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 Table of Contents  
Year : 2021  |  Volume : 37  |  Issue : 4  |  Page : 388-393

Depression, anxiety, stress, and resilience among the primary survivors of natural disaster: A study with special reference to Kerala Flood

Department of Social Work, Central University of Tamil Nadu, Thiruvarur, Tamil Nadu, India

Date of Submission27-Jul-2020
Date of Decision14-Aug-2020
Date of Acceptance13-Sep-2020
Date of Web Publication25-Nov-2021

Correspondence Address:
Ms. S R Rahana
Department of Social Work, Central University of Tamil Nadu, Thiruvarur - 610 104, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijsp.ijsp_238_20

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Background: Kerala, the southernmost state in India experienced the worst flood in its history, in August 2018. The disaster led its survivors to psychological trauma, along with several other impacts. Aims: The present study assessed the mental health status and level of resilience among the primary survivors in the postdisaster phase of Kerala flood, and the possible interlinkage of demographic factors with the study variables. Materials and Methods: The study has done on a sample of 50 primary survivors of flood selected using a purposive sampling method. Two rating scales-Depression Anxiety Stress Scale-21 and brief resilience scale-were used for collecting data, along with a sociodemographic information sheet prepared by the researcher, which was administered in a face to face interview with the participants. IBM SPSS software (version 21) was used for data analysis and statistical tests such as t-test, analysis of variance, and Pearson's correlation tests were used to interpret the data. Results: Results revealed the prevalence of depression, anxiety, and stress among the survivors in the postdisaster phase. Statistically significant difference was found in depression and stress scores in terms of education, where survivors with higher education showed lower stress and depression. Results also showed a comorbidity of depression, anxiety, and stress and a negative correlation between resilience and stress scores. Conclusions: The disaster had a significant impact on the survivors' mental health and need medical interventions to address it. The educational status and resilience level of the survivors are important determinants of postdisaster mental health.

Keywords: Mental health, natural disaster, primary survivor, resilience

How to cite this article:
Rahana S R, Sam JM, Udhayakumar P. Depression, anxiety, stress, and resilience among the primary survivors of natural disaster: A study with special reference to Kerala Flood. Indian J Soc Psychiatry 2021;37:388-93

How to cite this URL:
Rahana S R, Sam JM, Udhayakumar P. Depression, anxiety, stress, and resilience among the primary survivors of natural disaster: A study with special reference to Kerala Flood. Indian J Soc Psychiatry [serial online] 2021 [cited 2022 Dec 9];37:388-93. Available from: https://www.indjsp.org/text.asp?2021/37/4/388/331124

  Introduction Top

In August 2018, Kerala, the southernmost state of India was hit by a devastating flood. Even though the geographical peculiarities of Kerala-its proximity to the sea with a coastline of nearly 600 km and presence of numerous rivers, lakes, backwaters, and estuaries-make it highly vulnerable to natural disasters, the flood that the state witnessed in 2018 was the worst ever floods in its history since the great deluge of 1924.[1]

The heavy downpour and the landslides of varying type and intensity that occurred simultaneously with that soaked almost the entire state. The disasters affected three-fourths of all villages across 14 districts in the state, ranging the impacts from temporary displacements of over 1.5 million people to deaths of about 498 people, where 15% of the total deaths constituted children.[2] The catastrophic effects of the flood, affecting every sphere of life, from destroyed crops to lost livelihood and uninhabitable shelters, in turn, led its survivors to psychological trauma.[3]

Even though the field of disaster mental health appears to have developed only recently, specifically after the 1990s,[4] the mental health issues following a disaster are being continuously reported all over the world and a wide range of studies have been done on the same.

Disasters can be varied in many respects, and the mental health impact it creates on its victims can also be varied. Studies specifically on the mental health impacts of floods are thus of much importance. Floods are the most common type of global natural disaster accountable for almost 53,000 deaths in the last decade.[5] Flooding affects people of all ages, can exacerbate or provoke mental health problems, and the majority of people may have distressing experiences immediately or longer period after the disaster.[6] The major mental health problems seen after a flood include posttraumatic stress disorder (PTSD), depression, and anxiety.[7] Various disasters that happened in India have also reported symptoms of anxiety and depression among the survivors and lower levels of psychological and physical functioning.[8] Human beings can come back from an adverse situation to normal, which is one of the basic instincts to survive. Resilience in response to natural disasters would be defined as an ability to bounce back and return to normal despite the plight and destruction as an aftermath of a disaster.[9]

The impacts of disasters on mental health can be influenced by the level of resilience of the survivors and several other demographic factors. Hence, understanding the mental well-being of disaster survivors in the postdisaster phase, including the resilience capacity of a community is of paramount importance, especially for providing immediate medical interventions for the affected, and in the long run, for appropriate policy development. In this context, the present study assessed the mental health status and level of resilience among the primary survivors in the postdisaster phase of the flood that happened in Kerala. The study looked into the possible interlinkage of demographic factors with the prevalence of depression, anxiety, and stress among the survivors, and on their level of resilience.

  Materials and Methods Top

Sample and procedure of the study

A causal comparative-design was used in the study, where the data was collected and analyzed quantitatively and variables were compared to see the effect of the independent variables on the dependent variable. The study was conducted at Pandanadu village in Alappuzha district of Kerala, one of the worst affected villages during the flood. A total of 50 primary survivors (17 males and 33 females) were included in the study using a purposive sampling method as the objective of the study was to see the effect of flood in people who were directly exposed to it. The data was collected in November 2018, two and a half months after the onset of the disaster. The researcher visited the field and administered the questionnaires in face-to-face interaction with the study participants. Informed consent was obtained from respondents who were ready to participate in the study. The people who were directly exposed to the flood were included in the study. People who are not permanent residents of the study area and who were not present there at the time of flood were excluded. Approval from the institutional ethical committee was obtained before the study.

Tools used

Two rating scales-Depression Anxiety Stress Scale and Brief Resilience Scale-were used for collecting data, along with a sociodemographic information sheet prepared by the researcher.

Depression anxiety stress scale 21

The Depression, Anxiety, and Stress Scale–21 items (DASS-21), developed by Syd Lovibond and Peter Lovibond in the year 1995, is a set of three self-report scales designed to measure the emotional states of depression, anxiety, and stress. Each of the DASS-21 scales contains seven items, divided into subscales with similar content. Scores of the depression, anxiety, and stress are calculated by summing the scores for the relevant items. The scores for each dimension have to be multiplied by two to get the final score. The score for each item in the scale range from 0 to 3. The severity labels for each scale include normal, mild, moderate, severe, and extremely severe.[10]

Brief resilience scale

It is a six-item scale used to assess the resilience developed by Smith et al. Responses for each item in the scale ranges from strongly disagree to strongly agree. The respondent gets a score of 1 for strongly disagree and 5 for strongly agree for each item. The total score can be calculated by summing the scores of each item and then dividing the total score by six. The score thus obtained can be categorized into low (1–2.99), normal (3–4.30), or high (4.31–5). The scale has adequate reliability, (α = 0.83, intraclass coefficient = 0.69) and adequate convergent, concurrent and predictive validity.[11]

Statistical analysis

Statistical analysis was carried out with IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp. Statistical tests such as t-test, analysis of variance (ANOVA), and Pearson's correlation tests were used to interpret the data.

  Results Top

[Table 1] summarizes the socio-demographic details of the study population. Sixty-six percent of the population was female (n = 33) and 34% of the population was male (n = 17). Forty percent of the population was in early adulthood (n = 20), 28% were in late adulthood and adolescents (n = 14) and middle adulthood consisted of 10% (n = 5) and 22% (n = 11) respectively. More than half of the study population (56%, n = 28) had secondary education, while 24% were graduates (n = 12). All respondents were from low or middle-income families, where 74% (n = 37) were from low-income families and 26% (n = 13) were from middle-income families.
Table 1: Sociodemographic characteristics of the respondents

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The study found the prevalence of depression, anxiety, and stress among the survivors in the postflood phase. This is summarized in [Table 2], where the percentage of various levels of depression, anxiety, and stress experienced by the participants is presented. Thirty percent of the respondents are normal in terms of depression (n = 15), while 22% are in mild (n = 11), 42% are in moderate (n = 21), and 6% are in severe levels (n = 3) of depression. Anxiety is also prevalent among survivors. While more than half of the study population was in a normal anxiety state (52%, n = 26), 6% had mild (n = 3), 30% had moderate (n = 15), and 10% had severe levels of anxiety (n = 5). One respondent (2%) reported extremely severe levels of anxiety. In the case of stress, the results showed that 58% had normal stress levels (n = 29) and 22% had mild stress (n = 11). Fourteen percent had moderate stress (n = 7), while 6% had severe levels of stress (n = 3). No one reported extremely severe levels of stress. The table also shows the resilience level of the survivors after the disaster. Forty-six percent of the study population had normal resilience level (n = 23), while 48% (n = 24) reported low level of resilience (n = 3). Six percent (n = 3) had a high level of resilience.
Table 2: The distribution of respondents in subdivisions of depression, anxiety and stress scale and resilience scale

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For further examination of the results, one-way ANOVA was carried out to find out if there is any significant difference in scores of depression, stress, anxiety, and resilience among the sample based on educational qualification. [Table 3] shows that there was a statistically significant difference in depression scores based on education (F {3, 46} =2.787, P <.05). An least significant difference (LSD) post hoc test was then carried out to find out the difference among different levels of education in terms of depression and it was found that depression scores were higher in the primary educated compared to secondary (mean difference [MD] = 4.73214, standard error [SE] = 2.29025) and graduate (MD = 5.87500, SE = 5.87500), significant at 0.05 level.
Table 3: One-way analysis of variance of depression scoresamong different levels of education

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[Table 4] shows that there was a statistically significant difference in stress scores among respondents with different levels of education (F {3, 46} =2.869, P < 0.05). An LSD post hoc test was carried out to see the difference in stress scores among various levels of education and it was found that those who were uneducated (MD = 11.66667, SE = 5.70614) and those who had only secondary education (MD = 6.80952, SE = 2.57777) had high stress scores compared to graduates, significant at 0.05 level.
Table 4: One-way analysis of variance of stress scores among different levels of education

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Pearson's correlation test was used to calculate the correlation between resilience and depression, anxiety, and stress. As expected, the results, presented in [Table 5], showed that scores of depression were positively correlated with scores of anxiety (r = 0.497, P < 0.01) and stress (r = 0.628, P < 0.01). Scores of anxiety were positively correlated with scores of stress (r = 0.644, P < 0.01).
Table 5: Correlation matrix between anxiety, depression, stress, and resilience

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Most importantly, as shown in [Table 5], the test revealed that the scores of resilience were negatively correlated with scores of stress (r = −0.409, P < 0.01), indicating that survivors with higher resilience scores are experiencing low stress.

Surprisingly, the analysis showed that there is no significant difference in scores of Depression (F {3, 46} =1.441, P > 0.05), Anxiety (F {3, 46} = 0.763, P > 0.05) Stress (F {3, 46} = 0.318, P > 0.05) and Resilience (F {3, 46} = 0.624, P > 0.05) based on the age category. Also, there was no significant difference in the scores of Depression (F {3, 46} = 0.385, P > 0.05), Anxiety (F {3, 46} = 0.937, P > 0.05) Stress (F {3, 46} = 1.443, P > 0.05) and Resilience (F {3, 46} = 1.339, P > 0.05) based on annual income of the family of the respondents.

A t-test showed that there was no significant difference in the scores of depression (t{48} = −0.909, P > 0.01), anxiety (t{48} = −0.253, P > 0.01) stress (t{48} = −0.030, P > 0.01) and resilience (t{48} = −0.317, P > 0.01) based on gender.

  Discussion Top

The current study, assessing the mental health status of Kerala flood survivors in the postdisaster phase, had arrived at four major findings. The first major finding of the present study showed that the primary survivors of the Kerala flood disaster are experiencing depression, anxiety, and stress at various levels of intensity, ranging from moderate to severe, which confirmed the findings of the study by Thomas et al.[12] Studies on the mental health outcomes of hurricane Sandy in the United States and of Uttarakhand disaster in India reported similar results, where the survivors were experiencing depression, anxiety, and PTSD in the postdisaster phase.[13],[14] Symptoms of anxiety and depression, along with lower levels of psychological and physical functioning were reported among the flood disaster survivors of northern India also.[8]

The prevalence and severity of the psychological impacts of a disaster may vary according to the nature and severity of the disaster. The flood that Kerala witnessed in 2018 affected every sphere of life, resulting in uninhabitable shelters to lost livelihood and the death of about 498 people all over the state.[1] Besides, most of the survivors were forced to move to the relief camps, often separating from the family members, and leaving their house and properties behind.[3] In this context, significant psychological impacts can certainly be anticipated, which was reflected in the results. This points towards the need for medical interventions-both immediate and long term-for addressing the mental health needs in a postdisaster phase.

The second major finding of the present study confirmed that prevalence of depression and anxiety significantly differ across survivors with different educational level, and it was found that stress was higher among illiterates and survivors with secondary education than graduates, and depression was higher among those with primary education than respondents with secondary education and graduation. These findings were similar to the results of several other studies in this regard. A study of the 2004 Indian Ocean tsunami revealed that posttraumatic stress reactivity measured 5 years after the tsunami was considerably lower among the better educated.[15] In another research among survivors of Ike hurricane, which was held after 5 months of the disaster, the results indicated that fewer years of education-a high school degree or equivalent, as opposed to some college or more years of education-were associated with a greater likelihood of depression.[16]

It is found that highly educated individuals are better aware of the disaster risk,[17] and are more likely to take on disaster preparedness.[18] The major practical implication of this finding lies in the fact that “high-risk awareness associated with education could contribute to vulnerability reduction behaviors.”[19] Several other empirical studies in this context show that highly educated individuals and societies are reported to have better preparedness and response to the disasters, suffered lower negative impacts, and can recover faster. This suggests that public investment in empowering people and enhancing human capacity through education can have a positive impact on reducing vulnerability and strengthening the ability to adapt in disaster situations.[19]

Regarding the resilience of the survivors, the study results indicated that the severity of stress was lower in persons with higher resilience. As suggested in a study conducted in Japan, the outcomes of a disaster rest on factors of resilience.[20] Several studies have proven that resilience was a substantial buffer for the mental health impacts of disasters. In a study done among the survivors of various disasters that happened in Fukushima, Japan, it was found that some survivors managed to endure the traumatic events relatively well, and resilience was a significant protective factor in dealing with such events.[21] Among the survivors of the Uttarakhand disaster in India, higher stress levels were observed among survivors of lower resilience.[22] As per the report of the International Centre for Migration and Health, the number of diagnosed cases of PTSD in India following a disaster was very few,[23] which was attributed to people's natural resilience and abilities to cope when faced by a disaster.[24]

It is important to assist individuals and communities to build and improve resilience, which is the gap that government authorities can interfere with. Several external factors can influence resilience, which includes loss of shelter, loss of livelihood, lack of food and water, financial losses, and displacement from the place of residence.[25] This is the point where the state can effectively intervene at the time of a disaster and thus can play a mediator role in determining the resilience level of individual survivors and of the community.

As expected, the scores of depression, anxiety, and stress were correlated. The comorbidity of these three psychiatric conditions, especially after a stressful event such as a disaster, was reported in several earlier studies and has important clinical implications. As pointed out in the study of Hermann and Whitman,[26] increased rate of depression was associated with increased stress, which is similar to the results of the present study. There are reports of comorbidity of depression and anxiety along with PTSD.[27] As reported in a study among the survivors of Lockerbie Disaster, depression always appeared along with PTSD, and stress and anxiety were found to be significant predictors of depression.[28]

Interestingly, the present study found no evidence on differences in the level of depression, anxiety, stress, or resilience-based on age, annual income, or gender of the study participants. These results are contradictory to several other studies that confirm the differences in the psychological impacts of disasters based on the above-mentioned factors.[29],[30] This can attribute to the specific characteristics of the study population. The study population was taken from an area where all of them belonged to either low or middle-income groups, and there were no huge differences in the economic status of the respondents. Further, the study had a disproportionate rate of male and female participants, which may influence the results of the study. Besides, as it was one of the severely affected areas in Kerala during the flood, all of the survivors were affected in similar levels of severity.

The current study is not free from limitations. First of all, the mental health status of the participants, before the onset of the disaster was not considered while analyzing the results. Therefore, it is difficult to attribute the reason for the psychological impairment of the respondents solely to the disaster. Also, as the sample is small and is taken from one of the severely affected areas during the flood (because the severity of the flood was different in different areas of Kerala), the results can't be over-generalized and cannot consider it as the situation of the whole state.

It is highly recommended for future studies in this regard to include samples from different geographical locations that are affected differently by the disaster, to have a clearer picture of the implications of a disaster on the mental health and resilience of its survivors. A sample with a more representative gender categorization and other demographical factors is crucial in understanding its effect on determining the nature and severity of the mental health impacts of disasters.

  Conclusions Top

The flood disaster in Kerala has made a significant impact on the mental health of its primary survivors. Medical interventions are needed in addressing the psychological impacts of a disaster in the postdisaster phase. Comorbidity of different psychiatric conditions should be expected after a disaster, which should be considered in clinical interventions. The educational status of the survivors can play a significant role in determining the nature and extent of the psychological impacts of a disaster. Resilience level can also be a determining factor on the same. Policy level implications should be based on the recognition that both the resilience level and educational status of survivors are two significant buffer zones in coping with the psychological impacts of disasters.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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