Research Report

PSYCHOLOGICAL EFFECTS IN IMMEDIATE AFTERMATH OF THE TSUNAMI – A KERALA EXPERIENCE

Harish M Tharayil1*, AM Fazal Mohamed2, CT Sudhir Kumar3, G Mohan Roy4, Varghese P Punnoose5

1Professor, Dept. of Psychiatry, Government Medical College, Kozhikode.
2Associate professor, Dept. of Psychiatry, Pushpagiri Medical College, Tiruvalla.
3Research and Development Centre, Alzheimer’s and Related Disorders Society of India, Kochi.
4Assistant Professor, Dept. of Psychiatry, Government Medical College, Thiruvananthapuram.
5Professor, Dept. of Psychiatry, Government Medical College, Kottayam.
*Correspondence: 11/1339, Blessing, Iringadan Palli Road, Kovoor PO, Calicut - 673 008.
Email: drharishmt@gmail.com

ABSTRACT

The tsunami waves wreaked havoc in coastal areas of the South Indian states of Kerala and Tamil Nadu in December 2004. Our team was involved in the care of those displaced to nearby hospitals and relief camps in the immediate few days following the disaster in Alappuzha district. This paper describes details of cases referred to psychiatrists by other doctors in those days. Out of the 43 cases referred for evaluation, 37 (86%) had a psychiatric diagnosis. 27 (60%) met the criteria for Acute Stress Disorder , (ASD). Some suffered from exacerbation of pre-existing disorders.

Keywords: Tsunami, acute stress disorder, depression

BACKGROUND

The tsunami waves which swept across several Asian coasts in December 2004 wreaked havoc in the coasts of the south Indian states like Kerala and Tamilnadu.1 In Kerala, the districts of Kollam and Alappuzha were the most affected. Staff from the Department of Psychiatry at Government TD Medical College, Alappuzha, was actively involved in the care of those displaced to nearby hospitals and relief camps in the immediate few days following the disaster.

A disaster, according to World Health Organization, is a severe disruption - psychological and psychosocial - which the affected community is unable to cope with.2 Survivors of a disaster may have evidence of physical trauma, but would have invariably sustained one or other form of emotional trauma. Disasters are classified into natural and man-made, and the rates of emotional distress are found to be higher following natural disasters.3

Extent of the psychological consequences of a disaster depends on five dimensions — Scope of the impact (geographical, number of people affected), its speed (sudden, gradual, or chronic), its duration, social preparedness of the community, and whether the community is geographically central or peripheral.4,5 Factors like the victims’ age, education, marital status, physical health, personality, coping skills, losses, and social support also play a role in deciding the impact.6 Immediately following a disaster, there may be numbing, decreased speech and movements, decreased attention span, disorientation, arousal symptoms, depression, panic attacks, excessive grief, suicidal ideation and survival guilt.6

Though this was not a planned research, we are reporting this data as it is important to understand how people respond to sudden, life changing catastrophes.

OBJECTIVES

To describe the sociodemographic profile of victims referred for psychiatric help, and the psychological effects in them, in the two weeks following the tsunami disaster.

METHODS

We are reporting our first hand experiences as mental health professionals who had to witness a sudden natural disaster unfolding its fury on a hapless, unprepared community. All authors took part in planning and analysis of the study and writing up of the paper. The first three authors were directly involved in data collection. All authors were working in Psychiatry department of Government TD Medical College, Alappuzha at that time.

Our team made thrice a week visits to hospitals and relief camps during the first two weeks following the disaster.  All cases referred to us were evaluated by clinical interviewing and mental status examination. Information gathered from patients and relatives were entered in a data sheet which covered basic demographic and clinical details. Diagnoses were made according to DSM – IV criteria.7 Hospital Anxiety and Depression Scale (HADS) was administered to the subjects as they were attending a medical service following a disaster.8,9 Informed consent was obtained from all subjects before data collection.

RESULTS

The results are presented in tables 1 to 4. Out of the 43 cases referred for evaluation, 37 (86%) had psychiatric diagnosis, either preexisting or new onset. Majority of the new onset cases were Acute Stress Disorder (ASD) (n=26; 60%). Six patients had depression — two of them had developed the illness after the disaster, while the others had been on treatment for preexisting depression as reported by them and supported by past medical records. Two were cases of bipolar disorder in remission. One patient was diagnosed with dysthymia, and another one had bipolar currently mixed state.  The sample received high scores on both the depression (15.1±4) and anxiety (15.3±3.68) subscales of HADS.

Table 1: Basic demographic data of the sample (n=43)

Mean age
Male 45.2
Female 41.4
Child 8.5
Gender Numbers
   Percentage
Male 15 35
Female 26 60
Children 2 5
Education

Primary 36   84
Secondary and above 7  16
Marital status

Married 32   74
Unmarried 5   12
Widow/widower   6  14

Table 2: How affected by Tsunami. (n=43)
How affected*   Numbers Percentage
Direct

Washed off      23 53
Injury to self     18 42
Lost house      21 49
Lost belongings /valuables  20 47
Lost means of livelihood 13 30
Indirect

Death of a family member 13   31
Injury to a family member  17  40
Death of a relative or close friend 15  35
Injury to a relative or close friend 2 47
Having to handle a dead body  2  5
Missing family members 1 2
Viewed TV visuals of disaster 1 2
*Many were affected in multiple ways.

  Table 3: Psychiatric diagnoses (n=43)
Diagnosis Numbers
   Percentage
Acute Stress Disorder 28 60
Mood disorders 10 23
Schizophrenia 1  2
No diagnosis 6 14

  Table 4: HADS subscale scores
Subscale Mean SD
Depression 15.1 4.0
Anxiety 15.3 3.68
Total 15.2 3.9

CONCLUSIONS

The exact prevalence of ASD (following a disaster) as currently defined is not known. A review reported Acute PTSD to have a prevalence of 7 – 90%.10 Lima et al. had found a ‘case’ness of 45% following an earthquake, which is a natural disaster of sudden onset like the tsunami.11 High levels of depression and anxiety had been found by van Kemp.12 Many studies had used retrospective assessments, and this approach has been criticized by Harvey and Bryant who found up to 75% errors in recalling at least one of the four ASD criteria.13

Ours is a first hand, on the spot evaluation of victims of a natural disaster done within two weeks by a team of psychiatrists. This may explain the high prevalence of pre-existing psychiatric morbidity in the sample, as the cases were referred by doctors who knew about the availability of psychiatrists at the site. The high prevalence of ASD is a cause of concern. Besides, the high scores on the HADS (15±4 on both subscales, >11 being taken as “case”), a self-rated scale, underscores the high levels of distress in the referred subjects. Both these points underline the need for ongoing mental health interventions after any major disaster.

LIMITATIONS

This was not a planned research work. As we were seeing cases referred for psychiatric evaluation by other doctors in the team, there is a chance for bias. This could explain the high level of morbidity in our sample.

REFERENCES

  1. 2004 Indian Ocean earthquake and tsunami. Wikipedia. [Internet] [cited 3rd September 2015] Available from: https://en.wikipedia.org/wiki/2004_Indian_Ocean_earthquake_and_tsunami.
  2. World Health Organization. Psychological consequences of disaster – Prevention and management. Geneva: WHO; 1991.
  3. Rubonis AV, Bickman L. Psychological impairment in the wake of disaster: the disaster – psychopathology relationship. Psychol Bull 1991; 109:384-99.
  4. Barton A. Communities in disaster. New York: Basic books; 1969.
  5. Green BL. Assessing levels of psychological impairment following disaster: consideration of actual and methodological dimensions. J Nerv Ment Dis 1982; 170(9):544-52.
  6. Kar GC. Disaster and mental health. Ind J Psychiatry 2000; 42(1):3-13.
  7. Diagnostic and Statistical Manual 4th Edition, (DSM – IV). New York: American Psychiatric Association; 1994.
  8. Zigmund AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983; 67:361-70.
  9. SnaithRP. The Hospital Anxiety And Depression Scale. Health Qual Life Outcomes 2003; Available from: http://www.hqlo.com/content/pdf/1477-7525-1-29.pdf
  10. Beecham JC, Davidson JRT, March JS. Anxiety disorders: Traumatic stress disorders. In: Tasman A, Kay J, Lieberman JA, editors. Psychiatry. London: John Wiley and sons; 2003.
  11. Lima BR, Chavez H, Samaniego N, Pompei MS, Pai S, Santacruz H, et al. Disaster severity and emotional disturbance: implications for primary mental health care in developing countries. Acta psychiatr Scand 1989; 79(1):74-82.
  12. Van Kamp I, Van Der Velden PG, Stellato RK,Jan Roorda, van Loon J, Kleber RJ, et al. Physical and mental health shortly after a disaster: First results from the Enschede firework disaster study. Eur J Public Health 2006; 16(3):252-8.
  13. Harvey AG, Bryant RA. Memory for ASD symptoms. A two year prospective study.J Nerv Ment Dis 2000; 170:602-7.

Source of support: None
Conflict of interest: None declared. The whole work was done utilizing travel facilities provided for doctors to visit the tsunami sites during the initial weeks following the disaster.