Posttraumatic stress disorder following the 2008 Wenchuan earthquake: A 10-year systematic review among highly exposed populations in China

Journal of Affective Disorders 243 (2019) 327–339

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Review article

Posttraumatic stress disorder following the 2008 Wenchuan earthquake: A 10-year systematic review among highly exposed populations in China Liang Yiminga,b, Cheng Jina,b, Ruzek Josef I.c, Liu Zhengkuia,b,

T

⁎

a

CAS Key Laboratory of Mental Health, Institute of Psychology, Beijing, China Department of Psychology, University of Chinese Academy of Sciences, Beijing, China c Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, USA b

A R T I C LE I N FO

A B S T R A C T

Keywords: Wenchuan earthquake 5.12 PTSD Prevalence China

Background: The 2008 Wenchuan earthquake was unprecedented in Chinese history both in terms of the magnitude of the quake itself and the scale of human suffering. Following the disaster, researchers reported on a wide range of mental health outcomes, especially posttraumatic stress disorder (PTSD). In this review, we assess the cumulative body of research evidence about PTSD across the first 10 years following the earthquake. Methods: We searched the literature in the PubMed, Web of Science, and China National Knowledge Infrastructure (CNKI) databases (from May 2008 to February 2018) using Wenchuan earthquake and PTSD as keywords. Results: We selected 58 relevant studies. Published findings from the selected period suggested a substantial burden of PTSD on highly exposed survivors. Studies have found that symptoms of PTSD have been associated with a range of risk factors, including sociodemographic factors, trauma exposure characteristics, post-disaster cognitive and emotional states, and social support. Studies have explored the factor structure of PTSD in the affected Chinese population, and researchers have developed a Chinese self-report measure of PTSD symptoms. Several treatments for PTSD have been evaluated, including some indigenous intervention methods. Limitations: Only a relatively small number of the studies used longitudinal assessments, and the consistency and effectiveness of measurement tools for PTSD require further exploration. More rigorous investigations of the effectiveness of interventions for the prevention and treatment of PTSD are needed. Conclusion: The 10-year body of literature is important for the future deployment of disaster relief and an increased understanding of PTSD in China.

1. Introduction Exposure to disaster has been shown to cause general distress as well as a range of psychological symptoms, including fear and anxiety, recurring disturbing intrusive memories, and depression. These symptoms can severely impair the affected individuals’ psychosocial functioning and quality of life (McMillan et al., 2017). Although the consequences of disasters may include a wide range of psychopathologies (Norris et al., 2002), posttraumatic stress disorder (PTSD) is an especially problematic disorder that is directly related to disaster-related traumatization (American Psychiatric Association [APA], 2013). PTSD is a maladaptive, disabling reaction caused by unusual threats or catastrophic events, and it has been regarded as the most commonly studied disorder after disasters (Lowell et al., 2018; Neria et al., 2008). In 1980, the American Psychiatric Association first officially added

PTSD to the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; APA, 1980). After several versions of the modification, the fifth edition (DSM-5), which is the most recent edition, was published (APA, 2013). The DSM-5 incorporates several significant modifications to the diagnostic criteria for PTSD that provide better coverage of trauma-related clinical presentations and maintain backward compatibility with the PTSD criteria from former editions (Weathers, 2017). However, to date, it remains unclear how the modifications to the organization and definition of PTSD symptoms may impact the latent structure of PTSD; the rationality and effectiveness of this version are still under discussion (Wang et al., 2015; Weathers, 2017). Therefore, the diagnostic criteria for PTSD following all types of traumatic events, including natural disasters, warrant further exploration. On May 12, 2008, an earthquake with a magnitude of 8.0 on the

⁎ Corresponding author at: Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, 16 Lincui Road, Chaoyang District, Beijing 100101, China. E-mail address: [email protected] (Z. Liu).

https://doi.org/10.1016/j.jad.2018.09.047 Received 29 May 2018; Received in revised form 27 August 2018; Accepted 15 September 2018 Available online 17 September 2018 0165-0327/ © 2018 Elsevier B.V. All rights reserved.

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which was a hard hit disaster area. Three months after the earthquake, the prevalence rates of suspected PTSD were 47.3% in Beichuan County and Dujiangyan City (hardest hit areas) and 10.4% (93 of 898) in Langzhong County (harder hit area) and Yaan County (hard hit area; Kun et al., 2013). One year later, several studies reported PTSD prevalence estimates ranging from 21.5% to 41.0% among survivors in different areas (Cheng et al., 2015; Xu and Song, 2011; Zhang et al., 2011b). Taken together, these studies presented initial evidence that a wide range of survivors suffered from PTSD after the Wenchuan earthquake. Many studies following the Wenchuan earthquake have explored the risk factors for PTSD, which were important for practical assessments to identify vulnerable populations (Kun et al., 2013; Wang et al., 2011c). Most researchers used self-report questionnaires to assess PTSD after the disaster because there were a large number of potential victims (Guo et al., 2017; Xu and Song, 2011). However, different researchers using the same assessment measures might choose a different cut-off criterion to determine PTSD status (e.g., Zhao et al., 2009; Xu and Song, 2011; Wen et al., 2012), so the consistency of the measurements must be discussed. In addition, most PTSD assessment instruments were translated from an English version that may not be fully applicable to the Chinese population (Wu et al., 2008). Thus, methods for assessing PTSD in Chinese cultures need be developed. The efficacy of psychological interventions is also worth noting because treatments play a crucial role in PTSD remission and recovery. The effectiveness of some traditional psychological interventions was verified after the disaster (Chen et al., 2014; Zang et al., 2013), and some interventions based on Chinese culture were also attempted (Zhu et al., 2014; Zhang et al., 2011a). In the past decade, many studies have focused on PTSD following the 2008 Wenchuan earthquake. The objective of this review is to systematically assess the prevalence of PTSD after the Wenchuan earthquake and to review the progress in understanding PTSD after the earthquake. Below, we review the body of research literature generated in the first 10 years following the Wenchuan earthquake, focusing on epidemiology, risk factors associated with PTSD symptomatology, the factor structure of PTSD in the affected Chinese population, the usage of assessments for PTSD in China, and outcome studies of treatments for PTSD.

Fig. 1. The location of areas most strongly affected after the earthquake. Table 1 Affected ranks of sampling areas.

Counties

Hardest hit areas

Harder hit areas

Hard hit areas

Wenchuan, Beichuan, Mao, Qingchuan, An, and Pingwu

Dayi

County: Qingshen

Baoji and Langzhong

Towns: Yongxing and Yongan Districts: Shuangliu and Xindu

(Towns) Cities

Mianzhu, Dujiangyan, Shifang, and Peng

(Districts)

Note: The information was retrieved from http://news.sohu.com/s2008/ wenchuanshangwang/. Mianzhu is a county-level city, so it was also called Mianzhu County in some articles.

Richter scale and a maximum intensity of 11.0 in the epicenter occurred in Sichuan Province in Southwest China. This earthquake was named after the epicenter of Wenchuan County. The Wenchuan earthquake was the most destructive earthquake since the founding of the People's Republic of China in 1949 and the deadliest since the 1976 Tangshan earthquake. According to a report issued by the Chinese Ministry of Civil Affairs in 2008, 69,227 people were killed, 374,643 were injured, another 17,923 were listed as missing, and approximately 4.8 million were left homeless as a result of the Wenchuan earthquake. China News reported that the Ministry of Civil Affairs categorized the areas affected by the Wenchuan earthquake into 3 levels (hard, harder, and hardest hit) based on the extent of destruction and/or death (Wei, 2008). The locations of the areas most affected after the earthquake are indicated in Fig. 1. In most selected articles, the samples were from the hardest hit areas, but some studies included samples from harder hit areas or hard hit areas. The affected levels of sampling areas from selected articles are listed in Table 1. Earthquakes are among the most destructive and frequent natural disasters, causing many deaths and injuries throughout human history. Survivors of earthquakes often suffer from long-lasting panic and mental problems, including PTSD (Neria et al., 2008). The combined incidence of PTSD after earthquakes was reported to be 23.66% in a recent meta-analysis (Dai et al., 2016), indicating that earthquakes cause tremendous psychological stress for survivors. Immediately following the Wenchuan earthquake, some studies found widespread PTSD symptoms among different populations. One month after the Wenchuan earthquake, the estimated initial prevalence of PTSD was 62.8% among 409 survivors in Qingchuan County, which was one of the hardest hit areas most severely affected by the earthquake (Wang et al., 2011c). Lau et al. (2010) conducted a cross-sectional survey one month after the earthquake and found that the PTSD prevalence rate was 22.3% among 3324 secondary school students living in Chengdu,

2. Method Using a multistep procedure, we collected scientific articles for review that were published between May 2008 (immediately following the Wenchuan earthquake) and February 2018. First, we conducted a search for peer-reviewed literature published from May 2008 to February 2018 in the electronic databases of PubMed, Web of Science, and China National Knowledge Infrastructure (CNKI). Articles were included for initial review if they included (a) a keyword related to the Wenchuan earthquake or the Sichuan earthquake, as Wenchuan is located in Sichuan province, China and (b) keywords related to PTSD, including posttraumatic stress disorder and PTSD. To ensure the quality of these studies, we included articles from the Sciences Citation Index, Social Sciences Citation Index, Chinese Science Citation Database and Chinese Social Sciences Citation Index. This initial search generated a total of 192 articles, of which 130 were published in English, and 62 were in Chinese. We next limited the articles according to the topics we wanted to discuss in this review, including the prevalence of PTSD and its risk factors, factor structure, assessment and treatment. Articles focusing on the biology of PTSD were excluded, as were case studies and review articles. Studies that focused on other psychiatric disorders (e.g., depression and generalized anxiety disorder) were also excluded from this review. In addition, some studies were excluded that focused on special populations, such as elderly people, the disabled or parents who lost their children. Eighty-seven articles met the standards for full-text 328

Journal of Affective Disorders 243 (2019) 327–339

Y. Liang et al.

Weathers et al., 1993]), cut-off criterion (because different studies used different cut-off criteria for the same instrument) and risk factors for PTSD found in each study. 3.1. Community studies We identified fifteen original community studies on PTSD conducted from 1 month to 96 months following the earthquake. All were cross-sectional in nature; one included repeated assessments. 3.1.1. Prevalence One month after the Wenchuan earthquake, the estimate of the initial PTSD prevalence rate in Qingchuan County was 62.8% (Wang et al., 2011c). One to two months after the earthquake, the prevalence rate in the city of Mianzhu was 86.2% (Zhang and Ho, 2011). Two months after the earthquake, the PTSD prevalence rate was estimated at 43.0% in Mianzhu County (Wang et al., 2009) and 12.4% in An County and Hongbai town of Shifang (Zhao et al., 2009). Three months after the earthquake, the PTSD prevalence rate was 45.5% (203 of 426) in Beichuan County (the hardest hit area) and 9.4% (52 of 556) in Langzhong County (a harder hit disaster area; Kun et al., 2009). Another study found a similar prevalence rate three months following the earthquake: rates of suspected PTSD were 47.3% (436 of 992 individuals studied) in Beichuan County and Dujiangyan City (the hardest hit area) and 10.4% (93 of 898 individuals studied) in Yaan County and Langzhong County (moderately hit area; Kun et al., 2013). Six months after the earthquake, the PTSD prevalence rate was 15.6% (Zhou et al., 2013). One year later, several studies reported that PTSD prevalence estimates ranged from 21.5% to 41.0% (Cheng et al., 2015; Xu and Song, 2011; Zhang et al., 2011b). Three years later, prevalence rates of PTSD were reported by 10.3% of the respondents from two severely affected villages (Zhang et al., 2015b). Another study found that the PTSD prevalence rate was 8.8% in the severely affected areas and 0.5% in the less severely affected areas three years after the earthquake (Wen et al., 2012). Five years later, the prevalence of PTSD among survivors was 9.2% in the town of Leigu in Beichuan County (Zhang et al, 2015). Eight years later, prevalence of PTSD was reported by 11.8% of the respondents from two severely damaged townships (Guo et al., 2017). A cross-sectional assessment repeated at several time points found a similar trend in the change of the PTSD prevalence rate: the prevalence of PTSD was 58.2% at 2 months, 22.1% at 8 months, 19.8% at 14 months, 19.0% at 26 months, and 8.0% at approximately 44 months after the earthquake (Guo et al., 2014). In summary, as time passed, the PTSD prevalence among survivors in the affected areas steadily dropped.

Fig. 2. Flow chart of study selection.

assessment. Since the sampling site, time and diagnostic criteria for clinical interviews as well as scale cut-offs are important for the estimation of prevalence rates, we developed three criteria for determining the articles’ estimated prevalence rates of PTSD. Some articles used the same sample, and we only included one of any such articles. Finally, we identified 58 peer-reviewed articles on PTSD following the Wenchuan earthquake that have been published since 2008. We classified these studies in the following way: (a) the prevalence rate of PTSD and risk factors (n = 45), (b) the factor structure of PTSD (n = 3), (c) method of PTSD assessment (n = 1) or (d) treatment of PTSD (n = 9). The selection process for these studies is shown in Fig. 2. 3. Epidemiology of PTSD following the Wenchuan earthquake Most of the studies on PTSD following the Wenchuan earthquake used the term prevalence rather than incidence. Prevalence has been defined as the percentage of old and new cases of a disease in the general population at a given time (Jekel et al., 2007, pp. 23–24), and incidence has been defined as the frequency of new cases of a disease in a certain range of people within a certain period of time (Last and Association, 2001, p. 145). Because the exposure duration was brief, and most studies did not measure previous history of PTSD among survivors, we have opted to use the term prevalence throughout this review. Notably, many of these studies were conducted using symptom checklists. Hence, using these self-report assessments without clinical interviews to detect probable PTSD might have elevated the reported prevalence rates. Our search identified 45 peer-reviewed articles on the prevalence of PTSD. We classified these studies as either (a) community studies (n = 15) or (b) studies of specific populations (n = 30), including medical rescue workers (n = 5), rescue officers and soldiers (n = 7), and children and adolescents (n = 18). In the 45 peer-reviewed articles, only five were longitudinal studies. Four of them surveyed children and adolescents, and one surveyed rescue workers and soldiers. Descriptions and results of these studies are presented in Table 2. The table is sectioned according to the population classification described above and provides a summary of each article, including the source, survey time, location of data collection, sample size, study design (i.e., cross-sectional or longitudinal), PTSD prevalence estimate, assessment instrument used (e.g., Structured Clinical Interview for DSM-IV [SCID; First et al., 1995], Impact of Event Scale-Revised Scale [IES-R; Weiss and Marmar, 1996], or PTSD Symptom Checklist [PCL;

3.1.2. Risk factors Studies conducted across the 10 year period found that many factors significantly increased the risk of PTSD, including demographic variables such as being female, a lower education level, being married, and being middle aged or elderly (Wang et al., 2009; Zhang et al., 2015b; Zhang and Ho, 2011; Zhang et al., 2011b); and characteristics of disaster exposure included the experiences of being buried, being injured in the earthquake, witnessing death and facing bereavement (Wen et al., 2012; Zhang et al., 2011b; Zhao et al.,2009; Zhou et al., 2013). The initial level of fear experienced during the earthquake and feelings of guilt were also associated with PTSD (Xu and Song, 2011; Zhang et al., 2015b; Zhang et al., 2011b). Low social support was related to the likelihood of developing PTSD (Xu and Song, 2011; Zhao et al.,2009). In addition, post-earthquake traumatic experience was found to be associated with PTSD (Guo et al., 2017). 3.2. Specific populations We identified 30 studies of specific populations, including medical rescue workers, rescue officers/soldiers and children/adolescents. Of 329

Time (month)

Place

1–2

2

2

3

3

6

12

12

12

36

Zhang and Ho, 2011

Wang et al., 2009

Zhao et al., 2009

Kun et al., 2009

Kun et al., 2013

Zhou et al., 2013

330

Xu and Song, 2011

Zhang et al., 2011b

Cheng et al., 2015

Zhang et al., 2015b

Two severely affected villages

Yongxing settlement in Mianyang

Beichuan County

19 severely affected counties

Dujiangyan, Beichuan County and Qingchuan County

Beichuan County and Dujiangyan vs. Yaan County and Langzhong County

Beichuan County vs. Langzhong County

An County and Hongbai Town of Shifang City

Mianzhu

Mianzhu

Community or general population Wang et al., 2011c 1 Qiaozhuang Town in Qingchuan County

Source

1890

(≥15 year) Whole

Adult

Adult

(≥15 year)

Whole

360

182

1181

2080

(≥15 year) Whole

(38.24 ± 8.82)

14207

Whole

(≥15 year)

1002

785

228

956

409

Sample size

Whole

(>11 year)

Whole

(≥15 year)

Whole

(≥15 year)

Whole

Adult

Population

Table 2 Journal articles focusing on PTSD prevalence among populations highly exposed to the Wenchuan earthquake.

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Study Design

10.3

39.6

41.0 26.3

vs.

21.5

vs. 10.4 15.6

47.3

45.5 vs. 9.4

12.4

43.0

86.2

62.8

PTSD Prevalence (%)

Total ≥50 (score on 1–5)

DSM-IV PCL-C

Total ≥44 (score on 1–5) SCID-I/NP

PCL-C

Total ≥50 (score on 1–5) vs. DSM-IV

DSM-IV PCL-C

SCID-I/P

DSM-IV

DSM-IV HTQ

total ≥44 (score on 1–5) HTQ

total ≥33 (score on 0–4) PCL-C

total ≥33 (score on 0–4) IES-R

total ≥50 (score on 1–5) IES-R

PTSD-SS

PTSD Instrument And cut-off

(continued on next page)

Female gender, having felt guilt

Older age, bereaved survivors and receipt of government financial support

Female gender, middle-aged and elderly people, bodily injury, loss of livelihood and initial fear during

Female gender, low education level, young people, Han nationality, low monthly income, low social support, feeling fear during the earthquake

Female gender, older age, living alone, buried or injured in the earthquake, operated on after the earthquake, witnessing someone injured or buried or die in the earthquake

Female gender, older age, unmarried/divorced/ widowed, no household income, ethnic minority, death of family member and damaged household

No household income, living in shelters or temporary houses, with damaged households, experiencing a death in the family

Female gender, experience of being buried, loss relatives, low social support

Female gender, lower educational level, being bereaved, and witnessing death

Female gender, married status, middle age, high trauma exposure level and negative emotions in Type-D personality

Female gender, married status, low education level, having deaths or injury of family, losses of possessions

Risk factors for PTSD

Y. Liang et al.

Journal of Affective Disorders 243 (2019) 327–339

36

60

96

2,8,14,26,44

Wen et al., 2012

Zhang et al., 2015a

Guo et al., 2017

Guo et al., 2014

331

14–17

14

24

Schenk et al., 2017

Xie et al., 2011

Yin et al., 2013

3

6

Liao et al., 2010

Gu et al., 2011

Rescue officers and soldiers Wu et al., 2012 1

6–12

Zhen et al., 2012

Medical rescue workers Wang et al., 2010 3

Time (month)

Source

Table 2 (continued)

Rescue cadets

Rescue troops

The first line of rescue troops to Wenchuan.

Entered severely afflicted area in 24 h

Rescue troops

Health care workers

Medical rescue workers

Medical rescue workers

China Red Cross disaster relief nurses

Health care workers

Adult

Adult

Adult

(≥15 year)

Whole

Population

The earliest time soldiers entered the Beichuan County

Mianzhu

Shifang, Mianzhu, Beichuan, Anxian, Dujiangyan, Qingchuan

Database of Wenchuan earthquake medical rescue workers

Mianzhu County and Shifang County

Yongan and Guangji township

Yongan and Guangji township

Leigu Town of Beichuan County

Wenchuan, Shifang, and Mianzhu vs. Shuangliu, Xindu, and Qingshen

Place

1024

116

1267

233

307

337

210

343

1066, 1344, 1210, 1174 and 1281

1369

684

2525

Sample size

Cross-sectional

Cross-sectional

Intervention study

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

3.4

4.3

8.4

1.7

2.3

17.0

30.0

19.3

58.2, 22.1, 19.8, 19.0 and 8.0

Repeated Crosssectional

Cross-sectional

11.8

9.2

8.8 vs. 0.5

PTSD Prevalence (%)

Cross-sectional

Cross-sectional

Cross-sectional

Study Design

DSM-IV

DSM-IV PTSD Symptoms Self rating Scale DSM-IV SCID-I/P

SI-PTSD

total ≥50 (score on 1–5)

DSM-IV PCL-C

total ≥33 (score on 0–4) PTSD7 & MINI

total ≥25 (score on 0–3) IES-R

total ≥33 (score on 0–4) TSSC

IES-R

mean score ≥2.0 (score on 0–1–3–5)

mean score ≥2.0 (score on 0–1–3–5) IES-R

total ≥50 (score on 1–5) IES-R

total ≥38 (score on 1–5) PCL-C

PCL-C

PTSD Instrument And cut-off

(continued on next page)

Body-disposing experience, being an only child, lower education level

Poor health, low social support, not satisfied with residence

Frequent residence change

Having been injured, experienced a water shortage, been disconnected from family and friends during the response, and have passive coping styles and neurotic personalities

Personality traits, prior disaster experience, and preexisting stress

Female, being bereaved, being injured, and higher intensity of initial fear

Female gender, being married, low education level, non-drinking, and poor self-perceived health status

Female gender, experienced fear, post-quake traumatic experience, direct exposure

Female gender, older people, low education level farmers and those with family member loss

Displacement, no regular income, two-week prevalence, receiving mental health support after the disaster, family members died or missing, injured due to the quake, witnessing death or injured

Risk factors for PTSD

Y. Liang et al.

Journal of Affective Disorders 243 (2019) 327–339

6

6

6

12

12

12

18

Ma et al., 2011

Fan et al., 2011

332

He et al., 2011

Chen et al., 2017

Jia et al., 2015

Ying et al., 2013

Sun et al., 2012

Dujiangyan

Wenchuan and Mao County

Wenchuan County

Qingchuan County

Mianzhu vs. Baoji

Dujiangyan

Mianzhu

Mianzhu

6, 24

Song et al., 2011

3

3, 12, 18

Zhang et al., 2010b

Mianzhu, Deyang, Shifang, Chengdu, Mianyang, Peng zhou, Zitong and Anxian

Xin et al., 2010

12

Yang et al., 2010

16 units were randomly selected to cover the rescue units of various mission areas in the Wenchuan earthquake

Chengdu

12

Hu et al., 2010

Place

Children and adolescents Lau et al., 2010 1

Time (month)

Source

Table 2 (continued)

296

Rescue troops

Children & adolescents (16–18, 16.54 ± 0.53)

Children & adolescents (8–19, 13.31 ± 2.27)

Children & adolescents (15.13 ± 1.75)

Children & adolescents (7–15, 11.7 ± 2.3)

Children & adolescents (13–18)

Children & adolescents (14.6 ± 1.3)

Children & adolescents (12–18, 13.8 ± 1.1)

Children & adolescents (15–20, 17.28 ± 0.79)

Children & adolescents

Rescue troops

984

3052

631

20749

482 vs. 785

2250

3208

587

3324

1024, 470

105, 74, 183

1071

Rescue troops

Rescue troops

Sample size

Population

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

Longitudinal

Repeated Crosssectional

Cross-sectional

Cross-sectional

Study Design

13.3

8.6

28.4

19.2

23.4 vs. 16.7

15.8

2.5

4.3

22.3

3.4, 2.1

6.7, 5.4, 0

5.7

3.5

PTSD Prevalence (%)

total ≥50 (score on 1–5)

DSM-IV PTSD-SS

DSM-IV CPSS

total ≥36 (score on 0–4) CPSS

total ≥30 (score on 0–1–3–5) UCLA-Teenager

total ≥50 (score on 1–5) CRIES-13

DSM-IV PTSD-SS

total ≥34 (score on 0–4) K-SADS-PL

LASC

CRIES > 30

total ≥50 (score on 1–5) SCID-Ⅰ/P DSM-IV

total ≥50 or mean of each dimension≥ 3 (score on 1–5) PCL-C

total ≥50 or mean of each dimension ≥3 (score on 1–5) PCL-C

PCL-C

PTSD Instrument And cut-off

(continued on next page)

Trapped or wounded, living in shelters, close ones were trapped/wounded/died, fear for close ones’ safety, house damage

Low social support

Younger, having felt extreme panic or fear, felt unable to escape from the disaster, having been trapped for a longer time, neuroticism, low socialization

Older age, getting trapped, having relatives and friends injured, witnessing death

Family member killed/ injured, direct witness of the tragic disaster

Female, buried/injured, parents injured, classmate(s) died, house destroyed, low social support, witnessing buried/wounded/dying,

Prior mental distress, absent from school, visited affected sites, scary news Female, seeing others' corpse and death, feeling severity of fear

Heavy workload

Anxiety, somatic symptoms, nervousness, negative coping

Risk factors for PTSD

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333

76

102

3,6,9,12

6, 12, 18

Wang et al., 2015

Wu et al, 2018

Hou et al., 2011

Zhang et al., 2012

Dujiangyan

Mianzhu

A high school located 10 km away from the epicenter

Students originally lived in Wenchuan

Wenchuan county and Dujiangyan

Mianzhu

Three most severely damaged middle schools

Mao County

Wenchuan,Pengzhou, Anxian, Dayi, Dujiangyan

Place

Children and adolescents (grade 7 and 10)

Children & adolescents (grade 4–8)

Children & adolescents (16.86 ± 0.58)

Children & adolescents (11–19)

Children & adolescents (12–20, 14.34 ± 1.51)

Children & adolescents (11–17, 13.6 ± 1.0)

Children & adolescents (12–19, 15.2 ± 1.8)

Children & adolescents (11–16, 13.8 ± 0.9)

Children & adolescents (9–17, 12.89 ± 2.25)

Population

1573

203

548

1677

2291

743

Longitudinal

Longitudinal

Longitudinal

Longitudinal

Cross-sectional

Cross-sectional

Cross-sectional

Cross-sectional

362

4604

Cross-sectional

Study Design

903

Sample size

21.0, 23.3, 13.5, 14.7

21.2, 19.2

9.7, 1.3, 1.6

36.5, 30.7, 24.8, 22.2

4.8

5.9

5.7

29.6

19.8

PTSD Prevalence (%)

Female gender and being a child with siblings

total ≥38 (score on 1–5) PCL-C

total ≥50 (score on 1–5)

(score on 0–1–3–5) PTSD-SS

total ≥50 (score on 1–5) CRIES total ≥30

Ethnic minorities

Loss of houses and property, being injured, deaths of family members, witness of death

Witnessed death, family members being killed, close friends seriously injured or being killed, having felt scared

Attributional style and anxiety sensitivity

Risk factors for PTSD

DSM-5 PCL-C

DSM-5 PCL-5

DSM-IV PCL-5

total ≥40 (score on 0–4) SCID-I/P

total ≥30 (score on 0–1–3–5) IES-R

CRIES

PTSD Instrument And cut-off

Note. CPSS = Child PTSD Symptom Scale; CRIES = Children's Revised Impact of Event Scale; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders Fourth Edition; DSM-V = Diagnostic and Statistical Manual of Mental Disorders Five Edition; HTQ = The Harvard Trauma Questionnaire; IES-R = Impact of Event Scale-Revised Scale; K-SADS-PL = Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children Lifetime version; LASC = Los Angeles Symptom Checklist; PCL-5 = the PTSD Checklist for DSM-V; PCL-C = the PTSD Checklist-Civilian Version; PCL-SS = the Posttraumatic Stress Disorder Self-Rating Scale; PTSD = post-traumatic stress disorder; PTSD7 = 7-Sympton Screening Scale for Post-Traumatic Stress Disorder; PTSD-SS = Post-traumatic Stress Disorder Self-Rating Scale; SCID-I/P = Structured Clinical Interview for DSM-IV-TR Axis I Disorder–Patient Edition; SCID-I/NP = nonpatient version of the Structured Clinical Interview for DSM-IV Axis I Disorders; SI-PTSD = Chinese version of Structured Interview for PTSD; TSCC = the Trauma Stress Symptom Checklist; UCLA- adolescent: the University of California at Los Angeles Posttraumatic Stress Disorder Reaction Index.

6,12,18,24

36

Tian et al., 2014

Fan et al., 2015

36

Pan et al., 2015

6,12

18

Huang et al., 2010

Chen et al., 2010

Time (month)

Source

Table 2 (continued)

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adolescents in Mianzhu, the PTSD prevalence was estimated at 4.3% three months post-earthquake (Xin et al., 2010). Six months after the earthquake, according to self-report checklists, the prevalence rate was estimated to range from 15.8% to 23.4% (Fan et al., 2011; He et al., 2011). Another study six months after the disaster used the Schedule for Affective Disorders and Schizophrenia for School-Age Children to diagnose PTSD, and the overall prevalence was 2.5% in a sample of 3208 adolescents (Ma et al., 2011). At the one-year time point, the prevalence ranged from 8.6% to 28.4% (Chen et al., 2017; Jia et al., 2015; Ying et al., 2013). Eighteen months after the earthquake, two research reports estimated PTSD prevalence rates at 13.3% and 19.8%, respectively (Huang et al., 2010; Sun et al., 2012). Thirty-six months after the disaster, one study using the IES-R estimated the prevalence at 29.6% (Pan et al., 2015), and another study using the SCID estimated the prevalence at 5.7% (Tian et al., 2014). Seventy-six months and one hundred and two months after the earthquake, the PTSD prevalence rates were estimated at 5.8% and 4.8%, respectively (Wang et al., 2015; Wu et al., 2018). Overall, the PTSD prevalence among children and adolescents was lower than that among adults.

these, 25 were cross-sectional, and 5 were longitudinal (see Table 2). 3.2.1. Medical rescue workers 3.2.1.1. Prevalence. The overall prevalence of PTSD among medical rescue workers was first reported at 19.3% three months after the Wenchuan earthquake (Wang et al., 2010). In one study that surveyed China Red Cross disaster relief nurses six to twelve months after the earthquake, the prevalence rate of PTSD was 30.0% in those participating in Wenchuan earthquake relief compared to that of 10.2% in a reference group of nonexposed Red Cross nurses (Zhen et al., 2012). Fourteen to seventeen months after the earthquake, the prevalence rate of PTSD among medical workers involved in response work within the first three months of the event was reported at 17%, as assessed via online questionnaire survey (Schenk et al, 2017). However, another study using the MiniInternational Neuropsychiatric Interview (MINI) reported a PTSD prevalence of 2.3% among basic medical personnel in 6 severely disaster-stricken areas 14 months after the earthquake (Xie et al., 2011). Two years after the earthquake, the prevalence rate for nurses in Mianzhu was 1.7%, while 8.2% reported low level PTSD symptoms (PCL-C total scores ranged 39–49; Yin et al., 2013).

3.2.3.2. Course. Most longitudinal studies following the Wenchuan earthquake were conducted among children and adolescents. In a longitudinal survey conducted in the first year after the earthquake among 1677 students who originally lived in Wenchuan but were relocated to Chengdu temporarily to enable them to receive regular schooling, the prevalence rates of PTSD were 36.5%, 30.7%, 24.8%, and 22.2% at 3, 6, 9, and 12 months post-quake, respectively (Hou et al., 2011). Another longitudinal study conducted in Mianzhu at 6 and 12 months post-quake found that the PTSD prevalence declined from 21.2% to 19.2% (Chen et al., 2010). Zhang et al. (2012) conducted a longitudinal study in a high school located 10 km away from the epicenter and found that the prevalence rates of PTSD were 9.7%, 1.3%, and 1.6% at 6, 12, and 18 months after the disaster, respectively. In another longitudinal investigation, Fan et al. (2015) found PTSD prevalence rates of 21.0%, 23.3%, 13.5% and 14.7% at 6, 12, 18 and 24 months post-quake, respectively. Five PTSD symptom trajectories were also observed in a study by Fan et al. (2015): resistance (65.3% of the sample), recovery (20.0%), relapse/remission (3.3%), delayed dysfunction (4.2%) and chronic dysfunction (7.2%).

3.2.1.2. Risk factors. These studies found that some aspects of the medical rescue conditions were associated with PTSD, such as experiencing a water shortage, being disconnected from family and friends during the response, frequently changing residences, and being dissatisfied with the circumstances of the residence (Schenk et al., 2017; Xie et al.,2011; Yin et al., 2013). In addition, passive coping styles, neurotic personalities, poor health, prior disaster experience, and preexisting stress significantly increased the risk of PTSD (Schenk et al., 2017; Yin et al., 2013; Zhen et al., 2012). 3.2.2. Rescue officers and soldiers 3.2.2.1. Prevalence. Rescue officers and soldiers had a lower prevalence of PTSD than other exposed populations. The prevalence of PTSD was first reported at 8.4% one month after the earthquake (Wu et al., 2012); three months post-quake, the prevalence was 4.3% (Liao et al., 2010). Six months after the earthquake, PTSD was reported in 3.4% of rescue cadets who entered severely affected areas within 24 h after the disaster, according to the SCID (Gu et al., 2011). Two studies reported one-year PTSD prevalence of 3.5% and 5.7%, respectively (Hu et al., 2010; Yang et al., 2010). A repeated cross-sectional assessment study reported PTSD prevalence rates of 6.7%, 5.7% and 0% at 3, 12, and 18 months after the earthquake, respectively (Zhang et al., 2010b).

3.2.3.3. Risk factors. Most child and adolescent research participants were aged 13 to 18 years; that is, most samples came from middle and high school students. These studies found that many factors significantly increased the risk of PTSD, including demographics such as female gender, older age or senior grade (Ma et al., 2011; Zhang et al., 2012) and exposure characteristics such as witnessing death or corpse, being buried/injured, experiencing the loss of family members, having a close family member or friend be trapped or injured, and losing one's house and property (Fan et al., 2011; Pan et al, 2015; Tian et al., 2014; Ying et al., 2013). Some cognitions and emotions related to earthquakes were also associated with the likelihood of developing PTSD, including feeling unable to escape from the disaster and fear (Chen et al., 2017; Pan et al, 2015). In addition, low social support and low socialization were related to PTSD (Chen et al., 2017; Jia et al., 2015).

3.2.2.2. Course. The literature includes one longitudinal study focusing on rescue troops, with measurements at 6 and 24 months after the earthquake (Song et al.,2011). At 6 months, 1024 soldiers were surveyed, and the prevalence was 3.4%. At 24 months, 470 of the sample soldiers were followed up, and the prevalence declined to 2.1%. Of the 16 soldiers who were diagnosed with PTSD at 6 months, 9 (56.25%) continued to meet diagnostic criteria at 24 months. 3.2.2.3. Risk factors. Higher risk for PTSD was found among rescue officers and soldiers meeting certain rescue criteria, such as bodydisposal experience and heavy workloads (Gu et al., 2011; Song et al., 2011). Some demographic factors significantly increased the risk for PTSD, including being an only child and having a lower education level (Gu et al., 2011). Anxiety, somatic symptoms, nervousness, and negative coping styles were also related to PTSD (Hu et al., 2010).

3.3. Burden of PTSD in the aftermath of the Wenchuan earthquake The research conducted in the past decade demonstrates that the post-earthquake burden of PTSD is substantial in both the short and long terms. As illustrated by the cumulative body of data, the prevalence of PTSD declined rapidly in the early period, but the rate of decline became slower over time. This tendency is more in line with a logarithmic function. To determine the development trend of PTSD prevalence regarding sampling time, we conducted linear regression analysis and logarithmic function curve fitting using the data from

3.2.3. Children and adolescents 3.2.3.1. Prevalence. One month after the earthquake, the PTSD prevalence rate was 22.3% among 3324 secondary school students living in Chengdu (Lau et al., 2010). In fifteen- to twenty-year-old 334

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Fig. 3. Correlations between PTSD prevalence and time.

incidence of PTSD drops sharply after 9 months and that the combined estimated incidence of PTSD at or before 9 months was 28.76%, while that estimated after 9 months was 19.48%. Compared to these estimates, the prevalence rate of PTSD in Wenchuan earthquake community studies was much higher than 23.66% in the first 3 months after the earthquake and was below 20% until 12 months. Overall, the findings of this large body of research indicate that the Wenchuan earthquake has had more devastating and long-lasting impacts for survivors (Fan et al., 2015; Guo et al., 2014; Kun et al., 2009; Wang et al., 2015). Medical rescue workers and rescue officers and soldiers experienced secondary psychological trauma in the disaster because they directly face the ruins of the disaster, casualties and constant aftershocks (Schenk et al., 2017; Yang et al., 2010). Thus, the PTSD prevalence among medical rescue workers and rescue soldiers who participated in the rescue work of the Wenchuan earthquake was significantly higher than the PTSD prevalence among those who did not experience these things (Hu et al., 2010; Zhen et al., 2012). The PTSD prevalence among medical rescue workers was relatively high within the initial 14 months following the earthquake. One important reason might be that most medical rescue workers were nurses and most were female, which is an important risk factor for PTSD (Cheng et al., 2018; Guo et al., 2017; Zhang et al., 2012). Two studies conducted 14 months after the earthquake showed a relatively low PTSD prevalence, indicating that most medical rescue workers could recover from PTSD at that time (Xie et al., 2011; Yin et al., 2013). Among rescue officers and soldiers, the prevalence of PTSD was relatively low. Reasons for this low prevalence might be male gender and having undergone professional training (Gu et al., 2011; Hu et al., 2010). During the response, the state and the public provided great support and attention to the work of rescue officers and soldiers, which had positive psychological impacts on these individuals (Zhang et al., 2010b). Structural interviews with rescue officers and soldiers also indicated that they were proud of their meaningful work and had positive thoughts regarding this experience, such as the opportunity to improve themselves and learn about responsibility (Hu et al., 2010).

community studies and child/adolescent studies with large samples (n ≥ 1000). Fig. 3A shows the correlation between PTSD prevalence (in percentages) and time since the earthquake (in months) in community studies. The results showed that the fit indicators of a logarithmic function (R2 = 0.71, p = .002) were better than those for the linear regression (R2 = 0.32, p = .088). Fig. 3B shows the correlation between PTSD prevalence (in percentages) and time since the earthquake (in months) in child/adolescent studies. The results also showed that a logarithmic function (R2 = 0.62, p = .002) better describes the data than linear regression (R2 = 0.39, p = .030). All the above results indicated that the PTSD development trend was more consistent with the changes described by a logarithmic function. That is, the prevalence of PTSD declined rapidly in the early period, whereas the rate of decline became slower in later periods and gradually stabilized. Hong and Efferth (2016) used data from the first four years after the Wenchuan earthquake and found that the relationship between PTSD prevalence and time after the earthquake was well in line with linear changes. The difference between these findings suggests the importance of long-term tracking for understanding trends in PTSD development. Comparing the PTSD prevalence of adults with that of children/ adolescents, the PTSD prevalence was much higher among adults than among children and adolescents in the first year following the earthquake. At present, the reasons for this finding are unclear. According to some conceptualizations, children and adolescents might be vulnerable due to a lack of effective coping styles for adaptation and recovery from a disaster (Braun-Lewensohn, 2015) and ready exposure to ongoing vicarious trauma exposure via TV or nonprofessional aid efforts (Yeung et al., 2016). However, the present results are not consistent with these suggestions. Most of the studies we reviewed found that the post-quake risk factors for PTSD in adults included marital status and being middle aged, while for children/adolescents, the risk factors included older age or senior grade (He et al., 2011; Wang et al., 2011c; Zhang and Ho, 2011). We speculate that adults might be more worried about managing day-to-day life in the aftermath and thus may experience more ongoing stress than children, which may contribute to the higher PTSD prevalence observed among adults (Wang et al., 2011c). This finding is likely because middle-aged people are responsible for the family's monetary income and the psychological support in China (Wang et al., 2011c). Some studies also found more risk factors for PTSD in the adult group; these factors were related to the maintenance of daily life, such as having no/low household income, a loss of livelihood, or receiving loans from banks or relatives after the disaster (Kun et al., 2009; Wang et al., 2011c; Zhang et al., 2011b). These risk factors also indirectly indicated that adults underwent more life pressure after the disaster. These conjectures warrant further investigation and validation in research. A meta-analysis found that the combined incidence of PTSD after earthquakes was 23.66% (Dai et al., 2016); it also indicated that the

3.4. Risk factors for PTSD The most consistently documented risk factors for PTSD across studies of Wenchuan earthquake-related PTSD were based on exposure to the disaster, including experiencing the loss of significant others’ lives, having physical injury, being buried, and witnessing death (He et al., 2011;Wang et al., 2011c; Zhou et al., 2013). These factors that related to the immediate threat of life were especially predictive of PTSD. Certain demographic factors, such as female gender, low education level, being married, and being middle aged or elderly, also significantly increased the risk of PTSD (" > Xin et al., 2010; Zhang and 335

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5. Methods for PTSD assessment

Ho, 2011, Zhang et al., 2011b). In addition, low social support was an important predictive factor (Ma et al., 2011; Xu and Song, 2011; Zhao et al., 2009). For medical rescue workers and rescue soldiers, PTSD was predicted by some factors related to working condition and personality, such as water shortage, disconnection from family, frequent residence changes, nervousness, and negative coping style (Hu et al., 2010; Schenk et al., 2017; Xie et al., 2011). These findings have important implications for rescue work after a disaster and for personnel selection.

PTSD is a mental disorder regularly assessed by clinical interviews using structured interviews such as the SCID (First et al., 1995) or the Clinician-Administered PTSD Scale (CAPS; Blake et al., 1995) as the gold standard. However, to obtain information about PTSD symptoms after the Wenchuan earthquake, most researchers used self-report questionnaires that are more readily available for a large number of potential victims after a major disaster, such as the PTSD Checklist (Weathers et al., 1993), the Impact of Event Scale (Weiss and Marmar, 1996), and the Child PTSD Symptom Scale (Foa et al., 2001). Only 7 of the 45 studies included in this review used clinical diagnostic interviews, and reliance on questionnaire measures may have resulted in elevated estimates of the prevalence of PTSD after the earthquake. For example, Pan et al. (2015) used the IES-R and estimated the PTSD prevalence at 29.6% thirty-six months after the disaster, while Tian et al. (2014) used the SCID and estimated the PTSD prevalence as 5.7% at the same time point. In different studies using the same assessment measures, the cut-off criterion to determine PTSD status varied. For example, total scores of 38, 44 and 50 were used as cut-off criteria for the PCL-C in different studies (e.g., Wen et al., 2012; Xu and Song, 2011; Zhao et al., 2009). The inconsistency in the cut-off criterion has created challenges in comparing results across studies. Moreover, most of the cut-off criteria are directly based on Western research, which may reduce the relevance of the research findings for non-Western cultures. Therefore, it will be important to study the psychometric properties of these screening instruments in China and to identify which self-report instruments are likely to be most effective in assessing probable PTSD diagnoses after natural disasters. Given that all the available PTSD assessment instruments were developed using Western cultural samples, significant questions regarding the psychometric characteristics and possible limitations of using these instruments across cultures still exist (Castillo, 1997; Wu et al., 2008). Moreover, the diagnostic categories may differ across cultures as well (Norris et al., 2001), and some items on the Chinese version of the scales that have been translated directly from the English version sometimes sound awkward and incomprehensible to Chinese audiences (Liu et al., 2014). After the Wenchuan earthquake, Liu et al. (2014) developed a Chinese PTSD self-rating scale—the Chinese PTSD Inventory (CPI)—that demonstrated high internal consistency and testretest reliability among another sample of debris-flow victims. Methods for assessing PTSD in Chinese cultures need further development and validation in the future.

4. Structure of PTSD The structure of PTSD symptoms has been debated since PTSD was first included in the DSM-III. The latent structure of PTSD symptoms described in the DSM-IV (APA, 1994) was the focus of intense controversy prior to the release of the DSM-5. In addition to the classical tripartite diagnostic model, several alternative models have been proposed in factor analytic studies (King et al., 1998; Lancaster et al., 2009). Of these alternative models, two alternative four-factor PTSD models have received the most empirical support (King et al., 2006; Yufik and Simms, 2010): the four-factor emotional numbing model (King et al., 1998) and the four-factor dysphoria model (Simms et al., 2002). Both models generally retain the basic DSM-IV structure, but the avoidance and numbing symptoms (Criterion C) are divided into two separate factors in the four-factor emotional numbing model, and the three hyperarousal symptoms (i.e., D1: sleep difficulty, D2: irritability, and D3: concentration problems) are combined with the numbing symptoms to form a dysphoria factor in the four-factor dysphoria model. Two studies conducted with Wenchuan earthquake survivors examined the structure of PTSD symptoms among adolescents (Wang et al., 2011a, d). Both studies supported a five-factor intercorrelated model composed of intrusion, avoidance, numbing, dysphoric arousal, and anxious arousal that was first proposed by Elhai et al. (2011). The five-factor model includes the two divisions of avoidance and numbing symptoms and hyperarousal symptoms found in the classical tripartite diagnostic model. After the DSM-5 was released, Wang et al. (2015) conducted a study to investigate the underlying dimensionality of DSM-5 PTSD symptoms. They found that an intercorrelated seven-factor model consisting of intrusion, avoidance, negative affect, anhedonia, externalizing behaviors, anxious arousal, and dysphoric arousal factors represented the DSM-5 PTSD symptoms significantly better than the alternative models. These studies provided support for existing conceptualizations of the structure of PTSD symptoms in Chinese culture. Nevertheless, all of them were based on DSM diagnostic criteria; one of the major concerns with the DSM pertains to whether its diagnostic categories are valid across cultures. Several cross-cultural studies have found that some of the distress characteristics reported by research participants were beyond what could be accounted for by the 17 criterion symptoms listed in the DSM-IV, while a few criterion symptoms in DSM-IV were rarely reported (Jenkins, 1996; Norris et al., 2001). More importantly, somatic symptoms are more frequently exhibited in Asian cultures and other non-Caucasian populations (Terheggen et al., 2001; Summerfield, 1999). Liu et al. (2014) conducted interviews with Wenchuan earthquake victims and found that they tended to report somatic problems such as headache, skeletal ache and backache, and even weight loss, in addition to some of the PTSD criteria symptoms. Liu and colleagues (Liu et al., 2014) coded the interview based on the DSM-IV-TR (APA, 2000) and found that in addition to the three thematic categories (intrusion, avoidance, and hyperarousal) of PTSD in the DSM-IV-TR, two other themes (somatization and negative emotions) were mentioned by most interviewees. Using principal component analysis, Liu and colleagues found a five-factor model composed of intrusion, avoidance, hyperarousal, dysphoria, and somatization. This study provided evidence for a specific structure of PTSD symptoms in Chinese culture and suggested that more research should be conducted in the future to explore and verify this structure in Chinese populations.

6. Treatment for PTSD after the Wenchuan earthquake Psychological interventions play a crucial role in PTSD remission and recovery. Trauma-focused cognitive behavior therapy (CBT) and eye movement desensitization and reprocessing (EMDR) have the most empirical support for efficacy in treating PTSD (Ehlers et al., 2010). Following the Wenchuan earthquake, many forms of assistance and intervention were provided, but only a few studies have focused on the efficacy of these interventions. We identified nine studies investigating treatments for PTSD in this context. A randomized controlled trial was conducted with 32 adolescents who experienced the Wenchuan earthquake (Chen et al., 2014). Participants were randomly assigned to three treatment groups: a short-term CBT group, a general supportive intervention group and a control group of nontreatment. The results showed that CBT was effective in reducing PTSD and depressive symptoms and improved psychological resilience and general support was only effective in improving psychological resilience, which indicated that short-term CBT was a robust intervention for those adolescent victims. Zang et al. (2013) conducted a randomized wait-list controlled pilot study to evaluate the efficacy of narrative exposure therapy (NET; Neuner et al., 2002) for PTSD in Beichuan 336

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studies reviewed here suggested that PTSD is associated with a range of risk factors including sociodemographic factors, trauma exposure characteristics, post-disaster cognitive and emotional states, and social support factors. These studies enriched the understanding of risk factors for PTSD in Chinese culture and could provide useful knowledge for practical assessments to identify victims at a high risk for mental disorders. Some risk factors among medical rescue workers and rescue soldiers have important implications for the personnel selection of rescue workers and work arrangements. Third, the symptom structure of PTSD was explored after the natural disaster, which promoted the development of the PTSD diagnostic model. In particular, findings related to a possible culturally specific Chinese structure of PTSD were meaningful for understanding the symptom structure of Chinese individuals; these findings suggested that the symptoms of somatization might be prevalent in Eastern culture and need to be recognized by clinicians. Fourth, a Chinese PTSD self-rating scale was developed after the earthquake, and this scale was more in line with Chinese symptoms and language habits. The scale improved the psychometric properties of Chinese measurements for PTSD but needs further validation in the future. Fifth, several treatment methods, including some indigenous culturally appropriate interventions, were investigated, and initial findings were positive. These studies demonstrate the practicality of some traditional interventions in Chinese culture and initially found that some cultural activities could alleviate the symptoms of PTSD, which has promoted the development of interventions for PTSD in China. However, a number of limitations exist in this body of literature. First, only a relatively small number of the studies used longitudinal assessments, and the duration of these studies was relatively short. It was hard to find adequate data to describe the course of PTSD, which would be valuable for guiding the design of intervention strategies and the effective use of intervention resources. Second, current research on trauma exposure factors has mainly been related to direct trauma exposure, which may determine the investigation method used. Future studies need to seek a better understanding of the impact of indirect trauma exposure and the process of traumatic impact by using other investigation methods, such as qualitative interviews. Third, the consistency and effectiveness of measurement tools require further exploration, as do examinations of the structure of PTSD in the Chinese population. Fourth, although some indigenous interventions were developed, these interventions as well as possible mechanisms of action require more robust studies of efficacy. Finally, PTSD after natural disasters exhibits specific characteristics, given the societal response to disaster survivors. Therefore, any generalization of these conclusions to PTSD caused by other trauma types needs to be made with caution.

County; NET emphasizes the importance of the habituation of the emotional response to a traumatic event and the construction of a detailed narrative of the event and its consequences. Twenty-two participants were randomly allocated to receive NET (n = 11) or the waiting-list (WL) condition (n = 11). The results showed that compared with WL, NET conferred significant reductions in PTSD symptoms, anxiety and depression, and the WL group showed a similar effect after treatment. The results indicated that NET was efficacious in treating PTSD among adults after the Wenchuan earthquake. Most interventions focus on symptoms, while interpersonal psychotherapy (IPT; De Mello et al., 2005) aims to change an individual's social support and current relationships in order to improve their mood and symptoms. Jiang et al. (2014) performed a randomized clinical trial study among adult survivors of the Wenchuan earthquake using 12 weekly sessions of IPT that were one hour each, and the results indicated that IPT is a promising treatment for reducing PTSD and depression. Some new intervention methods and tools were also tried after the earthquake. A 512 Psychological Intervention Model (512 PIM) was developed based on the standard Mitchell critical incident stress debriefing approach adapted to address unique characteristics of Chinese military rescuers (Wu et al., 2012). All 2368 participants were randomly assigned to the ‘‘512 PIM’’ group, a debriefing group or a control group. The 512 PIM was demonstrated to be an effective psychological intervention for reducing symptoms of PTSD, anxiety, and depression for military rescuers following this crisis. Moreover, compared with the debriefing and control groups, the 512 PIM group had significantly lower scores of PTSD. A Chinese version of the My Trauma Recovery website, developed as a guided self-help intervention for PTSD, was also demonstrated to significantly reduce PTSD symptoms in a randomized control trial with a waiting-list control condition (Wang et al., 2013). In addition, some interventions based on Chinese culture have also been explored. Chinese calligraphic handwriting requires an integration of the body, mind and character (Zhu et al., 2014). Recent research has gradually established calligraphy therapy as an indigenous and complementary practice which can improve individuals’ behavioral and psychosomatic conditions (Xu et al., 2013). In a 30-day calligraphic training conducted by Zhu et al. (2014) to validate the efficacy of calligraphy therapy among childhood survivors, participants were not experts in Chinese calligraphy and required a brush to write mediumsized characters by tracing on copybook pages. The results indicated significant decreases in both hyperarousal symptom levels and levels of cortisol, a stress hormone secreted by the adrenal cortex that is considered an informative biomarker of PTSD, in the experimental group compared to the control group (Sriram et al., 2012). Acupoint stimulation originating from traditional Chinese medicine was also shown to be effective for PTSD following the Wenchuan earthquake (Zhang et al., 2011a, 2010a). In addition, Mahjong play, an indigenous activity in China, was shown to improve mental health by improving social support after the earthquake (Zhu et al., 2009).

Conflicts of interest The authors have no conflicts of interest to declare.

7. Concluding implications and limitations Authors' contributions

Based on the 10-year body of literature focusing on PTSD following the Wenchuan earthquake, we have highlighted key findings related to post-disaster PTSD prevalence and issues related to the development of PTSD in affected populations. First, the burden of PTSD among highly exposed disaster survivors was substantial. Long-term observations by researchers have promoted an understanding of the development trend of PTSD prevalence, which was described by a logarithmic function. The decline rate of PTSD prevalence was rapid soon after the earthquake but slowed down as time passed. This observation indicates that most victims suffering from PTSD could gradually recover during the early stage, while the remaining victims take a longer time and might have more difficultly recovering from PTSD. This finding implies that more effort needs to be made during the later stages of clinical work for people who are having difficulty recovering from PTSD. Second, the

Yiming Liang and Jin Cheng searched, read and collated the literature. Zhengkui Liu presented the structure of the article. Josef I. Ruzek provided suggestions for modification. All authors wrote the article.

Funding This work was supported by the programs of Pioneer Initiative of the Chinese Academy of Sciences, Feature Institutes Program (TSS2015-06) and Consulting and Appraising Project of Chinese Academy of Sciences (Y7CX134003). 337

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Acknowledgments

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