Post-tsunami mental health: A cross-sectional survey of the predictors of common mental disorders in South India 9–11 months after the 2004 Tsunami

O R I G I N A L A R T I C L E

Post-tsunami mental health: A cross-sectional survey of thepredictors of common mental disorders in South India 9–11months after the 2004 TsunamiChristina George1 MD, Libu Gnanaseelan Kanakamma2 MD, Jacob John1 MSW, Ginesh Sunny1 MSW,Alex Cohen3 PhD & Mary J De Silva3 PhD

1 Department of Psychiatry, Dr SMCSI Medical College, Trivandrum, Kerala, India

2 Department of Community Health, Dr SMCSI Medical College, Trivandrum, Kerala, India

3 Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK

Keywordscommon mental disorders, disaster, mental

health

CorrespondenceChristina George MD, Department of Psychiatry,

Dr SMCSI Medical College, Karakonam,

Trivandrum, Kerala 695059, India.

Tel: +914712250233

Fax: +91 04712250239

Email: [email protected]

Received 23 January 2012

Accepted 25 March 2012

DOI:10.1111/j.1758-5872.2012.00196.x

AbstractIntroduction: The Asian earthquake and subsequent tsunami of Decem-ber 2004, one of the largest natural disasters in history, resulted in thedeaths of over 250,000 people and massive destruction in eight countries.The mental health consequences of the disaster remain relatively poorlyexplored. This study sought to go beyond the dose-response paradigm toexamine the effect of pre-disaster socio-cultural variables on commonmental disorders (CMD) after the tsunami.Methods: A cross-sectional survey was conducted 9–11 months after the2004 tsunami in a low-income setting in South India to assess the asso-ciation between CMD, disaster-related losses and pre-disaster socio-cultural variables in a convenience adult sample of tsunami survivors.Results: Sixty-four percent (339) of the 532 individuals sampled andincluded in the analysis screened positive for CMD. Multivariate analysisshowed that female gender, older age, poor quality marital life before thedisaster and death of a primary family member due to the tsunami wereassociated with CMD.Discussion: A large majority of the sample in an area of South Indiascreened positive for CMD 9–11 months after the tsunami. These dataserved as an impetus in planning a long-term, five-year post-disasterintervention. Accurate longitudinal data about risk and protective factorsafter a disaster are needed to plan medium- and long-term interventions.

Introduction

The Asian earthquake and subsequent tsunami ofDecember 2004, one of the largest natural disasters inhistory, resulted in the deaths of over 250,000 peopleand massive destruction in eight countries (John et al.,2007). 10,872 individuals were reported to have losttheir lives in India (Sengupta and WHO, 2005)However, there have been few reports of the psycho-logical sequelae of the Indian Ocean tsunami. Thissurvey was part of a broader program to plan a psy-chosocial intervention for disaster survivors.

Disaster mental health has been dominated bystudies on post-traumatic stress disorder (PTSD) (Ozer

et al., 2003; Chang et al., 2005; John et al., 2007; Cairoet al., 2010). However, manifestations of distress fol-lowing a disaster may involve a broad range of reac-tions (WHO, 2007). Common mental disorders (CMD)comprise anxiety and depressive disorders. The exist-ence of these disorders in the post-disaster contexthave been demonstrated both in indigenous (Holli-field et al., 2008) as well as tourist survivors (Hussainet al., 2011) of the 2004 tsunami. Although these dis-orders are classified as separate diagnostic categories inthe International Classification of Diseases, 10th Revi-sion (ICD-10) (WHO, 1992) the term CMD is oftenused to describe them as a group because of the highlevel of comorbidity and similarities in epidemiological

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Offi cial journal of thePacifi c Rim College of Psychiatrists

Asia-Pacific Psychiatry ISSN 1758-5864

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Copyright © 2012 Blackwell Publishing Asia Pty Ltd

characteristics and treatment responsiveness (Gold-berg and Huxley, 1992; Tyrer, 2001).

There is evidence that there are high levels ofpsychopathology following disasters (Norris et al.,2002; WHO, 2007). The World Health Organization(WHO) has predicted that in the year following adisaster, 30–50% of the population will experiencesome form of psychological distress and, overall, therewould be up to a 20% increase in the prevalence ratefor mild to moderate CMD (WHO, 2007).

In a review of disaster-affected samples, Norriset al. indicated that populations from developing coun-tries showed higher levels of emotional and mentaldisorders as compared to those from developed coun-tries, with up to 50% of those experiencing naturaldisasters in developing countries suffering from clini-cally significant distress or criterion level psychopathol-ogy (Norris et al., 2002).

There is evidence that psychological distress per-sists following a disaster (Bland et al., 1996, 2005; Carret al., 1997; Salcioglu et al., 2003; Van Griensven et al.,2006; Hollifield et al., 2008). Van Griensven et al. havereported elevated levels of PTSD, anxiety and depres-sive symptoms nine months after the 2004 tsunami.Hollifield et al. have demonstrated the persistence ofpsychiatric disorders as much as 21 months after thetsunami with the prevalence of PTSD, depression andanxiety at 21%, 16% and 30%, respectively. Blandet al. demonstrated persistence of psychological dis-tress with an additional 30% prevalence of PTSD 10years following earthquake exposures in Italy.

Evidence also suggests that tourist survivors are atrisk of developing mental health problems followingexposure to a natural disaster (Johannesson et al.,2009; Kraemer et al., 2009; Hussain et al., 2011).Hussain et al. reported high levels of PTSD (36.5%)and major mood disorders (28.5%), 2.5 years follow-ing exposure to the disaster in Norwegian survivors ofthe 2004 tsunami. In another sample of Swiss touristsurvivors, 16.8% of the study population showed evi-dence of PTSD (Johannesson et al., 2009).

The dose-response paradigm has dominated thefield of disaster mental health, with research showingan association between the degree of exposure andpost-disaster psychological distress (Bland et al., 1996,2005; Carr et al., 1997; Ozer et al., 2003; Salcioglu et al.,2003; John et al., 2007; Kumar et al., 2007; Tang, 2007;Hollifield et al., 2008). Norris et al. opined that thelong-term effects of acute stressors (individual-levelaspects of exposure) on psychological distress operatethrough their effects on chronic stressors and thatthese factors have not been adequately studied. Someof the chronic risk factors predicting post-disaster psy-

chological distress include living in a highly disruptedcommunity; female gender, being single, age of 40–60years, number of traumatic experiences, and povertyand low socio-economic status (Norris et al., 2002; Sal-cioglu et al., 2003; Chang et al., 2005; Roberts et al.,2007, 2008).

This study examined the association between pre-disaster socio-cultural factors which may predispose orbuffer an individual against CMD following a disaster,exposure to the disaster as measured by disaster-related losses, and post-tsunami prevalence of CMD ina low-income setting in South India.

Methods

Design

The study was a cross-sectional survey of CMD,disaster-related losses and pre-disaster socio-culturalvariables in the coastal belt of the Kanyakumari dis-trict in Tamil Nadu, South India, 9–11 months afterthe 2004 tsunami. The study was conducted in accord-ance with the ethical principles originating in the Dec-laration of Helsinki. The study was reviewed andapproved by the institutional ethical review board.

Setting

The coastal belt of the Southern district of Kanyaku-mari in the state of Tamil Nadu, India, was severelyaffected by the 2004 tsunami (Sengupta and WHO,2005). The district is divided into nine blocks (Plan-ning Commission, 2010), of which the coastal blocksof Agastheeswaram, Rajackamangalam, Kurutham-kode and the municipality of Colachel were severelyaffected with loss of lives due to the tsunami. Of these,Colachel municipality with a population of 23,787(Census of India, 2001) sustained the highest densityloss with nearly 500 deaths. Following the tsunami,the existing public and mental health care systemswere severely overburdened.

Sample

The sample was chosen from the most severelyaffected region of the district, in the coastal blocks ofAgastheeswaram, Rajackamangalam, Kuruthamkodeand the municipality of Colachel. These blocks werechosen because of the loss of lives due to the tsunami,implying significant disaster impact. A location waschosen randomly in each of these blocks and samplingwas started from there. Non-probability sampling

C. George et al. Post-tsunami mental health

105Asia-Pacific Psychiatry 4 (2012) 104–112


technique was used to select subjects. All patients pro-vided informed consent after procedures had beenexplained and prior to enrollment. Data was collectedfrom individuals above the age of 18 years fromhouseholds and temporary shelters in the affectedarea. In the study period, information was gatheredfrom 532 individuals.

Measures

The questionnaire was administered in the local lan-guage by 30 community fieldworkers with at leasthigh school education (matric.), recruited from thetarget population. The questionnaire took on average30 minutes to complete. As well as being engaged incommunity-based developmental activities prior tothe disaster, the fieldworkers were part of the post-disaster intervention team, thereby ensuring theywere sensitive to the local cultural and context. Thesevolunteers had received up to 50 hours of training inbasic disaster mental health, including interventionsand interviewing techniques. Following this, the field-

workers attended a five-hour initial training session inadministration of the questionnaire. The training wasconducted by C.G. Over the next two weeks, as part ofcontinued training, each of the community workersadministered the instruments under the supervision ofqualified social workers, prior to collection of data forstudy purposes.

CMD was assessed using the 12-item version ofthe General Health Questionnaire (GHQ 12), whichhas been extensively used to measure CMD in differ-ent cultural settings (Goldberg and Williams, 1988;Chan, 1993; Jacob et al., 1997), including in a post-disaster context (Carr et al., 1997; Salcioglu et al.,2003). The Tamil version of the GHQ-12, which hasbeen validated for use in rural Tamil Nadu, in clinicalas well as community settings (Kuruvilla et al., 1999;John et al., 2006), was used. A cut-off of 3/4 on theGHQ to determine a screen positive case/non-case ofCMD was based on previous research involving Tamil-speaking community samples (John et al., 2006).

As per our conceptual framework (Figure 1),potential risk factors for CMD comprised socio-

Socio d hidemographic factors:Age, gender, marital status, education

Pottentialbuffering factors:Q li f i l

Preexisting sociocultural

Quality of marital relationship, family support, community support, frequency fsociocultural

factors:Religion, family structure, occupation, housing type

of prayer

housing type, chronic illness

Severity of expossure to disaster:Loss of livelihood means, loss of

Common mental dissorders

,property, loss of family member

Figure 1 Conceptual framework for analysis.

Post-tsunami mental health C. George et al.



demographic variables measured at the time of thesurvey (age, gender, marital status, education level)and pre-disaster socio-cultural variables whererespondents were asked to report longstanding factorsprior to the tsunami (occupation, type of house,family structure, religion, pre-existing chronic illness).Pre-disaster factors that may have buffered an indi-vidual against the negative impact of the tsunamicomprised the perceived quality of their marital life,support from family and community, and a marker ofreligious belief (frequency of praying). The extent oflosses due to the disaster was assessed using “yes/no”responses to the following questions: damage to prop-erty; loss of livelihood means; and loss of a primaryfamily member (defined as parents, siblings or chil-dren) as a result of the tsunami.

Analysis

Analyses were conducted using Stata version 11.0(StataCorp, College Station, TX, USA). Prevalenceestimates for CMD, socio-demographic and pre-disaster characteristics and tsunami-related losseswere calculated. Chi-square tests were used to assessthe association between individual risk factors andCMD. Multivariate logistic regression was used toselect those variables that were independent riskfactors for CMD as follows. Variables were entered inthe model in three stages. First, all socio-demographicvariables were entered, followed by all pre-disastercharacteristics, then potential buffering factors, andfinally all tsunami-related losses. Within each set ofrisk factors, Wald tests were used to assess the contri-bution of each variable to the model. The variablemaking the least significant contribution (defined asan overall Wald test P-value of 0.05) was excluded andthe model re-fitted. This process was repeated untilonly those variables that made a significant contribu-tion to the model remained. Backwards selection ofrisk factors was used as the effect of each variable in amodel depends upon the other variables in thatmodel; thus their relative importance cannot beassessed unless all other variables are included in themodel. The final model therefore contained only thosevariables that were significantly associated with CMD.

Results

Description of sample

Five hundred and thirty-three individuals wererecruited into the study with one later excluded due to

missing data (final number included in the analy-sis = 532). Table 1 describes the sample. Sixty-fourpercent (95% CI: 60–68%) (n = 339) screened posi-tive for CMD (a GHQ score of 4 and above). Fifty-seven percent of the sample were women and themean age was 39.2 years (SD = 13.4, range 18–85).Eighty-six percent were still married after the tsunamiand nearly one-fifth were illiterate.

Before the tsunami, 69% reported that they livedin nuclear family structures, the vast majority (88%)were Catholic, and over one-third reported sufferingfrom a chronic illness. Levels of potential bufferingfactors were reported to be high before the tsunamiwith roughly three-quarters of the population report-ing that the quality of their marital life was high, thatfamily support was good, and that their communityhelps one another in times of need.

Nearly all respondents (93%) reported impair-ment in their means of livelihood as a result of thedisaster, while over half reported destruction of prop-erty. Eight percent had lost a primary family memberdue to the disaster.

Risk factors for CMD

Table 1 reports the results of the bivariate associationbetween CMD and each potential risk factor. Womenwere more likely to suffer from CMD than men(P = 0.03). Age was significantly associated with CMD,with individuals aged younger than 30 years being lesslikely to suffer from CMD in comparison with otherage groups (P = <0.001). No other socio-demographicvariables were associated with CMD. In addition, nopre-disaster socio-cultural variables were significantlyassociated with risk of CMD post-tsunami. Pre-tsunami, a high-quality marital life was associatedwith reduced risk of CMD, but no other potentiallybuffering factors were significant. In terms of tsunami-related losses, only the loss of a primary familymember was associated with increased risk of CMD.

These results were mirrored in the results of themultivariate logistic regression (Table 2), with gender,age, quality of marital life and loss of a primary familymember the only variables which showed an inde-pendent significant association with CMD. Womenhad odds nearly two times greater than men of havingCMD (OR 1.86, 95% CI 1.26, 2.75), while those agedabove 30 had roughly two times greater odds of suf-fering from CMD than those younger than 30 years.Having a low-quality marital relationship before thetsunami was associated with more than double theodds of suffering from CMD post-tsunami (OR 2.45,95% CI 1.18, 5.). The strongest risk factor for CMD




Table 1. Association between common mental disorders (CMD) and demographic and socio-cultural variables and disaster-related loss

CMD case (GHQ � 4) Non-case (GHQ � 3) Total

P-value

n = 339 (64%) n = 193 (36%) n = 532 (100%)

n (%) n (%) n (%)

Socio-demographic characteristic

Gender

Male 134 (40) 95 (49) 229 (43) 0.03

Female 205 (60) 98 (51) 303 (57)

Age group, years

<30 73 (22) 73 (38) 146 (27) <0.001

30–39 93 (27) 44 (23) 137 (26)

40–49 98 (29) 35 (18) 133 (25)

50+ 75 (22) 41 (21) 116 (22)

Marital status

Married 296 (88) 162 (84) 458 (86) 0.078

Widowed/separated/divorced 13 (4) 4 (2) 17 (3)

Single 27 (8) 26 (14) 53 (10)

Missing 4 (1)

Education level

Illiterate 64 (19) 33 (17) 97 (18) 0.869

Up to grade 9 213 (63) 123 (64) 336 (63)

Grade 10–college 62 (18) 37 (19) 99 (19)

Pre-disaster characteristics

Occupation†

Yes 155 (46) 99 (51) 254 (48) 0.216

No 184 (54) 94 (49) 278 (52)

Type of house

Katcha/tin roof 115 (34) 70 (36) 185 (35) 0.858

Concrete 114 (34) 62 (32) 176 (33)

Tiled 110 (32) 61 (32) 171 (32)

Family structure

Nuclear 239 (71) 127 (66) 366 (69) 0.261

Joint 100 (29) 66 (34) 166 (31)

Religion

Christian 297 (88) 171 (89) 468 (88) 0.736

Other 42 (12) 22 (11) 64 (12)

Chronic illness

Yes 135 (40) 64 (33) 199 (37) 0.127

No 204 (60) 129 (67) 333 (63)

Pre-disaster potential buffering factors

Quality of marital life

High 254 (75) 152 (79) 406 (76) 0.015

Low 43 (13) 10 (5) 53 (10)

N/A (not married) 42 (12) 31 (16) 73 (14)

Quality of family support

Good 261 (77) 152 (79) 413 (78) 0.638

Poor 78 (23) 41 (21) 119 (22)

Community help in times of need

Yes 239 (71) 142 (74) 381 (72) 0.450

No 100 (29) 51 (26) 151 (28)

Frequency of prayer

Monthly/weekly 122 (36) 58 (30) 180 (34) 0.164

Daily 217 (64) 135 (70) 352 (66)

Tsunami-related losses

Loss of livelihood

No 26 (8) 12 (6) 38 (7) 0.532

Yes 313 (92) 181 (94) 494 (93)

Loss of property

No 147 (43) 77 (40) 224 (42) 0.436

Yes 192 (57) 116 (60) 308 (58)

Loss of primary family member

No 299 (88) 190 (98) 489 (92) <0.001

Yes 40 (12) 3 (2) 43 (8)

One observation was dropped due to missing data on loss of life, n = 532 not 533.†There was large number of respondents without an occupation because many women were homemakers and this was classified as no occupation.GHQ, General Health Questionnaire.




was suffering the loss of a primary family member,with those suffering such a loss having more thanseven times the odds of suffering from CMD thanthose who did not (OR 7.41, 95% CI 2.23, 24.68).

Discussion

This study was set in the aftermath of the tsunami andexamined the risk factors for CMD following the dis-aster, including pre-disaster characteristics which maypredispose individuals to CMD following a disaster, ormay help to buffer them against its negative effects.

The prevalence of CMD 9–11 months after thedisaster was 64%. While this figure is high, otherstudies have also predicted very high levels of psycho-logical distress following a natural disaster. Estimatesfrom WHO indicate that up to 50% of the populationmay experience psychological distress, with an addi-tional increase in the one-year prevalence rates to20% for mild to moderate CMD (WHO, 2007). Thesepredictions are confirmed by recently publishedresearch indicating the persistence of psychologicalsymptoms in the aftermath of a disaster (Bland et al.,1996, 2005; Carr et al., 1997; Salcioglu et al., 2003; VanGriensven et al., 2006; Hollifield et al., 2008). Forexample, 50% of the population surveyed in post-conflict Sudan met the symptom criteria for depres-sion (Roberts et al., 2007) compared with 67% of asurvey of internally displaced persons in Uganda(Roberts et al., 2008).

The bulk of the literature in disaster mental healthhas involved trauma-focused data (Bland et al., 1996,2005; Carr et al., 1997; Ozer et al., 2003; Salciogluet al., 2003; John et al., 2007; Hollifield et al., 2008).The present study goes further to explore the associa-tion between the pre-disaster socio-cultural back-grounds of individuals exposed to the disaster andCMD. Other research has indicated that the long-termeffects of acute stressors on CMD operate throughtheir effects on chronic adversities for adults (Norriset al., 2002; Roberts et al., 2007, 2008; Cairo et al.,2010). This study has examined the relationshipbetween CMD in the post-disaster context and someof these risk factors, such as gender, marital status, ageand socio-economic status. This study indicated olderage and being female are risk factors, but no othersocio-demographic characteristics. As older age andfemale gender are risk factors for CMD across varyingsettings (Patel et al., 1997, 1999), these findings maynot be specific to disaster survivors. We speculate thatmiddle aged and older individuals may have beenrelatively more distressed due to them bearing thegreatest levels of responsibility whereas youngerpeople may have been more likely to feel that they canrebuild their lives (Hussain et al., 2011).

Previous research has demonstrated an associa-tion between event-related variables, such as disrup-tion and severity of exposure and increasedpsychological impairment (Bland et al., 1996, 2005;Carr et al., 1997; Ozer et al., 2003; Salcioglu et al.,2003; John et al., 2007; Kumar et al., 2007; Tang,2007; Hollifield et al., 2008). In this sample, post-disaster adversities were common with almost allrespondents having lost some livelihood means, 58%having lost property and 8% having lost a primaryfamily member. However, in contrast to other studiesshowing disaster-related damage predicts psychologi-cal outcomes (Bland et al., 1996, 2005; John et al.,2007; Kumar et al., 2007; Tang, 2007) only the loss ofa primary family member was associated with CMD inthe analysis. This may largely be due to the yes/noresponse to these questions, which did not record theextent of losses due to the disaster. An additionalexplanation is that in a context where so many havelost so much, losing property or livelihood in them-selves are not predictive of CMD, as so many othershave experienced the same losses.

In the analysis, only quality of marital relationswas associated with CMD. This may be because thepopulation under study was largely from the fishingcommunity with high levels of community embedded-ness (Subramanian, 2003) and with a tradition offorming early and relatively stable marital dyads, a

Table 2. Logistic regression for factors associated with common mental

disorders (CMD) (GHQ � 4) in tsunami survivors in South India†

OR 95% CI P-value

Pre-disaster socio-demographic characteristics

Gender

Male 1.00

Female 1.86 1.26, 2.75 0.002

Age, years

<30 1.00

30–39 2.09 1.24, 3.53 0.006

40–49 2.73 1.58, 4.70 <0.001

50+ 1.87 1.09, 3.21 0.024

Pre-disaster potential buffering factors

Quality of marital life

High 1.00

Low 2.45 1.18, 5.27 0.017

N/A (not married) 1.12 0.64, 1.97 0.686

Tsunami-related losses

Loss of primary family member

No 1.00

Yes 7.41 2.23, 24.68 0.001

†n = 532, variables which made a significant contribution to the model.

GHQ, General Health Questionnaire.




social structure which may have afforded some protec-tion from the psychological consequences of the disas-ter. The lack of an association between community andfamily support may be due to the communal impact ofthe tsunami whereby whole communities wereaffected leaving traditional coping mechanisms, such asfamily and community support structures, unable todeal with the impact of the disaster.

Methodological limitations

The survey was cross-sectional, and while we canimpose a theoretical conceptual framework of howvariables may inter-relate on our analysis, it is notpossible to determine the direction of causality.Second, respondents were drawn from a conveniencesample due to the constraints of a non-governmentalorganization working in a post-disaster setting. Thismay help explain the high prevalence of CMD as it islikely that the interviewers (who were also working inthe disaster relief effort) came into contact with themost severely affected portions of the communitywho, therefore, were more likely to suffer from CMD.Therefore, generalizability of findings to less severelyaffected populations may be limited. Third, recall biascould have been introduced in the measurement ofpre-disaster variables with an individual’s experienceof the disaster, affecting how they reported character-istics of their life before the tsunami. Also, the relativelack of association with risk factors in this analysis maybe due to these questions actually measuring back-ground socio-demographic characteristics rather thanmore immediate concerns, such as access to food,shelter and sanitation. The sample is homogenous interms of socio-demographic profile, as those stillremaining in temporary shelters (often very close totheir original home) 9–11 months post-disaster aremore likely to be from more disadvantaged popula-tions, this lack of diversity further explaining the lackof association of CMD with variables such as educationand employment. Finally, the questions measuringtsunami-related losses were limited to physical lossesonly and were not discriminatory in terms of theextent of those losses. Aspects of actual exposure tothe trauma and psychological reaction during thetrauma itself were not a focus of study, a furtherlimitation of the study given the evidence that disasterexposure could also determine post-disaster mentalhealth outcomes. Aspects of disaster exposure andpsychological reactions during the disaster were notcollected as there were no easily accessible facilities forexpert intervention in the community in the event ofre-traumatization during interviewing.

Conclusion

Indications that socio-demographic characteristicsmay affect an individual’s risk of developing CMDafter a disaster suggests that it may be worthwhile tobriefly measure these variables when conducting anassessment of the mental health needs of individualsfollowing a disaster as they may assist in identifyingindividuals needing possible targeted prolonged inter-ventions. The consistent finding from this and otherstudies that women are more prone to psychologicaldistress following disasters and that the baseline levelsof CMD are higher in women indicates that post-disaster interventions should specifically target theneeds of women. The associations of CMD withmarital disharmony and middle age even in the post-disaster context is not surprising in this communitywith high levels of value attached to forming stablemarital dyads, and its emphasis on responsibility to thefamily. This highlights the need for an understandingof longstanding locally relevant issues in the aftermathof a disaster, to ensure that mental health interven-tions are culturally appropriate.

This investigation showing persistently high levelsof CMD one year after the disaster served as animpetus to continue the intervention for 5 years in thearea, ensuring that medium and long-term distresswere addressed as per WHO recommendations (Sen-gupta and WHO, 2005) The ongoing bio-psychosocialintervention in the area undertaken by the maininvestigator (CG) and the mental health team at Dr.SMCSI Medical College, with the support of CBMInternational, though initiated in the post-disaster sce-nario, has led to the development of a community-focused mental health program (Cohen et al., 2011).The development of mental health systems has beendescribed in other developing countries in the post-tsunami context (Prasetiyawan et al., 2006). Accuratelongitudinal data about locally relevant risk and pro-tective factors after a disaster is needed to plan cultur-ally sensitive and contextually appropriate mediumand long-term interventions that may enhance thelong-term impact of the intervention.

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Post-tsunami mental health: A cross-sectional survey of the predictors of common mental disorders in South India 9–11 months after the 2004 Tsunami