ARTICLE_disaster and mental health

Blackwell Science, LtdOxford, UKPCNPsychiatry and Clinical Neurosciences1323-13162004 Blackwell Science Pty LtdApril 2004582110116Review ArticleNatural disasters and mental health in AsiaM. Kokai et al.

Psychiatry and Clinical Neurosciences (2004), 58, 110–116

Review Article

Natural disaster and mental health in Asia

MASAHIRO KOKAI, md, phd,1 SENTA FUJII, md,2 NAOTAKA SHINFUKU, md, phd3 AND
GLEN EDWARDS, psyd3
1Department of Neuropsychiatry, Hyogo College of Medicine, Nishinomiya, 2Department of Psychiatry and
3International Center for Medical Research, Kobe University School of Medicine, Kobe, Japan

Abstract The purpose of the present article was to review the literature on disaster mental health in relation
Key words to natural disasters such as earthquakes, volcanic eruptions, typhoons and cyclones throughout
Asia. Articles reviewed show that disaster psychiatry in Asia is beginning to emerge from and leave
behind the stigma attached to mental health. The emergence of the acceptance of disaster mental
health throughout Asia can be attributed in part to the acceptance of the notion of post-traumatic
stress disorder (PTSD). This has allowed greater involvement of mental health professionals in
providing ongoing support to survivors of natural disasters as well as providing greater opportu-
nities for further research. Also, articles reviewed in the present paper commonly suggested the
need for using standardized diagnostic tools for PTSD to appropriately interpret the discrepancy
of results among studies. The importance of post-disaster support services and cultural differences
is highlighted.

Asia, earthquake, mental health, natural disaster, post-traumatic stress disorder.

INTRODUCTION earthquake. The earthquake struck Kobe city and the
Southern part of Hyogo Prefecture, killing more than
The authors reviewed a range of articles on natural 5500 people within the first 24 h and leaving some
disasters and mental health in Asia. The review focused 300 000 homeless.1
primarily on three kinds of natural disasters common
in Asia. They are earthquakes, volcanic eruptions, and Following the devastating earthquake, the notion of
typhoons and cyclones. Although there are numerous PTSD was widely accepted by survivors, volunteers,
articles on disaster mental health to be found in Asia, mental health professionals and the media in Japan.
the majority relate to mental health problems and post- Acceptance was due in part to the fact that PTSD did
traumatic stress disorder (PTSD) resulting from man- not have the stigma often associated with other psychi-
made disasters. Articles on Vietnam veterans and atric diagnoses. In the present paper, the authors focus
Indochina refugees comprise the majority of papers in on articles relating to mental health problems of natu-
this subject area. There are a few articles that look at ral disaster survivors in the past three decades through-
mental health problems of the atomic bomb survivors out Asia.
of Hiroshima and Nagasaki. Although some 50 years
have elapsed, some survivors continue to suffer from BACKGROUND
the physical and psychological consequences of the
Atomic bombings in 1945. Natural disasters impact on large numbers of people
throughout the world. According to statistics from the
The discipline of disaster mental health is a relatively Red Cross Society, Asia is the most disaster-prone area
new concept in Asia and PTSD was little known in of the world. One reason cited for the high incidence of
Japan until January 1995 following the Hanshin Awaji disasters in Asia is its geographic location. Earth-
quakes are particularly common in the Asian region
Correspondence address: Dr Masahiro Kokai, 1–1 Mukogawa-cho, because East and South-east Asia is situated on the
Nishinomiya, Hyogo 663-8501, Japan. Email: [email protected] ‘Circum-Pacific Seismic Belt’. This Pacific area is
engraved by several trenches and stretches from the
Received 16 April 2003; revised 1 September 2003; accepted 8 Sep- Aleutian Trench to the Philippine or Mariana Trench,
tember 2003.

Natural disasters and mental health in Asia 111

and is spread over the junction of several plates such as to present a clinically significant symptomatic response
North American, Eurasian, Pacific and Philippine Sea as a consequence of exposure to stressful events, extent
Plates. Also, in South Asia (Bangladesh, India, Nepal of loss, social disorganization and lack of community
etc.), the Eurasian Plate overrides the Indian Plate.2 support. Recently in Asian countries, a number of stud-
The collision of these tectonic plates has over the years ies on earthquake-related mental health problems has
created a myriad of devastating earthquakes. been published with the gradual introduction of PTSD
and its diagnostic criteria. However, significant issues
The enormous destruction resulting from earth- remain unresolved with regard to post-disaster psycho-
quakes results in the loss of life, homes and infrastruc- pathology. Theses include such factors as how often the
ture. The effect of a tsunami that may follow the disaster survivors meet the full criteria for diagnosable
earthquake frequently adds to the destruction and loss mental disorders, what types of disorders are fre-
of life and property. Furthermore, the instability of quently linked to the impact of the disaster, whether
plates or crust of the earth in the Pacific area sustains the post-disaster psychopathology is transient or long-
many active volcanoes, constituting the so-called ‘Ring lasting, and whether post-disaster psychological reac-
of Fire’ ranging from Alaska to South America. In tions are universal in nature or if they are bound to
addition, most Asian countries are situated within the social, cultural and economic factors.
zone of the ‘Typhoon Belt’ or lie in the path of tropical
cyclones.3 In Japan the Hanshin Awaji earthquake struck in
mid-winter of 1995, with a recorded magnitude of 7.2
In addition to typhoons and cyclones with their vio- on the Richter scale. It affected 3.5 million people and
lent winds and extremely heavy rainfall, the monsoon more than 20 cities and towns in the south-west of
rains often cause uncontrollable floods in the areas Hyogo prefecture and the adjacent area. The final
along the rivers or lakes. Thus people living throughout number of deaths resulting from the earthquake rose
Asian are constantly menaced by violent natural disas- to approximately 6500.4
ters. According to World Disaster Report 2001, distrib-
uted by the International Federation of Red Cross and Following the earthquake Kato et al. assessed the
Red Crescent Societies, of approximately 3 billion peo- frequency of short-term, post-traumatic symptoms
ple in the world affected by disasters from 1967 to 1991, among a group of evacuees.5 A total of 142 people
some 85% lived in Asia. under the age of 60 years and elderly people from
emergency shelters who had been living in the area
Despite the commonality of disasters throughout close to the epicenter were assessed using the Post-
Asia, the number of published studies on disaster- Traumatic Symptom Scale. This was undertaken during
related psychological distress in the region is limited. the third week following the earthquake. Another shel-
This may be due in part to the fact that psychiatry or tered group of 123 young and elderly subjects from the
stress-associated psychiatry is not well recognized. same community was assessed in the eighth week.
Recently, however, the increased attention to PTSD Results from the first group found that subjects
following earthquakes, mass poisoning, and floods has from both age groups experienced sleep disturbance,
promoted disaster psychiatry within Asian countries. depression, hypersensitivity and irritability. In the sec-
ond group, the percentage of younger subjects experi-
Kokai and Shinfuku reviewed articles on pathologic encing symptoms did not decrease, while elderly
stress response in Asian people resulting from wars subjects showed a significant decrease in most of the
and natural disasters, and then suggested the possibility symptoms.
of somatization as an alternative expression of psycho-
logical distress to disasters.4 The aim of the present arti- The discrepancy between the age groups and the
cle was to survey reports and studies on disaster poor rate of emotional and psychological recovery in
psychiatry in Asia and evaluate clinical manifestations younger subjects was partly explained by the psycho-
of post-disaster psychopathology and the factors con- logical burden of catering for family members and
tributing to the psychological recovery from traumatic reconstructing their community. This was in contrast
exposure. To our knowledge, no reviewing article on with retired people, who had experienced previous
the acute and chronic psychiatric effects of disasters in disasters such as the mass bombing during World War
Asia has been carried out. II.5 Caution must be exercised, however, in openly
accepting previous disaster experience as a determin-
DISASTER MENTAL HEALTH IN ASIA ing factor leading to greater recovery.

Earthquakes Research of the rates of psychiatric morbidity
among community samples exposed to natural disas-
Psychological effects of earthquakes have received ters have methodological limitations. However, a few
increased attention in past decades. The studies on reports have used the results of surveys from clinical
disaster aftermath indicate that many victims are likely

112 M. Kokai et al.

case research to evaluate the prevalence of psychiatric period following the disaster.10 The prevalence of mor-
morbidity following the Hanshin-Awaji earthquake. bidity was approximately threefold higher than that of
Kokai et al. carried out clinical observation in an out- other community samples or health screening clinics
patient service of a university hospital situated in the formerly examined by them using the epidemiological
affected area.6 Anxiety disorder suffered from the instrument, Chinese Health Questionnaire-12 (CHQ-
direct impact of the traumatic experience was the most 12). The morbidity was seen most clearly in women of
common disorder reported within the first month fol- middle age. The degree of destruction of homes was
lowing the earthquake. After the first month the disor- correlated with the CHQ-12 total scores. With regard
der steadily decreased. Reports of depression were to PTSD symptoms assessed using the DSM-IV crite-
closely related to unemployment, enormous financial ria, re-experience of the event and increased arousal
cost and burden for reconstruction of homes, physical was prevalent while symptoms related to avoidance or
fatigue and interpersonal hardships at the relocation emotional numbing were relatively low. The study con-
sites. Like the anxiety disorder cases, the number of cluded by suggesting that early psychiatric interven-
disaster-related depression cases gradually decreased tion, including pharmacological treatment for acute
within 1 year. stress, is indicated during the early stages following a
disastrous earthquake.
The same study found that the prevalence of PTSD
diagnosed by Diagnostic and Statistical Manual of While the studies mentioned so far mainly focus on
Mental Disorders (4th edn; DSM-IV) criteria was post-earthquake psychopathology and an epidemio-
reported in only six cases among 322 new psychiatric logical point of view, Wang et al. investigated the rela-
outpatient cases at the psychiatric department of the tionship between PTSD rates and the importance of
university hospital during a 6 month period after the psychosocial intervention.11 Data for their research
Hanshin Awaji earthquake.6 A study by Mita et al. were collected following an earthquake that struck the
reported a finding of 21.1% of PTSD cases using the northern part of China in 1998.
criteria of ICD-10 Classification of Mental and Behav-
ioural Disorders in outpatient samples.7 The number Researchers compared the rate of PTSD 9 months
was estimated to be around 5% when the DSM-IV cri- after the event in two villages: one was located adja-
teria were applied. Another report using the DSM-IV cent to the epicenter and the other some distance from
criteria of the occurrence of PTSD observed among the epicenter. Surprisingly, they found a lower rate of
outpatients in more severely affected areas adjacent to PTSD in the number of cases located adjacent to the
the epicenter, described a higher rate of 19.8%.8 The epicenter, where there was a higher level of initial
difference between the result and that using different exposure to the disaster area. These findings contradict
instruments for assessment highlights the need for cau- most previous studies.6,12–14
tion in interpreting results, as well as a need for meth-
odological standardization. In general, psychiatric morbidity was significantly
related to destruction of houses, destruction of posses-
The middle- and long-term health effects relating to sions in the affected area and was higher in the victims
general chronic disease of survivors has also been a closer to the epicenter of earthquake. One reason
subject of study. Findings pointed to a correlation given to explain the finding was the prompt and higher
between deterioration in the condition of survivors level of post-disaster support and intervention to the
with a chronic disease caused by psychological factors. adjacent area.11 This was thought to mitigate the impact
Inui et al. demonstrated that glycemic control was of initial exposure and reduce the probability of PTSD
aggravated among diabetic patients in Kobe but not in occurrence.
Osaka, an area close to Kobe following the Hanshin
Awaji earthquake.9 Further, the General Health Ques- Villages far from the epicenter were neglected, with
tionnaire (GHQ) scores were significantly higher in few supported by government and other agencies. The
patients in Kobe than in Osaka. The study demon- aforementioned findings highlight the importance of
strated that psychological problems following the post-disaster supports as a key factor in reducing
earthquake might be responsible for the aggravation of PTSD among disaster victims. The researchers also
glycemic control in diabetic patients. In this context, a found that the use of DSM (3rd edn, revised; III-R) cri-
psychosomatic interaction of disaster survivors should teria resulted in a much higher frequency of PTSD
not be neglected. compared with the use of DSM-IV. They recom-
mended that a uniform criterion of DSM-IV diagnosis
In 1999, a devastating earthquake struck a central for PTSD be used in further research. Also, they sug-
area of Taiwan. Chen et al. reported on the high prev- gested that the cultural factor of underreporting the
alence rate of psychiatric presentations in 525 subjects severity of the symptoms due to the reluctance to
who presented at a mobile clinic during a 1 month express psychological stress in Chinese culture may
explain the lower rates of PTSD.11 This may also help

Natural disasters and mental health in Asia 113

explain the relatively lower PTSD occurrence in recent ever, this trend has begun to change over the past
studies on disaster psychiatry among Asian countries. decade. Disaster mental health has contributed in var-
ious ways to reducing the stigma attached to psychiatry
Volcanic eruptions in a few Asian countries.

On Miyakejima Island in Japan the highest mountain In Japan and the Philippines mental health profes-
peak, Oyama, has repeatedly erupted over the years. sionals became increasingly involved in emergency and
Following the eruption in 1983 a series of studies over long-term intervention teams following several volca-
a 31/2 year period focused on the psychological and nic eruptions in the 1990s. Increasingly, they have
physiological changes of residents on the island.15 taken a more active role in disaster management, pre-
Three sequential assessments of the general health sta- paredness and response and have gained greater
tus of 269 victims in severely damaged areas were understanding of the survivors’ responses to disasters.
carried out using the 20-item questionnaire and elabo- In addition, they have participated in mental health
rated on by the researchers based on the Cornell Med- care of survivors and undertaken research and ongoing
ical Index. education in disaster mental health.16,17

Following the eruption there were no reported cases However, it has not been easy to overcome the reluc-
of loss of life or serious injury. However, of the survi- tance or prejudice to psychiatric intervention common
vors involved in the study, 63% reported the destruc- among the general population. When a volcano located
tion of their home by the pyroclastic flow of the in Nagasaki prefecture, Japan repeatedly erupted over
volcano.15 Disaster-related PTSD or other significant 4 years, the Fukae town suffered heavy damage result-
psychiatric disorders were not reported. The result of ing in 44 deaths and the destruction of 2500 homes. To
the assessment indicated that the symptom severity assist in reducing prejudice and stigma associated with
increased in most items, in particular for items relating mental health, a mental health support team from
to tendency to lose temper, drink alcohol, fatigability, Nagasaki deliberately set out to introduce carefully
myalgia, hypertension, headache, and palpitation. designed activities to mitigate ambivalent feelings
Only the items relating to the loss of appetite and towards mental health among the survivors of the Mt
weight loss indicated a positive outcome. One explana- Unzen-Fugen eruption in 1991.16
tion given to this symptom constellation is that it may
reflect a stress response leading to increased appetite. Team members chose to move away from the ‘med-
It is of interest to note that results during the study ical model’ of mental health care by discarding their
period showed increased stress reactions for the group white clinical coats and outreaching into the commu-
who had lost their home and equally for those who had nity. They achieved this by organizing recreation activ-
suffered no loss of their home. ities such as ballgames as the first step in engaging the
community collectively.16 The mental health support
Also, adverse environmental conditions after the team worked closely with other medical personnel to
volcanic eruption could produce a wide range of long- assist evacuees who escaped from the ongoing volcanic
lasting negative psychological effects on the commu- activity. A report on the psychiatric intervention by the
nity as a whole.15 In the case of the volcanic eruption of health team following the disaster focused on their
Miyakejima no serious mental health problems were experience of their mental health intervention.
recorded. This may well be the result of PTSD and
other disaster mental health symptoms not being given The first health investigation was in December 1991
due attention in Japan. using the GHQ-30, to which a total of 56.8% of 7402
evacuees over the age of 16 years responded. The per-
Disaster psychiatry in Asia remained relatively dor- centage of people who scored more than 8 points val-
mant until the 1980s. One reason for this can be found ued for a cut-off was 66.9% among the evacuees in
in the stigma attached to mental health problems in contrast with 9.8% among the control group that was
Asian countries. Psychiatry or mental health activities selected from two towns close to the danger area but
received low recognition and were not supported or which had escaped the disaster. Actual supporting
welcomed by the general public. Mental health prob- activities such as counseling visits by community nurses
lems were seen to be synonymous with being danger- were performed based on the results of the health
ous and lazy, and were something to explain the investigation. A follow-up study in one area of the dis-
condition of the possessed. Individuals were reluctant tricts indicated that the percentage of people who
to disclose their emotional or psychological problems scored over 8 points was reduced to 34.8% from 70.5%
to others particularly after being mentally traumatized. 4 years after the first investigation.
This behavior led to survivors and their family mem-
bers being reluctant to seek mental health care. How- Psychiatrists identified 76 victims who needed ther-
apeutic crisis intervention out of 150 interviewed dur-
ing 2 years from June 1992. Women in the middle age

114 M. Kokai et al.

group were at greater risk. As to the prevalence of an acknowledgment of the potential mental health
mental illness, 58% were categorized as having depres- outcomes from disaster and other stressful traumatic
sion, while 12% were diagnosed with PTSD. The out- events. A wide variety of studies also suggests depres-
come of crisis intervention recorded 54 remissions, six sion and anxiety symptoms, alcohol abuse, and psycho-
cases of exacerbation, six cases of relapse, and 10 cases somatic symptoms as potential disaster sequelae.
in which there was no change. It was concluded that
psychological dysfunction at the time of crisis Regarding the spectrum of acute stress responses,
improved in general with appropriate support.16 Van der Kolk et al. in their study of 395 traumatized
treatment-seeking subjects and 125 non-treatment-
In a later follow-up study of the Mt Unzen-Fugen seeking subjects who had also been exposed to trau-
eruption, Ohta et al. reported on the change over time matic experience, found that PTSD, dissociation, som-
of the long-term post-disaster mental distress of the atization and emotional dysregulation were highly
evacuees.18 interrelated.19 As a conclusion, they pointed out that
PTSD, dissociation, somatization and emotional dys-
Some 245 evacuees were evaluated using the GHQ- regulation represent a spectrum of adaptation to
30 and its factor analysis. They found that the factor trauma. They often occur together, but traumatized
scores for depression did not improve until 44 months individuals may suffer from various combinations of
after the initial eruption. This was in contrast to the symptoms over time.
improvement of the remaining four factors. The
authors reasoned that adverse difficulties faced by the Research interests in trauma psychiatry include the
evacuees in reconstructing their homes, re-uniting the survey on acute symptoms as predictors for later psy-
community and the difficulties associated with read- chopathology. For example, subjects with ASD would
justing to daily life situations may have been respon- be more liable to develop PTSD. However, the hypoth-
sible for the findings. The possibility of depressive esis is yet to be conclusive.
symptoms lingering longer and various clusters of
symptoms persisting in victims of natural disaster are One of the reports addressing this hypothesis and
important factors that require additional research. To based on the study in an Asia–Pacific region was car-
enhance psychosocial assistance to victims, families ried out by Staab et al.20 They investigated 385 individ-
and caretakers of disasters, disaster psychiatry has a uals who experienced five typhoons that struck the
responsibility to undertake ongoing research to pro- Guam islands in 1992. Although there were no fatali-
vide information that will assist such populations. ties, survivors were scattered over a wide area and suf-
fered minor injuries. One week after the typhoon they
Howard et al. interviewed 351 tribal and non-tribal used their own version of a 23-item scale approximat-
disaster survivors 6 years after they were displaced ing DSM-IV diagnosis of ASD to classify subjects into
when Mount Pinatubo erupted in the Philippines in three groups: probable ASD; an early traumatic stress
June 1991, causing the largest volcanic disaster of the response (ETSR); and no acute diagnosis. The criteria
century.17 Prevalence rates for psychiatric disorders of ETSR were composed of those of ASD without dis-
were similar to those obtained in other studies of psy- sociative symptoms.
chiatric intervention in natural disasters.6,16 Major
depression and anxiety disorder including PTSD was The study found subjects with probable ASD were
the most frequent diagnosis. In the study the authors significantly more likely to develop PTSD 8 months
emphasized diagnosis using a DSM-IV-based semi- after the first typhoon and somewhat more likely to
structured diagnostic instrument and its translation develop depression than other exposed individuals.
found to be comparable between Americans and Fili- Because subjects with ETSR did not have a poorer
pinos including aboriginal inhabitants.17 outcome, all acute stress symptoms do not have the
same prognostic value. Furthermore, dissociative
Typhoon and cyclone symptoms may be one of the factors contributing to
the development of PTSD from an early phase of
Although PTSD is strongly emphasized in the litera- post-disaster psychopathology. However, symptom
ture on disaster psychiatry and in studies of trauma- assessment and diagnostic procedure of the first study
tized survivors, problems related to an early phase of step were based on the mailed questionnaires sur-
post-disaster psychopathology are neither homoge- veyed 8 months after the first typhoon. Some recall
neous nor universal phenomena. bias accompanying the retrospective study is not
entirely discarded. Further, because the subjects were
Both DSM-IV and ICD-10, the two most widely junior enlisted personnel and spouses in the US mili-
applied diagnostic systems, have included acute stress tary community, results of this study may not be com-
disorder (ASD) or acute stress reaction, PTSD and parable with the traumatic reactions observed in
adjustment disorder in their classifications, reflecting Asian individuals.20

Natural disasters and mental health in Asia 115

A serial observation of psychiatric symptoms in the Increased recognition in 1990s
affected population in Sri Lanka after the cyclone
disaster of 1978 was reported.21 The work was under- In the Philippines mental health professionals began to
taken prior to the classification of PTSD in the DSM- join with emergency and long-term intervention teams
III in 1980. Although the cluster of symptoms or tech- following the Bagio Earthquake and Pinatubo volcanic
nical terms associated with the disorder was not fre- eruptions in the 1990s. In Japan, the Hanshin Awaji
quently used in the paper, the nature of developing earthquake marked the turning point in the popular-
traumatic stress towards psychological dysfunctions ization of PTSD and the need for mental health care
was explained. In addition, an interesting mechanism for survivors. In China and Taiwan also there was a
for the emergence of PTSD symptoms of a community rapid growing awareness of the need to establish disas-
in a developing country was explained. Patrick and ter psychiatry and related mental health activities.
Patrick identified two groups of people having early
(within the first 4 weeks after the cyclone) and delayed Scarcity of research on disaster psychiatry in Asia
(after 1 month) manifestation of their symptoms, in the
affected area.21 The number of the published studies on disaster-
related psychological distress in Asia is limited. This is
The symptomatology and its prevalence rate in all probably due to the fact that the notion of disaster psy-
subjects in the area were distributed as follows: anxiety chiatry or stress-associated psychiatry is not well rec-
84%, phobia (excessive avoidance behavior) 68%, ognized. Recently, however, an increased number of
depression 41%, hallucinations (mainly in the form of papers related to PTSD and disaster psychiatry has
high frequency whistling sound) and passivity feelings appeared in Japan, China and the Philippines.
13%, suicidal ideation 41%, and disaster syndrome
(apathy, aimless wandering, mute and motionless Need for standardized diagnostic criteria and its
behavior) 23%. In the control area, the reported symp- diagnostic tools
toms were observed only within the first 4 weeks and
were not observed after 1 month. Women were repre- Post-traumatic stress disorder is part of a wide range of
sented more in the latter group. The authors studied psychological reactions to disaster. The most common
factors contributing to the delayed onset of symptoms mental health manifestations include anxiety, insomnia
in the affected area. They reasoned that group cohe- and depression. Somatization is discussed as the com-
siveness, strong community identity, realization of mon form of reaction to disaster in Asia. However, this
losses of other families, sympathy and sharing by the was not confirmed. There exists a surprising large dif-
community members, and continued habitation in ference between ICD-10 and DSM-IV for the diagnos-
damaged homes acted as reminders and reinforce- tic criteria for PTSD. Researchers have also found that
ment. They concluded that the importance of early the use of DSM-III-R criteria resulted in a much higher
intervention within the community setting in a devel- frequency of PTSD compared with that of DSM-IV.
oping country must not be overlooked.21 Currently the The uniform criteria of DSM-IV diagnosis for PTSD
importance of early mental health intervention is gen- are recommended for further investigations.
erally accepted as the hallmark of emergency interven-
tion after catastrophic disasters, irrespective of Role of early intervention and support to mitigate
developing or developed countries in Asia.22 adverse effects

SUMMARY Several studies in Asia show the importance of post-
disaster support as a key factor in reduction of PTSD
Importance of disaster psychiatry in Asia. among disaster victims. The relatively low prevalence
of PTSD compared to that in other countries (Mexico,
Asian countries are constantly menaced by violent nat- Azerbaijian etc.) could be attributed to strong family
ural disasters. From approximately 3 billion people in and community ties, lower expression of psychological
the world affected by disasters from 1967 to 1991, content, and inclination to somatization of distress.
approximately 85% lived in Asia. Disaster causes a
wide range of psychological distress as well as physical Role of PTSD in reducing stigma of mental health
and social distress. However, there has been little problems in Asia
attention given to the impact of disasters on mental
health following disasters throughout Asia. This was Post-traumatic stress disorder is considered to be a rare
considered to be a result of the strong stigma attached diagnosis in that it does not have the stigma associated
to mental health problems.

116 M. Kokai et al.

with other psychiatric diagnoses.The wide use of PTSD diabetes mellitus. Arch. Intern. Med. 1998; 158: 274–
has contributed to a decrease in the stigma attached to 278.
post-disaster mental illness in Japan and in the Philip- 10. Chen CC, Yeh TL, Yang YK et al. Psychiatric morbidity
pines. This may also be true for other Asian countries. and post-traumatic symptoms among survivors in the
early stage following the 1999 earthquake in Taiwan. Psy-
CONCLUSION chiatry Res. 2001; 15: 13–22.
11. Wang X, Gao L, Shinfuku N, Zhang H, Zhao C, Shen Y.
Disaster psychiatry in Asia did not exist as a psychiatric Longitudinal study of earthquake-related PTSD in a ran-
discipline until the 1980s. However, during the 1980s domly selected community sample in north China. Am. J.
and 1990s, disaster mental health gained an increase in Psychiatry 2000; 157: 1260–1266.
attention as a result of major disasters in Asia. 12. Sharan P, Chaudhary G, Kavathkar SA, Saxena S. Pre-
liminary report of psychiatric disorder in survivors of a
At present, disaster mental health is being recog- severe earthquake. Am. J. Psychiatry 1996; 153: 556–558.
nized as an important psychiatric discipline in many 13. Goenjian AK, Najarian LM, Pynoos RS. Posttraumatic
Asian countries. Also, it will be a useful tool to deal stress disorder in elderly and younger adults after the
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natural disasters as well as manmade disasters in Asia. 151: 895–901.
14. Shore JH, Tatum EL, Vollmer WM. Psychiatric reactions
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