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Chapter 7 - Long-Term Course of PTSD and Depression Among Adults, Mediating and Moderating Factors in Recovery, and Current Trends for Treatment

Published online by Cambridge University Press:  20 May 2022

By
Armen Goenjian ,
Alan Steinberg  and
Robert Pynoos
Edited by
Armen Goenjian ,
Alan Steinberg  and
Robert Pynoos
Armen Goenjian
Affiliation:
David Geffen School of Medicine; UCLA/Duke University National Center for Child Traumatic Stress
Alan Steinberg
Affiliation:
UCLA/Duke University National Center for Child Traumatic Stress
Robert Pynoos
Affiliation:
UCLA/Duke University National Center for Child Traumatic Stress
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Summary

At 1.5 years post-Spitak-earthquake, elderly survivors had significantly less intrusive and more hyperarousal symptoms (e.g., startle, hypervigilance, irritability, insomnia) than younger adults, indicating that treatment for the elderly requires more focus on hyperarousal symptoms (e.g., use of anxiety management techniques).

At 1.5- and 4.5-years post-earthquake, two groups of adults, exposed to severe trauma (earthquake and political violence), experienced comparably high levels of PTSD and depressive symptoms. The results dispelled the prior notion that natural disasters result in less severe reactions and underscore the importance of using objective and subjective measurements to determine exposure severity. They also showed that previous exposure to political violence had an additive effect on subsequent earthquake exposure-related PTSD severity.

The twenty-three-year prospective study among adult survivors of the earthquake showed that a substantial portion of the population (11.6%) still had PTSD related to the earthquake, and another 9.9% had PTSD related to post-earthquake traumas (e.g., fights, accidents, etc.). Risk factors for PTSD at twenty-three-year follow-up included baseline depression, job loss, post-earthquake traumas, and chronic medical illnesses. The chapter also presents important findings from other disaster studies, including the effect of cumulative trauma, delayed onset PTSD, increased mortality associated with PTSD and depression, and comparisons of recommended treatments for PTSD and depression and their limitations.

Keywords

disastersviolenceearthquakecoursePTSDdepressionadditive effecttreatments for PTSD
Type
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Lessons Learned in Disaster Mental Health
The Earthquake in Armenia and Beyond
 , pp. 111 - 136
Publisher: Cambridge University Press
Print publication year: 2022

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References

Acierno, R., Ruggiero, K. J., Galea, S., Resnick, H. S., Koenen, K., Roitzsch, J., … & Kilpatrick, D. G. (2007). Psychological sequelae resulting from the 2004 Florida hurricanes: implications for post-disaster intervention. American Journal of Public Health, 97, S103–S108. https://doi.org/10.2105/AJHP.2006.087007Google Scholar
Andrews, B., Brewin, C. R., Philpott, R., & Stewart, L. (2007). Delayed-onset post-traumatic stress disorder: a systematic review of the evidence. American Journal of Psychiatry, 164, 1319–1326.Google Scholar
Armenian, H. K., Melkonian, A. K., & Hovanesian, A. P. (1998). Long-term mortality and morbidity related to degree of damage following the 1988 earthquake in Armenia. American Journal of Epidemiology, 148, 1077–1084.Google Scholar
Armenian, H. K., Morikawa, M., Melkonian, A. K., Hovanesian, A. P., Haroutunian, N., Saigh, P. A., … & Akiskal, H. S. (2000). Loss as a determinant of PTSD in a cohort of adult survivors of the 1988 earthquake in Armenia: implications for policy. Acta Psychiatrica Scandinavica, 102(1), 58–64. https://doi.org/10.1034/j.1600–0447.2000.102001058.x/pdfGoogle Scholar
Ano, G. G., & Vasconcelles, E. B. (2005). Religious coping and psychological adjustment to stress: a meta-analysis. Journal of Clinical Psychology, 61, 461–480. https://doi.org/10.1002/jclp.20049CrossRefGoogle ScholarPubMed
Bradley, R., Greene, J., Russ, E., Dutra., L., & Western, D. (2005). A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry, 162, 214–227. https://doi.org/10.1176/appi.ajp.162.2.214Google Scholar
Bergin, A. E., & Jensen, J. P. (1990). Religiosity of psychotherapists: a national survey. Psychotherapy, 27, 3–7.CrossRefGoogle Scholar
Boscarino, J. A. (2004). Post-traumatic stress disorder and physical illness: results from clinical and epidemiologic studies. Annals of the New York Academy of Sciences, 1032, 141–153. https://doi.org/10.1196/annals.1314011Google Scholar
Boscarino, J. A. (2008). Prospective study of PTSD and early-age heart disease mortality among Vietnam veterans: implications for surveillance and prevention. Psychosomatic Medicine, 70(6), 668–676. https://doi.org/10.1097/PSY.0b013e31817bccafCrossRefGoogle ScholarPubMed
Bryant, R. A., Gallagher, H. C., Gibbs, L., Pattison, P., MacDougall, C., Harms, L., … & Lusher, D. (2017). Mental health and social networks after disaster. American Journal of Psychiatry, 174(3), 277–285. https://doi.org/10.1176/appi.ajp.2016.15111403Google Scholar
Bryant, R. A., Gibbs, L., Gallagher, H. C., Pattison, P., Lusher, D., MacDougall, C., … & Forbes, D. (2018). Longitudinal study of changing psychological outcomes following the Victorian Black Saturday bushfires. Australian & New Zealand Journal of Psychiatry, 52(6), 542–551. https://doi.org/10.1177/0004867417714337Google Scholar
Cao, C., Wang, L., Wu, J., Li, G., Fang, R., Cao, X., … Elhai, J. (2018). Patterns of post-traumatic stress disorder symptoms and post-traumatic growth in an epidemiological sample of Chinese earthquake survivors. Frontiers in Psychology, 9, 1549. https://doi.org/10.3389/fpsyg.2018.01549Google Scholar
Carlson, E. B., & Rosser-Hogan, R. (1991). Trauma experiences, post-traumatic stress, dissociation, and depression in Cambodian refugees. American Journal of Psychiatry, 148, 1548–1551.Google Scholar
Cerda, M., Bordelois, P. M., Galea, S., Norris, F., Tracy, M., & Koenen, K. C. (2013). The course of post-traumatic stress symptoms and functional impairment following a disaster: what is the lasting influence of acute vs. ongoing traumatic events and stressors? Social Psychiatry and Psychiatric Epidemiology, 48, 385–395.Google Scholar
Chan, C. S., & Rhodes, J. E. (2013). Religious coping, post-traumatic stress, psychological distress, and post-traumatic growth among female survivors four years after Hurricane Katrina. Journal of Traumatic Stress, 26(2), 257–265.CrossRefGoogle ScholarPubMed
Courtois, C. A., Sonis, J., Brown, L. S., Cook, J., Fairbank, J. A., Friedman, M., Schultz, P. (2017). American Psychological Association Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults. Adopted as APA Policy February 24, 2017.Google Scholar
Cuijpers, P., Karyotaki, E., De Wit, L., Eber, D. D. (2020). The effects of fifteen evidence-supported therapies for adult depression: a meta-analytic review. Psychotherapy Research, 30(3), 279–293. https://doi.org/10.1080/10503307.2019.1649732.CrossRefGoogle ScholarPubMed
Currier, J. M., McDermott, R. C., Farnsworth, J. K., & Borges, L. M. (2019). Temporal associations between moral injury and post-traumatic stress disorder symptom clusters in military veterans. Journal of Traumatic Stress, 32, 382–392.Google Scholar
Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Middleton, J. C., … & Gaynes, B. N. (2016). Psychological treatments for adults with post-traumatic stress disorder: a systematic review and meta-analysis. Clinical Psychology Review, 43, 128–141. https://doi.org/10.1016/j.cpr.2015.10.003.Google Scholar
Dao, T. K., Chu, D., Springer, J., Gopaldas, R. R., Menefee, D. S., Anderson, T., … & Nguyen, Q. (2010). Clinical depression, post-traumatic stress disorder, and comorbid depression and post-traumatic stress disorder as risk factors for in-hospital mortality after coronary artery bypass grafting surgery. Journal of Thoracic and Cardiovascular Surgery, 140, 606–610.Google Scholar
Demirchyan, A., Goenjian, A. K., & Khachadourian, V. (2015). Factor structure and psychometric properties of the Posttraumatic Stress Disorder (PTSD) Checklist and DSM-5 PTSD symptom set in a long-term post-earthquake cohort in Armenia. Assessment, 22(5), 594–606. https://doi.org/10.1177/1073191114555523.Google Scholar
Divsalar, P., & Dehesh, T. (2020). Prevalence and predictors of post-traumatic stress disorder and depression among survivors over 12 years after the Bam Earthquake. Neuropsychiatric Disease and Treatment, 16, 1207–1216.Google Scholar
Edmondson, D., Gamboa, C., Cohen, A., Anderson, A. H., Kutner, N., Kronish, I., … & Muntner, P. (2013). Association of post-traumatic stress disorder and depression with all-cause and cardiovascular disease mortality and hospitalization among Hurricane Katrina survivors with end-stage renal disease. American Journal of Public Health, 103, e130–e137. https://doi.org/10.2105/AJPH.2012.301146.Google Scholar
Farnsworth, J. K. (2019). Is and ought: descriptive and prescriptive cognitions in military-related moral injury. Journal of Traumatic Stress, 32, 373–381.Google Scholar
Favaro, A., Zaetta, C., Colombo, G., & Santonastaso, P. (2004). Surviving the Vajont disaster: psychiatric consequences 36 years later. Journal of Nervous and Mental Disorders, 192, 227–231.Google Scholar
Fernandez, C. A., Vicente, B., Marshall, B. D. L., Koenen, K. C., Arheart, K. L., Kohn, R., … & Buka, S. L. (2017). Longitudinal course of disaster-related PTSD among a prospective sample of adult Chilean natural disaster survivors. International Journal of Epidemiology, 46(2), 440–452. https://doi.org/10.1093/ije/dyw094.Google ScholarPubMed
Forbes, D., Creamer, M., Bisson, J. I., Cohen, J. A., Crow, B. E., Foa, E. B., … & Ursano, R. J. (2010). A guide to guidelines for the treatment of PTSD and related conditions. Journal of Traumatic Stress, 23(5), 537–552. https://doi.org/10.1002/jts.20565.Google Scholar
Galea, S., Tracy, M., Norris, F., & Coffey, S. F. (2008). Financial and social circumstances and the incidence and course of PTSD in Mississippi during the first two years after Hurricane Katrina. Journal of Traumatic Stress, 21, 357–368. https://doi.org/10.1002/jts.20355.CrossRefGoogle ScholarPubMed
Gao, X., Leng, Y., Guo, Y., Yang, J., Cui, Q., Geng, B., … Zhou, Y. (2019). Association between earthquake experience and depression 37 years after the Tangshan earthquake: a cross-sectional study. BMJ Open, 9, e026110. https://doi.org/10.1136/bmjopen-2018-026110.Google Scholar
Geng, F, Zhou, Y, Liang, Y, & Fan, F. (2018). A longitudinal study of recurrent experience of earthquake and mental health problems among Chinese adolescents. Frontiers in Psychology, 9, 1259. https://doi.org/10.3389/fpsyg.2018.01259.Google Scholar
Goenjian, A., Najarian, M., Pynoos, R. S., Steinberg, A. M., Manoukian, G., Tavosian, A., & Fairbanks, L. (1994a). Post-traumatic stress disorder in adults and elderly after the 1988 earthquake in Armenia. American Journal of Psychiatry, 151, 895–901.Google Scholar
Goenjian, A., Najarian, L. M., Pynoos, R. S., Steinberg, A. M., Petrosian, P., Setrakyan, S., & Fairbanks, L. A. (1994b). Post-traumatic stress reactions after single and double trauma. Acta Psychiatrica Scandanavia, 90, 214–221.Google Scholar
Goenjian, A. K, Najarian, L. M., Steinberg, A. M., Fairbanks, L. A., Tashjian, M., & Pynoos, R. S. (2000). A prospective study of post-traumatic stress, anxiety, and depressive reactions after earthquake and violence. American Journal of Psychiatry, 157, 911–916.Google Scholar
Goenjian, A. K., Khatchadourian, V., Armenian, H., Demirchyan, A., & Steinberg, A. M. (2018). Post-traumatic stress disorder 23 years after the 1988 Spitak earthquake in Armenia. Journal of Traumatic Stress, 31, 47–56.Google Scholar
Goenjian, A. K., Steinberg, A. M., Walling, D., Bishop, S., Karayan, I., & Pynoos, R. (2020). 25-year follow-up of treated and not-treated adolescents after the Spitak earthquake: course and predictors of PTSD and depression. Psychological Medicine, 1–13. Advance online publication: https://doi.org/10.1017/S0033291719003891.Google Scholar
Green, B. L., Lindy, J. D., Grace, M. C., Gleser, G. C., Leonard, A. C., Korol, M., & Winget, C. (1990). Buffalo Creek survivors in the second decade: stability of stress symptoms. American Journal of Orthopsychiatry, 60, 43–54. https://doi.org/10.1037/h0079168.Google Scholar
Harville, E. W., Shankar, A., Dunkel Schetter, C., & Lichtveld, M. (2018). Cumulative effects of the Gulf oil spill and other disasters on mental health among reproductive-aged women: The Gulf Resilience on Women’s Health Study. Psychological Trauma: Theory, Research, Practice, and Policy, 10(5), 533–541. https://doi.org/10.1037/tra0000345.Google Scholar
Horowitz, M. J., Wilner, N., Marmar, C., & Krupnick, J. (1980). Pathological grief and the activation of latent self-images. American Journal of Psychiatry, 137(10), 1157–1162. https://doi.org/10.1176/ajp.137.10.1157.Google Scholar
Hull, A. M., Alexander, D. A., & Klein, S. (2002). Survivors of the Piper Alpha oil platform disaster: long-term follow-up. British Journal of Psychiatry, 181, 433–438. https://doi.org/10.1192/bjp.181.5.433.Google Scholar
Imel, Z. E., Laska, K., Jakupcak, M., & Simpson, T. L. (2013). Meta-analysis of dropouts during treatment for post-traumatic stress disorder. Journal of Consulting and Clinical Psychology, 81, 394–404. https://doi.org/10.1037/a0031474.Google Scholar
Jafari, H., Heidari, M., Heidari, S., & Sayfouri, N. (2020). Risk factors for suicide behaviours after natural disasters: a systematic review. Malaysian Journal of Medical Sciences, 27(3), 20–33. https://doi.org/10.21315/mjms2020.27.3.3.Google Scholar
Johannsen, M., Damholdt, M. F., Zachariae, R., Lundorff, M., Farver-Vestergaard, I., & O’Connor, M. (2019). Psychological interventions for grief in adults: a systematic review and meta-analysis of randomized controlled trials. Journal of Affective Disorders, 253, 69–86. https://doi.org/10.1016/j.jad.2019.04.065.CrossRefGoogle ScholarPubMed
Kaniasty, K., & Norris, F. H. (2008). Longitudinal linkages between perceived social support and post-traumatic stress symptoms: sequential roles of social causation and social selection. Journal of Traumatic Stress, 21, 274–281. https://doi.org/10.1002/jts.20334.Google Scholar
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Post-traumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048–1060.CrossRefGoogle ScholarPubMed
King, D. W., Taft, C., King, L. A., Hammond, C., & Stone, E. R. (2006). Directionality of the association between social support and post-traumatic stress disorder: a longitudinal investigation. Journal of Applied Social Psychology, 36(12), 2980–2992. https://doi.org/10,1111/j.0021–9029.2006.00138.x.Google Scholar
Krug, E. G., Kresnow, M. J., Peddicord, J. P., Dahlberg, L. L., Powell, K. E., Crosby, A. E., & Annest, J. L. (1999). Suicide after natural disasters. New England Journal of Medicine, 340(2), 148.Google Scholar
Li, X., Jun Aida, J., Hikichi, H., Kondo, P., & Kawachi, I. (2019). Association of post-disaster depression and post-traumatic stress disorder with mortality among older disaster survivors of the 2011 Great East Japan earthquake and tsunami. JAMA Network Open, 2(12), e1917550. https://doi.org/10.1001/jamanetworkopen.2019.17550.Google Scholar
Liang, Y., Cheng, J., Ruzek, J., & Liu, Z. (2019). Post-traumatic stress disorder following the 2008 Wenchuan earthquake: a 10-year systematic review among highly exposed populations in China. Journal of Affective Disorders, 243, 327–339.Google Scholar
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clinical Psychology Review, 29, 695–706. https://doi.org/10.1016/j.cpr.2009.07.003.Google Scholar
Lundorff, M., Holmgren, H., Zachariae, R., Farver-Vestergaard, I., & O’Connor, M. (2017). Prevalence of prolonged grief disorder in adult bereavement: a systematic review and meta-analysis. Journal of Affective Disorders, 212, 138–149. https://doi.org/10.1016/j.jad.2017.01.030.CrossRefGoogle ScholarPubMed
McDonald, S. D., & Calhoun, P. S. (2010). The diagnostic accuracy of PTSD checklist: a critical review. Clinical Psychology Review, 30, 976–987.Google Scholar
McFarlane, A. C. (1988). The longitudinal course of post-traumatic morbidity. The range of outcomes and their predictors. Journal of Nervous and Mental Disease, 176, 30–39.Google Scholar
Morgan, L., Scourfield, J., Williams, D., Jasper., A., & Lewis, G. (2003). The Aberfan disaster: 33-year follow-up of survivors. British Journal of Psychiatry, 182, 532–536. https://doi.org/10.1192/bjp.182.6.532.Google Scholar
Najarian, L. M., Sunday, S., Labruna, V., & Barry, I. (2011). Twenty year follow-up of adults traumatized during childhood in Armenia. Journal of Affective Disorders, 135, 51–55. https://doi.org/10.1016/j.jad.2011.06.038.Google Scholar
Norris, F. H., Perilla, J. L., Riad, J. K., Kaniasty, K., & Lavizzo, E. A. (1999). Stability and change in stress, resources, and psychological distress following natural disaster: findings from Hurricane Andrew. Anxiety Stress & Coping, 12, 363–396.Google Scholar
Pitman, R. K., van der Kolk, B. A., Orr, S. P., & Greenberg, M. S. (1990). Naloxone-reversible analgesic response to combat-related stimuli in post-traumatic stress disorder: a pilot study. Archives of General Psychiatry, 47(6), 541–544. https://doi.org/10.1001/archpsyc.1990.01810180041007.Google Scholar
Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Foa, E. B. (2010). A meta-analytic review of prolonged exposure for post-traumatic stress disorder. Clinical Psychology Review, 30, 635–641. https://doi.org/10.1016/j.cpr.2010.04.007.Google Scholar
Robins, L. N., Helzer, J. E., Croughan, J., & Ratcliff, K. S. (1981). National Institute of Mental Health Diagnostic Interview Schedule. Its history, characteristics, and validity. Archives of General Psychiatry, 38(4), 381–389. https://doi.org/10.1001/archpsyc.1981.01780290015001.Google Scholar
Ruskin, J., Rasul, R., Schneider, S., Bevilacqua, K., Taioli, E., & Schwartz, R. M. (2018). Lack of access to medical care during hurricane Sandy and mental health symptoms. Preventive Medicine Reports, 10, 363–369. https://doi.org/10.1016/j.pmedr.2018.04.014.CrossRefGoogle ScholarPubMed
Schnurr, P. P., Spiro, A., & Paris, A.H. (2000). Physician-diagnosed medical disorders in relation to PTSD symptoms in older male military veterans. Health Psychology, 19(1), 91–97. https://doi.org/10.1037//0278-6133.19.1.91.Google Scholar
Schumm, J. A., Briggs-Phillips, M., & Hobfoll, S. E. (2006). Cumulative interpersonal traumas and social support as risk and resiliency factors in predicting PTSD and depression among inner-city women. Journal of Traumatic Stress, 19, 825–836. https://doi.org/10.1002/jts.20159.Google Scholar
Smith, B., Pargament, K., Brant, C., & Oliver, J. (2000). Noah revisited: religious coping by church members and the impact of the 1993 Midwest flood. Journal of Community Psychology, 28, 169–186. https://doi.org/10.1002/(SICI)1520-6629(200003)28:23.0.CO;2-I.Google Scholar
Steenkamp, M. M., Litz, B. T., Hoge, C. W., & Marmar, C. R. (2015). Psychotherapy for military-related PTSD: a review of randomized clinical trials. JAMA, 314(5), 489–500. https://doi.org/10.1001/jama.2015.8370.Google Scholar
Steinglass, P., & Gerrity, E. (1990). Natural disasters and post-traumatic stress disorder: short-term vs. long-term recovery in two disaster affected communities. Journal of Applied Social Psychology, 20, 1746–1765. https://doi.org/10.1111/j.1559-1816.1990.tb01509.x.Google Scholar
Suliman, S., Mkabile, S. G., Fincham, D. S., Ahmed, R., Stein, D. J., & Seedat, S. (2009). Cumulative effect of multiple traumas on symptoms of post-traumatic stress disorder, anxiety, and depression in adolescents. Comprehensive Psychiatry, 50(2), 121–127. https://doi.org/10.1016/j.comppsych.2008.06.006.Google Scholar
Sutker, P. B., Allain, A. N. Jr., Winstead, D. K. (1993). Psychopathology and psychiatric diagnoses of World War II Pacific theater prisoner of war survivors and combat veterans. American Journal of Psychiatry, 150, 240–245.Google Scholar
Utzon-Frank, N., Breinegaard, N., Bertelsen, M., Borritz, M., Eller, N. H., Nordentoft, M, … & Bonde, J. P. (2014). Occurrence of delayed-onset post-traumatic stress disorder: a systematic review and meta-analysis of prospective studies. Scandinavian Journal of Work, Environment & Health, 40(3), 215–229. https://doi.org/10.5271/sjweh.3420.Google Scholar
Wang, B., Ni, C., Chen, J., Liu, X., Wang, A., Shao, Z., … & Yan, Y. (2011). Post-traumatic stress disorder 1 month after the 2008 earthquake in China: Wenchuan earthquake survey. Psychiatry Research, 187(3), 392–396.Google Scholar
Watkins, L. E., Sprang, K. R, & Rothbaum, B. O. (2018). Treating PTSD: a review of evidence-based psychotherapy interventions. Frontiers in Behavioral Neuroscience, 12, 258. https://doi.org/10.3389/fnbeh.2018.00258.Google Scholar
Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, Y., Weeks, W. B., & Friedman, M. J. (2013). Meta-analysis of the efficacy of treatments for post-traumatic stress disorder. Journal of Clinical Psychiatry, 74(6), e541–e550. https://doi.org/10.4088/JCP.12r08225.Google Scholar
Wittouck, C., Van Autreve, S., De Jaegere, E., Portzky, G., & van Heeringen, K. (2011). The prevention and treatment of complicated grief: a meta-analysis. Clinical Psychology Review, 31(1), 69–78. https://doi.org/10.1016/j.cpr.2010.09.005.Google Scholar
Zhang, Y., & Ho, S. M. (2011). Risk factors of post-traumatic stress disorder among survivors after the 512 Wenchuan earthquake in China. PLoS One, 6(7), e22371. https://doi.org/10.1371/journal.pone.0022371.CrossRefGoogle ScholarPubMed

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