The impact of the Paris terrorist attacks on the mental health of resident physicians

Effects of mass casualty incidents on anxiety, depression, and post-traumatic stress disorder among doctors and nurses: a systematic review

OBJECTIVES

Doctors and nurses suffer different mental health conditions following traumatic incidents. We systematically synthesized existing evidence on the prevalence of anxiety, depression, and post-traumatic stress disorder (PTSD) and their associated risk factors among doctors and nurses following mass casualty incidents (MCIs).

STUDY DESIGN

Systematic review.

METHODS

Seven databases were searched (2010-2022) with peer-reviewed articles in English using the predefined keywords. Two reviewers screened the titles, abstracts, and full texts using the eligibility criteria and extracted data independently. We used the National Institutes of Health Quality Assessment Tools (NIH-QAT) and the Critical Appraisal Skills Programme checklist (CASP) to measure the quality appraisal of the included studies.

RESULTS

A total of 5170 articles were retrieved, and 2512 articles were assessed by title and abstract (53 were eligible for full-text review). Finally, we included 19 studies. Most were assessed as of fair quality with a considerable risk of bias. PTSD was the highest-reported mental health condition. Nurses reported higher mental conditions, particularly PTSD. Two sets of risk factors (personal and workplace) are associated with anxiety, depression, and PTSD were found.

CONCLUSIONS

MCIs have a significant impact on the mental health outcomes of emergency health workers. Preventive measures should be designed considering the high-risk group, personal, and organizational risk factors of mental health outcomes.

Storylines of Trauma in Health Professions Education: A Critical Metanarrative Review

PHENOMENON

Learners in medical education are often exposed to content and situations that might be experienced as traumatic, which in turn has both professional and personal implications. The purpose of this study was to synthesize the literature on how trauma has been conceptualized and approached within medical education, and the implications thereof.

APPROACH

A metanarrative approach was adopted following the RAMESES guidelines. Searches of 7 databases conducted in January 2022 with no date limitations yielded 7,280 articles, of which 50 were identified for inclusion through purposive and theoretical sampling. An additional 5 articles were added from manual searches of reference lists. Iterative readings, interpretive and reflexive analysis, and research team discussions were performed to identify and refine metanarratives.

FINDINGS

Five metanarratives were identified, including the concept of trauma, the trauma event, the person with trauma, the impact of trauma, and addressing trauma, with each metanarrative encompassing multiple dimensions. A biomedical concept of trauma predominated, with lack of conceptual clarity. Theory was not integrated or developed in the majority of articles reviewed, and context was often ambiguous. Trauma was described in myriad ways among studies. Why certain events were experienced as trauma and the context in which they took place were not well characterized. The impact of trauma was largely concentrated on harmful effects, and manifestations beyond symptoms of post-traumatic stress were often not considered. Furthermore, the dominant focus was on the individual, yet often in a circumscribed way that did not seek to understand the individual experience. In addressing trauma, recommendations were often generic, and earlier research emphasized individually-focused interventions while more recent studies have considered systemic issues.

INSIGHTS

Multiple dimensions of trauma have been discussed in the medical education literature and from many conceptual standpoints, with biomedical, epidemiologic, and individualized perspectives predominating. Greater precision and clarity in defining and understanding trauma is needed to advance research and theory around trauma in medical education and the associated implications for practice. Exploring trauma from intersectional and collective experiences and impacts of trauma and adapting responses to individual needs offers ways to deepen our understanding of how to better support learners impacted by trauma.

"The Wild West:" Nurse Experiences of Responding to the 2017 Las Vegas Mass Shooting

OBJECTIVE

The purpose of this study was to explore the experiences of nurses who responded to a public mass shooting in 2017.

METHODS

This qualitative study was conducted with a sample of nurses who responded to a mass shooting, recruited purposively from a hospital in Las Vegas, Nevada. Intensive interviews were conducted with a total of 7 nurses, audio-recorded and transcribed for thematic analysis.

RESULTS

Six themes were developed from interview data: (1) "The worst night of my life": Overrun and overwhelmed; (2) Unexpected altruism and benevolence of patients and staff; (3) "The Wild West": Giving victim care by improvising beyond rules; (4) Experiencing a range of reactions in the immediate aftermath and in the long term; (5) Shifts in nursing practice and evolving team dynamics; and (6) Defining realistic approaches to support staff mental health and mass casualty preparation.

CONCLUSION

Nurses who were involved in responding to the public mass shooting described the event as life-altering. Given the critical role of nurses in responding to mass shootings, it is essential to consider how nurses can be supported in the aftermath of these events and how mass disaster preparation can include attention to the needs of nurses.

Prevalence of Post-Traumatic Stress Disorder (PTSD) in Healthcare Workers following the First SARS-CoV Epidemic of 2003: A Systematic Review and Meta-Analysis

The world is still in the grip of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, with putative psychological consequences for healthcare workers (HCWs). Exploring the prevalence of post-traumatic stress disorder (PTSD) during the first SARS-CoV-1 epidemic in 2003 may inform us of the long-term effects of the actual pandemic, as well as putative influencing factors such as contact with the virus, time effects, or the importance of some sociodemographic data. This information may help us develop efficient preventive strategies. Therefore, we conducted a systematic review and meta-analysis on the prevalence of PTSD in HCWs following the SARS-CoV-1 in 2003. PubMed, Embase, Google Scholar, Psychinfo, and Web of Science were searched until September 2022. Random-effects meta-analyses were stratified by the time of follow-up. We included 14 studies: 4842 HCWs (32.0 years old, 84% women). The overall prevalence of PTSD was 14% (95CI 10 to 17%). The prevalence of PTSD was 16% (8 to 24%) during the epidemic, 19% (16 to 22%) within 6 months after the epidemic, and 8% (4 to 13%) more than one year after the end of the epidemic. The longest follow-up was three years after the epidemic, with 10% of HCWs with PTSD. Nevertheless, the prevalence of PTSD was significantly lower more than one year after the end of the epidemic than the first six months after the epidemic (Coefficient -10.4, 95CI -17.6 to -3.2, p = 0.007). In conclusion, the prevalence of PTSD in HCWs was high during the first epidemic of SARS-CoV in 2003 and remained high in the long term. The lessons from the SARS-CoV-1 epidemic may help prevent a wave of PTSD following the latest COVID-19 pandemic.

Physicians' Response and Preparedness of Terrorism-Related Disaster Events in Quetta City, Pakistan: A Qualitative Inquiry

Background

Besides catastrophes, infrastructural damages, and psychosocial distress, terrorism also imposes an unexpected burden on healthcare services. Considerably, adequately-prepared and responsive healthcare professionals affirms effective management of terrorism-related incidences. Accordingly, the present study aimed to evaluate physicians' preparedness and response toward terrorism-related disaster events in Quetta city, Pakistan.

Methods

A qualitative design was adopted. Physicians practicing at the Trauma Center of Sandeman Provincial Hospital (SPH), Quetta, were approached for the study. We conducted in-depth interviews; all interviews were audio-taped, transcribed verbatim, and analyzed for thematic contents by a standard content analysis framework.

Results

Fifteen physicians were interviewed. The saturation was achieved at the 13th interview however we conducted another two to validate the saturation. The thematic content analysis revealed five themes and 11 subthemes. All physicians have experienced, responded to, and managed terrorism-related disaster events. They were prepared professionally and psychologically in dealing with a terrorism-related disaster. Physicians identified lack of disaster-related curricula and training, absence of a standardized protocol, recurrence of the disaster, and hostile behavior of victim's attendants during an emergency as critical barriers to effective terrorism-related disaster management. Among limitations, all respondents mentioned workspace, and resources as a foremost constraint while managing a terrorism-related disaster event.

Conclusion

Although physicians understood the abilities and had the required competencies to mitigate a terrorism-related disaster, lack of workspace and resources were identified as a potential barrier to effective disaster management. Based on the results, we propose reconsideration and integration of the medical curriculum, particularly for terrorism-related disaster management, collaboration, and communication among various stakeholders to manage terrorism-related disaster events competently.

Recommendations for the pharmacological treatment of treatment-resistant depression: A systematic review protocol

INTRODUCTION

Depression is a serious and widespread mental health disorder. Although effective treatment does exist, a significant proportion of patients with depression fail to respond to antidepressant treatment trials, a condition named treatment-resistant depression. Efficient approach should be given this condition in order to revert the burden caused by depression. Clinical practice guidelines (CPGs) are evidence-based health promotion instruments to improve diagnosis and treatment. CPGs recommendations for treatment-resistant depression must be trustworthy. The objective of the proposed study is to systematically identify, appraise the quality of CPGs for the treatment of depression and elaborate a synthesis of recommendations for treatment-resistant depression of CPGs considered to be of high quality and with high quality recommendations.

METHODS AND ANALYSIS

We will search the databases of organizations, such as PubMed, Embase, Cochrane Library, PsycInfo, and the Virtual Health Library, and organizations that develop CPGs. Three independent researchers will assess the quality of the CPGs and their recommendations using the AGREE II and AGREE-REX instruments, respectively. Given the identification of divergences and convergences as well as weak and strong points among high quality CPGs, our work may help developers, clinicians and eventually patients.

ETHICS AND DISSEMINATION

No ethical approval is required for a systematic review, as no patient data will be used. The research results will be disseminated in conferences and submitted to a peer reviewed journal.

Impact of the COVID-19 pandemic on the mental health of professionals in 77 hospitals in France

The COVID-19 pandemic has led to significant re-organisation of healthcare delivery in hospitals, with repercussions on all professionals working in healthcare. We aimed to assess the impact of the pandemic on the mental health of professionals working in health care institutions and to identify individual and environmental factors influencing the risk of mental health disorders. From 4 June to 22 September 2020, a total of 4370 professionals responded to an online questionnaire evaluating psychological distress, severity of post-traumatic stress symptoms, stress factors, and coping strategies. About 57% of the professionals suffered from psychological distress, and 21% showed symptoms of potential post-traumatic stress. Professionals working in radiology, those working in quality/hygiene/security and nurses' aides were the most affected groups. The media focus on the crisis, and a high workload were the most prevalent stress factors, followed by uncertainty regarding the possibility of containing the epidemic, the constantly changing hygiene recommendations/protocols, and the lack of personal protective equipment. The use of coping strategies, notably positive thinking, helped to mitigate the relation between perceived stress and mental health disorders. The COVID-19 pandemic has had far-reaching negative repercussions for all professionals, with some sectors more markedly affected. To prevent mental health disorders in professionals during a public health crisis, support services and management strategies within hospitals should take account of the importance of positive thinking and social support.

Anxiety, Depression and Posttraumatic Stress Disorder after Terrorist Attacks: A General Review of the Literature

Terrorism, though not well-defined, is a violent act that has been shown to have longstanding effects on the mental health of those who witness it. The aim of this general literature review is to explore the effect that terrorism has on posttraumatic stress disorder (PTSD), major depressive disorder (MDD) and anxiety disorders, as well as the bio-psycho-social determinants that mediate its impact. This paper describes the prevalence, risk factors, protective factors, common presentations and interventions identified for PTSD, depression and anxiety disorders occurring following terrorist attacks. We conducted a literature search in MEDLINE using a number of keywords detailed below. After applying inclusion and exclusion criteria, we kept 80 articles, which we summarized in tabular form. A majority of articles found detailed the impact of terrorism on PTSD, and took place in a Western, mainly American setting. The main factors that impacted the presentation of mental illness include gender, ethnicity, social supports, socioeconomic status, level of preparedness, level of exposure, pre-existing trauma and mental illness, and subsequent life stressors. The main intervention detailed in this article as showing evidence post-terrorism is trauma-focused cognitive-behavioural therapy. This study highlights the importance of this topic, and in particular, its implications for public health policy and practice.

Mental health impact among hospital staff in the aftermath of the Nice 2016 terror attack: the ECHOS de Nice study

BACKGROUND

The Nice terror attack of July 14, 2016 resulted in 84 deaths and 434 injured, with many hospital staff exposed to the attack, either as bystanders on site at the time of the attack ('bystander exposure') who may or may not have provided care to attack victims subsequently, or as care providers to victims only ('professional exposure only'). The objective of this study is to describe the impact on mental health among hospital staff by category of exposure with a particular focus on those with 'professional exposure only', and to assess their use of psychological support resources.

METHOD

An observational, cross-sectional, multicenter study conducted from 06/20/2017 to 10/31/2017 among all staff of two healthcare institutions in Nice, using a web questionnaire. Collected data included social, demographic and professional characteristics; trauma exposure category ('bystanders to the attack'; 'professional exposure only'; 'unexposed'); indicators of psychological impact (Hospital Anxiety and Depression Scale); PTSD (PCL-5) level; support sought. Responders could enter open comments in each section of the questionnaire, which were processed by inductive analysis.

RESULTS

804 staff members' questionnaires were analysed. Among responding staff, 488 were exposed (61%): 203 were 'bystanders to the attack', 285 had 'professional exposure only'. The staff with 'professional exposure only' reported anxiety (13.2%), depression (4.6%), suicidal thoughts (5.5%); rates of full PTSD was 9.4% and of partial PTSD, 17.7%. Multivariate analysis in the 'professional exposure only' category showed that the following characteristics were associated with full or partial PTSD: female gender (OR = 2.79; 95% CI = 1.19-6.56, p = 0.019); social isolation (OR = 3.80; 95% CI = 1.30-11.16, p = 0.015); having been confronted with an unfamiliar task (OR = 3.04; 95% CI = 1.18-7.85; p = 0.022). Lastly, 70.6% of the staff with 'professional exposure only' with full PTSD did not seek psychological support.

CONCLUSION

Despite a significant impact on mental health, few staff with 'professional exposure only' sought psychological support. Robust prevention and follow-up programs must be developed for hospital staff, in order to manage the health hazards they face when exposed to exceptional health-related events such as mass terror attacks.

STUDY REGISTRATION

Ethical approval for the trial was obtained from the National Ethics Committee for Human Research (RCBID N° 2017-A00812-51).

Psychological impact of an acute intervention on medical-psychological emergency unit professionals: the example of hurricane Irma

BACKGROUND

Medical-psychological emergency units (Cellules d'Urgence Médico-Psychologiques, CUMP) are deployed following major events where there is a risk of psychological trauma, in order to provide acute and proper psychological care for the victims.

AIMS

To describe and evaluate the risk of a psychological impact on CUMP professionals after their participation in the aftermath of the hurricane Irma natural disaster. CUMP teams consist of medical and paramedical staff, who can have permanent or volunteer status. We reasoned that there might be a psychological and emotional impact on CUMP professionals, despite their own expertise in the field, after their intervention following hurricane Irma.

METHOD

A cross-sectional survey was conducted during a feedback meeting. Participating professionals completed a sociodemographic questionnaire and the Professional Quality of Life (ProQOL) scale (5th French version), which is composed of three subscales: compassion satisfaction, burnout and secondary traumatic stress (STS).

RESULTS

A total of 53 participants were included with 24 (45.3%) psychiatrists, 15 (28.3%) paramedical staff and 14 (26.4%) psychologists. The median age was 46 years (range 39-55.5) and 29 (54.7%) were women. We found that psychiatrists compared with other professions had higher secondary traumatic stress scores (P = 0.007) and that volunteer psychiatrists had higher burnout scores than permanent psychiatrists (P = 0.03).

CONCLUSIONS

These preliminary results suggest a psychological impact attributable to leadership status, which was reserved for psychiatrists. The results also underline the need for a supportive accompaniment for such teams by promoting formation improvement, psychological support and team cohesion.

A qualitative study to investigate the psychosocial effects of operational deployments on Medical Emergency Response Team personnel

The stressors associated with emergency medical teams responding to critical incidents are well documented; however, the impact of such duties on the UK military personnel had never been investigated. This study explored the psychosocial effects of Medical Emergency Response Teams (MERT) operating in Afghanistan to inform the development of a Resilience Model. A structured and contextually relevant process could then be applied for a team's preparation for, delivery of and recovery from, their duties. A qualitative cross-sectional design used semi-structured interviews and 15 multidisciplinary team members participated. Interviews were transcribed verbatim and data were systematically analysed using grounded theory. Emergent theory poses that developing resilience against the demands of this role is dependent upon personnel having a realistic understanding of the deployed environment by phased immersion within it. This preparatory training generates situational awareness, trust and strong team cohesion, which together with peer and organizational support are necessary factors to effectively cope with the role. To limit the costs of caring, there is a need for MERT personnel to segregate the physiological and emotional aspects of delivering care to the injured; those unable to do so may be at greater risk of poor mental health outcomes. The preparatory training of MERT personnel must be further developed to provide an immersive environment that more closely matches the reality of the role. A period of stability is required post deployment with the support of peers to enable personnel to more efficiently transition back to their home life.

Lifestyle Factors and Other Influences on Medical Students Choosing a Career in Emergency Medicine

OBJECTIVE

The purpose of this study was to determine which lifestyle factors influence medical students who choose a career in emergency medicine (EM).

METHODS

Final-year medical students from 10 medical schools were surveyed after the National Residency Match Program match but prior to graduation regarding preferred medical specialty and lifestyle preferences. Responses from students pursuing EM regarding importance of lifestyle factors were compared to students interested in other specialties.

RESULTS

A total of 453 of 1,575 invited medical students completed an electronic survey. EM was the third most preferred specialty. Students selecting EM were less likely to endorse "having control of work schedule" as being important (p < 0.005), but more likely to endorse "having time off work" as important (p < 0.05). When students were asked what specific factors were important in choosing a specialty, EM students differed from other students in the importance of flexible work schedule, time outside of work, and balance between work and personal life (p < 0.001). Fewer EM students endorsed that having a "low-stress work day" was an important consideration in their specialty choice (p < 0.001).

CONCLUSIONS

In this study representing 10 medical schools, graduating medical students who prefer EM as opposed to other specialties exhibit differences in lifestyle factors deemed important when choosing a specialty as a physician. Further investigation regarding any potential link to these factors and career longevity is warranted.

Symptoms of Anxiety, Depression, and Peritraumatic Dissociation in Critical Care Clinicians Managing Patients with COVID-19. A Cross-Sectional Study

Rationale: Frontline healthcare providers (HCPs) during the coronavirus disease (COVID-19) pandemic are at high risk of mental morbidity.

Objectives: To assess the prevalence of symptoms of anxiety, depression, and peritraumatic dissociation in HCPs.

Methods: This was a cross-sectional study in 21 ICUs in France between April 20, 2020, and May 21, 2020. The Hospital Anxiety and Depression Scale and the Peritraumatic Dissociative Experience Questionnaire were used. Factors independently associated with reported symptoms of mental health disorders were identified.

Measurements and Main Results: The response rate was 67%, with 1,058 respondents (median age 33 yr; 71% women; 68% nursing staff). The prevalence of symptoms of anxiety, depression, and peritraumatic dissociation was 50.4%, 30.4%, and 32%, respectively, with the highest rates in nurses. By multivariable analysis, male sex was independently associated with lower prevalence of symptoms of anxiety, depression, and peritraumatic dissociation (odds ratio of 0.58 [95% confidence interval, 0.42–0.79], 0.57 [95% confidence interval, 0.39–0.82], and 0.49 [95% confidence interval, 0.34–0.72], respectively). HCPs working in non–university-affiliated hospitals and nursing assistants were at high risk of symptoms of anxiety and peritraumatic dissociation. Importantly, we identified the following six modifiable determinants of symptoms of mental health disorders: fear of being infected, inability to rest, inability to care for family, struggling with difficult emotions, regret about the restrictions in visitation policies, and witnessing hasty end-of-life decisions.

Conclusions: HCPs experience high levels of psychological burden during the COVID-19 pandemic. Hospitals, ICU directors, and ICU staff must devise strategies to overcome the modifiable determinants of adverse mental illness symptoms.

Original Research: Exploring the Effects of a Nurse-Initiated Diary Intervention on Post-Critical Care Posttraumatic Stress Disorder

BACKGROUND

Critical illness survivors may develop posttraumatic stress disorder (PTSD) following critical illness and hospitalization. Left untreated, PTSD may result in poor health outcomes.

PURPOSE

This study sought to examine the effects of a nurse-initiated diary intervention on PTSD development and symptom severity in critical illness survivors with varying levels of mentation.

METHODS

The study used a pretest-posttest control group design. Patients who were hospitalized in a critical care unit for more than 24 hours were recruited at a single medical center with two such units. All participants completed a pretest on day 2 of critical care hospitalization; the intervention group participants also received a diary. All participants received a posttest one month after critical care discharge. The variables examined were PTSD severity and symptoms of avoidance, intrusion, and hyperarousal. Variables were measured using the Impact of Event Scale-Revised. Diaries were written by the patient, visitors, and interdisciplinary team members, and kept by the patient.

RESULTS

A total of 134 participants completed the study. The intervention group participants experienced significantly fewer PTSD symptoms than the control group participants. PTSD was found to be of concern in 35 (26%) of all participants: five in the intervention group and 30 in the control group.

CONCLUSIONS

For critical illness survivors, a collaborative diary-writing intervention during hospitalization and after discharge can mitigate post-critical care PTSD. Participants who received diaries had a lower incidence of PTSD symptoms than controls; and at follow-up, they indicated that the diary intervention was worthwhile. We recommend the use of collaborative diary writing to help critical illness survivors in working through their experiences.

Factors associated with PTSD and partial PTSD among first responders following the Paris terror attacks in November 2015

During the evening of 13 November 2015, the deadliest terror attacks in France in recent times occurred in the Paris area. Overall, 130 people were killed, 643 were physically injured and several thousands were psychologically impacted. Thousands of first responders, including health professionals, firefighters, affiliated volunteers and police officers were mobilized that night and during the subsequent weeks. The aims of our study were to measure the psychological impact on first responders in terms of post-traumatic stress disorder (PTSD) and partial PTSD as well as associated factors 12 months after the 13 November 2015 terrorist attacks. First responders who had intervened during the night and/or the aftermath of the terror attacks had the possibility of answering a web-based study 8-12 months after the attacks. They satisfied criterion A of the DSM 5 definition of PTSD. PTSD and partial PTSD were measured using the PCL-5. Gender, age, educational level, exposure, first responder category, mental health and traumatic event history, training and social support were all analysed as potential factors associated with PTSD and partial PTSD, using multinomial logistic regression. Overall, 663 participants were included in this analysis. Prevalence of PTSD in our sample went from 3.4% among firefighters to 9.5% among police officers and prevalence of partial PTSD from 10.4% among health professionals to 23.2% among police officers. Low educational level and social isolation were associated with PTSD and partial PTSD. Intervention on unsecured crime scenes and lack of training were associated with PTSD. Special attention should be given to first responders living in social isolation, those with low educational levels and those who intervene in unsecured crime scenes. Education and training about the potential mental health consequences of mass trauma intervention should be developed.