In the first year after the World Trade Center attacks, the proportion of individual counseling visits ending in referral to mental health treatment services decreased through time from about 30 to 6 percent of first visits and from 30 to 4 percent of follow-up visits (Figure 1). Between one and two years after the attacks, the proportion of visits ending in a referral slowly increased to about 18 percent for first visits, while the proportion for follow-up visits remained generally steady (about 4 to 6 percent) (Figure 1). Overall, 59,526 of 684,500 (9 percent) visits for individual counseling for which visit information was available (10 percent of first visits and 6 percent of follow-up visits) ended with a referral to professional mental health services.
Results of hierarchical MIXNO models indicated that the strongest predictor of receiving a referral to professional mental health services was the number of event reaction categories scored as present (z=197.2, p<.001). Referrals were received by 386 of 43,898 individuals (1 percent) with no categories, 2,977 of 77,392 (4 percent) with one category, 6,736 of 107,306 (6 percent) with two categories, 11,579 of 144,295 (8 percent) with three categories, and 37,848 of 311,609 (12 percent) with four categories. The second-strongest predictor was risk category (z=-85.2, p<.001), with the following groups accounting for more referrals: individuals who were directly affected by the attacks (persons who were injured, World Trade Center or school evacuees, World Trade Center employees absent on the day of the attack, or persons who experienced significant damage to their home) (6,447 of 49,213 persons, or 13 percent); those who were rescue or recovery workers (1,729 of 13,584, or 13 percent); those who had a physical disability or preexisting trauma, mental health, or substance abuse problem (11,843 of 94,914 persons, or 12 percent); those who experienced loss of family (4,184 of 33,830, or 12 percent); those who experienced job loss (7,985 of 69,056, or 12 percent); and uniformed personnel (8,791 of 88,566, or 10 percent). Categories of risk were hierarchic; for example, an individual who experienced both job loss and loss of family was considered to be in the latter category.
Compared with persons in the other risk categories, children categorized as belonging to the risk group of schoolchildren and members of the general population had fewer referrals (3,328 of 86,343 schoolchildren, or 4 percent, and 15,219 of 248,994 members of the general population, or 6 percent). Age was also related to referral to professional mental health services (z=66.1, p<.001), with adults being more likely than children to receive a referral (54,969 of 576,074 adults, or 10 percent, compared with 4,260 of 105,244 children, or 4 percent).
The model including time variables was significant above and beyond the model that did not include terms representing months since the World Trade Center attacks (χ2=6,501.2, df=4, p<.001), indicating that time and type of visit (first or follow-up) through time exerted an independent effect above and beyond the other variables in the model (z=2.0, p<.05 for month2, z=-40.2, p<.001 for visit type by month, and z=8.6, p<.001 for visit type by month2; findings were not significant for month alone).