ABSTRACT:

Objective:

To examine the prevalence of psychiatric symptoms and associated factors in the adult population of Brumadinho (MG), after the dam collapse.

Methods:

We included 2,740 participants with information about symptoms of post-traumatic stress disorder (PTSD), depression, anxiety, thoughts of death/self-harm, and poor sleep quality collected in 2021. Prevalence values of all conditions were estimated to compare the prevalence of psychiatric symptoms with the participants’ sociodemographic characteristics and place of residence. Pearson’s c2 test was used, with Rao Scott’s correction. Crude and adjusted logistic regressions estimated odds ratios and 95% confidence intervals to assess the association between psychiatric symptoms and participants’ characteristics.

Results:

The most common condition was depressive symptoms (29.3%), followed by post-traumatic stress symptoms (22.9%) and anxious symptoms (18.9%). Regarding the association between participants’ characteristics in the adjusted analysis, being a female and living in a mining area was positively associated with symptoms of PTSD, depression, anxiety, thoughts of death/self-harm, and poor sleep quality. A positive association was also found between high school education and post-traumatic stress symptoms. In contrast a negative association was found between being aged ≥60 years and symptoms of PTSD, depression, and anxiety.

Conclusion:

High prevalence values were found for all psychiatric symptoms after the dam failure in Brumadinho. Being a female, living in the mining area, being ≥60 years old, and having an educational level were all associated with the psychiatric symptoms investigated.

Keywords:
Technological disasters; Structure collapse; Prevalence; Psychiatric symptoms; Associated factors

INTRODUCTION

Disaster is defined as a severe interruption of the functioning of a community or society on any scale due to dangerous events that interact with conditions of exposure, vulnerability, and capacity, causing human, material, economic or environmental losses. The term disaster is generally replaced by the word emergency when there are biological or technological risks or conditions that cause severe damage to health¹1 Centre for Research on the Epidemiology of Disasters. Human cost of disaster. An overview of the last 20 years (200-2019) [Internet]. 2022 [cited on Aug 19, 2022]. Available from: https://www.preventionweb.net/files/74124_humancostofdisasters20002019reportu.pdf
https://www.preventionweb.net/files/7412... .

In the last 20 years, 7,348 disasters have been recorded, causing the death of approximately 1.23 million people and affecting more than 4 billion individuals. China and India were the most affected nations in this period, while Brazil ranked 10th²2 United Nations Office for Disaster Risk Reduction. Disaster [Internet]. 2022 [cited on Aug 18, 2022]. Available from: https://www.undrr.org/terminology/disaster
https://www.undrr.org/terminology/disast... . Disasters have different causes and can be classified as natural or technological, determining the emergence of different psychopathological profiles³3 Neria Y, Nandi A, Galea S. Post-traumatic stress disorder following disasters: a systematic review. Psychol Med 2008; 38(4): 467-80. https://doi.org/10.1017/S0033291707001353
https://doi.org/10.1017/S003329170700135... –⁷7 Rubonis AV, Bickman L. Psychological impairment in the wake of disaster: the disaster-psychopathology relationship. Psychol Bull 1991; 109(3): 384-99. https://doi.org/10.1037/0033-2909.109.3.384
https://doi.org/10.1037/0033-2909.109.3.... .

Since the 20th century, technological disasters (TDs), a malfunction of a technological structure or human error in technology control or handling⁸8 Shaluf IM. Technological disaster stages and management. Disaster Prevention and Management 2008; 17(1): 114-26. https://doi.org/10.1108/09653560810855928
https://doi.org/10.1108/0965356081085592... , have led to a significant increase in people being exposed to traumatic situations⁹9 Baum A, Fleming R, Davidson LM. Natural disaster and technological catastrophe. Environment and Behavior 1983; 15(3): 333-54. https://doi.org/10.1177/0013916583153004
https://doi.org/10.1177/0013916583153004... . In addition, evidence shows that exposure to TDs is associated with high prevalence of different psychiatric conditions¹⁰10 North CS, Pfefferbaum B. Mental health response to community disasters: a systematic review. JAMA 2013; 310(5): 507-18. https://doi.org/10.1001/jama.2013.107799
https://doi.org/10.1001/jama.2013.107799... –¹³13 Kim YM, Park JH, Choi K, Noh SR, Choi YH, Cheong HK. Burden of disease attributable to the Hebei Spirit oil spill in Taean, Korea. BMJ Open 2013; 3(9): e003334. https://doi.org/10.1136/bmjopen-2013-003334
https://doi.org/10.1136/bmjopen-2013-003... .

In January 2019, a new TD took place in Minas Gerais with the rupture of a dam run by the company Vale S/A in Brumadinho. This rupture was considered the most significant work accident ever recorded in Brazil and the second biggest industrial disaster of the 21^st century¹⁴14 Mato Grosso. Justiça do Trabalho. Tribunal Regional do Trabalho da 23a Região. Rompimento em Brumadinho, maior acidente de trabalho do Brasil, completa três anos [Internet]. 2022 [cited on Jun 28, 2022]. Available from: https://portal.trt23.jus.br/portal/noticias/música-do-dia-rompimento-em-brumadinho-maior-acidente-de-trabalho-do-brasil-completa-três
https://portal.trt23.jus.br/portal/notic... . According to Noal et al.¹⁵15 Noal DS, Rabelo IVM, Chachamovich E. The mental health impact on individuals affected by the Vale dam rupture. Cad Saúde Pública 2019; 35(5): e00048419. https://doi.org/10.1590/0102-311X00048419
https://doi.org/10.1590/0102-311X0004841... , the magnitude of the disaster, the number of deaths and missing persons, the destruction of homes and public spaces, in addition to the direct and indirect exposure of the population to mud, water, and dust contaminated by heavy metals, and the destruction of the ecosystem (contamination of the Paraopeba River) were important negative impact factors on the mental health of survivors.

However, studies with a representative sample of the population of Brumadinho to verify the burden of mental problems have not yet been carried out. This knowledge will help us understand how these problems are distributed in the municipality and support the planning of systematic actions to monitor this population. Therefore, the present study was carried out with participants aged ≥18 years from the baseline sample of the Brumadinho Health Project¹⁶16 Peixoto SV, Firmo JOA, Fróes-Asmus CIR, Mambrini JVM, Freitas CM, Lima-Costa MF, et al. Projeto Saúde Brumadinho: aspectos metodológicos e perfil epidemiológico dos participantes da linha de base da coorte. Rev Bras Epidemiol 2022; (supl 2): E220002. https://doi.org/10.1590/1980-549720220002.supl.2.1.
https://doi.org/10.1590/1980-54972022000... , and the prevalence of psychiatric symptoms and associated factors were assessed.

METHODS

Source of Data

Brumadinho Health Project is a population-based cohort study designed to represent the city’s population in a particular age group (≥12 years). It aims to produce information on health-related conditions of the population residing in the municipality to help the health service to provide better care to residents. The baseline sample was built in 2021¹⁶16 Peixoto SV, Firmo JOA, Fróes-Asmus CIR, Mambrini JVM, Freitas CM, Lima-Costa MF, et al. Projeto Saúde Brumadinho: aspectos metodológicos e perfil epidemiológico dos participantes da linha de base da coorte. Rev Bras Epidemiol 2022; (supl 2): E220002. https://doi.org/10.1590/1980-549720220002.supl.2.1.
https://doi.org/10.1590/1980-54972022000... , and the interviews were done between June and December.

The Research Ethics Committee of Fiocruz Minas approved the Brumadinho Health Project (20814719.5.0000.5091), and all participants signed the Informed Consent Form and/or the Informed Assent Term of the underage, accompanied by an informed consent signed by their caregivers/guardians.

The sampling plan considered three estimation domains:

1. Region directly affected by the failure of the tailings dam at the Córrego do Feijão mine (MG), including communities that had contact with tailings mud or river water contaminated by tailings;

2. People who lived in a mining activity area;

3. Region not directly affected by the dam failure or mining activity.

These domains were defined by grouping census sectors based on the Brazilian Institute of Geography and Statistics (IBGE) data from 2019.

All households in the regions considered affected by the tailings mud or mining activity (census) were included, as well as a random sample of households in regions considered not directly affected by the event. Residents of selected households were enrolled in all domains, and those aged ≥12 years at the time of the home visits were invited to the study. More details can be found on the project website (http://www.minas.fiocruz.br/saudebrumadinho/), in the article on its methodology¹⁶16 Peixoto SV, Firmo JOA, Fróes-Asmus CIR, Mambrini JVM, Freitas CM, Lima-Costa MF, et al. Projeto Saúde Brumadinho: aspectos metodológicos e perfil epidemiológico dos participantes da linha de base da coorte. Rev Bras Epidemiol 2022; (supl 2): E220002. https://doi.org/10.1590/1980-549720220002.supl.2.1.
https://doi.org/10.1590/1980-54972022000... . For this analysis, participants aged ≥18 years were included.

Psychiatric Symptoms

The outcomes of this study included psychiatric symptoms assessed through the application of screening scales for symptoms of post-traumatic stress disorder (PTSD), depressive disorder, and anxiety disorder. Presence of suicidal and self-mutilation ideas and worsening of sleep quality were also evaluated through self-reported information.

Post-traumatic stress symptoms (PTSD) were assessed using the Post-Traumatic Stress Disorder Checklist — Civilian Version (PCL-C)¹⁷17 Weathers FW, Litz BT, Herman DS, Huska JA, Keane TM. The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. San Antonio: Paper presented at the 9th Annual Meeting of the International Society for Traumatic Stress Studies; 1992.. The PCL-C was developed for the general population and is not related to a specific traumatic event. It helps one obtain information on PTSD indicators and post-traumatic symptoms. It is a self-report instrument with 17 items based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)¹⁸18 American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV. 4th ed. Washington: American Psychiatric Association; 2000.. Respondents choose the items that disturbed them in the last month and classified them on a Likert scale, where 1 means nothing and 5 a lot. The instrument assessment can be performed by an algorithm¹⁹19 Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist (PCL). Behav Res Ther 1996; 34(8): 669-73. https://doi.org/10.1016/0005-7967(96)00033-2
https://doi.org/10.1016/0005-7967(96)000... or global score (cut-off point)¹⁷17 Weathers FW, Litz BT, Herman DS, Huska JA, Keane TM. The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. San Antonio: Paper presented at the 9th Annual Meeting of the International Society for Traumatic Stress Studies; 1992.. Its semantic equivalence to Brazil was evaluated by Berger et al.²⁰20 Berger W, Mendlowicz MV, Souza WF, Figueira I. Equivalência semântica da versão em português da Post-Traumatic Stress Disorder Checklist – civilian version (PCL-C) para rastreamento do transtorno de estresse pós-traumático. Rev Psiquiatr 2004; 26(2): 167-75. https://doi.org/10.1590/S0101-81082004000200006
https://doi.org/10.1590/S0101-8108200400... . The validation was performed by Bringhenti et al.²¹21 Bringhenti ME, Luft CDB, Oliveira WF. Transtorno de estresse pós-traumático em acidentes de trânsito: validação de escala. Psico-USF 2010; 15(2): 193-203. https://doi.org/10.1590/S1413-82712010000200007
https://doi.org/10.1590/S1413-8271201000... , with individuals who had been injured in traffic accidents. In this validation, the PCL-C was transformed in a Likert scale of 10 rather than 5 items, like the original¹⁷17 Weathers FW, Litz BT, Herman DS, Huska JA, Keane TM. The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. San Antonio: Paper presented at the 9th Annual Meeting of the International Society for Traumatic Stress Studies; 1992.. The adoption of the PCL-C algorithm was chosen for the analysis. In this method, the presence of PTSD was considered when the score was ≥3 for at least one item in questions 1 to 5 (Criterion B), three items in questions 6 to 12 (Criterion C), and two items in questions 13 to 17 (Criterion D)¹⁹19 Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist (PCL). Behav Res Ther 1996; 34(8): 669-73. https://doi.org/10.1016/0005-7967(96)00033-2
https://doi.org/10.1016/0005-7967(96)000... .

Depressive symptoms were estimated by the Patient Health Questionnaire-9 (PHQ-9)²²22 Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16: 606-13. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
https://doi.org/10.1046/j.1525-1497.2001... , a nine-question questionnaire that assesses the depressive symptoms described in the DSM-IV (depressed mood, anhedonia, sleep problems, tiredness or lack of energy, change in appetite or weight, feelings of guilt or worthlessness, problems with concentration, feeling sluggish or restless, and suicidal thoughts)¹⁸18 American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV. 4th ed. Washington: American Psychiatric Association; 2000.. Brazilian psychiatrists performed the translation of PHQ-9, and one of the authors of the original instrument performed its back-translation²³23 Fraguas Jr R, Henriques Jr SG, De Lucia MS, Iosifescu DV, Schwartz FH, Menezes PR, et al. The detection of depression in medical setting: a study with PRIME-MD. J Affect Disord 2006; 91(1): 11-7. https://doi.org/10.1016/j.jad.2005.12.003
https://doi.org/10.1016/j.jad.2005.12.00... . The frequency of each symptom in the last two weeks is evaluated on a 0 to 3 Likert scale, corresponding to the answers “never”, “several days”, “more than half of the days” and “almost every day”, respectively. In the Brazilian version, the scale has an additional question that assesses the interference of depressive symptoms in the performance of daily activities. In this study, the validated cut-off point ≥9 was adopted²⁴24 Santos IS, Tavares BF, Munhoz TN, Almeida LSP, Silva NTB, Tams BD, et al. Sensibilidade e especificidade do Patient Health Questionnaire-9 (PHQ-9) entre adultos da população geral. Cad Saúde Pública 2013; 29(8): 1533-43. https://doi.org/10.1590/0102-311X00144612
https://doi.org/10.1590/0102-311X0014461... .

Anxiety symptoms were assessed based on the General Anxiety Disorder-7 (GAD-7)²⁵25 Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006; 166(10): 1092-7. https://doi.org/10.1001/archinte.166.10.1092
https://doi.org/10.1001/archinte.166.10.... , a brief instrument for assessing, diagnosing, and monitoring anxiety²⁵25 Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006; 166(10): 1092-7. https://doi.org/10.1001/archinte.166.10.1092
https://doi.org/10.1001/archinte.166.10.... , validated according to the DSM-IV²⁶26 Kroenke K, Spitzer RL, Williams JBW, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007; 146(5): 317-25. https://doi.org/10.7326/0003-4819-146-5-200703060-00004
https://doi.org/10.7326/0003-4819-146-5-... . The GAD-7 is composed of seven items arranged on a four-point scale: 0 (never) to 3 (almost every day), with a score ranging from 0 to 21 for signs and symptoms of the last few weeks. This analysis considered the validated cut-off point ≥10²⁷27 Moreno AL, DeSousa DA, Souza AMFLP, Manfro GG, Salum GA, Koller SH, et al. Factor structure, reliability, and item parameters of the brazilian-portuguese version of the GAD-7 questionnaire. Temas Psicol 2016; 24(1): 367-76. http://dx.doi.org/10.9788/TP2016.1-25.
http://dx.doi.org/10.9788/TP2016.1-25... –²⁸28 Bergerot CD, Laros JA, Araujo TCCF. Avaliação de ansiedade e depressão em pacientes oncológicos: comparação psicométrica. Psico-USF 2014; 19(2): 187-97. https://doi.org/10.1590/1413-82712014019002004
https://doi.org/10.1590/1413-82712014019... .

Self-reported ideas of death and self-harm were obtained by means of the ninth question of the PHQ-9: “In the last two weeks, how many days have you thought about hurting yourself in some way or that it would be better to be dead?”. The answer was selected on a Likert scale where 0 means “never”; 1, “less than a week”; 2, “a week or more”; and 3, “almost every day”. For the analysis, response 0 was classified as absence of suicidal idea, while responses 1, 2 and 3 were related to the presence of suicidal thoughts.

Self-reported poor sleep quality is assessed in the questionnaire by the question: “How do you classify your sleep quality?”. The answer uses a Likert scale where 0 is “excellent”; 1 is “good”; 2 is “regular”; 3 is “bad”; and 4 is “very bad”. For the analysis, responses 0, 1, and 2 were coded as no complaints about sleep quality, while 3 and 4 as worsened sleep quality.

This study also considered the variables gender, age (18–59 years, 60 years or older), marital status [not married (single/divorced/widowed), married], self-reported skin color (white, black), education (no education, complete/incomplete elementary school, complete/incomplete high school, complete/incomplete higher education), and place of residence. In addition, the variable self-reported skin color was classified as dichotomous [white, black (brown/black)]. We made this choice because yellow and indigenous ethnic groups’ frequency was 0.88 and 0.29%, respectively.

Statistical Analysis

Statistical analyses were made in the Stata 17 software. Due to the complex stratified design of the sample, the analyses were performed with weighting factors and correction for the sample design. The svy command was used in the evaluation. Initially, the prevalence of symptoms of PTSD, depression, anxiety, suicidal ideation, and worse sleep quality was estimated for the total sample. Then, Pearson’s χ² test with Rao-Scott correction was used to compare the prevalence with the characteristics of the participants.

Finally, univariate and multivariate logistic regressions were used to estimate odds ratios (OR) and 95% confidence intervals (95%CI), which allowed us to assess the association of symptoms of PTSD, depression, anxiety, suicidal ideation and worse sleep quality with the participants’ sociodemographic characteristics and place of residence.

Ethical Aspects

The Brumadinho Health Project was approved by the Research Ethics Committee of Fundação Oswaldo Cruz of Minas Gerais. All participants signed an informed consent form.

RESULTS

From the 3,080 baseline participants, 2,740 (88.9%) provided complete information regarding the variables included in this analysis. Participants had a mean age of 48.4 years (95%CI 47.2–49.6), were mostly female (56.7%), had no higher education (78.2%), and lived in areas that were not directly affected by the dam failure or had mining activities (95.3%). Other characteristics are shown in Table 1.

Prevalence of Psychiatric Symptoms

Table 2 shows the prevalence of psychiatric symptoms in the whole sample and by participants’ characteristics. Depressive symptoms (29.3%) and PTSD (22.9%) had the highest prevalence values, while self-reported suicidal ideation or self-harm had the lowest values (12.6%).

For all psychiatric symptoms, the prevalence was statistically higher in women, ranging from 16.2% (95%CI 13.7–18.9) for suicidal ideation or self-harm to 37.1% (95%CI 33.8–40, 6) for depressive symptoms. Differences were seen in age groups, with higher prevalence among younger people, except for ideas of death and self-harm. Self-reported skin color was significantly associated with PTSD symptoms, with higher prevalence among black people. Educational level was significantly associated with symptoms of PTSD, depression and thoughts of death or self-harm. There were also statistically significant differences between the places of residence and all outcomes.

Crude and Adjusted Analyses

The crude analysis (supplementary table) showed a positive association between being a female and living in a mining activity area with all psychiatric symptoms. The OR values ranged from 2.09 (95%CI 1.61–2.75) for anxiety symptoms to 2.50 (95%CI 1.98–3.15) for depressive symptoms in females; and from 1.41 (95%CI 1.08–1.85) for self-reported worse sleep quality to 2.33 (95%CI 1.81–3.09) for anxiety symptoms in residents of mining areas.

On the other hand, participants who lived in the directly affected region showed a positive association for PTSD, depressive and anxious symptoms. Regarding age, being aged ≥60 was negatively associated with symptoms of PTSD, depression, anxiety, and self-reported poor sleep quality. A positive association was found between self-reported non-white skin and having the complete elementary and high schools (OR=5.73; 95%CI 1.54–21.41) with PTSD symptoms.

The multivariate analysis (Table 3) showed female participants and residents of mining areas positively associated with all psychiatric symptoms. The OR values ranged from 2.27 (95%CI 1.71–3.01) for anxiety symptoms to 2.70 (95%CI 2.13–3.43) for depressive symptoms among females; and from 1.40 (95%CI 1.04–1.88) for self-reported worsening of sleep quality to 2.31 (95%CI 1.73–3.09) for anxiety symptoms among residents of mining areas.

Similarly, residents of the directly affected area maintained a positive association with symptoms of PTSD (OR=1.44; 95%CI 1.12–1.82), depression (OR=1.36; 95%CI 1.08– 1.72), and anxiety (OR=1.48; 95%CI 1.14–1.91). On the other hand, participants aged ≥60 years showed a persistent negative association with symptoms of PTSD (OR=0.56; 95%CI 0.38–0.81), depression (OR=0.68; CI95 % 0.49–0.94) and anxiety (OR=0.46; 95%CI 0.31–0.68). Finally, as for the educational level, only complete high school was associated with PTSD symptoms (OR=4.33; 95%CI 1.13–16.6).

DISCUSSION

This study selected a sample representative of the population aged ≥18 years in Brumadinho and showed high prevalence values for all investigated psychiatric symptoms. Depressive symptoms was the most prevalent condition (29.3%). On the other hand, the prevalence of symptoms of PTSD and anxiety was 22.9 and 18.9%, respectively. Finally, there was a positive association between being a female residing in mining activity areas, and presenting with symptoms of PTSD, depression, anxiety, ideas of death/self-harm, and worse sleep quality. Furthermore, high school education and PTSD symptoms were positively associated, while being ≥60 years old and symptoms of PTSD, depression, and anxiety were negatively associated.

The prevalence of different psychiatric symptoms in Brumadinho is higher than that observed in the Brazilian population²⁹29 Santomauro DF, Herrera AMM, Shadid J, Zheng P, Ashbaugh C, Pigott DM, et al. Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. Lancet 2021; 398(10312): 1700-12. https://doi.org/10.1016/S0140-6736(21)02143-7
https://doi.org/10.1016/S0140-6736(21)02... and consistent with the literature, which demonstrates the negative impact of disasters on survivors’ mental health¹⁰10 North CS, Pfefferbaum B. Mental health response to community disasters: a systematic review. JAMA 2013; 310(5): 507-18. https://doi.org/10.1001/jama.2013.107799
https://doi.org/10.1001/jama.2013.107799... –¹²12 Neves MCL, Roque M, Freitas AA, Garcia F. PRISMMA: Pesquisa sobre a saúde mental das famílias atingidas pelo rompimento da barragem de Fundão em Mariana. Belo Horizonte: Corpus; 2018.. The prevalence of PTSD symptoms was 22.9%. This estimate is lower than the one described in a review on PTSD epidemiology after TDs (30–60%)³⁰30 Galea S, Nandi A, Vlahov D. The epidemiology of post-traumatic stress disorder after disasters. Epidemiol Rev 2005; 27: 78-91. https://doi.org/10.1093/epirev/mxi003
https://doi.org/10.1093/epirev/mxi003... . However, the prevalences of the aforementioned epidemiological study were estimated within the first year after the disasters, while our rates were obtained two years after. In any case, the prevalence of PTSD symptoms found in Brumadinho was higher than the values reported after two years of the Mariana dam failure (MG)¹²12 Neves MCL, Roque M, Freitas AA, Garcia F. PRISMMA: Pesquisa sobre a saúde mental das famílias atingidas pelo rompimento da barragem de Fundão em Mariana. Belo Horizonte: Corpus; 2018..

Depression is one of the most common psychiatric disorders. Its prevalence is usually only lower than PTSD in studies on the impact of disasters on the population, but it may rank first among psychiatric disorders in places where its prevalence is high. Although there are no studies about the prevalence of depression in Brumadinho, a recent article reported that Brazilian rates are among the highest³¹31 Bromet E, Andrade LH, Hwang I, Sampson NA, Alonso J, Girolamo G, et al. Cross-national epidemiology of DSM-IV major depressive episode. BMC Med 2011; 9: 90. https://doi.org/10.1186/1741-7015-9-90
https://doi.org/10.1186/1741-7015-9-90... , which explains why depressive symptoms ranked first here.

Some studies, although very few, have investigated the prevalence of other psychiatric symptoms and have shown a high prevalence of generalized anxiety disorders¹¹11 Goldmann E, Galea S. Mental health consequences of disasters. Annu Rev Public Health 2014; 35: 169-83. https://doi.org/10.1146/annurev-publhealth-032013-182435
https://doi.org/10.1146/annurev-publheal... ,¹²12 Neves MCL, Roque M, Freitas AA, Garcia F. PRISMMA: Pesquisa sobre a saúde mental das famílias atingidas pelo rompimento da barragem de Fundão em Mariana. Belo Horizonte: Corpus; 2018., suicide risk¹²12 Neves MCL, Roque M, Freitas AA, Garcia F. PRISMMA: Pesquisa sobre a saúde mental das famílias atingidas pelo rompimento da barragem de Fundão em Mariana. Belo Horizonte: Corpus; 2018.,³²32 Kessler RC, Galea S, Gruber MJ, Sampson NA, Ursano RJ, Wessely S. Trends in mental illness and suicidality after Hurricane Katrina. Mol Psychiatry 2008; 13(4): 374-84. https://doi.org/10.1038/sj.mp.4002119
https://doi.org/10.1038/sj.mp.4002119... , and sleep disorders¹²12 Neves MCL, Roque M, Freitas AA, Garcia F. PRISMMA: Pesquisa sobre a saúde mental das famílias atingidas pelo rompimento da barragem de Fundão em Mariana. Belo Horizonte: Corpus; 2018.,³³33 Kim Y, Lee H. Sleep problems among disaster victims: a long-term survey on the life changes of disaster victims in Korea. Int J Environ Res Public Health 2021; 18(6): 3294. https://doi.org/10.3390/ijerph18063294
https://doi.org/10.3390/ijerph18063294... . Our study’s findings agree with the literature: high prevalence of anxiety symptoms, ideas of death and self-harm, and self-reported poor sleep quality.

Regardless of their etiology, what disasters have in common is the negative impact on the physical and mental health of survivors¹¹11 Goldmann E, Galea S. Mental health consequences of disasters. Annu Rev Public Health 2014; 35: 169-83. https://doi.org/10.1146/annurev-publhealth-032013-182435
https://doi.org/10.1146/annurev-publheal... ,³⁴34 Mollica RF, Cardozo BL, Osofsky HJ, Raphael B, Ager A, Salama P. Mental health in complex emergencies. Lancet 2004; 364(9450): 2058-67. https://doi.org/10.1016/S0140-6736(04)17519-3
https://doi.org/10.1016/S0140-6736(04)17... . Therefore, different studies investigate the prevalence of psychiatric disorders after different disasters³⁵35 Parker G, Lie D, Siskind DJ, Martin-Khan M, Raphael B, Crompton D, et al. Mental health implications for older adults after natural disasters--a systematic review and meta-analysis. International Psychogeriatrics 2016; 28(1): 11-20. https://doi.org/10.1017/S1041610215001210
https://doi.org/10.1017/S104161021500121... –³⁸38 Dyregrov A, Yule W, Olff M. Children and natural disasters. Eur J Psychotraumatol 2018; 9(Suppl 2): 1500823. https://doi.org/10.1080/20008198.2018.1500823
https://doi.org/10.1080/20008198.2018.15... . However, significant variations in prevalence may stem from different degrees of exposure, types of disasters, definition of cases, and populations studied.

The degree of exposure to a disaster is probably the most significant predictor of psychiatric symptoms¹1 Centre for Research on the Epidemiology of Disasters. Human cost of disaster. An overview of the last 20 years (200-2019) [Internet]. 2022 [cited on Aug 19, 2022]. Available from: https://www.preventionweb.net/files/74124_humancostofdisasters20002019reportu.pdf
https://www.preventionweb.net/files/7412... ,⁷7 Rubonis AV, Bickman L. Psychological impairment in the wake of disaster: the disaster-psychopathology relationship. Psychol Bull 1991; 109(3): 384-99. https://doi.org/10.1037/0033-2909.109.3.384
https://doi.org/10.1037/0033-2909.109.3.... –¹⁰10 North CS, Pfefferbaum B. Mental health response to community disasters: a systematic review. JAMA 2013; 310(5): 507-18. https://doi.org/10.1001/jama.2013.107799
https://doi.org/10.1001/jama.2013.107799... . Therefore, survivors who were on-scene during the disaster were more likely to develop psychiatric symptoms than those who were indirectly affected. In addition, evidence suggests that TDs have a more significant negative impact on mental health than natural disasters⁴4 Norris 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): 207-39. https://doi.org/10.1521/psyc.65.3.207.20173
https://doi.org/10.1521/psyc.65.3.207.20... .

Concerning case definition, screening scales determine prevalence higher than in structured or semi-structured clinical interviews applied by laypersons or certified professionals³⁹39 Brugha TS, Bebbington PE, Jenkins R. A difference that matters: comparisons of structured and semi-structured psychiatric diagnostic interviews in the general population. Psychological Medicine 1999; 29(5): 1013-20. https://doi.org/10.1017/s0033291799008880
https://doi.org/10.1017/s003329179900888... . Finally, the elderly are at lower risk of developing symptoms of PTSD, depression, and substance abuse³⁵35 Parker G, Lie D, Siskind DJ, Martin-Khan M, Raphael B, Crompton D, et al. Mental health implications for older adults after natural disasters--a systematic review and meta-analysis. International Psychogeriatrics 2016; 28(1): 11-20. https://doi.org/10.1017/S1041610215001210
https://doi.org/10.1017/S104161021500121... ,³⁶36 Siskind DJ, Sawyer E, Lee I, Lie DC, Martin-Khan M, Farrington J, et al. The mental health of older persons after human-induced disasters: a systematic review and meta-analysis of epidemiological data. Am J Geriatr Psychiatry 2016; 24(5): 379-88. https://doi.org/10.1016/j.jagp.2015.12.010
https://doi.org/10.1016/j.jagp.2015.12.0... . At the same time, middle-aged adults are more likely to develop psychiatric symptoms as they experience more significant stress and responsibilities in life¹¹11 Goldmann E, Galea S. Mental health consequences of disasters. Annu Rev Public Health 2014; 35: 169-83. https://doi.org/10.1146/annurev-publhealth-032013-182435
https://doi.org/10.1146/annurev-publheal... ,³⁵35 Parker G, Lie D, Siskind DJ, Martin-Khan M, Raphael B, Crompton D, et al. Mental health implications for older adults after natural disasters--a systematic review and meta-analysis. International Psychogeriatrics 2016; 28(1): 11-20. https://doi.org/10.1017/S1041610215001210
https://doi.org/10.1017/S104161021500121... .

Finally, it is essential to emphasize that data collection occurred in 2021, during the COVID-19 pandemic. In this period, studies from different countries⁴⁰40 Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. Gen Psychiatr 2020; 33(2): e100213. https://doi.org/10.1136/gpsych-2020-100213
https://doi.org/10.1136/gpsych-2020-1002... –⁴⁴44 Pierce M, Hope H, Ford T, Hatch S, Hotopf M, John A, et al. Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population. Lancet Psychiatry 2020; 7(10): 883-92. https://doi.org/10.1016/S2215-0366(20)30308-4
https://doi.org/10.1016/S2215-0366(20)30... , including Brazil⁴⁵45 Campos JADB, Martins BG, Campos LA, Marôco J, Saadiq RA, Ruano R. Early psychological impact of the COVID-19 pandemic in Brazil: a national survey. J Clin Med 2020; 9(9): 2976. https://doi.org/10.3390/jcm9092976
https://doi.org/10.3390/jcm9092976... –⁴⁷47 Feter N, Caputo EL, Doring IR, Leite JS, Cassuriaga J, Reichert FF, et al. Sharp increase in depression and anxiety among Brazilian adults during the COVID-19 pandemic: findings from the PAMPA cohort. Public Health 2021; 190: 101-7. https://doi/10.1016/j.puhe.2020.11.013
https://doi/10.1016/j.puhe.2020.11.013... , showed high rates of psychiatric disorders due to social distancing measures. Thus, the high prevalence of psychiatric symptoms in Brumadinho can be the result of negative impact on the mental health of residents not only because of the dam failure, but also because of the ­pandemic.

As to sociodemographic variables, previous studies have shown that some of them are associated with psychiatric symptoms¹¹11 Goldmann E, Galea S. Mental health consequences of disasters. Annu Rev Public Health 2014; 35: 169-83. https://doi.org/10.1146/annurev-publhealth-032013-182435
https://doi.org/10.1146/annurev-publheal... ,⁴⁸48 Dirkzwager AJE, Grievink L, van der Velden PG, Yzermans CJ. Risk factors for psychological and physical health problems after a man-made disaster. Prospective study. Br J Psychiatry 2006; 189: 144-9. https://doi.org/10.1192/bjp.bp.105.017855
https://doi.org/10.1192/bjp.bp.105.01785... ,⁴⁹49 Sayed S, Iacoviello BM, Charney DS. Risk factors for the development of psychopathology following trauma. Curr Psychiatry Rep 2015; 17(8): 612. https://doi.org/10.1007/s11920-015-0612-y
https://doi.org/10.1007/s11920-015-0612-... . Being a female is the most consistent factor for the appearance of different psychiatric disorders⁴⁸48 Dirkzwager AJE, Grievink L, van der Velden PG, Yzermans CJ. Risk factors for psychological and physical health problems after a man-made disaster. Prospective study. Br J Psychiatry 2006; 189: 144-9. https://doi.org/10.1192/bjp.bp.105.017855
https://doi.org/10.1192/bjp.bp.105.01785... ,⁴⁹49 Sayed S, Iacoviello BM, Charney DS. Risk factors for the development of psychopathology following trauma. Curr Psychiatry Rep 2015; 17(8): 612. https://doi.org/10.1007/s11920-015-0612-y
https://doi.org/10.1007/s11920-015-0612-... , as reported in this study. Although the mechanism responsible for the difference in psychiatric symptoms between men and women is not fully understood, some conditions contribute to this inequality. Among the main factors, the type of disaster and the numerous differences between men’s and women’s biological/physiological functions⁵⁰50 Pierce M, Hope H, Ford T, Hatch S, Hotopf M, John A, et al. Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population. Lancet Psychiatry 2020; 7(10): 883-92. https://doi.org/10.1016/S2215-0366(20)30308-4
https://doi.org/10.1016/S2215-0366(20)30... ,⁵¹51 DeSantis SM, Baker NL, Back SE, Spratt E, Ciolino JD, Maria MMS, et al. Gender differences in the effect of early life trauma on hypothalamic-pituitary-adrenal axis functioning. Depress Anxiety 2011; 28(5): 383-92. https://doi/10.1002/da.20795
https://doi/10.1002/da.20795... , the ability to overcome stressful situations⁵²52 Christiansen DM, Berke ET. Gender- and sex-based contributors to sex differences in PTSD. Curr Psychiatry Rep 2020; 22(4): 19. https://doi/10.1007/s11920-020-1140-y
https://doi/10.1007/s11920-020-1140-y... and social support⁵³53 McGuire AP, Gauthier JM, Anderson LM, Hollingsworth DW, Tracy M, Galea S, et al. Social support moderates effects of natural disaster exposure on depression and posttraumatic stress disorder symptoms: effects for displaced and nondisplaced residents. J Trauma Stress 2018; 31(2): 223-33. https://doi.org/10.1002/jts.22270
https://doi.org/10.1002/jts.22270... ,⁵⁴54 Pfefferbaum B, North CS. Children, and families in the context of disasters: implications for preparedness and response. Fam Psychol 2008; 24(2): 6-10. https://doi/10.1901/jaba.2008.24-6
https://doi/10.1901/jaba.2008.24-6... stand out.

Recently, socioeconomic variables such as educational level have been used to assess the impact of disasters in the short and long terms⁵⁵55 Frankenberg E, Sikoki B, Sumantri C, Suriastini W, Thomas D. Education, vulnerability, and resilience after a natural disaster. Ecol Soc 2013; 18(2): 16. https://doi/10.5751/ES-05377-180216
https://doi/10.5751/ES-05377-180216... . For example, individuals with lower educational levels are more likely to live in areas affected by disasters, lose their homes and stay in shelters or temporary housing. On the other hand, those with higher education have more opportunities, are healthier, receive better wages, have higher life expectancies, and live in less affected areas⁵⁶56 Lutz W, Samir KC. Global human capital: integrating education and population. Science 2011; 333(6042): 587-92. https://doi/10.1126/science.1206964
https://doi/10.1126/science.1206964... .

Regarding age, a negative association was observed between being aged ≥60 years and symptoms of PTSD, depression, and anxiety, which is explained by better-coping skills to adverse situations and traumatic events that this group acquired throughout life⁵⁷57 Smith MM, Saklofske DH, Keefer KV, Tremblay PF. Coping strategies and psychological outcomes: the moderating effects of personal resiliency. J Psychol 2016; 150(3): 318-32. https://doi.org/10.1080/00223980.2015.1036828
https://doi.org/10.1080/00223980.2015.10... , or the greater resilience of the elderly in accepting and adapting to adverse changes in life⁵⁸58 MacLeod S, Musich S, Hawkins K, Alsgaard K, Wicker ER. The impact of resilience among older adults. Geriatr Nurs 2016; 37(4): 266-72. https://doi.org/10.1016/j.gerinurse.2016.02.014
https://doi.org/10.1016/j.gerinurse.2016... .Lastly, living in a mining area probably represents a greater chance of exposure to a new dam failure, as participants of these regions have a more consistent association with psychiatric symptoms than the population directly affected by the disaster.

Our study has the following advantages: inclusion of a sample representative of the municipality; high response rate; investigation of different psychiatric symptoms using standardized and validated instruments; differentiation of prevalence values and association with psychiatric symptoms according to the participants’ area of residence; and intensive training of field and laboratory teams.

Limitations should also be mentioned, including the absence of important information that would guarantee a more accurate and less speculative interpretation of results. As an example, we can cite the lack of previous information about the prevalence of psychiatric symptoms in a given period, which prevents the evaluation of variations over time and the impact of specific situations such as the economic crisis (2016), the dam collapse (2019) and the COVID-19 pandemic (2020/2021) on the mental health of Brumadinho residents. Furthermore, the study’s cross-sectional design is also a limitation; it makes it impossible to establish causal relationships as they do not prove the existence of a temporal sequence between sociodemographic characteristics, place of residence, and subsequent development of psychiatric symptoms.

Our study shows a high prevalence of different psychiatric symptoms after the Brumadinho dam disaster. There was a positive association between being a female and living close to a mining area and symptoms of PTSD, depression, anxiety, ideas of death/self-harm and worse sleep quality. There was also a positive association between educational level and PTSD symptoms, and a negative association between being aged ≥60 years and symptoms of PTSD, depression, and anxiety. The investigation of other factors associated with psychiatric symptoms after the Brumadinho dam failure will improve the understanding of the complex relationship between this event and the mental health of the population.

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