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Tsunami Reactions Teach Crucial Lessons About Trauma, Recovery

Thai adults who survived 2004's devastating tsunami may benefit more from normalization of their lives, while children seem to derive more benefit from therapy.

Thai adults recorded higher rates of depression and anxiety than of posttraumatic stress disorder (PTSD) following the 2004 Indian Ocean tsunami, especially if they were more directly affected by the disaster.

Both children and adults closest to the devastation, however, exhibited more PTSD symptoms than did those from unaffected villages, according to two recent reports by a multinational team of researchers.

The collaborative reports by Warunee Thienkrua, M.Sc., Frits van Griensven, Ph.D., and numerous colleagues from the Thai Ministry of Health and the U.S. Centers for Disease Control and Prevention appeared in the August 2 Journal of the American Medical Association.

The researchers randomly sampled households in camps for displaced persons in the heavily affected Phang Nga province and in villages in less-affected Phuket and Krabi provinces. This first set of interviews took place in February 2005, two months after the December 26, 2004, tsunami that killed an estimated 200,000 people in half a dozen countries. Mental health problems would have disappeared or become permanent at this point after the tsunami, providing a better baseline for research, said the researchers.

Nearly all the displaced persons had lost their homes or most of their property, and half could no longer work at their previous jobs. Half said the tsunami left a family member killed or missing.

Exposure to such trauma is the key to subsequent symptoms but not the only factor, said Armen Goenjian M.D., a research professor of psychiatry at the David Geffen School of Medicine at UCLA.

"Just being in a traumatic situation doesn't mean you're exposed to trauma," said Goenjian in an interview with Psychiatric News. "You must be exposed and frightened."

The high rates of anxiety and depression among adults are understandable, since a loss of livelihood is usually associated with other kinds of losses within the victim's family and community, he pointed out. "They're not only suffering themselves, but they can no longer perform as a parent, a worker, or a student."

Cultural Considerations Crucial

The studies also revealed aspects of the Thai response to the tsunami that are important when planning mental health interventions following disasters in other cultures, said the authors. Some tsunami survivors reported hearing voices or seeing ghosts. Many tsunami victims were lost to the sea or not identified, and thus funerals could not be held for them.

"Thai culture dictates that appropriate funeral rituals for the dead are necessary for their ghosts to come to rest," said the authors, and are a normal part of Thai beliefs, not a symptom of mental illness.

Cultural aspects must be considered in planning a mental health care response, Goenjian noted. "In cultures where the metaphysical and spiritual are important, people may interpret stimuli culturally. `Seeing ghosts' may be misinterpreted by outsiders as quasi-hallucinations but they are not symptoms of psychosis in this context. Also, some people may have difficulty articulating their distress in psychological terms."

Children Responded Differently

For children, the key risk for PTSD was experiencing the tsunami, not being displaced. Children from affected villages were at higher risk, regardless of whether they were displaced, the researchers found. Using multivariate analysis, the research team found that having felt extreme panic or fear resulted in a nine times higher risk of PTSD symptoms.

Having felt one's own or a family member's life to have been threatened and enduring an evacuation delay were significantly associated with development of PTSD among the children surveyed. Feeling that one's life or a family member's was in danger also predicted a sixfold higher risk for depression. The survey did not record specific injuries among the children or whether they had been orphaned or lost siblings in the tsunami.

"There's no reason for major intervention [for all children], but it is important to intervene for high-risk groups," said Goenjian. Even a short screening can identify these high-risk youngsters. As a rough guide, he said, clinicians can begin with those who have had high exposure to the traumatic event and then move on to those who have lost parents.

In Phang Nga, 371 displaced adults and 322 nondisplaced adults were interviewed in Thai. Interviewers also contacted 368 people in less-affected Krabi and Phuket. They were asked questions from the Medical Outcomes Study-36 Short-Form Health Survey, the Harvard Trauma Questionnaire, and the Hopkins Checklist-25. The Phang Nga cohort was reinterviewed in September 2005.

The researchers' analysis indicated that displacement was not associated with mental illness or PTSD symptoms in adults. However, loss of livelihood was significantly and independently associated with PTSD, anxiety, and depression.

In a follow-up survey of displaced persons nine months later, symptoms of all three conditions had declined—from 11.9 percent to 7 percent of the surveyed population for PTSD, from 36.9 percent to 24.8 percent for anxiety, and from 30.2 percent to 16.7 percent for depression. Nonsignificant declines occurred among those who were not displaced by the disaster.

Grief, loss, and uncertainty about the future following the tsunami's devastation appeared to contribute to anxiety and depression among the adults, while PTSD symptoms may reflect the trauma of the tsunami itself, the investigators concluded.

Their research shows that different intervention approaches to children and adults may be appropriate following disasters. "Children may benefit from therapeutic interventions, while for adults, contextual interventions aimed at the restoration of livelihood may be more appropriate," they said.

"Mental Health Problems Among Adults in Tsunami-Affected Areas in Southern Thailand" is posted at <http://jama.ama-assn.org/cgi/content/full/296/5/537>; "Symptoms of Posttraumatic Stress Disorder and Depression Among Children in Tsunami-Affected Areas in Southern Thailand" is posted at <http://jama.ama-assn.org/cgi/content/full/296/5/549>.

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