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International Journal of Disaster
Medicine
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Impact of bereavement among relatives in Italy and
Sweden after the Linate airplane disaster
Kerstin Bergh Johannesson a; Stefano Stefanini a; Tom Lundin a; Roberto Anchisi a
aNational Center for Disaster Psychiatry, Department of Neuroscience, University of
Uppsala, Uppsala, Sweden
Online Publication Date: 01 January 2006
To cite this Article: Johannesson, Kerstin Bergh, Stefanini, Stefano, Lundin, Tom
and Anchisi, Roberto (2006) 'Impact of bereavement among relatives in Italy and
Sweden after the Linate airplane disaster', International Journal of Disaster
Medicine, 4:3, 110 - 117
To link to this article: DOI: 10.1080/15031430600969034
URL: http://dx.doi.org/10.1080/15031430600969034
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ORIGINAL ARTICLE
Impact of bereavement among relatives in Italy and Sweden after the
Linate airplane disaster
KERSTIN BERGH JOHANNESSON, STEFANO STEFANINI, TOM LUNDIN &
ROBERTO ANCHISI
National Center for Disaster Psychiatry, Department of Neuroscience, University of Uppsala, Uppsala, Sweden
Abstract
Objectives: Victims of major disasters are at risk for development of post-traumatic stress disorder (PTSD). The aim of this
study was to compare two groups of bereaved relatives from Italy and Sweden, and to examine the role of psychosocial
support and psychological reactions 18 months after traumatic bereavement. Methods: In all, 153 bereaved relatives of
deceased victims in the Milano/Linate aeroplane crash were assessed by a questionnaire. Reactions of psychological distress
were measured by the Impact of Event Scale-Revised (IES-R). Results: In the whole group, 53.2% showed symptoms
indicating that they might meet the DSM-IV criteria for PTSD. The frequency was higher among the Italian relatives
(58.7%) compared with the Swedish relatives (42.6%). Females showed more signs of post-traumatic reactions compared
with males in the total population, as did spouses and parents within the Italian group. The general health status, measured
by subjective evaluation, was significantly affected in both groups as a result of the disaster. A significant recovery after 18
months was reported, although not to the pre-accident level. The Swedish relatives had a pattern of using more
psychotherapy compared with the Italians, among whom it was more common to use medication for both anxiety and
sleeping problems. The need for psychotherapy and medication was related to higher scores on IES-R. Conclusions: (1)
Traumatic losses deeply affect bereaved relatives. Health is affected and a large group of these relatives develop strong
symptoms of post-traumatic stress. (2) Swedish bereaved relatives seem to be more apt to ask for professional help, e.g.
psychotherapy, while in Italy it is more common to rely on family, friends and medication. (3) Acute organized psychosocial
support in the aftermath can possibly facilitate for victims to handle a traumatic loss but it does not prevent the development
of strong post-traumatic reactions. Future investigations may show how it is possible to optimize the help with more specific
interventions of support and treatment.
Key words: Airplane disaster, bereavement, post-traumatic reactions, traumatic grief, general health, psychosocial support,
Linate
Introduction
On 8 October 2001, a Scandinavian Airline System
(SAS) MD-87 aircraft crashed into a small private
Cessna plane on the runway at Milan’s Linate airport
before take-off (Figure 1). The weather was bad.
Unsatisfactory technical conditions at the airport in
combination with human mistakes from the control
tower were later found to explain the cause of the
disaster. The plane, with an estimated speed of 320
kilometers per hour (200 mph), ran into a baggage-
handling hangar, where it exploded. No one in the
aircrafts survived. A total of 118 people were killed
(Figure 2 and Table I).
Two main organizations in Italy offered immedi-
ate psychosocial support. The Society of Airport
Services (SEA) activated a group of psychologists
from the Hospital San Raffaele in Milan, who,
together with the staff of the Italian Red Cross,
psychologists and social workers of the Legal
Institute of Medicine offered help and support.
SAS – in collaboration with Alitalia – activated
‘EOS’, a non-profit organization which offered
support and recognition to the Italian relatives of
the victims. The practical and logistical elements of
the psychosocial support in the first 24 hours were
managed by the Italian Red Cross (CRI), which
provided structure, means of transportation and
collaboration with various active agencies (e.g. the
National Fire Department and the staff of the City
Council of Milan). The Italian Red Cross also
continued to work in the next few days, assisting in
the personal delivery of the death certificates to the
relatives. The Italian Red Cross also contributed to
the organization of a major religious memorial
ceremony in the Cathedral of Milan 1 week after
Correspondence: Kerstin Bergh Johannesson, National Center for Disaster Psychiatry, Department of Neuroscience, University of Uppsala, Emmy Rappes
va¨g 10, 750 17 Uppsala, Sweden. Fax: +46 18 611 88 90. E-mail: kerstin.bergh.johannesson@akademiska.se
International Journal of Disaster Medicine. 2006; 4: 110–117
ISSN 1503-1438 print/ISSN 1651-3037 online #2006 Taylor & Francis
DOI: 10.1080/15031430600969034
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the disaster. Medical services were offered by
specialists at the University of Milan, Department
of Legal Medicine. At the SAS main office in
Stockholm, the emergency response organization
was activated. The whole staff of the SAS Executive
Emergency group was gathered within 1 hour after
the crash. At noon, about 100 members of the SAS
support team were on their way from Stockholm and
Copenhagen to Linate. A first group of relatives of
the Swedish victims arrived in Milan the same night
and a second group arrived the following morning.
All relatives who wanted to go to Milan were offered
the opportunity to do so. Physicians, psychologists, a
priest and translators were brought in. During the
night a hotel was activated to offer accommodation
for the Scandinavian families. A psychologist from
San Raffaele Hospital and a support team from the
Italian Red Cross were located at the hotel to
support these families. Medical needs were managed
by the Scandinavian physicians and by Italian
physicians from the University of Milan. Two days
after the disaster, the Scandinavian group of
bereaved relatives was accompanied to the location
of the disaster by the Italian Red Cross and the
National Fire Department.
Through its offices in Sweden, Denmark, Norway,
Finland, the USA and the UK, SAS has maintained
contact with the families through the Family
Assistance Support Team (FAST). The FAST
group continued to have an active, outreaching
approach towards the relatives through the first year.
After one year they were still available on initiatives
from the families. If necessary they assisted persons
in need of crisis counselling and psychotherapy to
get professional help. The Italian and Swedish
groups of relatives seem to have had fairly equal
access to support during the acute and intermediate
phase as regards medical, practical/social and psy-
chological needs. In the long-term phase the
Swedish population seem to have had a more active
psychological support from the air company organi-
zation. The SAS company agreed to support the
economic costs of professional individual crisis
therapy for the relatives who needed it. After one
year, on the anniversary of the disaster, SAS offered
the relatives (four members from each family) the
opportunity to go to Milan for a memorial service.
The company compensated for transportation,
board and lodging. Self-help groups were estab-
lished in both Italy and Scandinavia. On 17 October
2001, the committee ‘8 Ottobre Per Non
Dimenticare’ (‘Do not forget the 8th of October’)
was constituted. The committee supply legal and
economic advice and promote organization of
gatherings for its members. The City Council of
Milan supported the committee with an office and
with financial support. On 23 February 2002, a
Scandinavian association for relatives was founded,
‘Skandinavisk fo¨rening fo¨r SK 686 8 oktober 2001’
(Scandinavian Association for SK 686 October 8,
2001). The association arranges meetings for the
bereaved relatives and facilitates economic and legal
advice.
The aim of this study was to compare two groups
of bereaved relatives from Italy and Sweden, and to
Figure 1. The MD-87 aircraft from Scandinavian Airplane
System (SAS) crashed into a small private Cessna plane, ran into
a baggage handling hangar and exploded.
Figure 2. A total of 118 people were killed in the disaster at Linate
airport.
Table I. Victims of the Linate airplane disaster.
Country of origin Victims
Italy 56
Sweden 21
Denmark 17
Norway 4
Finland 4
UK 1
USA 1
SAS crew 6
Ground staff (Italy) 4
Crew Cessna (Germany) 2
Passengers Cessna (Italy) 2
Total 118
Bereavement following Linate aircraft disaster 111
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examine the role of psychosocial support and psy-
chological reactions 18 months after the traumatic
bereavement.
Materials and methods
Subjects and procedures
Italian and Swedish bereaved family members of
77 deceased victims of the Linate disaster were
approached by mail 18 months after the plane crash.
They had been informed of the study by the self-help
organizations. A total of 247 questionnaires were
distributed, 184 to Italian and 63 to Swedish close
relatives. All the data were collected anonymously.
Measures
Questionnaires and scales were translated into Italian
and Swedish. A special questionnaire was compiled
for the study. The aim was to cover the following
areas: socio-demographic background variables, pre-
and post-accident somatic and mental health (esti-
mated on a Likert scale 1–10, 10 being the best), the
need for different types of medical and psychosocial
support (acute and in the long-term phase), the use
of drugs (antidepressants, anxiolytics and sleeping
pills). A similar questionnaire was used after the
Estonia ferry disaster (1). The Impact of Event
Scale-Revised (IES-R) (2,3, T. Lundin personal
communication) is a widely used, valid and reliable
22-item scale measuring subjective distress caused by
intrusion, avoidance and hyperarousal, symptoms
that are common in post-traumatic stress disorder
(PTSD) according to DSM-IV. In this revised
version, subjects were asked to indicate on a scale
from 0 to 4 how disturbing symptoms were during
the previous 7 days. A cut-off score of 33 and above
on the combined subscales Intrusion +Avoidance
was chosen to indicate a significant post-traumatic
stress reaction. A score of 33 points indicates a score
that lies above a possible mean of 30 (maximum 60)
and reflects a considerable rated disturbance.
Statistics
SPSS for Windows, version 11.5 software (4) was
used to input and analyse the data. Non-parametric
methods were needed owing to skewed distributions
and heterogeneity of variance. x
2
test was used to
assess whether two or more samples each consisting
of frequency data differed significantly from each
other. Kruskal-Wallis test was used to compare three
or more samples with different subjects. For multi-
ple contrast using rank sums we utilized Dunn’s
test. The McNemar test measured significance of
changes. The relationship between variables was
assessed by means of Spearmans rank correlation
coefficient. We used Wilcoxon’s test for related
data to analyse whether the ranks in one group
are typically larger or smaller than the ranks in
the other group. The significance level was set at
pv0.05.
Results
The response rate was 62% for the total group, 56%
for the Italian group (n5103) and 84% for the
Swedish group (n550). The difference in response
rate was not statistically significant. The 153
responders had an average age of 45 years (mini-
mum 18, maximum 91). In the total group of
responders 65% were women; 58% in the Swedish
group and 68% in the Italian group. The difference
was not statistically significant.
In both investigated populations there was a
similar pattern of relationship with the deceased
person: 27.2% were spouses, 22.2% were children,
29.4% were parents and 20.9% were siblings.
Post-traumatic reactions
The findings of the analysis indicate that 53.2% of
the bereaved relatives were above the cut-off level –
58.7% of the Italian group and 42.6% of the
Swedish group – indicating a high level of post-
traumatic stress with strong symptoms of intrusion
and avoidance at the time of the follow-up.
Table II shows an overview regarding the means
of IES-R subscales at 18 months post-disaster. The
two populations had similar results in IES-R except
for in the IES subscale Hyperarousal.
In comparison of the median scores the tendency
is a lower median in the Swedish population
(Figures 3 and 4).
Table II. Mean values and standard deviations (SDs) of IES-R for Italian and Swedish bereaved relatives.
Subscale
Italy Sweden Total
pvalueMean SD Mean SD Mean SD
Intrusion 19.06 5.81 18.40 6.37 18.85 5.98 NS
Avoidance 14.81 7.51 14.19 7.68 14.6 7.55 NS
Hyperarousal 14.92 7.20 11.45 7.94 13.78 7.60 0.01
Intrusion +Avoidance 33.77 11.41 32.72 12.75 33.42 11.85 NS
Total Intrusion +Avoidance +Hyperarousal 48.78 17.35 44.13 19.62 47.23 18.20 NS
112 K. Bergh Johannesson et al.
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Post-traumatic reactions versus relationship, age and
gender
Parents and spouses had higher mean scores in IES-
R compared with children and siblings (pv0.05).
The differences are most of all explained within the
Italian population. Within the Swedish group there
were no differences between the groups of relatives.
Also, age affected the results within the Italian
group, especially in the subscales Intrusion and
Hyperarousal. Higher age was positively correlated
with higher scores. Male relatives in total had lower
scores in the subscales Avoidance and Hyperarousal
and the combined Intrusion +Avoidance
(Table III). The impact of gender influenced the
results more in the Italian group than in the Swedish
group. Italian men had lower mean scores in
Intrusion and Avoidance compared with Italian
women. Swedish men had lower levels of Intrusion
and Hyperarousal compared with Swedish women
18 months after the Linate plane crash.
Physical and mental health
The bereaved relatives indicated that their physical
and mental health was seriously affected during the
weeks after the accident compared to one year before
the accident (pv0.005) (Figure 5). The impact
remained at 18 months compared to 1 year before
(pv0.005).
There was a clear tendency in evaluating an
improvement of health at follow-up (pv0.05), even
if this did not mean a recovery to the originally
estimated level. The tendency was the same in both
groups.
Psychosocial support
There was a slight difference in the pattern as to how
the two populations had used the psychosocial
support organization (pv0.05). It was most com-
mon in both populations to use individual crisis
consultation for acute psychosocial support. The
Italian group indicated to a higher degree ‘no
contact’ or ‘telephone contact’. Within the Swedish
group it was somewhat more common to take part in
‘group session and major gatherings’. Besides the
organized acute support Italian bereaved relatives
were more likely than Swedes to indicate, ‘family/
friends or employer’ and ‘family doctor’ or ‘no
contact’ (pv0.05). The Swedish group indicated the
need for psychotherapy to a higher degree.
At the time of the investigation the need for
psychotherapy was more likely (pv0.05) to be
expressed by Swedish relatives (44.7%) compared
with Italian relatives (24.0 %). Italian relatives
indicated to a higher degree ‘no need for help’ and
‘other help’.
Long-term psychosocial support and post-traumatic stress
reactions
The need for treatment such as psychotherapy and
medication was found to be related to higher scores
on Avoidance and combined scores of Intrusion +
Avoidance, compared with need for help from
employer or family and friends.
Medication
During the acute phase it was more common for
Italian relatives to indicate the use of antidepressants
and tranquillizers (45%) compared with the Swedish
relatives (18.4%). At follow-up 18 months after the
disaster the difference still remained (pv0.05), even
if the use of medication in total had decreased
considerably (21% and 6.1%, respectively).
About half of the respondents had used medica-
tion for sleeping disturbances right after the disaster,
with a similarity between the two populations. The
need for medication for sleep decreased but it was
twice as common among Italian relatives (26%)
Figure 3. Nationality and IES-R median score for Intrusion +
Avoidance.
Figure 4. Nationality and IES-R median total scores.
Bereavement following Linate aircraft disaster 113
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compared with Swedish relatives (12.2%) to use
medication for sleeping problems at follow-up 18
months after the disaster.
Non-responders
In total there were 92 non-responders – 81 Italians
and 11 Swedes. Among Italian non-responders, 59%
were female, compared with 27% in the Swedish
group. In the male group 41% were Italian
compared with 73% in the Swedish group. Among
Italian non-responders, 28% were spouses, 14%
children, 33% parents and 25% siblings.
Discussion
Unexpected losses of close family members are
always traumatic (5). Losing a close relative follow-
ing a traumatic event is one of the most difficult
things a person can face and can increase the risk of
developing PTSD (6). It is especially difficult to lose
a child. Usually there is no possibility of mental
preparation for handling the loss. It has been shown
by many authors that people who experience a major
disaster and acute stress reactions continue to
experience stressful changes and have a significant
risk for later development of PTSD (7–12). It takes
years to process the traumatic grief after the loss of a
close family member (13), but a good social network
and adequate social support can facilitate the
processing (14). Other factors can contribute to
the ability to handle a loss, such as resilience and
other personal resources. Aeroplane accidents as a
rule affect people during active age, people in the
middle of their lives, many in the middle of their
careers, or in some other aspects with most of their
future in front of them. This can be a complicating
factor for the bereaved individual as regards proces-
sing the loss.
Both society and individuals have a responsibility
to support victims after major disasters. Major
catastrophes can also offer important opportunities
to examine the responses of individuals to a single
extreme, well-defined stressor (15). In particular,
major catastrophes present the opportunity to study
the interaction between features of the traumatic
event and the individuals in relation to the outcome
of the event (16). Psychological reactions following
airline disasters share many characteristics with
reactions following other disasters, both human
and natural. However, aircraft disasters and terrorist
attacks against airplane companies belong to the
most feared incidences in modern civilization
(17,18). The psychological impact is enormous.
Crew and passengers are almost always completely
helpless regarding the ability to avoid the disaster.
Studies concerning airplane disasters, such as those
at Lockerbie (19) and Faro (20), reported high
prevalence of PTSD in the years following the
disaster. Six months after the airplane disaster in
Bijlmermeer (21), 26% of the exposed responders
had signs of PTSD. The condition was strongly
correlated to loss and material damage. Kleber and
Brom (22) estimated that in general approximately
20–30% of the victims develop PTSD after a
disaster. After an airplane accident in Sweden (the
air traffic accident in Gottro¨ra in 1991), when an
SAS aircraft carried out an emergency landing in a
country field with 126 passengers, and all survived,
21% of the passengers still showed symptoms of a
post-traumatic stress disturbance 3 years after the
accident (23). Groups at high risk for later psycho-
pathology include the bereaved, the severely injured,
people with prior mental illness, low socioeconomic
status, or multiple sources of stress, the elderly,
children and adolescents, and those with limited or
no social support system (18,24). Green et al. (13)
found that loss of a household member was asso-
ciated with major depression 18–26 months post-
disaster and continued to predict major depression
Table III. Mean values and standard deviations (SDs) in IES-R, for women, men and the total group.
Subscale
Women Men Total
pvalueMean SD Mean SD Mean SD
Intrusion 20.2 5.7 16.75 5.95 18.85 5.98 0.05
Avoidance 15.91 7.39 12.29 7.33 14.6 7.55 0.05
Hyperarousal 15.14 7.40 11.31 7.41 13.78 7.60 0.05
Intrusion +Avoidance 36.05 11.18 28.88 11.69 33.42 11.85 0.05
Intrusion +Avoidance +Hyperarousal 51.25 17.04 40.16 18.13 47.23 18.20 0.05
Figure 5. Subjective evaluation of health before and weeks after
the disaster (in retrospect) and 18 months after the disaster.
114 K. Bergh Johannesson et al.
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14 years post-disaster. In a longitudinal study of
widows, Vachon et al. (14) reported that among
mediating influences, social support was the
most important factor in explaining 1 month post
bereavement distress.
People involved in major accidents or disasters
will have significant emotional, practical and social
needs, especially if there is a loss of a close family
member or friend. One of these needs can be to visit
the site of the event or see the body of the beloved
one as a way to make the unreal become more real
(23,25). Helping organizations and helpers must,
especially in the immediate aftermath, anticipate
these needs and offer a pro-active response towards
the victims. Early intervention for trauma should be
designed to increase social support (26). The need
for information is often a dominant and fundamental
urge. In these circumstances a combination of
various interventions, support and counselling are
required. Effects of early intervention have been
discussed. Chemtob et al. (27) found that psycho-
logical debriefing decreased the signs of post-
traumatic stress 6 months after a natural disaster.
Several authors claim that availability of positive
social support and the inclination to use it facilitates
an individual’s recovery (26).
In this study we found a strong impact of the
bereavement, reflected in high scores in IES-R and
in the subjective evaluation of how health was
affected in the two populations, who otherwise were
similar in age and in relationship to the deceased
person. There was a tendency for somewhat lower
IES scores in the Swedish group. This tendency of
somewhat lower IES scores in the Swedish popula-
tion might tentatively be influenced by the access
to psychotherapy. Professional psychotherapy can
possibly help people to deal with traumatic loss more
actively, while medication offers symptom reduction
but not trauma processing in itself.
Not surprisingly, we found that spouses and
parents were the groups that scored highest on
IES-R subscales when comparing different groups of
relatives. This could possibly reflect the patterns of
attachment – those of spouses and of parents toward
children being strongest. Also here the tendency was
stronger in the Italian population with a greater
homogeneity within the Swedish population.
Possibly the difference also can reflect the fact that
the Swedish group had a greater access to psycho-
social support and psychotherapy during the first
year, while in Italy this type of support was more
rare. Another finding was that male gender scored
lower on the IES scale, both on the Intrusion and
Avoidance scale, and with a similar pattern in both
populations. The percentage of women was higher in
the Italian group than in the Swedish group, which
also might explain the national difference. From
other studies it has been shown that PTSD
symptoms are more common among women, which
partly seems to be confirmed by the IES scores in
this study.
Regarding subjective evaluation of health we
found a similar pattern in both groups in the acute
phase and also a similar pattern of some recovery in
both populations, even if it did not return to the
original level. However, it is important to underline
that this is a subjective retrospective evaluation.
Nevertheless, the pattern was very similar to that
among relatives measured 13 months after the
Estonia disaster. Holbrook et al. (28) reported
similar findings of patients sustaining major physical
injuries assessing their quality of life 18 months post
trauma; 80% of these patients continued to have
scores below a healthy norm. The findings might
indicate that a physical injury could affect general
well-being in a somewhat similar way as after loss of
a loved one.
The groups had used similar types of help in the
acute phase. In the long-term phase the two
populations differed when compared regarding the
type of support. It was much more common for
relatives in the Swedish group to ask for psychother-
apy compared with the Italian relatives. There was
no relationship between type of acute support and
stress symptoms at 18 months follow-up, which
perhaps cannot be expected regarding the character
of the trauma. This can in some way confirm the
statement of Shalev (29) that single-session inter-
ventions are unlikely to make substantial differences
in long-term adjustment. Traumatic loss takes time
to realize and become reality and accordingly grief
takes a long time to process. Single acute interven-
tions may be necessary but are seldom enough.
Within the Italian population it was more com-
mon to use medication for both anxiety and
depressive disorders as well as for sleeping problems,
a pattern that was similar both in the acute phase
and 18 months later. This might reflect a difference
in both cultural attitude and tradition between Italy
and Sweden regarding how individuals deal with
traumatic loss and how they ask for and give support
after disasters. In contrast to Italy, Sweden has for
many years developed a public organization for
psychosocial disaster support. In Sweden there
might also be a more developed system for access
to professional psychotherapy in the long-term
phase. In this case the SAS company’s family
support organization offered the possibility for active
follow-up during the first year for the Scandinavian
relatives and economically supported crisis therapy.
In Italy it might be more common to rely on support
from family, friends and family doctors.
The data indicate severe post-trauma symptoms in
both groups, with a higher proportion than has been
reported in earlier studies. One possible explanation
might be that all investigated subjects in this study
were bereaved close relatives, a group that is not
investigated so often. Processing traumatic loss might
Bereavement following Linate aircraft disaster 115
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be more difficult and takes a longer time than other
traumatic experiences. Another explanation could be
that in this study we used the revised version of the
IES-R, with measurement of the amount of distress
regarding PTSD symptoms, unlike the earlier ver-
sion, which measured the frequency of distress.
The response rate was far higher within the
Swedish population than within the Italian popula-
tion, which is similar to experiences from other
research projects. High response rates might reflect a
national character trait in Sweden. However, it can
also mean a limitation in comparing the two
populations, with a higher percentage of women
within the Italian group who did not respond.
It is fairly unique to be able to compare two
populations from different cultural backgrounds,
which is a strength of this study. Methodologically,
retrospective questions are always a weakness in a
study, which means that caution is necessary in
interpreting some of the results. Also, the very fact of
differences in cultural backgrounds can explain some
of the differences that were found in the study.
Another limitation is that no particular grief or
depression scale was used, which possibly could have
differentiated somewhat more between response
patterns.
Conclusions
Three conclusions can be drawn from this study.
First, traumatic losses deeply affect bereaved rela-
tives. Health is affected and a large group develop
strong symptoms of post-traumatic stress. Second,
Swedish bereaved relatives seem to be more apt to
ask for professional help, e.g. psychotherapy, while
in Italy it is more common to rely on family, friends
and medication. Third, acute organized psychosocial
support in the aftermath of a disaster can possibly
facilitate victims in their handling of a traumatic loss
but it does not prevent the development of strong
post-traumatic reactions. Future investigations may
show how it is possible to optimize the help with
more specific interventions of support and treat-
ment.
Acknowledgements
Special thanks to the Swedish National Board of
Health and Welfare and the National Center for
Disaster Psychiatry, University of Uppsala, for
providing the opportunity to carry out this study.
We thank Dr Lennart Jansson, University of Uppsala,
and Dr Per-Olof Michel, National Center for Disaster
Psychiatry, for valuable comments. We also wish to
thank Prof. Paolo Moderato, University of Parma, Dr
Paolo Pettinaroli, President of the Italian Committee
‘8 Ottobre Per Non Dimenticare’ and Mrs Annette
Forsman, President of the Swedish Committee
‘Skandinavisk fo¨rening fo¨r SK686’. The study was
approved by the Uppsala University Hospital Ethics
Committee. Participation was voluntary.
References
1. Bergh Johannesson K. Arbete vid Uppsalas Kriscentrum.
[Psychosocial support at the Uppsala Crisis Center.]
Lakartidningen. 1997;94:1198–202 (in Swedish).
2. Weiss DS. The Impact of Event Scale-Revised. In: Wilson JP,
Keane TM, editors. Assessing psychological trauma and
PTSD. 2nd edn, New York: Guilford Press, 2004: 168–89.
3. Weiss DS, Marmar CR. The Impact of Event Scale-Revised.
In: Wilson JP, Keane TM, editors. Assessing psychological
trauma and PTSD. New York: Guilford Press, 1997: 399–411.
4. Howitt D, Cramer D. A guide to computing statistics with
SPSS for Windows. Dorset: Prentice Hall, 2001.
5. Lundin T. Traumatic grief and its relation to PTSD.
Psychiatry. 2004;1:2–4.
6. Breslau N. Oral presentation at the International Society
for Traumatic Stress Studies (ISTSS) Meeting, Toronto,
November 2005.
7. Koopman C, Classen C, Spiegel D. Multiple stressors
following a disaster and dissociative symptoms. In:
Ursano RJ, Fullerton CS, editors. Posttraumatic stress
disorder. Washington: American Psychiatric Press, 1997.
8. Marmar CR, Weiss DS, Metzler T. Peri traumatic dissocia-
tion and posttraumatic stress disorder. In: Marmar CR,
Bremner JD, editors. Trauma, memory, and dissociation.
Washington: American Psychiatric Press, 1998.
9. Shalev AY, Freedman S, Peri T, Brandes D, Sahar T, Orr SP,
et al. Prospective study of posttraumatic stress disorder and
depression following trauma. Am J Psychiatry. 1998;155:
630–7.
10. Fullerton SC, Ursano RJ, Kao T, Bharitya VR. Disaster-
related bereavement: acute symptoms and subsequent
depression. Aviat Space Environ Med. 1999;70:902–9.
11. North CS, Kawasaki A, Spitznagel EL, Hong BA. The course
of PTSD, major depression, substance abuse and somatiza-
tion after a natural disaster. J Nerv Ment Dis. 2004;192:
823–9.
12. Bryant RA. Predicting posttraumatic stress disorder from
acute reactions. J Trauma Dissociation. 2005;6:5–15.
13. Green BL, Lindy JD, Grace MC, Gleser GC, Leonard AC,
Korol M, et al. Buffalo Creek survivors in the second decade:
stability of stress symptoms. Am J Orthopsychiatry. 1990;60:
43–54.
14. Vachon M, Rogers J, Lyall WA, Lancee WJ, Sheldon AR,
Freeman SJ. Predictors and correlates of adaptation to
conjugal bereavement. Am J Psychiatry. 1982;139:998–1002.
15. Hull AM, Alexander DA, Klein S. Survivors of the Piper
Alpha oil platform disaster: long-term follow-up study. Br J
Psychiatry. 2002;181:433–8.
16. Alexander DA. Psychiatric intervention after the Piper Alpha.
J R Soc Med. 1991;84:8–11.
17. Butcher JN, Dunn LA. Human responses and treatment
needs in airline disasters. In: Gist R, Lubin B, editors.
Psychosocial aspects of disaster., Oxford: John Wiley & Sons
1982;86–119.
18. Gerson BPR, Carlier IVE. Plane crash crisis intervention: a
preliminary report from the Bijlmermeer, Amsterdam. Journal
of Crisis Intervention and Suicide Prevention. 1993;14:109–16.
19. Brooks N, McKinlay W. Mental health consequences of the
Lockerbie disaster. J Trauma Stress. 1992;5:527–43.
20. van Duin MJ, Overdijk WIE, Wijkhuis LJJ. De Faro-ramp:
overlevendenden en nabestaanden aan het woord. [The Faro
crash: inquiry among survivors and relatives.] Interim report,
The Hague, Crisis Research Team, 1998.
21. Carlier IVE, Gersons BPR. Stress reactions in disaster victims
following the Bijlmermeer plane crash. J Trauma Stress.
1997;10:329–35.
116 K. Bergh Johannesson et al.
Downloaded By: [Uppsala University Library] At: 16:29 25 September 2007
22. Kleber RJ, Brom D. Coping with trauma: theory, prevention
and treatment. Amsterdam: Swet & Zeitlinger, 1992.
23. Michel PO, Lundin T, Otto U. Psykotraumatologi. [Psycho-
traumatology.] Lund: Studentlitteratur 2001;112–43 (in
Swedish).
24. Brewin CR, Andrews B, Valentine JD. Meta-analysis of
risk factors for post-traumatic stress disorders in trauma-
exposed adults. J Consult Clin Psychol. 2000;66:748–66.
25. Seynaeve GJR. European Policy Paper concerning different
aspect of psycho-social support for people involved in major
accidents and disaster. Psycho-Social Support in Situation of
Mass Emergency, Brussels, 2001.
26. Litz BT, Gray MJ, Bryant RA, Adler AB. Early interventions
for trauma: current status and future directions. American
Psychological Association, Clinical Psychology: Science and
Practice. 2002;9:112–34.
27. Chemtob CM, Thomas S, Law W, Cremniter D. Post
disaster psychosocial intervention: a field study of the impact
of debriefing on psychological distress. Am J Psychiatry.
1997;154:415–17.
28. Holbrook TL, Anderson JP, Sieber WJ, Browner D, Hoyt DB.
Outcome after major trauma: 12 month and 18 month follow-
up results from the Trauma Recovery Project. J Trauma.
1999;46:765–73.
29. Shalev AY. Stress management and debriefing: historical
concepts and present patterns. In: Raphael B, Wilson JP,
editors. Psychological debriefing. Cambridge: Cambridge
University Press 2000;17–31.
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