The Espa survey aims to measure the psychological impact of the November 13, 2015, attacks on individuals who were directly exposed to them or who had a loved one involved in or killed as a result of the attacks.

Espa is one of the few studies worldwide that attempts to describe the use of specialized care by these particularly vulnerable populations. 575 people participated in this first wave of the survey. They were asked whether they recalled receiving psychological care from healthcare specialists at the various on-site response units deployed for this purpose near the attack sites, whether they had consulted a psychologist or psychiatrist through the standard system for addressing psychological issues in France (medical-psychological centers, public hospitals, private practices), and whether or not they had begun regular psychological follow-up.

The study received support from healthcare professionals working on the ground. They also offered to supplement the survey by asking participants about their use of victim support organizations, which, given the needs expressed, also provided psychological support.

We were thus able to explore the proportion of people who received psychological follow-up among respondents, among those directly threatened, among direct witnesses, among bereaved individuals, and among those exhibiting post-traumatic stress disorder or high scores on depression or anxiety symptoms. Finally, we examined the association between immediate psychological care and the use of regular care among individuals exhibiting the symptoms defined above.

Two-thirds of those surveyed sought psychological counseling in the months following the attacks. Visits to a specialist (39%) and regular counseling (33%) were more common than visits to a general practitioner (17%). The low rate of visits to general practitioners contrasts with the fact that, typically, general practitioners are the primary source of psychological support in Europe and the United States.

One possible explanation for this difference is the provision of free psychological care offered by the Ministry of Health. There is greater use of care among those suffering from post-traumatic stress disorder (PTSD), depression, or both. However, eyewitnesses suffering from PTSD were more likely not to have sought regular care than those who were directly threatened (65% and 35%, respectively). Receiving psychological support as part of the response deployed on the ground immediately after the attacks (35%) and visiting a victims’ association (16%) were both associated with engaging in regular psychological follow-up. Very few participants (1%) initiated regular care directly without having previously reported receiving one-time care. A visit to a specialist was the most common of these steps.

This use of multiple care services highlights the importance of coordinating the various support mechanisms for mental health disorders over time in a post-attack context. In particular, the involvement of general practitioners in screening for disorders and referring patients to specialists, and, on the other hand, the role of support groups in facilitating the initiation of regular care when necessary. This initial phase of Espa also shows that greater efforts should be made to support bystanders.

The main objectives of this second wave are to assess, five years after the attacks of November 13, 2015, the psychological and traumatic impact on the highly exposed population, and to determine the use of psychological care over the past few years.

For participants in both phases of the survey, it will be important to track changes in mental health status between these two periods. Another question is: Is there a link between receiving regular psychological care and improved mental health, as measured by psychometric scale scores?

It will also be possible, using participants’ Social Security numbers*, to compare self-reported data with actual utilization of reimbursed care. Analyzing these indicators over a long period—specifically, from five years before the attacks up to 10 years afterward—will allow us to track the onset and/or progression of chronic conditions and link them to exposure to the attacks. We will also compare healthcare utilization in this population to that of a socio-demographically comparable sample drawn from the general population.

The Espa study is an open cohort. Aside from those who participated in the first phase, this second wave is also open to anyone meeting the inclusion criteria, regardless of whether they participated in the first wave**.