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9-11, Personal Stress, Mental Health, and Sense of Control Among Older Adults

¹ School of Public Health
² School of Medicine
³ College of Public Service, Saint Louis University, Missouri.
⁴ Indiana University School of Medicine, Indianapolis, Indiana.
⁵ Regenstrief Institute for Health Care, Indianapolis, Indiana.
⁶ Saint Louis Veterans Administration Medical Center, St. Louis, Missouri.
⁷ Indianapolis Veterans Administration Medical Center, Indianapolis, Indiana.

Address correspondence to Fredric D. Wolinsky at the School of Public Health, Saint Louis University, 3545 Lafayette Street, Room 372, St. Louis, MO 63104-1314. E-mail: wolinsky{at}slu.edu. After July 1, 2003, address correspondence to Fredric D. Wolinsky, 200 Hawkins Drive, E205 General Hospital, Iowa City, IA 52242.

	Abstract

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Objectives. We assessed whether the events of 9-11 affected the personal stress, mental health, or sense of control of older adults participating in an ongoing longitudinal study, and whether baseline characteristics were associated with the magnitude of any such changes.

Methods. Personal stress, mental health, and sense of control were measured at baseline and at six bimonthly follow-up interviews among 1,662 patients. Of these, 437 had the opportunity to complete three interviews before and after 9-11, with 291 (67%) completing all six. We performed graphic comparisons, paired t tests, classification based on standard errors of measurement (SEMs), and multiple linear regressions for patients who completed all six interviews.

Results. No noticeable changes in aggregate trends for personal stress or mental health were associated with 9-11. However, 9-11 was associated with an aggregate decline in sense of control. This decline in sense of control was greater among those who were working for pay, had more comfortable incomes, and reported greater religiosity.

Discussion. Older adults more closely resembling those who died during 9-11 and those with greater levels of religiosity were most likely to have their sense of control affected by this catastrophic event.

A MAJOR theme in social gerontology is the way that older adults respond to stressful life events (Antonovsky, 1979, 1987; Ekerdt et al., 2002; Pearlin, Menaghan, Lieberman, & Mullan, 1981; Selye, 1956). Sometimes these events are normative, as in the case of disability, retirement, or bereavement (Riley & Foner, 1968; Riley, Foner, & Waring, 1988; Riley, Johnson, & Foner, 1972). These events are considered normative because most individuals experience them over their life course, although at different points in chronological time (Riley, 1973; Schaie, 1965). In general, adaptation to normative events and a return to normalcy are feasible, although the adjustment period varies and depends on available coping skills and resources (Rowe & Kahn, 1998; Solomon, Salend, Rahman, Liston, & Reuben, 1992). Nonnormative events, however, are another matter. Like the Holocaust, the Great Depression, or World War II, these are often simultaneously thrust upon an entire cohort (Ryder, 1965). Moreover, nonnormative events likely have a more long-lasting effect on an entire cohort, often resulting in profound generational shifts in values, beliefs, and attitudes (Brokaw, 1998, 1999, 2001).

Although prospective cohort studies may be designed to assess the response to normative events, this is usually not feasible for the study of nonnormative events. Indeed, most of the literature on responses to nonnormative events comes from postevent, archival, or longitudinal studies that follow up unrepresentative samples (Elder, 1974, 1986, 1987; Elder, Pavalko, & Clipp, 1993; Schulz, Heckhausen, & Locher, 1991). In this brief report we seize the opportunity to evaluate whether 9-11 affected the personal stress, mental health, or sense of control of older adults participating in an ongoing longitudinal study.

	Methods

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Sample
As part of a study of clinically relevant change in the health-related quality of life of patients, we recruited older adults receiving primary care from an inner-city academic general internal medicine practice in Indianapolis or the outpatient clinics at the St. Louis Veterans Administration Medical Center. Patients were potentially eligible if they were identified by a computerized review of the electronic medical record that used age and medical criteria approved by three expert physician panels. All patients had to have a scheduled visit from August of 2000 through November of 2001, and they had to meet the criteria for coronary artery disease or congestive heart failure (CAD/CHF), chronic obstructive pulmonary disease (COPD), or asthma. The age criterion for CAD/CHF and COPD was 50 years old or older, whereas it was 18 years old or older for asthma. The patient's primary care physician then reviewed the medical record and confirmed that the patient had the target disease. Finally, each confirmed patient who kept a scheduled visit received a brief screening interview to verify that a physician had told the patient that he or she had the target disease, that the patient acknowledged having symptoms associated with the disease, and to confirm that the patient had access to a working telephone. Of the 2,493 English-speaking patients who satisfied all of these criteria, 1,662 (67%) were successfully enrolled into the study. Most patients received their baseline telephone interview within 3 days of enrollment.

Because our purpose was to determine whether 9-11 affected existing trends in personal stress, mental health, or sense of control, only patients with three interviews both before and after 9-11 were selected for analysis. Fewer data points would not have permitted differentiation of minor fluctuations from more enduring changes. Moreover, given the design of the larger study, no patient could have had more than seven bimonthly interviews.

A total of 437 patients were enrolled between January 14, 2001 and May 11, 2001, and each had the opportunity to complete three bimonthly interviews before and after 9-11. Of these, 291 patients (67%) completed all six interviews. A comparison of this subsample of 291 patients with the other 1,371 patients in the larger study indicated few significant differences. The 291 patient subsample included more men (69% vs. 60%) and was slightly better educated (11.8 vs. 11.2 years). No differences were found on personal stress, mental health, or sense of control at baseline.

Personal Stress
The National Opinion Research Center (NORC) National Health Survey (McHorney & Lerner, 1991) personal stress scale includes two items: (a) In general, how much stress or pressure have you experienced in your daily living in the past 4 weeks—would you say none, a little, a good bit, quite a bit, or a great deal? and (b) To what extent do you feel that the stress or pressure you have experienced in your life has affected your health—would you say not at all, slightly, moderately, quite a bit, or extremely? The resulting scale was transformed such that 0 reflects maximal stress and 100 reflects minimal stress (M = 57.0, SD = 27.4, and =.691).

Mental Health
The Mental Health Inventory (MHI-5) scale from the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36; Version 2; Ware, Kosinski, & Dewey, 2000) includes five items that share a common stem (How much of the time during the past 4 weeks have you ...) followed by (a) been nervous; (b) felt so down in the dumps that nothing could cheer you up; (c) felt calm and peaceful; (d) felt downhearted and depressed; and (e) been happy? Also shared is the five-option response set—all of the time, most of the time, some of the time, a little of the time, and none of the time. After items 3 and 5 were reverse coded, the resulting scale was transformed such that 0 reflects the worst mental health and 100 reflects the best mental health (M = 63.3, SD = 21.2, and =.829).

Sense of Control
Mirowsky and Ross' (1991) eight-item sense of control measure reflects Rotter's (1966) internal–external approach, but it balances claiming versus denying responsibility. The items are as follows: (a) I am responsible for my own successes; (b) I can do just about anything I really set my mind to; (c) my misfortunes are the result of mistakes I have made; (d) I am responsible for my failures; (e) the really good things that happen to me are mostly luck; (f) there's no sense planning a lot—if something good is going to happen it will; (g) most of my problems are due to bad breaks; and, (h) I have little control over the bad things that happen to me. Items 1–4 (coded -2, -1, 0, 1, and 2 for strongly disagree, disagree, don't know, agree, and strongly agree, respectively) reflect responsibility (internal), and items 5–8 (reverse coded) reflect fatalism (external). The eight-item scale was transformed such that 0 reflects positions of maximal fatalism and 100 reflects positions of maximal responsibility (M = 59.7, SD = 13.5, and =.714).

Covariates
Three categories of covariates were considered: demographics, socioeconomic status indicators, and psychosocial factors. Demographics included age, gender, and race. Age was measured in years (M = 64.3 and SD = 10.4; range = 39–91). Gender was measured with a binary variable coded 1 for males (68.7%). Race was measured by a binary variable coded 1 for Whites (65.3%).

Socioeconomic status indicators included education, employment history, and subjective income. Education was measured in years of completed schooling (M = 11.8 and SD = 3.1; range = 0–25). Employment status was measured with a set of three dummy variables reflecting working for pay (16.2%), being retired (40.9%), and not having a substantial history of labor force participation (42.9%; the reference group). Subjective income was measured by a binary variable reflecting patient reports that their incomes were comfortable (26.8%).

Psychosocial factors included social support and religiosity. Social support was measured by a five-item subset ( =.852) of the Medical Outcomes Study social support scale (Sherbourne & Stewart, 1991). To facilitate interpretation, we collapsed the scale score into a binary marker coded 1 for those in the top quintile (20%). Religion was measured with a two-item scale ( =.806) and used the summary religiosity and spirituality items from the Fetzer instrument (Fetzer Institute, 1999). To facilitate interpretation, we collapsed this scale score into a binary marker coded 1 for those in the top tertile (31%).

Analytic Approach
There were three phases to the analysis. The first was a graphic presentation of the aggregate trends. The second phase involved paired t tests of the interviews immediately before and after 9-11, as well as the calculation of standard errors of measurement (SEM), where SEM was defined as the standard deviation of the instrument multiplied by the square root of 1 minus its reliability coefficient (Anastasi & Urbina, 1987). Finally, multiple linear regression (Allison, 1999) was used to determine whether the covariates were significantly associated with any observed response to 9-11.

	Results

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Graphic Comparisons
Figure 1 displays the means of personal stress, mental health, and sense of control over the six interviews. The dashed lines between the third and fourth interviews indicate the occurrence of 9-11. During the period before 9-11, a monotonic increase in the personal stress score (indicative of better coping) and the sense of control score (indicative of claiming greater responsibility) are apparent, but mental health appears stable. In the period after 9-11, improvements in personal stress scores continue (a drop at the fifth interview notwithstanding), and mental health remains stable. Sense of control after 9-11, however, suffers an immediate decline followed by a gradual restoration to the before 9-11 level.

View larger version (18K): [in this window] [in a new window]   Figure 1. Stress; mental health; and sense of control before and after 9-11

	Discussion

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We examined whether 9-11 affected the personal stress, mental health, or sense of control of 291 older adult patients in an ongoing longitudinal study. Each patient completed three bimonthly interviews prior to and after 9-11. No alterations in aggregate trends were observed for personal stress and mental health. A modest trend of claiming greater responsibility was interrupted by 9-11, resulting in an immediate decline followed by a gradual restoration to the before 9-11 level. At the individual level, important change (i.e., 1 SEM) did occur for a substantial proportion of patients on all three outcomes. Only the magnitude of the change in the sense of control, however, was associated with any of the covariates. Greater declines in sense of control occurred for those working for pay, having a comfortable income, and reporting greater religiosity.

Three questions remain to be answered. First, why did 9-11 not alter the aggregate trends in personal stress or mental health? We submit that because the two-item personal stress scale focuses on how daily pressures affect one's life and health, the nonnormative events of 9-11 had little relevance, at least among older adults in Indianapolis and St. Louis. Similarly, the five mental health items tap depressive symptoms (being nervous, down, calm, downhearted, or happy), and the reaction to 9-11 would likely be more palpable to measures that targeted feelings of anxiety, anger, frustration, or revenge.

Second, why did 9-11 alter the aggregate trend for sense of control? The answer lies at the heart of what the sense of control measures. More than anything else, sense of control is a representation of the patient's view of the just world perspective. A nonnormative event with profound devastation that brought international terrorism to American shores would likely be viewed as a shocking violation of the just world perspective, especially among a cohort predisposed to claim responsibility for their own successes and failures.

Such an answer, however, implies that the bulk of the 9-11 effect should have registered with the items reflecting fatalism. To address this, we replicated the analyses at the subscale level (not shown). Prior to 9-11, both the responsibility and fatalism subscales exhibited an aggregate trend toward greater internal control. The responsibility subscale immediately declined after 9-11, but then it resumed its upward trend. In contrast, after its 9-11 decline, the fatalism subscale was at plateau. Moreover, although none of the covariates predicted the magnitude of the 9-11 decline in the responsibility subscale, the magnitude of the 9-11 decline in the fatalism subscale (R² =.048) was significantly greater for those having a comfortable income (ß = -.155) and reporting greater religiosity (ß = -.122), and the insignificant (p =.104) effect of working for pay was comparable with that observed for the eight-item sense of control measure (ß = -.108).

The final question to be answered is, Why was the magnitude of the reaction in sense of control to the events of 9-11 associated with working for pay, having a comfortable income, and reporting greater religiosity? The increased risk of decline associated with these three factors is opposite that expected from the extant literature (Mirowsky & Ross, 1991). We submit that the increased risk reflects both the greater affinity of older adults with these characteristics for the just world perspective, and the similarity of the 9-11 victims to them.

	Acknowledgments

 
This research was supported by grants from the Agency for Healthcare Research and Quality to Dr. Wolinsky (Grant R01 HS-09692) and Dr. Wyrwich (Grant K01 HS-07632). We thank Elena M. Andresen, Michael A. Counte, James G. Gurney, and Sally R. Wolinsky for their comments on earlier drafts. The opinions expressed here are those of the authors and do not necessarily reflect those of the funding agencies, academic, research, or governmental institutions involved.

	Footnotes

 
Decision Editor: Charles F. Longino, Jr., PhD

Received for publication November 7, 2002. Accepted for publication November 8, 2002.

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