Risk Factors for Depression Among Civilians After the 9/11 World Trade Center Terrorist Attacks: A Systematic Review and Meta-Analysis.
Introduction: The development of depressive symptoms among the population of civilians who were not directly involved in recovery or rescue efforts following the 9/11 World Trade Center (WTC) terrorist attacks is not comprehensively understood. We performed a meta-analysis that examined the associations between multiple risk factors and depressive symptoms after the 9/11 WTC terrorist attacks in New York City among civilians including survivors, residents, and passersby. Methods: PubMed, Google Scholar, and the Cochrane Library were searched from September, 2001 through July, 2016. Reviewers identified eligible studies and synthesized odds ratios (ORs) using a random-effects model. Results: The meta-analysis included findings from 7 studies (29,930 total subjects). After adjusting for multiple comparisons, depressive symptoms were significantly associated with minority race/ethnicity (OR, 1.40; 99.5% Confidence Interval [CI], 1.04 to 1.88), lower income level (OR, 1.25; 99.5% CI, 1.09 to 1.43), post-9/11 social isolation (OR, 1.68; 99.5% CI, 1.13 to 2.49), post-9/11 change in employment (OR, 2.06; 99.5% CI, 1.30 to 3.26), not being married post-9/11 (OR, 1.59; 99.5% CI, 1.18 to 2.15), and knowing someone injured or killed (OR, 2.02; 99.5% CI, 1.42 to 2.89). Depressive symptoms were not significantly associated with greater age (OR, 0.86; 99.5% CI, 0.70 to 1.05), no college degree (OR, 1.32; 99.5% CI, 0.96 to 1.83), female sex (OR, 1.24; 99.5% CI, 0.98 to 1.59), or direct exposure to WTC related traumatic events (OR, 1.26; 99.5% CI, 0.69 to 2.30). Discussion: Findings from this study suggest that lack of post-disaster social capital was most strongly associated with depressive symptoms among the civilian population after the 9/11 WTC terrorist attacks, followed by bereavement and lower socioeconomic status. These risk factors should be identified among civilians in future disaster response efforts.