REVIEW

Mental Health and Psychosocial Support after
the Great East Japan Earthquake
Yutaka Kato, Hiroyuki Uchida and Masaru Mimura

Department of Neuropsychiatry, School of Medicine, Keio University, Tokyo, Japan(Received for publication on December 14, 2011)(Accepted for publication on January 10, 2012)

Since the Great East Japan Earthquake, Keio University School of Medicine has, at the request of theTokyo Metropolitan Government, provided mental health and psychosocial support to those living in
Soma City in Fukushima Prefecture. This report covers the types of support provided in Soma Cityand discusses previous studies that were used as the model for current support practice and the results
gained from actual performance. Also included is a summary of the objectives that were or were notachieved for medical support compared with recommendations from previous studies. Furthermore,
future directions for medical support are also discussed. (Keio J Med 61 (1) : 15–22, March 2012)

Keywords: mental health, disaster medicine, earthquakes, tsunamis, psychiatry

Introduction

swered that their mental health state was poor comparedwith their condition prior to the event.5 The maximum
impact on mental health is reported to occur directly aftera disaster and to persist for about a week; there is usually some improvement after 1 month. However, there aremany cases in which an unhealthy mental state persists
even after 6 months to 1 year. The most important partof psychiatric care after a disaster is to accurately monitor the changes in the mental state of the victims and toprovide appropriate cures and care for their conditions.
This report describes the types of medical support that
Keio University School of Medicine offered to Soma
City in Fukushima Prefecture, as well as the details of
psychiatric care and the method of intervention after thedisaster. This article also gives an overview of medical
interventions in Soma City and the city’s unusual history
in relation to psychiatric care, as well as discussing thebest support methods for this type of situation.

The most significant event of 2011 was, without any
doubt, the Great East Japan Earthquake of March 11.
There is no disagreement with the fact that it caused unprecedented damage. News reports about the earthquake
have become somewhat more moderate in tone now, butthere are still news items that can shock us. Fukushima
Prefecture not only suffered from the tsunami caused by
the earthquake but also from damage to its nuclear power
plant that resulted in radiation leaks and the contamination of agricultural products. These multiple problems
place Fukushima on a different level from other regions interms of suffering. Unfortunately, harmful rumors havecontinued to spread. Japan has been fighting against “invisible radiation threats” for almost 1 year, and it seems
that people are exhausted by the situation but do not yet
see any end to it. As a result, it would be hard to disagreewith the assertion that the people of Fukushima Prefecture have suffered the worst effects of the earthquake.
Damage to the victims of the great earthquake is not
only physical but can have a significant psychologicalcomponent as well.1–4 In a previous study based on aself-completed questionnaire, about 60% of the victimsof the Mid-Niigata Prefecture Earthquake of 2004 an-

The Keio University Medical Support TeamThe Department of Neuropsychiatry at Keio University
School of Medicine received a request from the Tokyo
Metropolitan Government to send some staff members
to Soma City about 1 month (April 12, 2011) after the

Reprint requests to: Yutaka Kato, MD, Department of Neuropsychiatry, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo
160-8582, Japan, E-mail: yutaka-k@db3.so-net.ne.jp
Copyright © 2012 by The Keio Journal of Medicine
15

Kato Y, et al: Mental Health after the Japan Earthquake

16

Great East Japan Earthquake. The Keio Medical Teamfor Mental Health and Psychosocial Support was made up
of one doctor, one clinical nurse, and one clerk who wereselected each week for three consecutive weeks (so a totalof 9 team members participated). The three doctors participating in the support program were Professor Masaru
Mimura, Dr. Hiroyuki Uchida, and Dr. Yutaka Kato, who
are the corresponding and co-authors of this article.
The Team was formed to provide support after theearthquake when the Soma General Hospital establisheda temporary psychiatric outpatient department on March
29, 2011, and has continuously provided voluntary medical care since then. Dr. Nishikawa from Osaka Medical College was the first to participate after arriving on
March 29, and other psychiatrists from all regions of Japan joined him later. They moved between the outpatient
department of Soma General Hospital and various emergency shelters to provide psychiatric diagnosis, treatment, and mental care for patients and victims. Each day,two to three doctors volunteered to provide support in
Soma City. After April 12, a support program also started
at the local government level, and we were sent to Soma
City to join the first government support group. According to the first interim report (March 11 to July 31, 2011)6
published by the disaster countermeasures office of Soma
City, the participating support groups and activity schedules of the Team were as follows: April 12 to May 10,
Tokyo Metropolitan Government; April 19–27, Ibaraki
Prefectural Government; May 9 to June 17, Tochigi Prefectural Government; May 17 to June 30, Yokohama City
Government; May 23 to July 30, Japanese Society of Psychosomatic Medicine; May 30 to July 23, Association of
Aichi Psychiatric Hospitals; May 30 to June 3, Japan Federation of Democratic Medical Institutions; June 7 to July
4, Nozoe Hospital; June 28 to July 29, Niigata Prefectural
Government.
Background of Soma City
Soma City in Fukushima Prefecture is located at thenorth end of the area called Hamadori (coastal area) andfaces the Pacific Ocean. While this city is part of Fukushima Prefecture, its cultural roots are also from the
Sendai metropolitan area in the present day. It was aprosperous castle town able to produce 60,000 koku (approximately 10.8 million liters) of crops under the SomaNakamura clan in the Edo Period (1603–1867), and has
been known as an honorable samurai town [it is the venue
for the Soma Nomaoi, the famous polo-like festival of thesamurai since the Heian Period (794–1185)]. Before theearthquake, the population was approximately 38,000,
with the elderly accounting for 25%. Primary industry
workers totaled 2500, while secondary industry workers
totaled 7300, and 10,000 were employed in tertiary industries.
Soma City has a very special place in the history of psy-

chiatric practice in Japan. It is where an unusual incident
took place at the end of the 19th century, the Soma incident, which has special implications with regard to psychiatric care even now. The incident gave rise to improvements in the legislation covering mental health in Japanand also was the origin of stigma regarding mental healthcare. The main character in this incident was Tomotane
Soma, the local lord of the Soma-Nakamura clan at thattime. Tomotane enrolled at Keio University in 1871. He
was about to marry the daughter of a noble family in
1876, when he suddenly claimed that the bride had been
exchanged for someone else. This claim was taken by his
family members as evidence of a psychotic disorder, andthe family asked the Imperial Household Agency to takehim into custody. He was shut in the confinement roomof the family mansion for a while and then was eventuallytransferred to a mental hospital.
In 1883, Takekiyo Nishigori, one of the retainers of theSoma-Nakamura clan, became suspicious of Tomotane’s
condition and imprisonment and claimed that his imprisonment was unjustifiable and part of a plot to steal his inheritance and property. Since the diseases diagnosed byhighly reputed doctors were inconsistent, the public firstthought of Nishigori’s act as loyal and he gradually gained
a lot of sympathy. Later on, he gained support from influential people of that era, such as Shinpei Goto (head of
the Home Ministry’s medical bureau), Toru Hoshi (Chairperson of the Lower House), and Ruikou Kuroiwa (founder of a gossip newspaper called Yorozu Choho), which resulted in more public attention. In 1887, Nishigori slipped
into the mental hospital of Tokyo-fu (Tokyo Prefecture)
where Tomotane was confined and succeeded in rescuing him. When Tomotane died in 1892, Nishigori claimed
that the cause of death was poisoning, and tried to prove
his theory by exhuming the body. Eventually, Nishigori
himself was arrested in 1893 for the sedition. During thisperiod, the citizens of Soma were influenced by the gossip newspaper Yorozu Choho, and reports in the mass media attracted interest throughout the whole country. Fromthat time, because it was believed that psychiatric professionals had colluded with the alleged conspiracy, not only
psychiatric hospitals and related clinics but also psychiatric outpatient departments at general hospitals were notaccepted inside Soma City.
Even just before the earthquake, prejudice toward thosewith psychiatric disorders was still deeply rooted in thisarea, so patients were forced to see doctors in neighboring Minami Soma City or Futabamachi, where the infrastructure was better developed, a consequence of theconstruction of the nearby nuclear power plant. Thenthe tsunami struck the Fukushima nuclear power plant,
and within a few days those hospitals and clinics wereshut down because they were in the exclusion zone, reducing care provision in areas where medical facilities
were already scarce. The Pacific coastal region that includes Soma City, Futabamachi, and Iwaki City is now

Keio J Med 2012; 61 (1): 15–22

called the “Sousou area,” with the initial characters ofeach city’s name making up the term. It is almost the sizeof a small prefecture and contains 200,000 people, but it
lost all facilities relating to psychiatric practice once theearthquake struck.
Psychosocial Intervention in Soma City
The support program needed to provide psychiatrictreatment immediately after the unprecedented earthquake disaster against the above-mentioned historicalbackground, with Soma City being very sensitive to issues surrounding mental illness. When giving psychiatric support, we refrained from introducing ourselves as
psychiatrists and assessed the psychiatric symptoms ofvictims (and volunteer staff from around the country) inan unobtrusive way. For patients with serious mental disorders, we needed to share information with nurses andmedical teams to immediately respond to danger signals.
Previous reports have shown that victims are particularly able to improve their mental state by sharing their
troubles and hardships with others. A study conducted after the Mid-Niigata Prefecture Earthquake revealed thatvictims who “could not speak” about their troubles andhardships to others had significantly worse mental statuscompared with those who “could speak”7. Accordingly,
we considered that victims would need to talk to others
about their problems to improve their mental state (taking
care not to be re-experiences of the disaster). Fortunately, before we arrived in the disaster area, the psychiatricteam of Fukushima Medical University had commenced
a support program under the direction of Professor Shinichi Niwa, and a certain level of support had already been
established and had progressed step by step. At the timeof introduction of medical support to a disaster area, asystem with a unified direction is a very important factor because such an organization understands psychiatric treatment in normal times and can collect situational
data from various medical volunteers around the country,
based on which they can provide appropriate advice. For
example, due to the situation at the nuclear power plantin Fukushima Prefecture, Hibarigaoka Hospital andother hospitals instantly lost their capacity of more than
840 beds. Also, these areas were designated as the prefecture’s emergency evacuation areas, so these hospitals
could not keep more than 5 patients for longer than 72
hours. However, thanks to the system with a unified direction, Fukushima Prefecture took appropriate actions
to overcome such sudden changes. This advantage might
be due to the presence of one medical university in eachprefecture as a national policy.
In addition, as a common issue in disaster support, wefound it difficult to provide a sense of stability to patients
through continuous medical support because the medical
support teams could not give long-term help due to thelimitation of the schedule and staff fatigue. Soon after17

arriving in the disaster zone, we heard victims and theirfamilies complaining about their “day-by-day medicalcare” and recognized that some consideration needed to
be given to changing the system despite our limited capacity. Nonetheless, the fact that the Department of Neuropsychiatry from Keio University could provide continuous medical care for at least 3 weeks was helpful. Also,
other medical support teams entered the disaster zone
after we left and could provide medical services in an organized fashion, so information on the length of support
may have been helpful. We performed medical intervention and environmental improvement through outpatient
treatment in the Public Soma General Hospital and also
examined patients who were suspected to have psychiatric disorders in the emergency shelters.
We based our work on previous study results regarding psychiatric intervention at the time of disasters. Most
data were accumulated around the time of the Vietnam
War and attracted attention again after the 9/11 terrorist
attacks in New York. Although space is limited, below
we additionally describe the facts known about medical
support programs associated with disaster recovery as
well as the focus of our medical support program.
Mental Health and Psychosocial Support
At the time of a disaster, analyzing and understanding
the immediate situation is the first priority. According
to the Inter-Agency Standing Committee (IASC),8 theactions to be taken when a disaster occurs can be summarized as analysis of the situation and a needs assessment (Table 1, modified from IASC8). First, on the assumption that several weeks or months would be needed
to complete these actions, immediate assessments were
performed by summarizing analysis data from several
sources with different viewpoints. Then, the estimationand evaluation of the number of patients with mental disorders such as epilepsy or alcohol and other substanceabuse were carried out, and information on the likely
changes in these numbers after the occurrence of a disaster was assessed. Further, creating a map of the support
programs was needed in order to clarify the role of medical professionals in the treatment of such mental disorders.9 The prevalence of mental disorders varies significantly depending on the local and cultural background.
For example, alcohol consumption is known commonly
to increase after the occurrence of natural disasters; however, it did not increase after the Great Hanshin-Awaji
Earthquake10 of 1995. Table 2 shows the WHO estimatesof changes in prevalence of mental disorders before andafter a natural disaster. Because the prevalence of severe
and mild to moderate disorders after a disaster can double
compared with normal times, it is necessary to treat thesepatients appropriately by providing the support of a psychiatric team. Detailed information on the psychologicalreaction patterns of patients over time has been report-

Kato Y, et al: Mental Health after the Japan Earthquake

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Table 1 Situation analysis and needs assessment
Carried out for several weeks or months continuously
Performed in numerous areas concurrently
Assessed based on cooperation and situation analysis of numerous regions

Rapid assessment

Support mapping

Epilepsy
Alcohol and other substance abuse disordersIntellectual disability (developmental delay/developmental
disorders)
Psychotic disorders
Severe emotional disorders
Other psychological complaints
Medically unexplained symptoms
Who?
Where?
What?
When?

Cooperation and coordination with organizations concerned

Table 2 Effect of a disaster on mental disorders (WHO estimates of prevalence)

Severe disorders (psychotic disorder/severe depression/anxiety
disorder with functional disorders)
Mild/moderate disorders (mild/moderate depression and anxiety
disorders)
Normal stress reactions (without pathologic significance)

ed by Norris, et al.11 and a summary is shown in Fig. 1.
Among the different patient groups, the resistance (blue),resilience (green), and recovery (orange) groups indicate
a good prognosis for recovery. In contrast, the relapsing/
remitting (red), delayed dysfunction (purple), and chronic dysfunction (gray) groups show a worse outcome andnatural recovery cannot be predicted, suggesting the needfor more support. As shown in Fig. 2, about 22% of patients were categorized into a poor prognosis group after
the natural disasters, including floods, in Mexico. Also,
as shown in Fig. 3, approximately 27% of patients werecategorized into a poor prognosis group after the 9/11 terrorist attacks in New York. It is worth underlining thatafter both manmade and natural disasters, approximately
75% of victims recover without any medical treatment,even if they show transient reactions to the disaster. However, when we went to the Great East Japan Earthquake
disaster zone, the prevalence of poor prognosis patterns
was felt to be higher than those cited above. This is because we were involved in the psychiatric treatment ofhigh-risk patients from the stricken area, although it isPrevalence 12 months before
the disaster

Prevalence 12 months after
the disaster

2%–3%

3%–4%

10%
No estimate

15%–20% (tends to decreaseover time)High (tends to decreaseover time)

important to keep in mind the possibility of resilience, assuggested in previous studies.
When introducing psychiatric treatment, the elementsthat can lead to rejection of psychiatric intervention by
victims should be borne in mind (Table 3, modified from
Hoge, et al. 12). The information in Table 3 is not related to natural disasters, but shows perceived barriers toseeking mental health services among American soldiersdispatched to Iran or Afghanistan, including those diagnosed with mental disorders; however, this information
might prove generally useful. As a reason for such rejection, in addition to the particular history of Soma City, weneed to understand that people do not greatly trust mental
health professionals, as indicated by the extremely highrate of 38% of soldiers with mental disorders who do nottrust mental health professionals, as shown in Table 3. An
epidemiological study conducted 11 years after the great
Hanshin-Awaji earthquake13 revealed that people withlong-term psychological changes did not exhibit helpseeking behavior, so further consideration is necessary
about the appropriate mode of psychiatric intervention.

Keio J Med 2012; 61 (1): 15–22

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Fig. 1 Hypothesized trajectories of the course of stress responses.
(Modified from Norris, et al.11)

Fig. 2 Trajectories of post-traumatic stress disorder (PTSD) symptoms among residents of Villahermosa and Teziutlán in Mexico (n= 561) after the 1999 flood.
(A) Resistance��������������������������������������������������������������������������������������������������������������������������������
(blue), resilience (green), and recovery (orange) indicate a good prognosis, whereas chronic dysfunction (gray) indicates a poor prognosis.
(B) A: Resistance (blue): 34.5%, B: Resilience (green): 32.0%, C: Recovery (orange): 11.4%, D&E: Chronic dysfunction (gray):22.0%. (Modified from Norris, et al.11)

Kato Y, et al: Mental Health after the Japan Earthquake

20

Fig. 3 Trajectories of PTSD symptoms among residents of the New York City metropolitan area (n = 1267) after the September 11,
2001, attacks.
(A) Resistance (blue), resilience (green), and recovery (orange) indicate a good prognosis, delayed dysfunction (purple) and chronic
dysfunction (gray) indicate a poor prognosis.
(B) A&B: Resistance (blue): 53.4%, C: Resilience (green): 10.1%, D: Recovery (orange): 9.3%, E: Delayed dysfunction (purple):
14.3%, F&G: Chronic dysfunction (gray): 13.0%. (Modified from Norris, et al.11)
Table 3 Perceived Barriers to Seeking Mental Health Services among All Study Participants (Soldiers and Marines)*

Perceived Barrier

Respondents Who
Met Screening
Criteria for a Mental
Disorder(N=731)

Respondents Who Did
Not Meet Screening
Criteria for a Mental
Disorder(N=5422)

no./total no. (%)
I don’t trust mental health professionals.
I don’t know where to get help.
I don’t have adequate transportation.
It is difficult to schedule an appointment.
There would be difficulty getting time off work for treatment.
Mental health care costs too much money.
It would be too embarrassing.
It would harm my career.
Members of my unit might have less confidence in me.
My unit leadership might treat me differently.
My leaders would blame me for the problem.
I would be seen as weak.
Mental health care doesn’t work.

241/641 (38)143/639 (22)117/638 (18)288/638 (45)354/643 (55)
159/638 (25)260/641 (41)319/640 (50)377/642 (59)403/637 (63)328/642 (51)413/640 (65)
158/638 (25)813/4820 (17)303/4780 (6)279/4770 (6)789/4748 (17)1061/4743 (22)456/4736 (10)852/4752 (18)1134/4738 (24)1472/4763 (31)1562/4744 (33)928/4769 (20)1486/4732 (31)444/4748 (9)*Data exclude missing values, because not all respondents answered every question. Respondents were asked to rate“each of the possible concerns that might affect your decision to receive mental health counseling or services if you ever
had a problem.” Perceived barriers are worded as on the survey. The five possible responses ranged from “strongly disagree”
to “strongly agree,” with “agree” and “strongly agree” combined as a positive response. Reproduced from Hoge, et al.12 Copyright©2004 Massachusetts Medical Society. All rights reserved.

Table 4 shows a comparison between IASC recommendations and the activities that the current support
team actually carried out in the disaster zone. IASC rec-ommendations are listed on the left side, and the actions
our support team took and their problems are listed on theright side (modified from Kashima et al.14). When con-

Keio J Med 2012; 61 (1): 15–22

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Table 4 Comparisons of actions between IASC recommendation and actual provision after the earthquake
IASC recommendations
Establish a comprehensive cooperation and coordination group fordisaster support
Collect and analyze data to judge actions actually taken and assess
their types
Recognize a variety of effects on victims. While there are victims
who are seriously affected and require special support, those withhigh resilience are highly functional
Using the local language, inquire about mental health in a safe andsupportive way, while keeping confidentiality
Improve government administration and integrate the mental healthservice for victims into the general health care service (and themental health service of the community, if possible)
Provide a wide range of support including psychological first aid(PFA) to those who are suffering from acute stressful conditions
Identify those who are seriously affected and establish effective
support systems for them
Develop medical care programs suitable for the community tosupport those at risk of institutionalization
Utilize media and other tools to provide accurate information about
stress relief and support services to victims

sidering the specialty of psychiatric care, we recognizedthrough this support program that the most necessary andmost difficult thing was “securing a treatment sequence.”
Taking into account the special background of Soma City
with respect to mental health problems, it would be difficult to achieve dramatic expansion and enhancement of
psychiatric treatment in this region by using the disaster as a trigger. In fact, we found that the situation was
beyond the capacity of the medical university staff andvolunteers. We hope that the sharing of our experiences
during these support activities and discussion of the problems we detected can contribute to better preparation for
future disasters.
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Actions taken after the Great East Japan Earthquake
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Data collection and analysis were done at the level of each prefecture. However, actions and data sharing at the municipal and national
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