Extended Mental Health Service Utilization Among Survivors of the Oklahoma City Bombing

Of 182 survivors first studied at six months (1), 99 who were directly exposed survivors of the Oklahoma City bombing responded to questions about mental health utilization at the seven-year assessment. There were no significant differences between the seven-year sample and the index study participants in gender, age, injuries, or psychiatric disorders. Additional details of the methods of the seven-year follow-up study are available in a previous publication (3).

The Washington University School of Medicine and University of Oklahoma Health Sciences Center Institutional Review Boards approved the index and follow-up studies. All participants provided written informed consent before participating and were offered $50 for their time and effort in completing the comprehensive assessment.

Variables of interest to this analysis were demographic characteristics, bombing injuries, hospitalization for bombing injuries, postdisaster psychiatric disorders, utilization of mental health services, and psychotropic medication use. The Diagnostic Interview Schedule for DSM-IV (DIS-IV) (8) assessed psychiatric disorders, and the Disaster Supplement provided data on other variables of interest (9). Diagnoses considered in this study were bombing-related PTSD and postdisaster major depression occurring at any time in the seven years after the bombing.

Participants were asked if they had sought any of several types of mental health care for problems with drugs, alcohol, or emotions resulting from the bombing, including psychological debriefing (group and individual sessions), support groups such as cosurvivor support groups or other established support groups (for example, Alcoholics Anonymous), counseling services from religious leaders (pastors, ministers, chaplains, rabbis, or priests), and mental health treatment by psychiatrists, family doctors, and nonphysician mental health professionals. Nonphysician mental health professionals were not identified by level of training or clinical experience. For each service received, the interval between the bombing and the time of first service receipt after the disaster and duration of the service were queried.

Descriptive statistics were reported, and chi square tests were used to explore associations among dichotomous variables of interest (2 × 2 contingency tables), with Fisher’s exact test substituted for cases with expected cell sizes less than five. Statistical analysis was conducted with SAS, version 9.2. The significance level was set at p<.05.

Time-insensitive demographic variables—sex, and injury and hospitalization caused by the bombing—were taken from the index study assessment. Time-sensitive age and education variables were constructed from the seven-year follow-up assessment data. Bombing-related PTSD and major depression occurring at any time after the bombing were measured by combining diagnostic data from all three assessments.

To explore service utilization after the bombing, we examined the interval between the bombing and the time of first use of mental health services and the duration of those services. We calculated service use patterns adapting first-order forward and backward Markov chain methods with data from all three assessments. [These methods are described in an online data supplement to this report.]

The 99 respondents in the sample for this analysis included 47 women and 52 men, with mean age of 49.3±9.8 years (range 26–70 years). Of these 99 directly exposed survivors, 85 (86%) received mental health services during the seven-year postdisaster period. The 14 survivors who did not receive services identified the following reasons: thinking that they did not need services, wanting to handle problems themselves, not knowing where to get help, and taking other actions. Bombing-related injuries were sustained by 86 (86%), and 21 (21%) were hospitalized for injuries. Nineteen (19%) had a current PTSD diagnosis, and ten (10%) had a current diagnosis of depression. At any time after the bombing, 42 (42%) had a diagnosis of bombing-related PTSD, and 42 (42%) had a diagnosis of major depression.

Of the 99 survivors who reported receiving some form of mental health services, the most common was psychological debriefing. Table 1 summarizes data on mental health service use patterns by survivors’ demographic characteristics. [Two tables in the online data supplement provide summaries by injury status and by presence of psychiatric disorders.] Participation in debriefing was associated with being injured in the bombing. Compared with other diagnostic groups, a larger proportion of those with bombing-related PTSD or postdisaster major depression used support groups. Most survivors with bombing-related PTSD (N=41, 98%) and postdisaster major depression (N=40, 95%) received some type of mental health services.

Psychiatrists treated 50% (N=21) of survivors with bombing-related PTSD and 48% (N=22) of those with postdisaster major depression. Nonpsychiatric mental health professionals treated 79% (N=33) of survivors with bombing-related PTSD and 79% (N=33) of those with postdisaster major depression. Survivors who received mental health treatment from any mental health professional or religious leader were more likely to be female and a college graduate and to have bombing-related injuries and PTSD or postdisaster major depression. Although 36% (N=36) of the survivors received mental health treatment from a family physician, these services were associated with bombing-related injuries and not with postdisaster psychiatric disorders.

Most respondents who received mental health services first received these interventions within two weeks of the bombing, most commonly debriefing and support groups. Survivors received debriefing only within the first six months. Some individuals received more than one type of intervention. After the first two weeks, care by family doctors, psychiatrists, and other mental health professionals increased over time. Treatment initiation was delayed for more than a year by six individuals who eventually saw psychiatrists and two who eventually consulted other mental health professionals. Duration of service use from various sources was longer than one year for 38% (N=33) of survivors who received services (N=87). Only 8% (N=7) of those receiving services reported that they were still receiving mental health treatment seven years after the bombing. [Tables in the online data supplement present additional data about time and duration of service use.]

Fifteen survivors reported taking psychotropic medications at some time during the seven-year follow-up period as a result of being upset by the bombing. These included selective serotonin reuptake-inhibitors for ten, an unknown antidepressant or other psychotropic for two, benzodiazepines for two, and sleeping pills for one. Use of an illicit drug was reported by one of the survivors.

In this sample of 99 directly exposed survivors of the Oklahoma City bombing, the vast majority (86%) received mental health interventions during the seven years after the bombing, with service use declining and changing in type over time. Informal interventions (debriefings, support groups, and assistance from clergy) represented most of the services used in the first two weeks—before PTSD and major depression can be diagnosed—at a time when services were abundant and public and professional attention was heightened. Use of more formal treatments occurred later. Most mental health service use occurred in the first year and was usually of finite duration. Few survivors were still receiving services at seven years.

Over half the survivors received debriefing, all within the first six months, consistent with the popularity at the time of debriefing interventions after disasters. Debriefing appears to have been a generic crisis intervention, not preferentially used by those with bombing-related PTSD or major depression, for whom more formal mental health interventions may be warranted.

Many survivors also received formal treatment from psychiatrists, other mental health professionals, and family doctors, but these services tended to begin later than the crisis interventions and usually ended before seven years postdisaster. The vast majority of those with postdisaster major depression (95%) and bombing-related PTSD (98%) received some type of mental health service, consistent with research demonstrating that individuals with PTSD are likely to access general medical or mental health services (10). More than three-fourths of the individuals with psychiatric disorders received interventions from nonphysician mental health professionals, whose level of training was not identified and may have varied considerably.

Despite their high rates of mental health utilization, only about only half the individuals with bombing-related PTSD or postdisaster major depression saw a psychiatrist. Although their reasons for not seeking treatment from a psychiatrist are unknown, other studies have identified many factors associated with traumatized individuals’ nonutilization of treatment from psychiatrists, such as avoidance symptoms of PTSD and resource constraints (11–13). Also, in this study, although 42% of survivors had bombing-related PTSD and 42% had postdisaster major depression during the seven-year follow-up period, only about half of either group saw a psychiatrist and only 15% of all respondents reported taking psychotropic medications for bombing-related problems at some time during the seven-year period. Both PTSD and major depression can be chronic and debilitating conditions (14), and given the chronicity of illness (3) and high rate of comorbid mental disorders (1) previously noted in our sample, treatment from a psychiatrist and psychotropic medication might have been appropriate for many more. The question raised by our study is how can disaster response efforts best identify the need for formal mental health treatments for people with mental disorders or who are most distressed? An empirically based disaster mental health training program developed by North and colleagues (15) addresses this issue, guiding professionals through disaster mental health assessment and the selection of interventions appropriate to identified needs.

In this study, receiving services of any kind was associated with female sex, injury and hospitalization for bombing injuries, and bombing-related PTSD and postdisaster major depression. Thus, in planning long-range mental health assistance after terrorism, resources will be disproportionately needed by women, the more severely exposed, and those with postdisaster psychiatric disorders. The data showed that in the short term, before disaster-related PTSD (four weeks) and incident cases of major depression (two weeks) can be diagnosed, informal interventions such as support or debriefing groups and religious counseling were highly utilized. Because a wide variety of mental health interventions was used by these survivors, future disaster planning should include diverse interventions with adjustments over time to accommodate the changing needs and preferences of survivors.

Limitations of this study include attrition: 182 individuals were in the index sample, and 99 (54%) were in the seven-year follow-up sample. If attrition was based on psychopathology or service use, then attrition of approximately one-third of the original sample may have led to underestimation of psychopathology or of utilization of mental health services (3). We did not assess service needs associated with psychiatric disorders other than PTSD and major depression, and we did not assess timing, duration, or doses of psychotropic medication. Because more than five years passed between the 17-month and seven-year follow-ups, participants may not have accurately recalled all treatment received and its timing. Finally, we did not examine the effectiveness of mental health interventions received.

Despite these limitations, our study is a unique, systematic investigation of long-term mental health needs and service utilization by individuals who were directly exposed to a major terrorist event. Results suggest that service needs are intense initially but that utilization may be expected to diminish over time (i.e., seven years). Reasons for this attrition are unclear; survivors may either improve with treatments or the passage of time or simply stop seeking help. In particular, survivors’ use of various mental health interventions, including informal types such as crisis intervention and support groups, in the first year after disaster and their continued use of more formal interventions beyond one year suggest the need for diverse interventions. Ensuring mental health delivery systems that provide seamless access to long-term care is especially important for those most severely exposed, those diagnosed as having PTSD or major depression after a disaster, and women.

This work was supported by award MIPT106-113-2000-020 from the Oklahoma City National Memorial Institute for Prevention of Terrorism (MIPT) and the Office of Justice Programs, National Institute of Justice, U.S. Department of Justice (DOJ) to Dr. Pfefferbaum and by grants MH40025 and MH68853 from the National Institute of Mental Health (NIMH) awarded to Dr. North. The views expressed are those of the authors and do not necessarily represent the official position of the MIPT, DOJ, NIMH, U.S. Department of Veterans Affairs, or U.S. government.

The authors report no competing interests.