Posttraumatic stress disorder: a serious post-earthquake complication

Earthquakes are unpredictable and devastating natural disasters. They can cause massive destruction and loss of life and survivors may suffer psychological symptoms of severe intensity. Our goal in this article is to review studies published in the last 20 years to compile what is known about posttraumatic stress disorder (PTSD) occurring after earthquakes. The review also describes other psychiatric complications that can be associated with earthquakes, to provide readers with better overall understanding, and discusses several sociodemographic factors that can be associated with post-earthquake PTSD

Method

A search for literature was conducted on major databases such as MEDLINE, PubMed, EMBASE, and PsycINFO and in neurology and psychiatry journals, and many other medical journals. Terms used for electronic searches included, but were not limited to, posttraumatic stress disorder (PTSD), posttraumatic symptoms, anxiety, depression, major depressive disorder, earthquake, and natural disaster. The relevant information was then utilized to determine the relationships between earthquakes and posttraumatic stress symptoms.

Results

It was found that PTSD is the most commonly occurring mental health condition among earthquake survivors. Major depressive disorder, generalized anxiety disorder, obsessive compulsive disorder, social phobia, and specific phobias were also listed.

Conclusion

The PTSD prevalence rate varied widely. It was dependent on multiple risk factors in target populations and also on the interval of time that had elapsed between the exposure to the deadly incident and measurement. Females seemed to be the most widely-affected group, while elderly people and young children exhibit considerable psychosocial impact.

Earthquake; posttraumatic stress disorder; mental health; major depressive disorder; anxiety; prevalence; risk factors

Author and year of publication	Country	Study design	Population	Sample size	Main findings
Dai et al., 2016⁷²	China	Meta-analysis of 46 studies		76,101	Using a random effects model, the combined incidence of PTSD after earthquakes was 23.66 %. The incidence of PTSD varied significantly across studies in relation to the time of assessment, gender, educational level, damage to one’s house, bereavement, bodily injury, and witnessing death.
Liu et al., 2016⁷³	Tibet	Cross-sectional	PTSD and its predictors among 4,072 Tibetan adolescents 3 years after the earthquake.	4,072	PTSD prevalence was 17.8%. Factors predictive of PTSD were age 14 or over, being a senior student, monitor, buried or injured, death or amputation of family member, more severe property loss, witnessing death, and having negative coping skills
Rahill et al., 2015⁷⁴	Haiti	Cross- sectional	2 groups of 16 women	16	This study included a small sample of women in Haiti who had suffered sexual violence perpetrated by non-intimate partners/strangers (NPSV). The psychological effects of NPSV included self-reported PTSD criteria, including physiological, neurological and psychological symptoms, avoidance, arousal, cognitive and mood changes, as well as significant distress/impairment in various areas of functioning.
Bianchini et al., 2015⁷⁵	L’Aquila (Italy)	Cross-sectional	College students two years after the 2009 L’Aquila earthquake, assessing coping strategies including posttraumatic growth and substance abuse	411	The posttraumatic growth (PTG) mean score was 35.23, underlining low positive coping strategies among student community. 43.8% of students reported an increase in alcohol use, 7.8% in cannabis and 15.8% in nicotine use in the post-earthquake period. However, 12.5 % of the students reported a decrease in alcohol use after the earthquake and 17.3% reported a PTG, showing positive behaviors and attitudes.
Cofini et al., 2015⁷⁶	L’Aquila (Italy)	Cross-sectional	Sample of 281 people aged >18 years and living in temporary housing after the earthquake	281	People living in temporary housing after the earthquake experienced high rates of PTSD. Prevalence of PTSD was 43%. Women and the non-employed were more vulnerable to PTSD, while, age and level of education were not associated with PTSD. People with PTSD exhibited denial, venting, behavioral disengagement and self-blame as coping strategies.
Shrestha, 2015⁷⁷	Nepal	Cross-sectional	Medical professionals at Manmohan Memorial Teaching Hospital (Kathmandu)	64	Prevalence rates of PTSD were 21.9% and 17.1% (using different cutoff score and diagnostic criteria) Females > males. No significant difference was observed according to age, marital status, profession, previous disaster experience, or tragic events with relatives.
Cénat & Derivois, 2014²⁴	France	Cross-sectional study	30 months after the 2010 earthquake disaster in Haiti, 1,355 participants, adults, aged 18 or over with no prior psychiatric illness, were enrolled on this study. All assessment variables were measured using a self-administered questionnaire.	1,355	The results of this French study showed prevalence rates of 36.75% of PTSD symptoms and 25.98% of depression 2.5 years after the disastrous earthquake affecting the capital and other cities across the country. Female gender, being young or a student, elderly, and unemployment were found to be risk factors for PTSD and Depression. Participants with a low level of education were shown to have the highest prevalence of depression. There were also significant links between peritraumatic distress and subsequent development of PTSD and depression.
Yokoyama et al., 2014³⁹	Japan	Cross-sectional survey	The survey was carried out in 3 municipalities of the northern part Honshu, Japan. 10,025 participants aged 18 or older were included and assessed with a health survey and a questionnaire.	10,025	In this Japanese study, 42.6% of survivors were determined to have MMHPs or SMHPs. In addition, many risk factors associated with mental health problems were determined: Female gender, younger age group, and frequency of relocation were of greatest significance. The study also emphasized the creation of permanent jobs and measures to attract firms to invest and establish plants in devastated areas as support for victims seeking new employment.
Feder et al., 2013¹¹	United States	Cross-sectional survey	200 adult earthquake survivors from affected areas of North-western Pakistan were recruited in this study and all variables of interest were completed by a self-administered questionnaire.	200	This study conducted by the Mount Sinai School of Medicine three years after the 2005 earthquake in Pakistan concluded that 64.6% of participants met criteria of probable PTSD three years after the deadly disaster. Female gender, lower education, loss of close family members, and negative religious coping were found to be associated with higher posttraumatic symptom levels. On the other hand, higher purpose in life was found to be associated with lower symptom levels and higher self-reported positive emotions.
Anwar et al., 2013²¹	Australia, WHO	Cross-sectional survey	Women aged 15 to 49 years and married at the time of survey, and who experienced and lived through the earthquake	425	This WHO study carried by the University of Sydney reported multiple sociodemographic and reproductive health factors as predictors of PTSD in women after the 2005 earthquake in Pakistan. In the conservative sociocultural context of Pakistan, social support was found to be one of the most important predictors of PTSD. Use of temporary accommodation, previous complications with pregnancies, abnormal vaginal discharge, use of injectable contraceptives, knowledge about STDs, and difficult access to health facilities were other significant risk factors for PTSD.
Zhou et al., 2013³⁸	China	Cross-sectional study	Age and Sex matched random sample of 10% of the respondents was chosen. Data was collected 6 months after the disaster.	14,207	The study reported prevalence of 15.57% of PTSD among survivors of earthquake. It identified several risk factors for PTSD: older age, female gender, living alone, being buried in the earthquake, injured in the earthquake, operated on after the earthquake, witnessing someone get injured in the earthquake, witnessing someone get buried in the earthquake, witnessing someone die in the earthquake. The study was unable to draw any relationship between the level of education and PTSD.
Ȫnder et al., 2006²⁸	Turkey	Cross-sectional survey	36 months after the 1999 Marmara earthquake in Turkey, 683 participants aged 18 or over were randomly selected from seven municipalities of Kocaeli City to be assessed by a face to face household interview survey called Marmara Earthquake Survey (MES).	683	This study showed that the 3-year period prevalence rates of PTSD and MDD were 19.2% and 18.7% respectively while the current point prevalence rates were 11.7% and 10.5% respectively. The prevalence of panic disorder, OCD, GAD, social phobias, and specific phobias were also found to be at least two times greater than the pre-earthquake national prevalence rates of these disorders. The study also found that psychological distress was significantly greater in the comorbid PTSD and MDD group than in the group with PTSD alone.
Sharan et al., 1996⁵⁵	India	Cross-sectional survey	56 participants aged 14 or older from 23 households in three villages in western India were interviewed.	56	The study reported a rate of 59% of psychiatric disorder post-earthquake in a rural community in India. Of these, PTSD (23%) and major depression (21%) were the most frequent disorders. Destruction of house and possessions and stress of losses and relocation were found to have acted as life-threatening risk factors.

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[1] Correspondence: Sajid S. Suriya. California Institute of Neurosciences (CIN). 2100 Lynn Road, Suite 120. Thousand Oaks, CA 91306. Tel.: +1 (805) 428-9688. Fax: +1 (805) 617-1743. Email: sajid.suriya@gmail.com