福島県立医科大学 学術機関リポジトリ

Title

Psychologic distress and QOL in medical staff after a disaster:
A longitudinal 4-year study

Author(s)Yabuki, Shoji; Takatsuki, Kozue; Ouchi, Kazuo

Citation

Fukushima Journal of Medical Science. 68(1): 25-35

Issue Date

2022

URL

http://ir.fmu.ac.jp/dspace/handle/123456789/1645

Rights© 2022 The Fukushima Society of Medical Science. This
article is licensed under a Creative Commons [AttributionNonCommercial-ShareAlike 4.0 International] license.

DOI

10.5387/fms.2021-19

Text Version publisher

This document is downloaded at: 2024-10-16T10:56:07Z

Fukushima Medical University

Psychologic distress and QOL after a disaster

Fukushima J. Med. Sci.,
Vol. 68, No. 1, 2022

25

[Original article]

Psychologic distress and QOL in medical staff after a disaster :A longitudinal 4-year study
Shoji Yabuki1)2), Kozue Takatsuki2), and Kazuo Ouchi1)
1)

Rehabilitation Center, Fukushima Medical University Hospital, Fukushima, Japan, 2)Department ofPain Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan(Received August 3, 2021, accepted January 13, 2022)

AbstractAiming to improve post-disaster care of medical staff, we conducted an early and ongoing assessment of post-disaster psychologic distress and quality of life (QOL) in one center of a disaster-response hospital. Twelve days after the Great East Japan Earthquake, as the Fukushima Daiichi Nuclear Power Plant crisis was unfolding, we began a survey to examine the physical and mental stateof medical staff to assess their motivation toward work. Surveys were administered in March 2011
(Survey 1), March 2012 (Survey 2), March 2013 (Survey 3), March 2014 (Survey 4), and March 2015
(Survey 5). Participants completed the Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), EuroQol (EQ-5D), and MOS Short-Form 36-item Health Survey (SF-36). Although BDI scores significantly improved over time following Survey 1, participants in their 30s had
significantly higher Survey 2 scores than those in their 40s/50s, and significantly higher Survey 3scores than those in their 20s. STAI scores significantly improved over time following Survey
1. However, participants in their 30s had significantly higher Survey 3 scores than those in their
20s. EQ-5D scores did not significantly vary among survey time points or age groups. SF-36
physical functioning, role physical, social functioning, role emotional, and mental health subscalescores significantly improved over time. In conclusion, post-disaster longitudinal changes, including recovery period, differed among age groups. Thus, age should be taken into account in longitudinal evaluations of psychologic distress and QOL in medical staff after a disaster and, as more recent events suggest, during a pandemic.
Key words : Fukushima Daiichi Nuclear Power Plant accident, psychologic distress, QOL, disaster,
longitudinal studyof life (QOL) among different age groups and professions, including medical staff during and after a disaster, may lead to better systems for addressing
personal consequences of disaster response andpost-disaster life6).
The Great East Japan Earthquake of 11 March2011 initiated a complex disaster including a major
tsunami, multiple aftershocks, and an ongoing nuclear power plant crisis. Psychologic distress was
subsequently observed in many Japanese people, as
nearly 20,000 were lost in the tsunami, and damage

Introduction
On 11 March 2020, exactly 9 years after theGreat East Japan Earthquake, the World Health Organization announced that the spread of COVID-19(SARS - CoV - 2 infection) had become a pandemic. This pandemic, in turn, has created a publichealth disaster that has increased psychologic distress, including anxiety and depression, in the global
population1,2), including medical staff3 5). Understanding psychologic distress and changes in quality-

Corresponding author : Shoji Yabuki MD, DMSc   E-mail : yabuki@fmu.ac.jp©2022 The Fukushima Society of Medical Science. This article is licensed under a Creative Commons [Attribution-NonCommercial-ShareAlike 4.0 International] license.
https://creativecommons.org/licenses/by-nc-sa/4.0/25

S. Yabuki et al.

26

at the Fukushima Daiichi Nuclear Power Plant resulted in substantial releases of radioactive material7 9). Even though medical staff in Fukushima generally had more knowledge about radiation than the
population at large, they, too, experienced disasterrelated anxiety. In the decade that followed, it has
been possible to examine longitudinal changes in
psychologic distress and quality of life (QOL)10 13).
The purpose of this study was to assess longitudinalchanges in psychologic distress and QOL in medical
staff working in Fukushima Prefecture after theGreat East Japan Earthquake, associated tsunami,
and the Fukushima Daiichi Nuclear Power Plant accident, with the goal of generating data on how best
to follow-up with medical staff experiencing psychologic distress and decreased QOL after a disaster. Although the 2011 disaster and the 2020 COVID-19 pandemic have different characteristics, theyshare various individual and societal risk issues, risk
trade-offs, and measures to recognize and adapt tothese risks14). The present findings may provide
useful information on how to follow-up with medical
staff experiencing psychologic distress and decreased QOL during or after a pandemic.
--

Subjects and methods
We conducted a survey to examine the physicaland mental state of medical staff after the disaster toassess their motivation toward work. We explained
the purpose of the survey to staff and obtained theirverbal consent to participate in this minimal risk research. The study received approval number 2020194 from the Ethics Committee of Fukushima Medical University, which is guided by local policy,
national law, and the World Medical Association
Declaration of Helsinki.
Participants were 19 medical staff working in
the Rehabilitation Center at Fukushima Medical
University Hospital, located about 60 km from the
Fukushima Daiichi Nuclear Power Plant. Alreadyequipped to deal with acute disease and trauma, this
hospital was among those in Fukushima Prefecture
specially designated for disaster response. Although the hospital itself was not severely damaged,
its municipal water supply was interrupted, necessitating extreme conservation measures during thefirst week of disaster response. For close to amonth, routine outpatient care was suspended, andpatients with chronic conditions were evacuated tofacilities outside the disaster area. Emergency carepatients were received, treated, and, if necessary,transferred, until routine hospital practice could beresumed.
Radiation levels around the hospital were monitored and disclosed to all staff. A brief peak, on parwith background radiation levels experienced in acommercial jet at cruising altitude, was followed by
rapid exponential decay. Nevertheless, medical
staff were worried about exposure to continuous
low-dose radiation.
Participants were 10 men and 9 women, 36.9 ±12.3 years old (mean ± standard deviation [SD]).
Five participants were in their 20s, eight were in
their 30s, three were in their 40s, and three were in
their 50s. Ten participants were physical therapists, three were occupational therapists, two were
speech therapists, two were doctors, one was anurse, and one was a nursing assistant. All participants had been working at the Rehabilitation Center
when the Great East Japan Earthquake and the Fukushima Daiichi Nuclear Power Plant accident occurred.
This prospective, observational study began 12days after the disaster, and continued for 4 years,
with five surveys in total. The surveys were administered in March 2011 (Survey 1), March 2012
(Survey 2), March 2013 (Survey 3), March 2014
(Survey 4), and March 2015 (Survey 5).
The survey questionnaires included the Beck
Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), EuroQol (EQ-5D), and MOS ShortForm 36 - item Health Survey (SF - 36). The informed consent process was conducted verbally,
with all center staff agreeing to participate.
BDI
This self- report questionnaire measures thepresence and severity of depression symptoms15,16). Higher scores indicate greater depression : minimal depression = 0-9, mild depression =10-16, moderate depression = 17-29, and severe
depression = 30-63. License to use the questionnaire is available from the following companies in Japan : SACCESS BELL (http://www.saccess55.
co.jp/), Chiba Test Center (http://www.chibatc.co.jp),
and Nihon Bunka Kagakusha (http://www.nichibun.
co.jp/).
STAI
This self- report questionnaire measures thepresence and severity of current symptoms of anxie t y a n d g e n e r a l i z e d p ro p e n s i t y t o b e a n x ious17 19). There are two subscales : the State Anxiety Scale (STAI-S) evaluates the current state ofanxiety, and the Trait Anxiety Scale (STAI-T) evalu-

Psychologic distress and QOL after a disasterates relatively stable aspects of anxiety proneness. The score range for each subtest is 20 80 ; higher scores indicate greater anxiety. A cutoff point of 39-40 for the STAI-S has been suggested
to detect clinically significant symptoms. License
to use the questionnaire is available from the following companies in Japan : SACCESS BELL (http://
www.saccess55.co.jp/), Chiba Test Center (http://
www.chibatc.co.jp), and Nihon Bunka Kagakusha(http://www.nichibun.co.jp/).
EQ-5D
This questionnaire is a standardized non-disease-specific instrument for describing and evaluating health-related QOL20 22). This instrument has
five dimensions (mobility, self-care, usual activities,
pain/discomfort, and anxiety/depression) with threelevels each. The descriptive system defines (35) =243 different states with utility scores that range
from 0.000-1.000. Higher scores indicate better
QOL. The questionnaire was used after registration with the EuroQol Office (https://euroqol.org).
-

SF-36
This questionnaire is a multi - item generichealth - related QOL survey intended to measure

Table 1.

STAI-S

STAI-T

EQ 5D-“general health concepts not specific to any age, disease, or treatment group”23 25). The SF-36 measures eight health domains : physical functioning(PF), role physical (RP), bodily pain (BP), general
health (GH), vitality (VT), social functioning (SF),role emotional (RE), and mental health (MH). The
SF-36 also generates a physical component summary (PCS) score, a mental component summary(MCS) score, and a role/social component summary(RCS) score26). The scale scores are calculated bysumming responses across scale items and thentransforming these raw scores to a 0 - 100 scale.
Computerized scoring algorithms are available andcan be used to produce norm - based T scores foreach scale (with a mean of 50 and SD of 10). Higher scores indicate better health. SF-36 was used
under license between our institute and iHope QOL(https://www.sf-36.jp/index.html).
-

Statistical analysis
We compared annual survey scores among thefollowing age groups : 20s (n = 5), 30s (n = 8), and40s/50s (n = 6). First, we used the Friedman test
to analyze changes in BDI, STAI, EQ-5D, and SF-36
scores over time (Tables 1 and 2). The Wilcoxon
signed-rank test and Bonferroni correction were ap-

Longitudinal changes in BDI, STAI, and EQ-5D scores during the 4-year period after the disasterAge group
BDI

27

Survey 1

Survey 2abSurvey 3

Survey 4

Survey 55.3 (6.1)
1.2 (1.3)

5.7 (5.7)
1.8 (2.9)ab

4.2 (4.8)
1.4 (1.5)

p<0.010.01

6.8 (6.5)
7.5 (5.5)

6.8 (6.1)h
3.2 (3.0)

0.02
0.07

40.9 (10.3)e39.8 (10.3)
38.8 (11.2)
44.7 (9.6)

34.5 (6.9)cd
31.0 (3.8)
37.0 (8.8)
34.2 (5.5)ip<0.001
0.02
0.03

Total

10.3 (12.5)

20s
30s

5.0 (4.3)
13.9 (16.8)

7.2 (6.9)
4.8 (4.2)
12.4 (7.4)h40s/50s

9.8 (10.3)

2.3 (2.3)

9.5 (7.3)
3.0 (2.5)

Total
20s
30s
40s/50s51.2 (11.1)de
46.6 (5.9)
49.6 (15.1)
57.0 (5.9) i

44.8 (8.8)c
46.4 (8.4)
47.0 (11.1)
40.5 (4.0)

42.2 (9.5)
34.2 (3.9)
49.1 (9.7)
39.7 (5.8)

Total
20s
30s
40s/50sfg

47.9 (13.1)
43.4 (5.9)
48.6 (18.7)
50.8 (8.5)jk

39.5 (9.6)
41.0 (8.3)
41.9 (12.6)

40.5 (10.7)
36.4 (8.4)
45.4 (13.6)

35.0 (4.1)k

Total
20s
30s
40s/50s

0.914 (0.153)
1.000 (0.000)
0.901 (0.209)
0.860 (0.109)

0.928 (0.134)
1.000 (0.000)
0.886 (0.175)
0.923 (0.120)gFriedman’s test

p<0.0137.5 (11.6)
32.2 (6.6)
37.4 (13.2)

f

33.6 (9.1)
30.8 (9.2)
35.8 (11.1)

p<0.001
0.03
0.10

37.3 (5.5)

42.2 (12.2)

33.2 (6.4)jp<0.010.960 (0.099)
1.000 (0.000)
0.958 (0.120)
0.929 (0.111)

0.972 (0.085)
1.000 (0.000)
0.961 (0.110)
0.964 (0.087)

0.946 (0.110)
1.000 (0.000)
0.934 (0.125)
0.915 (0.132)

0.03
1.00
0.16
0.23

Data are shown as mean values (standard deviation).
BDI : Beck depression inventory, STAI : State-Trait Anxiety Inventory, STAI-S : State anxiety scale, STAI-T : Trait
anxiety scale, EQ-5D : EuroQoL utility score.
a-k : Wilcoxon signed-rank test and Bonferroni correction were performed after Friedman’s test.
a, b, e, g, h, k : p < 0.05
c, d, f, i, j : p < 0.01

S. Yabuki et al.

28
Table 2.

Longitudinal changes in SF-36 scores during the 4-year period after the disasterAge group

Survey 1

Survey 2

Survey 3

Survey 4

Survey 5Friedman’s
test p-value

PF

Total
20s
30s
40s/50s

54.8 (5.4)a55.7 (3.2)
54.2 (7.7)
54.8 (3.5)

55.4 (4.8)b
56.4 (3.2)
53.8 (6.8)
56.6 (1.9)

54.6 (6.0)
57.8 (0.0)
52.4 (8.4)
54.8 (3.5)

55.8 (4.0)c
57.8 (0.0)
55.1 (3.7)
54.8 (5.8)

54.2 (6.0)abc
57.1 (1.6)
53.8 (7.6)
52.4 (5.9)

p<0.001
0.02
0.10
0.08

RP

Total
20s
30s
40s/50s50.1 (12.3)d49.1 (11.5)
49.9 (15.2)
51.3 (10.9)

51.7 (13.0)f
55.7 (0.0)
46.2 (19.4)
55.7 (0.0)

54.1 (6.9)g55.7 (0.0)
52.0 (10.6)
55.7 (0.0)

53.1 (5.9)e55.7 (0.0)
51.6 (7.9)
53.0 (5.3)

52.4 (8.2)defg
55.7 (0.0)
50.7 (9.9)
51.8 (9.5)

p<0.001
0.01
0.02
0.01

BP

Total
20s
30s
40s/50s55.4 (9.0)
58.9 (3.9)
54.8 (10.3)
53.2 (10.5)

55.3 (10.5)
58.9 (3.9)
54.7 (15.7)
53.2 (4.8)

54.7 (7.1)
55.3 (6.3)
57.9 (5.4)
50.0 (8.2)

54.6 (8.0)
61.7 (0.0)
54.5 (9.4)
48.7 (3.8)

54.2 (7.6)
60.3 (3.2)
55.6 (5.4)
47.2 (7.8)

0.05
0.18
0.04
0.60

GH

Total
20s
30s
40s/50s

54.9 (10.7)
58.4 (10.1)
52.4 (13.9)
55.3 (5.9)

53.8 (10.6)
59.1 (7.7)
47.6 (12.3)
58.5 (3.0)

54.5 (10.9)
60.0 (8.7)
48.6 (12.8)
58.0 (6.2)

55.5 (10.0)
61.8 (6.7)
54.2 (11.9)
52.2 (8.3)

55.4 (10.4)
62.1 (8.7)
49.9 (10.4)
57.1 (8.8)

0.79
0.49
0.14
0.14

VT

Total
20s
30s
40s/50s

47.0 (11.3)
51.1 (7.7)
45.8 (14.0)
45.0 (10.7)

48.9 (8.7)
44.7 (5.4)r48.2 (9.6)
54.3 (8.7)

50.3 (8.7)
51.8 (3.7)
45.8 (10.5)
55.2 (6.6)

52.4 (8.5)
53.7 (6.2)
54.2 (8.7)
48.8 (9.9)

54.7 (8.3)
58.2 (4.9)r50.6 (10.7)
57.4 (4.4)

0.05
0.04
0.12
0.02

SF

Total
20s
30s
40s/50s44.5 (17.5)
51.9 (8.4)
42.5 (20.9)
40.9 (19.0)

52.6 (9.6)i
57.0 (0.0)
46.5 (12.9)
57.0 (0.0)

52.3 (11.1)
57.0 (0.0)
49.0 (16.4)
52.7 (5.3)

52.9 (10.3)h57.0 (0.0)
48.2 (15.0)
55.9 (2.6)

52.6 (8.6)hi
55.7 (2.9)
49.0 (12.3)
54.9 (3.3)

p<0.001
0.01
0.22
0.10

RE

Total
20s
30s
40s/50s45.1 (12.5)j
48.6 (11.2)s
47.7 (14.3)t38.7 (10.3)w

52.3 (8.3)k56.1 (0.0)
47.7 (11.6)u55.4 (1.7)

52.6 (10.4)l56.1 (0.0)
47.7 (15.3)v
56.1 (0.0)

52.3 (8.0)m
56.1 (0.0)
48.8 (11.3)
54.0 (3.5)

54.3 (5.4)jklm
56.1 (0.0)s51.9 (8.0)tuv
56.1 (0.0)w

p<0.001p<0.01p<0.01p<0.01

MH

Total
20s
30s
40s/50s45.2 (14.4)o50.2 (7.3)
44.8 (19.0)
41.5 (12.4)x49.4 (9.2)n50.7 (6.5)
46.1 (11.7)
53.4 (6.2)

51.0 (9.0)
55.6 (4.1)
44.8 (10.9)
55.4 (2.2)

52.1 (8.9)
55.6 (7.0)
49.8 (10.2)
52.3 (8.9)

54.5 (7.8)no57.7 (8.1)
51.2 (9.5)
56.3 (2.8)xp<0.01
0.06
0.13
0.02

PCS

Total
20s
30s
40s/50s61.4 (10.7)w
59.5 (8.3)
60.3 (8.5)
64.4 (15.5)

56.8 (8.2)
59.5 (4.1)
55.4 (11.8)
56.4 (3.9)

56.1 (4.9)
57.2 (5.0)
57.2 (4.5)
53.6 (5.3)

56.2 (4.8)
60.1 (2.4)
57.5 (4.0)
51.2 (3.1)

53.6 (7.6)w
58.6 (7.0)
54.4 (5.1)
48.6 (8.8)

0.02
0.99
0.13
0.07

MCS

Total
20s
30s
40s/50s

48.3 (13.4)
54.2 (5.7)
46.3 (17.5)
46.0 (12.0)

49.7 (10.7)
48.9 (7.2)
47.7 (12.4)
53.7 (6.9)

50.5 (9.1)
53.8 (3.9)
45.7 (12.1)
54.2 (3.6)

52.4 (8.4)
56.3 (7.0)
52.6 (10.0)
49.0 (6.6)

54.6 (9.0)
59.3 (6.7)
50.3 (11.0)
56.6 (5.4)

0.15
0.17
0.10
0.28

RCS

Total
20s
30s
40s/50s40.4 (17.2)q43.4 (12.3)
42.3 (18.4)
35.4 (20.7)

49.6 (10.7)
53.7 (4.3)
44.7 (14.7)
53.4 (2.4)

50.9 (10.9)
53.5 (4.1)
47.5 (16.3)
53.3 (3.6)

50.0 (10.4)
51.1 (2.9)
45.0 (14.0)
55.7 (5.4)

51.0 (8.7)q50.3 (5.4)
49.3 (12.1)
53.9 (5.2)

0.02
0.05
0.32
0.33

Data are shown as mean values (standard deviation).
SF- 36 : MOS Short- Form 36- item Health Survey, PF : physical functioning, RP : role physical, BP : bodily pain,
GH : general health, VT : vitality, SF : social functioning, RE : role emotional, MH : mental health, PCS : physical component summary, MCS : mental component summary, RCS : role/social component summary
a-x : Wilcoxon signed-rank test and Bonferroni correction were performed after Friedman’s test.
a, d, h, o, p, q, r, s, t, u, v, x : p < 0.05
b, c, e, f, g, i, j, k, l, m, n, w : p < 0.01

Psychologic distress and QOL after a disaster

plied after the Friedman test to compare data fromthe different surveys for each age group (Tables 1
and 2). The Mann-Whitney U test and Bonferroni
correction were applied after performing the Kruskal- Wallis test to compare scores among the agegroups (Tables 3 and 4). A p-value of less than 0.05
was considered statistically significant. All analyses were performed using IBM SPSS statistical software (version 26.0, SPSS Inc., Chicago, IL, USA).

29

BDI
The mean total BDI score at Survey 1 was 10.3
points. The mean score improved with statisticalsignificance over time after Survey 1. Scores forthe participants in their 30s also significantly improved over time (Table 1). However, the scoresfor participants in their 30s were significantly higher(i.e., worse) than those for participants in their
40s/50s in Survey 2 and those for participants intheir 20s in Survey 3 (Table 3, Figure 1).

Results

STAI

All participants completed the surveys at all annual time points. Although two staff retired fromthe hospital at age 60 during the survey period, they
continued living in Fukushima City, and their questionnaires were collected. None of the participants
discontinued working at the Rehabilitation Center
because of the Fukushima Daiichi Nuclear Power
Plant accident.

The mean total STAI-S score at Survey 1 was
51.2 points. The score significantly improved overtime after Survey 1. The scores for participants intheir 40s/50s also significantly improved over time
(Table 1). However, the scores for participants intheir 30s were significantly higher (i.e., worse) thanthose for participants in their 20s in Survey 3 (Table
3, Figure 2).
The mean total STAI-T score at Survey 1 was

Table 3. Intergenerational changes in BDI, STAI, and EQ-5D scores during the 4-year period after thedisasterSurvey 1

Survey 2

20s

BDI
STAI-S

5.0 (4.3)

13.9 (16.8)

9.8 (10.3)

0.73

46.6 (5.9)

49.6 (15.1)

57.0 (5.9)

0.11Survey 4

Survey 530s

40s/50s

STAI-T

43.4 (5.9)

48.6 (18.7)

50.8 (8.5)

0.58

EQ-5D

1.000 (0.000)

0.901 (0.209)

0.860 (0.109)

0.11

a

a

BDI

4.8 (4.2)

12.4 (7.4)

2.3 (2.3)

0.01

STAI-S46.4 (8.4)

47.0 (11.1)

40.5 (4.0)

0.46

STAI-T

41.0 (8.3)

41.9 (12.6)

35.0 (4.1)

0.40

EQ 5D

1.000 (0.000)

0.886 (0.175)

0.923 (0.120)

0.32

BDI

b

1.2 (1.3)b

9.5 (7.3)

3.0 (2.5)

0.01

STAI-S34.2 (3.9)c

49.1 (9.7)c

39.7 (5.8)

0.04

STAI-T

36.4 (8.4)

45.4 (13.6)

37.3 (5.5)

0.22

EQ-5D

1.000 (0.000)

0.958 (0.120)

0.929 (0.111)

0.38

BDI
STAI-S

1.8 (2.9)

6.8 (6.5)

7.5 (5.5)

0.17

39.8 (10.3)

38.8 (11.2)

44.7 (9.6)

0.62

-

Survey 3

Kruskal-Wallis test p-value

BDI/STAI/EQ-5D

STAI-T

32.2 (6.6)

37.4 (13.2)

42.2 (12.2)

0.20

EQ-5D

1.000 (0.000)

0.961 (0.110)

0.964 (0.087)

0.68

BDI
STAI-S

1.4 (1.5)

6.8 (6.1)

3.2 (3.0)

0.16

31.0 (3.8)

37.0 (8.8)

34.2 (5.5)

0.27

STAI-T

30.8 (9.2)

35.8 (11.1)

33.2 (6.4)

0.67

EQ-5D

1.000 (0.000)

0.934 (0.125)

0.915 (0.132)

0.40

Data are shown as mean values (standard deviation).
BDI : Beck depression inventory, STAI : State-Trait Anxiety Inventory, STAI-S : State anxiety scale,
STAI-T : Trait anxiety scale, EQ-5D : EuroQoL utility score.
a, b, c : Mann-Whitney U test and Bonferroni correction were performed after Kruskal-Wallis test.
a, b, c : p < 0.05

S. Yabuki et al.

30
Table 4.

Intergenerational changes in SF-36 scores during the 4-year period after the disaster
SF-36

20s

30s

40s/50s

Kruskal-Wallis test p-value

PF
RP
BP

55.7 (3.2)
49.1 (11.5)
58.9 (3.9)

54.2 (7.7)
49.9 (15.2)
54.8 (10.3)

54.8 (3.5)
51.3 (10.9)
53.2 (10.5)

0.81
0.74
0.70

GH
VT
SF
RE
MH
PCS
MCS
RCS

58.4 (10.1)
51.1 (7.7)
51.9 (8.4)
48.6 (11.2)
50.2 (7.3)
59.5 (8.3)
54.2 (5.7)
43.4 (12.3)

52.4 (13.9)
45.8 (14.0)
42.5 (20.9)
47.7 (14.3)
44.8 (19.0)
60.3 (8.5)
46.3 (17.5)
42.3 (18.4)

55.3 (5.9)
45.0 (10.7)
40.9 (19.0)
38.7 (10.3)
41.5 (12.4)
64.4 (15.5)
46.0 (12.0)
35.4 (20.7)

0.62
0.56
0.73
0.19
0.54
0.86
0.63
0.68

Survey 2

PF
RP
BP
GH
VT
SF
RE
MH
PCS
MCS
RCS

56.4 (6.2)
55.7 (0.0)
58.9 (3.9)
59.1 (7.7)
44.7 (5.4)
57.0 (0.0)
56.1 (0.0)
50.7 (6.5)
59.5 (4.1)
48.9 (7.2)
53.7 (4.3)

53.8 (6.8)
46.2 (19.4)
54.7 (15.7)
47.6 (12.3)
48.2 (9.6)
46.5 (12.9)
47.7 (11.6)
46.1 (11.7)
55.4 (11.8)
47.7 (12.4)
44.7 (14.7)

56.6 (1.9)
55.7 (0.0)
53.2 (4.8)
58.5 (3.0)
54.3 (8.7)
57.0 (0.0)
55.4 (1.7)
53.4 (6.2)
56.4 (3.9)
53.7 (6.9)
53.4 (2.4)

0.76
0.23
0.13
0.09
0.21
0.04
0.23
0.40
0.62
0.47
0.27

Survey 3

PF
RP
BP
GH
VT
SF
RE
MH
PCS
MCS
RCS

57.8 (0.0)
55.7 (0.0)
55.3 (6.3)
60.0 (8.7)
51.8 (3.7)
57.0 (0.0)
56.1 (0.0)
55.6 (4.1)
57.2 (5.0)
53.8 (3.9)
53.5 (4.1)

52.4 (8.4)
52.0 (10.6)
57.9 (5.4)
48.6 (12.8)
45.8 (10.5)
49.0 (16.4)
47.7 (15.3)
44.8 (10.9)
57.2 (4.5)
45.7 (12.1)
47.5 (16.3)

54.8 (3.5)
55.7 (0.0)
50.0 (8.2)
58.0 (6.2)
55.2 (6.6)
52.7 (5.3)
56.1 (0.0)
55.4 (2.2)
53.6 (5.3)
54.2 (3.6)
53.3 (3.6)

0.08
0.50
0.14
0.22
0.25
0.27
0.10
0.08
0.33
0.24
0.96

Survey 4

PF
RP
BP
GH
VT
SF
RE
MH
PCS
MCS
RCS

57.8 (0.0)
55.7 (0.0)
61.7 (0.0)a61.8 (6.7)
53.7 (6.2)
57.0 (0.0)
56.1 (0.0)
55.6 (7.0)
60.1 (2.4)b56.3 (7.0)
51.1 (2.9)

55.1 (3.7)
51.6 (7.9)
54.5 (9.4)
54.2 (11.9)
54.2 (8.7)
48.2 (15.0)
48.8 (11.3)
49.8 (10.2)
57.5 (4.0)
52.6 (10.0)
45.0 (14.0)

54.8 (5.8)
53.0 (5.3)
48.7 (3.8)a52.2 (8.3)
48.8 (9.9)
55.9 (2.6)
54.0 (3.5)
52.3 (8.9)
51.2 (30.1)b49.0 (6.6)
55.7 (5.4)

0.21
0.42
0.01
0.25
0.72
0.25
0.29
0.60
0.01
0.22
0.22

Survey 5

PF
RP
BP
GH
VT
SF
RE
MH
PCS
MCS
RCS

57.1 (1.6)
55.7 (0.0)
60.3 (3.2)c62.1 (8.7)
58.2 (4.9)
55.7 (2.9)
56.1 (0.0)
57.7 (8.1)
58.6 (7.0)
59.3 (6.7)
50.3 (5.4)

53.8 (7.6)
50.7 (9.9)
55.6 (5.4)
49.9 (10.4)
50.6 (10.7)
49.0 (12.3)
51.9 (8.0)
51.2 (9.5)
54.4 (5.1)
50.3 (11.0)
49.3 (12.1)

52.4 (5.9)
51.8 (9.5)
47.2 (7.8)c
57.1 (8.8)
57.4 (4.4)
54.9 (3.3)
56.1 (0.0)
56.3 (2.8)
48.6 (8.8)
56.6 (5.4)
53.9 (5.2)

0.28
0.51
0.01
0.19
0.23
0.62
0.23
0.30
0.07
0.12
0.66

Survey 1

Data are shown as mean values (standard deviation).
SF-36 : MOS Short-Form 36-item Health Survey, PF : physical functioning, RP : role physical, BP : bodily
pain, GH : general health, VT : vitality, SF : social functioning, RE : role emotional, MH : mental health,
PCS : physical component summary, MCS : mental component summary, RCS : role/social component
summarya, b, c : Mann-Whitney U test and Bonferroni correction were performed after Kruskal-Wallis test.
a, b, c : p < 0.01

Psychologic distress and QOL after a disaster

31

Figure 3

Figure 1

STAI-T score

BDI score

60

16
14

*★ p<0.05

*

12

50
40

★

10
8

30

6

20

4
2
0

Survey1

NS

10

*

★

Survey2

Survey3

20s

30s

0
Survey4

Survey5

Survey1

Fig. 1. Longitudinal changes in BDI score
The scores for participants in their 30s were significantly higher (i.e., worse) than those for participants in their 40s/50s in Survey 2 and those forparticipants in their 20s in Survey 3.
We applied a Mann-Whitney U test and Bonferroni
correction after conducting a Kruskal-Wallis test.
BDI : Beck Depression Inventory

Survey220s

40s40s/50s

Survey3
30s

Survey4

Survey540s/50s
40s-

Fig. 3 Longitudinal changes in STAI-T scores
There were no significant differences among theage groups.
We applied a Mann-Whitney U test and Bonferroni
correction after conducting a Kruskal-Wallis test.
STAI-T : State-Trait Anxiety Inventory-Trait
Figure 4

Figure 2

EQ-5D score

1
STAI-S score

0.8

60

*

50
40

0.4

*

30

0.2

20

* p<0.05

10
0

NS

0.6

0

Survey1

Survey2
20s

Survey1

Survey2
20s

Survey3
30s

Survey4

Survey540s/50s
40s-

Fig. 2. Longitudinal changes in STAI-S scores
The scores for participants in their 30s were significantly higher (i.e., worse) than those for participants in their 20s in Survey 3.
We applied a Mann-Whitney U test and Bonferroni
correction after conducting a Kruskal-Wallis test.
STAI-S : State-Trait Anxiety Inventory-State

Survey3
30s

Survey4

Survey540s/50s
40s-

Fig. 4 Longitudinal changes in EQ-5D scores
There were no significant differences among theage groups.
We applied a Mann-Whitney U test and Bonferroni
correction after conducting a Kruskal-Wallis test.
EQ-5D : EuroQol-5 dimensions

SF-36
47.9 points. This score significantly improved overtime after Survey 1. The score for participants intheir 40s/50s also significantly improved over time
(Table 1). There were no significant differences
between the age groups (Table 3, Figure 3).
EQ-5D
The mean EQ-5D score in Survey 1 was 0.914.
This score was stable and did not significantly
change with time (Table 1). Additionally, there
were no significant differences among age groups(Table 3, Figure 4).

The total subscale scores for PF, RP, SF, RE,
and MH significantly improved over time after Survey 1. VT scores among participants in their 20s
and RE scores among those in their 20s, 30s, and40s/50s significantly improved over time. Additionally, PCS and RCS scores significantly improved
over time (Table 2).
A comparison between the age groups showedthat BP scores among participants in their 40s/50s
were significantly lower (i.e., worse) than thoseamong participants in their 20s in Survey 4 andthose in their 30s in Survey 5 (Table 4, Figure5). The Survey 4 PCS scores were also significantly lower among participants in their 40s/50s thanS. Yabuki et al.

32

among participants in their 20s (Table 4, Figure 6).

Discussion
This longitudinal study on psychologic distressand QOL in medical staff after a disaster demonstrated a tendency toward recovery. However,there were differences among age groups in somelongitudinal changes, such as the recovery period.
Psychologic distress
Disasters, such as pandemics or nuclear power
plant accidents, are likely to affect mental health in
Figure 5
SF-36 BP score

70
60
50
40

**

★★

**

★★

30
p<0.01
**
★★

20
10
0

Survey1

Survey2
20s

Survey3
30s

Survey4

Survey540s40s/50s

Fig. 5 Longitudinal changes in SF-36 BP scores
BP scores for participants in their 40s/50s weresignificantly lower (i.e., worse) than those for participants in their 20s in Survey 4 and Survey 5.
We applied a Mann-Whitney U test and Bonferroni
correction after conducting a Kruskal-Wallis test.
SF-36 : MOS Short-Form 36-item Health Survey
BP : bodily pain
Figure 6
SF-36 PCS score

70

*

60
50

*

40
30
20

* p<0.01

100Survey1

Survey2
20s

Survey3
30s

Survey4

Survey540s40s/50s

Fig. 6. Longitudinal changes in SF-36 PCS scores
PCS scores in Survey 4 were significantly lower
among participants in their 40s/50s compared withparticipants in their 20s.
We applied a Mann-Whitney U test and Bonferroni
correction after conducting a Kruskal-Wallis test.
SF-36 : MOS Short-Form 36-item Health Survey
PCS : physical component summary

affected populations in general and medical staff inparticular. Several studies have assessed mental
health in public health nurses27) and disaster medical
assistance team members 28,29). However, thesecross-sectional studies did not examine changes inmental health over time.
Several longitudinal studies have examinedchanges in mental health in caregivers and residents
in Fukushima Prefecture. Fujitani et al. reported
that a substantial number of caregivers working inFukushima Prefecture exhibited signs of emotional
exhaustion, feelings of low personal accomplishment, and psychologic distress 2 years after the Fukushima Daiichi Nuclear Power Plant disaster 10). Oe et al. reported that 3 years after the
Fukushima Daiichi Nuclear Power Plant accident,
the prevalence of general psychologic distressamong residents in the evacuation zone was higher
in both men and women, compared with normal Japanese levels in non-disaster settings11). In addition,
Orui et al. reported that evacuees and residents fromthe area affected by the Fukushima Daiichi Nuclear
Power Plant accident exhibited signs of delayedmental health recovery 7 years after the disaster12). These results suggest that disaster-related
negative effects on mental health can persist forseveral years or more. Our results for medical staff
indicate that disaster-related depression and anxiety
significantly improved over time. However, recovery was delayed among participants in their 30s
compared with participants in their 20s and 40s/50s.
This may reflect the likelihood that those in their
30s have young families that either evacuated while
medical workers remained, or, if families stayed together, there may have been greater concerns about
exposure to low - dose radiation. BDI and STAI
scores at 3 years (Survey 4) and 4 years (Survey 5)
after the disaster were not significantly different. Thus, follow-up assessments of psychologic
distress in medical staff should be continued for atleast 3 years, especially for participants in their30s. Risk factors associated with distress measures during the COVID-19 pandemic include female gender, younger age (≤40 years), and frequent
exposure to social media/news about COVID-1930).
Kohzaki et al. administered a questionnaire survey to citizens, doctors, and medical students both
inside and outside Fukushima in 2011 and 201331).
They reported that medical students who had recently studied radiation biology showed much lessongoing anxiety compared with other groups. Thissuggests that appropriate knowledge of the risks associated with a disaster can help to reduce anxiety.

Psychologic distress and QOL after a disaster

QOL
QOL, as evaluated by the EQ-5D, was relatively high 12 days after the disaster (Survey 1) and did
not change over the following 4 years. However,scores on five of the eight SF-36 subscales, as wellas the RCS score, significantly improved overtime. In contrast, the PCS score significantly decreased over time. Participants in their 40s/50s
obtained significantly lower BP and PCS scorescompared with participants in their 20s. Thesefindings suggest that the SF-36 is able to evaluate
health-related QOL in greater detail than the EQ5D. Furthermore, among participants in their
40s/50s, physical QOL decreased over time, although mental QOL significantly improved. However, this decline in physical- health QOL among
participants in their 40s/50s may have more to dowith physiological changes related to aging 32) .
Khachadourian et al. examined the associations between demographic characteristics, trauma exposure, and psychosocial variables in terms of QOL 23
years after the 1988 Spitak earthquake in Armenia33). They found that older age, current depression, post- traumatic stress disorder, and anxiety
were negatively associated with QOL. These data
indicate that age is an important factor in disaster
responses, and that long - term follow- up assessments of QOL should be conducted in affected individuals.
There are several limitations to the present
study. First, the number of participants was small,and came from a single institution’s rehabilitation
center. Second, the follow-up period was not particularly long for evaluating post-disaster changes inmental health and QOL. Third, the versions of thequestionnaires used in this study were not the mostrecent. The EQ-5D has been updated to the EQ5D-5L34) and the BDI to the BDI-II15). Fourth, thisstudy did not include medical staff working directly
in disaster response or radiation emergency medicine, who may have experienced different psychologic trajectories. Fifth, we did not include a control group. To demonstrate more conclusively thatthe disaster had a direct effect on participants, acomparison group that was not exposed to the disaster would be needed. Finally, in this study, we did
not evaluate participants’ families. Psychologic
distress experienced by family members may affectthe mental health of participants. Further studies
that include family members are needed to more accurately evaluate the effect of disasters on medical
staff.

33

The authors believe that the strengths of thestudy are the following. First, the survey involved
multiple assessment tools. Second, it was rapidly
implemented at a hospital directly affected by theGreat East Japan Earthquake and directly involved
in responding to the combined earthquake, tsunami,
and nuclear crisis. Third, although limited to a single center at a single institution, a conscientious informed consent process secured 100% participation
across the full spectrum of professions employed by
the center. Fourth, voluntary participation was
sustained throughout 5 annual surveys, even amongstaff who retired during the observation period.
In conclusion, a compound disaster can affectlevels of psychologic distress and QOL among medical staff, including those not directly involved in disaster response. The finding that longitudinalchanges such as recovery period differed among age
groups leads us to believe that age is an importantconsideration in the pathology of psychologic distress and in the pathway to improving QOL in medical staff after a disaster. We dare to imagine that
our study will inspire readers to anticipate the needfor similar post-disaster investigations, in order proceed with similar speed, larger cohorts, and appropriate control groups.

Acknowledgment
We would like to express our gratitude to thestaff working at the Rehabilitation Center, Fukushima Medical University Hospital, for continuing towork after the disaster and for completing the questionnaire five times over a 4-year period. We arealso grateful to Associate Professor Kyoko Shibata,
PhD, for making useful comments regarding the statistical analysis. We thank Sydney Koke, MFA, andDiane Williams, PhD, from Edanz Group (https://jp.edanz.com/ac) for editing a draft of this manuscript.

Conflict of interest disclosure
We have no conflicts of interest pertaining tothis manuscript.

References
1.

2.

Gao J, Zheng P, Jia Y, et al. Mental health problems and social media exposure during COVID-19
outbreak. PLoS One, 15 : e0231924, 2020.
Rogers JP, Chesney E, Oliver D, et al. Psychiatricand neuropsychiatric presentations associated with

34

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

S. Yabuki et al.
severe coronavirus infections : A systematic review and meta- analysis with comparison to the
COVID-19 pandemic. Lancet Psychiat, 7 : 611627, 2020.
Chen Q, Liang M, Li Y, et al. Mental health carefor medical staff in China during the COVID- 19
outbreak. Lancet Psychiat, 7 : e15-16, 2020.
Huang J, Liu F, Teng Z, et al. Care for the psychological status of frontline medical staff fighting
against COVID - 19. Clin Infect Dis, Apr 3 :ciaa385, 2020.
Ripp J, Peccoralo L, Charney D. Attending to theemotional well-being of the health care workforce
in a New York City health system during the COVID - 19 pandemic. Acad Med, 95 : 1136 - 1139,
2020.
Labrague LJ, de Los Santos JAA. Fear of COVID-19, psychological distress, work satisfaction andturnover intention among frontline nurses. J
Nurs Manag, 29 : 395-403, 2021.
Yabe H, Suzuki Y, Mashiko H, et al. Psychologicaldistress after the Great East Japan Earthquake andFukushima Daiichi Nuclear Power Plant accident : Results of a mental health and lifestyle survey through the Fukushima Health Management
Survey in FY2011 and FY2012. Fukushima J Med
Sci, 60 : 57-67, 2014.
Harada N, Shigemura J, Tanichi M, Kawaida K,
Takahashi S, Yasukata F. Mental health and psychological impacts from the 2011 Great East Japan
Earthquake disaster : A systematic literature review. Disaster Mil Med, Sep 2 : 1-17, 2015.
Yabuki S, Ouchi K, Kikuchi S, Konno S. Pain,
quality of life and activity in aged evacuees living in
temporary housing after the Great East Japan
Earthquake of 11 March 2011 : A cross-sectional
study in Minamisoma City, Fukushima Prefecture. BMC Musculoskelet Disord, 16 : 246,
2015.
Fujitani K, Carroll M, Yanagisawa R, Katz C.
Burnout and psychiatric distress in local caregivers
two years after the 2011 Great East Japan Earthquake and Fukushima Nuclear Radiation disaster. Community Ment Health J, 52 : 39-45, 2016.
Oe M, Fujii S, Meda M, et al. Three-year trend
survey of psychological distress, post-traumaticstress, and problem drinking among residents inthe evacuation zone after the Fukushima Daiichi
Nuclear Power Plant accident [The Fukushima
Health Management Survey]. Psychiatry Clin
Neurosci, 70 : 245-252, 2016.
Orui M, Nakajima S, Takebayashi Y, et al. Mental
health recovery of evacuees and residents from
Fukushima Daiichi Nuclear Power Plant accident
after seven years-Contribution of social network
and a desirable lifestyle. Int J Environ Res Public

13.

14.

15.

16.

17.

18.
19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

Health, 15 : 2381, 2018.
Nishi D, Susukida R, Usuda K, Yamanouchi Y.
Psychological distress among people in Fukushima
prefecture before and after the Great East Japan
Earthquake using a nation-wide survey. Psychiatry Clin Neurosci, 72 : 876-878, 2018.
Murakami M, Kobayashi T, Ochi S, Goto A, Igarashi Y. Thinking about COVID-19 from Fukushima and Fukushima from COVID-19. (in Japanese)
Japanese Journal of Risk Analysis, 30 : 195-202,
2021.
Smarr KL, Keefer AL. Measures of depression
and depressive symptoms. Arthrit Care Res, 63 :S454-466, 2011.
Beck AT, Steer RA. Manual for the Beck Depression Inventory. The Psychological Corporation,
San Antonio (TX), 1987.
Spielberger CD, Gorsuch RL, Lushene RE. STAI
Manual. Consulting Psychologists Press, California, 1970.
Julian LJ. Measures of anxiety. Arthrit Care
Res, 63 : S467-472, 2011.
Addolorato G, Ancona C, Capristo E, et al. Stateand trait anxiety in women affected by allergic andvasomotor rhinitis. J Psychosom Res, 46 : 283289, 1999.
Tsuchiya A, Ikeda S, Ikegami N, et al. Estimating
an EQ-5D population value set : The case of Japan. Health Econ, 11 : 341-353, 2002.
Brooks R with the EuroQol Group. EuroQol :The current state of play. Health Policy, 37 : 5372, 1996.
EuroQol Group. EuroQol—A new facility for themeasurement of health - related quality of life.
Health Policy, 16 : 199-208, 1990.
Fukuhara S, Ware JE Jr, Kosinski M, Wada S, Gandek B. Psychometric and clinical tests of validityof the Japanese SF-36 Health Survey. J Clin Epidemiol, 51 : 1045-1053, 1998.
Fukuhara S, Bito S, Green J, Hsiao A, Kurokawa
K. Translation, adaptation, and validation of the
SF-36 Health Survey for use in Japan. J Clin Epidemiol, 51 : 1037-1044, 1998.
Busija L, Pausenberger E, Haines TP, Haymes S,
Buchbinder R, Osborne RH. Adult measures ofgeneral health and health-related quality of life.
Arthrit Care Res, 63 : S383-412, 2011.
Suzukamo Y, Fukuhara S, Green J, Kosinski M,
Gandek B, Ware JE. Validation testing of a threecomponent model of Short Form - 36 scores. J
Clin Epidemiol, 64 : 301-308, 2011.
Yokoyama Y, Hirano K, Sato M, et al. Activities
and health status of dispatched public health nurses
after the great East Japan earthquake. Public
Health Nurs, 31 : 537-544, 2014.
Matsuoka Y, Nishi D, Nakaya N, et al. Concern

Psychologic distress and QOL after a disaster

29.

30.

31.

over radiation exposure and psychological distressamong rescue workers following the Great East Japan Earthquake. BMC Public Health, 12 : 249,
2012.
Nishi D, Koido Y, Nakaya N, et al. Peritraumatic
distress, watching television, and posttraumaticstress symptoms among rescue workers after theGreat East Japan Earthquake. PLoS One, 7 :e35248, 2012.
Xiong J, Lipsitz O, Nasri F, et al. Impact of COVID-19 pandemic on mental health in the general
population : A systematic review. J Affect Disord,
277 : 55-64, 2020.
Kohzaki M, Ootsuyama A, Moritake T, Abe T, Kubo
T, Okazaki R. What have we learned from a ques-

32.

33.

34.

35

tionnaire survey of citizens and doctors both insideand outside Fukushima? : Survey comparison between 2011 and 2013. J Radiol Prot, 35 : N1-17,
2015.
Tieland M, Trouwborst I, Clark BC. Skeletal
muscle performance and aging. J Cachexia Sarcopenia Muscle, 9 : 3-19, 2018.
Khachadourian V, Armenian HK, Demirchyan A,
Goenjian A. Loss and psychosocial factors as determinants of quality of life in a cohort of earthquake survivors. Health Qual Life Outcomes,
13 : 13, 2015.
Devlin NJ, Brooks R. EQ-5D and the EuroQol
group : Past, present and future. Appl HealthEcon Health Policy, 15 : 127-137, 2011.