Six years after the wave. Trajectories of posttraumatic stress following a natural disaster

Behavioral activation is associated with post-disaster mental health: Secondary longitudinal analysis from a population-based study

OBJECTIVE

Interventions in post-disaster environments may be accelerated by identifying protective behavioral factors adding incremental value to models of psychopathology using longitudinal methods. One protective behavior applicable to post-disaster contexts is behavioral activation (BA). BA is defined here as a behavioral pattern involving presence of valued activity engagement. While relevant post-disaster, the incremental value of BA behaviors in predicting longitudinal post-disaster outcomes is not well understood. We hypothesized that higher baseline engagement in behaviors consistent with a BA framework would predict decreased posttraumatic stress disorder (PTSD) symptom severity, depression symptom severity, and sleep disturbance approximately 3, 6, and 12 months after hurricane survivors completed baseline measures.

METHODS

The current study is a secondary analysis from a randomized controlled trial of a disaster mental health digital intervention. Participants completed surveys at baseline and approximately 3, 6, and 12 months post-enrollment. Correlations and hierarchical regression analyses were calculated following data screening to predict PTSD symptom severity, depression symptom severity, and sleep disturbances.

RESULTS

Controlling for alcohol use, prior trauma, displacement, and intervention condition, higher baseline BA consistently predicted less PTSD symptom severity, depression symptom severity, and sleep disturbances.

CONCLUSION

Results suggest that post-disaster interventions should consider addressing BA. The study provides evidence that BA is potentially an important protective factor longitudinally predicting sleep disturbances and psychopathology after natural disasters.

Trajectories of post-traumatic stress in sepsis survivors two years after ICU discharge: a secondary analysis of a randomized controlled trial

BACKGROUND

Post-traumatic stress has been identified as a frequent long-term complication in survivors of critical illnesses after sepsis. Little is known about long-term trajectories of post-traumatic stress and potentially modifiable risk factors following the ICU stay. Study objective was to explore and compare different clinical trajectories of post-traumatic stress symptoms in sepsis survivors up to two years after discharge from ICU.

METHODS

Data on post-traumatic stress symptoms by means of the Post-traumatic Symptom Scale (PTSS-10) were collected in sepsis survivors at one, six, 12 and 24 months after discharge from ICU. Data on chronic psychiatric diagnoses prior ICU were derived from the primary care provider's health records, and data on intensive care treatment from ICU documentation. Trajectories of post-traumatic symptoms were identified ex post, discriminating patterns of change and k-means clustering. Assignment to the trajectories was predicted in multinomial log-linear models.

RESULTS

At 24 months, all follow-up measurements of the PTSS-10 were completed in N = 175 patients. Three clusters could be identified regarding clinical trajectories of PTSS levels: stable low symptoms (N = 104 patients [59%]), increasing symptoms (N = 45 patients [26%]), and recovering from symptoms (N = 26 patients [15%]). Patients with initially high post-traumatic symptoms were more likely to show a decrease (OR with 95% CI: 1.1 [1.05, 1.16]). Females (OR = 2.45 [1.11, 5.41]) and patients reporting early traumatic memories of the ICU (OR = 4.04 [1.63, 10]) were at higher risk for increasing PTSS levels.

CONCLUSION

Post-traumatic stress is a relevant long-term burden for sepsis patients after ICU stay. Identification of three different trajectories within two years after ICU discharge highlights the importance of long-term observation, as a quarter of patients reports few symptoms at discharge yet an increase in symptoms in the two years following. Regular screening of ICU survivors on post-traumatic stress should be considered even in patients with few symptoms and in particular in females and patients reporting traumatic memories of the ICU.

Resilience and Disaster: Flexible Adaptation in the Face of Uncertain Threat

Disasters cause sweeping damage, hardship, and loss of life. In this article, we first consider the dominant psychological approach to disasters and its narrow focus on psychopathology (e.g., posttraumatic stress disorder). We then review research on a broader approach that has identified heterogeneous, highly replicable trajectories of outcome, the most common being stable mental health or resilience. We review trajectory research for different types of disasters, including the COVID-19 pandemic. Next, we consider correlates of the resilience trajectory and note their paradoxically limited ability to predict future resilient outcomes. Research using machine learning algorithms improved prediction but has not yet illuminated the mechanism behind resilient adaptation. To that end, we propose a more direct psychological explanation for resilience based on research on the motivational and mechanistic components of regulatory flexibility. Finally, we consider how future research might leverage new computational approaches to better capture regulatory flexibility in real time.

Illusory posttraumatic growth is common, but genuine posttraumatic growth is rare: A critical review and suggestions for a path forward

Over the last 2.5 decades, trauma researchers have increasingly become interested in posttraumatic growth (PTG) - the concept that some people experience growth as a result of trauma exposure. I begin by reviewing extant research on PTG, with a focus on measurement and conceptual issues. Expanding on arguments made by others, I distinguish between three forms of PTG, 1) perceived PTG, which is an individual's beliefs about their own PTG, 2) genuine PTG, which is veridical growth following adversity, and 3) illusory PTG, which is motivated fabrications of PTG. Perceived PTG is extremely common, as over half of individuals exposed to a potentially traumatic event (PTE) report moderate or greater levels of PTG. I review evidence that most self-reports of PTG are greatly exaggerated and argue that perceived PTG is mostly illusory PTG. I propose five reasons for the disconnect between perceived PTG and genuine PTG, including design flaws in the current measurements, emotional biases that favor perceived PTG, the inherent appeal of PTG, cultural expectations, and problems of definition. I then review the empirical evidence concerning the prevalence rate of genuine PTG, coming to the bold conclusion that the occurrence of genuine PTG is very rare, contradicting current fundamental beliefs about PTG. I recommend researchers focus on the key areas of measurement and etiology of genuine PTG, which are necessary to create interventions that foster genuine PTG. I conclude by outlining a path to steer the scientific progression of PTG back in the right direction.

Incidence and factors impacting PTSD following the 2005 Eyre Peninsula bushfires in South Australia - A 7 year follow up study

OBJECTIVES

To identify the incidence and factors impacting post-traumatic stress disorder (PTSD) at 6 months, 2 and 7 years following the 2005 Eyre Peninsula bushfires in South Australia.

METHODS

A questionnaire was used to assess symptoms.

DESIGN AND SETTING

A longitudinal follow-up study with responses collected from a self-report booklet.

PARTICIPANTS

179 respondents were present at 6 months post bushfires, with 103 and 87 participants at 2 and 7 years, respectively.

MAIN OUTCOME MEASURES

PTSD rates and its precipitating factors.

RESULTS

The proportion of PTSD cases at times 1, 2 and 3 were 13.4% (24/179), 10.7% (11/103), and 4.8% (4/87), respectively. At 6 months, terrifying experience of fire reduced odds of developing PTSD (Odds Ratio [OR]: 0.45; 95% CI 0.21-0.96) while relocation increased odds (OR: 2.93; 95% CI 1.06-8.08). At 2 years, relocation (OR: 6.81; 95% CI 1.07-43.41) was a positive predictor. At 7 years, personal loss from the fires (OR: 2.82; 95% CI 1.17-6.77) positively predicted PTSD.

CONCLUSION

PTSD rates declined over time. Relocation may be a proxy measure of high levels of emotional trauma. Those most traumatised probably decided to relocate, and hence, relocation should be considered a trigger for PTSD in the aftermath of bushfire.

Media perception and trust among disaster survivors: Tsunami survivors' interaction with journalists, media exposure, and associations with trust in media and authorities

A critical part of disaster communication is media coverage in the interface of the afflicted, media, and authorities. One communication key is building trust. Disaster survivors encounter journalists in a high-stress context, but little is known about their perceptions of these interactions and the subsequent media exposure. The aim of this study is to explore how survivors 6 years after a major disaster perceived their encounters with journalists and exposure in the media, as well as their level of trust in the media, compared with government and authorities. Data were used from a longitudinal study of Swedish tourists, repatriated from the 2004 Indian Ocean tsunami, surveyed up to 6 years after the tsunami to assess posttraumatic stress (PTS) and effects on mental health. At 6 years after, the survey included questions about survivors' perceptions of journalist interactions (reported by n = 311), of their own media exposure (n = 177), and survivors' trust in media organizations and public authorities (n = 1,181). Tsunami survivors mainly perceived interactions with journalists as being professional. There were 14% who reported that the interactions were supportive and 17% that the interactions were a strain. Similarly, most participants had a neutral view concerning the subsequent media coverage or exposure, although 12% experienced media exposure as stressful and 12% reported that it had been involuntary. Finally, the survivors indicated higher confidence and trust in Swedish radio and TV as compared to the Swedish authorities, and the participants' level of trust in the media was associated with their perceptions of journalists, r = 0.34, p < 0.001, and media coverage, r = 0.47, p < 0.001. Disaster survivors mainly agreed with emotionally neutral statements about interacting with the media, the performance of journalists on site, and their own media exposure. Nonetheless, a substantial minority found the encounters and exposure to be negative, and the results suggest a link between personal experiences or perceptions and trust in the media.

Time course of symptoms in posttraumatic stress disorder with delayed expression: A systematic review

OBJECTIVE

To examine the hypothesis that PTSD with delayed expression in some cases occurs without subthreshold PTSD symptoms above background levels bridging the gap between the traumatic exposure(s) and the clinical diagnosis.

METHODS

We performed systematic searches of peer-reviewed papers in English referenced in Pubmed, Embase, or PsycINFO and ascertained 34 prospective studies of PTSD symptom trajectories identified by latent class growth statistical modeling. Studies with delayed and low-stable trajectories provided appropriate data for this study. We computed the difference between the delayed trajectory PTSD symptom sumscore and the low-stable PTSD sumscore at the observed points in time after the traumatic event(s).

RESULTS

In 29 study populations, the latent class growth analyses displayed delayed trajectories, and in these, we identified 110 data points (% PTSD sumscore difference/months since traumatic exposure). The median PTSD symptom sumscore was 25% higher during the initial 6 months among individuals in the delayed trajectory compared to those in low-stable trajectory. From this level, the difference widened and reached a plateau of 40-50% higher. The variation was large, and the baseline participation rate and loss to follow-up were exceeding 25% in the majority of the studies. Heterogeneity of populations, measures, and analyses precluded formal meta-analysis.

CONCLUSION

Delayed PTSD is preceded by PTSD symptoms during the first year in most cases. Still, few individuals may experience an asymptomatic delay. The results underpin the rationale for monitoring PTSD symptoms and may inform forensic assessments in that delayed PTSD without symptoms bridging the traumatic event is rare.

Sex-differential PTSD symptom trajectories across one year following suspected serious injury

BACKGROUND

Recent years have shown an increased application of prospective trajectory-oriented approaches to posttraumatic stress disorder (PTSD). Although women are generally considered at increased PTSD risk, sex and gender differences in PTSD symptom trajectories have not yet been extensively studied.

OBJECTIVE

To perform an in-depth investigation of differences in PTSD symptom trajectories across one-year post-trauma between men and women, by interpreting the general trends of trajectories observed in sex-disaggregated samples, and comparing within-trajectory symptom course and prevalence rates.

METHOD

We included N = 554 participants (62.5% men, 37.5% women) from a multi-centre prospective cohort of emergency department patients with suspected severe injury. PTSD symptom severity was assessed at 1, 3, 6, and 12 months post-trauma, using the Clinician-Administered PTSD Scale for DSM-IV. Latent growth mixture modelling on longitudinal PTSD symptoms was performed within the sex-disaggregated whole samples. Bayesian modelling with informative priors was applied for reliable model estimation, considering the imbalanced prevalence of the expected latent trajectories.

RESULTS

In terms of general trends, the same trajectories were observed for men and women, i.e. resilient, recovery, chronic symptoms and delayed onset. Within-trajectory symptom courses were largely comparable, but resilient women had higher symptoms than resilient men. Sex differences in prevalence rates were observed for the recovery (higher in women) and delayed onset (higher in men) trajectories. Model fit for the sex-disaggregated samples was better than for the whole sample, indicating preferred application of sex-disaggregation. Analyses within the whole sample led to biased estimates of overall and sex-specific trajectory prevalence rates.

CONCLUSIONS

Sex-disaggregated trajectory analyses revealed limited sex differences in PTSD symptom trajectories within one-year post-trauma in terms of general trends, courses and prevalence rates. The observed biased trajectory prevalence rates in the whole sample emphasize the necessity to apply appropriate statistical techniques when conducting sex-sensitive research.

The dynamic course of psychological outcomes following the Victorian Black Saturday bushfires

OBJECTIVES

To profile the long-term mental health outcomes of those affected by the 2009 Black Saturday bushfires and to document the course of mental health since the disaster.

METHOD

The longitudinal Beyond Bushfires study included 1017 respondents (Wave 1; 3-4 years after the fires), 736 (76.1%) at Wave 2 (5 years after the fires) and 525 (51.6%) at Wave 3 (10 years after the fires). The survey indexed fire-related and subsequent stressful events, probable posttraumatic stress disorder, major depressive disorder, alcohol use, severe distress and receipt of health services for mental health problems.

RESULTS

Relative to their status 3-4 years after the fires, there were reduced rates of fire-related posttraumatic stress disorder (6.2% vs 12.2%), general posttraumatic stress disorder (14.9% vs 18.7%) and severe distress (4.4% vs 7.5%) at 10 years. There were comparable rates between Wave 1 and Wave 3 for depression (10.9% vs 8.3%) and alcohol abuse (21.8% vs 18.5%). Of people in high-affected regions, 22.1% had posttraumatic stress disorder, depression or severe distress at Wave 3. One-third to one-half of participants who reported probable posttraumatic stress disorder or depression at any assessment did not display the disorder at the next assessment. Worsening of mental health at Wave 3 was associated with the extent of property loss, exposure to recent traumatic events or recent stressful life events. Only 24.6% of those with a probable disorder had sought professional help for this in the previous 6 months.

CONCLUSION

Approximately one-fifth of people from high-affected areas have a probable psychological disorder a decade after the fires. Mental health appears to fluctuate for those who are not consistently resilient, apparently as a result of ongoing stressors. The observation that most people with probable disorder are not receiving care highlights the need for further planning about managing long-term mental health needs of disaster-affected communities.

Trajectories of Posttraumatic Growth and Their Associations With Quality of Life After the 2011 Tohoku Earthquake and Tsunami

The 2011 Tohoku earthquake and tsunami in Japan was an extraordinarily stressful incident that caused harmful psychological reactions, such as posttraumatic stress disorder (PTSD), among affected individuals. However, a proportion of exposed individuals experienced posttraumatic growth (PTG), characterized by a noticeable degree of personal strength, spirituality, life appreciation, perception of new possibilities in life, and enhanced relationships with others. Some researchers have argued that these positive reactions may be an illusory change related to coping with traumatic events. We examined trajectory patterns related to PTG Inventory (PTGI) subscales to elucidate the existence of both real and illusory growth regarding quality of life (QoL), utilizing group-based trajectory models. Three online questionnaires were distributed at 6 months (N = 2,554; M age = 47.04 years, SD = 12.62), 12 months (N = 887; M age = 48.11 years, SD = 12.43), and 42 months (N = 560; M age = 48.86 years, SD = 12.25) postdisaster. Participants responded to items related to demographic characteristics, disaster experiences, posttraumatic stress symptoms, PTG, and QoL. Three main PTG trajectories emerged, characterized by growth, no growth, and illusory growth, with QoL as a time invariant covariate. Compared with the growth trajectory, the odds ratios (ORs) for no growth ranged from 2.27 to 5.04; for illusory growth, the ORs ranged from 2.09 to 4.67. To our knowledge, this was the first study to report growth trajectories related to PTGI subscales and their underlying differences in psychological mechanisms and processes following the 2011 Tohoku earthquake and tsunami.

Anxiety and resilience in the face of natural disasters associated with climate change: A review and methodological critique

In the past two decades, climate change-related natural disasters, such as hurricanes, floods, and droughts have become increasingly frequent and severe, impacting the emotional and psychological well-being of those who are directly or indirectly exposed to them. Despite great interest in understanding differences in anxiety and resilience in response to natural disasters, enthusiasm appears to outstrip empirical clarity, as there remains considerable ambiguity as to determinants of resilient or pathological outcomes following exposure to natural disasters. In addition, there are several major methodological limitations in climate change and related natural disaster research, including the use of univariate analyses, cross-sectional design, and retrospective measures. Keeping these limitations in mind, we first review literature examining the mental health outcomes of natural disasters. Findings suggest that, overall, resilience is more common than pathological outcomes. Second, we use a multi-dimensional framework of resilience to selectively review factors at the event, individual, as well as family and community levels that could help inform resilient or pathological outcomes. Finally, we consider key limitations and future directions for research and practice in the field of anxiety and resilience in response to climate disasters.

Threats to Mental Health and Well-Being Associated with Climate Change

Climate change is a contributor to extreme weather events and natural disasters. The mental health effects of climate change are multifaceted, with post-traumatic stress disorder and depression predominant. This paper aims to describe the impact of climate change on mental health conditions, including risk and protective factors related to the expression of mental health conditions post-disaster, as well as a discussion of our local experience with a devastating wildfire to our region within Canada. The risk of the development of mental health conditions post-disaster is not equally distributed; research has consistently demonstrated that specific risk factors (e.g., gender, socioeconomic status and education, pre-existing mental health symptomatology), are associated with increased vulnerability to mental health conditions following natural disasters. There are multiple strategies that must be undertaken by communities to enhance adjustment and coping post-disaster, including improved access to care, inter-agency cooperation, enhanced community resiliency, and adequate preparation.

Closing the Psychological Treatment Gap During the COVID-19 Pandemic With a Supportive Text Messaging Program: Protocol for Implementation and Evaluation

BACKGROUND

Coronavirus disease (COVID-19) has spread globally with far-reaching, significant, and unprecedented impacts on health and everyday life. Threats to mental health, psychological safety, and well-being are now emerging, increasing the impact of this virus on world health. Providing support for these challenges is difficult because of the high number of people requiring support in the context of a need to maintain physical distancing. This protocol describes the use of SMS text messaging (Text4Hope) as a convenient, cost-effective, and accessible population-level mental health intervention. This program is evidence-based, with prior research supporting good outcomes and high user satisfaction.

OBJECTIVE

The project goal is to implement a program of daily supportive SMS text messaging (Text4Hope) to reduce distress related to the COVID-19 crisis, initially among Canadians. The prevalence of stress, anxiety, and depressive symptoms; the demographic correlates of the same; and the outcomes of the Text4Hope intervention in mitigating distress will be evaluated.

METHODS

Self-administered anonymous online questionnaires will be used to assess stress (Perceived Stress Scale), anxiety (Generalized Anxiety Disorder-7 scale [GAD-7]), and depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]). Data will be collected at baseline (onset of SMS text messaging), the program midpoint (6 weeks), and the program endpoint (12 weeks).

RESULTS

Data analysis will include parametric and nonparametric techniques, focusing on primary outcomes (ie, stress, anxiety, and depressive symptoms) and metrics of use, including the number of subscribers and user satisfaction. Given the large size of the data set, machine learning and data mining methods will also be used.

CONCLUSIONS

This COVID-19 project will provide key information regarding prevalence rates of stress, anxiety, and depressive symptoms during the pandemic; demographic correlates of distress; and outcome data related to this scalable population-level intervention. Information from this study will be valuable for practitioners and useful for informing policy and decision making regarding psychological interventions during the pandemic.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/19292.

Different Trajectories of Prolonged Grief in Bereaved Family Members After Terror

Introduction: The loss of a loved one in a terror incident is associated with elevated risk for mental health disorders such as prolonged grief disorder (PGD) and posttraumatic stress disorder (PTSD), but the long- term adaptation after such losses are not well understood. This study aims to explore the trajectories of PGD among parents and siblings (n = 129) after the 2011 terror attack on Utøya Island, Norway. Methods: The 19-item Inventory of Complicated grief (ICG) was used to measure PGD at 18, 28, and 40 months post-loss. Latent class growth analysis (LCGA) was used to identify trajectories of grief and a multinomial regression analysis was conducted to examine predictors of class membership. Results: The analysis identified three grief trajectories; moderate/decreasing class (23%), high/slow decreasing class (64%), and a high/chronic class (13%). Predictors of high/slow recovery or chronic grief was female gender, previous depressive symptoms, and intrusion and avoidance symptoms. Conclusion: The findings highlights the difficult grief process and slow recovery that characterizes the majority of close family members bereaved by a terror-incident. Community mental health programs should strive for both early outreach and long-term follow-up after such incidents.

Trajectories of grief, depression, and posttraumatic stress in disaster-bereaved people

BACKGROUND

Previous latent trajectory studies in adult bereaved people have identified individual differences in reactions postloss. However, prior findings may not reflect the complete picture of distress postloss, because they were focused on depression symptoms following nonviolent death. We examined trajectories of symptom-levels of persistent complex bereavement disorder (PCBD), depression, and posttraumatic stress disorder (PTSD) in a disaster-bereaved sample. We also investigated associations among these trajectories and background and loss-related factors, psychological support, and previous mental health complaints.

METHODS

Latent class growth modeling was used to identify distinct trajectories of PCBD, depression, and PTSD symptoms in people who lost loved ones in a plane disaster in 2014. Participants (N = 172) completed questionnaires for PCBD, depression, and PTSD at 11, 22, 31, and 42 months postdisaster. Associations among class membership and background and loss-related variables, psychological support, and previous mental health complaints were examined using logistic regression analyses.

RESULTS

Two PCBD classes emerged: mild (81.8%) and chronic (18.2%) PCBD. For both depression and PTSD, three classes emerged: mild (85.6% and 85.2%), recovered (8.2% and 4.4%), and chronic trajectory (6.2% and 10.3%). People assigned to the chronic PCBD, depression, or PTSD class were less highly educated than people assigned to the mild/recovered classes.

CONCLUSIONS

This is the first latent trajectory study that offers insights in individual differences in longitudinal symptom profiles of PCBD, depression, and PTSD in bereaved people. We found support for differential trajectories and predictors across the outcomes.

Development and initial validation of the job loss grief scale

Background: Research on complicated grief (CG) symptoms following job loss is surprisingly rare. Involuntary job loss can turn someone's world upside down and can result in loss of identity, social contacts, and self-worth. In this study, we drew on the literature on major life events in conceptualizing involuntary job loss as a significant and potentially devastating life event. Objectives: The aim of this study was to develop and evaluate an instrument that measures job loss-related CG symptoms, the Job Loss Grief Scale (JLGS). The purpose of the JLGS is to foster systematic research on CG symptoms following job loss. Design: A cross-sectional study Methods: We recruited Dutch workers who had lost their job, 130 men and 158 women with an average age of 49.6 years. To examine the psychometric properties of the JLGS and its associations with other concepts we conducted correlational and confirmatory factor analyses. Results: CFA revealed that the JLGS was a one-dimensional instrument, and that CG symptoms were distinguishable from depression and anxiety symptoms. Conclusion: The JLGS is a reliable and valid instrument to measure job loss-related CG symptoms. The availability of the JLGS could stimulate systematic research on the antecedents and consequences of involuntary job loss.

Predictors of Posttraumatic Stress Symptom Trajectories Following the Fatal 2011 Christchurch, New Zealand Earthquake

People respond differently to potentially traumatic events. To explore predictors of a chronic and delayed trajectory of posttraumatic stress symptoms (PTSS) after a natural disaster, we analyzed psychometric data collected from 412 residents of Christchurch, New Zealand after a 6.3 magnitude earthquake struck in February 2011. Participants from suburbs with different levels of socioeconomic status (SES) and earthquake impact completed a door-to-door survey 4-7 months after the earthquake (Time 1; N = 600) and again 10-11 months after the earthquake (Time 2; N = 412). The survey included the Acute Stress Disorder Scale, the Patient Health Questionnaire's nine-item Depression subscale, and the Generalized Anxiety Disorder-7 scale, along with single-item measures of variables including aftershock anxiety and family tension. Hobfoll's conservation of resources theory was used to guide data interpretation. High levels of depression, odds ratio (OR) = 1.24, and anxiety, OR = 1.24, at Time 1 significantly predicted membership in the chronic trajectory. Predictors of a delayed onset of symptoms included increased aftershock anxiety, OR = 1.29, and family tension, OR = 1.35, over time, as well as living in an area defined as being of low, OR = 5.36, or medium, OR = 11.39, SES. Results highlight risk factors for elevated PTSS and resources that individuals can use to offset threatened loss. These findings have implications for service providers, agencies, and the public.

The course of chronic and delayed onset of mental illness and the risk for suicidal ideation after the Great East Japan Earthquake of 2011: A community-based longitudinal study

This study investigated how the course of a mental illness is distributed and evaluated the risk factors and suicidality of chronic and delayed onset mental illness after the Great East Japan Earthquake. The first, second, and third waves of this study were conducted in 2012, 2013, and 2014, respectively. Psychological distress, suicidal ideation, and socio-demographics were assessed by a self-report questionnaire for affected residents (N = 1473; 768 females, 52.1%; average age = 66.3 years, ranged from 20 to 89 years). Prevalence of mental illness was 10.0%, 14.7%, and 11.8% in the first, second, and third waves, respectively. Prevalence of mental illness for three years was found to be 21.4% and of remission, chronic, and delayed-onset course was 5.0% (2.9-7.1%), 3.6% (1.6-5.8%), and 6.2% (4.2-8.4%), respectively. Psychological distress and serious damage to their homes in the first wave predicted chronic course. Psychological distress in the first wave, living at temporary housing, and unemployment in the third wave increased risk for delayed onset. Among the participants, 9.8% reported suicidal ideation. Chronic or delayed onset course showed a higher risk of suicidal ideation. Many residents, who showed high risk of suicidality, still suffer from mental illness requiring housing, occupation, and psychological support.

Trajectories of posttraumatic stress disorders among children after the Wenchuan earthquake: a four-year longitudinal study

Background: Previous research has demonstrated heterogeneous patterns of posttraumatic stress disorder (PTSD) among children following disasters. However, no clear consensus has been reached regarding the postdisaster trajectories of PTSD among children. Objective: The current study examined the trajectories of PTSD among children after exposure to the Wenchuan earthquake and explored potential predictors of distinct PTSD trajectories. Methods: A four-year longitudinal study was conducted to follow 301 children who were evaluated for PTSD symptoms following the Wenchuan earthquake. Trauma exposure and some pre-existing characteristics were measured at four months after the disaster, and PTSD symptoms were measured at 4, 16, 29, 40 and 52 months after the disaster. The trajectories were identified with Latent Growth Mixture Modelling, and the predictors were explored with multinomial logistic regression. Results: The following three latent PTSD trajectories were found among children: resilient (74.9%), relapsing (17.7%) and recovery (7.5%). Trauma exposure was more likely to be related to a more severe trajectory of PTSD, having experienced prequake trauma was more likely to be related to the recovery trajectory and school 2 was more likely to be related to the relapsing trajectory. Conclusion: These findings provide novel insights into children's postdisaster response patterns. Individual heterogeneity existed in posttraumatic reactions. This longer-term longitudinal study captured more detailed and accurate information about the development of these trajectories. Trauma exposure and previous traumatic experience were linked to malignant development of PTSD.

Trajectories of prolonged grief one to six years after a natural disaster

Background

The long-term trajectories of prolonged grief are poorly understood. The aims were to examine the course of grief among bereaved disaster survivors up to six years post loss and factors predicting worse bereavement outcome. A third aim was to explore differences in grief indicators between trajectories.

Methods

Bereaved Swedish tourists who survived the 2004 Indian Ocean tsunamis responded to surveys including the Inventory of Complicated Grief 1 to 6 years after the disaster. Latent growth mixture modeling was used to identify longitudinal trajectories of grief. Multinomial logistic regression analysis was used to examine predictors of class membership.

Results

Three trajectories were identified: resilient (41% of the sample), recovering (48%), and chronic (11%). The strongest predictor of chronic grief was the loss of one’s child. When examining grief indicators, the chronic trajectory was characterized by not accepting the loss, while yearning was common in all trajectories.

Conclusions

This study highlights the importance of considering how traumatically bereaved individuals can be affected by loss for several years after a disaster, especially after losing one’s child. An inability to accept the loss, more so than yearning, appears to characterize bereaved survivors at risk of a chronic trajectory of grief.

Sex differences in post-traumatic stress disorder in cardiovascular patients after the Great East Japan Earthquake: a report from the CHART-2 Study

Aims

The temporal changes and sex differences in post-traumatic stress disorder (PTSD) after natural disasters remain unclear. Therefore, we examined the prevalence, prognostic impacts, and determinant factors of PTSD after the Great East Japan Earthquake (GEJE) of 11 March 2011 in cardiovascular (CV) patients registered in the Chronic Heart Failure Analysis and Registry in the Tohoku District (CHART)-2 Study (n = 10 219), with a special reference to sex.

Methods and results

By self-completion questionnaires of the Japanese-language version of the Impact of Event Scale-Revised (IES-R-J), the prevalence of PTSD, defined as IES-R-J score ≥25, was 14.8, 15.7, 7.4, and 7.5% in 2011, 2012, 2013, and 2014, respectively. The PTSD rate was higher in women than in men in all years (all P < 0.01). During a median 3.5-year follow-up period, the patients with PTSD in 2011 more frequently experienced a composite of all-cause death and hospitalization for acute myocardial infarction, stroke, and heart failure than those without PTSD [adjusted hazard ratio (aHR) 1.27, P < 0.01]. Importantly, the prognostic impacts of PTSD on all-cause death (aHR 2.10 vs. 0.87, P for interaction = 0.03) and CV death (aHR 3.43 vs. 0.90, P for interaction = 0.02) were significant in women but not in men. While insomnia medication was a prominent determinant factor of PTSD in both sexes during 2011-14, economic poverty was significantly associated with PTSD only in men.

Conclusion

After the GEJE, marked sex differences existed in the prevalence, prognostic impacts, and determinant factors of PTSD, suggesting the importance of sex-sepcific mental stress care in disaster medicine.

Trajectories of resilience and dysfunction following potential trauma: A review and statistical evaluation

Given the rapid proliferation of trajectory-based approaches to study clinical consequences to stress and potentially traumatic events (PTEs), there is a need to evaluate emerging findings. This review examined convergence/divergences across 54 studies in the nature and prevalence of response trajectories, and determined potential sources of bias to improve future research. Of the 67 cases that emerged from the 54 studies, the most consistently observed trajectories following PTEs were resilience (observed in: n = 63 cases), recovery (n = 49), chronic (n = 47), and delayed onset (n = 22). The resilience trajectory was the modal response across studies (average of 65.7% across populations, 95% CI [0.616, 0.698]), followed in prevalence by recovery (20.8% [0.162, 0.258]), chronicity (10.6%, [0.086, 0.127]), and delayed onset (8.9% [0.053, 0.133]). Sources of heterogeneity in estimates primarily resulted from substantive population differences rather than bias, which was observed when prospective data is lacking. Overall, prototypical trajectories have been identified across independent studies in relatively consistent proportions, with resilience being the modal response to adversity. Thus, trajectory models robustly identify clinically relevant patterns of response to potential trauma, and are important for studying determinants, consequences, and modifiers of course following potential trauma.

The performance of the IES-R for Latinos and non-Latinos: Assessing measurement invariance

Violent acts on university campuses are becoming more frequent. Enrollment rates of Latinos at universities is increasing. Research has indicated that youths are more susceptible to trauma, particularly Latinos. Thus, it is imperative to evaluate the validity of commonly used posttraumatic stress measures among Latino college students. The Impact of Event Scale-Revised (IES-R) is one of the most commonly used metrics of posttraumatic stress disorder symptomatology. However, it is largely unknown if the IES-R is measuring the same construct across different sub-samples (e.g. Latino versus non-Latino). The current study aimed to assess measurement invariance for the IES-R between Latino and non-Latino participants. A total of 545 participants completed the IES-R. One- and three-factor scoring solutions were compared using confirmatory factor analyses. Measurement invariance was then evaluated by estimating several multiple-group confirmatory factor analytic models. Four models with an increasing degree of invariance across groups were compared. A significant χ2 difference test was used to indicate a significant change in model fit between nested models within the measurement invariance testing process. The three-factor scoring solution could not be used for the measurement invariance process because the subscale correlations were too high for estimation (rs 0.92-1.00). Therefore, the one-factor model was used for the invariance testing process. Invariance was met for each level of invariance: configural, metric, scalar, and strict. All measurement invariance testing results indicated that the one-factor solution for the IES-R was equivalent for the Latino and non-Latino participants.

Bayesian PTSD-Trajectory Analysis with Informed Priors Based on a Systematic Literature Search and Expert Elicitation

There is a recent increase in interest of Bayesian analysis. However, little effort has been made thus far to directly incorporate background knowledge via the prior distribution into the analyses. This process might be especially useful in the context of latent growth mixture modeling when one or more of the latent groups are expected to be relatively small due to what we refer to as limited data. We argue that the use of Bayesian statistics has great advantages in limited data situations, but only if background knowledge can be incorporated into the analysis via prior distributions. We highlight these advantages through a data set including patients with burn injuries and analyze trajectories of posttraumatic stress symptoms using the Bayesian framework following the steps of the WAMBS-checklist. In the included example, we illustrate how to obtain background information using previous literature based on a systematic literature search and by using expert knowledge. Finally, we show how to translate this knowledge into prior distributions and we illustrate the importance of conducting a prior sensitivity analysis. Although our example is from the trauma field, the techniques we illustrate can be applied to any field.

Survivors' experiences of consequences and recovery five years after a major bus crash

RATIONALE

There is a lack of long-term follow-up studies focused on injured and uninjured survivors' experiences of the recovery process after major traffic crashes.

AIM

To explore all survivors' experiences of long-term physical and psychological consequences and recovery 5 years after a major bus crash.

METHODOLOGICAL DESIGN AND JUSTIFICATION

A qualitative design was used to explore experiences in a 5-year follow-up study.

RESEARCH METHODS

Participants were 54 survivors of a bus crash with 56 survivors and six fatalities. Telephone interviews were analysed with qualitative content analysis.

RESULTS

The first category, 'Being resilient or suffering in daily life', has four subcategories covering quick recovery, suffering in daily life, distress in traffic situations and long-term pain. Reasons for quick recovery among survivors were previous crisis experiences, travelling alone, being uninjured and not being exposed to traumatic impressions. For the other survivors, being reminded of the crash caused disturbing reactions, such as sweating, anxiety and flashbacks. Survivors avoided going by bus if they could. A group of the injured survivors was still suffering from limiting and painful injuries. The second category, 'Reassessing oneself and social connections', has three subcategories covering self-awareness, impact on relationships and connectedness. Survivors either developed a stronger bond to their significant other or separated from their partner within the first couple of years. Friendships and a sense of connectedness among survivors were sources of long-lasting comfort and support. The theme overarching the categories is 'Visible and existential marks in everyday life', representing the various ways in which the crash influence the survivors' lives.

CONCLUSION

There is a need for more information about disruptive long-lasting consequences, such as travel anxiety, and available treatments. Initially, health-promoting connectedness can be facilitated by treating survivors as a group of people who belong together, from the day of the crash and throughout the recovery process.

Similarity in symptom patterns of posttraumatic stress among disaster-survivors: a three-step latent profile analysis

Background: Individuals express symptoms of posttraumatic stress in various ways, noted for example in the many symptom combinations in the diagnostic manuals. Studies aiming to examine differences of symptom presentations by extracting latent classes or profiles indicate both the presence of subtypes with differing symptomatology and subtypes distinguished by severity levels. Few studies have examined subtype associations with long-term outcomes. Objective: The current study aimed to apply latent profile analysis on posttraumatic stress (PTS) in a highly homogenous sample of Swedish tourists exposed to the 2004 Southeast Asia tsunami and to examine if classes differed in their long-term outcome. Methods: An latent profile analysis was conducted using self-report data collected one year after the disaster from 1638 highly exposed survivors that endorsed ≥ 1 symptom of PTS. Associations were examined between the classes and predictors of PTS (loss of a relative or friend, subjective life threat) and levels of PTS at a three-year follow up. Results: The latent profile analysis indicated four classes: minimal, low, moderate, and severe symptoms. The classes were distinguished mainly by their levels of PTS. Loss of a relative or friend and subjective life threat were associated with a higher likelihood of belonging to any other class than the minimal class. The severity level of the classes at one year were predictive of PTS severity at the three-year follow-up. Conclusions: Homogeneous profiles of posttraumatic stress differing mainly in symptom severity were found in this sample of disaster survivors. Profile diversity may be related to sample variation and unmeasured confounders rather than reflect qualitatively different disorders.

Trajectories of traumatic stress symptoms during conflict: A latent class growth analysis

BACKGROUND

The ways in which traumatic stress symptoms unfold under situations of ongoing threat and trauma exposure are poorly understood. The current study aims to identify traumatic stress symptom trajectories during conflict, as well as potential risk factors.

METHODS

Experience sampling methods were used to study traumatic stress symptoms during the 2014 Israel-Gaza conflict in 100 Israeli civilians exposed to rocket fire. Summary reports of traumatic symptoms were made twice-daily for 30 days via mobile phone.

RESULTS

Latent class growth analysis revealed four distinct classes (low, reducing, moderate, and high) characterised by their trajectory of traumatic stress symptoms during the conflict. Female gender, not being in a relationship, and higher prior trauma exposure were identified as potential risk factors.

LIMITATIONS

Data were not collected in the early phase of the conflict, the sample was relatively small, and only traumatic stress symptoms were investigated as outcomes.

CONCLUSIONS

This study identified heterogeneous traumatic stress symptom trajectories among civilians during a conflict, with different subgroups showing distinct response patterns over time, associated with various risk factors. Investigating responses to ongoing trauma, and identifying predictors of different stress symptom trajectories has clinical implications for the targeted delivery of interventions. Further exploration of heterogeneous trajectories could potentially elucidate mechanisms that drive resilience and recovery, including in situations of ongoing exposure such as during conflict.

Exploring Injury Panorama, Consequences, and Recovery among Bus Crash Survivors: A Mixed-Methods Research Study

OBJECTIVE

The aim of this study was to explore physical and mental consequences and injury mechanisms among bus crash survivors to identify aspects that influence recovery.

METHODS

The study participants were the total population of survivors (N=56) from a bus crash in Sweden. The study had a mixed-methods design that provided quantitative and qualitative data on injuries, mental well-being, and experiences. Results from descriptive statistics and qualitative thematic analysis were interpreted and integrated in a mixed-methods analysis.

RESULTS

Among the survivors, 11 passengers (20%) sustained moderate to severe injuries, and the remaining 45 (80%) had minor or no physical injuries. Two-thirds of the survivors screened for posttraumatic stress disorder (PTSD) risk were assessed, during the period of one to three months after the bus crash, as not being at-risk, and the remaining one-third were at-risk. The thematic analysis resulted in themes covering the consequences and varying aspects that affected the survivors' recoveries. The integrated findings are in the form of four "core cases" of survivors who represent a combination of characteristics: injury severity, mental well-being, social context, and other aspects hindering and facilitating recovery. Core case Avery represents a survivor who had minor or no injuries and who demonstrated a successful mental recovery. Core case Blair represents a survivor with moderate to severe injuries who experienced a successful mental recovery. Core case Casey represents a survivor who sustained minor injuries or no injuries in the crash but who was at-risk of developing PTSD. Core case Daryl represents a survivor who was at-risk of developing PTSD and who also sustained moderate to severe injuries in the crash.

CONCLUSION

The present study provides a multi-faceted understanding of mass-casualty incident (MCI) survivors (ie, having minor injuries does not always correspond to minimal risk for PTSD and moderate to severe injuries do not always correspond to increased risk for PTSD). Injury mitigation measures (eg, safer roadside material and anti-lacerative windows) would reduce the consequences of bus crashes. A well-educated rescue team and a compassionate and competent social environment will facilitate recovery. Doohan I , Björnstig U , Östlund U , Saveman BI . Exploring injury panorama, consequences, and recovery among bus crash survivors: a mixed-methods research study. Prehosp Disaster Med. 2017;32(2):165-174.

Acute stress disorder

Acute stress disorder (ASD) was introduced in DSM-IV to describe posttraumatic stress disorder (PTSD) symptoms that (a) occur in the initial month after trauma and (b) predict subsequent PTSD. Longitudinal studies have shown that most people who develop PTSD do not initially meet ASD criteria, which led to the decision in DSM-5 to limit the ASD diagnosis to describing acute stress reactions without any predictive function. Controlled trials have shown that trauma-focused cognitive behavior therapy is the treatment of choice for ASD, and is superior to pharmacological interventions. Recent longitudinal studies have challenged previous conceptualizations of the course of posttraumatic stress, and highlighted that people follow different trajectories of adaptation that are influenced by events that occur after the acute posttraumatic period.

Posttraumatic Stress among Not-Exposed Traumatically Bereaved Relatives after the MS Estonia Disaster

Background

Little is known about posttraumatic stress (PTS) reactions in bereaved individuals following loss in disaster who were not directly exposed to disaster. The aim of the present study was to examine the course of PTS up to three years after losing relatives in the MS Estonia ferry disaster, one of the worst maritime disasters in modern times.

Methods

Seven postal surveys were sent out over three years post-disaster. The respondents were invited and added consecutively during the three years and 938 relatives participated in one or more of the surveys, representing 89% of the MS Estonia’s Swedish victims. The survey included the Impact of Event Scale (IES) to measure PTS. Latent growth curve modeling was used to analyze PTS over time.

Results

The majority of bereaved individuals had high levels of PTS. At three years post-loss, 62% of the respondents scored above the recommended cut-off value on the IES. Over time, PTS symptoms declined, but initially high symptoms of PTS were associated with a slower recovery rate.

Conclusion

The present finding suggests that being an indirectly-exposed disaster-bereaved close-relative can lead to very high levels of PTS which are sustained for several years.

Predictors of severe psychological distress trajectory after nuclear disaster: evidence from the Fukushima Health Management Survey

OBJECTIVES

The Fukushima Daiichi Nuclear Power Plant accident, which occurred after the Great East Japan Earthquake and Tsunami in March 2011, may have a considerable long-term impact on the lives of area residents. The aims of this study were to determine the trajectories of psychological distress using 3-year consecutive data, and to find predictive factors of severe distress that may also prove useful for public health intervention.

METHODS

Data were obtained on 12 371 residents who were registered in the municipalities categorised as complete evacuation areas for 3 years after the disaster and who completed an assessment in each of the 3 years.

RESULTS

Using group-based trajectory modelling, we identified four trajectory patterns distinguished by the levels of psychological distress, which gradually improved over time in all trajectories. Subjective sleep insufficiency, problem drinking, poor social support and perception of radiation risk 3 years after the accident were associated with the severity of psychological distress, according to the multivariate analysis.

CONCLUSIONS

The identified factors may be useful for community-based mental healthcare over the long term following a nuclear disaster.