Unseen Wounds: PTSD Among Search and Rescue Teams Responding to the February 6, 2023 Earthquake in Türkiye

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

I read the article very carefully and found the topic very interesting.

The introductory section was well described by the authors.

The method and experimental design, although simple, are scientifically rigorous.

The analysis of the results and statistical conclusions are well done and, above all, are accompanied by excellent graphs and representations.

The discussions are thoroughly argued and the division into different points makes for very easy reading.

The work is well done in all its parts and I believe it deserves to be published in its current form.

Author Response

RESPONSE TO REVIEWER-1

Comment 1: I read the article very carefully and found the topic very interesting.

Response 1: Dear Reviewer, I deeply appreciate your encouraging words for the manuscript.

Comment 2: The introductory section was well described by the authors.

Response 2: Dear Reviewer, I deeply appreciate your encouraging words for the manuscript.

Comment 3: The method and experimental design, although simple, are scientifically rigorous.

Response 3: Dear Reviewer, thank you very much for your valuable comments.

Comment 4: The analysis of the results and statistical conclusions are well done and, above all, are accompanied by excellent graphs and representations.

Response 4: Dear Reviewer, your valuable insights were deeply appreciated.

Comment 5: The discussions are thoroughly argued and the division into different points makes for very easy reading.

Response 5: Dear Reviewer, thank you very much for your positive comments.

Comment 6: The work is well done in all its parts and I believe it deserves to be published in its current form.

Response 6: Dear Reviewer, I deeply thank you. Yours truly

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript presents a compelling investigation into the prevalence and severity of post-traumatic stress disorder (PTSD) among search and rescue (SAR) personnel following the catastrophic earthquake in Türkiye. The topic is highly relevant to disaster psychology and occupational health, and the authors employ a validated instrument (PCL-5) on a sizable sample. However, some aspects of the manuscript require revision to improve its methodological transparency, analytic rigor, and interpretive depth.

• The study is presented as cross-sectional, which is appropriate for initial assessments; however, more clarity is needed on how participants were recruited. You mention that 4,000 were contacted but do not explain how these individuals were identified or approached. Were all SAR workers given equal access to the survey? If convenience or purposive sampling was used, please explicitly acknowledge the potential for sampling bias.
• The response rate (619 out of 4,000) is reasonable but still subject to self-selection effects, especially considering the psychological nature of the study. This must be discussed as a limitation.
• The use of the PCL-5 instrument is appropriate and well-described. However, it's unclear whether a Turkish-validated version of the scale was used. Please clarify if linguistic and cultural adaptations were performed or if prior validation in Türkiye exists.
• The use of arbitrary cutoffs for symptom severity (e.g., "normal," "mild," "moderate") lacks citation. Please specify the source or justification for these thresholds.
• Your statistical approach is ambitious and multi-layered, involving t-tests, ANOVA, SEM, and PLS-SEM. This is commendable, but the rationale for using both SEM and PLS-SEM is not adequately explained. Were these used for model comparison? For handling non-normality? Please clarify.
• Several p-values are reported without corresponding effect sizes (e.g., Cohen's d, η²), making it difficult to assess practical significance. Including these would strengthen your results section.
• Tables are extensive and data-rich, but some (e.g., Table 5, Table 6) are dense and difficult to interpret. Consider simplifying presentation or splitting them into more readable formats.
• The finding that individuals with higher education and greater experience showed greater PTSD symptom severity is counterintuitive and should be more thoughtfully explored. Possible explanations such as increased cognitive rumination, leadership stress, or secondary exposure accumulation are worth discussing. Similarly, the gender findings (women reporting more severe symptoms across multiple domains) are consistent with existing literature but should be presented carefully to avoid overgeneralization. Consider cultural and societal factors that might contribute to these differences.
• The discussion touches on relevant literature but remains somewhat descriptive. Consider framing your findings using established theoretical models, such as the Diathesis-Stress Model, the Cumulative Trauma Theory and/or the Conservation of Resources (COR) Theory for occupational stress. These frameworks may help explain the non-linear relationship between experience, age, and PTSD severity.

- Your limitations section is currently underdeveloped. Please expand it to address the use of self-report data and possible social desirability bias, the lack of longitudinal follow-up, the recall bias in symptom reporting four months post-event, and the absence of clinical diagnosis (PCL-5 provides provisional screening, not confirmation).

- Your conclusions are generally well-aligned with the findings, but consider adding more actionable implications. For example, recommendations for psychological screening protocols in SAR teams, proposals for resilience training or early intervention programs, and the need for longitudinal mental health monitoring in post-disaster contexts.

- The manuscript would benefit from language editing to improve readability and reduce redundancy.

- Violin plots and structural model diagrams are informative but require better captions and clearer axis labels.

- Please remove repetitive citations of earthquake details across multiple sections.

 

Comments on the Quality of English Language

The manuscript would benefit from careful language editing to improve clarity, flow, and reduce repetition, particularly in the discussion and conclusion sections.

Author Response

Dear reviewer we deeply appreciate your encouraging words regarding the manuscript. We are further grateful for your acknowledgment of the study's focus on search and rescue (SAR) personnel and the use of a validated instrument (PCL-5) with a sizable sample. We also appreciate your constructive comments which improved the manuscript with respec to the methodological transparency, analytic rigor, and interpretive depth. Regarding your comment, we have strictly addressed your comments for further clarification, robustness and theoratical frame for the manuscript. We hope the revision version will meet the expectations. Please find the comment below point by point. Yours truly

Comment 1- The study is presented as cross-sectional, which is appropriate for initial assessments; however, more clarity is needed on how participants were recruited. You mention that 4,000 were contacted but do not explain how these individuals were identified or approached. Were all SAR workers given equal access to the survey? If convenience or purposive sampling was used, please explicitly acknowledge the potential for sampling bias.

Response 1- Thank you for your insightful and constructive comment. We deeply appreciate your comments concerned with the participant involvement. The participants were composed of the individiuals who were officially registered with the Disaster and Emergency Management Authority (AFAD) as search and rescue (SAR) workers during the February 6, 2023 Earthquake in Türkiye. We were officially provided an Access to the contact liste of SAR personnel. From the list, 4000 individuals were randomly selected and were sent an online questionnaire through institutional email and internal communication platforms.  All recipients had equal access to the survey link. However, participation was voluntary and depended on the individuals’ willingness to respond. We have now included this clarification in the “Study Design and Participants” section and acknowledged the potential for sampling bias due to the use of purposive and voluntary response sampling.

The added and revised part is as follows:

“In June 2023, around four months after the earthquake struck southern Turkey, a cross-sectional survey including a sample of 619 people was conducted. It was voluntary to participate. The participants were AFAD personnel who participated in search and rescue missions after the earthquake on February 6. Purposive sampling was used, focusing on those who were formally listed as members of the search and rescue response team by the Disaster and Emergency Management Authority (AFAD). The research team obtained a contact list from AFAD, and 4,000 people were chosen at random and contacted through internal message platforms and email, among other institutional communication methods. The online survey platform was equally accessible to everyone who was contacted. However, individual consent and willingness to fill out the survey were prerequisites for participation. As a result, we recognize the possibility of sample bias as a limitation, as also further noted in limitation section of the present study. Daniel and Cross's recommendations [33] were used to calculate the sample size for the participants.

 

Comment 2- The response rate (619 out of 4,000) is reasonable but still subject to self selection effects, especially considering the psychological nature of the study. This must be discussed as a limitation.

Response 2- We deeply acknowledge of your comments and fully agree that the response rate of 15.5% (619 out of 4,000) may be influenced by self-selection bias, especially due to the psychological nature of the survey, which may have attracted individuals experiencing higher distress or, conversely, those more comfortable sharing their experiences. This potential limitation has now been explicitly acknowledged in the revised manuscript under the “Highlights and Limitations” section. We have added a sentence discussing how voluntary participation could introduce bias and potentially affect the generalizability of the findings. Please find the revised version below.

Added or revised section is as follows:

“An further significant constraint is to the possibility of self-selection bias. The voluntary nature of participation may have resulted in an overrepresentation of people with either higher emotional awareness or more severe psychological problems, even if the response rate of 15.5% (619 out of 4,000) is within acceptable bounds for online psychological surveys. This might affect how broadly the results can be applied to the larger group of SAR personnel participating in the earthquake response.”

 

Comment 3- The use of the PCL-5 instrument is appropriate and well-described. However, it's unclear whether a Turkish-validated version of the scale was used. Please clarify if linguistic and cultural adaptations were performed or if prior validation in Türkiye exists.

Response 3-Thank you for highlighting this important point. We confirm that the Turkish-validated version of the PCL-5 was used in this study. The scale was previously translated and culturally adapted into Turkish, and its psychometric properties were examined and validated in several studies conducted in Türkiye (e.g., Boysan et al., 2017; Aker et al., 2019). The Turkish version has demonstrated strong internal consistency and construct validity in various populations. We have now clarified this in the “Data Collection Tools” section and added relevant citations to support this point.

The added sections are as follows:

The PCL-5, which was employed in this investigation, has been psychometrically verified in Turkey and has already undergone linguistic and cultural adaptation. To guarantee semantic and conceptual equivalency, the adaptation procedure involved forward and reverse translation, expert panel evaluation, and pilot testing. The Turkish version of the PCL-5 has good construct validity, convergent validity, and internal consistency across a range of Turkish populations, according to studies Boysan et al. (2017). As a result, this version was thought to be appropriate for evaluating PTSD symptoms among Turkish search and rescue personnel.

 

Comment 4- The use of arbitrary cutoffs for symptom severity (e.g., "normal," "mild," "moderate") lacks citation. Please specify the source or justification for these thresholds.

Response 4-  Dear Reviewer, we would like to thank you very much for the valuable critiques. The severity cutoffs used in our study were adapted from the guidelines provided by Weathers et al. (2013), who developed the PCL-5 instrument, and from subsequent studies that proposed score ranges for symptom severity classification in clinical and research contexts (e.g., Bovin et al., 2016; Wortmann et al., 2016). These thresholds-while not diagnostic-offer a practical framework for interpreting symptom burden across populations. We have now cited these references and clarified this approach in the revised version of the manuscript.

Added to the  Results

 These cutoff values were based on empirical scoring recommendations used in clinical research applying the PCL-5, including those by Weathers et al. (2018), Bovin et al. (2016), and Wortmann et al. (2016), who suggested symptom severity classifications to support non-diagnostic interpretation and clinical screening in post-disaster settings.

Bovin, M. J., et al. (2016). Psychometric properties of the PTSD Checklist for DSM-5 (PCL-5) in veterans. Psychological Assessment, 28(11), 1379–1391. https://doi.org/10.1037/pas0000254
Wortmann, J. H., et al. (2016). Psychometric analysis of the PCL-5 in a sample of recently returned veterans. Psychological Assessment, 28(11), 1392–1403. https://doi.org/10.1037/pas0000260

 

Comment 5- Your statistical approach is ambitious and multi-layered, involving t-tests, ANOVA, SEM, and PLS-SEM. This is commendable, but the rationale for using both SEM and PLS-SEM is not adequately explained. Were these used for model comparison? For handling non-normality? Please clarify.

Response 5- Thank you for this valuable comment. We agree that clarification is needed regarding the use of both SEM and PLS-SEM in our study. Initially, we employed covariance-based SEM (using LISREL) to evaluate model fit based on maximum likelihood estimation, focusing on overall model structure and theoretical consistency. However, we observed that the data did not fully meet the assumptions of multivariate normality. Therefore, to address potential violations of normality and enhance model robustness, we also conducted PLS-SEM as a complementary method. PLS-SEM, being a variance-based approach, is more suitable for non-normal data and complex models with smaller sample sizes. Our goal was not direct model comparison but to confirm the stability and consistency of latent construct relationships under different estimation conditions. This rationale has now been clarified in the revised "Statistical Analysis" section of the manuscript. Please find the revision as follows:

Added to the  Statistical Analysis

 

In addition to covariance-based SEM, PLS-SEM analysis was also conducted to ensure robustness of the model, particularly due to indications of non-normality in the dataset. While SEM (via LISREL) was used to examine theoretical model fit through maximum likelihood estimation, PLS-SEM served as a complementary method better suited for data that deviates from normality and for models with relatively complex latent structures. Our aim was not to compare model performance directly but to validate structural relationships using both parametric and non-parametric estimation techniques. This dual approach helped confirm the internal consistency of the proposed PTSD model under different statistical assumptions.

Comment 6- Several p-values are reported without corresponding effect sizes (e.g., Cohen's d, η²), making it difficult to assess practical significance. Including these would strengthen your results section.

Response 6- Thank you for your insightful suggestion. We agree that including effect size measures is essential for assessing the practical significance of the findings. Accordingly, we have recalculated key statistical comparisons using appropriate effect size metrics. For independent-samples t-tests, Cohen’s d was computed; for one-way ANOVA tests, partial eta squared (η²) values were reported. These values have now been added to the “Results” section in relevant tables and narrative descriptions. We believe these additions improve the interpretability and practical relevance of our findings.

Added to the Statistical Analysis

Effect size measures were calculated to assess the practical significance of the findings. For independent-samples t-tests, Cohen’s d values were reported, and for ANOVA analyses, partial eta squared (η²) values were used. Cohen's d values were interpreted as small (0.2), medium (0.5), and large (0.8); η² values were interpreted as small (0.01), medium (0.06), and large (0.14) effects, following established following guidelines (Cohen, 1988; Lakens, 2013).

Added to the references

Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum.
Lakens, D. (2013). Calculating and reporting effect sizes to facilitate cumulative science: a practical primer for t-tests and ANOVAs. Frontiers in Psychology, 4, 863. https://doi.org/10.3389/fpsyg.2013.00863

Comment 7- Tables are extensive and data-rich, but some (e.g., Table 5, Table 6) are dense and difficult to interpret. Consider simplifying presentation or splitting them into more readable formats.

Response 7- Thank you for your constructive critiques. We fully agree that Tables 5 and 6, while comprehensive, may appear dense and overwhelming to readers. To improve clarity and readability, we have revised these tables. Table 5 has been split into parts in different colours. Table 6 highlights significant values with p values < 0.05 in bold. We believe these changes make the tables more accessible and enhance interpretability without sacrificing data richness.

 

Additions are marked as follows:

Table 5

Re-experiencing (Items 1–5) green

Avoidance (Items 6–7) yellow

Negative Alterations (Items 8–15) blue

Hyperarousal (Items 16–20) purple

Table 6.

The significant values (p < 0.05) were marked in bold.

 

Comment 8- The finding that individuals with higher education and greater experience showed greater PTSD symptom severity is counterintuitive and should be more thoughtfully explored. Possible explanations such as increased cognitive rumination, leadership stress, or secondary exposure accumulation are worth discussing. Similarly, the gender findings (women reporting more severe symptoms across multiple domains) are consistent with existing literature but should be presented carefully to avoid overgeneralization. Consider cultural and societal factors that might contribute to these differences.

Response 8- Dear Reviewer, thank you for your helpful comments. We agree that the finding that people with more education and experience have higher PTSD symptoms should be looked into more. In response, we have expanded the discussion to include possible psychological mechanisms such as thinking too much, feeling more responsible, and experiencing more trauma over time, especially in leadership roles.

Also, our findings on gender are in line with previous research, but we are aware that we cannot generalise them too much. We have updated the relevant section to include social and cultural factors that could be affecting the differences we see in how people with PTSD behave in Turkey. These factors include gender norms, how people express their emotions, and who looks after whom. The changes will provide a more detailed understanding of the results and make our discussion more culturally sensitive.

 

Additions or revised versions are as follows:

 Added to the Educational Status of the Participants

Contrary to the prevailing assumption that individuals with greater knowledge and experience would exhibit higher levels of resilience, our findings revealed a contradictory outcome. Higher education has been demonstrated to exacerbate symptoms of Post-Traumatic Stress Disorder (PTSD) by increasing cognitive rumination, defined as the prolonged and repetitive consideration of traumatic events. This is a compelling argument. Moreover, individuals with extensive experience frequently assume leadership roles, a situation which can engender heightened psychological distress through exposure to the trauma and moral injury experienced by others, in addition to an augmented responsibility for decision-making. The intensity of symptoms in this subgroup may also be influenced by secondary traumatization, defined as the accumulation of indirect trauma exposure over time.

Added to the  Gender Status of the Participants

Whilst the present finding that women reported more severe PTSD symptoms across multiple domains is consistent with former studies, it can be acknowledged that such differences should be interpreted with caution. Cultural and societal expectations in Türkiye, such as traditional gender roles and emotional expressiveness, may influence how trauma is experienced and reported. It is hypothesised that women may be more socially permitted or encouraged to acknowledge psychological distress, whereas men may underreport due to stigma or internalised norms of emotional suppression. Furthermore, caregiving responsibilities and emotional labour, which are often shouldered disproportionately by women in disaster contexts, may serve to exacerbate psychological vulnerability. These cultural dynamics emphasise the necessity of contextualised interpretations of gender differences in trauma responses.

 

Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129(1), 52–73.
Figley, C. R. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. Brunner/Mazel.
Nolen-Hoeksema, S. (2000). The role of rumination in depressive disorders and mixed anxiety/depressive symptoms. Journal of Abnormal Psychology, 109(3), 504–511.

Comment 9- The discussion touches on relevant literature but remains somewhat descriptive. Consider framing your findings using established theoretical models, such as the Diathesis-Stress Model, the Cumulative Trauma Theory and/or the Conservation of Resources (COR) Theory for occupational stress. These frameworks may help explain the non-linear relationship between experience, age, and PTSD severity.

Response 9- Dear Reviewer, thank you for your helpful recommendation. We agree that using theoretical frameworks can make our findings clearer. So, we have updated the discussion to include important psychological models. The Diathesis-Stress Model is used to explain why some people are more vulnerable than others, and what their pre-existing traits and cognitive sensitivity might be. The Cumulative Trauma Theory is a way of explaining how repeated exposure among experienced professionals can lead to more severe symptoms over time. We also use the Conservation of Resources (COR) Theory to show how the continuous use of resources (emotions, psychology and society) may affect experienced workers' ability to deal with trauma. These additions help us to understand the observed non-linear patterns related to age, experience, and how severe PTSD symptoms are better.

 

Added to the discussion

 Work Experiences of the Participants

The observed non-linear relationship between professional experience and PTSD severity can be better understood through the lens of Cumulative Trauma Theory, which posits that repeated exposure to traumatic events can lead to a buildup of psychological burden, even in resilient individuals. In accordance with this theory, experienced search and rescue workers may not only encounter a greater number of traumatic events over time, but also carry unresolved emotional residues from previous missions, which serve to amplify responses to new traumas.

Moreover, the Conservation of Resources (COR) Theory posits that psychological distress escalates in response to the perception of a threat to or actual loss of personal, social, or material resources. In the case of highly experienced personnel, prolonged exposure has been shown to gradually deplete emotional reserves, social support, or a sense of efficacy, resulting in reduced coping capacity over time. This finding contributes to the understanding that greater experience does not necessarily guarantee greater resilience.

Furthermore, the Diathesis-Stress Model provides a framework for understanding individual variability in PTSD symptoms. The model posits that individuals possess varying levels of vulnerability (diathesis), which interact with environmental stressors (e.g. exposure to disaster scenes) to determine psychological outcomes. Higher education and professional experience have been shown to correlate with increased cognitive processing, heightened awareness of responsibility, and leadership-related pressures. These factors have the potential to amplify stress reactions rather than mitigate them.

Added to the references

Hobfoll, S. E. (1989). Conservation of resources: A new attempt at conceptualizing stress. American Psychologist, 44(3), 513–524.
Neuner, F., Schauer, M., Karunakara, U., Klaschik, C., Robert, C., & Elbert, T. (2004). Psychological trauma and evidence for enhanced vulnerability for posttraumatic stress disorder through previous trauma among West Nile refugees. BMC Psychiatry, 4(1), 34.
Ingram, R. E., & Luxton, D. D. (2005). Vulnerability-stress models. In B. L. Hankin & J. R. Z. Abela (Eds.), Development of Psychopathology: A Vulnerability-Stress Perspective (pp. 32–46). Sage.

 

Comment 10- Your limitations section is currently underdeveloped. Please expand it to address the use of self-report data and possible social desirability bias, the lack of longitudinal follow-up, the recall bias in symptom reporting four months post-event, and the absence of clinical diagnosis (PCL-5 provides provisional screening, not confirmation).

Response 10- Thank you for this helpful and positive suggestion. We completely agree that the limitations section can be improved by clearly talking about the methods used. In the updated version of the document, we have added more information about the limitations to help explain: (1) The fact that the data was based on self-reports, which might be subject to social desirability bias; (2) the cross-sectional nature of the study, which means it cannot show cause and effect or track long-term outcomes; (3) recall bias due to people reporting symptoms they experienced four months after the event; and (4) the absence of clinical diagnostic confirmation, as the PCL-5 is a screening tool rather than a diagnostic instrument. We believe these additions make the study's methodology clearer and more balanced.

 

Added to the Highlights and Limitations

It is important to acknowledge the limitations of this study. Initially, the data were collected through self-report questionnaires, which may be subject to biases such as social desirability, over- or underreporting, and inaccurate introspection. Secondly, the study employed a cross-sectional design, which limits the ability to make causal inferences or observe changes in psychological symptoms over time. Thirdly, as the data were gathered approximately four months after the earthquake, participants' recollections of their psychological responses may have been influenced by recall bias, potentially affecting the accuracy of symptom reporting. Fourthly, although the PCL-5 is a widely utilised and validated instrument for the assessment of PTSD symptoms, it remains a screening tool and does not supersede a formal clinical diagnosis by a mental health professional. Consequently, the prevalence and severity levels reported herein should be interpreted as provisional, not definitive. Finally, given that participation was voluntary, it is possible that individuals experiencing greater psychological distress or interest in the topic may have been more likely to respond, thus introducing a potential self-selection bias.

Comment 11- Your conclusions are generally well-aligned with the findings, but consider adding more actionable implications. For example, recommendations for psychological screening protocols in SAR teams, proposals for resilience training or early intervention programs, and the need for longitudinal mental health monitoring in post-disaster contexts.

Response 11- Thank you for this thoughtful suggestion. We agree that incorporating more actionable implications would enhance the practical relevance of our findings. In the revised conclusion section, we have added specific recommendations for implementing structured psychological screening protocols within SAR teams, introducing resilience-building and early intervention programs, and establishing systems for longitudinal mental health monitoring after major disasters. These proposals are grounded in our findings and aligned with global best practices in disaster mental health.

Addition to the conclusion section

In light of the findings, several actionable implications are worth highlighting. First, search and rescue (SAR) teams should be routinely screened for PTSD symptoms using validated tools like the PCL-5 as part of post-disaster debriefing protocols. Early identification of individuals at risk could enable timely psychological intervention. Second, incorporating resilience training programs and psychological preparedness modules into SAR personnel training curricula may help build coping capacity before deployment. Third, establishing early intervention systems-including peer support networks and access to trauma-informed counseling-can mitigate the progression of distress symptoms. Finally, longitudinal monitoring of mental health outcomes should be integrated into disaster response strategies to track changes over time, assess intervention effectiveness, and ensure sustained psychological well-being among responders. These measures are crucial for maintaining both the effectiveness and the well-being of SAR personnel in future disaster scenarios.

Comment 12- The manuscript would benefit from language editing to improve readability and reduce redundancy.

Response 12- Thank you for your valuable feedback. In response, the manuscript has undergone a thorough language revision to improve clarity, coherence, and readability. We have reduced repetitive expressions, simplified complex sentence structures, and ensured that terminology is used consistently throughout the text. We believe that these revisions have enhanced the overall quality and flow of the manuscript.

Comment 13- Violin plots and structural model diagrams are informative but require better captions and clearer axis labels.

Response 13- Thank you for your helpful comment. In the updated version of the document, we have made the figure captions for all the violin plots and structural model diagrams clearer. This means they now provide more detailed explanations of what is being displayed. Also, the labels on the axes have been made clearer. All variable names are spelled out in full, and the units of measurement are clearly specified where applicable. These changes were made to make the visual parts of the manuscript easier for readers to understand.

Additions or changes are as below:

Figure 3. The violin plot shows how the total PTSD symptom severity scores are spread. The parts of the plot that are wider show a higher number of responses for that particular symptom. The white dot shows the median, and the thick black bar shows the interquartile range.Y-axis: Likert grates X-axis: Density of responses

Comment 14- Please remove repetitive citations of earthquake details across multiple sections.

Response 14- Dear Reviewer, thank you for your observation. We acknowledge that earthquake-related details were unnecessarily repeated in several sections of the manuscript. In response, we have revised the text to eliminate redundant information and ensured that the main details regarding the earthquake (e.g., magnitude, date, affected region) are presented concisely in the Introduction only. Other sections now refer to the event without repeating full descriptions. We believe this improves the overall readability and cohesion of the manuscript.

Reviewer 3 Report

Comments and Suggestions for Authors

1. The study was conducted approximately four months after the earthquake, but the authors do not explain why this particular time frame was chosen. PTSD symptomatology can evolve (acute vs delayed onset), and a clearer rationale would help contextualize the clinical relevance of the findings.

2. The authors do not mention whether participants were screened for prior psychiatric history (possible LoS), use of psychotropic medication, or current psychological treatment, all of which could influence the severity of PTSD symptoms. This omission limits interpretability.

3. The authors note that higher education levels were associated with more severe PTSD symptoms and offer a sociocognitive explanation (e.g., greater empathy, higher awareness). While interesting, this claim would benefit from a more cautious tone or empirical citation. As it stands, it reads as conjectural.

4. The paper presents results from both LISREL-based SEM and PLS-SEM, but does not clearly explain the rationale for using both. Were they used to cross-validate findings? What was the advantage of PLS-SEM in this context? Clarifying this would strengthen the methodological transparency

Conclusion: This is a strong manuscript that warrants publication following minor revisions. Addressing the points above would enhance the scientific clarity and rigor of the work.

Comments on the Quality of English Language

Minor editing may be advised.

Author Response

Comment 1: The study was conducted approximately four months after the earthquake, but the authors do not explain why this particular time frame was chosen. PTSD symptomatology can evolve (acute vs delayed onset), and a clearer rationale would help contextualize the clinical relevance of the findings.

 

Response 1: Thank you for this insightful observation. We should note the rationale for conducting the survey four months post-disaster. According to DSM-5 diagnostic criteria, PTSD symptoms that persist beyond one month after the traumatic event are considered clinically significant and no longer part of the "acute stress reaction" phase. By selecting a four-month interval, we aimed to assess the persistence of symptoms beyond the acute phase while still capturing responses before they become confounded by long-term recovery processes or chronic adaptation. This timeframe aligns with previous studies that have assessed PTSD prevalence among first responders within 3–6 months after disasters, as it is considered a clinically relevant window for identifying both acute and emerging delayed-onset cases (North et al., 2011; Galea et al., 2008).  

North, C. S., Pfefferbaum, B., Kawasaki, A., Lee, S., & Spitznagel, E. L. (2011). Psychosocial adjustment of directly exposed survivors 7 years after the Oklahoma City bombing. Comprehensive Psychiatry, 52(1), 1–8. https://doi.org/10.1016/j.comppsych.2010.04.003

Galea, S., Nandi, A., & Vlahov, D. (2008). The epidemiology of post-traumatic stress disorder after disasters. Epidemiologic Reviews, 27(1), 78–91. https://doi.org/10.1093/epirev/mxi003

 

Comment 2: The authors do not mention whether participants were screened for prior psychiatric history (possible LoS), use of psychotropic medication, or current psychological treatment, all of which could influence the severity of PTSD symptoms. This omission limits interpretability.

Response 2: Dear Reviewer, we deeply thank you for your comments. We agree with you. In this regard, we have already inserted the necessity of the psychiatric history (possible LoS), use of psychotropic medication, or current psychological treatment. Our words were as “There is a significant need for practices aimed at preserving and improving the mental health of professionals involved in disasters and emergencies. Before disasters, providing psychological training to participants can be a crucial step in raising awareness of their own psychological reactions”. Since the history of the psychological of the members are confidential, it is not /not be allowed to use such data. Instead, the regular training programmes should be given to the members before emergence of a disaster. 

 

Comment 3: The authors note that higher education levels were associated with more severe PTSD symptoms and offer a sociocognitive explanation (e.g., greater empathy, higher awareness). While interesting, this claim would benefit from a more cautious tone or empirical citation. As it stands, it reads as conjectural.

 

Response 3: We appreciate this valuable observation. We agree with you, deeply appreciate your comments. We have revised the text to adopt a more cautious tone and added references where possible. Specifically, we now emphasize that while our findings showed higher PTSD symptoms among participants with higher education, the underlying reasons remain speculative and may involve factors such as heightened empathy or awareness, as suggested by prior studies. We have rephrased the statement to avoid overstating the explanation and to clearly indicate that further research is needed to confirm these mechanisms. We have added a paragraph. It is as follows:

“Overall, the present study reports that participants with higher education levels exhibited greater PTSD symptoms compared to those with lower education levels. While the mechanisms underlying this association remain unclear, previous studies suggest that individuals with higher education may have heightened awareness of disaster-related risks or greater empathic sensitivity, which could intensify emotional responses to trauma. However, further research is needed to clarify these relationships.”

 

Comment 4: The paper presents results from both LISREL-based SEM and PLS-SEM, but does not clearly explain the rationale for using both. Were they used to cross-validate findings? What was the advantage of PLS-SEM in this context? Clarifying this would strengthen the methodological transparency

Response 4: Dear Reviewer, thank you for pointing out this important methodological issue. We have now clarified the rationale for using both LISREL-based SEM and PLS-SEM. Specifically, LISREL-based SEM was initially used due to its strong foundations in covariance-based structural modeling and its ability to test model fit against theoretical expectations. However, given that some of our data (e.g., PCL-5 items) did not fully meet normality assumptions and were ordinal in nature, we additionally employed PLS-SEM, which is more robust with non-normally distributed data and smaller sample sizes for complex models. The use of both approaches allowed us to cross-validate the findings, ensuring that the relationships among latent constructs were stable and not artifacts of a single estimation method.

Overall, we really thank you for your valuable comments. We hope our responses meet your comments. Yours truly