
|Quarter 4                                                                                                                                                                                                                                                                                       
|                                                                                                                                                                                                                                                                                                
|2001                                                                                                                                                                                                                                                                                            
|Quarters 1-3                                                                                                                                                                                                                                                                                    
|                                                                                                                                                                                                                                                                                                
|Quarter 4                                                                                                                                                                                                                                                                                       
|                                                                                                                                                                                                                                                                                                
|NYC = New York City.
		NY CMSA = New York Consolidated Metropolitan Statistical Area.
		C-CMSA = Combined Consolidated Metropolitan Statistical Areas of Los Angeles, Detroit, and Chicago.
		Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 2000 and 2001.

## 1.3 Format of Report and Explanation of Tables

The following chapters compare specific aspects of behavior associated with substance use and mental health within and between geographical areas.  The topic areas include substance use and treatment (Chapter 2), mental health problems and treatment (Chapter 3), and religiosity (Chapter 4).  Data on some measures are available only for the year 2001 because the survey did not collect them in 2000.  The appendices contain technical details about the survey methodology, the geographical areas, statistical methods and limitations of the data, mental health treatment variable specifications, and detailed prevalence and standard error tables.

The text, figures, and tables present prevalence measures for each topic by geographic area.  The estimates for illicit drug, alcohol, and cigarette use are discussed in terms of past month use as well as frequency of use (e.g., among smokers, the mean number of days cigarettes were smoked during the past month) and quantity of use (e.g., among drinkers, the mean number of drinks consumed per day during the past month).  For discussions of substance abuse treatment, estimates center on current, past month, and past year service utilization, while mental health treatment focuses on past year service utilization.  The section on mental health problems focuses on the prevalence of psychological distress and treatment.  The section on religiosity addresses the perceived importance of religion for respondents.  Statistical methods and limitations of the data are described in ***Appendix C***.  Information about construction of distress and disorder variables is discussed in ***Appendix D***.  Figures are shown in the text to highlight key findings, and detailed tables are shown in ***Appendix E***.

Data for illicit drug, alcohol, and cigarette use; substance abuse treatment; mental health treatment; and religiosity are generally presented for persons aged 12 or older or aged 18 or older.  When warranted, prevalence estimates for persons aged 12 to 17 are discussed.  The discussion of mental health problems, however, is limited to those aged 18 or older because this information was not collected from youths aged 12 to 17.  Gender differences are also summarized across these topics when justified.

The reporting of results is based on statistical hypothesis testing that focuses on the comparison of estimates from the first three quarters of 2001 with estimates from the fourth quarter of 2001.  These simple trend analyses are done for each of the three areas of interest (NYC, NY CMSA, and C-CMSA).  Statistically significant results are indicated with an "a" on ***Tables E.1 to E.15*** in ***Appendix E***.  A second set of tests incorporated the 2000 data and assessed whether the trend within 2001 was different from the trend that had been observed in 2000. These tests provide a crude seasonal adjustment for the pre- versus post-September 11 comparison.  Significant results for the seasonally adjusted tests are indicated with a "b" on ***Tables E.1 to E.15***.  A third set of tests assessed whether the trends in NYC and the NY CMSA were different from the trends in the C-CMSA.  Significant results for these tests are indicated with an "a" on ***Tables E.16 to E.25***.  A final test that compares trends in NYC and the NY CMSA with trends in the C-CMSA with a seasonal adjustment was also done ("b" on ***Tables E.16 to E.25***), but these tests are not discussed in the report.  Details of these comparisons and statistical tests are provided in ***Appendix C***.



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|This page was last updated on May 10, 2003.SAMHSA, an agency in the Department of Health and Human Services, is
        the Federal Government's lead agency for improving the quality and
        availability of substance abuse prevention, addiction treatment, and
        mental health services in the United
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