As of the end of October 2011, seven months after the Great Eastern Japan Earthquake, the number of lives lost has reached 19 515 (15 829 confirmed dead and 3686 missing). Miyagi Prefecture recorded the greatest loss of life (11 501 dead or missing), followed by Iwate Prefecture (6106) and Fukushima Prefecture (1874). There are still 71 578 people who cannot return to their homes, and most of the shelters (735 were operated at peak period) have been closed. Only four shelters in Kesennuma City (Miyagi) and two in Minami-Sohma City (Fukushima) are still open. In terms of the loss of life, the Great Eastern Japan Earthquake is the third largest natural disaster in modern Japanese history since Meiji Restoration. It is sad to note that this same area was also the site of the second largest natural disaster in recent Japanese history (Meiji-Sanriku Earthquake, 1896) (Table 1). The Japanese Psychogeriatric Society and the editors of Psychogeriatrics express our most sincere condolences to the people who have suffered as a result of the Great Eastern Japan Earthquake.
Table 1. Natural disasters in Japan in the post-Meiji Era (1868–2010)
n.a. not applicable.
1 September 1853
15 June 1896
28 October 1891
17 January 1995
26–27 September 1959
A massive 9.0-magnitude earthquake, the fourth largest earthquake in the world in 100 years, struck the Tohoku area, in northern Japan, at 14:46 (JST) Friday, 11 March 2011. It caused serious damage to buildings and houses in a wide area. The earthquake occurred in the 200 × 500 km2 area along Tohoku's Pacific coast and was followed by a devastating tsunami. The massive tides, which reached 7–15 m in height, wiped out houses, bridges and buildings – everything in its path. Water from the tsunami reached 5 km inland and destroyed all infrastructure along the Pacific coast of Tohoku, including Iwate, Miyagi and Fukushima prefectures. More than 60 000 people were affected by tsunami, and 111 000 houses were destroyed, forcing 133 719 people into a mere 735 shelters. The massive quake and subsequent tsunami were of the extreme variety that occurs once every several hundred years, but for people in the region, it only marked the beginning of the tragedy (Tables 2,3).
Table 2. Population affected by the Great Eastern Japan Earthquake
Number of shelters
People in shelters
Number of people affected by tsunami
1 330 147
2 348 165
2 029 064
Table 3. Comparison of death rates per age group after the Great Eastern Japan Earthquake and the Hanshin-Awaji Earthquake
Area (km2) flooded by tsunami
Number of houses
Affected by flood
The earthquake and tsunami hit the Fukushima I Nuclear Power Plant with unbridled ferocity. When the earthquake occurred, the reactors for units 1, 2 and 3 were in operation, and those for units 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 intended. However, fuel rods continued to give off extreme heat for a long time, which caused the coolant water inside the reactor to boil and increased the risk that the reactor would boil dry. The emergency core cooling system circulates water inside the reactor using electric power from sources other than the nuclear power plant itself. However, in the Unit 1 reactor, power generators for operating the emergency core cooling system broke down, and 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 to melt. The melted alloy caused a chemical reaction with the water and led to a discharge of hydrogen, causing the Unit 1 reactor walls to explode on Saturday, 12 March at 15:36. A hydrogen explosion occurred in the Unit 3 reactor on Monday, 14 March at 11:01. Then, on Tuesday morning, 15 March at 6:00, there was an accident at the Unit 2 reactor in which the pressure-control room appeared to have been damaged. It was feared that exposure of the fuel rods to the air sparked a fire that led radioactive material to leak, though it was contained therein. Meanwhile, water used to cool spent fuel rods in the Unit 4 reactor could no longer be circulated because of the loss of power, and an explosion occurred at this reactor. To avoid exposure to radioactive material, the government issued an evacuation order to people within a 20-km radius of the Fukushima I Nuclear Power Plant. The people living in a 20–30-km radius of the nuclear plant were ordered to stay inside to avoid possible exposure to radioactive materials.
Many professionals responded promptly to help people in the affected area immediately after the earthquake. Within a few days, many medical teams, including psychiatric specialists, were dispatched to the region. The Japanese Society of Psychiatry and Neurology and the Japanese Psychogeriatric Society actively participated in volunteer efforts by collecting and distributing information and sending mental health teams.1,2
GEOGRAPHICAL DISTRIBUTION OF VICTIMS
Most earthquake victims were located in Iwate, Miyagi, or Fukushima prefectures along the Pacific coast of the Tohoku area. In fact, 99.6% of those affected were from these prefectures. The distribution of victims by municipality (i.e. city, town or village) makes it clear that majority of dead or missing people were from along the Pacific Ocean, indicating that the tsunami was likely the cause of their demise. There are 37 municipalities facing the coast line in these three prefectures, and 99.3% of victims were from these cities, towns and villages. Figure 1 show the distribution of victims in Iwate, Miyagi, and Fukushima prefectures by local municipal community, and it is clear that most victims were located in communities facing the Pacific coast.
On 17 January 1995, the 7.3-magnitude Great Hanshin Earthquake struck the city of Kobe (Hyogo Prefecture), causing 6434 deaths and leaving 310 000 people homeless. Since this earthquake directly hit one of Japan's megalopolises, buildings and infrastructure were destroyed, and city life was paralyzed. There have been many research papers published discussing the psychological impact on those affected by this quake; these have advised on the necessity of having emergency mental health services in place for victims.3–12
The death toll in Kobe alone from the Hanshin-Awaji Earthquake, also known as the Great Hanshin Earthquake, was 4573, which was 0.31% of the city's population. After the Great Eastern Japan Earthquake, the mortality rate was higher than 0.31% in 24 out of 37 coastal communities. The highest ratio, 10.5%, was recorded in Otsuchi-cho (Iwate), followed by 9.3% in Onagawa-cho (Miyagi) and 8.7% in Rikuzentakata-shi (Iwate). These figures clearly demonstrate that the earthquake-triggered tsunami unleashed merciless violence.
AGE DISTRIBUTION OF THE VICTIMS
When the distribution of the victims is plotted according to age, it is clear that elderly people age 60 years and older were more affected than the younger generations (Fig. 2). Overall, 63.1% of victims were 60 years and older, and more specifically, 44.7% were 70 years and older. From experience, we know that natural disasters disproportionately kill weaker individuals, including the elderly, children, or handicapped. This trend was repeated during the Great Eastern Japan Earthquake.
As the tsunami was the primary cause of death after the Great Eastern Japan Earthquake, it is interesting to compare the age distribution of victims with that of the Hanshin-Awaji Earthquake. Figure 3 shows the age distribution of the deceased from both earthquakes. As in the 2011 earthquake, elderly people were disproportionately affected by the Hanshin-Awaji Earthquake, but this uneven distribution is more prominent in the Great Eastern Japan Earthquake. Elderly people were more likely to be killed and missing in the wake of the tsunami than younger people.
MEDICAL RESOURCES IN IWATE, MIYAGI AND FUKUSHIMA
Generally speaking, the younger generations tend to live in metropolitan areas, and most of the Tohoku area, including Iwate, Miyagi and Fukushima, has experienced dwindling populations, except in the large cities. The population of these three prefectures has been gradually decreasing since at least 1980; Iwate Prefecture started losing its population in 1980, Fukushima in 1995 and Miyagi in 2000. At the same time, the local population structure has aged. As shown in Table 4, the ratio of elderly people in the Tohoku area is higher than the national average (20.0%), especially in Iwate (25.6%) and Fukushima (23.4%). The per capita number of medical doctors, general hospitals, clinics is below the national average. However, the number of psychiatric hospitals, psychiatric beds, and nursing homes in the region is slightly higher than the national average (Table 4).
Table 4. Distribution of medical services in the Tohoku area and all of Japan
Ratio of elderly (≥65) population
Number of doctors (per 100 000)
Number of general hospitals (per 100 000)
Number of clinics (per 100 000)
Number of psychiatric hospitals (per 100 000)
Number of psychiatric beds (per 100 000)
Nursing homes (per 100 000)
1 330 530
2 594 (194.9)
2 347 975
5 106 (217.5)
1 580 (67.3)
2 028 752
3 905 (192.5)
1 468 (72.4)
128 057 352
286 699 (223.9)
99 083 (77.4)
Unfortunately, 11 out of 380 hospitals in Iwate, Miyagi and Fukushima prefectures were totally destroyed by the earthquake, and another 289 hospitals were partially damaged. This rendered 45 hospitals incapable of taking outpatients and 84 hospitals incapable of admitting inpatients.
Before the disaster, there was already a shortage of medical resources in this area. The earthquake has radically aggravated this situation.
UNMET NEED FOR MENTAL HEALTH CARE OF THE ELDERLY
In the early period after the disaster, inpatients from psychiatric hospitals and nursing homes that were no longer functional were transferred to adequate institutions in nearby prefectures.
Volunteer teams sent to the affected area have reported some of their findings. Most mental health teams were sent to temporary shelters where many families were forced to live together. Most of these families are helping each other to create some level of normalcy in daily life, but the elderly have not been well integrated into these communities.
Many of the elderly are in a fragile physical and/or mental condition. They are slow to respond to any changes. Even though the elderly are good at maintaining routine activity, they are sometimes resistant to changes in their lifestyle. When they were moved to shelters, many elderly lost stable cognitive function, which has made independent life in shelters difficult, especially for those with behavioural and psychological symptoms such as aggression, anxiety, depression or delusion. The elderly in shelters have shown some similarities with elderly in emergency rooms;13 antipsychotics could be prescribed to improve their conditions.14 However, environmental adjustment and proper psychotherapy seem to work better than medication. For many elderly used to independent living, simple guidance and advice is enough to help them better adjust to their new environment.
Seven months after the disaster, many people moved into temporary houses built by the government and began their new lives. Some elderly were again forced to change their living environments, which may cause difficulty in maintaining their daily routines.15 Psychogeriatric professionals have abundant experience in taking care of unstable elderly people,16,17 and it is time for us to help those in the affected areas to ensure that the elderly can function in their daily lives.