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published online 16 May 2013Asia Pac J Public HealthMiao Xu

Xiao Pan, Weizhi Liu, Guanghui Deng, Taosheng Liu, Jin Yan, Yunxiang Tang, Wei Dong, Yi Cui andChina

High School Students in Worst-Hit Areas 3 Years After the Wenchuan Earthquake in Symptoms of Posttraumatic Stress Disorder, Depression, and Anxiety Among Junior

  

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Original Article

Symptoms of Posttraumatic Stress Disorder, Depression, and Anxiety Among Junior High School Students in Worst-Hit Areas 3 Years After the Wenchuan Earthquake in China

Xiao Pan, MMed1,2, Weizhi Liu, MSc1,2, Guanghui Deng, PhD1,2, Taosheng Liu, MD, PhD1,2, Jin Yan, MD, PhD1,2, Yunxiang Tang, MD, PhD1,2, Wei Dong, MSc1,2, Yi Cui, MSc1,2 and Miao Xu, MMed3

AbstractThe aim of this study was to examine symptoms of posttraumatic stress disorder (PTSD), depression, and anxiety among junior high school students in worst-hit areas 3 years after the Wenchuan earthquake. Analyses were carried out on 373 of the 377 students enrolled. In addition to obtaining demographic characteristics, the Impact of Event Scale–Revised, the Zung Self-rating Depression Scale, the Zung Self-rating Anxiety Scale, and an Earthquake exposure screening scale were administered. It was found that 29.6%, 44.8%, and 37.6% of participants reported clinical symptoms of PTSD, depression, and anxiety, respectively. PTSD, depression, and anxiety were highly comorbid. Having witnessed someone being killed, family members being killed, close friends seriously injured or being killed, and felt scared remained as significant predictors for PTSD. Having witnessed someone seriously injured and felt scared remained as significant predictors for depression. Having witnessed someone seriously injured, witnessed someone being killed, and felt scared remained as significant predictors for anxiety.

Keywordsanxiety, depression, earthquake, posttraumatic stress disorder, prevalence, risk factors

Introduction

Posttraumatic stress disorder (PTSD) is a common psychiatric disorder following traumatic events that cause intensive fear, helplessness, or loss. PTSD seriously interferes with an indi-vidual’s daily life functions and is often comorbid with depression and anxiety. If left untreated, PTSD may continue for years, resulting in severe functional and emotional impairments and negative consequences for both the sufferer and society as a whole.1

1Second Military Medical University, Shanghai, China2The PLA Mental Health Research Center, Shanghai, China3Changhai Hospital, Shanghai, China

Corresponding Author:Guanghui Deng, Department of Psychology, Second Military Medical University,800 Xiangyin Road, Shanghai 200433, China. Email: bfbedu@126.com

488625 APHXXX10.1177/1010539513488625Asia-Pacific Journal of Public HealthPan et alresearch-article2013

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On May 12, 2008, the Wenchuan earthquake measuring 8.0 on the Richter scale occurred in the Sichuan province of southwest China. Based on a Chinese government update, about 70 000 people were killed, 374 643 injured, and 17 923 listed as missing, and about 4.8 million were rendered homeless (http://news.sina.com.cn/c/2008-09-25/183514499939s.shtml). It was con-sidered one of the deadliest and the most devastating natural disasters to have ever occurred in China. Schools collapsed, more than 5300 children were confirmed dead or missing (http://www.gov.cn/jrzg/2009-05/07/content_1306695.htm), and a substantial proportion of those fortunate enough to escape were seriously injured. Besides deaths, physical injuries, and economic losses, the earthquake resulted in serious mental health outcomes in many people.

Almost all the literature on the Wenchuan earthquake is the outcome of studies conducted in 12 months.2-8 However, the prevalence rate of PTSD, depression, and anxiety in the survivors 3 years after the earthquake was seldom discussed in postdisaster studies. An increasing number of studies have reported the prevalence rate of PTSD and have identified risk factors for PTSD among student survivors of the earthquake.8-10 However, few studies have examined junior high school students, who are sensitive to stressful life events in their early adolescence. Our study has been specially designed to investigate the symptoms of PTSD, depression, and anxiety among junior high school students 3 years after the earthquake in the developing world.

Research has also shown inconsistent findings on the influences of disaster exposure vari-ables (eg, bodily injury, death/injuries of family members, loss of livelihood, and witnessing the disaster) on PTSD, depression, and anxiety symptoms. Several studies showed that PTSD, depression, and anxiety were related to loss of livelihood2,5,11 and deaths or injury among family members2,8,11,12 but not related to whether the victims witnessed the disastrous scenes.12,13 Roussos et al14 found that for adolescent victims of the Greece earthquake, PTSD was positively associated with severe house damage but not with the death of or injuries to family members, whereas neither house damage nor the loss of family members was associated with depressive symptoms.

The purpose of this study was to (a) report the prevalence and severity of PTSD, depression, and anxiety among Chinese junior high school students 3 years after the 2008 Wenchuan earth-quake and (b) identify potential associations with and risk factors for PTSD, depression, and anxiety.

Methods

Participants

A cross-sectional survey was conducted 3 years after the Wenchuan earthquake. Participants were junior high school students from 2 junior high schools (grades 7-9) in Mao County (41 km from the epicenter, with about 110 000 people). Mao County was one of the worst-hit areas in the Wenchuan earthquake. All students in the 2 junior high schools—377 adolescents in total—were target participants. Informed written consent was obtained from adolescents’ guardians, together with oral approvals from participants. All 377 students agreed to participate. Of the sample, 373 (98.9%) returned questionnaires following the procedure described below. These investigations, with the class as the unit, were conducted by 4 well-trained and experienced investigators with training in epidemiology who received unified training about how to explain items in self-admin-istered questionnaires and to keep students from talking to each other when filling out the ques-tionnaire. The investigation process took about 30 minutes per class. Students who were transferred from other schools after the Wenchuan earthquake and who did not experience the Wenchuan earthquake were excluded (n = 11).

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Instruments

The demographic questionnaire items included gender, age, and grade. Our earthquake-related event exposure measure was the sum of 10 events that could have occurred during or after the earthquake. The 10 earthquake-related events included having been in serious danger (E1), hav-ing witnessed someone being seriously injured (E2), having witnessed someone being killed (E3), having family members seriously injured (E4), having family members being killed (E5), having close friends seriously injured or being killed (E6), having been seriously injured (E7), having one’s house seriously damaged (E8), having witnessed a tragic scene after the earthquake (E9), and having felt scared (E10). The first 9 questions were coded into yes/no items; the 10th question assessed the intensity of fear related to the earthquake measured on a Likert scale, rang-ing from 1 = slightly to 3 = intense.

PTSD symptoms were assessed using the Chinese version of the Impact of Event Scale–Revised (IES-R). IES-R15 is a self-assessment instrument widely used to measure traumatic stress. The IES-R has 3 subscales: avoidance (8 questions), intrusion (8 questions), and hyper-arousal (6 questions). IES-R measures are similar to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for PTSD issued by the American Psychiatric Association16,17and have good psychometric properties.18 The IES-R consists of 22 items, each scored from 0 (no problems) to 4 (frequent problems), and the total score ranges from 0 to 88. Summing scores for all symptoms generates an overall severity score. A higher score indicates more severe PTSD symptoms. A cutoff score of 40 (total score) has been suggested to classify whether or not a child has clinically significant PTSD symptoms.19 The IES-R subscales have demonstrated high internal consistency, with Cronbach’s α ranging from .79 to .91, and test-retest reliability α ranging from .51 to .94.15 The Chinese version of the IES-R has been found to have satisfactory psychometric properties, comparable to the original English version.20,21

The Chinese version of the SDS was used to determine the prevalence of depressive symp-toms. The Chinese form of the SDS has been translated from the Zung Self-rating Depression Scale (1985). It has been shown to have adequate reliability and validity.22 A total standard score of 53 has been suggested to be a cutoff point to screen depressive disorders for Chinese, with acceptable sensitivity and specificity.23-25

The Chinese version of the Self-Rating Anxiety Scale (SAS) was used to determine the preva-lence of anxiety symptoms. The SAS is a 20-item, self-report measure designed to assess anxiety. A total standard score of 50 has been suggested to be a cutoff point to screen for anxiety disorders for Chinese, with acceptable sensitivity and specificity.26,27

Ethics Statement

This study was approved by the ethics committees of Second Military Medical University. Informed written consent was obtained from children’s guardians, together with oral approvals from participants, before the testing session according to the Declaration of Helsinki.

Statistical Analysis

Descriptive analyses were conducted to determine demographic characteristics of the entire sam-ple. Demographic and earthquake exposure data and PTSD, depression, and anxiety symptoms were compared using a χ2 test between PTSD and non-PTSD groups, depression and nondepres-sion groups, and anxiety and nonanxiety groups as defined by the IES-R cutoff, SDS cutoff, and SAS cutoff. Multivariate logistic regression analyses were performed to examine the

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independent associations between each study variable (except grade) and PTSD, depression, or anxiety. Statistical tests of the regression estimates or odds ratios (ORs) were based on Wald statistics. ORs and their 95% confidence intervals (CIs) are presented to show the association. P < .05 was considered statistically significant. Data were analyzed using SPSS version 17.0 (SPSS Inc, Chicago, IL).

Results

General Information

Of 377 participants, 373 (98.9%) completed measures of PTSD, depression, and anxiety. We excluded 11 participants who were transferred from other schools after the Wenchuan earthquake and who did not experience it. Finally, the sample (n = 362) consisted of 158 (43.6%) boys and 204 (56.4%) girls. The mean age was 13.8 (standard deviation = ±0.9) years (range = 11-16 years).Of the participants, 45.9% were in grade 7, 37.3% were in grade 8, and 16.9% were in grade 9.

Altogether, 76.8% of participants reported having been in serious danger, respectively, 60.2% and 37.0% reported witnessing someone being seriously injured and being killed, 38.4% and 26.8% reported family members being injured or being killed, 29.0% reported close friends being injured or being killed, 19.6% reported being seriously injured, and 81.2% reported their house being seriously damaged. Approximately 82% of participants witnessed the tragic events directly after the earthquake, and 64%, 27%, and 9% participants felt intense, moderate, and slightly fear.

Prevalence of PTSD, Depression, and Anxiety

Based on the cutoff of 40 found to be optimal for specificity and sensitivity earlier, 107 (29.6%) participants were diagnosed to be suffering from PTSD (Table 1). There were no significant dif-ferences in having witnessed someone being killed, having family members seriously injured, or having close friends seriously injured or being killed between the “yes” and “no” groups. Female gender (χ2 value = 4.944; P < .05), age (χ2 value = 45.757; P < .001), grade (χ2 value = 6.860; P < .05), being in serious danger (χ2 value = 52.570; P < .001), witnessing someone being seri-ously injured (χ2 value = 22.439; P < .001), house seriously damaged (χ2 value = 70.738; P < .001), witnessing a tragic scene after the earthquake (χ2 value = 74.028; P < .001), and feeling scared (χ2 value = 109.701; P < .001) were significantly associated with increased prevalence of PTSD symptoms. However, those who had no family members killed (χ2 value = 4.121; P < .05) and no one seriously injured (χ2 value = 18.925; P < .001) had a significantly higher prevalence of PTSD symptoms.

Based on the cutoff of 53 found to be optimal for specificity and sensitivity earlier, 162 (44.8%) participants overall were diagnosed to be suffering from depression (Table 1). There were no significant differences in gender, having witnessed someone being killed, or having fam-ily members seriously injured between the “yes” and “no” groups. Age (χ2 value = 93.988; P < .001), grade (χ2 value = 26.037; P < .001), in serious danger (χ2 value = 50.000; P < .001), wit-nessing someone being seriously injured (χ2 value = 25.284; P < .001), house seriously damaged (χ2 value = 69.358; P < .001), witnessing a tragic scene after the earthquake (χ2 value = 66.765; P < .001), and feeling scared (χ2 value = 115.111; P < .001) were significantly associated with increased prevalence of depression symptoms. However, those who had no family members being killed (χ2 value = 22.222; P < .001), had no close friends seriously injured or being killed (χ2 value = 13.062; P < .001), and were not seriously injured (χ2 value = 47.802; P < .001) had a significantly higher prevalence of depression symptoms.

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Table 1. Symptoms of PTSD, Depression, and Anxiety Associated With Child Characteristics and Earthquake-Related Experiences in Junior High School Students Following the 2008 Wenchuan Earthquake, China (n = 362).a

PTSD (n = 107, 29.6%) Depression (n = 162, 44.8%) Anxiety (n = 136, 37.6%)

Variable Percentage n χ2 Percentage n χ2 Percentage n χ2

Gender 4.944* 3.556 2.941 Male 11.6% 42 19.1% 69 16.0% 58 Female 18.0% 65 25.7% 93 21.5% 78 Age (years) 45.757*** 93.988*** 73.779*** 12 2.8% 10 3.3% 12 2.2% 8 13 7.7% 28 10.2% 37 10.2% 37 14 11.0% 40 20.4% 74 16.0% 58 15 7.7% 28 9.9% 36 8.3% 30 16 0.3% 1 0.8% 3 0.8% 3 Grade 6.860* 26.037*** 21.588*** 7 12.7% 46 22.1% 80 18.2% 66 8 10.2% 37 15.2% 55 13.3% 48 9 6.6% 24 7.5% 27 6.1% 22 Earthquake-related experiences Having been in serious

danger (E1)52.570*** 50.000*** 49.441***

Yes 25.1% 91 34.8% 126 30.1% 109 No 4.4% 16 9.9% 36 7.5% 27 Having witnessed someone

being seriously injured (E2)

22.439*** 25.284*** 38.118***

Yes 21.5% 78 31.2% 113 28.7% 104 No 8.0% 29 13.5% 49 8.8% 32 Having witnessed someone

being killed (E3)0.084 2.000 0.265

Yes 15.2% 55 19.9% 72 19.6% 71 No 14.4% 52 24.9% 90 18.0% 65 Having family members

seriously injured (E4)0.084 2.469 1.059

Yes 15.2% 55 19.6% 71 17.1% 62 No 14.4% 52 25.1% 91 20.4% 74 Having family members

being killed (E5)4.121* 22.222*** 23.059***

Yes 11.9% 43 14.1% 51 11.0% 40 No 17.7% 64 30.7% 111 26.5% 96 Having close friends

seriously injured or being killed (E6)

2.701 13.062*** 15.559***

Yes 12.4% 45 16.0% 58 12.4% 45 No 17.1% 62 28.7% 104 25.1% 91 Having been seriously

injured (E7)18.925*** 47.802*** 28.265***

Yes 8.6% 31 10.2% 37 10.2% 37 No 21.0% 76 34.5% 125 27.3% 99 Having one’s house seriously

damaged (E8)70.738*** 69.358*** 67.765***

Yes 26.8% 97 37.0% 134 32.0% 116 No 2.8% 10 7.7% 28 5.5% 20 Having witnessed a

tragic scene after the earthquake (E9)

74.028*** 66.765*** 64.971***

Yes 27.1% 98 36.7% 133 31.8% 115 No 2.5% 9 8.0% 29 5.8% 21 Having felt scared (E10) 109.701*** 115.111*** 111.588*** Intense 23.8% 86 32.0% 116 28.2% 102 Moderate 5.0% 18 10.5% 38 7.7% 28 Slightly 0.8% 3 2.2% 8 1.7% 6

Abbreviation: PTSD, posttraumatic stress disorder.a*P < .05; **P < .01; ***P < .001.

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Based on the cutoff of 50 found to be optimal for specificity and sensitivity earlier, 136 (37.6%) participants overall were diagnosed to be suffering from anxiety (Table 1). There were no significant differences in gender, having witnessed someone being killed, or having family members seriously injured between the “yes” and “no” groups. Age (χ2 value = 73.779; P < .001), grade (χ2 value = 21.588; P < .001), being in serious danger (χ2 value = 49.441; P < .001), witnessing someone being seriously injured (χ2 value = 38.118; P < .001), having one’s house seriously damaged (χ2 value = 67.765; P < .001), witnessing tragic scenes after the earthquake (χ2 value = 64.971; P < .001), and feeling scared (χ2 value = 111.588; P < .001) were significantly associated with increased prevalence of anxiety symptoms. However, those who had no family members being killed (χ2 value = 23.059; P < .001), had no close friends seriously injured or being killed (χ2 value = 15.559; P < .001), and had no serious injuries (χ2 value = 28.265; P < .001) had a significantly higher prevalence of anxiety symptoms.

Comorbidity Among PTSD, Depression, and Anxiety

The prevalence of comorbid conditions can be summarized as follows: among 362 junior high school students, 58 (16.0%) scored higher than the cutoff scores on all 3 measures. Depression and anxiety were more likely to be comorbid (28.7%), followed by comorbidity of PTSD and depression (23.2%), and comorbidity of PTSD and anxiety (20.4%).

Associations of PTSD, Depression, and Anxiety With Characteristics and Exposures in Junior High School Students

The results indicated that having witnessed someone being killed (OR = 1.884; 95% CI = 1.151-3.084; P < .05), having family members being killed (OR = 2.189; 95% CI = 1.297-3.693; P < .01), having close friends seriously injured or being killed (OR = 1.873; 95% CI = 1.124-3.120; P < .05), and having felt scared (OR = 2.323; 95% CI = 1.472-3.667; P < .001) remained as significant predictors for PTSD (Table 2). Having witnessed someone seriously injured (OR = 1.945;

Table 2. Stepwise Logistic Regression of Different Risk Factors to Predict PTSD, Depression, and Anxiety With Child Characteristics and Earthquake-Related Experiences in Junior High School Students Following the 2008 Wenchuan Earthquake, China (N = 362).

Variables β SE Wald Value P Value OR 95% CI

PTSD Having witnessed someone being killed (E3) .633 0.251 6.349 .012 1.884 1.151-3.084 Having family members being killed (E5) .783 0.267 8.611 .003 2.189 1.297-3.693 Having close friends seriously injured or

being killed (E6).628 0.26 5.807 .016 1.873 1.124-3.120

Having felt scared (E10) .843 0.233 13.112 .000 2.323 1.472-3.667Depression Having witnessed someone being seriously

injured (E2).665 0.225 8.724 .003 1.945 1.251-3.024

Having felt scared (E10) .435 0.175 6.197 .013 1.545 1.097-2.177Anxiety Having witnessed someone being seriously

injured (E2).815 0.264 9.568 .002 2.260 1.348-3.788

Having witnessed someone being killed (E3) .719 0.248 8.369 .004 2.052 1.261-3.339 Having felt scared (E10) .538 0.193 7.756 .005 1.713 1.173-2.501

Abbreviations: PTSD, posttraumatic stress disorder; SE, standard error; OR, odds ratio; CI, confidence interval.

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95% CI = 1.251-3.024; P < .01) and having felt scared (OR = 1.545; 95% CI = 1.097-2.177; P < .05) remained as significant predictors for depression. Having witnessed someone seriously injured (OR = 2.260; 95% CI = 1.348-3.788; P < .01), having witnessed someone being killed (OR = 2.052; 95% CI = 1.261-3.339; P < .01), and having felt scared (OR = 1.713; 95% CI = 1.173-2.501; P < .01) remained as significant predictors for anxiety.

Discussion

In this study, well-validated measures were used to assess PTSD, depression, and anxiety symp-toms. The prevalence rates of PTSD, depression, and anxiety symptoms were 29.6%, 44.8%, and 37.6%, respectively. The prevalence of psychological symptoms was consistent with those from other studies—for example, a PTSD diagnosis in 30.7% of the adolescents recruited among high school students 21 months after the L’Aquila 2009 earthquake in Italy.9 The prevalence rates of probable PTSD, anxiety, and depression were 26.3%, 49.8%, and 49.6% among survivors in hard-hit regions 1 year after the earthquake in Wenchuan.2 Our results suggested that 3 years after the earthquake in Wenchuan, PTSD, depression, and anxiety were still the main issues affecting the mental health of survivors of the disaster. Other studies showed lower prevalence rates of probable PTSD, depression, and anxiety after the Wenchuan earthquake. For example, prevalence rates of PTSD, anxiety, and depressive symptoms were 13.4%, 22.7%, and 16.1% 1 year after the earthquake in Wenchuan.7 However, compared with studies of children and adoles-cents after earthquakes in other countries, the overall prevalence of PTSD symptoms in our sample is lower. Kolaitis and colleagues found that 6 months after the Athens earthquake, 40% to 78% of child survivors reported PTSD symptoms.28 The differences in prevalence of PTSD symptoms may reflect differences in participants, measures used to assess psychopathology, time points of assessment following the earthquake, and cultural differences in coping styles and social support systems.

PTSD tended to be comorbid with depression and anxiety. The prevalence of comorbid condi-tions among PTSD, depression, and anxiety is 16.0%. Depression and anxiety were more likely to be comorbid (28.7%). These findings were consistent with those found in Acierno et al,29 Fan et al,8 and Liu et al.7 For example, among children 6 months after the Wenchuan earthquake, the prevalence of comorbid PTSD, depression, and anxiety is 8%. Anxiety and depression were more likely to be comorbid (18.3%) than PTSD and anxiety (13.3%).8 Among the children who reported PTSD, 80.9% and 54.7% also reported anxiety and depression, respectively.29

Consistent with previous studies,2,4,7 our results showed that children who felt intensely scared were more likely to have symptoms of PTSD, depression, and anxiety. A follow-up study showed that extreme fear played an important role in the symptoms of anxiety, depression, and PTSD 1 year after the earthquake.7 In addition, our results indicated that although 3 years have passed, the students’ emotional memory of the Wenchuan earthquake is still clear.

Based on logistic regression models, having seen someone being seriously injured or killed, having family members being killed, having close friends seriously injured or being killed, and having felt scared were significantly associated with PTSD, depression, and anxiety symptoms. These findings were consistent with those from previous studies.2,4,6-8 For junior high school students who witnessed someone injured or being killed or who had lost family members and close friends during the earthquake, those traumatic events may have aroused intense fear. As we mentioned earlier, PTSD, depression, and anxiety symptoms were closely related with fear. These results may help identify the survivors with an increased risk for PTSD, depression, or anxiety. Because disaster-related psychological sequelae may last for many years,30 actions should be taken to minimize the possible negative impacts. A long-term regular psychological intervention program should be established to improve mental health conditions of survivors in earthquake-affected areas.

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However, gender was not related to symptoms of the 3 disorders. This finding was inconsis-tent with those from some studies.2,8,21 Although the prevalence rates varied across studies, a consistent finding is that female adolescent survivors were at higher risk than male adolescent survivors to develop PTSD, anxiety, and depression.2,10,13 The reason may be that gender differ-ences could have gradually disappeared 3 years after the 2008 Wenchuan earthquake.

Several limitations of this study should be noted. First, participants were a convenience sam-ple from 2 junior high schools (grades 7-9) in the district for logistic reasons. It is uncertain whether our findings could be generalized to all students in this area. Second, although the instru-ments used in this study have satisfactory psychometric properties, they are screening measures to identify potential clinical cases with PTSD, depression, and anxiety disorders. Further research using a standard clinical interview would be important to estimate the prevalence of PTSD, depression, and anxiety disorders among junior high school students in this area.

Our research reported the prevalence of and risk factors for PTSD, depression, and anxiety among junior high school students 3 years after experiencing the 2008 Wenchuan earthquake in China. The results showed that PTSD, depression, and anxiety symptoms were prevalent mental health problems in Chinese junior high school students after the earthquake. Earthquake expo-sures were associated with PTSD, depression, and anxiety symptoms. These findings have important implications for psychosocial intervention, prevention, and future research. Specific care and mental health interventions should be provided to those adolescents at risk for mental health problems, such as those who feel scared. Thus, our results highlight the need for further studies investigating the impact of traumatic loss in these populations.

Acknowledgments

The authors would like to acknowledge the support of the headmasters and teachers of the schools in Mao County who participated in the study.

Authors’ Note

XP and WL contributed equally to this work.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publi-cation of this article: National Funds of Social Science, China (12BGL096); Shanghai Committee of Education, China (12ZS081); and Research Foundation of Second Military Medical University, China (JYC2011010).

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