1. Introduction
Natural disasters have profoundly impacted human physical and psychological well-being throughout history. Türkiye, a country prone to natural disasters and earthquakes, has faced significant devastation over the years and continues to cope with the long-term effects of these events on individuals. Earthquakes in particular stand out as one of the most traumatic natural disasters due to their sudden and unpredictable nature, leading to widespread destruction and loss of life. Large-scale earthquakes can have long-lasting psychological effects on affected individuals, with posttraumatic stress disorder (PTSD) one of the most prominent outcomes resulting from intense stress and traumatic experiences [
1].
On 6 February 2023, two powerful earthquakes with magnitudes of Mw 7.7 and Mw 7.6 struck southeastern Türkiye within nine hours of each other, unleashing one of the deadliest natural disasters in the country’s modern history. The tremors affected an area spanning over 110,000 square kilometers and directly impacted more than 13 million people across 11 provinces. These earthquakes caused unprecedented destruction across the region, resulting in over 50,000 confirmed deaths and hundreds of thousands of injuries [
2]. Thousands of buildings—including apartment blocks, hospitals, and schools—collapsed instantly, while critical infrastructure such as roads and communication networks were rendered inoperable. The initial hours were marked by chaos and silence: countless individuals lay trapped under debris, many of them still alive, their voices fading as time passed. For survivors, the horror was not only the destruction but also the unbearable helplessness of hearing loved ones and strangers cry out from beneath the rubble—calls that would go unanswered.
In the days following the earthquake, temperatures dropped below freezing. Snowfall and biting cold added a cruel dimension to the tragedy, as displaced families gathered around improvised fires in open fields without electricity, heating, or clean water. Tens of thousands were forced to spend nights in cars, under tarps, or in hastily erected tents with little protection against the harsh winter. The delivery of aid was hampered by damaged roads and overwhelmed systems, and in some regions, help did not arrive for days. Bodies recovered from the rubble had to be laid to rest swiftly in mass graves due to health concerns, often without proper identification or religious rituals. In many cities, the scent of concrete dust and death lingered in the air for weeks.
As the acute phase gave way to prolonged crisis, hundreds of thousands of survivors were relocated to tent cities and container settlements, where some of them continue to live more than two years later. Aftershocks—some exceeding magnitude 5.0—persisted for months, sustaining a climate of chronic threat and reactivating trauma responses. The loss of homes, family members, routines, and a sense of safety have left deep psychological scars. Children who witnessed the collapse of their homes, adults who buried loved ones without closure, and entire communities that vanished in minutes now struggle with an invisible aftermath: grief, guilt, and despair. Under such conditions, mental health is not a secondary concern—it is a cornerstone of recovery.
The impact of such disasters is not limited to the general population—health-care workers are also significantly affected. These professionals not only experience the trauma firsthand but also bear the responsibility of providing essential medical services under extreme conditions. In natural disasters like these, health-care workers form the backbone of survival support and disaster management. However, many health-care workers lost their homes, family members, and even their lives, while health-care facilities also suffered extensive damage, rendering some of them inoperable. The earthquakes forced many health-care workers to leave the region, creating a severe shortage in medical services. According to data from the Turkish Medical Association, 463 health-care workers, including 107 physicians, lost their lives in the earthquake-affected regions, while 6 health-care workers, including 5 physicians, were reported missing [
3]. To address this gap, from the first day of the disaster, 21,204 physicians and 62,590 health-care workers were deployed to the affected areas on five-day shifts to provide medical assistance and support recovery efforts [
4]. However, ensuring the continuity of mental health services and maintaining established therapeutic relationships in the long term required innovative solutions.
One of the authors of this study was directly involved in post-earthquake relief efforts, and upon returning, observed the severe shortage of mental health professionals in the affected areas. Access to mental health support through specialized organizations was limited due to challenges in physically reaching the affected population, a shortage of qualified health-care professionals, financial constraints, and the social stigma connected with mental health care. As of then, digital mental health interventions had not been implemented in Türkiye’s public or university hospitals except from our clinic. Recognizing the urgent need for continued psychiatric support, our clinic answered with an immediate digital mental health-care response, offering remote consultations to earthquake survivors. This experience highlighted the critical role of telepsychiatry, not only in PTSD assessment but also in the management of preexisting chronic psychiatric conditions.
In recent years, technological advancements have facilitated the expansion of telemedicine and telepsychiatry, making mental health support more accessible to larger populations in the aftermath of disasters. Regardless of whether a disaster occurs, health cannot be discussed without considering mental health. When physical access to health-care services is disrupted, telepsychiatry serves as a vital tool for ensuring continued mental health support and recovery [
5]. Tele-mental health interventions were found to play a key role in delivering trauma-informed care to populations affected by natural disasters [
6]. Following the Kahramanmaraş earthquakes, the demand for telepsychiatry services increased significantly, demonstrating their effectiveness in enhancing psychological well-being.
The hospital conducting this study has been utilizing telepsychiatry since the COVID-19 pandemic, during which our clinic also conducted group therapy sessions through telepsychiatry [
7]. In accordance with the Ministry of Health’s guidelines [
8], we also utilize telepsychiatry services to monitor postpartum depression in new mothers. Also, because we are one of the few gender dysphoria clinics operating in Türkiye, we find that telepsychiatry serves a great tool to follow up patients experiencing gender dysphoria who face challenges in accessing hospital-based care. These experiences have proven quite valuable, extending telepsychiatric services beyond disaster victims to individuals in remote locations with limited access to mental health care. Our unit swiftly utilized its existing telepsychiatry infrastructure by establishing a disaster clinic within the first week of the earthquake.
This study aimed to examine the sociodemographic factors associated with PTSD development, assess traumatic stress symptoms, and evaluate the effectiveness of telepsychiatry services and psychiatric medication following the February 6 earthquakes. By gaining deeper insights into the psychiatric impact of traumatic experiences on earthquake survivors and optimizing psychosocial support systems, we sought to study the effectiveness of telepsychiatry services in order to enhance disaster mental health services for the future. This research highlights the importance of providing psychoeducation and self-care information to affected individuals in the region. Additionally, this study highlights the relevance of digital approaches for mental health follow-up in disaster settings, in line with recent meta-reviews on the efficacy of web-based interventions for trauma-related conditions [
9].
4. Discussion
This study employed a naturalistic, observational design to investigate the psychological impact of the 6 February 2023 earthquakes in Türkiye through a telepsychiatry-based intervention. A total of 211 individuals were initially screened via the General Health Questionnaire (GHQ-12), and 189 participants scoring ≥ 13 were considered at psychological risk. Of these, 156 individuals residing in the disaster area and opting for follow-up were assessed with the PTSD Checklist—Civilian Version (PCL-C) and the Beck Depression Inventory (BDI) at the end of the first month. After excluding three individuals due to acute psychiatric conditions, the final sample included 153 participants. PCL-C scores showed a significant decline from a baseline mean of 42.47 (SD = 12.22) to 33.02 (SD = 12.23) at the six-month follow-up, indicating substantial symptom improvement. All PCL-C subscales—re-experiencing, avoidance, and hyperarousal—demonstrated significant reductions. Additionally, BDI scores at baseline were high (mean = 36.39, SD = 9.69), and regression analysis revealed that greater PTSD symptom reduction was associated with higher education and perceived social support, while trauma history predicted poorer outcomes. Of the initial cohort, 143 participants completed the six-month follow-up, validating the feasibility and effectiveness of telepsychiatry in delivering post-disaster mental health care under extraordinary conditions.
In this study, we observed that women were more likely to experience persistent posttraumatic symptoms—findings that align with prior post-disaster research. Zhou et al. identified female gender, older age, and solitary living as predictors of PTSD symptom persistence six months after the Wenchuan earthquake [
14]. The influence of gender on posttraumatic stress responses is strongly supported in the literature. Numerous studies have demonstrated that women are more vulnerable to developing PTSD compared to men. A review by Farooqui et al. (2017) [
15] encompassing 77 earthquake studies and a meta-analysis by Nemeroff et al. (2006) [
16] both revealed that women were nearly twice as likely as men to develop PTSD. Field research conducted after the 2023 Türkiye Kahramanmaraş earthquakes also confirmed this finding, reporting a PTSD prevalence in women that was approximately double that of men [
17]. Similarly, analyses of earthquakes in Iran, Pakistan, and Haiti have identified female gender as a significant risk factor [
18,
19]. After the 2011 earthquake in Japan, older women were also found to have a 1.6-fold higher prevalence of PTSD symptoms compared to men [
20]. These findings across diverse populations suggest that women may be more susceptible to trauma due to biological and psychosocial mechanisms. Heightened sensitivity to stress hormones, a tendency to interpret trauma as more threatening, and the burden of traditional gender roles are among the proposed contributors to this increased risk [
21,
22]. Our predominantly female sample underscores the need to consider gender-specific risk factors. In our experience, women survivors of the earthquake often faced unique stressors that exacerbated their mental health symptoms. Several participants reported intense psychological distress stemming from the lack of private sanitation facilities, limited access to menstrual hygiene products, and the burden of sharing cramped tent or container spaces with their spouses—particularly among those experiencing intimate partner violence. These compounded vulnerabilities frequently contributed to the persistence or worsening of depressive and posttraumatic symptoms. Through telepsychiatry, many of these women were able to access confidential support, receive psychoeducation on trauma and coping, and when appropriate, initiate pharmacological treatment. Despite infrastructural limitations, remote care provided a crucial lifeline for these patients, demonstrating the viability and importance of telepsychiatry in addressing gender-specific needs after disasters. In our experience, women may be more prone to intrusive rumination and emotional overprocessing following trauma, which has been shown to mediate PTSD severity [
23]. This gendered vulnerability is also supported by findings in adolescents, where female participants consistently exhibited higher levels of depression, anxiety, and PTSD-related symptoms post-earthquake [
24]. Digital access also may present an additional gender-related challenge. Although telepsychiatry offers a promising route for care continuity, women in certain conditions may face unique barriers, such as limited digital literacy, cultural stigma, and concerns over data privacy. These factors can hinder engagement with digital mental health services, especially in post-disaster contexts [
13].
In our study, lower educational attainment was significantly associated with increased severity of PTSD symptoms. This finding aligns with a substantial body of literature underscoring the impact of education on posttraumatic psychological outcomes. Following the Wenchuan earthquake, large-scale analyses identified low education as a significant risk factor for PTSD development [
22,
25]. Similarly, in a systematic review by Sirotich and Camisasca (2024) [
26], low educational status was highlighted among the primary sociodemographic risk factors for disaster survivors, alongside unemployment and financial hardship. This vulnerability may stem from limited problem-solving skills, reduced access to information and services, and less effective coping strategies among individuals with lower education. These individuals also tend to have weaker social support networks and are more likely to engage in adverse health behaviors [
26]. The stronger and more persistent PTSD symptoms observed among participants with lower education in our sample further support this risk profile. Therefore, post-disaster interventions should incorporate educational and socioeconomic indicators into risk assessments to enable early identification and targeted support for high-risk groups.
A history of trauma also emerged as a significant risk factor for more severe post-disaster symptoms. This finding aligns with existing literature suggesting that prior trauma may serve as an additional vulnerability factor in the face of new traumatic events. The literature on complex trauma shows that early-life interpersonal trauma—such as childhood abuse, neglect, or loss—can increase vulnerability to anxiety and trauma-related disturbances in adulthood [
27]. Research has shown that previously traumatized individuals are significantly more likely to develop PTSD after a disaster [
25,
28]. Meta-analyses focusing on post-earthquake mental health consistently identify prior trauma as a strong risk factor for PTSD [
22]. Individuals with earlier trauma may experience subsequent disasters as a reactivation of past experiences, thereby intensifying their psychological response [
29]. This vulnerability appears to be especially pronounced when the past and current traumas share thematic or contextual similarities. Cumulative traumatic exposures may deplete coping resources and amplify stress reactions in a synergistic manner, while also heightening preexisting anxiety and perceived danger in the world [
30]. The persistence of PTSD symptoms among trauma-experienced participants in our sample supports these mechanisms. These findings underscore the importance of systematically screening for trauma history in post-disaster interventions and providing targeted support to individuals with prior traumatic exposure.
Conversely, certain factors appeared to buffer participants against persistent symptoms. Our study found a significant association between lack of social support and the severity of PTSD symptoms, aligning with extensive evidence in the literature emphasizing the critical role of social support in posttraumatic psychological recovery. Numerous studies have shown that strong perceived social support serves as a protective factor against posttraumatic stress, whereas low levels of support are linked to increased PTSD risk [
25]. For instance, meta-analyses examining risk factors after natural disasters have demonstrated that adequate social support significantly reduces the likelihood of developing PTSD. The “social support deterioration” model proposed by Kaniasty and Norris (1995) suggests that the gradual erosion of social networks after disasters may impair coping capacities and exacerbate psychological distress [
31]. In line with this, research following the 2008 Wenchuan earthquake found that individuals with strong social support had significantly lower PTSD rates [
22]. Social support not only facilitates the recovery process but also acts as a buffer against the adverse effects of extreme stress. Although some longitudinal studies indicate that the protective effects of support may diminish over time—or even re-trigger trauma in some contexts—overall, the evidence supports its beneficial role. Strengthening social ties and maintaining support networks in the aftermath of disasters remain essential strategies for both PTSD prevention and psychological resilience [
26]. These findings align with studies showing that psychological strengths at the individual and family level—such as strength-based parenting—can promote resilience and even posttraumatic growth, especially when mediated by traits like optimism [
32].
The digital delivery of psychiatric care played a crucial role in our intervention model reducing PTSD symptoms over a six-month period. Our findings add to the growing evidence base that guided digital interventions, particularly those involving synchronous therapist contact, can be effective and cost-efficient alternatives to face-to-face therapy in the treatment of PTSD and depression. Synchronous modalities such as video consultations are especially valuable in enhancing therapeutic alliance and treatment adherence compared to asynchronous methods [
9]. There is growing evidence in the literature that telepsychiatry can fill critical gaps in care, particularly in regions where infrastructure has been damaged or access to specialists is limited. For instance, Augusterfer et al. (2018) reported that telepsychiatry and digital health technologies have effectively supported post-disaster mental health services in over 85 countries [
33]. Similarly, following the 2015 earthquake and floods in Pakistan, a regional telepsychiatry network successfully provided psychiatric care where in-person services were unavailable [
34]. Reinhardt et al. (2019) also emphasized that telepsychiatry reduced waiting times, improved access, and was generally well accepted by both patients and clinicians [
35]. The symptom improvement observed in our sample provides a real-world example of telepsychiatry’s potential efficacy in managing PTSD. Although the number of controlled studies remains limited, current data suggest that this modality offers significant advantages in terms of service continuity and early intervention [
36,
37]. Therefore, telepsychiatry should be considered a viable and effective alternative in post-disaster settings where face-to-face care is not feasible. However, it should not be overlooked that access inequities remain a challenge, especially for individuals from marginalized or economically disadvantaged groups who may lack the infrastructure or digital literacy needed to fully engage with these platforms [
9]. There is also a larger systemic issue that should be addressed when it comes to the use of telepsychiatry. As Ahmed and Heun emphasize, the absence of internationally standardized guidelines for electronic mental health and psychosocial support in humanitarian settings creates a barrier to quality and equity in service delivery. There is a need for structured frameworks that address not only clinical care but also ethical, logistical, and technological aspects of digital interventions [
37].
Several post-disaster telepsychiatry interventions have been reported following major earthquakes, providing a basis for comparison with the current study.
Table 7 summarizes key characteristics of telepsychiatry studies after the 2010 Haiti earthquake, the 2008 Wenchuan (China) earthquake, and the 2005 Pakistan earthquake, including each study’s design, population, intervention, and main findings. Notably, prior efforts demonstrated the feasibility of remote mental health care in disaster settings. For example, in post-earthquake rural Haiti (2010), a pilot initiative integrated a visiting U.S. psychiatrist with local providers at five clinics, using the WHO mhGAP protocol to support treatment of common mental disorders [
38]. A retrospective review from that Haiti program found that 65 patients were seen (most with depression, epilepsy, or chronic mental illnesses) and 90% required follow-up care. Importantly, very few patients identified the earthquake as the direct cause of their psychiatric symptoms, underscoring substantial preexisting mental health needs [
38]. In China (Wenchuan 2008), an innovative approach was a web-based self-help program (My Trauma Recovery) evaluated in an RCT. In that study, trauma survivors who used the internet-delivered intervention had significantly reduced PTSD symptoms compared to controls, with large effect sizes observed after 1 month of use and sustained improvement at 3 months [
39,
40]. In Pakistan (2005), where mountainous terrain and infrastructure damage limited in-person care, telepsychiatry was implemented to connect specialists with remote field clinics. Reports from Pakistan’s telepsychiatry program describe it as a practical and feasible strategy for delivering psychiatric rehabilitation to displaced survivors in austere settings [
40].
In our study, a strong association was found between the severity of posttraumatic depressive symptoms and PTSD symptom levels. Participants with higher Beck Depression Inventory (BDI) scores exhibited more severe and persistent PTSD symptoms. This finding aligns with extensive literature indicating that PTSD and depression frequently co-occur in the aftermath of trauma. For instance, in a study conducted after the 1999 Marmara earthquake, the lifetime prevalence of PTSD and major depressive disorder (MDD) was found to be 19.2% and 18.7%, respectively, and 37.5% of those with PTSD also met diagnostic criteria for depression [
41]. Similarly, studies following the 2010 Haiti and 2008 Sichuan earthquakes reported strong correlations between PTSD and depressive symptoms [
19,
42]. Research has consistently shown that the co-occurrence of these disorders is associated with more severe clinical presentations and poorer recovery outcomes. In our sample, higher BDI scores were predictive of persistent PTSD at the six-month follow-up, suggesting that depression may contribute to the chronicity of PTSD. Therefore, screening for depressive symptoms in post-disaster mental health assessments is essential for identifying individuals at risk for PTSD. As emphasized in previous studies, those who develop depression after trauma are also highly susceptible to PTSD, highlighting the need for integrated psychosocial interventions that address both conditions simultaneously [
24].
It has been widely emphasized in the literature that the comorbidity of chronic PTSD and depression is highly prevalent following earthquakes. For instance, after the 1999 Marmara earthquake, the prevalence of PTSD was reported to be 23%, while the rate of comorbid depression was 16% [
29]. Similarly, a meta-analysis on the 2010 Haiti earthquake indicated that approximately a quarter of survivors exhibited PTSD symptoms and a third showed depressive symptoms [
19]. In certain samples, the rate of comorbidity was even higher: for example, 39.2% of adolescents affected by the 2017 Jiuzhaigou earthquake exhibited both PTSD and depression [
43]. The frequent co-occurrence of PTSD and depression can lead to more severe and treatment-resistant symptom trajectories. Indeed, a study conducted after the Haiti earthquake demonstrated a significant positive correlation between PTSD and depressive symptom severity [
44]. Depression often develops secondarily in the aftermath of trauma and may contribute to the chronicity of PTSD. In line with this, a study on child survivors of the Lushan earthquake reported that PTSD symptoms typically emerged earlier than depressive symptoms, suggesting that depression might exacerbate preexisting trauma-related distress [
44]. Longitudinal studies further support this interaction: for instance, one study showed that while PTSD symptoms significantly decreased 13 months after an earthquake, depression levels—measured by the Beck Depression Inventory (BDI)—remained largely unchanged [
45]. This finding highlights that untreated depression may sustain PTSD symptoms over time. Furthermore, higher BDI scores have been associated with more severe PTSD symptoms among earthquake survivors [
44]. The findings of our current study are largely consistent with the existing literature: we similarly observed that depression was prevalent among chronic PTSD cases and that higher BDI scores were positively correlated with greater PTSD symptom severity. Although some variability in prevalence rates has been reported across different studies—for instance, comorbidity rates tend to be higher among adolescents compared to adults [
43]—there is a general consensus that PTSD and depression comorbidity constitutes a major clinical challenge following earthquakes. Accordingly, the literature emphasizes the critical importance of early identification and comprehensive treatment of both disorders among disaster survivors [
45]. Early psychosocial interventions have been suggested to be effective in alleviating PTSD symptoms and preventing the chronicity of PTSD by simultaneously treating comorbid depression [
45]. Furthermore, given that psychiatric problems can persist for many years after major earthquakes—for example, PTSD and depression rates remained as high as 11.8% and 24.8%, respectively, even eight years after the Wenchuan earthquake [
46]—it is recommended that long-term follow-up and intervention programs be systematically planned.
The phenomenon that PTSD symptoms may spontaneously diminish over time is well documented in the literature. Although the majority of individuals exposed to trauma experience some PTSD symptoms during the first few weeks, these typically subside on their own. It has been reported that only a small proportion of trauma-exposed individuals (approximately 8%) fail to exhibit this “natural recovery” and go on to develop PTSD [
47]. Longitudinal studies have shown that there is a marked decrease in PTSD symptoms during the acute posttrauma period, typically within the first 3 to 6 months. For instance, meta-analytic evidence indicates that PTSD prevalence is around 25% within the first month following trauma, but this rate decreases by approximately a third by the third month. Similarly, a systematic review found that nearly half of individuals diagnosed with PTSD achieved remission within three years without receiving any formal treatment [
48]. Rates of natural recovery can vary depending on factors such as the type of trauma and the initial symptom profile. Indeed, recovery over time tends to be higher among individuals exposed to single-incident and unintentional traumas (e.g., natural disasters), whereas it is reported to be lower following human-made, intentional traumas [
49]. When examining symptom dimensions, individuals exhibiting pronounced hyperarousal symptoms have been found to experience poorer outcomes—namely persistently elevated symptom levels—at 12 months, suggesting that spontaneous recovery is less likely in this subgroup [
50]. On the other hand, protective factors such as social support play a critical role in the process of natural recovery: strong social support following trauma has been shown to reduce the risk of developing PTSD and to facilitate the spontaneous resolution of symptoms [
47]. These findings have fueled debate over whether immediate, intensive psychological intervention is necessary for every individual exposed to trauma. The prevalence of natural recovery has led clinicians to adopt a “watchful waiting” or active monitoring approach in some cases. In particular, for individuals who exhibit relatively mild symptoms within the first few weeks, it is often recommended to allow time for potential spontaneous recovery before initiating formal treatment [
48,
51]. Universal early interventions—such as single-session structured psychological debriefing—have not been found effective in preventing chronic PTSD, and in some cases may even disrupt the natural course of recovery. Indeed, it has been suggested that prematurely pathologizing normal acute stress reactions after trauma may undermine individuals’ confidence in their own coping abilities. Accordingly, current clinical guidelines recommend monitoring individuals who exhibit PTSD symptoms within the first month posttrauma through regular follow-up, allowing time for spontaneous recovery. Trauma-focused treatments should be initiated only if symptoms fail to improve significantly over time or become more severe [
51]. In conclusion, longitudinal research on the natural course of PTSD has shown that a significant reduction in symptom severity occurs within 6 to 12 months for a substantial proportion of cases. However, a subset of individuals may experience a chronic course lasting for years in the absence of clinical intervention [
48,
49]. In the present study, the decrease observed in PCL-C scores at the 6-month follow-up aligns with the natural recovery trajectory emphasized in the literature. However, early identification of high-risk individuals who do not exhibit spontaneous recovery is crucial, as timely clinical intervention for these individuals is essential to prevent the long-term development of chronic PTSD [
50,
51].
Advances in artificial intelligence (AI) are poised to augment telepsychiatry by triaging patients, tracking symptoms, and providing chatbot-based support at scale. During the COVID-19 pandemic, for example, an AI-driven virtual triage system handled millions of online symptom-check encounters and effectively flagged individuals with mental health needs for care referral [
52]. Such AI triage tools can rapidly detect early signs of distress in large populations, potentially accelerating access to treatment during disasters. Likewise, AI chatbots are emerging as a scalable means of delivering psychological support. A recent trial of a generative AI “therapy chatbot” found significant reductions in users’ depression and anxiety symptoms—a 51% drop in depressive symptoms on average—comparable to outcomes from traditional therapy. Participants reported trusting the chatbot and engaging with it much like a human therapist [
53]. These findings demonstrate the potential for AI-assisted telepsychiatry to scale mental health-care delivery and enable early symptom detection in crisis settings when human resources are overwhelmed. Integrating AI-based triage and monitoring into telepsychiatry platforms could help prioritize high-risk cases, while chatbot assistants might provide immediate psychosocial support or psychoeducation to those awaiting professional care. Early studies underscore improved treatment adherence and symptom outcomes with such tools [
54].
5. Limitations and Future Directions
Despite its strengths, this study has several limitations that should be acknowledged. First, the sample predominantly consisted of female participants, which introduces a gender imbalance that may affect the generalizability of the findings. Second, the recruitment methods—largely based on digital outreach and online appointment systems—may have favored individuals who were digitally literate and had stable internet access. This likely excluded certain vulnerable subgroups, including older adults, individuals from lower socioeconomic backgrounds, and those with severe psychiatric symptoms or cognitive impairments, who may have been unable to access or engage with telepsychiatry services. These selection biases must be taken into account when interpreting the findings and considering their applicability to the broader population of disaster survivors.
Second, the study primarily focused on PTSD and depressive symptoms, without including structured assessments for anxiety disorders, sleep disturbances, or substance use, which are commonly observed comorbidities in post-disaster contexts. Expanding the diagnostic scope in future studies would yield a more comprehensive understanding of posttrauma psychiatric trajectories.
Third, although the six-month follow-up provides valuable insight into symptom evolution, longer-term functional outcomes (e.g., return to work, social reintegration, quality of life) were not assessed. Future longitudinal studies should incorporate these dimensions to evaluate real-world recovery.
Additionally, variables related to treatment fidelity—such as session attendance, adherence to medication, and dropout rates—were not systematically collected, limiting conclusions on the practical sustainability of telepsychiatric interventions.
Another important limitation is the inability to statistically compare outcomes between patients who received pharmacotherapy in addition to psychoeducation and those who received only psychoeducation. Since this was a naturalistic study, treatment allocation was not randomized or based on clinical judgment. Such comparisons would be confounded by indication: patients not receiving medication were generally more stable at baseline, which might inherently predict better outcomes independently of the intervention type.
A consistent theme in the recent literature is the need to expand the scope of outcomes evaluated in post-disaster mental health research beyond the traditional focus on PTSD and depression. Historically, disaster studies have emphasized PTSD, but anxiety disorders, sleep disturbances, substance misuse, and functional impairments are also prevalent and consequential among survivors [
55]. For instance, insomnia is highly prevalent after mass trauma: one study found 38% of adolescents reported persistent sleep problems even 12–24 months after the 2008 Wenchuan earthquake. Increased alcohol and substance use is another documented post-disaster issue, often co-occurring with anxiety and depression and potentially hindering recovery [
55] Additionally, disasters can lead to significant functional impairment in daily life: survivors may struggle with work productivity, school performance, or family responsibilities due to ongoing psychological and cognitive effects [
56]. Experts now argue that future research and intervention trials should systematically include anxiety, insomnia, substance use, and functional recovery as key outcomes alongside PTSD and depressive symptoms [
55,
56]. By capturing this broader range of psychosocial consequences, studies can provide a more nuanced understanding of recovery trajectories and treatment needs. In turn, this could inform the development of holistic interventions, for example, integrating sleep restoration programs, substance use counseling, or rehabilitation services into post-disaster mental health care. Emphasizing diverse outcomes will also help identify individuals who, despite not meeting PTSD criteria, still endure serious post-disaster hardships (like chronic insomnia or impaired functioning) and would benefit from targeted support. Ultimately, broadening outcome measures is essential to advance a comprehensive, survivor-centered approach to mental health in disaster contexts, ensuring that interventions address all dimensions of well-being and not just trauma-related syndromes.
Lastly, cultural attitudes toward mental health and digital care were not directly explored, despite their likely impact on service utilization and treatment engagement. Future research should address these social-contextual variables to develop culturally responsive, trauma-informed digital care models.
Future studies should aim to test scalable, evidence-based telepsychiatry protocols through randomized controlled trials while integrating user-centered design to optimize engagement and accessibility—especially in under-resourced populations.
Future studies should also evaluate the applicability and effectiveness of telepsychiatry across various disaster scenarios, including floods, wildfires, and forced displacement. Additionally, research conducted in diverse cultural and geographic contexts is essential to determine the adaptability of remote mental health interventions.