Post-Traumatic Stress Disorder in Earthquake Survivors Living in Temporary Shelter Areas in Hatay Central Districts: A Cross-Sectional Study

Post-Traumatic Stress Disorder in Earthquake Survivors Living in Temporary Shelter Areas in Hatay Central Districts: A Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Post-Traumatic Stress Disorder in Earthquake Survivors Living in Temporary Shelter Areas in Hatay Central Districts: A Cross-Sectional Study Ertan Yılmaz, Mehmet Erdem This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5781679/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 May, 2025 Read the published version in BMC Psychiatry → Version 1 posted 6 You are reading this latest preprint version Abstract Background: The 2023 Kahramanmaraş earthquakes resulted in extensive destruction, significant loss of life, and widespread displacement, with Hatay province being the most severely affected region. Earthquake survivors residing in temporary shelters face an elevated risk of long-term psychological consequences, particularly post-traumatic stress disorder (PTSD) and depression. This study aims to assess the prevalence of PTSD and depression among earthquake survivors in temporary shelter areas within the central districts of Hatay and to identify associated risk factors contributing to PTSD. Methods: This cross-sectional, population-based study was conducted among 400 adult earthquake survivors following the 2023 Kahramanmaraş earthquakes. Participants were selected using a multistage cluster sampling method. Data on participants' sociodemographic characteristics, earthquake experiences, and psychiatric history were collected through self-report questionnaires. PTSD was assessed using the PTSD Checklist for DSM-5 (PCL-5), while depression was evaluated using the Beck Depression Inventory Results: PTSD was identified in 29.0% of participants, while depression was observed in 38.8%. Key risk factors for PTSD included unemployment (OR=2.590, p=0.004), the loss of a family member (OR=2.351, p=0.017), a pre-existing psychiatric diagnosis prior to the earthquakes (OR=2.245, p=0.007), alcohol use (OR=2.310, p=0.019), smoking (OR=1.663, p=0.044), and experiencing a high level of fear during the earthquakes (OR=2.151, p=0.002). Conclusions: These findings highlight the critical need for large-scale psychosocial support and intervention programs in the post-disaster period. Identifying risk factors for PTSD may aid in the development of targeted treatment strategies and preventive interventions for affected individuals. Post-Traumatic Stress Disorder PTSD Earthquake Risk Factors Temporary Shelter Earthquake survivors Background Earthquakes, classified as natural disasters, are recognized as traumatic events due to their widespread impact, causing loss of life and destruction on a large scale. A key distinction between earthquakes and other disasters is that affected individuals must continue to live with the persistent risk of recurrence (1). Earthquakes can have significant consequences for both physical and psychological health. Post-disaster traumatic stress reactions encompass a broad spectrum, ranging from grief, fear, and anxiety to more severe psychiatric conditions, such as post-traumatic stress disorder (PTSD). Among the psychiatric disorders that may arise following traumatic events, PTSD is one of the most extensively studied and most prevalent (2). According to the DSM-5 criteria, exposure to a traumatic event, which is a key diagnostic criterion for PTSD, may occur through direct experience or witnessing actual or threatened events involving death, serious injury, or sexual violence. PTSD is characterized by multiple symptom clusters, including intrusion, avoidance, negative alterations in cognition and mood, and changes in arousal and reactivity (3). Research on PTSD has demonstrated that the prevalence of PTSD among disaster survivors ranges from 5–60% (4), which is significantly higher than its prevalence in the general population, ranging from 0–3.8% (5). One of the major challenges posed by disasters is the potential permanence of psychological effects in some survivors. According to the National Comorbidity Survey, one-third of disaster survivors continue to experience PTSD symptoms even a decade after the traumatic event (6). In a 25-year follow-up study, Goenjian et al. highlighted that PTSD and depression became chronic in most survivors of the Armenian earthquake; however, they noted that early psychological interventions could have lasting positive effects (7). Similarly, a study conducted three years after the Nepal earthquake found PTSD in approximately one-fifth of participants (8). Zhang et al. reported a PTSD prevalence of 10.3% three years post-Wenchuan earthquake in China (9). Various risk factors encountered before, during, and after a disaster can contribute to the development of psychopathology in its aftermath. Pre-disaster risk factors include age, gender, education level, pre-existing psychiatric disorders, and adverse childhood experiences. Risk factors during the disaster encompass proximity to the earthquake epicenter, trauma severity, and the loss of a loved one. Post-disaster risk factors involve the loss of social support and ongoing life stressors (10,11). Among the Kahramanmaraş earthquakes, the epicenter of the first, with a magnitude of 7.7 on the Richter scale, was in the Pazarcık district of Turkey’s Kahramanmaraş province. This earthquake occurred at 04:17 on February 6, 2023. The epicenter of the second earthquake, which had a magnitude of 7.6, was in the Elbistan district of the same province and occurred at 13:30 on the same day (12). These two earthquakes affected a vast area encompassing 11 provinces, including Kahramanmaraş and Hatay, with the total population of these regions accounting for approximately 16% of Turkey’s population (13). The World Health Organization (WHO) classified this disaster as a " Level 3 Emergency," the highest level of emergency response (14). Following the initial earthquakes, a third earthquake, with a magnitude of 6.4, struck the Yayladağı district of Hatay province at 20:04 on February 20, 2023. Since the first earthquake, more than 33,000 aftershocks have been recorded as of May 6, 2023. According to official reports, the earthquakes resulted in over 50,000 fatalities and more than 100,000 injuries. The number of collapsed and severely damaged buildings is estimated at approximately 500,000. The economic cost of this disaster to Turkey is estimated to be approximately 85 billion United States (US) dollars (13) Hatay province experienced the highest level of destruction and loss of life from these earthquakes. Notably, 40% of all earthquake-related fatalities occurred in Hatay (15). Consequently, the sample for this study was selected from individuals residing in temporary shelter areas within the central districts of Hatay, namely Antakya and Defne. To the best of our knowledge, no population-based study has yet examined the mental health outcomes of adult earthquake survivors in Hatay province and the associated risk factors. Based on official data regarding these earthquakes, we hypothesized that residents of Hatay’s central districts experienced significant exposure to earthquake-induced trauma, leading to a high prevalence of PTSD and depression in these areas. To evaluate this hypothesis, the primary outcome of this study was defined as the prevalence of PTSD and depression among individuals living in temporary shelter areas within the central districts of Hatay. The secondary outcome was identified as the risk factors contributing to these conditions. Identifying these factors may facilitate in the development of targeted psychosocial support programs and appropriate treatment interventions for earthquake survivors. Materials and Methods Study Design and Setting This study was designed as a cross-sectional, population-based study. Ethical approval was obtained from the Ethics Committee of Hatay Mustafa Kemal University in accordance with the Declaration of Helsinki (Approval Date: 29.08.2023, Approval No: 26). The study was conducted in the central districts of Hatay, specifically Antakya and Defne, during October and November following the earthquakes. Population and Sample The research was conducted in a single city. Clusters for the research sample were selected from both central districts, Antakya and Defne, located in the heart of Hatay, the city most severely affected by the earthquake and where the greatest destruction occurred. The study population consisted of adults living in container cities within the Antakya and Defne districts of Hatay province. According to municipal authorities, as of the study period, approximately 70,000 individuals were living in 48 container cities in Antakya, while approximately 10,000 individuals were residing in 18 container cities in Defne, totaling around 80,000 people in temporary shelter areas in the central districts of Hatay. The expected incidence was estimated at 50% based on previous studies, with a target sample size of at least 384 participants, calculated using a 5% margin of error and a 95% confidence interval (16). Multistage cluster sampling was employed to select participants for the study. Container cities with a population of fewer than 1,000 residents, as well as those housing officials from outside the province who had not directly experienced the earthquakes, were excluded from the sampling frame. Consequently, 10 individuals were randomly selected from each of the 40 container cities with 30 located in Antakya and 10 in Defne, using simple random sampling. Thus, the final study sample comprised a total of 400 participants across these 40 groups. Individuals who were unavailable for interviews during the day due to work commitments were approached again in the evening. If participants could not be reached in both attempts or declined to participate in the study, replacement participants were selected from neighboring containers in equal numbers to maintain the sample size. Study Inclusion Criteria Being an earthquake survivor Being over 18 years old Living in temporary shelter Holding citizenship of the Republic of Turkey Having the cognitive capacity to understand and answer the questionnaire Having volunteered to participate in the study 7. Exclusion Criteria Residing in permanent residences Residing outside the borders of Antakya and Defne districts Data Collection Prior to data collection, a pilot study was conducted with 10 participants as part of the training provided to the interviewers by the researchers. Study data were collected using self-report questionnaires completed by participants with assistance from two university graduate interviewers, one male and one female. For participants who had difficulty reading the questionnaire, interviewers read the questions aloud. Before administering the questionnaire, the interviewers informed participants about the study's objectives and the questionnaire's content. Written and verbal consent was obtained prior to participation. The questionnaire was administered either in the participants’ containers or in other preferred locations near their residences. Completion of the questionnaire took approximately 45–60 minutes. Participants did not receive any financial compensation for their participation in the study. Measures The questionnaire, developed by the researchers, comprised 38 questions assessing participants' sociodemographic characteristics (age, gender, education level, income level) and adverse events experienced before, during, and after the earthquakes. Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5) The PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (PCL-5), is a 20-item self-report instrument developed in accordance with DSM-5 criteria for PTSD. It assesses PTSD symptoms, which are categorized into four symptom clusters reflecting the DSM-5 diagnostic criteria: reexperiencing, avoidance, negative alterations in cognition and mood, and hyperarousal. Each item is scored on a scale from 0 to 4, with a maximum possible total score of 80 points (17). The validity and reliability of the Turkish version of the PCL-5 were established by Boysan et al. (18). Their study determined that a total PCL-5 score of 47 or higher was the optimal cutoff value for predicting PTSD, with a sensitivity of 82% and a specificity of 71% Beck Depression Inventory (BDI) The Beck Depression Inventory (BDI), developed by Beck et al., is a 21-item self-report instrument designed to assess the severity of depression in individuals using a 4-point Likert scale (19). Each item is scored between 0 and 3, with a maximum possible total score of 63 points.The validity and reliability of the Turkish version of the BDI were established by Hisli, who reported a Cronbach’s alpha coefficient of 0.80 (20). Statistical Analysis Statistical analyses were conducted using SPSS 21.0 (Statistical Product and Service Solutions for Windows, Version 21.0, IBM Corp., Armonk, NY, USA, 2012). Descriptive statistics, including row percentages, means, and standard deviations, were used to summarize the data. Pearson’s chi-square test and the chi-square test with Yates’ continuity correction were applied to compare two or more groups in terms of categorical variables. Student’s t -test was used to assess the relationship between two continuous variables and the dependent variable. Independent variables that exhibited significant associations in binary analyses were included in a backward logistic regression analysis to identify the factors that predict the dependent variable. A probability ( p ) value of ≤ 0.05 was considered statistically significant. Results The final study sample comprised 400 individuals, replacing the 83 individuals (17.2%) who declined participation with an equal number of residents from neighboring containers. The mean age of the sample was 38.0 ± 14.4 years, with 53% female and 47% male participants. Participants’ sociodemographic characteristics are summarized in Table 1 . Table 1 The Relationships between Participants' Sociodemographic Characteristics and the Development of PTSD Variables Overall sample PTSD, yes PTSD, no p-value ** % % * % * Gender Female 53.0 66.0 34.0 0,020 Male 47.0 76.6 23.4 Marital status Single 19.3 75.3 24.7 0,473 Married 64.8 72.2 27.8 Widowed/divorced/spouse deceased 16.0 60.9 39.1 Education level Primary education or below 53.0 68.4 31.6 0,223 Secondary education or above 47.0 73.9 26.1 Employment status Unemployed 74.5 66.8 33.2 0,001 Employed 25.5 83.3 16.7 Lives alone or with family Alone 8.5 70.6 29.4 0,956 a With family 91.5 71.0 29.0 Smoking status Smoker 51.0 63.7 36.3 0,001 Nonsmoker 49.0 78.6 21.4 Alcohol use status Drinker 12.3 53.1 46.9 0,005 a Nondrinker 87.8 73.5 26.5 Mean ± SD Mean ± SD Mean ± SD Age 38.0 ± 14.4 36.6 ± 14.5 36.6 ± 13.9 0.202 b * Row Percentage, ** Pearson’sChi-Square test, a Chi-square test with Yates continuity correction, b Student’s t-test, SD; Standard Deviation According to PCL-5 scores, 29.0% of participants met the criteria for PTSD, while 38.8% were diagnosed with depression based on BDI scores. PTSD prevalence was higher among female participants (34.4%) compared to male participants (23.4%) ( p = 0.020). Additionally, PTSD was diagnosed in 74.5% of unemployed individuals compared to 25.5% of employed individuals ( p = 0.001), 36.3% of smokers compared to 21.4% of non-smokers ( p = 0.001), and 87.8% of alcohol users compared to 12.3% of non-drinkers ( p = 0.005) (Table 1 ). The associations between participants' experiences before, during, and after the earthquakes and the development of PTSD are summarized in Table 2 . The mean fear score during the earthquakes was significantly higher among individuals diagnosed with PTSD (8.1 ± 2.5) compared to those without a PTSD diagnosis (6.8 ± 2.9) ( p < 0.001). Similarly, the mean total BDI scores were 23.7 ± 9.8 for individuals with PTSD and 11.7 ± 7.5 for those without PTSD ( p < 0.001). Table 2 The Relationships between the Events that the Participants Experienced Before, During and After the Earthquakes and the Development of PTSD Variables Overall Sample (%) PTSD, no (%) PTSD, yes (%) p-value Previous psychiatric disorder No 83 75.0 25.0 < 0.001 Yes 17 51.5 48.5 Familial history of psychiatric disorder No 88 72.3 27.3 0.058 a Yes 12 58.3 41.7 Trapped under rubble No 88.8 72.4 27.6 0.121 a Yes 11.3 60 40 Physical injuries No 69.8 75.3 24.7 0.004 Yes 30.3 61.2 38.8 Waiting for relatives to be rescued from the rubble No 50.3 77.6 22.4 0.003 Yes 49.8 64.3 35.7 Participated in rescue efforts No 82.3 70.5 29.5 0.753 a Yes 17.8 73.2 26.8 Damage to the house Destroyed in major and aftershock earthquakes 25.8 63.1 36.9 0.040 Not destroyed (heavily, moderately or slightly damaged or undamaged) 74.3 73.7 26.3 Lost a member of the family No 88 73.6 26.4 0.004 a Yes 12 52.1 47.9 Lost relatives No 23 73.0 27.0 0.933 Yes 77 71.1 28.9 Lost a close friend No 32.5 80.0 20.0 0.006 Yes 67.5 66.7 33.3 Place of residence after the earthquakes Always lived in Hatay 28.5 74.6 25.4 0.322 Lived outside Hatay for a while 71.5 69.6 30.4 Loss of income No 15.5 85.5 14.5 0.010 a Yes 84.5 68.3 31.7 Psychiatric disorder after the earthquakes No 90.8 73.3 26.7 0.003 a Yes 9.3 48.6 51.4 Mean ± SD Mean ± SD Mean ± SD p-value Fear level (between 0 and 10) 7.2 ± 2.9 6.8 ± 2.9 8.1 ± 2.5 < 0.001 b Total PCL-5 score 36.3 ± 159 28.5 ± 11.1 55.4 ± 16.9 < 0.001 b Total BDI score 15.2 ± 9.9 11.7 ± 7.5 23.7 ± 9.8 < 0.001 b * Row Percentage, ** Pearson’sChi-Square test, a Chi-square test with Yates continuity correction, b Student’s t-test, SD; Standard Deviation. The fear level was measured on a scale from 0 to 10. It was analyzed as a categorical variable, with the median fear score of 8 designated as the cutoff value for predicting PTSD. Backward logistic regression analysis was conducted for 14 binary independent variables with a p -value of less than 0.10, considering PTSD development as the dependent variable. The R² value of the final model was calculated as 0.232 ( p < 0.001) (Table 3 ). Table 3 Risk Factors for PTSD Revealed by Backward Logistic Regression Analysis Predictors B p-value OR %95 CI Unemployed 0.952 0.004 2.590 1.358–4.937 Lost a member of the family 0.855 0.017 2.351 1.167–4.737 Alcohol use 0.837 0.019 2.310 1.147–4.650 Previous psychiatric disorder 0.809 0.007 2.245 1.253–4.025 Fear score 0.766 0.002 2.151 1.326–3.489 Lost a close friend 0.634 0.024 1.885 1.087–3.266 Smoking 0.509 0.044 1.663 1.013–2.730 OR = Odds Ratio, CI = Confidence Interval According to the model, unemployed individuals had a 2.590-fold higher risk of developing PTSD. Those who lost a family member due to the earthquakes had a 2.351-fold higher risk, alcohol users had a 2.310-fold higher risk, individuals with a pre-existing psychiatric disorder had a 2.245-fold higher risk, those with a fear score of 9 or above had a 2.151-fold higher risk, individuals who experienced the loss of a close friend due to the earthquakes had a 1.884-fold higher risk, and smokers had a 1.663-fold higher risk of developing PTSD. Discussion This study demonstrated that the higher prevalence of PTSD and depression remained notably high among earthquake survivors residing in temporary shelter areas in Hatay city center approximately one year after the 2023 Kahramanmaraş earthquakes. PTSD was identified in 29.0% of participants, while depression was observed in 38.8%. Studies conducted shortly after an earthquake typically report a higher prevalence of PTSD. Early studies on the Kahramanmaraş earthquakes reported PTSD prevalence rates ranging from 54.1–72.5% (21, 22). Similarly, in a study conducted in the early post-disaster period in the Gölcük district of Kocaeli province, the epicenter of the Marmara earthquake, Başoğlu et al. identified a PTSD prevalence of 43% (23). Following the Wenchuan earthquake in China, PTSD was detected in approximately two-thirds of participants in a study conducted within the first month (24). However, studies conducted one year later reported PTSD prevalence rates between 21.5% and 41% (25), which aligns with the findings of this study. A meta-analysis conducted by Dai et al. found that studies conducted within the first nine months following an earthquake report a higher incidence of PTSD compared to those conducted afterward (26). The severity of trauma and proximity to the earthquake's epicenter are critical factors influencing PTSD development (27, 28). The February earthquake was one of the most devastating in the country's history. Given that the study was conducted in the region experiencing the highest levels of destruction and fatalities, the observed PTSD prevalence rates are not unexpected. In a study conducted by Kilpatrick et al., the proportion of adults in the United States who had experienced trauma during their lifetime was reported as 89.7%, while the lifetime prevalence of PTSD was 8.3% (29). These findings highlight the importance of identifying additional factors contributing to PTSD, as trauma exposure alone is insufficient for its development. In this context, one of the key objectives of this study was to determine the predictors of PTSD. Multivariate analysis further identified unemployment after the earthquakes, fear experienced during the earthquakes, the loss of a family member due to the earthquakes, the loss of a close friend due to the earthquakes, alcohol use, smoking, and a pre-existing psychiatric disorder as significant predictors of PTSD. Unemployment following the earthquakes emerged as the most significant risk factor for PTSD development. Unemployment may contribute to PTSD development through both financial instability and the loss of a social environment. Notably, unemployment was prevalent within the study population. The data collection period faced with a challenging phase in which temporary accommodation centers provided shelter, yet employment opportunities had not been fully reestablished. The high unemployment rate serves as a critical indicator of the disaster’s severity. Numerous studies conducted after other earthquakes have consistently demonstrated an association between financial losses, loss of regular income, and PTSD (16, 30, 31). Furthermore, a 5.5-year follow-up study conducted after the 2011 Japan earthquake identified a strong relationship between job loss and persistent PTSD. Additionally, subjective economic losses were associated with the delayed onset of PTSD in the same study (32). In a study examining the relationship between unemployment and PTSD following the Chilean earthquake, it was proposed that the development of PTSD could help explain unemployment through an alternative model. The study also hypothesized a potential reciprocal interaction among stress, unemployment, and psychological outcomes, suggesting the emergence of a bidirectional relationship (33). Another significant predictor of PTSD was the level of fear experienced during the earthquakes. This finding aligns with previous studies conducted following earthquakes (34–38) and highlights the role of subjective trauma experiences in PTSD development. An increased perception of threat from the traumatic event, coupled with low controllability of stressors, further elevates the likelihood of traumatic stress occurring (39–42). The amygdala plays a crucial role in threat perception and fear regulation. In a study involving individuals exposed to war trauma, Wingen et al. found that severe stress heightened the reactivity of the amygdala and insula. They also emphasized that individual differences in threat perception were associated with variability in amygdala activity regulation (43). A study conducted with torture survivors demonstrated that prior preparation for trauma can mitigate symptoms of traumatic stress and general psychopathology. However, natural disasters such as earthquakes are unpredictable events for which individuals cannot prepare, and they are often followed by aftershocks. Such disasters can disrupt an individual’s fundamental belief that the world is structured, meaningful, and safe, thereby contributing to the development of traumatic stress (44). Several studies conducted following the Marmara earthquake have highlighted that factors such as being inside a building during the earthquake and proximity to the earthquake's epicenter were significant determinants of the level of fear experienced at the time of the event (35, 36). The region where this study was conducted is located near the epicenters of the earthquakes, which occurred at a time when the majority of the population was indoors. The loss of a family member or a close friend has been identified as a significant predictor of PTSD. Similarly, a meta-analysis by Tang et al. found that bereavement significantly increases the risk of developing PTSD (37). Furthermore, a study conducted 10 years after the Wenchuan earthquake reported that the loss of close family members was a significant risk factor for the development of long-term PTSD (45). This finding aligns with the well-documented observation that traumatic stress symptoms are triggered and sustained by adverse life events (38,46). However, several studies have suggested that bereavement is not a direct predictor of PTSD. Zhang emphasized that the nature of the relationship with the deceased, rather than the number of losses, plays a crucial role in the development of PTSD following an earthquake (47). In a follow-up study conducted by Karamustafalıoğlu et al., while harm or loss affecting one's relatives was a predictor of PTSD in the short term, this association was not observed ten years after the earthquake. The same study identified avoidance behavior as a predictor of PTSD (48). Given that the region where this study was conducted has a cultural structure characterized by strong family ties, it is understandable that bereavement may contribute to PTSD development. The loss of a family member or close relative may have exacerbated the individual's difficulty in processing the trauma by reducing the availability of essential social support needed for coping. In addition to a history of alcohol use and smoking prior to the earthquakes, a pre-existing psychiatric disorder also emerged as a significant predictor of PTSD. Similarly, several studies have reported that prior trauma and pre-traumatic psychopathology are strong predictors of PTSD ( 46, 49, 50). In a study conducted with disaster victims, North et al. found that while one-third of participants developed psychiatric disorders, only one-fifth developed a new psychiatric disorder following the disaster. This suggests that the majority of psychiatric diagnoses made after the disaster were pre-existing conditions (51). However, this study did not assess traumatic experiences occurring before the earthquakes. Several studies have demonstrated that individuals with a history of PTSD following previous traumatic experiences are at an increased risk of developing PTSD in response to subsequent traumatic events (52, 53). In other words, the presence of prior trauma-induced psychopathology, rather than the traumatic experience itself, is a critical determinant of whether subsequent traumas will lead to psychopathology. Thus, individuals predisposed to pathological responses to stressors are more likely to develop PTSD following subsequent traumatic events. Several studies have reported a high incidence of co-occurrence between PTSD and alcohol or tobacco use disorders (54). Following the L'Aquila earthquake in Italy, an increase in alcohol and tobacco consumption was observed among individuals both with and without a psychiatric diagnosis with no reported decrease among any participants (55). In contrast, a study conducted after the September 11 terrorist attacks in the United States observed a slight decrease in alcohol consumption, although other studies reported increases in both alcohol and tobacco use (56,57). The relationship between PTSD and substance use disorders is bidirectional; PTSD may contribute to increased alcohol consumption and smoking as coping mechanisms to alleviate its effects. Conversely, alcohol use and smoking can alter an individual’s stress response, heightening anxiety and arousal levels, thereby facilitating PTSD development (58). Although participants in this study were asked about their alcohol and tobacco use, the presence of alcohol or tobacco use disorders and whether individuals had received treatment for such disorders were not assessed. Therefore, the findings on the association between PTSD and substance use should be interpreted with caution. Limitations This study has several limitations. First, the prevalence of PTSD and depression was assessed using self-report questionnaires rather than clinical interviews. Second, interviewer assistance for participants who had difficulty reading the questionnaire may have introduced response bias. Third, the study sample included only individuals residing in container cities, excluding those living in their own homes, which may limit the generalizability of the findings to the broader population. Finally, the study focused solely on earthquake-related traumas, without evaluating potential pre-earthquake traumatic experiences. However, the study also has several strengths. It was designed as a population-based study with a robust sampling method and conducted in one of the regions most severely affected by the earthquakes, enhancing the reliability of its findings Conclusions This study found that approximately one-third of participants residing in temporary shelters one year after the 2023 Kahramanmaraş earthquakes diagnosed with PTSD, while more than one-third were diagnosed with depression. These findings highlights the critical need for large-scale and early psychosocial interventions in the post-disaster period. Several factors were identified as significant risk factors for PTSD, including unemployment following the earthquakes, a pre-existing psychiatric disorder, the loss of a family member or close friend due to the earthquakes, smoking, alcohol use, and the level of fear experienced during the earthquake. Based on these factors, high-risk groups for PTSD can be identified, enabling the development of effective preventive and treatment strategies. The social and economic instability experienced by earthquake survivors further underscores the importance of individualized mental health support. Future longitudinal studies that incorporate the impact of pre-earthquake traumatic experiences may offer a more comprehensive understanding of the development and trajectory of PTSD. Continuous monitoring of mental health in disaster-affected regions is essential for establishing sustainable, long-term mental health strategies. Declarations Acknowledgements: We would like to thank the participants of our study and the interviewers who provided assistance in data collection . Clinical trial number: not applicable. Ethical considerations: This study was approved by the Ethics Committee of Hatay Mustafa Kemal University in accordance with the Declaration of Helsinki (Approval Date: 29.08.2023, approval no: 26) Consent to participate: The interviewers provided the participants with detailed information about the study's objectives and the questionnaire prior to its administration. Both written and verbal consent were obtained from all participants. Consent for publication: Not applicable as this study does not include any identifying data. Declaration of conflicting interest: The authors declare no conflict of interest. Funding statement: No financial support was received for this study. Data availability: The data underlying this article will be shared on reasonable request to the corresponding author. Authors' Contributions : Ertan Yılmaz : Conceptualization, Investigation, Methodology, Writing-original draft, Writing-review editing, Data curation, Project administration Mehmet Erdem : Conceptualization, Methodology, Writing- review editing, Supervision, Visualization, Software, Formal analysis, Resources References Rubonis AV, Bickman L. Psychological impairment in the wake of disaster: the disaster-psychopathology relationship. Psychol. Bull . 1991;109(3): 384–99. doi:10.1037/0033-2909.109.3.384 North CS. Current research and recent breakthroughs on the mental health effects of disasters. Curr. Psychiatry Rep. 2014; 16(10):481. doi:10.1007/s11920-014-0481-9 American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington, D.C.: American Psychiatric Association Publishing; 2013. Galea S, Nandi A, Vlahov D. The Epidemiology of Post-Traumatic Stress Disorder after Disasters. 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Prevalence of posttraumatic stress disorder and comorbid depression in earthquake survivors in Turkey: an epidemiological study. J Trauma Stress 2004; 17(2): 133–41. doi:10.1023/B:JOTS.0000022619.31615.e8 Livanou M, Başoǧlu M, Salcioǧlu E, Kalendar D. Traumatic stress responses in treatment-seeking earthquake survivors in Turkey. J Nerv Ment Dis. 2002;190(12): 816–23. doi:10.1097/01.NMD.0000041958.58852.1D Salcioǧlu E, Başoǧlu M, Livanou M. Long-term psychological outcome for non-treatment-seeking earthquake survivors in Turkey. J Nerv Ment Dis . 2003;191(3): 154–60. doi:10.1097/01.NMD.0000054931.12291.50 Tang B, Deng Q, Glik D, Dong J, Zhang L. A Meta-Analysis of Risk Factors for Post-Traumatic Stress Disorder (PTSD) in Adults and Children after Earthquakes. Int J Environ Res Public Health. 2017;14(12):1537. doi:10.3390/ijerph14121537 Sirotich AC, Camisasca E. PTSD risk factors in earthquake survivors and their families: a systematic review. Eur J Psychotraumatol , 2024;15(1): 2365477. doi:10.1080/20008066.2024.2365477 Lancaster CL, Cobb AR, Lee HJ, Telch M. The role of perceived threat in the emergence of PTSD and depression symptoms during warzone deployment. Psychol. Trauma: Theory Res. Pract. Policy 2016;8(4): 528–34. doi: 10.1037/tra0000129. PMID: 27348069. Ozer EJ, Best SR, Lipsey TL, Weiss DS. Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol Bull . 2003;129(1): 52–73. doi: 10.1037/0033-2909.129.1.52. Salcioglu E, Urhan S, Pirinccioglu T, Aydin S. Anticipatory fear and helplessness predict PTSD and depression in domestic violence survivors. Psychol Trauma: Theory Res. Pract. Policy. 2017;9(1): 117–25. doi:10.1037/tra0000200 Dokkedahl SB, Lahav Y. Peritraumatic dissociation and posttraumatic stress symptoms: the moderating role of perceived threat. European Journal of Psychotraumatology. 2024:15(1). doi:10.1080/20008066.2024.2338670 Van Wingen GA, Geuze E, Vermetten E, Fernandez G. Perceived threat predicts the neural sequelae of combat stress. Mol Psychiatry. 2011;16(6): 664–71. doi:10.1038/mp.2010.132 Başoǧlu M, Mineka S, Paker M, Aker T, Livanou M, Gök S. Psychological preparedness for trauma as a protective factor in survivors of torture. Psychol Med. 1997;27(6): 1421–33. doi:10.1017/s0033291797005679 Lu B, Zeng W, Li Z,Wen J. Risk factors of post-traumatic stress disorder 10 years after Wenchuan earthquake: a population-based case–control study. Epidemiol Psychiatr Sci. 2021;30: e25. doi:10.1017/S2045796021000123 Cénat JM, McIntee SE, Blais-Rochette C. Symptoms of posttraumatic stress disorder, depression, anxiety and other mental health problems following the 2010 earthquake in Haiti: A systematic review and meta-analysis. J Affect Disord. 2020;273:55-85. doi:10.1016/j.jad.2020.04.046 Zhang Z, Shi Z, Wang L, Liu M. One year later: Mental health problems among survivors in hard-hit areas of the Wenchuan earthquake. Public Health. 2011;125(5): 293–300. doi:10.1016/j.puhe.2010.12.008 Karamustafalıoğlu OK, Fostick L, Çevik M, Zukerman G, Tankaya O, Güveli M, et al. Ten-Year Follow-Up of Earthquake Survivors: Long-Term Study on the Course of PTSD Following a Natural Disaster. J Clin Psychiatry. 2023;84(2): 22m14377. doi:10.4088/JCP.22m14377 Tortella-Feliu M, Fullana MA, Pérez-Vigil A, Torres X, Chamorro J, Littarelli SA, et al. Risk factors for posttraumatic stress disorder: An umbrella review of systematic reviews and meta-analyses. Neurosci Biobehav Rev. 2019;107:154-65. doi:10.1016/j.neubiorev.2019.09.013 Tural U, Coşkun B, Onder E, Corapçioğlu A, Yildiz M, Kesepara C. et al. Psychological consequences of the 1999 earthquake in Turkey. J Trauma Stress. 2004;17(6): 451–9 doi:10.1007/s10960-004-5793-9 North CS, Oliver J and Pandya A Examining a Comprehensive Model of Disaster-Related Posttraumatic Stress Disorder in Systematically Studied Survivors of 10 Disasters. Am J Public Health. 2012; 102(10): e40. doi:10.2105/AJPH.2012.300689 Breslau N, Peterson EL and Schultz LR. A second look at prior trauma and the posttraumatic stress disorder effects of subsequent trauma: a prospective epidemiological study. Arch Gen Psychiatry. 2008;65(4): 431–7 doi:10.1001/archpsyc.65.4.431 Breslau N and Peterson EL Assaultive violence and the risk of posttraumatic stress disorder following a subsequent trauma. Behav Res Ther: 2010;48(10):1063–6. doi:10.1016/j.brat.2010.07.001 Pericot-Valverde I, Elliott RJ, Miller ME, Tidey JW, Gaalema DE. Posttraumatic stress disorder and tobacco use: A systematic review and meta-analysis. Addict Behav 2018; 84: 238-47 doi:10.1016/j.addbeh.2018.04.024 Pollice R, Bianchini V, Roncone R, Casacchia M. Marked increase in substance use among young people after L'Aquila earthquake. Eur Child Adolesc Psychiatry. 2011;20(8):429-30. doi:10.1007/s00787-011-0192-2 Vlahov D, Galea S, Resnick H, Ahern J, Boscarino JA, Bucuvalas M, et al. Increased use of cigarettes, alcohol, and marijuana among Manhattan, New York, residents after the September 11th terrorist attacks. Am J Epidemiol. 2002;155(11):988-96. doi:10.1093/aje/155.11.988 Knudsen HK, Roman PM, Johnson JA, Ducharme LJ. A changed America? The effects of September 11th on depressive symptoms and alcohol consumption. J Health Soc Behav. 2005;46(3):260-73. doi:10.1177/002214650504600304 Brady KT, Sinha R Co-occurring mental and substance use disorders: the neurobiological effects of chronic stress. Am J Psychiatry 2005;162(8): 1483–93. doi:10.1176/appi.ajp.162.8.1483 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 07 May, 2025 Read the published version in BMC Psychiatry → Version 1 posted Editorial decision: Accepted 28 Apr, 2025 Reviews received at journal 20 Apr, 2025 Reviewers agreed at journal 20 Apr, 2025 Reviewers invited by journal 14 Apr, 2025 Submission checks completed at journal 29 Mar, 2025 First submitted to journal 27 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5781679","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":442704178,"identity":"07ce6254-44bd-485d-9d45-1d5635b5b94e","order_by":0,"name":"Ertan Yılmaz","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYPACCwYG+ccHHwBZPHyEVTODCAkgTks2AGlhI0FLjhmIZCCohV/6/MHPhW0S0fINx9Iqv+bYybAxMD98dAOPFsm+ZGbpmW0SuY2Nzcduy25LBjqMzdg4B48WgzPMDNK8QC3NzGxptyW3MQO18LBJ49Nif4aZ+TdISxsbj1mx5LZ6wloMeJjZwLb08PCYMX7cdpiwFokzzGbWPOckcmdIsCVLM247zsPGTMAv/D2Mj2/zlNnkzp/BfPDjz23V9vzszQ8f49MCBozQuGDmAZOElIPBH6jWH0SpHgWjYBSMgpEGAHT3PQwH9u4lAAAAAElFTkSuQmCC","orcid":"","institution":"Hatay Mustafa Kemal University","correspondingAuthor":true,"prefix":"","firstName":"Ertan","middleName":"","lastName":"Yılmaz","suffix":""},{"id":442704179,"identity":"b8bb88fa-d675-41d1-90ad-d5a31cc9bebb","order_by":1,"name":"Mehmet Erdem","email":"","orcid":"","institution":"Hatay Mustafa Kemal University","correspondingAuthor":false,"prefix":"","firstName":"Mehmet","middleName":"","lastName":"Erdem","suffix":""}],"badges":[],"createdAt":"2025-01-07 13:23:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5781679/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5781679/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12888-025-06919-9","type":"published","date":"2025-05-07T15:57:44+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82537567,"identity":"b0994014-0754-48a0-b21d-66871c60d851","added_by":"auto","created_at":"2025-05-12 16:08:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1172504,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5781679/v1/e03dc0f5-b0d7-40ec-abfc-0dbaf57e7aea.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Post-Traumatic Stress Disorder in Earthquake Survivors Living in Temporary Shelter Areas in Hatay Central Districts: A Cross-Sectional Study","fulltext":[{"header":"Background","content":"\u003cp\u003eEarthquakes, classified as natural disasters, are recognized as traumatic events due to their widespread impact, causing loss of life and destruction on a large scale. A key distinction between earthquakes and other disasters is that affected individuals must continue to live with the persistent risk of recurrence (1).\u003c/p\u003e \u003cp\u003eEarthquakes can have significant consequences for both physical and psychological health. Post-disaster traumatic stress reactions encompass a broad spectrum, ranging from grief, fear, and anxiety to more severe psychiatric conditions, such as post-traumatic stress disorder (PTSD). Among the psychiatric disorders that may arise following traumatic events, PTSD is one of the most extensively studied and most prevalent (2). According to the DSM-5 criteria, exposure to a traumatic event, which is a key diagnostic criterion for PTSD, may occur through direct experience or witnessing actual or threatened events involving death, serious injury, or sexual violence. PTSD is characterized by multiple symptom clusters, including intrusion, avoidance, negative alterations in cognition and mood, and changes in arousal and reactivity (3).\u003c/p\u003e \u003cp\u003eResearch on PTSD has demonstrated that the prevalence of PTSD among disaster survivors ranges from 5\u0026ndash;60% (4), which is significantly higher than its prevalence in the general population, ranging from 0\u0026ndash;3.8% (5).\u003c/p\u003e \u003cp\u003eOne of the major challenges posed by disasters is the potential permanence of psychological effects in some survivors. According to the National Comorbidity Survey, one-third of disaster survivors continue to experience PTSD symptoms even a decade after the traumatic event (6). In a 25-year follow-up study, Goenjian et al. highlighted that PTSD and depression became chronic in most survivors of the Armenian earthquake; however, they noted that early psychological interventions could have lasting positive effects (7). Similarly, a study conducted three years after the Nepal earthquake found PTSD in approximately one-fifth of participants (8). Zhang et al. reported a PTSD prevalence of 10.3% three years post-Wenchuan earthquake in China (9).\u003c/p\u003e \u003cp\u003eVarious risk factors encountered before, during, and after a disaster can contribute to the development of psychopathology in its aftermath. Pre-disaster risk factors include age, gender, education level, pre-existing psychiatric disorders, and adverse childhood experiences. Risk factors during the disaster encompass proximity to the earthquake epicenter, trauma severity, and the loss of a loved one. Post-disaster risk factors involve the loss of social support and ongoing life stressors (10,11).\u003c/p\u003e \u003cp\u003eAmong the Kahramanmaraş earthquakes, the epicenter of the first, with a magnitude of 7.7 on the Richter scale, was in the Pazarcık district of Turkey\u0026rsquo;s Kahramanmaraş province. This earthquake occurred at 04:17 on February 6, 2023. The epicenter of the second earthquake, which had a magnitude of 7.6, was in the Elbistan district of the same province and occurred at 13:30 on the same day (12). These two earthquakes affected a vast area encompassing 11 provinces, including Kahramanmaraş and Hatay, with the total population of these regions accounting for approximately 16% of Turkey\u0026rsquo;s population (13).\u003c/p\u003e \u003cp\u003eThe World Health Organization (WHO) classified this disaster as a \u003cb\u003e\"\u003c/b\u003eLevel 3 Emergency,\" the highest level of emergency response (14). Following the initial earthquakes, a third earthquake, with a magnitude of 6.4, struck the Yayladağı district of Hatay province at 20:04 on February 20, 2023. Since the first earthquake, more than 33,000 aftershocks have been recorded as of May 6, 2023.\u003c/p\u003e \u003cp\u003eAccording to official reports, the earthquakes resulted in over 50,000 fatalities and more than 100,000 injuries. The number of collapsed and severely damaged buildings is estimated at approximately 500,000. The economic cost of this disaster to Turkey is estimated to be approximately 85\u0026nbsp;billion United States (US) dollars (13)\u003c/p\u003e \u003cp\u003eHatay province experienced the highest level of destruction and loss of life from these earthquakes. Notably, 40% of all earthquake-related fatalities occurred in Hatay (15). Consequently, the sample for this study was selected from individuals residing in temporary shelter areas within the central districts of Hatay, namely Antakya and Defne.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, no population-based study has yet examined the mental health outcomes of adult earthquake survivors in Hatay province and the associated risk factors. Based on official data regarding these earthquakes, we hypothesized that residents of Hatay\u0026rsquo;s central districts experienced significant exposure to earthquake-induced trauma, leading to a high prevalence of PTSD and depression in these areas.\u003c/p\u003e \u003cp\u003eTo evaluate this hypothesis, the primary outcome of this study was defined as the prevalence of PTSD and depression among individuals living in temporary shelter areas within the central districts of Hatay. The secondary outcome was identified as the risk factors contributing to these conditions. Identifying these factors may facilitate in the development of targeted psychosocial support programs and appropriate treatment interventions for earthquake survivors.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eThis study was designed as a cross-sectional, population-based study. Ethical approval was obtained from the Ethics Committee of Hatay Mustafa Kemal University in accordance with the Declaration of Helsinki (Approval Date: 29.08.2023, Approval No: 26). The study was conducted in the central districts of Hatay, specifically Antakya and Defne, during October and November following the earthquakes.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePopulation and Sample\u003c/h3\u003e\n\u003cp\u003eThe research was conducted in a single city. Clusters for the research sample were selected from both central districts, Antakya and Defne, located in the heart of Hatay, the city most severely affected by the earthquake and where the greatest destruction occurred. The study population consisted of adults living in container cities within the Antakya and Defne districts of Hatay province. According to municipal authorities, as of the study period, approximately 70,000 individuals were living in 48 container cities in Antakya, while approximately 10,000 individuals were residing in 18 container cities in Defne, totaling around 80,000 people in temporary shelter areas in the central districts of Hatay. The expected incidence was estimated at 50% based on previous studies, with a target sample size of at least 384 participants, calculated using a 5% margin of error and a 95% confidence interval (16). Multistage cluster sampling was employed to select participants for the study. Container cities with a population of fewer than 1,000 residents, as well as those housing officials from outside the province who had not directly experienced the earthquakes, were excluded from the sampling frame.\u003c/p\u003e \u003cp\u003eConsequently, 10 individuals were randomly selected from each of the 40 container cities with 30 located in Antakya and 10 in Defne, using simple random sampling. Thus, the final study sample comprised a total of 400 participants across these 40 groups.\u003c/p\u003e \u003cp\u003eIndividuals who were unavailable for interviews during the day due to work commitments were approached again in the evening. If participants could not be reached in both attempts or declined to participate in the study, replacement participants were selected from neighboring containers in equal numbers to maintain the sample size.\u003c/p\u003e \u003cp\u003e \u003cem\u003eStudy Inclusion Criteria\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eBeing an earthquake survivor\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eBeing over 18 years old\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLiving in temporary shelter\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHolding citizenship of the Republic of Turkey\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHaving the cognitive capacity to understand and answer the questionnaire\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHaving volunteered to participate in the study\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\n\u003ch3\u003e7. Exclusion Criteria\u003c/h3\u003e\n\u003cp\u003eResiding in permanent residences\u003c/p\u003e \u003cp\u003eResiding outside the borders of Antakya and Defne districts\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003ePrior to data collection, a pilot study was conducted with 10 participants as part of the training provided to the interviewers by the researchers. Study data were collected using self-report questionnaires completed by participants with assistance from two university graduate interviewers, one male and one female. For participants who had difficulty reading the questionnaire, interviewers read the questions aloud. Before administering the questionnaire, the interviewers informed participants about the study's objectives and the questionnaire's content. Written and verbal consent was obtained prior to participation. The questionnaire was administered either in the participants\u0026rsquo; containers or in other preferred locations near their residences. Completion of the questionnaire took approximately 45\u0026ndash;60 minutes. Participants did not receive any financial compensation for their participation in the study.\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003eThe questionnaire, developed by the researchers, comprised 38 questions assessing participants' sociodemographic characteristics (age, gender, education level, income level) and adverse events experienced before, during, and after the earthquakes.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePost-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5)\u003c/h2\u003e \u003cp\u003eThe PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (PCL-5), is a 20-item self-report instrument developed in accordance with DSM-5 criteria for PTSD. It assesses PTSD symptoms, which are categorized into four symptom clusters reflecting the DSM-5 diagnostic criteria: reexperiencing, avoidance, negative alterations in cognition and mood, and hyperarousal. Each item is scored on a scale from 0 to 4, with a maximum possible total score of 80 points (17). The validity and reliability of the Turkish version of the PCL-5 were established by Boysan et al. (18). Their study determined that a total PCL-5 score of 47 or higher was the optimal cutoff value for predicting PTSD, with a sensitivity of 82% and a specificity of 71%\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eBeck Depression Inventory (BDI)\u003c/h3\u003e\n\u003cp\u003eThe Beck Depression Inventory (BDI), developed by Beck et al., is a 21-item self-report instrument designed to assess the severity of depression in individuals using a 4-point Likert scale (19). Each item is scored between 0 and 3, with a maximum possible total score of 63 points.The validity and reliability of the Turkish version of the BDI were established by Hisli, who reported a Cronbach\u0026rsquo;s alpha coefficient of 0.80 (20).\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were conducted using SPSS 21.0 (Statistical Product and Service Solutions for Windows, Version 21.0, IBM Corp., Armonk, NY, USA, 2012).\u003c/p\u003e \u003cp\u003eDescriptive statistics, including row percentages, means, and standard deviations, were used to summarize the data. Pearson\u0026rsquo;s chi-square test and the chi-square test with Yates\u0026rsquo; continuity correction were applied to compare two or more groups in terms of categorical variables. Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e-test was used to assess the relationship between two continuous variables and the dependent variable. Independent variables that exhibited significant associations in binary analyses were included in a backward logistic regression analysis to identify the factors that predict the dependent variable. A probability (\u003cem\u003ep\u003c/em\u003e) value of \u0026le;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe final study sample comprised 400 individuals, replacing the 83 individuals (17.2%) who declined participation with an equal number of residents from neighboring containers. The mean age of the sample was 38.0\u0026thinsp;\u0026plusmn;\u0026thinsp;14.4 years, with 53% female and 47% male participants. Participants\u0026rsquo; sociodemographic characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe Relationships between Participants' Sociodemographic Characteristics and the Development of PTSD\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOverall sample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePTSD,\u003c/p\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePTSD,\u003c/p\u003e \u003cp\u003eno\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value **\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003cb\u003e*\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003cb\u003e*\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0,020\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0,473\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWidowed/divorced/spouse deceased\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary education or below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,223\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary education or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eEmployment status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eLives alone or with family\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0,956\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWith family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSmoking status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSmoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNonsmoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eAlcohol use status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDrinker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0,005\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNondrinker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.0\u0026thinsp;\u0026plusmn;\u0026thinsp;14.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.6\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36.6\u0026thinsp;\u0026plusmn;\u0026thinsp;13.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.202\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003e*\u003c/b\u003eRow Percentage, \u003cb\u003e**\u003c/b\u003e Pearson\u0026rsquo;sChi-Square test, \u003csup\u003ea\u003c/sup\u003eChi-square test with Yates continuity correction, \u003csup\u003eb\u003c/sup\u003eStudent\u0026rsquo;s t-test,\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eSD; Standard Deviation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAccording to PCL-5 scores, 29.0% of participants met the criteria for PTSD, while 38.8% were diagnosed with depression based on BDI scores. PTSD prevalence was higher among female participants (34.4%) compared to male participants (23.4%) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.020). Additionally, PTSD was diagnosed in 74.5% of unemployed individuals compared to 25.5% of employed individuals (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001), 36.3% of smokers compared to 21.4% of non-smokers (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001), and 87.8% of alcohol users compared to 12.3% of non-drinkers (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The associations between participants' experiences before, during, and after the earthquakes and the development of PTSD are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The mean fear score during the earthquakes was significantly higher among individuals diagnosed with PTSD (8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5) compared to those without a PTSD diagnosis (6.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, the mean total BDI scores were 23.7\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8 for individuals with PTSD and 11.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5 for those without PTSD (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe Relationships between the Events that the Participants Experienced Before, During and After the Earthquakes and the Development of PTSD\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall Sample (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePTSD,\u003c/p\u003e \u003cp\u003eno\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePTSD,\u003c/p\u003e \u003cp\u003eyes\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious psychiatric disorder\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamilial history of psychiatric disorder\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.058\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTrapped under rubble\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.121\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysical injuries\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWaiting for relatives to be rescued from the rubble\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParticipated in rescue efforts\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.753\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDamage to the house\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDestroyed in major and aftershock earthquakes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.040\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot destroyed (heavily, moderately or slightly damaged or undamaged)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLost a member of the family\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLost relatives\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.933\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLost a close friend\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlace of residence after the earthquakes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways lived in Hatay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.322\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLived outside Hatay for a while\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLoss of income\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.010\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePsychiatric disorder after the earthquakes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFear level (between 0 and 10)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal PCL-5 score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.3\u0026thinsp;\u0026plusmn;\u0026thinsp;159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55.4\u0026thinsp;\u0026plusmn;\u0026thinsp;16.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal BDI score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.2\u0026thinsp;\u0026plusmn;\u0026thinsp;9.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.7\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003e*\u003c/b\u003eRow Percentage, \u003cb\u003e**\u003c/b\u003e Pearson\u0026rsquo;sChi-Square test, \u003csup\u003ea\u003c/sup\u003eChi-square test with Yates continuity correction, \u003csup\u003eb\u003c/sup\u003eStudent\u0026rsquo;s t-test, SD; Standard Deviation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe fear level was measured on a scale from 0 to 10. It was analyzed as a categorical variable, with the median fear score of 8 designated as the cutoff value for predicting PTSD.\u003c/p\u003e \u003cp\u003eBackward logistic regression analysis was conducted for 14 binary independent variables with a \u003cem\u003ep\u003c/em\u003e-value of less than 0.10, considering PTSD development as the dependent variable. The \u003cem\u003eR\u0026sup2;\u003c/em\u003e value of the final model was calculated as 0.232 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRisk Factors for PTSD Revealed by Backward Logistic Regression Analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%95 CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUnemployed\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.952\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.590\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.358\u0026ndash;4.937\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLost a member of the family\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.855\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.351\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.167\u0026ndash;4.737\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlcohol use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.837\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.310\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.147\u0026ndash;4.650\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrevious psychiatric disorder\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.809\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.245\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.253\u0026ndash;4.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFear score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.766\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.326\u0026ndash;3.489\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLost a close friend\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.634\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.885\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.087\u0026ndash;3.266\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSmoking\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.509\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.044\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.663\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.013\u0026ndash;2.730\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eOR\u0026thinsp;=\u0026thinsp;Odds Ratio, CI\u0026thinsp;=\u0026thinsp;Confidence Interval\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAccording to the model, unemployed individuals had a 2.590-fold higher risk of developing PTSD. Those who lost a family member due to the earthquakes had a 2.351-fold higher risk, alcohol users had a 2.310-fold higher risk, individuals with a pre-existing psychiatric disorder had a 2.245-fold higher risk, those with a fear score of 9 or above had a 2.151-fold higher risk, individuals who experienced the loss of a close friend due to the earthquakes had a 1.884-fold higher risk, and smokers had a 1.663-fold higher risk of developing PTSD.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrated that the higher prevalence of PTSD and depression remained notably high among earthquake survivors residing in temporary shelter areas in Hatay city center approximately one year after the 2023 Kahramanmaraş earthquakes. PTSD was identified in 29.0% of participants, while depression was observed in 38.8%. Studies conducted shortly after an earthquake typically report a higher prevalence of PTSD.\u003c/p\u003e \u003cp\u003eEarly studies on the Kahramanmaraş earthquakes reported PTSD prevalence rates ranging from 54.1\u0026ndash;72.5% (21, 22). Similarly, in a study conducted in the early post-disaster period in the G\u0026ouml;lc\u0026uuml;k district of Kocaeli province, the epicenter of the Marmara earthquake, Başoğlu et al. identified a PTSD prevalence of 43% (23). Following the Wenchuan earthquake in China, PTSD was detected in approximately two-thirds of participants in a study conducted within the first month (24). However, studies conducted one year later reported PTSD prevalence rates between 21.5% and 41% (25), which aligns with the findings of this study.\u003c/p\u003e \u003cp\u003eA meta-analysis conducted by Dai et al. found that studies conducted within the first nine months following an earthquake report a higher incidence of PTSD compared to those conducted afterward (26). The severity of trauma and proximity to the earthquake's epicenter are critical factors influencing PTSD development (27, 28).\u003c/p\u003e \u003cp\u003eThe February earthquake was one of the most devastating in the country's history. Given that the study was conducted in the region experiencing the highest levels of destruction and fatalities, the observed PTSD prevalence rates are not unexpected.\u003c/p\u003e \u003cp\u003eIn a study conducted by Kilpatrick et al., the proportion of adults in the United States who had experienced trauma during their lifetime was reported as 89.7%, while the lifetime prevalence of PTSD was 8.3% (29). These findings highlight the importance of identifying additional factors contributing to PTSD, as trauma exposure alone is insufficient for its development. In this context, one of the key objectives of this study was to determine the predictors of PTSD.\u003c/p\u003e \u003cp\u003eMultivariate analysis further identified unemployment after the earthquakes, fear experienced during the earthquakes, the loss of a family member due to the earthquakes, the loss of a close friend due to the earthquakes, alcohol use, smoking, and a pre-existing psychiatric disorder as significant predictors of PTSD.\u003c/p\u003e \u003cp\u003eUnemployment following the earthquakes emerged as the most significant risk factor for PTSD development. Unemployment may contribute to PTSD development through both financial instability and the loss of a social environment. Notably, unemployment was prevalent within the study population. The data collection period faced with a challenging phase in which temporary accommodation centers provided shelter, yet employment opportunities had not been fully reestablished. The high unemployment rate serves as a critical indicator of the disaster\u0026rsquo;s severity.\u003c/p\u003e \u003cp\u003eNumerous studies conducted after other earthquakes have consistently demonstrated an association between financial losses, loss of regular income, and PTSD (16, 30, 31). Furthermore, a 5.5-year follow-up study conducted after the 2011 Japan earthquake identified a strong relationship between job loss and persistent PTSD. Additionally, subjective economic losses were associated with the delayed onset of PTSD in the same study (32). In a study examining the relationship between unemployment and PTSD following the Chilean earthquake, it was proposed that the development of PTSD could help explain unemployment through an alternative model. The study also hypothesized a potential reciprocal interaction among stress, unemployment, and psychological outcomes, suggesting the emergence of a bidirectional relationship (33).\u003c/p\u003e \u003cp\u003eAnother significant predictor of PTSD was the level of fear experienced during the earthquakes. This finding aligns with previous studies conducted following earthquakes (34\u0026ndash;38) and highlights the role of subjective trauma experiences in PTSD development. An increased perception of threat from the traumatic event, coupled with low controllability of stressors, further elevates the likelihood of traumatic stress occurring (39\u0026ndash;42).\u003c/p\u003e \u003cp\u003eThe amygdala plays a crucial role in threat perception and fear regulation. In a study involving individuals exposed to war trauma, Wingen et al. found that severe stress heightened the reactivity of the amygdala and insula. They also emphasized that individual differences in threat perception were associated with variability in amygdala activity regulation (43).\u003c/p\u003e \u003cp\u003eA study conducted with torture survivors demonstrated that prior preparation for trauma can mitigate symptoms of traumatic stress and general psychopathology. However, natural disasters such as earthquakes are unpredictable events for which individuals cannot prepare, and they are often followed by aftershocks. Such disasters can disrupt an individual\u0026rsquo;s fundamental belief that the world is structured, meaningful, and safe, thereby contributing to the development of traumatic stress (44).\u003c/p\u003e \u003cp\u003eSeveral studies conducted following the Marmara earthquake have highlighted that factors such as being inside a building during the earthquake and proximity to the earthquake's epicenter were significant determinants of the level of fear experienced at the time of the event (35, 36). The region where this study was conducted is located near the epicenters of the earthquakes, which occurred at a time when the majority of the population was indoors.\u003c/p\u003e \u003cp\u003eThe loss of a family member or a close friend has been identified as a significant predictor of PTSD. Similarly, a meta-analysis by Tang et al. found that bereavement significantly increases the risk of developing PTSD (37). Furthermore, a study conducted 10 years after the Wenchuan earthquake reported that the loss of close family members was a significant risk factor for the development of long-term PTSD (45). This finding aligns with the well-documented observation that traumatic stress symptoms are triggered and sustained by adverse life events (38,46).\u003c/p\u003e \u003cp\u003eHowever, several studies have suggested that bereavement is not a direct predictor of PTSD. Zhang emphasized that the nature of the relationship with the deceased, rather than the number of losses, plays a crucial role in the development of PTSD following an earthquake (47). In a follow-up study conducted by Karamustafalıoğlu et al., while harm or loss affecting one's relatives was a predictor of PTSD in the short term, this association was not observed ten years after the earthquake. The same study identified avoidance behavior as a predictor of PTSD (48). Given that the region where this study was conducted has a cultural structure characterized by strong family ties, it is understandable that bereavement may contribute to PTSD development. The loss of a family member or close relative may have exacerbated the individual's difficulty in processing the trauma by reducing the availability of essential social support needed for coping.\u003c/p\u003e \u003cp\u003eIn addition to a history of alcohol use and smoking prior to the earthquakes, a pre-existing psychiatric disorder also emerged as a significant predictor of PTSD. Similarly, several studies have reported that prior trauma and pre-traumatic psychopathology are strong predictors of PTSD ( 46, 49, 50). In a study conducted with disaster victims, North et al. found that while one-third of participants developed psychiatric disorders, only one-fifth developed a new psychiatric disorder following the disaster. This suggests that the majority of psychiatric diagnoses made after the disaster were pre-existing conditions (51). However, this study did not assess traumatic experiences occurring before the earthquakes.\u003c/p\u003e \u003cp\u003eSeveral studies have demonstrated that individuals with a history of PTSD following previous traumatic experiences are at an increased risk of developing PTSD in response to subsequent traumatic events (52, 53). In other words, the presence of prior trauma-induced psychopathology, rather than the traumatic experience itself, is a critical determinant of whether subsequent traumas will lead to psychopathology. Thus, individuals predisposed to pathological responses to stressors are more likely to develop PTSD following subsequent traumatic events.\u003c/p\u003e \u003cp\u003eSeveral studies have reported a high incidence of co-occurrence between PTSD and alcohol or tobacco use disorders (54). Following the L'Aquila earthquake in Italy, an increase in alcohol and tobacco consumption was observed among individuals both with and without a psychiatric diagnosis with no reported decrease among any participants (55). In contrast, a study conducted after the September 11 terrorist attacks in the United States observed a slight decrease in alcohol consumption, although other studies reported increases in both alcohol and tobacco use (56,57).\u003c/p\u003e \u003cp\u003eThe relationship between PTSD and substance use disorders is bidirectional; PTSD may contribute to increased alcohol consumption and smoking as coping mechanisms to alleviate its effects. Conversely, alcohol use and smoking can alter an individual\u0026rsquo;s stress response, heightening anxiety and arousal levels, thereby facilitating PTSD development (58). Although participants in this study were asked about their alcohol and tobacco use, the presence of alcohol or tobacco use disorders and whether individuals had received treatment for such disorders were not assessed. Therefore, the findings on the association between PTSD and substance use should be interpreted with caution.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, the prevalence of PTSD and depression was assessed using self-report questionnaires rather than clinical interviews. Second, interviewer assistance for participants who had difficulty reading the questionnaire may have introduced response bias. Third, the study sample included only individuals residing in container cities, excluding those living in their own homes, which may limit the generalizability of the findings to the broader population. Finally, the study focused solely on earthquake-related traumas, without evaluating potential pre-earthquake traumatic experiences. However, the study also has several strengths. It was designed as a population-based study with a robust sampling method and conducted in one of the regions most severely affected by the earthquakes, enhancing the reliability of its findings\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study found that approximately one-third of participants residing in temporary shelters one year after the 2023 Kahramanmaraş earthquakes diagnosed with PTSD, while more than one-third were diagnosed with depression. These findings highlights the critical need for large-scale and early psychosocial interventions in the post-disaster period. Several factors were identified as significant risk factors for PTSD, including unemployment following the earthquakes, a pre-existing psychiatric disorder, the loss of a family member or close friend due to the earthquakes, smoking, alcohol use, and the level of fear experienced during the earthquake. Based on these factors, high-risk groups for PTSD can be identified, enabling the development of effective preventive and treatment strategies. The social and economic instability experienced by earthquake survivors further underscores the importance of individualized mental health support.\u003c/p\u003e \u003cp\u003eFuture longitudinal studies that incorporate the impact of pre-earthquake traumatic experiences may offer a more comprehensive understanding of the development and trajectory of PTSD. Continuous monitoring of mental health in disaster-affected regions is essential for establishing sustainable, long-term mental health strategies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the participants of our study and the interviewers who provided assistance in data collection\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eClinical trial number:\u0026nbsp;\u003c/em\u003enot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthical considerations:\u003c/em\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThis study was approved by the Ethics Committee of Hatay Mustafa Kemal University in accordance with the Declaration of Helsinki (Approval Date: 29.08.2023, approval no: 26)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent to participate:\u003c/em\u003e The interviewers provided the participants with detailed information about the study\u0026apos;s objectives and the questionnaire prior to its administration. Both written and verbal consent were obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication:\u003c/em\u003e Not applicable as this study does not include any identifying data.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDeclaration of conflicting interest:\u0026nbsp;\u003c/em\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding statement:\u003c/em\u003e No financial support was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData availability:\u0026nbsp;\u003c/em\u003eThe data underlying this article will be shared on reasonable request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; Contributions\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eErtan Yılmaz : Conceptualization, Investigation, Methodology, Writing-original draft, Writing-review editing, Data curation, Project administration\u003c/p\u003e\n\u003cp\u003eMehmet Erdem\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eConceptualization,\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eMethodology, Writing- review editing, Supervision, Visualization, Software, Formal analysis, Resources\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRubonis AV, Bickman L. Psychological impairment in the wake of disaster: the disaster-psychopathology relationship. Psychol. Bull\u003cem\u003e. \u003c/em\u003e1991;109(3): 384\u0026ndash;99. doi:10.1037/0033-2909.109.3.384\u003c/li\u003e\n\u003cli\u003eNorth CS. Current research and recent breakthroughs on the mental health effects of disasters. Curr. Psychiatry Rep. 2014; 16(10):481. doi:10.1007/s11920-014-0481-9\u003c/li\u003e\n\u003cli\u003eAmerican Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington, D.C.: American Psychiatric Association Publishing; 2013.\u003c/li\u003e\n\u003cli\u003eGalea S, Nandi A, Vlahov D. The Epidemiology of Post-Traumatic Stress Disorder after Disasters. Epidemiol Rev. 2005;27(1):78\u0026ndash;91. doi:10.1093/epirev/mxi003.\u003c/li\u003e\n\u003cli\u003eBromet EJ, Atwoli L, Kawakami N, Navarro-Mateu F, Piotrowski P, King AJ, et al. Post-traumatic stress disorder associated with natural and human-made disasters in the World Mental Health Surveys. Psychol Med. 2017;47(2):227\u0026ndash;41. doi:10.1017/S0033291716002026\u003c/li\u003e\n\u003cli\u003eKessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52(12):1048\u0026ndash;60. doi:10.1001/archpsyc.1995.03950240066012\u003c/li\u003e\n\u003cli\u003eGoenjian AK, Steinberg AM, Walling D, Bishop S, Karayan I, Pynoos R. 25-year follow-up of treated and not-treated adolescents after the Spitak earthquake: course and predictors of PTSD and depression. Psychol Med\u003cem\u003e.\u003c/em\u003e 2021; 51(6): 976\u0026ndash;88. doi:10.1017/S0033291719003891.\u003c/li\u003e\n\u003cli\u003eAcharya Pandey R, Chalise P, Khadka S, Chaulagain B, Maharjan B, Pandey J, et al. Post-traumatic stress disorder and its associated factors among survivors of 2015 earthquake in Nepal. BMC Psychiatry. 2023;23(1): 340. doi:10.1186/s12888-023-04836-3\u003c/li\u003e\n\u003cli\u003eZhang W, Duan G, Xu Q, Jia Z, Bai Z, Liu W, et al. A Cross-sectional Study on Posttraumatic Stress Disorder and General Psychiatric Morbidity Among Adult Survivors 3 Years After the Wenchuan Earthquake, China. Asia-Pacific journal of public health, 2015; 27(8): 860\u0026ndash;70. doi:10.1177/1010539515602089.\u003c/li\u003e\n\u003cli\u003eNorris FH, Friedman MJ, Watson PJ, Byrne CM, Diaz E, Kaniasty K. 60,000 disaster victims speak: Part I. An empirical review of the empirical literature, 1981-2001. Psychiatry: 2002;65(3): 207\u0026ndash;39. doi:10.1521/psyc.65.3.207.20173\u003c/li\u003e\n\u003cli\u003eSayed S, Iacoviello BM, Charney DS. Risk factors for the development of psychopathology following trauma. Curr Psychiatry Rep. 2015;17(8):612. doi:10.1007/s11920-015-0612-y.\u003c/li\u003e\n\u003cli\u003eSofta M. 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Shattered ground, resilient souls: examining coping strategies, social support, and earthquake exposure\u0026rsquo;s effects on post-traumatic stress disorder symptoms among adolescent and young adults survivors of the 2023 earthquake in T\u0026uuml;rkiye. Curr Psychol. 2024; 43: 21745-55. doi:10.1007/s12144-024-05995-6\u003c/li\u003e\n\u003cli\u003eBaşoǧlu M, Salcioǧlu E and Livanou M. Traumatic stress responses in earthquake survivors in Turkey. J Trauma Stress. 2002; 15(4): 269\u0026ndash;76. doi:10.1023/A:1016241826589\u003c/li\u003e\n\u003cli\u003eWang B, Ni C, Chen J, Liu X, Wang A, Shao Z, et al. Posttraumatic stress disorder 1 month after 2008 earthquake in China: Wenchuan earthquake survey. Psychiatry Res. 2011;187(3): 392\u0026ndash;6. doi:10.1016/j.psychres.2009.07.001\u003c/li\u003e\n\u003cli\u003eLiang Y, Cheng J, Ruzek JI, Liu Z. Posttraumatic stress disorder following the 2008 Wenchuan earthquake: A 10-year systematic review among highly exposed populations in China. 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J Psychiatr Res. 2021;136:452\u0026ndash;9. doi:10.1016/j.jpsychires.2020.08.016\u003c/li\u003e\n\u003cli\u003eSerrano C, Leiva-Bianchi M, Ahumada F, Araque-Pinilla F. What is the association between post-traumatic stress disorder and unemployment after a disaster? Int J Occup Med Environ Health. 2021;34(6):755-66. doi: 10.13075/ijomeh.1896.01557.\u003c/li\u003e\n\u003cli\u003eBaşoǧlu M, Kili\u0026ccedil; C, Şalcioǧlu E, Livanou M. Prevalence of posttraumatic stress disorder and comorbid depression in earthquake survivors in Turkey: an epidemiological study. J Trauma Stress\u003cem\u003e \u003c/em\u003e2004; 17(2): 133\u0026ndash;41. doi:10.1023/B:JOTS.0000022619.31615.e8\u003c/li\u003e\n\u003cli\u003eLivanou M, Başoǧlu M, Salcioǧlu E, Kalendar D. Traumatic stress responses in treatment-seeking earthquake survivors in Turkey. 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Am J Psychiatry 2005;162(8): 1483\u0026ndash;93. doi:10.1176/appi.ajp.162.8.1483\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Post-Traumatic Stress Disorder, PTSD, Earthquake, Risk Factors, Temporary Shelter, Earthquake survivors","lastPublishedDoi":"10.21203/rs.3.rs-5781679/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5781679/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe 2023 Kahramanmaraş earthquakes resulted in extensive destruction, significant loss of life, and widespread displacement, with Hatay province being the most severely affected region. Earthquake survivors residing in temporary shelters face an elevated risk of long-term psychological consequences, particularly post-traumatic stress disorder (PTSD) and depression. This study aims to assess the prevalence of PTSD and depression among earthquake survivors in temporary shelter areas within the central districts of Hatay and to identify associated risk factors contributing to PTSD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis cross-sectional, population-based study was conducted among 400 adult earthquake survivors following the 2023 Kahramanmaraş earthquakes. Participants were selected using a multistage cluster sampling method.\u003c/p\u003e\n\u003cp\u003eData on participants' sociodemographic characteristics, earthquake experiences, and psychiatric history were collected through self-report questionnaires. PTSD was assessed using the PTSD Checklist for DSM-5 (PCL-5), while depression was evaluated using the Beck Depression Inventory\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003ePTSD was identified in 29.0% of participants, while depression was observed in 38.8%. Key risk factors for PTSD included unemployment (OR=2.590, p=0.004), the loss of a family member (OR=2.351, p=0.017), a pre-existing psychiatric diagnosis prior to the earthquakes (OR=2.245, p=0.007), alcohol use (OR=2.310, p=0.019), smoking (OR=1.663, p=0.044), and experiencing a high level of fear during the earthquakes (OR=2.151, p=0.002).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThese findings highlight the critical need for large-scale psychosocial support and intervention programs in the post-disaster period. Identifying risk factors for PTSD may aid in the development of targeted treatment strategies and preventive interventions for affected individuals.\u003c/p\u003e","manuscriptTitle":"Post-Traumatic Stress Disorder in Earthquake Survivors Living in Temporary Shelter Areas in Hatay Central Districts: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-15 08:50:20","doi":"10.21203/rs.3.rs-5781679/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2025-04-28T11:34:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-20T07:34:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"105327200973462105890674695437249867384","date":"2025-04-20T07:24:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-14T12:17:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-29T10:57:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2025-03-27T15:14:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"efc2c8cb-fce3-4241-b0d2-be69f304c8c9","owner":[],"postedDate":"April 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-12T16:03:02+00:00","versionOfRecord":{"articleIdentity":"rs-5781679","link":"https://doi.org/10.1186/s12888-025-06919-9","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2025-05-07 15:57:44","publishedOnDateReadable":"May 7th, 2025"},"versionCreatedAt":"2025-04-15 08:50:20","video":"","vorDoi":"10.1186/s12888-025-06919-9","vorDoiUrl":"https://doi.org/10.1186/s12888-025-06919-9","workflowStages":[]},"version":"v1","identity":"rs-5781679","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5781679","identity":"rs-5781679","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}