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Full text of "WTC NYU Bellevue Clinical Center"

Langone Medical Center 



WTC Health Program 
NYUSOM Clinical Center of Exeelle 
at Bellevue Hospital Center * 



^e. 



Denise Harrison M.D. 
11-9-2011 



General Demographics 



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Gender 


Male = 81.2% \ 
Female = 18.8% 


Age Range 


28-86 


Mean Age 


48.9 


Language Spoken 


English = 92.2% 
Spanish = 7.8% 


Percentage of Mental 
Health Referrals 


30.2% 


Percentage Referred to 
Treatment Program 


33.1% 


Total Cohort 


2232 


Total Unique Patients in 
Treatment 


635 



Langone Medical Center 



Race/Ethnicity (N=2232) 

0.7%. 




□ White/Caucasian 

□ Black/African- American 

□ Asian/Pacific Islander 
■ Multiple/Mixed 

□ Other 



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Langone Medical Center 



Work Status (N=2232) 




Retired ■ Unemployed 



□ Disabled ■ Employed 



■ Have Insurance 
□ No Insurance 



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Langone Medical Center 



Occupations (N=2232) 



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1% 












0% 0%^ 




15% 


11% y 






3%_ 












8% 












3%. 






46%/ 






1%_ 












■ Construction 


D Law Enforcement 


■ Public Sector 




D Transportation 


D Healthcare 


■ Office/Professional 




■ Technical & Utilities 


□ C 1 e ani ng/M ai nte nance 


D Firefighter (FDNY) 




□ News A gene j 




D Federal Employee 


□ Other 





Langone Medical Center 



Percentages of Mental Health Symptoms (N^635) 



25.0% 



20.0% 



15.0% 



10.0% 



5.0% 



0.0% 




A 



& 



jA 



/? 



>r 



Sr 



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I Individual Symptoms 



I Co-Morbidity 



Langone Medical Center 



Percentages of Patients with Diagnoses (N=fc§5) 



50.0% 
40.0% 
30.0% 
20.0% 
10.0% 
0.0%) 



49.9% 




/ 



£ 



a t 



^ 



15.2° 



n 






& 






t 






£ 



10% 



i 



/ 



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Langone Medical Center 



Percentages of Patients with Cancer Diagnoses 




c «7 J& J& c «7 

£ £ # £ 

c? (J c? C? cf 

& 4° £ 3? & 

^ ° 






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Langone Medical Center 



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Treating Posttraumatic Stress 

Disorder in First Responders: 

A Systematic Review 

Peter T. Haugen and Mark Evces 

New York University 

WTC Health Program NYU Clinical Center of 

Excellence 

Daniel S. Weiss 
University of California, San Francisco 

Langone Medical Center 



Background 



First responders: 

• Paid professionals and volunteers responding to 
emergencies 

• High levels of work demands 

• Routine exposure to both physical and 
psychological stressors 

• Unique exposure recognized in revision to PTSD 
in upcoming DSM-5 

- A4: "Experiencing repeated or extreme exposure to aversive 
details of the events... e.g., first responders collecting body parts. 
[italics added]" 



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Langone Medical Center 



Psychiatric outcomes in fire 
responders 

• DepreSSiOn (e.g., Tak et al. 2007) 

• Somatic or psychosomatic complaints (e.g., 

Witteveen et al., 2006) 

• ChrOniC fatigue (e.g., Spinhoven & Verschuur, 2006) 

• DiffiCUltieS With alCOhOl (e.g., Stewart etal. 2004) 



Posttraumatic stress disorder 



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Langone Medical Center 



Prevalence of PTSD in first 
responders 

• No nationally representative, large scale 
studies 

• Variable rates: 

- 7-19% in active duty police officers (Maia et al. 

2007) 

- 46% in volunteer disaster workers responding 
to a disaster (Mitchell et al. 2004) 



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Langone Medical Center 



Estimating prevalence of PTSp in 
first responders 

• Military population as comparison group 

• National Vietnam Veterans' Readjustment 

SUrVey (Kulkaetal. 1990) 

- Nationally representative 

- Years post-exposure 

• ~15% full PTSD (Kulkaetal. 1990) 

• ~1 1% partial PTSD (weissetai.1992) 



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Langone Medical Center 



Prevalence of PTSD in first 
responders 

• 225,465 first responders with full PTSD 

- 15% x 1,503,100 

• 1 65,341 first responders with partial PTSD 

- 11% x 1,503,100 



,W WW, 



• ^ 



390,806 first responders nationally with 
full or partial PTSD 



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Langone Medical Center 



Goals of current systematic review 

• Conduct literature review of status of 
treatment outcome studies for PTSD in 
first responders 

- Psychosocial treatment 

- Pharmacological treatment 

- Combined psychosocial and pharmacological 
treatments 



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Langone Medical Center 



Study inclusion criteria 



Inclusion criteria 

- Psychological or 
pharmacological 
intervention was delivered 

- Subjects were first 
responders 

- Subjects had primary 
diagnosis of PTSD based 
on DSM or ICD criteria 

- PTSD diagnosis or 
symptom status was chief 
study outcome 



Psychosocial treatment 
studies 

- Compared two active 
treatment groups or one 
active group to a 
nonspecific control or wait- 
list group 

Pharmacological 
treatment studies 

- Compared drug treatment 
to placebo or active 
comparator 



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Langone Medical Center 



Literature Review Exclusion FlovihQhart 

Major Exclusion Criteria Were Not Mutually Exclusive 



Potential relevant 
articles: 
A/=845 



Articles excluded: n=21, Not in English 



Articles evaluated 

against criteria: 

n=824 



Articles excluded: n=807 

Not a treatment study: n=672 
Sample not first responders: n=629 
PTSD not primary outcome: n=479 



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Langone Medical Center 



Articles included in 

review: 

n=17 



Difede, J., Malta, L. S., Best, S. R., Henn-Haase, CTlM^tzler, T. J., 
Bryant, R. A., & Marmar, C. R. (2007). A randomized cohtcplled clini 
treatment trial for World Trade Center attack-related PTSljh^disasI 
workers. Journal of Nervous and Mental Disease, 195, 861-861 





Treatment Completers 




CBT(A/=7)Mean(SD) 


TAU(A/=14)Mean(SD) 






Pre 


Post 


Pre 


Post 


ES 


CAPS 


44.43(14.82) 


19.57 (15.93) b 


48.50(10.81) 


46.07 (20.77) 


1.37 


PCL 


37.71 (10.70) 


23.43 (4.12) b 


46.69(12.37) 


41.31 (12.99) c 


1.66 




Intent-to-Treat Sample 




CBT(A/=15)Mean(SD) 


TAU(A/=16)Mean(SD) 






Pre 


Post 


Pre 


Post 


ESa 


CAPS 


51.73(17.04) 


40.13 (25.52) b 


50.50(13.30) 


48.38 (21 .43) b 


— 


PCL 


38.31 (14.60) 


30.62 (15.14) b 


47.36(12.14) 


42.36 (13.08) b 


— 




CBT Group (A/= 6) Self-Report Measures at 3-Month Follow Up 


PCL 


24.83(5.91) 


a Posttreatment between-group effect sizes (Cohen's d) (Cohen, 1988) were calculated for significant findings and trends only, 
b, c Posttreatment means in the same row with superscripts that differ indicate significant differences, 
d Variable was nonnormally distributed. 



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Langone Medical Center 



Gersons, B. P. R., Carlier, I. V. E., Lamberts, R. D., S^V^n der Kolk, B. 
(2000). Randomized clinical trial of brief eclectic psychotherapy for po| 
officers with posttraumatic stress disorder. Journal of Traurhajic Stresl 
13,333-347. 



Criterion 


Baseline 


After 4 Treatment 
Sessions 


Posttest (End of 
Treatment) 


Follow-up 1 1 


No PTSD 
BEP (n= 22) 
Wait list {n= 20) 






31% 
35% 


91 
50** 


96 
35** 


<6 PTSD Symptoms 
BEP 
Wait list 






23% 
30% 


77 
15** 


91 
30** 


No Reexperiencing Symptoms 
BEP 
Wait list 






5% 
20% 


55 
15** 


68 
20** 


<3 Avoidance Symptoms 
BEP 
Wait list 






32% 
45% 


82 
60 


91 
40*** 


<2 Hyperarousal Symptoms 
BEP 
Wait list 






14% 
10% 


68 
20** 


68 
30* 


Resumption of Police Work 
BEP 
Wait list 


18 
25 


59% 
60% 


77 
70 


86 
60* 



^>K)i 



or Brief Eclectic Psychotherapy (BEP) and n = 20 for wait list 

Langone Medical Center 

001 



1 N= 1 9 for Wait List Control 



Summary 

-400,000 U.S. first responders with PTSD sympti 

845 articles;17 focus on treatment of first responded 
PTSD 

2 RCTs of psychosocial treatment 

RCTs of pharmacotherapy or combined treatment 

CBT and BEP treatments are examined 

Effect sizes are large 

Based on the studies identified, treatment guidelines 
are questionable 



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Langone Medical Center 



Barriers to treatment research 
with first responders 

• Duty status 

- Active-duty associated with lower levels of treatment 
referral and engagement 

• Stigma concerns 

- Negatively evaluated by peers and/or leadership (Hogeet 

al., 2004) 

• Changes in job status 

- Unsought, negative changes in job duties or reduced 
pay 

• Lack of academic institution affiliation 

- First responder organizations unaffiliated, unlike 
Veteran Administration Health System 



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Langone Medical Center 



Recommendations 

1 . Begin with treatments with strongest 
preliminary evidence for efficacy with first 
responders: CBT and BEP 

2. Psychosocial and pharmacological treatments 
identified in non-RCTs should be tested in 
RCTs 

3. Psychosocial and pharmacological treatments 
represented in current treatment guidelines for 
PTSD need to be studied 

- Especially those validated with active duty military personnel, 
subject group with many similarities to first responders 



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Langone Medical Center 



Recommendations 

• Focus on non-law enforcement populations 

- Majority of studies focus on law enforcement 

• Assess duty status as a potential moderator 
during- and post-treatmtent 

- Duty status is associated with exposure to traumatic 
stressors, which may complicate treatment and 
attenuate outcomes 



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Langone Medical Center 



Evaluation of Respiratory Synjpto 

In WTC Responders 

• Respiratory Symptoms Common Among 
WTC Responders 

• Cough, Dyspnea, Wheezing are common 
respiratory complaints. 

• Two groups : WTC responders with 
abnormal spirometry and WTC responders 
with symptoms and normal spirometry 



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Langone Medical Center 



Evaluation of Respiratory Synjpto 

In WTC Responders 

• Over 9000 WTC responders 72% have 
normal spirometry results despite 
respiratory symptoms. 

(Herbert etal EH P, 2006) 



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Langone Medical Center 



Evaluation of Respiratory Synjpto 

In WTC Responders 

Distal Airway Function in Symptomatic Subjects With Normal 

Spirometry Following WTC Dust Exposure. 
( Berger et al Chest 2007; 1 32:1 275-1 282) 

• Evaluated 1 74 subjects with respiratory symptoms and normal 
spirometry 

• Impedance Oscilometry was performed to determine resistance at 5 
Hz, 5-20 Hz and reactance area. 

• Forty Three patients were tested for frequency dependence of 
compliance. 

• Testing was repeating after brochodilation 



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Langone Medical Center 



Evaluation of Respiratory Synjpto 

In WTC Responders 

• Despite normal spirometry mean 
resistance at 5 , 5-20HZ and reactance 
area were elevated 

• Resistance and reactance normalized 
after bronchodilation. 



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Langone Medical Center 



Evaluation of Respiratory Synjpto 

In WTC Responders 

Conclusions 

Symptomatic Individuals with WTC dust 
exposure and normal spirometry displayed 
airway dysfunction based on the following. 

• Elevated airway resistance and frequency 
dependence of resistance determined by IOS 

• Heterogeneity of distal airway function 
demonstrated by elevated reactance area on 
oscilometry and FDC 



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Langone Medical Center 



Evaluation of Respiratory Syn^pto 

In WTC Responders 

• Reversibility of these functional abnormalities to or 
toward normal following administration of bronchodilator. 

• Since spirometry results were normal in all subjects 
these abnormalities likely reflect dysfunction in airways 
more distal to those evaluated by spirometry 

• Evaluation of distal airway when spirometry results are 
normal is important in evaluating 
occupational/environmental hazards 



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Langone Medical Center 



Evaluation of Respiratory Synjpto 

In WTC Responders 

Respiratory Symptoms Were associated 
with Lower Spirometry Results During the 
first Examinations of WTC Responders. 

(Udasin et al JOEM January 201 1 , Volume 83 Issue 
1 p49-54) 

• Looked at 1 8,685 responders with dyspnea wheezing 
and cough (wet and dry) 

• The mean FEV1 and FVC were lower for participants 
who reported persistent respiratory symptoms 



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Langone Medical Center 



Evaluation of Respiratory Synjpto 

In WTC Responders 

• Responders reporting respiratory 
symptoms also had larger bronchodilator 
response. 

Conclusion 

Responders reporting chronic persistent cough, 
wheezing or dyspnea at first medical 
examination were more likely to have lower lung 
function and brochodilator responsiveness 
compared to those without symptoms. 



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Langone Medical Center 



Conclusions 

Similar to most people with Occupational/Environment; 
Exposures WTC responders present medical conditions 
which may have diverse etiologies. 

This includes not just respiratory and mental health 
conditions but other disorders such as GERD and Sleep 
Apnea. 

This unique population allows for the study of multiple 
diagnostic and treatment modalities that can be applied 
to responders in future disasters. 



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Langone Medical Center