Background

Since the beginning of 2015, France has experienced several waves of major terrorist attacks.

Following the events of January 2015 in Île-de-France, the Île-de-France Regional Health Agency (ARS) Île-de-France and Santé publique France launched the I.M.P.A.C.T.S. epidemiological survey (investigation of post-attack trauma and therapeutic and support care), which aims to measure the consequences of these events on those affected and to understand their care and support pathways.
This epidemiological survey was led regionally by Santé publique France Île-de-France, with the support of the ARS Île-de-France.

Objectives

The main objective of the survey is to assess the potential consequences of the January 2015 attacks in the Île-de-France region among individuals who were directly or indirectly affected by them.

This survey aims to:

• assess, within the population, the psychological (return to normalcy, anxiety or depression, onset of post-traumatic stress disorder, etc.) and social repercussions, as well as the broader impact on daily life,

• describe the coping strategies adopted by individuals in the aftermath of the events, to identify factors that influence the decision to seek care or support.

It explores not only the feelings and experiences of direct victims (those injured or threatened) and their loved ones, as well as witnesses living or working near the events, but also the responders involved at the scene.

Thus, the purpose of this study is to provide public health stakeholders with tools to assess the impact on mental health and to improve the quality of care for patients who were victims of the January 2015 attacks. The goal is to derive organizational recommendations to optimize coordination among the various stakeholders when managing this type of crisis, particularly regarding how to design appropriate support for victims (psychological, social, and legal).

Methodology

The study took place from June 1, 2015, to October 30, 2015, and involved 430 exposed individuals.

An initial “recruitment” phase was implemented to identify individuals eligible to participate in the study:

• initial recruitment was conducted using lists of names compiled in the immediate aftermath of the attacks by first responders, the health services of the Assistance Publique des Hôpitaux de Paris, and medical-psychological emergency response teams, as well as by associations and support networks for victims,

• A second round of recruitment was conducted through active field research to identify witnesses living or working in the immediate vicinity of the attacks (within a 100-meter radius of the events).

A second phase, known as the inclusion phase, was conducted by telephone, online, or via mail, to verify eligibility criteria and identify individuals willing to participate in the survey. A 5-minute inclusion questionnaire was developed for this purpose.

Then, an individual face-to-face interview with a trained and qualified psychologist was offered to collect specific data based on the interviewee’s personal experiences.

This methodology made it possible to explore not only the direct victims (those injured or threatened) but also responders who were involved at the scene and witnesses living or working near the events. This latter group is not usually the subject of active outreach by medical-psychological and support services. Individual interviews were conducted by psychologists trained in psychological trauma with eligible individuals who had given their consent to participate.

Survey Population

The survey population consists of all individuals aged 16 and older who were directly or indirectly exposed to the attacks of January 7, 8, and 9, 2015, carried out in the Île-de-France region, as well as during the attackers’ escape routes.

Specifically, the survey included victims (injured individuals, hostages), direct or indirect witnesses, family members or close relatives of the victims of these attacks, people residing or working in the immediate vicinity of the sites of the events at the time of the incidents, as well as emergency medical responders (professionals and volunteers) and law enforcement and response personnel who responded to the scenes of the attacks and hostage-takings in the immediate aftermath of the events.

This survey population corresponds to the affected individuals defined as those who were exposed to the terrorist attacks according to “Criterion A” (Stressor) of the definition of Post-Traumatic Stress Disorder in the 5th edition of the “Diagnostic and Statistical Manual of Mental Disorders” (DSM).

Furthermore, participation in the survey was voluntary, and each person contacted was entirely free to participate or not. Under no circumstances will results be released that could identify individuals, either directly or indirectly. The data will remain strictly confidential and will be used solely within the scope of this study, in accordance with the provisions of the French Data Protection Act (CNIL).

I.M.P.A.C.T.S received approval from the CNIL on May 21, 2015, and from the Committee for the Protection of Human Subjects on June 6, 2015.

Study Partners

This study was presented on January 26, 2015, to the Directorate General for Health, which provided its support. It was funded by the Foundation for Assistance to Victims of Terrorism.

This public interest survey was presented on March 30, 2015, to all stakeholders involved in the trauma care system that was established in the immediate aftermath of the attacks and received their support.

The heads of the Medical-Psychological Emergency Units (Cump) and the psychiatric emergency departments at Hôtel-Dieu are integral to this work and actively participate in it.

The following are represented on the study’s steering committee:

• The Ministry of the Interior

• The Ministry of Justice

• The Armed Forces Health Service

• The Paris Courthouse

• The National Police

• The Paris Police Prefecture

• The Paris Fire Department

• Paris Public Hospital System - SAMU / CUMP

• The French Red Cross

• Paris Civil Protection

• The National Federation of Victims of Terrorist Attacks and Mass Accidents (FENVAC)

• Paris Victim Assistance

• Children’s Relief Organization (OSE)

The investigators are qualified and experienced psychologists recruited by the University of Paris XIII. They have been trained to serve as trusted intermediaries, providing information tailored to the needs and expectations expressed regarding health, social, and legal matters.

Results

The I.M.P.A.C.T.S. study showed that terrorist attacks have a significant impact on the civilian population and highlights the importance of providing care to prevent adverse effects on mental health. As for professionals, the impact on their mental health was less severe thanks to the training they received and early intervention.

Among the civilian population

Trauma still palpable 6 months later

Preliminary results reveal that the psychological trauma remains very significant. Thus, six months after the attacks, nearly 4 in 10 people still exhibited at least one mental health disorder: post-traumatic stress (20%); major depression (10%); anxiety disorders (30%). The survey also confirms that the more people were exposed to the attacks (directly or indirectly threatened, having seen/heard the terrorists and/or victims), the more severe the psychological trauma.

Furthermore:

• 1 in 4 people had consulted a doctor for a health issue unrelated to the events and not of a psychological nature,

• 1/3 of these people were unable to work due to health issues resulting from the events,

• 6% had still not returned to work six months later.

Significant medical and psychological care

More than half of those exposed received medical and psychological care or some form of support. Those who received early care experienced half as many symptoms six months later as the others. The study shows that only 4% of civilians directly threatened sought care on their own initiative.

The survey thus highlights the importance of care in preventing mental health impacts. Identifying all victims—whether mere witnesses or those directly threatened—to offer them medical and psychological support is a major challenge, as these individuals do not spontaneously think to consult a healthcare professional or to speak about it.

Among professionals

Particularly Vulnerable Responders

Faced with this exceptional situation, the mobilization of professionals during the events was particularly intense: on the first day, emergency responders and law enforcement were on the scene for an average of 11 hours, and one-third of professionals responded at multiple sites.

Following the events, the average duration of deployment related to these events was 17 days for emergency responders and 29 days for law enforcement.

Health consequences

Preliminary results reveal that the psychotraumatic impact was less significant among responders than in the civilian population: 3% of responders reported post-traumatic stress disorder, and 14% had at least one anxiety disorder such as anxiety or agoraphobia. It was observed that the psychopathological consequences of the event varied depending on whether or not the individual had received specific training prior to the psychological stress.

Among responders, those in law enforcement were the most exposed to the threat and experienced the greatest loss.

Professionals were heavily engaged with victims in terms of both duration and emotional intensity. The impact on the mental health of professionals was less severe thanks to the training they received and early intervention. The survey results highlight the importance of expanding training in stress management and the consequences of psychological trauma to prevent adverse health effects.