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Article
The Mental Health Consequences of Mass Shootings
Sarah R. Lowe1 and Sandro Galea2
Abstract Mass shooting episodes have increased over recent decades and received substantial media coverage. Despite the potentially widespread and increasing mental health impact of mass shootings, no efforts to our knowledge have been made to review the empirical literature on this topic. We identified 49 peer-reviewed articles, comprised of 27 independent samples in the aftermath of 15 mass shooting incidents. Based on our review, we concluded that mass shootings are associated with a variety of adverse psychological outcomes in survivors and members of affected communities. Less is known about the psychological effects of mass shootings on indirectly exposed populations; however, there is evidence that such events lead to at least short-term increases in fears and declines in perceived safety. A variety of risk factors for adverse psychological outcomes have been identified, including demographic and pre-incident characteristics (e.g., female gender and pre-incident psychological symptoms), event exposure (e.g., greater proximity to the attack and acquaintance with the deceased), and fewer psychosocial resources (e.g., emotion regulation difficulties and lower social support). Further research that draws on pre-incident and longitudinal data will yield important insights into the processes that exacerbate or sustain post-incident psychological symptoms over time and provide important information for crisis preparedness and post-incident mental health interventions.
Keywords mass shootings, school shootings, mass trauma, posttraumatic stress, major depression, psychosocial resources, risk and protective factors
Over the past few decades, mass shooting episodes—defined
as events involving one or more persons attempting to kill
multiple people, and at least one unrelated person, in an area
occupied by multiple unrelated persons (Blair & Martaindale,
2013)—have received substantial media coverage and captured
public attention. Recent investigations have suggested that mass
shooting episodes are becoming more frequent. For example, a
report by researchers at the Texas State University identified
84 episodes in the United States between 2000 and 2010 and
noted a trend toward increasing frequency of time (Blair &
Martaindale, 2013). An investigation by the Mother Jones
news organization, using a slightly different definition of mass
shootings (events that were ‘‘senseless, random, or at least public
in nature’’), identified 70 episodes occurring between 1982 and
2012 and noted a recent surge in these events, with nearly half
occurring since 2006.
In addition to the increasing frequency of mass shootings
episodes, key events over the past decade have had unusually
large numbers of fatalities and injuries—for example, 33 fatal-
ities and 23 injuries in the 2007 Virginia Tech massacre, 12
fatalities and 58 injuries in the 2012 Aurora, Colorado theater
shooting, and 28 fatalities and 2 injuries in the Sandy Hook ele-
mentary school shooting in Newtown, Connecticut (Follman,
Aronsen, & Pan, 2014). In an epidemiological review of school
shootings, Shultz, Cohen, Muschert, and Flores de Apodaca,
(2013) noted that just three events (Columbine, Sandy Hook,
and Virginia Tech) accounted for over half of the fatalities in
the 215 incidents between 1990 and 2012.
Research indicates that exposure to assaultive violence, or
learning that a close friend or loved one has faced such expo-
sure, is associated with an increased incidence of a range of
negative mental health outcomes, among them posttraumatic
stress disorder (PTSD) and major depression (MD; e.g.,
Breslau et al., 1996; Lowe, Blachman-Forshay, & Koenen,
2015). It is therefore likely that mass shootings exert a psycho-
logical toll on their direct victims and members of the commu-
nities in which they took place. Moreover, media coverage of
mass shootings and their aftermath reaches far beyond affected
communities to the entire nation and beyond. As shown in the
1 Department of Epidemiology, Columbia University, Mailman School of Public
Health, New York, NY, USA 2 Department of Epidemiology, Boston University School of Public Health,
Boston, MA, USA
Corresponding Author:
Sarah R. Lowe, Department of Epidemiology, Columbia University, Mailman
School of Public Health, 722 West 168th Street, Room 720-F, New York, NY
10032, USA.
Email: [email protected]
TRAUMA, VIOLENCE, & ABUSE 2017, Vol. 18(1) 62-82 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1524838015591572 journals.sagepub.com/home/tva
aftermath of the September 11 terrorist attacks (9/11), such
indirect exposure can have mental health consequences (Hen-
ricksen, Bolton, & Sareen, 2010). For example, in the National
Epidemiologic Survey of Alcohol and Related Conditions,
indirect exposure to 9/11 through the media was associated
with increased risk for mood, anxiety and substance use disor-
ders, and PTSD, relative to no reported 9/11 exposure (Hen-
ricksen et al., 2010).
Despite the potentially widespread and increasing mental
health impact of mass shooting episodes, no efforts to our
knowledge have been made to synthesize the extant literature
on this topic. In this article, we therefore aim to conduct a
review of empirical investigations on the mental health conse-
quences of mass shootings. We provide an overview of this
body of research, including the prevalence and predictors of
various mental health outcomes. Based on this review, we
make recommendations for future research and post-incident
interventions.
Method
We conducted a literature search in PsycInfo and PubMed data-
bases, using both general terms (e.g., shooting, tragedy), and
names of specific events (e.g., Columbine, Sandy Hook) com-
piled from comprehensive lists of mass shootings (Follman,
Aronsen, Pan, & Caldwell, 2013; Henriques, 2013; Shultz
et al., 2013). In our review, we used the aforementioned defini-
tion of mass shootings: events involving one or more persons
attempting to kill multiple people, and at least one unrelated
person, in an area occupied by multiple unrelated persons
(Blair & Martaindale, 2013). We included events that took
place in any country in the world. We limited our search to arti-
cles in peer-reviewed, English language journals that included
quantitative indices of post-event mental health, including
symptoms of psychiatric disorders (e.g., PTSD and MD) and
general symptoms that cut across disorders (e.g., psychological
distress and fear). We therefore excluded qualitative studies,
and quantitative studies that focused solely on other outcomes
(e.g., perceptions of social solidarity and coping strategies). In
addition to studies identified through database searches, refer-
ence lists of articles on this topic were reviewed to identify
additional studies.
The coding processes consisted of two main steps. First, we
coded for study characteristics. We recorded the mass shooting
event that was the focus of each study, including the year, loca-
tion, context, demographic characteristics of the perpetrator, and
numbers of injuries and fatalities during the incident, and
whether the study focused on more than one event. We noted
instances in which data from the same sample were used across
different analyses to determine how many independent samples
were there across the studies. In addition, we noted whether the
sample was affected (defined as direct victims of the shooting or
members of the community in which the shooting took place) or
remote (defined as consisting primarily of members outside of
the affected community, e.g., national samples or students at a
university in a difficult region), basic characteristics of the
sample (e.g., whether participants were students or emergency
personnel), sample sizes, and timing of assessments.
Second, we coded the prevalence estimates and predictors of
mental health outcomes in each study. We recorded the mental
health outcomes assessed, the measures and diagnostic classifi-
cation systems used, and the prevalence of psychiatric disor-
ders. We then listed significant predictors of mental health
outcomes and, in doing so, specified the mental outcome
included in the analysis (e.g., diagnosis or symptom severity
score, change in symptoms over time) and timing of assess-
ment. Finally, we noted results that went beyond prevalence
estimates and predictors, such as those focused on mechanisms
leading to mental health outcomes.
Both authors formulated the article selection process, inclu-
sion criteria, and coding scheme. The first author conducted the
literature search, coded selected articles, and checked and
rechecked coding for accuracy, and the second author oversaw
the review process and provided regular feedback.
Study Characteristics
We identified a total of 49 studies on 15 different mass shoot-
ing incidents that took place from 1984 to 2008. Three of the
studies focused on two different events combined. Table 1 pro-
vides basic information on each event (e.g., location, number of
injuries, and fatalities) in chronological order. Thirteen events
took place in the United States, and two took place in Finland.
The majority of events (n ¼ 9) were in a secondary school or university context, whereas the remainder took place in other
locations (e.g., local businesses). In total, there were 27 inde-
pendent samples (three from studies focusing on two different
events combined). Of the 27 independent samples, 22 were
classified as affected samples and 5 as remote samples (two
affected and one remote from the studies focusing on two dif-
ferent events combined).
Post-Shooting Mental Health Outcomes
Table 2 denotes the mental health outcomes included in each
study, as well as the measures used to assess them and the clas-
sification system used to determine prevalence estimates if this
information was available.
Psychiatric Disorders and Prevalence Estimates
PTSD. Posttraumatic stress symptoms (PTSS) were reported in the majority of studies—36 studies from 18 independent sam-
ples. Eighteen of these studies (from 14 independent samples)
included a prevalence estimate of PTSD. The lowest PTSD pre-
valence reported was 3% among parents of children exposed to an elementary school shooting 6–14 months post-incident,
determined using conservative Diagnostic and Statistical Man-
ual of Mental Disorders, Third Edition, Revised (DSM-III-R)
criteria with the PTSD–Reaction Index (PTSD-RI; Schwarz
& Kowalski, 1991a). The highest prevalence reported was
91% among children in the same study, using liberal
Lowe and Galea 63
(proposed) DSM-IV criteria and the children’s version of the
PTSD-RI (Schwarz & Kowalski, 1991b).
Major depression. The second most commonly assessed psychia- tric disorder was MD. MD symptoms were assessed in 16 stud-
ies using 10 independent samples, and the prevalence of MD
was estimated in 8 studies using 7 independent samples. The
lowest prevalence of MD was 4.9% among survivors of the 1991 cafeteria shooting in Killeen, TX, assessed 1 year after
the event using the Diagnostic Interview Schedule for DSM-
III-R (North, Smith, & Spitznagel, 1997). The highest preva-
lence was 71%, detected in a combined sample of Virginia Tech and Northern Illinois University (NIU) students 2 weeks
after the attacks at their respective campuses, assessed using
the Center for Epidemiologic Studies Short Depression Scale
(Vicary & Fraley, 2010).
Other psychiatric disorders. In addition to PTSD and MD, preva- lence estimates were provided for the following psychiatric dis-
orders: generalized anxiety disorder (GAD; three studies and
three independent samples): range: 0.0–0.9%; acute stress disor- der (one study): 33%; alcohol-related conditions (e.g., alcohol abuse, alcohol dependence, alcoholism; four studies, four inde-
pendent samples) range: 0–9%; drug use disorder (one study): range: 0–0.7%; panic disorder (two studies and two independent samples) range: 1–2.4%; adjustment disorder (one study): 9.1%; social phobia (one study): 3%; and antisocial personality
disorder (one study): 0–0.8% (Classen, Koopman, Hales, & Spiegel, 1998; Johnson, North, & Smith, 2002; North, Smith,
McCool, & McShea, 1989; North et al., 1997; Séguin et al.,
2013; Trappler & Friednman, 1996).
Comparing Prevalence Estimates
There are at least four issues to consider when comparing the
prevalence estimates of mental health outcomes across the
studies in our review. First, variation in sample characteristics
that, as discussed in more detail later, could influence post-
event mental health, including variation in demographic char-
acteristics and exposure to the incident. Second, there is wide
variation in the timing of assessments, spanning from approx-
imately 1 week to 32 months post-incident. As shown in studies
with multiple waves (e.g., Nader, Pynoos, Fairbanks, & Freder-
ick, 1990; North et al., 1997), the prevalence of psychiatric dis-
orders tends to decrease over time, limiting the extent to which
estimates at varying time points after different events can be
compared. Third, different measures and diagnostic criteria
were used across the studies, which could certainly affect pre-
valence rates. The influence of diagnostic criteria on preva-
lence rates was most clearly demonstrated in the aftermath of
the 1988 elementary school shooting, wherein the prevalence
of PTSD among child survivors at 6–14 months post-incident
ranged from 8% to 91% and among their parents from 3% to 54% using conservative DSM-III-R criteria and liberal
Table 1. Summary of Mass Shooting Incidents and Characteristics of Peer-Reviewed Studies.
Year Location Context Perpetrator Fatalities Injuries
Peer- Reviewed Articles
Samples (Affected, Remote)
1984 Los Angeles, CA Elementary school Adult African American male
3 14 2 1 (1, 0)
1984 San Ysidro, CA Fast food restaurant Adult White male 21 15 1 1 (1, 0) 1987 Russellville, AR Four local businesses Adult White male 2 4 1 1 (1, 0) 1988 Winnetka, IL Elementary school Adult White female 2 5 6 3 (3, 0) 1991 Killeen, TX Cafeteria-style restaurant Adult White male 24 20 5 2 (2, 0) 1992 St. Louis, MO Courthouse Adult White male 1 5 1 1 (1, 0) 1993 San Francisco, CA Office building Adult White male 6 14 1 1 (1, 0) 1994 Brooklyn, NY Brooklyn Bridge Adult Lebanese-born
immigrant male 1 3 1 1 (1, 0)
1999 Columbine, CO High school Two adolescent White males
15 21 3 3 (0, 3)
2006 Montreal, Quebec, Canada
University (Dawson College) Adult Indo-Canadian male
2 17 1 1 (1, 0)
2007 Tuusula, Finland High school (Jokela High School) Adolescent White male 9 19 3 1 (1, 0) 2007 Blacksburg, VA University (Virginia Polytechnic Institute
and State University) Adult South Korean
male 33 25 11 4 (3, 1)
2008 DeKalb, IL University (Northern Illinois University) Adult White male 6 18 8 2 (2, 0) 2008 Conway, AR University (University of Central
Arkansas) Four adult African
American males 2 1 1 1 (1, 0)
2008 Kauhajoki, Finland University (Seinäjoki University of Applied Sciences)
Adult White male 11 1 1 1 (1, 0)
Note. Affected samples included participants who lived in the communities in which the incident occurred; participants did not have to be directly exposed to the event. Remote samples included members of other communities and nationally representative samples. Table does not include three studies that each focused on two different events (two affected samples, one remote sample).
64 TRAUMA, VIOLENCE, & ABUSE 18(1)
T a b
le 2 .
S u m
m ar
y o f th
e F in
d in
gs F ro
m P e e r-
R e vi
e w
e d
S tu
d ie
s o n
th e
P sy
ch o lo
gi ca
l E ff e ct
s o f M
as s
S h o o ti n g
In ci
d e n ts
.
A u th
o r
(Y e ar
) N
S am
p le
T im
in g
M e n ta
l H
e al
th O
u tc
o m
e s
(M e as
u re
; C
la ss
if ic
at io
n S ys
te m
) P re
va le
n ce
P re
d ic
to rs
1 9 8 4 —
E le
m e n ta
ry sc
h o o l in
L o s
A n ge
le s,
C A
(1 a)
P yn
o o s
e t
al .
(1 9 8 7 )
1 5 9
E le
m e n ta
ry sc
h o o l st
u d e n ts
(a ff ec
te d )
1 m
o n th
P T
S D
(P T
S D
-R I,
D S M
-I II )
P T
S D
: 6 0 .4
% P T
S S ,1
m o n th
:P ro
x im
it y
to at
ta ck
,g re
at e r
ac q u ai
n ta
n ce
w it h
th e
d e ce
as e d
vi ct
im (1
b )
N ad
e r,
P yn
o o s,
F ai
rb an
k s,
an d
F re
d e ri
ck (1
9 9 0 )
1 0 0
a 1
m o n th
, 1 4
m o n th
s P T
S D
(P T
S D
-R I,
D S M
-I II );
G ri
e f (b
ri e f in
ve n to
ry )
— P T
S S , 1 4
m o n th
s: P ro
x im
it y
to at
ta ck
, gr
e at
e r
ac q u ai
n ta
n ce
w it h
th e
d e ce
as e d
vi ct
im ; G
ri e f:
gr e at
e r
ac q u ai
n ta
n ce
w it h
th e
d e ce
as e d
1 9 8 4 —
F as
t- fo
o d
re st
au ra
n t
in S an
Y si
d ro
, C
A (1
) H
o u gh
e t
al .
(1 9 9 0 )
3 0 3
M id
d le
-a ge
d M
e x ic
an A
m e ri
ca n
w o m
e n
fr o m
th e
co m
m u n it y,
b u t
w h o
w e re
n o t
d ir
e ct
ly in
vo lv
e d
in th
e in
ci d e n t
(a ff ec
te d )
6 – 9
m o n th
s P T
S D
(s ca
le d e ri
ve d
fo r
th e
st u d y,
b as
e d
o n
th e
D IS
; D
S M
-I II );
M D
(C E S -D
)
P T
S D
, p o st
-i n ci
d e n t:
1 2 .6
% ;
P T
S D
, p as
t- m
o n th
: 6 .8
% S e ve
re P T
S D
(s ig
n ifi
ca n ce
of tr
en d s n ot
te st
ed ):
w id
o w
e d , se
p ar
at e d
o r
d iv
o rc
e d
st at
u s,
o ld
e r
ag e , n o
ch ild
re n
at h o m
e , lo
w e r
in co
m e , u n e m
p lo
ym e n t,
h av
in g
fr ie
n d s/
re la
ti ve
s in
vo lv
e d
in e ve
n t,
fa ir
– p o o r
p h ys
ic al
h e al
th , h ig
h e r
M D
sy m
p to
m s.
M ild
P T
S D
(s ig
n ifi
ca n ce
of tr
en d s n ot
te st
ed ):
m id
d le
-a ge
,h av
in g
th re
e o r
m o re
ch ild
re n
at h o m
e , m
id d le
in co
m e , h av
in g
fr ie
n d s/
re la
ti ve
s in
vo lv
e d
in th
e e ve
n t,
fa ir
– p o o r
p h ys
ic al
h e al
th
1 9 8 7 —
F o u r
lo ca
l b u si
n e ss
e s
in R
u ss
e llv
ill e , A
R (1
) N
o rt
h , S m
it h ,
M cC
o o l,
an d
S h e a
(1 9 8 9 )
1 8
E m
p lo
ye e s
at tw
o o f th
e fo
u r
lo ca
l b u si
n e ss
e s
w h o
w e re
e it h e r
at w
o rk
d u ri
n g
th e
sh o o ti n g
(n ¼
1 5 ) o r
ab se
n t
(n ¼
1 1 ; a ff ec
te d )
4 – 6
w e e k s
P T
S D
, M
D , G
A D
, A
lc o h o lis
m (D
IS /D
is as
te r
S u p p le
m e n t,
D S M
-I II )
P T
S D
: 5 .6
% ; M
D : 1 6 .7
% ;
G A
D : 0 .0
% ; A
lc o h o lis
m :
0 .0
%
—
1 9 8 8 —
E le
m e n ta
ry sc
h o o l in
W in
n e tk
a, IL
(1 a)
S ch
w ar
z an
d K
o w
al sk
i (1
9 9 1 a)
1 3 0
E le
m e n ta
ry sc
h o o l st
u d e n ts
(n ¼
6 4 )
an d
th e ir
p ar
e n ts
(n ¼
6 6 ; a ff ec
te d )
6 – 1 4
m o n th
s P T
S D
(P T
S D
-R I,
D S M
-I II -R
, lib
e ra
l m
o d e ra
te an
d co
n se
rv at
iv e
cr it e ri
a)
P T
S D
, ch
ild re
n , D
S M
-I II -R
: 5 0 %
, (l ib
e ra
l) , 4 1 %
(m o d e ra
te ),
8 %
(c o n se
rv at
iv e );
P T
S D
, p ar
e n ts
, D
S M
-I II -R
, p ro
p o se
d : 3 9 %
(l ib
e ra
l) ,
2 4 %
(m o d e ra
te ),
3 %
(c o n se
rv at
iv e )
P T
S D
, ch
ild re
n (p
re d ic
to rs
o f d ia
gn o si s
b a se
d o n
lib er
a l,
m o d er
a te
, o r
co n se
rv a ti ve
cr it er
ia ):
p e rc
e p ti o n
th at
h e
o r
sh e
w o u ld
ge t
sh o t
o r
w as
in d an
ge r
d u ri
n g
e ve
n t,
in cr
e as
e d
p h ys
ic al
sy m
p to
m s,
in cr
e as
e d
vi si
ts to
sc h o o l n u rs
e , in
cr e as
e d
o r
n e w
fe ar
s, gu
ilt . P T
S D
, p ar
e n ts
(p re
d ic
to rs
o f
d ia
gn o si s
b a se
d o n
lib er
a l,
m o d er
a te
, o r
co n se
rv a ti ve
cr it er
ia ):
fe lt
n u m
b ,s
ca re
d ,o
r fe
ar fu
l th
at th
e al
le ge
d p e rp
e tr
at o r
w as
st ill
o n
th e
lo o se
(c o n ti n u ed
)
65
T a b
le 2 .
(c o n ti n u e d )
A u th
o r
(Y e ar
) N
S am
p le
T im
in g
M e n ta
l H
e al
th O
u tc
o m
e s
(M e as
u re
; C
la ss
if ic
at io
n S ys
te m
) P re
va le
n ce
P re
d ic
to rs
(1 b )
S ch
w ar
z an
d K
o w
al sk
i (1
9 9 1 b )
1 3 0
a 6 – 1 4
m o n th
s P T
S D
(P T
S D
-R I;
D S M
-I II ,
D S M
-I II -R
[s am
e p re
va le
n ce
s as
S ch
w ar
z &
K o w
al sk
i, 1 9 9 1 a]
, p ro
p o se
d D
S M
-I V
, lib
e ra
l, m
o d e ra
te , an
d co
n se
rv at
iv e
cr it e ri
a)
P T
S D
, ch
ild re
n , D
S M
-I II ,
p ro
p o se
d D
S M
-I V
: 9 1 %
, 4 1 %
(l ib
e ra
l) , 6 1 %
, 4 1 %
(m o d e ra
te ),
1 6 %
, 9 %
(c o n se
rv at
iv e );
P T
S D
, p ar
e n ts
, D
S M
-I II , p ro
p o se
d D
S M
-I V
: 5 2 %
, 5 4 %
(l ib
e ra
l) ,
1 6 %
, 2 4 %
(m o d e ra
te ),
4 %
, 6 %
(c o n se
rv at
iv e )
—
(2 a)
S ch
w ar
z an
d K
o w
al sk
i (1
9 9 2 a)
2 4
S ch
o o l p e rs
o n n e l (a
ff ec
te d )
6 m
o n th
s P T
S D
(P T
S D
-R I;
D S M
-I II )
— P T
S S : p e rs
o n al
it y
tr ai
ts —
gu ilt
an d
re se
n tm
e n t,
in se
cu ri
ty , an
d p sy
ch as
th e n ia
(2 b )
S ch
w ar
z an
d K
o w
al sk
i (1
9 9 2 b )
2 4
S u b sa
m p le
co m
p le
te d
2 w
av e s
(n ¼
1 3 ; a ff ec
te d )a
6 m
o n th
s, 1 8
m o n th
s P T
S D
(P T
S D
-R I;
D S M
-I II );
M D
(B D
I) ; G
A D
(S T
A I)
— P T
S S , 6
m o n th
s: lo
ss to
fo llo
w -u
p
(2 c)
S ch
w ar
z, K
o w
al sk
i, an
d M
cN al
ly (1
9 9 3 )
2 4
S u b sa
m p le
co m
p le
te d
2 w
av e s
(n ¼
1 2 ; a ff ec
te d )a
6 m
o n th
s, 1 8
m o n th
s P T
S D
(P T
S D
-R I;
D S M
-I II );
M D
(B D
I) ; G
A D
(S T
A I)
— P T
S S , 6
m o n th
s: e n la
rg e m
e n t
o f re
ca ll
o f
e m
o ti o n al
e x p e ri
e n ce
s (h
yp e ra
ro u sa
l) ,
lif e
th re
at e x p e ri
e n ce
s (h
yp e ra
ro u sa
l) ,
an d
se n so
ry e x p e ri
e n ce
s (a
vo id
an ce
, h yp
e ra
ro u sa
l, to
ta l P T
S S ),
la ck
o f
d im
in is
h m
e n t
in re
ca ll
o f e m
o ti o n al
e x p e ri
e n ce
s (i n tr
u si
o n );
P T
S S , 1 8
m o n th
s: e n la
rg e m
e n t
in re
ca ll
o f se
n so
ry e x p e ri
e n ce
s (h
yp e ra
ro u sa
l) ; M
D sy
m p to
m s,
1 8
m o n th
s: la
ck o f
d im
in is
h m
e n t
in re
ca ll,
p e rc
e iv
e d
ab ili
ty to
h an
d le
st re
ss ;G
A D
sy m
p to
m s:
la ck
o f
d im
in is
h m
e n t
in re
ca ll
o f e m
o ti o n al
e x p e ri
e n ce
s (3
) S lo
an ,
R o ze
n sk
y, K
ap la
n ,
an d
S an
d e rs
(1 9 9 4 )
1 4 0
E m
e rg
e n cy
re sp
o n d e rs
(a ff ec
te d )
6 m
o n th
s P T
S D
(I E S
In tr
u si
o n
an d
A vo
id an
ce )
— P T
S S :f
iv e
in d ic
at o rs
o f jo
b st
re ss
d u ri
n g
th e
e ve
n t—
e x p o su
re to
tr au
m at
ic st
im u li,
ad ve
rs e
w o rk
e n vi
ro n m
e n t,
ti m
e p re
ss u re
, q u an
ti ta
ti ve
w o rk
lo ad
, an
d q u al
it at
iv e
w o rk
lo ad
(i n tr
u si
o n
an d
av o id
an ce
)
1 9 9 1 —
C af
e te
ri a-
st yl
e re
st au
ra n t
in K
ill e e n , T
X (1
a) N
o rt
h , S m
it h ,
an d
S p it zn
ag e l
(1 9 9 4 )
1 3 6
S u rv
iv o rs
(e .g
., re
st au
ra n t
p at
ro n s
an d
e m
p lo
ye e s,
e m
e rg
e n cy
re sp
o n d e rs
; a ff ec
te d )
1 – 2
m o n th
s P T
S D
, M
D , P D
, G
A D
, A
A /
A D
, D
A /D
D , A
S P D
(D IS
; D
S M
-I II -R
)
A t
1 – 2
m o n th
s— P T
S D
: 2 8 .6
% P T
S D
, 1 – 2
m o n th
s: fe
m al
e ge
n d e r,
p re
- in
ci d e n t
M D
(a m
o n g
fe m
al e
p ar
ti ci
p an
ts o n ly
), an
y p re
-i n ci
d e n t
p sy
ch ia
tr ic
d ia
gn o si
s (a
m o n g
fe m
al e
p ar
ti ci
p an
ts o n ly
), p o st
-i n ci
d e n t
M D
, an
y p o st
- in
ci d e n t
p sy
ch ia
tr ic
d is
o rd
e r
(a m
o n g
fe m
al e
p ar
ti ci
p an
ts o n ly
), se
e in
g a
d o ct
o r
o r
co u n se
lo r,
ta k in
g m
e d ic
at io
n (c o n ti n u ed
)
66
T a b
le 2 .
(c o n ti n u e d )
A u th
o r
(Y e ar
) N
S am
p le
T im
in g
M e n ta
l H
e al
th O
u tc
o m
e s
(M e as
u re
; C
la ss
if ic
at io
n S ys
te m
) P re
va le
n ce
P re
d ic
to rs
(1 b )
N o rt
h , S m
it h ,
an d
S p it zn
ag e l
(1 9 9 7 )
1 2 4
a 1 – 2
m o n th
s, 1
ye ar
P T
S D
, M
D , P D
, G
A D
, A
A /
A D
, D
A /D
D , A
S P D
(D IS
; D
S M
-I II -R
)
A t
1 – 2
m o n th
s— M
D : 1 0 .3
% ,
P D
: 2 .3
% , G
A D
: 0 .7
% , A
A /
A D
: 7 .5
% , D
A /D
D : 0 .0
% ,
A S P D
: 0 .0
% ; A
t 1
ye ar
— P T
S D
: 1 7 .7
% , M
D : 4 .9
% ,
P D
: 2 .4
% , G
A D
: 0 .9
% , A
A /
A D
: 5 .7
% , D
A /D
D : 0 .8
% ,
A S P D
: 0 .7
%
P T
S D
, e it
h e r/
b o th
1 – 2
m o n th
s an
d 1
ye ar
: fe
m al
e ge
n d e r,
an y
p re
-i n ci
d e n t
p sy
c h ia
tr ic
d ia
g n o
si s
(a m
o n g
fe m
al e
p a rt
ic ip
an ts
o n ly
), an
y o th
e r
p o
st -
in c id
e n t
p sy
c h ia
tr ic
d is
o rd
e r,
an y
o th
e r
li fe
ti m
e p sy
c h ia
tr ic
d is
o rd
e r,
p re
- in
c id
e n t
M D
, M
D at
1 – 2
m o n th
s, li fe
ti m
e M
D (1
c) N
o rt
h ,
S p it zn
ag e l,
an d
S m
it h
(2 0 0 1 )
1 3 6
a 1 – 2
m o n th
s, 1
ye ar
, 3
ye ar
s P T
S D
, M
D , P D
, G
A D
, A
A /
A D
, D
A /D
D , A
S P D
(D IS
; D
S M
-I II -R
)
— P T
S D
, 1 – 2
m o
n th
s: lo
w e r
ac ti
v e
o u tr
e ac
h an
d in
fo rm
e d
p ra
g m
at is
m co
p in
g at
1 – 2
m o n th
s; P T
S D
, 1
ye ar
: lo
w e r
in fo
rm e d
p ra
g m
a ti
sm co
p in
g at
1 – 2
m o n th
s; P T
S D
, 3
ye ar
s: lo
w e r
in fo
rm e d
p ra
g m
at is
m co
p in
g at
1 – 2
m o n th
s; M
D ,
1 – 2
m o
n th
s: lo
w e r
in fo
rm e d
p ra
g m
at is
m co
p in
g at
1 – 2
m o n th
s; M
D ,
3 ye
ar s:
lo w
e r
ac ti
ve o u tr
e ac
h co
p in
g at
1 – 2
m o
n th
s; A
n y
d is
o rd
e r,
1 – 2
m o
n th
s: lo
w e r
ac ti
ve o u tr
e ac
h an
d in
fo rm
e d
p ra
g m
at is
m co
p in
g at
1 – 2
m o
n th
s; A
n y
d is
o rd
e r,
1 ye
ar :
lo w
e r
in fo
rm e d
p ra
g m
at is
m co
p in
g at
1 – 2
m o
n th
s; A
n y
d is
o rd
e r,
3 ye
ar s:
lo w
e r
in fo
rm e d
p ra
g m
at is
m an
d re
c o n ci
li at
io n
ac c e p ta
n c e
co p in
g at
1 – 2
m o n th
s (1
d )
N o rt
h ,
M cC
u tc
h e o n ,
S p it zn
ag e l,
an d
S m
it h
(2 0 0 2 )
1 1 6
a 1 – 2
m o n th
s, 1
ye ar
, 3
ye ar
s P T
S D
, M
D , P D
, G
A D
, A
A /
A D
, D
A /D
D , A
S P D
(D IS
; D
S M
-I II -R
)
A t
3 ye
ar s—
P T
S D
: 1 8 %
, M
D : 1 0 %
N o
n re
c o
v e ry
fr o
m P T
S D
, 3
y e ar
s: fu
n c ti
o n a l
in te
rf e re
n c e
d u e
to sy
m p to
m s,
h a v in
g se
e n
a m
e n ta
l h e a lt
h p ro
fe ss
io n a l
a t
1 – 2
m o
n th
s; n o
n re
c o
v e ry
fr o
m M
D ,
3 y e a rs
: fa
m il y
h is
to ry
o f
d e p re
ss io
n ,
p ar
e n ta
l h is
to ry
o f
tr e a tm
e n t
fo r
d ri
n k in
g p ro
b le
m s
(2 )
S e w
e ll
(1 9 9 6 )
9 2
P e rs
o n s
e it
h e r
d ir
e c tl
y e x p o
se d
(e .g
., re
st a u ra
n t
p a tr
o n s)
o r
in d ir
e c tl
y e x p o
se d
(e .g
., re
la ti
v e s
o f
d ir
e c tl
y e x p o
se d ;
a ff
e ct
e d )
1 w
e e k , 3
m o n th
s P T
S D
(m o d u le
fr o m
th e
P D
I, D
S M
-I V
) P T
S D
, 1
w e e k : 3 8 .7
% P T
S D
, 1
w e e k : P re
-i n ci
d e n t
P T
S D
; P T
S D
n o n re
co ve
ry , 3
m o n th
s: L o w
e r
tr au
m a-
re la
te d
co n st
ru ct
e la
b o ra
ti o n
(c o n ti n u ed
)
67
T a b
le 2 .
(c o n ti n u e d )
A u th
o r
(Y e ar
) N
S am
p le
T im
in g
M e n ta
l H
e al
th O
u tc
o m
e s
(M e as
u re
; C
la ss
if ic
at io
n S ys
te m
) P re
va le
n ce
P re
d ic
to rs
1 9 9 2 —
C o u rt
h o u se
in S t.
L o u is
, M
is so
u ri
(1 )
Jo h n so
n , N
o rt
h ,
an d
S m
it h
(2 0 0 2 )
8 0
E m
p lo
ye e s
at co
u rt
h o u se
an d
o ff ic
e s
o f in
vo lv
e d
in d iv
id u al
s; su
b sa
m p le
co m
p le
te d
2 w
av e s
(n ¼
7 7 ;
a ff ec
te d )
6 – 8
w e e k s,
1 ye
ar ,
3 ye
ar s
P T
S D
, M
D , P D
, G
A D
, A
U D
, D
U D
(D IS
/D is
as te
r su
p p le
m e n t)
A t
6 – 8
w e e k s—
P T
S D
: 5 %
, M
D : 4 %
; P D
: 1 %
; G
A D
: 0 %
; A
U D
: 9 %
; D
U D
: 0 %
; A
t e it h e r
6 – 8
w e e k s,
1 ye
ar ,
o r
3 ye
ar s—
P T
S D
: 1 0 %
P T
S S , 6 – 8
w e e k s:
yo u n ge
r ag
e , b e in
g m
ar ri
e d ,l
o w
e r
e d u ca
ti o n ,f
e e lin
g lik
e th
e in
ci d e n t
h ad
ca u se
d th
e m
a gr
e at
d e al
o f
h ar
m (t
o ta
l P T
S S , re
e x p e ri
e n ci
n g)
, re
p o rt
in g
th at
th e
in ci
d e n t
w as
ve ry
u p se
tt in
g (a
vo id
an ce
), p e rc
e iv
e d
la ck
o f
re co
ve ry
(a vo
id an
ce ),
m e n ta
l h e al
th se
rv ic
e u ti liz
at io
n (r
e e x p e ri
e n ci
n g,
av o id
an ce
, an
d h yp
e ra
ro u sa
l)
1 9 9 3 —
O ff ic
e b u ild
in g
in S an
F ra
n ci
sc o , C
A (1
) C
la ss
e n ,
K o o p m
an , H
al e s,
an d
S p ie
ge l(
1 9 9 8 )
3 6
O ff ic
e e m
p lo
ye e s;
su b sa
m p le
co m
p le
te d
2 w
av e s
(n ¼
3 2 ;
a ff ec
te d )
1 w
e e k , 7 – 1 0
m o n th
s P T
S D
(I E S , D
T S , D
S M
-I II -R
); A
S D
(S A
S R
Q )
A t
1 w
e e k —
A S D
: 3 3 .3
% P T
S D
, 7 – 1 0
m o n th
s: A
S D
sy m
p to
m s
(D T
S to
ta l,
IE S -R
in tr
u si
o n , an
d IE
S -R
av o id
an ce
)
1 9 9 4 —
B ro
o k ly
n B ri
d ge
in B ro
o k ly
n , N
Y (1
) T
ra p p le
r an
d F ri
e d n m
an (1
9 9 6 )
2 2
Y o u th
w h o
w e re
in th
e va
n th
at w
as ta
rg e t
o f sh
o o ti n g
(s u rv
iv o rs
); 1 1
st u d e n ts
, ag
e -m
at ch
e d
an d
fr o m
th e
sa m
e co
m m
u n it y
(c o m
p ar
is o n ; a ff ec
te d )
8 w
e e k s
P T
S D
(D S M
-I V
; P T
S D
sy m
p to
m sc
al e , IE
S -R
, cl
in ic
al in
fo rm
at io
n );
M D
(B D
I, cl
in ic
al in
fo rm
at io
n ),
G A
D sy
m p to
m s
(B A
I, cl
in ic
al in
fo rm
at io
n )
A m
o n g
su rv
iv o rs
— P T
S D
: 3 6 .4
% ; M
D : 4 5 .5
% ;
A d ju
st m
e n t
D is
o rd
e r
w it h
an x ie
ty : 9 .1
% ; A
d ju
st m
e n t
d is
o rd
e r
w it h
m ix
e d
an x ie
ty an
d d e p re
ss e d
m o o d : 9 .1
%
P T
S S : b e in
g a
su rv
iv o r
(v s.
m e m
b e r
o f
co m
p ar
is o n
gr o u p ; in
tr u si
o n
an d
av o id
an ce
); M
D sy
m p to
m s:
b e in
g a
su rv
iv o r
(v s.
m e m
b e r
o f co
m p ar
is o n
gr o u p );
G A
D sy
m p to
m s:
b e in
g a
su rv
iv o r
(v s.
m e m
b e r
o f co
m p ar
is o n
gr o u p )
1 9 9 9 —
H ig
h sc
h o o l in
C o lu
m b in
e , C
O (1
) S tr
e te
sk y
an d
H o ga
n (2
0 0 1 )
1 2 2
F e m
al e
co lle
ge st
u d e n t
at R
o ch
e st
e r
In st
it u te
o f
T e ch
n o lo
gy , as
se ss
e d
p re
- in
ci d e n t
(n ¼
2 0 )
an d
p o st
- in
ci d e n t
(n ¼
1 0 2 ; re
m o te
)
(v ar
ie d )
P e rc
e iv
e d
sa fe
ty (6
it e m
s) —
P e rc
e iv
e d
sa fe
ty : p re
-i n ci
d e n t
sa m
p le
(v s.
p o st
-i n ci
d e n t
sa m
p le
), b e in
g in
th e
F in
e A
rt s
o r
L an
gu ag
e an
d L it e ra
tu re
d e p ar
tm e n ts
(v s.
th e
S o ci
o lo
gy d e p ar
tm e n t)
(2 )
B re
n e r,
S im
o n ,
A n d e rs
o n ,
B ar
ri o s,
an d
S m
al l
(2 0 0 2 )
1 5 ,3
4 9
P ar
ti ci
p an
ts in
th e
1 9 9 9
n at
io n al
sc h o o l- b as
e d
Y o u th
R is
k B e h av
io r
S u rv
e y,
as se
ss e d
p re
- in
ci d e n t
(n ¼
1 2 .0
4 9 )
an d
p o st
-i n ci
d e n t
(n ¼
3 ,3
0 0 ;
re m
o te
)
(v ar
ie d )
In te
rp e rs
o n al
vi o le
n ce
(8 it e m
s) , S u ic
id e
(5 it e m
s) —
It e m
‘‘f e lt
to o
u n sa
fe to
go to
sc h o o l’’
: p o st
- in
ci d e n t
sa m
p le
(v s.
p re
-i n ci
d e n t
sa m
p le
), e ff e ct
st ro
n ge
r in
ru ra
l (v
s. su
b u rb
an an
d u rb
an )
ar e as
. It
e m
‘‘c o n si
d e re
d su
ic id
e ’’:
p re
-i n ci
d e n t
sa m
p le
(v s.
p o st
-i n ci
d e n t
sa m
p le
), e ff e ct
o n ly
in su
b u rb
an an
d ru
ra l ar
e as
. It
e m
‘‘m ad
e a
su ic
id e
p la
n ’’:
p re
-i n ci
d e n t
sa m
p le
(v s.
p o st
-i n ci
d e n t
sa m
p le
), e ff e ct
o n ly
in su
b u rb
an an
d ru
ra l ar
e as (c o n ti n u ed
)
68
T a b
le 2 .
(c o n ti n u e d )
A u th
o r
(Y e ar
) N
S am
p le
T im
in g
M e n ta
l H
e al
th O
u tc
o m
e s
(M e as
u re
; C
la ss
if ic
at io
n S ys
te m
) P re
va le
n ce
P re
d ic
to rs
(3 )
A d d in
gt o n
(2 0 0 3 )
8 ,3
9 7
P ar
ti ci
p an
ts in
th e
1 9 9 9
S ch
o o l
C ri
m e
S u p p le
m e n t
to th
e N
at io
n al
C ri
m e
V ic
ti m
iz at
io n
S u rv
e y,
as se
ss e d
p re
-i n ci
d e n t
(n ¼
5 ,6
2 0 )
an d
p o st
- in
ci d e n t
(n ¼
2 ,7
7 7 ; re
m ot
e)
(v ar
ie d )
A vo
id an
ce (7
it e m
s) , F e ar
o f
vi ct
im iz
at io
n (2
it e m
s) —
It e m
‘‘h o w
o ft
e n
ar e
yo u
af ra
id th
at so
m e o n e
w ill
at ta
ck o r
h ar
m yo
u at
sc h o o l? ’’:
p o st
-i n ci
d e n t
sa m
p le
(v s.
p re
- in
ci d e n t
sa m
p le
)
2 0 0 6 —
D aw
so n
C o lle
ge (D
C )
in M
o n tr
e al
, Q
u e b e c
(1 )
S é gu
in e t
al .
(2 0 1 3 )
9 4 8
D C
st u d e n ts
an d
e m
p lo
ye e s
(a ff ec
te d )
1 8
m o n th
s L if e ti m
e an
d p o st
-i n ci
d e n t
p sy
ch ia
tr ic
d is
o rd
e rs
(m e as
u re
s ad
ap te
d fr
o m
th e
2 0 0 2
C an
ad ia
n C
o m
m u n it y
H e al
th S u rv
e y)
P re
va le
n ce
o f an
y p sy
ch ia
tr ic
d is
o rd
e r:
3 0 %
; P o st
- in
ci d e n t
in ci
d en
ce ra
te s—
P T
S D
: 1 .8
% ; M
D : 5 %
; A
lc o h o l d e p e n d e n cy
: 5 %
; S o ci
al p h o b ia
: 3 %
; A
n y
p sy
ch ia
tr ic
d is
o rd
e r
at p o st
-i n ci
d e n t,
w it h
p re
- in
ci d e n t
o n se
t: 1 2 %
In ci
d e n ce
o f an
y p sy
ch ia
tr ic
d is
o rd
e r:
G re
at e r
an d
cl o se
r e x p o su
re (s
ta ti st
ic s
n o t
re p o rt
ed )
2 0 0 7 —
H ig
h sc
h o o l in
Jo k e la
, F in
la n d
(1 a)
H ar
av u o ri
, S u o m
al ai
n e n ,
B e rg
, K
iv ir
u u su
, an
d M
ar tt
u n e n
(2 0 1 1 )
2 3 1
a 4
m o n th
s P o st
tr au
m at
ic d is
tr e ss
(I E S );
P T
S D
(I E S );
P sy
ch ia
tr ic
d is
tu rb
an ce
(G H
Q )
— P o st
tr au
m at
ic d is
tr e ss
: b e in
g ap
p ro
ac h e d
o r
in te
rv ie
w e d
b y
jo u rn
al is
ts ; P sy
ch ia
tr ic
d is
tu rb
an ce
: h ig
h e r
m e d ia
e x p o su
re
(1 b )
S u o m
al ai
n e n ,
H ar
av u o ri
, B e rg
, K
iv ir
u u su
, an
d M
ar tt
u n e n
(2 0 1 1 )
2 3 1
Jo k e la
H ig
h S ch
o o l st
u d e n ts
. U
n e x p o se
d co
m p ar
is o n
gr o u p
o f st
u d e n ts
fr o m
a d if fe
re n t
h ig
h sc
h o o l in
F in
la n d
(n ¼
5 2 6 ; a ff ec
te d )
4 m
o n th
s P o st
tr au
m at
ic d is
tr e ss
(I E S );
P T
S D
(I E S );
P sy
ch ia
tr ic
d is
tu rb
an ce
(G H
Q );
C h an
ge s
in su
b st
an ce
ab u se
d u ri
n g
p as
t 6
m o n th
s (1
it e m
)
A m
o n g
e x p o se
d —
P o st
tr au
m at
ic d is
tr e ss
: 4 2 .8
% ; P T
S D
: 1 9 .2
% ;
P sy
ch ia
tr ic
d is
tu rb
an ce
: 3 1 .7
% ; In
cr e as
e in
su b st
an ce
ab u se
d u ri
n g
p as
t 6
m o n th
s: 1 3 .3
%
P o
st tr
au m
at ic
d is
tr e ss
: E x p o
se d
(v s.
u n e x p o se
d );
P T
S D
: fe
m al
e ge
n d e r,
e x p o se
d (v
s. u n e x p o se
d ),
se ve
re o r
e x tr
e m
e e x p o
su re
(v s.
m il d
to si
gn if ic
an t
e x p o su
re ),
lo w
e r
p e rc
e iv
e d
su p p o rt
fr o m
fa m
il y
an d
fr ie
n d s;
P sy
ch ia
tr ic
d is
tu rb
a n c e : o ld
e r
ag e , fe
m al
e ge
n d e r,
li vi
n g
w it
h o n e
b io
lo g ic
al p a re
n t
o r
o th
e rw
is e
(v s.
li vi
n g
w it
h b o
th b io
lo g ic
al p a re
n ts
), e x p o se
d (v
s. u n e x p o
se d ),
lo w
e r
p e rc
e iv
e d
so c ia
l su
p p o
rt fr
o m
fa m
il y,
p re
v io
u s
m e n ta
l su
p p o
rt fr
o m
a n o
n gu
a rd
ia n
ad u lt
(1 c)
M u rt
o n e n ,
S u o m
al ai
n e n ,
H ar
av u o ri
, an
d M
ar tt
u n e n
(2 0 1 2 )
Jo k e la
H ig
h S ch
o o l st
u d e n ts
(a ff ec
te d )
4 m
o n th
s P o st
tr au
m at
ic d is
tr e ss
(I E S );
P T
S D
(I E S );
P sy
ch ia
tr ic
d is
tu rb
an ce
(G H
Q )
— P o st
tr au
m at
ic d is
tr e ss
: h av
in g
b e e n
o ff e re
d cr
is is
su p p o rt
; P T
S D
: n o t
p e rc
e iv
in g
cr is
is su
p p o rt
as h e lp
fu l;
P sy
ch ia
tr ic
d is
tu rb
an ce
: h av
in g
b e e n
o ff e re
d cr
is is
su p p o rt
, n o t
p e rc
e iv
in g
cr is
is su
p p o rt
as h e lp
fu l
(c o n ti n u ed
)
69
T a b
le 2 .
(c o n ti n u e d )
A u th
o r
(Y e ar
) N
S am
p le
T im
in g
M e n ta
l H
e al
th O
u tc
o m
e s
(M e as
u re
; C
la ss
if ic
at io
n S ys
te m
) P re
va le
n ce
P re
d ic
to rs
2 0 0 7 —
V ir
gi n ia
T e ch
(V T
) in
B la
ck sb
u rg
, V
A (1
a) F al
la h i an
d L e si
k (2
0 0 9 )
3 1 2
S tu
d e n ts
fr o m
C e n tr
al C
o n n e ct
ic u t
S ta
te U
n iv
e rs
it y
(r em
o te
)
3 w
e e k s
A S D
(1 3 -i te
m s,
D S M
-I V
) —
A S D
sy m
p to
m s:
o ld
e r
ag e
(n ig
h tm
ar e s)
, fe
m al
e ge
n d e r
(f e ar
), ra
ci al
/e th
n ic
m in
o ri
ty st
at u s
(s u ic
id al
id e at
io n ,
re p la
yi n g
th e
e ve
n t)
, m
o re
h o u rs
o f T
V w
at ch
in g
(i n tr
u si
ve th
o u gh
ts , sl
e e p
d is
tu rb
an ce
s, d is
tr ac
ti o n , fe
ar , st
o m
ac h
u p se
t, d e p re
ss io
n , d is
o rg
an iz
at io
n ,
re p la
yi n g
o f th
e e ve
n t,
an d
an ge
r) (1
b )
F al
la h i,
A u st
ad ,
F al
lo n , an
d L e is
h m
an (2
0 0 9 )
3 1 2
a 3
w e e k s
P sy
ch ia
tr ic
sy m
p to
m s
(u n sp
e ci
fi e d )
— P sy
ch ia
tr ic
sy m
p to
m s:
fe ar
s o f b e in
g p e rs
o n al
ly h ar
m e d
o n
ca m
p u s,
fe ar
s th
at a
si m
ila r
in ci
d e n t co
u ld
o cc
u r
o n
ca m
p u s,
gr e at
e r
e x p o su
re to
n e w
s m
e d ia
,g re
at e r
ti m
e d is
cu ss
in g
th e
in ci
d e n t
w it h
fa m
ily ,
gr e at
e r
ti m
e d is
cu ss
in g
th e
in ci
d e n t
w it h
fr ie
n d s
(2 a)
L it tl e to
n ,
A x so
m , an
d G
ri lls
-T aq
u e ch
e l
(2 0 0 9 )
1 9 3
F e m
al e
V T
st u d e n ts
(a ff ec
te d )
P re
-i n ci
d e n t,
2 m
o n th
s, 6
m o n th
s
M D
(C E S -D
); G
A D
(F D
A S )
— P sy
ch o lo
gi ca
l d is
tr e ss
(l at
e n t
va ri
ab le
o f
M D
an d
G A
D sy
m p to
m su
b sc
al e s)
, 6
m o n th
s: h ig
h e r
re so
u rc
e lo
ss at
2 an
d 6
m o n th
s, lo
w e r
re so
u rc
e ga
in at
2 an
d 6
m o n th
s (2
b ) L it tl e to
n , G
ri lls
- T
aq u e ch
e l,
an d
A x so
m (2
0 0 9 )
2 9 3
a P re
-i n ci
d e n t,
2 m
o n th
s, 6
m o n th
s
P T
S D
(D S M
-I V
; P S S -S
R )
A t
2 m
o n th
s— P T
S D
: 3 0 %
; A
t 6
m o n th
s— P T
S D
: 2 3 %
P T
S S , 2
m o n th
s: H
ig h e r
re so
u rc
e lo
ss at
2 m
o n th
s p o st
-i n ci
d e n t.
P T
S S , 6
m o n th
s: h ig
h e r
re so
u rc
e lo
ss at
2 an
d 6
m o n th
s (2
c) G
ri lls
- T
aq u e ch
e l,
L it tl e to
n , an
d A
x so
m (2
0 1 1 )
2 9 8
a P re
-i n ci
d e n t,
2 m
o n th
s, 6
m o n th
s
G A
D (F
D A
S );
Q u al
it y
o f L if e
(W H
O -Q
O L )
— G
A D
sy m
p to
m s,
2 m
o n th
s (e
m o ti o n al
, p h ys
io lo
gi ca
l, co
gn it iv
e , an
d b e h av
io ra
l su
b sc
al e s)
: h ig
h e r
p re
-s h o o ti n g
G A
D sy
m p to
m s
(a ll
su b sc
al e s)
, h ig
h e r
e x p o su
re (b
e h av
io ra
l) , lo
w e r
se lf -w
o rt
h (a
ll su
b sc
al e s)
, h ig
h e r
se n se
o f
ra n d o m
n e ss
(e m
o ti o n al
), lo
w e r
fa m
ily su
p p o rt
(e m
o ti o n al
, p h ys
io lo
gi ca
l, co
gn it iv
e );
Q u al
it y
o f L if e , 2
m o n th
s (p
h ys
ic al
, p sy
ch o lo
gi ca
l, so
ci al
, an
d e n vi
ro n m
e n t
su b sc
al e s)
: lo
w e r
e x p o su
re (p
h ys
ic al
), h ig
h e r
se lf -w
o rt
h (a
ll su
b sc
al e s)
, lo
w e r
se n se
o f ra
n d o m
n e ss
(p h ys
ic al
, p sy
ch o lo
gi ca
l) , h ig
h e r
fa m
ily su
p p o rt
(a ll
su b sc
al e s)
, h ig
h e r
fr ie
n d
su p p o rt
(e n vi
ro n m
e n t)
(c o n ti n u ed
)
70
T a b
le 2 .
(c o n ti n u e d )
A u th
o r
(Y e ar
) N
S am
p le
T im
in g
M e n ta
l H
e al
th O
u tc
o m
e s
(M e as
u re
; C
la ss
if ic
at io
n S ys
te m
) P re
va le
n ce
P re
d ic
to rs
(2 d )
L it tl e to
n ,
A x so
m , an
d G
ri lls
-T aq
u e ch
e l
(2 0 1 1 )
3 6 8
a P re
-i n ci
d e n t,
2 m
o n th
s, 6
m o n th
s, 1
ye ar
P T
S D
(D S M
-I V
; P S S -S
R );
M D
(C E S -D
); G
A D
(F D
A S )
A t
2 m
o n th
s— M
D : 1 9 %
; A
t 6
m o n th
s— M
D : 2 2 %
; A
t 1
ye ar
— P T
S D
: 2 7 %
, M
D :
2 4 %
P T
S S , 6
m o n th
s: P T
S S
at 2
m o n th
s, m
al ad
ap ti ve
co p in
g at
2 m
o n th
s; P T
S S , 1
ye ar
: P T
SS an
d m
al ad
ap ti ve
co p in
g at
6 m
o n th
s; P sy
ch o lo
gi ca
l d is
tr e ss
(l at
e n t
va ri
ab le
o f M
D an
d G
A D
sy m
p to
m su
b sc
al e s)
, 2
m o n th
s: p re
-i n ci
d e n t
d is
tr e ss
; P sy
ch o lo
gi ca
l d is
tr e ss
, 6
m o n th
s: P sy
ch o lo
gi ca
l d is
tr e ss
an d
m al
ad ap
ti ve
co p in
g at
2 m
o n th
s; P sy
ch o lo
gi ca
l d is
tr e ss
,1 ye
ar :P
sy ch
o lo
gi ca
ld is
tr e ss
an d
m al
ad ap
ti ve
co p in
g at
6 m
o n th
s (2
e ) L it tl e to
n , G
ri lls
- T
aq u e ch
e l,
A x so
m , B ye
, an
d B u ck
(2 0 1 2 )
2 1 5
a P re
-i n ci
d e n t,
2 m
o n th
s, 6
m o n th
s, 1
ye ar
P T
S D
(D S M
-I V
; P S S -S
R );
M D
(C E S -D
) —
P T
S S , 1
ye ar
: p re
-i n ci
d e n t
se x u al
vi ct
im iz
at io
n , lo
w e r
b e n e vo
le n ce
b e lie
fs at
2 m
o n th
s, lo
w e r
fa m
ily su
p p o rt
at 2
m o n th
s; M
D sy
m p to
m s,
1 ye
ar : p re
- in
ci d e n t
se x u al
vi ct
im iz
at io
n , lo
w e r
b e n e vo
le n ce
b e lie
fs at
2 m
o n th
s, lo
w e r
fa m
ily su
p p o rt
at 2
m o n th
s (3
a) H
u gh
e s
e t
al .
(2 0 1 1 )
4 ,6
3 9
V T
st u d e n ts
(a ff e ct
e d )
3 – 4
m o n th
s, 1
ye ar
P T
S D
(T S Q
, D
S M
-I V
) P T
S D
: 1 5 .4
% P T
S D
: fe
m al
e ge
n d e r,
h ig
h e r
e x p o su
re to
fi rs
t in
ci d e n t
o f at
ta ck
, in
ab ili
ty to
co n ta
ct cl
o se
fr ie
n d s
d u ri
n g
in ci
d e n t,
d e at
h o f a
cl o se
fr ie
n d , d e at
h o f a
fr ie
n d
o f ac
q u ai
n ta
n ce
(3 b )
S m
it h , A
b e yt
a, H
u gh
e s,
an d
Jo n e s
(2 0 1 4 )
2 4 5
S u b sa
m p le
o f b e re
av e d
p ar
ti ci
p an
ts w
h o
co m
p le
te d
fo llo
w -u
p as
se ss
m e n ts
(a ff ec
te d )a
3 – 4
m o n th
s, 1
ye ar
P T
S D
(T S Q
, D
S M
-I V
); G
ri e f
(8 -i te
m m
e as
u re
) —
G ri
e f se
ve ri
ty : h ig
h e r
P T
S S
at 3 – 4
m o n th
s, lo
w e r
se lf -e
ff ic
ac y,
gr e at
e r
d is
ru p te
d w
o rl
d vi
e w
(4 a)
H aw
d o n
an d
R ya
n (2
0 1 1 )
3 6 3
V T
st u d e n ts
an d
fa cu
lt y
(a ff ec
te d )
5 m
o n th
s, 9
m o n th
s, an
d 1 3
m o n th
s
E m
o ti o n al
an d
b e h av
io ra
l w
e ll-
b e in
g (C
D C
d e p re
ss io
n sc
re e n e r,
W A
I, it e m
as se
ss in
g p ro
d u ct
iv it y)
— L o w
e r
e m
o ti o n al
an d
b e h av
io ra
l w
e ll-
b e in
g, 5
m o n th
s, 9
m o n th
s, an
d 1 3
m o n th
s: lo
w e r
so ci
al so
lid ar
it y
at 5
m o n th
s, 9
m o n th
s, an
d 1 3
m o n th
s
(4 b )
H aw
d o n
an d
R ya
n (2
0 1 2 )
5 4 3
V T
st u d e n ts
(a ff ec
te d )
5 m
o n th
s E m
o ti o n al
an d
b e h av
io ra
l w
e ll-
b e in
g (C
D C
d e p re
ss io
n sc
re e n e r,
W A
I, it e m
as se
ss in
g p ro
d u ct
iv it y)
— L o w
e r
e m
o ti o n al
an d
b e h av
io ra
l w
e ll-
b e in
g: fe
m al
e ge
n d e r,
k n o w
in g
a vi
ct im
o f
th e
in ci
d e n t,
lo w
e r
o ve
ra ll
so ci
al su
p p o rt
, la
ck o f p ar
ti ci
p at
io n
o n
a co
m m
u n it y
te am
, h av
in g
se e n
a p ro
fe ss
io n al
co u n se
lo r
af te
r th
e in
ci d e n t,
fe w
e r
in -p
e rs
o n
co n ve
rs at
io n s
w it h
fa m
ily , fe
w e r
vi rt
u al
co n ve
rs at
io n s
w it h
fa m
ily , fe
w e r
vi rt
u al
co n ve
rs at
io n s
w it h
fr ie
n d s,
an d
lo w
e r
so ci
al so
lid ar
it y
(c o n ti n u ed
)
71
T a b
le 2 .
(c o n ti n u e d )
A u th
o r
(Y e ar
) N
S am
p le
T im
in g
M e n ta
l H
e al
th O
u tc
o m
e s
(M e as
u re
; C
la ss
if ic
at io
n S ys
te m
) P re
va le
n ce
P re
d ic
to rs
2 0 0 8 —
N o rt
h e rn
Il lin
o is
U n iv
e rs
it y
(N IU
) in
D e K
al b , IL
(1 a)
S te
p h e n so
n ,
V al
e n ti n e r,
K u m
p u la
, an
d O
rc u tt
(2 0 0 9 )
6 9 1
F e m
al e
N IU
st u d e n ts
(a ff ec
te d )
P re
-i n ci
d e n t,
2 – 4
w e e k s
P T
S D
(D E Q
, D
S M
-I V
) —
P T
S S , 2 – 4
w e e k s:
h ig
h e r
an x ie
ty se
n si
ti vi
ty (p
h ys
ic al
an d
co gn
it iv
e co
n ce
rn s)
, h ig
h e r
e x p o su
re
(1 b )
F e rg
u s,
R ab
e n h o rs
t, O
rc u tt
, an
d V
al e n ti n e r
(2 0 1 1 )
5 8
S u b sa
m p le
o f p ar
ti ci
p an
ts w
it h
h ig
h e st
an d
lo w
e st
le ve
ls o f e x p o su
re p ar
ti ci
p at
e d
in a
la b o ra
to ry
e x p e ri
m e n t
(a ff ec
te d )a
6 w
e e k s
P T
SD (D
E Q
, D
SM -I V
); M
D (D
A SS
-2 1 );
G A
D (D
A SS
-2 1 )
— P T
S S , 6
w e e k s:
H ig
h e r
n e ga
ti ve
af fe
ct w
h ile
w ri
ti n g
an d
re ad
in g
ab o u t
e ve
n t;
M D
sy m
p to
m s,
6 w
e e k s:
H ig
h e r
n e ga
ti ve
af fe
ct w
h ile
re ad
in g
ab o u t
th e
in ci
d e n t;
G A
D sy
m p to
m s,
6 w
e e k s:
H ig
h e r
n e ga
ti ve
af fe
ct w
h ile
w ri
ti n g
an d
re ad
in g
ab o u t
th e
in ci
d e n t
(1 c)
K u m
p u la
, O
rc u tt
, B ar
d e e n ,
an d
V ar
k o vi
tz k y
(2 0 1 1 )
5 3 2
a P re
-i n ci
d e n t,
2 – 4
w e e k s,
8 m
o n th
s
P T
S D
(D E Q
, D
S M
-I V
) P re
-i n ci
d e n t—
S ig
n if ic
an t
P T
S S : 2 0 .8
% ; A
t 2 – 4
w e e k s—
S ig
n if ic
an t
P T
S S :
4 9 .4
% ; A
t 8
m o n th
s— S ig
n if ic
an t
P T
S S : 1 1 .4
%
P T
S S ,
2 – 4
w e e k s:
n o
n -W
h it
e ra
ce /
e th
n ic
it y
(a vo
id an
c e
an d
h y p e ra
ro u sa
l) ,
h ig
h e r
p re
-i n ci
d e n t
tr au
m a
e x p o
su re
, h ig
h e r
p re
-i n ci
d e n t
e x p e ri
e n ti
a l
av o id
a n c e ,
h ig
h e r
p e ri
tr a u m
at ic
d is
so c ia
ti o
n ;
P T
S S ,
8 m
o n th
s: h ig
h e r
e x p o su
re ,
h ig
h e r
P T
S S
at 2 – 4
w e e k s,
h ig
h e r
e x p e ri
e n ti
a l
av o id
an c e
at 2 – 4
w e e k s
(1 d )
L it tl e to
n ,
K u m
p u la
, an
d O
rc u tt
(2 0 1 1 )
6 9 1
a P re
-i n ci
d e n t,
2 – 4
w e e k s,
8 m
o n th
s
P T
S D
(D E Q
, D
S M
-I V
— P T
S S ,
2 – 4
w e e k s:
n o
n -A
fr ic
a n
A m
e ri
ca n
ra ce
/e th
n ic
it y ,
h ig
h e r
p re
-i n c id
e n t
tr au
m a
e x p o
su re
, h ig
h e r
p re
-i n ci
d e n t
st re
ss ,
h ig
h e r
e x p o su
re ;
P T
S S ,
8 m
o n th
s: A
si a n
A m
e ri
c an
ra ce
/e th
n ic
it y,
h ig
h e r
p re
-i n ci
d e n t
tr au
m a
e x p o
su re
, h ig
h e r
p re
-i n ci
d e n t
G A
D sy
m p to
m s,
h ig
h e r
e x p o
su re
, h ig
h e r
P T
S S
at 2 – 4
w e e k s,
h ig
h e r
re so
u rc
e lo
ss (1
e )
M e rc
e r
e t
al .
(2 0 1 2 )
2 3 5
S u b sa
m p le
o f p ar
ti ci
p an
ts w
h o
p ro
vi d e d
D N
A sa
m p le
s (a
ff ec
te d )a
P re
-i n ci
d e n t,
2 – 4
w e e k s
P T
S D
(D E Q
, D
S M
-I V
) —
P T
S S ,
ch an
ge in
sy m
p to
m s
fr o m
p re
- in
ci d e n t
to 2 – 4
w e e k s:
rs 2 5 5 3 1
A /A
ge n o
ty p e , 5 -H
T T
L P R
m u lt
im ar
k e r
lo w
- e x p re
ss in
g ge
n o
ty p e s
(c o n ti n u ed
)
72
T a b
le 2 .
(c o n ti n u e d )
A u th
o r
(Y e ar
) N
S am
p le
T im
in g
M e n ta
l H
e al
th O
u tc
o m
e s
(M e as
u re
; C
la ss
if ic
at io
n S ys
te m
) P re
va le
n ce
P re
d ic
to rs
(1 f)
B ar
d e e n ,
K u m
p u la
, an
d O
rc u tt
(2 0 1 3 )
6 9 1
a P re
-i n ci
d e n t,
2 – 4
w e e k s,
8 m
o n th
s
P T
S D
(D E Q
, D
S M
-I V
); M
D (D
A S S -2
1 );
G A
D (D
A S S -
2 1 );
S tr
e ss
(D A
S S -2
1 )
P T
S S ,
2 – 4
w e e k s:
h ig
h e r
p re
-i n ci
d e n t
p o
st tr
au m
at ic
st re
ss ,
h ig
h e r
e x p o
su re
, h ig
h e r
e m
o ti
o n
re gu
la ti
o n
d if fi cu
lt ie
s at
p re
-i n ci
d e n t
an d
2 – 4
w e e k s;
P T
S S ,
h ig
h e r
e m
o ti
o n
re gu
la ti
o n
d if fi cu
lt ie
s at
2 – 4
w e e k s
an d
8 m
o n th
s; G
e n e ra
l D
is tr
e ss
(l at
e n t
co n st
ru c t
o f
M D
, G
A D
, an
d st
re ss
), 2 – 4
w e e k s:
p re
- in
ci d e n t
ge n e ra
l d is
tr e ss
, h ig
h e r
e x p o su
re ,
h ig
h e r
e m
o ti
o n
re gu
la ti
o n
d if fi c u lt
ie s
at 2 – 4
w e e k s;
G e n e ra
l d is
tr e ss
(l at
e n t
co n st
ru c t
o f
M D
, G
A D
, an
d st
re ss
), 8
m o n th
s: h ig
h e r
e m
o ti
o n
re gu
la ti
o n
d if fi cu
lt ie
s at
2 – 4
m o
n th
s an
d 8
m o n th
s (1
g) O
rc u tt
, B o n an
n o , H
an n a,
an d
M ir
o n
(2 0 1 4 )
6 6 0
a P re
-i n ci
d e n t,
2 – 4
w e e k s,
8 m
o n th
s, 1 4
m o n th
s, 2 0
m o n th
s, 2 6
m o n th
s, an
d 3 2
m o n th
s
P T
S D
(D E Q
, D
S M
-I V
) —
P o st
tr au
m at
ic st
re ss
, ch
ro n ic
d ys
fu n ct
io n
tr aj
e ct
o ry
: P re
-i n ci
d e n t
tr au
m a
e x p o su
re , h ig
h e r
p re
-i n ci
d e n t
e x p e ri
e n ti al
av o id
an ce
, h ig
h e r
e x p o su
re ,
h ig
h e r
e m
o ti o n
re gu
la ti o n
d if fi cu
lt ie
s (l im
it e d
ac ce
ss to
st ra
te gi
e s,
la ck
o f
e m
o ti o n al
cl ar
it y)
at 8
m o n th
s (2
) H
ar tn
e tt
an d
S k o w
ro n sk
i (2
0 1 0 )
5 5
N IU
st u d e n ts
(a ff ec
te d )
P re
-i n ci
d e n t,
2 – 3
w e e k s
M o o d
(P o M
S )
— —
2 0 0 8 —
C e n tr
al A
rk an
sa s
U n iv
e rs
it y
(C A
U )
in C
o n w
ay , A
R (1
) M
cI n ty
re ,
S p e n ce
, an
d L ac
h la
n (2
0 1 1 )
5 6 9
C A
U st
u d e n ts
(a ff ec
te d )
1 w
e e k
E m
o ti o n al
R e ac
ti o n s
(7 -i te
m sc
al e )
— E m
o ti o n al
re ac
ti o n s:
fe m
al e
ge n d e r
(c o n fu
si o n , fe
ar , sa
d n e ss
, la
ck o f
ca lm
n e ss
, an
d p an
ic )
2 0 0 8 —
S e in
äj o k i U
n iv
e rs
it y
o f A
p p lie
d S ci
e n ce
s (S
U A
S )
in K
au h aj
o k i,
F in
la n d
(1 )
T u ru
n e n ,
H ar
av u o ri
, P u n am
äk i,
S u o m
al ai
n e n , an
d M
ar tt
u n e n
(2 0 1 4 )
1 3 7
S U
A S
st u d e n ts
(a ff ec
te d )
4 m
o n th
s, 1 6
m o n th
s, an
d 2 8
m o n th
s
P T
S D
(I E S );
D is
so ci
at iv
e sy
m p to
m s
(A -D
E S ),
P T
G (P
T G
I)
— P T
S S , 4
m o n th
s: p re
o c cu
p ie
d at
ta ch
m e n t
st y le
(t o ta
l P T
S S , av
o id
an c e
su b sc
a le
); D
is so
c ia
ti ve
sy m
p to
m s,
4 m
o n th
s: n o
n se
c u re
at ta
ch m
e n t
st y le
s; D
is so
c ia
ti ve
sy m
p to
m s,
1 6
m o
n th
s: n o
n se
c u re
at ta
ch m
e n t
st y le
s; L o
w e r
P T
G , 1 6
m o
n th
s: av
o id
an t
at ta
c h m
e n t
st y le
(r e la
ti n g
to o th
e rs
su b sc
al e );
L o
w e r
P T
G , 2 8
m o
n th
s: av
o id
an t
at ta
ch m
e n t
st yl
e (r
e la
ti n g
to o th
e rs
su b sc
al e )
(c o n ti n u ed
)
73
T a b
le 2 .
(c o n ti n u e d )
A u th
o r
(Y e ar
) N
S am
p le
T im
in g
M e n ta
l H
e al
th O
u tc
o m
e s
(M e as
u re
; C
la ss
if ic
at io
n S ys
te m
) P re
va le
n ce
P re
d ic
to rs
2 0 0 7
an d
2 0 0 8 —
S ch
o o ls
in Jo
le k a
an d
K au
h aj
o k i,
F in
la n d
(c o m
b in
e d )
(1 )
V u o ri
, H
aw d o n ,
A tt
e , an
d R
äs än
e n
(2 0 1 3 )
6 4 9
R an
d o m
sa m
p le
o f re
si d e n ts
in Jo
le k a
(n ¼
3 3 0 )
an d
K au
h aj
o k i (n ¼
3 9 1 ;
a ff ec
te d )
6 – 7
m o n th
s W
o rr
y (3
it e m
s) —
W o rr
y (a
b o u t
te rr
o ri
sm , lo
ca l cr
im e , an
d sc
h o o l sh
o o ti n gs
): L o w
e r
so ci
al so
lid ar
it y,
m o re
p u n it iv
e at
ti tu
d e s
to w
ar d
cr im
e
2 0 0 7
an d
2 0 0 8 —
V T
an d
N IU
(c o m
b in
e d )
(1 )
K am
in sk
i, K
o o n s-
W it t,
T h o m
p so
n , an
d W
e is
s (2
0 1 0 )
1 ,9
5 2
C o lle
ge st
u d e n ts
fr o m
th e
U n iv
e rs
it y
o f S o u th
C ar
o lin
a (r
em o te
)
P re
-V ir
gi n ia
T e ch
, p o st
-V ir
gi n ia
T e ch
, p re
-N IU
, p o st
-N IU
(1 ti m
e p o in
t p e r
p ar
ti ci
p an
t)
F e ar
(5 it e m
s) —
F e ar
o f w
al k in
g al
o n e
d u ri
n g
th e
d ay
: p o st
- V
ir gi
n ia
T e ch
as se
ss m
e n t,
p re
-N IU
as se
ss m
e n t,
n o n -W
h it e
ra ce
/e th
n ic
it y,
re si
d e n ce
o n
ca m
p u s;
F e ar
o f w
al k in
g al
o n e
af te
r d ar
k : as
se ss
m e n t
af te
r V
ir gi
n ia
T e ch
, yo
u n ge
r ag
e , fe
m al
e ge
n d e r,
re si
d e n ce
o n
ca m
p u s;
F e ar
o f
cr im
e : p o st
-V ir
gi n ia
T e ch
as se
ss m
e n t,
yo u n ge
r ag
e , fe
m al
e ge
n d e r,
re si
d e n ce
o n
ca m
p u s;
F e ar
o f m
u rd
e r:
p o st
-V ir
gi n ia
T e ch
as se
ss m
e n t,
p o st
-N IU
as se
ss m
e n t,
yo u n ge
r ag
e , fe
m al
e ge
n d e r,
n o n -W
h it e
ra ce
/e th
n ic
it y,
re si
d e n ce
o n
ca m
p u s;
F e ar
o f w
e ap
o n
at ta
ck : p o st
-V ir
gi n ia
T e ch
as se
ss m
e n t,
p o st
-N IU
as se
ss m
e n t,
yo u n ge
r ag
e , fe
m al
e ge
n d e r
(2 )
V ic
ar y
an d
F ra
le y
(2 0 1 0 )
2 8 4
V T
(n ¼
1 2 4 )
an d
N IU
(n ¼
1 6 0 )
st u d e n ts
(a ff ec
te d )
2 w
e e k s
an d
8 w
e e k s
P T
S D
(P S S -S
R ),
M D
(C E S D
-1 0 )
A t
2 w
e e k s—
P T
S D
: 6 4 %
; M
D : 7 1 %
; A
t 8
w e e k s—
P T
S D
: 2 2 %
; M
D : 3 0 %
P T
S D
, 2
w e e k s:
F e m
al e
ge n d e r,
k n o w
in g
o n e
o f th
e vi
ct im
s; M
D sy
m p to
m s,
2 w
e e k s:
F e m
al e
ge n d e r,
k n o w
in g
o n e
o f
th e
vi ct
im s
N o te
.U n d e r
e ac
h e ve
n t,
n u m
b e ri
n g
is u se
d to
d e n o te
w h e n
st u d ie
s u se
d d at
a fr
o m
th e
sa m
e sa
m p le
,w it h
st u d ie
s p re
se n te
d in
ch ro
n o lo
gi ca
lo rd
e r
b y
p u b lic
at io
n d at
e .F
o r
e x am
p le
,f o r
th e
1 9 8 4
e le
m e n ta
ry sc
h o o ls
h o o ti n g
in L o s
A n ge
le s,
C A
, tw
o st
u d ie
s fr
o m
th e
sa m
e sa
m p le
ar e
lis te
d an
d la
b e le
d ac
co rd
in gl
y: (1
a) P yn
o o s
e t
al . (1
9 8 7 )
an d
(1 b )
N ad
e r,
P yn
o o s,
F ai
rb an
k s,
an d
F re
d e ri
ck (1
9 9 0 ).
W h e n
th e re
w e re
m u lt ip
le sa
m p le
s u n d e r
e ac
h e ve
n t,
th e
sa m
p le
s w
e re
o rd
e re
d ch
ro n o lo
gi ca
lly b y
p u b lic
at io
n d at
e o f th
e fi rs
t st
u d y
w it h in
e ac
h sa
m p le
. T
h e
ta b le
lis ts
b iv
ar ia
te as
so ci
at io
n s
o n ly
if m
u lt iv
ar ia
te re
su lt s
w e re
u n av
ai la
b le
; if
p re
va le
n ce
w as
re p o rt
e d
in m
u lt ip
le p u b lic
at io
n s
fo r
th e
sa m
e sa
m p le
,t h e
fi gu
re th
at in
cl u d e d
a h ig
h e r
# o f p ar
ti ci
p an
ts is
in cl
u d e d . A
A /A
D ¼
al co
h o l ab
u se
o r
d e p e n d e n ce
; A
S D ¼
ac u te
st re
ss d is
o rd
e r;
A S P D ¼
an ti so
ci al
p e rs
o n al
it y
d is
o rd
e r;
A U
D ¼
al co
h o l u se
d is
o rd
e r;
B A
I ¼
B e ck
A n x ie
ty In
ve n to
ry ; B D
I ¼
B e ck
D e p re
ss io
n In
ve n to
ry ; C
D C ¼
C e n te
rs fo
r D
is e as
e C
o n tr
o l;
C E S -D ¼
1 0 -i te
m C
e n te
r fo
r E p id
e m
io lo
gi c
S tu
d ie
s S h o rt
D e p re
ss io
n S ca
le ; D
A S S -2
1 ¼
D e p re
ss io
n an
d A
n x ie
ty S tr
e ss
S ca
le s-
2 1
it e m
ve rs
io n ; D
A /D
D ¼
d ru
g ab
u se
o r
d e p e n d e n ce
; D
E Q ¼
D is
tr e ss
in g
E ve
n ts
Q u e st
io n n ai
re ; D
IS ¼
d ia
gn o st
ic in
te rv
ie w
sc h e d u le
; D
T S ¼
D av
id so
n T
ra u m
a S ca
le ; D
U D ¼
d ru
g u se
d is
o rd
e r;
F D
A S ¼
F o u r
D im
e n si
o n al
A n x ie
ty S ca
le ; G
A D ¼
ge n e ra
liz e d
an x ie
ty d is
o rd
e r;
G H
Q ¼
G e n e ra
l H
e al
th Q
u e st
io n n ai
re ; IE
S ¼
Im p ac
t o f
E ve
n ts
S ca
le ; M
D ¼
m aj
o r
d e p re
ss io
n ; N
IU ¼
N o rt
h e rn
Il lin
o is
U n iv
e rs
it y;
P D ¼
p an
ic d is
o rd
e r;
P D
I ¼
p sy
ch ia
tr ic
d ia
gn o st
ic in
te rv
ie w
; P o M
S ¼
P ro
fi le
o f M
o o d
S ta
te s;
P T
G I ¼
P o st
tr au
m at
ic G
ro w
th In
ve n to
ry ; P S S -S
R ¼
P T
S D
S ym
p to
m S ca
le -S
e lf
R e p o rt
; P T
S D ¼
p o st
tr au
m at
ic st
re ss
d is
o rd
e r;
P T
S D
-R I ¼
; P o st
tr au
m at
ic S tr
e ss
-R e ac
ti o n
In d e x ; P T
S S ¼
p o st
tr au
m at
ic st
re ss
sy m
p to
m s/
se ve
ri ty
; S A
S R
Q ¼
S ta
n fo
rd A
cu te
S tr
e ss
R e ac
ti o n
Q u e st
io n n ai
re ; S T
A I ¼
S ta
te T
ra it
A n x ie
ty In
ve n to
ry ; T
S Q ¼
T ra
u m
a S cr
e e n in
g Q
u e st
io n n ai
re ; V
T ¼
V ir
gi n ia
T e ch
; W
A I ¼
W e in
b e rg
e r
A d ju
st m
e n t
In ve
n to
ry ; W
H O
-Q O
L ¼
W o rl
d H
e al
th O
rg an
iz at
io n
Q u al
it y
o f L if e
S ca
le – B ri
e f.
a S am
e sa
m p le
d e sc
ri p ti o n
as th
e p re
ce d in
g st
u d y.
74
(proposed) DSM-IV criteria, respectively (Schwarz & Kowalski,
1991a, 1991b).
Other Mental Health Outcomes
Although most studies in our review reported on symptoms and
prevalence estimates of psychiatric disorders, others included
mental health outcomes that were not specific to any disorder.
Fourteen studies (12 independent samples) utilized inventories
or items assessing constructs that cut across disorders, includ-
ing psychiatric disturbance, stress, grief, mood, emotional reac-
tions, worry, and fear (e.g., McIntyre, Spence, & Lachlan,
2011; Suomalainen, Haravuorti, Berg, Kiviruusu, & Marttunen,
2011; Vuori, Hawdon, Atte, & Räsänen, 2013). Four studies
(three independent samples) included positive indices of men-
tal health—emotional and behavioral well-being, quality of
life, and posttraumatic growth (Grills-Taquechel, Littleton,
& Axsom, 2011; Hawdon & Ryan, 2011, 2012; Turunen, Har-
avuori, Punamäki, Suomalainen, & Marttunen, 2014). Finally,
one study (Orcutt, Bonanno, Hanna, & Miron, 2014) utilized
trajectory analysis of PTSS over seven waves to (one pre- and
six post-incident) in the context of the NIU campus shooting.
The majority of participants (60.9%) were in a minimal impact resilience trajectory, reporting low levels of symptoms
at each wave and a small elevation in symptoms at the first
post-incident wave only.
Assessing the Mental Health Impact of Mass Shootings
In reviewing the studies, we noted how investigators assessed
whether participants’ symptoms reflected the impact of the mass
shooting, versus ongoing mental health difficulties that might
have been present before the incident took place. Certainly, per-
sonality disorders, which are conceptualized as enduring and
pervasive phenomenon, are unlikely to be the result of a single
event. Symptoms that were asked without reference to the mass
shooting episode, including MD and GAD symptoms, also might
have been present prior to the shooting incident. Although other
outcomes were directly in reference to the mass shooting inci-
dent, including PTSD and acute stress disorder, they too could
be influenced by preexisting psychopathology.
Three methods were used to address this issue. First, three
independent samples included both pre- and post-incident data.
The significance of pre- to post-incident changes in mental
health reached was assessed in one of these samples (Hartnett
& Skowronski, 2010). The investigators found that students’ rat-
ings of four negative moods states (depression, tension, fatigue,
and confusion) did not significantly differ between pre- and post-
incident assessment; however, they reported significantly higher
anger at the post-incident assessment. In the two other samples,
significance of changes in mental health from pre- to post-
incident was not assessed. However, descriptive data suggested
short-term increases in depression and PTSS (e.g., Littleton,
Axsom, & Grill-Taquechel, 2009; Orcutt et al., 2014).
Second, two studies assessed mental health impacts through
comparison of samples who faced different levels of exposure,
with results indicating higher symptomatology in directly
exposed subsamples. Students at Joleka High School in Fin-
land, where a shooting took place, had significantly higher
posttraumatic distress and psychiatric disturbance than students
in another city in Finland (Suomalainen et al., 2011). In the
aftermath of the 1994 Brooklyn Bridge shooting, levels of
PTSS, depression, and anxiety were higher in youth who
directly experienced the attack than an age-matched compari-
son group of youth in the same community who were not
directly exposed (Trappler & Friednman, 1996).
Finally, three studies drew on data from ongoing investiga-
tions of remote samples to assess the mental health impact of mass
shootings, as well as their broader effects on indirectly exposed
populations. For example, in the aftermath of the 1999 Columbine
massacre, researchers drew on national school-based surveys
with assessments spanning from pre- to post-incident in 1999 and
found that students’ perceptions of safety at school declined after
the attack (Addington, 2003; Brener, Simon, Anderson, Barrios,
& Small, 2002). Interestingly, students’ reports of suicidal idea-
tion and plans also significantly decreased after Columbine, per-
haps indicative some form of widespread posttraumatic growth
(e.g., increased appreciation of life), although this finding was
limited to students living in rural and suburban areas (Brener
et al., 2002). Two other investigations of remote college student
samples have shown increased fears (e.g., of walking alone, of
crime) and decreased perceived safety from pre- to post-
incident (Kaminski, Koons-Witt, Thompson, & Weiss, 2010;
Stretesky & Hogan, 2001).
Predictors of Adverse Mental Health Outcomes
Table 2 also includes significant predictors of adverse mental
health outcomes in each of the study. These predictors can be
divided roughly into three categories: (1) demographics and
pre-incident characteristics, (2) incident exposure, and (3)
post-incident functioning and psychosocial resources.
Demographic and Pre-Incident Characteristics
Demographic characteristics have frequently been included as
predictors of mental health. Most consistently, female gender
has been shown to be a predictor of post-incident psychological
adversity, associated with increased odds of PTSD (e.g., North,
Smith & Spitznagel, 1994; Suomalainen et al., 2011), higher
levels of fear (Fallahi & Lesik, 2009), and lower levels of emo-
tional and behavioral well-being (Hawdon & Ryan, 2012) in
affected samples, and higher fear in a remote sample (Vicary
& Fraley, 2010). One proposed explanation for this difference
is that women are more likely to employ a ruminative coping
style, increasing the severity and chronicity of their symptoms
(e.g., McIntyre et al., 2011; Palus, Fang, & Prawitz, 2012).
Indicators of socioeconomic disadvantage, although less
often included in post-incident studies, have also been consis-
tently associated with poor mental health. For example, in the
aftermath of the 1984 shooting at a fast food restaurant in
Lowe and Galea 75
California, higher prevalences of severe PTSD were documen-
ted among community members with lower income or who
were unemployed, relative to their counterparts (Hough et al.,
1990). Lower education was also associated with higher PTSS
among survivors of the 1992 St. Louis courthouse shooting
(Johnson et al., 2002). Among an adolescent sample, not living
with two biological parents was associated with higher psy-
chiatric disturbance (Suomalainen et al., 2011).
Other demographic characteristics have been less consis-
tently associated with post-incident mental health outcomes.
For example, younger and older age have each been associated
with adverse outcomes in both community and college student
samples (Fallahi & Lesik, 2009; Hough et al., 1990; Johnson
et al., 2002; Kaminski et al., 2010). Racial/ethnic minority
status has also been inconsistently associated with outcomes.
Two studies have found non-White race to be associated with
more severe post-incident symptoms (Fallahi & Lesik, 2009;
Kaminski et al., 2010). In contrast, among female NIU stu-
dents, African American ethnicity was associated with lower
PTSS at 2–4 weeks post-incident, whereas Asian ethnicity was
associated with higher PTSS at 8 months post-incident (Littleton,
Kumpula, & Orcutt, 2011).
Few studies have investigated whether marital and parent
status affect risk for post-incident adversity. Hough and col-
leagues (1990) found higher prevalences of severe PTSD
among widowed, divorced, or separated persons (relative to
married and single persons) and among adults with no children
at home (relative to those with 1–3 or more children); however,
the significance of these trends was not assessed. In contrast,
Johnson, North, and Smith (2002) found that being married,
relative to single or divorced, widowed, or separated, was asso-
ciated with higher PTSS.
Only one study to our knowledge has investigated the role of
genetic risk variants in predicting post-incident outcomes.
Among a subsample of NIU female students who provided
DNA samples, variants within the serotonin transporter gene
were associated with significantly greater increases in PTSS
from pre-incident to 2–4 weeks post-incident (Mercer et al.,
2012). An additional finding showing that family history of
mental illness predicted lack of recovery in MD at 3 years after
the 1991 Killeen, TX, restaurant shooting also suggests a
potential genetic contribution to post-incident responses
(North, McCutcheon, Spitznagel, & Smith, 2002).
Similarly, the results of several investigations have shown
that pre-incident psychological functioning is a strong predictor
of post-incident functioning. A retrospective assessment of
PTSD was found to predict post-incident PTSD among survivors
of the 1991 Texas restaurant shooting (Sewell, 1996). In the
aftermath of the same incident, reports of pre-incident psychia-
tric diagnosis were also associated with increased risk for PTSD
among female survivors (North et al., 1994, 1997). Among ado-
lescents exposed to the Joleka High School shooting, previous
‘‘mental support’’ from a nonguardian adult, a proxy for pre-
event functioning, was associated with increased risk for psy-
chiatric disturbance (Suomalainen et al., 2011). More recent
studies in the aftermath of college shootings have drawn on
pre-incident data and found significant associations between pre-
and post-incident assessments of mental health (e.g., Grills-
Taquechel et al., 2011; Littleton, Kumpula, et al., 2011).
A related set of findings has found that prior trauma expo-
sure increases risk for psychological adversity in the aftermath
of shooting incidents. For example, in the study of female Vir-
ginia Tech survivors, those who had experienced sexual victi-
mization prior to the event were at increased risk of PTSS
and depression 1 year after the shooting (Littleton, Grills-
Taquechel, Axsom, Bye, & Buck, 2012). Among the NIU
student sample, higher pre-incident trauma exposure was pre-
dictive of higher PTSS at two post-incident time points (Lit-
tleton, Kumpula, et al., 2011), as well as increased odds of
a nonresilient trajectory of PTSS over time (Orcutt et al.,
2014).
Incident Exposure
Indices of greater incident exposure, including proximity to an
attack, acquaintance with the deceased, and higher scores on
exposure inventories (with items assessing, e.g., seeing or hear-
ing the events and physical injuries), have consistently been
associated with more severe psychological reactions (e.g.,
Hawdon & Ryan, 2012; Littleton, Kumpula, et al., 2011;
Pynoos et al., 1987). There is some evidence that the impact
of milder forms of exposure on mental health decreases over
time. For example, in the aftermath of the NIU shooting,
moderate, severe, and extreme exposure (relative to no direct
exposure) were associated with higher PTSS 2–4 weeks post-
incident, whereas only extreme exposure was associated with
higher PTSS at 8 months post-incident (Littleton, Kumpula
et al., 2011).
In addition, emotional reactions during and after the incident
have been found to predict later psychological responses. For
example, students’ perceptions that they would be shot or were
in danger during the 1988 Illinois elementary school shooting
increased risk for PTSD (Schwarz & Kowalski, 1991a). Kum-
pula, Orcutt, Bardeen, and Varkovitzky (2011) assessed NIU
students’ experiences of peritraumatic dissociation—altered
awareness and depersonalization or derealization—during the
event and found them to be predictive of higher PTSS 2–4
weeks post-incident. Other investigators have drawn on longi-
tudinal data to show that earlier post-incident symptoms are
positively associated with symptoms at later time points (e.g.,
Bardeen, Kumpula, & Orcutt, 2013; Smith, Abeyta, Hughes,
& Jones, 2014). For example, acute stress disorder symptoms
1 week after the 1993 San Francisco office building shooting
were associated with increased odds for PTSD 7–10 months
post-incident. Being offered post-incident crisis support and
early post-incident use of mental health services have also
served as proxies of adverse initial responses, and have been
predictive of higher psychiatric symptoms later on (e.g., Mur-
tonen, Suomalainen, Haravuori, & Marttunen, 2012; North
et al., 2002). Interestingly, Murtonen, Suomalainen, Haravuori,
and Marttunen (2012) found that students’ perceptions that
early crisis support was unhelpful was also associated with
76 TRAUMA, VIOLENCE, & ABUSE 18(1)
more severe symptoms, suggesting that survivors who do not
benefit from early interventions might be at particular risk of
long-term mental health problems.
How events are perceived and remembered have also been
found to predict mental health outcomes. For example, after the
1992 St. Louis courthouse shooting, survivors’ perception that
the incident had caused them a great deal of harm, that it was
very upsetting, and that they had not recovered were each asso-
ciated with higher PTSS (Johnson et al., 2002). A small study
of school personnel in the aftermath of the 1988 Illinois ele-
mentary school shooting assessed participants’ changes in
reports of emotional, life threat, and sensory experiences dur-
ing the attack, and found that those whose reports became more
intense over time (enlargement of recall) or did not become less
intense over time (lack of diminishment of recall) tended to
have more severe symptoms (Schwarz, Kowalski, & McNally,
1993).
Other investigations have focused on indirect exposure to
events in affected and remote samples. For example, Joleka
High School students who reported higher media exposure
were at increased risk of post-incident psychiatric disturbance
(Haravuori, Suomalainen, Berg, Kiviruusu, & Marttunen,
2011). In a remote college student sample, greater exposure
to news media after the Virginia Tech shooting was associated
with significantly higher psychiatric symptoms (Fallahi, Aus-
tad, Fallon, & Leishman, 2009). Significantly higher symptoms
were also found among students who reported more time dis-
cussing the incident with family and friends, indicating that
informal conversations may serve as an additional form of indi-
rect exposure (Fallahi et al., 2009). Associations between indirect
exposure and mental health could be due in part to self-selection
and reverse causation, such that participants with more severe
symptoms might be more likely to seek out media exposure and
initiate conversations on the event. Further research employing
longitudinal and experimental designs could address these
considerations.
Post-Incident Functioning and Psychosocial Resources
As noted previously, early post-incident mental health
responses have been found to prospectively predict later post-
incident mental health responses (e.g., Bardeen et al., 2013).
In a similar vein, different classes of psychiatric symptoms
have been positively associated in cross-sectional assessments.
For example, among female survivors of the 1991 Texas res-
taurant shooting, a diagnosis of any other psychiatric disorder
was associated with increased odds of PTSD (North et al.,
1994); among the full sample, there was also significant con-
cordance between post-incident MD and PTSD. Studies have
also documented associations between post-incident fears and
PTSS in affected and remote samples (Fallahi & Lesik, 2009;
Schwarz & Kowalski, 1991a).
Research has further suggested interrelations between men-
tal and physical health problems. Higher prevalences of both
mild and severe PTSD were observed in affected community
members with fair or poor physical health, versus those with
good or excellent physical health, in the aftermath of the
1984 California fast-food restaurant shooting. Among children
directly exposed to the 1988 Illinois elementary school shoot-
ing, increased physical symptoms and visits to the school nurse
were associated with increased risk of PTSD (Schwarz &
Kowalski, 1991a). In the absence of longitudinal research, the
direction of the relationship between post-incident mental and
physical health remains unclear. Additional considerations are
whether physical health symptoms are manifestations of poor
mental health or whether preexisting physical health symptoms
or pre- to post-incident changes in physical health account for
significant associations.
In terms of psychosocial resources, research has focused on
personality characteristics, beliefs and attitudes, coping styles,
and social relationships as predictors of mental health out-
comes. Personality characteristics that have been associated
with adverse outcomes include guilt and resentment, insecur-
ity, and anxiety sensitivity (Schwarz & Kowalski, 1992a;
Stephenson, Valentiner, Kumpula, & Orcutt, 2009). Beliefs
that events are random and uncontrollable, and punitive atti-
tudes toward crime have also been associated with adverse
outcomes, whereas greater self-efficacy, sense of meaning,
spirituality and perceived benevolence of others have shown
to be protective factors (Littleton et al., 2012; Smith et al.,
2014; Vuori, Hawdon, Atte, & Räsänen, 2013).
Coping styles have been differentially associated with out-
comes. Forms of coping that involve taking action, cognitive
processing of the incident, and acceptance have been associ-
ated with lower levels of symptoms (e.g., North, Spitznagel,
& Smith, 2001; Sewell, 1996), whereas ruminative and avoi-
dant coping styles have been found to increase risk (e.g.,
Littleton et al., 2012). To some extent, means of coping in the
aftermath of an incident could represent more pervasive diffi-
culties and ways of approaching one’s experiences. In this
vein, studies drawing on pre-incident data have found those
emotion regulation difficulties and experiential avoidance,
or the tendency to disengage from difficult emotions, sensa-
tions, thoughts, and memories, to be prospective predictors
of post-incident symptoms (e.g., Bardeen et al., 2013; Kum-
pula, Orcutt, Bardeen, & Varkovitzky, 2011).
Similarly, indicators of fewer social resources (e.g., lower
perceived social support and lower social solidarity) have been
consistently associated with adverse post-incident outcomes
(e.g., Hawdon & Ryan, 2012; Littleton et al., 2012; Suomalai-
nen et al., 2011), and these differences could be driven in part
by stable personality characteristics. For example, nonsecure
attachment styles were significantly associated with higher
PTSS and lower posttraumatic growth in relationships with
others among students after a college campus shooting in Fin-
land (Turunen, Haravuori, Punamäki, Suomalainen, & Marttu-
nen, 2014).
On the other hand, researchers have been informed by Con-
servation of Resources (COR) theory (Hobfoll, 1989), which
suggests that change in psychosocial resources, rather than sta-
bility, increases risk for adverse psychological outcomes. Sup-
porting COR theory, Littleton and colleagues found that
Lowe and Galea 77
survivors’ reports of loss of life direction and pride, optimism,
and interpersonal resources (e.g., companionship) were associ-
ated with higher PTSS and psychological distress (Littleton
Axsom, et al., 2009; Littleton, Grills-Taquechel, & Axsom,
2009; Littleton, Kumpula, et al., 2011). Lower levels of
resource gain, however, were significantly associated with
higher psychological distress, suggesting that only negative
changes in resources are associated with adverse outcomes.
Processes Leading to Adverse Mental Health Outcomes
In our review, we noted findings that went beyond documenting
prevalence estimates and predictors by exploring the mechan-
isms contributing to mental health outcomes over time. A total
of seven studies (from three independent samples) did so, all
conducted within the past decade. In general, two types of
mechanisms were explored across these studies. First, studies
assessed pathways from pre-incident risk factors to post-
incident mental health through post-incident risk factors. One
example is a study in the aftermath of the NIU shooting showing
that students’ pre-incident experiential avoidance was positively
associated with their post-incident reports of peritraumatic disso-
ciative experiences, which in turn were positively associated
with PTSS (Kumpula et al., 2011). Another study of student sur-
vivors of the Virginia Tech attack found that prior sexual victi-
mization was indirectly associated with PTSS and depression
through lower self-worth, benevolence beliefs, and social sup-
port (Littleton et al., 2012).
Second, studies explored the ways in which risk factors
and mental health influence each other over time through
cross-lagged models. For example, a longitudinal study in
the aftermath of the Virginia Tech shooting found reciprocal
relationships between psychological distress and maladap-
tive coping from 2 months to 6 months, and 6 months to
1 year post-incident, suggesting that psychological distress
could perpetuate itself by undermining coping mechanisms
(Littleton, Axsom et al., 2011). This was not the case for the
model containing PTSS, wherein the paths from PTSS to
maladaptive coping reached statistical significance, but
those from maladaptive coping to PTSS did not (Littleton
et al., 2011). Another study employed cross-lagged model-
ing and found significant bidirectional relationships between
emotion regulation difficulties and PTSS from pre-incident
to 2–4 weeks after the NIU shooting, whereas only the path
from emotion regulation difficulties to PTSS was significant
from 2-4 weeks to 8 months post-incident (Bardeen et al.,
2013). For the model containing general distress, only the
path from distress to emotion regulation difficulties was sig-
nificant from pre-incident to 2—4 weeks post-incident,
whereas only the path from emotion regulation difficulties
to distress was significant from 2-4 weeks to 8 months
post-incident (Bardeen et al., 2013).
Taken together, the few studies in our review that investi-
gated mechanisms contributing to post-incident mental health
suggest a complex interplay between risk factors and outcomes
that depend in part on the timing of assessment and outcome
assessed. Further research exploring these processes will help
to establish conceptual models of pathways to post-shooting
mental health.
Discussion
The purpose of this review has been to review the extant liter-
ature on mental health in the aftermath of mass shootings. The
research to date provides evidence that these events can have
mental health consequences for victims and members of
affected communities, leading to increases in PTSS, depres-
sion, and other psychological symptoms. The few studies on
remote samples further suggest that these events can have at
least short-term psychological effects, for example, increased
fears and declines in perceived safety, on persons living far out-
side of the affected communities. These effects are not distrib-
uted equally, however, and research has identified several risk
factors for adverse outcomes, including demographic charac-
teristics (e.g., female gender and lower socioeconomic status),
higher pre-event trauma exposure and psychological symp-
toms, greater direct and indirect event exposure, and lack of
psychosocial resources (e.g., emotional regulation difficulties,
experiential avoidance, and low social support).
Although the extant body of research offers some conclu-
sions about the mental health effects of mass shootings, more
research is needed to better understand the mechanisms
through which risk and protective factors contribute to longer
term outcomes. There is a particular need for studies in the
aftermath of high-impact events. For example, we identified
no studies of affected samples in two recent events with unu-
sually high numbers of casualties—the 2012 shootings at the
Aurora movie theater and Sandy Hook elementary school.
Researchers and institutional review boards might be hesitant
to conduct studies in the aftermath of such events due to con-
cerns about retraumatizing or otherwise taking advantage of
victims. Notably, however, the majority (85%) of NIU students who completed a post-incident experimental study reported
that they would participate in the study again (Fergus, Raben-
horst, Orcutt, & Valentiner, 2011). Although a single data
source, these results suggest some evidence that study partici-
pation might not have adverse effects. Research in the after-
math of other traumatic events suggests that some persons
who have experienced trauma may actually derive benefits
from research participation (e.g., Griffin, Resick, Waldorp, &
Mechanic, 2003).
Further studies that draw on pre-incident data from ongoing
investigations would provide greater insight into the role of
pre-event functioning and trauma exposure on psychological
responses. In a similar vein, studies that include multiple waves
of follow-up data would allow for an enhanced understanding
of longitudinal patterns of responses and the processes that lead
to chronic symptoms. The research could also be enriched by
further studies that include positive outcomes (e.g., resilience
and posttraumatic growth) and incorporate additional sources
of data, including genetic variants and information on commu-
nity characteristics and resources. In addition to further
78 TRAUMA, VIOLENCE, & ABUSE 18(1)
research on affected samples, more investigations are needed to
understand the broader impact of mass shootings on unaffected
communities. It was notable that only 5 of the 28 identified
samples focused on remote populations; as such, our conclu-
sions regarding the widespread mental health effects of mass
shootings are tentative at best.
Additional research would also inform interventions to pre-
vent and treat post-incident mental health problems. The first
step in prevention would be to decrease the likelihood that mass
shooting events occur in the first place. The rarity of these
events precludes the use of statistical modeling to predict their
occurrence (Swanson, 2011). Researchers have accordingly
advised against the use of risk profiles, which have the poten-
tial for false positives bias, and stigmatization (Reddy et al.,
2001). Instead, a deductive threat assessment approach in
which a team of professionals gathers information about a par-
ticular case to assess the likelihood that a violent episode will
occur, and formulates a response based on that assessment,
have been proposed (e.g., Cornell & Allen, 2011; Reddy
et al., 2011). Others have suggested the need for promoting
positive school climates in which there is open dialogue
between students, teachers, and administrators to reduce the
likelihood of school shootings (Mulvey & Cauffman, 2001),
and efforts to improve access to and continuity of high-
quality mental health services for people with serious mental
illness to prevent violent behaviors among this group (Swanson,
2011). Finally, others have noted the high rates of gun ownership
and firearm mortalities in the United States compared to those in
other developed countries as evidence of the need for a range of
efforts to reduce gun access (e.g., Shultz, Cohen, Muschert, &
Flores de Apodaca, 2013). An observational study showing
declines in firearm-related deaths, suicides and homicides, and
a complete absence of mass shooting episodes, in Australia a
decade after gun law reforms aiming to limit civilian access
to semiautomatic and pump-action shotguns and rifles pro-
vides support for such efforts (Chapman, Alpers, Agho, &
Jones, 2006).
In addition to preventing mass shootings, it would be impor-
tant to develop interventions to address mental health problems
in their wake. Trained crisis response teams that establish
safety, evaluate the psychological needs of victims, connect
survivors with a range of services to meet their needs, and eval-
uate response efforts have been proposed to mitigate the effects
of school violence (Crepeau-Hobson, Sievering, Armstrong, &
Stonis, 2012). Hobfoll and colleagues (2007) have also identi-
fied five empirically supported principles for mental health
responses to mass trauma—promoting a sense of safety, calm-
ing, a sense of self- and community-efficacy, connectedness,
and hope.
The empirical research also lends support for approaches
that identify survivors most at risk of adverse outcomes, includ-
ing women, persons of lower socioeconomic status, those who
faced higher levels of exposure, and persons lacking strong
social support networks. Furthermore, extant studies suggest
interventions that enhance emotion regulation and active cop-
ing skills and that encourage engagement with and acceptance
of emotions, thoughts, memories, and sensory experiences
(e.g., Metz et al., 2013). These skill-building interventions
could be part of the standard curriculum and could promote
resilience after a range of traumatic events and stressors.
The recommendations for future research, policy, and prac-
tice are made with caution, given the limitations of this review.
For example, although our efforts to identify studies meeting
our inclusion criteria were exhaustive, we did not track such
data as the total number of articles identified across all of
our searches, and the number that were dropped based on
each criterion. In addition, although the first author checked
and rechecked coding for accuracy, articles were not double-
coded, and a system for establishing the reliability of the article
screening and coding process was not developed and applied.
Taken together, these limitations suggest a need for a more sys-
tematic review, particularly as additional literature on this topic
is published. Further reviews could also apply broader inclu-
sion criteria, for example, to provide insight into the influence
of direct and indirect exposure to mass shootings on other
domains of functioning (e.g., physical health and social func-
tioning). Inclusion of non-English language articles could shed
additional light on the influence of mass shootings on mental
health cross-culturally. Qualitative studies could also be inte-
grated to provide a richer sense of the patterns and predictors
of mental health in the aftermath of shootings. Our review of
predictors also focused on factors that account for significant
variation in post-shooting mental health within each study, and
we did not attend to potential between-study sources of varia-
tion, such as differences in samples (e.g., age-group and extent
of exposure), procedures (e.g., timing of assessment), and event
characteristics (e.g., single vs. multiple shooters, number of
injuries and fatalities). Future research could examine within- and
between-study variability simultaneously using meta-analytic
techniques. Finally, we did not compare the prevalence esti-
mates and predictors of mental health outcomes in the after-
math of mass shootings to those in the aftermath of other
traumatic events. Inclusion of mass shootings on trauma inven-
tories in future epidemiological studies would provide insight
into this issue.
In summary, the limited research suggests that mass shoot-
ing incidents can lead to an array of mental health problems in
survivors and members of affected communities. Furthermore,
they have been associated with increased fears and decreased
perceptions of safety in indirectly exposed populations. A vari-
ety of risk and protective factors have been identified, includ-
ing demographic characteristics, pre-event trauma exposure
and functioning, event exposure, and psychosocial resources.
Further research that explores the processes contributing to
long-term psychological responses will yield important impli-
cations for post-incident interventions to reduce mental health
impacts.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Lowe and Galea 79
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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Author Biographies
Sarah R. Lowe, PhD, is an associate research scientist in the Depart-
ment of Epidemiology at the Columbia University Mailman School of
Public Health. Her research centers on long-term psychological
responses to traumatic events and the roles of secondary stressors and
social conditions in shaping outcomes. She is currently working on
projects exploring such relationships among survivors of Hurricane
Sandy in New York City, cleanup workers from the 2010 Deepwater
Horizon oil spill, and trauma-exposed residents of Detroit, Michigan,
and Atlanta, Georgia. She received her PhD in clinical psychology
from the University of Massachusetts, Boston, in 2012, and completed
her clinical internship at New York Presbyterian/Weill Cornell Med-
ical Center. Her dissertation on trajectories of psychological distress
among low-income female survivors of Hurricane Katrina was
awarded the Chancellor’s Distinguished Dissertation Award at Uni-
versity of Massachusetts Boston, as well as the Best Dissertation on
a Topic Relevant to Community Psychology Award from the Society
for Community Research in Action (American Psychological Associ-
ation Division 27). She will be joining the Department of Psychology
at Montclair State University as assistant professor in September 2015.
Sandro Galea is a physician and an epidemiologist. He is the dean and
a professor at the Boston University School of Public Health. Prior to
his appointment at Boston University, he served as the Anna Cheskis
Gelman and Murray Charles Gelman Professor and Chair of the
Department of Epidemiology at the Columbia University Mailman
School of Public Health where he launched several new educational
initiatives and substantially increased its focus on six core areas:
chronic, infectious, injury, life course, psychiatric/neurological, and
social epidemiology. He previously held academic and leadership
positions at the University of Michigan and at the New York Academy
of Medicine. In his own scholarship, he is centrally interested in the
social production of health of urban populations, with a focus on the
causes of brain disorders, particularly common mood-anxiety disor-
ders, and substance abuse. He has long had a particular interest in the
consequences of mass trauma and conflict worldwide, including as a
result of the September 11 attacks, Hurricane Katrina, conflicts in
sub-Saharan Africa, and the American wars in Iraq and Afghanistan.
This work has been principally funded by the National Institutes of
Health, Centers for Disease Control and Prevention, and several foun-
dations. He has published over 500 scientific journal articles, 50 chap-
ters and commentaries, and nine books, and his research has been
featured extensively in current periodicals and newspapers. His latest
book, coauthored with Dr. Katherine Keyes, is an epidemiology text-
book, Epidemiology Matters: A New Introduction to Methodological
Foundations. He has a medical degree from the University of Toronto
and graduate degrees from Harvard University and Columbia Uni-
versity. He was named one of TIME magazine’s epidemiology inno-
vators in 2006. He is the past president of the Society for
Epidemiologic Research and an elected member of the American
Epidemiological Society and of the Institute of Medicine of the
National Academies of Science. He serves frequently on advisory
groups to national and international organizations. He has formerly
served as chair of the New York City Department of Health and Men-
tal Hygiene’s Community Services Board and as member of its
Health Board.
82 TRAUMA, VIOLENCE, & ABUSE 18(1)
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/FlattenerPreset << /ClipComplexRegions true /ConvertStrokesToOutlines false /ConvertTextToOutlines false /GradientResolution 300 /LineArtTextResolution 1200 /PresetName ([High Resolution]) /PresetSelector /HighResolution /RasterVectorBalance 1 >> /FormElements true /GenerateStructure false /IncludeBookmarks false /IncludeHyperlinks false /IncludeInteractive false /IncludeLayers false /IncludeProfiles true /MarksOffset 9 /MarksWeight 0.125000 /MultimediaHandling /UseObjectSettings /Namespace [ (Adobe) (CreativeSuite) (2.0) ] /PDFXOutputIntentProfileSelector /DocumentCMYK /PageMarksFile /RomanDefault /PreserveEditing true /UntaggedCMYKHandling /UseDocumentProfile /UntaggedRGBHandling /UseDocumentProfile /UseDocumentBleed false >> ] /SyntheticBoldness 1.000000 >> setdistillerparams << /HWResolution [288 288] /PageSize [612.000 792.000] >> setpagedevice
