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Abstract

Objective: To investigate quality of life and related risk factors of Taiwanese earthquake survivors with different psychiatric disorders 21 months after the earthquake.

Method: This was a population survey. Trained assistants used the Medical Outcomes Study Short Form-36 (MOS SF-36) and questionnaires to interview 461 respondents (209 males and 252 females) 16 years or older who were equally exposed to the earthquake. Psychiatrists interviewed the same respondents using the Mini-International Neuropsychiatric Interview (MINI), with an adjusted response rate of 79.9%.

Results: The prevalence of varied psychiatric disorders in earthquake survivors ranged from 3.3% to 18%. However, there was almost a positive trend in quality of life in survivors among the following groups: posttraumatic stress disorder combined with major depressive episode; major depressive episode; posttraumatic stress disorder; other psychiatric diseases; and healthy mentality groups on the physical aspect or mental aspect of the MOS SF-36. When survivors were elderly or female and had experienced prominent financial loss immediately after the earthquake, social network change, and mental impairment, their quality of life tended to be worse.

Conclusion: The earthquake survivors had a higher percentage of psychiatric disorders. The risk factors that affected quality of life in survivors were age, female sex, financial loss, social network change, and mental impairment.

Keywords

earthquake Medical Outcomes Study Short Form-36 (MOS SF-36)Mini-International Neuropsychiatric Interview (MINI)quality of life risk factors

Most studies [1–5] have shown evidence of psychological sequelae in patients after disaster, including posttraumatic stress disorder (PTSD), major depressive episode (MDE), sleep disorder, anxiety, and substance abuse. The most common disaster-related psychiatric diagnoses are MDE and PTSD, which are strongly associated [3–5]. In the 20th century, many of the most devastating natural disasters have been earthquakes [1], [6], [7]. Unlike many other natural disasters, earthquakes usually provide no warning, their impact can be widespread and severe, and effects are often ongoing.

Research into the short-term psychological effects of earthquakes has revealed an elevated prevalence of psychological problems among earthquake survivors [2], [3],[8–12]. Presumably, one would expect that most respondents prefer positive health status, and those respondents experiencing a lower quality of life are usually willing to invest more time in improving their healthrelated quality of life (HRQOL). Understanding how a catastrophic earthquake and its sequelae affect people is necessary for determining their quality of life. Wang et al. [13] found that earthquake exposure was associated with a multidimensional impairment in quality of life, including physical, psychological, and environmental domains. The victims also suffered significantly more psychological distress in terms of depression, somatization and anxiety. Some studies [14], [15] have shown that when subjects with physical illness experience disaster, their prognosis and quality of life become worse. Dixon et al. [16] also reported an association between medical comorbidity with poorer self-reported physical health and greater psychotic and depressive symptoms.

The questionnaire developed by Ware et al. [17] is one of the most commonly used generic HRQOL questionnaires. It is used to demonstrate the applicability of quality of life measurements in helping health professionals to identify the physical, mental, and social problems of subjects with physical illness in different phases of the clinical process [18–20]. In addition, the International Quality of Life Assessment project was conducted to test the conceptual equivalence and crosscultural relevance of the Medical Outcomes Study Short Form-36 (MOS SF-36) among different countries [21]. One Taiwanese version of the MOS SF-36 has been conducted [22]. Although most studies [14], [15], [23] used the MOS SF-36 to examine the relationship between physical illness and quality of life, a few reports have examined the relationship between mental disorder and quality of life [24], [25], especially the relation between earthquake-related psychiatric impairment and quality of life [13]. A MEDLINE search revealed no articles that used the MOS SF-36 to examine the quality of life of earthquake survivors. However, some articles [23], [24] have shown a negative relationship between PTSD or major depression and quality of life. The purpose of our study was to use the MOS SF-36 to investigate quality of life and related risk factors in a Taiwanese community population that had different psychiatric disorders 21 months after an earthquake.

Method

Subjects

Tong-Chi village was selected for evaluation because the residents were considered equally exposed to the effects of the earthquake of September, 1999. Household registrations indicated that the village had 736 residents (357 male and 379 female) 16 years or older. The mean age for these residents was 51.3 ±?18.0 years (range: 16–98); 53.0% of the residents were 50 years or older. Education level was primary school or below (56.0%). Most were married (77.6%). No sex differences were demonstrated for basic information items. We later learned that the household registrations included 159 persons that had left Tong-Chi village before the earthquake (manifested as vacant households). There were 461 respondents in total (209 male and 252 female), giving an overall response rate of 62.6% of the total registered population. However, when the vacant households were taken into account, the adjusted response rate was 79.9% (461/577). The mean age of the respondents was 54.3 ±?17.2 years (range: 17–91). Education level was primary school or below for 63.7% of the respondent group. Most were married (79.1%). Except for age, no significant differences were demonstrated for other basic information comparing residents and respondents. Most of the departures from Tong-Chi involved younger residents who had left due to academic or economic concerns, which is the probable reason that the mean age of the respondents was greater than that of the registered population [26].

Instrument

Five psychiatrists, and one epidemiologist designed the questionnaires to investigate risk factors. The questionnaires included several parts: (i) background information concerning age, sex, education, and marital status; (ii) financial problems after the earthquake, such as individual financial loss, prominent financial loss immediately after the earthquake, or family income loss; (iii) social network change or family loss; and (iv) psychiatric impairment, including sleep disturbance [12], [26]. Several benefits of the Taiwanese version of the Mini-International Neuropsychiatric Interview (MINI) are brevity, simplicity, clarity, increased sensitivity and specificity and ease of administration [12], [26], [27]. The relatively short instrument was designed to provide just enough diagnostic information to make good clinical decisions while investigating the 17 Axis I diagnoses. Priority was given to the identification of current disorders, with no attempt made to identify the diagnostic subtypes of psychotic disorders. The MOS SF-36 [17], [21] had ‘health change in the past year’ (HC) and two dimensions (physical component summary [PCS] and mental component summary [MCS]) that attempt to estimate health-related functions for eight subscales: ‘physical functioning’; ‘role limitations due to physical problems’; ‘bodily pain’; ‘general health’; ‘role limitations due to emotional problems’; ‘vitality’; ‘social functioning’; and ‘mental health’.

Procedure

To train six research assistants, the psychiatric team conducted a 2-week psychiatric training program. The psychiatric team also arranged a 1-week training program to instruct psychiatrists in the use 360 QUALITY OF LIFE AND RELATED RISK FACTORS IN EARTHQUAKE SURVIVORS of the Taiwanese version of the MINI. The details of this training program have been documented previously [12], [26].

The research assistants then used questionnaires to collect basic information and related risk factor information from all residents 16 years or older, with analogous information for non-respondents derived from local government records. The research assistants used the MOS SF-36 to investigate quality of life in respondents, whereas psychiatrists interviewed these residents using the MINI. To ensure the reliability of the measure, both of the psychiatrists and research assistants did not communicate the interview results during the study period. At both visits, the purpose of the research project was explained in detail. If the residents refused to participate at this point, only their demographic information was collected using the appropriate questionnaire. Informed consent forms were obtained from all respondents, together with approval from local government authorities and the Department of Health, Republic of China.

Respondents were divided into five groups by psychiatrists' diagnoses: posttraumatic stress disorder and major depressive episode (PTSD and MDE); major depressive episode (MDE); posttraumatic stress disorder (PTSD); other psychiatric diseases (Others); and healthy mentality (Healthy) groups. The related risk factors and quality of life among the five groups were then compared. We also compared the related risk factors through the use of the standardized scores of the MOS SF-36 subscales.

Data analysis

A comparison of the demographic data for the respondents of the five groups was conducted using the ?2 test. Subsequent to summing the Likert-scaled items in the MOS SF-36 survey, each scale is then standardized, so responses can range from 0 (lowest level of functioning) to 100 (highest level). Analysis of variance was used to examine the differences of each subscale score of the MOS SF-36 for each diagnostic group and Scheffé's test was used at post-examination. We also used a multiple regression model with stepwise analysis to study significant main effect variables and to estimate the magnitude of the effects. All the data were analyzed with SPSS version 10.0 statistical software.

Results

A total of 144 (31.2%) of the 461 respondents had one or more psychiatric diagnoses. These 144 respondents were divided by psychiatrists' diagnoses into the following groups: PTSD and MDE group, 23 (5.0%); MDE group, 15 (3.3%); PTSD group, 23 (5.0%); and Others group, 83 (18.0%). The remaining 317 respondents (68.8%) were placed in the Healthy group. There were no significant findings among sex, age, and education level. Respondents in the PTSD and MDE group had a higher percentage of single marital status (including single, divorced, and widowed) compared with other groups (Table 1). Table 2 shows the mean score differences in the subscales among the five groups. There was almost a positive trend in quality of life among the PTSD and MDE, MDE, PTSD, Others, and Healthy groups. Table 3 shows the results of multiple regression analyses to predict varied degrees of risk factors that affected the scores of the quality of life subscales. The results indicated that there were negative correlations among age, education, prominent financial loss immediately after earthquake, and sleep disturbance in the ‘physical functioning’ subscale (adjusted R² = 0.29). There were negative correlations among age, current marital status, family income loss, social network change, and PTSD combined with MDE subjects in the ‘role limitation due to physical problems’ subscale (adjusted R² = 0.13). There were negative correlations among age, prominent financial loss immediately after earthquake, female sex and sleep disturbance in the ‘bodily pain’ subscale (adjusted R² = 0.20). There were negative correlations among age, social network change, grief due to family loss, male sex and sleep disturbance in the ‘general health perception’ subscale (adjusted R² = 0.25). There were negative correlations among social network change, PTSD combined with MDE, and MDE subjects in the ‘social functioning’ subscale (adjusted R² = 0.32). There were negative correlations among current marital status, social network change, PTSD combined with MDE, MDE and PTSD in the ‘role limitation due to emotional problems’ subscale (adjusted R² = 0.18). There were negative correlations among age, sex, prominent house damage, social network change, sleep disturbance, PTSD combined with MDE and MDE subjects in the ‘vitality’ subscale (adjusted R² = 0.17). Finally, there were positive correlations among age, current marital status, other psychiatric diseases, and Healthy subjects, but there were negative correlations among prominent financial loss immediately after earthquake, social network change, sleep disturbance, and PTSD combined with MDE in the ‘mental healthy’ subscale (adjusted R² = 0.34).

Table 1.

Demographic data of patients with psychiatric diseases among 461 Tong-Chi village respondents

Table 2.

Comparison of quality of life for each of the diagnostic groups in 461 respondents 21 months after an earthquake

Table 3.

Multiple regression to predict scores of subscales of MOS SF-36 in 461 respondents 21 months after an earthquake

Table 4 shows the results of multiple regression analysis to predict varied degrees of risk factors that affected PCS, MCS, and HC. There were negative correlations among age, prominent financial loss immediately after earthquake, social network, and sleep disturbance in the PCS. There were negative correlations among sex, prominent house damage, social network change, sleep disturbance, PTSD combined with MDE, MDE and PTSD in the MCS. There were negative correlations among age, PTSD combined with MDE, MDE and PTSD in the HC.

Table 4.

Multiple regression to predict physical component summary, mental component summary, and reported change in health in 461 respondents 21 months after an earthquake

Discussion

We believe that the strengths of this study are as follows. First, this was a population survey with no sampling bias, and no significant differences were found comparing basic information for respondents and nonrespondents. Second, other workers have supported the validity of the MINI [26], [27] to obtain diagnostic criteria and the MOS SF-36 to determine quality of life [17], [21]. Third, all the MINI diagnoses were made by psychiatrists. Fourth, this article is one of a few articles that have examined earthquake survivors' quality of life and psychiatric disorders. However, the limitations of this study are: (i) the prevalence of major depressive episode before earthquake was derived from the respondents' recall (by MINI-based diagnosis) and this maybe have a recall bias; (ii) lacking of the past traumatic experience of respondents before earthquake may be a cumulative or vulnerability factor influencing a proportion of the sample.

Even 21 months after the earthquake, 31.2% of respondents still had one or more psychiatric disorders. The results seemed to mildly decrease in comparison with results from an immediate post-earthquake study [9], [12], but those respondents had a higher percentage of psychiatric disorders compared with a previous study performed before the earthquake in Taiwan [28]. The Taiwan Psychiatric Epidemiological Project, conducted from 1982 to 1986, used the multistage random sampling method with 5005, 3004 and 2995 subjects selected, respectively, from metropolitan Taipei, two small towns and six rural villages. It reported a prevalence rate for major depressive episodes of 0.97% for one of the study villages similar to Tong-Chi village without an earthquake. Other Taiwanese reports [12] showed the prevalence rate of major depressive episode before the earthquake of 2.8% (1998), and immediately after the earthquake of 9.5% (1999). Our study at 21 months after the earthquake had the prevalence rate of 8.2% (2001), which still remains higher that the earlier reports which did not assess earthquake survivors [28]. This study showed a positive correlation between earthquake and mental disorders. The results are similar to other studies [1–5],[7], [13]. Our study showed that respondents with PTSD combined with MDE had a higher rate of single marital status (including single, divorced and widowed). Therefore, single marital status seems to be one of the possible risk factors for developing PTSD combined with MDE. There was almost a positive trend in quality of life in survivors among the PTSD and MDE, MDE, PTSD, Others and Healthy groups (all subscales except ‘bodily pain’ and ‘social functioning’). When earthquake survivors developed PTSD or MDE, especially PTSD combined with MDE, their quality of life became significantly worse. Our results are similar to those of Malik et al. [23] and Schonfeld et al. [25]. In addition, we found that there were fewer mean differences between ‘physical functioning’ and ‘role limitation due to physical problems’ subscale in the PTSD, Others and Healthy groups, but there were prominent mean differences in the PTSD and MDE and MDE groups, especially in the PTSD and MDE group. Similar results were found between ‘role limitation due to emotional problems’ and ‘mental health’ subscales. These results suggested that PTSD combined with MDE had the greatest negative impact on respondents, followed by MDE. Therefore, the feelings of the respondents in the PTSD and MDE and MDE groups were that their role limitations due to physical functioning or emotional functioning were poor. The mean scores on the PCS in the PTSD, Others and Healthy groups and on the MCS in the Others and Healthy groups were similar to the scores of the healthy US population [29]. However, the mean scores of the PCS and MCS dimension in the PTSD and MDE and MDE groups were significantly lower than those of the Healthy group. These results suggest that the quality of life in subjects who develop PTSD and/or MDE would be worse than those in the Others or Healthy group.

In the quality of life subscales, prominent potential risk factors were noted, including age, sex, current marital status, prominent financial loss immediately after earthquake, social network change and mental status. When subjects were elderly, there was a significant negative correlation in the PCS dimension of quality of life but no negative correlation in the MCS dimension except the ‘vitality’ subscale. Because more than half of the respondents who developed PTSD combined with MDE were married, there was a significant negative correlation of ‘role limitation due to physical problems’ or ‘role limitation due to emotional problems’ subscale in PTSD and MDE respondents. Mental disorders, especially PTSD combined with MDE, may be a true risk factor to ‘role limitation due to physical problems’ or ‘role limitation due to emotional problems’ subscale. Although there was no significant differences in most PCS subscale scores, the ‘bodily pain’, ‘general health perception’, and MCS scores in female respondents were less than those in male respondents. Some studies [30], [31] have shown that financial loss affects physical and psychological health. However, Taiwanese culture emphasizes the family not the individual. Therefore, individual loss and decreased income did not show any significant effects on physical and psychological health. In addition, there was less opportunity to work after the earthquake and most family incomes decreased. The decrease of family income did not produce any significant effects, except on ‘role limitation due to physical problems’ subscale. However, prominent financial loss immediately after earthquake (severe house damage) had a negative effect on PCS dimension, especially ‘physical functioning’ and ‘bodily pain’ subscale. House damage often induced physical injuries. In addition, in some cases house reconstruction led respondents to live in a temporary asylum or other housing arrangement, which strongly affected individual ‘mental health’ scores.

The importance of social supports and life events and their relationship to physical and psychological health has been amply documented [13], [30], [32]. Because social support has been proposed as a key resource for overcoming life crises, when social networks change, the physical or mental aspects of life quality are strongly influenced. In Tong-Chi, the typical house architecture is relatively simple, so even where the earthquake caused severe structural damage, residents typically managed to escape from their houses. The more significant effect of the house damage was a social network change, which had a negative effect on quality of life. However, unlike in other townships, there were relatively few deaths and injuries, which minimized the confounding effects of family loss [12].

L'eger et al. [33] found insomnia related to worse health status regardless of whether it was a cause or consequence. We showed that when respondents had difficulties sleeping, there was a significant negative correlation with a quality of life result similar to L'eger et al. [33]. Lack of sleep influenced the physical aspect of life quality in PTSD or MDE respondents. In addition, insomnia influenced the mental aspect of life quality in PTSD and/or MDE respondents, but quality of life in who developed other psychiatric disorders was not so influenced. There was a trend in quality of life in survivors among the PTSD and MDE, MDE, PTSD, Others and Healthy groups. The results suggest a negative correlation between quality of life and psychiatric disorders, especially PTSD and/or MDE.

Footnotes

Acknowledgements

The study was supported by a grant from the Republic of China Department of Health.

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