摘要：Objectives. We examined the extent to which the stress paradigm linking psychosocial stressors to mental health status has focused disproportionate attention on microlevel social stressors to the detriment of macrolevel stressors. Also, we assessed the effects of the terrorist attacks of September 11, 2001, on subsequent mental health among participants in a Midwestern cohort study. Methods. Respondents in a 6-wave longitudinal mail survey completed questionnaires before September 11, 2001, and again in 2003 and 2005. Regression analyses focused on measures of negative terrorism-related beliefs and fears, as well as psychological distress and deleterious alcohol use outcomes measured both before and after September 11. Results. Negative terrorism-related beliefs and fears assessed in 2003 predicted distress and drinking outcomes in 2005 after control for sociodemographic characteristics and pre–September 11 distress and drinking. Conclusions. The events of September 11 continue to negatively affect the mental health of the American population. Our results support the utility of according greater attention to the effects of such macrolevel social stressors in population studies embracing the stress paradigm. The stress paradigm guiding research on the effects of psychosocial stressors on mental health outcomes 1 – 4 initially addressed exposure to stressful life experiences involving acute life events, such as the death of significant others, or chronic stressors, such as financial difficulties, as predictors of negative mental health outcomes. An important limitation of stress research has been its narrow focus on micro- or individual-level stressors to the detriment of broader macrolevel social stressors. Stress researchers 3 , 5 , 6 reviewing the stressors typically studied in large representative samples have noted the predominant focus on individual-level stressors (e.g., stress caused by life-changing events). Although some studies have also addressed more macrolevel stressors such as economic recessions 7 and adverse living conditions, 8 Wheaton 5 noted that the macro–micro distinction highlights the fact that typical life event or role strain scales have excluded macrolevel traumas such as war stress, nuclear accidents, and natural disasters. For example, Holahan et al., 9 in their longitudinal study of stress, coping, and depression, addressed acute and chronic stressors involving experiences in 8 life domains: spouse, children, extended family, physical health, home, neighborhood, finances, and work. With the exception of neighborhood, all of these constitute microlevel domains. In Wheaton’s review of the social stress literature, he further emphasized the continuing predominant focus on individual stressors and noted that “we also can and should consider political, military and social events and conditions that act as social stressors.” 6 (p288) A few researchers have included more macrolevel experiences. For example, the work of Turner et al. has addressed adversities such as “[being] in combat in a war, [living] near a war-zone, [being] present during a political uprising [and being] in a major fire, flood, earthquake or other natural disaster.” 10 (p232) However, this focus constitutes more the exception than what is typical in the overall literature. In a different although related perspective on the evolution of the stress paradigm, Link and Phelan argued that the stress literature has gradually shifted from interest in “social conditions as fundamental causes of diseases” 11 (p85) to intervening mechanisms involving the ways in which individuals cope with these conditions. They concluded that “while the current approach focuses on the individual, it can readily be seen that economic and political forces shape individuals’ exposure to risks.” 11 (p85) This perspective suggests the importance of historical contexts and changes over time in social conditions, which play etiological roles in detrimental mental health outcomes (e.g., the extent to which social institutions such as the state may be viewed as unable to provide a sense of safety for their citizens). 12 The events of September 11, 2001, signaled a major change in the sociopolitical context in the United States, highlighting the salience of political terrorism as a continuing threat to individuals’ sense of safety and well-being. A sizable literature has demonstrated that the September 11 attacks adversely affected the mental health of individuals across the nation 13 – 16 as well as those most directly affected in New York, Washington, DC, and western Pennsylvania. 17 – 19 These empirical studies, conducted in the immediate aftermath of the attacks, demonstrated elevated symptoms of depression, anxiety, and posttraumatic stress disorder (PTSD) and increased alcohol consumption. Subsequent studies conducted between 2 months 20 and 6 months 21 , 22 after September 11 demonstrated lingering feelings of distress and increased use of alcohol and other substances, including cigarettes and marijuana, relative to the period before September 11. It should be noted that research addressing alcohol use outcomes has been much more limited than research addressing manifestations of psychological distress alone. However, one national study, conducted shortly after September 11, showed decreased rather than increased alcohol consumption. 12 The extent to which the relatively immediate mental health effects of September 11 revealed in most studies have lingered is just beginning to be addressed. Boscarino et al. 23 found that exposure to psychological trauma related to the World Trade Center attack in New York City was associated with increased alcohol consumption 2 years after the attack. Richman et al. 24 demonstrated that a substantial percentage of a Midwestern population maintained negative beliefs and fears about their future safety linked to threats of future terrorist attacks in 2003 and that, after they controled for distress and drinking before September 11, these beliefs were significantly associated with distress and problematic drinking. However, a major limitation of that study was that terrorism-related beliefs and fears were measured at the same time point as distress and drinking outcomes, and thus the causal direction of the relationship between terrorism-related fears and mental health was ambiguous. In this study, we further address the salience of post–September 11 beliefs and fears in terms of mental health outcomes. That is, we examined the extent to which these fears and beliefs, as assessed in 2003, predicted a range of distress and alcohol use outcomes in 2005 after controlling for previous distress and alcohol use. We also examined gender differences given evidence indicating that such post–September 11 effects are more pronounced among women than among men. 13 , 17
