Reducing depressive symptoms afterthe Great East Japan Earthquake inolder survivors through group exerciseparticipation and regular walking:a prospective observational study

Taishi Tsuji,1 Yuri Sasaki,1 Yusuke Matsuyama,2 Yukihiro Sato,2 Jun Aida,2

Katsunori Kondo,1,3 Ichiro Kawachi4

To cite: Tsuji T, Sasaki Y,Matsuyama Y, et al. Reducingdepressive symptoms afterthe Great East JapanEarthquake in older survivorsthrough group exerciseparticipation and regularwalking: a prospectiveobservational study. BMJOpen 2017;7:e013706.doi:10.1136/bmjopen-2016-013706

▸ Prepublication history andadditional material isavailable. To view please visitthe journal (http://dx.doi.org/10.1136/bmjopen-2016-013706).

Received 2 August 2016Revised 10 January 2017Accepted 9 February 2017

For numbered affiliations seeend of article.

Correspondence toDr Taishi Tsuji;tsuji.t@chiba-u.jp

ABSTRACTObjectives: Survivors of the 2011 Great East JapanEarthquake have an increased risk of depressivesymptoms. We sought to examine whetherparticipation in group exercise and regular walkingcould mitigate the worsening of depressive symptomsamong older survivors.Design: Prospective observational study.Setting: Our baseline survey was conducted in August2010, ∼7 months prior to the Great East JapanEarthquake and tsunami, among people aged 65 orolder residing in Iwanuma City, Japan, which sufferedsignificant damage in the disaster. A 3-year follow-upsurvey was conducted in 2013.Participants: 3567 older survivors responded to thequestionnaires predisaster and postdisaster.Primary outcome measures: Change in depressivesymptoms was assessed using the 15-item GeriatricDepression Scale (GDS).Results: From predisaster to postdisaster, the meanchange in GDS score increased by 0.1 point (95% CI−0.003 to 0.207). During the same interval, thefrequency of group exercise participation and dailywalking time also increased by 1.9 days/year and1.3 min/day, respectively. After adjusting for allcovariates, including personal experiences of disaster,we found that increases in the frequency of groupexercise participation (B=−0.139, β=−0.049, p=0.003)and daily walking time (B=−0.087, β=−0.034,p=0.054) were associated with lower GDS scores.Interactions between housing damage and changes ingroup exercise participation (B=0.103, β=0.034,p=0.063) and changes in walking habit (B=0.095,β=0.033, p=0.070) were marginally significant,meaning that the protective effects tended to beattenuated among survivors reporting more extensivehousing damage.Conclusions: Participation in group exercises orregular walking may mitigate the worsening ofdepressive symptoms among older survivors who haveexperienced natural disaster.

INTRODUCTIONThe frequency of natural disasters such ashurricanes, floods and earthquakes has beenincreasing worldwide.1 The experience ofdisaster presents a significant burden on themental health of survivors.2–4 Depression inolder adults is strongly associated with beinghouse-bound,5 which may lead to a declinein physical and cognitive function and even-tually to premature death.6 To clarify thefactors that contribute to mental healthrecovery after a disaster, several postdisastersurveys have been previously conducted.7–9

However, these studies have relied on survi-vors’ recollection of their predisaster mentalhealth status, potentially contributing torecall bias, that is, the experience of disastercan colour the respondents’ assessment oftheir status ex ante. Clearly, it would be desir-able to have predisaster information on survi-vors in order to avoid information bias.10 Tothe best of our knowledge, only two studiesexamining mental health status prior todisaster events have been conducted.11 12 Bothstudies suggested that major disaster was asso-ciated with an increase in the risk for common

Strengths and limitations of this study

▪ The strength of this study is the unprecedentedand fortuitous availability of information predat-ing the disaster.

▪ The study design enabled us to effectivelyaddress the problem of recall bias that occurs inmost studies conducted in postdisaster settings.

▪ Selection bias might have occurred because ofthe 59% response rate to the baseline survey.

▪ The measurements rely entirely on self-reporteddata.

Tsuji T, et al. BMJ Open 2017;7:e013706. doi:10.1136/bmjopen-2016-013706 1

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mental health disorders independently of previous mentalhealth status and other potentially confounding factors.Furthermore, a previous study suggested that dwellinghouse damage caused by major disasters was associatedwith worsening depressive symptoms in older survivors.13

Little evidence, however, is available for the prevention ofmental health problems from a public health interventionperspective.Physical activity, which is a modifiable behaviour, has

the benefit of preventing or alleviating depressive symp-toms14 15 and of treating depression16 17 in older adults.It has also been found that regular walking is by far themost prevalent physical activity in older adults18 and hasprotective effects for depression.19 20 Participation ingroup exercises may be particularly effective for mentalhealth promotion in the elderly by enhancing social par-ticipation in addition to physical activity.21 22 However, itis unclear whether the same benefits can be alsoobtained following the experience of natural disaster.Following the Great East Japan Earthquake on March

11, 2011, various health promotion interventions—including group exercise programmes for older adults—were initiated in disaster-stricken areas to address thehealth needs of survivors.23 24 Tomata and colleagues24

reported that there was no significant psychologicalbenefit from attending group exercises once a monthamong middle-aged and older survivors in disaster-stricken areas. Possible reasons for this null finding wereinsufficient exercise frequency and sampling bias24 asparticipants might have had good health, behaviour andawareness before the disaster and might not have suf-fered much damage as a result of the disaster.The purpose of the present study was to examine

whether participation in group exercise and regularwalking could mitigate the worsening of depressivesymptoms among older survivors of the Great East JapanEarthquake after taking into account predisaster mentalhealth status. We hypothesised that participation ingroup exercises or regular walking may mitigate the wor-sening of depressive symptoms among older survivorswho have experienced natural disaster. These associa-tions, however, may differ according to the extent ofdamage caused by the disaster.

METHODSStudy designOur longitudinal study was conducted in Iwanuma City,a coastal municipality in the Miyagi prefecture, Japan,located ∼80 km west of the epicentre of the Great EastJapan Earthquake that occurred on 11 March, 2011.Iwanuma City (total population 44 000) suffered tremen-dous damage from the earthquake and tsunami: 180people were killed,25 and 48% (29 km2) of the land wasinundated by seawater.26 Our study takes advantage ofthe coincidence that Iwanuma City happened to be oneof the field sites of the Japan Gerontological EvaluationStudy ( JAGES) Project,27 28 a nationwide, ongoing

prospective cohort study that started in 2010 to investi-gate the social and behavioural factors associated withhealthy ageing. As part of the baseline survey for theJAGES project cohort, we conducted a census of alladults aged 65 years or older living in Iwanuma City inAugust 2010, 7 months prior to the earthquake. A 3-yearfollow-up survey was conducted in November 2013,2 years and 7 months after the earthquake. Aftersending the questionnaires to all older adults living inIwanuma City in the follow-up survey, we visited all theresidences to collect the completed questionnaires. Theparticipant flow chart is shown in figure 1.29

Study participants were selected for the Iwanumaproject based on the following inclusion criteria: respon-dents from the 2010 and 2013 surveys who had no lim-itations in activities of daily living (ADL) (ie, they couldindependently walk, bathe and visit the toilet) at thebaseline survey in 2010.All participants gave informed consent.

MeasurementsChange in depressive symptomsWe assessed depressive symptoms using the 15-itemGeriatric Depression Scale (GDS)30 31 as a continuousvariable in 2010 and 2013. The score range is 0–15 andhigher value means greater severity of depressive symp-toms. Change in depressive symptoms calculated by sub-tracting the score in 2010 from that in 2013.

Changes in group exercise participation and regular dailywalkingIn predisaster and postdisaster surveys, we ascertainedthe frequency of group exercise participation (4 days/week or more, 2–3 days/week, once a week, 1–3 time(s)/month, a few times/year or none), as well as regulardaily walking behaviour (

perform IADL. As an index of the personal experienceof disaster damage, we asked about housing damage (1no damage, 2 some damage, 3 partial destruction, 4almost destroyed or 5 complete destruction), as well asthe death of family member(s), while changes inincome were calculated by subtracting the figurereported in 2010 from that in 2013.

Statistical analysesBecause 2061 (57.8%) respondents in the analytic panelsample (n=3567) had missing data for one or moreitems in the 2010 and/or 2013 surveys, we performedmultiple imputation. We created 20 multiple imputeddata sets which included all measurement variablesusing a multivariate normal imputation method under amissing at random assumption, and combined the esti-mated parameters using Rubin’s combinationmethods.33 34

We compared the respondents’ characteristicsbetween complete cases without ADL impairments atbaseline (n=1449) versus those who had missing dataand/or had ADL impairments at baseline (n=2118).Pearson’s correlation coefficient (r) and one-way analysis

of variance (ANOVA) were used to investigate the rela-tionship of exposure with change in depressive symp-toms. Multiple linear regression models were used toexamine the association of change in group exercise par-ticipation/regular walking before and after the disasterwith change in depressive symptoms. The following fourmodels were constructed. Changes in frequency ofgroup exercise participation and changes in dailywalking time were converted into Z-scores and wereincluded in crude model. In model 1, sex and age wereadded to crude model. In model 2, we added three setsof covariates: (1) covariates evaluated only at baseline(disease status and educational attainment), (2) covari-ates measured in the 2010 and the 2013 surveys(impaired ADL, changes in drinking habits and smokinghabits, job status, equivalent income and IADL score)and (3) covariates ascertained just on the 2013 survey(housing damage and death of family members). Model3 added interaction terms: change in group exercise par-ticipation × housing damage and change in walkinghabit × housing damage. These models were also con-structed in participants with GDS score

STATA 13/SE (StataCorp, College Station, Texas, USA)for all statistical analyses and multiple imputations withthe statistical significance set at p

Table 1 Participants’ characteristics and comparison between participants with and without missing data and/or activities of daily living impairments at baseline

Total(n=3567)

Complete caseswithout ADLimpairments atbaseline(n=1449)

Participants who had missing data and/or had ADL impairments at baseline(n=2118)

Number ofvalid responses Mean/n SD/% Mean/n SD/%

Number of validresponses Mean/n SD/% p Value

Geriatric Depression Scale, scoreBaseline 3074 3.7 3.4 3.1 3.1 1625 4.1 3.6

Table 2 Multiple linear regression of changes in group exercise participation and walking habit (converted into Z-scores) with change in depressive symptoms byanalysing multiply imputed data sets (n=3335–3339, crude model and model 1)

Crude model Model 1B 95% CI β t p Value B 95% CI β t p Value

Change in group exercise participation(44.5 days/year)

−0.188 −0.290 to −0.086 −0.061 −3.63

Table 3 Multiple linear regression of changes in group exercise participation and walking habit (converted into Z-scores) with change in depressive symptoms byanalysing multiply imputed data sets (n=3335–3339, models 2 and 3)

Model 2 Model 3B 95% CI β t p Value B 95% CI β t p Value

Change in group exercise participation(44.5 days/year)

−0.156 −0.256 to −0.057 −0.051 −3.07 0.002 −0.139 −0.239 to −0.038 −0.049 −3.00 0.003

Change in walking habit(30.7 mins/day)

−0.098 −0.199 to 0.003 −0.034 −1.90 0.058 −0.087 −0.189 to 0.016 −0.034 −1.93 0.054

Age (year) 0.006 −0.013 to 0.024 0.012 0.59 0.558 0.005 −0.013 to 0.024 0.011 0.55 0.585Sex (1 men, 2 women) −0.119 −0.364 to 0.126 −0.020 −0.95 0.341 −0.119 −0.364 to 0.125 −0.020 −0.96 0.339

Psychological disorder (0 no, 1 yes) −0.769 −2.194 to 0.655 −0.029 −1.06 0.290 −0.774 −2.199 to 0.651 −0.029 −1.06 0.287Disease status (0 no, 1 one or more)* −0.203 −0.426 to 0.019 −0.029 −1.79 0.074 −0.207 −0.430 to 0.016 −0.029 −1.82 0.069Educational attainment (year) 0.053 0.007 to 0.098 0.042 2.28 0.022 0.053 0.008 to 0.098 0.043 2.31 0.021Impaired ADL (0 no, 1 impaired) 0.568 0.025 to 1.110 2.950 2.05 0.040 0.584 0.041 to 1.126 3.032 2.11 0.035Changes in drinking habits

Non→drink. −0.563 −1.236 to 0.111 −0.029 −1.64 0.101 −0.570 −1.238 to 0.098 −0.029 −1.67 0.095Drink.→non 0.213 −0.221 to 0.646 0.018 0.96 0.336 0.203 −0.229 to 0.635 0.018 0.92 0.357Non→non −0.028 −0.281 to 0.225 −0.005 −0.22 0.827 −0.034 −0.286 to 0.219 −0.006 −0.26 0.793

Changes in smoking habitsSmoke.→non 0.841 0.285 to 1.396 0.051 2.97 0.003 0.826 0.274 to 1.378 0.050 2.93 0.003Non→smoke. 1.308 −0.185 to 2.801 0.035 1.72 0.086 1.267 −0.227 to 2.762 0.034 1.66 0.097Smoke.→smoke. −0.308 −0.667 to 0.051 −0.027 −1.68 0.093 −0.304 −0.661 to 0.054 −0.027 −1.67 0.096

Changes in job statusNo→working 0.284 −0.422 to 0.990 0.017 0.79 0.429 0.297 −0.403 to 0.997 0.018 0.83 0.405Working→no 0.624 0.171 to 1.078 0.056 2.70 0.007 0.630 0.176 to 1.083 0.057 2.72 0.007No→no 0.270 −0.027 to 0.566 0.037 1.79 0.074 0.274 −0.023 to 0.570 0.038 1.81 0.071

Dwelling house damage(1 no damage→5 complete destruction)

0.212 0.105 to 0.319 0.074 3.90

walking time and risk.19 However, the relationship wasweak for walking at an easy pace (

Research Grant (No. 24140701) from the Japanese Ministry of Health, Labourand Welfare.

Disclaimer The funding sources had no role in study design, data collectionand analysis, decision to publish or preparation of the manuscript.

Competing interests None declared.

Ethics approval The Ethics Committee at the Graduate school of Medicine,Chiba University, approved the study protocol.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

Open Access This is an Open Access article distributed in accordance withthe Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license,which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, providedthe original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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Reducing depressive symptoms after the Great East Japan Earthquake in older survivors through group exercise participation and regular walking: a prospective observational studyAbstractIntroductionMethodsStudy designMeasurementsChange in depressive symptomsChanges in group exercise participation and regular daily walkingCovariates

Statistical analyses

ResultsDiscussionReferences