Psychology
2011. Vol.2, No.2, 132-137
Copyright © 2011 SciRes. DOI:10.4236/psych.2011.22021
Double Disaster: Mental Health of Survivors of Wildfires
and Earthquake in a Part of Greece
Vicky Papanikolaou1, Dimitrios Adamis2,3, Robert C. Mellon4,
Gerasimos Prodromitis4, John Kyriopoulos1
1Department of Health Service Management, National School of Public Health, Athens, Greece;
2Research and Academic Institute of Athens, Athens, Greece;
3Institute of Psychiatry, Kings College, HSPR Department, London, UK;
4Department of Psychology, Panteion University of Social and Political Sciences, Athens, Greece.
Received December 16th, 2010; revised February 8th, 2011; accepted February 22nd, 2011
This paper investigates stress related psychological morbidity in individuals who experienced two disasters 11
months apart (wildfire and earthquake) in a rural area of Greece. A sample of 150 participants has been assessed
after the wildfires and after the earthquake using the Symptom Checklist 90-Revised. Survivors had elevated
levels of psychopathology in all subscales of the SCL-90–R after the earthquake. Significant risk factors for fur-
ther development of psychopathology were damages to property and complete loss of property from both disas-
ters. Double disasters can cause considerable psychological symptoms in victims and there are r easons for policy
makers to create services in order to help and improve the mental health of those affected but also to help them
rebuild their property.
Keywords: Double Disaster, Greece, Psychopathology, Psychological Distress, Adults
Introduction
Natural disasters are frequent events in Greece. It is esti-
mated that from 1980 to 2008, 61 natural disasters happened
and the average number of people killed per year were 54 while
the average number of affected people per year was 10,426.
Earthquakes and wildfires are among the most frequent natural
disasters and they have also caused the most profound eco-
nomic damages (EM-DAT, 2010).
In August of 2007 an intense and destructive wildfire broke
out in the Peloponnesus peninsula in Greece. This was the
worst of the century in Greece. The fires expanded rapidly and
raged out of control for several days. Sixty to eighty people
were reported killed and 5,392 people were affected from the
disaster (EM-DAT, 2010). About 1,500 square kilometres of
forests, olive trees, farmland, and villages were burned in these
fires and the economic damages were estimated around
1,750,000 (X 1,000) US$. A national disaster was declared and
the areas affected by the fires were designated for further sup-
port.
A year later, in July 2008, a deadly earthquake hit the same
area (Peloponnesus) with a moment magnitude of 6.5, accord-
ing to the Athens Geodynamic Institute. The number of people
killed varied in the reports from 2-6, the injured were more than
220 and at least 2,000 people were reported homeless. The
number of affected people was estimated at around 3,708
(EM-DAT, 2010).
After the August wildfires it was perhaps the first time that
the need for an effective public health planning for disasters
was recognised, in order to deliver specific services and to pro-
vide sufficient resources for treating mental disorders, reducing
symptoms, and preventing future problems to those affected by
the disaster. In addition, it was recognised that it was necessary
to estimate the impact of the natural disasters on the mental
health of victims. Parts of this planning were also to carry out
research and to evaluate the affected population mental health
problems.
Although natural disasters differ widely, they usually have
some common characteristics in terms of the risks of survivors’
developing psychopathology and mental distress. Life threat,
injury to oneself or family member, death of loved ones, and
property loss were among the risk factors which have been
indentified (Norris et al., 2002; Norris, Friedman, Watson,
2002). All of these factors exist typically in any natural disaster.
The consequences of these disorders can be long lasting. In
addition, a different kind of disaster may have a different im-
pact on mental health (Norris, Friedman, Watson, 2002) and it
has been suggested (Weiss, Saraceno, Saxena, & van Ommeren,
2003) that it is important to distinguish continuing situations (e.g.,
ongoing war, ongoing drought) fr om acute ones, because chronic
disasters result in simultaneous acute and ongoing disas-
ter-related problems. However, th e impact of double acute disas-
ters in short time on the mental health of survivors is less studied.
Here, the present study investigates the psychological dis-
tress six months after the wildfires and one month after the
earthquake in a selected community population subsample in
the rural region of Peloponnesus, Greece.
In particular, the study aims to (a) assess the differences in
the prevalence of psychopathology 6 months after the wildfires
and one month after the earthquake, and (b) examine socio-
demographic, and disaster related losses variables predictive of
psychiatric casenes s .

V. PAPANIKOLAOU ET AL. 133
Method
Design of the Stu dy
The first phase of the study (6 months after the wildfires)
was a cross sectional case control study. The two samples
(cases and controls) were closely matched for gender, age,
educational, marital and regional distributions. Participants
were residents aged from 18 years to 65 years old who lived in
the five prefectures designated by the Hellenic Republic Minis-
try of Interior to be disaster areas. The number of respondents
surveyed in each prefecture was proportional to its adult popu-
lation. The sample was composed of 409 residents of desig-
nated disaster areas and 391 residents of directly adjoining
areas in which there was no fire damage in the immediate vi-
cinity. For more details about the methods for this phase see
(Mellon, Papanikolau, & Prodromitis, 2009).
Participants
For the second phase of study which is examined here, the
recruited population were a subsample (n = 150) of those af-
fected from wildfires and who lived mainly in the affected from
the earthquake area (see also Figure 1). They were reassessed in
one month’s time after the earthquake (five months after first
assessment and 11 months after the wildfire disaster). The par-
ticipants were residents aged from 18 years to 65 years old.
Measurements
1) Demographic characteristics (age, gender, educational
background, marital status, occupation). All the demographic
characteristics were self-reported. Age was categorised in five
groups, education in three, marital status in four and occupation
in three.
2) Symptom Checklist 90-Revised (SCL-90-R) (Derogatis &
Psychometric, 1992). A Greek validated version of SCL-90-R
was used (Donias, Karastergiou, & Manos, 1991). A sensitivity
of 0.98 and a specificity of 0.74 in indicating active psychiatric
patients of SCL-90-R were reported (Donias, Karastergiou, &
Manos, 1991). The SCL-90-R has 90 items, which measure the
degree of distress experienced by the individual during the last
7 days, using a 5-point scale (0 to 4) that ranges from “not at
all” to “extremely.” The SCL-90R can be scored for nine symp-
tom dimensions (Somatization, Obsessive-Compulsive, Inter-
pesonal Sensitivity, Depression, Anxiety, Hostility, Phobic
Anxiety, Paranoid, and Psychoticism). In addition to the nine
scales, there are three global indices that are computed. The
Global Severity Index (GSI), is the sum of all the nonzero re-
sponses, divided by 90, (if there are no missing responses) and
reflects both the number of symptoms endorsed and the inten-
sity of perceived distress. The Positive Symptom Total (PST) is
defined as the number of symptoms to which the patient indi-
cates a nonzero response. This is a measure of the number of
symptoms endorsed. Thus, it can be interpreted as a measure-
ment of symptoms span. The Positive Symptom Distress Index
(PSDI) is calculated by dividing the sum of all item values by
the PST; this is a measure of “intensity” corrected for the num-
ber of symptoms. The internal consistency reliability of
SCL-90-R was found quite satisfactory ranging from a 0.77 for
the dimension of Psychoticism to 0.90 for Depression. Simi-
larly test retest reliability was found ranging from 0.78 for the
dimension of Hostility to 0.90 for Phobic Anxiety. Regarding
validity, the sensitivity of SCL-90-R to detect psychiatric cases
was reported equal to 0.90 and specificity to 0.87 (Derogatis &
Psychometric, 1992).
3) Number and type of losses as a result of the fire or the
earthquake including: a) damage to property (Yes vs. No), b)
Missi ng n = 38.
Missing answers on
SCL-90-R or “fake
good or bad”
Missing n = 12.
Missing answers on
SCL-90-R or “fake
good or bad”
1
st
“wave”
Included n = 112 2
n
d
“wave”
Included n = 138
Finally analysed n = 112
1
st
“wave”
Eligible and Approached
N = 150
2
n
d
“wave”
Eligible and Approached
N = 150
Figure 1.
Chart flow of participants.

V. PAPANIKOLAOU ET AL. 134
complete damage and loss of property (Yes vs. No), c) personal
injury or injury of a close family member (Yes vs. No), and d)
deaths of close family members (Yes vs. No). The responses to
questions a and b were mutually exclusive. If more than one
loss had happened all of them counted (number of losses). Also
the types of losses were self-reported and the number of losses
was calculated from the different types.
Procedure
Data were collected in face-to-face interviews. In the first
wave of assessments interviewers asked if there was an adult in
the random sampled household (at least 18 years of age) who
would be willing to participate anonymously. In each house-
hold only one interview was conducted. In the second wave of
assessments the same individual from the same household was
asked again to participate in the survey.
Ethics
The study has been approved by the Ministry of Health and
informed consent was obtained from each participant.
Analysis
The Q Local v 2.1.11, (NCS Pearson Inc, MN, USA), was
used for the estimation of the standardized T scores from the
raw data for the SCL-90-R scale. Data were analysed with
PASW (SPSS) v18, using appropriate paired test statistics. For
the non-normally distributed data, non-parametric tests were
used. To estimate the effects of losses and individual character-
istics on the caseness status, as it was recorded with the
SCL-90-R scale, a multinomial logistic regression model was
constructed.
Results
Demographic Characteristics of the Sample
A total number of 150 subjects took part in both “waves” of
the survey, of whom 75 (50%) were males. The demographic
characteristics are presented in Table 1.
Psychological Distress after the Wildfires and the
Earthquake
To investigate the differences of psychological symptoms as
they were measured with the SCL-90-R scale between the two
assessments (after wildfires and after the earthquake) a paired
test was used. As the variables did not conform to a normal
distribution, a non-parametric test was used (Wilcoxon Signed
Ranks Test). Because of missing answers in SCL-90-R, or same
answer in all 90 questions or fake “good or bad”, the total
number of participants analysed were N = 112 (Figure 1). Table
2 shows some descriptive statistics ( N, mean, SD) of each vari-
able and the statistical significance of the comparisons. As it
can be seen from Table 2 all the participants had significantly
increased psychological distress after the earthquake in all the
measured symptoms and the three indices of SCL-90-R com-
pared to the previous 5 months ago.
Number and Ty p e o f Los ses
Table 3 shows the numbers and the percentages of the indi-
viduals who had each type of loss. The number of losses was
estimated by adding each category of loss: the minimum is 0
and the maximum 3.
Caseness
A caseness, according to SCL-90-R, is when a respondent
has a GSI score greater or equal to a T score of 63 or if any of
two dimensions scores are greater than or equal to a T score of
63. Thus, in the first wave of assessments (n = 112) 23 cases
were identified (20.5%) while in the second (n = 138) 93 cases
(67.4%). In the total analysed sample (N = 103) 23 participants
(22.3%) were not cases in both assessments, 58 (56.3%) were
new cases, 15 (14.6%) remained the same and 7 (6.8%) have
recovered. There was a significant increase of cases after the
earthquake (McNemar Test, x2 = 38.462, df: 1, p < .001) com-
pared to cases after the wildfires.
Effects of Socio-Demographic Factors and Losses
from the Disasters on the Caseness
To further investigate the factors that significantly influence
the caseness status (new cases, constantly cases, recovered
cases, and never cases) a multinomial regression model was
conducted. The caseness status (four levels) was the dependent
variable and demographic characteristics (gender, age, educa-
tion, occupation, and marital status), type of losses and the
number of losses were the independent variables. Table 4
shows only the significant effects of the independent variables
on the caseness status.
As it can be seen from Table 4 new cases were more likely to
be those who had old and new damages to their property and
those who have completely lost their property from both natural
disasters compared to those who did not develop significant
psychopathology (no cases in both assessments). However, they
were less likely to have deaths of loved ones. In addition, those
who were constantly cases in both waves of the survey were
Table 1.
Demographic characteristics of the sample.
Count
(N = 150)N%
18 - 25 27 18.0
26 - 35 31 20.7
36 - 45 32 21.3
46 - 55 32 21.3
Age group
56 - 65 28 18.7
Primary school 39 26.0
Secondary s chool 93 62.0 Education
College/university 18 12.0
married 103 68.7
single 41 27.3
divorced 1 .7
Marital status
widowed 5 3.3
professional occupation 22 14.7
sales and customer se rv ice occupation 19 12.7
Occupation
elementary occupation 109 72.7

V. PAPANIKOLAOU ET AL. 135
Table 2.
Comparison between the assessments.
N Mean Std. Deviati on (1-2) Z Sig. (2-tailed)
Somatisati on 2 138 65.17 9.891
Somatisati on 1 112 50.62 11.296 –7.231a p < .001
Obsessive -compulsive (OC) 2 138 60.23 9.337
Obsessive -compulsive (OC) 1 112 48.59 10.010 –6.794a p < .001
Interpersonal sensitivity (IS) 2 138 60.25 9.849
Interpersonal sensitivity (IS) 1 112 49.21 8.680 –6.554a p < .001
Depression 2 138 63.06 9.099
Depression 1 112 52.04 9.862 –6.750a p < .001
Anxiety 2 138 57.11 11.333
Anxiety 1 112 47.55 10.558 –5.935a p < .001
Hostility 2 138 55.51 10.005
Hostility 1 112 49.33 9.666 –4.587a p < .001
Phobic anxie t y 2 138 58.90 10.295
Phobic anxie t y 1 112 51.86 7.933 –5.171a p < .001
Paranoid 2 138 62.22 10.792
Paranoid 1 112 51.46 10.459 –6.269a p < .001
Psychotism 2 138 56.30 10.786
Psychotism 1 112 47.47 7.428 –5.743a p < .001
GSI 2 138 63.09 9.226
GSI 1 112 48.95 11.053 –7.454a p < .001
PSDI 2 138 58.72 7.137
PSDI 1 112 50.53 9.634 –6.377a p < .001
PST 2 138 61.91 8.995
PST 1 112 48.59 11.464 –7.098a p < .001
a. Based on positive ranks.
Table 3.
Number and type of losses in t h e t w o w a v e s o f as s e s s m e n t s.
First wave n
(%) Second wave n (%)
No 58 (38.7) 30 (20)
damages to pr operty Yes 92 (61.3) 120 (80)
No 117 (78) 12 5 (83.3)
complete loss of property Yes 33 (22) 25 (16.7)
No 144 (96) 141 (94)
injuries of individual or
close members of the family Yes 6 (4) 9 (6)
No 141 (94) 138 (92)
deaths of close members Yes 9 (6) 12 (8)
0 21 (14) 8 (5.3)
1 118 (78.7) 12 0 (80)
2 11 (7.3) 20 (13.3)
the numbe r of losses
3 - 2 (1.3)
more likely to be males (borderline significance) and those who
had completely lost their property in both disasters.
Discussion
The results show that the one disaster after another increases
the psychopathology of the survivors. Only few victims had
recovered (in terms of psychopathology) from the first disaster
during the five months time and none of the examined factors
contributed significantly to their recovery. Previous research in
survivors of disasters has showed that the psychological dis-
tress and psychopathology after disasters are long lasting (Nor-
ris et al., 2002; Norris, Friedman, Watson, 2002; Weiss et al.
2003). Those who were constantly cases during the five
months’ time were more likely to be males and to have com-
pletely lost their property by the two disasters. It seems that
during the time between the disasters, they had tried to rebuild
their property but the new disaster destroyed everything again.
This perhaps explains why the male gender was a risk factor.
Culturally in Greece and especally in rural areas males are i

V. PAPANIKOLAOU ET AL. 136
Table 4.
Parameter Estimates (only significant results) fro m m ul t i no m i al an a l ys i s .
Casenessa B Std. ErrorWald df Sig.
Intercept 17.9632.803 41.070 1 **
Not at all damages –0.8291.955 0.180 1 NS
New damages –0.2840.787 0.131 1 NS
Old damages –3.3321.489 5.009 1 *
Old and new damages 0b . . 0
Complete loss of property (no) –20.1221.971 104.224 1 **
Complete loss of property (New) –16.8362.230 57.025 1 **
Complete loss of p roperty (Old) –18.9191.811 109.176 1 **
Complete loss of property (old and new) 0b . . 0
Deaths (no) 2.806 1.218 5.308 1 .*
Deaths (New) 0.268 1.583 0.029 1 NS
Deaths (Old) 0b . . 0
Old caseness
(recovered n = 7) No significant effects of examined variables
Intercept 19.7642.759 51.315 1 **
Male 1.789 0.911 3.858 1 *
Female 0b . . 0 .
Complete loss of property (no) –20.1011.217 272.957 1 **
Complete loss of property (New) –18.3571.692 117.674 1 **
old and new
(constantly caseness = 15)
Complete loss of property (old and new) 0b . . 0
a. The reference category is: no caseness in both assessments; b. This parameter is set to zero because it is redundant; Statistical significant p < .05
marked *, p < .001 marked **, NS = no significance
responsible for the building and the maintenance of property
thus conceivably they are under more stress. Although the fe-
male gender has been identified in literature as a risk factor to
develop psychopathology after disasters (Norris et al., 2002)
not all the studies agree with it (e.g. Den Ouden, 2007) while
others reported that females are more likely to develop depres-
sion or phobia (Heir & Weisaeth, 2008; Hussain, Weisaeth &
Heir, 2010). In addition, when we analysed the data separately,
ignoring the first wave of assessments we did not find any sig-
nificant effect of gender on the caseness (analysis was not re-
ported in the results). Similarly, analysis of the total sample of
the wildfires victims (first wave of assessments), gender was
found not to influence the caseness but females were more
likely to develop somatisation symptoms (Unpublished data).
However, a previous study after a series of disasters (storm,
tornado, floods, exposure to dioxin) in St. Louis area (USA) in
1982 (Solomon, Smith, Robins, & Fischbach, 1987) reported
that males and females differ in how they display negative ef-
fects of disaster exposure. Males showed increased symptoms
of alcohol abuse and depression as a result of either personal, or
both personal and indirect, exposure to disaster, while the psy-
chopathology of females was not affected by the personal ex-
posure to disaster. Thus males are more prone to develop
symptomatology in directed exposure to disaster compared to
females (Solomon, Smith, Robins, & Fischbach, 1987).
Furthermore, those who became new cases in terms of psy-
chopathology after the earthquake were those who had property
losses in both disasters. It seems that the new losses had an
additive effect on the development of psychopathology. Al-
though material losses seem to be a risk factor for caseness, it is
surprising that injuries to oneself or to a family member had not
any effect. In addition, deaths of loved ones seem to be a pro-
tective factor for psychological caseness. However, it is impor-
tant to note here that the number of deaths was small, so the
power to detect true differences is low. Also, the official num-
ber of deaths reported for the second disaster (earthquake) was
two, and those two (if not more) have accounted for twelve
(affected) survivors. This could happen as the disaster area was
rural and the family ties are perhaps tighter. On the contrary,
the number of injured was high but injuries did not have any
effect on psychopathology. However, similar findings have
been reported by others (Heir & Weisaeth, 2008; Clayer, Book-
less-Pratz, & Harris, 1985). In fact, Heir and Weisaeth (Heir &
Weisaeth, 2008) pointed out that having a near relative or close
friend injured could be a protective factor because of distraction,
and because a caretaking role for a close relative may increase
resilience and self efficacy.
This study also has limitations. First of all, the number of
participants in the second wave of assessments and inevitably
the comparison with the first wave of assessments is relatively
small. Because, as we discussed above, the number of deaths
was small, maybe the effect of deaths on psychological distress
is wrongly estimated. Since the number of participants was
fixed from the first wave of assessments and given that the
study was purely observational and pragmatic we could not
increase the number of participants at the second wave of as-

V. PAPANIKOLAOU ET AL. 137
sessments. Similarly, we have found some risk factors from
variables which we have measured and maybe other unob-
served factors have also influenced the psychopathology in both
disasters. A second more important limitation of this study is
that the sample may be biased. In the second wave of assess-
ments the sample was not random as in the first. Simply, we
followed-up those who participated in the first part of the study
and we have included those who lived in the most affected from
the earthquake area (prefecture of Ilia). Thus, it is very likely
that we have compared a less affected from wildfires popula-
tion with the most affected from the earthquake and thus the
differences in psychopathology perhaps were more pronounced.
In addition, the time of assessments after the disaster was un-
equal. Our data can only be interpreted in one way; that is, a
disaster after another increases psychological distress. On the
other hand, despite these limitations this study is maybe the
first which examined the impact of two “acute” natural disas-
ters on the mental health of victims.
Thus, it seems from the above that two natural disasters in
relatively short time increase the psychological distress of the
affected population. Risk factors for further development of
psychopathology are damages to property and complete loss of
property. It can also be concluded that it takes time for the
psychological distress to cease after a disaster.
These findings have implications for policy makers, disaster
response agencies, and communities affected by disaster. If the
losses are risk factors for producing psychological distress then
efforts to protect positions or to replace them to some degree
may reduce distress and thus reduce the impact of disaster on a
community.
Our findings are similar with general disaster literature de-
spite cultural differences. Loss of property and income together
with life threat were significantly related to distress in previous
studies e.g. (Gibbs, 1989; O’Neill et al., 1999; Freedy et al.,
1994; Smith, & Freedy, 2000 ) .
Thus there are reasons for policy makers not only to create
services in order to help and improve the mental health of those
affected but also to support victims in restoring their properties.
Acknowledgements
The study has been funded by the Ministry of Health & So-
cial Solidarity within the framework of Health Disaster Man-
agement in cooperation with World Association for Disaster
Emergency Medicine.
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