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Delayed recovery of caregivers from social dysfunction and psychological distress after the Great East Japan Earthquake
Journal of Affective Disorders 148 (2013) 413–417
Contents lists available at SciVerse ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Preliminary communication
Delayed recovery of caregivers from social dysfunction and psychological distress after the Great East Japan Earthquake Minoru Sawa a,b,n, Yoneatsu Osaki b, Hiraki Koishikawa a a b
Department of Psychiatry, Kameda Medical Center, Japan Division of Environmental and Preventive Medicine, Department of Social Medicine, Faculty of Medicine, Tottori University, Japan
a r t i c l e i n f o
abstract
Article history: Received 26 October 2012 Accepted 7 November 2012 Available online 20 December 2012
Background: In April 2011, two hundred and eighty residents who were suffering from intellectual disabilities and their eighty caregivers at nine facilities in Fukushima were evacuated and moved to Chiba, Japan after the Great East Japan Earthquake. We investigated the impact of the evacuation after the earthquake on the caregiver burden. Method: There were 41 participants from Chiba as a reference group and 32 participants from Fukushima as a case group included. Data were collected regarding their demographics and the General Health Questionnaires 12 (GHQ-12) score for both groups in two different points. Results: The evacuation was linked to a follow-up GHQ-12 global score Z 3 (RR ¼ 4.52, 95%CI; 1.32– 15.47). There was no significant improvement of the GHQ-12 global score in the case group from Fukushima for the follow-up data compared to the baseline data. Social dysfunction had continued in the case group from the baseline data (po 0.01) during the follow-up period (po 0.001). A statistically significant difference was noted for the case group from Fukushima regarding psychological distress in the follow-up data (po 0.01), which was not found in the baseline data (p¼ 0.07). Limitations: The sample size was limited to a non-randomized and unmasked sample of 73 patients. No causal relationship could be determined due to the cross-sectional nature of the study. Conclusions: The caregivers from Fukushima exhibited more psychiatric morbidity, which persisted for the duration of their evacuation after the earthquake. It is important to provide long-term support for such caregivers who have been evacuated after a major disaster. & 2012 Elsevier B.V. All rights reserved.
Keywords: Caregiver burden Earthquake Evacuation Psychological distress Social dysfunction
1. Introduction The Great East Japan Earthquake occurred on March 11, 2011. The magnitude was 9.0, which made it the most powerful earthquake on record in Japan. The source zone boundary extended 450 km north and south, and 200 km east and west. The height of the tsunami produced due to this earthquake was more than 10 m, and in some cases was over 40 m high. The earthquake and the tsunami resulted in immense damage in the Tohoku and Kanto areas, and also led to widespread radiation contamination due to the accident at the Fukushima-Daiichi nuclear plant. According to the report from the National Police Agency, there were 15,866 confirmed deaths, 2946 people missing, and 6108 injured as of June 25, 2012. The earthquake and the following tsunami had also inflicted enormous structural damages on houses, businesses and other buildings. The extent of the damage is still uncertain because n Corresponding author at: Department of Psychiatry, Kameda Medical Center 929 Higashicho Kamogawa, Chiba 296-8602, Japan. Tel.: þ 81 4 7092 2211; fax: þ 81 4 7099 1198. E-mail address: [email protected] (M. Sawa).
0165-0327/$ - see front matter & 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jad.2012.11.011
some areas have remained submerged due to the tsunami. The National Police Agency confirmed on June 25, 2012 that there had been 130,436 complete building collapses (20,659 in Fukushima) and 262,975 partial collapses (69,104 in Fukushima). Due to this damage and the subsequent accident at the Fukushima-Daiichi nuclear plant, many people had to leave their original houses and had to evacuate to other places. Because of this damage, 280 residents who were suffering from mental retardation and their 80 caregivers at nine facilities in Fukushima were evacuated and moved to Kamogawa, Chiba, Japan in April 2011. There were about 14,636 mentally retarded patients (1168 patients in Soso area where there was the major area of the nuclear evacuation zone) and 46 facilities (seven facilities in Soso area) for those patients in Fukushima in total before the earthquake. A total of approximately 1300 caregivers (about 130 caregivers in Soso area) for those patients with mental retardation originally worked in Fukushima. Kamogawa is located about 300 km away from the FukushimaDaiichi nuclear plant. The residents and caregivers were moved to a facility which was originally intended for youth in Kamogawa, Chiba. At the beginning of February 2012, they were still staying in Kamogawa because it was difficult to find a suitable facility in
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M. Sawa et al. / Journal of Affective Disorders 148 (2013) 413–417
Fukushima. The caregivers were under high stress due to the lack of a plan for the future and the continuing separation from their families. We performed a cross-sectional study regarding the caregiver burden after the earthquake. According to the previous study, there was a statistically significant difference regarding the psychiatric morbidity for the caregivers from Fukushima due to evacuation. In this study, we sent out questionnaires to the caregivers from Fukushima, as well as to caregivers who were originally working at an equivalent facility in Chiba to perform a case-reference study. We herein report our investigation of the differences in the presence of psychiatric morbidity between the baseline data and the follow-up data in the caregivers who had been evacuated. We also discuss that long-term support should be provided for both the caregivers for disabled residents, as well as the residents themselves, in case such a disaster should occur in the future.
There were 46 participants from both groups. The response rate to the baseline questionnaires was 83% for the case group from Fukushima and 77% for the reference group from Chiba. Of these initial respondents, five participants dropped out from the reference group, and fourteen from the case group. Therefore, there were 41 remaining participants (24 males and 17 females) from the reference group from Chiba and 32 participants (17 males and 15 females) from the case group originally from Fukushima. The mean age was 39.68 in the reference group and 45.00 in the case group. The demographic characteristics of the participants are presented in Table 1. The study protocol was approved by the Kameda General Hospital Institutional Review Board (approval number; 11-062) and Tottori University Ethics Committee (approval number: 1879). Written informed consent was obtained from each participant after a complete description of the study was provided. 2.2. Statistical analysis
2. Methods The participant caregivers were all over the age of 20. As described above, there were nine facilities from Fukushima which we defined as the case group. We chose three facilities in Chiba as the reference group, which several psychiatrists independently determined equivalent level facilities for disabled persons with regard to the severity of mental retardation, social function and staff assignments in the facilities. 2.1. Data collection This was a case-reference follow-up study, in which the baseline data for the case group Fukushima were collected in August 2011, and the reference baseline data were collected by January 2012. We sent out the General Health Questionnaires 12 (GHQ-12), as well as additional questions about the participants’ gender, age, and years of employment (Jacob et al., 1997; Kilic et al.,1997; Hankins, 2008) to both groups through February 2012. The study participants were divided into two groups: the caregivers originally from Fukushima (the case group) and those originally from Chiba, defined as the reference group. Item scores were coded according to the GHQ method (all items coded 0-0-1-1) (Goldberg and Williams, 1988). The data were collected by the main researcher, who was a psychiatrist, and by co-researchers, who were psychiatrists and a nurse. A statistical analysis was performed with the assistance of a co-researcher who was an expert in clinical epidemiology.
Before analyzing the data in the present study, we performed a Mann–Whitney U test to confirm that there was no impact of the participants dropping out on the baseline data regarding the distribution of the GHQ-12 scores, which we used as the outcome of this study. All data were screened for normality, homogeneity of variance, and outliers. Categorical variables were compared using a chi-square test and Fisher’s exact test, and Student’s t test was used for continuous variables. We confirmed that the baseline GHQ-12 global score, follow-up GHQ-12 global score and the years of employment were not normally distributed. We performed a Mann–Whitney U test to examine the groups for differences in the GHQ-12 global scores, as well as the years of employment. We thereafter performed a Wilcoxon signed rank test to examine the differences between the baseline data and the follow-up data for both groups. Correlation coefficients were calculated for demographic variables (gender, age) and relevant clinical variables (the presence of evacuation, years of employment, the presence of a score Z3 for the baseline GHQ-12 global score, a score Z3 for the follow-up GHQ-12 global score, and a scoreZ 8 for the follow-up GHQ-12 global score). Variables with an absolute valueZ0.5 that exhibited a significant relationship between the various variables were considered to have a strong correlation. A strong correlation was observed in the baseline GHQ-12 global score and the follow-up GHQ-12 global score in this case. According to the previous study performed in Japan, we used 2/3 as the cut-off for the GHQ-12 global score and a score Z3 was considered to indicate psychiatric morbidity (Takusari et al., 2011). Furthermore, based on the recent study performed by Russ
Table 1 The distribution of the demographic and clinical characteristics of the participants from the reference (Chiba) and case (Fukushima) groups. Demographic and clinical characteristics
Gender Male Female Age (years) Baseline GHQ global score Follow-up GHQ global score Years of employment (years) Comparison of the baseline GHQ-12 global score with the follow-up GHQ-12 global score Follow-up GHQ-12 global scoreZ 8
Reference group (N ¼41)
Case group (N ¼ 32)
p value
N 24
% 58.5
N 17
% 53.1
17 Mean 39.68 3.49 3.32 9.90 p ¼ 0.72
41.5 SD 12.44 3.39 3.03 7.19
15 Mean 45.00 6.28 6.75 17.13 p ¼ 0.59
46.9 SD 11.67 4.45 3.82 12.94
3
7.3
16
50.0
p ¼0.64
p ¼0.07 p o0.01 p o0.001 p ¼0.04
Gender; Chi-square value¼0.21, degree of freedom ¼1. Age; two-sample t test. Baseline GHQ global score, follow-up GHQ global score, and years of employment; Mann– Whitney U test. Comparison of the baseline GHQ-12 global score with the follow-up GHQ-12 global score; Wilcoxon signed rank test.
M. Sawa et al. / Journal of Affective Disorders 148 (2013) 413–417
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et al. (2012), psychological distress is known to be associated with an increased risk of mortality. We considered that a higher GHQ-12 global score itself was problematic. A follow-up GHQ-12 global score Z8 was equal to the 75th percentile of the distribution, which we considered to be a more severe condition. The number and percentage of the participants with a follow-up GHQ-12 global score Z8 for each group is presented in Table 1. A logistic regression analysis was performed which consisted of the presence of a higher GHQ-12 global score as the dependent variable and gender, age, years of employment, and the presence of evacuation as the covariates. In the previous study of the general Japanese population, Doi and Minowa (2003) identified two major factors, psychological distress (items 2, 5, 6, 9, 10, and 11) and social dysfunction (items 1, 3, 4, 7, and 8) . We performed the Mann–Whitney U test to examine the groups for differences in the GHQ-12 integrate score for each of these factor items. Statistical significance was set at p o0.05. All tests were twosided, and all of the statistical analyses were conducted using the SPSS version 18.0 software program (SPSS Inc., Chicago, Illinois).
logistic regression analysis for the follow-up data. A scoreZ3 for the follow-up GHQ-12 global score was associated with the evacuation (RR¼4.52, 95%CI; 1.32–15.47). In addition, a score of Z8 for the follow-up GHQ-12 global score was associated with the evacuation (RR ¼13.57, 95%CI; 2.91–63.28). These results are presented in Table 2. According to Mann–Whitney U test, the social dysfunction persisted in the case group originally from Fukushima from the baseline survey (po0.01) through the follow-up evaluation (p o0.001). In contrast, a statistically significant difference emerged for the case group from Fukushima regarding psychological distress in the follow-up data (p o0.01), which was not found in the baseline data (p¼0.07), thus indicating that they were suffering from even greater distress than they were initially. These results are presented in Table 3.
3. Results
In this study, there was a statistically significant difference between the follow-up GHQ-12 global score based on whether patients had been evacuated. A higher follow-up GHQ-12 global score was linked to the evacuation after the disaster, which was not only a psychiatric problem but also increased the risk of mortality (Russ et al., 2012). No statistically significant difference was found in the case group originally from Fukushima between baseline and follow-up GHQ-12 global score, which means there was no improvement in the psychiatric morbidity with the passage of time after evacuation. This follow-up study showed that the social dysfunction was not resolved for the duration of their evacuation after the earthquake, and furthermore, there was even new psychological distress noted in the follow-up data for the caregivers from Fukushima.
We confirmed that there was no impact of the participants who dropped out with regard to the distribution of the baseline or follow-up GHQ-12 global score as determined by the Mann– Whitney U test in both of the groups. The mean values for the baseline GHQ-12 global scores were 3.49 for the reference group and 6.28 for the case group originally from Fukushima. The clinical characteristics of the participants are presented in Table 1. We performed Shapiro–Wilk tests to check for the normality of the continuous variables, including the patient age, years of employment, and baseline/follow-up GHQ-12 global scores. Only the participants’ age was normally distributed. A statistically significant difference was found for the caregivers from Fukushima, in that they had a higher baseline GHQ-12 global score (po0.01) as well as higher follow-up GHQ-12 global scores (p o0.001) in the Mann–Whitney U tests. According to the Wilcoxon signed rank test performed to examine the differences between the baseline data and the follow-up data for both groups, there was no statistically significant difference in either of the groups. The results from a logistic regression analysis indicated that the presence of evacuation (Relative Risk (RR)¼3.01, 95% Confidential Interval (CI); 0.95–9.53) did not produce a statistically significant relative risk for the presence of a score Z3 for the baseline GHQ-12 global score, but a trend was noted (p ¼0.06). We performed a similar
4. Discussion 4.1. The principal findings
4.2. Strengths and limitation of the study It is of great importance that statistically significant differences were found in the follow-up GHQ-12 global scores even in this small sample of participants based in the presence of evacuation. In particular, our findings indicate that social dysfunction has not only persisted but also that psychological distress has newly emerged for these caregivers evacuated from Fukushima. Previous studies have showed that the psychological stress continues for a long period after a large-scale disaster, such as an earthquake (Toyabe et al., 2006, 2007) therefore the result
Table 2 The results of the logistic regression analysis of the higher GHQ-12 global scores. Higher GHQ-12 global scores and covariates Model 1
Model 2
Model 3
Relative risk A baseline GHQ-12 global scoreZ 3 Age (every 1 year increase) Gender (female/male) The presence of evacuation (Cases/Reference group) Years of employment (every 1 year increase) A follow-up GHQ-12 global scoreZ 3 Age (every 1 year increase) Gender (female/male) The presence of evacuation (Cases/Reference group) Years of employment (every 1 year increase) A follow-up GHQ-12 global scoreZ 8 Age (every 1 year increase) Gender (female/male) The presence of evacuation (Cases/Reference group) Years of employment (every 1 year increase)
Model 1, Model 2 and Model 3; adjusted by age, gender, the presence of evacuation, and years of employment.
95% CI
p value
0.97 1.68 3.01 0.99
0.92–1.02 0.58–4.84 0.95–9.53 0.93–1.04
0.20 0.34 0.06 0.63
0.99 1.82 4.52 0.99
0.94–1.04 0.60–5.54 1.32–15.47 0.93–1.05
0.61 0.29 0.02 0.65
0.97 4.01 13.57 1.05
0.90–1.04 1.04–15.39 2.91–63.28 0.97–1.13
0.37 0.04 o 0.01 0.22
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Table 3 The results of the Mann–Whitney U tests of the differences in psychological distress and social dysfunction between the Case and Reference groups. GHQ-12 combination items
A baseline GHQ-12 Psychological distress (items 2, 5, 6, 9, 10, and 11) Social dysfunction (items 1, 3, 4, 7, and 8) A follow-up GHQ-12 Psychological distress (items 2, 5, 6, 9, 10, and 11) Social dysfunction (items 1, 3, 4, 7, and 8)
Reference group
case group
p value
Mean
SD
Mean
SD
2.27 0.93
2.24 1.29
3.34 2.22
2.39 2.04
0.07 o0.01
2.37 0.56
2.20 1.00
3.78 2.38
2.03 2.00
o0.01 o0.001
of this follow-up study are consistent with those of the previous studies. There are limitations to the methodology used in the present study that should be pointed out. First, the sample size was limited to a non-randomized and unmasked sample of 73 patients. Therefore, the results of the present study cannot be generalized beyond the sample. Second, no causal relationship could be determined due to the cross-sectional nature of the study. Although these limitations were present, we made efforts to investigate factors in two different points (baseline data and follow-up data), which would enable the possibility of a causal relationship to be assessed, so that temporary findings would not be misunderstood. 4.3. The important differences in the results in relation to other studies The previous studies have generally focused on the psychological distress of the general population, vulnerable victims (as described below) and the rescuers of those victims. For example, Toyabe et al. (2006) reported that the elderly exhibited impaired psychological recovery after the earthquake. Children, elderly or disabled persons are considered to be disaster victims (Takada et al., 1995). Raphael et al. (1991) reported that the rescuers of such victims experience a psychological response to disasters, and insisted that it is essential to provide support to them, as well as to the victims. The present study makes a unique and specific point that caregivers themselves were disaster victims, and like the general population, had difficulty in coping with unfamiliar circumstances after the immense disaster. The burden on the caregivers at nursing homes in Japan was already problematic before the disaster (Doi and Ogata, 2000; Furumura, 2011). Caregivers in Japan work for long hours with low pay, which leads to a shortage of such caregivers. After the disaster, the residents with mental retardation and their caregivers from Fukushima had to move to find a temporary shelter because the evacuated area was expanded due to the nuclear accident. This led to even more stress for the caregivers from Fukushima because the residents with mental retardation had poor adaptability to environmental change. The caregivers had to stay with the residents for a long period until suitable facilities in Fukushima, where their family lived, could be found. According to the previous study by Kuwabara et al. (2008), psychological distress was a significant problem immediately in the general Japanese population after the disaster, but was decreased by 5 months after the earthquake. They reported that some factors were associated with an impaired psychological recovery, such as being with unfamiliar people and living in a temporary shelter (Kuwabara et al., 2008). In this present case, the caregivers from Fukushima had to stay in temporary apartments, were separated from their families, and continued having to care for the residents who were suffering from intellectual
disabilities, who were often more difficult to care for because they were upset by the changes. In addition to these factors, some caregivers from Fukushima lost their houses and loved ones, had family members who had been injured, or had family members who were continuing to be exposed to the elevated level of radiation in Fukushima. The mentality of Japanese people might also have led to a delayed recovery because some of the caregivers from Fukushima reported that they felt guilty feeling if they left their professional position because it would lead to a shortage of manpower. 4.4. Significance of the study To provide an explanation of the implications of this study, we would like to present an actual episode related to the caregivers from Fukushima during the period of evacuation. Caregivers had less interaction after the evacuation from Fukushima. Soon after moving to Chiba, they tend to live by themselves after working and ate outside less frequently or enjoyed free time less frequently with other people. Some caregivers reported consuming more alcohol alone in their apartment than before. We had a meeting with middle-rank caregivers to allow them to regularly share the information regarding caregivers who were burned out. We encouraged those caregivers who were considered to have a risk of developing psychiatric disorders to come to the counseling office or hospital. We also provided information regarding typical issues related to daily living, such that which restaurant we recommended and where they could enjoy themselves near their apartment. Some caregivers came to our outpatient service but some had been resigned from their job. There was an accident which led to the death of a resident outside the evacuated facility. The caregivers from Fukushima presented with extreme exhaustion and some caregivers were critical of themselves. After this tragedy, caregivers tend to secure residents better. Some residents required environmental adjustment and were administered more psychotropic medications, which might not have been required if the residents had stayed in their original facilities in Fukushima. We considered reporting the increased incident/accident rate of residents after the evacuation. However, the criteria regarding how to classify incidents/ accidents might have been changed due to the emergency situation. Therefore, it was difficult to compare the rates due to the evacuation after the earthquake with their usual rate when they were in Fukushima. The possible explanations and implications of this study for clinicians and policymakers are that caregivers may have ambivalent feelings about staying with disabled persons. This is because they are worried about deciding to give their work priority over their family and friends. They feel guilty about leaving their job because it would result in a larger burden for the rest of the caregivers. It was also difficult for the caregivers to find an appropriate job near their family in Fukushima, as the facilities where such jobs are available were widely destroyed. These
M. Sawa et al. / Journal of Affective Disorders 148 (2013) 413–417
findings of the present study indicate that it is important to provide adequate long-term support not only to the disaster victims, such as children, elderly people, and disabled persons but also to their caregivers following such an immense disaster. This study was an observational study. Therefore, it still remains unclear how long the social dysfunction and psychological distress of caregivers remain, and how the interventional plan would be effective. Future research should focus on providing an effective support system for the caregivers who have been evacuated after an immense disaster and have had a traumatic experience. Role of funding source This study received no funding.
Conflict of interest The authors report no conflict of interest.
Acknowledgments We were grateful for the patience of every participant in completing our study.
References Doi, Y., Ogata, K., 2000. Psychiatric distress and related risk factors of family caregivers who care for the demented elderly at home. Nihon Koshu Eisei Zasshi 47, 32–46. Doi, Y., Minowa, M., 2003. Factor structure of the 12-item General Health Questionnaire in the Japanese general adult population. Psychiatry and Clinical Neurosciences 57, 379–383.
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Furumura, M., 2011. Difficulties faced by caregivers at group homes for elderly with dementia and related factors. Nihon Koshu Eisei Zasshi 58, 583–594. Goldberg, D.P., Williams, P., 1988. A user’s guide to the General Health Questionnaire. Basingstoke NFER-Nelson. Hankins, M., 2008. The reliability of the twelve-item general health questionnaire (GHQ-12) under realistic assumptions. BMC Public Health 8, 355. Jacob, K.S., Bhugra, D., Mann, A.H., 1997. The validation of the 12-item General Health Questionnaire among ethnic Indian women living in the United Kingdom. Psychological Medicine 27, 1215–1217. ¨ Kilic, C., Rezaki, M., Rezaki, B., Kaplan, I., Ozgen, G., Sa˘gduyu, A., Ozturk, M.O., 1997. General Health Questionnaire (GHQ12 & GHQ28): psychometric properties and factor structure of the scales in a Turkish primary care sample. Social Psychiatry and Psychiatric Epidemiology 32, 327–331. Kuwabara, H., Shioiri, T., Toyabe, S., Kawamura, T., Koizumi, M., Ito-Sawamura, M., Akazawa, K., Someya, T., 2008. Factors impacting on psychological distress and recovery after the 2004 Niigata-Chuetsu earthquake, Japan: community-based study. Psychiatry and Clinical Neurosciences 62, 503–507. Raphael, B., Meldrum, L., O’Toole, B., 1991. Rescuer’s psychological response to disaster. British Medical Journal 303, 1346. ¨ Russ, T.C., Stamatakis, E., Hamer, M., Starr, J.M., Kivimaki, M., Batty, G.D., 2012. Association between psychological distress and mortality: individual participant pooled analysis of 10 prospective cohort studies. British Medical Journal 345, e4933. Takada, S., Shintani, Y., Sohma, O., Tsuneishi, S., Uetani, Y., Nakamura, H., 1995. Difficulties of families with handicapped children after the Hanshin-Awaji earthquake. Acta paediatrica Japonica 37, 735–740. Takusari, E., Suzuki, M., Nakamura, H., Otsuka, K., 2011. Mental health, suicidal ideation, and related factors among workers from medium-sized business establishments in northern Japan: comparative study of sex differences. Industrial Health 49, 452–463. Toyabe, S., Shioiri, T., Kuwabara, H., Endoh, T., Tanabe, N., Someya, T., Akazawa, K., 2006. Impaired psychological recovery in the elderly after the Niigata-Chuetsu Earthquake in Japan: a population-based study. BMC Public Health 6, 230. Toyabe, S., Shioiri, T., Kobayashi, K., Kuwabara, H., Koizumi, M., Endo, T., Ito, M., Honma, H., Fukushima, N., Someya, T., Akazawa, K., 2007. Factor structure of the General Health Questionnaire (GHQ-12) in participants who had suffered from the 2004 Niigata-Chuetsu Earthquake in Japan: a community-based study. BMC Public Health 7, 175.
Contents lists available at SciVerse ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Preliminary communication
Delayed recovery of caregivers from social dysfunction and psychological distress after the Great East Japan Earthquake Minoru Sawa a,b,n, Yoneatsu Osaki b, Hiraki Koishikawa a a b
Department of Psychiatry, Kameda Medical Center, Japan Division of Environmental and Preventive Medicine, Department of Social Medicine, Faculty of Medicine, Tottori University, Japan
a r t i c l e i n f o
abstract
Article history: Received 26 October 2012 Accepted 7 November 2012 Available online 20 December 2012
Background: In April 2011, two hundred and eighty residents who were suffering from intellectual disabilities and their eighty caregivers at nine facilities in Fukushima were evacuated and moved to Chiba, Japan after the Great East Japan Earthquake. We investigated the impact of the evacuation after the earthquake on the caregiver burden. Method: There were 41 participants from Chiba as a reference group and 32 participants from Fukushima as a case group included. Data were collected regarding their demographics and the General Health Questionnaires 12 (GHQ-12) score for both groups in two different points. Results: The evacuation was linked to a follow-up GHQ-12 global score Z 3 (RR ¼ 4.52, 95%CI; 1.32– 15.47). There was no significant improvement of the GHQ-12 global score in the case group from Fukushima for the follow-up data compared to the baseline data. Social dysfunction had continued in the case group from the baseline data (po 0.01) during the follow-up period (po 0.001). A statistically significant difference was noted for the case group from Fukushima regarding psychological distress in the follow-up data (po 0.01), which was not found in the baseline data (p¼ 0.07). Limitations: The sample size was limited to a non-randomized and unmasked sample of 73 patients. No causal relationship could be determined due to the cross-sectional nature of the study. Conclusions: The caregivers from Fukushima exhibited more psychiatric morbidity, which persisted for the duration of their evacuation after the earthquake. It is important to provide long-term support for such caregivers who have been evacuated after a major disaster. & 2012 Elsevier B.V. All rights reserved.
Keywords: Caregiver burden Earthquake Evacuation Psychological distress Social dysfunction
1. Introduction The Great East Japan Earthquake occurred on March 11, 2011. The magnitude was 9.0, which made it the most powerful earthquake on record in Japan. The source zone boundary extended 450 km north and south, and 200 km east and west. The height of the tsunami produced due to this earthquake was more than 10 m, and in some cases was over 40 m high. The earthquake and the tsunami resulted in immense damage in the Tohoku and Kanto areas, and also led to widespread radiation contamination due to the accident at the Fukushima-Daiichi nuclear plant. According to the report from the National Police Agency, there were 15,866 confirmed deaths, 2946 people missing, and 6108 injured as of June 25, 2012. The earthquake and the following tsunami had also inflicted enormous structural damages on houses, businesses and other buildings. The extent of the damage is still uncertain because n Corresponding author at: Department of Psychiatry, Kameda Medical Center 929 Higashicho Kamogawa, Chiba 296-8602, Japan. Tel.: þ 81 4 7092 2211; fax: þ 81 4 7099 1198. E-mail address: [email protected] (M. Sawa).
0165-0327/$ - see front matter & 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jad.2012.11.011
some areas have remained submerged due to the tsunami. The National Police Agency confirmed on June 25, 2012 that there had been 130,436 complete building collapses (20,659 in Fukushima) and 262,975 partial collapses (69,104 in Fukushima). Due to this damage and the subsequent accident at the Fukushima-Daiichi nuclear plant, many people had to leave their original houses and had to evacuate to other places. Because of this damage, 280 residents who were suffering from mental retardation and their 80 caregivers at nine facilities in Fukushima were evacuated and moved to Kamogawa, Chiba, Japan in April 2011. There were about 14,636 mentally retarded patients (1168 patients in Soso area where there was the major area of the nuclear evacuation zone) and 46 facilities (seven facilities in Soso area) for those patients in Fukushima in total before the earthquake. A total of approximately 1300 caregivers (about 130 caregivers in Soso area) for those patients with mental retardation originally worked in Fukushima. Kamogawa is located about 300 km away from the FukushimaDaiichi nuclear plant. The residents and caregivers were moved to a facility which was originally intended for youth in Kamogawa, Chiba. At the beginning of February 2012, they were still staying in Kamogawa because it was difficult to find a suitable facility in
414
M. Sawa et al. / Journal of Affective Disorders 148 (2013) 413–417
Fukushima. The caregivers were under high stress due to the lack of a plan for the future and the continuing separation from their families. We performed a cross-sectional study regarding the caregiver burden after the earthquake. According to the previous study, there was a statistically significant difference regarding the psychiatric morbidity for the caregivers from Fukushima due to evacuation. In this study, we sent out questionnaires to the caregivers from Fukushima, as well as to caregivers who were originally working at an equivalent facility in Chiba to perform a case-reference study. We herein report our investigation of the differences in the presence of psychiatric morbidity between the baseline data and the follow-up data in the caregivers who had been evacuated. We also discuss that long-term support should be provided for both the caregivers for disabled residents, as well as the residents themselves, in case such a disaster should occur in the future.
There were 46 participants from both groups. The response rate to the baseline questionnaires was 83% for the case group from Fukushima and 77% for the reference group from Chiba. Of these initial respondents, five participants dropped out from the reference group, and fourteen from the case group. Therefore, there were 41 remaining participants (24 males and 17 females) from the reference group from Chiba and 32 participants (17 males and 15 females) from the case group originally from Fukushima. The mean age was 39.68 in the reference group and 45.00 in the case group. The demographic characteristics of the participants are presented in Table 1. The study protocol was approved by the Kameda General Hospital Institutional Review Board (approval number; 11-062) and Tottori University Ethics Committee (approval number: 1879). Written informed consent was obtained from each participant after a complete description of the study was provided. 2.2. Statistical analysis
2. Methods The participant caregivers were all over the age of 20. As described above, there were nine facilities from Fukushima which we defined as the case group. We chose three facilities in Chiba as the reference group, which several psychiatrists independently determined equivalent level facilities for disabled persons with regard to the severity of mental retardation, social function and staff assignments in the facilities. 2.1. Data collection This was a case-reference follow-up study, in which the baseline data for the case group Fukushima were collected in August 2011, and the reference baseline data were collected by January 2012. We sent out the General Health Questionnaires 12 (GHQ-12), as well as additional questions about the participants’ gender, age, and years of employment (Jacob et al., 1997; Kilic et al.,1997; Hankins, 2008) to both groups through February 2012. The study participants were divided into two groups: the caregivers originally from Fukushima (the case group) and those originally from Chiba, defined as the reference group. Item scores were coded according to the GHQ method (all items coded 0-0-1-1) (Goldberg and Williams, 1988). The data were collected by the main researcher, who was a psychiatrist, and by co-researchers, who were psychiatrists and a nurse. A statistical analysis was performed with the assistance of a co-researcher who was an expert in clinical epidemiology.
Before analyzing the data in the present study, we performed a Mann–Whitney U test to confirm that there was no impact of the participants dropping out on the baseline data regarding the distribution of the GHQ-12 scores, which we used as the outcome of this study. All data were screened for normality, homogeneity of variance, and outliers. Categorical variables were compared using a chi-square test and Fisher’s exact test, and Student’s t test was used for continuous variables. We confirmed that the baseline GHQ-12 global score, follow-up GHQ-12 global score and the years of employment were not normally distributed. We performed a Mann–Whitney U test to examine the groups for differences in the GHQ-12 global scores, as well as the years of employment. We thereafter performed a Wilcoxon signed rank test to examine the differences between the baseline data and the follow-up data for both groups. Correlation coefficients were calculated for demographic variables (gender, age) and relevant clinical variables (the presence of evacuation, years of employment, the presence of a score Z3 for the baseline GHQ-12 global score, a score Z3 for the follow-up GHQ-12 global score, and a scoreZ 8 for the follow-up GHQ-12 global score). Variables with an absolute valueZ0.5 that exhibited a significant relationship between the various variables were considered to have a strong correlation. A strong correlation was observed in the baseline GHQ-12 global score and the follow-up GHQ-12 global score in this case. According to the previous study performed in Japan, we used 2/3 as the cut-off for the GHQ-12 global score and a score Z3 was considered to indicate psychiatric morbidity (Takusari et al., 2011). Furthermore, based on the recent study performed by Russ
Table 1 The distribution of the demographic and clinical characteristics of the participants from the reference (Chiba) and case (Fukushima) groups. Demographic and clinical characteristics
Gender Male Female Age (years) Baseline GHQ global score Follow-up GHQ global score Years of employment (years) Comparison of the baseline GHQ-12 global score with the follow-up GHQ-12 global score Follow-up GHQ-12 global scoreZ 8
Reference group (N ¼41)
Case group (N ¼ 32)
p value
N 24
% 58.5
N 17
% 53.1
17 Mean 39.68 3.49 3.32 9.90 p ¼ 0.72
41.5 SD 12.44 3.39 3.03 7.19
15 Mean 45.00 6.28 6.75 17.13 p ¼ 0.59
46.9 SD 11.67 4.45 3.82 12.94
3
7.3
16
50.0
p ¼0.64
p ¼0.07 p o0.01 p o0.001 p ¼0.04
Gender; Chi-square value¼0.21, degree of freedom ¼1. Age; two-sample t test. Baseline GHQ global score, follow-up GHQ global score, and years of employment; Mann– Whitney U test. Comparison of the baseline GHQ-12 global score with the follow-up GHQ-12 global score; Wilcoxon signed rank test.
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et al. (2012), psychological distress is known to be associated with an increased risk of mortality. We considered that a higher GHQ-12 global score itself was problematic. A follow-up GHQ-12 global score Z8 was equal to the 75th percentile of the distribution, which we considered to be a more severe condition. The number and percentage of the participants with a follow-up GHQ-12 global score Z8 for each group is presented in Table 1. A logistic regression analysis was performed which consisted of the presence of a higher GHQ-12 global score as the dependent variable and gender, age, years of employment, and the presence of evacuation as the covariates. In the previous study of the general Japanese population, Doi and Minowa (2003) identified two major factors, psychological distress (items 2, 5, 6, 9, 10, and 11) and social dysfunction (items 1, 3, 4, 7, and 8) . We performed the Mann–Whitney U test to examine the groups for differences in the GHQ-12 integrate score for each of these factor items. Statistical significance was set at p o0.05. All tests were twosided, and all of the statistical analyses were conducted using the SPSS version 18.0 software program (SPSS Inc., Chicago, Illinois).
logistic regression analysis for the follow-up data. A scoreZ3 for the follow-up GHQ-12 global score was associated with the evacuation (RR¼4.52, 95%CI; 1.32–15.47). In addition, a score of Z8 for the follow-up GHQ-12 global score was associated with the evacuation (RR ¼13.57, 95%CI; 2.91–63.28). These results are presented in Table 2. According to Mann–Whitney U test, the social dysfunction persisted in the case group originally from Fukushima from the baseline survey (po0.01) through the follow-up evaluation (p o0.001). In contrast, a statistically significant difference emerged for the case group from Fukushima regarding psychological distress in the follow-up data (p o0.01), which was not found in the baseline data (p¼0.07), thus indicating that they were suffering from even greater distress than they were initially. These results are presented in Table 3.
3. Results
In this study, there was a statistically significant difference between the follow-up GHQ-12 global score based on whether patients had been evacuated. A higher follow-up GHQ-12 global score was linked to the evacuation after the disaster, which was not only a psychiatric problem but also increased the risk of mortality (Russ et al., 2012). No statistically significant difference was found in the case group originally from Fukushima between baseline and follow-up GHQ-12 global score, which means there was no improvement in the psychiatric morbidity with the passage of time after evacuation. This follow-up study showed that the social dysfunction was not resolved for the duration of their evacuation after the earthquake, and furthermore, there was even new psychological distress noted in the follow-up data for the caregivers from Fukushima.
We confirmed that there was no impact of the participants who dropped out with regard to the distribution of the baseline or follow-up GHQ-12 global score as determined by the Mann– Whitney U test in both of the groups. The mean values for the baseline GHQ-12 global scores were 3.49 for the reference group and 6.28 for the case group originally from Fukushima. The clinical characteristics of the participants are presented in Table 1. We performed Shapiro–Wilk tests to check for the normality of the continuous variables, including the patient age, years of employment, and baseline/follow-up GHQ-12 global scores. Only the participants’ age was normally distributed. A statistically significant difference was found for the caregivers from Fukushima, in that they had a higher baseline GHQ-12 global score (po0.01) as well as higher follow-up GHQ-12 global scores (p o0.001) in the Mann–Whitney U tests. According to the Wilcoxon signed rank test performed to examine the differences between the baseline data and the follow-up data for both groups, there was no statistically significant difference in either of the groups. The results from a logistic regression analysis indicated that the presence of evacuation (Relative Risk (RR)¼3.01, 95% Confidential Interval (CI); 0.95–9.53) did not produce a statistically significant relative risk for the presence of a score Z3 for the baseline GHQ-12 global score, but a trend was noted (p ¼0.06). We performed a similar
4. Discussion 4.1. The principal findings
4.2. Strengths and limitation of the study It is of great importance that statistically significant differences were found in the follow-up GHQ-12 global scores even in this small sample of participants based in the presence of evacuation. In particular, our findings indicate that social dysfunction has not only persisted but also that psychological distress has newly emerged for these caregivers evacuated from Fukushima. Previous studies have showed that the psychological stress continues for a long period after a large-scale disaster, such as an earthquake (Toyabe et al., 2006, 2007) therefore the result
Table 2 The results of the logistic regression analysis of the higher GHQ-12 global scores. Higher GHQ-12 global scores and covariates Model 1
Model 2
Model 3
Relative risk A baseline GHQ-12 global scoreZ 3 Age (every 1 year increase) Gender (female/male) The presence of evacuation (Cases/Reference group) Years of employment (every 1 year increase) A follow-up GHQ-12 global scoreZ 3 Age (every 1 year increase) Gender (female/male) The presence of evacuation (Cases/Reference group) Years of employment (every 1 year increase) A follow-up GHQ-12 global scoreZ 8 Age (every 1 year increase) Gender (female/male) The presence of evacuation (Cases/Reference group) Years of employment (every 1 year increase)
Model 1, Model 2 and Model 3; adjusted by age, gender, the presence of evacuation, and years of employment.
95% CI
p value
0.97 1.68 3.01 0.99
0.92–1.02 0.58–4.84 0.95–9.53 0.93–1.04
0.20 0.34 0.06 0.63
0.99 1.82 4.52 0.99
0.94–1.04 0.60–5.54 1.32–15.47 0.93–1.05
0.61 0.29 0.02 0.65
0.97 4.01 13.57 1.05
0.90–1.04 1.04–15.39 2.91–63.28 0.97–1.13
0.37 0.04 o 0.01 0.22
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Table 3 The results of the Mann–Whitney U tests of the differences in psychological distress and social dysfunction between the Case and Reference groups. GHQ-12 combination items
A baseline GHQ-12 Psychological distress (items 2, 5, 6, 9, 10, and 11) Social dysfunction (items 1, 3, 4, 7, and 8) A follow-up GHQ-12 Psychological distress (items 2, 5, 6, 9, 10, and 11) Social dysfunction (items 1, 3, 4, 7, and 8)
Reference group
case group
p value
Mean
SD
Mean
SD
2.27 0.93
2.24 1.29
3.34 2.22
2.39 2.04
0.07 o0.01
2.37 0.56
2.20 1.00
3.78 2.38
2.03 2.00
o0.01 o0.001
of this follow-up study are consistent with those of the previous studies. There are limitations to the methodology used in the present study that should be pointed out. First, the sample size was limited to a non-randomized and unmasked sample of 73 patients. Therefore, the results of the present study cannot be generalized beyond the sample. Second, no causal relationship could be determined due to the cross-sectional nature of the study. Although these limitations were present, we made efforts to investigate factors in two different points (baseline data and follow-up data), which would enable the possibility of a causal relationship to be assessed, so that temporary findings would not be misunderstood. 4.3. The important differences in the results in relation to other studies The previous studies have generally focused on the psychological distress of the general population, vulnerable victims (as described below) and the rescuers of those victims. For example, Toyabe et al. (2006) reported that the elderly exhibited impaired psychological recovery after the earthquake. Children, elderly or disabled persons are considered to be disaster victims (Takada et al., 1995). Raphael et al. (1991) reported that the rescuers of such victims experience a psychological response to disasters, and insisted that it is essential to provide support to them, as well as to the victims. The present study makes a unique and specific point that caregivers themselves were disaster victims, and like the general population, had difficulty in coping with unfamiliar circumstances after the immense disaster. The burden on the caregivers at nursing homes in Japan was already problematic before the disaster (Doi and Ogata, 2000; Furumura, 2011). Caregivers in Japan work for long hours with low pay, which leads to a shortage of such caregivers. After the disaster, the residents with mental retardation and their caregivers from Fukushima had to move to find a temporary shelter because the evacuated area was expanded due to the nuclear accident. This led to even more stress for the caregivers from Fukushima because the residents with mental retardation had poor adaptability to environmental change. The caregivers had to stay with the residents for a long period until suitable facilities in Fukushima, where their family lived, could be found. According to the previous study by Kuwabara et al. (2008), psychological distress was a significant problem immediately in the general Japanese population after the disaster, but was decreased by 5 months after the earthquake. They reported that some factors were associated with an impaired psychological recovery, such as being with unfamiliar people and living in a temporary shelter (Kuwabara et al., 2008). In this present case, the caregivers from Fukushima had to stay in temporary apartments, were separated from their families, and continued having to care for the residents who were suffering from intellectual
disabilities, who were often more difficult to care for because they were upset by the changes. In addition to these factors, some caregivers from Fukushima lost their houses and loved ones, had family members who had been injured, or had family members who were continuing to be exposed to the elevated level of radiation in Fukushima. The mentality of Japanese people might also have led to a delayed recovery because some of the caregivers from Fukushima reported that they felt guilty feeling if they left their professional position because it would lead to a shortage of manpower. 4.4. Significance of the study To provide an explanation of the implications of this study, we would like to present an actual episode related to the caregivers from Fukushima during the period of evacuation. Caregivers had less interaction after the evacuation from Fukushima. Soon after moving to Chiba, they tend to live by themselves after working and ate outside less frequently or enjoyed free time less frequently with other people. Some caregivers reported consuming more alcohol alone in their apartment than before. We had a meeting with middle-rank caregivers to allow them to regularly share the information regarding caregivers who were burned out. We encouraged those caregivers who were considered to have a risk of developing psychiatric disorders to come to the counseling office or hospital. We also provided information regarding typical issues related to daily living, such that which restaurant we recommended and where they could enjoy themselves near their apartment. Some caregivers came to our outpatient service but some had been resigned from their job. There was an accident which led to the death of a resident outside the evacuated facility. The caregivers from Fukushima presented with extreme exhaustion and some caregivers were critical of themselves. After this tragedy, caregivers tend to secure residents better. Some residents required environmental adjustment and were administered more psychotropic medications, which might not have been required if the residents had stayed in their original facilities in Fukushima. We considered reporting the increased incident/accident rate of residents after the evacuation. However, the criteria regarding how to classify incidents/ accidents might have been changed due to the emergency situation. Therefore, it was difficult to compare the rates due to the evacuation after the earthquake with their usual rate when they were in Fukushima. The possible explanations and implications of this study for clinicians and policymakers are that caregivers may have ambivalent feelings about staying with disabled persons. This is because they are worried about deciding to give their work priority over their family and friends. They feel guilty about leaving their job because it would result in a larger burden for the rest of the caregivers. It was also difficult for the caregivers to find an appropriate job near their family in Fukushima, as the facilities where such jobs are available were widely destroyed. These
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findings of the present study indicate that it is important to provide adequate long-term support not only to the disaster victims, such as children, elderly people, and disabled persons but also to their caregivers following such an immense disaster. This study was an observational study. Therefore, it still remains unclear how long the social dysfunction and psychological distress of caregivers remain, and how the interventional plan would be effective. Future research should focus on providing an effective support system for the caregivers who have been evacuated after an immense disaster and have had a traumatic experience. Role of funding source This study received no funding.
Conflict of interest The authors report no conflict of interest.
Acknowledgments We were grateful for the patience of every participant in completing our study.
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