Mental health support for healthcare workers after the Great East Japan Earthquake: Five years on

March 11, 2016 will mark the fifth anniversary of the Great East Japan Earthquake (GEJE), an unprecedented and disastrous combination of earthquake, tsunami, and Fukushima nuclear disaster. The 9.0 magnitude earthquake recorded a maximum intensity level (7 on the Japan Meteorological Agency seismic intensity scale) in Honshu, Japan's largest island. The earthquake was so powerful that more than 5,000 aftershocks occurred in the following year; it moved Honshu 2.4 meters east, and shifted the Earth on its axis by about 10-25 cm. Subsequent tsunami waves were as high as 40 meters in the hardest hit areas (World Health Organization, 2012). More than 18,000 people either died or are still missing, and the number of evacuees as of October 2015 was 191,000 (Reconstruction Agency, 2015). As well as physical and financial effects, this disaster had a profound psychosocial impact on those affected. A vast majority was resilient and recovered from their horrendous experiences. Internationally, people remarked on the fortitude of the Japanese people: instead of chaos there was civility and calm as people waited in turn for water and food. Across Japan there was voluntary self-restraint as people conserved electricity by turning off lights, elevators, and heaters to combat shortages created by the loss of the nuclear plants (Belson & Onishi, 2011). For a small number of individuals, however, effects have persisted in the form of mental disorders (e.g. posttraumatic stress disorder [PTSD], depression, or anxiety disorders), increased alcohol use, or suicide– consequences strongly associated with socioeconomic factors, such as financial, housing, employment, and education issues (Harada et al., 2015). The impact of the disaster was particularly heightened among vulnerable populations, such as evacuees, children, older people, and those with preexisting physical or mental disorders (Yamashita & Shigemura, 2013; Kukihara et al., 2014; Harada et al., 2015; Inoue et al., 2015). The Fukushima Daiichi nuclear disaster has represented an extensive challenge to residents. It resulted in the nuclear meltdown of the reactor, radioactive material release, mandatory evacuation, and continuing social disruption. This accident was the second worst nuclear power plant disaster since the 1986 Chernobyl disaster, although Fukushima's radiation level was substantially lower than Chernobyl's (Steinhauser et al., 2014). The United Nations Scientific Committee on the Effects of Atomic Radiation report (2013) concluded that radiation doses affecting Fukushima's general public are generally low or very low, and no discernible increased incidence of radiation-related health effects is expected. These reports, however, are not always helpful in mitigating residents’ distress. In nuclear disasters, some people become preoccupied with their health and have medically unexplained physical symptoms (Bromet et al., 2009). Radioactive materials are not perceptible, and cause considerable fear and uncertainty. People are not sure of what to drink and eat, where to stay, what to avoid, and who to trust or believe. Some attribute physical changes to radiation exposure, without concrete evidence. The Fukushima disaster also showed that affected people are potential targets of scapegoating, discrimination, and stigmatization (Shigemura et al., 2012; Tone & Stone, 2014; Hasegawa et al., 2015), as occurred with the survivors of the Hiroshima and Nagasaki atomic bombs and the Chernobyl disaster (Honda et al., 2002; Asukai et al., 2012; Bromet, 2012). Research has highlighted the psychological burden of disaster support workers. They potentially risk their own safety to fight against threats, visible or invisible. They strive to search, rescue, and support the affected for recovery, restoration, and revival. Support workers are exposed to overwhelming stressors and are, thus, susceptible to vicarious trauma (cumulative psychological effects of working with the survivors of traumatic events) or secondary traumatic stress (the stress stemming from helping a traumatized individual) (Palm et al., 2004; Creamer & Liddle, 2005). Among the disaster workers of the September 11, 2001 World Trade Center attacks, overall PTSD symptom prevalence was remarkably high at 12.4% (Perrin et al., 2007). During the GEJE, disaster workers were tested by challenges. Disaster workers of all kinds were affected by work-related stressors, as well as extreme work overload (Fukasawa et al., 2015; Sakuma et al., 2015). On top of that, many were also disaster victims, and struggled with their conflicting roles (Sato et al., 2015). Mental health effects were reported among various professionals, such as defense personnel (Dobashi et al., 2014), nuclear power plant workers (Shigemura et al., 2012), government workers (Fukasawa et al., 2015), and healthcare workers (Matsuoka et al., 2012), including nurses, public health nurses, and medical volunteers (Harada et al., 2014; Yokoyama et al., 2014; Sato et al., 2015). Many GEJE healthcare worker studies demonstrate their overwhelming stressors and struggles. Immediately after the disaster, Disaster Medical Assistance Team (DMAT) personnel were dispatched from all over the country to the affected area. Among 424 DMAT workers one month post-disaster, the proportions of people with probable psychological distress and depression were 4.0% and 21.4% respectively, and concern over radiation exposure was associated with adverse outcomes (Matsuoka et al., 2012). In a study of 1,294 Miyagi workers 14 months after the disaster, medical workers (along with municipality workers) showed higher rates of probable mental health symptoms than firefighters; their mental health outcomes were associated with lack of rest (Sakuma et al., 2015). Every disaster is different. Mother Nature will affect us in abrupt, unpredictable, and uncontrollable ways. Novel technologies are evolving, as are novel threats. We cannot totally predict future events, but we still need to be prepared for a wide range of disasters. Education and training for various scenarios will be essential to mitigate the subsequent chaos. Disaster studies are not easy to conduct. Given their sudden nature, there are always limits to conducting rigorous research studies with pre-disaster controls or randomized samples. For mental health studies, we tend to focus on the impact of the disaster itself, but also need to take into account the confounders of socioeconomic factors, as well as daily life stressors before, during, and after a disaster. Emerging studies of the GEJE help us to teach lessons on how to reduce the health impact on various populations; in particular, we are learning much about the psychological impact on ourselves, the healthcare workers. These findings will be helpful in future to learn how to mitigate and cope with the enormous stress that disaster work imposes. Education and training programs will benefit if they include psychosocial support elements for healthcare workers, as well as for those affected. In order to achieve this, we need to think about our mental health support systems, not only in times of disaster, but in everyday practice. The authors are grateful to Professor Teresa Stone (Yamaguchi University Graduate School of Medicine) for her valuable suggestions on our initial draft.