During the first six months after the earthquake, the diaspora Psychiatric Outreach Program (POP) therapists treated children and adolescents in schools and adults in tents, hospitals, factories, and mobile clinics. Successful implementation of the program depended on careful recruitment and preparation of the therapists and establishing strong working relationships with local partners. Therapists started their rotations in the earthquake zone by first meeting with Health and Education Ministry personnel, then school principals to get their approval to work with teachers and students. Therapists addressed the psychological needs of the principals and teachers before and during the time they worked with the students. Trauma-grief-focused group therapy was provided to students. Those who had severe symptoms were seen individually after the group meetings. Most therapists experienced mild anxiety and depressive symptoms during their tenure. Few were vicariously traumatized and were unable to continue working. The relief work had a positive impact on the professional lives of many who later excelled as educators and therapists. Because of the ongoing shortage of local therapists, a three-year teaching/training program was initiated by POP therapists to prepare qualified local psychotherapists. Graduates who were licensed by the Ministry of Health worked alongside the diaspora therapists in the schools and clinics. The chapter describes lessons learned from our experiences and mistakes.

The chapter describes the ravages of the 1988 Spitak earthquake in northern Armenia and the geopolitical problems in the Caucasus region, leading to a war between Armenia and Azerbaijan. The widespread destruction, lack of essential materials due to blockade by the neighboring countries, the Soviet Union’s political turmoil and eventual collapse, and poor economy were significant factors that delayed recovery from the earthquake. The chapter also describes the existing mental health system in Soviet Armenia, the role of the clergy, and the inception of the Psychiatric Outreach Program (POP) by volunteer therapists from the diaspora shortly after the earthquake. The initial objective of POP was to provide care to the survivors for six months. Because of the pervasiveness of the psychological problems, the POP expanded its mission to include a teaching and training program for local professionals and paraprofessionals. These newly trained therapists worked alongside the consultants from the diaspora. Subsequently, two clinics were built in the earthquake zone, and the POP therapists serviced the population of Gumri, Spitak, and the adjacent villages for the next two decades. During those years, important trauma-related studies were conducted to determine the progression of stress reactions and the effectiveness of trauma-grief-focused psychotherapy.

The Spitak earthquake offered a unique opportunity to conduct family studies of the genetics of post-traumatic stress disorder (PTSD) and related conditions, including depression and anxiety. The multigenerational families that participated in the Spitak Earthquake Genetic Study (SEGS) were recruited from the devastated city of Gumri. The participants (3 to 5 generations) were exposed to horrific earthquake-related traumatic experiences contemporaneously. After adjusting for sex, age, and multiple environmental risk factors, the heritability of vulnerability of PTSD (42%) was significant. Additionally, vulnerabilities for depression and anxiety were also significantly heritable. These three phenotypes were genetically correlated, indicating pleiotropy, i.e., they shared genes. Using complex co-variate analyses, we found an association of specific serotonergic genes (THP2 and THP1) and a dopaminergic gene (COMT) with PTSD and a serotonergic gene (5HTTLRP) with depression. These findings suggest that carriers of variants of these genes are at risk for PTSD and depression, respectively. Whole genome sequencing found another interesting gene, OR4C3, among those with PTSD. The gene codes for an olfactory receptor that shares a domain structure with many neurotransmitters. The chapter also discusses recent advances and challenges in genetic research.

This chapter provides an overview of the components of the evolving conceptual model since the 1988 Spitak earthquake that guided the intervention and research arms of our work in Armenia. With the concept of traumatic stress as the gateway to post-trauma sequelae and recovery, we recognized the important contributions made by post-trauma adversities and the pervasiveness of trauma and loss reminders in the aftermath. Individual and ecological factors were seen as making powerful contributions to the impact and course of recovery, especially in terms of factors associated with resistance, resilience, vulnerability, adjustment, maladjustment, and pathology. The traumatic stress pathway is embedded in a developmental perspective, with the understanding that child, adolescent, and adult development plays an overarching role across all aspects of the conceptual framework. In addition, cultural and religious factors are also seen as integral. Implications of the conceptual model for data collection metrics and methodology, as well as intervention strategies are also discussed.

At 1.5- and five-year follow-ups after the Spitak earthquake, there was a significant dose–response relation between earthquake exposure and severity of PTSD and depression. The more severely exposed Spitak group had higher PTSD and depression scores than the less severely exposed group from Gumri. However, at twenty-five years, this relation had dissipated. PTSD severity of the Spitak group that had experienced comparatively fewer post-earthquake adversities (lack of heat, electricity, food, medicine, housing, transportation) and post-earthquake traumatic experiences (e.g., fights, accidents) was comparable to that of the Gumri group; while depression severity of the Gumri group, which had been significantly lower than the Spitak group at baseline, was higher at follow-up. The detrimental impact of adversities was greater for depression than for PTSD.

Risk factors for PTSD and depression at twenty-five years included adversities, baseline PTSD and separation anxiety severity, loss of home, and chronic medical illnesses. Social support by family and friends emerged as a protective factor. Compared with those who lost one parent and controls, orphans were at greater risk for clinical depression. Although there was a decrease in PTSD rates from baseline to twenty-five years post-earthquake (48% to 22%), earthquake-related PTSD remained a significant public health problem. Alleviation of adversities, improving the social ecology, and monitoring chronic medical illnesses should be considered essential components of disaster recovery programs.

There is a paucity of long-term treatment outcome studies among children and adolescents after natural disasters. This chapter summarizes findings from three long-term studies among severely traumatized early adolescents after the 1988 Spitak earthquake in Armenia, including a twenty-five-year follow-up that represents the most extended prospective treatment outcome study to date after a disaster. School-based trauma-grief-focused psychotherapy was provided at 1.5 years post-earthquake. The intervention addressed trauma and loss experiences due to the earthquake; post-trauma distress reactions, including PTSD and grief; current problems and adversities; trauma and loss reminders, interpersonal conflicts, and developmental progression. The findings showed significant long-term benefits of treatment in reducing PTSD and depressive symptoms. We also present findings regarding differences in recovery trajectories among treated and not treated subjects and risk and protective factors associated with PTSD and depression. Despite the improvements, a sub-group of the students continued to experience earthquake-related chronic PTSD and depressive symptoms at twenty-five-year follow-up, indicating the need for ongoing surveillance of severely traumatized survivors. The findings underscore the benefit of post-disaster therapeutic intervention, social support by family members and friends, and the need for assistance by governmental and non-governmental agencies to mitigate post-disaster adversities that contributed significantly to the chronicity of symptoms.

This chapter summarizes the organizational and clinical lessons learned in implementing and conducting a post-disaster recovery program. It underscores the importance of a hierarchical approach with a centralized chain of command. This approach can facilitate recovery by mitigating adversities and removing roadblocks to community recovery. Supporting and empowering affected local governments and civil society, however incremental, plays a central role in extending assistance to underprivileged sectors. Likewise, working with the school hierarchy provides the necessary support to implement a school-based psychological intervention. Working with international donors and relief organizations should be a centralized “demand-driven” process rather than an “all aid is welcome” approach. Care for those with serious medical conditions, the displaced elderly, the homeless, and orphans should take priority over non-urgent mental health needs.

Before engaging with survivors, preparation of therapists for the hardships of fieldwork and providing support, supervision, and respite during fieldwork can minimize disabling reactions, e.g., vicarious traumatization and burn-out. Empowering mental health providers to take proper actions based on local socio-cultural norms rather than mechanically applying foreign knowledge can significantly improve the outcome of interventions. Most victims experience a combination of symptoms from different diagnostic categories, not only PTSD and depression but also grief reactions, substance abuse, and anxiety. Additionally, survivors have to contend with multiple adversities (e.g., loss of housing and jobs, financial problems) that will compound their psychological reactions. Effective therapists are flexible and adjust treatment according to the most pressing psychosocial needs of the survivors.

At 1.5 years post-Spitak-earthquake, elderly survivors had significantly less intrusive and more hyperarousal symptoms (e.g., startle, hypervigilance, irritability, insomnia) than younger adults, indicating that treatment for the elderly requires more focus on hyperarousal symptoms (e.g., use of anxiety management techniques).

At 1.5- and 4.5-years post-earthquake, two groups of adults, exposed to severe trauma (earthquake and political violence), experienced comparably high levels of PTSD and depressive symptoms. The results dispelled the prior notion that natural disasters result in less severe reactions and underscore the importance of using objective and subjective measurements to determine exposure severity. They also showed that previous exposure to political violence had an additive effect on subsequent earthquake exposure-related PTSD severity.

The twenty-three-year prospective study among adult survivors of the earthquake showed that a substantial portion of the population (11.6%) still had PTSD related to the earthquake, and another 9.9% had PTSD related to post-earthquake traumas (e.g., fights, accidents, etc.). Risk factors for PTSD at twenty-three-year follow-up included baseline depression, job loss, post-earthquake traumas, and chronic medical illnesses. The chapter also presents important findings from other disaster studies, including the effect of cumulative trauma, delayed onset PTSD, increased mortality associated with PTSD and depression, and comparisons of recommended treatments for PTSD and depression and their limitations.