A 13-year follow-up study of posttraumatic stress disorder in flood victims in Huarong China

1. A 13-year follow-up study of posttraumatic stress disorder in flood victims in Huarong China Shimin Hu, PhD candidate School of Public Health, Central South University 2014.8.19

2. Contents • 1. Introduction • 2. Methods • 3. Results and Discussion • 4. Acknowledgments

3. Introduction—conception of PTSD • Posttraumatic stress disorder（PTSD）is a severe and complex disorder precipitated by exposure to a psychologically distressing event and is characterized by persistent intrusive memories about the traumatic event, persistent avoidance of stimuli associated with the trauma, and persistent symptoms of increased arousal.

4. Introduction—rates of PTSD

5. Introduction—chronicity of PTSD Oil platform disasters World Trade Center Disaster Oklahoma city bombing Buffalo Creek dam collapse chronicity rate of PTSD within the range of 6.3-68.9%. Oil platform disasters revealed chronic PTSD can persist for over 27 years.

6. Introduction—harm of chronic PTSD A long disease course leads to huge burdens on the society, patients' families, and patients themselves. Importantly, patients with chronic PTSD experience significantly impaired quality of life. Doctor et al study demonstrated that chronic PTSD patients are willing to give up 34% of their life span to live the rest of their life without PTSD.

7. Introduction—aim of this study No study to our knowledge has focused on the prognosis of PTSD for more than 10 years after a flood. China’s Hunan province in 1998 and 1999 PTSD---8.6% Natural progression of PTSD---unknown Aim: In this study, we analyzed the chronicity rate of PTSD and associated prognostic factors in part of these victims 13 years after the flood.

8. Methods--Participants This study was a subsequent follow-up study of a large community-based survey. Previous study: Covered 8 counties (Yueyang, Lingxiang, Huarong, Qianlianghu, Ziyang, Anxiang, Datonghu, Longshan) that had been directly exposed to the 1998–1999 flood in Hunan province, China. 7 years of age or over-- enrolled A total of 2875 (8.6%) subjects were diagnosed as PTSD according to the DSM-IV criteria. Current study: Huarong—540 PTSD patients, 16 years of age or over, 439 victims enrolled

9. Methods—PTSD outcome The interviewers were trained in using PTSD Checklist-Civilian version (PCL-C) questionnaire developed from DSM-IV, which was also used in our former survey in 2000. 17 symptoms scored as 0 = none, 1 = slight, 2 = moderate, 3 = severe, and 4 = extreme (≥2 symptom positive) 3 sets of diagnostic criteria: B(5), C(7), and D(5) the re-experiencing cluster B: ≥1 positive symptoms the avoidance cluster C: ≥3 positive symptoms the hyperarousal cluster D: ≥2 positive symptoms

10. Methods—Individual characteristics demographic characteristics Flood-related stressors After 2000, have you experienced or witnessed an incident, which almost caused death or serious injury and caused you to be frightened? life-threatening experiences, death of a loved one, victimization after the flood physical illness/injury caused or exacerbated by the flood, extreme physical adversity ,extreme psychological adversity, major property loss, income loss, and housing adversity gender, age, and education level frequency of general collective action Post-flood severe stressors

11. Methods—Individual characteristics frequency of general collective action General collective action means participating in the activities organized by the following groups: political party, trade union, environmental group, parents’ / school association, tenants’ / residents’ group or neighbourhood watch, church organization, voluntary service group, pensioners group /organization, social club / working men’s club, sports club and the Women’s Institute Situation in 2000: date of previous study Situation around 2006: according to the memory, collected currently Situation in 2012: collected currently

12. Methods—Statistical methods 1. Post-flood severe stressors---- if positive, exclude 2. two new indicators: “fluctuation of frequency and total score of frequency”, according to the direction of change of frequency of three periods: 2000, around 2006, and 2012 “total score of frequency”: integration of frequency of three periods 3. grouped victims with constant score of frequency into a group to analyze the date separately

13. Results and Discussion Baseline data 439 individuals were selected for this study + 151 were visited at their home 30 died of old age = 173 temporarily left to find work in other cities 85 migrated to other villages or counties + + 151 were visited at their home 9 subjects with positive answer of Post-flood severe stressors 144 victims included -- =

14. Table 1. Comparison of Individual characteristics between subjects interviewed (n = 144) and unreachable (n = 288) more young subjects among the unreachable victims

15. Table 2. DSM-IV criterion symptoms of PTSD reported by 144 subjects with PTSD 13-year after first exposure to flood The positive rate of Group C was much lower than group B and D. Although the dates were not list, the positive rate of 3 symptom group were undoubtedly all 100% in 2000. Group C had biggest drops in positive rate (P<0.000, by 2 test, have not shown in table).

16. Table 3. Independent prognosis factors for current PTSD, expressed in OR and adjusted ORs of 6 models Note: FGCA= Frequency of General Collective Action; Constant Score model only have 87 victims involved; *p < .05; ** p < .01; *** p < .001.

17. interpretation of table 3 Flood-related stressors in our study included some factors reflecting the quality and privacy of life during post-disaster temporary resettlement. These may suggest that keeping victims safe with adequate food and clothing is very important but not enough post disaster. Government should take the privacy of living and calming nerves into consideration. Participating in general collective action can strengthen victims’ contact with society, and may have a positive impact on prognosis of PTSD through individual appraisal processes (i.e. primary and secondary appraisal), social support, and coping behavior. Our study therefore suggests that more social participation is beneficial to the recovery of PTSD.

18. Conclusion This study suggests the existence of chronicity in PTSD victims of flood. Remission of the avoidance/numbing symptoms plays an important role in the recovery from PTSD. More social participation is beneficial to the recovery of PTSD and re-building a high quality life after a disaster with help from society or the government could reduce the development of chronic PTSD in flood victims.

19. limitations • sample size is small • PTSD symptoms often fluctuate. Observations on relapsing-remitting and late-onset symptoms' trajectories may add more information to the current one level measurement.

20. Acknowledgments • This study was supported by the Fundamental Research Funds for the Central Universities of Central South University (2013zzts289) and Specialized Research Fund for the Doctoral Program of Higher Education（20130162110054）. • Aizhong Liu, Hongzhuan Tan, Reuben Cofie, Jia Zhou, Tubao Yang, Xuemin Tang contribute a lot to this study.

21. The end Thank you!