Acta Psychiutr Scund 1996: Y3: 477-481 Printed in UK a11 rights reserved

Copyright Q Munksgaard 1996 ACTA PSYCHIATRICA

SCANDINAVICA ISSN 0001-6901

Post-traumatic symptoms among younger and elderly evacuees in the early stages following the 1995 Hanshin-Awaji earthquake in Japan

Kato H, Asukai N, Miyake Y, Minakawa K, Nishiyama A. Post- traumatic symptoms among younger and elderly evacuees in the early stages following the 1995 Hanshin-Awaji earthquake in Japan. Acta Psychiatr Scand 1996: 93: 477-481. 0 Munksgaard 1996.

We assessed the frequency of short-term, post-traumatic symptoms among evacuees of the Hanshin-Awaji earthquake. A total of 67 younger subjects (under 60 years) and 75 elderly subjects (60 years or above) were interviewed during the third week after the earthquake, and 50 and 73 subjects, respectively, were interviewed during the eighth week. All subjects were assessed using the Post-Traumatic Symptom Scale. During the first assessment, subjects from both age groups experienced sleep disturbances, depression, hypersensitivity and irritability. During the second assessment, the percentage of younger subjects experiencing symptoms did not decrease, while elderly subjects showed a significant decrease in 8 of 10 symptoms. This may have been due to such factors as decreased psychological stress, extensive social networks, and previous disaster experiences in the case of the elderly subjects.

Introduction

On 17 January 1995, at 05.46 hours, the Hanshin- Awaji earthquake struck Kobe city and the sur- rounding areas of western Japan with a magnitude of 7.2 on the Richter scale. The earthquake caused about 5500 deaths, damaged or destroyed more than 150 000 homes, and over 300 000 people were evacuated to more than 1000 shelters in the disaster areas. Although Japan is often subject to natural disasters, the psychological effects on disaster vic- tims have not been widely studied. Only a few studies have investigated the long-term effects of natural disasters in Japan (1-3).

The field of disaster psychiatry has continued to expand (4-7), and studies of the psychological consequences of large-scale earthquakes in Ecuador (8), Armenia (9, 10) and the San Francisco Bay area (11) have been published recently. Previous research has dealt primarily with the long-term effects, while only a few studies have investigated the short-term effects of disasters (12). This is because in a large-scale natural disaster, relief activ- ities take a high priority over experimental study of

H. Kato’, N. Asukai’, Y. Miyake’, K. Minakawa’, A. Nishiyama’ ’Disaster Victim Assistance Program, Hyogo Organization of Mental Health, Kobe and ’Department of Social Psychiatry, Tokyo Institute of Psychiatry. Tokyo. Japan

Key words: natural disaster: victim psychology: post-traumatic stress disorder

Nozomu Asukai. Department of Social Psychiatry, Tokyo Institute of Psychiatry, 2-1-8, Kamikitazawa, Setagaya-ku, Tokyo 156, Japan

Accepted for publication November 4, 1995

the victims. To impose psychometric measurements on exhausted victims would be inappropriate. In addition, transient after-effects are of little interest to researchers.

Despite this, estimation of the incidence rate and course of psychological distress in the short term following disaster is important for establishing dis- aster epidemiology and/or implementing practical relief efforts in the early stages following disasters. A few studies have indicated that short-term psycho- logical distress occurs in a considerable proportion of victims. Parker ( 13) found that psychological dysfunction increased initially ( 58%) and continued even after 10 weeks (41%) in evacuees of Cyclone Tracy. Lima et al. ( 8 ) reported that 40% of patients in primary health care clinics in the disaster area showed emotional distress for 3 months following the Ecuador earthquake. After the San Francisco Bay area earthquake, Cardena & Spiegel ( 11 ) found that dissociative symptoms, including other related pathological features, occurred more frequently shortly after the earthquake than 4 months later in psychology and medical students.

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However, our understanding of the short-term, post-traumatic symptoms in severely affected vic- tims is still inadequate. In addition, differences between age groups are unclear, although Goenjian et al. ( 10) suggested that there are some differences in the long-term effects of disasters. The Hanshin- Awaji earthquake provided us with an opportunity to investigate these issues.

Material and methods

Our study was conducted with the assistance of mental health care professionals at a shelter (public school buildings) in the mid-west part of Kobe. Two thousand people were forced to stay in the shelter immediately after the earthquake. The popu- lation of the shelter decreased week by week, but people whose houses were damaged or destroyed and who had no alternative housing remained in the shelter. Two primary care clinics were estab- lished in the shelter, and volunteer psychiatrists provided a consultation service for the victims. While daily consultation services continued, evacuees in the shelter were interviewed for our study on two occasions, the first assessment being made during the third week after the earthquake, and the second assessment during the eighth week. Mental health care professionals (psychiatrists, clin- ical psychologists and psychiatric liaison nurses), accompanied by hospital nurses, visited all rooms in the shelter and interviewed the evacuees. A total of 142 subjects (61 males and 81 females) were interviewed during the first assessment and 123 people (55 males and 68 females) were interviewed during the second assessment. All of these subjects were included in our study. A large number of evacuees in the shelter worked during the day or left to salvage their belongings, so were unavailable for interview. While the total number of subjects in our study appears to be small, refusal to participate in the interview was rare. There was some overlap of subjects between the first and second assessments, but the magnitude of overlap is not clear because the identity of some of the subjects was unknown. However, the overlap among identified subjects was small. The age of subjects in the first assessment ranged from 12 to 84 years (average 55.2 years) and in the second assessment it ranged from 12 to 85 years (average 58.6 years). There were 67 younger subjects (under 60 years of age) and 75 elderly subjects (60 years or above) in the first assessment. In the second assessment, there were 50 younger subjects, and 73 elderly subjects. The sex ratio was similar between the first and second assessments for both age groups. In addition, almost all subjects had lost their homes, so the degree of residential damage was similar.

As part of the interview, a health status checklist, including 10 items from the Post-Traumatic Symptom Scale (PTSS-10) (14, 15), was used. The scale is normally a self-rating questionnaire, but in our study the interviewers evaluated each item and checked the symptom list. The PTSS-10 is believed to measure specific post-disaster stress in victims ( 14). The wording in the scale was altered specific- ally to reflect this disaster.

Data analysis

To handle problems associated with incomplete subject sampling, we neglected the small overlap of subjects and considered the first and second assess- ment subjects in each age group as independent sets. Therefore, the validity of the statistical analysis was restricted to some extent. Between the two time points, the percentage of subjects experiencing each symptom was analysed using a Chi-square test, and the number of symptoms experienced by each sub- ject was compared using a two-tailed Mann- Whitney U-test.

Results

The percentage of subjects experiencing each symp- tom is shown in Table 1. A substantial number of subjects from both age groups experienced ‘Difficulty with sleep’, ‘Depression’, ‘Startle easily at sudden noises or unexpected movements’, and ‘Irritability’ in the third week after the earthquake. Conversely, the percentage of subjects experiencing ‘Reluctance to talk with others’, ‘Nightmares about the disaster’, and ‘Bad conscience, self-accusations or guilt’ was relatively small, even during the third week.

A discrepancy was found between the age groups when comparing the percentage of subjects experi- encing symptoms in the third week vs. the eighth week. Among the younger subjects, there was no significant decrease in the percentage of subjects experiencing symptoms in the second assessment, although reduction in physical tension approached significance. The percentage of subjects experiencing ‘Irritability’ and ‘Reluctance to talk’ increased slightly. Conversely, among the elderly subjects, the percentage of subjects experiencing any of the 10 symptoms decreased substantially, showing a stat- istically significant decrease for eight symptoms (P<0.05). A higher percentage of younger subjects experienced ‘Irritability’ ( x 2 = 5.25, df= 1, P= 0.022) and ‘Reluctance to talk’ (x2=6.20, df=1, P=O.O13) than elderly subjects in the second assess- ment. ‘Depression’ and ‘Guilt’ were experienced by a higher percentage of elderly than younger subjects in the first assessment, but the reverse situation was

Post-traumatic symptoms after the 1995 Hanshin earthquake

Table 1 Percentage of subjects experiencing post-traumatic symptoms in each age group during the third and eighth week after the earthquake

Post-traumatic symptoms

Age under 60 years Age 2 6 0 years ~~

Third week (n=67) Eighth week (n=50) Third week (n=75) Eighth week ln=73) 1%) (%) P-value” (%I (YO) P-value”

1. Difficulty with sleep 2 Depression 3. Startles easily at sudden noises or unexpected

4. Irritability 5. Fear when approaching the place of the incident 6 Frequent mood swings 7 Physical tension 8. Reluctance to talk with others 9. Nightmares about the disaster

movements (hypersensitivity)

10. Bad conscience, self-accusations or guilt

58 37 43

40 18 19 21 15 9 5

46 NSb 28 NS 32 NS

46 NS 16 NS 18 NS 8 NS

20 NS 10 NS 4 NS

a Significance by Chi-square test (df = 1) between the third and eighth weeks NS. P 2 0 05.

observed in the second assessment. The number of symptoms experienced by each subject did not decrease significantly among the younger subjects during the time-course of the third and eighth week, but did decrease significantly among the elderly subjects (Table 2).

Discussion

There are two types of event which can occur with respect to a geographical community, namely cent- ral and peripheral events (4) . The Hanshin-Awaji earthquake was a central type of disaster for our subjects. In a central event, the entire physical and organizational structure of the community is affec- ted due to destruction and displacement of the population. In addition, the trauma experienced is not restricted to the time of the event, but may continue for a relatively long period afterwards, if accompanied by many subsequent traumas (4). Our results demonstrate the occurrence and course of short-term, post-traumatic symptoms in survivors of a central-type disaster. Consistent with the results

Table 2. Number of PTSS-10 symptoms among younger and elderly evacuees

Age under 60 years

68 51 41

41 28 24 20 16 13 13

45 19 26

26 15 10 4 6 7 1

0.01 0.001 0.05

0 05 NS

0.02 0.01 0 01

NS 0.01

of previous studies, a substantial proportion of our subjects experienced some post-traumatic symp- toms, particularly sleep disturbances, depression, hypersensitivity and irritability.

Goenjian et al. ( 10) suggested that elderly victims experienced greater hyperarousal symptoms than younger adults in the long term, but we did not observe such a tendency in the early post-impact stage. We anticipated that the elderly would be a more vulnerable population. However, the percent- age of elderly evacuees experiencing post-traumatic symptoms decreased, even during the early post- impact stage, while the percentage of younger evacuees experiencing such symptoms tended to remain about the same.

There may be several reasons for this discrepancy. During the first 3 weeks, both age groups were exposed almost equally to the stress of acute impact. However, by the eighth week, another type of psychological stress may have started to affect the younger evacuees. The psychological stress of recon- structing their lives, the lives of their families, and finding new jobs may have been greater for the

Age 2 6 0 years

-

-

Third week (n=67) Eighth week (n=50) Third week (n=75) Eighth week (n=73)

Number of symptoms n 1%) n 1%) P-value” n ( % I n (%) P-valuea

0 17 (251’ 12 1241 8 111) 24 (331 1-2 22 (33) 19 (38) 24 132) 31 (42) 3-5 15 (22) 15 (30) 28 (37) 16 (22) 2 6 13 (20) 4 (8) 15 (20) 2 (3)

Average number of symptoms (SD) 2.7 12.5) 2 3 (2.1) NS 3.2 12.2) 1.6 (1.7) 0.0001

”Mann-Whitney &test (two-tailed) was used to compare the number of symptoms in each subject between the two time points Mean values are shown, with SD in parentheses

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younger subjects than for the elderly who were retired and receiving a pension. In addition, the elderly subjects had lived in the local community for longer, so they may have established a better social network in the shelter than the younger evacuees. Therefore the elderly subjects could pro- vide each other with psychological support. Another possible reason concerns previous disaster experi- ences. The elderly subjects were born before 1935, so had lived through the adversities of the Second World War, including severe destruction of cities by heavy bombing. Conversely, almost all of the younger subjects were experiencing a large-scale, centralized disaster for the first time, so recovery from the psychological impact may have been delayed compared to that in elderly subjects.

However, a previous study reported that symp- toms such as sleep disturbances and irritability did not predict the degree of psychological impairment (8) . It is unlikely that a major disorder can be diagnosed as a consequence of disaster within such a short period of time (14). Accordingly, our find- ings concerning short-term effects should not be regarded as a predictor for long-term distress in the future.

The interpretation of our data is limited due to several methodological problems. Our subjects were not randomly selected from the entire population of the shelter, but from evacuees who remained in the shelter during the daytime. Consequently, the results may be biased toward an overestimation of the severity of symptoms. In addition, the degree of inter-rater reliability is not clear, because the interviewers were given only limited guidance regarding symptom evaluation. However, all of the interviewers were mental health care professionals, and we supervised both the first and second assessments.

Questions regarding the loss of loved ones as a result of the disaster, and past history of psychiatric illnesses, were not necessarily included in the inter- view. The interviewers only asked about these topics if the subjects volunteered information about them. Consequently, it is not clear whether pre-impact psychiatric morbidity and the degree of distress due to loss of loved ones were comparable between the subjects in the first and second assessments.

The absence of controls was another limitation of the present study. The living environment of the shelters was uncomfortable because they were crowded, offered little privacy and had no heating equipment. These environmental factors may have been confounding. We could compare our findings with the unpublished data of another study con- ducted by Mizoguchi (personal communication) after the earthquake, using the same health status checklist. He found that hypersensitivity occurred

in 43% of young students at the School of Nursing in the disaster area during the fourth week after the earthquake. This finding was comparable with our results. However, the percentage of subjects suffering from sleep disturbances ( 23?4), depression (23%) and irritability (24%) was substantially lower than in our study. Most of those students were neither evacuees nor victims of the centralized disaster. Therefore, the living environment of the shelter, in addition to residential damage, may have increased the percentage of subjects experiencing these symptoms in our study.

Another problem may be the reluctance of people to seek psychological help. Only a few people have an absolute requirement for assistance from psycho- logical care professionals (8). Therefore it is difficult to develop appropriate mental health care services for non-clinical victims, although a more highly developed crisis support system in the immediate aftermath of a disaster has been found to decrease post-traumatic symptomatology subsequently ( 16). The screening attempts in our study may have helped to overcome this problem. They were effect- ive in detecting post-traumatic symptoms, and allowed for short debriefing sessions for non- clinical victims.

Acknowledgements

We are grateful to all those individuals who voluntarily particip- ated in the relief efforts to aid the evacuees, and for their co-operation in this study.

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