Psychiatry Research 253 (2017) 383–390

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Suicidality associated with PTSD, depression, and disaster recovery status MARK
among adult survivors 8 years after the 2008 Wenchuan earthquake in
China
⁎
Jing Guoa, , Huan Heb, Mingqi Fua, Ziqiang Hanc, Zhiyong Qud, Xiaohua Wangd, Liding Guana
a
School of Sociology, Huazhong University of Science and Technology, Wuhan 430074, PR China
b
Department of Public Administration, Southwestern University of Finance and Economics, Chengdou 610074, PR China
c
Institute for Disaster Management and Reconstruction, Sichuan University, Chengdu 610065, PR China
d
School of Social Development and Public Policy, China Institute of Health, Beijing Normal University, Beijing 100875, PR China

A R T I C L E I N F O A B S T R A C T

Keywords: It has been eight years since the Wenchuan earthquake. We don’t know how the lives of those affected by the
Suicidality disaster may remain blighted by its effects, or how many remain thus affected. The aim of the present study was
PTSD to examine the relationship of disaster exposure, PTSD, depression and suicidal behaviors, using data from a
Depression cross-sectional survey conducted in earthquake-affected areas of China. 1369 participants were recruited from
Disaster recovery
two different sites that were severely affected by the Wenchuan earthquake. The survey assessed suicidality
(suicidal ideation, plans and attempts) and other mental health issues. Probable PTSD was assessed using the
Impact of Event Scale-Revised (IES-R). The Center for Epidemiologic Studies Depression Scale (CES-D) Chinese
edition was used to assess depressive symptoms. The results showed that 11.2% of participants felt that their
lives had not yet recovered from the effects of the Wenchuan earthquake, even after eight years. Suicidal
ideation, plans, and attempts were reported by 9.1%, 2.9%, and 3.3%, respectively, of the respondents. PTSD,
depression, and perceived non-recovery were highly associated with suicidality. These results indicate that
suicidality can be a long-term mental health sequela of disaster. Targeted, long-term suicide prevention
programs for adult survivors should be further developed.

1. Introduction
On May 12, 2008, a magnitude 8.0 earthquake struck the north-
western part of China's Sichuan province. It left 69,227 people dead,
374,643 injured, 17,923 missing, and millions homeless (SCIOC, 2008).
It is clear that earthquakes and their sequelae present a major global
public health problem. In the aftermath of disasters, survivors are at
increased risk for posttraumatic stress disorder (PTSD), anxiety, depres-
sion, and suicide (Altindag et al., 2005; Krug et al., 1998). Since the
Wenchuan earthquake, studies have examined some of its mental health
consequences, but most of these studies have focused on PTSD,
depression and posttraumatic growth. Very few have looked at suicid-
ality. Prior studies found that the prevalence rates of posttraumatic
stress disorder prevalence rates found in the early studies ranged from
13.0% to 84.8% (Wang et al., 2009; Zhang and Ho, 2011), and one
study found PTSD symptoms among 18.7% of those who had endured
both the earthquake and a mudslide one month later in the same area
(Chen et al., 2014). A repeated cross-sectional survey found PTSD
prevalences of 58.2%, 22.1%, 19.8%, 19.0% and 8.0% among survi-
vors, 2, 8, 14, 26 and 44 months, respectively, after the earthquake
(Guo et al., 2014a). In addition, using a randomly selected sample of
adults in Mianzhu City and Anxian County (two severely damaged sites
in Sichuan province), one study found a prevalence of probable
depression of 22.9% 6 months after the earthquake (Guo et al.,
2014b). Another community-based study, with 340 respondents, ex-
amined the relationship between personal strengths and posttraumatic
growth, and found significant and positive correlations between them
(Duan and Guo, 2015). These studies, however, did not examine either
risk factors for, or prevalences of, suicidality.
A few studies of the long-term sequelae of other earthquakes have
examined the issue of suicidality. One of these found that suicide rates
increased in the first year after the earthquake, but that by the fourth
year the increases were nonsignificant (Krug et al., 1998). Another
study puzzled about the relatively small apparent impact of an earth-
quake, compared to other life stressors, such as the death of a relative,
on suicide risk (Chou et al., 2003). In addition, although most studies

⁎
Corresponding author.
E-mail address: jing624218@163.com (J. Guo).

http://dx.doi.org/10.1016/j.psychres.2017.04.022
Received 4 October 2016; Received in revised form 7 February 2017; Accepted 11 April 2017
Available online 12 April 2017
0165-1781/ © 2017 Elsevier B.V. All rights reserved.
J. Guo et al.
have found more severe symptomatology immediately after a disaster
than over the long term, some have found that the psychological
sequelae can persist for many years (Guo et al., 2014a). A recent
systematic review (Xiao et al., 2011) found that the number of
published journal articles on the health consequences of an earthquake
tends to drop dramatically 2 years after the earthquake, reflecting the
lack of research attention to the long term impact of disasters on the
affected populations. The Wenchuan earthquake occurred eight years
ago, and one recent study did examine the long-term prevalences of
PTSD and depression among its survivors (Guo et al., 2016a), but did
not look at suicidality.
Guo et al. proposed a stage task model to explain long-term health
outcomes following an earthquake (Guo et al., 2016b). This model was
developed based on the results of research we conducted after the
Wenchuan earthquake. We suggested that the prevalences of mental
health problems fluctuate with time, and that different sets of factors
account for the mental health sequelae at different stages. In general,
most individuals who develop mental health problems following a
disaster will experience some recovery from them; but little attention
has been paid to the long-term aspects of this process. We would now
like to suggest that a complex set of factors influence the development
of suicidality over different stages following an earthquake. These
factors include: 1) general personal factors, 2) pre-disaster mental
health status, 3) extent of personal and family recovery from the effects
of the disaster. The majority of existing studies have focused on the
relationship between suicidality and the first two types of factors
(Miletic et al., 2015; Stratta et al., 2014), while little is known
regarding the relationship between perceived non-recovery from dis-
aster, and suicidality. We don’t know what proportion of Wenchuan
earthquake survivors feel that they have not yet recovered from the
effects of the disaster, or what the consequences of such lack of
recovery may be. To the best of our knowledge, few studies have
focused on suicidality among adult survivors of the Wenchuan earth-
quake, and none have examined their suicide risk from a disaster
recovery perspective.
According to interpersonal psychological theory, traumatic events
that can result in the development of PTSD and other mental disorders
can also increase the risk of suicide attempts among affected individuals
(Capron et al., 2012). Over 90% of those who die by suicide suffer from
mental health disorders (Capron et al., 2012). PTSD has been shown to
be a risk factor for suicide among adult disaster survivors in the U.S.
Army (Ramsawh et al., 2014). Many studies have reported that
depression is highly associated with suicide in the general population
(Mosqueiro et al., 2015). Although some studies have examined the
relationship between depression and suicidality in disaster-affected
samples (Ran et al., 2014), most of these studies have been based only
on inpatient or adolescent samples. The findings of existing studies,
with regard to the interrelationship of PTSD, depression and suicidality
have been inconsistent. Moreover, most of these studies used small,
non-representative samples of earthquake survivors. Thus, the degrees
to which PTSD and depression affect suicidal ideation, plans, and
attempts among disaster survivors remain unknown.
Furthermore, there is still a lot of controversy surrounding the topic
of suicide. One study that was based on the U.S. National Comorbidity
Survey found that being female, married, younger, and less educated,
and having mental disorders, were factors associated with an increased
risk of suicidal ideation (Kessler et al., 1999). However, another study
examined the relationship between age and suicidality in Canada, and
found only that older age was significantly associated with more
determined and planned suicide attempts (Turecki, 2005). Gender
difference has also been examined in prior studies. A study conducted
in Taiwan found that the female suicide rate per 100,000 persons
increased from 6.1 in 1998 to 14.2 in 1999, after the Nantou earth-
quake, whereas the male suicide rate showed substantial increases in
both 2000 and 2001, indicating a delayed effect (Yip, 2009). Such
variability in study findings on the risk factors of suicide may be due to
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Psychiatry Research 253 (2017) 383–390
differences in culture, in the type of disaster, in the time elapsed
between the onset of the disaster and data collection, in methods of
sampling and case detection, or in definitions of suicide. The present
study provided the opportunity to examine the risk factors of suicide in
a Chinese, long-term post-earthquake context.
The objectives of the present study were to estimate the prevalences
of suicidal ideation, plans, and attempts 8 years after the Wenchuan
earthquake, and to examine the relationship of general disaster
recovery, PTSD, and depression with suicidality, using data from a
cross-sectional survey conducted in China. This subject has yet to be
studied from a long-term perspective in a Chinese population. Our
research may help improve theory and practice in the field by
identifying the factors that are associated with suicidality. The findings
will have implications for long-term post-disaster suicide prevention
efforts.
2. Methods
2.1. Study design and participants
Our data were drawn from a community-based, cross-sectional
survey conducted among survivors of the Wenchuan earthquake in
February 2016, eight years after the earthquake. Participants were
recruited from two different sites in the area that was severely affected
by the earthquake. The first site was the township of Yongan (115.7 km
from the epicenter), which is located in a mountainous area. Over 90%
of the buildings in Yongan were damaged in the earthquake. The second
site was the township of Guangji (58.3 km from the epicenter), which is
located on a plain. Over 96% of the buildings in Guangji were damaged
in the earthquake. These two townships were selected because they
both were close to the epicenter, although at somewhat different
distances, both suffered severe destruction in the earthquake, and had
similar socioeconomic and demographic characteristics before the
earthquake.
The cross-sectional survey used a combined multi-stage systematic
sampling and convenience sampling design to select participants. At the
first stage, 12 of the total 29 villages were randomly selected from the
two survey townships. In the second stage, households, rather than
individuals, were systematically selected, using registration informa-
tion from the village, as the basic unit for the entire survey. But for a
small number of villages where many of the former residents were no
longer residing in their homes, systematic sampling was not feasible;
non-random sampling methods were therefore also used in these
villages. Adults over age 16 from each household were selected for
participation. 50 subjects could not be reached when the research team
made more than three attempts to visit them, and 16 subjects refused to
participate in the survey. The actual samples achieved amounted to a
total of 1369 adults. A higher than 90% response rate was achieved.
These samples were representative of two townships that were severely
affected by the Wenchuan earthquake.
Face-to-face interviews were conducted, in Mandarin Chinese and in
local language, by 22 college students from Mianyang Normal
University. All of the interviewers were Psychology majors, and were
thoroughly trained before the survey. The inter-rater reliability was
good (r=0.9, n=22 interviewers). The training included five sessions,
covering: introduction to the study, sampling design and procedures,
review of the questionnaire, methods and techniques of interviewing,
potential difficulties in the survey. The interviewers were required to
show their documents and identification at the participants’ houses, and
explain the purpose of the interview, prior to receiving permission to
enter. The interview was generally conducted in a quiet space in the
house, so that the participant's responses would not be affected by their
family members. Because most of the participants were older adults,
and had low levels of education, the interviewers read each question to
the respondents, and then wrote their answers down on the question-
naire. The interviewers would also explain the questions to the
J. Guo et al.
participants in the local language, if the respondent had trouble
understanding the printed question. The average interview time was
1 h.
The study protocol was approved by the Institutional Review Board
of Tongji Medical College, Huazhong University of Science and
Technology, Wuhan, China. All participants gave oral consent after
being informed of the purpose of the survey and their right to refuse to
participate.
2.2. Measurement
Three aspects of suicidality were assessed in the survey, using an
instrument designed based on a review of the existing literature (Kessler
et al., 2005). Suicidal ideation was measured by the question, “Have
you thought seriously about suicide since the earthquake?” Suicide
plans was assessed by “Since the earthquake, have you ever made plans
to commit suicide?” Suicide attempts were assessed by, “Since the
earthquake, have you ever attempted suicide?” These questions have
been widely used for assessing suicidality in China and other countries
(Scocco et al., 2008; Sun et al., 2017).
Posttraumatic stress disorder was assessed by the Impact of Event
Scale-Revised (IES-R)(Weiss and Marmar, 1997), a self-report instru-
ment widely used in the field of traumatic stress. It includes 22 items
used to measure the three major symptom clusters of PTSD: intrusion,
avoidance, and hyper-arousal. The IES-R's measures have been found to
have good and stable psychometric properties (Creamer et al., 2003).
The Chinese version of the IES-R has been found to have satisfactory
psychometric properties, comparable to those of the original English
version (Chen et al., 2007; Wu and Chan, 2003). Participants were
asked to indicate the frequency of their distress using 4 response
options (0= not at all, 1= seldom, 3= sometimes, 5= often) (Chan
et al., 2012, 2011; Qu et al., 2012a, 2012b). Subscale scores were
calculated as the means of the responses to all of the items in the
specific subscale, and the total score was calculated as the mean
response across all items. Since there is no recommended cutoff point
for the IES-R (Christianson and Marren, 2012), this study adopted a
mean score of 2.0 across all items of the IES-R, as the cutoff point, as
was done in earlier studies (Chan et al., 2011; Guo et al., 2015; Qu
et al., 2012a, 2012b). One earlier study using this cutoff point reported
a sensitivity of 0.89 and a specificity of 0.90 (Wohlfarth et al., 2003).
The internal consistency coefficient (Cronbach's alpha) of the whole
scale in the present study was 0.93.
Depression
The Chinese edition of the Center for Epidemiologic Studies
Depression Scale (CES-D)(Wang, 1999) was used to assess probable
major depression. This scale is the most widely used depression-
screening scale and has been used in many community-based studies.
The Chinese version of the CES-D scale has shown good reliability and
validity across all age groups in urban populations (Zhang et al., 2010).
In our study, we used 21 as the cutoff point, as this has been shown to
be a good predictor for major depression in Chinese populations (Cheng
and Chan, 2005). The internal consistency coefficient (Cronbach's
alpha) of the whole scale in the present study was 0.88.
Social support
The Social Support Rating Scale (SSRS), which was developed in
China, was used to assess the current level of overall social support
received by each subject (Xiao, 1994). The SSRS, which includes 10
items, is a self-report instrument using a four-point response scale,
ranging from 1 to 4. The SSRS measures three dimensions of social
support: objective support, subjective support and utilization of sup-
port. The questionnaire has shown good validity and reliability among
the Wenchuan earthquake survivors (Ma et al., 2011). This study
assessed social support, because previous studies have suggested that
social support can buffer the impact of stress, and reduce suicide risk
(Kotler et al., 2001).
Recovery status was assessed by “Have you recovered from the
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Psychiatry Research 253 (2017) 383–390
Wenchuan earthquake? (0=No, 1= Yes)”. “Recovery,” in disaster
research, commonly refers to “bringing the post-disaster situation to
some level of acceptability” which may or may not be the same as the
pre-impact level (Chang, 2010). Some studies have focused on house-
holds and housing reconstruction (Tse et al., 2013) as incubators of
recovery. Each disaster has different characteristics; high-magnitude
earthquakes, because they often destroy homes and cause physical
injuries and deaths, can have particularly devastating effects on the
lives of individuals and communities. In this study, we defined disaster
recovery as perceived full recovery, referring to people's quality of life,
and livelihoods, having been brought back to pre-disaster levels.
Traumatic exposure to the Wenchuan earthquake was defined as
having been trapped or injured, or seen other people trapped or injured,
in the earthquake (0=No, 1= Yes).
Demographics, socioeconomic status
The following demographic and socioeconomic information was
also collected in the survey: location of residence (Yongan/Guangji);
gender (female/male); ethnicity (Han/minority, the latter including
Qiang, Tibetan, Hui, Mongol and other minority groups); religious
belief (Yes/No); age (16–35 years/35–55 years/ > 55 years); marital
status (married/ divorced/widowed); education level (primary school
or below /middle school or above); employment (farmer/unemployed/
employed); self-reported household income level (poor/middle in-
come/rich).
2.3. Statistical analysis
Descriptive statistics were calculated for all of the socio-demo-
graphic and confounding variables, by perceived recovery status.
Univariate regression analysis was conducted to examine the relation-
ship of suicidal ideation, plans, and attempts with the socio-demo-
graphic variables, social support, PTSD, depression, and perceived
recovery status. Three logistic regression models were used to examine
the risk factors associated with suicidal ideation, plans, and attempts,
respectively. Then, the whole sample was divided into 8 groups to
examine the combined effects of perceived recovery status, PTSD, and
depression, on suicidality. A further logistic regression analysis was
then performed, to examine the combined effects of these factors on
suicidal ideation. All P values were derived from adjusted Wald F tests
based on these regression models. SPSS 22.0 (SPSS Inc, Chicago, IL) was
used for statistical analysis.
3. Results
3.1. Descriptive analysis
The respondents were mainly female, married, and members of the
Han ethnic group that makes up most of the population of China. Also,
because the surveyed townships were both located in a rural area, most
of the participants were farm workers with relatively low levels of
education. The median age of the participants was 56 years and their
mean age was 54.34 years (SD=15.9). In the survey area, many of the
younger residents were migrant workers. These young people were
often absent from their homes or otherwise hard to reach. As a result,
the mean age of the participants was older than the mean age of the
local register population, and the sample was thus more representative
of the older and non-migrant worker parts of the population, which is
typical rural population in rural area of current China. 13.1% of
participants had religious beliefs, with most of them being Buddhists.
28.1% of participants considered themselves to be poor (low-income).
11.2% of respondents reported, eight years after the earthquake, that
they had not yet recovered it. Those saying they had not recovered
tended to be from Yongan township, female, younger, unmarried, and
low-income (Table 1).
The factors associated with suicidal ideation, plans and attempts are
presented in Table 2. The prevalence of suicidal ideation was signifi-
J. Guo et al. Psychiatry Research 253 (2017) 383–390

Table 1 3.2. Regression analysis

Descriptive characteristics of study population by recovery status (N=1369).
Table 3 presents the results of the binary logistic regression analysis
Total Yes, recovered No, not
recovered examining the risk factors of suicidality. Controlling for potential
N (%) N (%) N (%) P-value confounding variables, it showed that PTSD was significantly associated
with suicidal ideation (AOR=2.39; 95% CI=1.35, 4.21), as was
Totala 1369(100) 1087(88.8) 149(11.2)
depression (AOR=2.78; 95% CI=1.73, 4.48). It also showed PTSD to
Location be significantly associated with suicide plans (AOR=2.56; 95%
Guangji 677(49.5) 618(92.1) 53(7.9) CI=1.05, 6.25), and suicide attempts (AOR=4.24; 95% CI=1.94,
Yongan 692(50.5) 569(85.6) 96(14.4) < 0.001
9.27). Compared to individuals saying they had recovered from the
Genderb earthquake, those reporting non-recovery were more likely to have had
Male 632(46.6) 562(90.9) 56(9.1)
suicidal ideation (AOR=2.13; 95% CI=1.20, 3.78), and made suicide
Female 725(53.4) 615(87.1) 91(12.9) 0.027
plans (AOR=3.07; 95% CI=1.24, 7.62).
Ethnicityc
Table 4 shows the combined effects of PTSD, depression, and
Han 1283(94.6) 1111(88.7) 142(11.3)
Minority 73(5.4) 67(93.1) 5(6.9) 0.249 perceived recovery status on suicidal ideation. Compared to individuals
reporting recovery from the disaster, and having neither PTSD nor
Religiousd
No 1181(86.9) 1030(89.2) 125(10.8) depression, those reporting non-recovery, and having PTSD and
Yes 178(13.1) 149(87.1) 22(12.9) 0.427 depressive symptoms, were more likely to report suicidal ideation
Agee
(AOR=9.03; 95% CI=2.89, 28.19). Also, among those who reporting
16–35 151(11.8) 121(82.3) 26(17.7) non-recovery, depression was predictive of suicidal ideation
35–55 484(37.8) 409(86.1) 66(13.9) (AOR=6.36; 95% CI=2.56, 15.81). Among individuals reporting
> 55 644(50.4) 579(92.3) 48(7.7) < 0.001 recovery, depression with PTSD (AOR=8.00; 95% CI=3.72, 17.22),
Marital statusf and without PTSD (AOR=2.64; 95% CI=1.49, 4.67) were both
Unmarried/divorce/ 234 (17.4) 193(84.6) 35(15.4) significantly related to suicidal ideation.
widowed
Married 1109(82.6) 974(90.0) 108(10.0) 0.018
4. Discussion
Educationg
Primary school or 942(69.5) 825(89.9) 93(10.1)
below
This study examined the risk factors of suicidality from a disaster
Middle school or 414(30.5) 351(86.7) 54(13.3) 0.088 recovery perspective, eight years after the Wenchuan earthquake. The
higher results provide evidence that earthquake survivors are at high risk for
Employmenth suicidal ideation, plans and attempts, especially if they have PTSD,
Farmer 633(46.8) 553(89.5) 65(10.5) and/or depression, and/or perceive themselves as not having recovered
Unemployed 380(28.1) 319(86.9) 48(13.1) from the disaster.
Employed 341(25.1) 306(91.1) 30(8.9) 0.198
Our results indicated that 9.1% of the participants had suicidal
Incomei ideation since the earthquake. The percentages reporting suicide plans
Poor 381(28.1) 304(82.8) 63(17.2) and suicide attempt were 2.9%, and 3.3%, respectively. These rates are
Middle Income 861(63.4) 770(91.2) 74(8.8)
Rich 115(8.5) 102(90.3) 11(9.7) < 0.001
higher than those found in a Chinese community-based epidemiological
study, which estimated the lifetime prevalences of suicidal ideation,
Direct exposure
plan, and attempts, to be 3.1%, 0.9%, and 1.0%, respectively (Lee et al.,
No 988(72.2) 867(89.6) 101(10.4)
Yes 381 (27.8) 320(87.0) 48(13.0) 0.176 2008). Possible reasons why people commit suicide after an earthquake
may be as follows: First, the survivors may be injured, or have lost
PTSD
No 1208(88.2) 1066(90.0) 118(10.0) family members, property or jobs. One survivor told us that she had lost
Yes 161(11.8) 121(79.6) 31(20.4) < 0.001 her son in the earthquake, and, as a result, had been required to take
Depression
care of her grandchild, which added enormous economic and psycho-
No 1209(75.2) 925(91.9) 81(8.1) logical stress to her life. Earthquake survivors may also need to relocate,
Yes 340(24.8) 262(79.4) 68(20.6) < 0.001 thereby losing many of their social connections. One prior study found
Social Support 38.6(6.86) 38.8(6.63) 36.8(8.34) 0.001 such social network disturbances to be significantly associated with
(Mean(SD))j
self-reported psychological distress (Bland et al., 1997). Thus, an
Note:
earthquake may not only require people to change their residences
a
means there is missing data for the recovery status variable for 33 subjects. and jobs, but also destroy the local social networks they depend on,
b
means there is missing data for 12 subjects. something that is highly associated with adverse mental health out-
c
means there is missing data for 13 subjects. comes and suicidal ideation (Santini et al., 2015). Acquired physical
d
means there is missing data for 10 subjects.
e disability, bereavement, and disruption of social networks have all been
means there is missing data for 90 missing data;
f
means there is missing data for 26 missing data. shown to be associated with hopelessness, PTSD, and depression, which
g
means there is missing data for 13 missing data. are also risk factors for suicide. In our study, we also found those who
h
means there is missing data for 15 missing data. with PTSD and depressive symptoms are more likely to contemplate
i
means there is missing data for 12 missing data.
suicide. Such individuals are also likely to have poor sleep quality, high
j
means “social support” is a continuous variable. Its mean and sd are shown in the
table.
negative affectivity, and unhealthy coping styles, which can also
contribute to suicidality. Thirdly, some of the survivors complained to
cantly higher among females, the religious, the aged, farmers, the poor, us about uneven distribution of emergency aid. The relationship
and those with low education. Individuals with earthquake exposure between villagers and village cadres in the survey area is conflictual.
who were unmarried/divorced/widowed were more likely to have Discrimination and inequality can induce people to simplify their
attempted suicide. In addition, perceived non-recovery, low social thinking and behavior, identifying themselves with the group and
support, PTSD, and depression were significantly related to suicidal rejecting members of other groups. This can lead to failure to consider
ideation, plans and attempts. the possible consequences of one's actions before one acts (Spring,
2011). Those who are often treated unfairly feel hopeless about both

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Table 2
Descriptive characteristics by suicidal ideation, plans and attempts after the earthquake.

Suicidal ideation Suicide plans Suicide attempts

N (%) OR (95%CI) N (%) OR (95%CI) N (%) OR (95%CI)

Total 124(9.1%) 39(2.9%) 1361(3.3%)

Location
Guangji 64(9.5) 1 18(2.7) 1 18(2.7) 1
Yongan 60(8.7) 0.91(0.63,1.31) 21(3.1) 1.16(0.61,2.19) 27(3.9) 1.50(0.82,2.75)

Gender
Male 34(5.4) 1 17(2.7) 1 15(2.4) 1
Female 87(12.0) 2.4(1.59,3.63)*** 22(3.1) 1.13(0.60,2.15) 29(4.0) 1.72(0.91,3.23)

Ethnicity
Han 118(9.2) 1 34(2.7) 1 39(3.1) 1
Minority 5(6.8) 0.73(0.29,1.84) 4(5.6) 2.15(0.74,6.24) 4(5.6) 1.87(0.65,5.38)

Religion
No 99(8.4) 1 30(2.6) 1 37(3.2) 1
Yes 23(12.9) 1.62(1.00,2.63)* 8(4.5) 1.80(0.81,3.98) 7(3.9) 1.26(0.55,2.87)

Age f
16–35 4(2.7) 1 3(2.0) 1 2(1.3) 1
35–55 52(10.7) 4.40(1.56,12.36)** 18(3.8) 1.91(0.56,6.57) 16(3.3) 2.55(0.58,11.23)
> 55 62(9.6) 3.89(1.39,10.86)** 16(2.5) 1.25(0.36,4.35) 24(3.7) 2.87(0.67,12.30)

Marital status
Married 97(8.8) 1 30(2.7) 1 29(2.6) 1
Unmarried/divorce/widow 24(10.3) 1.19(0.74,1.91) 8(3.4) 1.27(0.57,2.80) 13(5.6) 2.18(1.11,4.25)*

Education
Middle/higher 21(5.1) 1 8(1.9) 1 10(2.4) 1
Primary /below 100(10.6) 2.23(1.37,3.62)*** 28(3.0) 1.56(0.71,3.46) 34(3.6) 1.52(0.74,3.10)

Job
Employed 17(5.0) 1 9(2.6) 1 9(2.6) 1
Farmer 77(12.2) 2.64(1.54,4.55)*** 20(3.2) 1.21(0.54,2.68) 22(3.5) 1.33(0.61,2.93)
Unemployed 28(7.4) 1.52(0.82,2.82) 8(2.1) 0.80(0.31,2.11) 14(3.7) 1.43(0.61,3.35)

Income
Rich 7(6.1) 1 4(3.5) 1 1(0.9) 1
Poor 58(15.2) 2.77(1.23.6.25)* 20(5.3) 1.56(0.52,4.64) 21(5.6) 6.73(0.90,50.55)
Middle 57(6.6) 1.10(0.49,2.46) 15(1.8) 0.49(0.16,1.52) 23(2.7) 3.14(0.42,23.50)

Exposure
No 81(8.2) 1 24(2.4) 1 25(2.5) 1
Yes 43(11.3) 1.43(0.97,2.11) 15(4.0) 1.65(0.85,3.17) 20(5.3) 2.13(1.17,3.89)***

PTSD
No 88(7.3) 1 26(2.2) 1 35(2.9) 1
Yes 36(22.4) 3.66(2.38,5.63)*** 13(8.1) 4.00(2.01,7.95)*** 10(6.2) 2.22(1.08,4.58)*

Depression
No 52(5.1) 1 13(1.3) 1 16(1.6) 1
Yes 72(21.2) 5.04(3.44,7.38)*** 26(7.7) 6.50(3.30,12.81)*** 29(8.6) 5.93(3.18,11.07)***

Recovery
Yes 88(7.4) 1 21(1.8) 1 31(2.6) 1
No 34(22.8) 3.69(2.38,5.73)*** 16(10.8) 6.69(3.41,13.14)*** 12(8.1) 3.27(1.64,6.52)***
Social supporta 36.09(6.60) 0.95(0.92,0.97)*** 35.95(7.96) 0.95(0.91,0.99)* 34.71(8.51) 0.93(0.89,0.96)***

Note:
*** P < 0.001,
** P < 0.01,
* P < 0.05. N, number; OR, odds ratio; 95% CI, confidence interval.
a
means social support is a continuous variable, and its mean and sd is listed in the table.

their lives and their society. The findings of this study remind us that
we need to pay more attention to the long-term consequences of
disasters, and adopt strategies to prevent or reduce disaster-related
suicides.
In our study, 11.2% of participants felt that their lives had not
recovered from the effects of the Wenchuan earthquake, even eight
years later. Females, younger people, the unmarried, divorced, and
widowed, and those with low incomes and low social support are more
vulnerable, over the long term, to the adverse effects of an earthquake.
Prior studies have suggested that women's greater vulnerability to the
effects of disasters may be due to their having stronger perceptions of
threat and loss of control, higher levels of peritraumatic dissociation,
insufficient social support resources, and greater vulnerability to abuse
of alcohol in an attempt to manage trauma-related symptoms like
intrusive memories and dissociation, as well as gender-specific acute
psychobiological reactions to trauma (Gavranidou and Rosner, 2003;
Olff et al., 2007). The findings of prior studies with regard to the effect
of age on the mental health outcomes of disasters have been incon-
sistent. One study suggested that it depended upon the social, econom-
ic, cultural, and historical context of the disaster-stricken setting (Norris
et al., 2002). But why did the younger respondents in our study find it
more difficult to recover from the disaster? A possible reason may be
that they were lacking in experience in dealing with a major crisis like
an earthquake. Older adults with earthquake experience would have

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J. Guo et al. Psychiatry Research 253 (2017) 383–390

Table 3
Binary logistic regression analysis predicting suicidal ideation, plans, and attempts.

Model 1-ideation Model 2-plans Model 3-attempts

AOR 95% CI AOR 95% CI AOR 95% CI

Location(Ref: Guangji)
Yongan 0.82 (0.50,1.33) 0.56 (0.22,1.39) 1.24 (0.58,2.65)

Gender(Ref: Male)
Female 2.76*** (1.64,4.66) 1.12 (0.47,2.67) 1.82 (0.83,3.98)

Age(Ref: 16–35)
35–55 5.18* (1.15,23.44) 2.85 (0.31,26.19) 4.34 (0.48,39.51)
> 55 3.99 (0.88,18.25) 1.96 (0.21,18.23) 5.05 (0.55,46.20)

Ethnicity(Ref: Han)
Minority 0.65 (0.21,1.99) 3.27 (0.77,13.88) 1.57 (0.42,5.93)

Religion(Ref: No)
Yes 0.75 (0.42,1.36) 0.54 (0.21,1.40) 1.08 (0.40,2.89)

Marital status(Ref: Unmarried/divorced/widowed)

Married 0.78 (0.42,1.47) 0.62 (0.21,1.83) 0.54 (0.23,1.30)

Education (Ref: Middle school or higher)

Primary school or below 0.91 (0.49,1.70) 1.34 (0.43,4.18) 1.09 (0.40,2.99)

Employment (Ref: Employed)

Farmer 2.13 (1.17,3.86)* 1.41 (0.48,4.17) 1.08 (0.44,2.62)
Unemployed 1.17 (0.52,2.62) 1.89 (0.52,6.87) 1.98 (0.67,5.90)

Economic status(Ref: Rich)

Poor 1.67 (0.64,4.34) 0.78 (0.19,3.10) 3.28 (0.41,26.40)
Middle Income 1.06 (0.41,2.72) 0.44 (0.11,1.75) 3.13 (0.40,24.72)

Direct Exposure(Ref: No)

Yes 1.14 (0.70,1.88) 1.40 (0.60,3.26) 2.17** (1.06,4.46)
Social Support 0.95** (0.92,0.98) 0.97 (0.91,1.03) 0.96 (0.91,1.02)

PTSD (Ref: No)

Yes 2.39** (1.35,4.21) 2.57 (0.99,6.66) 1.09 (0.43,2.74)

Depression (Ref: No)

Yes 2.78*** (1.73,4.48) 2.56* (1.05,6.25) 4.24*** (1.94,9.27)

Recovery status (Ref: Recovered)

No 2.13* (1.20,3.78) 3.07* (1.24,7.62) 1.54 (0.61,3.86)

Note:
*** P < 0.001,
** P < 0.01,
* P < 0.05. AOR, Adjusted odds ratio.

Table 4 Unmarried and lower-income individuals have fewer of the social and
Combined effect of PTSD, depression, and recover status for suicidal ideation after other resources needed to help them recover from an earthquake. This
adjusting confounding variables.
implies that public health officials and healthcare providers should
AOR 95%CI provide targeted disaster mitigation training or advice to women and
younger people, and help to ensure continuing supplies of financial
Combined effects (Ref: Recovered*No PTSD*No support for vulnerable populations.
depression)
The most important finding of this study is that PTSD, depression,
Recovered*PTSD*No depression 2.09 (0.75,5.80)
Recovered*No PTSD* depression 2.64** (1.49,4.67) and perceived non-recovery from disaster are, together, predictive of
Recovered*PTSD*depression 8.00*** (3.72,17.22) suicidality. Previous studies have reported that PTSD and depressive
Not recovered*NO PTSD*No depression 2.32 (0.95,5.66) symptoms are significantly associated with suicidal ideation (Ran et al.,
Not recovered*PTSD*No depression 10.43 (0.96,113.28) 2014). This is consistent with our finding that depression is significantly
Not recovered*No PTSD*depression 6.36*** (2.56,15.81)
related to suicidal ideation, plans and attempts, while PTSD is
Not recovered*PTSD*depression 9.03*** (2.89,28.19)
associated only with suicidal ideation. Different from prior studies,
Note: the present study examined these relationships eight years after a high-
*** P < 0.001, magnitude earthquake, emphasizing the disaster recovery aspect. After
** P < 0.01, eight years, the earthquake continues to affect a large percentage of the
* P < 0.05. AOR, Adjusted odds ratio.
affected people, making it difficult for them to recover. PTSD, depres-
sion, and perceived non-recovery are all stressors that can afflict
had more skill and knowledge about how to seek for support from their
disadvantaged individuals after an earthquake, disrupting their life
families and social support systems (Shenk et al., 2010). Previous
routines, quality of life, and social functioning, increasing their
studies have confirmed the importance of prior experience as a
healthcare costs, sometimes also leading to job loss, possibly along
moderator of the mental health impact of disasters among adults
with the need to devote more time and energy to caring for family
(Norris and Murrell, 1988). Our findings also support the idea that
members. If several of these stressors are afflicting a particular person,
social support is an important protective factor against disaster
he or she may find it unbearable and wish to die. Our findings show that
recovery failure, and that social networks can help to buffer stress.
disaster-related psychological sequelae may last for many years, and

388
J. Guo et al.
that long-term suicide prevention strategies including screening, train-
ing, and intervention programs for adult survivors should be further
developed. A comprehensive approach including programs that help to
rebuild local residents’ relationships within their communities, en-
couraging them to collaborate on recovery and support activities, and
offering mental health support for those affected, is needed. Females,
the unmarried, divorced and widowed, and others who may have
difficulty recovering from the effects of an earthquake, should be
targeted by mental health service and intervention programs.
Our study has several strengths not found in previous post-earth-
quake studies. Its disaster recovery perspective is unique. It examines
the combined effects of perceived non-recovery and mental disorders
on suicidal ideation. In addition, to our knowledge, it is one of the first
studies of suicidality in earthquake survivors 8 years after an earth-
quake, and is also one of very few studies of the psychological sequelae
of a catastrophic natural disaster in a non-Western population. Besides
these strengths, the present study has several weaknesses that should
also be mentioned. First, as a cross-sectional study, it is insufficient for
determining causal relationships. Future studies using longitudinal data
to explore the risk factors of suicidality in more depth are needed.
Second, not all potential confounding factors were measured and
adjusted for in the analyses, such as coping style, culture, life events,
etc. In addition, we did not have data on the pre-earthquake mental
health status and suicidality of the respondents. Third, sampling was
not completely random, meaning that the representativeness of our
sample for the rural Chinese population was imperfect. Older people
were overrepresented, while migrant workers were underrepresented,
in our sample.
5. Conclusions
Our findings indicate that suicidality is a long-term health issue
among survivors of the Wenchuan earthquake, even after 8 years.
PTSD, depression, and perceived non-recovery can combine to raise
suicidality risk. These findings may have implications for the develop-
ment of improved suicide prevention programs for adult earthquake
survivors.
Funding
The study was supported by The Fundamental Research Funds for
the Central Universities, HUST: 2016AD011. The funders had no role in
study design, data collection and analysis, decision to publish or
preparation of the manuscript.
Disclosure statement
No competing financial interests exist.
Acknowledgments
The authors thank Ms. Cordelia Fuller for her careful edit of the
paper, and all those who helped to collect the data and those who
kindly volunteered to participate in the study. The authors further
express their deepest condolences to all of the families and individuals
who lost family members or relatives in the 2008 Wenchuan earthquake
disaster.
References
Altindag, A., Ozen, S., Sir, A., 2005. One-year follow-up study of posttraumatic stress
disorder among earthquake survivors in Turkey. Compr. Psychiatry 46 (5), 328–333.
Bland, S.H., O'Leary, E.S., Farinaro, E., Jossa, F., Krogh, V., Violanti, J.M., Trevisan, M.,
1997. Social network disturbances and psychological distress following earthquake
evacuation. J. Nerv. Ment. Dis. 185 (3), 188–194.
Capron, D.W., Cougle, J.R., Ribeiro, J.D., Joiner, T.E., Schmidt, N.B., 2012. An interactive
model of anxiety sensitivity relevant to suicide attempt history and future suicidal
389
Psychiatry Research 253 (2017) 383–390
ideation. J. Psychiatr. Res. 46 (2), 174.
Chan, C.L.M., Wang, C.W., Qu, Z., Lu, B.Q., Ran, M.S., Ho, A.H., Yuan, Y., Zhang, B.Q.,
Wang, X., Zhang, X., 2011. Posttraumatic stress disorder symptoms among adult
survivors of the 2008 Sichuan earthquake in China. J. Trauma. Stress 24 (3),
295–302.
Chan, C.L.M., Wang, C.W., Ho, A.H.Y., Qu, Z.Y., Wang, X.Y., Ran, M.S., Mao, W.J., Lu,
B.Q.B., Zhang, B.Q., Zhang, X.L., 2012. Symptoms of posttraumatic stress disorder
and depression among bereaved and non-bereaved survivors following the 2008
Sichuan earthquake. J. Anxiety Disord. 26 (6), 673–679.
Chang, S.E., 2010. Urban disaster recovery: a measurement framework and its application
to the 1995 Kobe earthquake. Disasters 34 (2), 303–327.
Chen, C., Tan, H., Liao, L., Chen, H., Chan, C., Cheng, J., Chen, C., Wang, T., Lu, M., 2007.
Long-term psychological outcome of 1999 Taiwan earthquake survivors: a survey of a
high-risk sample with property damage. Compr. Psychiatry 48, 269–275.
Chen, H., Chen, Y., Au, M., Feng, L., Chen, Q., Guo, H., Li, Y., Yang, X., 2014. The
presence of post-traumatic stress disorder symptoms in earthquake survivors one
month after a mudslide in southwest China. Nurs. Health Sci. 16 (1), 39–45.
Cheng, S.T., Chan, A.C., 2005. The Center for Epidemiologic Studies Depression Scale in
older Chinese: thresholds for long and short forms. Int. J. Geriatr. Psychiatry 20 (5),
465–470.
Chou, Y.J., Huang, N., Lee, C.H., Tsai, S.-L., Tsay, J.-H., Chen, L.S., Chou, P., 2003.
Suicides after the 1999 Taiwan earthquake. Int. J. Epidemiol. 32 (6), 1007–1014.
Christianson, S., Marren, J., 2012. The Impact of Event Scale - Revised (IES-R). MEDSURG
Nursing 21 (5), pp. 321–322.
Creamer, M., Bell, R., Failla, S., 2003. Psychometric properties of the Impact of Event
Scale—Revised. Behav. Res. Ther. 41 (12), 1489–1496.
Duan, W., Guo, P., 2015. Association between virtues and posttraumatic growth:
preliminary evidence from a Chinese community sample after earthquakes. PeerJ 3
(4), e883.
Gavranidou, M., Rosner, R., 2003. The weaker sex? Gender and post-traumatic stress
disorder. Depress. Anxiety 17 (3), 130–139.
Guo, J., Wu, P., Tian, D., Wang, X., Zhang, W., Zhang, X., Qu, Z., 2014a. Post-traumatic
stress disorder among adult survivors of the Wenchuan earthquake in China: a
repeated cross-sectional study. J. Anxiety Disord. 28 (1), 75–82.
Guo, J., Wang, X., Yuan, J., Zhang, W., Tian, D., Qu, Z., 2015. The symptoms of
posttraumatic stress disorder and depression among adult earthquake survivors in
China. J. Nerv. Ment. Dis. 203 (6), 469–472.
Guo, J., He, H., Qu, Z., Wang, X., Liu, C., 2016a. Post-traumatic stress disorder and
depression among adult survivors 8 years after the 2008 Wenchuan earthquake in
China. J. Affect. Disord. 210, 27–34.
Guo, J., Zhou, Q., Zhang, Z., 2016b. Long impact of earthquake on Post-traumatic Stress
Disorder. Adv. Psychol. Sci. 24 (10), 1534–1543.
Guo, S., Tian, D., Wang, X., Xiao, Y., He, H., Qu, Z., Zhang, X., 2014b. Protective Effects of
social support content and support source on depression and its Prevalence 6 months
after Wenchuan earthquake. Stress Health 31 (5), 382–392.
Kessler, R.C., Borges, G., Walters, E.E., 1999. Prevalence of and risk factors for lifetime
suicide attempts in the National Comorbidity Survey. Arch. General. Psychiatry 56
(7), 617–626.
Kessler, R.C., Berglund, P., Borges, G., Nock, M., Wang, P.S., 2005. Trends in suicide
ideation, plans, gestures, and attempts in the United States, 1990–1992 to
2001–2003. Jama J. Am. Med. Assoc. 293 (20), 2487–2495.
Kotler, M., Efroni, R., Amir, M., Iancu, I., 2001. Anger, impulsivity, social support, and
suicide risk in patients with posttraumatic stress disorder. J. Nerv. Ment. Dis. 189 (3),
162–167.
Krug, E.G., Kresnow, M., Peddicord, J.P., Dahlberg, L.L., Powell, K.E., Crosby, A.E.,
Annest, J.L., 1998. Suicide after natural disasters. New Engl. J. Med. 338 (6),
373–378.
Lee, S., Fung, S.C., Tsang, A., Liu, Z.R., Huang, Y.Q., He, Y.L., Zhang, M.Y., Shen, Y.C.,
Nock, M.K., Kessler, R.C., 2008. Lifetime prevalence of suicide ideation, plan, and
attempt in metropolitan China. Acta Psychiatr. Scand. 116 (6), 429–437.
Ma, X., Liu, X., Hu, X., Qiu, C., Wang, Y., Huang, Y., Wang, Q., Zhang, W., Li, T., 2011.
Risk indicators for post-traumatic stress disorder in adolescents exposed to the 5.12
Wenchuan earthquake in China. Psychiatry Res. 189 (3), 385–391.
Miletic, V., Lukovic, J.A., Ratkovic, N., Aleksic, D., Grgurevic, A., 2015. Demographic risk
factors for suicide and depression among Serbian medical school students. Social.
Psychiatry Psychiatr. Epidemiol. 50 (4), 633–638.
Mosqueiro, B.P., Rocha, N.S.D., Fleck, M.P.D.A., 2015. Intrinsic religiosity, resilience,
quality of life, and suicide risk in depressed inpatients. J. Affect. Disord. 179,
128–133.
Norris, F.H., Murrell, S.A., 1988. Prior experience as a moderator of disaster impact on
anxiety symptoms in older adults. Am. J. Community Psychol. 16 (5), 665–683.
Norris, F.H., Kaniasty, K., Conrad, M.L., Inman, G.L., Murphy, A.D., 2002. Placing Age
Differences in Cultural Context: a Comparison of the Effects of Age on PTSD After
Disasters in the United States, Mexico, and Poland. J. Clin. Geropsychology 8 (3),
153–173.
Olff, M., Langeland, W., Draijer, N., Gersons, B.P., 2007. Gender differences in
posttraumatic stress disorder. Psychol. Bull. 133 (2), 183–204.
Qu, Z., Tian, D., Zhang, Q., Wang, X., He, H., Zhang, X., Huang, L., Xu, F., 2012a. The
impact of the catastrophic earthquake in China's Sichuan province on the mental
health of pregnant women. J. Affect. Disord. 136 (1–2), 117–123.
Qu, Z., Wang, X., Tian, D., Zhao, Y., Zhang, Q., He, H., Zhang, X., Xu, F., Guo, S., 2012b.
Posttraumatic stress disorder and depression among new mothers at 8 months later of
the 2008 Sichuan earthquake in China. Arch. Women'S. Ment. Health 15 (1), 49–55.
Ramsawh, H.J., Fullerton, C.S., Mash, H.B.H., Ng, T.H.H., Kessler, R.C., Stein, M.B.,
Ursano, R.J., 2014. Risk for suicidal behaviors associated with PTSD, depression, and
their comorbidity in the U.S. Army. J. Affect. Disord. 161, 116–122.
J. Guo et al.
Ran, M.S., Zhang, Z., Fan, M., Li, R.H., Li, Y.H., Ou, G.J., Jiang, Z., Tong, Y.Z., Fang, D.Z.,
2014. Risk factors of suicidal ideation among adolescents after Wenchuan earthquake
in China. Asian J. Psychiatry 13, 66–71.
Santini, Z.I., Koyanagi, A., Tyrovolas, S., Haro, J.M., 2015. The association of relationship
quality and social networks with depression, anxiety, and suicidal ideation among
older married adults: findings from a cross-sectional analysis of the Irish Longitudinal
Study on Ageing (TILDA). J. Affect. Disord. 179, 134–141.
Scocco, P., de Girolamo, G., Vilagut, G., Alonso, J., 2008. Prevalence of suicide ideation,
plans, and attempts and related risk factors in Italy:: Results from the European Study
on the Epidemiology of Mental Disorders-World Mental Health study. Compr.
Psychiatry 49 (1), 13–21.
Shenk, D., Mahon, J., Kalaw, K.J., Ramos, B., Tufan, I., 2010. Understanding the disaster
experience of older adults by gender: the experience of survivors of the 2007
earthquake in Peru. Health care Women Int. 31 (11), 965–980.
Spring, Ú.O., 2011. Social Vulnerability, Discrimination, and Resilience-building in
Disaster Risk Reduction. Springer Berlin Heidelberg.
State Council Information Office of China (SCIOC), 2008. Report of the progress of post-
disaster relief after the Wenchuan earthquake.
Stratta, P., Capanna, C., Carmassi, C., Patriarca, S., Di, E.G., Riccardi, I., Collazzoni, A.,
Dell'Osso, L., Rossi, A., 2014. The adolescent emotional coping after an earthquake: a
risk factor for suicidal ideation. J. Adolesc. 37 (5), 605–611.
Sun, L., Zhou, C., Xu, L., Li, S., Kong, F., Chu, J., 2017. Suicidal ideation, plans and
attempts among medical college students in china: the effect of their parental
characteristics. Psychiatry Res. 247, 139–143.
Tse, C.W., Wei, J., Wang, Y., 2013. Social Capital and Disaster Recovery: evidence from
Sichuan Earthquake in 2008. Social Science Electronic Publishing.
390
Psychiatry Research 253 (2017) 383–390
Turecki, G., 2005. Dissecting the suicide phenotype: the role of impulsive–aggressive
behaviours. J. Psychiatry Neurosci. Jpn. 30 (6), 398–408.
Wang, L., Zhang, Y., Wang, W., Shi, Z., Shen, J., Li, M., Xin, Y., 2009. Symptoms of
posttraumatic stress disorder among adult survivors three months after the Sichuan
earthquake in China. J. Trauma. Stress 22 (5), 444–450.
Wang, X.D., 1999. Psychological assessment scale manual. Chin. Ment. Health J.
200–202.
Weiss, D.S., Marmar, C.R., 1997. The Impact of Event Scale—revised. In: Wilson, J.P.,
Keane, T.M. (Eds.), Assessing Psychological Trauma and PTSD: A Practitioner's
Handbook. Guilford Press, N Y.
Wohlfarth, T.D., van den Brink, W., Winkel, F.W., ter Smitten, M., 2003. Screening for
posttraumatic stress disorder: an evaluation of two self-report scales among crime
victims. Psychol. Assess. 15 (1), 101–109.
Wu, K.K., Chan, K.S., 2003. The development of the Chinese version of Impact of Event
Scale–Revised (CIES-R). Social. Psychiatry Psychiatr. Epidemiol. 38 (2), 94–98.
Xiao, S., 1994. Theoretic basis and research application of the social support appraisal
scale. J. Clin. Psychiatry ( Chin.) 4, 98–100.
Xiao, Z.L., Wen, J., Zhao, H., Tan, Q.W., LV, X., Yan, Fb, 2011. A bibliometric analysis on
post-earthquake health issue related literature. Chin. J. Evid. Based Med. 11 (5).
Yip, P., 2009. Effects of an earthquake on suicide rates in Nantou, Taiwan. Br. J.
Psychiatry J. Ment. Sci. 194 (2), 190 (190).
Zhang, J., Wu, Z., Fang, G., Li, J., Han, B.X., 2010. Development of the Chinese age norms
of CES-D in urban area. Chin. Ment. Health J. 24 (2), 139–143.
Zhang, Y., Ho, S., 2011. Risk Factors of Posttraumatic Stress Disorder among Survivors
after the 512 Wenchuan Earthquake in China. PLoS One 6 (7), e22371.