The authors reviewed a range of articles on natural disasters and mental health in Asia. The review focused primarily on three kinds of natural disasters common in Asia. They are earthquakes, volcanic eruptions, and typhoons and cyclones. Although there are numerous articles on disaster mental health to be found in Asia, the majority relate to mental health problems and post-traumatic stress disorder (PTSD) resulting from manmade disasters. Articles on Vietnam veterans and Indochina refugees comprise the majority of papers in this subject area. There are a few articles that look at mental health problems of the atomic bomb survivors of Hiroshima and Nagasaki. Although some 50 years have elapsed, some survivors continue to suffer from the physical and psychological consequences of the Atomic bombings in 1945.
The discipline of disaster mental health is a relatively new concept in Asia and PTSD was little known in Japan until January 1995 following the Hanshin Awaji earthquake. The earthquake struck Kobe city and the Southern part of Hyogo Prefecture, killing more than 5500 people within the first 24 h and leaving some 300 000 homeless.1
Following the devastating earthquake, the notion of PTSD was widely accepted by survivors, volunteers, mental health professionals and the media in Japan. Acceptance was due in part to the fact that PTSD did not have the stigma often associated with other psychiatric diagnoses. In the present paper, the authors focus on articles relating to mental health problems of natural disaster survivors in the past three decades throughout Asia.
Natural disasters impact on large numbers of people throughout the world. According to statistics from the Red Cross Society, Asia is the most disaster-prone area of the world. One reason cited for the high incidence of disasters in Asia is its geographic location. Earthquakes are particularly common in the Asian region because East and South-east Asia is situated on the ‘Circum-Pacific Seismic Belt’. This Pacific area is engraved by several trenches and stretches from the Aleutian Trench to the Philippine or Mariana Trench, and is spread over the junction of several plates such as North American, Eurasian, Pacific and Philippine Sea Plates. Also, in South Asia (Bangladesh, India, Nepal etc.), the Eurasian Plate overrides the Indian Plate.2 The collision of these tectonic plates has over the years created a myriad of devastating earthquakes.
The enormous destruction resulting from earthquakes results in the loss of life, homes and infrastructure. The effect of a tsunami that may follow the earthquake frequently adds to the destruction and loss of life and property. Furthermore, the instability of plates or crust of the earth in the Pacific area sustains many active volcanoes, constituting the so-called ‘Ring of Fire’ ranging from Alaska to South America. In addition, most Asian countries are situated within the zone of the ‘Typhoon Belt’ or lie in the path of tropical cyclones.3
In addition to typhoons and cyclones with their violent winds and extremely heavy rainfall, the monsoon rains often cause uncontrollable floods in the areas along the rivers or lakes. Thus people living throughout Asian are constantly menaced by violent natural disasters. According to World Disaster Report 2001, distributed by the International Federation of Red Cross and Red Crescent Societies, of approximately 3 billion people in the world affected by disasters from 1967 to 1991, some 85% lived in Asia.
Despite the commonality of disasters throughout Asia, the number of published studies on disaster-related psychological distress in the region is limited. This may be due in part to the fact that psychiatry or stress-associated psychiatry is not well recognized. Recently, however, the increased attention to PTSD following earthquakes, mass poisoning, and floods has promoted disaster psychiatry within Asian countries.
Kokai and Shinfuku reviewed articles on pathologic stress response in Asian people resulting from wars and natural disasters, and then suggested the possibility of somatization as an alternative expression of psychological distress to disasters.4 The aim of the present article was to survey reports and studies on disaster psychiatry in Asia and evaluate clinical manifestations of post-disaster psychopathology and the factors contributing to the psychological recovery from traumatic exposure. To our knowledge, no reviewing article on the acute and chronic psychiatric effects of disasters in Asia has been carried out.
DISASTER MENTAL HEALTH IN ASIA
Psychological effects of earthquakes have received increased attention in past decades. The studies on disaster aftermath indicate that many victims are likely to present a clinically significant symptomatic response as a consequence of exposure to stressful events, extent of loss, social disorganization and lack of community support. Recently in Asian countries, a number of studies on earthquake-related mental health problems has been published with the gradual introduction of PTSD and its diagnostic criteria. However, significant issues remain unresolved with regard to post-disaster psychopathology. Theses include such factors as how often the disaster survivors meet the full criteria for diagnosable mental disorders, what types of disorders are frequently linked to the impact of the disaster, whether the post-disaster psychopathology is transient or long-lasting, and whether post-disaster psychological reactions are universal in nature or if they are bound to social, cultural and economic factors.
In Japan the Hanshin Awaji earthquake struck in mid-winter of 1995, with a recorded magnitude of 7.2 on the Richter scale. It affected 3.5 million people and more than 20 cities and towns in the south-west of Hyogo prefecture and the adjacent area. The final number of deaths resulting from the earthquake rose to approximately 6500.4
Following the earthquake Kato et al. assessed the frequency of short-term, post-traumatic symptoms among a group of evacuees.5 A total of 142 people under the age of 60 years and elderly people from emergency shelters who had been living in the area close to the epicenter were assessed using the Post-Traumatic Symptom Scale. This was undertaken during the third week following the earthquake. Another sheltered group of 123 young and elderly subjects from the same community was assessed in the eighth week. Results from the first group found that subjects from both age groups experienced sleep disturbance, depression, hypersensitivity and irritability. In the second group, the percentage of younger subjects experiencing symptoms did not decrease, while elderly subjects showed a significant decrease in most of the symptoms.
The discrepancy between the age groups and the poor rate of emotional and psychological recovery in younger subjects was partly explained by the psychological burden of catering for family members and reconstructing their community. This was in contrast with retired people, who had experienced previous disasters such as the mass bombing during World War II.5 Caution must be exercised, however, in openly accepting previous disaster experience as a determining factor leading to greater recovery.
Research of the rates of psychiatric morbidity among community samples exposed to natural disasters have methodological limitations. However, a few reports have used the results of surveys from clinical case research to evaluate the prevalence of psychiatric morbidity following the Hanshin-Awaji earthquake. Kokai et al. carried out clinical observation in an outpatient service of a university hospital situated in the affected area.6 Anxiety disorder suffered from the direct impact of the traumatic experience was the most common disorder reported within the first month following the earthquake. After the first month the disorder steadily decreased. Reports of depression were closely related to unemployment, enormous financial cost and burden for reconstruction of homes, physical fatigue and interpersonal hardships at the relocation sites. Like the anxiety disorder cases, the number of disaster-related depression cases gradually decreased within 1 year.
The same study found that the prevalence of PTSD diagnosed by Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) criteria was reported in only six cases among 322 new psychiatric outpatient cases at the psychiatric department of the university hospital during a 6 month period after the Hanshin Awaji earthquake.6 A study by Mita et al. reported a finding of 21.1% of PTSD cases using the criteria of ICD-10 Classification of Mental and Behavioural Disorders in outpatient samples.7 The number was estimated to be around 5% when the DSM-IV criteria were applied. Another report using the DSM-IV criteria of the occurrence of PTSD observed among outpatients in more severely affected areas adjacent to the epicenter, described a higher rate of 19.8%.8 The difference between the result and that using different instruments for assessment highlights the need for caution in interpreting results, as well as a need for methodological standardization.
The middle- and long-term health effects relating to general chronic disease of survivors has also been a subject of study. Findings pointed to a correlation between deterioration in the condition of survivors with a chronic disease caused by psychological factors. Inui et al. demonstrated that glycemic control was aggravated among diabetic patients in Kobe but not in Osaka, an area close to Kobe following the Hanshin Awaji earthquake.9 Further, the General Health Questionnaire (GHQ) scores were significantly higher in patients in Kobe than in Osaka. The study demonstrated that psychological problems following the earthquake might be responsible for the aggravation of glycemic control in diabetic patients. In this context, a psychosomatic interaction of disaster survivors should not be neglected.
In 1999, a devastating earthquake struck a central area of Taiwan. Chen et al. reported on the high prevalence rate of psychiatric presentations in 525 subjects who presented at a mobile clinic during a 1 month period following the disaster.10 The prevalence of morbidity was approximately threefold higher than that of other community samples or health screening clinics formerly examined by them using the epidemiological instrument, Chinese Health Questionnaire-12 (CHQ-12). The morbidity was seen most clearly in women of middle age. The degree of destruction of homes was correlated with the CHQ-12 total scores. With regard to PTSD symptoms assessed using the DSM-IV criteria, re-experience of the event and increased arousal was prevalent while symptoms related to avoidance or emotional numbing were relatively low. The study concluded by suggesting that early psychiatric intervention, including pharmacological treatment for acute stress, is indicated during the early stages following a disastrous earthquake.
While the studies mentioned so far mainly focus on post-earthquake psychopathology and an epidemiological point of view, Wang et al. investigated the relationship between PTSD rates and the importance of psychosocial intervention.11 Data for their research were collected following an earthquake that struck the northern part of China in 1998.
Researchers compared the rate of PTSD 9 months after the event in two villages: one was located adjacent to the epicenter and the other some distance from the epicenter. Surprisingly, they found a lower rate of PTSD in the number of cases located adjacent to the epicenter, where there was a higher level of initial exposure to the disaster area. These findings contradict most previous studies.6,12–14
In general, psychiatric morbidity was significantly related to destruction of houses, destruction of possessions in the affected area and was higher in the victims closer to the epicenter of earthquake. One reason given to explain the finding was the prompt and higher level of post-disaster support and intervention to the adjacent area.11 This was thought to mitigate the impact of initial exposure and reduce the probability of PTSD occurrence.
Villages far from the epicenter were neglected, with few supported by government and other agencies. The aforementioned findings highlight the importance of post-disaster supports as a key factor in reducing PTSD among disaster victims. The researchers also found that the use of DSM (3rd edn, revised; III-R) criteria resulted in a much higher frequency of PTSD compared with the use of DSM-IV. They recommended that a uniform criterion of DSM-IV diagnosis for PTSD be used in further research. Also, they suggested that the cultural factor of underreporting the severity of the symptoms due to the reluctance to express psychological stress in Chinese culture may explain the lower rates of PTSD.11 This may also help explain the relatively lower PTSD occurrence in recent studies on disaster psychiatry among Asian countries.
On Miyakejima Island in Japan the highest mountain peak, Oyama, has repeatedly erupted over the years. Following the eruption in 1983 a series of studies over a 3½ year period focused on the psychological and physiological changes of residents on the island.15 Three sequential assessments of the general health status of 269 victims in severely damaged areas were carried out using the 20-item questionnaire and elaborated on by the researchers based on the Cornell Medical Index.
Following the eruption there were no reported cases of loss of life or serious injury. However, of the survivors involved in the study, 63% reported the destruction of their home by the pyroclastic flow of the volcano.15 Disaster-related PTSD or other significant psychiatric disorders were not reported. The result of the assessment indicated that the symptom severity increased in most items, in particular for items relating to tendency to lose temper, drink alcohol, fatigability, myalgia, hypertension, headache, and palpitation. Only the items relating to the loss of appetite and weight loss indicated a positive outcome. One explanation given to this symptom constellation is that it may reflect a stress response leading to increased appetite. It is of interest to note that results during the study period showed increased stress reactions for the group who had lost their home and equally for those who had suffered no loss of their home.
Also, adverse environmental conditions after the volcanic eruption could produce a wide range of long-lasting negative psychological effects on the community as a whole.15 In the case of the volcanic eruption of Miyakejima no serious mental health problems were recorded. This may well be the result of PTSD and other disaster mental health symptoms not being given due attention in Japan.
Disaster psychiatry in Asia remained relatively dormant until the 1980s. One reason for this can be found in the stigma attached to mental health problems in Asian countries. Psychiatry or mental health activities received low recognition and were not supported or welcomed by the general public. Mental health problems were seen to be synonymous with being dangerous and lazy, and were something to explain the condition of the possessed. Individuals were reluctant to disclose their emotional or psychological problems to others particularly after being mentally traumatized. This behavior led to survivors and their family members being reluctant to seek mental health care. However, this trend has begun to change over the past decade. Disaster mental health has contributed in various ways to reducing the stigma attached to psychiatry in a few Asian countries.
In Japan and the Philippines mental health professionals became increasingly involved in emergency and long-term intervention teams following several volcanic eruptions in the 1990s. Increasingly, they have taken a more active role in disaster management, preparedness and response and have gained greater understanding of the survivors’ responses to disasters. In addition, they have participated in mental health care of survivors and undertaken research and ongoing education in disaster mental health.16,17
However, it has not been easy to overcome the reluctance or prejudice to psychiatric intervention common among the general population. When a volcano located in Nagasaki prefecture, Japan repeatedly erupted over 4 years, the Fukae town suffered heavy damage resulting in 44 deaths and the destruction of 2500 homes. To assist in reducing prejudice and stigma associated with mental health, a mental health support team from Nagasaki deliberately set out to introduce carefully designed activities to mitigate ambivalent feelings towards mental health among the survivors of the Mt Unzen-Fugen eruption in 1991.16
Team members chose to move away from the ‘medical model’ of mental health care by discarding their white clinical coats and outreaching into the community. They achieved this by organizing recreation activities such as ballgames as the first step in engaging the community collectively.16 The mental health support team worked closely with other medical personnel to assist evacuees who escaped from the ongoing volcanic activity. A report on the psychiatric intervention by the health team following the disaster focused on their experience of their mental health intervention.
The first health investigation was in December 1991 using the GHQ-30, to which a total of 56.8% of 7402 evacuees over the age of 16 years responded. The percentage of people who scored more than 8 points valued for a cut-off was 66.9% among the evacuees in contrast with 9.8% among the control group that was selected from two towns close to the danger area but which had escaped the disaster. Actual supporting activities such as counseling visits by community nurses were performed based on the results of the health investigation. A follow-up study in one area of the districts indicated that the percentage of people who scored over 8 points was reduced to 34.8% from 70.5% 4 years after the first investigation.
Psychiatrists identified 76 victims who needed therapeutic crisis intervention out of 150 interviewed during 2 years from June 1992. Women in the middle age group were at greater risk. As to the prevalence of mental illness, 58% were categorized as having depression, while 12% were diagnosed with PTSD. The outcome of crisis intervention recorded 54 remissions, six cases of exacerbation, six cases of relapse, and 10 cases in which there was no change. It was concluded that psychological dysfunction at the time of crisis improved in general with appropriate support.16
In a later follow-up study of the Mt Unzen-Fugen eruption, Ohta et al. reported on the change over time of the long-term post-disaster mental distress of the evacuees.18
Some 245 evacuees were evaluated using the GHQ-30 and its factor analysis. They found that the factor scores for depression did not improve until 44 months after the initial eruption. This was in contrast to the improvement of the remaining four factors. The authors reasoned that adverse difficulties faced by the evacuees in reconstructing their homes, re-uniting the community and the difficulties associated with readjusting to daily life situations may have been responsible for the findings. The possibility of depressive symptoms lingering longer and various clusters of symptoms persisting in victims of natural disaster are important factors that require additional research. To enhance psychosocial assistance to victims, families and caretakers of disasters, disaster psychiatry has a responsibility to undertake ongoing research to provide information that will assist such populations.
Howard et al. interviewed 351 tribal and non-tribal disaster survivors 6 years after they were displaced when Mount Pinatubo erupted in the Philippines in June 1991, causing the largest volcanic disaster of the century.17 Prevalence rates for psychiatric disorders were similar to those obtained in other studies of psychiatric intervention in natural disasters.6,16 Major depression and anxiety disorder including PTSD was the most frequent diagnosis. In the study the authors emphasized diagnosis using a DSM-IV-based semi-structured diagnostic instrument and its translation found to be comparable between Americans and Filipinos including aboriginal inhabitants.17
Typhoon and cyclone
Although PTSD is strongly emphasized in the literature on disaster psychiatry and in studies of traumatized survivors, problems related to an early phase of post-disaster psychopathology are neither homogeneous nor universal phenomena.
Both DSM-IV and ICD-10, the two most widely applied diagnostic systems, have included acute stress disorder (ASD) or acute stress reaction, PTSD and adjustment disorder in their classifications, reflecting an acknowledgment of the potential mental health outcomes from disaster and other stressful traumatic events. A wide variety of studies also suggests depression and anxiety symptoms, alcohol abuse, and psychosomatic symptoms as potential disaster sequelae.
Regarding the spectrum of acute stress responses, Van der Kolk et al. in their study of 395 traumatized treatment-seeking subjects and 125 non-treatment-seeking subjects who had also been exposed to traumatic experience, found that PTSD, dissociation, somatization and emotional dysregulation were highly interrelated.19 As a conclusion, they pointed out that PTSD, dissociation, somatization and emotional dysregulation represent a spectrum of adaptation to trauma. They often occur together, but traumatized individuals may suffer from various combinations of symptoms over time.
Research interests in trauma psychiatry include the survey on acute symptoms as predictors for later psychopathology. For example, subjects with ASD would be more liable to develop PTSD. However, the hypothesis is yet to be conclusive.
One of the reports addressing this hypothesis and based on the study in an Asia–Pacific region was carried out by Staab et al.20 They investigated 385 individuals who experienced five typhoons that struck the Guam islands in 1992. Although there were no fatalities, survivors were scattered over a wide area and suffered minor injuries. One week after the typhoon they used their own version of a 23-item scale approximating DSM-IV diagnosis of ASD to classify subjects into three groups: probable ASD; an early traumatic stress response (ETSR); and no acute diagnosis. The criteria of ETSR were composed of those of ASD without dissociative symptoms.
The study found subjects with probable ASD were significantly more likely to develop PTSD 8 months after the first typhoon and somewhat more likely to develop depression than other exposed individuals. Because subjects with ETSR did not have a poorer outcome, all acute stress symptoms do not have the same prognostic value. Furthermore, dissociative symptoms may be one of the factors contributing to the development of PTSD from an early phase of post-disaster psychopathology. However, symptom assessment and diagnostic procedure of the first study step were based on the mailed questionnaires surveyed 8 months after the first typhoon. Some recall bias accompanying the retrospective study is not entirely discarded. Further, because the subjects were junior enlisted personnel and spouses in the US military community, results of this study may not be comparable with the traumatic reactions observed in Asian individuals.20
A serial observation of psychiatric symptoms in the affected population in Sri Lanka after the cyclone disaster of 1978 was reported.21 The work was undertaken prior to the classification of PTSD in the DSM-III in 1980. Although the cluster of symptoms or technical terms associated with the disorder was not frequently used in the paper, the nature of developing traumatic stress towards psychological dysfunctions was explained. In addition, an interesting mechanism for the emergence of PTSD symptoms of a community in a developing country was explained. Patrick and Patrick identified two groups of people having early (within the first 4 weeks after the cyclone) and delayed (after 1 month) manifestation of their symptoms, in the affected area.21
The symptomatology and its prevalence rate in all subjects in the area were distributed as follows: anxiety 84%, phobia (excessive avoidance behavior) 68%, depression 41%, hallucinations (mainly in the form of high frequency whistling sound) and passivity feelings 13%, suicidal ideation 41%, and disaster syndrome (apathy, aimless wandering, mute and motionless behavior) 23%. In the control area, the reported symptoms were observed only within the first 4 weeks and were not observed after 1 month. Women were represented more in the latter group. The authors studied factors contributing to the delayed onset of symptoms in the affected area. They reasoned that group cohesiveness, strong community identity, realization of losses of other families, sympathy and sharing by the community members, and continued habitation in damaged homes acted as reminders and reinforcement. They concluded that the importance of early intervention within the community setting in a developing country must not be overlooked.21 Currently the importance of early mental health intervention is generally accepted as the hallmark of emergency intervention after catastrophic disasters, irrespective of developing or developed countries in Asia.22
Importance of disaster psychiatry in Asia.
Asian countries are constantly menaced by violent natural disasters. From approximately 3 billion people in the world affected by disasters from 1967 to 1991, approximately 85% lived in Asia. Disaster causes a wide range of psychological distress as well as physical and social distress. However, there has been little attention given to the impact of disasters on mental health following disasters throughout Asia. This was considered to be a result of the strong stigma attached to mental health problems.
Increased recognition in 1990s
In the Philippines mental health professionals began to join with emergency and long-term intervention teams following the Bagio Earthquake and Pinatubo volcanic eruptions in the 1990s. In Japan, the Hanshin Awaji earthquake marked the turning point in the popularization of PTSD and the need for mental health care for survivors. In China and Taiwan also there was a rapid growing awareness of the need to establish disaster psychiatry and related mental health activities.
Scarcity of research on disaster psychiatry in Asia
The number of the published studies on disaster-related psychological distress in Asia is limited. This is probably due to the fact that the notion of disaster psychiatry or stress-associated psychiatry is not well recognized. Recently, however, an increased number of papers related to PTSD and disaster psychiatry has appeared in Japan, China and the Philippines.
Need for standardized diagnostic criteria and its diagnostic tools
Post-traumatic stress disorder is part of a wide range of psychological reactions to disaster. The most common mental health manifestations include anxiety, insomnia and depression. Somatization is discussed as the common form of reaction to disaster in Asia. However, this was not confirmed. There exists a surprising large difference between ICD-10 and DSM-IV for the diagnostic criteria for PTSD. Researchers have also found that the use of DSM-III-R criteria resulted in a much higher frequency of PTSD compared with that of DSM-IV. The uniform criteria of DSM-IV diagnosis for PTSD are recommended for further investigations.
Role of early intervention and support to mitigate adverse effects
Several studies in Asia show the importance of post-disaster support as a key factor in reduction of PTSD among disaster victims. The relatively low prevalence of PTSD compared to that in other countries (Mexico, Azerbaijian etc.) could be attributed to strong family and community ties, lower expression of psychological content, and inclination to somatization of distress.
Role of PTSD in reducing stigma of mental health problems in Asia
Post-traumatic stress disorder is considered to be a rare diagnosis in that it does not have the stigma associated with other psychiatric diagnoses. The wide use of PTSD has contributed to a decrease in the stigma attached to post-disaster mental illness in Japan and in the Philippines. This may also be true for other Asian countries.
Disaster psychiatry in Asia did not exist as a psychiatric discipline until the 1980s. However, during the 1980s and 1990s, disaster mental health gained an increase in attention as a result of major disasters in Asia.
At present, disaster mental health is being recognized as an important psychiatric discipline in many Asian countries. Also, it will be a useful tool to deal with and mitigate mental health problems caused by natural disasters as well as manmade disasters in Asia.