One morning in 2003, almost a year and a half after Anthony Yacopino had stopped looking for the remains of 9/11 victims at the Fresh Kills Landfill in Staten Island, he was sitting in his Bay Shore home when his heart started pounding so hard he could see his shirt moving.
The 34-year-old NYPD detective drove to Stony Brook University Medical Center, where tests showed nothing abnormal. "The cardiologist said, 'Hey, look, nothing's wrong with your heart. What's going on?' " Yacopino said. "I opened up like a deluge. I started crying and shaking."
The doctor suggested Yacopino had had a panic attack. The episodes soon became more frequent -- daily "little flutters" or big ones too overpowering to ignore. Three or four months later, when he was waiting outside a courtroom to testify on a case, he collapsed.
"The next thing I know, my legs go out from under me and, boom, I'm sitting in the chair panting like I had just run up 10 flights of stairs," he recalled.
On Sept. 11, 2001, Yacopino was on the Long Island Expressway on his way to a training session when he saw the second plane, United Airlines Flight 175, hit the south tower. He was sent to area hospitals to interview survivors, but found few. He was ordered to go to the police academy on 20th Street in Manhattan and then told to report to Bellevue Hospital Center on First Avenue.
"From there, my unit was the first to start a family bereavement center. . . . Thousands were trying to flood into the city to identify victims. . . . After two days we moved to the Armory on 26th Street, where 300 to 400 chairs had been set up. You started at the end of the chairs and you kept moving," interviewing people, he said. " 'What kind of watch was he wearing, did they have scars from surgery?' "
From there he went to the Fresh Kills Landfill, where he worked until February 2002, sifting through debris. They were days of overwhelming anger, frustration, profound shock and loss.
A decade after Sept. 11, 2001, Yacopino is one of about 1,000 Long Islanders of the 5,000 area first responders being monitored who continue to have symptoms of PTSD, said Dr. Benjamin Luft, director of the Long Island World Trade Center Medical Monitoring and Treatment Program in Islandia. About 10 percent of them also show signs of depression, a separate diagnosis from PTSD.
The panic attacks were not Yacopino's only problems. Low-flying planes "freaked me out," he said. He had flashbacks when he would recall his weeks working in the bereavement center. He would recall his disgust as he sifted through debris at the landfill looking for bits of human remains, anything that might help someone know the fate of a loved one.
He was haunted by guilt that he hadn't himself sacrificed, that he wasn't the "hero" his father, whom he idolized -- a former NYPD cop who died in October 2002 -- had been. He found himself compulsively watching TV shows about 9/11, replaying the attacks.
Worried about his health, in early 2004 he went to Luft's program, where he filled out a questionnaire. He was told that -- like a soldier returning from war -- he had post-traumatic stress disorder. He burst into tears.
The number of first responders showing mental health problems doesn't appear to be diminishing. The 2010 annual report on 9/11 health from the New York City Department of Health and Mental Hygiene stated that PTSD "is the most common WTC-related health effect among exposed adults."
"If anything, we have seen a slight increase in the number who present with mental health issues, including PTSD and depression," said Dr. Fatih Ozbay, medical director of the World Trade Center Mental Health Program at Mount Sinai Medical Center. "The reason for that is not very clear, but there is definitely persistence."
Thomas Demaria, psychologist and director of the C.W. Post 9/11 Families Center, said he is still getting new patients with 9/11-related mental health problems.
"A lot of responders didn't seek help right away," Demaria said. "They thought they were still able to do their job and also felt that those who needed attention were the 9/11 families [of victims]."
Differences across groups
The "persistence" of mental health problems Ozbay cited doesn't appear to be the same in all groups. Among 13,000 9/11 New York City firefighters being monitored, the rate of PTSD has fallen from about 12 percent to 7 percent in the last three years. However, about 19 percent show signs of depression, according to the latest data.
Dr. David Prezant, chief medical officer of the FDNY, said finding that many firefighters with depression was unexpected. He theorized that PTSD had "morphed" into depression in some cases, or perhaps exists simultaneously with PTSD. "Another is that PTSD long term can become depression."
It also could be that firefighters coping with other chronic 9/11-related diseases, such as asthma, become depressed.
"If you are a firefighter who has defined yourself as someone who can climb six flights of stairs with a 100-pound pack on your back and you can no longer do that, this could lead to a loss of identity and depression," he said.
Ozbay said that certain groups have been found to have higher rates of PTSD: those who arrived at Ground Zero in the first 24 hours and stayed for extended periods of time; workers and volunteers not trained in disaster work; and people who performed tasks not common to their occupation.
"The most important example is the construction worker who ended up picking up body parts," Ozbay said.
That is what happened to Alex Jack, 58, of Woodbury, who owned a demolition company and had gone to Ground Zero to help remove rubble and ended up sifting through debris on the bucket brigade. Jack, who was diagnosed in 2005 with PTSD when he went in for premarital counseling with Demaria, said he is still haunted by a red Converse sneaker he found that contained a mangled foot.
Other first responder studies have found that women and Latinos are more susceptible to PTSD. Dr. Sandro Galea, chair of the department of epidemiology at Columbia University's Mailman School of Public Health, said Latinos in New York City may be more isolated and lack social support. As for women, "that's a really big, open question," he said.
Another question is how PTSD affects other medical conditions and vice versa. Luft's center was just awarded $1.5 million for a three-year federal study to explore this issue. Over the years, Luft and others have observed that the asthma, say, of a first responder with PTSD tends to be worse than that of someone with no mental health diagnosis.
"We don't fully understand all of the risk factors biologically and psychologically," he said. "We want to know what is causing what and where do you make the intervention."
Despite their persistence, mental health problems still carry a stigma. Yacopino said he retired in May 2010, from the NYPD after 20 years without ever disclosing his PTSD to his fellow officers.
The James Zadroga 9/11 Health and Compensation Act of 2010 -- which sets aside a $2.77-billion compensation fund -- doesn't cover those with "only mental and emotional injuries," although those with PTSD or depression who have other medical conditions would be covered.
Galea voiced the opinion of many who have dealt with 9/11 responders struggling to cope with mental health problems.
"It's unfair," he said. "I think we need to go beyond the dichotomy between the mind and body and consider it as a health condition . . . rather than in isolation."