Train accidents are common and are extremely stressful. The experience of a train crash involves a threat to life, an existential threat, loss of control, and a state of unimaginable chaos in the face of death.Reference Forsberg and Saveman1, Reference Hagström2 Associated stressors for survivors include personal bereavement and physical injuries.Reference Lundin3 However, studies on psychiatric disorders following train accidents are remarkably scant.Reference Elklit and Jørgensen4 Probably, mental health consequences are not assessed, and this results in most survivors not getting related assessments and appropriate support.Reference Zadey5
Various posttraumatic stress symptoms (PTSS) such as reliving, nightmares, intrusive thoughts, and functional impairments have been reported following train accidents.Reference Hagström2 Compared with other commuters, accident survivors have been reported to have higher PTSS which was significantly associated with physical injuries.Reference Selley, King and Peveler6 Reportedly the PTSS following train accidents continue for a long period.Reference Maltais, Généreux and Roy7, Reference Maltais, Lavoie-Trudeau and Labra8, Reference Tyano, Iancu and Solomon9 Similarly, many studies have reported posttraumatic stress disorders (PTSD) with a variable range of prevalence from 19%Reference Elklit and Jørgensen4-59.4%.Reference Miniati, Palagini, Caruso, Mauri, Marazziti and Dell’Osso10 In addition to PTSD, there are reports of depression and anxiety disorder.Reference Elklit and Jørgensen4 All these highlight the need for evaluation and intervention studies.
Recent theories of PTSD combine the stimulus and response components, with a cognitive model involving trauma memory, meaning, interpretation, and appraisal.Reference Bisson11, Reference Ehlers and Clark12 In addition to trauma experiences such as exposure intensity, physical damage, and economic losses,Reference Rodrigues, Barletta and Nery13 its processing is dependent on several factors such as the cause of trauma, ability to assimilate, personal coping strategies, pre-trauma vulnerability, and support available.Reference Pinarowicz14 Besides the direct victims of a major traumatic event, family members and close relatives,Reference Kar15 local people who witness the traumatic event, and the supporting professionals such as rescuers, disaster workers,Reference Kar16 and medical personnel who care for the injured are also indirectly affected. Directly and indirectly affected people may process their experiences differently, and it is essential to study the outcome in these separate groups.
The 2023 Odisha Train Accident
There was a catastrophic triple train accident near Balasore in Odisha, India on June 2, 2023; in which 296 passengers were reportedly killed and over 1200 were injured,17 making it one of the most traumatic train accidents. Following the accident, as there were no adequate facilities at the local health care systems, passengers were moved to different hospitals, some more than 100 kilometers away.Reference Zadey5 There was further trauma for the affected passengers and their families, which included a lack of information and communication, and instances of unidentified and incorrectly labeled bodies.Reference Zadey5 Furthermore, many survivors had long-term consequences because of injury and disability.
Rationale for the Study
Train accidents are common in India,18 and are associated with considerable life-changing injuries and fatalities,Reference Bagaria, Banerjee and Gupta19 having major consequences for the lives of the affected passengers and their families. There are no studies in India about the stress-related mental health outcomes of survivors of train accidents, health professionals involved in the acute care of injured passengers, and the local community who were indirectly affected. In the above context, we intended to study the PTSS, PTSD, quality of life (QOL), and associated socio-demographic and experience-related risk factors in the surviving passengers, comparing them with health professionals and the local community. In addition, we checked anxiety and depression among the passengers.
Methods
Study Design
It was a cross-sectional observational study, which was part of a project to provide psychosocial support for train accident survivors.
Setting
The study was conducted at the Department of Psychiatry in a medical college hospital where a large proportion of train accident survivors were treated. It is a tertiary-level referral center for the region.
Participants
The sample for this study consisted of 3 groups. The first group was the passengers of the train accident who were 18 years of age or above. The passengers who were not willing to participate or those who did not provide consent were excluded. The second group included health professionals (nurses and doctors) who treated the injured passengers in the hospital. The third group included people from the local community who were acutely aware of the accident.
Variables
The outcome variables were PTSS, PTSD based on the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5),20 degree of stress, overall QOL, and health satisfaction. Additionally, anxiety and depression were also assessed for the passengers.
Data sources and measurement
Assessments were done using a predesigned form which included information about the project, the consenting process, and the questionnaires involving trauma and mental health issues. Specifically, we checked the experience of the trauma, witnessing the injured and dead passengers on the site, in the hospital, and coverage over the TV news channel. We asked the participants for their overall stress experience through the question, “How distressed were you with the train accident?” with a response on a Likert scale of 1 being “not at all” to 5 being “most distressed.”
We assessed posttraumatic stress symptoms using the PTSD checklist (PCL-5)Reference Weathers, Litz and Keane21 for all the participants. The PCL-5 is a 20-item self-rated questionnaire, corresponding to the DSM-5 symptom criteria for PTSD.20 The responses are rated on a 5-point Likert scale (0 being “not at all” to 4 being “extremely,” with a total score range of 0-80. 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 which requires at least: 1 B item (questions 1-5), 1 C item (questions 6-7), 2 D items (questions 8-14), 2 E items (questions 15-20).
We assessed overall QOL and satisfaction related to health through specific items of the WHO QOL BREF questionnaire (WHOQOL-BREF).Reference Kar, Swain and Patra22, 23
Additionally, from the passengers, we collected information about trauma, physical injury (minor: requiring first aid; moderate: hospitalization; and serious: life-threatening injuries, those which required a blood transfusion, surgery, ICU, etc.), and information about treatment, hospital days, and admission to ICU.
We also studied the anxiety of the passengers using a 7-item General Anxiety Disorder (GAD-7),Reference Spitzer, Kroenke and Williams24 a self-rated scale with items scored as 0 (not at all) to 3 (nearly every day), with a total score range of 0-21, which are categorized as none (0-4), mild (5-9), moderate (10-14), and severe (15-21).
Depression of the passengers was assessed through a self-rated 9-item Patient Health Questionnaire PHQ-9) scale.Reference Kroenke, Spitzer and Williams25 The items are scored as 0 (not at all) to 3 (nearly every day) with a total score range of 0-27, and are graded as none (0-4), mild (5-9), moderate (10-14), moderately severe (15-19), and severe (20-27).
Demographic details (age, education, marital status, religion, occupation, residence, family type, and self-reported socioeconomic status) were collected from all participants through a pre-designed questionnaire.
Data collection
The passengers were identified from the list prepared following their medical assessment, and were contacted through phone. Clinical psychologists and psychiatrists contacted the survivors and explained the project objectives and the available support. The assessments were conducted using an online questionnaire. The questionnaires were self-rated; however, mental health professionals (clinical psychologists, psychiatric nurses, and psychiatrists) helped survivors in the data collection process through telephone.
The doctors and nurses in the treating hospital were approached and provided the study link to complete after discussing the project with them. The link for the questionnaire was circulated to the local community through voluntary organizations, citizen groups, and forums by the researchers. Detailed information about the project was available in the link, and there was scope for discussion with the researchers.
Questionnaires were prepared in local languages, such as Odia, Hindi, and Bengali, and English, as the passengers were spread across different linguistic regions. The clinical psychologists involved in the research were proficient in using these languages.
Ethics
The project was approved by the Institutional Ethics Committee (No: 1456; Date 16/08/2023). The reasons for the psychosocial assessments were explained to the participants. Anonymity and the option to withdraw from the assessment without assigning any reason were highlighted. It was assured that psychosocial intervention would be provided irrespective of the participation in the study. Those who agreed to participate following the discussion about the study were requested to provide informed consent through the electronic format. All the victims who could be contacted were offered the psychosocial intervention regardless of their participation in the study.
Statistical methods
Data was entered in Excel and quality checked. The data was analyzed with SPSS version 28. We analyzed descriptive statistics of demographic variables and trauma experience. The chi-square test was used to study the association between categorical variables of participants with or without PTSD. We used t test to compare the means, and ANOVA while comparing more than 2 means. We studied the correlation among variables by Pearson’s test. The odds ratio (OR) was calculated to check the risk of variables contributing to the presence of PTSD. We used regression analysis to check for variables that predicted the diagnosis of PTSD. Where appropriate, the 95% confidence interval (95% CI) of the findings was provided. We checked the internal consistency of the scales used in the study through Cronbach’s alpha, which was 0.942 for PCL-5, 0.937 for PHQ-9, and 0.950 for GAD-7 for the studied sample, suggesting good reliability. Statistical significance was considered for P value below 0.05.
Results
Participants’ Demographics
The sample included 58 passengers, 42 health professionals, and 65 participants from the local community. Their mean ages ± SD were 31.1 ± 8.2, 33.9 ± 8.7, and 39.4 ± 16.9 years, respectively. The demographic details are given in Table 1. Most passengers were male (84.5%), married (69.0%), with education up to high school (86.2%), from rural backgrounds (84.5%) and nuclear families (56.9%), half of them were unemployed, and half were below the poverty line.
Sociodemographic profile of the sample
Trauma experience
The trauma experiences of the sample are given in Table 2. There were obvious differences among the groups, with a significantly higher proportion of passengers reporting different types of traumatic experiences. Reported distress scores (mean ± SD) of passengers (3.8 ± 1.3), health professionals (3.0 ± 1.4), and community participants (3.1 ± 1.6) differed significantly (F = 4.7, P < 0.05).
The trauma experience of all the participants
PTSS
The PTSS reported by the sample are given in Table 3. Commonly reported symptoms included intrusive memories (36.4%), feeling upset while reminded of the experience (33.9%), avoidance of memories (30.9%), avoiding external reminders (26.1%), repeated dreams (23.6%), and strong negative feelings (20.6%). Among the PTSS, a significantly higher proportion of passengers had strong negative feelings, loss of interest, feeling distant or cut off, irritability, or anger outbursts compared to the other 2 groups.
Posttraumatic stress symptoms reported by the participants
The PTSS score of passengers (18.9 ± 15.9) was higher than that of health professionals (13.6 ± 12.3) and community participants (13.9 ± 12.7). Overall comparison of PTSS scores in the 3 groups was not significant (F = 2.6, P = .076). PTSS score was significantly correlated with self-reported stress score (r = .488, P < 0.001), and negatively correlated with QOL (r = -.344, P < 0.001) and health satisfaction (r = -.321, P < 0.001).
PTSD and associated factors
According to DSM-5 criteria, PTSD was present in 12 (20.7%, 95% CI: 11.2-33.4) passengers, 8 (19.0%, 95% CI: 8.6-34.1) health professionals, and 5 (7.7%, 95% CI: 2.6-17.1) community participants. The proportion of passengers with PTSD was significantly (χ2 = 4.35, P < 0.05) higher than that of community participants.
We analyzed associations of various sociodemographic and trauma experiences among participants with or without PTSD (Table 4). There was no significant association with any sociodemographic group. The mean age of persons with PTSD (32.9 ± 10.8 years) did not differ significantly from those without (35.5 ± 13.5). Among the traumatic experiences, only 1 variable of seeing dead bodies of the passengers either at the accident site, hospital, or elsewhere (OR= 3.5, 95% CI: 1.2-9.8) had a significantly higher risk. Considering the whole sample, persons with PTSD (n = 25) reported significantly higher PTSS score based on PCL-5 (39.0 ±13.4 vs. 11.4 ± 9.2, P < 0.001) and self-reported distress (4.2 ± 1.1 vs. 3.2 ± 1.5, P < 0.01) compared with those without. Otherwise, these 2 groups were comparable in age, QOL, and satisfaction in health.
Factors associated with PTSD
Further, a linear regression analysis was carried out to examine the contributing role of variables which were found significant in the bivariate analyses in predicting PTSD diagnosis. Degree of distress due to accident (B = .059, 95% CI: .023-.094) and seeing dead bodies (B = 0146, 95% CI: .039-.253) contributed significantly (Model RReference Hagström2= .097, adjusted RReference Hagström2 = .085, F= 8.7, P < 0.001).
Factors associated with posttraumatic stress among passengers
The PTSS score of the passengers significantly (P < 0.001) correlated with reported stress score (r = .508), anxiety (r = .824), and depression (r = .896), and negatively correlated with QOL (r = -.491) and satisfaction with health (r = -.630). The age of the passengers correlated with reported stress (r = .308, P < 0.05) and anxiety (r = .281, P < 0.05), suggesting that the higher the age, the higher the reported stress and anxiety.
We compared passengers with (n =12) or without (n =46) PTSD for associated factors (Table 5). Fear of death, anxiety, and depression were significantly associated with PTSD. Passengers with PTSD had significantly higher self-reported stress (4.5 ± 0.8 vs. 3.6 ± 1.4, P < 0.05) and less satisfaction with health status (1.8 ± 0.4 vs. 2.8 ± 1.0, P < 0.01); however, their ages and QOL were comparable. Most passengers with PTSD identified as having mental health issues (83.3% vs. 37.0%, P < 0.01).
Factors associated with PTSD in passengers
We studied the factors contributing to PTSD diagnosis among passengers with a regression analysis. The variables that were significantly associated with PTSD in bivariate analyses were entered. Only 1 of the variables, seeing dead bodies of the passengers (B = .294, 95% CI: .072-.516), contributed significantly (Model R2= .541, adjusted R2 = .487, F= 10.0, P < 0.001).
Anxiety and depression of passengers
Among the passengers, 34.5% had a mild, 13.8% had a moderate, and 5.2% had a severe level of anxiety based on GAD-7 scores, suggesting that around 19% had a potential anxiety disorder. Similarly, 36.2% had mild, 15.5% had moderate, and 3.4% had severe levels of depression according to PHQ-9, which would mean that 18.9% may have depressive disorder. More than half (58.3%) of the passengers with PTSD had moderate or severe levels of anxiety, and half of them had moderate to severe depression. Passengers with PTSD had significantly higher scores of anxiety (11.8 ± 4.7 vs. 4.1 ± 3.9, P < 0.001) and depression (12.0 ± 6.5 vs. 4.0 ± 3.7, P < 0.001) compared to those without.
QOL
Considering the overall QOL (F = 23.7, P <0.001) and health satisfaction (F = 9.6, P < 0.001), the 3 groups differed significantly, with passengers having the worst scores among the 3 groups. Categorically, a majority (62.1%) of passengers reported poor or very poor QOL, compared to 9.5% of health professionals and 13.9% of the community participants (P < 0.001). Similarly, most (68.9%) passengers were dissatisfied or very dissatisfied with their health compared to 16.7% of health professionals and 27.7% of community participants (P < 0.001).
Limitations
There are a few limitations to the study. Most of the passengers (87.9%) in the sample were admitted to the hospital while others were at least medically assessed; therefore, it may be difficult to generalize the findings to all passengers who travelled that day, as many of them were not assessed medically or their contact details were not available. However, the sample included a range of passengers with minor to severe injuries, not just severe ones. In addition, not all the passengers in the available list could be contacted due to issues related to contact details and connectivity. Family members of the passengers are a specifically vulnerable group, especially of the deceased; and they could not be included in this study due to unavailability of contact details. The railway workers, a highly at-risk group that was exposed to the accident, were also not included.Reference Doroga and Baban26, Reference Mehnert, Nanninga and Fauth27
The sample size of persons from the local community was small. Although the study link was circulated through multiple contact persons and local voluntary organizations, the response was limited. There might be various factors influencing the response from local communities, such as inability to find any personal benefit, lack of time, etc. In addition, there were the limitations of telephone-based remote assessments compared to clinical in-person assessments.
Discussion
To our knowledge, this is the first study on mental health outcomes of train accident survivors compared with health professionals and individuals from the local community. It highlighted the mental health needs of the affected people, which might help to organize appropriate care.
This study tried to find out the prevalence of PTSS and PTSD among study participants who were directly or indirectly affected by a catastrophic train accident. It was observed that PTSS were commonly reported; a higher proportion of passengers had PTSD compared to control groups. Witnessing dead bodies was significantly associated with PTSD in general, whereas specifically, among the passengers, the factors were fear of death, anxiety, and depression. Similarly, a significantly higher proportion of passengers with PTSD reported having mental health issues.
Prevalence of PTSS and PTSD
It was observed that PTSS was common in all the groups, with a range of 8.5% (taking risks or doing harmful things) to 36.4% (repeated, disturbing memories), which was also the most common among the passengers. The intrusive traumatic memories of the accident are known to remain ingrained for many survivors, although some overcome these over a period.Reference Forsberg and Saveman1, Reference Miniati, Palagini, Caruso, Mauri, Marazziti and Dell’Osso10 The PTSS with the significant difference among the groups were strong negative feelings, loss of interest in enjoyable activities, feeling distant or cut off from other people, and feeling irritable, angry, and aggressive; all of these were reported more by the passengers. While trauma symptoms differentiating directly and indirectly affected people were identified, the findings also suggested that considerable proportions in both groups had PTSS. Trauma and psychological symptoms of indirectly affected persons have been reported.Reference Kar, Krishnaraaj and Rameshraj28 This highlights the need for trauma-related interventions for all the affected population.
Based on the DSM-5 criteria, PTSD was present in 20.7% of the passengers studied, which was slightly higher than the proportion (19.0%) of health professionals taking care of them; but significantly more compared with that (7.7%) among people from the local community. The observed PTSD prevalence in this study is higher than the rate (0.2%) reported in the general population in IndiaReference Chandna, Suhas and Patley29 and the proportion (0.22%) of psychiatric outpatients with PTSD in a tertiary psychiatric center,Reference Krishnakumari, Munivenkatappa and Hegde30 but lower than those following catastrophic natural events in India.Reference Kar, Samantaray and Kar31–Reference Kar and Jagadisha33 A study on victims of a motor vehicle accidents in India reported a higher (32.4%) prevalence of PTSD.Reference Arora, Belsiyal and Rawat34 The reported range of PTSD prevalence after train accidents varies widely.Reference Elklit and Jørgensen4, Reference Miniati, Palagini, Caruso, Mauri, Marazziti and Dell’Osso10 Following the accident, an active rescue effort and medical support were arranged by the local authorities,Reference Zadey5 and these actions might have had some moderating effect on the stress impact, as early support might decrease the risk of PTSD.Reference Mann, Marwaha and Torrico35–38 Meanwhile, lower perceived support is linked to higher PTSS.Reference Brienza, Suffoletto and Kuhn39 It is reported that support from family, friends, and fellow passengers is important in the recovery process of train crash survivors.Reference Forsberg and Saveman1
Contributing factors
PTSS is commonly observed in people directly or indirectly affected by trauma,Reference Kar, Krishnaraaj and Rameshraj28 including first responders, nurses, doctors, and psychologists.Reference Kar16 Exposure to trauma through work as a health professional or disaster responder is also known to be associated with PTSS and PTSD.Reference Bahadirli and Sagaltici40–Reference Tahernejad, Ghaffari and Ariza-Montes42 Reportedly local communities also get affected, and this may have long-lasting effects.Reference Arnberg, Rydelius and Lundin43, Reference Chung, Farmer and Werrett44 This indicates that there is a need for assessment and support for these people who were indirectly affected. In essence, while taking care of direct victims, it is important to assess and remediate the stress symptoms of indirectly affected people (i.e., health care professionals, rescuers, and local communities).Reference Zadey5 The support may be in the form of public education, through online or group-based support for managing stress symptoms (i.e., relaxation techniques) and facilitating positive coping strategies, as well as specific therapy for those experiencing certain disorders.
Considering the sociodemographic variables, persons with PTSD were comparatively younger, less educated, from a nuclear family, married, and unemployed; and considering the socioeconomic status, fewer of them were below the poverty line and more were in the upper group; however, these were not statistically significant. A higher risk of PTSD at lower educational levels has been reported,Reference Vilaplana-Pérez, Sidorchuk and Pérez-Vigil45, Reference North, Oliver and Pandya46 suggesting higher vulnerability in this category. Based on the factors related to trauma experience, only seeing dead bodies was significantly associated with PTSD. This suggests a need to take appropriate measures to limit exposure to dead bodies following a catastrophic event with loss of life.
Besides the PTSS score, persons with PTSD had significantly higher self-reported distress compared to those without. High perceived stress has been linked to PTSD,Reference Gori, Topino and Musetti47 and can continue long term.Reference Maltais, Généreux and Roy7 Experience of higher distress following a traumatic event has been reported to indicate the possibility of developing stress-related disorders, specifically PTSD.Reference Shalev48 Various trauma-related experiences of the passengers were significantly more common compared with the other groups (Table 2), which was obvious. Seeing dead bodies of passengers was a consistent factor that predicted PTSD in all the study participants and specifically among the passengers. The majority (80.0%) of participants with PTSD witnessed dead bodies in the hospital and elsewhere, compared to 53.6% of those without PTSD. Similarly, a study on a motor vehicle accidents found that witnessing death and perceived death threats were determinants for PTSD.Reference Arora, Belsiyal and Rawat34 Witnessing mass casualty and being forced to deal with the death of loved ones can worsen mental health in the short and long term.Reference Zadey5 However, in our study, physical injury and its severity, hospitalization, and ICU treatment did not differentiate those with or without PTSD.
It appeared that media coverage had some contribution to psychological stress following the accident (Table 2). While slightly more than half of the passengers reported being affected by the media coverage, most health professionals and community participants reported being distressed by the coverage. Portrayal of traumatic images in the media, often repetitively, might have played a role, suggesting that media need to be more considerate while showing the disaster’s impact on human life. Amelioration of the impact of trauma through discretion warnings and adherence to other journalistic principlesReference Leoni, Radford and Schulman49 needs to be specifically evaluated.
In the context of trauma, the outcome is also influenced by the risk resilience framework, where resources and protective factors counterbalance the impact of disaster on individuals.Reference First50 It has been reported that resilience has a negative relationship with anxiety, depression, and PTSD.Reference Dhungana, Koirala and Ojha51 Although we did not study resilience specifically, it was evident from the findings that PTSD was linked to those with heightened stress perception, specifically seeing dead bodies and having mental health problems such as anxiety and depression. Supporting the affected individuals in working through the stress, assimilating, managing through positive coping strategies, and using specific interventions for improving resilienceReference Iacoviello and Charney52 might help.
Specific factors related to passengers
PTSD among the passengers was significantly associated with those who were afraid for their lives (Table 5). This factor has been known to contribute to the stress impact, symptoms, and disorder during various traumatic events and disasters.Reference Martz53, Reference Simske, Joseph and Rascoe54 Screening for the presence of fear of death early might help to identify vulnerable individuals to provide support. Significantly more passengers with PTSD in this study recognized that they had mental health issues. This is important, as awareness may help in seeking intervention, for which appropriate information and facilities should be made available to affected persons.
Anxiety, depression, and PTSD
Among the passengers in this study, PTSD was associated with higher levels of depression and anxiety (Table 5). These disorders reportedly co-occur in injury cases.Reference van der Vlegel, Polinder and Toet55–Reference Wiseman and Curtis57 The association of anxiety, depression, and PTSD as comorbid conditions is well established in various contexts.Reference Kar, Samantaray and Kar31, Reference Kar and Bastia58, Reference Spinhoven, Penninx and van Hemert59 Their significant association as observed in this study of train accident survivors suggests that comorbidity should be explored, which might help in intervention planning.
QOL
The impact on QOL was evident, with significantly more passengers having poorer QOL and dissatisfaction with their health than the comparison groups. There could be various reasons. In the immediate aftermath of the Odisha train accident, the mental health care needs of the passengers were not met.Reference Zadey5 It is known that the impact of trauma affects QOL negatively; and poorer QOL in trauma survivors,Reference Danielsson, Schultz Larsen and Nørgaard60, Reference Kovačević, Miškulin and Ličanin61 especially those with direct exposureReference Akanni, Edeh and Agbir62 and severe injury,Reference Baranyi, Leithgöb and Kreiner63 has been well-reported. Anxiety, depression, and PTSD are contributors to poorer QOL;Reference Martin-Herz, McMahon and Malzyner64, Reference Pacella, Hruska and Delahanty65 unmet mental health needs of the affected people may influence it more. Based on this, it appears comprehensive person-specific intervention plans for accident survivors are required,Reference Kar66 which might help the recovery process from trauma-related mental health problems and improve QOL.
Conclusion
A considerable proportion of passengers, health professionals, and people from the local community had PTSS and PTSD following the 2023 Odisha train accident, which highlighted that the trauma affected many indirectly exposed persons besides the passengers. Seeing dead bodies was significantly associated with PTSD in all participants, whereas fear of death, anxiety, and depression were additional factors for passengers. A high proportion of passengers with PTSD reported having mental health issues. In addition, most participants were affected by the media coverage of the incident showing traumatic pictures. The findings highlighted the interventions needed for the affected people. Future studies should explore mental health of all passengers, including those who did not need physical check-ups or interventions following the accident, as well as the family members of the passengers (both of the survivors and deceased). Their needs should be assessed and interventions provided for all affected individuals. There is a need for follow-up research to investigate long-term outcomes of mental health problems, including comparisons of individuals who received or did not receive psychosocial support.
Author contribution
NK: Conceptualization, Methodology, Analysis, Writing Original Draft and reviewing; SPS: Methodology, Investigation, Resources, Writing –Review and editing; SP: Methodology, Investigation, Resources, Writing –Review and editing; SB: Investigation, Resources, Writing –Review and editing; SM: Investigation, Resources, Writing –Review and editing; SSB: Investigation, Resources, Writing –Review and editing; BP: Investigation, Resources, Writing –Review and editing: SK: Methodology, Software, Resources, Data Curation, Writing –Review and editing
Acknowledgments
The project was supported by Brajaballav Kar, PhD, KIIT University, Bhubaneswar; Aditya Kumar Jena, MA; Quality of Life Research and Development Foundation, Bhubaneswar, India; and The Institute of Insight, UK.
Competing interests
None.
