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The Tigers became known for their suicide bombings, which they were among the first militants to pioneer , and deployment of child soldiers. In , the U. But watchdog groups say both the LTTE and the army were guilty of war crimes and rights abuses. According to the United Nations, about 40, civilians were killed in the final stages of the civil war. Tourism dropped sharply during the war years, hitting a low point after a tsunami devastated Sri Lanka in There were only , visitors in ; the industry has since recovered to attract 2 million visitors last year.

The final, intense period of the civil war left hundreds of thousands of Tamils displaced, thousands of whom are still missing. Communal tensions reignited last year: In the central district of Kandy, Buddhist Sinhalese mobs attacked mosques and Muslim establishments. In response, Colombo imposed a nationwide state of emergency. In , Sri Lankan authorities reported that 32 Sri Lankans had joined the Islamic State, but the terrorist group is not known to have a presence in the country.

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Thank you for being an FP reader. To get access to this special FP Premium benefit, subscribe by clicking the button below. Sri Lankan officials inspect St. Sebastian's Church in Negombo, north of Colombo, after multiple explosions targeting churches and hotels on April The targets. View Comments. Tags: Religion , Sri Lanka , Terrorism. Mr Biddle is one of the winners who will attend an awards ceremony which will be held on the afternoon on May 25 in the Coldra Court Hotel where the overall Pride of Gwent winner for will be announced.

See photos images. Get involved with the news in your community. Send your stories and photos now. Continue reading. Witnesses sought after woman died in crash at Cwm, near Ebbw Vale 3. Off-road biker makes 'horror film' discovery while cycling forest trail Long delays on motorway after crash blocked one lane. Crash involving cement lorry and van closes A southbound at Llanellen Bridge. 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 ].


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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.

JMSN was responsible for writing the drafts of this paper. ACV and SG were responsible for revising the paper critically for important intellectual content. All authors read and approved the final manuscript. National Center for Biotechnology Information , U. BMC Psychiatry. Published online Jun 1. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Received Mar 14; Accepted Jun 1. This article has been cited by other articles in PMC. Abstract Background Terrorist attacks are traumatic events that may result in a wide range of psychological disorders for people exposed.

A Few of the Chosen: Survivors of Terrorism

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.

Background The scientific study of the psychological consequences of disasters has come a long way in the last decade [ 1 , 2 ]. Method 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.

Open in a separate window. Figure 1. Flowchart of the studies included in the review. Search Results 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. 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. Results 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.

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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.

Discussion The reviewed literature suggests that terrorist attacks are a risk factor for the development of MDD, mainly in the first months after its occurrence, and in certain at-risk populations. 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 ].

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. Conclusions 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.

Competing interests The authors declare that they have no competing interests.

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The epidemiology of post-traumatic stress disorder after disasters. Epidemiologic Reviews. Psychological consequences of the M terrorist attacks in Madrid. General conceptualization of the studies and results in the general population. Post-traumatic stress disorder following disasters: A systematic review. Psychological Medicine. In: Terrorism and disaster Individual and community mental health interventions. Trauma, terrorism, and disaster; pp. A proposed universal medical and public health definition of terrorism.

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Prevalence, comorbidity and service utilization for mood disorders in the United States at the beginning of the twenty-first Century. Work and psychiatric disorder in the Whitehall II Study. J Psychosom Res. Cost of lost productive work time among US workers with depression. Terrorism, mental health, and September Lessons learned about providing mental health services to a traumatized population.

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