Background

1. Post-traumatic stress disorder, depression and generalised anxietydisorder in adolescents after a natural disaster: a study of comorbidity Nilamdhad et.al.26 July 2006 Clinical Practice and Epidemiology in Mental Health 2006, 2:17 doi:10.1186/1745-0179-2-17

2. Background • September of the 1989 HURRICAINE HUGO • Category 5 hurricane • the most damaging hurricane ever recorded at that particular time • struck Guadeloupe, Montserrat, St. Croix, Puerto Rico, Antigua and South Carolina • killed 109 people, left nearly 100,000 homeless, and $10 billion in damage overall

3. Background • September of the 1989 • HURRICAINE HUGO • At 3 months, more than 5% school-aged children had posttraumatic stress syndrome • After one year the rates of PTSD ranged from 1.5% in black males to 3.8–6.2% in the emaining groups.

4. Background • January 17, 1994, 4:31 AM (Pacific Standard Time in Northridge) • NORTHRIDGE EARTHQUAKE • Northridge, LA, California • moment magnitude of 6.7 • ground acceleration was one of the highest ever instrumentally recorded in an urban area in North America • 72 deaths , over 9,000 injured • estimated $20 billion in damage, one of the costliest natural disasters in U.S. history

5. Background • January 17, 1994, 4:31 AM (Pacific Standard Time in Northridge) • NORTHRIDGE EARTHQUAKE • 28.5% of children had mild to moderate PTSD at one year

6. Background • Monday, July 16, 1990, at 4:26 PM (local time) • 1990 LUZON EARTHQUAKE • 125 km-long ground rupture that stretched from Dingalan, Aurora to Kayapa, Nueva Vizcaya • 1,621 people were killed in the earthquake

7. Background • April 2, 1991 • MOUNT PINATUBO ERUPTION • phreatic eruptions occurring near the summit along a 1.5 km long fissure • Over the next few weeks, small eruptions continued, dusting the surrounding areas with Volcanic ash. Seismographs recorded hundreds of small earthquakes every day.

8. Background • psychiatric morbidity among children and adult survivors of massive disasters in the third World far exceeds those found following disasters in United States communities • Studies from south Asian countries are almost non-existent even though the frequency and the extent of natural disasters in this part of the world are

9. Background • considerable trauma during childhood and adolescence can etch an indelible signature in the individual's development and may lead to future disorders

10. Background • Reports suggest that post-disaster psychiatric morbidity in adolescents continues for years • However studies have noted underestimation of both the intensity and the duration of the stress reactions in children

11. The study

12. The Study • October 29, 1999 • super-cyclone with a wind speed of 260 to 300 kilometer per hour hit Orissa, in the East Coast of India continued for 72 hours. • Tidal waves from sea at a height of 7 meters came 15 kilometers inland at various places and swept away almost everything.

13. The Study • October 29, 1999 • INDIA SUPER CYCLONE • Affected over 15 million people; around 10,000 persons were killed; and there was massive loss to properties and livelihood. • Thousands of villages were marooned for over two weeks before they could gain access to relief services

14. Objectives of the Study • To Determine: • (i) proportion of adolescents exhibiting post-traumatic psychiatric symptoms • (ii) prevalence of PTSD, major depressive disorder (MDD), and generalized anxiety disorders (GAD), and • (iii) prevalence of comorbidity • in a group of adolescent students in rural areas, • 14 months after the super-cyclone of Orissa • Determine sociodemographic factors and effect of morbidity on performance in school

15. Methods

16. Methodology • All the students studying in standard 9 & 10 of two high schools in the most severely affected district were taken as subjects of the study. • Mini International Neuropsychiatric Interview for children and adolescents (MINI-KID) was used for evaluation of symptoms and diagnosis of MDD, PTSD & GAD

17. Methodology • MINI-KID allows for the explanation of words and concepts in the questions if the child or adolescent does not understand a particular symptom. • Preparation involved translation to Oriya (local language) & retranslation to English which was piloted before the study.

18. Methodology • The diagnoses were based on DSM IV criteria • Additional data collected included: • Family structure (nuclear or joint) • Socioeconomic Status (following local guidelines) • Educational background of the parents • Main earning source for the family

19. Methodology • Data collection was done 14 months after the supercyclone. • The questionnaire was administered individually by one of the authors with a parent or teacher present. • Chi-square test was used to test association between categorical variables. • Significance value was set at 0.05.

20. Results

21. All adolescents reported significant damage to their houses (making them uninhabitable), starvation, and lack of treatment for physical ailments in the initial few days after the cyclone. • witnessed the devastated scene with dead and mutilated bodies damaged houses, uprooted trees • The victims had to depend on outside relief for months; some of them had to live in the shelters for weeks to months. • None of the adolescents had exposure to any other psychiatric evaluation or formal intervention before the study.

24. Adolescents with Psychiatric disorders • Adolescents belonging in the middle socioeconomic status were hit the hardest • Psychopathologies which significantly differentiated the cases from non-cases were a mixture of depression, anxiety and post-traumatic stress symptoms

25. Cases had following PTSD symptoms significantly more: • dreams, vivid memory, avoidance, trouble remembering few aspects of disaster, did not have strong feeling about things, felt that life would be shortened and they would die soon, sleep problems, trouble paying attention, nervousness, and remaining upset about these symptoms.

26. Depressive symptoms • decreased interest and anhedonia, tiredness, guilt feeling, impaired concentration and death wish or suicidal ideas. • GAD symptoms • worrying most days, feeling tense, grouchy or annoyed and trouble sleeping.

27. Educational impairment was also very apparent among those affected and may be manifested as lack of motivation and purposelessness in studying among students • School has become and activity to spend time rather than to study

28. Comorbidity • Sixteen adolescents (39.0%) out of 41 who had any psychiatric diagnosis had comorbidity. • Prevalence of comorbidity in adolescents with • 48.3% with PTSD • 63.2% with MDD • 76.9% with GAD. • Six adolescents had MDD and PTSD, • 4 had PTSD and GAD, • 2 had GAD and MDD and • 4 had all three diagnoses.

29. The comorbidity was not only due to the symptomatic overlap amongst these diagnoses, but considerable prevalence of various core symptoms of each of these diagnoses were also observed in others.

30. Examples: • depressive symptoms were significantly present in adolescents who had PTSD compared to those who did not have PTSD: • Anhedonia • Tiredness • Death wish and suicidal ideas • Anxiety symptoms that were significantly present in adolescents with PTSD were worry and difficult to stop worrying

31. Adolescents with comorbidity were significantly differentiated from the ones with only one diagnosis by the following symptoms: • decrease concentration • not having strong feeling about things • Worry • Worrying most days • and feeling tense • Depressed mood was present in 98.8% of adolescents with comorbidity compared to 68.0% of those without

32. There were no significant differences in the prevalence of diagnoses in male and female adolescents although there were a few differences in the presentation of symptoms

33. PTSD • Symptoms of dreams of the disaster and having a strong memory of it was markedly stronger in males • Similarly more males had avoidance and tried not to think about it and felt cut off from other people • More females than males reported startle reactions

34. GAD • more males compared to females felt it hard to stop worrying and had trouble falling asleep and waking up in the middle of night

35. Depression • Significantly more numbers of males reported decreased interest or Anhedonia, change in appetite or weight, and lack of concentration • More females reported guilty feeling or feeling bad about self • More males reported difficulty in studiesandfailure in examinations

36. Discussion

37. Discussion • Adolescents exposed to super-cyclone exhibited a wide range of post-traumatic symptoms • PTSD – most common • Considerable proportion with MDD and GAD

38. Discussion • Difficult to compare different disasters • Other factors: nature and intensity of the trauma, personal loss, individual vulnerabilities, post disaster adversities and psychosocial support

39. Discussion • Post-disaster psychological support influences psychiatric morbidity • Priority was obtaining basic needs subjects did not receive formal psychological support • Psychological support from disaster workers was unavailable • Psychologicsequelae was not evaluated and managed  possible cause of high prevalence of psychiatric morbidity

40. Discussion • Majority of adolescents were not having syndromal psychiatric disorders • Protective factors: informal psychological support (close-knit Indian villages)

41. Discussion Co-morbiditiy • Considerable proportion of victims with GAD, MDD, PTSD had co-morbidities like: -Depression with PTSD -GAD with PTSD -Overlap of GAD, PTSD, MDD • Thus, it is important to look for co-morbids to give a holistic picture to reactions to catastrophic stressors to help in the management plan of victims

42. Discussion Gender differences • F>M (depression), F<M (PTSD)  but not significant • F: guilt • M: hard to stop worrying, anhedonia, difficulty concentrating, problems with school performance • Therefore gender differences depend on various other factors (i.e. higher exposure to trauma)

43. Discussion Limitations • No standardized diagnostic instrument (in Oriya), but English was studied in schools • No information on pre-cyclone psychiatric morbidity • Other confounding risk factors: death in family, serious physical trauma, supportive factors

44. Discussion Limitations • Comparison with unexposed control population would have been helpful • Only MDD, GAD, PTSD studies, presence of other disorders possible

45. Conclusion • A considerable proportion of adolescents suffered from and had syndromal psychiatric diagnoses 1 year post-trauma • High overlap of symptoms and co-morbidity suggest that post-disaster presentation in a combination of PTSD, GAD, MDD • Screening and intervention for related psychiatric disorders is needed