Identification and treatment of Nepal 2015 earthquake survivors with posttraumatic stress disorder by nonspecialist volunteers: An exploratory cross-sectional study.

CONTEXT: In April 2015, a major earthquake struck northern regions of Nepal affecting one-third of the population, and many suffered mental health problems. AIMS: This study aimed to conduct a preliminary investigation of prevalence and feasibility of brief therapy for posttraumatic stress disorder (PTSD) among earthquake survivors. SETTINGS AND
DESIGN: This is an exploratory cross-sectional study of prevalence and feasibility of brief trauma-focused therapy for PTSD among survivors 3 and 11 months after the earthquake in affected areas near Kathmandu.
METHODOLOGY: A team of local nonspecialist mental health volunteers was trained to identify survivors with PTSD using the PTSD checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5) (cutoff score 38). They were trained to deliver either shortened versions of narrative exposure therapy (NET)-revised or group-based control-focused behavioral treatment (CFBT).
RESULTS: Altogether, 333 survivors were surveyed (130 in July 2015 and 203 in March 2016) with PCL-5 as the screening instrument, using the cutoff score of 38 or more for diagnosing PTSD. A PTSD prevalence of 33% was noted in 2015 and 28.5% in 2016. This drop of 4.5% prevalence in the intervening 8 months suggests that a significant number of survivors are still suffering from PTSD. Most participants were female, aged 40 or above, married, and poorly educated. Compared to the brief (four sessions) individual NET-revised, a group-based CFBT was found more acceptable and affordable.
CONCLUSIONS: PTSD is common following earthquake trauma, and if untreated, survivors continue to suffer for a long time. Management of PTSD should be included in future disaster management plans.

INTRODUCTION

In April 2015, a 7.8 magnitude earthquake struck Nepal, killing 8316, injuring 17,866 people, and traumatizing over 2 million people in 15 out of 75 districts of Nepal.[1] Earthquake survivors are at a risk of developing mental health disorders including posttraumatic stress disorder (PTSD).[2] Some form of psychosocial support was provided soon after the Nepal earthquake,[3] but it remains unknown how many survivors continue experiencing grief and PTSD. Compared to the 2010 Haiti earthquake, Nepal's health-care system responded well to physical trauma,[4] but the country was not prepared for the psychological aftermath of the earthquake.[5]

PTSD in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is defined by reexperiencing, avoidance of stimuli associated with the trauma, negative cognitions and mood, and increased arousal that cause functional impairment as a consequence of exposure to a catastrophic event that involves actual or threatened death, serious injury, or sexual violence.[6] Earthquakes occurring in developing countries tend to result in more severe PTSD and for longer periods.[7] For instance, in the 2005 Kashmir earthquake, 55.2% of women and 33.4% of men suffered from PTSD).[8] Following 2008 earthquake in Wenchuan, China, the prevalence of PTSD was 58.2% at 2 months, 22.10% at 8 months, 19.8% at 14 months, and 19% at 26 months.[9]

Meta-analyses have showed that trauma-focused treatments are more effective than nontrauma-focused ones,[10] and international guidelines advise using trauma-focused therapies to reduce PTSD symptoms a few weeks after a disaster.[11] However, the disaster-related PTSD literature is scanty. In a recent systematic study, Lopes et al.[12] identified 11 studies using cognitive behavioral therapy-based therapy, and the results suggested that only two types of trauma-focused therapies have evidence base for the treatment of PTSD after earthquakes: control-focused behavioral treatment (CFBT)[1314] and narrative exposure therapy (NET).[15]

The CFBT-based mental health-care model for earthquake survivors has been designed after the 1999 Turkey earthquake as an intervention to facilitate natural recovery processes by restoring sense of control over anxiety, fear, or distress.[16] Its underlying principle is to reduce helplessness responses by encouraging behaviors that are likely to enhance sense of control over stressor events and life in general. Basoglu andSalcioglu[16] have conducted a series of studies to test the effectiveness of several applications of CFBT. In a randomized controlled trial[13] of single-session CFBT conducted 30 months after the earthquake, 59 participants with chronic PTSD were offered CFBT for 60 min. Significant treatment effects were found on all measures, with self-rated global improvement rates of 49% at week 6, 80% by week 12, 85% by week 24, and 83% by 1–2-year follow-up. CFBT has also been used in groups of 20–30 survivors. The treatment steps are the same as in individual treatment. Evidence is also emerging regarding the usefulness of a CFBT self-help manual. Based on an earlier study,[1417] they claim that “when the manual is delivered after an initial assessment by the therapist, about 50% of the survivors are likely to read it and comply with instructions, and of these, over 80% are likely to recover.” The rationale given for the benefit is that the improvement in traumatic stress is the long-term active efforts of the participant after the session. Self-help manual may be the only means of help in the posttrauma phase, especially when disasters begin to disappear from media headlines, and national and international communities start forgetting about the survivors.

Originally, NET was developed as an intervention for the treatment of PTSD resulting from exposure to multiple and continuous traumatic stressors.[18] Instead of defining a single event as a target in therapy, NET encourages patients construct a narration of their whole lives, following the timeline of their lives from birth to the present, while focusing on a detailed report of the traumatic experiences.[19] Zang et al.[15] evaluated the efficacy of NET for PTSD in Chinese survivors from the 2008 Sichuan earthquake. A comparison of pre- and post-test and follow-up showed a statistically significant reduction of PTSD symptoms in the group receiving NET. In a further study, NET was shortened from the usual 8–10 sessions to 4 sessions (NET-revised [NET-R]) and was found equally effective.[20]

The postearthquake mental health was among the least assessed, recorded, prioritized, attended, and programmed areas of disaster response,[5] and the psychosocial recovery program by the Government of Nepal did not include any long-term intervention for PTSD. There was a need to identify an evidence-based brief therapy for chronic PTSD of earthquake survivors. The aim of the present study was to investigate what proportion of Nepal earthquake survivors suffered from PTSD, and whether nonspecialist mental health workers can be trained to provide short-term trauma-focused therapies to people with PTSD. This article presents the findings of our feasibility study carried out in Nepal in July 2015 and training work in March 2016.

The primary aim of the study was to find what proportion of people were showing signs of PTSD with a view to explore the acceptability and feasibility of short-term trauma therapy provided by nonspecialist volunteers. The study proposal was approved by the Nepal Health Research Council (Reg. no. 293/2015).

METHODOLOGY

The study investigated the prevalence of PTSD and feasibility of short-term trauma-focused therapies in two stages by training psychologist graduates and mental health workers. Following a cross-sectional survey design, we investigated the point prevalence of PTSD 3 and 11 months after the earthquake. The Strengthening The Reporting of OBservational Studies in Epidemiology guidelines[21] were followed as far as possible. Regarding the therapy, we explored NET-R in the first, and both NET-R and group CFBT in the second stage.

Feasibility study in July 2015

In a cross-sectional survey, participants were recruited from two low earthquake exposure (EE) areas near Kathmandu–Bungmati (Khoicha and Farsidol villages), and a moderate EE area in Kirtipur (Panga village). Individuals willing to be interviewed on the survey day (July 6, in Bungmati and July 11, 2015 in Kirtipur) were recruited for the study. Some potential participants, especially men, could not be recruited, as they had gone to their paddy fields for seasonal agricultural purposes.

Although only one person died due to earthquake in Bungmati, several houses were badly damaged. In Kirtipur, 18 people had died, several hundreds injured, and scores of houses and businesses were destroyed, and participants were recruited from one camp with temporary shelters.

Procedure

A team of 43 volunteer mental health workers (13 for Bungmati and 30 for Kirtipur), including psychiatrists, nurses, and psychologists, conducted the survey. A majority of them (72%) were female with no prior training in PTSD.

Prior to the study, volunteers were offered a 2-day intensive training by two British psychiatrists (authors AJ and RN) in grief, trauma-related counseling, and PTSD, followed by NET. All volunteers were thoroughly trained in interview procedures, methods and techniques of interviewing. As most survivors were illiterate, questionnaires were read out to them and answers were documented by the interviewers. Challenges of recruiting volunteers are reported elsewhere.[22]

Measures

Demographic and socioeconomic information were collected in screen-positive participants, including age, sex, marital status, occupation, economic status, and education level.

All adults (aged 18 and above) were initially screened, using the Nepalese version of 4-item Primary Care PTSD Screen (PC-PTSD)[23] by a pair of interviewers through door-to-door visit. The questions are related to nightmares, avoidance, arousal, and numbness/detachment. If a person answered “yes” to any 3 items, he/she was considered “positive.” In a second round of the interview, all screen-positive participants were assessed for probable PTSD using the Nepali version of the PTSD checklist for DSM-5 (PCL-5).[24] The PCL-5 is a 20-item self-report measure that assesses the DSM-5 symptoms of PTSD.[6] The self-report rating scale is 0-4 for each symptom, with descriptors ranging from “0 = not at all” to “4 = extremely,” and the total score ranges from 0 to 80. A provisional PTSD diagnosis can be made by treating each item rated as 2 = “Moderately” or higher as a symptom endorsed, then following the DSM-5 diagnostic rule. A PCL-5 cutoff score of 38 has been recommended as a minimum threshold for diagnosing PTSD by the National Center for PTSD (www.ptsd.va.gov).

All screen-positive survivors (PCL-5 score >38) were offered four individual sessions of NET-R, each session lasting 60–90 min; the first three sessions were delivered daily, while the last session was given after a gap of 1–2 days. The details of NET-R sessions are outlined in Box 1.

Box 1

Narrative exposure therapy-revised sessions

Second study in March 2016

We learned three important lessons from our 2015 feasibility study: (a) Instead of the 4-item PC-PTSD,[23] the 20-item PCL-5[24] should be used as many screen-positive people were PCL negative, (b) therapy should be provided by professionals with prior knowledge and training of mental health and psychological interventions because social workers felt out of depth during therapy sessions, and (c) both group-based and individual therapies should be explored for individual therapy, even a brief one may not be affordable in the context of mass trauma.

We decided to conduct the second study in March 2016, 1 year after the 2015 earthquake in a high EE area of Bhaktpur where almost half of the victims had psychiatric morbidity.[5] We decided to investigate the suitability of both NET-R and group CFBT with a self-help manual adapted from the “recovering from earthquake” chapter of Basoglu andSalcioglu's excellent manual, “A Mental Healthcare Model for Mass Trauma Survivors.”[16] This could be delivered to groups of 20–30 survivors. Each treatment session was delivered within 1–2 h (90 min on an average), at the interval of 2 weeks as outlined in Box 2.[16]

Box 2

Two-session group control-focused behavioral treatment based on self-help manual (adapted from Basoglu and Salcioglu)

For this study, we identified and trained thirty fresh psychology graduates through the Nepal Psychological Association and offered a 2-day trauma-focused training. All volunteers were trained together by AJ and RN on day 1 covering acute stress, grief, and PTSD resulting from earthquake, as well as in using survey instruments. On the 2nd day, volunteers were divided into two groups; one half received training in the 4-session (90 min each) daily individual NET-R and the other half in the 2-session (90 min each) manual-based CFBT over a period of 2 weeks.

Posttraumatic stress disorder screening

The participants were recruited from the local population of Bhaktpur municipality with high exposure level (such as death in the family or destruction of their house). The volunteers already found the local police record of 330 families with at least one death in each family. The volunteers conducted a door-to-door community screening program using PCL-5 questionnaire. All the thirty volunteers worked in pairs, and each pair screened about 10–15 survivors per day. Volunteers were offered free transport, breakfast, lunch, and dinner at a local hotel, which was the office base for the first 2 weeks in March 2016. They were also offered Rs. 500 (equivalent of $5) per day as daily allowance.

Trauma-focused therapies

All adult survivors (aged 18 and above) in Bhaktpur fulfilling the DSM-5 criteria for PTSD were randomly offered either individual NET-R or group CFBT over a period of 2 weeks at the survey base hotel. Therapists were offered daily on-site supervision by the trainers AJ and RN during the working hours between 9 am and 4 pm.

Based on the Bhaktpur experience, we used only one session of group CFBT in Nuwakot. All five volunteers were tasked to start screening work before the visit by the trainers in 10 days' time. Two out of five volunteers conducted the CFBT for screen-positive survivors under the supervision of the trainers on the day of their visit. They were advised to continue screening and running CFBT groups for all suspected survivors in Nuwakot district.

RESULTS

Demographic characteristics

Altogether, 165 individuals were recruited and 159 completed the questionnaire, with a response rate of 96.3%. There were 138 screen-positive participants in Bungmati and 21 in Kirtipur, and most were married, female, and illiterate [Table 1]. Most women were homemakers, and men were laborers or farmers.

Table 1

The characteristics of posttraumatic stress disorder study sample (n=159) in 2015 study

Some participants experienced difficulties in grasping the concepts of “dissociation” and “flashbacks” in PCL-5 and required rephrasing by the interviewers.

Posttraumatic stress disorder prevalence

Table 1 shows the details of screen-positive and PTSD diagnosis. Of 109 participants in Bungmati, 32 (29.4%) adults were screen positive (scoring ≥3 on PC-PTSD), compared to Kirtipur temporary shelters, where a high proportion (10/21; 48%) was screen positive.

Of the 32 screen-positive cases in Bungmati, 9 (28.1%) were diagnosed with PTSD compared to 5 out of 10 (50%) in Kirtipur. The overall prevalence of PTSD in the two villages was 10.8% (14/130), but the overall prevalence among screen-positive individuals was 33% (14/42). Compared to Bungmati, the rate was very high (50%) in Kirtipur, where people lived in tents and temporary shelters. Most were married females aged 60 and above, and their average PCL-5 score was 44.8.

Posttraumatic stress disorder diagnosis

Due to the sample characteristics (earthquake survivors), the DSM criterion A was considered satisfied. The presence of PTSD was determined by means of the items corresponding to DSM-5 criteria for PTSD,[6] and a diagnosis of probable PTSD was made if the participants score 38 or more on PCL-5.

Trauma-focused therapy in March 2016

In Bhaktpur, out of 260 survivors approached, 203 participated in the survey. All participants were adult over the age of 18, of which most were aged 40 or above. A vast majority (71%) were female, and most were unmarried (29%). Of the 203 completing PCL-5, 58 (28.5%) were screen positive nearly a year after the earthquake in April 2015 (compared to 33% in July 2015). Demographic and PCL-5 details of screen-positive participants are given in Table 2.

Table 2

Characteristics of survivors with probable posttraumatic stress disorder (n=58 out of 203) in 2016 study

A provisional (probable) PTSD diagnosis was made by treating each item as 2 (moderately or higher as a symptom endorsed), then following the DSM-5 diagnostic rule. Data analysis of PTSD symptom clusters revealed that the most troubling problem for the survivors was “intrusion symptoms” [at “4” Table 2] in terms of distressing memories, unpleasant dreams, flashbacks, and physiological reaction. On the other hand, the median score for criterion D symptom cluster (negative alterations in cognition and mood) was minimal at “1” and that of the other two clusters was moderate at “2.”

Trauma-focused therapy

All 58 participants with provisional PTSD diagnosis were randomly divided into two groups – 29 to receive NET-R individually and another half to receive group CFBT on two occasions 2 weeks apart.

While 11 patients turned up for individual NET-R on the 1st day, only 4 came on day 2, and none thereafter despite telephone reminders and request to come to the therapy site. For the group CFBT, 15 participants attended the training given by a psychologist volunteer fluent in local Newari language. The session was observed and supervised by AJ. Participants were given a copy of the CFBT self-help manual to practice exposure and nonavoidance daily as homework for the next 2 weeks. All of them were invited to attend the follow-up training, but no one could attend.

In Nuwakot, out of 100 survivors screened for PTSD, 30 scored 38 or more on PCL-5 and over 10 of them showed signs of prolonged grief. Only 16 people with provisional PTSD diagnosis came for the group CFBT delivered in Nepalese language by a pair of trained volunteers. The session was observed by the trainers (AJ and RN), who felt that these mental health volunteers were able to engage the participants well using the self-help manual. The volunteers were requested to screen all suspected earthquake survivors in the neighboring villages and offer them a free copy of the manual. No follow-up study was planned at that time.

DISCUSSION

This is probably the first and only PTSD study in Nepal after the 2015 earthquake. Although this was an exploratory study, the findings of its two phases provide important information of PTSD prevalence and the suitability of mass-level trauma-focused therapy. The findings of the study cannot be generalized as the sample did not represent affected population of all 14 districts.

Prevalence of posttraumatic stress disorder

Our survey of earthquake survivors in various parts of Nepal has revealed that a significant proportion of survivors (around 28.5%) still suffer from PTSD, 11 months after the earthquake. This PTSD prevalence is similar to rates reported elsewhere (between 10.3% and 49%).[7] However, our rates are lower than 55.2% reported a year after the Kashmir earthquake[8] and higher than 22.1% reported 8 months after the 2008 China earthquake in China.[9] These differences may be explained by factors such as the earthquake intensity, type of exposure, sample selection procedure, and methodological differences across the studies.[7]

Although it was an exploratory study covering only four out of 14 districts affected by the earthquake, findings of our work in July 2015 and March 2016 suggest that the PTSD prevalence has dropped by only 4.5% (from 33% in 2015 to 28.5% in March 2016) over a period of 7 months. Around one-third of survivors still suffer from PTSD, which will prevent them from returning to normal life in the absence of effective treatment.

Out of the four DSM-5 PTSD symptom clusters, Nepalese earthquake survivors scored high on criterion B symptoms (reexperiencing) and low on the new criterion D symptoms (negative alterations in cognition and mood). These findings may be important for PTSD patients in the Indian subcontinent, in terms of whether to use DSM-5 or the proposed criteria for the ICD-11 due to come out in 2017. For the Nepalese patients with PTSD, reexperiencing may be easier to report than the vague and subtle changes in cognition and mood. Both systems have incorporated a number of modifications to their earlier counterpart classification systems (DSM-IV and International Classification of Diseases, 10th revision [ICD-10]). The key component of ICD-11 approach is an increased focus on the clinical utility of diagnoses and their accessibility to frontline workers. The emphasis on clinical use and simplicity of ICD is useful to many low-income countries with less developed mental health services.[25] To tighten the diagnosis of PTSD, the definition of reexperiencing in the ICD-11, as a reliving of the event, has become central, and is based on the evidence that reliving is a feature that distinguishes PTSD from other posttraumatic intrusive symptoms.[26]

Short-term trauma therapies

The present study found that local mental health workers can be trained in brief trauma therapies at short notice that a self-help manual-based group CFBT may be more appropriate for less educated rural population. The effectiveness of the NET-R and CFBT was not evaluated as it was beyond the scope of the study. However, both forms of therapies have been successfully tried in China[14] and Turkey,[15] respectively.

Traumatic stress is a fear-related process, yet most treatments used with mass trauma survivors, such as psychological debriefing, counseling, and psychosocial support strategies,[3] do not address the issue of trauma-induced anxiety or fear as the primary causal process. A nonevidence-based intervention does not result in improvement in PTSD or at best provides only partial or modest effects, as demonstrated by a study of Ugandan survivors of war and displacement.[27] In the immediate aftermath of the Nepal earthquake, training was provided to a pool of psychiatrists and to medical doctors in the affected districts to identify people with mental health needs and establish a referral mechanism for patients needing additional support.[28] As the response shifted from relief to recovery and rehabilitation, the responsibility of addressing “remaining needs” for mental health subcluster was passed on by the WHO to the Nepal's Ministry of Health and Population. In a country where basic rehabilitation of survivors has not been completed in a year, it is not surprising to see no plans for their mental health needs.

CONCLUSIONS

This feasibility study revealed that a significant proportion of Nepal earthquake survivors (28.5%) still show signs of probable PTSD nearly 1 year after the trauma. It was reassuring to find that mental health workers, especially psychology graduates, can be trained to identify and treat survivors with suspected PTSD using group-based brief trauma-focused therapy, at a negligible cost.

It is crucial for the Department of Health to include long-term management plan for mental health problems including PTSD as part of disaster response strategy. The CFBT self-help manual published by the Nepal Psychological Association may be used after future disasters. In addition, the Department of Health should consider commissioning a randomized controlled trial to evaluate short- and long-term effectiveness of a brief trauma-focused therapy, to be used at short notice.

Financial support and sponsorship

This study was supported by the Nepalese Doctors' Association UK, and Health Exchange Nepal with a nominal fund for logistic cost of the study in July 2015 and March 2016. All other work was voluntary, and the British psychiatrists had traveled from London to Kathmandu at their own cost.

Conflicts of interest

There are no conflicts of interest.