Cancer risk among World Trade Center rescue and recovery workers: A review.

Twenty years after the September 11th, 2001 terrorist attacks, the association between exposures present at the World Trade Center (WTC) site and the risk of several specific types of cancer has been reported among rescue and recovery workers. The authors' objective was to conduct an updated review of these data. Most studies have found elevated rates of both prostate and thyroid cancers compared with rates in the general population, and some have reported statistically significant differences for the rates of all cancers as well. Studies including a larger combined cohort of WTC-exposed rescue and recovery workers from 3 main cohorts have since replicated findings for these cancers, with additional years of follow-up. Among this combined cohort, although a lower-than-expected standardized incidence ratio for all cancers was observed, WTC exposure was also related to an increased risk of cutaneous melanoma and tonsil cancer. Importantly, another study found that WTC-exposed rescue and recovery workers who are enrolled in the federally funded medical monitoring and treatment program experienced improved survival post-cancer diagnosis compared with New York state patients with cancer. On the basis of these combined cohort studies, the full effect of WTC exposure on cancer risk is becoming clearer. Consequently, the authors believe that surveillance of those with WTC exposure should be continued, and in-depth analysis of epidemiologic, molecular, and clinical aspects of specific cancers in these workers should be pursued.

A systematic review of otologic injuries sustained in civilian terrorist explosions.

PURPOSE: Determine the prevalence of otological symptoms and tympanic membrane perforation, healing rates of tympanic membrane perforation with surgical and conservative management, and hearing function in civilian victims of terrorist explosions. METHODS: A systematic review was conducted with searches on Medline, Embase, EMCare and CINAHL for publications between the 1st January 1945 and 26th May 2023. Studies with quantitative data addressing our aims were included. This review is registered with PROSPERO: CRD42020166768. Among 2611 studies screened, 18 studies comprising prospective and retrospective cohort studies were included. RESULTS: The percentage of eardrums perforated in patients admitted to hospital, under ENT follow up and attending the emergency department is 69.0% (CI 55.5-80.5%), 38.7% (CI 19.0-63.0%, I2 0.715%) and 21.0% (CI 11.9-34.3%, I2 0.718%) respectively. Perforated eardrums heal spontaneously in 62.9% (CI 50.4-73.8%, I2 0.687%) of cases and in 88.8% (CI 75.9-96.3%, I2 0.500%) of cases after surgery. Common symptoms present within one month of bombings are tinnitus 84.7% (CI 70.0-92.9%, I2 0.506%), hearing loss 83.0% (CI 64.5-92.9%, I2 0.505%) and ear fullness 59.7% (CI 13.4-93.4%, I2 0.719). Symptomatic status between one and six months commonly include no symptoms 57.5% (CI 46.0-68.3%), hearing loss 35.4% (CI 21.8-51.8%, I2 0.673%) and tinnitus 15.6% (CI 4.9-40.0%, I2 0.500%). Within one month of bombings, the most common hearing abnormality is sensorineural hearing loss affecting 26.9% (CI 16.9-40.1%, I2 0.689%) of ears 43.5% (CI 33.4-54.2%, I2 0.500) of people. CONCLUSION: Tympanic membrane perforation, subjective hearing loss, tinnitus, ear fullness and sensorineural hearing loss are common sequelae of civilian terrorist explosions.

A 15-year follow-up study of mortality in a pooled cohort of World Trade Center rescue and recovery workers.

INTRODUCTION: Hazardous exposures from the World Trade Center (WTC) terrorist attacks have been linked to increased incidence of adverse health conditions, often associated with increased mortality. We assessed mortality in a pooled cohort of WTC rescue/recovery workers over 15 years of follow-up. MATERIALS AND METHODS: We analyzed mortality through 2016 in a pooled and deduplicated cohort of WTC rescue/recovery workers from three WTC-exposed cohorts (N = 60,631): the Fire Department of the City of New York (FDNY); the WTC Health Registry (WTCHR); and the General Responder Cohort (GRC). Standardized mortality ratios (SMRs) were estimated to assess mortality vs. the US and NY state populations. Multivariable Cox proportional hazards models were used to examine associations of WTC exposures (date of first arrival, working on the WTC debris pile) with mortality risk. RESULTS: There were 1912 deaths over 697,943.33 person-years of follow-up. The SMR for all-cause mortality was significantly lower-than-expected, both when using US (SMR 0.43, 95% confidence interval [CI] 0.42-0.45) and NYS (SMR 0.51, 95% CI 0.49-0.53) as reference populations. SMRs were not elevated for any of the 28 major causes of death. Arriving at the WTC site on 9/11-9/17/2001 vs. 9/18/2001-6/30/2002 was associated with 30-50% higher risk of all-cause, heart disease and smoking-related mortality in non-FDNY/non-GRC members. Conversely, arriving on 9/11/2001 vs. 9/18/2001-6/30/2002 was associated with 40% lower all-cause and smoking-related mortality risk in FDNY members. Working on vs. off the WTC pile was associated with an increased risk of all-cause mortality in non-FDNY/non-GRC members (adjusted hazard ratio [aHR] 1.25, 95% CI 1.04-1.50), and cancer-specific mortality in GRC members (aHR 1.39, 95% CI 1.05-1.84), but lower mortality risks were found in FDNY members. CONCLUSIONS: We did not observe excess mortality among WTC rescue/recovery workers compared with general populations. However, significantly increased mortality risks among some sub-groups with high WTC exposure warrant further investigation.

The breakdown of antiracist norms: A natural experiment on hate speech after terrorist attacks.

Terrorist attacks often fuel online hate and increase the expression of xenophobic and antiminority messages. Previous research has focused on the impact of terrorist attacks on prejudiced attitudes toward groups linked to the perpetrators as the cause of this increase. We argue that social norms can contain the expression of prejudice after the attacks. We report the results of a combination of a natural and a laboratory-in-the-field (lab-in-the-field) experiment in which we exploit data collected about the occurrence of two consecutive Islamist terrorist attacks in Germany, the Würzburg and Ansbach attacks, in July 2016. The experiment compares the effect of the terrorist attacks in hate speech toward refugees in contexts where a descriptive norm against the use of hate speech is evidently in place to contexts in which the norm is ambiguous because participants observe antiminority comments. Hate toward refugees, but not toward other minority groups, increased as a result of the attacks only in the absence of a strong norm. These results imply that attitudinal changes due to terrorist attacks are more likely to be voiced if norms erode.

Prevalence of increased alcohol use and alcohol use disorders in adult victims of terrorist attacks: a systematic and meta-analytic review.

Background: Previous studies have reviewed the evidence on the increase in alcohol consumption after a terrorist attack. However, an increase does not necessarily imply the presence of an alcohol use disorder.Objectives: To conduct a systematic and meta-analytic review of the literature on the prevalence of increased alcohol consumption and alcohol use disorders in adult exposed to terrorism.Methods: A search of PsycINFO, MEDLINE and PTSDpubs identified 29 studies published up to March 2023 in which 38 adult samples totaling 282,753 persons exposed to terrorism were assessed. Using inverse variance heterogeneity models, pooled prevalence rates of increased alcohol use and alcohol use disorders were calculated.Results: 6% (95% CI [2.9, 9.5]) of the adults exposed to a terrorist attack increased their alcohol consumption. The prevalence of increased alcohol use varied depending on the degree of exposure (p = .006, R2 = .18) and the procedure for measuring increases (p = .043, R2 = .37). The prevalence of alcohol use disorders in adults exposed to a terrorist attack was 5.5% (95% CI [3.7, 7.5]), a rate that was not higher than that obtained in the general population and varied depending on the type of alcohol disorder (p = .015, R2 = .30).Conclusions: A relevant number of adults exposed to terrorist attacks will subsequently increase their alcohol consumption, but this increase is not associated with an increase in the prevalence of alcohol use disorders. Effects of terrorism on people's health are potentially widespread, but concerns of excessive alcohol use after terrorist attacks may be unwarranted.

Learning from terrorist mass casualty incidents: a global survey.

BACKGROUND: Reports published directly after terrorist mass casualty incidents frequently fail to capture difficulties that may have been encountered. An anonymised consensus-based platform may enable discussion and collaboration on the challenges faced. Our aim was to identify where to focus improvement for future responses. METHODS: We conducted a mixed methods study by email of clinicians' experiences of leading during terrorist mass casualty incidents. An initial survey identified features that worked well, or failed to, during terrorist mass casualty incidents plus ongoing challenges and changes that were implemented as a result. A follow-up, quantitative survey measured agreement between responses within each of the themes using a Likert scale. RESULTS: Thirty-three participants responded from 22 hospitals that had received casualties from a terrorist incident, representing 17 cities in low-middle, middle and high income countries. The first survey identified themes of sufficient (sometimes abundant) human resource, although coordination of staff was a challenge. Difficulties highlighted were communication, security, and management of blast injuries. The most frequently implemented changes were education on specific injuries, revising future plans and preparatory exercises. Persisting challenges were lack of time allocated to training and psychological well-being. The follow-up survey recorded highest agreement amongst correspondents on the need for re-triage at hospital (90% agreement), coordination roles (85% agreement), flexibility (100% agreement), and large-scale exercises (95% agreement). CONCLUSION: This survey collates international experience gained from clinicians managing terrorist mass casualty incidents. The organisation of human response, rather than consumption of physical supplies, emerged as the main finding. NHSH Clinical Effectiveness Unit project registration number: 2020/21-036.

Provision of pre-hospital medical care for terrorist attacks.

The delivery of medical care to the severely injured during major incidents and mass casualty events has been a recurring challenge for decades across the world. From events in resource-poor developing countries, through richly funded military conflicts, to the most equipped of developed nations, the provision of rapid medical care to the severely injured during major incidents and mass casualty events has been a priority for healthcare providers. This is often under the most difficult of circumstances.1,2 Whilst mass casualty events are a persistent global challenge, it is clear in developed countries that patients and their families demand and expect a high standard of care from their rescuers, that this care should be delivered rapidly, and this should be of the highest quality possible.3 Whilst there is respect afforded to those who 'run towards danger' during a high-threat situation, first responders are subjected to a high degree of scrutiny for their actions, even when the circumstances they are presented with are considered to be extraordinary.4 Likewise, even for those who are catastrophically injured beyond salvage, society expects the response to be dignified, calculated, and thorough.3.

Local alliances and rivalries shape near-repeat terror activity of al-Qaeda, ISIS, and insurgents.

We study the spatiotemporal correlation of terrorist attacks by al-Qaeda, the Islamic State of Iraq and Syria (ISIS), and local insurgents, in six geographical areas identified via k-means clustering applied to the Global Terrorism Database. All surveyed organizations exhibit near-repeat activity whereby a prior attack increases the likelihood of a subsequent one by the same group within 20 km and on average 4 (al-Qaeda) to 10 (ISIS) weeks. Near-response activity, whereby an attack by a given organization elicits further attacks from a different one, is found to depend on the adversarial, neutral, or collaborative relationship between the two. When in conflict, local insurgents respond quickly to attacks by global terror groups while global terror groups delay their responses to local insurgents, leading to an asymmetric dynamic. When neutral or allied, attacks by one group enhance the response likelihood of the other, regardless of hierarchy. These trends arise consistently in all clusters for which data are available. Government intervention and spillover effects are also discussed; we find no evidence of outbidding. Understanding the regional dynamics of terrorism may be greatly beneficial in policy making and intervention design.

Design and validation of a preparedness evaluation tool of pre-hospital emergency medical services for terrorist attacks: a mixed method study.

INTRODUCTION: Terrorist attacks are one of the human problems that affect many countries, leaving behind a huge toll of disabilities and deaths. The aim of this study was to use a mixed-method analysis to design and validate an evaluation tool for pre-hospital emergency medical services for terrorist attacks. METHODS: The present study is a mixed-method (qualitative and quantitative) study that was conducted in two phases. In the qualitative phase (item generation), semi-structured interviews were conducted with 34 Iranian emergency medical technicians who were selected through a purposive sampling method and a scoping literature review was conducted to generate an item pool for the preparedness evaluation of Emergency Medical Services (EMS) in terrorist attacks. In the quantitative phase (item reduction), for validity of tool face, content and construct validity, were performed; for tool reliability, the test and retest and intra-class correlation coefficient were evaluated. RESULTS: At the first stage, 7 main categories and 16 subcategories were extracted from the data, the main categories including "Policy and Planning", "Education and Exercise "," Surge Capacity", "Safety and Security", "Command, Control and Coordination", "Information and Communication Management "and "Response Operations Management". The initial item pool included 160 items that were reduced to 110 after assessment of validity (face, content and construct). intra-class correlation coefficient (ICC = 0.71) examination and Pearson correlation test (r = 0.81) indicated that the tool was also reliable. CONCLUSION: The research findings provide a new perspective to understand the preparedness of pre-hospital emergency medical services for terrorist attacks. The existing 110-item tool can evaluate preparedness of pre-hospital emergency medical services for terrorist attacks through collecting data with appropriate validity and reliability.

No Local Birth Sex Ratio Changes following the August 2019 Shootings in Montgomery County, Ohio, and in El Paso County, Texas.

OBJECTIVE: In humans, males are born slightly in excess of females. Many factors have been shown to affect this ratio, including stressful events such as terrorist attacks. Two shootings occurred in early August 2019 in the Oregon District in Dayton, Montgomery County, Ohio, and in El Paso County, Texas, in the USA. This study was carried out in order to identify whether there were any effects on sex ratio at birth at the state or county level 3-5 months later. SUBJECT AND METHODS: Births by sex, month of birth (2015-2019), and county were obtained for Ohio and Texas from the website of the Centers for Disease Control and Prevention. Ordinary linear logistic regression was used to assess the time trend in the probability of boys and to investigate changes in the trend functions. Poisson regression (SAS GENMOD) and linear logistic regression using SAS procedure LOGISTIC was applied. RESULTS: This study analyzed 2,623,714 live births, 1,939,938 in Texas (sex odds [SO] 1.044) and 683,776 in Ohio (SO 1.045). The only significant effect noted was seasonality (month) at the state level. CONCLUSION: It has been postulated that male fetal loss in pregnant women during stressful periods may occur in accordance with the Trivers-Willard hypothesis. Several studies have found significant effects after terrorist attacks in the USA (as well as in other countries), but this study did not reveal such effects. This may be due to several reasons including underpowered datasets and the possibility that populations may be becoming relatively immured to these events.

Army Public School Terrorist Attack - Perceptions and Experiences of school children of Karachi.

Objectives: To explore the experiences and perceptions of school children of Karachi after the Army Public School (APS) attack. Methods: It was a qualitative transcendental phenomenological study. Data collection started nine months after the attack, in September 2015, and continued till November 2019. Study participants were school children from Army, Government, and Private schools. The sampling strategy was convenience. Data collection of 53 students was done by focus group discussions and in depth interviews. Data analysis was performed using the phenomenological analytical techniques of Colaizzi. Results: Inductive analysis of the qualitative data gave rise to three themes - The journey beyond fear, Response of parents and schools and Role of media. Conclusion: The study concluded that the APS attack was the source of emotional distress and fear for the school children of Karachi as they personalized the event due to the nature of the attack. Immediately after the incident, they were in anger, grief, and fear, which altered their daily life activities and caused apprehensions in socializing and attending school. However, later they became highly motivated to study and gained courage. This motivation is revenge from terrorists as they wanted to keep children away from schools.

Post-traumatic stress disorder and the association with overweight, obesity, and weight change among individuals exposed to the World Trade Center disaster, 2003-2016.

BACKGROUND: Among Veterans, post-traumatic stress disorder (PTSD) has been shown to be associated with obesity and accelerated weight gain. Less is known among the general population. We sought to determine the impact of PTSD on body mass index (BMI) and weight change among individuals with exposure to the World Trade Center (WTC) disaster. METHODS: We examined individuals from the WTC Health Registry. PTSD symptoms were assessed on multiple surveys (Waves 1-4) using the PTSD Checklist-Specific. Three categories of post-9/11 PTSD were derived: no, intermittent, and persistent. We examined two outcomes: (1) Wave 3 BMI (normal, overweight, and obese) and (2) weight change between Waves 3 and 4. We used multivariable logistic regression to assess the association between PTSD and BMI (N = 34 958) and generalized estimating equations to assess the impact of PTSD on weight change (N = 26 532). Sex- and age-stratified analyses were adjusted for a priori confounders. RESULTS: At Wave 3, the observed prevalence of obesity was highest among the persistent (39.5%) and intermittent PTSD (36.6%) groups, compared to the no PTSD group (29.3%). In adjusted models, persistent and intermittent PTSD were consistently associated with a higher odds of obesity. Weight gain was similar across all groups, but those with persistent and intermittent PTSD had higher estimated group-specific mean weights across time. CONCLUSIONS: Our findings that those with a history of PTSD post-9/11 were more likely to have obesity is consistent with existing literature. These findings reaffirm the need for an interdisciplinary focus on physical and mental health to improve health outcomes.

A game theory approach for risk analysis and security force deployment against multiple coordinated attacks.

The proposed model determines the allocation of security forces in response to terrorist events with a series of coordinated attacks such as the Paris terror attacks in 2015. Two games are constructed, representing the two stages needed for the rapid deployment of security forces. The first stage applies a firearms assault game to analyze the interaction behaviors between the response agent (or security force commander) and the attackers in each response district. The terrorist threat value (TV) during a firearms assault event can then be derived from the mixed strategy Nash equilibrium. The TVs are input to the second stage for computing the Shapley value for each event, in terms of the majority of TVs of all firearms assaults. The Shapley values are then used to create a set for reallocation of the limited security forces to respond to the multiple firearms assaults. The experimental results show the proposed division to fairer than the proportional division for allocating security forces.

Entropy and Network Centralities as Intelligent Tools for the Investigation of Terrorist Organizations.

In recent years, law enforcement authorities have increasingly used mathematical tools to support criminal investigations, such as those related to terrorism. In this work, two relevant questions are discussed: "How can the different roles of members of a terrorist organization be recognized?" and "are there early signs of impending terrorist acts?" These questions are addressed using the tools of entropy and network theory, more specifically centralities (degree, betweenness, clustering) and their entropies. These tools were applied to data (physical contacts) of four real terrorist networks from different countries. The different roles of the members are clearly recognized from the values of the selected centralities. An early sign of impending terrorist acts is the evolutionary pattern of the values of the entropies of the selected centralities. These results have been confirmed in all four terrorist networks. The conclusion is expected to be useful to law enforcement authorities to identify the roles of the members of terrorist organizations as the members with high centrality and to anticipate when a terrorist attack is imminent, by observing the evolution of the entropies of the centralities.

THE ROLE OF ADVERSE CHILDREN'S EXPERIENCE IN THE DEVELOPMENT OF PSYCHOLOGICAL DISORDERS AMONG PARTICIPANTS IN ANTI-TERRORISM OPERATION.

OBJECTIVE: The aim: The sense of our research was to examine the reason for the consequential links between negative childhood experiences and the mental state of participants of anti-terrorist operations. PATIENTS AND METHODS: Materials and methods: A standard "Adverse Childhood Experiences (ACEs)" questionnaire was used to obtain primary data. Conflict tactics scales were used to determine emotional, physical, and domestic violence in respondents. RESULTS: Results: The study evaluated 7 categories of ACEs: physical indifference (lack of care and protection); emotional neglect (lack of love); physical violence (pushing, grabbing or slapping); emotional violence (scolded, insulted or suppressed); sexual violence; domestic violence and a family history of mental disorders, diseases or alcohol abuse. All respondents were divided into two groups: those who had psychological disorders and those who were healthy. CONCLUSION: Conclusions: The data obtained in the study indicate that the chances of having psychological disorders increase in those fighters who complained of emotional violence - the feeling of humiliation; physical violence - those who were beaten in childhood; domestic violence was manifested in the fact that the mother was beaten; disadvantaged families where a family member has used drugs or abused alcohol; the presence of depression in parents.

[The urologist confronted with a mass killing]. / Le chirurgien urologue face à une tuerie de masse.

INTRODUCTION: Following the Paris attacks in 2015, the French hospital system has had to organize itself in mass casualties of serious injuries, especially hemorrhagic shock. Recent experience shows that the first flow of casualties is spontaneously directed to the structure closest to the events, whether it is suitable or not. Any surgeon can face such a crisis regardless of their practice structure, because terrorist attacks are unpredictable. The urologist must anticipate the responsibilities that they might be forced to shoulder in such a situation. MATERIAL AND METHOD: A systematic literature review based on PubMed, Embase and Google Scholar was conducted between January 2000 and June 2021. RESULTS: In addition to a coordinator role, reserved for the most experienced, his visceral surgical expertise would allow a urologist to apply damage control (DC) at each stage. We describe here the principles of DC, in particular the DC laparotomy including its strategy concerning genitourinary lesions. DISCUSSION: Whatever his role (sorter, organizer, technician) in the management of a mass casualties of hemorrhagic injuries, an urologist has to know the principles of DC. A damage control laparotomy (stage 1 of DC) requires the urologist surgeon to never seek to perform a primary reconstruction procedure but to favor speed and efficiency (both on the hemostatic and urostatic side) to lead the injured patient stabilized to faster in intensive care unit (stage 2). Revision surgery called "definitive surgical management" (stage 3) will be performed anyway at the end of this period.

Non-participation and attrition in a longitudinal study of civilians exposed to the January 2015 terrorist attacks in Paris, France.

BACKGROUND: Non-participation and attrition are rarely studied despite being important methodological issues when performing post-disaster studies. A longitudinal survey of civilians exposed to the January 2015 terrorist attacks in Paris, France, was conducted 6 (Wave 1) and 18 months (Wave 2) after the attacks. We described non-participation in Wave 1 and determined the factors associated with attrition in Wave 2. METHODS: Multivariate logistic regression models were used to compare participants in both waves with those who participated in the first wave only. Analyses were performed taking the following factors into account: socio-demographic characteristics, exposure to terror, peri-traumatic reactions, psychological support, perceived social support, impact on work, social and family life, and mental health disorders. Characteristics of new participants in Wave 2 were compared with participants in both waves using a chi-square test. RESULTS: Of the 390 persons who were eligible to participate in the survey, 190 participated in Wave 1 (participation rate: 49%). The most frequently reported reason for non-participation was to avoid being reminded of the painful event (32%, n = 34/105). In Wave 2, 67 were lost to follow-up, 141 people participated, of whom 123 participated in Wave 1 (re-participation rate: 65%) and 18 were new. Attrition in Wave 2 was associated with socio-demographic characteristics (age, French origin) and location during the attacks, but not with terror exposure or mental health disorders. Compared with those who participated in both waves, new participants declared less social and psychological support since the attacks. CONCLUSIONS: Attrition at 6 months was not associated with exposure to terror or mental health disorders, which indicates that any bias in future analyses on IMPACTS on mental health outcomes will be limited. Our findings suggest the importance of adapting similar surveys for people of foreign origin and of improving strategies to avoid attrition of younger people, for example by using social media, peers, and the educational environment. The present study also revealed that a high level of exposure to terror and a lack of social and psychological support after a terrorist event could impede individuals' participation in similar surveys in the short term.

Children's Exposure to Single Incidents of Terrorism: Perspectives Over 25 Years Since the Oklahoma City Bombing.

PURPOSE OF REVIEW: This paper traces advances in our knowledge about children's exposure and reactions to terrorist events over the last 25 years, beginning with the 1995 Oklahoma City bombing, and offers observations about cross-cutting issues including implications for services. RECENT FINDINGS: Direct and indirect interpersonal exposures have been examined in community samples and in samples of children selected because of their event experiences. Despite its present exclusion from the stressor criterion for a diagnosis of posttraumatic stress disorder, considerable research has documented an association between children's initial subjective reaction and outcomes. Few studies have examined the influence of community or distant effects on outcomes, but contact with media coverage has been well studied. This review confirms the central role of exposure in influencing children's reactions to terrorist incidents and supports recent efforts to distinguish specific experiences that constitute children's event exposures.

The Sydney Lindt café siege: The role of the consultant psychiatrist.

BACKGROUND: In December 2014, after a 16-hour siege of the Lindt café in Sydney, Iranian-born gunman Man Haron Monis shot dead a hostage precipitating the police action which broke the siege. OBJECTIVE: This paper reviews the demographic and other factual details of Monis as documented by the NSW Coroner's Inquest and critically analyses the published findings of the Coroner particularly in relation to the role of the psychiatrist who advised senior police and negotiators during the siege. RESULTS: At the time of the siege, there was no formal protocol that delineated the role of a psychiatrist in hostage negotiations. Despite the psychiatrist's credentials including his extensive experience with siege-hostage incidents and his counter-terrorist training, the Coroner was unfairly critical of the psychiatrist. CONCLUSION: The Coroner's censure of the psychiatrist was clearly prejudiced by hindsight bias. During the siege, the psychiatrist properly considered and evaluated all the available intelligence and other information known about the gunman. As the psychiatrist advised, Monis was a narcissist and the siege was not an Islamic State-inspired terrorist attack. Given that he announced he was armed with a bomb, Monis represented a 'credible threat' to the hostages. The psychiatrist's endorsement of the police strategy to 'contain and negotiate' was prudent in the circumstances. The Coroner's disparagement of the senior psychiatrist may have the unintended consequence that psychiatrists may be reluctant to assist in hostage-sieges or other critical incidents.

Use of mental health supports by civilians exposed to the November 2015 terrorist attacks in Paris.

BACKGROUND: The use of mental health supports by populations exposed to terrorist attacks is rarely studied despite their need for psychotrauma care. This article focuses on civilians exposed to the November 2015 terrorist attacks in Paris and describes the different combinations of mental health supports (MHSu) used in the following year according to type of exposure and type of mental health disorder (MHD). METHODS: Santé publique France conducted a web-based survey of civilians 8-11 months after their exposure to the November 2015 terrorist attacks in Paris. All 454 respondents met criterion A of the DSM-5 definition of post-traumatic stress disorder (PTSD). MHD (anxiety, depression, PTSD) were assessed using the PCL-5 checklist and the Hospital Anxiety and Depression Scale. MHSu provided were grouped under outreach psychological support, visits for psychological difficulties to a victims' or victim support association, consultation with a general practitioner (GP), consultation with a psychiatrist or psychologist (specialist), and initiation of regular mental health treatment (RMHT). Chi-squared tests highlighted differences in MHSu use according to type of exposure (directly threatened, witnessed, indirectly exposed) and MHD. Phi coefficients and joint tabulations were employed to analyse combinations of MHSu use. RESULTS: Two-thirds of respondents used MHSu in the months following the attacks. Visits to a specialist and RMHT were more frequent than visits to a GP (respectively, 39, 33, 17%). These were the three MHSu most frequently used among people with PTSD (46,46,23%), with depression (52,39,20%), or with both (56,58, 33%). Witnesses with PTSD were more likely not to have RMHT than those directly threatened (respectively, 65,35%). Outreach support (35%) and visiting an association (16%) were both associated with RMHT (Phi = 0.20 and 0.38, respectively). Very few (1%) respondents initiated RMHT directly. Those who indirectly initiated it (32%) had taken one or more intermediate steps. Visiting a specialist, not a GP, was the most frequent of these steps. CONCLUSION: Our results highlight possibilities for greater coordination of mental health care after exposure to terrorist attacks including involving GP for screening and referral, and associations to promote targeted RMHT. They also indicate that greater efforts should be made to follow witnesses.