The experience of a traumatic event, such as a terrorist attack, is associated with psychological and physical disorders that can persist over long periods of time. In terms of public health, it is important to quantify the frequency of these disorders, to identify the risk and protection factors for post-traumatic sequelae and to gain a better understanding of the treatment offered to those involved in order to propose possible avenues for improvement and recommendations for prevention, screening and mental health care. For this reason, Santé publique France had already been mobilised to set up epidemiological studies in the wake of the January 2015 attacks (IMPACTS survey, with the support of the Foundation for Victims of Terrorism and the Île de France Regional Health Agency).
On 13 November 2015, another series of terrorist attacks took place in Paris and the neighbouring city of Saint-Denis: three bombings in Saint-Denis, three shootings, one bombing and one large-scale shooting and hostage incident at the Bataclan in Paris. 130 people were killed and 643 were injured. Thousands of first responders were mobilised that night and in the weeks that followed. In response to the attacks of November 2015, Santé publique France launched a specific public health study named ESPA 13 Novembre, for "Enquête de santé publique post-attentats du 13 novembre 2015". ESPA 13 Novembre is part of a more global transdisciplinary research programme called 13-Novembre. This programme is led scientifically by Inserm and the CNRS and administratively by HESAM University (Hautes Écoles Sorbonne Arts et Métiers Université).
The article published this month  in the journal Occupational Medicine provides new insights into the use of mental health care by first responders after the attacks.
3 questions for Yvon Motreff, Santé publique France
First of all, it should be remembered that the ESPA 13 Novembre survey was aimed at all people who met the criteria for an exposure that could lead to the development of post-traumatic stress disorder (PTSD). Participants included people directly exposed and relatives of the deceased or injured , as well as first responders.
The article that has just been published deals with first responders, i.e. anyone who, in the context of their professional or associative activity, was mobilised on the night of 13 November 2015 or during the following 3 weeks. Few studies have investigated the frequency of post-traumatic stress disorder among first responders and data on the use of care in this population is scarce. In addition, and for the first time in France for this type of survey, we analysed the reasons for first responders with PTSD and/or depression not engaging in mental health care.
Between 7 July and 10 November 2016, 663 first responders (firefighters, Paris civil security, Red Cross, police, AP–HP hospital staff) agreed to participate and completed the questionnaire: 34% were health professionals, 32% were Paris firemen, 20% were members of civil protection associations and 14% were police officers. The presence of probable post-traumatic stress disorder was 4.8% and varied from 3.4% (firefighters) to 9.5% (police forces) depending on the category of responder.
The study of factors associated with PTSD (complete or partial), which was the subject of a previous publication, highlighted several factors that help to identify populations at risk and thus guide screening and treatment. These factors include a low level of education, participation in an intervention at an unsecured site, and a feeling of social isolation. Preparation and training are factors that seem to play a protective role against PTSD. This illustrates the importance of continuing training and awareness-raising activities for anyone who could potentially intervene in the aftermath of terrorist attacks.
This new publication shows that among the first responders with full or partial PTSD or depression, almost two-thirds had not engaged in regular psychological follow-up care. The initiation of regular psychological treatment is associated with a history of mental health care, post-immediate psychological support and the presence of full or partial PTSD or depression. For people with full or partial PTSD or depression, the reasons given for not seeking care were non-recognition of the need for care, organisational reasons, financial reasons and fear of being stigmatised.
Our results indicate that regular access to mental health care for staff who responded to the attacks needs to be improved.
Our results show that a large proportion of the first responders who needed care did not get it. There are several complementary approaches that can favour the use of care. Firstly, information and training on the mental health problems that can arise following a potentially traumatic intervention must be reinforced. Indeed, owing to their profession and culture, it is difficult for first responders to admit that they may need care. It is therefore important to raise awareness of these risks among first responders, to train them to recognise the symptoms of potential disorders and empower them to be open about such symptoms with colleagues or health professionals. This dimension should really form an integral part of their professional skills and practices. Information and training can be provided upon the initial recruitment of first responders but should also be continued throughout their career. Specific awareness-raising activities could also be carried out after a potentially traumatic intervention.
Secondly, our results also show a virtuous circle where immediate support is associated with post-immediate support, which in turn fosters awareness of the need to seek care. The implementation of immediate and post-immediate support therefore seems to be an interesting line of approach to encouraging engagement in care.
Our results also indicate that the practical arrangements for accessing care need to be carefully adapted to the needs of first responders. For some, it may be easier to seek support from within their institution, for others, on the contrary, the therapist would have to be external to the institution but without this option becoming a financial burden or being too complicated to organise and carry out.
Finally, first responders could be systematically offered mental health assessments after potentially traumatic interventions such as terrorist attacks. This, for example, was the case with all Paris firefighters who intervened in the aftermath of the attacks on 13 November 2015. Routine annual assessments could also be put in place to review the situation each year, which would allow treatment to be offered before a disorder becomes chronic.
A survey conducted by the Nice University Hospital, to which Santé publique France contributed, has shown similar results for hospital staff exposed to the attacks of 14 July 2016, i.e., a prevalence of PTSD of 9% and low use of care, since less than 30% of staff with PTSD had engaged in regular psychological treatment.
Longitudinal studies carried out among first responders to the 9/11 attacks in New York, 2001, show a highly variable impact across individuals: some suffered from disorders that persist several years after exposure and others showed an improvement in their condition, while certain people with no disorders a year after the event developed problems later on. Apart from these American studies, post-terrorist attack research is mainly cross-sectional, which does not reveal trends over time and possible causal links. This is why a second phase of investigation was launched 5 years after the attacks of 13 November 2015. Aimed at estimating the psycho-traumatic impact in the longer term and evaluating the evolution since the first phase, the survey will also make it possible to describe and compare engagement in mental health care since the attacks. This second phase of ESPA 13 Novembre ran from 6 November 2020 to 5 April 2021. Almost 500 first responders took part, of which about two-thirds had already participated in the first phase. The first results are expected by the end of 2022.
Further long-term research is essential to better understand the different reactions and responses to terror attacks, as well as the factors that influence them. To fully understand the impact of the attacks on French society and the contributing factors, it is necessary to compare them with similar events in other countries. In this respect, it is essential to strengthen international collaboration.
For more information:
On other articles cited:
Vandentorren S, Pirard P, Sanna A, Aubert L, Motreff Y, Dantchev N, Lesieur S, Chauvin P, Baubet T. Healthcare provision and the psychological, somatic and social impact on people involved in the terror attacks in January 2015 in Paris: cohort study. Br J Dermatol. 2018 Apr;212(4):207-214.
Motreff Y, Baubet T, Pirard P et al. Factors associated with PTSD and partial PTSD among first responders following the Paris terror attacks in November 2015. J Psychiatr Res 2019;121:143–150.
Use of mental health supports by civilians exposed to the November 2015 terrorist attacks in Paris. Pirard P, Baubet T, Motreff Y, Rabet G, Marillier M, Vandentorren S, Vuillermoz C, Stene LE, Messiah A. BMC Health Serv Res. 2020 Oct 20;20(1):959. doi: 10.1186/s12913-020-05785-3.
Bentz L, Vandentorren S, Fabre R, Bride J, Pirard P, Doulet N, Baubet T, Motreff Y, Pradier C. Mental health impact among hospital staff in the aftermath of the Nice 2016 terror attack: the ECHOS de Nice study. BMC Public Health. 2021 Jul 10;21(1):1372.
On the ESPA 13 Novembre survey:
 Y Motreff, P Pirard, C Vuillermoz, G Rabet, M Petitclerc, L Eilin Stene, T Baubet, P Chauvin, S Vandentorren, Mental health care utilization by first responders after Paris attacks, Occupational Medicine, 2021;, kqab150.