International Journal of Mental Health

ISSN: 0020-7411 (Print) 1557-9328 (Online) Journal homepage: http://www.tandfonline.com/loi/mimh20

The Impact of Disaster on Mental Health:

Prospective and Retrospective Analyses

Glorisa Canino, Milagros Bravo, Maritza Rubio-Stipec & Michael Woodbury

To cite this article: Glorisa Canino, Milagros Bravo, Maritza Rubio-Stipec & Michael Woodbury
(1990) The Impact of Disaster on Mental Health: Prospective and Retrospective Analyses,
International Journal of Mental Health, 19:1, 51-69, DOI: 10.1080/00207411.1990.11449153

To link to this article: https://doi.org/10.1080/00207411.1990.11449153

Published online: 04 Sep 2015.

Submit your article to this journal

View related articles

Citing articles: 66 View citing articles

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=mimh20

Download by: [ECU Libraries] Date: 07 January 2018, At: 22:40

 1111.1 MCIII. Hcallh, Vol. 19, No.1, pp. 51~9
M. E. Sharpe, Inc., 1990

GLORISA CANINO, MILAGROS BRAVO,

MARITZA RUBIO-STIPEC, AND
MICHAEL WOODBURY

The Impact of Disaster on

Mental Health: Prospective
and Retrospective Analyses
Downloaded by [ECU Libraries] at 22:40 07 January 2018

The fIrst major islandwide survey of mental disorders of the adult population of
Puerto Rico was completed in 1984 [1]. This survey provided estimates of prev-
alence rates and correlates of specific mental disorders according to DSM-III
criteria [2] by using the Diagnostic Interview Schedule (DIS). A year later, in
October 1985, torrential rains throughout Puerto Rico caused extensive and disas-
trous mudslides that left 180 people dead and disrupted the lives of thousands of
others. As a consequence of the mudslides, more than four thousand people were
forced to live in public shelters for months, and more than nineteen thousand people
had to rectify serious damage to property.
Since the area covered by the 1984 islandwide survey included the regions
affected by the rains, there was an unusual opportunity to assess the effects of the
disaster on a sample of the people previously interviewed. And since only a portion
of the island was inundated, a control group of subjects previously interviewed and
not affected by the floods was also available.
Here we shall report the results of a survey of people exposed and not exposed to
the 1985 floods. The survey was designed to determine the effect of the disaster on
mental health symptoms and diagnoses and to determine the extent to which this
effect was influenced by either demographic characteristics or previous symptoms.
The main question posed is whether a specific disaster is related to the onset of
symptoms and/or psychiatric diagnoses not present before that disaster. We also
present information on the onset of new symptoms following the disaster and ana-
lyze them retrospectively and prospectively.
A number of disaster characteristics and consequences have been previously
associated with the risk of developing mental symptoms or disorders in the victims.
In fact, disasters characterized by a high proportion of affected to non affected

The authors are all associated with the University of Puerto Rico. Dr. eanino is with the
Office of the Dean for Academic Affairs, University of Puerto Rico, Mental Health Secretar-
iat, P.O. Box 5067, San Juan, Puerto Rico 00936. Dr. Bravo is also with the Office of the
Dean for Academic Affairs; Ms. Rubio-Stipec, with the Department of Economics; and Dr.
Woodbury, with the Department of Psychiatry.

51
 52 GLORISA CANINO EJ AL.

individuals; by a sudden, unexpected onset for which there is little warning; by a

potential for recurrence; and by terror, horror, and a threat to lives and property
have been associated with an increased rate of psychological impairment [3,4]. The
disaster we are studying had most of these stressful characteristics. It was inherently
uncontrollable, unexpected (almost no forewarning was given by the Weather Bu-
reau and local authorities), and had a very great and extensive impact (it caused
considerable personal and material damage to many communities); many people
were exposed to horrifying experiences, such as seeing their relatives die in the
mudslides, feeling their lives threatened by the floods, and experiencing long-last-
ing effects through relocation and evacuation. It is no wonder that this disaster was
called one of the worst tragedies of the century in Puerto Rico.
Downloaded by [ECU Libraries] at 22:40 07 January 2018

Depressive, anxiety, and post-traumatic symptoms have been frequently associ-

ated with disaster stress [5-8V Alcoholic and somatic symptoms have also been
sometimes associated with exposure to disasters [5,6,9]. Most previous studies of
the effects of disasters and the emergence of mental symptoms have used cross-sec-
tional designs and have seldom included controls.
Recent developments in psychiatric epidemiology have included the develop-
ment of structured diagnostic interviews (such as the Diagnostic Interview Schedule
[DIS][1O]) that, because they provide computer-generated algorithms for specific
disorders, can be applied to large population samples. As a result of this develop-
ment, several studies have used the DIS in large community-based samples to
investigate the effects of particular disasters [7,11].2 Most of these studies (except
for the Times Beach study in Missouri [12]) have used cross-sectional samples and
control groups (except for the Mexico City study3).
Although different types of disasters occurring in culturally diverse populations
have been studied, some consistent findings have been observed in the retrospective
assessments. Significant increases in the postdisaster prevalence of depression, gen-
eralized anxiety, and post-traumatic stress disorder (PTSD) were observed in the
exposed people in the volcanic eruption of Mount St. Helens [7], in the Mexico City
earthquakes,4 and in the floods and toxic contamination in Missouri [11], where, in
addition, there were increases in alchohol abuse/dependence and phobia in the
directly exposed population. In terms of new symptoms, a significantly higher pro-
portion of exposed than unexposed people reported the onset of new depressive and
PTSD symptoms in the Missouri study when retrospectively analyzed. The prospec-
tive analyses of this same study reported by Robins and co-workers [12] did not
identify any significant psychopathologic disaster effects except for the onset of
new post-traumatic symptoms in those exposed to the disaster. The floods and
dioxin intoxication in Missouri did not cause the onset of new mental disorders or
symptoms except for those of PTSD and phobias. The higher rate of phobias was
accounted for by the exposed group's initially higher rate before the disaster. Rob-
ins and colleagues [12] suggest that the results may be partly due to the facts that
none of their respondents suffered serious injury or death of relatives, that the
number of people exposed in their panel sample was small, and that humans seem to
be resilient and have a great capacity to overcome adverse circumstances. Actually,
 PROSPEcrfVE AND RETROSPEcrfVE ANALYSES 53

it is difficult to determine whether the lack of postdisaster mental symptoms re-

ported in this study is due to the low level of exposure of the respondents or to the
use of a prospective design.
One of the disadvantages of post-study-only designs is difficulty in disentangling
true increases in psychopathology from the apparent increases that can result from
the tendency of those exposed to blame the disaster for problems that actually
predated it, or difficulty in subjects' recalling and dating symptoms. The present
study controls for some of these methodological artifacts by presenting data that
have been both prospectively and retrospectively analyzed. Compared with Robins
and co-workers [12], we have a larger number of previously assessed respondents
who were exposed to the disaster, some of whom experienced a threat to life or
Downloaded by [ECU Libraries] at 22:40 07 January 2018

suffered the death of a relative. Moreover, since the mental health status of some of
the disaster's victims had been previously assessed, we were able to determine the
extent to which the disaster had affected the mental health of these victims. Any
psychological effects would therefore be considered more likely to be due to the
deleterious consequences of the stressor itself inasmuch as previous symptoms and
demographic characteristics were accounted for.
In addition to increasing mental morbidity in a population, disasters may have a
more chronic effect, changing daily life in such a way that people feel distressed,
that the quality of their life and relationships has deteriorated, or that their physical
health has been compromised. Often stresses such as unemployment, which may be
a consequence of the disaster, result in great economic hardship for the family, and
may affect family or marital relationships, adding to the already overwhelming
stressors experienced. In fact, Robins and co-workers [12] have reported that disas-
ter victims feel more overwhelmed by daily problems, report a greater decline in
their health status and more loss in employment than the unexposed. Furthermore,
these changes in the quality of life of the respondents were not due to predisaster
differences between the groups. For this reason, we shall present information not
only on the effect of disaster stress on mental morbidity but also on perception of
health and utilization of health services, loss of employment, marital breakups, and
feelings of distress.

Methods

Population and sample

The study sample was designed to increase the chance of obtaining not only people
exposed to the 1985 disaster but also those exposed and previously interviewed in
1984. The island of Puerto Rico was divided into exposed and unexposed areas.
The classification was based on civil defense reports and on-site inspections; re-
cently constructed communities housing the displaced disaster victims (identified
through the Housing Department) were also classified as disaster areas. All persons
interviewed in 1984 living in the specific disaster areas and a systematic random
sample of those previously interviewed but not living in disaster areas were in-
 54 GLORISA CANINO ET AL.

cluded in the prospective sample. We were able to obtain 375 previously inter-
viewed adults (ages, 20-68), with a response rate of 86.6%. New participants were
sampled in two steps. First, two probability samples of households located in ex-
posed and unexposed communities were chosen. Then, a single person (aged 17-67
years) was chosen in each household, using a sampling scheme designed to provide
a sex and age distribution similar to that of the total population [13]. We were able
to obtain 537 new participants, with a response rate of 92.9% on first interviews.
Thus, our total sample consists of 912 persons, 375 previously interviewed and
537 newly interviewed. The 375 previously interviewed constitute the prospective
sample since information about symptoms was obtained through administration of
the same instrument at two different times (1984 and 1987). We refer to the total
Downloaded by [ECU Libraries] at 22:40 07 January 2018

sample of 912 as the retrospective sample, since the information about symptoms
for all participants was obtained through retrospective recall.

Instruments and measures

The DIS. The field research instrument used in this study was a Spanish version of
the Diagnostic Interview Schedule/Disaster Supplement (DIS/DS), an adapted ver-
sion of the DIS [10] designed to evaluate the mental health of disaster victims [14].
It is a structured schedule designed for use by trained lay interviewers that allows
criterion-based diagnostic assessments for the study of mental symptoms and disor-
ders. A symptom is scored positive if it has ever been experienced by the respon-
dent, meets severity criteria, and is not entirely explained by physical illness or
substance use. In addition to symptom questions, the DIS/DS includes items related
to interpersonal dysfunction at work and with friends and family and items related
to, among others, feeling overwhelmed by problems, self-perception of health, em-
ployment, and marital status.
The DIS/DS was translated into Spanish and adapted for our study. It included 9
(of 12) DSM-III disorder schedules: major depressive episode, dysthymia, post-
traumatic stress disorder (PTSD), alcohol and drug abuse/or dependence (DAD),
generalized anxiety (GA), panic, and antisocial personality disorder (ASP). Since
somatization is a low-prevalence disorder, the somatic symptoms included were
those that form an empirically defined symptom scale [15]. Five of the diagnoses
present in our DIS/DS version had been studied in our 1984 epidemiological study.
However, the presence of PTSD, GA, DAD, and ASP was not assessed in 1984;
hence, there is no prospective information on these disorders. For this reason, the
first two are included only in the analyses of the retrospective sample, and data on
DAD and ASP are reported prospectively.
The diagnostic schedules of the DIS used in 1984 had been made appropriate for
the Puerto Rican population and culture through a comprehensive, cross-cultural
adaptation that took into account the semantic, content, technical, criterion, and
conceptual equivalence among the languages and cultures involved [16]. Its reliabil-
ity and concordance with clinical diagnoses had been assessed [17], and the results
obtained were comparable with those of similar studies in the United States [10,18].
 PROSPECJIVE AND RETROSPECJIVE ANALYSES 55

Although formal reliability studies were not done for the diagnoses added in our
1987 survey (PTSD, GA, DAD, and ASP), these diagnoses have been shown to be
reliable in general population surveys on the mainland. The procedure for adapting
the measures for use in Puerto Rico followed that used with the 1984 instrument.
We successfully pretested the complete DlSIDS before use with 30 community
subjects from different socioeconomic strata. The purpose of this testing was to
ascertain feasibility of administration, mainly intelligibility of the items and length
of the interview.
New symptoms or diagnoses. As previously noted, the main question to be an-
swered by our study was whether a disaster might be considered related to the onset
of new symptoms and/or new psychiatric diagnoses not present before the disaster.
Downloaded by [ECU Libraries] at 22:40 07 January 2018

The inherent differences in design between the prospective and the retrospective
data required different definitions of what constituted a new symptom or diagnosis.
The determination of new symptoms in the prospective sample was made by sub-
tracting the sum of lifetime symptoms reported in 1987 from those reported in
1984. This measure took into account lifetime symptoms reported in 1984, but not
in 1987. New diagnoses in the prospective sample referred to lifetime diagnoses
not present in 1984, but present in 1987. Determination of new symptoms in the
retrospective sample was made through analyses of onset probes. If a symptom was
scored positive (lifetime), the respondent was asked for the date of the first experi-
ence of that symptom. Then, through computer analyses of those dates, it was
determined whether the symptom occurred for the first time before or after the
disaster. Symptoms that were reported as starting after October 1985 (the date of the
disaster) were considered new symptoms in the retrospective sample. New diagno-
ses in the retrospective sample were similarly determined; they referred to cases that
met diagnostic criteria for each particular disorder for the first time after 1985. In
the determination of new diagnoses for the retrospective data bank, not every symp-
tom had to have its onset after the disaster (some might have been present before the
disaster), but all the criteria for the disorder had not been met until after the disaster.
Disaster exposure. The section of the DISIDS evaluating disaster exposure was
revised in order to adapt it to our conceptual framework and the Puerto Rican
disaster. The adaptation was based on information collected in unstructured inter-
views with disaster victims. For example, we added items to measure death of a
family member, friend, or neighbor and serious threat to one's self or family.
Items that classified participants in terms of the degree of exposure stress levels
were included in the structured questionnaire. Four disaster exposure levels were
defined: severe, moderate, near, and no exposure. Both personal and material losses
or threats were considered. "Severe exposure" referred to both severe damage to
property and relocation (temporary or permanent), or to the loss of family members
by death, or to serious threat to own or family member's life. "Moderate exposure"
referred to damage to property or relocation, or to the death or serious life threat to
significant other's life (no family member), or to moderate threat to family member.
"Near exposure" referred to only slight or no damage to own property, but consid-
erable damage to neighbors', or to death or life threat to neighbors or nearby
 56 GLORISA CANINO lIT AL.

Table 1

Description of Degree of Exposure to Disaster

Retrospective Prospective
sample (n = 912) sample (n = 375)

Exposed Exposed
Degree of
exposure (n = 321) 0/0 (n = 77) %
Downloaded by [ECU Libraries] at 22:40 07 January 2018

Property damage 178 55.5 22 28.6

Relocation because of 103 75.2 12 44.4

disaster

Death or life threat to 48 15.0 14 18.2

family

Feeling of threat to self 133 41.4 17 22.1

during disaster

community members. For the univariate analyses reported in this paper, we opted
for two groups, collapsing the moderately and severely exposed into what we call
the "exposed" group, and the nearly exposed and nonexposed into the
"nonexposed" group. Classification by four exposure levels would have resulted in
very small numbers for most of the analyses since the prospective data included a
small number of subjects.

Identification of the exposed sample

Of the 375 previously interviewed respondents in the disaster area (our prospective
sample), the number of those reporting actual exposure to the disaster was much
less than we had expected (77), leaving a much larger unexposed group (298). Of
those exposed, about a third suffered property damage, about half had to be relo-
cated because of the disaster, about a quarter of them felt their life endangered, and
18% reported death or life threat to family (See Table 1). It is obvious that a greater
number of exposed respondents in the retrospective sample suffered the serious
consequences of the disaster. Around half of the exposed in the retrospective sample
had property damage and felt their life was endangered during the disaster.
The exposed and unexposed samples had generally similar demographic charac-
teristics (See Table 2), except for education level. In both samples the exposed were
significantly less well educated than the unexposed. This difference was not re-
flected in other measures; no differences were observed between groups in either
sample in terms of age or median family income, the latter being uniformly low. In
the prospective sample, the exposed group included significantly more males.
 PROSPECTIVE AND RETROSPECTIVE ANALYSES 57

Table 2

Demographic Characteristics of Subjects Classified by Exposure

Prospective data en =375)

Exposure

Demographic Exposed Unexposed

characteristics N (77) 0/0 N (298) %

Downloaded by [ECU Libraries] at 22:40 07 January 2018

Sex

Male 42 54.6 125 42.0·

Female 35 45.5 173 58.0

Age
17-24 13 16.9 35 11.7
25-44 41 53.2 152 51.0
45-68 23 29.9 111 37.3

High school graduate 40 52.0 161 54.0·

Annual median family $8,256 $8,880
income

Retrospective data en =912)

Exposure

Demographic Exposed Unexposed

characteristics N (321) % N (591) %

Sex
Male 145 45.2 244 41.3
Female 176 54.8 347 58.7

Age
17-24 77 24.0 134 22.7
25-44 151 47.0 254 43.0
45-68 93 29.0 203 34.4

High school graduate 144 44.9 307 52.0·

Annual median family $6,432 $7,872
income

Note: Significant differences between groups were established by t-tests.

*p ~ 0.05.
 58 GLORISA CANINO ET AL.

Table 3

Disaster Effect on New Psychiatric Diagnoses

Prospective data (n = 375)

Percent with diagnoses

Exposed Unexposed

Diagnoses N (77) % N (298) %

Depressive disorders a 6 7.8 13 4.4

Downloaded by [ECU Libraries] at 22:40 07 January 2018

Alcohol abuse/dependence 4 5.2 10 3.4

Panic disorder 2 2.6 6 2.0

Retrospective data (n = 912)

Percent with diagnoses

Exposed Unexposed

Diagnoses N (321) N (591) %

Depressive disorders a 7 2.2 6 1.0

Alcohol abuse/dependence 4 1.3 5 0.9
PTSD b 12 3.7 4 0.7***
Generalized anxiety 31 9.7 36 6.1*
Panic disorder 5 1.2 8 1.4

Note: Significant differences between groups were established by t-tests.

'Refers to major depressive disorder and/or dysthymia.
bRefers to post-traumatic stress disorder.
*p::; 0.05; ***p ::; 0.001.

the prospective sample, the exposed group included significantly more males.

Results

Psychiatric diagnoses and their symptoms

Table 3 shows the new mental disorders for exposed and unexposed groups in both
the prospective and retrospective samples. The prospective sample reveals a trend
for the exposed group to have a higher rate of new cases of depressive disorders and
alcohol abuse and/or dependence than the unexposed. However, these differences
did not reach significance. The same trend is observed in the retrospective sample.
Significant differences between the groups are observed only for PTSD and general-
ized anxiety, these being also the most prevalent disorders for which criteria were
met after the disaster. Unfortunately, since we did not measure these diagnoses in
 PROSPECTIVE AND RETROSPECTIVE ANALYSES 59

Table 4

Disaster Effect on New Mental Symptoms

Prospective data (n = 375)

Exposed Unexposed

Mental Standard Standard

symptoms Mean deviation Mean deviation

Depressive 0.31 1.5 -0.15 1.46**

Alcoholic 0.08 2.04 -1.0 1.49
Panic 0.05 2.24 -0.18 2.74
Somatization -0.38 1.61 -0.31 1.64
Downloaded by [ECU Libraries] at 22:40 07 January 2018

Total 0.06 3.7 -0.75 4.22

Retrospective data (n = 912)

Exposed Unexposed

Mental Standard Standard

symptoms Mean deviation Mean deviation

Depressive 0.69 1.18 0.48 0.93**

Alcoholic 0.11 0.46 0.08 0.50
Panic 0.12 1.05 0.07 0.83
Somatization 0.32 0.78 0.21 0.66*
PTSD 0.18 0.88 0.09 0.55
Generalized anxiety 0.42 1.2 0.26 0.94*
Total 1.84 3.01 1.19 2.34***

Note: Significant differences between groups were established by I-tests.

*p ~ 0.05; ** P ~ 0.01; *** P ~.0.001.

our 1984 study, the effect on them of exposure to the disaster could not be deter-
mined. The greater prevalence of these disorders in those exposed to disasters has
been corroborated in several cross-sectional designs relying on retrospective recall
[7,11].5
A pattern similar to that identified at the diagnostic level is observed at the
symptom level (See Table 4). For depressive symptoms in both the retrospective
and prospective samples, the differences between groups reached significance.
Moreover, new somatic symptoms and the total number of symptoms in the
retrospective sample were found to be significantly more frequent in the exposed
group. Surprisingly, PTSD symptoms were not significantly different in the ex-
posed compared with the unexposed subjects. Further analyses revealed that there
were more people in the exposed groups who were "threshold cases" before the
disaster, that is, who met three of the four criteria necessary for a diagnosis of
PTSD. Thus, in the exposed group, the addition of a few postdisaster symptoms
 60 GLORISA CANINO ET AL.

was sufficient for this group to meet the PTSD criteria.

Negative mean number of symptoms are estimated in the unexposed group of the
prospective sample (See Table 4). This suggests a tendency for those previously
interviewed to report fewer lifetime symptoms in the second interview than in the
first. A similar decline in the second DIS interviews had been observed previously
in other samples [19,20]. The fact that, with the exception of somatic symptoms in
the prospective sample, the other symptoms evaluated in the exposed group did not
yield negative rates suggests that even though a decline must have occurred, the
disaster effect may have overridden this tendency.
Many factors must be taken into account before we can confidently determine a
"true" disaster effect. For instance, the exposed and unexposed groups in both
Downloaded by [ECU Libraries] at 22:40 07 January 2018

samples differed in educational level, and in the prospective sample, in sex ratio.
This is important because our 1984 survey established that sex, age, and education
were associated with risk for psychopathology [1). Of particular importance in our
present analyses was the fact that low educational level was significantly associated
with higher rates of mental disorders, a finding that has been documented in other
studies as well [21,22]. We also found that the risk for some disorders, particularly
depression and alcoholism, was gender related. Furthermore, other studies (e.g.,
[23]) have established that once criteria for one mental disorder are met, the risk for
meeting criteria for other disorders is significantly increased. Applying this to our
study, we should expect that if a person had mental symptoms or diagnoses before
the disaster, he or she would be more prone to have them after the disaster-not
necessarily because of the stressful event, but just because the passage of time
increases risk in already vulnerable people. In fact, previous research has well
documented that predisaster diagnostic and symptom levels are the best predictors
of postdisaster disorders [11).
Another important factor that must be considered before we can determine a
disaster effect is whether the particular study subject has been previously inter-
viewed with the same instrument. Earlier research suggests that participants pre-
viously assessed with the DIS (in our study, the prospective sample, n = 375) tend
to report fewer symptoms on a second interview [19], a tendency we shall refer to
as a "report effect." For all these reasons, we considered it necessary to analyze
whether the results of our univariate analyses were explained by the disaster itself or
whether they were due to the sex, age, education, previous symptoms, or report
effect of the person exposed.
Table 5 presents the significant findings of ten multiple regression analyses that
describe the association between number of symptoms and exposure to the disaster
after accounting for age, sex, education, report effect, and previous symptoms. One
regression analysis model was specified for each set of new postdisaster symptom
outcomes (i.e., depression, PTSD) in both the prospective and the retrospective data
banks. Variables in the analytic model were entered into the analysis in two steps:
first, covariates (sex, education, age, report effect, and previous symptoms), and
second, level of exposure to the disaster.
Our results indicate that after simultaneously accounting for demographic fac-
 PROSPECflVE AND RETROSPECflVE ANALYSES 61

Table Sa

Regression Analyses of Influence of Exposure to Disaster on New

Symptoms, Retrospectively Evaluated Sample (N 912) (Step 2) =
Depressive Somatic Alcoholic Dysthymia

Variables B SEa B SE B SE B SE
Gender (male) -0.05 0.07 -0.10 0.06t 1.59 0.13' -O.OS 0.07

Age (yrs.)

17-24 0.16 0.09 t -0.05 0.07 -0.45 0.16 O.OS 0.09

Downloaded by [ECU Libraries] at 22:40 07 January 2018

45-6S 0.14 O.ost 0.00 0.06 0.13 0.15 O.OS O.OS

Education (yrs.)
0-11 0.17 0.09t 0.35 0.07' 0.01 0.16 0.13 0.09
13+ 0.18 0.10t -0.01 0.08 -0.17 0.18 0.03 0.10

Interview -0.07 0.08 0.03 0.06 -0.05 0.13 0.01 0.07

status

Predisaster 1.08 0.02' 1.05 0.02' 1.80 0.17 1.0S 0.02"

symptoms

Exposure 0.09 0.03" 0.05 0.02" 0.12 0.05" 0.08 0.03"

level

R2 0.69 0.71 0.27 0.71

251.46 286.99 43.27 273.53

Note: Note: Reference groups for covariates are: female for sex, 25-44 yrs, age span for age, 12
yrs. of schooling for education, and not previously interviewed for report status.
aB= regression coefficient; SE= standard error.
* P $ 0.05; t P $ 0.10.

tors, report effect, and previous symptoms, the higher the level of exposure to the
disaster, the greater was the number of new dysthymic, major depression, and PTSD
symptoms in the cross-sectional retrospective sample. The prospective data confirm
that exposure to the disaster increased depressive and somatic symptoms. The asso-
ciation with dysthymic symptoms was significant at the 0.05 level. Although for
major depression and somatic symptoms the results did not reach significance, the
relationship to disaster exposure and symptoms in the prospective data bank is in
the same direction as in the retrospective one, and the magnitude of the regression
coefficients are not significantly different (see Table 5). However, the standard
errors for exposure in the latter group are larger since it is a smaller sample, thus
producing a loss in statistical power to detect significance. The results therefore
suggest that a "true disaster effect" is present in dysthymic, major depression, and
 62 GLORfSA CANINO ET AL.

Table 5b

Regression Analyses of Influence of Exposure to Disaster on

New Symptoms, Prospectively Evaluated Sample (N = 375) (Step 2)

Depressive Somatic Alcoholic Dysthymia

Variables 8 SEa 8 SE 8 SE 8 SE

Gender (male) 0.01 0.16 -0040 0.13- 0046 0.17* -0.11 0.15

Age (yrs.)
17-24 -0.23 0.24 -0.20 0.19 0.06 0.26 -0.11 0.23
45-68 0.21 0.17 0.14 0.14 -0.25 0.17 0.29 0.17
Downloaded by [ECU Libraries] at 22:40 07 January 2018

Education (yrs.)
0-11 -0.19 0.20 -0.04 0.16 -0.25 0.20 -0.26 0.20
13+ -0.30 0.22 -0.32 0.17 -0.21 0.21 -0.38 0.21

Predisaster
symptoms 0.57 0.05- 0.33 0.04- 0.70 0.03 0.58 0.05-

Exposure level 0.14 0.08t 0.07 0.06 0.05 0.08 0.14 0.07-

R 0.32 0.27 0.62 0.34

F 24.82 19.61 84.13 27.25

Note: Reference groups for covariates are: female for sex, 25-44 yrs. age span for age, and 12
yrs. of schooling for education.
aB= regression coefficient; SE= standard error.
* p::; 0.05; t p::; 0.10.

somatic symptoms and that this effect is observed when retrospectively or prospec-
tively evaluated.
As expected, dysthymic symptoms were found to be more common in females.
Major depressive symptoms were more common in the younger age group. Previous
symptoms were strongly associated with a greater number of symptoms following
the disaster for all diagnostic groupings in both the retrospective and the prosp'~tive
samples, confirming the results obtained in the Missouri disaster reported by Robins
and co-workers [12].
The multivariate PTSD findings did not confirm our prior hypothesis that the
differences between the exposed and the unexposed were due to differences in
previous symptoms. Our retrospective findings thus confirm those of other studies
that have found new PTSD symptoms developing in the postdisaster period.
After accounting for previous symptoms and demographic differences, neither
new alcoholic nor panic symptoms were significantly associated with exposure to
the disaster. This result was consistently observed in the retrospective and prospec-
tive samples, which suggests that the significant associations observed in the uni-
variate analyses were probably due to demographic characteristics and to the greater
 PROSPECTIVE AND RETROSPECTIVE ANALYSES 63

number of alcoholic symptoms experienced before the disaster by those in the

exposed group. A significant disaster effect was not observed for panic symptoms,
possibly because of the fact that the main question in the DIS that inquires about
panic symptoms precludes the possibility of having a positive symptom if the panic
was due to any known stressful event. DSM-III criteria require that the panic symp-
toms not be due to a life-threatening situation or to marked physical exertion.
No significant "report effect" was observed. The number of new symptoms
associated with any of the diagnoses reported did not seem to vary with the person's
previous experience with the instrument used (the DIS).

Impact of the disaster on

Downloaded by [ECU Libraries] at 22:40 07 January 2018

daily functioning and health

In our 1984 study, we observed that, as in other cultures, people who were in need
of psychiatric services seldom sought help in the specialized sector, but rather
consulted their general practitioners [24]. To explore this relationship, we compared
people exposed to the disaster with those not exposed in terms of their utilization of
general health services for mental health problems. The results of the univariate
analysis indicated a significantly greater use of general health services for mental
health problems among the exposed compared with the unexposed, the percentage
of the former being 21.5, and of the latter, 12.4 (P < 0.01). Nevertheless, these
findings need to be interpreted with caution since the exposed and the unexposed
may have differed in their utilization of health services before the disaster. For this
and most of the analyses reported in this section, we do not have prospective
information; it is therefore possible that any significant differences observed be-
tween the exposed and the unexposed are due to predisaster differences between the
groups. Recency and onset probes that permitted us to establish retrospectively
whether an event occurred before or after the disaster were applied only to symp-
toms.
We also analyzed the impact that a disaster of this nature had on the physical
health of its victims. Previous research had found poorer health among disaster
victims [11,25]. Our findings indicated that those exposed to the disaster reported
poor health more frequently than the unexposed (see Table 6). A prospective analy-
sis of this same variable by Robins and co-workers [12] revealed that the exposed
subjects who had reported excellent or good health before the disaster more fre-
quently showed a decline in health status than those who had not been exposed,
which lends credibility to our results. However, it should be noted that this decline
in health status was transient, subsiding within a year of the disaster.
Table 7 shows the extent to which the disaster affected the exposed and
unexposed's perception of their daily functioning at work and with relatives,
spouse, and friends. As can be seen, no differences can be observed between groups
in terms of their perception of daily functioning with the exception of feeling
overwhelmed by problems, which was more common among the exposed. One
would logically expect that because of the multiple stresses victims of catastrophes
 64 GLORISA CANINO ET AL.

Table 6

Evaluation of Health Before and After the Disaster,

Retrospective Data (N=912)
Exposed Unexposed

Health status N 0/0 N 0/0

GHsa predisaster 82 25.6 148 25.0

Excellent 123 38.4 248 42.0
Good 98 30.6 175 29.6
Poor 17 5.3 20 3.4
Downloaded by [ECU Libraries] at 22:40 07 January 2018

GHS postdisaster
Excellent 84 26.3 143 24.2
Good 101 31.6 221 37.4
Fair 111 34.7 205 34.7
Poor 24 7.5 22 3.7*

Health decline since 37 11.6 61 10.3

disaster
Limitations in activity 64 20.2 17 20.0

Note: Significant differences between groups were established by t-tests.

"GHS = General health status.
*P:50.05.

experience, they would feel more distressed and overwhelmed. However, we must
caution against assuming that this may be a true disaster effect. Robins and col-
leagues [12] studied pre- and postdisaster measures of daily functioning and found
that even before the disaster, the exposed group was already more distressed in
terms of daily functioning than the unexposed group, most likely because their
lower socioeconomic level compromised their mental health.
In spite of the fact that we had no prospective information regarding the
respondents' perception of their daily functioning, we had other objective measures
of functioning (at work and with spouse) that could be evaluated prospectively. By
analyzing the employment and marital status of the exposed and unexposed in 1984
and 1987, we were able to determine whether the disaster was related to subsequent
unemployment among the employed, or to a breakup in those married in 1984. Al-
though Table 7 shows no significant differences in unemployment between the
exposed and the unexposed, there was a clear trend for a greater percentage of the
exposed to experience marital breakup (6.5% compared with 3.7% for the unex-
posed).

Discussion

The present study is one of the few that can not only report a before and after
evaluation of the mental health of those exposed and unexposed to a major disaster
 PROSPEcrrvE AND RETROSPEcrrvE ANALYSES 65

Table 7

Interpersonal Dysfunction Associated with Exposure to Disaster,

Retrospective Data (N=912)

Interpersonal Exposed Unexposed

dysfunction N % N 0/0

At work 227 71.16 405 68.9

With friends/ 215 67.2 363 61.4

relatives
Downloaded by [ECU Libraries] at 22:40 07 January 2018

With spouse 145 84.8 301 89.1

(if married)

With children 215 93.5 398 93.2

Overwhelmed by 36 11.3 47 8.0··

problems

Note: Significant differences between groups were established by t-tests.

**P~ 0.01.

but also contrast this prospective method of assessment with a retrospective analy-
sis. Since it is possible that findings of other studies of disasters are artifacts of the
retrospective and cross-sectional designs employed, it is important to contrast the
results obtained prospectively and retrospectively. Furthermore, our study is one of
the few in which mental morbidity is ascertained by means of a diagnostic instru-
ment that provides specific psychiatric diagnosess based on DSM-III nosology and
that includes an unaffected control group.
In general, our results confirm those of other disaster studies [6,7]6 that have
reported that onset of depression, generalized anxiety, and post-traumatic stress
disorder was significantly more common among those exposed to a disaster than
among the unexposed. The increase in these stress-related disorders in the exposed
indicates that disaster stress increased the mental morbidity of this popdation, at
least when retrospectively evaluated.
Our results appear to differ from those of Robins and co-workers [12], who
reported no effects of the Times Beach disasters except for post-traumatic distress
symptoms. Methodological differences (in number of DIS interviews, time elapsed
between the disaster and the study, and definition of new symptoms) and differ-
ences in the degree of disaster exposure of the two samples may explain the discrep-
ancy. We are in the process of analyzing the two data banks (those of Puerto Rico
and St. Louis) to control for methodological differences in an attempt to explain
more adequately our apparently discrepant results.
On the other hand, in agreement with the Times Beach prospective analyses, we
were not able to identify a disaster effect on new alcoholic symptoms. New post-
 66 GLORlSA CANlNO ET AL.

traumatic stress disorder and symptoms were observed more commonly in those
exposed to the disaster when retrospectively analyzed. Although we were not able
to analyze this disorder prospectively, it was only for PTSD symptoms that Robins
and colleagues [12] were able to identify a disaster effect on those previously
interviewed, leading us to believe that possibly for this syndrome and for depression
a true disaster effect exists.
We are inclined to think that depressive and somatic symptoms are true out-
comes of disasters for various reasons. First, the disaster effect on new depressive
and somatic symptoms and disorders was confirmed retrospectively and prospec-
tively. Second, the psychiatric morbidity in terms of new depressive or somatic
symptoms could not be explained by mediating variables or known risk factors such
Downloaded by [ECU Libraries] at 22:40 07 January 2018

as sex, age, education, and previous symptoms. Third, most other similar studies
have found depressive symptoms to be common among disaster victims. This effect
has been confIrmed-independent of the nature of the disaster, the culture studied,
or the instrument used to ascertain depressive symptoms-in earthquakes in Mexico
City and Ecuador [26],1 in volcanic eruptions in Colombia [6] and the USA [7], in
floods in West Virginia [5], and in the nuclear accident at Three Mile Island [27].
In spite of our belief that depressive and somatic symptoms were affected by the
Puerto Rican disaster, we must point out that the magnitude of the effects was
small. Before controlling for the demographic variables, the difference between the
exposed and the unexposed was about 0.5 of a symptom, and after controlling for
the variables, the difference was not more than 0.2. This small difference may be
due in part to the length of the period between the floods and our field survey, or it
may simply reflect the subtlety of a disaster effect. If the effect is indeed subtle,
then a study would need a very large sample to detect it.
Our results also seem to confirm those of other investigations [11,12] in that no
difference between exposed and unexposed groups was observed with regard to
alcoholic symptoms. Thus, exposure to disasters does not seem to increase the
likelihood of emergence of new alcoholic symptoms.
Besides determining the disaster's impact on our subjects' mental health, we
considered it important to determine the extent to which it had affected their percep-
tion of their physical health and daily functioning, their utilization of health ser-
vices, and their marriage and employment. Even if the stress associated with
catastrophic events may not initially affect a person's mental health, it can have
adverse effects on his or her daily functioning and physical health and thus increase
the risk for subsequent mental health problems. Our fIndings indicated that people's
daily functioning was not affected by the disaster except for the exposed who felt
particularly overwhelmed by problems, a natural reaction to the stressful conse-
quences of the disaster. On the other hand, the exposed reported significantly poorer
health and utilized general health services more frequently for mental health prob-
lems. These findings need to be interpreted with caution since they might be related
to poorer health and greater utilization of health services among the exposed before
the disaster.
In conclusion, our data point to the fact that disasters are important stressors that
 PROSPECTIVE AND RETROSPECTIVE ANALYSES 67

affect the victims' mental functioning and morbidity. The need for primary, second-
ary, and tertiary intervention strategies is thus apparent, particularly in developing
countries, where a large proportion of the population is of low socioeconomic and
educational level, which places people at risk not only for mental disorders but for
suffering more dramatically the adverse consequences of a disaster. Our data sug-
gest the need for training mental health workers, crisis intervention counselors, and
general health practitioners in identifying the population at risk (the poor, the uned-
ucated, those with a previous psychiatric history) and undertaking specific interven-
tions for the treatment of the most common stress-induced disorders and symptoms,
i.e., post-traumatic stress disorder and somatic and depressive symptoms. Interven-
tions must take into account the potential stresses on marriage and the economic
hardships caused by unemployment. Furthermore, there is a need to consider expan-
Downloaded by [ECU Libraries] at 22:40 07 January 2018

sion of mental health and general health services since they will be utilized more
frequently by those exposed to disasters. This is of particular importance in devel-
oping countries, where the health services, particularly the specialized mental health
services, are inadequate to meet even the routine demands [26].

Acknowledgments

This research was supported by grant Ro I-MH-36230 from the National Institute of
Mental Health, Rockville, MD.
The authors gratefully acknowledge the assistance of the following for their care-
ful review of this manuscript and for their valuable contribution to the implementa-
tion of the research: Dr. Patrick Shrout, Columbia University; Dr. Julio Ribera,
Veterans Administration Hospital, San Juan, P.R.; Rafael Caraballo and Cruz Maria
Lopez, field supervisors; Jose Martinez, data analyst; and Elizabeth Pastrana, secre-
tary.

Notes

1. M.E. Medina-Mora, R. Tapia. 1. Caraveo, l. Sepulveda, & l.R. de la Fuente (1988)

Trastomos psiquiatricos en una poblaci6n de damnificados. Unpublished manuscript. In-
stituto Mexicano de Psiquiatrfa y Direcci6n General de Epidemiologia. Mexico.
2. Ibid.
3. Ibid.
4. Ibid.
5. Ibid
6. Ibid.

References

1. Canino, G., Bird, H., Shrout, P.E., Rubio-Stipec, M., Bravo, M., Martfnez, R., Ses-
man, M., & Guevara, L.M. (1987) The prevalence of specific psychiatric disorders in Puerto
Rico. Archives ofGeneral Psychiatry, 44,727.
2. American Psychiatric Association (1980) Diagnostic and statistical manual of mental
disorders (3rd ed.). Washington, DC: American Psychiatric Association.
 68 CLORISA CANINO IT AL.

3. Bolin, R. (1986) Disaster characteristics and psychosocial impact. In B.J. Sowder &
M. Lystad (Eds.), Disasters and mental health: Contemporary perspectives and innovation in
services to disaster victims. Washington, DC: American Psychiatric Press. Pp. 11-35.
4. Baum, A., & Davidson, L.M. (1986) A suggested framework for studying factors that
contribute to trauma in disaster. In B.J. Sowder & M. Lystad (Eds.), Disasters and mental
health: Contemporary perspectives and innovation in services to disaster victims. Washing-
ton, DC: American Psychiatric Press. pp. 37-47.
5. Gieser, G.c., Green, B.L., & Winget, C.N. (1981) Prolonged psychosocial effects 0/
disaster: A study at Buffalo Creek. New York: Academic Press.
6. Lima, B.R., Cruz, H.S., Lozano, 1, Luna, J., & Pai, S. (1988) La atenci6n primaria de
salud mental en las victim as del desastre de Armero, Colombia. Acta Psiquiatrica y
Psicol6gica de America Latina, 34,13.
7. Shore, 1H., Tatum, E.L., & Vollmer, W. (1986) Psychiatric reactions to disaster: The
Mount St. Helens experience. American Journal a/Psychiatry, 143, 590.
Downloaded by [ECU Libraries] at 22:40 07 January 2018

8. Bennet, G. (1970) Bristol Floods 1968. Controlled survey of effects on health of

local <.:ommunity disaster. British Medical Journal, 3, 454.
9. Logue, J.N., Hansen, H., & Struning, E. (1981) Some indications of the long-term
health effects of a natural disaster. Public Health Reports, 96, 67.
10. Robins, L.N., Helzer, J.E., Croughan, 1., & Ratcliff, K.S. (1981) The NIMH Diagnos-
tic Interview Schedule: Its history, characteristics, and validity. Archives 0/ General Psychia-
try, 38, 381.
11. Smith, E.M., Robins, L.N., Przubeck, T.R., Goldring, E., & Solomon, S. (1986)
Psychosocial consequences of a disaster. In 1. Shore & L. Robins (Eds.), Psychosocial disas-
ter stress studies: New methods and findings. Washington, DC.: American Psychiatric Press.
Pp.49-76.
12. Robins, L.N., Fischback, R.L., Smith, E.M., Cottler, L.B., & Solomon, S.D. (1986)
Impact of disaster on previously assessed mental health. In 1. Shore & L. Robins (Eds.),
Psychosocial disaster stress studies: New methods and findings. Washington, DC: American
Psychiatric Press. Pp. 21-48.
13. Kish, L. (1965) Survey sampling. New York: Wiley.
14. Robins, L.N., & Smith, E. (1983) The Diagnostic Interview Schedule Disaster Sup-
plement. St. Louis, MO: Washington University School of Medicine.
15. Rubio-Stipec, M., Shrout, P., Bird, H., Canino, G., & Bravo, M. (1989) Empirically
defined syndromes in the DIS. Journal a/Consulting and Clinical Psychology, 1(1), 30.
16. Bravo, M., Canino, G., & Bird, H. (1987) EI DIS en Espanol: Su traducci6n y
adaptaci6n en Puerto Rico. Acta Psiquidtrica y Psicol6gica de America Latina, 33,27.
17. Canino, G., Bird, H., Shrout, P.E., Rubio, M., Bravo, M., Martinez, R., Sesman, M.,
Guzman, A, Guevara, L.M., & Costas, H. (1987) The Spanish DIS: Reliability and concor-
dance with clinical diagnosis in Puerto Rico. Archives o/General Psychiatry, 44, 120.
18. Burnam, A., Kamo, M., Hough, R.L., Escobar, 1L., & Forsythe, AB. (1983) The
Spanish Diagnostic Interview Schedule: Reliability and comparison with clinical diagnosis.
Archives a/General Psychiatry, 43,1189.
19. Robins, L.N. (1985) Epidemiology: Reflections on testing the validity of psychiatric
interviews. Archives o/General Psychiatry, 42, 918.
20. Eaton, W.W., Kramer, M., Anthony, J.C., Dryman, A, Shapiro, S., & Locke, B.
(1989) The incidence of specific DIS/DSM-III mental disorders: Data from the NIMH Epide-
miologic Catchment Area Program. Acta Psychiatrica Scandinavica, 79, 163.
21. Allen, L.R., & Britt, D.W. (1983) Social class, mental health, and mental illness: The
impact of resources and feedback. In R.D. Feiner, LA. Jason, IN. Moritsugu, & S.S. Farber (Eds.),
Preventive psychology: Theory, research & practice. New York: Pergamon Press. pp. 149-61.
22. Robins, L.N., Helzer, J.E., Weissman, M.M., Orvaschel, H., Gruenberg, E., Burke,
1.D., & Regier, D.A (1984) Lifetime prevalence of specific psychiatric disorders in three
sites. Archives o/General Psychiatry, 41,949.
 PROSPECTIVE AND RETROSPECTIVE ANALYSES 69

23. Boyd, I H., Burk, I, Gruenberg, C.E., Holzer, D.S., Rae, George, L.K., Kamo, M.,
Stolzman, A., McEvoy, L., & Nestadt, G. (1984) Exclusion criteria of DSM-ill. Archives of
General Psychiatry, 41, 983.
24. Martfnez, L., Sesman, M., Bravo, M., Canino, G., & Rubio-Stipec, M. Utilizacion de
servicios de salud en Puerto Rico por personas con trastomos mentales. Acta Psiquiatrica y
Psicol6gica de America Latina. In press.
25. Melick, M.E., Logue, IN., & Frederick, I (1982) Stress and disaster. In L. Goldberg
& S. Breznitz (Eds.), Handbook of stress: Theoretical & clinical aspects. New York: The
Free Press. Pp. 613-30.
26. Lima, B.R., & Gaviria, M. (Eds.) The psychosocial consequences of disasters: The
Latin American experience. Chicago: The University ofIllinois Simon Bolivar Program.
27. Bromet, E., & Dunn, L. (1981) Mental health of mothers nine months after the Three
Mile Island accident. Urban and Social Change Review, 14(2), 12.
Downloaded by [ECU Libraries] at 22:40 07 January 2018