Background

Following the attacks of November 13, 2015, Santé publique France launched the first phase of a major epidemiological survey in 2016: the Post-Attack Public Health Survey of November 2015 (ESPA November 13). Nearly 1,400 people participated. The results show a significant impact on the mental health of those involved and offer valuable insights for improving support for victims, as well as for the professionals and volunteers who responded in the aftermath of these events*.

This project is part of the November 13 Program, a large-scale, 12-year transdisciplinary program (2016–2028) funded primarily by the Investments for the Future initiative via the ANR and led scientifically by the CNRS and Inserm.

Objectives

The objectives of the ESPA November 13 study are:

• to assess the psychological trauma (post-traumatic stress disorder, depression, anxiety, prolonged grief, addictions, suicide risk) 8 months and then 4 years after the November 2015 attacks and identify associated factors

  • for individuals who already participated in the first phase of the study in 2016, to also examine the evolution of this impact and the associated factors

• to describe and compare the use of healthcare services since the events and identify the associated factors

  • For those who agreed to provide their Social Security number, estimate the impact of the attacks on the use of healthcare services through follow-up 5 years before and 10 years after the attacks.

• to provide individuals with a way to assess their mental health and, if they wish, to be referred

Study Population

Post-traumatic stress disorder (PTSD) can occur in people who have been exposed to death or a threat of death, or to serious injury. It manifests as intrusive thoughts, avoidance behaviors, intense neurogenic reactions, as well as cognitive and mood disturbances that last at least one month and interfere with daily life (significant repercussions on family and social relationships, work capacity, and the onset of morbidities). The study population consists of individuals whose exposure during the November 2015 attacks meets Criterion A of the DSM-5 definition of PTSD.

This includes:

• civilians who were directly threatened or injured,

• civilians who were direct witnesses to the event,

• civilians who suddenly learned of the involvement of a person they considered close to them in these events, or even of that person’s death,

• responders who, as part of their professional or volunteer work, were mobilized to provide care for victims of the attacks and the exposed population at the attack sites or in care facilities; to secure the attack sites or conduct criminal investigations; or to rehabilitate the attack sites.

Methodology

Study Procedure

The interview was conducted via an online questionnaire.

An initial screening questionnaire was used to verify that the respondent met the study criteria (location of the attack in which they were involved, PTSD diagnostic criteria A) and that they were of legal age. If the person was eligible, they were then informed of the study’s objectives, protection and confidentiality guarantees, and were also asked to provide their Social Security number (or National Registry Number [NIR]), thereby allowing access to their healthcare history and utilization data from the National Health Data System (SNDS). The respondent was free to refuse; this did not prevent them from accessing the epidemiological questionnaire. The time required to complete the questionnaire was estimated at between 30 and 45 minutes. It was also possible to complete it in multiple sessions.
A dedicated hotline allowed participants to reach a psychologist from 10 a.m. to 10 p.m., six days a week, for assistance with completing the questionnaire or if psychological support was needed.

Data collected

Data from the inclusion questionnaire

Age; exposure to events; consent to participate in the study; last name, first name, mailing address, email (to notify of results); current phone number (for access to the epidemiological questionnaire); potential participation in the first phase of the study in 2016; consent to access SNDS data; NIR, date of birth, and gender (for respondents who agreed to access to their SNDS data);

Data from the epidemiological questionnaire

Sociodemographic information; Experience of the November 2015 attacks (only for individuals who did not participate in the first phase of the study in 2016); intervention modalities (for intervention providers); factors influencing mental health: classic risk factors, perceived quality of social support and difficulty sharing, media exposure and feelings; Impact on health (mental health disorders and psychosocial impact, substance use disorders, somatic health problems); professional impact and impact on daily life; use of care systems: use of internal health services (for practitioners) and external services, perceived need for care and perception; use of support organizations and perception; information and access to rights; space for free expression.

Personal Data Security

The ESPA November 13 survey, classified as research involving human subjects with minimal risk and minimal coercion, has received a favorable opinion from a Human Protection Committee (CPP) as well as authorization from the National Commission for Information Technology and Civil Liberties (CNIL).
The processing of personal data carried out by and under the responsibility of Santé publique France, within the framework of this survey, is based on the fulfillment of a mission in the public interest.
Santé publique France ensures the security of personal data by using an HDS-certified hosting provider for the online data collection phase. Specific technical and IT resources have been implemented within the Agency for the results analysis phase.
The study is scheduled to conclude in 2027. The data, including that from the SNDS, will be retained until 2028 before being destroyed.
The processing of your data is not mandatory. You may exercise your right to access, correct, or delete your data, as well as your right to restrict or object to the processing of such data, at any time by contacting the project team.

Preliminary Results: ESPA-November 13, Phase 1

The study aimed to assess the psychological trauma and healthcare utilization among individuals exposed to the terrorist attacks of November 2015. Post-traumatic
stress disorder (PTSD) can occur in people who have been exposed to death or a threat of death, or to serious injury. It manifests as intrusive thoughts, avoidance behaviors, intense neurogenic reactions, as well as cognitive and mood disturbances that last at least one month and interfere with daily life (significant repercussions on family and social relationships, work capacity, and the onset of morbidities). The study population consists of individuals whose exposure during the November 2015 attacks meets Criterion A of the DSM-5 definition of PTSD.

Civilian Population

A total of 575 civilians responded to the questionnaire, and 526 were included in the study (those involved in the attacks at the Bataclan, the outdoor cafes, the Stade de France, and in Saint-Denis on November 18). Among them, 32% (169) were directly threatened, 27% (141) were direct witnesses, 18% (98) were nearby witnesses (residents, on the streets), and 22% (118) had no direct exposure but were either bereaved (95) or close to someone who was directly threatened (23).

Regarding the psychotraumatic impact, probable PTSD was observed in 54% of those directly threatened, 27% of on-site witnesses, 21% of nearby witnesses, and 54% of those who had lost a loved one.
Regarding comorbidities, significant depressive symptoms were found (particularly among those with PTSD), with 49% among the bereaved, 36% among those directly threatened, and 26% among witnesses. Among the bereaved, moreover, 66% experience what is termed complicated grief (of whom 81% also report PTSD). An increase or even initiation of psychoactive
substance use (alcohol, tobacco, cannabis, medications) is noted in 43% of respondents.
Excluding those who were injured, 83% of respondents reported physical symptoms whose onset or worsening they believe is linked to the attacks.
Regarding social repercussions, 56% of those who were employed at the time of the attacks reported taking time off work. Another 5% were still unable to return to work 8 to 11 months after the events.
The factors most frequently associated with PTSD are: severity of exposure, female gender, low socioeconomic status, a history of psychiatric treatment or illness, a history of other traumatic disorders, social isolation, and significant peri-traumatic experiences.

Regarding the use of ongoing and regular medical and psychological care, among the 475 respondents, only 33% reported having sought such care (and up to 46% of those with PTSD). Seeking care is associated with the individual’s exposure (63% of bystanders and 46% of bereaved individuals did not seek care), as well as with the number of related physical problems. Given the high rate of refusal of care, the reasons cited are: inopportune timing (28%), unsuitable treatment modalities (28%), lack of perceived need (20%), lack of care offered (14%), lack of trust, discomfort, or poor rapport with the first therapist consulted (12%), difficulty accessing care (11%), and financial reasons (11%).

Study Population

A total of 837 responders completed the questionnaire, and 698 were included in the study (those involved in the attacks at the Bataclan, the outdoor cafes, the Stade de France, and Saint-Denis on November 18; securing crime scenes; judicial investigations; and the care of physically and psychologically injured individuals). Among them, 240 (34.4%) were healthcare professionals (hospital staff, reservists, emergency first responders, SAMU, initial psychological support, CUMP, follow-up care, …), 208 (29.8%) belonged to the Paris Fire Brigade (BSPP), 136 (19.5%) were members of accredited civil protection associations (volunteers, first responders, social workers), 95 (13.6%) were members of the police force, and 17 (2.4%) were employees of the cities of Paris and Saint-Denis.

Overall, 5% of responders showed signs of probable PTSD. This proportion was 3.5% among Paris firefighters, 4.5% for healthcare professionals and volunteers from civil protection associations, and 9.9% among law enforcement officers. As with most post-attack studies, an association was found between PTSD and the level of exposure to the attacks. Interventions at sites defined as unsafe involved more than three-quarters of firefighters, half of association volunteers, one-third of police officers, and 8% of healthcare professionals; among them, 7.7% met the criteria for probable PTSD. In addition to the responders’ occupational exposure, their personal involvement also plays a role. Although the association between the onset of PTSD and the loss of a loved one could not be established, 9% of responders were affected by the death of a loved one or the direct threat to a loved one by terrorists.
First responders constitute a population at risk for psychological trauma, as nearly half had already experienced a traumatic event in their lives prior to the attacks. Approximately one-third had already responded to the previous attacks in January 2015.

As a bulwark against this vulnerability, social support and the preparedness of professional responders emerge as protective factors. Training on psychosocial risks, awareness of the psychological consequences that individuals may experience following a traumatic intervention, training in psychological first aid, and finally, a known point of contact for potential assistance with psychosocial risks were reported by 40.28%, 43.06%, 66.83%, and 22.24% of respondents, respectively.

Conclusion

The impact of the attacks on mental health is significant, both among those directly exposed and among those indirectly involved (witnesses, bereaved individuals). The health impact extends far beyond mental disorders alone. The events also affect social integration. It is therefore important to raise awareness and provide training in the screening of PTSD and other conditions among those at high risk—both directly (those under threat, witnesses) and indirectly (bereaved individuals, relatives of direct victims).
This screening enables the provision of appropriate long-term referral, care, and treatment, which mitigates the intensity, duration, and social complications of all post-traumatic conditions. For professionals responding to such events, it is important that various institutions prioritize social support as well as preparation for managing stress and the consequences of psychological trauma.