Earthquakes stand at the forefront of experiences that cause serious anxiety and fear, alongside causing deaths, physical injuries, and economic losses.Reference Zhang, Wang and Shi1 Initially developing as a form of defense mechanism, these reactions can sometimes become permanent, leading affected individuals to develop various mental disorders such as post-traumatic stress disorder (PTSD), anxiety, depression, and sleep disorders.Reference Saeed and Gargano2
PTSD is the most commonly observed psychological disorder following earthquakes, and it is generally characterized by symptoms such as “hypervigilance, re-experiencing, and avoidance, typically developing after exposure to threats of death, serious injury, or sexual violence.”Reference Goldmann and Galea3 While the rates vary, a meta-analytic study reported that approximately 1/4 (23.66%) of survivors of major earthquakes met the diagnostic criteria for PTSD.Reference Dai, Chen and Lai4 On the other hand, numerous studies have shown that PTSD symptoms are more prevalent, with rates ranging between 10% and 87%.Reference Xu and Song5 This difference is attributed to factors such as the severity of the earthquakes, the degree of exposure to the disaster, the timing of the assessment, and the measurement methods used.Reference Goldmann and Galea3 Factors predisposing individuals to develop PTSD include female gender, age at the time of trauma, previous traumas and adverse childhood experiences, severity of the trauma, lack of social support following trauma, family history of psychiatric disorders, and additional life stress.Reference Rooney, Hallauer and Xie6, Reference Brewin, Andrews and Valentine7
PTSD is commonly associated with other mental disorders. Although data are limited, it has been noted that over 80% of trauma survivors meet diagnostic criteria for at least 1 other mental disorder, with major depressive disorder being the most prevalent (52%).Reference Cao, Wang and Cao8, Reference Rytwinski, Scur and Feeny9 While data on the comorbidity of PTSD and anxiety are more limited, studies conducted after earthquakes in Greece, Armenia, Pakistan, and China have shown that 1 in 5 survivors experiences significant anxiety symptoms.Reference Cénat, McIntee and Blais-Rochette10 Existing anxiety has been associated with increased susceptibility to developing PTSD and depression.Reference Williamson, Jaffee and Jorge11 Findings from longitudinal studies have shown that, while PTSD symptoms improve following a high-impact disaster, typically within the first few months to 12 months or longer, the prevalence rates of depression and anxiety, however, tend to remain stable over time rather than decreasing.Reference Heanoy and Brown12
On February 6, 2023, 2 major earthquakes occurred with magnitudes of 7.7 and 7.6, centered in the southeastern part of Türkiye with their epicenters in the Pazarcik and Elbistan districts of Kahramanmaraş.13
These earthquakes, which occurred 8 hours apart, affected 11 provinces where approximately 15 million people used to live. Due to the extent of the affected area, destructive force, and loss of life, it was considered as “the disaster of the century.” These earthquakes claimed the lives of 50 783 people; 7302 of whom were refugees, and injured 107 000 others. Hundreds of thousands of homes and businesses were destroyed. 14 Thousands of aftershocks, along with severe winter conditions, prompted millions of people to flee their provinces.
Although there have been only a few studies focusing on the prevalence of early-stage PTSD following an earthquake, they have shown that the 2023 Kahramanmaraş earthquakes have led to significant mental health issues for many people. Three months after the earthquakes, Ilhan et al. reported that the prevalence of PTSD among survivors was 51.4%.Reference İlhan, Berikol and Eroğlu15 In a study covering the 3rd and 4th months after the earthquakes, Akcay et al. found high trauma levels among affected individuals with factors such as being young, female and single, low income, pre-existing mental illness, being trapped under rubble, loss or injury of family members, home damage, temporary housing, significant financial loss, and migration were associated with the severity of trauma.Reference Akçay, Beydili Gürbüz and Koca16 However, as far as we know, there is no study investigating the long-term psychological effects of the Kahramanmaraş earthquakes on survivors and the symptoms of post-traumatic stress, depression, and anxiety together.
Based on the severity of the earthquakes, the extent of the losses incurred, and the lack of data, the main objectives of this study are to evaluate the levels of trauma, anxiety, and depression in adult survivors living in the most severely affected areas in the 12th month of the Kahramanmaraş earthquakes and to determine the risk and protective factors related to these mental disorders. It is hoped that understanding the current psychological problems of survivors and their associated factors will provide guidance for the development of relevant planning and treatment programs as well as for the reconstruction of society.
Methods
Participants and Study Protocol
This study is cross-sectional and was conducted in the twelfth month after the Kahramanmaraş earthquakes. Individuals who participated in the study were determined by virtual snowball sampling method and were invited to participate in an online survey constructed using Google Forms. Data were collected between January 6, 2024 and January 15, 2024. Because the researchers’ family and/or social circles were in the earthquake-affected area, the first participants consisted of the researchers and their social networks. These participants’ social accounts played a key role in reaching participants from other provinces.
Participants were sent a survey consisting of 3 subunits and a total of 60 questions. In the first section of the survey, sociodemographic characteristics (age, gender, education level, occupation, etc.) and questions about the earthquake which were prepared by the authors (location during the earthquake, injuries, loss of life and property, migration from the province, etc.) were included. The second section consisted of questions from the Post-Earthquake Trauma Level Determining Scale, and the third section included questions from the Hospital Anxiety and Depression Scale. Data from individuals aged 18 and over who voluntarily agreed to participate were included in this study. Data from individuals who were not exposed to the February 6 earthquakes were not included in the analyses. Before responding to the online survey, participants were informed about the content of the study and their consent to participate voluntarily was obtained. No financial incentives were provided to the participants.
The minimum sample size was determined to be at least 5 times the number of independent variables in the study [n>5k (k: number of independent variables)].Reference Alpar17 Accordingly, the minimum number of participants was determined to be 300.
Ethical approval required for the research was obtained from the Non-Interventional Publication Ethics Committee of Inonu University (2023/5365).
Data Collection Tools
Post-Earthquake Trauma Level Determining Scale (PETLDS)
PETLDS is a self-report scale developed as suitable for the culture in Türkiye, following the 2011 Van Earthquake. It was created to screen for post-traumatic stress symptoms that may emerge in individuals after an earthquake and to assess the severity of these symptoms. The scale evaluates trauma responses across 5 dimensions: “Behavior Problems” (appetite loss, increased anger/aggressiveness, nightmares, and claustrophobia due to fear of another earthquake), “Emotive Limitedness” (loss of hope for the future, loss of a sense of the life’s meaning, decreased will to live, and feelings of helplessness/weakness), “Affective Response” (embarrassment from needing help, increased attention on behaviors/relationships after the earthquake, greater appreciation of life, becoming more emotional/crying unreasonably), “Cognitive Structure” (worries about children/parents/acquaintances/friends, persistent anxiety about another earthquake, re-experiencing the earthquake, worries about the future), and “Sleep Problems” (waking up suddenly, difficulty falling asleep, and reduced overall sleep duration). It contains 20 items, with each offering 5-point Likert options (1 = I do not agree at all to 5 = I completely agree). The lowest score that can be obtained is 20, and the highest is 100. The higher scores indicate an escalation in the level of individuals’ affectedness by the earthquake. In the original study, a score range of 52.385±5.051 corresponds to a threshold value indicating that individuals are traumatized. Scores above or below this value indicate a high or low level of post-earthquake traumatic symptoms, respectively. The internal reliability coefficient calculated for all items of the scale was found to be 0.87.Reference Tanhan and Kayri18
Hospital Anxiety and Depression Scale (HADS)
HADS was used to assess the participants’ risk of anxiety and depression, as well as to track their level and severity changes. Zigmond and Snaith established the 4-point Likert scale, which includes 14 questions.Reference Zigmond and Snaith19 Aydemir et al. assessed Turkish validity and dependability. The lowest possible score on each the subscale is 0 and the highest is 21. In the validity and reliability research, the cut-off thresholds for the anxiety subscale and the depression subscale were set at 10 and 7, respectively, with scores over these levels deemed abnormal.Reference Aydemir, Guvenir and Kuey20 Kucukelci demonstrated that the scale may be utilized on healthy persons.Reference Küçükelçi21
Data Analyses
Qualitative data from the variables included in the study were summarized as numbers (percentage). The Kolmogorov-Smirnov test was used to determine if quantitative data fit a normal distribution. Quantitative data without a normal distribution were summarized using the median (minimum-maximum), whereas those with a normal distribution were described with the mean±standard deviation. In statistical studies, categorical variables were compared using the Pearson chi-square test and the Yates-corrected chi-square test. For quantitative variables, the Mann-Whitney U test was used to compare 2 independent groups, and the Kruskal-Wallis test was used when there were more than 2 separate groups to compare. For multiple comparisons, pairwise comparisons were performed using the Mann Whitney U test with Bonferroni correction for the Kruskal Wallis test. The Sperman Rho correlation coefficient was used to see whether there were any relationships between variables. Multiple logistic regression was performed to estimate the odds ratio and identify independent predictors of anxiety, depression, and post-traumatic stress. While constructing the model, the anxiety and depression subdomains of HADS, as well as the PETLDS total scores, were selected as the 3 dependent variables, and the relevant data were translated into binary categorical data using the following criteria. In this study, PETLDS total scores above 52.385, as well as HADS depression scores greater than 7 and HADS anxiety scores greater than 10, were considered indicative of abnormal psychological effects. Because there were 3 dependent variables, 3 distinct binary logistic regression models were used to analyze the data. Before applying the relevant models, each dependent variable was compared to all variables listed in Table 1 (excluding the province where the earthquake occurred), and a logistic regression model was constructed using each dependent variable and the statistically significant independent variables. The multiple and enter approach was used to do a logistic regression analysis. A p value <0.05 indicated statistical significance in the analysis. The Hosmer-Lemeshow and Omnibus tests were used to assess model and coefficient adequacy (P>0.05 and P<0.05, respectively). All analyses were carried out using IBM SPSS Statistics 26.0 for Windows (New York, USA).
Characteristics of the participants
Results
Characteristics of Study Participants
A total of 2600 people participated in the study. Data from 56 individuals who did not meet the study criteria were not included in the analysis. The analysis was conducted on 2544 participants. The mean age of the participants was 36.67±11.68 years, with 954 being male and 1590 female. Among them, 1691 individuals (66.47%) reported experiencing a previous earthquake, 1269 (49.88%) had lost a loved one in the earthquake, and 1312 (51.57%) had to migrate temporarily after the earthquake. The number of individuals who received psychiatric help after the earthquake was 216 (8.49%). The characteristics of the participants and the data regarding their experiences before and after the earthquakes are presented in Table 1.
Participants’ scale scores and prevalence of psychological symptoms
The participants’ mean PETLDS total score was 58.14 ± 18.18, indicating a high level of post-traumatic stress symptoms.Reference Tanhan and Kayri18 Based on the cut-off values of the scales, 59.5% reported high post-traumatic stress, 44.2% high anxiety, and 61% high depressive symptoms, suggesting that a substantial proportion of them were experiencing clinically significant psychological distress. These findings are presented in Table 2.
Scale scores and psychological impact rates of participants
SD: Standard Deviation.
Comparison of anxiety, depression, and trauma levels by province of residence.
In the comparison of depression, anxiety, and trauma levels by province of residence among participants, it was found that Adiyaman province had the highest levels of anxiety and depressive symptoms, while Malatya province exhibited most severe levels of trauma (p< 0.001), based on the thresholds above cut-off values. The distribution of depression, trauma, and anxiety rates according to province of residence is given in Table 3.
Distribution of anxiety, depression, and trauma levels by province
Each column with the same letter refers to categories whose proportions are not significantly different from each other at the 0.05 level. *: Pearson chi-square test.
Correlation between trauma, anxiety, and depression scores.
Spearman’s rho correlation was used to examine the correlations between PETLDS and HADS subscale scores, and the results are presented in Table 4. According to the findings, a significant positive correlation was detected between all PETLDS subdimensions and HADS anxiety and depression subscale scores. There was also a significant positive correlation between the PETLDS total score and the total scores of anxiety and depression.
Correlation matrix of association between trauma, anxiety, and depression
*: Spearman’s rho correlation coefficient; **: p<0.01.
Factors affecting the severity of anxiety, depression, and post-traumatic stress
According to the multiple logistic regression analysis of factors affecting the severity of anxiety, it was found that being female, unemployment, having a low income, a history of psychiatric disorder, smoking, and past traumatic experiences were all associated with a higher risk of developing anxiety. Additionally, home and workplace damage, and loss or injury of a loved one were linked to elevated anxiety symptoms.
Having a low level of education, a history of psychiatric disorder, the presence of a chronic internal disease, smoking, past traumatic experiences, home and workplace damage, and having to take shelter elsewhere in the days immediately after the earthquake were found to be associated with an increase in depressive symptoms. The experience of physical injury during the earthquake and the injury of a loved one were also linked to higher depressive symptom levels.
Factors associated with high trauma levels included female gender, low household income, a history of psychiatric disorders, and smoking. Additionally, past traumatic experiences, temporary relocation to another province after the earthquake, home and workplace damage, and the injury or loss of a loved one emerged as significant contributor to post-traumatic stress.
Past traumatic experiences, smoking, damage to home and workplace during the earthquake, and injury of a loved one were found to be common variables determining the severity of trauma, depression, and anxiety. The results of this analysis are presented in Table 5.
Regression analysis of factors affecting the severity of anxiety, depression, and post-traumatic stress
Discussion
This research examines anxiety, depression, and trauma levels, along with the associated factors, among survivors in 11 provinces affected in the 12th month by the Kahramanmaraş earthquakes in Türkiye.
The twin earthquakes that occurred on February 6, 2023 not only caused material and human losses but also had significant negative effects on the mental health of the affected population. In a study conducted by Bahar et al., between the third and fourth months following the earthquake, involving 221 participants exposed to the disaster, the mean PETLDS score was reported as 59.36±14.71, indicating high levels of trauma among survivors.Reference Bahar and Çuhadar22 Likewise, Tayhan et al. reported a similar mean score of 58.7±18.3 in their study involving 708 adult participants, conducted 9 months after the earthquakes.Reference Tayhan and Korkmaz23 In the present study, despite 1 year having passed since the earthquake, the mean PETLDS score among participants was found to be 58.14±18.18, suggesting that individuals still exhibited high trauma levels. Furthermore, 59.5% of the survivors showed symptoms of post-traumatic stress, 61% exhibited signs of depression, and 44.2% had significant anxiety symptoms. Given the severity of the earthquakes that occurred, it is not surprising that such high prevalence rates were observed. The rates of psychological symptoms identified in this study were approximately comparable to those reported among severely affected survivors 1 year or more after the earthquakes in Türkiye,Reference Altindag, Ozen and Sir24 Wenchuan,Reference Zhang, Shi and Wang25 and Gumri.Reference Goenjian, Steinberg and Najarian26 However, the methodological and contextual diversity across earthquake-related studies has hindered direct comparisons. Nonetheless, our findings are meaningful in demonstrating that time alone is insufficient to mitigate the psychological consequences of such a devastating disaster.Reference Cénat and Derivois27, Reference Adhikari Baral and K28 On the other hand, although the psychological impact of the earthquakes was so high, it was striking that only 8.49% of the participants received professional help. Whereas, shortly after the earthquake, health services began to be offered for free at the remaining hospitals and mobile health centers, and numerous psychosocial support teams worked in the field for months.29 Although our study could not provide an explanation for why earthquake survivors utilized mental health services so little, this result may be related to factors such as difficulties in meeting basic needs like shelter, food, and heating; transportation issues; personal prejudices; low awareness; and the fear of being stigmatized. Considering the long-term losses that such psychological impacts may cause, answering this question will be important in guiding mental health care policies.
Epidemiological studies on disasters have shown that demographic variables such as gender, occupation, age, economic status, and history of comorbid disease; pre-traumatic conditions such as past traumatic experiences and adverse life events; earthquake-related experiences predict an increased prevalence of psychopathological symptoms.Reference Saeed and Gargano2, Reference Auxéméry30–Reference Wrenger, Lange and Langer34 In this study, female gender was found to be the strongest common demographic predictor exacerbating of both post-traumatic stress and anxiety symptoms. This has already been studied and attributed to women’s stronger perceptions of threat and loss of control, perception of insufficient social support resources, greater ability to express emotions, and gender differences in neuro-endocrine responses.Reference Adhikari Baral and K28, Reference Kolaitis and Olff35 Therefore, all these factors may explain the high trauma levels in our female participants. Furthermore, women’s ability to express their emotions more easily may constitute one of the factors contributing to their higher participation rates in the study. However, more detailed studies are needed to draw definitive conclusions.
The analyses showed that strongest demographic variable in predicting the severity of depressive symptoms was a history of psychiatric disorders. Additionally, it was one of the common variables associated with the severity of trauma, anxiety, and depressive symptoms, as in past traumatic experiences and smoking. Aside from the losses and traumatic conditions caused by the earthquake, these identified factors may have increased the susceptibility to the development of psychiatric morbidity by causing disruptions in the neurohumoral systems effective in the stress response.Reference Gül and Eryılmaz36 Hence, the findings suggest that priority should be given to individuals at risk, particularly women and those with a history of mental illness, in the treatment of survivors of earthquakes.
Previous studies have revealed that earthquake-related variables such as proximity to the epicenter,Reference Xu and Song37 the death or loss of a loved one, injury, displacement, financial losses, and lack of regular income are vulnerability factors that increase the risk of more severe psychopathological outcomes following the disasters.Reference Saeed and Gargano2, Reference Kwon, Maruyama and Morimoto38–Reference McGuire, Gauthier and Anderson40 In a study conducted following Hurricane Ike in Texas in September 2008, it was found that hurricane-related and post-hurricane traumatic events and stressors significantly increased the risk of post-traumatic stress symptoms and functional impairment, independently of pre-existing vulnerabilities such as a history of depression, PTSD, or prior life events.Reference Cerdá, Bordelois and Galea41 In this study as well, factors such as damage to homes and workplaces, relocation after the earthquake, injury or death of a loved one during the earthquake, personal injury during the earthquake, and staying outside one’s own home in the days following the earthquake were found to be factors associated with the increase in nearly all mental symptoms. “The disaster of the century” resulted in hundreds of thousands of homes and workplaces being destroyed or damaged. In Malatya alone, it was reported that 20 000 businesses and 5000 residences were destroyed in the earthquake.Reference Cerdá, Bordelois and Galea41 People suddenly faced unemployment, economic difficulties, and housing problems. Over the past year, the government, civil society organizations, and the public made intensive efforts to heal the wounds in the earthquake-affected region. Container markets and cities were set up to partially meet the needs of earthquake survivors.42 However, our findings indicate that such social supports were insufficient in coping with the stress that developed after the earthquake. Therefore, expanding income-generating activities and job opportunities, and resolving housing issues promptly will contribute significantly to improving community mental health.43
Contrary to studies that show a relationship between proximity to the epicenter and trauma levels,Reference Xu and Song37 this study could not establish a direct relationship between proximity to the epicenter and psychological impact. Despite Kahramanmaraş being the epicenter, it was observed that the highest scoring provinces on the scales were Malatya (distance from the epicenter: 217.7 km), Adiyaman (distance from the epicenter: 161.8 km), and Hatay (distance from the epicenter: 176.5 km). Although these provinces were distant from the epicenter, they experienced the highest life and material losses due to the alignment of seismic waves and poor ground quality.Reference Galea, Nandi and Vlahov44, 45
Additionally, although not examined in this study, reports in social media and the press suggested that the earthquakes on February 6 activated new fault lines in the region, raising expectations of another major earthquake.46 Perhaps this sense of “uncertainty” has kept people in these provinces constantly on edge. Indeed, in the literature, “uncertainty” is recognized to cause a series of cognitive, emotional, and behavioral damages over time. It is also considered a fundamental component of all anxiety disorders that diminish problem-solving abilities.47 Therefore, in these provinces where the fear of earthquakes still persists, it may be beneficial for the authorities to implement measures, such as expanding psycho-social support services, regularly informing the public about new developments and measures taken, and monitoring the news presented in the media.
One of the important findings in this study was the significant correlation between all 3 scales and subscales, along with high comorbidity rates. Our study revealed that 47.75% of individuals with high trauma levels were accompanied by significant depressive symptoms, and the symptoms of all 3 disorders were significantly higher in 910 (35.77%) people. Furthermore, a positive correlation was found between the total and subscale scores of PETLDS and the scores of the HADS anxiety subscale and depression subscale. This result indicates that trauma-related symptoms operate in a consistent manner and are also associated with anxiety and depression. It aligns with previous studies showing that individuals who have experienced severe trauma are at high risk for post-traumatic stress, anxiety, and depressive reactions, supporting the notion that the presence of 1 can be used to predict the others.Reference Farooqui, Quadri and Suriya31, Reference Carleton48–Reference Miguel-Tobal, Cano-Vindel and Gonzalez-Ordi50 The strong correlations among these reactions are attributed in the literature to their shared etiology (trauma exposure), the potential of trauma-related symptoms to contribute to the later emergence of depression and anxiety, the mutually reinforcing nature of these symptoms, the compounding impact of post-traumatic adversities, and the symptom overlap between categories, all of which suggest that these psychological responses may not be entirely independent.Reference Goenjian, Steinberg and Najarian26 If these comorbid conditions are not recognized and proactively addressed, they can negatively impact clinical outcomes and overall patient well-being.Reference Dursun51 For this reason, the finding suggests that mental health providers must be cautious of the high risk of comorbidity when treating patients affected by the earthquake.
Limitations and Future Directions
This study has limitations that need to be acknowledged. First, while the study reached earthquake-affected regions and achieved a relatively large sample size, inviting participants through electronic means may have excluded those without access to such technologies, potentially biasing the evaluation. Second, the gender composition of the current sample was predominantly composed of women. Therefore, the results may not fully reflect the general population. Third, due to the cross-sectional nature of the research, its ability to determine long-term psychological effects is limited. Fourth, self-report scales were used to measure psychiatric symptoms in the study, assessing only the level of symptoms. Given that psychiatric diagnosis relies on structured clinical interviews and functional neuroimaging, the findings may be misleading. Thus, our study might overestimate the prevalence of mental health problems compared to clinical diagnosis. Fifth, it did not examine variables such as belief, self-esteem, optimism, and perceived control, which could be related to trauma responses.Reference Norris, Friedman and Watson33 Finally, despite the high levels of post-traumatic stress, depression, and anxiety symptoms, the design of the study was insufficient to explain the reasons for survivors getting or not getting psychiatric help. Future studies addressing these limitations will help provide definitive conclusions. Despite all these limitations, to our knowledge, this study is the first to investigate the mental health of survivors in Kahramanmaraş earthquakes in the twelfth month of the disaster. Therefore, the findings will provide preliminary data for future studies.
Conclusion and Recommendations
As a result, the most cautious interpretation of the above findings is that the regional population continues to experience significant mental distress almost a year after the earthquake. In this study, it was found that the socio-demographic characteristics of survivors and their experiences before, during, and after event had an impact on their post-earthquake stress levels. Our findings demonstrate that symptoms of anxiety and depression, as well as post-traumatic stress, remain prevalent in the post-disaster period.
Considering the relationship between participants’ demographic characteristics and the severity of psychological impact, it is crucial to take individual characteristics into account when planning mental health services to be provided after the earthquake. Comprehensive disaster intervention strategies that include early diagnosis, ongoing monitoring, and sustainable psychosocial support programs, particularly for high-risk groups, could help prevent the persistence of psychological symptoms post-earthquake. It is also important to urgently address basic needs. Because survivors rarely seek psychiatric help, preparing educational posters, organizing public seminars, and developing accessible service programs such as home visits and mobile clinics could encourage awareness and facilitate access to treatment. Additionally, it seems essential for administrators to have psychosocial teams with comprehensive knowledge and practical skills in trauma, ready to provide high-quality services in disaster management and post-disaster recovery, to ensure the well-being of public health after disasters.
Author contribution
Study design: NC; Data collection: HS, MS, BKT; Data analysis: İBÇ; Manuscript writing: NC and ŞNİM.
Acknowledgments
We are deeply grateful to all earthquake survivors who kindly took part in this study.
Funding statement
This study did not have any sources of funding.
Competing interests
The authors report no conflicts of interest.
