Disaster and recovery

Background: Most people who survive a disaster respond with psychological reactions, but only a minority suffer from lasting psychological problems. Despite evidence of the significance of specific exposures for impaired psychological health after disaster, the relative importance of single exposures remains unclarified. With regard to predisaster factors, the relevance of prior life events is not definite. As for postdisaster factors that influence health, this study of tourist survivors of the Indian Ocean tsunami of 2004 brought about a unique opportunity for studying a population which was spared most of the secondary disruption otherwise common to natural disasters. It also enabled the investigation of the impact of disaster experience on other groups than the most extremely exposed, and the highlighting of the issue of recovery, with special emphasis on intervention in the form of support. Disaster research is still evolving concerning which survivors should be candidates for intervention, and also on how to determine forms of intervention that may be beneficial. It is clear that support, particularly in the form of perception of available support, is important for psychological outcome following disaster. However, many questions remain concerning formalised support, and the role of supportive intervention. Aim: To investigate the impact of a disaster on the psychological health of survivors of the 2004 Indian ocean tsunami, with special consideration of types of exposure, risk factors, and the role of social support for recovery. Methods: The study is based on a questionnaire collected 14 months after the disaster from 1 505 citizens of Stockholm who were in the disaster area. Different disaster exposures were categorised and controlled for in all analyses along with sociodemographic variables. In addition, in Study IV, a population survey of Stockholm was used for comparison, and participants were matched on 8 variables. Main outcomes in all four studies were psychological distress and posttraumatic stress according to validated instruments. Suicidal ideation (Study II) and sick leave (Study IV) were also used as outcomes. Logistic regression analyses were used. Results: The experience of multiple disaster exposures was associated with increased likelihood for reporting of psychological symptoms on all outcomes. Specifically, in Study I, survivors that had experienced life threat were more likely to report above cut off on both outcomes. Study II showed that despite the powerful effect of the disaster experience, life events during childhood and adolescence did have an impact on psychological symptoms. In Study III, support was categorised in indices comprising social support or various sources of formalised support. Satisfaction with all received support within an index predicted an increased likelihood of a better psychological outcome, whereas dissatisfaction with at least one support source constituted a risk for psychological symptoms. Associations were found for formalised support, as well as social support. Study IV showed that participants who had experienced only one or two of the stated types of exposures were more likely to report psychological distress, but not sick leave, compared to the population sample. The least exposed group was less likely to report sick leave than the population sample. Conclusion: Provided the absence of secondary disruptions, survivors of a natural disaster can be expected to recover well, with the exception of the multiply exposed. Survivors who report the experience of life threat should be considered for outreach programmes. When survivors are questioned, assessment of symptoms and dysfunction should be supplemented with evaluation of performance. Also, investigating survivors opinions of support should be standard after disasters. Individuals dissatisfied with support should be approached and offered alternative support from other sources or in other formats