Mental health care and East Japan Great Earthquake
THE JAPANESE SOCIETY of Psychiatry and Neurology (JSPN) and the editors of Psychiatry and Clinical Neurosciences (PCN) would like to express our sincere condolences to the people who have suffered from the East Japan Great Earthquake (the Tohoku–Pacific Ocean Earthquake) 3.11.
A massive 9.0-magnitude earthquake occurred in the Pacific Ocean nearby Northeastern Japan, Friday March 11, 2011 at 14:46 (JST), causing serious damage to almost all of the Tohoku area and part of the Kanto area. The Tohoku area is the northern part of Japan including Fukushima, Miyagi, Iwate, Aomori, Akita and Yamagata prefectures. Kanto is the governmental and commercial center of Japan including Tokyo and Yokohama, together with seven prefectures. The cities damaged by the earthquake are Iwaki, Minamisohma, Sohma, Iwanuma, Natori, Sendai, Higashiatsushima, Ishinomaki, Kesennuma, Rikuzentakada, Ofunato, Kamaishi, Miyako, Kuze, and Hachinohe, all of which face the Pacific Ocean coast of Tohoku. Even in Tokyo, some modern buildings have cracks in walls, and skyscrapers trembled for several minutes, which was enough to terrify people working and living in this area. However, it was only a prelude to the merciless disaster by natural threat following the quake.
People living in the Tohoku and Kanto areas suffered from frequent aftershocks several times a day in the following days. Though the magnitude of each aftershock was smaller than the main quake, they were high enough to cause survivors to feel frightened and terrified in the blackouts and cold winter weather in the affected areas.
The earthquake triggered in the 200 × 500-km area along the Pacific coast of Tohoku, and the tsunami was the next disaster. Just after the earthquake, the tsunami was forecasted and the tsunami warning was issued by the authorities, giving the order to evacuate. The power of natural disaster was, however, beyond our imagination. The massive tides of 7–15 m in height wiped out houses, bridges, buildings and everything else. The tsunami water went 5 km inland destroying all infrastructure for living.
Japan has experienced frequent earthquakes because it is located above the intersection of the four earth plates. Japan should have been well prepared with advanced technology for earthquake forecast and prevention system and many know-hows against earthquakes and tsunami; in fact, ‘tsunami’ has become the global term, originating from the Japanese language, meaning high tides.
, Epicenters of Tohoku-Kanto Earthquake; , Inner circle: evacuation area (within 20 km radius); outer circle: stay indoors area (within 30 km radius).
The East Japan Great Earthquake is the fourth largest earthquake recorded in the world since 1900, after the Temuco-Valdivia, the Chile earthquake (22 May 1960; M9.5, 1655 deaths); the Prince William Sound, Alaska earthquake (28 March 1964; M9.2, 131 deaths); and the earthquake off the West Coast of Northern Sumatra, Indonesia (26 December 2004; M9.1, 227 898 deaths) (Table 1). The death toll is now 12 259 and will inevitably climb higher as the recovery of bodies in tsunami-hit coastal areas goes into full swing. A total of 15 315 are still missing and about 530 000 people are staying in more than 2600 temporary shelters.
Table 1. Significant earthquakes with over 50,000 deaths since 1900
| 1. 1976 07 27||Tangshan, China (39.6N 118.0E)||255,000||7.5|
| 2. 2004 12 26||Sumatra (3.30N 95.87E)||227,898||9.1|
| 3. 2010 01 12||Haiti region (18.445 -72.571)||222,570||7.0|
| 4. 1920 12 16||Haiyuan, Ningxia, China (36.5N 105.7E)||200,000||7.8|
| 5. 1923 09 01||Kanto, Japan (35.3N 139.5E)||142,800||7.9|
| 6. 1948 10 05||Ashgabat, Turkmenistan (37.95N 58.32E)||110,000||7.3|
| 7. 2008 05 12||Eastern Sichuan, China (31.002 103.322)||87,587||7.9|
| 8. 2005 10 08||Pakistan (34.53N 73.58E)||86,000||7.6|
| 9. 1908 12 28||Messina, Italy (38.15N 15.68E)||72,000||7.2|
|10. 1970 05 31||Chimbote, Peru (9.36S 78.87W)||70,000||7.9|
DAMAGE TO THE NUCLEAR POWER PLANT
The East Japan Great Earthquake and the following tsunami hit Fukushima No. 1 nuclear power station with unbridled ferocity. When the earthquake occurred, reactors 1, 2, and 3 were in operation, and Nos. 4, 5, and 6 were at rest for regular maintenance. Immediately after the huge tremor, the control rods were automatically deployed and the reactors were successfully stopped as scheduled. However, fuel rods continued to give off extreme heat for a long time, even after reactors have ceased operating, which caused the coolant water inside the reactor to boil, leading to the risk of the reactor boiling dry. The emergency core cooling system (ECCS) is designed and implemented to prevent this from occurring. The system circulates water inside the reactor using electric power from sources other than the nuclear power plant itself, and also features a doughnut-shaped structure called a suppression pool, to cool high-pressure steam into water. Spent fuel rods removed from reactors need to be kept permanently cooled with circulating water. However, in the Fukushima No. 1 plant, power generators for operating the ECCS broke down. Although the generators were designed to keep operating even after very strong tremors, the tsunami was of a scale beyond anticipation, and might have thrown seawater on the generators.
The temperature began to rise rapidly inside the reactor, which had lost its coolant functions. As a result, the metal tubes containing the fuel rods began melting down. In addition, the melted alloy caused a chemical reaction with the water, leading to a discharge of hydrogen, which caused the explosions of the No. 1 reactor building walls on Saturday, March 12, 15:36. A hydrogen explosion also occurred with reactor No. 3 on Monday, March 14, 11:01. In the damaged reactors, the temperature continued to rise and a huge quantity of coolant water evaporated, leading to the risk that the exposed parts of the fuel rods above the water may melt. Although Tokyo Electric Power Co. workers poured seawater into the reactors using pump vehicles, the operation did not go smoothly due to the fear of contamination from radioactive material.
Then, on Tuesday morning, March 15, 6:00, there was an accident at the No. 2 reactor in which the pressure-control room appeared to have been damaged. It is feared that exposure of the fuel rods to the air sparked a fire that led to leakage of the radioactive material contained therein. Meanwhile, water used to cool spent fuel rods in the No. 4 reactor could no longer be circulated due to the loss of power, and an explosion occurred at reactor No. 4 simultaneously.
To avoid exposure to radioactive material, the government issued an evacuation order to the people within a radius of 20 km of the Fukushima Daiichi Nuclear plant. The people living in a 20–30 km radius of the nuclear plant, were ordered to stay inside in order to avoid possible exposure to radioactive materials. The basic principle of a nuclear power accident is to stop, to cool down and to close in any leakage of radioactive materials. Even though the first step was successfully done, the second and even third tactics were not effective in the case of the Fukushima No. 1 Nuclear power plant.
JSPN ACTIVITY IN MENTAL HEALTH CARE
The news of the Great Earthquake spread across Japan and to the world in a few hours. Considering the magnitude of the quake and the wide area affected by the tsunami, it was almost certain that this would become one of the most serious natural disasters in the history of Japan. All Japanese TV channels broadcast news on the quake 24 hours for several days. Many rescue teams were sent to the affected areas trying to save and help as many human lives as possible. It is well known that 72 hours after the quake the possibility of survival would be drastically reduced and prompt rescue activity was essential. Fire departments, police departments together with the Japanese Self Defense Forces, the US Navy and many volunteer rescue teams from all over the world were called in to the affected area. The Japanese Society of Psychiatry and Neurology (JSPN), the academic association of over 16 000 psychiatrists, responded to the disaster promptly by trying to collect necessary information and arrange any required actions to help people in the affected area. JSPN uploaded a message to its homepage for the victims in the Tohoku-Kanto area on March 15 and started to offer volunteer work for mental health care.
The Message from the President of JSPN, Haruo Kashima, conveyed his condolences to the victims and expressed his willingness to help people in the affected area:1
March 15, 2011
The Tohoku–Pacific Ocean Earthquake and Tsunami:
A message from the Japanese Society of Psychiatry and Neurology
The Japanese Society of Psychiatry and Neurology would like to take this opportunity to express its condolences for the unimaginable losses endured by all those affected by the Tohoku–Pacific Ocean Earthquake and Tsunami.
We are certain that people are struggling to deal with all the thoughts and feelings resulting from this disaster, at the same time as they work to cope with its impact. For its part, the Japanese Society of Psychiatry and Neurology will do everything in its power to support all persons affected by this tragedy.
Given the harsh conditions faced by survivors, there are doubtless persons who will feel overwhelmed by their emotions, and that their hearts will break under the strain. However, we have no doubt that, with time, it is possible to persevere and pull through this difficult period.
After a disaster, people often talk about ‘psychological care.’ As mental health professionals, we define this word as 1) mental health service, in which proper mental health services and psychiatric care are provided as needed, and 2) psychosocial support, in which wider caring effort should be provided by offering practical help without relying on specific counseling discipline. This refers to the act of organizing comprehensive support for both physical and daily life needs, while keeping an eye on people's steps toward recovery. We value the strength of communal support and help by people from other areas. We will strive to work with local authorities and other organizations involved to provide easily accessible mental health service and psychosocial care, and will do this in a way that does not hinder survivors' journey toward recovery.
In challenging times, it is common to increase one's intake of things like alcohol, tobacco, and caffeine (coffee, tea, green tea, etc.), but it is important to be aware that these substances can also trigger anxiety and insomnia. People may experience difficultly in recognizing how tired they are, or expressing how they truly feel; they may also feel frustrated or suddenly agitated. It has been established that these symptoms naturally improve on their own, in most cases. But if they persist for several days, or if they are troubling, we urge people to consult a health care professional. We also believe that special attention must be paid to the needs of those persons who, while enduring their own personal losses, are participating in relief and recovery efforts.
Finally, in circumstances such as these, we often see the spread of gossip and unfounded rumors, which can end up causing even greater anxiety for people already struggling to deal with the impact of a disaster. We call on all health care workers participating in relief efforts to confirm the source and reliability of information they may disseminate.
The Japanese Society of Psychiatry and Neurology
MENTAL HEALTH CARE IN DISASTER
Recent disasters due to earthquakes include the Haiti earthquake (12 January 2010, M7.0) in which more than 222 570 were killed and 300 000 injured. The Eastern Sichuan earthquake (12 May 2008, M7.9) was another disaster in China with 69 195 killed and 374 177 injured. At least 15 million people were evacuated from their homes and more than 5 million were left homeless. Reports of the Haiti2–4 and Sichuan earthquakes5–8 from mental health view points are all instructive in figuring out the tactics for the East Japan Great Earthquake.
Earthquakes are relatively frequent in Japan and some of them have been serious enough to cause damage to human life for several months. The most recent disaster caused by earthquake is the Hanshin-Awaji (Kobe) Earthquake (16 January 1995, M6.9), which caused 5502 deaths, with 36 896 injured. About 310 000 people were evacuated to temporary shelters. Over 200 000 buildings were damaged or destroyed. Numerous fires, gas and water main breaks and power outages caused severe damage to lifelines of city life. Owing to the long-lasting effects to the mental health of the victims, may reports by mental health professionals have been published.9–18 The JSPN organized a special symposium on mental health of Hanshin-Awaji Earthquake on May 17, 1995, 4 months after the disaster.9
Other earthquake disasters in the central part of Japan, the Niigata-Chuetsu Earthquake (23 October 2004, M6.8),19–21 the Noto Peninsula Earthquake,22 and the Hokkaido Earthquake23 were studied and reported on their effects to mental health for many years. Other disasters caused by floods,24 massive traffic accidents,25,26 and the Ehimemaru accident, in which a Japanese high school training ship was hit and sunk by a collision with a US Navy submarine,27 were also studied and analyzed from psychiatric view points.
All reports pointed out the common findings that weaker people, like the elderly, children, and the mentally handicapped, tend to become the first victims of the disaster. Under the critical situations, mentally handicapped people have less chance of being helped, and sometimes they are the first to be neglected under circumstances. The East Japan Great Earthquake might be no exception.
Japan's relatively large elderly population presents a particular challenge for rescue and relief in what is already a disaster of epic proportions. About 23 percent of Japan's 127 million people are age 65 or over28 and the psychiatry emergency system for the elderly has been under discussion for many years.29 Japan's rural areas have been in decline for years, and many of the small coastal towns hit hardest by the tsunami had seen an exodus of young people moving to cities for work. At least 11 men and women perished inside a retirement home in Kesennuma, where they faced freezing temperatures for 6 days. Elderly dementia patients in a temporary shelter readlily show behavioral and psychological symptoms due to insufficient care and a stressful living situation.30–33 Fourteen senior citizens died after being moved to a temporary shelter in a school gym because their hospital was in the evacuation zone near the damaged Fukushima nuclear power plant.
Some psychiatric hospitals and nursing homes for the elderly are located in the suburbs of the city or in small towns that are relatively isolated by public transportation. Some psychiatric hospitals affected by the tsunami were severely damaged and in-patients had to be transferred to other psychiatric hospitals. Many schizophrenic and depressive patients who are under medication lost their drugs due to the disaster and they could easily relapse due to the abrupt discontinuation of the medication. They are vulnerable to various stresses in temporary shelters.
Children in shelters are apparently cheerful, but it can be easily speculated that the unusual living situation may cause burden to them. Many survivors experienced observing the disaster of the tsunami wiping out everything, and those extraordinary experiences will surely cause trauma in many children who survived this disaster. Those affected children should be monitored closely for the possible occurrence of post-traumatic stress disorder,34–36 according to their gender,37 temperaments,38 resilience,39 or physiological parameters.40
The effect of the East Japan Earthquake will not terminate within months. Psychiatric services will be absolutely essential for longer term than the medical services for physical diseases. The JSPN, Japanese Association of Psychiatric Hospitals, and departments of psychiatry in medical schools are sending psychiatric service teams to the affected areas in coordination with psychiatry departments of Tohoku University, Fukushima Medical College, and Iwate Medical College, which are located in the middle of the affected area. A long-term program to support those weak people in the affected area should be implemented and kept functioning over the coming years to secure the mental health of the people in the affected area.