The 30‐year mental health legacy of the <scp>C</scp>hernobyl disaster
Authors: Johan M. Havenaar, Evelyn J. Bromet, Semyon Gluzman
Journal: World Psychiatry (2016)

Thirty years ago, on April 26, 1986, the Chernobyl nuclear power plant exploded, emitting tons of radionuclides into the atmosphere and exposing millions of people in Ukraine and neighboring countries to the fallout. Ultimately, 350,000 people living near the plant were permanently relocated, and 600,000 military and civilian personnel from throughout the Soviet Union were recruited as clean-up workers (locally referred to as liquidators). By the 20th anniversary (2006), ∼6,000 children under age 18 in 1986 were diagnosed with papillary thyroid cancer1, an otherwise rare disease. At the 25th anniversary (2011), the liquidators were found to have increased rates of leukemia, other hematological malignancies, thyroid cancer, and cataracts2. Yet, from a public health perspective, the biggest impact of the Chernobyl disaster throughout the years has been on mental health, specifically major depression, anxiety disorders, post-traumatic stress disorder (PTSD), stress-related symptoms, and medically unexplained physical symptoms3. The most vulnerable segments of the population have been women from the Chernobyl region who were pregnant or had young children in 1986, and liquidators, particularly those who worked at the site in April to October, 1986. The mental health effects were fueled in part by an exaggerated sense of the danger to health from presumed exposure to radiation, that was propelled by the local medical community and government officials. Liquidators, evacuees and people living in contaminated regions were officially labeled as "sufferers" or "Chernobyl victims", terms that were adopted by the mass media. Being recognized as a Chernobyl "victim" entitled people to financial, medical and educational compensation, which, combined with continuous monitoring by local and international organizations, may have had an iatrogenic effect on psychological well-being1. In our 25-year review of the impact of Chernobyl on mental health3, we concluded that the psychological consequences, especially for mothers and liquidators, continued to be a concern, and that mental health care in affected regions was not adequate to meet their needs. Given the extensive literature on comorbidity of mental and physical health, we also called on surveillance and long-term medical studies to integrate mental health measures into their assessment protocols. To our knowledge, the latter recommendations have not yet been fully embraced. Between the 25th and 30th anniversaries, with a single exception, no new epidemiologic studies of the long-term mental health aftermath of Chernobyl were conducted. Rather, recent publications are based on data obtained prior to 2011. The exception is a health registry study in Tallinn, Estonia, that found an increase in clinical diagnoses of nervous system disorders and intentional self-harm in liquidators compared to controls4. Other recently published research on liquidators includes a survey from Tallinn that confirmed findings from Ukraine about elevated rates of common mental disorders and suicidal ideation5, and papers on neurocognitive abnormalities in Ukrainian liquidators6. However, in sharp contrast to Chernobyl cancer studies, the results reported in the latter studies from Ukraine have not been verified by an international panel of experts. Consistent with findings from early studies conducted in Gomel (Belarus) and Bryansk (Russia), two recent papers analyzed data from general population surveys conducted prior to 2011 and found poorer life satisfaction and socio-economic well-being among residents of areas with mildly elevated levels of radiation (albeit within normal limits of natural background radiation) compared to other areas. The authors also estimated that these socio-economic adversities had a substantial negative impact on Ukraine's global gross domestic product7, 8. The authors inferred that these differences were a consequence of negative risk perceptions about radiation, though these perceptions were not measured directly. To our knowledge, no other reliably sampled, general population surveys of affected regions have been published. In our 25 year review, we pointed out that findings regarding the cognitive functioning of children exposed in utero or as infants were inconsistent and suggested that any plans for continued monitoring of their health should include neurocognitive and psychological measures as well as indicators of social and occupational functioning. This cohort is now in their early 30s. No new light has been shed on this highly contentious issue. We maintain that the most reliable, direct and transparent evidence points to no significant impact of (low-level) radiation exposure on this cohort. However, we continue to advocate for a long-term study of the biopsychosocial and neuropsychiatric wellbeing of this cohort compared to demographically similar controls. This is particularly critical because early childhood exposure to major stress, which many of these children experienced as a result of their mothers' and physicians' concerns about their health and life expectancy, is a well-established risk factor for adult onset psychopathology. It is also imperative that such a long-term study be conducted collaboratively by international experts and local scientists, as was the case in our own research, and that dissemination of study findings be done by local authorities entrusted with the welfare of the population. It is unfortunate that not a single Chernobyl related mental health intervention trial has been published. On the other hand, it is important to emphasize that the majority of people we and others have studied in relation to Chernobyl did not have a psychiatric diagnosis or elevated psychiatric symptomatology. Indeed, what has been missing from past research is an emphasis on understanding resilience. The importance of identifying and treating psychologically vulnerable individuals after disasters is incontrovertible. However, it is equally important not to overstate the effect, as this may further contribute to a culture of victimhood. There is growing concern in Ukraine about the neuropsychiatric effects of the war on the Eastern border on combat personnel. It is important to determine if rates of PTSD in this personnel (particularly among combat soldiers who are the children of liquidators and the in utero Chernobyl exposed cohort raised in an atmosphere tainted by Chernobyl stress) are similar to those reported for other countries. International cooperation in a study of the long-term health and mental health effects of Chernobyl may not only be relevant to settling disagreements about the neurocognitive outcomes of exposed children generally, but may shed light on whether their early life exposure to stress is a risk factor for maladaptive response to extreme stress later in life. Johan M. Havenaar1, Evelyn J. Bromet2, Semyon Gluzman3 1North Coast Area Health Service, Lismore, Australia; 2Departments of Psychiatry and Preventive Medicine, Stony Brook University, Stony Brook, NY, USA; 3Ukrainian Psychiatric Association, Kiev, Ukraine