Social determinants associated with suicidality, depression, anxiety and posttraumatic stress in adolescents after the earthquake 2016 in Ecuador

Background The Ecuadorian earthquake in April 16th was the second strongest and deadliest in 2016 worldwide, with approximately one million people affected. In this paper, we analyze the psychological impact and the relationship between mental health events and various social determinants related to the earthquake, nine months after the event. We conducted an analytical cross-sectional study, applying anonymous surveys to 319 adolescents 13-19 years old. Suicidal tendency, depression, anxiety and post-traumatic stress (PTSD) were evaluated via the Child PTSD Symptom Scale (CPSS), Spence Children's Anxiety Scale , Okasha Suicidality Scale, and the Center for Epidemiologic Studies Depression Scale (CES-D) in addition to an adapted seven-questions survey aimed for measuring social determinants related to the earthquake. We found a high prevalence of suicidal ideations and behavior, posttraumatic stress, depression and anxiety compared to international studies. Even though adolescents currently living in shelters had higher levels of anxiety, their suicidal tendency was signicantly lower than those living in their own home or in the home of relatives. Finally, social determinants are not associated with suicidality and mental health events, with the exception of economic damage suffered by the family.


Suicidal risk
The Okasha Suicitality Scale was created by Okasha et al in 1981 and ws used to determine the risk of commiting suicide within this comunity (39). This scale measures suicide risk and consists of 4 items: 1. Have you ever thought that life is not worth it? 2. Have you ever wanted to be dead? 3. Have you ever thought about ending your life? 4. Have you attempted suicide?
The rst three items have a 0 to 3 format as a response option (never, almost never, sometimes, many times). In the present study a fth item was added: Have you made any plans to take your life?, since the plan plays an important role for the assessment of suicide risk (40).
The original scale was translated into Spanish and validated by Salvo et al. (Except, Melipillán and Castro, 2009) in a teenage population in Chile with an internal consistency of 0.89. The cut-off point for the subscale of suicidal ideations, to identify people with high suicidal tendencies, was set at 5 points (41).

Social determinants
An adapted seven-questions survey based on the study conducted by Díaz, Quintana and Vogel was used to explore the social determinants around the earthquake (23). The questionnaire contained seven items that were intended to identify the social determinants that might be linked to suicide after an earthequake. The questions were intended to explore the timeline realeted to the earthquake, the degree of damage in houses and the consecutive economic losses, the current housing and the housing just after the earthquake, the physical damages and life losses affecting theirselves and their relatives and the psychological support (if any) that was available just after the disaster.

Data source
The data for this study was obtained throught the use of ve instruments to explore the entire context of the children affected by the natural disaster and their reponses.

Bias
In this study we try to include all adolescents who voluntarily decided to participate, so we could avoid selection bias. In turn, the use of 5 validated surveys of closed questions will allow us to reduce the risk of inferring the opinions of the participants. Finally, we have considered the subsequent analysis of the data to try to avoid design bias to the maximum.

Study Size
A non-probabilistic sampling design was used in three schools in Muisne, Ecuador. A convenience sample was obtained because of their convenient accessibility within the town, the open-doors attitude from the schools' authorities and the researcher experience working in the area.

Statistic analysis
The Student's t-test was used to compare the means obtained in the measured scales (suicidal tendency and other mental health events between the samples) between the samples according to the presence or absence of different social determinants mentioned above. For this, each of the social determinants was dichotomized according to their presence (0 if the damage has been slight or nonexistent and 1 if it has been serious). To contrast the dichotomized variables with the demographic variables (gender and age), the Pearson Chi-square test was used. The SPSS version 22 program was used for the calculations.

General Results
The total sample consisted of 319 participants, from 3 different schools. The participants were between the ages of 13 and 19, with an average of 16.07 (SD = 1.91), corresponding a 48.1% of the sample to men and 51.9% to women. Of the total student sample, 55% had been found on the island side of Muisne during the earthquake, 27% were located on the mainland of Muisne parish and the remaining 17% in some other part of Ecuador. Table 1 show several descriptive statistical data such as: simple size, mean values, standard deviation, signi cance level (alpha value) and internal consistency for each of the main variables collected in this study: suicidal tendency, depression, post-traumatic stress disroder symptoms and anxiety. Less than a half of the students who participated, indicated that they had never had suicidal ideations. Around 30% declared that during the last nine months they thought sometimes or many times that life is not worth it and wished they were dead. Also, 20% thought sometimes or many times about ending their lives, and 13% on several occasions have made concrete plans to commit suicide.

Suicide attemts
Regarding suicide attempts, 205 adolescents (65%) indicated that they had never attempted suicide, while 23 (7%) claimed to have tried once, 12 (4%) twice, 8 (3%) three times and 4 (1%) four or more times. Is important to remark that there was a high number of absence of answers to this question, because 21% (n = 65) refused to answer it.
On the other hand, female adolescents suffered from signi cantly higher levels of suicidal ideations than men, being the most frequent expression in them the "desire to be dead", with almost 60% of adolescent girls who claim to have wished sometimes during the last nine months being dead, compared to 44% of boys. In addition, 40% (women) and 34% (men) of the participants indicated that they had ever thought that life is not worth it. In the same way, one in ve men claimed to have thought about ending their lives, compared to around 43% of female adolescents.
There were also obvious gender differences in suicide plans and the number of suicide attempts during the last nine months. While the data indicate that 27% of women had made plans at some time, only 15% of men declared the same. Regarding previous suicide attempts, 20% of women reported having tried at least once to take their own lives, compared to only 9% of men.
Depression prevalence Table 2 reports the prevalence of depression, posttraumatic stress and suicidal tendency for the total sample considering their age and gender. The prevalence of depression and post-traumatic stress is high, since approximately one third of the participants appear to be affected by at least one of these alterations. In addition, it is observed that women have signi cantly higher scores in the four variables compared to men.  Table 3 reports the ANOVA results of the effect that various social determinants resulting from the earthquake have on the suicidal tendency of adolescents: depression, anxiety and post-traumatic stress. It is noteworthy that shelter accommodation (o cial or uno cial) has no effect on mental health events in the rst stage after disaster.