|AWARD PAPER: DR. G. C. BORAL AWARD II
|Year : 2015 | Volume
| Issue : 1 | Page : 29-36
Psychological well-being in primary survivors of Uttarakhand disaster in India
Srikant Sharma1, Satyam Sharma1, Manisha Chandra1, Shaily Mina2, Yatan Pal Singh Balhara3, Rohit Verma3
1 Department of Psychiatry, Post Graduate Institute of Medical Education and Research and Dr. Ram Manohar Lohia Hospital, New Delhi, India
2 Department of Psychiatry, Lady Hardinge Medical College and Smt. S. K. Hospital, New Delhi, India
3 Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||3-Aug-2015|
Dr. Rohit Verma
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
Introduction: After the 2004 Tsunami, India faced the worst natural disaster in Uttarakhand causing devastating floods and landslides. Besides the material harm, the disaster also has a massive impact on individual's mental health, and the impact is perceived more in developing countries due to being densely populated with limited resources. The current study is an attempt to evaluate the psychological impact and its risk factors in Uttarakhand disaster. Methods: This cross-sectional study was conducted after 1 month of disaster in the primary survivors. All the included subjects were administered the semi-structured proforma for assessing the sociodemographic profile and the assessment instruments: Impact of events scale-revised (IES-R), depression anxiety stress scale and life orientation test-revised (LOT-R). Data were imputed and analyzed using Statistical Package for Social Sciences version 17.0.1 (SPSS Inc., Chicago, IL, USA). Results: About 58% subjects had posttraumatic stress disorder and significantly severe levels of depression, anxiety, and stress were noted in 45.3%, 57%, and 44.2% subjects, respectively. A physical illness was present in 36% subjects. Loss of at least one family member was reported by 12.8% subjects. LOT-R scores were negatively correlated to IES-R. Conclusion: Psychological morbidity in the immediate post-disaster period is high. Higher levels of depression, anxiety and stress with development of negative outlook regarding their future is observed with increasing age. Increasing age, lower educational levels, physical illness, loss of a family member, and pessimistic expectations were associated with adverse psychological sequelae.
Keywords: Depression, disaster, psychological, stress, survivors, Uttarakhand
|How to cite this article:|
Sharma S, Sharma S, Chandra M, Mina S, Singh Balhara YP, Verma R. Psychological well-being in primary survivors of Uttarakhand disaster in India. Indian J Soc Psychiatry 2015;31:29-36
|How to cite this URL:|
Sharma S, Sharma S, Chandra M, Mina S, Singh Balhara YP, Verma R. Psychological well-being in primary survivors of Uttarakhand disaster in India. Indian J Soc Psychiatry [serial online] 2015 [cited 2019 Jul 15];31:29-36. Available from: http://www.indjsp.org/text.asp?2015/31/1/29/161998
| Introduction|| |
India faced the country's worst natural disaster, since the 2004 Tsunami, in June 2013 when a multi-day cloudburst centered on the North-Indian state of Uttarakhand caused devastating floods and landslides triggering one of the worst humanitarian disasters in Uttarakhand region affecting over 100,000 people and claiming over 5000 lives.  Though, some parts of Himachal Pradesh, Haryana, Delhi, and Uttar Pradesh in India, some regions of Western Nepal, and some parts of Western Tibet also experienced heavy rainfall, over 95% of the casualties occurred in Uttarakhand. India is prone to natural disasters and is considered as one of the most disaster-prone area in the world due to its climatic and geographical features with 58.7% of land mass prone to earthquakes, 12% to floods, 68% to drought, and 8% to cyclone. 
Disaster is understood as a sudden unexpected event leading to vast losses in form of ecological, economical, psychosocial, and psychological which exceeds the coping capacity of the affected society, cause of which can be either natural or manmade.  It affects individuals, families, and community in many spheres from death to disability, loss of job, home, and social ties. Besides the physical loss, it also has a massive impact on individual's mental health. The psychological response post-disaster has been divided into various phases-evaluations of damage, heroic phase, honeymoon phase, disillusionment, and reconstruction. Few studies have divided these phases as immediate, short-term, and long-term sequelae. Immediate period is the time when the disaster is occurring followed by short-term lasting 3-9 months and then comes the long-term phase, which in some cases even persists lifelong.  Duration of each of the phases vary depending upon the cause of disaster, enormity of disaster, extent of community affected, its preparedness, ongoing disruption, support, past exposure to similar situation, sociodemographic and individual factors of the victim, female gender, age, low socioeconomic status, ethnicity, migrant population, previous psychiatric illness, personality, physical, and mental well-being. 
The prevalence of psychological problems is witnessed in very high proportion of the survivors ranging from 20% to 35% after a natural disaster. The prevalence of psychopathology increases by 17% after a disaster in contrast to pre-disaster period.  A cluster of symptoms in disaster survivors as "disaster syndrome" has been mentioned which is characterized by stunned and apparently disengaged behavior with prevalence varying between 25% and 75%. 
Common psychiatric conditions seen after a disaster are - posttraumatic stress disorder (PTSD), grief reaction, depression, anxiety, and substance use.  High-risk of suicide is also found after a disaster.  Stress reactions, clinging behavior, heightened dependency are few of the symptoms to be looked for in children and adolescent group during the disaster.  Elderly population is at greater risk of exposure to psychological breakdown since India being a joint family setup causes an immense transition in the living arrangement after the disaster which this group finds difficult to cope with.
The impact of a disaster is perceived more in developing countries due to being densely populated with limited resources.  Figley et al. listed five criteria for the determination of a disaster's impact: (a) knowledge about the magnitude of loss, (b) knowledge of the hazard, (c) knowledge of recurring risk, degree of warning and preparedness at the individual as well as at the community level, (d) scope of impact to community functioning, and finally, (e) chance of escaping during or immediately after the disaster strikes. 
There have been many researches done on the impact of disaster on mental wellbeing but there is disparity in research practices, prevailing policies, and the services provided in developing countries like India depriving the vast majority of the benefit of modern psychiatric treatments. The purpose of the current study was to expand current knowledge regarding psychological reactions to traumatic events and the relationship between optimistic and pessimistic traits among survivors of Uttarakhand disaster in India. The study aimed to evaluate the acute psychological impact and its risk factors in Uttarakhand disaster among primary survivors.
| Methods|| |
The study was conducted in August 2013, after 1 month of Uttarakhand disaster. The cases in the study population were defined as primary survivors of the flood. As defined by Young et al.,  a primary survivor is the individual exposed directly to the disaster.
Impact of events scale-revised
This is a self-rating scale of trauma-related symptoms and is now the most extensively used scale of its kind worldwide. , The impact of events scale (IES) measures current subjective emotional distress related to a specific event.  It is recognized as a valid self-report tool for assessing traumatic stress.  The IES consists of a total score and three subscales: (1) avoidance, (2) hypervigilance, and (3) intrusiveness; these are consistent with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR) diagnostic criteria for PTSD, which include symptoms of avoidance, hyper excitability, and flashbacks.  However, the original IES cannot measure hyper-arousal, which is one of the core characteristics of PTSD. Weiss and Marmar developed the revised IES (IES-R) to include hyper-arousal.  In the IES-R, the 15 questions of the original IES were expanded into 22 questions and were reconstructed to measure 8 intrusion symptoms, 8 avoidance symptoms, and 6 hyper-arousal symptoms. The scoring system was also modified: The original IES evaluated the frequency of the symptoms during the preceding week using a four-point scale (0-1-3-5), and the IES-R evaluates the severity of the symptoms during the preceding week using a five-point scale (0-4). Higher scores indicate greater severity of symptoms. Creamer et al. reported that a total score of 33 on the IES-R is a predictor of PTSD.  A significant relationship between IES-R scores and number of symptoms of PTSD has been demonstrated.  IES-R has been used in Indian research studies and validated with Indian populations. ,,
Depression anxiety stress scale
This is a 42-item self-report measure of depression, anxiety, and stress.  The depression and anxiety subscales of the depression anxiety stress scale (DASS) are reported to be consistent with Clark and Watson's constructs of low positive affect and physiological hyper-arousal, although the correspondence of stress to their negative affect construct is unclear. , Psychometric studies, however, suggest that the DASS measures general psychological distress while still maintaining some distinction between the three separate constructs.  The current study utilized the short-form version of the DASS, which consists of 21 items in comparison to the 42-items of the long form.  It consists of three 7-item subscales with each item scored on a four-point Likert scale, ranging from 0 (did not apply to me at all) to 3 (applied to me very much or most of the time). Total scores are calculated by summing the items on each subscale, giving a score range of 0-21 on each subscale. Scores above 10, 7, and 12 on the depression, anxiety, and stress subscales, respectively are indicative of severe levels. The DASS shows good convergent and discriminant validity, and high internal consistency and reliability and have been previously used in Indian population with Cronbach's alpha reported at 0.94, 0.88, and 0.93 for depression, anxiety, and stress, respectively. ,
Life orientation test-revised
Life Orientation Test (LOT) is designed to express generalized expectations of positive life events and measures dispositional optimism.  It is a self-report questionnaire assessing an individual's tendency to expect positive compared to negative outcomes. LOT has 12 items consisting of 8 items (four fillers) and reflects a single bipolar dimension in which higher scores indicate greater optimism or less pessimism. Conversely, the LOT optimism and pessimism subscale scores reflect separate unipolar dimensions. The revised version (LOT-R) has 10 items (6-item measure with four additional filler items) with 3 items being positively phrased, and 3 items being negatively phrased.  Participants rated each item by indicating the extent of their agreement on a five-point Likert scale, ranging from "strongly agree" to "strongly disagree." Items are summed to produce a total score (from 0 to 24 points) as well as separate optimism and pessimism subscale scores. Overall, the higher the score, the higher the level of optimism is reported. Research has demonstrated test-retest reliability of 0.68, 0.60, 0.56, and 0.79, at 4, 12, 24, and 28 months, respectively. 
Though the IES-R, DASS, and LOT-R are self-administered questionnaires, bearing in mind the low literacy levels of the local population and lack of familiarity with questionnaires, the scales were used as an interviewer-administered questionnaire in this study. A single interviewer read out the questions to each of the subjects in this study population and recorded their oral response.
All the primary survivors coming in contact with the treating team during the study period of 2 weeks and providing informed consent were included in the study with convenience sampling. Subjects below 18 years of age or reporting previous history of psychiatric illness were excluded. All the included subjects were administered the semi-structured performa for assessing the sociodemographic profile and the assessment instruments. The study was non-funded and ethical considerations were kept in keeping with the Helsinki declaration.
Data were imputed and analyzed using Statistical Package for Social Sciences version 17.0.1 (SPSS Inc., Chicago, IL, USA). Analysis of variance was done to determine in between group differences based on sociodemographic parameters, loss of a family member, presence or absence of PTSD and optimism-negativism trait. Internal consistency of IES-R, DASS, and LOT-R was assessed by Cronbach's alpha coefficient, and values of 0.70 or greater were considered satisfactory. Pearson's correlation was used to calculate the correlation between different questionnaires and other variables such as sociodemographic parameter and total number of family members.
| Results|| |
A total of 86 subjects were included in the current study. All subjects consented to participate after having been explained the aims of the study, procedures involved, and time required for participation. The mean age of the subjects was 36.9 ± 14.2 years. The mean number of individuals in the families of subjects was 5 ± 2.05. [Table 1] provides the sociodemographic details of the study population.
Impact of events scale-received scale and subscales revealed high reliability (IES-R-intrusion α = 0.81, IES-R-avoidance α = 0.83, IES-R-hyper-arousal α = 0.83, and IES-R-total α = 0.88). Significant relationships (P < 0.001) were found between the individual IES-R subscales and total scores.
The internal consistency reliability was high for the DASS total scale and each subscale according to Cronbach's coefficient alphas: Total (α = 0.88); depression (α = 0.82); anxiety (α = 0.85); and stress (α = 0.82). The Pearson correlation coefficient between the subscales was significant (r = 0.88-0.93, P < 0.001).
For LOT-R scale, the reliability was significant with Cronbach's α ranging from 0.70 to 0.77 for individual items and 0.76 for a total score. All the items were significantly correlated with each other and total scores (P < 0.01).
About 58% subjects scored more than 33 on IES-R. Significantly severe levels of depression, anxiety, and stress were noted in 45.3%, 57%, and 44.2% subjects, respectively [Table 2]. A physical illness was present in 36% subjects.
Loss of at least one family member was reported by 11 (12.8%) subjects while others (n = 75, 87.2%) themselves suffered but without losing any family member. On comparing the groups based on loss of a family member, a significant score was found in all the assessment scales [Table 3]. Similarly, the presence of physical illness also led to significant differences on all scales.
There was no significant difference on gender comparison for any scale scores (IES-R-intrusion: 0.41; IES-R-avoidance: 0.42; IES-R-hyper-arousal: 0.29; IES-R-total: 0.37; DASS-D: 0.73; DASS-A: 0.29; DASS-S: 0.09; LOT-R: 0.67).
Based on the marital status, there was no significant group difference in scores of IES-R-intrusion: 0.93, IES-R-avoidance: 0.21, IES-R-hyper-arousal: 0.14, IES-R-total: 0.13, DASS-D: 0.06 and DASS-A: 0.33. However, married subjects had higher scores of DASS-S and lower scores of LOT-R (P = 0.01 and 0.004, respectively).
On comparison by education, there was a significant difference in P value for all scale scores (IES-R-intrusion: 0.01; IES-R-avoidance: 0.01; IES-R-hyper-arousal: 0.01; IES-R-total: 0.01; DASS-D: 0.01; DASS-A: 0.01; DASS-S: 0.002; LOT-R: 0.04).
There was no significant difference in assessment scale scores on the basis of family background, family type, socioeconomic status, and total number of family members.
Losing a family member in the incident was positively correlated to scale scores of IES-R-Intrusion (r = 0.28, P = 0.01), IES-R-hyper-arousal (r = 0.27, P = 0.01), IES-R-total (r = 0.25, P = 0.01), DASS-D (r = 0.25, P = 0.01), and DASS-A (r = 0.23, P = 0.03) but not to IES-R-Avoidance (r = 0.20, P = 0.05), and DASS-S (r = 0.17, P = 0.11). The scores were negatively correlated to LOT-R scores (r = −0.32, P = 0.003).
As expected, increasing age positively correlated with being married (r = 0.71, P < 0.000) and negatively correlated to a higher education (r = −0.24, P = 0.02). Increasing age was positively correlated to assessment scale scores of IES-R-intrusion (r = 0.27, P = 0.01), IES-R-avoidance (r = 0.25, P = 0.02), IES-R-hyper-arousal (r = 0.24, P = 0.02), IES-R-total (r = 0.26, P = 0.01), DASS-D (r = 0.25, P = 0.02), DASS-A (r = 0.21, P = 0.04), and DASS-S (r = 0.32, P = 0.002) and was negatively correlated to LOT-R scores (r = −0.35, P = 0.001).
Being married was negatively correlated to LOT-R scores (r = −0.31, P = 0.004). Education family background, family type, socioeconomic status, and total number of family members were not found to be significantly correlated to any assessment scale scores.
LOT-R scores were negatively correlated to scale scores of IES-R-intrusion (r = −0.67, P < 0.001), IES-R-avoidance (r = −0.63, P < 0.001), IES-R-hyper-arousal (r = −0.69, P < 0.001), IES-R-total (r = −0.67, P < 0.001), DASS-D (r = −0.61, P < 0.001), DASS-A (r = −0.57, P < 0.001), and DASS-S (r = −0.59, P < 0.001).
| Discussion|| |
The current study evaluated psychological health after 1 month in 86 survivors of Uttarakhand disaster. It was observed that about 58% of survivors had PTSD and severe levels of depression and anxiety were noted in 45.3% and 57% subjects, respectively. About 44% had perceived the disaster situation as a significant stressor.
Indian studies have reported the prevalence of psychiatric morbidity after natural disaster ranging from 8% to 89%.  The prevalence varies according to the type and extent of natural disaster encountered. The prevalence of psychiatric morbidity is reportedly lower in natural disasters of smaller region involvement like that of 7.8% in a study in Delhi slum following a fire disaster,  while the prevalence is reportedly higher in disasters involving larger areas for, e.g., 80% in Tsunami or 89% in Latur earthquake. , Similar to findings of the current study, the prevalence of PTSD, depression, and anxiety disorders is reported to be highest among the psychological disorders encountered in such populations.  Worldwide data also supports these findings of the high prevalence of mental disorders in disaster affected population.  High prevalence rates in the study could be attributed to factors such as Uttarakhand being a backward place in terms of resources available, transportation facility, disaster preparedness, poor construction of houses, which caused massive impact.
Literature reports of mixed findings when considering the importance of age in disaster survivors. In a study of Chernobyl victims, older adults displayed lesser fears of health risks than younger individuals.  In a summary of Gulf-war related studies, it was observed that younger adults reported more psychological distress and health complaints compared to older adults.  Conversely, findings of stronger concerns or depression by elderly survivors in the aftermath of natural disasters have also been reported.  Indian studies on the aftermath of a natural disaster have also highlighted the acute psychological effects, specifically the risk of PTSD and depression, to be more in elderly people. , In accordance with the findings of Indian disaster data, increasing age was found to be positively affected by the impact of the event having higher levels of depression and anxiety. Furthermore, disaster was found to be more stressful in older age group. This could be due to the potential for deprivation and physical ailment, cognitive problems leading to decreased capacity to cope with a sudden change in the environment, dependency on others, and reluctance to seek medical aid. Furthermore in India, the majority of the elderly group stay in the joint family so they might find it difficult to handle a situation independently. The study also highlighted that older age group had a lack of positive outlook regarding their future.
Earlier studies have found lower socioeconomic status to be associated with increased post-disaster distress.  The study on mental health consequences of super-cyclone in Orissa reported that persons with lower socioeconomic status were more affected especially by anxiety and depressive disorders and equally affected by PTSD. The insignificant difference observed could be due the disproportionate population in the current study with the majority of the population belonging to the lower socioeconomic status.
In harmony with previous studies, psychiatric morbidity was found to be more prevalent in those with lesser or no education as compared to higher education. ,, The reason could be that lower educated group are mainly from lower socioeconomic status, therefore, face more impact of financial loss in the form of job, land, and home. They may be deprived of any financial backup like life policies, which would aid in recovering the losses.
Evaluation of gender in the majority of the studies has found females to be having a more psychological impact after the disaster in comparison to men. , However, few studies in contrary to above have opposite findings of males having more psychiatric morbidity in comparison to females.  The reason that the current study found no significance of gender could be noncomparability in the two groups due to significantly more male participants in the study sample. Furthermore, males being expected to being heroic or independent, have amplified chances of self-destructive "coping strategies" involving interpersonal violence and substance abuse, and masculinity norms which may limit their ability to ask for needed help.  Other reason could be the gender role defined in Indian society with males being portrayed as a protector of the family, which inadvertently would discourage him to portray symptoms.
It was observed that three-fourth of the participants were married. Married individuals had more stress and negative prospect regarding their future. Reason could be that there might have been separation or death of one of the couples acting itself as a significant stressor.  Furthermore, both single and married couple had comparability in terms of prevalence of anxiety and depression. Solomon et al. inferred exposed married couples faced new marital and parental challenges and burdens after disasters and, therefore, become as vulnerable as a single survivor.  Other reason could be that preexisting marital discord, which got aggravated in disaster further affecting their existing stress level and also decreasing their tolerance to stress.
Not only did loss of a family member rendered survivors to suffer more psychological problems, but also developed more pessimistic expectations toward future in them compared to survivors who had not lost any family member. Similar to current observations, a study in Norwegians who lost family and were themselves directly exposed to the Tsunami reported the presence of complicated grief to be almost twice in comparison to the nonloss group.  Stroebe et al. that loss of loved ones and direct trauma or life-threat in combination may intensify both grief and posttraumatic stress reactions, and can delay, prolong or even hinder processing of the loss and also have long-term effect on individual's mental health.  Furthermore, closer the relationship of the survivor with the death of family member more is the severity of the psychiatric symptomatology. Studies have mentioned two types of exposure: A proximal exposure, which refers to events and consequences that occur during the approximate period of the disaster itself, that is, loss of someone, and a distal exposure in the disaster's aftermath, that is, loss of home. More proximal the exposure more is the distress in turn leading to psychiatric problems.  Kar et al. mentions death in the family as a significant factor increasing the vulnerability for psychiatric morbidity, PTSD, anxiety disorders, and depressive disorders.  Studies also report that there is an association between more violent loss (either natural or manmade) and the prevalence of both depression and PTSD. ,, In an investigation of bloody Sunday, investigators found highest IES-R mean scores in the immediate family of victims who lost their lives.  Factors, which can further worsen the psychopathology are a lack of social support, female gender, loss of a child, and lack of confirmation of the death.  Indian culture is family oriented which has a strong emotional bonding among the family members with a strong reliance on family for social support in comparison to developed countries. Therefore, a sudden loss of a member during a disaster is perceived as very stressful ending up having a psychological breakdown. This type of family structure causes hindrance in accepting support from others.  Fatalism, a tendency to attribute the suffering to a higher power, such as nature or God, is practiced in Indian culture. It has been suggested that in the event of distress, such practice can lead to poor psychological outcomes because one's personal power is perceived as minimal.  There is need for an integrated approach to creating a more cohesive and coherent disaster preparedness and prevention, in which people at risk receive, understand and act on the warning information conveyed, along with a region specific post-disaster action plan. 
Though the current study is limited by its sample size and cross-sectional assessment, it depicts the immediate disaster aftermath psychological morbidity. A larger sample could not be accumulated due to a shortage of resources and personnel.
The results were compelling and it is likely the findings were related to the disaster event, but without baseline data for the study population or comparison to a similar population it is difficult to accept that the findings were entirely the result of the stressing event. Furthermore, as this was a convenience sampling method, it is possible that the participants may or may not be representative of the total exposed population making the understanding of the generalizability of study difficult.
Future studies should prospectively follow-up the Uttarakhand survivors in the longer term to evaluate the psychological morbidity and develop effective interventions for managing them.
| Conclusion|| |
There is a high prevalence of psychological morbidity in the immediate post-disaster period. Increasing age has higher levels of depression, anxiety, and stress with the development of negative outlook regarding their future. Increasing age, lower educational levels, physical illness, loss of a family member, and pessimistic expectations were associated with adverse psychological consequences.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]