Prevalence of Posttraumatic Stress Disorder and Associated Psychiatric Disorders in Earthquake Victims After the Elazig Earthquake in 2020

doi:10.21203/rs.3.rs-4837861/v1

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Prevalence of Posttraumatic Stress Disorder and Associated Psychiatric Disorders in Earthquake Victims After the Elazig Earthquake in 2020

https://doi.org/10.21203/rs.3.rs-4837861/v1

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Objective:This study investigated the prevalence of PTSD and accompanying mental illnesses in Elazig Earthquake survivors, aiming to identify risk factors for PTSD and the prevalence of depression and anxiety.

Method:The sample comprised 320 earthquake survivors aged 18 and above who experienced the earthquake. The participants completed a sociodemographic data form, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Clinician-Administered PTSD Scale (CAPS), and Traumatic Experiences Checklist (TEC).

Results:The study found that the prevalence of PTSD among earthquake victims was 13.1%. Additionally, 24.37% of participants experienced moderate to severe depression, while 25.32% had moderate to severe anxiety.

Conclusion:Identifying potential risk factors for mental illness development after an earthquake and providing targeted psychiatric support to at-risk individuals can help prevent the onset of PTSD and other psychiatric disorders.

Psychiatry

Earthquake

Posttraumatic Stress

Anxiety

Depression

A disaster is an occurrence that disrupt the normal conditions of existence, occurs unexpectedly, has negative social and economic effects, cannot be prevented, and is beyond the coping capacity of the exposed society. Around one million earthquakes occur in the world every year, and some of them cause great loss of life and property. Turkey is located in the Alpine-Himalayan Earthquake Belt, which is one of the most active seismic belts. The geological structure of Turkey is also prone to earthquakes, more than 90% of which is a risky area in terms of earthquakes (Ergünay, 2007). Earthquakes that cause loss of life and property occur approximately every two years in Turkey. On 24.01.2020, an earthquake with a magnitude of 6.8 occurred, the epicenter of which was the Sivrice district of Elazig. After this earthquake, which lasted for about 20 seconds, there were more than 900 aftershocks, the largest of which was 5.1 magnitude, for 3 days (Peker and Şanlı, 2022). 41 people died and thousands of buildings were damaged in the earthquake.

Although the history of disasters is as old as the history of humanity, the evaluation of their psychiatric effects is quite new. Drawing attention to post-disaster psychiatric help entered the agenda of the World Health Organization (WHO) after 1995 (Yehuda et al., 2015). Studies have shown that the lifetime prevalence of exposure to natural disasters is 22% and the most common is earthquake with 8% (Briere and Elliott, 2000). Post-disaster studies have reported that the most common mental illness is posttraumatic stress disorder (PTSD). PTSD is followed by depression and anxiety disorders, respectively (Fergusson et al., 2014).

PTSD is a mental disorder that occurs after exposure to traumatic events. PTSD is characterized by flashback-like dissociation reactions, efforts to avoid traumatic thoughts, and feelings, persistent negative cognition, sleep disorders, and symptoms of overstimulation. PTSD occurs in approximately 5–10% of the population (Yehuda et al., 2015).

The prevalence of PTSD and other accompanying mental illnesses in 320 earthquake victims were investigated in this study. Since the most common accompanying psychiatric disorders in the literature review are generalized anxiety disorder (GAD) and major depressive disorder (MDD), these two psychiatric diagnoses were emphasized. It is also aimed to examine the risk factors that facilitate the development of PTSD.

Participants

Our sample consists of 320 earthquake victims. After the participants were informed about the content and their written consent was obtained; socio-demographic data form, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Clinician-Administered PTSD Scale (CAPS) and Traumatic Experiences Checklist (TEC) were applied (Beck et al., 1961; Beck et al., 1988; Blake et al., 1995; Nijenhuis et al., 2002). The scales were filled in by face-to-face interviews with earthquake victims in psychosocial support units in the prefabricated campus.

Statistical Analysis

Data was evaluated by using the Statistical Package for the Social Sciences (SPSS) version 21.0. Chi-square test was used to compare categorical variables. The conformity of continuous variables to the assumption of normal distribution was evaluated with the Shapiro Wilk test, and since the data were not normally distributed, the Mann-Whitney U test was used to compare continuous variables between two independent groups, and the Kruskal Wallis test was used to compare between more than two independent groups. Dunn-Bonferroni post hoc test was performed for assessing whether multiple pairs of samples are significantly different from each other after the Kruskal Wallis test. In statistical analyses, p < 0.05 was accepted as significance level.

The study was carried out with the participation of 320 earthquake victims, of which 176 (55.0%) were female. The mean age of the participants was 36.08 ± 13.79 (min = 18, max = 86, median = 35). The sociodemographic characteristics of the participants are summarized in Table 1.

Table 1

The sociodemographic characteristics of the earthquake victims
		n	%
Gender	Female	176	55.0
Gender	Male	144	45.0
Marital status	Single	133	41.6
	Married	174	54.4
	Widow	8	2.5
	Divorced	5	1.5
Educational status	Illiterate	19	5.9
	Literate	8	2.5
	Primary school	33	10.3
	Middle school	25	7.8
	High school	77	24.1
	University	158	49.4
Residential area	Village	29	9.1
	Town	14	4.4
	City	277	86.7
Economical status	Low income	78	24.4
	Moderate income	225	70.3
	High income	17	5.3
Occupation	Student	89	27.8
	Officer	72	22.5
	Housewife	64	20.0
	Private sector employee	32	10.0
	Worker	28	8.8
	Unemployed	19	5.9
	Retired	16	5.0

25.6% (n = 82) of the participants smoke and 5% (n = 16) consume alcoholic beverages. 21.9% (n = 70) of the participants have an organic disease. While 16.6% (n = 53) of the participants had a history of psychiatric disorder in the past, 16.9% (n = 54) had a family history of psychiatric disorder. The doses of drugs were increased in 5,9% (n = 19) of the earthquake victims who were using drugs.

The relationship between PTSD and demographic characteristics is given in Table 2. BDI scores of earthquake victims who used alcohol were significantly higher than those who did not use alcohol (p = 0.03). Both BDI and BAI scores of earthquake victims with organic disease were significantly higher than those without organic disease (respectively p = 0.005, p < 0.001). Both BDI and BAI scores of earthquake victims with a previous suicide attempt were significantly higher (respectively p = 0.007, p = 0.03). PTSD development was significantly higher in those with a previous history of psychiatric disorder and those with a family history of psychiatric disorder (respectively x² = 9.840, p = 0.002; x² = 6.830, p = 0.009).

Table 2

The relationship between PTSD and demographic characteristics
	Post Traumatic Stress Disorder
Değişkenler	Yes		None
Değişkenler	n	%	n	%	x²	p
Gender					0.090	0.765
Female	24	13.6	152	86.4
Male	18	12.5	126	87.5
Marital status					3.765	0.052
Married	17	9.8	157	90.2
Non-married	25	17.1	121	82.9
Educational status					2.680	0.444
Illiterate	1	5.3	18	94.7
Primary and middle school	12	18.2	54	81.8
High school	9	11.7	68	88.3
University	20	12.7	138	87.3
Residential area					0.098	0.755
Village and town	5	11.6	38	88.4
City	37	13.4	240	86.6
Economical status					2.926	0.232
Low income	12	15.4	66	84.6
Moderate income	30	13.3	195	86.7
High income	0	0	17	100.0
Occupation					7.011	0.030
Officer	3	4.2	69	95.8
Private sector employee / worker	11	18.3	49	81.7
Unemployed	28	14.9	160	85.1

The incidence of PTSD was found to be significantly higher in those who or their relatives were buried in the earthquake and those who lost their relatives in the earthquake (p < 0.001). The incidence of PTSD was also significantly higher in those who witnessed the injury or death of someone in the earthquake (p = 0.01). The BDI scores were significantly higher in those who were under the rubble in the earthquake (p = 0.001), those whose relatives or neighbors were under the rubble (p = 0.043), who witnessed someone die or injured during the earthquake (p = 0.001), and who had lost a relative in the earthquake (p = 0.001). It was observed that the incidence of PTSD was significantly higher in those who had financial loss after the earthquake (p = 0.005), those whose houses were damaged (p = 0.005), those who could not receive social (p = 0.029) and psychological (p = 0.037) support, and those who had a traumatic experience related to the earthquake.

BDI scores were found to be significantly higher in those who had financial loss after the earthquake (p = 0.024), those who stayed in a prefabricated settlement (p = 0.010), those who benefited from social support (p = 0.006), and those who had a traumatic experience related to the earthquake (p < 0.001). BAI scores were found to be significantly higher in those who received psychological support after the earthquake (p < 0.006) and those who had a traumatic experience related to the earthquake (p < 0.001). BDI scores were found to be significantly higher in non-married (p = 0.008), low-income (p < 0.001), and unemployed earthquake victims (p < 0.001). BAI scores were significantly higher in women (p < 0.001), those with low economic status (p = 0.030), and unemployed earthquake victims (p < 0.001).

The relationship between the presence of PTSD and BDI, BAI, CAPS scores, and the number of non-earthquake traumatic experiences are given in Table 3.

Table 3

The relationship between the presence of PTSD and BDI, BAI, CAPS scores, and the number of non-earthquake traumatic experiences
	PTSD		p
	Yes Median (1st Quarter − 3rd Quarter)	None Median (1st Quarter − 3rd Quarter)
BDI score	21 (15–27)	9 (3–14)	< 0.001
BAI score	18 (10–27)	6 (3–13)	< 0.001
CAPS score	39 (32–50)	9 (3–15)	< 0.001
The number of non-earthquake traumatic experiences	1 (0–2)	0 (0–1)	0.056
PTSD: Post Traumatic Stress Disorder, BDI: Beck Depression Inventory, BAI: Beck Anxiety Inventory, CAPS: Clinician-Administered PTSD Scale

The study was carried out with the participation of 320 earthquake victims. The number of earthquake victims developing PTSD is 42 (13.1%). 1.5 years after the Düzce earthquake, 430 earthquake victims were interviewed and 41.9% PTSD and 28.4% GAD were observed (Kılıç and Ulusoy; 2003). It is possible to detect higher PTSD rates in earthquakes that cause great loss of life and property, such as the Düzce earthquake. In a study conducted on 1498 earthquake victims 9 months after the Van earthquake, PTSD was found to be 35.5% (Boztas et al., 2019).

The prevalence of PTSD differed significantly among occupational groups. The worsening of the economic situation in these groups and the fact that problems such as job loss after the earthquake may play a role in the development of this situation. In a study conducted with 1498 people after the Van earthquake, the prevalence of PTSD and related risk factors were tried to be determined. In the results of the study, being diagnosed with MDD, being unemployed, and having a low-income level were considered risk factors for the development of PTSD (Boztas et al., 2019). Although the relationship between gender and marital status variables and the development of PTSD does not always show a consistent relationship in the literature, some studies have shown that female gender and being married carry a higher risk. In a study conducted on university students after the Düzce earthquake, it was determined that being a woman carries a higher risk of perceiving trauma as severe (Baloğlu et al., 2005). In our study, we found that there was no statistically significant effect of gender and marital status on the development of PTSD.

Having a previous psychiatric diagnosis is a facilitating factor for both depression and PTSD. In fact, some studies have evaluated previous psychiatric diagnosis as a risk factor (Breslau et al., 1999). Increasing the dose of psychiatric drugs may be preferred as a way of coping with newly developing mental problems in individuals with a current psychiatric diagnosis or in individuals who use drugs without a diagnosis after the earthquake. The fact that the depression and anxiety scale scores were high in the same group is a finding that supports our interpretation. Having a family history of psychiatric disorder alone is a risk factor for a person to have a mental illness. In this context, the results of our study are compatible with the literature.

The prevalence of PTSD and depression was found to be higher in those who or their relatives were crushed in the earthquake and those who lost their relatives in the earthquake. In a study conducted on 320 high school students after the Van earthquake, CAPS scores were higher in those who were buried under debris and those who lost their relatives (Ediz and Gülbahçe, 2019). It has been shown in many studies that the loss of a loved one after an earthquake facilitates the development of PTSD (Livanou et al., 2002). A highly significant correlation was found between witnessing someone's death or injury in an earthquake and the development of PTSD. In a study examining the leading factors for the development of PTSD after 10 disasters at different times, witnessing someone's death or injury after the disaster was accepted as a factor that facilitates the development of PTSD (North et al., 2012).

The BDI score was found to be significantly higher in those who are unmarried, have a low economic level, are unemployed, use alcohol, have comorbidities, have attempted suicide, have a previous psychiatric diagnosis, have a history of psychiatric disorder in the family, have been crushed by the earthquake, and have lost a relative in the earthquake. We found that 20.31% of the earthquake victims in our sample had moderate depression and 4.06% had severe depression. Three years after the Marmara earthquake, in a study conducted with 769 participants, the prevalence of PTSD and MDD was reported as 40% and 18%, respectively. In a study conducted with the participation of 1355 people after the Haiti earthquake, the prevalence of PTSD and MDD was reported as 36.7% and 25.9%, respectively (Cenat and Derivois, 2014). In a study conducted after the Gölcük earthquake, data similar to our findings were obtained. It was concluded that the depression scores of the unemployed participants were significantly higher than the scores of the officer participants. Again, in the same study, it was observed that the depression levels of the participants with low income level were significantly higher than the participants with moderate income level (Baytar, 2017). It can be thought that individuals with limited financial means both have more losses during the earthquake and have poor social opportunities after the earthquake, increasing the traumatic effect of the event. In many studies, it has been determined that the risk of developing MDD is lower in married individuals than in single individuals (Işık et al., 2013). The relationship between demographic variables and depression is consistent with the literature.

The fact that an individual has experienced a mental disorder before the traumatic event has been shown in some studies in the literature as a risk factor for PTSD and MDD (Breslau et al., 1999). In our study, the BDI score was significantly higher in those who had financial loss after the earthquake and those who had severe damage to their home after the earthquake. In a study conducted with 1060 people one year after the Marmara earthquake, it was shown that the development of PTSD in earthquake victims is closely related to factors such as damage at home and loss of relatives (Başoğlu et al., 2004). The BDI score was found to be significantly higher in those who stayed in the prefabricated settlement after the earthquake, those who benefited from social support, and those who had a traumatic experience related to the earthquake. Stress factors such as staying in a narrow area and away from the city center, being away from family and usual social environment may have paved the way for the development of depressive symptoms. Although the importance of social support is overemphasized, studies have had difficulties in defining this concept functionally, and therefore social support has not always been seen as a reliable predictor for PTSD and depression (Başoğlu et al., 2004). In our study, it can be thought that individuals who do not need social and psychiatric support are less exposed to the negative effects of the earthquake and therefore seek less support. Again, since 70.3% (n = 225) of the individuals included in the study have a moderate economic level, it can be thought that the need for social support is less.

Moderate GAD was detected in 15.94% of the participants in our study group, and severe GAD in 9.38%. BAI scores were found to be significantly higher in patients with comorbidities, suicide attempts, previous psychiatric diagnoses and family psychiatric diagnoses, those who received psychological support after the earthquake, and those who had a traumatic experience related to the earthquake. In the study carried out with 198 participants 14 months after the earthquake in Nepal, 20% of the earthquake victims had significant anxiety symptoms (Thapa et al., 2018). In a study conducted with 267 people who participated in search and rescue efforts in the earthquake after the Pakistan earthquake, 20% of the participants had significantly higher scores on the scales used for the diagnosis of GAD (Ehring et al., 2011). The rates we found in our study are consistent with those found in similar studies. Anxiety scores were significantly higher in women, those with low economic status and those who were not working. In a study conducted by interviewing 2080 people after the earthquake in the city of Wenchuan; it has been determined that female gender and poor economic status are risk factors for the development of anxiety (Tang et al., 2018). After the 2010 earthquake in Kovancılar, Elazig, the anxiety levels of women were found to be significantly higher in a study conducted to measure the level of anxiety on 101 earthquake victims (Bilici et al., 2013). In a study conducted after the Düzce earthquake, it was determined that women developed psychopathology at a higher rate than men (Aksaray et al., 2006).

Those who felt the earthquake severely or very severely had a significantly higher BAI score than those who felt the earthquake mildly or moderately. Experiencing the earthquake with greater intensity may increase the risk of developing anxiety (Ayaksız, 1999). Since studies on this subject are limited in the literature, it can be considered as a variable that needs investigation. In our study, the existence of past traumatic experiences was examined as earthquake-related and others. According to our results, it is seen that only earthquake-related traumatic experiences are a factor that increases anxiety.

Depression and anxiety scores were found to be significantly higher in those with PTSD. No significant correlation was found between the number of non-earthquake traumatic experiences and PTSD. In the study conducted after the 1988 Armenia earthquake, it was seen that depressive disorder developed at a rate of 52%, and it was found that PTSD accompanied 70% of these people (Armenian et al., 2000). In a study investigating the anxiety, depression and PTSD levels of those who experienced the earthquake years after the Gölcük earthquake, it was seen that individuals with high scores in the scales filled in for PTSD had high scores in depression and anxiety (Baytar, 2017).

Parallel to the increase in the number of disasters, the fact that natural disasters such as earthquakes pave the way for mental illnesses has had an important place in the agenda of psychiatry in recent years. The biggest limitation of our study İS the small sample size. It is necessary to reach more participants in order to generalize the results to the population and increase their reliability. It has been determined that factors such as loss of a relative and being under a dent were found to be highly significant in all three diseases related to the development of mental illness. For this reason, precautions to be taken before an earthquake gain importance. Providing the first psychiatric support to the individuals in the risk group after the earthquake as soon as possible and monitoring these individuals with certain follow-ups may prevent the development of PTSD and other psychiatric disorders. The high depression scale scores of earthquake survivors staying in temporary settlements after the earthquake may be a guide for the necessity and improvement of psychosocial service units that serve for a long time in these regions.

" Informed consent/ Patient consent and Ethical Statement:

Written informed consent was obtained from all participants that they wanted to voluntarily participate in the study. The present study was approved by the Firat University School of Medicine Local Ethics Committee (Date:19/01/2021, No:257), and the principles reported in the Declaration of Helsinki were strictly followed in all study procedures."

Conflict of interest statement:

There is no conflict of interest between the authors.

Acknowledgement:

Not applicaple.

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The authors declare no competing interests.

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Prevalence of Posttraumatic Stress Disorder and Associated Psychiatric Disorders in Earthquake Victims After the Elazig Earthquake in 2020

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Abstract

1. Introduction

2. Material and Method

3. Results

4. Discussion

5. Conclusion

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Acknowledgement:

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