BOOK PREVIEW
On December 7, 1988, a strong trembler of magnitude 6.9 on the Richter scale shook northwestern Armenia, causing widespread destruction and death. In Gumri, the second-largest city in Armenia, more than half of the structures were severely damaged or destroyed, and 7% of the population died. The city of Spitak near the epicenter was almost totally leveled, and 16% of the population perished. In the aftermath of the earthquake, Armen Goenjian, MD, LDFAPA, FACGS, initiated and directed the Psychiatric Outreach Program and, with a group of dedicated volunteer mental health professionals, provided services to the survivors for more than 2 decades.
Dr Goenjian and his colleagues from UCLA—Alan Steinberg, PhD, and Robert Pynoos, MD—have studied the psychological sequelae of the earthquake in Armenia and other major disasters in the United States, Greece, Nicaragua, Taiwan, Honduras, Thailand, and Japan. They have recently published the book Lessons Learned in Disaster Mental Health: The Earthquake in Armenia and Beyond. The book provides a comprehensive overview of the most sustained comprehensive mental health recovery and research program implemented after a natural disaster.
The book covers the program’s evolution, from the initial acute phase of clinical fieldwork to its expansion as a 3-year teaching and training program of local therapists to the building of 2 mental health clinics in the devastated cities. It provides a wealth of longitudinal data about the course of posttraumatic stress disorder (PTSD), depression, grief, and separation anxiety among treated and not treated subjects.
“One of the reasons these treatment studies are unique is that preadolescents were followed up to 25 years after the earthquake,” according to Dr Goenjian, a full research psychiatrist at the Semel Institute for Neuroscience and Human Behavior at UCLA.
“Almost all reported follow-up treatment outcome studies have been conducted 2 years or less after a disaster. Only a handful have followed subjects up to 5 years,” said Dr Steinberg, Associate Director of the UCLA/Duke University National Center for Child Traumatic Stress.
In controlled studies, adolescents who received trauma- and grief-focused therapy at 1.5 years postearthquake, PTSD and depressive symptoms were significantly less than in the control group at 5 years, and the benefits were maintained at the 25-year follow-up. The new analyses showed that symptoms in both the treatment and the control groups plateaued between 4 and 5 years after the earthquake. “The findings indicate the importance of providing clinical intervention within the first few years and subsequent monitoring for chronic psychiatric and medical problems among the severely affected survivors,” Dr Goenjian said. “Those with baseline severe PTSD and/or depression had significantly more chronic medical illnesses.”
Another finding was the significant impact that postdisaster adversities (often called “the disaster after the disaster”) played in perpetuating PTSD and depressive symptoms. The findings underscore the important role that governmental and nongovernmental agencies could play in the recovery of survivors by providing housing, heat, electricity, means for transportation, and medical services on a timely basis. “These types of supportive measures supplement the benefits of psychotherapy and apply to other types of natural and manmade disasters, wars, and violence, including domestic ones,” Dr Goenjian said.
Another valuable chapter is on moral development and conscience functioning. “Adolescents from Spitak exposed to severe earthquake trauma manifested pathological interference with conscience functioning,” Dr Steinberg said. For example, “These youth felt that they lost their conscience after the earthquake—that their conscience doesn’t work anymore—and thought that it was justifiable to act without consideration of morality to survive.”
“The multigenerational genetic studies showed the heritability of vulnerability to PTSD, depression, and anxiety. They also showed pleiotropy—ie, sharing of genes between PTSD, depression, and anxiety,” Dr Goenjian said. They also identified 2 serotonergic genes (TPH1 and TPH2) and 1 dopaminergic gene (COMT) associated with PTSD. The Whole Exon Sequencing results showed an association between OR4C3 (the gene for olfactory receptors) and PTSD. Carriers of these genes had a higher risk for PTSD. “Such results give us hope that advances in psychiatric genetics will one day be translated into therapeutic and preventive approaches,” Dr Goenjian said.
The book also discusses important organizational successes and pitfalls of implementing the postdisaster recovery program. Regarding factors related to the performance of therapists and minimizing burnout, helpful steps included vetting applicants before enrollment; holding regular predeparture group meetings with new members to disseminate information accumulated from previous groups and foster esprit de corps; providing guidelines for decorum, such as refraining from political and religious activism; and being respectful of local traditions, customs, and religious practices.
Therapists worked in pairs to provide support to one another. They had regular debriefings with peers or group leaders to discuss challenging cases and their own stress reactions to the painful realities. They also took weekly rest days. These measures helped minimize burnout.
“Despite the many emotional and physical hardships of working in the aftermath of the earthquake, almost all of the therapists acknowledged that providing help to the survivors was one of their most gratifying life experiences,” Dr Goenjian said.
He concluded by saying, “My favorite chapter that represents the soul of the book is the chapter including the heart-wrenching compassionate memoirs of the 2 therapists.”
Mr Millman is a senior media relations officer at UCLA Health. Dr Steinberg is the associate director of the National Center for Child Traumatic Stress in the UCLA Department of Psychiatry. Dr Goenjian is board certified in psychiatry. He is a research professor of psychiatry at UCLA Geffen School of Medicine and the Chief Medical Officer of CenExel-CNS Network.