A Few of the Chosen: Survivors of Terrorism

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What’s Behind the Terrorist Attacks in Sri Lanka?

We appreciate your feedback. This enables us to compare prevalence rates of MDD with previous epidemiological surveys and between studies carried out after different terrorist attacks. However, MDD is not the sole disorder within the unipolar spectrum and extant research after terrorism has also highlighted the high prevalence and impairment associated with other forms of depression, such as mild or minor depression.

Including these other forms of depression, together with the risk factors associated with it, could be of research and public health interest. Our review highlights some key areas that are important for future research and may serve to guide intervention. First, the course of MDD after terrorist attacks remains unclear. That is why greater efforts are needed to elucidate the course of MDD after terrorist attacks. Second, there is very limited literature about psychological constructs that may be associated with MDD after terrorist attacks [ 3 , 9 ].

It would be interesting, in this context, to analyze the role played by other variables that have been shown to be related to MDD, such as attributional style [ 59 ], self-esteem [ 60 ] or response styles to depression [ 61 ], and to examine the way in which certain psychological variables interact with other sociodemographic variables to predict the onset of MDD. For example, it is possible to analyze which psychological factors mediate the relationship between MDD and gender. This line of research will be useful in helping to identify the persons with higher probability of developing MDD following a terrorist attack and to improve the efficacy of the interventions from which they will benefit.

Third, more research is needed on the role of MDD in psychiatric comorbidity after terrorist attacks. Although some reviewed studies have reported high rates of comorbidity between MDD and PTSD, more works are needed to have a better understanding of this relationship.

For example, an interesting objective would be to examine the form in which both pathologies vary over the time after terrorism. In this line, some authors have recently documented the important role that depressive symptoms plays in the development and persistence of stress post-traumatic symptoms after different traumatic events [ 62 ]. Fourth, some of the studies in this revision included victims who had been bereaved [ 33 , 37 ].

Although not reported in these papers, differences in the prevalence of MDD may exist between victims who have been directly injured by a terrorist attack and those who have been bereaved. Moreover, bereaved people could develop other psychological problems, such as complicated grief syndrome. A number of studies support the differentiation between complicated grief and MDD [ 63 , 64 ], and some authors have shown that it is a usual reaction in bereaved people after terrorism [ 65 ]. A clear definition of victims in future works could provide us with a better understanding of the psychological consequences in people directly and strongly exposed to terrorism.

The studies reviewed here, together with future research efforts in this field, should help to inform planned public mental health response that aims to mitigate the consequences of terrorist attacks by estimating the possible number of persons with MDD after such attacks, the potential course of the psychopathological burden, and the detection of populations at risk of developing these problems. Major Depressive Disorder.

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Diagnostic and Statistical Manual of Mental Disorders. March 11, terrorist attacks in Madrid. September 11, terrorist attacks in New York. Posttraumatic Stress Disorder. This article is published under license to BioMed Central Ltd. Major depressive disorder following terrorist attacks: A systematic review of prevalence, course and correlates.

A Few of the Chosen: Survivors of Terrorism - Rodger J. Bille - Google книги

BMC Psychiatry 11 Abstract Background Terrorist attacks are traumatic events that may result in a wide range of psychological disorders for people exposed. Methods A systematic review was performed. Results A total of reports were identified, 11 of which were eligible for this review: 6 carried out with direct victims, 4 with persons in general population, and 1 with victims and general population. Conclusions Methodological limitations in the literature of this field are considered and potentially important areas for future research such as the assessment of the course of MDD, the study of correlates of MDD or the comorbidity between MDD and other mental health problems are discussed.

Selection criteria Type of event studied Our review focused only on studies carried out after human-made, intentional, terrorist attacks, limiting our search to studies that were designed and conducted at a specific time and place and not including, therefore, investigations on the impact of other kinds of disasters e. Type of population assessed We focused our review on studies carried out in adult populations, including either persons in the general population or persons directly affected by a terrorist attack.

Type of assessment methodology used Several studies in the field have adopted a dimensional approach, using scales that assess the frequency or intensity of certain symptoms associated with MDD. Search strategy Figure 1 presents the flow chart for the selection of the included studies. A four-step procedure was used. First, a search of the peer-reviewed literature in the PsycINFO and Medline databases was conducted without time limit using the following keywords: depression, terrorist, terrorism, mental health, disaster and trauma.

Searches were undertaken between January 12 and 16, The initial database search identified potentially eligible studies for this review. Second, two independent reviewers analyzed the title and abstracts of all retrieved studies and excluded those which did not meet the selection criteria. The majority of studies excluded in this step were papers that analyzed psychological consequences different from MDD, other kinds of disasters not categorized as terrorist attacks or other populations that were not either direct victims nor general population.

Third, full manuscripts were obtained for all publications included after the second step. We examined the complete text of the articles and once again eliminated those which did not comply with the selection criteria. The majority of studies excluded in this step were papers that analyzed the psychological consequences of terrorist attacks without assessing MDD with diagnostic criteria. Fourth, to verify that our final sample was comprehensive and that our search was appropriate, we compared it with previous review papers [ 1 , 3 , 6 ].

Figure 1 Flowchart of the studies included in the review. Our search identified 11 studies of MDD following terrorist attacks: 6 were carried out with victims, 4 with general population samples, and one with victims and general population. Of these, 9 were cross-sectional studies and 2 were cohort studies. The most relevant information of each reviewed study is summarized in Tables 1 studies with victims and 2 general population studies. In these, information about the terrorist attacks, assessment time, sample size, method and main results MDD prevalence is shown.

Table 1 Studies of major depression prevalence in victims of terrorist attacks. Current depression past month Table 2 Studies of major depression prevalence in general population. Prevalence and course of MDD after terrorist attacks Results in direct victims One of the first studies with direct victims was carried out by Abenhaim, Dab, and Salmi [ 28 ]. Results in the general population Terrorist attacks can have an effect on the population that is directly assaulted or even on an entire nation [ 20 , 21 ].

Correlates of MDD after terrorist attacks The correlates of MDD reported in the reviewed studies were classified as pretraumatic, peri-traumatic, posttraumatic, and sociodemographic factors. Pretraumatic factors Several of the studies discussed up to this point have shown that the probability of suffering MDD after a terrorist attack was increased by at least twofold among those who had experienced at least one stressful situation in the 12 months prior to the terrorist attack [ 8 , 32 , 35 , 37 ].

Peri-traumatic factors Variables that have an impact during or some time immediately after the attack are included in this category.

Posttraumatic factors The factors or events that occurred in the weeks or months after the terrorist attack were classified in this category. Sociodemographic factors Of all the sociodemographic variables studied, the clearest relation was found between gender and the risk of MDD following the terrorist attacks, with women having consistently higher prevalence of MDD after these events. Overview of the excluded studies Excluded studies that assess the prevalence of other psychological problems after terrorist attacks have generally been focused on PTSD.

Limitations of the literature in the field First, although we only included studies that assessed MDD based on diagnostic criteria, most of them used instruments that did not include an assessment of either manic or psychotic symptoms, therefore we could not classify the disorder beyond probable MDD [ 8 ].

A Few of the Chosen: Survivors of Terrorism

Limitations of the review In relation to the characteristics of our review, we only considered studies that had assessed samples of direct or indirect adult victims. Implications for future research in this field Our review highlights some key areas that are important for future research and may serve to guide intervention. Epidemiologic Reviews. General conceptualization of the studies and results in the general population. Psychological Medicine. Terrorism and disaster Individual and community mental health interventions.

Prehosp Disaster Med. An empirical review of the empirical literature, Disaster and mental health. J Nerv Ment Dis. PhD Thesis. J Cons Clin Psychol. Ann Rev Clin Psychol. Ann Rev Psychol. Acta Psych Scand. J Psychosom Res. New Engl J Med. Spanish J Psychol.

Psqi Biol. History, rationale, and description. Arch Gen Psych. J Clin Epidem. Br J Psychiatry. Eur Psychiatry. The results of several revisions of the consequences of disasters have shown that terrorism may be associated with a greater risk of psychopathology than other disasters [ 6 ]. This characteristic, along with the increase in terrorist attacks that have struck various cities of the USA and Europe in recent years, have turned terrorism into a problem of interest, both for clinicians and for public health professionals.

A substantial body of research, much of which has been carried out after the September 11, terrorist attacks in New York and the March 11, terrorist attacks in Madrid, has documented the extent to which terrorism can affect the mental health of populations [ 3 , 6 ]. Of the specific psychiatric disorders studied, literature has been mainly focused on posttraumatic stress disorder PTSD , with several reviews documenting the course and correlates of this disorder [for a review see [ 1 , 3 ]].

However, less is known about major depressive disorder MDD. The study of MDD may facilitate a more complete understanding of the psychopathological burden of trauma, which may help to design more effective population-level mental health interventions in the aftermath of terrorism [ 4 , 7 - 9 ]. Terrorist attacks can produce reactions of intense fear and horror and generate a profound sense of loss for the people involved, both of which may underlie the development of MDD [ 10 , 11 ]. Moreover, a positive association between the occurrence of stressful events and the probability of developing a MDD has been consistently documented in the literature [for a review, see [ 12 , 13 ]].

Therefore, it is plausible that MDD prevalence may increase after disasters. This, together with the high prevalence of MDD in the general population [ 14 , 15 ] and the substantial personal, social, and economic consequences of this disorder [ 16 - 18 ], suggests that MDD may be an important focus in the study of the psychological effects of terrorism. However, with few exceptions [ 8 ], most of the data on MDD after terrorist attacks has been gathered in studies that also present data on other psychological problems typically reporting MDD and PTSD jointly and carried out in the context of a very specific event, at a given time and place, without comparing the results obtained with other prevalence rates.

On the other hand, there is heterogeneity in the methodology used to assess MDD, with several studies using scales that assess the frequency or intensity of certain symptoms associated with MDD and not diagnostic measures , that may hamper the correct prediction of expected rates of MDD. All this limits our ability to draw generalizable inferences about MDD after terrorist attacks and suggests that a systematic review may make an important contribution to the field [ 6 ]. We present a review of the empirical research focused on the study of MDD as a consequence of terrorism in two specific populations: direct victims people who experienced the event in first person either because they were injured in the attack, or suffered material losses, or lost relatives or close friends [ 19 ] and indirect victims people in the general population.

Two specific goals were established for the review: a to systematically review the results of studies that analyzed the prevalence and course of MDD following terrorist attacks and b to document the main correlates associated with this disorder. Our intention is to draw inferences that may help future research in the field and potentially guide the implementation of practical interventions when terrorist attacks do occur.

Our review focused only on studies carried out after human-made, intentional, terrorist attacks, limiting our search to studies that were designed and conducted at a specific time and place and not including, therefore, investigations on the impact of other kinds of disasters e. We focused our review on studies carried out in adult populations, including either persons in the general population or persons directly affected by a terrorist attack. We excluded work that focused on specific population subgroups such as emergency personnel, children, etc. Several studies in the field have adopted a dimensional approach, using scales that assess the frequency or intensity of certain symptoms associated with MDD.

These studies preclude a diagnosis of MDD. Although some studies overcome this problem using different cut-off points to document MDD prevalence [ 20 , 21 ], this can lead to different conclusions depending on the cut-off point used [ 22 ] and to an overestimation of the presence of this disorder in the population [ 23 ]. Moreover, it is difficult compare the prevalence of MDD reported by investigations when a dimensional approach is used.

Therefore, we only took into account the assessment of MDD based on diagnostic criteria, mainly based on the DSM international classification. Also, although some studies in the field use the term "incidence" rather than "prevalence", none of them were designed to ensure that persons were free from psychopathology before the occurrence of the terrorist attack. Therefore, and following other authors [ 1 , 3 ], we shall use the term prevalence in general throughout. A four-step procedure was used. First, a search of the peer-reviewed literature in the PsycINFO and Medline databases was conducted without time limit using the following keywords: depression, terrorist, terrorism, mental health, disaster and trauma.

Searches were undertaken between January 12 and 16, The initial database search identified potentially eligible studies for this review. Second, two independent reviewers analyzed the title and abstracts of all retrieved studies and excluded those which did not meet the selection criteria. The majority of studies excluded in this step were papers that analyzed psychological consequences different from MDD, other kinds of disasters not categorized as terrorist attacks or other populations that were not either direct victims nor general population.

Third, full manuscripts were obtained for all publications included after the second step. We examined the complete text of the articles and once again eliminated those which did not comply with the selection criteria. The majority of studies excluded in this step were papers that analyzed the psychological consequences of terrorist attacks without assessing MDD with diagnostic criteria.

Fourth, to verify that our final sample was comprehensive and that our search was appropriate, we compared it with previous review papers [ 1 , 3 , 6 ]. Our search identified 11 studies of MDD following terrorist attacks: 6 were carried out with victims, 4 with general population samples, and one with victims and general population. Of these, 9 were cross-sectional studies and 2 were cohort studies. In these, information about the terrorist attacks, assessment time, sample size, method and main results MDD prevalence is shown.

Note: "Current depression" refers to people who suffer from major depression at the time of the interview. Note: "Current depression" refers to people who suffer from major depression at the time of the interview; "Depression since terrorist attacks" refers to those who have suffered major depression at any given time since terrorist attacks.

In our review, most studies examine the impact of terrorist attacks in Madrid March 11, and New York September 11, Nevertheless, one study assesses the impact of different terrorist attacks occurred in France between and , another one assesses the consequences of the Oklahoma City Bombing , and yet another one compares the consequences of the Oklahoma City Bombing with the attack on the US embassy in Nairobi, Kenya One of the first studies with direct victims was carried out by Abenhaim, Dab, and Salmi [ 28 ].

These authors studied the consequences of 21 terrorist attacks that occurred in France between and Data were collected between 4 months and 3 years after the attacks. Results showed an overall prevalence of MDD of After the Oklahoma City bombing in , which caused the death of people and left more than wounded, several studies were carried out with persons selected from the record of victims of the Health Department of Oklahoma.

In the first study, using a sample of victims, North et al. In another investigation, North et al. The goal was to compare the mental health of populations exposed to terrorism in different continents--North America and Africa--using a similar methodology in both studies. Results showed no significant differences in the prevalence of MDD in these populations in both men and women. There were no differences in the prevalence of other pathologies such as PTSD or panic disorder suggesting comparable consequences of terrorist events across very different contexts.

In Spain, several studies analyzed the psychopathological consequences of the terrorist attacks of March 11, , in Madrid. In these attacks, ten bombs placed on four suburban trains caused the death of people and wounded approximately This study documented a prevalence of MDD of Similar results were found in two other studies that assessed a sample of victims who requested medical assistance in various Madrid hospitals on the day of the terrorist attacks, despite differences in the assessment instruments and the methodology between them.

The prevalence of MDD was Results are contradictory with regard to the course of MDD. On the other hand, after the March 11, attacks, whereas Conejo-Galindo et al. Terrorist attacks can have an effect on the population that is directly assaulted or even on an entire nation [ 20 , 21 ]. Several studies have documented the consequences of terrorist attacks on the population as a whole. Galea et al. They found a prevalence of current MDD of 9. These findings were replicated in another cross-sectional sample studied 4 months after the attacks [ 36 ]. Person et al. Data showed that the prevalence of MDD was 3.

Miguel-Tobal et al. Using a methodology similar to the one employed by Galea et al.

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The prevalence of current MDD in this case was 8. The correlates of MDD reported in the reviewed studies were classified as pretraumatic, peri-traumatic, posttraumatic, and sociodemographic factors. Several of the studies discussed up to this point have shown that the probability of suffering MDD after a terrorist attack was increased by at least twofold among those who had experienced at least one stressful situation in the 12 months prior to the terrorist attack [ 8 , 32 , 35 , 37 ]. Variables that have an impact during or some time immediately after the attack are included in this category.

Among them, the emotional reaction in the immediate aftermath of the attack has been shown to be a significant predictor of subsequent MDD. Across studies, the risk of developing MDD one month after the terrorist attacks, or of still suffering from MDD six months after the terrorist attacks, is approximately three times higher in those with symptoms of panic during or shortly after the attacks [ 8 , 35 , 37 ]. Similar results were shown in the people who admitted having been afraid to die or of being injured during the attack [ 37 ].

The factors or events that occurred in the weeks or months after the terrorist attack were classified in this category. Among them, the occurrence of stressful events or the loss of psychosocial resources after the terrorist attacks is noteworthy. Having experienced more stressful situations after September 11, , multiplied the probability of suffering from MDD by between 1.

In addition, the loss of psychosocial resources has been associated with MDD in other study [ 35 ]. Of all the sociodemographic variables studied, the clearest relation was found between gender and the risk of MDD following the terrorist attacks, with women having consistently higher prevalence of MDD after these events. This result has been documented in direct victims of terrorist attacks [ 32 , 33 ] and in the general population [ 32 , 35 , 37 ].

Other variables commonly analyzed, such as age, race, or ethnicity, do not show a consistent relation with MDD in these studies. For example, being Hispanic was a significant predictor of MDD one month [ 35 ] but not 6 months [ 8 ] after the September 11, attacks or, with respect to age, prevalence of MDD was lower in older people after September 11, attacks [ 35 ] but not after the March 11, terrorist attacks [ 37 ]. Nonetheless, variables such as the economical or educational level were not associated with a differential risk for the onset of MDD.

Several studies have assessed the proximity of residence to the place where the terrorist attacks occurred and the relation of this variable with subsequent MDD. In contrast with the findings in the assessment of PTSD [ 3 ], the proximity of one's residence has not been consistently shown to be a predictor variable of MDD, at least in the works with general population [ 37 ].

Results are inconsistent with respect to social support. Whereas in some studies the perception of social support in the months prior to the terrorist attack was shown to be a negative predictor of MDD [ 35 , 37 ], in other works no significant association between these variables was found [ 8 , 32 ]. Excluded studies that assess the prevalence of other psychological problems after terrorist attacks have generally been focused on PTSD. The research literature suggests that the burden of PTSD in persons exposed to disasters is significant.

Furthermore, a common result is that the prevalence of PSTD in the aftermath of a natural disaster is often lower than the rates documented after human-made disasters such as terrorist attacks [ 1 , 3 , 6 ]. Other studies not included in our review examined the prevalence of MDD after natural disasters or chronic exposure to trauma. Some of the natural disasters evaluated have been the Turkey earthquakes [ 38 ], the Asian Tsunami [ 39 ], the hurricane in Florida [ 40 ] or the hurricane Katrina [ 41 ].

Natural disasters affect broad geographic areas, leading investigators to study populations that often include both direct and indirect victims [ 3 ]. Consequently, reports of MDD prevalence rates after natural disasters vary widely. Focused on chronic exposure to trauma, different studies have examined the significant impact of terrorism in the Israeli population since the beginning of the Al Aqsa intifada in September In a study conducted in April-May , Bleich et al.

In another population-based study carried out between January and December [ 43 ], This difference between Arabs and Jews has been shown in other studies, and is consistent with both MDD as well as other psychological problems [ 44 , 45 ], suggesting that the mental health impact of terrorism differs among diverse groups living in Israel. Along the same line, different authors have documented the psychological impact of impending forced settler disengagement in Gaza.


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Hall et al. Other papers have assessed the predictors of depressive symptoms in population-based cohort studies [ 11 , 47 ]. Together with victims and general population, specific population sub-groups e. In contrast to the findings in the assessment of PTSD, where the prevalence of PTSD among rescue workers is higher than in the general population [ 4 ], prevalence of MDD in rescue workers seems to be lower than in victims or in general populations, as different studies carried out after March terrorist attacks have clearly shown [ 48 ].

On the other hand, the impact of terrorism in children and adolescents reveals that a substantial proportion of youth reports a wide array of clinical needs and functional impairments months after an attack [see 49 for a review].