# 【特集：新型コロナ感染症関連レター】
## The Importance of Providing Systematic Mental Health Care in the COVID-19 Pandemic: Reflecting on the 2011 Fukushima Nuclear Accident*

\author{
Arinobu HORI**, Toyoaki SAWANO***,****, \\ Akihiko OZAKI***** and Masaharu TSUBOKURA****
}

\begin{abstract}
Healthcare workers are at additional risk of Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infection, and there have been extensive discussions on their mental health consequences. We draw attention to four observations in disaster relief workers (DRWs) coping with the aftermath of the Great East Japan Earthquake (GEJE) in 2011 to inquire this problem profoundly.

1. The uplift and exhaustion of DRWs in the honeymoon phase after a disaster

2. The denial of trauma and depression in the acute post-disaster period

3. Little awareness of the importance of grief care among disaster survivors

4. Manifest of mental distress during the post-disaster restoration phase, when social disparities emerge

5. The importance to guarantee the economic activities of DRWs to maintain their livelihoods

DRWs tend to be left in a vulnerable position to respond to a disaster. Deliberate support for such DRWs is decisively required in the context of COVID-19 pandemic.
\end{abstract}

Key Words: Covid-19, Fukushima nuclear accident, the Great East Japan Earthquake (GEJE), disaster relief worker, Mental Health

As of October 2020, the number of people with coronavirus disease (Covid-19) and related fatalities globally has exceeded 40.7 million and 1.12 million, respectively (WHO, 2020). Healthcare workers are at additional risk of Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infection, and there have been extensive discussions on their physical and mental health consequences. To facilitate the discussion, we draw attention to five observations in disaster relief workers (DRWs) coping with the aftermath of the Great East Japan Earthquake (GEJE) in 2011. In the case of coronavirus pandemic and nuclear accidents, both are characterized by the fact that the disaster does not easily become a past event but remains an existing threat for a long time. In that case, many disaster survivors are hardly to reflect on the suffering of the past and are expected to continue to serve the community as DRWs. In the field of disaster mental health, trauma and grief are major issues, and depression as a response to them is likely to be of interest. However, more attention should also be paid to manic responses to trauma and grief by those who must work as DRWs in disaster areas.


## 1. The uplift and exhaustion of DRWs in the honeymoon phase after a disaster

Firstly, an elevated sense of community unity and morality known as the Honeymoon Phase occurs soon after disasters, and altruistic behavior emerges (Raphael, 1986). The passion and dedication of DRWs usually declines in some months, as they carry out their rescue and reparation work, in appalling and often dangerous conditions. However, a nuclear accident or pandemic requires that it would be sustained for longer periods. While highly motivated local DRWs carried out their long, arduous, and thankless tasks, a lack of a systematic support system made them especially vulnerable to mental disorders and other physical health problems (Sawano et al., 2016; Tanisho et al., 2016).

## 2. The denial of trauma and depression in the acute post-disaster period and the neglect of self-care

Secondly, in Fukushima after the GEJE, researches have shown that not a few populations were in denial about the pain associated with their loss, trauma, and changes in the lives of people like the DRWs. Those with depression and post-traumatic stress disorder (PTSD) peaked in the immediate aftermath of GEJE and gradually declined (Yabe et al., 2014). Nonetheless, the number of depressed survivors who visited mental clinics soon after the disaster decreased (Hisamura et al., 2017; Hori et al., 2016). The number of patients in a manic state increased in psychiatric institutions in Fukushima Prefecture during 2011 (Hisamura et al., 2017). The manic state includes denying one's own plight or that of the community while despising the importance of self-care. A case of bipolar disorder and PTSD while working as a DRW for a local municipality after the earthquake, tsunami, and nuclear power plant accident, which he himself experienced harshly was reported (Hori et al., 2020). Sakuma et al. (2020) conducted a survey on long-term trajectories for PTSD symptoms in local municipality and hospital medical workers in Miyagi Prefecture, which was severely damaged by the tsunami following the GEJE. According to the survey, $6.7 \%$ of respondents showed a course of fluctuating or chronic trajectory with long-term social functioning decline (Sakuma et al., 2020). Some of these people may need specialized psychiatric treatment However, there is still no systematic intervention for trauma-related problems with disaster survivors in Japan. The fact that the post-GEJE suicide rate in Fukushima Prefecture has not decreased is of the utmost concern (Takebasyashi et al., 2020).

## 3. Little awareness of the importance of grief care among disaster survivors

Thirdly, there was little awareness of the importance of grief care among survivors including DRWs. Psychological interventions for PTSD and bereavement from the loss of family members require specific expertise, (Sun et al., 2020) and thus have not been sufficiently implemented in response to the GEJE. Such measures should be implemented especially for DRWs in other areas that have encountered disasters

## 4. Manifest of mental distress during the post-disaster restoration phase, when social disparities emerge

Fourthly, the mental distress of DRWs following the GEJE who had been overloaded with work began as the Honeymoon Phase ended, and the restoration work proceeded. Of note, this phenomenon was accompanied by problems derived from social disparities (Raphael, 1986). Systemic mental health care, such as countermeasures for PTSD and depression, was provided to those working for public organizations or large companies such as the Tokyo Electric Power Company, (Tanisho, 2016) but was insufficient for those working for small associations or private organizations. In the case of COVID-19, comprehensive mental health measures should be developed, especially for health care workers who do not work for large organizations.

## 5. The importance to guarantee the economic activities of DRWs to maintain their livelihoods

Finally, in addition to psychological support for DRWs, it is also necessary to guarantee the economic activities of DRWs to maintain their livelihoods. For example, those who have returned to the areas ordered to be evacuated as a result of the nuclear accident will have to conduct business in areas where the population
is declining and where there are negative reputations about the effects of radiation. Likewise, hospitals treating Covid-19 patients may face discrimination from the public against their staff for fear of infection, and at the same time, the number of patients with nonCovid-19 diseases may decrease. Whether returning to the disaster area or accepting treatment for Covid-19 patients, by contributing to the response to the disaster, they are assuming a significant risk to the economic activities of their daily lives. Legislators and policy makers should make decisions that reward the contributions of DRWs.

DRWs tend to be left in a vulnerable position to respond to a disaster. However, DRWs themselves often deny their own need to be cared for, as they often uplift themselves to recover from disasters. The consequences of the denial could be seen years later. Deliberate support for such DRWs is decisively required.

## References

Hisamura, M., Hori, A., Wada, A., Miura, I., Hoshino, H., Itagaki, S., Kunii, Y., Matsumoto, J., Mashiko, H., Katz, C. L., Niwa, S. I. (2017) Newly admitted psychiatric inpatients after the 3.11 disaster in Fukushima, Japan, Open J. Psychiatr, 7, 131-146. doi:10.4236/ojpsych.2017.73013

Hori, A., Hoshino, H., Miura, I., Hisamura, M., Wada, A., Itagaki, S., Kunii, Y., Matsumoto, J., Mashiko, H., Katz, C. L., Yabe, H., Niwa, S. I. (2016) Psychiatric outpatients after the 3.11 complex disaster in Fukushima, Japan, Ann Glob Health, 82(5), 798-805. doi:10.1016/j.aogh.2016.09.010

Hori, A., Takebayashi, Y., Tsubokura, M., Kim, Y. (2020) PTSD and bipolar II disorder in Fukushima disaster relief workers after the 2011 nuclear accident, BMJ Case Rep, 13(9), e236725. doi: 10.1136/bcr2020-23672

Raphael, B. (1986) When Disaster Strikes: How Individuals and Communities Cope with Catastrophe. New York: Basic Books.

Sakuma, A., Ueda, I., Shoji, W., Tomita, H., Matsuoka, H., Matsumoto, K. (2020) Trajectories for posttraumatic stress disorder symptoms among local disaster recovery workers following the Great East
Japan Earthquake: Group-based trajectory modeling, $J$ Affect Disord, 274, 742-751. doi:10.1016/j.jad. 2020.05.152

Sawano, T., Tsubokura, M., Ozaki, A., Leppold, C., Nomura, S., Shimada, Y., Ochi, S., Tsukada, M., Nemoto, T., Kato, S., Kanazawa, Y., Ohira, H. (2016) Non-communicable diseases in decontamination workers in areas affected by the Fukushima nuclear disaster: a retrospective observational study, $B M J$ Open, 6(12), e013885. doi:10.1136/bmjopen-2016013885

Sun, Y., Bao, Y., Lu, L. (2020) Addressing mental health care for the bereaved during the COVID-19 pandemic, Psychiatry Clin Neurosci, 74(7), 406-407. doi: 10.1111/pen. 13008

Takebayashi, Y., Hoshino, H., Kunii, Y., Niwa, S. I., Maeda, M. (2020) Characteristics of disaster-related suicide in Fukushima prefecture after the nuclear accident, Crisis, 6, 1-8. doi: 10.1027/0227-5910/ a000679

Tanisho, Y., Shigemura, J., Kubota, K., Tanigawa, T., Bromet, E. J., Takahashi, S., Matsuoka, Y., Nishi, D., Nagamine, M., Harada, N., Tanichi, M., Takahashi Y., Shimizu, K, Nomura, S., Yoshino, A., Fukushima NEWS Project Collaborators. (2016) The longitudinal mental health impact of Fukushima nuclear disaster exposures and public criticism among power plant workers: the Fukushima NEWS Project study, Psychol Med, 46(15), 3117-3125. doi:10.1017/S00 $3329171600194 \mathrm{X}$

World Health Organization. (2020) WHO Coronavirus Disease (COVID-19) Dashboard, https://covid19. who.int/ (Access: 22, Oct, 2020)

Yabe, H., Suzuki, Y., Mashiko, H., Nakayama, Y., Hisata, M., Niwa, S., Yasumura, S., Yamashita, S., Kamiya, K., Abe, M., Mental Health Group of the Fukushima Health Management Survey (2014) Psychological distress after the Great East Japan Earthquake and Fukushima 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(1), 57-67. doi: 10.5387/fms.2014-1