More than six months after the Indian Ocean tsunami took nearly 300,000 lives and left more than 1 million people without homes, many in the affected areas are still living in fear, according to two psychiatrists who have worked with disaster relief personnel and tsunami survivors.

Terror inspired by the great walls of water that flooded villages and cities from India to Thailand on December 26, 2004, keeps fishermen from venturing out to sea and children from playing on beaches they once loved, said Jagannathan Srinivasaraghavan, M.D., who prefers to be know as Dr. Van or Ashok Van, and Ramaswamy Viswanathan, M.D., D.Sc.

The two psychiatrists shared their experiences with Psychiatric News and in reports to APA leadership, including members of APA's Committee on the Psychiatric Dimensions of Disaster.

"We were struck by the emotional devastation" of tsunami survivors, said Viswanathan.

Viswanathan is an associate professor of clinical psychiatry, director of the psychiatric consultation-liaison service, and medical director of the Anxiety Disorders Program at the State University of New York Downstate Medical Center. Van is a professor and chief of the Division of Community and Public Psychiatry at Southern Illinois University School of Medicine and medical director of the Choate Mental Health Center in Anna, Ill.

Their journey to the miles of devastated coastline in south India and Sri Lanka began in April with a two-day conference on disaster relief in Chennai, India, one of the tsunami-affected areas. They served as APA delegates to the Asia-Pacific Congress on Disaster Mitigation.

There, Viswanathan presented a seminar on psychobiological responses to trauma, and Van served as a discussant.

After the conference, Van and Viswanathan visited two coastal villages in Chennai, in southern India. Through SEWA International, a nongovernmental organization providing disaster relief to tsunami-affected areas, they arranged to visit Oodaimanagar, a fishing village, where they met with fishermen and their families and local merchants.

Though there were no lives lost in Oodaimanagar since villagers were able to escape, there was considerable property loss, Viswanathan reported." People lost their livelihoods," he said.

Seaside merchants lost entire inventories, and fishermen lost their boats and nets, he pointed out, and have been unable to make a living.

The few who were able to salvage their boats "are afraid of going out to sea," he said, "and if they do, they don't venture far" because they don't want to be away from their families if another tsunami strikes.

Fishermen are not the only ones who live in fear. Children who used to play on the sandy shores now stay away from the water, he noted, and many families reported being afraid to sleep should another tsunami catch them unprepared.

Such hypervigilance and avoidance behaviors may be symptoms of posttraumatic stress disorder (PTSD), Viswanathan acknowledged.

"Contrary to what we've heard in some circles—that PTSD is not common following disasters in developing countries—we found plenty of people spontaneously reporting symptoms characteristic of PTSD," he said. However, he emphasized that they did not evaluate or diagnose individual villagers.

An even greater number of survivors reported symptoms of depression and other problems, such as substance abuse, he noted.

From Oodaimanagar, the psychiatrists traveled a short distance to Foreshore Estates, a residential area where 45 people died. There they visited with Lakshmi Vijayakumar, M.D., a psychiatrist who set up a tent to offer psychiatric services, including counseling and medication, to tsunami survivors. Many of these families were "emotionally devastated and don't want to speak with anyone, so she and her staff are gently trying to reach out to them in their homes as well," Viswanathan said.

On the heels of the visit to Chennai, Van arranged with SEWA International to travel to Sri Lanka, where nearly 40,000 people died. Viswanathan could not accompany him as he had work-related obligations in the United States.

A 10-hour car trip brought Van from the West coast of Sri Lanka across the mountains to Batticaloa, a city of about a half million on the East coast. He visited areas such as Navaladi, one of the worst-hit areas of Sri Lanka.

"The whole place was wiped out," he recalled. "I saw one staircase—just a staircase—leading up to nothing."

He also saw a large banyan tree that on the day of the tsunami held as many as 40 people who clung to its branches as the water roared past. The water soon uprooted the tree, which was carried away, and everyone drowned, he was told by the SEWA representative traveling with him.

He also noted that every house was separated from the next with barbed wire, which contributed to the demise of many. "Once the waves came, clothing caught on the wire, and people couldn't rise up." He described stories told to him by survivors as "heart-wrenching."

During a visit to a temporary shelter, he spoke with an individual who endured the deaths of 22 family members.

One of the tsunami survivors was a widow employed as a domestic helper for a family in another country. She learned from a friend that the tsunami had killed her mother, but the family employing her refused to let her go home.

"They caught her attempting suicide and beat her" in retaliation, Van said. "The humane thing to do was to have let that woman return immediately."

Her 37-year-old brother lost all five of his children.

While in Batticaloa, Van trained 30 community volunteers at several sites to provide psychosocial support to tsunami survivors and advised them about where to refer those with signs of suicidality or severe PTSD.

One of those places is Batticaloa General Hospital, which has a 26-bed psychiatric unit run by Dr. Ganesan, who goes by one name, as is common in Sri Lanka. He is the only psychiatrist available to serve a population of 1.3 million people.

It is the only psychiatric unit on the East coast of Sri Lanka, but stigma keeps many in need of services away.

Since most Sri Lankans with mental health problems "approach faith healers and priests as their first line of psychiatric treatment, the number of patients coming to the unit is manageable," Van said. In addition, patients are not admitted to the hospital unless there is a family member who is willing to be admitted and stay with the patient during the hospitalization.

Indeed, family support is crucial in a country where there are fewer than 40 psychiatrists to serve 20 million people, he acknowledged.

"Most survivors relied on the support and understanding of family and their faith" to cope with their anguish.

Though Van accomplished a great deal during his weeklong stay in Sri Lanka—he trained another 30 volunteers in Sri Lanka's Ampara district and visited psychiatric facilities, an orphanage, and a number of temporary shelters—he said he would have liked to do more. In July he returned to Sri Lanka to continue his work there.

In an article he wrote in the June newsletter of the Illinois Psychiatric Society, he asked the unanswerable: "How do you console a mother who lost several children or a mother whose child is swept away from her arms?" and "How do we make the world understand that humane behavior is more than opening up the wallet—it has to come from the heart to understand the pain of our fellow human beings.... Privately, I shed tears later." ▪