Superstorm Sandy came ashore nearly three years ago, pummeling the New England and Mid-Atlantic coast and becoming one of the deadliest and costliest storms to ever hit the U.S. This week, the Sandy Child and Family Health Study released two new reports finding that the health impacts of Sandy continue to linger, illustrating the deep mental footprint left by catastrophic disasters and the challenges of long-term recovery.

Led by researchers at Rutgers University and New York University, the Sandy Child and Family Health Study is based on 1,000 face-to-face interviews with adults in the nine most-affected counties in New Jersey, with questions related to evacuation and recovery as well as health and well-being. Designed to be representative of the 1 million New Jersey residents caught in Sandy’s path and based on a similar approach used after Hurricane Katrina, the study reported that more than 100,000 residents experienced significant damages to their homes due to Sandy. Among those with home damage, more than a quarter reported moderate to severe mental health distress and 14 percent reported signs of post-traumatic distress more than two years after the disaster.

“The similarities between Hurricanes Katrina and Sandy are quite disturbing,” said David Abramson, a principal investigator on the study and director of the Program on Population Recovery and Resiliency at New York University, in a news release. “Many adults and children are still experiencing emotional and psychological effects, so long after the storm passed. In a significant number of cases, housing damage is at the heart of the problem, and it’s very concerning to hear that so many of the federally financed programs have ended even though the needs still clearly persist.”

The findings released this week are published in two reports — the PLACE Report, which focuses on issues related to evacuation, housing, community and restoration, and the PERSON Report, which focuses on physical health, mental health and children’s health. Researchers conducted the resident interviews between August 2014 and May 2015. In the PERSON Report, the authors write:

Exposure to a disaster is among the most complex environmental contributors to poor health that individuals and communities may face. Rather than a single acute exposure, such as a lightning strike, there is often an “exposure continuum” in large-scale disaster settings. The disaster event may generate exposure to multiple hazards and they may unfold over time: for example, there may be traumas associated with exposure to the kinetic force of a hurricane, earthquake or tornado. A disaster may lead to an enduring toxic environment that includes potential exposure to heavy metals, fungi, or other hazardous substances present in the water, soil, air, or surrounding buildings and infrastructure. Beyond that, there is the potential for a more insidious ongoing exposure after a disaster: the fraught emotional landscape of an uncertain environment in which the struggles of daily living can present many steep challenges to recovery and that exact a psychological toll.

Among the study’s health findings, researchers found that regardless of their incomes, people who experienced major damage to their homes reported “remarkably similar” effects to people with household incomes of less than $20,000 a year — a strata the report described as “deep poverty.” For example, among those with significantly damaged homes, 17 percent reported problems making rent or mortgage, 18 percent did not have enough money for utilities and 9 percent often didn’t have enough money for food. In regard to environmental health issues, adults who were exposed to mold were two-and-a-half times as likely as those not exposed to mold to receive an asthma diagnosis and were twice as likely to report mental health distress.

Regarding post-traumatic stress disorder, the study uncovered rates described as fairly typical among people who’ve experienced a disaster in the previous two to three years. However, the study did find that higher rates of PTSD were associated with worse housing damage — for example, the PTSD rate among people with little or no housing damage was 3.5 percent, while the rate among those with major damage was 13 percent. Rates of moderate mental distress were also linked to the severity of housing damage.

Among the children who lived through Superstorm Sandy, those whose homes experienced just minor damage were at particularly high risk for psychological and mental issues. For example, the report found that children in homes with minor storm damage were more than four times as likely to be sad or depressed and more than twice as likely to have problems sleeping. Interestingly, children in homes with minor damage were at greater than those in homes with major damage, which researchers said might be attributed to “greater stress due to burdens on their parents or possibly because they are living in homes that are still undergoing repairs, which can serve as a perpetual reminder of Sandy and prevent closure.”

Researchers wrote that their health findings held a number of implications for policymakers and responders. For instance, based on findings connecting mold exposure and mental distress, the report recommended that mold mitigation efforts include a mental health component. In addition, the report encouraged housing assistance programs to speed up repairs in households with minor children to mitigate mental and emotional health impacts.

“By far, one of the least understood aspects of disaster management is how to make recovery from catastrophic events efficient and rapid, so that people can return to a state of normalcy as quickly as possible,” said Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University’s Earth Institute, in a new release. “This prolonged uncertainty and persistent trauma are very difficult for families and especially traumatic for children.”

To download copies of the two Sandy Child and Family Health Study reports, click here.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.