Will Trauma Hit Home for the Holidays?

Remember Elvis Presley’s mournful musical prediction that he was in for a blue Christmas? The narrow cultural reference aside, are Americans heading into an especially blue holiday season?Consider this triple-whammy of stressors and their potential cumulative impact:

• The so-called “holiday blues” that are attributed to loneliness, unrealistic expectations, disruptions in everyday routines, family tensions or other stressful circumstances that are associated with the period from Thanksgiving to New Year’s (see “Holiday Blues” below);
• Seasonal Affective Disorder (SAD), which is relatively rare, and the much more common subsyndromal cousin S-SAD, triggered by the approach of winter’s shortened daylight hours (see “Bright Lights, Circadian Rhythms” below); and
• The nationwide grief, fear and anxiety that are the legacy of the atrocities visited upon New York City and Washington, D.C., on September 11, 2001, and their widening aftershocks of loss, dread, anthrax scares, and war. Psychology researchers, sociologists, epidemiologists, and others are already trying to identify and dissect the behavioral and mental health impacts of the terrorists attacks. One question is whether there are heightened effects for those who are already vulnerable to increased affective disorders during the winter and holiday season. Another is how the events of 9-11 affect people who are otherwise not at-risk.

Clore

Gerald Clore, of the University of Virginia, an APS Fellow and Charter Member who investigates how multiple sources of affect combine, says his laboratory studies show that “as people have a harder and harder time parsing their subjective experience and keeping track of what their affective reactions are due to, they do add together, or accumulate.”

But, he says, it’s not easy to tease apart the triggers. “A major problem is that we have only one window on our own affective reactions-our feelings in the moment-and it is no more possible to tell where part of a larger consistent set of feelings came from than it is to keep track of water from the hot and cold taps as they fill the sink in the morning.”

Joseph P. Forgas, an APS Fellow who heads the Affect Research Laboratory at the University of New South Wales in Sydney, Australia, agrees that it is “reasonable to assume that multiple negative-affect producing events can have a cumulative influence on mood states.”

“We find this in some experiments,” Forgas says, “in which we induce multiple or repeated moods to produce more prolonged affective states. So, yes, I think it is possible that the current fear and uncertainty are likely to be prolonged when people have additional time to reflect on these issues.”

He cautions, however, that “much depends on the nature of that reflection. Merely repeating and mentally rehearsing the same negative thoughts and information may prolong the effect, but there is also evidence that trying to digest and re-interpret negative experiences constructively-for example, by writing about them-does help alleviate the aversive mood state.”

Still, Forgas says, it is “very likely that recent events have shaken people’s belief and trust in ‘normal,’ secure patterns of life and made them feel more exposed and threatened worldwide. This represents a serious interruption in routine thought patterns and activities, and should lead to the kind of magnification of affective responses we observe in the laboratory.”

Nolen-Hoeksema

HOMELAND INSECURITY

Young

“I can only speculate,” says APS Member Michael Young, of Illinois Institute of Technology, “but this winter may well be a high risk time for psychological problems. There will probably be an increased risk for both subclinical and clinical disorders. On the other hand, in times of war, people generally feel a greater sense of community and greater sense of purpose, and those are protective factors against psychological problems.

“I don’t know what the rates of disorders were during World War II. People were losing friends and relatives during that war, but there was also a high sense of purpose and identity. How that actually works out is a social and cultural issue. Whether over the coming months we’ll see a general sense of purpose and identity is an empirical question,” says Young.

Keane

Great Britain during World War II serves as an “excellent example,” agrees APS Fellow Terence M. Keane, who heads the behavioral sciences division of the National Center for PTSD at the Veterans’ Administration Healthcare System in Boston. “How did the British sustain themselves amid the terrible bombings? They did it through very strong leadership, community support, and adhering to a wide range of social and community mores. Together, this unified the people and helped them to maintain their spirit. Similar things need to be instituted here.”

The sprouting of American flags in yards and from buildings and cars across the nation, and the singing of “God Bless America” at virtually every public opportunity are all helpful, says Keane.

“These are very protective things-along with looking out for your neighbors, looking out for other Americans, remaining in contact with family members and friends and people you work with, all of this coupled with strong leadership at all levels, from the president down to our bosses in our workplaces and our religious leaders. These are the times when leadership is critically important from all of these sources.”

BEYOND GROUND ZERO

Biostatistician David W. Smith, then with the College of Public Health at the University of Oklahoma, questioned a scientific sampling of about a thousand adults in Oklahoma City’s metropolitan area to “measure the effects of the bombing on the larger community, particularly psychological and emotional effects.” He found that, compared to a control population (Indianapolis), the Oklahomans reported twice as much stress, psychological distress, PTSD components and intrusive thoughts related to the bombing. They also reported twice as much alcohol use, more of them had started smoking, and smokers were smoking more often. All these differences continued to persist more than a year after the bombing.

Smith concluded that the “exposure” to the bombing included more than half the adults in the metropolitan area. “For an extended period of time,” he says, “primary care practitioners should screen their patients, who may normally not be considered victims, for exposure to the effects of a terrorist disaster.”

ONGOING TRAUMA

In fact, he says, “We’re not post anything. We’re in a peri-traumatic experience. The attacks of September 11, the fear of additional attacks, and now the fear of anthrax and other biological weapons-the traumatic event is ongoing.”

Keane began investigating PTSD even before it was called that-in 1977 when, just after receiving his doctorate, he joined the VA Medical Center at the University of Mississippi. Among his first patients were young Vietnam War veterans with severe alcohol problems. “I was trying to understand why they were drinking and stumbled into how they were disturbed by dreams, nightmares and flashbacks of their experiences (in Vietnam). That was the beginning point for me.”

Keane helped write the first grant proposal (to the U.S. Department of Veterans’ Affairs) to study what came to be known as PTSD and has been studying it ever since. He moved to Boston’s VA facility in 1985 and, four years later, the hospital was chosen as the site of the National Center for PTSD, working with three other hospitals. The Center has since added a fourth hospital (in Hawaii) and a women’s division, also in Boston.

“Part of the diagnostic criteria for PTSD,” Keane explains, “is that you or a loved one are exposed to a traumatic experience. So, wives and other family members of those who died are clear candidates. Although not directly exposed, they are just one very small step away from such exposure.”

NO BRIGHT LINE

“The general population, in this case, is further down the continuum,” Keane says, “but was clearly exposed, even if not directly. If you live in New York City, you were clearly more exposed than if you live in Atlanta or Austin. If you work in the Sears Tower or the TransAmerica Building in San Francisco, you might feel much more exposed than people who work in low-rise buildings.”

Psychological science now knows a great deal about PTSD from the Vietnam War, and a great deal about the PTSD impact of sexual assault and from natural and technological disasters, “but we’ve never had an experience like this,” Keane says.

Our newly stressed-out world is making urgent demands on psychological scientists, not only to develop effective science-based interventions to help victims cope, but also to understand and help prevent future terrorist attacks. Many are now asking fundamental questions, such as: What population-wide repercussions did it unleash and how do we measure them? How much do we know about the likely effects of formerly unthinkable events? What do we need to know? How should we go about finding answers? Do we even have the right equipment in our toolbox? (See “New Tools” below)

RISING TO THE CHALLENGES

The National Institute of Mental Health (NIMH) is encouraging investigators to do just that. (See “NIMH’s RAPID Response” below)

“In the conversations I’ve had with people at NIMH,” says Keane, “they are well aware there may be ways of going about trying to understand this that are different from what we’ve done in the past. The goal is to try to improve our readiness and our response should these sorts of things happen again. NIMH is thinking very broadly about how we can scientifically generate a new knowledge base that will inform public policy in the wake of traumatic events. This necessarily requires bringing together the best scientific minds to try to understand what research methods might be employed.”

Keane said he has suggested that the NIMH comb its currently funded research protocols in the New York City area for those which might develop potentially useful new information, then invite those investigators to expand their work to take into account the effects of the attacks on population segments they are already studying. “The objective would be to identify investigators who have data sets that might serve as a baseline, and to ask them to submit proposals for additional funding,” says Keane.

“The big question that is being asked right now is, how do you manage to treat large populations exposed to traumatic events with a mental health system that is already struggling? What’s needed, and how are we going to deliver it?”

Also of importance is how to target services for greatest effectiveness. Especially vulnerable to PTSD-like symptoms, Keane says, are those who have had previous psychological stress. “It’s the interaction of the exposure variable with the personal characteristics variable. Have you been traumatized before? Have you had depression, or general anxiety disorder? If so, you may be at greater risk of developing post-traumatic symptoms.”

For those people, Keane says, “it is very important that they remain open to discussion of what’s happened, and about their fears of what may happen, but to limit the amount they follow the news or watch television. You certainly don’t want to suppress or ignore discussion, that’s not realistic, but at the same time you want to be able to sleep, you want to be able to eat properly, exercise properly, and not become absorbed with every detail … (What’s needed) is a balancing of expressing and receiving new information, processing that information and then going on about your normal everyday activities, cautiously, in an informed way.”

CONFLICTS IN COPING STYLES

Michigan’s Nolen-Hoeksema had already collected psychological profile data on a few hundred Bay Area subjects before the earthquake, investigating how different individuals coped with stress and how those coping styles contributed to or relieved depression. Following the earthquake, she re-interviewed the same subjects about their reactions, examining for both PTSD and depression and a variety of other stressors, and comparing her findings to her baseline data. What she learned, she says, could be useful now.

“In the earthquake studies,” she says, “some people really wanted to talk a great deal about what had happened, whereas others wanted to talk about it for a while and then get off the subject. Each one felt strongly that the way they coped was the right way. Each was saying, in effect, ‘I know the right way to feel, and you shouldn’t feel the way you do.'”

Differing coping styles, Nolen-Hoeksema says, “creates conflict between family members and friends because one wants to keep talking about it-in this case the September 11 attacks-and the other may be completely saturated with it, can’t stand hearing or talking about it any longer, and in fact blows up at the other person. It causes resentment, feelings of betrayal in the one who feels the need to talk, and probably feelings of guilt and anger in the one who blows up as well.”

In an earlier study, Nolen-Hoeksema had followed subjects for 18 months after the death of a loved one and found that the increased depression among those who felt the most conflict over their coping styles persisted 18 months out.

Such conflict often peaks during holiday season, she says, when families gather and prior conflicts resurface. “If you then add the arousal that our current situation creates,” Nolen-Hoeksema says, “I think that’s fuel for an explosion.”

Much of the nation may be going through similar episodes now, her research suggests. To find out, she and a colleague are extending her earlier work to a student population’s reaction to the September 11 attacks, investigating how those students are coping with it, whether they feel friends and family are supporting their coping styles or creating conflicts because of them, and to what degree those conflicts are associated with symptoms of depression.

Young, a SAD researcher, says he may also do a follow-up study at the Illinois Institute of Technology, where “we have a student population we’ve already studied for seasonality.” For all its horror, “the current environment does provide an opportunity for studying these interactions, both from basic science and public health perspectives,” Young says.

Australia’s Forgas assigns high priority to research that might develop “a better understanding of how affective states operate and how they impact on our thinking, judgments and behaviors.”

“This whole area has been largely neglected by psychologists in the past,” Forgas says, “and most of what we know has been discovered only in the past 20 years or so. I believe that carefully controlled laboratory studies can give us a fundamental understanding of the influence of affective states on thinking and judgments.”

Holiday Blues

The distresses that for some are part of emotionally-charged holiday season hardly appear on the radar screens of psychological science. But there are a number of interesting questions around the notion that at-risk individuals may be more susceptible to affective problems during the holidays because of the nature of the season.

“There hasn’t been much specific field research on how routine vs. open-ended, unstructured, holiday activities generally impact on people’s thinking and their emotional states,” says Joseph P. Forgas, who heads the Affect Research Laboratory at the University of New South Wales in Sydney, Australia. “I am not even sure if the ‘holiday blues’ is a statistically reliable event, or something that is anecdotally known. It may well be that most people actually feel happy during holidays, but we don’t hear much about this since it is expected. Those who get depressed are more likely to arouse attention and so we may overestimate the frequency of this occurrence.”

The APS Fellow does note, however, that holidays interrupt “routine, everyday, habitual activity” and that this interruption “allows more difficult, problematic issues to come to the fore. Many of these problems can elicit negative affect, as they relate to unsolved, enduring issues not adequately dealt with during ‘normal’ times, when more routine demands take up all spare cognitive capacity.”
“Holiday times are stressful for many people because they don’t have family, or because they do,” says APS Member Michael Young, of the Illinois Institute of Technology. “At holiday time, there are a lot of associations with growing up, being either especially happy or facing especially difficult times. Memories of the past are one source of stress, but so are current family issues. In stressful families, you usually find a lot of stress when the family gets together. Some people cope excellently despite horrible circumstances, others can’t cope even with mildly stressful circumstances. The vulnerable people will respond to milder stresses with psychological problems.”

Experiments at Forgas’s Affect Research Laboratory typically involve inducing positive or negative affective states in people-for example by asking them to watch a happy or sad film, or to think about happy or sad events-and then asking them to make judgments about various issues, to interact with others, to engage in discussions and negotiations, and similar tasks. “This allows us to measure carefully how the induced affective state influences their responses,” Forgas says.

Such experiments show that the more complex and demanding a problem, the more magnified its affective influences, because people need to rely all the more on memory-based, stored information to deal with it, but if they are influenced by a negative affect-such as holiday stress-they’ll tend to access negative information and could end up perpetuating or exacerbating the affective state.

“We have several experiments that show that a negative- or a positive-mood state tends to have a far greater impact on judgments and responses when people think about serious, difficult problems in their personal lives and relationships, compared to more easy, superficial problems,” Forgas says.

Bright Lights, Circadian Rhythms

It is possible that people who suffer from Seasonal Affective Disorders (SAD) are prime targets for even more severe depression during the holidays. “We’re fairly confident that people who do have a long-term diagnosis of SAD become more symptomatic during stressful periods of their lives,” says Michael Terman, of Columbia University, an APS Fellow and Charter Member. “We might predict that in SAD patients, we’re going to see higher levels of symptom severity this winter than in previous years.” And because it’s a fuzzy line that separates clinical SAD from its much more common subsyndromal cousin (S-SAD), more people who experience S-SAD are likely to rise to the clinically severe level of the disorder.

As daylight hours diminish in the fall, many people begin to experience “winter doldrums.” Those with the severest symptoms are clinically diagnosed as having SAD, marked by at least two successive annual episodes of major depression that begin in October or November, peak in January and February, and subside as spring approaches. The depression typically is accompanied by a rising appetite for carbohydrates, weight gain, daytime fatigue and loss of concentration, anxiety and longer periods of sleep.

As might be expected, SAD is more prevalent in northern climates, where winter days are shorter, than southern. One survey indicated that about 6 percent of New York City’s population may have had clinically diagnosed SAD, compared to 2 percent in Florida. Many others, however, experience “subsyndromal” S-SAD. For example, the New York survey found 18 percent who reported milder SAD symptoms that were bothersome, and another 35 percent noted symptoms but no complaints.

LIGHT SLEEPERS

“All these years, what’s been typical is that all patients were instructed to wake up at 6 a.m. for light therapy,” says Terman, who recently discovered something that threw that into question. “For some people, that’s going to be much too early,” he says now.

That’s because in deciding when to administer the light therapy, what’s important is not the time of day but the “time” on each patient’s circadian clock-where the person is in his or her daily cycle of melatonin production. The “bottom” of the cycle may occur at 6 a.m. for one person and at 8 a.m. for another. By timing the light therapy using that clock, the circadian rhythm can be more effectively advanced or delayed.

Terman’s major insight this year, he says, “was the realization that the onset of melatonin production correlates very highly with the spontaneous sleep interval. If we find the midpoint of sleep, that’s likely to start approximately six hours after the onset of a person’s melatonin production. From that we can predict, plus or minus an error factor, and make a best guess” about when to begin light therapy.

He has now gone another step, using a “morningness and eveningness” questionnaire to chart phases of melatonin secretion more closely. “A person with a high evening score on the questionnaire begins melatonin secretion later than one with a high morning score,” he explains.

The questionnaire was tested this summer and posted on the Internet this fall. (It can be accessed at www.cet.org/AutoMEQ.htm.) The 19-item questionnaire takes about 10 minutes to complete and gives those who take it immediate feedback on:

• Their morningness-eveningness scores (whether they are “larks” or “owls”)
• Their “type” relative to others
• An estimate of when their brain starts producing melatonin
• An estimate of their “natural bedtime” as guided by their internal body clock
• An estimate of the best time in the morning to use bright light therapy

“It’s already being used by hundreds of people,” Terman says. “They’re catching on very quickly.”

The ideal, he says, would be for patients to test their own melatonin levels at home and calculate precisely when to start light therapy, but such a home test isn’t yet available. However, it’s getting closer: melatonin levels can now be detected from saliva, so blood samples are no longer necessary. Saliva samples can then be taken to a laboratory for analysis and calculation of the timing of therapy. However, even this is not yet widely available.

Although bright light is the first defense against SAD, it isn’t the only one. At least two others show promise:

1. Dawn simulation: While the patient sleeps, a specialized apparatus gradually lights the room to mimic pre-sunrise springtime dawn, even though it is still dark outdoors in wintertime. A week of such exposure has been shown to produce an antidepressant response, earlier awakening and melatonin phase advances.
2. High density negative air ionization: This intervention was effective in a placebo controlled trial, but how it works is still unknown. “Although further clinical trials are needed,” says Terman, it “appears to hold promise as an alternative or adjunct.”

“We are now running a replication trial,” he says, “trying to enhance the reception of negative ions, literally by grounding the patient to the ionizing system. Ions are delivered during sleep. The patient lies on a conductive bedsheet that is grounded. Thus, the flow of ions is directed to the body rather than to the radiator or television or phone. We’re trying to minimize the variability and estimate how effective it is relative to a placebo. It’s part of a five-year NIMH trial that’s now entering its final stages. We should see results in a year or two.”

The distinction between SAD and S-SAD may have little clinical importance: significant improvement in patients with S-SAD have been achieved in clinical trials using the same therapies that work on SAD. “In other words,” says Terman, “the lower severity of depressed mood should not imply that reduced exposure to bright light will be sufficient to relieve winter symptoms.”

DUAL VULNERABILITY

“Depression is often a recurring disorder,” Young says. “I had been studying how people go in and out of episodes and how that might tell us something about the mechanisms, what made them change from their usual selves to being depressed. But it’s hard to design research to study that because it’s hard to know in advance when people are going to be depressed. You have to take someone with a history of depression and wait for them to get depressed.”

In the early 1990s, he teamed with psychological biologist Charmaine Eastman at Rush Medical Center, who was doing biological rhythms research. SAD was “a perfect model for studying depression,” he says, “because people would get depressed every year at about the same time, so I started studying SAD with her, looking at the interaction of biological and psychological factors.” It was in that work that he developed his “dual vulnerability” hypothesis.

“According to my hypothesis, some people who have more severe physiological changes also have higher vulnerability for depression symptoms. These are probably the same psychological depression vulnerabilities that go along with other kinds of depression. It’s a general model my students and I are looking at, to develop a theory of how to think about the biological and psychological factors, how they combine and interact to produce depression. We have several studies going on.”

A “hot” area of SAD research right now, he says, is the search for the paths along which light messages are transmitted to the brain’s biological clock: “It appears that there are receptors and nerves from the eye to the SCN that are not visual receptors, that there are other receptors in the retina that transmit that information. Investigators are trying to figure out what and where they are, because we need to know the basic biology.

“The real frontier, however, is not just more biology,” says Young. “The real frontier is the interaction of biology and psychology. I think SAD is one of the great areas for actually studying that interaction. In SAD, we have a well-defined biological component: we know it’s seasonal, and it has to do with light, so it’s the biology of light reception and our biological clock that we have to understand. We have a more focused picture of what the biology is for SAD than we do for depression in general, so because of that, it’s a ripe area to study these interactions.”

Unfortunately, he says, funding for such research is scarce. “We’re really in a bad place. SAD research is not funded very well.”

Needed: New Tools, Better Data

When biostatistician David W. Smith, formerly of the University of Oklahoma, set out to study the effects of the Oklahoma City bombing on the general population, he could find no survey instruments that met his needs.

“We have a variety of public systems in place that do a good job of meeting the needs of victims in the immediate aftermath of a disaster, man-made, natural, or intentional man-made,” says Smith, “but I must emphasize: we do not have any systems to deal with the long term impact of such disasters on everyone else.”

“The public mental health impacts of such disasters, including both the personal psychological effects and the social effects, are unknown,” according to Smith. In order to understand these impacts, we have to make a commitment to measuring the important effects, and we have to commit to research that helps us to measure what is important and helps us make sound public decisions using the resulting information.”

The 1995 bombing in Oklahoma City, Smith says, “brought out the best in people who contributed all the materials and services you need-batteries, shovels, even laundry services. Why did they do this? Did it do the contributors any good? We don’t know, and we should if we are going to meet the future needs of our society.”

In Oklahoma, “we had to invent the whole thing,” he says. No instruments existed that fit his requirements. That pointed out a glaring need among researchers: baseline data are sorely lacking because the tools don’t exist to collect them.

The Diagnostic Interview Schedule (DIS) of over 100 questions was too cumbersome for his telephone survey of 1,000 persons in Oklahoma and another 750 in the control population of Indianapolis. In any event, the DIS is a diagnostic device, not a screening tool, and at that point (1995) had never been used in a telephone survey.

The National Health Interview Survey (NHIS) had no distress-related questions in 1995. It now has six-two on anxiety, four on depression-which Smith says is a “teeny tiny start”-but it is not city or region-specific, so it does not offer the possibility of extracting baseline data for a specific area of the country.

“We might be able to select out the responses for the largest metropolitan areas, such as New York City,” Smith says,”and I’d love to get my hands on that data (to do post-terrorist attack comparisons), but what if it had been in a smaller urban area, where there are probably too few responses to be useful, even if we could separate them out?”

Finally, the Center for Disease Control and Prevention’s Behavioral Risk Factors Survey System (BRFSS) has a module that includes psychological distress questions, and thousands are surveyed in each state each year using BRFSS, but states are free to select the modules they want. “We need to include those questions on NHIS,” Smith says, so that they are asked nationwide.

However it is constructed, he says, “I believe we need a national and local system of surveys that collect ongoing data about the impacts of disasters. We need estimates for the areas where disasters occur, and we need estimates for comparison or control areas. We need information from both before and after disasters. This information can be used to make estimates of the true impact, since we will already know what the usual responses are without a disaster.”

CHECKLIST OF RESEARCH GAPS

“Complex problems,” Smith says, “may be greatly ameliorated by advance activities such as preparing a simple disaster kit that includes a radio, flashlight, potable water, and some emergency food. This kind of activity involves everyone in planning for a disaster, gives them some understanding and belief that they may be involved, and may permit them to feel that they have participated in disaster relief if they use their supplies to help others.

“Mind you, I have no reason to think that this is beneficial in any way. The point is that we need research to begin to understand what we can do before, during, and after a disaster to alleviate its long-term consequences.”

Smith said “tailored, special-purpose surveys” are also needed to assess the social and psychological status of the population, conducted periodically after any disaster. He suggests such special purpose surveys measure:

• Exposure to the disaster, tailored to the event
• The social impact of the disaster, such as changes in work habits, social habits, and disability
• Changes in health behavior, such as smoking, drinking and exercise
• Psychological impacts of the disaster, including screening for anxiety, PTSD, acute stress disorder and depression
• Workplace, travel, and home disruption
• Social support
• Reaction to the disaster-personal and behavioral, private and public

“We even need more research to determine what we should be measuring,” he says. “These are only the start. Are we ready for this? No, we are not ready. We are not asking what the public health impact is for everyone, not just the immediate victims, and over the long term, not just the short term.”

NIMH’s Rapid Response

Within a month of the September 11 terrorist attacks, the National Institute of Mental Health (NIMH) issued an invitation to the scientific community to apply for fast-track funding of a broad range of studies “to better understand the nature of problems people experience, the types of help they seek, and the readiness of our health and human service delivery systems to provide needed care and treatment.” Protocols are also being developed internally at the institute.

The “Rapid Assessment Post-Impact of Disaster (RAPID) Research Grant Program” covers a laundry list of research needs in psychological, physiological, biological and behavioral reactions to trauma; risk factors for mental health sequelae (including post-traumatic stress disorder, depression and substance abuse), and optimal provision of mental health services, prevention and treatment.

A list of seven broad categories of invited research is posted on the NIMH web site. Although heavily weighted toward the needs of immediate victims, survivors and rescue workers, it does include epidemiological research on “the mental and physical health impact on … community members” as well. Details are posted at www.nimh.nih.gov/home.cfm#breaking.

“Collecting information in the difficult days and weeks following a disaster presents special challenges,” the NIMH announcement cautions. “[F]oremost among them is the need for investigators to attach the highest priority to standards of privacy, dignity, and courtesy in their interactions with participants who were affected in any way by an event under study.

“Only through research that is conducted in accordance with such standards will we gain information needed to enhance our capability to heal the psychological wounds that may be associated with disasters and to prevent long-term or recurring psychological distress.”

NIMH has promised that RAPID applications and grants related to the tragedy will be administered “with maximum flexibility … (including) a lifting of the stated dollar cap for applications.”