Treating Psychological Problems After Catastrophic Disasters
Armen Goenjian on his humanitarian work and research in Armenia.
Posted June 24, 2020
Though trauma often happens to people, it does not always come in the form of a catastrophic disaster. When such large-scale events occur, survivors are often left with significant and long-lasting psychological problems. Treating PTSD and depression post-disaster can be challenging, but there is promising research about some long-term treatment solutions.
Armen Goenjian received his B.S. at the American University of Beirut and M.D. at the University of Tennessee. He was trained in Psychiatry at UCLA, Reiss Davis Child Study Center, and VA Sepulveda. He is a Diplomate of the American Board of Psychiatry and Neurology, and Diplomate of the American Board of Geriatrics. Goenjian is a Research Psychiatrist at UCLA Geffen School of Medicine, and the Chief Medical Officer at Collaborative Neuroscience Network, where he conducts clinical trials on novel psychiatric and neurologic medications. He has been in the private practice of psychiatry since 1975.
JA: How did you first get interested in this topic?
AG: It goes back to December 7, 1988. I was on my way to work in Los Angeles. Suddenly there was a newsflash on the radio reporting that a devastating earthquake had effaced the city of Spitak in Armenia—thousands had died, and many were homeless in freezing temperatures. The television footage depicting the widespread death and destruction evoked old memories. I had flashbacks to my youth when Armenian Genocide survivors used to tell us harrowing stories of the decimation of innocent women and children. The indelible memories had not gone away; they resurfaced. I thought that this time I might have an opportunity to do something helpful for the victims.
In 1988, Armenia was part of the Soviet Union. As an American, it was hard for me to go there. After overcoming a few hurdles, I was able to travel there. In the next few months, along with a group of dedicated clinicians, we organized the Psychiatric Outreach Program. We began by treating children in schools in the two hardest-hit cities: Spitak at the epicenter and Gumri 16 miles further away. Subsequently, we opened two clinics and trained local therapists to work in the schools and the clinics for the next two decades.
JA: What was the focus of your study?
AG: Our main objective was to provide treatment to the survivors. We started gathering data periodically after the first year to measure the prevalence of commonly occurring psychological problems and gauge the effectiveness of the treatment we were providing. Over the following two decades, we measured the course of PTSD and depression among treated and not-treated children and adults; risk and protective factors associated with PTSD and depression; the effect of trauma on moral development and conscience functioning; the heritability of vulnerability to PTSD and genes associated with the vulnerability; the effect of trauma and PTSD on neurohormones; and the effect of exposure to double trauma (i.e., war and earthquake).
The disaster presented a unique situation where we did not have to adjust for potentially confounding factors in our studies. We did not have to disentangle such variables as mixed racial groups or different types of traumas happening at different periods and having a wide range of severity of the exposure. Also, the fact that the local population typically does not migrate allowed us to do multigenerational genetic studies and follow the same subjects for extended periods over time.
JA: What did you discover in your study?
AG: Among adolescents exposed to the earthquake where there was a high death toll (7 percent of the population in Gumri and 16 percent in Spitak) and widespread destruction, a significant portion of the population still met criteria for PTSD 25 years after the earthquake (9 percent of the treated Gumri group, 16 percent not-treated Gumri group, and 22 percent of the Spitak group). Likewise, depression levels were high in these cities with severe exposure and loss of life.
Such findings represent an ongoing public health problem that requires strategies across service settings to be better prepared for catastrophic events and have systems in place to assess and identify the vulnerable populations and provide needed services.
These findings are relevant to our society, where we face rampant gun violence, an increase of weather-related catastrophic disasters (hurricanes, flooding, tornadoes), ongoing community and school violence, domestic violence, sexual and other types of abuse, and most recently the coronavirus pandemic.
We also found that trauma-grief focused therapy provided at 1½ years after the earthquake had long-lasting benefits. The school-based screening and treatment program that was provided benefited a generation of adolescents as they transitioned to adulthood.
JA: Is there anything that surprised you in your findings or that you weren't fully expecting?
AG: In this 25-year follow-up, we assessed adults we had studied when they were adolescents at 1½ and 5 years. There were several striking findings. The treatment benefits we had observed at 5 years were retained over the 25 years.
The next intriguing finding was the severity and pattern of depression. We compared depression among two non-treated groups with different levels of trauma. The group from the city of Gumri, where there was substantially less death and destruction, as expected, had lower levels of depression compared to the group from Spitak at 1½ years after the earthquake. But at the 25-year follow-up, the level of depression was significantly lower in the Spitak group, along with a greater decline of PTSD severity. These findings were attributable to the lesser degree of post-earthquake adversities (heat, gas, electricity, transportation, food, and housing) in Spitak, consistent with city-wide lower unemployment and poverty.
Also, we found an association of both PTSD and depression with chronic medical illnesses, such as hypertension, diabetes, arthritis, and pulmonary illnesses, suggesting that PTSD is a risk factor for both additional mental and physical health conditions. The association of persistent PTSD and depression with chronic medical illness points to the need for targeted outreach services across physical and behavioral health systems.
JA: How might readers apply what you found to their lives?
AG: After catastrophic disasters, it is common for adults, children, and adolescents to experience symptoms of PTSD and depression. Those with the most traumatic disaster-related experiences are at the greatest risk for these reactions. Post-disaster adversities, sometimes called “the disaster after the disaster,” can present additional difficulties and contribute to the course of PTSD and depression.
The take-home message is that there are now very effective treatments for disaster-related PTSD and depression that are provided by behavioral health professionals trained and experienced in the area of trauma. Also, providing and receiving support from family and friends can make an important contribution to promoting the recovery process.
Relaxation techniques, such as Progressive Muscle Relaxation or Slow Diaphragmatic Breathing, are also helpful measures. Good examples of how to do these are available on YouTube.
It is important to avoid self-medicating with habit-forming drugs or alcohol.
JA: How can readers use what you found to help others?
AG: People who have been through a disaster may feel anxious, confused, helpless, or abandoned. It is very important to help those experiencing such symptoms by providing different types of support, e.g., social, material, and emotional. For example, you can help someone with money to repair their car, listen empathically to how they feel, help them problem-solve current difficulties, compliment them on constructive things that they are doing, or spend time with them doing enjoyable activities.
Don’t feel rejected when the survivor becomes irritated and does not want to continue a conversation. They may not be ready to share their traumatic experiences and reactions. Wait until they are ready, then listen to what they have to say.
JA: What are you currently working on that you might like to share about?
AG: My colleagues and I are writing a book on the lessons we and others have learned from research and relief work done after catastrophic disasters. We hope that this book will make an important contribution to our national preparedness and response to better meet the challenges of future disasters.
Goenjian, A., Steinberg, A., Walling, D., Bishop, S., Karayan, I., & Pynoos, R. (2020). 25-year follow-up of treated and not-treated adolescents after the Spitak earthquake: Course and predictors of PTSD and depression. Psychological Medicine, 1-13. doi:10.1017/S0033291719003891
Dr. Goenjian has been a psychiatric consultant to the World Health Organization, UNICEF various governments, including Greece, Turkey, Taiwan, Honduras, and Nicaragua. After the 1988 Spitak earthquake, he initiated and directed the Psychiatric Outreach Program in Armenia for 20 years. The program provided treatment to thousands of survivors and training to local professionals and para-professionals in two devastated cities, Spitak and Leninakan, where they had built two mental health clinics to provide free care to people in both cities and the villages in the vicinity.
He has been the primary investigator of multiple post-disaster studies, including in Armenia, Greece, and Nicaragua. His research has been published extensively in peer-reviewed journals including the American Journal of Psychiatry, British Journal of Psychiatry, The Journal of the American Academy of Child and Adolescent, Psychological Medicine, etc.
He is Lifetime Distinguished Fellow of the American Psychiatric Association. He has been the recipient of various awards for his research and humanitarian work related to natural disasters including from FEMA, the American Psychiatric Association, the Greek Government, and the President of Armenia.