Disaster-related psychiatric disorders among survivors of flooding in Ladakh,India

Abstract

Background:

Heavy rainfall in northern India in August 2010 caused flash floods, seriously damaging homes and infrastructure. There have been no major disasters in the history of Ladakh, and no surveys on post-disaster psychiatric disorders have been conducted in this area.

Aims and methods:

To examine the impact of this disaster in Ladakh one month post-disaster, we visited Choglamsar, located near the town of Leh, where the flood had the most severe impact. In total, 318 survivors (mean age: 58.6 years; female–male ratio: 59.7%; Tibetan refugees: 86.2%) participated in the survey. We used the two-item Patient Health Questionnaire (PHQ-2) along with questions covering background characteristics and disaster exposure. A psychiatrist interviewed the survivors with a single or double positive score in the PHQ-2 or with post-traumatic stress disorder (PTSD) symptoms.

Results and conclusion:

There were only two PTSD cases and five of major depressive disorders. PTSD and depression were less common in the Tibetan cultural areas than in other areas. The social background and temperamental characteristics of the Tibetan culture may play a suppressive role in psychiatric disorders.

Keywords

Disaster depression post-traumatic stress disorder Tibetan Ladakhi

Background

At midnight on 5 August 2010, a localized downpour caused flash floods in Ladakh in northern India. Approximately 200 people reportedly died and about 10,000 others suffered various problems due to this disaster. Choglamsar, located near the town of Leh, where there is a settlement of refugees from Tibet, was the hardest hit. Catastrophic flooding occurred when the water level of a river rose dramatically. Many, reportedly, had no time to escape the midnight torrent of mud and rubble. Even a month after the disaster, many residents continued to live as refugees in temporary shelters. Rains are a rarity in the mountainous region of Ladakh, located at an average altitude of 3,500 m above sea level. The local people said that they had never heard of flooding on this scale in the long history of this region.

Disasters often result in severe physical and psychological symptoms. Many of these symptoms are temporary and patients show spontaneous recovery. However, some can be long lasting. Depending on the severity and duration of symptoms, the condition may be diagnosed as a psychiatric disorder, for example post-traumatic stress disorder (PTSD). PTSD is a psychiatric sequelae of disasters, whether natural or otherwise – for example earthquakes, floods, explosions, traffic accidents, crimes, atrocities, terrifying experiences, and war or battle trauma. Threats to life, major injuries, sensations of fear or helplessness, and so on, exert potent psychiatric shocks and can cause PTSD. When characteristic stress symptoms, such as those described in the next paragraph, are recognized in trauma victims, the condition is diagnosed as PTSD.

Studies report an increase in psychiatric disorders (including not only PTSD but also panic disorder, depression, phobia and alcohol dependency) following natural disasters (Weisaeth, 1995). However, their extent of prevalence appears to show wide variation. The cause of this variation would appear to be differences in survey methods, the type and extent of disasters, countermeasures against disasters, cultural backgrounds, and so on. There have been no major disasters in the history of Ladakh and, understandably, no surveys on post-disaster psychiatric disorders. This study aimed to understand the psychological impact of the Ladakh disaster on the victims in terms of their sociocultural characteristics.

Methods

We conducted a survey in September 2010 in Choglamsar, where the disaster was most severe. The interviews were conducted one month after the disaster, as post-disaster symptoms are supposed to take about a month to manifest. It was difficult to conduct psychiatric interviews with all residents. Therefore, we surveyed and interviewed a fair-sized sample of 318 residents, who had volunteered for the study.

Early diagnosis of depression in the local population is important. Therefore, screening tools for various types of depression, such as the Patient Health Questionnaire (PHQ; Spitzer, Kroenke & Williams, 1999), have been developed. Tools that take less time are favoured if sensitivity and specificity are maintained (Mahoney et al., 1994). The two-item PHQ (PHQ-2) is an abridged version of the PHQ and, as its name suggests, asks a question covering two items. The question is: ‘How often have you been bothered by any of the following problems over the past two weeks? (1) Little interest or pleasure in doing things; and (2) Feeling down, depressed, or hopeless.’

We screened all participants for depression using the PHQ-2. We judged the residents who answered ‘yes’ to either or both of the PHQ-2 items as having ‘suspected depression’. This was followed by physical examination, where we confirmed the presence or absence of concrete symptoms of anxiety, fear, depression, insomnia, irritability, reduced motivation, sensory paralysis, and so on, considering the damage to houses or suffering of families. Those who showed strong symptoms were then diagnosed by a psychiatrist who assessed them for psychiatric disorders. The psychiatrist used semi-structured questions, according to the Diagnostic and statistical manual of psychiatric disorders, 4th edn, text revision (DSM-IV-TR) (American Psychiatric Association, 2002).

Moreover, we conducted a questionnaire survey of participants regarding health conditions, for example: history of ailments and disorders; lifestyle habits such as exercise, addictions and diet; and social conditions, such as marital status and education. In addition, we measured height, weight and blood pressure, and conducted blood tests.

Results

The subjects of this survey were 318 residents (128 men (40.3%), 190 women (59.7%); mean age: 58.6). Table 1 shows the baseline characteristics of the subjects. None had ever been diagnosed with a psychiatric disorder. Twenty-six participants showing positive PHQ-2, or strong psychiatric symptoms, were interviewed by a psychiatrist. Fragmentary PTSD symptoms were observed in many of the residents, for example they often remembered experiences of anxiety or fear at the time of the disaster. Many of these, however, are common enough among people in disaster areas; therefore, most of them did not constitute particular syndromes recognizable as disorders.

Table 1.

General characteristics.

Characteristics	n	%
Number	318
Female	190	59.7
Age ± SD	58.6 ± 12.5
Ethnic group
Ladakhi	44	13.8
Tibetan	274	86.2
Religion
Tibetan Buddhism	318	100
Occupation
Housewife	90	28.5
Inoccupation	70	22.2
Labour	57	18.0
Business	40	12.7
Monk/Nun	17	5.4
Farmer	2	0.6
Others	42	13.2

PTSD is diagnosed as a psychiatric disorder in which the subject feels a considerable level of distress or when his/her daily living is hampered by a series of PTSD symptoms (DSM-IV-TR diagnostic criterion F). Only two of the 318 subjects surveyed were clinically diagnosed with PTSD.

Here we report three cases: that of a patient who coped well with stress and two others who developed PTSD after the disaster.

Case 1: 51-year-old Tibetan woman

This woman was born in Tibet. She moved to the Changthang Plateau at the time of the Tibetan resistance movement, living a nomadic life. Fourteen years ago, all her livestock were killed in a heavy snowfall. Thereafter, she has been living in Leh. She is a homemaker, divorced from her husband, and lives with her five children and a niece. She was awakened by the roar of the flood. She tried to escape but was engulfed in a muddy torrent and swept away. She and her family survived by holding onto a large tree trunk. Her house was completely buried under sand. She now lives in a tent. At the medical examination, she had a somewhat gloomy expression and depressed mood, and complained of difficulty sleeping. Around the time of the day when the disaster had struck, she often felt anxiety and could not sleep. Fatigability, reduced appetite, reduced concentration, a feeling of worthlessness, and so on, were not found. She never thought of committing suicide as, believing in the teaching of Karma, she felt that those committing suicide would not be reborn. She never fails to go to the pagoda each morning and pray. She spends her days doing household chores or reading Buddhist texts. Her favourite pastime had been making carpets, but she cannot do this any longer as she is living in a tent. Although she has suffered greatly and has no promising prospects, she said: ‘I am all right, because I have experienced similar situations in the past. I worry more about the old people nearby who live in the same tent.’ During the medical examination, she was praying with her rosary beads. Her conditions did not interfere with her daily life and therefore did not meet the criteria of PTSD or depression. We listened attentively to and empathized with her, and advised her to consult physicians at the local hospital in case of any health problems.

Case 2: 47-year-old Tibetan woman; PTSD

This woman was born in Tibet. At approximately age seven, she moved to the Changthang Plateau because of the Tibetan resistance movement. She has been living in Leh since her marriage. She is a homemaker and her husband runs a small business in Kashmir. She has six children, four of whom live in a school dormitory. She now lives with her husband, two children and two nephews. Although there was no direct damage to her house or family, mud flows had come near her house and she witnessed many people fleeing. Her husband rescued a man buried in the mudslide. They took care of him. Since then, she dreams every day of a man covered with mud. She has become very sensitive to noises and vibrations. She is even startled by the passing of a car or the blowing of the wind. Her hyperesthesia is especially strong at night; a loud sound would make her go out to check whether a flood was coming. In the daytime, there is no one else in the house. If she stays home, memories of the disaster haunt her. Therefore, she spends the daytime in the neighbouring house until her husband comes home. She is afraid of going to the toilet, for the fear of being locked in. Earlier, she would read Buddhist books in her spare time. However, they interest her no longer. We did not find insomnia, decreased appetite, fatigability, decreased concentration, suicidal thoughts, and so on.

Because she had all three major symptoms of PTSD (re-experience, hyperarousal and avoidance) and her symptoms had persisted for more than one month, she was diagnosed with PTSD and was prescribed anti-anxiety drugs. We explained to her that we thought that the present symptoms were the result of psychological trauma of the disaster and that they were ‘normal reactions to an abnormal situation’.

Case 3: 56-year-old Tibetan woman; PTSD + major depressive disorder

This woman was the eldest among five children of a poor farmer in the Changthang Plateau. She married at the age of 23 and has since lived in Leh. She is a homemaker living with her husband, who is a soldier. Her four children live in Delhi. They are university and high-school students. She sees her children only once a year. When the flood occurred, she was asleep at home. When the flood hit her house with a roar, she escaped. It was completely dark and she could not walk well because of the mud. However, she managed to escape to a school on a hill. She stayed at the school for a week. Later, she moved to a shelter provided by the government. Since then, she has been living there with her own and another family (six people altogether) in a tent. Her house was swallowed by the muddy torrent and destroyed. Every morning, when she goes to clear up the wreck that was once her house and belongings, she feels depressed. The thought of floods coming again makes her anxious. She was told that her house needed to be rebuilt. It will take at least two years to build a new house. She does not have enough money for this and feels helpless. Before the flood, she would to go to the pagoda to pray and would do all the household chores. However, since the disaster, she has lost all motivation.

At the interview, we found that she was suffering from chronic loss of interest, depressed mood, fatigability, self-accusation, reduced concentration and psychomotor retardation, as well as suicidal thoughts, re-experience, hyperarousal and paralysis in general responsiveness. Therefore, her condition was diagnosed as PTSD accompanied by major depressive disorder. As she suffered from strong suicidal thoughts, we prescribed an antidepressant, advised her to go to the only psychiatric clinic in the local area, and wrote a referral letter to the clinic.

Discussion

Victims of disasters experience life-threatening or unexpected events and are often displaced. These experiences cause both physical and mental trauma. Anxiety and other mental disturbances due to an extraordinary event are normal psychological reactions. Events in an individual’s life, such as an accident or crime, can also lead to such reactions. However, large-scale disasters can affect entire communities. Interestingly, the local victims may be actually less aware of the invisible psychological stress and trauma because they are busy reconstructing their lives. In the case of the disaster being studied, the most commonly reported symptom seemed to be fear of being at home and falling asleep. This was because the disaster occurred in the middle of the night when most victims were sleeping at home.

The incidences of PTSD in local populations in some major natural disasters are as follows:

36% after Typhoon Rusa in the Republic of Korea (Lee et al., 2003)

36% after the Major Turkish Earthquake (Kilic & Ulusoy, 2003)

46% after the flood in Mexico (Norris, Murphy, Baker & Perilla, 2004).

The prevalence of major depressive disorder reportedly ranges from 6.4% to 11% (Wu et al., 2006). In our study, despite the fact that the subjects surveyed were displaced and that many had lost family members, there were only two PTSD cases and five of major depressive disorders among 318 subjects. These numbers were lower than those reported for disasters in other areas. The psychological effects of the disaster vary with the intensity of the shock, vulnerability of the victims and various environmental factors. Study methods also vary with the time and context of study, subjects and method of evaluation. Therefore, simply comparing the frequencies of PTSD or depression across studies may not be an adequate method of comparing the psychiatric effects of various disasters. However, if we bear this caveat in mind, we may be able to compare the findings of various natural disasters meaningfully. Incidentally, there was only one psychiatrist in the town of Leh, who started working in the general hospital a year before we undertook this study. Therefore, the residents were not familiar with psychiatry. Even residents suffering from psychiatric symptoms thought that they were victims of the ‘disaster’. None thought that the condition was a ‘disease’. None of the residents had complained of psychiatric symptoms, such as insomnia and depressive mood, until they were asked about the symptoms.

Although the present study was undertaken after the disaster, we found the prevalence of major depressive disorder to be lower than that reported elsewhere for other regions where the subjects were community-dwelling elderly persons. Social and cultural background and ethnic disposition are considered the main reasons for lower frequencies of PTSD and major depressive disorders in this region. Past studies of disasters have identified several protective factors against PTSD. One of them is social support (Johnson & Thompson, 2008). Ladakhis and Tibetans have strong social bonding. Many of them give more importance to supporting others close to them than worrying about their own pain or suffering. We have seen this in Case 1. Many other disaster victims also ignored their own symptoms and instead worried about the health of their aged parents or neighbours. Such social support among family members or neighbours may function as a deterrent to the development of PTSD or depression.

Religion appears to have been another positive help. Ladakhis and Tibetans are devout Buddhists and many saw their misfortune as resulting from bad Karma, that is, past misdeeds. They believed that performing regular rituals would convince the offended gods to be more favourable. A report on PTSD among Cambodian refugees in New Zealand (Cheung, 1994) shows that those who had strong Buddhist beliefs (about reincarnation, fate and the meaning of suffering) were able to accept their trauma and suffering as necessary ordeals that help to ensure a better state in the next world. It is possible that such strong beliefs inhibit the development of PTSD (Holtz, 1998; Shrestha et al., 2008).

Successful experience in dealing with stress is known to exert inhibitory effects on the development of PTSD (McMillen, Smith & Fisher, 1997). Of the study subjects 86.2% were Tibetans, most of whom had undergone the traumatic experience of the Tibetan resistance movement in the 1960s. Furthermore, among them were people who had lost their livestock in heavy snows in the 1980s, and were forced to give up their nomadic lifestyle and move to Leh. Thus, many residents said ‘I have had a worse experience in the past’, as in Case 1. Such experiences may have helped them cope with abnormal situations with greater maturity and resilience.

The presence of protective factors, such as those described above, possibly helped to inhibit the development of PTSD in Ladakhis and Tibetans. However, PTSD developed when the stress overcame these protective factors, as in Cases 2 and 3.

Our literature survey revealed no reports of PTSD after natural disasters in Tibetan culture. This appears to be the first report of PTSD in this culture area. Recent advances in psychiatric research have revealed that PTSD is not only a psychological disorder but is also accompanied by neurobiological abnormalities. Elevated noradrenergic reactions, decreased hypothalamic-pituitary-adrenocortical system functions, hippocampal atrophy on diagnostic imaging, and so on, have been reported (Shin, Rauch, & Pittman, 2005; Southwick, Rasmusson, Barron & Arnsten, 2005). The above observations suggest that psychiatric phenomena, such as re-experience, avoidance, psychiatric paralysis and hyperarousal, constituting symptoms of PTSD, involve a common pathway regardless of cultural differences.

However, the problem of variation in psychiatric disorders across cultures is enormous and the data are varied. Therefore, it is difficult to present a coherent and consistent picture. Diseases that fall into the major categories of DSM-IV, such as depression and schizophrenia, are observed worldwide, but specific symptoms, courses and social reactions show considerable local variation. For example, the relationship between the expression of depressed mood and the symptoms of depression is said to be influenced by race and ethnicity (Blazer, Landerman, Hays, Simonsick & Saunders, 1998). Researchers have indicated that neglecting social and cultural differences might lead to misdiagnoses, and that clinicians, when diagnosing patients from other ethnic or cultural backgrounds, must take such background into account (Evans & Mottram, 2000).

Although PTSD is neurobiologically universal to all humans, the expression of symptoms may be culture-specific. Many past reports on PTSD have been built on questionnaire-based surveys. However, this might not represent true prevalence because a screening tool produced based on western medical practice does not necessarily consider the actual cultural background. This is because PTSD symptoms might have different values or meanings in different cultures and some symptoms might not be perceived as distressing. In the present study, we considered indigenous expressions of disorder and idioms of distress, and our interview of the participants focused on hearing their narratives. That is, we asked them their thoughts about the causes of their symptoms and about the nature and course of the disease. This report is the first to use this method in probing stress-related disorders after the 2010 natural disaster in Ladakh.

Limitations

This study has several limitations. First, we did not select the subjects by random sampling. Rather, we studied residents who volunteered to participate. Therefore, it is possible that many of those who chose not to volunteer showed psychiatric symptoms. Second, PHQ-2 and PTSD diagnosis have not been validated for Ladakhi or Tibetan context. This limitation is true for most research in the developing world and is important because of likely ethnocultural variations in PTSD (Marsella, Friedman, Gerrity & Scurfield, 1996). Finally, even if the first survey has found no major problems, symptoms can develop after a certain latency period, or health damage may manifest due to new stressors, such as prolongation of refugee life, in the future. Therefore, a follow-up survey is desirable.

Conclusion

We have discussed the psychological impacts of the Ladakh disaster on the basis of cases with PTSD and major depressive disorders that developed after the disaster, and by considering the Tibetan cultural background. Our evaluation of psychological impacts on the subjects did not mechanically follow the criteria based on western cultures. Instead, it considered local cultural factors in surveying the development of PTSD and major depressive disorders. Our finding seems to indicate that social or cultural background factors and the ethnic temperament of Tibetans might have played important roles in suppressing the development of PTSD and major depressive disorders. We believe that these findings will aid in providing clinical care to the people of Ladakh and help understand the hardiness and resilience that characterizes this under-studied population.

Footnotes

Acknowledgements

This study was conducted as part of the medical survey on ‘Human Life, Aging, and Disease in High-Altitude Environments: Physiomedical, Ecological and Cultural Adaptation in Highland Civilizations’ (Representative: Kiyohito Okumiya) of the Research Institute for Humanity and Nature. It was supported by a Grant-in-Aid for Scientific Research (C) No. 22590668. We thank Professor Toshihiro Tsukihara, Faculty of Education and Regional Studies, for his invaluable cooperation in the Ladakh survey. We also thank project members and Ladakh residents who participated in this survey.

References

American Psychiatric Association. (2002). Diagnostic and statistical manual of psychiatric disorders, 4th edn, text revision. Washington, DC: American Psychiatric Association.

Blazer

D. G.

Landerman

L. R.

Hays

J. C.

Simonsick

E. M.

Saunders

W. B.

(1998). Symptoms of depression among community-dwelling elderly African-American and white older adults. Psychological Medicine, 28, 1311–1320.

Cheung

(1994). Posttraumatic stress disorder among Cambodian refugees in New Zealand. International Journal of Social Psychiatry, 40, 17–26.

Evans

Mottram

(2000). Diagnosis of depression in elderly patients. Advances in Psychiatric Treatment, 6, 49–56.

Holtz

T. H.

(1998). Refugee trauma versus torture trauma: A retrospective controlled cohort study of Tibetan refugees. Journal of Nervous and Mental Disease, 186, 24–34.

Johnson

Thompson

(2008). The development and maintenance of post-traumatic stress disorder (PTSD) in civilian adult survivors of war trauma and torture: A review. Clinical Psychology Review, 28, 36–47.

Kilic

Ulusoy

(2003). Psychological effects of the November 1999 earthquake in Turkey: An epidemiological study. Acta Psychiatrica Scandinavica, 108, 232–238.

Lee

Hah

Y. S.

Kim

K. J.

Kim

J. H.

Kwon

Y. H.

Park

J. K.

Lee

N. Y.

(2003). A field study of post-traumatic stress disorder in a community after typhoon Rusa. Taehan Kanho Hakoe Chi, 33, 829–833.

McMillen

J. C.

Smith

E. M.

Fisher

R. H.

(1997). Perceived benefit and mental health after three types of disaster. Journal of Consulting and Clinical Psychology, 65, 733–739.

10.

Mahoney

Drinka

T. J.

Abler

Gunter-Hunt

Matthews

Gravenstein

Carnes

(1994). Screening for depression: Single question versus GDS. Journal of the American Geriatrics Society, 42, 1006–1008.

11.

Marsella

A. J.

Friedman

M. J.

Gerrity

E. T.

Scurfield

R. M.

(Eds) (2006). Ethnocultural aspects of posttraumatic stress disorder: Issue, research, and clinical applications. Washington, DC: American Psychological Association Press.

12.

Norris

F. H.

Murphy

A. D.

Baker

C. K.

Perilla

J. L.

(2004). Postdisaster PTSD over four waves of a panel study of Mexico’s 1999 flood. Journal of Traumatic Stress, 17, 283–292.

13.

Shin

Rauch

Pittman

(2005). Structural and functional anatomy of PTSD: Findings from neuroimaging research. In Vasterling

Brewin

(Eds), Neuropsychology of PTSD: Biological, cognitive, and clinical perspectives (pp. 59–82). New York: Guilford Press.

14.

Shrestha

N. M.

Sharma

van Ommeren

Regmi

Makaju

Komproe

… de Jong

J. T.

(2008). Impact of torture on refugees displaced within the developing world: Symptomatology among Bhutanese refugees in Nepal. Journal of the American Medical Association, 280, 443–448.

15.

Southwick

Rasmusson

Barron

Arnsten

(2005). Neurobiological and neurocognitive alterations in PTSD: A focus on norepinephrine, serotonin, and the hypothalamic-pituitary-adrenal axis. In Vasterling

Brewin

(Eds), Neuropsychology of PTSD: Biological, cognitive, and clinical perspectives (pp. 27–58). New York: Guilford Press.

16.

Spitzer

R. L

Kroenke

Williams

J. B.

(1999). Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Journal of the American Medical Association, 282, 1737–1744.

17.

Weisaeth

(1995). Disaster, risk and preventive intervention. In Raphael

Burrows

G. W.

(Eds), Handbook of studies on preventive psychiatry (pp. 301–322). London: Elsevier.

18.

H. C.

Chou

F. H.

C. Y.

Tsai

K. Y.

Ou-Yang

W. C.

… Chen

M. C.

(2006). Survey of quality of life and related risk factors for a Taiwanese village population 3 years post-earthquake. The Australian and New Zealand Journal of Psychiatry, 40, 355–361.