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August 2006Vol. 25(7):47–58CCLLIINNIICCAALLGGUUIIDDEELLIINNEESS FFOORRAADDUULLTTSSEEXXPPOOSSEEDDTTOO TTHHEEWWOORRLLDDTTRRAADDEECCEENNTTEERRDDIISSAASSTTEERR•Five years after the World Trade Center (WTC) attack, many New Yorkers continue to suffer disaster-associated physical and mental health conditions. • Primary care providers should ask patients about WTC exposure, especially patients with respiratory symptoms, reflux disease, mental health problems, or substance use disorders.• Providers should know how to identify, evaluate, treat, and refer patients with conditions thatcould be associated with exposure to the disaster. • Because physical and mental health conditions are often intertwined, a coordinated approachto care usually works best and referral may be necessary. The World Trade Center (WTC) terrorist attackand its aftermath exposed hundreds of thou-sands of people to debris, dust, smoke, andfumes. Studies conducted after September 11, 2001,among rescue and clean-up workers,1-4office work-ers,5building evacuees,6and residents of lowerManhattan7-9showed an increase in respiratory andother physical and mental health problems, includingpost-traumatic stress disorder. Many New Yorkers have health problems that couldbe associated with – or made worse by – exposure tothe attack and its aftermath. Primary care physiciansneed to know how to identify, evaluate, treat, and ifnecessary, refer these individuals to expert care.This publication suggests how clinicians can take a brief exposure history and describes commonhealth problems that could be caused orexacerbated by exposure to the disaster. It offers algorithms to evaluate and care for exposed individuals, andprovides brief tools to assess andtreat physical and mental health disorders. Resourcesare also featured, including information about free (or need-based) treatment programs that may benefitWTC-exposed individuals (Resources).While these recommendations are targeted to adults,some principles and diagnostic methods may be appli-cable to children and adolescents. Consult appropriateresources such as the American Academy of Pediatricsfor general (non-WTC-specific) pediatric guidelines(Resources).

48 CITY HEALTH INFORMATION August 2006EXPOSURES AND POTENTIAL HEALTH EFFECTSPhysical ExposuresThe collapse and burning of the WTC and neighboringbuildings released a complex mixture of irritant dust, smoke,and gaseous materials. Pulverized concrete, glass, plastic,paper, and wood produced alkaline dust. The dust cloud alsocontained heavy metals, as well as asbestos and othersubstances that may be carcinogenic. In addition, smokereleased from the persistent fires in the months that followedalso contained hazardous and potentially carcinogenicsubstances.Environmental test results showed that the composition ofdust and smoke released into the air and deposited on indoorand outdoor surfaces varied by date and location.10Individual exposure to contaminants was determined byduration, site, activities, and use of appropriate protectiveequipment. Health effects related to these exposures may alsovary, depending on the intensity and duration of exposure aswell as on underlying medical conditions, tobacco use, andindividual susceptibility. Although heavy metals were detected in the air and dust,clinical tests performed on specimens from more than 10,000firefighters showed no clinically significant concentrations ofmercury, lead, or beryllium.11Heavy metals are usually clearedfrom the blood and urine within months of exposure.Mental Health ImplicationsFor many New Yorkers, the trauma of September 11thtriggered or exacerbated depression, anxiety, or substanceuse disorders.12,13Many survivors witnessed the death of friends and co-workers;thousands lost family members in the attacks. In the wake of the disaster, rescue, recovery, and other workers andvolunteers, as well as residents, office workers, and studentsin downtown Manhattan were subjected to daily stress formonths.14-16Serious psychological distress was documented 2 or 3 years later among many survivors of collapsed ordamaged buildings.6IDENTIFYING WTC-RELATED CHRONICMEDICAL CONDITIONSWhen assessing for WTC-related disease, clinicians shouldconsider:• Direct exposure to the cloud of debris and dust released bythe collapse of the towers;• Duration, type, and intensity of exposure to dust, smoke,and fumes in the days and months after the disaster;• Whether onset of symptoms occurred after, but within plau-sible proximity to, WTC pollutant or trauma exposure.While the dust, smoke, and fumes caused by the disasterextended beyond lower Manhattan, the heaviest exposuresoccurred in the immediate vicinity of the attacks. Most individuals who developed respiratory illness did sowithin 6 months of exposure to the disaster site. For others,symptom onset was gradual, occurring a year or more afterexposure. Because individuals have different levels of tolerance, theintensity of symptoms may not be directly proportional toexposure.Other risk factors for WTC-associated illness may be identifiedin the future. Providers should monitor the literature as moreinformation about WTC-related diseases becomes available. Table 1. Key Occupational and ResidentialExposure History QuestionsAsk: “Were you exposed to the World Trade Center disaster?”If patient answers yes, ask further questions regarding thenature and duration of exposure, such as:1) Were you showered by the cloud of debris and dustwhen the towers collapsed? 2) Were you in Manhattan on the streets near the WorldTrade Center at the time of the impact of the planes, thecollapse of the towers, or shortly afterwards?3) Did you work or volunteer at the World Trade Center siteproviding rescue and recovery, cleanup, construction, orsupport services, or at the World Trade Center RecoveryOperation on Staten Island or on a barge? What tasksdid you perform? Did you consistently use a respirator? If so, describe what kind.4) If you lived, worked, volunteered, or attended school inlower Manhattan in the months after September 11th,what was the condition of your home, work, or school?5) Are there other WTC-related exposures that concern you?Possible Exposure ScenariosExamples of possible exposure scenarios include, butare not limited to, the following:• Being caught in the dust cloud on 9/11• Working on the pile, dismantling damaged building structures in the surrounding rubble, or handling WTCdebris without adequate protection• Cleaning affected commercial and residential buildings in lower Manhattan• Cleaning or reoccupying homes covered in dust• Being exposed to high levels of dust or smoke while restoring services in lower Manhattan

Vol. 25 No. 7 NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE 49PHYSICAL HEALTH CONDITIONS The physical health problems discussed in this publication arecommon and may not be WTC-related even among personsexposed to the disaster. The algorithm (Figure 1, see infold) andtreatment options offered here are applicable regardless of thecause of illness.Evaluate the patient for WTC exposure (Table 1). Inhalationand ingestion of WTC dust and fumes may have caused new ill-ness or exacerbated preexisting conditions (Table 2). The mech-anism may be an irritant-induced process in which symptomspersist due to inflammation in addition to the initial exposure.17Develop a diagnosis and treatment plan that covers upper air-way, lower airway, and reflux disease.18,19Symptoms may bedue to multiple causes; combination treatment may be useful.Continue treatments even if only partially effective.18Alwaysevaluate the patient’s adherence to the treatment regimenbefore altering it. Assess the patient’s ongoing environmental and occupational exposures and counsel accordingly. A briefreview of the diagnosis and treatment of the most commonlyassociated conditions follows.Upper airway cough syndrome (UACS)Upper airway cough syndrome (UACS), formerly termed post-nasal drip syndrome, is commonly caused by chronic rhino-sinusitis and rhinitis (allergic and irritant-induced). Improvementor resolution of cough in response to treatment is a key factor inconfirming the diagnosis. Symptoms: cough, nasal congestion, postnasal drip, frequentneed to clear the throatSigns: mucus in the oropharynx, cobblestone appearance ofthe oropharyngeal mucosaDiagnostic evaluation: history, physical, and response toempiric treatmentTreatment: See Table 3. Specific signs and symptoms of the 2 main causes of UACS(chronic rhino-sinusitis and rhinitis) are described on page 50.Table 2. Potentially WTC-AssociatedConditions Inhalation or ingestion of WTC dust and fumes affectedthe mucous membranes of the nose, sinuses, pharynx,gastrointestinal (GI) tract, and respiratory tract. The symptoms and signs of these conditions include:• Sinus, nasal, and postnasal congestion• Heartburn, hoarseness, and throat irritation• Shortness of breath and wheezing• Chronic coughSome clinicians have described a syndrome consisting of a triad that is typified by:• Upper airway cough syndrome (postnasal drip syndrome)• Asthma/reactive airways dysfunction syndrome (RADS)• Gastroesophageal reflux disease (GERD)/laryngopharyn-geal reflux disease (LPRD)Table 3. Treatment of upper airway cough syndrome (UACS) (including chronic rhino-sinusitis, and rhinitis*) • Daily nasal saline spray or irrigation/lavage with or without both antihistimines (eg, loratidine) and oral decongestants (eg, phenylephrine,†) for 5 to 7 days‡• Topical decongestants (eg, oxymetazoline†) for a maximum of 3 days if severe mucosal swelling is noted• Nasal steroids (eg, budesodine†) if nasal and throat symptoms persist or increase after therapy with lavage and decongestants aloneNasal steroid therapy must be continued for at least 2 weeks before any clinical improvement will be noted.If symptoms improve, therapy should be continued for 2 to 3 months.• Be alert to bacterial superinfection of the sinuses if the patient experiences fever and/or chills, persistent purulent nasal discharge with maxillary, tooth, or unilateral facial pain, sinus tenderness, or progressively worsening symptoms. Sinus infection should be treated with antibiotics.• Consider sinus CT scan and ENT consultation if symptoms are severe and persistent after 3 months of treatment.* Clinical practice guidelines have been published recently for upper airway cough syndrome (UACS), previously called postnasal drip syndrome (PNDS),20and for chronic rhino-sinusitis.21† Mention of this medication does not imply a preference of this medication over other medications in the same class or category.‡ A meta-analysis indicates that an antihistamine-decongestant combination is superior to antihistamine alone to reduce symptoms.22

Chronic rhino-sinusitisSymptoms: nasal congestion with clear to purulent discharge,postnasal drip, cough, facial pressure/pain, nosebleeds, reducedor altered sense of smell, fatigue, maxillary dental pain, earpressure/fullnessSigns: inflammation of the nasal mucosa and paranasal sinusesfor more than 3 monthsRhinitis (allergic and irritant-induced)Symptoms: cough; sneezing; postnasal drip; reduced oraltered sense of smell; fatigue; lacrimation; itchy eyes, nose,and/or throatSigns: allergic “shiners” (dark circles under eyes); nasalcrease (across lower half of nasal bridge); pale, swollen orboggy nasal mucosa; thin, watery, nasal secretions; cobble-stoning of posterior pharynxAsthma/reactive airways dysfunction syndrome (RADS)Some people exposed to the WTC disaster area have developedirritant-induced asthma or reactive airways dysfunctionsyndrome (RADS). Symptoms: shortness of breath; chest tightness; wheezing;cough; phlegm; possible triggering of symptoms by upperrespiratory infections, seasonal allergies, exercise, fragrances,or extremes of temperature or humidity; recurrent episodes ofrespiratory infections requiring antibiotic treatmentSigns: pulmonary examination may be normal or may showtachypnea, wheezing, prolonged expiratory phase of respiration,hyperresonance to chest percussion, use of accessory musclesDiagnostic evaluation: history, physical, CXR, spirometry,response to empiric treatmentTreatment: See Table 4.Gastroesophageal reflux disease (GERD)Laryngopharyngeal reflux disease (LPRD)GERD and LPRD are closely related disorders. GERDresults from the reflux of gastric contents into the esophagus.LPRD results from the reflux of gastric contents into the lar-ynx/pharynx and is an often unrecognized cause of laryngealinflammation.GERD Symptoms: substernal/epigastric burning, acid regur-gitation, dyspepsia, cough made worse with meals or at night LPRD Symptoms: hoarseness or other vocal changes, sorethroat, cough, sensation of having a lump in the throatGERD Signs: may be absent if mild disease, may note ery-thema/esophagitis on endoscopy if symptoms are severe orpersistentLPRD Signs: may be absent on regular physical exam, maynote erythema/edema of larynx on laryngoscopy Diagnostic evaluation: history, physical, and response toempiric treatmentTreatment: See Table 5.Chronic Cough Patients may present with symptoms not clearly distinctive of the 3 syndromes described above and may present withchronic cough alone.25Evaluation of a WTC-exposed individ-ual with chronic cough is addressed in Figure 1 (see infold).Take a careful history, including all symptoms. Initiate smok-ing cessation, discontinue ACE inhibitor, and avoid environ-mental or occupational triggers — all can be irritants —before proceeding through the algorithm (Figure 1, see infold). Perform a targeted physical examination. Next, determinewhether the individual’s symptoms and exam suggest a spe-cific diagnosis (ie, UACS, asthma, or GERD – all discussedabove). If symptoms/signs are consistent with UACS orGERD, attempt empiric treatment for the suspected underlyingdisorder. When symptoms/signs are consistent withasthma/RADS, or cough alone is present, pursue a full work-up beginning with a chest x-ray. Evaluate and treat abnormal-ities identified on chest x-ray before continuing with the50 CITY HEALTH INFORMATION August 2006TOBACCO USEThe risk and severity of many WTC-related diseases are heightened by tobacco use. Exposure to secondhand smoke may alsoexacerbate WTC-related diseases. All WTC-exposed people and their family members who use tobacco should be advised toquit, and all who attempt to quit should be provided with medications to help them quit. Smokers can access the Smokers’Quitline by calling 311. Information on the treatment of nicotine addiction is available at:www.nyc.gov/html/doh/downloads/pdf/chi/chi21-6.pdfTable 4. Treatment of asthma/reactiveairways dysfunction syndrome (RADS)• Basic therapy for mild persistent asthma consists of a combi-nation of a daily inhaled corticosteroid (eg, budenoside*)combined with a short-acting inhaled bronchodilator (eg,albuterol*) as needed for the relief of symptoms. Closelymonitored treatment for at least 3 months may be necessaryto show clinical improvement. • For patients with more frequent symptoms, continue inhaledsteriods and consider adding long-acting inhaled beta ago-nists (eg, salmeterol*) or leukotriene modifiers (eg, mon-telukast sodium*) under careful monitoring.• For assistance with treatment management, follow the step-wise treatment guidelines based on symptom severity devel-oped by the National Heart, Lung and Blood Institute:www.nhlbi.nih.gov/guidelines/asthma/execsumm.pdf.23,24• Referral to a pulmonologist is recommended for patients withrefractory symptoms despite adherence to therapy.* Mention of this medication does not imply a preference of this medication overother medications in the same class or category.

Vol. 25 No. 7 NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE 51algorithm. Order spirometry if chest x-ray is normal (or find-ings are determined to be unrelated to current symptoms).Attempt empiric treatment of asthma/RADS for individualswith obstructive or normal patterns on spirometry. Patients may require further work-up including, but not limitedto, high resolution chest CT (inspiratory and expiratoryviews) and full pulmonary function testing. Refer to a pul-monologist as needed. Management should focus on diagnos-ing and treating the specific etiology of the cough, but symp-tomatic treatment (ie, cough suppression) may also be help-ful provided that a full evaluation is underway.Other Possibly Associated Pulmonary ConditionsConsult a WTC Medical Monitoring and Treatment Center(Resources) for further information about these and othermedical problems currently under evaluation: • Interstitial lung diseases• Chronic bronchitis/non-asthmatic eosinophilic bronchitis• Rare reports of pulmonary eosinophilic infiltrates,26granu-lomatous pneumonitis,27and bronchiolitis obliterans28• Other lung diseasesPatients may also present with other as yet unexplainedconditions that require additional diagnostic evaluation.Although the dust cloud contained heavy metals, there is norecognized need to perform blood or urine testing for heavymetals in the absence of specific indicative symptoms.As depicted in Figure 1 (see infold), patients may requireevaluation and treatment from specialists or a WTC medicalmonitoring and treatment program. These programs do notprovide general primary care services and thereforecomplement rather than supplant the role of the primary carephysician. A list of these programs is provided in the WTCHealth Registry Resource Guide (Resources).TABLE 5. Treatment of Gastroesophageal Reflux Disease (GERD) and LaryngopharyngealReflux Disease (LPRD)*If the patient’s history is typical for uncomplicated GERD/LPRD, an initial trial of empiric therapy is appropriate. Empiric therapyincludes lifestyle modifications and acid suppression. • Proton pump inhibitors (PPIs) (eg, omeprazole†) provide symptomatic relief and healing of esophagitis in the highest percentageof patients. Treatment consists of a PPI for 4–8 weeks, followed by on-demand or maintenance PPI. In some cases with partialresponse or acid breakthrough, BID doses may be necessary with the second dose given before the evening meal.29• Histamine-2 receptor antagonists (eg, ranitidine†) may also be used and are an effective treatment in many patients with lesssevere GERD/LPRD or as an adjunct with difficult to control GERD, particularly when taken at times known to trigger GERDsymptoms (eg, before exercise or heavy meal, before bedtime). In most cases, response to PPI is superior to response to histamine-2 receptor antagonists treatment.• Prokinetic agents (eg, metoclopramide†) may be used to augment treatment.30• Always evaluate the adequacy of and adherence to the treatment regimen before changing it.• Reflux disease should be treated aggressively to improve quality of life and because of its association with gastrointestinal disease (dysphagia, peptic stricture, Barrett’s esophagus, and esophageal cancer) and with respiratory disease (laryngitis, sinusitis, asthma, and chronic cough). • If empiric therapy is unsuccessful or symptoms suggest complicated disease, consider referral to a gastroententerologist.*A clinical practice guideline for evaluation and treatment of chronic cough due to GERD31and updated clinical guidelines for the treatment of GERD19have recently been published.†Mention of this medication does not imply a preference of this medication over other medications in the same class or category.Preventive health measures recommendedfor persons with a history of WTC-relatedillness• Tobacco cessation and elimination of exposure to second-hand smoke is essential to control UACS, asthma/RADS,and GERD/LPRD.• Counsel the patient to avoid, to the greatest extent possible,occupational or recreational exposures that are known toexacerbate illness.• Annual influenza vaccination is advised to reduce the riskof complications of influenza infection.• Pneumococcal vaccination is recommended for those withpulmonary disease.• Diet modification and weight control are integral to the control of GERD.• Screening for depression and substance abuse is recom-mended during routine visits. If patients screen positive,appropriate counseling and referral should be provided.

Disease ReportingHealth care professionals are legally mandated to report thediagnosis of occupational respiratory diseases, including thoseresulting from exposures at the WTC site. To obtainoccupational lung disease reporting forms, please contact theNew York State Occupational Lung Disease Registry(Resources). Substances released by the collapse of the towers couldpotentially cause cancers, which generally have a long latencyperiod. New York State Public Health law requires physicians —along with all other health care providers and entities — toreport every case of cancer they diagnose or treat to the NewYork State Department of Health (NYSDOH). To obtaincancer reporting forms, please contact the New York StateCancer Registry (NYSCR) (Resources). Accurate, timely, andcomplete reporting is essential to monitoring and under-standing the extent of WTC-related disease.MENTAL HEALTH CONDITIONS People who were injured in the collapse of buildings, who wit-nessed the injury or death of others during the attack, or who wereinvolved in rescue and recovery efforts, experienced considerablepsychological stress and direct trauma. Indirect trauma may alsohave resulted from the loss of a loved one or from constant expo-sure to graphic media coverage of the attacks. WTC-related physical illness or economic hardship may also have caused psy-chological stress. For most individuals, acute stress symptomsabated quickly, within a month, but some developed disorderssuch as post-traumatic stress disorder (PTSD), depression, gener-alized anxiety disorder (GAD), or a substance use disorder.15,32Primary care providers can serve an important role in the iden-tification, evaluation, treatment, and referral of trauma-relatedmental health disorders.15,33• Be alert to risk factors and signs that may indicate one ofthese disorders.• Establish a trauma history and screen for mental health disor-der risk factors (Table 6).• Assess for symptoms of PTSD (Table 7), depression (Table 8),GAD (Table 10), and substance use disorders (Table 11).• Educate patients about normal stress reactions.• Diagnose/manage these conditions consistent with treatmentguidelines.34,35Primary care providers can either make a diagnosis based ontheir assessment and treat accordingly, or refer patients to amental health professional for evaluation and treatment.Post-Traumatic Stress Disorder PTSD may develop in individuals exposed to traumaticevent(s) where the threat of serious injury or death occurs andthe individual’s response involves intense fear, helplessness,or horror. PTSD is characterized by all of the followingsymptoms that either arise immediately or after a lag time,and cause significant distress or impaired functioning:36,37• Re-living of the traumatic event in the form of nightmaresand flashbacks, and• Avoidance of reminders of the event, such as places,activities, and people, or feeling emotionally detached or numb, and• Hyperarousal such as insomnia, irritability, hypervigilance,or an exaggerated startle reaction Differential DiagnosisDiagnosing PTSD may be difficult because people withPTSD often suffer from other psychiatric disorders and mayalso initially report physical complaints (Table 7). Symptoms of these disorders and their physical manifesta-tions may complicate the recognition of PTSD and may alsoincrease the risk of suicidal behavior often associated withthese disorders.36-38Depression Depression is a disabling condition that affects many aspects of a person’s life and overall functioning. People who directlywitnessed the WTC attacks and those who participated in therescue and recovery efforts may be at increased risk for devel-oping depression, with or without PTSD.39Depression is characterized by feelings of extreme sadness,anhedonia, guilt, helplessness, hopelessness, insomnia, inabil-ity to concentrate, loss of appetite, and thoughts of suicideand/or death. It may occur only once, but is more commonly a recurring condition.40-4352 CITY HEALTH INFORMATION August 2006Table 6: Factors That Increase the Likelihoodof Developing Mental Health DisordersRelated to the WTC DisasterWTC-Specific• Personally witnessing events on 9/11 that induced horror,including:Airplanes hitting the towersBuildings collapsingFriends, relatives or colleagues getting injured or killedPeople falling or jumping from the towers• Exposure to the dust cloud• Sustaining an injury• Experiencing a panic attack at the time of the WTC disasterGeneral• Previous exposure to trauma• Personal history of a psychiatric or medical disorder• Family history of psychiatric disorder• Young age• Female gender• Lack of social support• Financial difficulties

A physician can simply and quickly screen for depression byusing a 2-question tool, the Patient Health Questionnaire-2(PHQ-2) (Table 8).44If the patient responds “yes” to eitherquestion, consider using the Patient Health Questionnaire 9(PHQ-9) (Table 8). This 9-item questionnaire can reliablydetect and quantify the severity of depression, and can be used tohelp monitor response to treatment (Table 8).45If the responseto question 9 on the PHQ-9 is positive, evaluate the patient’ssuicide risk (Table 9).The comprehensive management of depression includes phar-macological intervention and non-pharmacological treatmentsuch as patient education, counseling, self management, referralif required, and ongoing monitoring. Increased physical activitycan prevent and reduce symptoms of depression.46Patientsshould be monitored frequently for treatment effectiveness, sui-cidality, and adverse effects common with antidepressant med-ication. When psychosis, suicidal ideation, or severe functionalimpairment are present, medication will be needed and hospital-ization may be required.Generalized Anxiety Disorder (GAD) Generalized Anxiety Disorder (GAD) is characterized by per-sistent, excessive, and uncontrollable worry and anxiety aboutdaily life and routine activities.47,48Diagnosis is based on all ofthe following49: • Excessive and uncontrolled anxiety and worry more daysthan not for at least 6 months• At least 3 of the following symptoms: Restlessness IrritabilitySleep disturbance FatigueDifficulty concentrating Muscle tension• Anxiety, worry, or physical symptoms that cause clinicallysignificant distress or functional impairment• Symptoms that are not the result of substance or medicationuse or abuse, or a general medical conditionOther symptoms of GAD include muscle aches, trembling,jumpiness, headache, difficulty swallowing, gastrointestinaldiscomfort, diarrhea, sweating, hot flashes, and feeling light-headed and breathless (Table 10).Patients suffering from GAD may also:• Feel chronically tense, anxious, and/or be disproportionatelyconsumed with worry48,50;• Expect the worst on a consistent basis;• Experience physical symptoms of anxiety51;• Experience chronic anxiety symptoms with short-term exacerbations48,50;• Experience anxiety to a degree that it adversely affects daily functioning.47,48The short-term goals for treatment should be to rapidlyreduce somatic symptoms and overwhelming anxiety; long-term goals include full recovery, preventing relapses, andtreating any comorbid disorder.52ScreeningConsider a diagnosis of PTSD for patients who answer yes to 3 of the following 4 questions.53In your life have you ever had any experience that was so frightening, horrible, or upsetting that in the past month you:• Have had nightmares about it or thought about it when youdid not want to? • Tried hard not to think about it or went out of your way toavoid situations that reminded you of it?• Were constantly on guard, watchful, or easily startled?• Felt numb or detached from others, activities, or your surroundings?Treatment36,37Treat PTSD with psychotherapy, pharmacotherapy, or a combina-tion of the two. Psychotherapy36,37• Exposure therapy: to reduce the arousal and distress associatedwith memories of trauma• Cognitive behavioral therapy: to identify and change harmfulthoughts and modify unwanted behavior related to trauma • Anxiety management (Table 9)Pharmacotherapy34,36The FDA has approved 2 selective serotonin reuptake inhibitors(SSRIs) to treat PTSD: • Sertraline (Zoloft©) • Paroxetine (Paxil©)If neither of these antidepressants is effective after approximately8 weeks, consider changing therapy to other antidepressants:• Venlafaxine (Effexor©) • Mirtazepine (Remeron©)• Duloxetine (Cymbalta©) • Bupropion (Wellbutrin©)Other psychotropic medications may have a role, especially incombination with antidepressants. These can include mood stabi-lizers such as valproic acid (for severe mood lability and generalPTSD symptoms), and anti-adrenergic medications such as cloni-dine (for hyperreactivity, nightmares, and panic symptoms).Because PTSD is often accompanied by other psychiatric disorders,it may be advisable to consult a psychiatrist for patients with com-plex psychopharmacological needs. Use of brand names is for informational purposes only and does not imply endorsement by the New York City Department of Health and Mental Hygiene.Table 7. Post-Traumatic Stress Disorder (PTSD) Screening and TreatmentFOR MANAGEMENT OF WTC-ASSOCIATED ILLNESS (FIGURES 1 & 2) AND RESOURCES, SEE THE INFOLD.53

54 CITY HEALTH INFORMATION August 2006Table 8: Depression Screening and TreatmentScreeningObserve, listen, and ask questions about the patient’s mood, level of functioning, energy, motivation, and any work-related or social problems. Begin with the Patient Health Questionnaire 2 (PHQ-2)44:During the past 2 weeks, have you experienced 1. Little interest or pleasure in doing things?2. Feelings of hopelessness? If either of the 2 PHQ-2 questions is positive, administer Patient Health Questionnaire 9 (PHQ-9).Patient Health Questionnaire 9 (PHQ-9)42,45Over the past 2 weeks, how often have you been bothered by any of the following problems (circle to indicate your answer)?Not at Several More than Nearly all days half the days every day1. Little interest or pleasure in doing things ........................................ 0 1 2 32. Feeling down, depressed, or hopeless .......................................... 0 1 2 33. Trouble falling asleep or staying asleep, or sleeping too much ........ 0 1 2 34. Feeling tired or having little energy .............................................. 0 1 2 35. Poor appetite or overeating ........................................................ 0 1 2 36. Feeling bad about yourself – or that you are a failure or have let yourself and your family down. .................................................... 0 1 2 37. Trouble concentrating on things, such as reading the newspaper or watching television...................................................................... 0 1 2 38. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual. .......................................... 0 1 2 39. Thoughts that you would be better off dead, or of hurting yourself in some way.* ................................................................ 0 1 2 3________ + ________ + ________ + ________ = __________TOTALPHQ-9 Scoring card for Severity Determination42,45For health care professional use only Add all numbers on the PHQ-9 circled by the patient.Not at all = 0, Several days = 1, More than half the days = 2, Nearly every day = 3. Interpretation of the Total Score1–4 Minimal depression, 5–9 Mild depression, 10–14 Moderate depression, 15–19 Moderately severe depression, 20–27 Severe depression* If the response to question 9 on the PHQ-9 is positive, evaluate the patient’s suicide risk (Table 9).

Substance Use Disorders Exposure to stress and trauma may increase the risk of develop-ing substance use disorders or cause relapse. Substance use disorders involve extended overuse of a substance marked bypersistent cravings, increased tolerance, and withdrawal symp-toms. Use characteristically continues despite resulting serious,persistent, and recurring psychological, physical, and socialproblems.54-57During the weeks and months following the WTCattack, there was an increase in cigarette and marijuana use58inNYC adults and a correlation between exposure to the attacksand alcohol dependence.59Substance abuse Substance abuse is a pattern of use that leads to clinicallysignificant impairment or distress but without the physicaldependence or loss of control over intake that characterizeaddiction. It is manifested by 1 or more of the following in the same 12-month period:• Failure to fulfill obligations at work, school, or home as a result of the abuse • Use in physically hazardous situations (such as driving) • Recurrent legal problems as a consequence of the abuse• Continued use despite persistent or recurring social problems Substance dependence (addiction) Dependence involves a preoccupation with a substance anddiminished control over its consumption. The hallmarks ofdependence are tolerance and withdrawal, and dependence isVol. 25 No. 7 NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE 55SSRIsEscitalopram (Lexapro®) Citalopram (Celexa®)Fluoxetine (Prozac®, Prozac®Weekly™)Duloxetine (Cymbalta®)Paroxetine (Paxil®, Paxil CR®)Sertraline (Zoloft®)Other New AgentsBupropion (Wellbutrin®, Wellbutrin SL®)Mirtazapine (Remeron®, RemeronSolTab®)Venlafaxine (Effexor®, Effexor XR®)Table 9: Assess For Suicide Risk If the response to question 9 on the PHQ-9 is positive, youmust evaluate the patient’s risk for suicide by assessing theirthoughts and plans. Detecting suicidal ideation can be life-saving. Asking patients about suicidal thoughts or plans willnot initiate suicidal thoughts, planning, or action. Assess for suicidal thoughts and plans: “Have you ever felt that life is not worth living?”“Did you ever wish you could go to sleep and just not wake up?”“Are you imagining that others would be better off without you?”“Are you having thoughts about killing yourself?”Assess for suicide risks including:• Prior suicide attempts (best indicator of future attempts)• Psychiatric comorbidity and substance use disorders• Access to firearms• Living alone• Poor social support• Male and elderly• Recent loss or separation• HopelessnessIf the patient is actively thinking of suicide, has made an attemptin the past, or has a plan for another attempt, arrange formental health consultation as soon as possible, or call 911 foremergency intervention.42,43TREATMENT (Table 8 continued)Psychotherapy Psychotherapy is effective for the treatment of depression alone or in combination with medication, and is particularly indicated forpatients with milder depression who do not wish to take medication.ExerciseAerobic exercise is an effective treatment for mild to moderate depression and is also effective as an adjunct to other treatmentmodalities for moderate to severe depression.46PharmacotherapySSRIs or other new agents are generally the drugs of first choice in preference to the older, but effective group of tricyclic antidepressants.In contrast to SSRIs and the other new agents, the tricyclic antidepressants can have uncomfortable and dangerous adverse effects and canbe lethal in overdose. Possible adverse effects of the SSRIs (and of venlafaxine, duloxetine, and bupropion), especially during the first daysof treatment, include feeling jittery, increased anxiety, headache, insomnia, sedation, and sexual problems. Bupropion has a lower inci-dence of sexual side effects than the other medications listed. Possible side effects of mirtazepine include sedation and weight gain.Monoamine oxidase inhibitors are now rarely prescribed due to adverse reactions and drug/dietary interactions.Use of brand names is for informational purposes only and does not imply endorsement by the New York City Department of Health and Mental Hygiene.

56 CITY HEALTH INFORMATION August 2006TreatmentRule out other possible causes for the symptoms before beginningany form of treatment for GAD. • Organic causes for anxiety include undiagnosed medicaldisorders such as hyperthyroidism, arrhythmias, chronicobstructive pulmonary disorders, coronary insufficiency, andpheochromocytoma. • Medications, as well as drugs such as alcohol, caffeine,nicotine, and cocaine (whether during intoxication orwithdrawal), can cause or exacerbate anxiety symptoms.Psychotherapy47,50,60Most effective when used in combination with pharmacotherapy, butcan be used as the initial treatment for patients with mild GAD. • Behavioral therapy: to modify the patient’s behavior • Cognitive therapy: to change unproductive and harmfulthought patterns • Cognitive-behavioral therapy: combination of behavioraltherapy and cognitive therapy Not at Several More than half Nearly everyall days the days dayGAD-7Over the past 2 weeks, how often have you been bothered by the following problems?1. Feeling nervous, anxious, or on edge 0 1 2 32. Not being able to stop or to control worrying 0 1 2 33. Worrying too much about different things 0 1 2 34. Trouble relaxing 0 1 2 35. Being so restless that it is hard to sit still 0 1 2 36. Becoming easily annoyed or irritable 0 1 2 37. Feeling afraid as if something awful might happen 0 1 2 3Total Score __________= Add Columns ________ + ________ + ________ + ________Table 10: Generalized Anxiety Disorder (GAD) Screening and Treatment Screening52Assess symptoms of GAD, level of functional impairment, and the presence of comorbid psychiatric conditions. The newlydeveloped GAD-7 assessment tool can help confirm the diagnosis of GAD.GAD-7 Severity DeterminationAdd all scores checked by the patient: ≥ 5–9 Mild anxiety ≥ 10–14 Moderate anxiety ≥ 15 Severe anxiety • Relaxation therapy: to develop techniques to effectively deal with stress Pharmacotherapy47,50,52,60The aim of pharmacotherapy is the management of the anxiety symptoms.• Antidepressants are effective for GAD (see Pharmacotherapyin Table 8). Escitalopram (Lexapro®), paroxetine (Paxil®), andvenlafaxine (Effexor®) are approved by the FDA for the treat-ment of GAD.• If needed, anxiolytics (benzodiazepines)* for prompt relief of symptoms:• Alprazolam (Xanax®) • Chlordiazepoxide (Librium®)• Clonazepam (Klonopin®) • Chlorazepate (Tranxene®)• Diazepam (Valium®) • Lorazepam (Ativan®)• Oxazepam (Serax®)*Benzodiazepines have the potential for abuse and dependence when used formore than several weeks.Use of brand names is for informational purposes only and does not imply endorsement by the New York City Department of Health and Mental Hygiene.manifested by 3 or more of the following in a 12-month period:• Symptoms of tolerance—using increased amount with the same or diminished effect• Symptoms of withdrawal after stopping substance use• Desire and unsuccessful attempts to cut down or control use• A great deal of time spent engaged in activities needed toobtain the substance • Neglect or abandonment of work, social, or recreationalactivities as a result of the use• Continued use despite health problems and negative social consequences

Vol. 25 No. 7 NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE 57Screen patients for problem drinking and substance use withthe CAGE-Adapted to Include Drugs (CAGE-AID) test(Table 11).For patients with unhealthy drinking levels or drug abuse, cli-nicians should use the Brief Intervention technique:• Provide clear, personalized advice about cutting down or abstaining.Listen reflectively – summarize and repeat what yourpatient says. Show concern and avoid confrontation – be on your patient’s side. When possible, linkalcohol/drug use to a specific medical condition. • Set mutually acceptable goals – involve your patient.Patients may be unwilling to abstain from drinking/druguse completely, but may agree to reduce consumption.• Offer practical advice, information, and treatment referrals.Help patients identify drinking/drug use triggers andpractical ways to cope. Common triggers include jobstress, money worries, chronic illness, family problems,depression, anxiety, and social isolation.• Prescribe medication if indicated.Three medications – naltrexone, acamprosate, and disulfi-ram – have been approved for the treatment of alcoholdependence. Buprenorphine, methadone, and naltrexoneare effective treatments for opioid dependence.• Provide regular follow-up to support efforts to reduce orstop drinking or abusing drugs.Three or 4 follow-up visits (or a combination of visits andphone support) increase effectiveness of brief intervention.63Brief counseling may be further reinforced by visits with orphone calls from health educators, nurse practitioners,physician assistants, alcohol counselors, and others.Patients with substance use disorders require ongoing care:monitoring, intervention, relapse-prevention, and referrals toTable 11. Substance Use Screening and TreatmentScreening61Ask the patient about current and past nicotine, alcohol, orother substance use.CAGE–AID (Adapted to Include Drugs) Test62Have you ever:• Thought you should... Cut down your drinking or drug use?• Become...Annoyed when people criticizedyour drinking or drug use?• Felt bad or...Guilty about your drinking or drug use?• Taken an...Eye-opener drink or used a drug to feel better in the morning?YES to 1 or 2 questions = Possible alcohol/drug use problemYES to 3 or 4 questions = Probable alcohol/drug dependenceBrief Intervention61,62All patients with possible or probable alcohol or substance abuseshould be provided with Brief Intervention. Brief Intervention is a5-step counseling technique that primary care practitioners canuse to help their patients reduce unhealthy drinking. 1. Evaluate the patient’s drinking pattern—healthy or unhealthy drinking?2. Advise patients who have unhealthy drinking habits.3. Set mutually acceptable goals.4. Offer advice, information, and treatment referrals and prescribe medication if indicated.5. Provide regular follow-up and support.The patient and primary care provider acknowledge the problemand set mutually acceptable goals. The primary care provideroffers advice, treatment, referrals (as needed), support, and follow-up (Resources). Treatment57,61Primary care providers play an important role in creating atreatment plan and supporting the patient in locating theappropriate program, support service, or network.Comprehensive care is critical, including addressing medicalneeds, monitoring progress, referring or consulting specialists,motivating the patient to change his/her lifestyle, maintainingremission and reducing the risk of relapse.Detoxification• May be the first step of treatment, usually lasting several days. • May include medications to address withdrawal symptoms, appropriate for the substance abused.Medical treatmentTreat related medical and/or mental health disorders.Psychotherapy Prescribe group and/or individual counseling. Pharmacotherapy for:•Alcohol dependence: Medications to maintain abstinence and to reduce chance of relapse:• Naltrexone (ReVia®)• Injectable naltrexone (long-acting) (Vivitrol®)• Acamprosate (Campral®)• Disulfiram (Antabuse®) •Opioid dependence: buprenorphine, methadone, naltrexone for maintenance treatment.Use of brand names is for informational purposes only and does not imply endorsement by the New York City Department of Health and Mental Hygiene.

58 CITY HEALTH INFORMATION August 2006improve treatment outcome. Relapse is common. Exposureto stress increases cravings and therefore the likelihood of arelapse.64Treatment planning should support the patient byaddressing acute medical needs, monitoring progress, con-sulting specialists or referring the patient to specialists, andmotivating the patient to make lifestyle changes. SUMMARYFive years after the terrorist attacks, New Yorkers and othersthroughout the country still experience WTC-associatedphysical and mental illness. All providers can play an importantrole in evaluating and treating these illnesses. Primary careproviders can address mental health problems when evaluatingpatients for respiratory ailments and other health problems. These guidelines supply information to suspect, diagnose,treat, and, if necessary, refer patients for additional evaluationand treatment. However, the guidelines do not consider allWTC-associated illnesses, and providers should monitor theliterature as more information on WTC-associated diseasebecomes available. ♦PRST STDU.S. POSTAGEPAIDNEW YORK, N.Y.PERMIT NO. 6174nyc.gov/healthMichael R. BloombergMayorThomas R. Frieden, MD, MPHCommissioner of Health and Mental HygieneOffice of the CommissionerJulie Myers, MD, Director of Special ProjectsDivision of EpidemiologyLorna E. Thorpe, PhD, Deputy CommissionerStephen Friedman, MD, MPH, Medical Research DirectorMark Farfel, ScD., Director, World Trade Center Health RegistryJim Cone, MD, MPH, Senior Consultant, World Trade Center Health RegistryDivision of Mental HygieneLloyd Sederer, MD, Executive Deputy CommissionerJorge Petit, MD, Associate Commissioner for Program ServicesMonika Eros-Sarnyai, MD, MA, Best Practices OfficerBureau of Public Health Training Azimah Ehr, MD, Assistant Commissioner Sharon Kay, MA, Director, Scientific CommunicationsMonica J. Smith, Medical Editor Bureau of CommunicationsCortnie Lowe, MFA, Executive EditorCopyright © 2006 The New York City Department of Health and Mental HygieneSuggested citation: Friedman S, Cone J, Eros-Sarnyai M, Prezant D, Szeinuk J, Clark N, MilekD, Levin S, Gillio R. Clinical Guidelines for Adults Exposed to the World Trade Center Disaster City Health Information. 2006;25(7):47–58.Photo Credits: Cover Photo: NYC DOHMH; Inside Photos: FEMA News PhotoReferences Available Online: www.nyc.gov/html/doh/downloads/pdf/chi/chi25-7-ref.pdfWTC Registry Resource Guide: www.nyc.gov/html/doh/html/wtc/wtc-resource.pdf DOHMH would like to thank the following external clinicaladvisors for their contributions:Sherry Baron, MD,NIOSH Kenneth Berger, MD,New York UniversityLinda Cocchiarella, MD,SUNY Stony BrookRafael De La Hoz, MD,Mount Sinai Medical CenterSandro Galea, MD, DrPH,University of Michigan Denise Harrison, MD,New York UniversityRobin Herbert, MD,Mount Sinai Medical CenterCraig L. Katz, MD,Mount Sinai Medical CenterKerry Kelly, MD,NYC Fire DepartmentStephen Levin, MD,Mount Sinai Medical CenterBenjamin Luft, MD,SUNY Stony BrookSteven Markowitz, MD,Queens CollegeDebra Milek, MD, Mount Sinai Medical CenterJacqueline Moline, MD,Mount Sinai Medical CenterDavid Prezant, MD,NYC Fire DepartmentJoan Reibman, MD,New York UniversityJaime Szeinuk, MD,Mount Sinai Medical Center Ken Spaeth, MD,Saint Vincent’s Medical CenterIris Udasin, MD,Rutgers UniversityAugust 2006 Vol.25(7):47–58

LIFENET • NYC DOHMH 24-hour, 7-days-a-week crisis hotline and informationand referral networkEnglish: (800) LIFENET/(800) 543-3638Spanish: (877) AYUDESE/(877) 298-3373Chinese (Asian LifeNet): (877) 990-8585Other languages: (800) LIFENET/(800) 543-3638TTY hard of hearing: (212) 982-5284www.mhaofnyc.org/2lifenet.html9/11 Mental Health and Substance Abuse Program• Financial assistance for mental health or substance abuse programs (800) LIFENETwww.9-11mentalhealth.orgAmerican Psychiatric Association, APA Answer Center• Referral to a local psychiatrist(888) 35-PSYCHwww.healthyminds.org/locateapsychiatrist.cfmAmerican Psychological Association• Telephone and online psychologist locator service(800) 964-2000www.apahelpcenter.orgNew York State Office of Alcoholism and Substance Abuse Services(OASAS)(800) 522-5353www.oasas.state.ny.usSubstance Abuse and Mental Health Services Administration• National Drug and Alcohol Treatment Referral Routing Service(800) 662-HELP/(800) 662-4357www.findtreatment.samhsa.govAlcoholics Anonymous (AA) World Services, Inc.(212) 870-3400www.aa.orgNational Institute on Alcohol Abuse and Alcoholism (NIAAA)(301) 443-3860www.niaaa.nih.govMENTAL HEALTH RESOURCESMEDICAL MONITORING AND TREATMENT PROGRAMS(offering free or need-based services)For rescue, recovery, and clean-up workers, and volunteers: WTC Medical Monitoring and Treatment ProgramThis program is a consortium of providers, including: Bellevue Hospital, Mt.Sinai Medical Center, Nassau County University Medical Center, QueensCollege Ground Zero Health Watch, SUNY-Stony Brook, UMDNJ-RobertWood Johnson University Hospital, and other providers nationwide.(888) 702- 0630, (212) 241-1554www.wtcexams.org For FDNY rescue and recovery workers: FDNY WTC Medical Monitoring and Treatment Program(718) 999-1858Email wtmed@fdny.nyc.gov or go to: www.nyc.gov/html/fdny/html/emp_resources/health_connections/2005/dec05.shtmlFor residents, clean-up, and other workers:Bellevue Hospital WTC Health Impacts Treatment Programvia Beyond Ground Zero Network at (212) 358-0295For residents and workers (medical screening examinations only): Charles B. Wang Community Health Center, Inc.(212) 966-0461 for general information (212) 379-6996 for an appointment www.cbwchc.orgFor federal employees (medical screening examinations only):WTC Federal Responder Medical Screening Program (866) 214-2040https://wtcophep.rti.orgPEDIATRICSFor pediatric (but not WTC-specific) guidelines:American Academy of Pediatricswww.aap.org/topics.html WORKERS COMPENSATIONFor workers compensation information:• To report a work-related illness, call: (888) 800-0029or go to: www.wcb.state.ny.us• For information on the change in New York State legislation thatextends the filing deadline, go to:www.ny.gov/governor/press/06/0814061.htmlREGISTRIESNY State Cancer RegistryThe New York State Department of Health is phasing in physicianreporting of cancers diagnosed and/or treated in ambulatory settings(eg, melanoma or prostate cancer). For cancer reporting forms, call:(518) 474-2255. NY State Occupational Lung Disease RegistryFor occupational lung disease reporting forms, call: (866) 807-2130or go to: www.health.state.ny.us/nysdoh/lung/lung.htmWTC-REGISTRY RESOURCE GUIDEFor updated resources available, go to:www.nyc.gov/html/doh/html/wtc/wtc-resource.pdf(Includes information about accessing WTC experts for physician consultation)MEDICAL RESOURCESMANAGEMENT OF WTC-ASSOCIATED ILLNESSESPhysical and mental health problems in people exposed to the disaster are often interrelated and require coordinated evaluation and treatment.FIGURE 1The algorithm provides guidance for diagnosis, treatment, management, and potential points of referral to a World Trade Centermonitoring or treatment program, or to another specialist (eg, otolaryngologist, pulmonologist, cardiologist, radiologist, or gas-troenterologist). Often, two or more conditions coexist and these conditions must be treated simultaneously to improve or resolvethe cough.18FIGURE 2The algorithm provides a guide for primary care practitioners to establish a management plan for identifying, screening, diagnosing,treating, and referring patients with mental health disorders related to the WTC disaster and other trauma exposures. Primary careproviders should consult a mental health specialist as needed for diagnosing, devising, and implementing a treatment plan. Referralto a specialist should be considered when:• The patient prefers it. • The diagnosis is unclear or the symptoms are severe.• Special treatment is required. • There is no significant improvement or there has been a relapse.• The patient has other psychiatric conditions • Patient has suicidal/homicidal thoughts or behavior.or severe psychosocial problems. • There is little or no improvement after treatment.SXsD/DXAsthma/Reactive airwaysdysfunction syndrome (RADS)?*Other conditions? Gastro-esophageal reflux disease (GERD)?*Laryngo-pharyngeal refluxdisease (LPRD)?Upper airway cough syndrome (UACS)?*• Chronic rhinosinusitis?• Allergic rhinitis? Chest x-ray (CXR)Abnormal chest x-rayNormal chest x-ray or old unrelated abnormalityEvaluate cause ofabnormality and treatNormalSpirometryObstructive pattern†or significant responseto bronchodilatorRestrictive or mixed pattern (no response to bronchodilator)Cough that worsens with meals or at night, dyspepsia, substernal/epigastric burning, acid regurgitation, hoarseness, sore throatIf inadequateresponse, consider:• Endoscopy• GI consult• ENT consult• Rx trial for UACS (Table 3)• Go to Step 4 of algorithm (CXR)If inadequate response, consider:• Rx trial for UACS (Table 3)• Chest CT (high resolution)• Methacholine challenge• Pulmonary consult• Induced sputum for eosinophils• Cardio-pulmonary evaluation, exercise test• Lung volumes, DLCO, ABG• Systemic steroids, antibiotics If inadequateresponse, consider:• Sinus CT scan• ENT consult• Rx trial for GERD (Table 5)• Go to Step 4 of algorithm (CXR)APPROACH TO THE PATIENT WITH CHRONIC COUGHAND A HISTORY OF WTC-RELATED EXPOSURECXRDX & RXSPIROMETRYCough alone,or wheezing or shortness of breath possibly made worse by URI, seasonal allergies, exercise, fragrances, cold airPostnasal drip, frequent need to clear throatSmoking cessationDiscontinue ACEinhibitorAdditional work-up recommended:• Lung volumes, DLCO, ABG• Chest CT (high resolution)• Pulmonary consultAbbreviations:ABG: Arterial blood gasCT: Computed tomogramDLCO: Diffusion capacity of the lung for carbon monoxideENT: Ear, nose & throatGI: GastrointestinalURI: Upper respiratory infectionHX & PEStep 1Step 2Step 3Step 4Step 5Step 6Step 7Rx trial for asthma/RADS(Table 4):• Inhaled steroids• BronchodilatorsRx trial for GERD(Table 5):• Diet & lifestyle modification• Proton pump inhibitorRx trial for UACS(Table 3):• Saline spray• Antihistamines & decongestants• Nasal steroidsHistory (Table 1)physical examinationCounsel to avoid second-hand smoke and other environmental and occupational stimuliFOLLOW-UP* Consider combined etiology.† Or with >15% decrease from pre-exposure FEV1, if availableIf cough orcondition persists:• Pulmonary consultChronic Cough andHistory of WTC ExposureEstablish past mental healthand trauma history, including exposure to the WTC attacksIdentify patients with possible mental health disorders• Assess risk• Assess signs and symptoms No response, or relapse If there is no response to initial treatment 8–12 weeks after the initiation, or relapse: • Consider dose adjustment or choose another medication • Consider adding or modifying psychotherapy • Consider augmenting therapy • Re-evaluate diagnosis • Consult mental health specialist • Refer patient to mental health specialist Make a diagnosisDiagnose all trauma-related mental health disorders according to the Diagnostic and Statistical Manualof Mental Disorders49• Determine if the patient meets diagnostic criteria • Apply differential diagnosis • Rule out or confirm other psychiatric comorbidities • Assess suicide risk Establish comprehensive treatment plan that includes:• Patient education, self-management support, and family involvement • Ongoing assessment (screening tools and assessing for suicide risk) • Psychotherapy and/or pharmacotherapyMANAGEMENT OF TRAUMA-RELATEDMENTAL HEALTH DISORDERS PharmacotherapyMild or moderate cases: Pharmacotherapy and/or psychotherapySevere cases: Pharmacotherapy and psychotherapy• Select and initiate treatment with first-line pharmacologic agent• Monitor treatment every 1–2 weeks as needed• Assess initial response in 4–6 weeksIf initial response (+):• Continue treatment• Reassess treatment in 8–12 weeks • Provide ongoing assessment for 9–12 months • Discontinue treatment slowly after that point if the patient is in remission (asymptomatic) Patient education• Describe and explain the disorder • Provide supportive lifestyle counseling • Discuss treatment options • Indicate the need for consistency and follow-up• Explain potential comorbidities• Discuss the benefits and availability of mental health specialist support • Encourage patients to improve their self-help capability Referral for psychotherapy Mild cases: Psychotherapy as initial treatment Moderate and severe cases: Psychotherapy in combination with pharmacotherapy • Monitor response every 6–12 weeks in conjunction with the therapist • Provide ongoing assessment for at least 9–12 months• Discontinue treatment if the patient is in remission (asymptomatic) Apply screening tools• Ask targeted screening questions.• Utilize screening instruments: • PTSD: Primary Care PTSD Screen (PC-PTSD) (Table 7) • Depression: Patient Health Questionnaire (PHQ-2 and, if positive, PHQ-9) (Table 8) • Generalized anxiety disorder: GAD-7 (Table 10) • Substance use disorders: CAGE-AID (Table 11)