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Risk Factors of Post-traumatic Stress Disorder for the Elderly People Experiencing Typhoon Morakot in Taiwan Aboriginal Communities
Yi-Lung Chen2, Chung-Sheng Lai3, Wu Tsung Chen4, Wen-Yao Hsu5, Yi-Cheng Wu1, Peng-Wei Wang1, Cheng-Sheng Chen1,
1 Department of Psychiatry, Department of Plastic Surgery3, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
2 Department of Psychology, 4Department of Medical Sociology and Social Work, Kaohsiung Medical University, Kaohsiung, Taiwan
5Department of Psychology, National Chengchi University, Taiwan
Correspondence:
Dr. Cheng-Sheng Chen, M.D.
Department of Psychiatry
Kaohsiung Medical University Hospital,
No. 100, Tzyou 1st Rd, Kaohsiung City, Taiwan 807 Telephone: 886-7-3121101 ext. 6816
E-mail: [email protected]
Grants: The study was funded by a grant from the National Science Council, Taiwan (98-).
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Objective:
This study aimed to investigate the risk factors associated with post-traumatic stress disorder (PTSD) in a mid- and old-age population who experienced the Typhoon Morakot in Taiwan.
Methods:
One hundred and twenty subjects, who were mostly aboriginal people, aged 55 years and above were invited to participate into this study. PTSD was assessed using Post-traumatic Stress Symptom Scale (PSS). The information regarding demographic characteristic, relocation, personal injury, family death, property damage and self-perceived health were collected.
Results:
The one-month prevalence rate for PTSD was 29.2%. Development of PTSD after the disaster was significantly associated with female (OR 3.63, 95% CI=1.11–11.88), relocation (OR 5.64, 95%
CI=1.60-19.88) and poor self-perceived health (OR 4.24, 95% CI=1.53-11.78) with controlling for age, education, personal injury, family death and property damage. Further adding depression into analysis, we found female (OR 4.66, 95% CI=1.16–18.80), relocation (OR 27.91, 95% CI=3.74-229.80), family death (OR 67.62, 95% CI=2.85-1063.68) and self-perceived health (OR 28.69, 95% CI=4.52-182.06) with controlling for age, education, personal injury, family death and property damage.
Conclusion:
Nearly 30% of the elderly people, female elderly people experiencing Typhoon Morakot, subjects with poorer self-perceived health, subjects experienced the death of relative and those who were relocated and those with depression were at higher risk to develop PTSD. There is a special concern for victims who are relocated by governmental program because they are more likely to develop PTSD symptoms after
experienced trauma. Resettlement and rehabilitation programs after a disaster need more considerations in psychological effect for victims.
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Introduction
People are likely to develop some kinds of mental health problems after a disaster occurred. The elderly is generally believed to be at higher risk to have mental problems after disasters (Hansson, Noulles, &
Bellovich, 1982). Although old age people may be equipped with effective coping strategies after having experienced life-long stressors (Bell, 1978), they also hold several aspects of disadvantages in economic, psychosocial, physical and so on (Brattberg, Parker, & Thorslund, 1996; Hancock, 1998; Ticehurst, Webster, Carr, & Lewin, 1996). The literature revealed the elderly are vulnerable to post-traumatic mental problems, especially for the minority elders (Yang et al., 2003).
Typhoon Morakot struck southern Taiwan, especially at the aboriginal communities, on August 8, 2009. It was one of the worst disaster ever happened in Taiwan. Nearly twenty-five thousands of residents had to forced migration, 408 missing, 924 people injured, and 619 people dead. It also caused losing more than 3 billion US dollars in damage. As the damaged area located near the higher mountains, where the
aboriginal people are living, the accessibility difficulty hindered the rescue and reconstruction efforts. The Taiwanese indigenous aborigines are Austronesian peoples, with linguistic and genetic link to other Austronesian ethnic groups, such as peoples of the Philippines, Malaysia, and Indonesia. Currently, the Taiwanese aboriginal people compose of about 2% of total Taiwan population. They are minor group in aspects of political, economic, culture, and even health in Taiwan (Cheng & Hsu, 1992; Ko, Liu, & Hsieh, 1994; Ralph-Campbell, Pohar, Guirguis, & Toth, 2006).
This study examined the prevalence, presentation of posttraumatic stress syndrome, and the condition of most common comorbid disorder with PTSD. There were two purposes in this study. The first purpose was to examine the prevalence of PTSD among the mainly aboriginal elders in Taiwan after struck by Typhoon Morakot. The second purpose was to explore risk factors of PTSD among the population.
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Methods
The study had been conducted from Nov, 2009 to Feb, 2010, just 3-6 months after the flooding disaster struck. As the life expectancy is about 10 years shorter among the aboriginal population than among the general population, we lowered our age inclusion criteria down to aged 55. Three major struck areas were selected for investigation, and they were Namaxia, Taoyuan, and Maolin of Kaohsiung County. Totally, there was estimated 500 people aged 55 or above living at the three area during the study period.
We enrolled study participants at the occasions who participated in ordinary physical examination at local medical units or those were temporally relocated to other safe area, usually military camps. Totally, there were 120 people were recruited in this study. Participants were interviewed to require above data by trained interviewers. Post-traumatic Stress Symptom Scale- Interview (PSS-I), which is a semistructured interview for the assessment of posttraumatic stress disorder. It contained 17 items, and each item was rated by 4 point scale: 0 = not at all, 1 = a little bit, 2 = somewhat, and 3 = very much. The cutoff value for PSS-I is ≧15. PSS-I has been examined and showed good reliability and validity (Foa, Riggs, Dancu,
& Rothbaum, 1993). Depression was assessed using Center for Epidemiological Studies Depression Scale 10 items version (CESD-10). It is a 4-point scale (range 0 to 3), and the higher indicating more severe.
The cutoff value for CESD-10 is ≧10. It is valid instrument to screening depression in older adults (Irwin, Artin, & Oxman, 1999). Another data were collected included 1) demographic characteristics: age, gender, and educational level; 2) trauma experiences: personal injury (yes or no), relative injury (yes or no), and property damage (yes or no); 3) relocation status: whether participants was relocated to
temporary shelters; 4) self-perceived health: to inquire about the subject’s health condition comparing to others (1 = very bad, 2 = bad, 3 = not different, 4 = better, 5 = much better).
To examine the association of each risk factor with PTSD, we used chi-square analyses and student t-test to deal with categorical and continuous variables, respectively. Multivariate logistic regression was used to determine the risk factors of subjects with PTSD.
Results
Prevalence
Altogether, 120 subjects took participation in this study, which composed of around 24% of total elderly population at the struck area. Three-fifths were female. The education most of study participants were primary school or below (86.7%). Ninety percent reported uninjured, while 5.8% experienced death of close families. Over one-fifth (20.8%) reported to have house damage. Thirty participants (25%) were relocated to temporary shelters. Thirty-seven (30.8%) assessed their health status was worse than the aged counterparts. Among them, 35 (29.2%) had PTSD. Among people with PTSD, twenty-seven subjects (77.1%) had concurrent depression.
Table 1 shows the association of each individual factor with PTSD. Univariate analyses revealed there were association between PTSD and sex, education level, personal injury, property damage, relocation and self-perceived health. The associated variables in the univariate analyses were entered into
controlling multivariate logistic regression analyses (table 2). In model 1, we found female gender (OR=3.63, 95% CI=1.11–11.88; p<0.05), self-perceived health (OR=4.24, 95% CI=1.53-11.78, p<0.01) and relocation (OR=5.64, 95% CI=1.60-19.88; p<0.01) were independent risk factors for PTSD. Lower education level and family death showed marginal statistical significance.
In model 2, we added depression variable into model 1. The variable of self-perceived health was no
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longer statistically significant. Only female gender and relocation remained as the risk factors after controlling for depression. Thus, there were two new risk factors in model 2, and they were family death (OR=67.62, 95% CI=2.85-1063.68; p<0.01) and depression (OR=28.69, 95% CI=4.52-182.06; p<0.001).
We further compared the PTSD symptom clusters between the inhabitants staying the flooding area and those were relocated. Relocated group had significantly higher scores on reexperiencing (relocated group:
mean=5.7, SD=3.2 vs. non-relocated group: mean=2.9, SD=2.8; t=4.39, p<0.001) and avoidance cluster (relocated group: mean=5.1, SD=4.4 vs. non-relocated group: mean=2.5, SD=4.1; t=2.89, p<0.005), but not arousal (relocated group: mean=5.5, SD=4.3 vs. non-relocated group: mean=4.4, SD=4.2; t=1.22, p=0.23).
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Discussion
This study showed that the prevalence of PTSD was 29.2% among the mid- to old-age population experiencing Morakot typhoon. The risk factors for PTSD were female gender, self-perceived health, relocation, family death and depression. Participants had been relocated to military campus experienced more symptoms of reexperience and avoidance, but not arousal, than not.
In this study, we found 29.2% of the middle to old age, mostly aboriginal, residents, had PTSD during 3-6 months after a flooding disaster. The prevalence of PTSD was possibly affected by age, culture and nature of trauma. The literature regarding the aging effect on PTSD is inconsistence. Some researchs suggested older adults are more resilient than younger adults after a natural disaster (Acierno, Ruggiero, Kilpatrick, Resnick, & Galea, 2006). On the other hand, findings that older adults are more vulnerable than younger after experiencing trauma have also been reported (Ticehurst, et al., 1996; Yang, et al., 2003). Compared to previous studies for the younger counterparts facing similar disaster, the prevalence of PTSD in this study was not higher. Also, age did not show to be a risk factor of PTSD in our analysis. The other possibility is that the age effect on PTSD might be affected by culture (Norris, Kaniasty, Conrad, Inman,
& Murphy, 2002). The study area located at the aboriginal communities. The relevant studies especially for the aboriginal elders are scant. It is possible that the distinct culture may prevent or worsen part of those aboriginal elders from PTSD.
Two epidemiological studies regarding prevalence of PTSD after a nature disaster had been conducted in Taiwan. The results showed PTSD prevalences after the Chi-Chi earthquake in Taiwan was 7.6% and 11.3% among general populations (Chou et al., 2004; Yang, et al., 2003). More specifically, the latter one divided participants into three groups based on age, and the elderly prevalence of PTSD in their finding was 19.3%. The prevalence of this study was higher than the two studies, even for the elderly population.
There were two possible speculations to explain the the higher prevalence of this study compared to the previous two studies. The first is that the disaster severity of Typhoon Morakot is worse than the Chi-Chi earthquake. However, according to disaster severity scale (DSS), which was one tool developed to assess and define disasters (de Boer, 1990). DSS has 7 dimensions to assess the severity of disasters, including the effect on the surrounding community, number of casualties, type of disasters, duration of disaster, radius of impact site, injuries sustained by living victims and rescue time. Base on the DSS, the total scores between Typhoon Morakot (score?) and Chi-Chi earthquake is close. Therefore, it is hard to say that the higher prevalence was accounting for the severity of disasters.
Second speculation is the aboriginal people may be more vulnerable than general population. Aboriginal people usually have less resources, low educational level, low socioeconomic status and so on, among which some of them are risk factors for PTSD we have mentioned above. In addition, minority status has been reported to be a risk factor of PTSD (Brewin, Andrews, & Valentine, 2000). The precise relationship between PTSD and minority status in Taiwan needs more studies. However, this phenomenon indicated the PTSD is not uncommon on the mainly aboriginal elderly in Taiwan.
Risk factors of PTSD in this study were self-perceived health, depression, female, experience of family death and relocation. Female gender and family death have been demonstrated in previous studies (Chou et al., 2007; Lai, Chang, Connor, Lee, & Davidson, 2003; Yang, et al., 2003). A relatively novel risk factor of this study was relocation. Relocation should be a better way to away from disaster. Relocations are often required following a natural disaster. It could be “temporary” relocation till the damaged area has been reconstructed, or be “permanent” resettlement. It is believed relocation is usually involuntary, even compulsory. It disrupts the people profound on sociocultural and economic aspects (Oliver-Smith, 1992).
Some studies did not find worse effect of relocation on PTSD (Chen, Lin, Tseng, & Wu, 2002; Najarian,
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Goenjian, Pelcovttz, Mandel, & Najarian, 1996; Yang, et al., 2003). In contrast, some researchers found relocation has adverse effect on PTSD (Galante & Foa, 1986; Goto, Wilson, Kahana, & Slane, 2006). The effect of relocation on mental health after an earthquake has been examined on women and their children, which indicated that group in the relocated city did not worse than the comparisons, but predisposed depression (Najarian, Goenjian, Pelcovitz, Mandel, & Najarian, 2001; Najarian, et al., 1996). There are few studies directly examined the relationship between relocation and PTSD on the elderly.
Our results support those being relocated had more severe symptoms of PTSD. The findings might be argued that those being relocated to temporary shelters may the ones experienced more house damage or personal injury, which were the main origin of PTSD. However, our analysis has controlled these
confounding factors and showed they had more severe PTSD symptoms, especially of reexperience and avoidance. It is possible that relocation had independent effect on PTSD. As the study participants who had been relocated were mostly compulsory move to the temporary shelters, in military campus, they would receive more psychological distress and disrupt their preexisting social support network. Our findings also showing there were higher scores in reexperience and avoidance, but not arousal cluster scores that may be explained relocations did not aggravate arousal coming from the following disaster threat but aggravated other PTSD symptoms clusters. Military campus could provide victims the sense of safety. After experiencing a traumatic event, people are more likely report lowered sense of safety (Bleich, Gelkopf, & Solomon, 2003). Offer a safe shelter may moderate the symptoms of hyperarousal of PTSD.
This is interesting finding indicates that relocation does not deteriorate all symptoms of PTSD; there may be some advantage to relocate people to military campus. Trying to absorb those advantages and
overcoming disadvantages that may improve the necessarily relocating process after a natural disaster.
The results raised a special psychological rehabilitation program especially for those being relocated in the future.
Limitation
There were some limitations in this study. First, the sample size of this study is small, causing the confidence intervals of odds ratio for some risk factors are too high. Second, because we focused on the elderly, the age range of this sample is narrow. Third, the prevalence rate of this study just reflects the time of data collection, 3-6 months after the disaster, and cannot generalize to other time frame. Finally, not all possible risk factors have been included in this study (e.g., Intelligence quality, social support).
Conclusion
In this study, we found the prevalence of PTSD was not uncommon among the mid- to old-age, mostly aboriginal, communities. Risk factors of PTSD were female gender, family death, low self-perceived health, depression and relocation. We suggested the elderly who were relocated required a special psychological program accompanied.
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Table 1 Demographic characteristics and trauma experience of participants
PTSD Non-PTSD Statistics
N (%) N (%)
Sex
Female 28(80%) 44(51.8%) χ2 =8.24
Male 7(20%) 41(48.2%) p<0.004
Age (Mean ± S.D.) 67.5(8.5) 66.8(9) t=0.38; p<0.703 Education
≦Primary school 34(97.1%) 70(82.4%) χ2 =5.49
>Primary school 1(2.9%) 15(17.6%) p<0.037 Personal injury
Non-injury 28(80%) 80(94.1%) χ2 =5.49
Injury 7(20%) 5(5.9%) p<0.039
Family death
Non-death 31(88.6%) 82(96.2%) χ2 =2.82
Death 4(11.4%) 3(3.5%) p<0.192
Property loss
Nothing loss 21(60%) 74(87.1%) χ2 =11.01
Property 14(40%) 11(12.9%) p<0.002 Relocation
Non-relocated 18(51.4%) 72(84.7%) χ2 =14.64
Relocated 17(48.6%) 13(15.3%) p<0.000 Self-perceived health
Better or unchanged 19(45.7%) 64(75.3%) χ2 =9.76
Worse 16(54.3%) 21(24.7%) p<0.003 Table 2 Summary of logistic regression of risk factors of PTSD
Model 1
PTSD vs non-PTSD O.R. (95% CI)
Sig
Model 2 PTSD vs
non-PTSD O.R.
(95% CI)
Sig
Sex (F / M) 3.63
(1.11-11.88)
0.017* 4.66 (1.16-18.80)
0.030*
Relocation 5.64
(1.60-19.88)
0.007** 27.91 (3.74-229.80)
0.002**
Self-perceived
health 4.24
(1.53-11.78) 0.006** 2.73 (0.84-8.92) 0.096 Education 14.11
(0.94-210.88)
0.055 10.23 (0.55-191.99)
0.120 Personal injury 1.01
(0.16-6.23) 0.99 0.58 (0.06-5.53) 0.632 Family death 10.72
(0.93-123.41)
0.057 67.62 (2.85-1063.68)
0.009**
Property Loss 2.01 (0.49-8.30)
0.333 1.79 (0.38-8.40) 0.460 Depression (without controlling
depression) 28.69
(4.52-182.06) 0.000***
Model 2: adding depression variable into model 1.
* P<0.05.
** P<0.01.
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*** P<0.001
137 災區老人健康復原工作模式計畫期末報告