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Acute symptoms and functional impairment related to September 11 terrorist attacks among rural community outpatients with severe mental illness.

An expert panel advising the Federal Response Plan for preparedness in terrorist attacks,1 particularly attacks involving weapons of mass destruction, has stated that our communities are not adequately prepared for the psychological and behavioral consequences of such events, which are predicted to be pervasive, enduring, and costly. Vicarious trauma in the community is documented for the most recent terrorist attacks in the United States (September 11, 2001,2 and the 1995 Oklahoma City bombing3,4) and has also been suggested with community serial murders.5 The definition of “community” appears to expand as the scale of terrorist attack expands—for example, stress reactions to September 11 were pervasive across the country2 (although most severe close to New York City), and the subsequent postal anthrax attacks in the United States resulted in a significant “false alarm” public health burden in both the United States6 and Europe.7 Review of the literature suggests that persons with severe mental illness (SMI) are more vulnerable than the general population to developing posttraumatic stress disorder (PTSD).8 This indicates that populations with SMI would be susceptible to clinical decompensation in the wake of terrorist attacks, yet to date we have no evidence of stress reactions since September 11 that are specific to these populations and related to the terrorist events. On the contrary, a study using the Department of Veterans Affairs national database of service utilization as a probe for increased morbidity9 found no statistically significant increase in service use among