The Great East Japan Earthquake and Mental Health Care
Facing Adversity
Tohokukai Hospital/MDMHCC
Hidekatsu Shirasawa
1. Introduction
On March 11, 2011, the largest earthquake in recorded Japanese history, a huge tsunami, and anuclear accident occurred, causing enormous damage from Tohoku to Kanto. The number of people
dead or missing was 24,829 (two months after the earthquake), and the number of evacuees in Iwate,
Miyagi, and Fukushima reached just under 130,000. Aftershocks continued; on April 12, 126 werecounted, and the Fukushima nuclear accident has not yet ended. The disruption of lifelines and trafficcaused by the earthquake made it extremely difficult to grasp the disaster situation, and the scale ofthe disaster and its wide area, which had never been experienced before, pose many challenges toour support activities. In this article, I would like to look back on the mental care activities after theearthquake and report on current problems.
2. Disaster Damage to Psychiatric Hospitals and Transfer of Admitted Patients
There are 38 hospitals with psychiatric beds in the prefecture, and 30 of them were damaged.
Among them, hospitals located in the coastal areas of Kesennuma, Ishinomaki, and Iwanuma
suffered from inundation and outflow due to the tsunami, and hospitals in Ishinomaki and Iwanuma
had to be closed because of difficulty in continuing medical treatment. The building of the Hospitalin south of Sendai collapsed and inpatients had to be moved to a gymnasium. Even if they were
spared direct damage, building damage and disruption of lifelines were serious for psychiatrichospitals, which often have many inpatients. In addition, the outpatient clinic function was
significantly reduced. According to the prefecture’s summary, the total damage to the facilities andequipment of psychiatric hospitals has reached about 2.5 billion yen.
Owing to the outage of two hospitals in Ishinomaki and Iwanuma, 291 patients were requested to
be transferred immediately. However, the difficulty of collecting information hindered theunderstanding of the situation of the disaster-stricken hospitals, inpatient information was leaked
because of the tsunami, and the psychiatric hospitals in the prefecture themselves were also damaged,
resulting in a shortage of staff. The shortage of supplies such as food and medicine became serious,and it was extremely difficult to promptly secure a host hospital because of a lack of prior disaster
response or agreement with related organizations. As a result, there were 38 hospitals in theprefecture (13 psychiatric hospitals, 15 internal medicine hospitals, and 10 facilities for the elderly),and 10 hospitals in Yamagata Prefecture cooperated from outside the prefecture. During hospitaltransfers, there were problems such as securing vehicles for transportation, and it took 20 days after
the disaster for all patients to be transferred.
A disaster medical care headquarters has been set up in the prefecture and a disaster medical
coordinator has been assigned, but unfortunately psychiatric medical care is outside that framework,and a public-private disaster relief system has not been established. Therefore, it can be said that theabove results were brought about by psychiatric institutions’ lack of disaster preparedness. In the
future, it will be necessary to build a solid support system in preparation for disasters.
3. Disaster and Stress
The greater the scale of a disaster, the greater the stress that strikes afterward. The Great East
Japan Earthquake was a complex combination of earthquake, tsunami, and radioactive
contamination, and was utterly unprecedented. Death and related fear, trauma, loss, drastic changes
in the environment, experiences of carnage at disaster sites, slow reconstruction and theconfrontation with reality it forces, loss of hope, anger, and burnout can all lead to long-term stress.
Rafael shows the psychological reactions of disaster survivors over time (Fig. 1). In the earlystages, alertness increases, and people experience shock, stunned self-defeat, emotional paralysis,
derealization, and fear. After that, over-awakening and alertness become stronger, and during thehoneymoon period, a feeling of mental upliftment continues. However, frustration andhypersensitivity to things remind people of the horrors immediately after the disaster. Fear, tremors,nausea, and so on occur. These are triggered and amplified by aftershocks. During the- 102 -

disillusionment period, there are differences among the survivors, causing collapse, fatigue, a feelingof unreality, helplessness, anger, depressed mood, guilt, and grief. They also cause physicalsymptoms such as insomnia, loss of appetite, palpitation, nausea, and vomiting. During the periodof improved adaptation between individuals and society (reconstruction period), the mood is stableand future prospects become clear. However, when encountering minor difficulties, individuals may
experience flashbacks or become depressed from the experience of loss. Looking back on the Great
Earthquake at this point, it seems that Rafael’s reaction status over time varies considerably fromperson to person. In fact, the young doctors who worked diligently to support the survivors lookedback and recalled that the honeymoon period was about three months, but the state and duration of
the reaction were not uniform. There were considerable individual differences based on personal
experiences and awareness.

Figure 1: Progress of Disaster Reactions
Response state

Shock

Honeymoon

Improvement ofself and society

Alarm
Disillusionment

Stable, predisaster level
The next disaster
Hours

MonthsWeeks(Rafael, B. Tr. By Tadashi Ishimaru. When Attacked by Disaster, p. 21,
Misuzu Shobo, 1989)

Everyone who has been affected by a disaster feels, among other things, (1) that the earthquake
and tsunami were scary, (2) sadness and loneliness at losing something important, (3) extreme
helplessness, (4) anger being forced to suffer such a fate, (5) regret and self-blame for not having
been able to help those close to them, (6) anxiety about the lack of prospects, and (7) indifference
and apathy toward everything. In addition, the changes that are likely to occur in the body are (1) I
can’t get tired, (2) insomnia and nightmares, early morning awakening, (3) poor memory, inability
to concentrate, and frustration, (4) nausea and loss of appetite, stomachache, (5) diarrhea andconstipation, (6) palpitations, sweating, cold hands and feet, and (7) headaches, joint pain, dizziness,changes in personality, and so on. These are acute stress reactions that anyone can experience.
Disaster-related mental illnesses include the acute stress reactions mentioned above, sudden
palpitations, dyspnea, dizziness, sometimes death-like intense anxiety panic disorder, shortness ofbreath, sweating, dizziness, and chest pain; generalized anxiety disorder with discomfort in theabdomen, numbness in the limbs, and a burning sensation; anxiety disorders including phobias,
flashbacks, dyspnea, PTSD, paralysis, sleeplessness/nightmares, anger, loss of appetite, depression,
inability to concentrate, inability to enjoy oneself, feelings of worthlessness, depression, and selfinjury; and alcohol-related disorders that cause physical and mental symptoms.
The following are examples.
Case 1: A woman in her 30s. She was recently selected for temporary housing, but thinking about
her hometown makes her cry. She returned from a mass shelter yesterday, and just looking at the sea
is enough for her to burst into tears. “Am I weird?” she asks. “I can sleep at night, but I dream ofdead people.”
Case 2: A woman in her 70s. She is in a shelter, and she feels a swaying sensation even though
there are no earthquakes. She wants to sleep soundly but won’t take sleeping pills because of thefear of an earthquake or tsunami occurring while she sleeps. Her life in the evacuation center
continues to drag on, and recently, it appears that she has started to become quite forgetful.
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4. Mental Health CareOn March 13, after the disaster, in accordance with the Disaster Countermeasures Basic Law, theprefecture requested other prefectures to dispatch mental care teams through the Ministry of Health,Labour, and Welfare. According to the Disaster Relief Act, the dispatch period was until October 31,
but part of it was continued until March 2012. In addition to the prefectural route, various university
psychiatry departments (through the Tohoku University Department of Psychiatry), teams from theJapan Psychiatry Clinic Association, and private volunteers also supported the survivors. The main
activities of these mental care teams were patrols and visits to evacuation centers in collaboration
with municipal health organizations. Initially, psychiatric relief activities were the main focus, butawareness activities for survivors, consultations, visits, and medical examinations were also carriedout. This wide range of initiatives gradually developed into community mental health activities, andwere taken over by local Health Centers and municipalities. According to the prefecture’s summary,the number of mental care teams dispatched peaked at a maximum of from the end of March to April,
and then gradually declined, reaching a total of 4519 people assisted as of October 31, with 11705
people eligible for support. Figure 2 shows the activities of these mental care teams from March to
October. During this period, 11,705 people were supported, including 909 children.

Figure 2: Mental Health Care Team Activities(Average Number of Support Targets Per Day)
Month

March

April

May

June

July

AugustSeptem- Octoberber

The numberof people

Psychiatricrelief work

Support target total(as of October 31) /11,705 /(including 909 children)
Shift to mental health and welfare activities
and local takeover※ From mental health and welfare wrap-up statistics

One week after the earthquake, the Prefectural Disability Welfare Division, Sendai City, Tohoku
University, and people involved in psychiatry in the prefecture gathered to hold mental carecountermeasure meetings to grasp the current situation of disaster area support and develop futurecare activities. Activities such as liaison and coordination were carried out for about half a year. In
July, the need for medium- to long-term mental care measures was discussed, and we visited theDisaster Mental Health Care Centers established in Hyogo and Niigata prefectures. In December,the MDMHCC was opened under the initiative of the prefecture.
Owing to the expansiveness of the disaster area, the MDMHCC was given a Stem Center in
Sendai and Regional Centers in Kesennuma and Ishinomaki. Table 1 shows the number of staff at
the MDMHCC. Even before the disaster, there was already a shortage throughout the prefecture ofmental health and medical staff and specialists; it was, therefore, rather difficult to meet our staffing
needs through prefectural hires alone, and we have made use of a national transfer/dispatch systemthrough the Ministry of Health, Labour, and Welfare. As of May 1, 2013, the number of staff is 57,
of which 38 are full-time and 19 are part-time. We have 11 psychiatrists, 19 psychiatric social
workers, 10 clinical psychologists, seven public health nurses, five nurses, one occupational therapist,and four clerical workers. In addition, we have installed transfer employees in Iwanuma, Ishinomaki,- 104 -Higashimatsushima, Kesennuma, Onagawa, and the Ishinomaki Public Health Center, where a totalof nine people are engaged in support activities.

57 staff members(38 full time, 19 part-time)

Full

part

1
3

4
21

Full

7
1
3
0
3
0
0
14

Part

0
1
1
0
11

Full

1
0
0
1
0
0
0
2

Total

Part

0
2
1
0
0
0
6

2
0
1
0
0
0
0
3

11
19
10
7
5
1
57
9

The main activities of the MDMHCC are raising public awareness; providing support for disastersurvivors, those who support municipalities, SWCs, Regional Comprehensive Support Centers, andactivities carried out in temporary housing and other communities; human resource development,
and research.
Table 2 shows the activity results of the MDMHCC from April 2012 to March 2013. There were
4,492 interview consultations, and the chief complaints were insomnia (22%), physical symptoms(19%), depression (17%), anxiety/fear (16%), lethargy (10%), and alcohol (10%). Backgroundfactors included the following: changes in the living environment (29%), domestic problems (15%),
economic life reconstruction problems (14%), loss of a loved one (11%), and unemployment/related
problems (8%). In addition, the number of telephone consultations was 1,945.

Table 2: MDMHCC Activity
Achievements(4/2012～3/2013)• Interview consultations: 4,492
Chief complaints: Insomnia 22%, physical symptoms 19%,
depression 17%, anxiety/fear 16%, lethargy 10%,alcohol 10%.
Background factors: Changes in the living environment 29%,
domestic problems 15%, economic life reconstruction
problems 14%, loss of a loved one 11%, and unemployment/related problems 8%.

• Telephone consultations: 1,945
The following introduces part of our work through an example case.
Case 3: Mrs. C, in her 60s, lives alone in private rental housing. She ran a company with her
husband on the coast before the earthquake. After spending some time in a shelter, she entered private
rental housing. She received a visit request from the city because she had a high K6 score on a private
rental housing health survey. At the time of the first visit, Mrs. C said, “When the tsunami came after
the big earthquake, my husband and I evacuated to the second floor of my house. My husband went

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to the first floor, saying there was something important he had to do. After a while, the tsunami
rushed in, so I went up to the roof from the second floor. When I looked down, my husband waswaving, caught in the tsunami. Close enough for me to touch. I told him to crawl up, but I guess hewas caught between some rubble, and couldn’t move. Eventually, I lost sight of him. After thetsunami had receded and I went downstairs, I found his dead body in the rubble. Why didn’t I stop
him from going down? I feel like I killed him myself. I wish I had died with him. That image of him
waving his hands at me is seared into my memory. Whenever I see others talking happily, I get so
jealous. Why did I have to go through such a horrible experience? I envy others. I avoid going out
during the day and try not to meet anyone. My son and his wife don’t come to see me; they’reapparently busy rebuilding their company. Sometimes I can’t sleep at night, and my doctor has given
me sleeping pills.” Mrs. C told me this story with tears in her eyes, and we decided to put her oncontinuing visitations.
5. In Place of a Summary
Many survivors are still forced to live in temporary or designated temporary housing. Figure 3
shows the results of the prefecture’s 2012 emergency temporary (container-type) housing resident
health survey and the 2011 private rental housing resident health survey. About 19% were ill and hada serious mental illness. Further, 9% had a K6 score of ≥13 (as compared to 4.6% in a national
survey), indicating severe mental illness, and 15% had insomnia, with their physical and mental
health undermined without any prospect of improvement. It is said that problematic behaviors suchas truancy, bullying, and violence are increasing for children and students, and at home, deteriorationof family relations due to domestic violence and divorce has become a problem. In addition,
supporters, including local government employees, are utterly exhausted, and support for themcontinues to be a major issue. Issues of concern in the future include the emergence of a scissor
disparity (between communities and individuals able to achieve reconstruction and those unable to
do so) as shown by our experiences following disasters such as the Great Hanshin and Niigata
Chuetsu-oki earthquakes. Amidst these circumstances, solutions to and countermeasures against
depression, dementia, alcohol/drug-related problems, suicide, and other issues will be required.
Figure 3: Emergency temporary housing (containertype) resident health survey (2012) and private
chartered housing (2011)

Containertype

PrivatePoor physical condition K6 ≥13 Insomnia Daytime drinking

To deal with these issues, the revitalization of community mental health activities centered on
cities and towns is essential. However, owing to this large-scale disaster, it is difficult for existing
community mental health systems to respond to the issues that will arise. There is, therefore, a needfor long-term municipal-level support systems, such as those offered by the MDMHCC. As it is wellknown that it is impossible to maintain or improve mental health without revitalizing the living
infrastructure, reconstruction must be completed with utmost haste. At the same time, from theperspective of maintaining and improving the physical and mental health of disaster victims, it may
be necessary for medical and health personnel to cooperate with each other within the region andrespond flexibly.
(Published in the April 2014 issue of Miyagi Medical Association Bulletin Vol. 819.)- 106 -