Section II
Research Reports and Other
Contributed Manuscripts

Research Report
Tohoku University Graduate School of Medicine,
Endowed Department of Preventive Psychiatry
Associate Professor – Kazunori Matsumoto
At the Endowed Department of Preventive Psychiatry, we engage in support and research
activities that will be of use to disaster survivors. This is done alongside the Tohoku University
Department of Psychoneurology and the Tohoku University Hospital Department of Psychiatry as
an arm of the Tohoku University Department of Psychiatry. In FY 2013, we collaborated with the
MDMHCC and affiliated organizations on research activities, the results of which we report below.
This report contains material adapted from the following publications: FY 2013 Ministry of Health,Labour, and Welfare Grant-in-Aid for Scientific Research Project Report, “Research on
Epidemiological Surveys to Determine the Status of Mental Illness and on the Development of
Effective Interventional Methods after the Great East Japan Earthquake” (Principal Investigator:
Hiroo Matsuoka); Seishin Medical Research Foundation Annual Report of Pharmacopsychiatry
Research, Vol. 46, FY 2012 Disaster Area Support Research Grant Pharmacopsychiatry Research
Results Report.
1. Research on Supporter Mental Health and Support Methods in Disaster-Affected Regions
In the event of a large-scale disaster, people of various occupations are involved in support during
the emergency, restoration, and reconstruction periods. Research focusing on the mental health ofworking people after such disasters has primarily targeted police officers and firefighters who
provide support as professional rescuers during the emergency period. It has been reported thatsymptoms corresponding to depression and PTSD persist for a long period.
However, after a disaster, long-term support activities through not only the emergency period but
also the recovery and reconstruction periods are necessary, and supporters engaged in selfless public
work are indispensable. These occupations include municipal staff, medical personnel, social welfare
service staff, teachers, and so on. Unfortunately, most of these individuals carry out long-term
support activities while continuing to live as survivors in affected areas. Many of these people havecontinued their support activities since the emergency period, and in addition to the stress of beinga survivor, they are believed to be subject to stress related to post-disaster support, putting them athigh risk of mental health problems.
In fact, even now, nearly three years after the Great East Japan Earthquake, many local supporters
are still engaged in support activities and reconstruction projects in areas where the damage wassevere. There was a newspaper report that the number of municipal employees taking leave owing
to mental illness is increasing, and measures to maintain mental health and prevent mental illness insupporters working in the disaster area are the current issues. However, the mental health of
supporters working these local public-interest jobs has not been well studied.
Therefore, we have conducted health surveys for municipal staff, medical personnel, SWC
members, and firefighters in the areas affected by the Great East Japan Earthquake and provided
support from a psychiatric standpoint. At the same time, we have planned a longitudinal survey toclarify the actual health state of staff and to help provide necessary support.
In this year’s report, we will demonstrate the results of other surveys conducted in 2012 and ofindices related to mental health in each occupational area, and examine and report on factors related
to poor mental health.
<Research Methods>
Our targets were (1) municipal staff, medical staff, and firefighters, (2) SWC members fromsix municipalities, and (3) nursing staff, all from disaster areas along the Tohoku coast.
(1) This survey was conducted with 1,788 people in May 2012, and the data of 1,479 (83%)
were analyzed. Here, we report the results of analysis conducted on data collected from municipal
staff (610 people), medical staff (357 people), and firefighters (328 people) who have been
engaged in support work since the disaster. Survey (1) was also conducted with 1,894 people in2013, and the data of 1,563 people are currently being analyzed.
(2) This survey was conducted from November 2012 to January 2013 with 1,048 people, andthe data of 823 (81.6%) were analyzed. SWC members can be divided into four groups: lifestylesupport counselors (190), clerical staff (199), long-term care staff (271), and others (163). In thisreport, each group was compared. We will also report on the data. Survey (2) was conducted from
November 2013 to January 2014, targeting SWC members in five disaster-affected municipalities.
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(3) The first survey was conducted from March to May 2012 with 473 nurses from fivehospitals in tsunami-stricken areas, and the data of 440 (90.9%) were analyzed. The second
survey was conducted in November 2012 with 179 nurses from hospitals affected by the tsunami,
and the data of 161 (89.9%) were analyzed. The third survey was conducted in November 2013
with 437 nurses from the hospitals included in the first survey, and the data of 209 (47.8%) people
were analyzed.
Survey items included the following: current work status and personal disaster status, current
health status, a depression and anxiety screening questionnaire (K6), evaluation of depressive
symptoms: Mind and Body Questionnaire (Patient Health Questionnaire, PHQ-9), and a 17-item
tool to evaluate PTSD severity (PCL).
The questionnaires clearly stated that participation was voluntary, and responses were only
collected after being sealed by the respondent to ensure that results would not be known to othersin the workplace. Respondents were made aware of the fact that after the survey, a psychiatrist,
clinical psychologist, and/or psychiatric nurse would be available to provide counseling for them,and were told that this counseling service could be used even if they did not submit a response.
This survey was conducted with the approval of the Ethics Committee of the Graduate School of
Medicine, Tohoku University.
<Research Results>(1) Survey of Municipal Staff, Medical Staff, and Firefighters (Figure 1)
Of the respondents, 56% were men, with an average age of 43 years. Further, 9% had family
members who were dead or missing, 23% had been relocated because of the disaster, and 55%
had been through an experience where they had feared for their life. In addition, regarding theworkplace 17% experienced a lack of communication and 39% experienced a lack of rest.
Regarding K6 results (valid responses: 967), the proportions of individuals with a total scoreof ≥13 points, indicating subjective awareness of their own high stress levels, were as follows:
11% for municipal staff, 15% for medical employees, and 3% for firefighters. In the 2010 census,
the average among Miyagi citizens was about 6%, making it clear that municipal and medical
staff experienced a high degree of mental distress. The proportions of individuals with a scoreof ≥10 points on the PHQ-9, which indicates a high risk of depression, were as follows: 24%
among municipal staff, 22% among medical employees, and 6% among firefighters. In addition,
9% of municipal staff, 9% of medical employees, and 3% of firefighters had a PCL score of ≥44
points, indicating high PTSD risk. In terms of both depression and PTSD risk, the proportion of
at-risk persons among firefighters was lower than among municipal and medical personnel.
Multivariate logistic regression analysis was used to clarify the factors involved in the risk ofmental illness. As a result, the factor with the highest odds ratio for PTSD high-risk status waslack of rest, at about five times higher. Lack of communication in the workplace was about threetimes higher. The odds ratios of employees who answered that their families were dead wasabout four times higher, and the odds ratio of employees who answered that they had moved
because of the disaster was about three times higher. The factors with the highest odds ratios forhigh depression risk were lack of communication in the workplace and inadequate rest, both ofwhich had odds ratios about three times higher than the average.

Municipal staff
Medical staff
Firefighters

K6≥13

PHQ-9≥10

PCL≥44

Figure 1: High-Risk Status (%) for Mental Distress (K6), Depression (PHQ-9), and PTSD
(PCL) by Occupation (May 2012)- 90 -

(2) Survey of SWC Members (Figure 2)
Of the respondents, 27% were men, with an average age of 47 years. Among the respondents,
9% indicated that their family members were dead or missing, 66% experienced a fear of death,and 26% had moved because of the disaster. Further, 37% were struggling with relationships in
the workplace, 38% experienced a lack of rest, and 30% were having a hard time because ofcriticism from residents.
Regarding K6 scores (valid responses: 784), the proportion of individuals with a total scoreof ≥10 points, indicating subjective awareness of their own high stress levels, was 18%. The
average of Miyagi citizens in the 2010 census was about 6%, indicating that a high proportion of
SWC members were in a state of mental distress. The proportion of individuals with a score of≥10 points on the PHQ-9 (valid responses: 781), which indicates a high risk of depression, was13%, whereas the proportion of those with a PCL score (valid responses: 763) of ≥44 points,
indicating a high risk of PTSD, was 4%. By occupation, life support counselors and clerical staff
experienced more mental distress than care workers and others.
Multivariate logistic regression analysis was used to clarify the factors involved in the risk ofmental illness. The highest odds ratio among the factors involved in high stress (K6 ≥10) was fora history of mental health treatment before the earthquake, followed by troubles with relationships
in the workplace and anxiety about one’s health. The factors involved in depressive symptoms
with the highest odds ratios were the same as those for high stress. Among the factors involvedin PTSD symptoms, the ones with the highest odds ratios were a history of mental healthtreatment before the earthquake, having a hard time with criticism from residents, and troubles
with relationships in the workplace.

Lifestyle support counselor
Clerical staff
Long-term caregiver

K6≥10

PCL≥44

PHQ-9≥10

Figure 2: High-Risk Status (%) for Mental Distress (K6), Depression(PHQ-9), and PTSD (PCL) Among SWC Members(November 2012–January 2013)(3) Survey of Nursing Staff (First Survey)
Women accounted for 98% of respondents, with an average age of 42 years. The proportionof those who had their homes completely or partially destroyed was 40%, and the proportion of
those who had moved because of the disaster was 29%. Of the respondents, 14% indicated that
their family members were dead or missing. In the analysis, nurses who were working at hospitals
that were directly damaged by the tsunami were categorized into the “tsunami-damaged” group,
whereas those working at hospitals affected by the earthquake but not directly damaged by thetsunami were categorized into the “tsunami-undamaged” group. The number of valid responses
was 136 for the tsunami-damaged group and 279 for the tsunami-undamaged group.
First, we report on the mental health of the entire subject pool. Regarding PTSD, 12.1% werehigh-risk (total PCL score ≥44 points). The proportion of people at high risk of depression (PHQ9 overall score ≥10) was 24%. However, it is said that standard cutoff values tend to pick up alarger-than-normal range of high-risk people after a disaster. Therefore, to identify those withhigher risk, PCL and PHQ-9 risk assessments were conducted by considering only those who fell
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into the top 10% of total scores. As a result, regarding PTSD, the tsunami-damaged group (14.5%)
tended to have significantly more high-risk persons than the tsunami-undamaged group (8%). As
for depression, there were significantly more high-risk individuals in the tsunami-damaged group(15%) than in the tsunami-undamaged group (8%).
Next, we examined the factors involved in the risk of mental illness using multivariate logistic
regression analysis. The causative factor with the highest odds ratio for high PTSD risk was“dead/missing persons in the family.” Regarding depression, the causative factors with the highest
odds ratios were “40 years old and over” and “direct tsunami damage to workplace.” A causative
factor that was observed to reduce risk was “support from family and friends.”<Discussion>
According to this survey, the percentage of individuals aware of the deterioration of theirmental health varied depending on their occupational area, and it was clear that the percentage ofmunicipal and medical staff who are at high risk of depression and PTSD is higher than that offirefighters. Past studies have shown that highly disaster-prepared occupations with professional
education and training in disaster response have a lower risk of mental illness, and our results are
consistent with those analyses. In addition, a survey of SWC members found differences between
occupations. Lifestyle support counselors were hired after the earthquake to provide direct
earthquake support, and we believe that they may bear a heavy mental burden because of direct
exposure to disaster stress and preparation. Likewise, clerical staff bear an increased mental
burden because of increases in the amount of coordination required and other administrative work.
On the contrary, it was considered that care workers had a lower mental burden than life
counseling support and clerical staff because they were performing almost the same work as
before the earthquake at the time of the survey one and a half years after the disaster. Regarding
factors related to the risk of mental illness, rather than those associated with direct disasterdamage, such as financial loss or deaths of family members, individual factors such as mental
health treatment history and workplace factors such as relationships were more closely related to
psychiatric symptoms. In addition, a survey revealed that many nurses in disaster-affected
hospitals had high symptoms of depression and PTSD.
Factors affecting the high risk of depression and PTSD among the people surveyed include
the direct impact of disaster loss/grief and environmental changes such as deaths of family
members and relocation due to the disaster, as well as post-disaster work environment, such aslack of rest and communication in the workplace. The fact that workplace communication isassociated with depression and PTSD risk is consistent with the idea that connections with people
are important for recovery from posttraumatic stress and loss/grief.
Although we are limited in the extent to which we can influence the direct consequences ofa natural disaster, creating an environment where it is easy to take a breather in the workplace,and enhancing communication in the workplace, are factors that can be dealt with, and in the
future, it is important that we consider specific measures in this regard. The results of this study
suggest that in workplaces where disaster relief is provided in the medium to long term, in
addition to the direct effects of the earthquake, changes in the current workplace environment ofsubordinate employees may have an impact on the deterioration of mental health. This is an
important result for the devising of medium- to long-term intervention methods for disastersupporters. In the future, we plan to continue our longitudinal surveys. Then, we will clarify inmore detail which factors affect the medium- to long-term mental health of supporters working
in disaster areas.
2. Research on Psychological Support Methods in Disaster Areas(1) Research on the Dissemination and Implementability of SPR
Miyagi Prefecture was severely damaged by the Great East Japan Earthquake, mainly in its
coastal areas, and survivors are experiencing physical and mental pressure. For this reason, it isconsidered that mental care for disaster survivors is necessary into the long-term, over years. Past
studies have shown that in the wake of a large-scale natural disaster, residents of disaster areas
have an increased likelihood of psychiatric disorders such as PTSD and depression, as well as
sub-symptomatic psychological problems that do not lead to psychiatric disorders. Psychological- 92 -

support for sub-symptomatic individuals subjectively aware of their own mental illness is,therefore, considered important for prevention.
Post-disaster psychological support has been researched and developed focusing on traumafocused methods and those performed immediately after the disaster and into the acute phase.
However, the effects of psychological support in the acute phase immediately after the disasterwere not superior to those of non-specific intervention methods. In addition, while it is known
that some psychological support methods are useful for the recovery/reconstruction period, apractical method combining multiple types of psychological support that is useful for a wide
range of survivors has not been developed.
SPR is a psychological support method for disaster recovery-phase use developed in 2010 by
the American National PTSD Center and the American National Child Traumatic Stress Network.
In June 2011, the Research Team of the Hyogo Disaster Mental Health Care Center translated andpublished a Japanese-language version of this method. SPR has been implemented in a variety of
post-disaster situations across countries; however, it has yet to be put to full use in Japan.
Therefore, we are conducting research on training for professionals to popularize SPR as well as
research on the feasibility of SPR in Japan.
① Research on Specialist Training for Dissemination of SPR
It would be of great practical significance to mental health countermeasures in areas
affected by the Great East Japan Earthquake if mental health specialists involved in actual
support were trained in SPR and able to use it with disaster survivors. However, in Japan,
methodologies for teaching the specialized skills used in psychological support are not wellestablished. In this study, we provided SPR training to specialists involved in mental healthcare in disaster areas, used questionnaires and qualitative surveys to clarify the utility andchallenges presented by SPR training, and sought to examine the feasibility of and issues
associated with SPR use in Japan.
<Research Methods>
SPR workshops were held on the following schedule for specialists engaged in mental care indisaster areas. Dr. Tomoko Osawa, a clinical psychologist from the Hyogo Prefecture Mental Care
Center, who has acquired the SPR trainer qualification, was asked to serve as a lecturer. After that, as
basic training, lectures and workshops on SPR were held for two days. SPR training was conductedthrice in 2012 and once in 2013, in Kesennuma on July 27 and 28. In addition, as a follow-up training,
we conducted a case study on SPR utilization cases twice in 2012 and once in 2013, in Kesennuma
on December 5.
A questionnaire survey on training content and SPR was conducted anonymously before and after
the basic training and after the follow-up training. Datapoints were assigned unique identifiers toallow them to be tracked from the basic training to the follow-up training after being concatenatedand anonymized. After the basic training, if the participants provided support to the survivors using
SPR in their own fields, they were requested to record this in the skill implementation log, to besubmitted during the follow-up training. The skill implementation log listed the technique used forsupport, support time, number of times support was provided, content of support, and any problems.
At the follow-up workshop, group discussions were held to examine the feasibility of SPR and related
problems, and the contents were recorded in meeting notes. Participation in the training andconsenting to research participation were distinguished from one another, and study participation was
limited to those who voluntarily provided their consent. The implementation of this study has been
approved by the Ethics Committee of the Graduate School of Medicine, Tohoku University.
<Research Results>
Regarding the number of participants in the workshop (the number in parentheses is the numberof those who have completed the entire training process), 18 people (17 people) participated in the
fourth basic training held this year, making a grand total of 99 people (75 people) who had participatedsince last year. Six people participated in the follow-up training for the third time, bringing the total
to 37 people. Among the participants, those who consented to research participation were selected.
The number of valid responses was 90 in the basic training questionnaire survey (four times), and 28
in the follow-up survey (three times). Only the first set of responses of those who attended follow-up- 93 -

training multiple times was used. As a result, only 24 valid responses were tracked from the basic andfollow-up training.
The attributes of the respondents of the basic training questionnaire were as follows:
men:women=23:67, age group distribution: 19% in their 20s, 43% in their 30s, 19% in their 40s, 17%in their 50s, and 2% in their 60s. Regarding occupations, 32% were psychiatrists, 19% werepsychiatric social workers, 18% were public health nurses, 17% were nurses, 6% were psychiatrists,
and 8% were classified as “others.” By experience of disaster/trauma support, the distribution was asfollows: 16% with no experience, 66% with a little experience, 14% with a fair amount, and 4% witha considerable amount.
According to the results of the questionnaire completed after the basic training (Fig. 3), 89%
stated that they considered the content of the training session related to their current line of work, and
85% had the desire to implement these skills in their practice. On the contrary, only 33.8% of the
respondents answered that they were confident in using it. As a result of the follow-up survey (N=24)
in the basic and follow-up training, the average value of the items about SPR increased overall afterparticipating in the follow-up training, and the increase in ease of understanding of the training wasparticularly significant. Also, in the post-follow-up training survey, the proportion of individuals who
provided cases for discussion (N=7), indicating that they would try to use SPR in their work, wassignificantly larger than the proportion among individuals who did not provide cases.
a. In response to questions about the utility of SPR in one’s own activities, we received comments
along the lines of the following: “Can’t this be used in groups such as consultation services and healthclasses?” and “The model in which the target person solves their own problem helped lighten theburden I felt regarding my compulsion as a supporter to ensure that all problems were fixed.”
b. Regarding whether or not they had actually tried (or wanted to try) using SPR, attendees
expressed that while it was difficult to use in structured sessions, they were making use of its essence.
c. Regarding difficulties in using SPR in their own activities, we received the following
comments: “It is important to think together because the ‘skill guidance’ section does not fit into
Japanese culture,” “Rather than blindly following the manual, you should implement the techniqueflexibly in accordance with the TPO,” “It is necessary to modify the expressions used in the manual
based on your own context,” and “In terms of skill matching, it’s important that you modify thetechnique when it doesn’t quite work out.”
d. Regarding what kind of training and supervision systems would make it easier to utilize SPR,
there were requests for “case studies” and “timely supervision.”

Strongly agree

Related to my current
work

Somewhat agree
I have the desire to implement thisNeutralSlightly disagree

I have the confidence
to implement thisStrongly disagree

Figure 3: SPR Training Impressions<Discussion>
From the results of the questionnaire survey after the basic training, it became clear that interest
in and motivation to try SPR were high, but confidence was low. After the follow-up training, it
became clear that the degree of understanding increased, and while further case studies increased the
motivation to actually practice SPR, confidence did not improve.

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These results suggest that while SPR training is important and can be beneficial, a format
involving just one basic training and one follow-up training is subject to limitations. It became clearthat it is necessary to prepare repeated case studies and an appropriate supervision system. In addition,in terms of the possibility of applying SPR in Japan and of using it in various support situations,
opinions seemed to indicate that while it may be applicable to a variety of support situations, rather
than a rigid structure, specific advice regarding how to flexibly apply the technique in one’s field andhow to verbally express and develop the elements of the manual was necessary.
Based on the above, we plan to implement regular case studies using Skype, conduct supervision
for cases using SPR in the disaster area, and study the effects of these efforts. In addition, we believe
application models are necessary to widely disseminate and raise awareness regarding SPR as asupport method. We think that a demonstration DVD about SPR utilization may serve this purpose
well, and we plan to consider it as a research area for the next FY.
② Research on the Implementability of SPR in JapanTo actually apply SPR in Japan, it is necessary to consider its implementability in disasterareas. Therefore, the purpose of this study is to cooperate with local governments in thedisaster area, apply SPR to disaster survivors, and examine its feasibility.
<Research Methods>
We took as our subjects individuals aged 18 or older who were living or working in District A of
Miyagi, a disaster area; individuals being treated at a psychiatric institution or with serious mental
symptoms were excluded. In addition, participants were limited to native Japanese speakers capableof understanding the research purpose and content and who provided written consent. A memorandum
was signed with the municipal government in District A, and with their cooperation, we conducted
the “Post-Disaster Stress Recovery Program” to recruit research participants, with a target populationof 15 individuals.
All the psychiatric health workers (nurses, public health nurses, psychologists, doctors, etc.) who
will provide support have undergone training by SPR trainers at the Hyogo Disaster Mental HealthCare Center, and SPR will be conducted under the supervision of these trainers and psychiatrists fromthe Tohoku University Hospital Department of Psychiatry. Pre-intervention evaluations will be
conducted after explaining the purpose of the study and obtaining written consent from those whomeet the selection criteria. The intervener will visit the participants for a 60-minute interview once
every one to two weeks, for a total of about five visits. A post-intervention evaluation and a twomonth follow-up evaluation will be performed after the intervention.
The primary endpoint is the total score of the General Health Questionnaire (GHQ-30).
Secondary endpoints are quality of life (QOL) (SF-8), posttraumatic stress symptoms (Impact ofEvent Scale-Revised, IES-R), resilience (Trauma Resilience Scale, TRS), self-efficacy (SE), andprogram satisfaction (Client Satisfaction Questionnaire, CSQ-8J). In addition, the impressions of the
program and each skill and their subsequent utilization will be evaluated by qualitative content
analysis. This study will be conducted with the guidance and cooperation of the municipal
government of District A.
The intervener will assess the overall mental state (including suicidal ideation) at each interview.
In addition, we have made it a requirement that if a participant becomes aware of a serious adverse
event or other unforeseen circumstance related to this study, they are to take the necessary measuresin cooperation with the section in charge of District A, who will refer involved persons to relatedorganizations including medical institutions, and otherwise make every effort to resolve any possible
issues. This study is being conducted with the approval of the Ethics Committee of the Graduate
School of Medicine, Tohoku University.
<Research Results>
In July 2013, we started recruiting participants. As of February 2014, the total number of applicants reached 18. Of these, three were unsuitable for the study, six dropped out before receiving theintervention, and one case was postponed. Thus, the remaining eight individuals began the intervention. Of these, four were prior intervention cases, and four were cases in which the intervention was
implemented after the start of the survey. No adverse events have been observed up to this stage inany of the eight participants involved, including prior intervention cases.
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Of the eight people who started the intervention, four have completed all sessions so far. As apreliminary analysis, we examined the evaluations before and after the four interventions, and foundthat the overall score on the GHQ-30, which is the primary endpoint, was lower after the intervention
than it was pre-intervention (Fig. 4).

Pre-intervention

Post-intervention

Figure 4: Change in GHQ-30 Score Before and After SPR Intervention (N=4) *Includes
Pre-Study Interventions<Discussion>
This study’s intervention began only in 2013, and has not yet reached the target number of cases. For
this reason, program feasibility has not yet been verified. However, no adverse events have been
observed, and the results of the preliminary analysis show that the GHQ-30 values for the four cases
in which the intervention was completed were lower than those before the intervention. Therefore, atpresent, it is suggested that SPR may be a safe and effective program in Japan as well. In the future,
we plan to increase the number of case subjects, analyze the transition to each endpoint when thetarget number of subjects is reached, and verify the feasibility of the program.
(2) Research on Exercise for the Mind and Heart Training Workshops for Residents and Supporters
in Areas Damaged by the Great East Japan Earthquake Aimed at Raising Public Awareness About
CBT
CBT is a psychological therapy method that uses approaches from both cognitive and behavioral
angles to heighten self-control in an effort to improve various problems in social interactions andresolve latent issues. CBT is indicated for depression, anxiety disorders, and a variety of other mental
illnesses and its effectiveness has been widely reported. In addition, it is effective against depressive
symptoms that do not quite approach the level of a mental illness and has been shown to prevent
mental illness. As a result, it has been applied broadly to non-medical settings as well.
Awareness of CBT in Japan has lagged behind other developed countries; to broadly spread it
throughout society, it is necessary that we establish effective training methods. In this study, in aneffort to achieve primary prevention, we implemented “Exercise for the Mind and Heart” training
workshops for residents and supporters in areas affected by the Great East Japan Earthquake; thesesessions were aimed at clarifying the basic ideologies and skills of CBT and at helping attendees learn
about stress care in daily life situations. We used post-session surveys to achieve a qualitative analysisof these sessions and thereby clarify the program’s utility and challenges. The objective of this study
is to clarify the feasibility of raising awareness about CBT in Japan and any issues pertaining thereto.
<Research Methods>
Last year, before disseminating it to the general public, CBT-based training was conducted forsupporters such as public health nurses who are actually dealing with citizens in the disaster areas of
Iwanuma City. It was conducted a total of six times from February to March 2013. This year, weorganized training sessions for the general public. In Iwanuma, we held them from June to July 2013
with the cooperation of the Health Promotion Division of the Health and Welfare Department of- 96 -

Iwanuma City Hall. In Sendai, we held them from October to November 2013 with the cooperationof the Sendai Mental Health and Welfare Center (Heart Port Sendai) and the Family Health Divisionsof Aoba Ward, Miyagino Ward, Wakabayashi Ward, and Taihaku Ward. Finally, we held sessions fromFebruary to March 2014 in Taihaku, Sendai, with the cooperation of the Heart Port Sendai and theFamily Health Division of Taihaku Ward, for a total of six sessions (because it was the end of the FY,
these are not included in this analysis).
After each training session, a questionnaire survey was conducted to obtain feedback on the
degree of understanding and impressions of the program. In addition, before and after the training
program, we used question items to learn the attributes of participants and to clarify the understanding
and retention of the training. The SF-8 was used as a measure of QOL, and the Characteristic SelfEfficacy Scale was used to measure whether or not participants’ self-efficacy was heightened bylearning and implementing CBT. In conducting the training, Dr. Yutaka Ono, Director of the CBTCenter, National Center of Neurology and Psychiatry, and Miyuki Tajima, Director of the ClinicalTechnology Development Office, National Center of Neurology and Psychiatry, both of whom havea wealth of experience in this area, provided valuable technical guidance. The implementation of thisstudy has been approved by the Ethics Committee of the Graduate School of Medicine, Tohoku
University.
<Results>
In the training held in Iwanuma City, the number of pre-registered people was 16 and an averageof 11 people participated. In Sendai City, the number of pre-registered people was 27 and the actual
number of participants was 15 people on average. The total number of participants was 33, of whomfour (12.1%) were men and 29 (87.9%) were women, with an average age of 48.7±12.8 years. The
most common occupation was housewives (11; 35.5%), followed by five part-time workers (16.1%)
and five unemployed people (16.1%). Regarding the damage situation, the homes of three people(9.4%) were completely or partially destroyed, while those of 13 people (40.7%) were mostly or
partially destroyed. When asked if they had felt that their lives had been in danger because of theearthquake, 20 people (62.5%) answered that they had either strongly or somewhat strongly felt so.
Regarding satisfaction with training, in Iwanuma City, an average of 95% of the supporters
answered that the difficulty level was just right. These figures were 87.5% and 88% for the generalpublic training sessions in Iwanuma and Sendai, respectively. In the training for supporters in
Iwanuma City, 99% answered that they could make use of CBT in future. In the training for thegeneral public in both Iwanuma and Sendai, 95% gave this response. Therefore, we believe that thetraining content was generally understood and accepted by all participants.
We had participants answer questionnaires before and after the training. Seventeen people who
attended five or more of the six sessions were surveyed for changes in their QOL and self-efficacy.
Regarding the Mental Component Summary (MCS) scores of the SF-8, an improvement was observed,
with an average of 41.6±8.4 before the training and an average of 45.6±8.3 after the training, but thedifference was not significant (Fig. 5). Regarding characteristic self-efficacy, the average was
68.9±9.9 before the training and 71.5 after the training, showing a trending improvement (Wilcoxon
Z=1.942, P=0.052) (Fig. 6).
Regarding understanding the basic ideas of CBT and retention, the results of a pre- and postsurvey conducted among the 17 people mentioned above clarified several trends. When asked if they
understood their cognitive tendencies, pre-training, only 38% (N=6) answered that they did, but thisfigure increased to 93% (N=14) post-training. When asked if they knew what thought patterns
strengthened feelings of depression or anxiety, 63% (N=10) said yes pre-training compared to 80%(N=12) post-training. When asked if they were able to recognize thought patterns that were harmful
to themselves and to actively switch away from them, 25% said yes pre-training (N =4) compared to
47% post-training (N=7). Finally, when asked if they were able to attentively evaluate how animplemented solution to a problem was changing the situation, 19% (N=3) said yes pre-training
compared to 47% (N=7) afterward.

- 97 -Mean SF-8 MCS(N=17)(please check if this should be“Mean SF-8 MCS Score)

Pre-training

Wilcoxon’s Z = 1.344
P=0.179

Post-training

Figure 5: Changes in QOL Before and After the Exercise for the Mind and Heart Training

Feelings of characteristic selfefficacy, mean values (N=17)

Wilcoxon’s Z = 1.942
P=0.052

Pre-training
Post-training
Figure 6: Changes in Self-Efficacy Before and After the Exercise for the Mind and Heart Training<Discussion>
This year, we held Exercise for the Mind and Heart training sessions for the general public in
Iwanuma and Sendai in cooperation with the government and related organizations such as Iwanuma
City Hall and Sendai City Hall. Last year, advance training was restricted to supporters, but this year
we were able to address the general public as well. Satisfaction with training was high, and many
people said that they enjoyed learning while actually experiencing the work. Regarding
understanding and retention, we received comments such as: “I became aware of my own cognitive
habits, and based on the idea of CBT, I became able to understand the relationship between thoughts,
moods, and behaviors, and to learn how to deal with stress.” From these results, we believe it ispossible to implement a cognitive-behavioral intervention in the form of training for the generalpublic after a disaster, and that this specific program is acceptable for the general public in disasterareas.
For changes in QOL and self-efficacy before and after the intervention, the sample size iscurrently small, and our results are still in their preliminary stages. At present, no significant change
was obtained in QOL and self-efficacy, but a trending level change was observed for self-efficacy.
Next year, we are planning multiple training sessions with larger sample sizes.
3. Survey of the Effects of Disaster Damage on Mental Health Care
The Great East Japan Earthquake caused massive damage throughout Miyagi Prefecture,
particularly in coastal areas. Psychiatric facilities, again primarily in coastal areas, sustained severe
damage, and the effects thereof have reached far and wide. In the wake of the disaster, some hospitals
have become unable to continue providing care because of the destruction of their facilities, and at
the same time, hospitals that sustained comparatively little damage have been met with a veritabledeluge of patients. Each facility is currently facing its own problems. Nevertheless, the state of- 98 -

psychiatric care throughout Miyagi and the specific troubles that have arisen in each psychiatricfacility are not entirely known, and thus the whole picture remains unclear.
It is critical that we investigate the impact of the Great East Japan Earthquake on mental healthcare in Miyagi to prepare for and make use of our experiences in the event of future large-scaledisasters. Thus, we implemented this study with the assistance of a Senshin Medical Research
Foundation Grant-in-Aid for Disaster Area Support Research Project titled “Status Survey of
Psychiatric Care in Psychiatric Institutions in Miyagi Following the Great East Japan Earthquake,”
and in collaboration with psychiatric hospitals and affiliated organizations in Miyagi Prefecture. In
this study, we explore the dynamics of patient movement through psychiatric care facilities after alarge-scale disaster. By surveying the damage done to psychiatric hospitals, we aim to clarify theeffects of the Great East Japan Earthquake on psychiatric care in Miyagi Prefecture and to contributeto countermeasures against future large-scale disasters.
<Methods>
We conducted a survey on the dynamics of patient movement through psychiatric medical
institutions in Miyagi Prefecture in the first year after the earthquake. Our targets were psychiatricinstitutions (psychiatric hospitals, psychiatric departments in general hospitals, clinics, etc.); we
requested consent to participate and distributed survey forms via post in April 2012. The survey asked
about the following information: degree of damage to each medical institution, number of newpatients immediately and one year after the earthquake, number of returning patients, number of
inpatients, number of patients with disaster-associated acute stress disorder (ASD) and PTSD, andrevisions made to disaster response policies, among other things. As an additional survey, we focusedon four psychiatric hospitals in Miyagi Prefecture, including two psychiatric hospitals in A city in the
coastal area, which were severely damaged by the earthquake, for one year after the earthquake andafter the earthquake. We investigated the situation of outpatients and inpatients for the previous three
years. Furthermore, with their cooperation, we investigated the medical records of two hospitals in
Miyagi Prefecture regarding the breakdown of diagnoses and reasons for hospitalization. This survey
was conducted with the approval of the Ethics Committee of the Graduate School of Medicine,
Tohoku University.
<Results>
Three psychiatric hospitals in Miyagi Prefecture were directly damaged by the tsunami.Two ofthem had to transfer their inpatients to other hospitals. An additional four hospitals were only able tooperate at significantly reduced capacity and were unable to care for outpatients or newly hospitalized
patients. Some of the hospitals that were able to continue providing care experienced a large increasein new patients in March, immediately after the disaster. A large number of patients without mental
illnesses were seen in psychiatry wards and so on because of their proximity to these facilities. On
the contrary, one year after the disaster, only a small number of patients were being seen at psychiatrichospitals for PTSD treatment. While the change in the number of patients returning to hospitals after
the disaster varied from facility to facility and we were unable to determine a unilateral increase or
decrease, the number of psychiatric patients admitted immediately after the disaster (in March)increased.
Throughout the prefecture as a whole, the number of new hospitalizations increased in March,especially in the psychiatric area. After that, there was no significant difference in the number ofpatients compared to the 12 months before the earthquake. At psychiatric hospitals that were close to
the disaster area and that continued operation, the numbers of new patients as well as inpatients in
March increased. Looking at the breakdown of newly admitted patients eight weeks after the disasterat the two hospitals that were close to the disaster area and maintained their functions, the number ofpatients in psychiatric wards was the highest. When we investigated the reasons for hospitalization atsome psychiatric hospitals, more than 60% were related to the earthquake. In some cases, patients
had stopped taking their medication because of the disaster, leading to hospitalization. After thedisaster, many psychiatric medical institutions were forced to make major revisions to their disaster
preparedness. We received responses that it became necessary for certain institutions to stockpile fueland food, secure storage locations and communication means such as satellite phones, and review
evacuation drills and regional networks.

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<Discussion>
After the Great East Japan Earthquake, three hospitals in Miyagi Prefecture were damaged by thetsunami, and other hospitals were also damaged. From the immediate post-disaster period to the acuteperiod, significant changes were observed in the trends of outpatients and inpatients at psychiatrichospitals, and their characteristics differed depending on the local disaster situation. Many community
residents other than patients with mental illness also visited psychiatric hospitals that were operating
in disaster-stricken areas, and support was provided to patients with physical as well as mental illness.
From the period immediately after the disaster to the acute period, the number of psychiatric inpatientsin Miyagi Prefecture increased as a whole, and in particular, the number of new hospitalizations forpatients with schizophrenia increased. These findings suggest that the immediate impacts of thedisaster (earthquakes, tsunamis, and evacuation) affected psychiatric patients, a vulnerable population,
more strongly than it did others. Additionally, a variety of factors including local disaster damage,reconstruction status, and changes in hospital admittance affected patient dynamics, and we found it
difficult to identify unilateral increases or decreases in the number of psychiatric patients.
In a large-scale disaster, psychiatric medical institutions can be directly damaged. Our results
clarify that during the immediate post-disaster and acute phases, there is a possibility that thehospitalization demand for patients transferred from damaged hospitals, patients whose condition has
worsened because of the disaster, or who have difficulty living in the community will increase sharply.
In addition, it has become clear that psychiatric hospitals that were operating in disaster areas played
important functions in disaster medicine, such as seeing not only their own patients but also
psychiatric patients from other hospitals and general physical medicine patients. The results of thissurvey indicate that it is necessary for psychiatric medical institutions to establish disasterpreparedness systems for collaboration and cooperation during peacetime, and that it is necessary toestablish a system for the provision of support to psychiatric medical institutions during the immediate
post-disaster and acute phases.
4. Qualitative Research on the Experiences of Psychiatric Hospital Nurses in Disaster Areas
Many medical institutions were damaged by the Great East Japan Earthquake. Some coastal
psychiatric hospitals were hit by the tsunami and were forced to become isolated. In such hospitals,
their own lives were at stake, and there was a struggle to protect a large number of patients withmental illness and to carry out large-scale evacuation and transportation. In addition, even at
psychiatric hospitals not directly affected by the tsunami, utilities were often cut off, and medical care
had to be continued in a situation where no medicine could be delivered.
In this way, nurses at psychiatric hospitals in the disaster area observed patients’ mental andphysical conditions in extreme conditions, and made decisions and acted with limited resources andinformation. No past natural disaster in Japan has devastated this many psychiatric institutions.
Therefore, we believe that there is incredible significance in recording the experiences of these nurses
for posterity, as it will lead to the examination of preventive measures and support methods in thefield of psychiatric nursing in the event of a future disaster.
The purpose of this study is to clarify disaster experiences unique to psychiatry from the experience of psychiatric hospital nurses in areas affected by the Great East Japan Earthquake, and to acquire knowledge useful for the development of future disaster prevention and mitigation measures forpsychiatric hospitals.
<Methods>
An approximately hour-long semi-structured interview will be conducted with 10–20 nurses frompsychiatric hospitals in coastal areas of Miyagi Prefecture. We will explain the purpose of this study
to the nursing managers of eligible psychiatric hospitals, request cooperation, and recruit nurse
research collaborators through these managers if cooperation is obtained. We will ask about theirexperiences as psychiatric nurses immediately after the earthquake, and what measures they think, inretrospect, were most useful or necessary. Data obtained through this process will be analyzed
qualitatively. This survey has been approved by the Ethics Committee of the Graduate School of
Medicine, Tohoku University.

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<Results>
From August to September 2013, we interviewed 17 nurses from five psychiatric hospital facilities incoastal areas of Miyagi Prefecture. We are currently analyzing the data we have collected.
<Note> This study is being conducted with the assistance of an FY 2013 Japan Society for Mental
Health and Nursing Research Grant, and is part of the activities of the Japan Society for Mental Healthand Nursing Disaster Assistance Special Committee.
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