Social and Mental Health Impact of Nuclear Disaster in Survivors: A Narrative Review

Caley Longmuir; Vincent I. O. Agyapong

doi:10.3390/bs11080113

Social and Mental Health Impact of Nuclear Disaster in Survivors: A Narrative Review

Longmuir, Caley;Agyapong, Vincent I. O. 2021-08-23 00:00:00 Review Social and Mental Health Impact of Nuclear Disaster in Survivors: A Narrative Review Caley Longmuir * and Vincent I. O. Agyapong Department of Psychiatry, University of Alberta, Edmonton, AB T6G 2R3, Canada; agyapong@ualberta.ca * Correspondence: clongmui@ualberta.ca Abstract: This narrative review synthesizes the literature on the psychological consequences of the Three Mile Island nuclear accident of 1979, the Chernobyl nuclear disaster of 1986, and the Fuku- shima nuclear disaster of 2011. A search was conducted on OVID for studies in English from 1966 to 2020. Fifty-nine studies were included. Living through a nuclear disaster is associated with higher levels of PTSD, depression, and anxiety. Decontamination workers, those living in closest proximity to the reactor, and evacuees experience higher rates of mental health problems after a nuclear dis- aster. Those with greater psychological resilience and social supports experience lower rates of psy- chological distress. Individual-level interventions, such as mindfulness training, behavioral activa- tion, and cognitive reappraisal training, have shown modest benefits on improving psychological wellbeing. At the population level, many of the measures in place aimed at reducing exposure to radiation actually increase individuals’ anxiety. Technology-based supports have been studied in other types of natural disasters and it may be beneficial to look at mobile-based interventions for future nuclear disasters. Keywords: radioactive hazard release; nuclear disaster; anxiety; depression; post-traumatic stress disorder; psychological resilience; community mental health services; health policy; post-disaster Citation: Longmuir, C.; interventions Agyapong, V.I.O. Social and Mental Health Impact of Nuclear Disaster in Survivors: A Narrative Review. Behav. Sci. 2021, 11, 113. https:// 1. Introduction doi.org/10.3390/bs11080113 Although nuclear disasters have been relatively uncommon throughout history, their psychological impact is long-lasting and widespread. This paper will describe the seque- Academic Editor: Gianluca Serafini lae of mental health conditions related to nuclear disasters that led to actual or threat of radiation exposure. This paper includes data from the Three Mile Island accident of 1979, Received: 11 May 2021 Accepted: 20 August 2021 the Chernobyl disaster of 1986, and the Fukushima Daiichi nuclear disaster of 2011. This Published: 23 August 2021 paper will not include exposure to radiation from medical means or nuclear warfare. Research on the psychological impact of nuclear disasters began in the aftermath of Publisher’s Note: MDPI stays neu- the Three Mile Island accident, which occurred in Pennsylvania in 1979. This was a level tral with regard to jurisdictional 5 nuclear disaster on the International Nuclear Event Scale (INES). In the initial period claims in published maps and institu- after the accident, Three Mile Island residents received contradictory information about tional affiliations. radiation exposure and an evacuation advisory was released for pregnant women and families with young children [1]. Although a radiation leak did occur from the plant, there has been no evidence to suggest that any residents of Three Mile Island were exposed to high enough levels of radiation to cause physiological consequences [1]. Nonetheless, the Copyright: © 2021 by the authors. Li- threat of radiation exposure still contributed to mental health distress in the residents of censee MDPI, Basel, Switzerland. Three Mile Island [1–7]. This article is an open access article The Chernobyl disaster was the first level 7 nuclear disaster in history and remains distributed under the terms and con- the biggest nuclear disaster to date. Despite the magnitude of this disaster, research on ditions of the Creative Commons At- the Chernobyl nuclear disaster is limited as research coming out of the Soviet Union dur- tribution (CC BY) license (http://crea- ing this time period was restricted. Research on the physiological consequences of the tivecommons.org/licenses/by/4.0/). Behav. Sci. 2021, 11, 113. https://doi.org/10.3390/bs11080113 www.mdpi.com/journal/behavsci Behav. Sci. 2021, 11, 113 2 of 20 Chernobyl nuclear disaster indicates several thousand thyroid cancer cases directly at- tributable to the disaster, increased prevalence of leukemia among decontamination workers, and 134 confirmed cases of acute radiation syndrome [8]. Approximately 50 peo- ple died as a result of high levels of acute radiation [8]. Research in the area of nuclear disasters proliferated exponentially in the aftermath of the Fukushima nuclear disaster of 2011. The Fukushima nuclear disaster was triggered by the Tohoku earthquake and tsunami. The earthquake, with a magnitude of 9.0, trig- gered an automatic shutdown of reactors and the subsequent tsunami flooded the nuclear power plant, which damaged the cooling system [8]. As with the Chernobyl nuclear dis- aster, the Fukushima nuclear disaster was classified as a level 7 nuclear disaster, but the evacuation area around the plant was much smaller and the health effects have been sig- nificantly lower [8]. Unlike Chernobyl, there were no deaths from acute radiation effects in Fukushima and no cases of acute radiation syndrome [8]. Despite this, 116,000 people had to be evacuated and many elderly and hospitalized people lost their lives in the evac- uation process [9]. Though nuclear accidents are uncommon, they lead to serious physical and mental health issues. There is a large breadth of literature on the physical consequences of nuclear disasters and radiation exposure, but psychological sequelae have been less widely stud- ied until recently. Research on the mental health consequences of the Fukushima nuclear disaster has recently been summarized by a two-part systematic review [10,11] and a sys- tematic qualitative review [12]. These articles summarize the psychological consequences of nuclear disasters, including increased levels of general psychological distress, depres- sive symptoms, post-traumatic stress symptoms [10], and radiation anxiety [12], as well as behavioral consequences, such as increased suicide rates [11]. There have been no re- views to date on the mental health consequences of nuclear disasters that include studies from multiple nuclear accidents. For the purposes of this review, radiation anxiety will be defined as health anxiety due to perceived radiation exposure, actual radiation exposure, or potential for radiation exposure in the future. This definition is based on previous re- search [10,11,13–17] and includes concern about current health status, delayed health ef- fects, and genetic effects on offspring and future generations. This paper aims to outline the impact of nuclear disasters on mental health. The types of psychological sequelae that most commonly occur after living through a nuclear disas- ter, including symptoms of post-traumatic stress disorder, depression, and anxiety, will be reviewed and the risk factors and protective factors surrounding the development of these conditions will be described. Specific groups of people, such as plant workers, clean- up workers, and those residing closest to the nuclear reactor, will be discussed, as they have an increased risk of exposure to radioactive material. Recommendations for future research, as well as policies and programs to mitigate the risk of development of mental health conditions post-nuclear disaster and to increase protective factors, will be ad- dressed. 2. Methods 2.1. Search Strategy A literature search of the MEDLINE database through OVID was conducted by one author (C.L.) in December 2020. The search used the MeSH terms “radioactive hazard release”, “nuclear reactors”, “radiation injuries”, “anxiety disorders”, “anxiety”, “depres- sive disorder”, “depression”, “dysthymic disorder”, “depression, reactive”, “adjustment disorders”, “suicide”, and “stress disorders, post-traumatic”. The stages of the literature search are presented in Figure 1. This search strategy yielded 287 research articles. Behav. Sci. 2021, 11, 113 3 of 20 Figure 1. Flow diagram of article selection process, based on Page et al. (2020) [18]. 2.2. Inclusion and Exclusion Criteria This review includes articles published in English between 1966 and 2020. We only included articles with a study population of adults who lived through a nuclear disaster. This excluded 11 studies on children, eight on animals, and two on people who did not experience a nuclear disaster firsthand. Thirty-four articles were excluded because of pub- lication type. Editorials, letters to the editor, policy papers, case reports, news articles, conference presentations, and research studies that were purely qualitative in nature were excluded. For inclusion in this review, the source of radiation in the study had to be from a nuclear disaster. This excluded 64 articles that pertained to radiation exposure from on- cology treatments, medical imaging, and other types of medical radiation. We excluded three studies on radiation secondary to the atomic bombings of Hiroshima and Nagasaki in 1945 and one study on a radioactive contamination accident secondary to stolen radio- therapy equipment in Goiania in 1987. Four articles were excluding for studying micro- wave radiation, tanning beds, or mobile phone radiation. We defined the outcome measures as “psychological consequences”, including, but not limited to, psychiatric diagnoses such as PTSD, depression, or anxiety, or clinically significant symptoms pertaining to these diagnoses. Two articles were excluded because they only studied acute stress in the peritraumatic period and did not address any other psychological consequences. We excluded studies with primarily physiological conse- quences as their outcomes. We also excluded studies that had “general psychological dis- tress” as their only outcome measure pertaining to mental health. This further limited the search by 26 papers. After applying the inclusion and exclusion criteria to the search re- sults, 59 studies were included in this review. Behav. Sci. 2021, 11, 113 4 of 20 3. Results Tables 1–3 summarize the key literature on the psychological consequences of nu- clear disasters. Table 1. Studies assessing psychological consequences of the Three Mile Island nuclear disaster. Reference/ Nuclear Sample Final Sample Size Study Period Outcomes Key Findings Disaster 121 (38 in TMI group, 32 Stress (psychologi- Residents of TMI exhibited more symptoms Residents of Three Mile in undamaged nuclear Baum et al. cal, behavioural, of stress (self-report, performance, and cate- Island and three control plant group, 24 in coal August 1980 (1983) [2] and biochemical cholamine levels) than the other three groups plant group, 27 in no measures) groups. plant group) Rates of psychiatric conditions did not in- Psychiatric patients December Mental health diag- 215 (151 from Three crease after the TMI accident. Greater psy- Bromet et al. treated in the six months 1979–January noses (SADS-L), Mile Island, 64 from chological distress was associated with lower (1982) [3] prior to the Three Mile 1980, March– general psychologi- comparison area) social support and perceiving the reactor as Island accident April 1980 cal distress (GSI) dangerous. Residents living within 5 Stress (psychologi- miles of Three Mile Is- cal, behavioral, and Residents of TMI exhibited more symptoms Davidson and 87 (52 in TMI group, 35 land and a control group January 1984 biochemical of stress (self-report, performance, and cate- Baum (1986) [1] in control group) of residents living at least measures), PTSS cholamine levels) and greater PTSS. 80 miles from TMI (IES) December 361 (257 who lived 1979, March Married women who de- within 10 miles of the 1980, Septem- Levels of psychological symptoms were simi- livered a child between Subclinical psycho- Dew et al. TMI facility, 104 who ber 1981, Sep- lar between groups at all timepoints. Pres- January 1978 and March logical sympto- (1987) [4] lived near a plant that tember 1982, ence of a pre-existing psychiatric diagnosis 1979 who experienced a matology (SCL-90) experienced widespread September predicted enduring distress in both groups. community-wide stressor layoffs) 1983 (layoff group only) Prince-Embury Residents of Three Mile Psychological symptoms were chronically el- November Psychological symp- and Rooney Island at the time of the 108 evated for residents who remained at TMI af- 1985 toms (SCL-90-R) (1988) [5] reactor restart in 1985 ter the 1979 accident. Residents of Three Mile A lowering of psychological symptoms oc- Prince-Embury Island at the time of the November Psychological symp- curred between 1985 and 1989 despite in- and Rooney reactor restart in 1985 64 1985, June toms (SCL-90-R) creased lack of control, less faith in experts, (1995) [6] still living in the area in 1989 and increased fear of developing cancer. Mothers from two semi- 436 (312 from Three Women with worse social support were more Solomon (1985) March–April Psychiatric disorder rural regions of Pennsyl- Mile Island, 124 from likely to develop a psychiatric disorder fol- [7] 1980 (SADS-L) vania (TMI and control) the control area) lowing the TMI nuclear accident. Abbreviations: GSI, Global Severity Index; IES, Impact of Event Scale; PTSS, post-traumatic stress symptoms; SADS-L, Schedule for Affective Disorders and Schizophrenia-Lifetime version; SCL-90, Symptom Checklist-90; SCL-90-R, Symp- tom Checklist-90-Revised; TMI, Three Mile Island. Table 2. Studies assessing psychological consequences of the Chernobyl nuclear disaster. Reference/ Nuclear Sample Final Sample Size Study Period Outcomes Key Findings Disaster Workers who experienced ARS reported Abramenko et Male clean-up Depressive 59 1986 more depressive symptoms than those who al. (2017) [19] workers symptoms did not. PTSD (IES-R), MDE Mothers with 797 (254 evacuees, 239 neigh- Evacuees reported more negative risk per- Adams et al. (CIDI), general psy- small children in borhood controls, 203 popula- 2005–2006 ceptions and poorer overall well-being than (2011) [20] chological distress Kyiv, Ukraine tion-based controls) the two control groups. (SCL-90) Evacuees had worse health, more Chernobyl- Mothers with Perceived health, Bromet et al. 600 (300 evacuees, 300 con- February–May related illness, higher Chernobyl-related small children in Chernobyl-related (2002) [21] trols) 1997 stress, and greater rates of PTSD (18% of Kyiv, Ukraine stress, PTSD (IES) evacuees vs. 9.7% of controls). Behav. Sci. 2021, 11, 113 5 of 20 Immigrants from the Common- 520 (87 from high-exposure PTSS (IES), depres- At eight years after the accident, the exposure Cwikel et al. wealth of Inde- areas, 217 from low-exposure sion (CES-D), soma- group had higher rates of PTSS, depressive 1993–1996 (1997) [22] pendent States areas, and 216 from compari- tization (SCL-90), symptoms, somatization, and anxiety than (CIS) living in Is- son areas) anxiety (SCL-90 the comparison group. rael Immigrants from PTSS (IES), depres- the Common- 520 (87 from high-exposure Rates of somatization, depressive symptoms, Cwikel and Ro- sive symptoms wealth of areas, 217 from low-exposure and PTSS symptoms improved at a slower zovski (1998) 1993–1996 (CES-D), somatiza- Independent States areas, and 216 from compari- rate for immigrants who were 55 and older [23] tion (SCL-90), anxi- (CIS) living in Is- son areas) compared to younger immigrants. ety (SCL-90 rael Participants who lived closer to the reactor Russian immi- Depression (BDI), Foster (2002) had higher levels of anxiety and PTSS 15 grants residing in 261 2001 anxiety (BAI), PTSS [24] years after the accident than those who lived New York City (MISS PTSD) further away. Depressive disor- Male clean-up ders, anxiety disor- Clean-up workers were more likely than con- workers sent to March–De- ders, alcohol abuse, trols to experience depression (18.0% vs. Chernobyl be- 692 (295 clean-up workers, cember 2002, and intermittent ex- 13.1%) and suicidal ideation (9.2% vs. 4.1%) Loganovsky et tween 1986 and 397 geographically matched December plosive disorder after the Chernobyl accident. Eighteen years al. (2008) [25] 1990 and geo- controls) 2003–June (CIDI), PTSD (IES), after the accident, rates of depression and graphically 2004 somatization (SCL- PTSD were still elevated in the clean-up matched controls 90), suicidal idea- workers compared to the control group. tion 241 (34 Chernobyl clean-up workers with PTSD and ARS, Radiation PTSD, Radiation PTSD includes “flashforward” 81 Chernobyl clean-up work- neurological defi- phenomena, somatoform disorders, and neu- Patients with PTSD ers with PTSD without ARS, cits, cognitive func- rocognitive deficits. Structural brain changes Loganovsky et and population 76 Chernobyl evacuees with 2011–2012 tions, neurophysio- were demonstrated in Chernobyl clean-up al. (2013) [26] controls PTSD, 28 Afghanistan war logic studies (EEG workers, and changes in bioelectrical brain veterans with PTSD, and 22 and carotid and cer- activity were demonstrated in Chernobyl sur- healthy controls without ebral ultrasounds) vivors with PTSD. PTSD) Men from Estonia who participated Compared to population rates, clean-up Rahu et al. in the Chernobyl 4786 1992–2002 Mortality workers had increased risk of suicide, but no (2006) [27] clean-up between elevated mortality risk. 1986 and 1991 Abbreviations: ARS, acute radiation sickness; BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; CES-D, Cen- ter for Epidemiologic Studies Depression Scale; CIDI, Composite International Diagnostic Interview; IES, Impact of Event Scale; IES-R, Impact of Event Scale-Revised; MDE, major depressive episode; MISS PTSD, Mississippi PTSD Scale; PTSD, post-traumatic stress disorder; PTSS, post-traumatic stress symptoms; SCL-90, Symptom Checklist-90. Table 3. Studies assessing psychological consequences of the Fukushima nuclear disaster. Reference/ Nuclear Sample Final Sample Size Study Period Outcomes Key Findings Disaster Post-traumatic growth, psychologi- Higher post-traumatic growth in volunteers Anderson et al. Fukushima Medical 494 (132 volunteers, 362 July 2014 cal distress (confu- than non-volunteers, but no difference in dis- (2016) [28] University students non-volunteers) sion, anger, and tressing symptoms. sadness) Clinical records of all March 2010– The risk of suicide attempt by high-mortality patients who visited Aoki et al. (2014) 981 (493 in control year, March 2011, Non-fatal suicide at- means was elevated for four months after the the Ohta Nishinouchi [29] 488 in study year) March 2011– tempts disaster. There was no change in rates of low medical center in the March 2012 lethality attempts. study period Psychological func- Cavanagh et al. Members of the U.S. tioning (PTSS, de- Self-reported use of cognitive reappraisal 120 July 2011 (2014) [30] Embassy in Tokyo pressive symptoms, was not related to psychological functioning, and life satisfaction) Behav. Sci. 2021, 11, 113 6 of 20 but demonstrated success using cognitive re- appraisal techniques was associated with fewer symptoms of depression and PTSS. Women living in Fu- kushima who regis- Depressive symp- 28% of women reported depressive symp- Goto et al. (2015) August 2010– tered their pregnan- 8196 toms (two-item toms. Living close to the reactor was associ- [31] July 2011 cies in a one-year pe- screening measure) ated with greater depressive symptoms. riod Women living in Fu- August 2011– 25% of mothers reported depressive symp- kushima who regis- Depressive symp- Goto et al. (2017) 13,109 (6686 in 2012, July 2012, Au- toms in 2012, and 24% reported depressive tered their pregnan- toms (two-item [32] 6423 in 2013) gust 2012–July symptoms in 2013. Higher radiation concern cies in a two-year pe- screening measure) 2013 was associated with depressive symptoms. riod 44.7% of decontamination workers reported Hidaka et al. Fukushima decontam- August–Octo- radiation anxiety. Socially isolated workers 512 Radiation anxiety (2016) [33] ination workers ber 2013 reported more anxiety over radiation expo- sure. March–June New patients in Fuku- Diagnosis of ASD, Increased incidence of new patients with 2010, March– Hori et al. (2016) shima outpatient psy- 2504 (771 in 2010, 1000 in PTSD, adjustment ASD and PTSD in 2011 and decreased inci- June 2011, [34] chiatry clinics in a 2011, 733 in 2012) disorder and de- dence of new patients with depression. These March–June three-month period pression (ICD-10) results returned to pre-disaster levels in 2012. May–June Fukushima nuclear 2011, May– power plant workers Psychological Dis- Post-traumatic stress response symptoms de- Ikeda et al. (2017) 1417 (1053 from Daiichi, June 2012, No- at TEPCO Daiichi (af- tress (K6), PTSS creased over time but remained elevated [35] 707 from Daini) vember 2013, fected reactor) and (IES-R) three years after the nuclear disaster. November Daini (intact reactor) Psychological dis- Behavioural activation was associated with tress (K6), physical lower psychological distress and less physi- Mothers with pre- 37 (18 in behavioural ac- August 2014, symptoms (BJSQ), cal symptoms at the one-month follow-up, Imamura et al. school children in Fu- tivation intervention September radiation anxiety, but not at three months. Behavioural activa- (2016) [36] kushima city and sur- group, 19 in control 2014, Novem- positive well-being tion was associated with higher life satisfac- rounding areas group) ber 2014 (liveliness and life tion and increased liveliness at the three- satisfaction) month follow-up. Women who received Maternal and Child 60,860 (16,001 in 2011, Depressive symp- 27% of mothers reported depressive symp- Ishii et al. (2017) Health Handbooks 14,516 in 2011, 15,218 in 2011–2014 toms (two-item toms in 2011, 26% in 2012, 25% in 2013, and [37] from municipal of- 2013, 14,516 in 2014) screening measure) 23% in 2014. fices in Fukushima from 2011 to 2014 Tokyo undergraduates had the most signifi- Trauma response cant traumatic response immediately after Undergraduates from 435 (106 from Fuku- September– (IES-R), depressive the earthquake. Fukushima undergraduates Ishikawa at al. universities in Fuku- shima, 176 from Tokyo, December symptoms (CES-D), had the highest levels of anger. Kyoto under- (2015) [38] shima, Tokyo, and 153 from Kyoto) 2013 anger (STAXI), anxi- graduates had more anxiety and depressive Kyoto ety (SEA) symptoms 2.5 years after the nuclear disaster than immediately after the accident. 46.5% of female college students reported de- Depressive symp- pressive symptoms. Higher radiation risk Ito et al. (2018) Female college stu- December toms (WHO-5), ra- 288 perception predicted reduced reproductive [39] dents 2015 diation risk percep- confidence, which was ultimately associated tion with increased depressive symptoms. 91.6% of decontamination workers reported at least one type of anxiety. Job security was Kakamu et al. Radiation decontami- August–Octo- 531 Type of anxiety the most common type of anxiety (41.8%) (2019) [40] nation workers ber 2013 and working hours was the least common (6.0%). Greater health anxiety was associated with Residents of Fuku- Health anxiety Kashiwazaki et al. 832 (416 from Fuku- more psychological distress. Mindfulness shima and Tokyo August 2018 (HAI), psychologi- (2020) [41] shima, 416 on Tokyo) was associated with lower health anxiety and aged 20–59 years cal distress (K6) less psychological distress. Behav. Sci. 2021, 11, 113 7 of 20 Adults living in tem- MDE, manic or hy- porary housing for The shelter group had a higher incidence of pomanic episode, three years after the 1941 (1089 in shelter new mood and anxiety disorders in the first Kawakami et al. June–August GAD, panic disor- nuclear disaster and a group, 852 in control year after the disaster, but not in subsequent (2020) [42] 2014 der, PTSD, and alco- control group of resi- group) years. The remission rate for mood and anxi- hol use disorder dents from non-disas- ety disorders was lower in the shelter group. (CIDI) ter areas of East Japan Citizens living in Fukushima were more anx- ious than those living outside Fukushima. Citizens, doctors, and September– Medical students who recently studied radia- Kohzaki et al. medical students in- 2487 (1557 in 2011, 930 in October 2011; Radiation anxiety tion biology were less anxious than the other (2015) [43] side and outside Fu- 2013) August–No- groups. All three groups reported dissatisfac- kushima vember 2013 tion with the government and TEPCO after the nuclear accident. PTSS (IES-R), de- 53.5% reported symptoms of PTSD, and Kukihara et al. Evacuees from Hirono 241 (116 men, 125 December pressive symptoms 66.8% reported symptoms of depression. Re- (2014) [44] Town women) 2011 (ZSDS), resilience silience was shown to be a protective factor (CD-RISC) for PTSD, depression, and general health. In elderly evacuees who did not report a de- pressive tendency at baseline, 37.2% had a Elderly evacuees Kuroda et al. May 2010, Depressive ten- depressive tendency at the second survey. without a baseline de- 438 (2017) [45] May 2013 dency (BCL) Depressive tendency was associated with fe- pressive tendency male sex, older age, and less engagement in social activities. Kuroda, Iwasa, Radiation anxiety, Higher health literacy was associated with Orui, Moriyama, 777 (606 from non-evac- August–Octo- discrimination and lower radiation anxiety in both areas and as- Nakayama, and Fukushima residents uation areas, 171 from ber 2016 prejudice based on sociated with lower discrimination and prej- Yasumura (2018) evacuation areas) radiation exposure udice in the evacuation areas. [13] 23.0% of participants reported anxiety and 12.0% engaged in radiation risk-averse be- Anxiety, radiation Kusama et al. haviours. Those with higher socioeconomic Residents of Japan 10,000 March 2012 risk-averse behav- (2018) [46] status felt less anxious, but engaged in more iours risk-averse behaviours than those with lower socioeconomic status. 23% of female participants and 17% of male Residents from Hira- December Lebowitz (2016) 466 (351 female, 115 participants met criteria for depression. The kata, Japan, and Otsu, 2011–March Depression (CES-D) [47] male) strongest predictors of depression were prop- Japan 2012 erty damage and younger age. Residents from Hira- December Relational satisfaction from both providing Lebowitz (2017) 466 (351 female, 115 kata, Japan, and Otsu, 2011–March Depression (CES-D) and receiving social support buffers against [48] male) Japan 2012 depression. 168 (92 from Town A where evacuation re- Fukushima public strictions were lifted employees working in Depression, PTSD, 17.9% of public employees met criteria for Maeda et al. (2016) several months after the March–Octo- two coastal towns that and suicide risk depression, and 4.8% met criteria for PTSD. [49] accident, 76 from Town ber 2013 were initially evacu- (MINI) 8.9% screened positive for suicide risk. B where evacuation or- ated ders remained at time of study) Radiation anxiety, Higher evaluation of the town’s decontami- Murakami et al. Residents of Maru- perceptions of radi- 174 March 2015 nation efforts was associated with a reduc- (2017) [14] mori Town, Japan ation risk, well-be- tion in radiation anxiety. ing Frequency of laugh- Laughing more frequently was associated Murakami, Hi- ter, mental health with lower radiation anxiety in the absence of rosaki et al. (2018) Fukushima evacuees 34.312 2011–2012 distress (K6), radia- mental health distress, but not in the pres- [50] tion anxiety ence of mental health distress. Certain radiation countermeasures were as- Murakami, Take- Fukushima Radiation anxiety, sociated with lower well-being (thyroid bayashi et al. 1023 August 2016 residents well-being exam, food inspection, explanatory meet- (2018) [51] ings), but the basic survey was associated Behav. Sci. 2021, 11, 113 8 of 20 with greater well-being. The thyroid exam is associated with less radiation anxiety. Japan Ground Self- 1, 6, and 12 Defense Force person- months post- PTSS (IES-R), psy- Duties with radiation exposure risk were not Nagamine et al. nel deployed to the 56,753 mission com- chological distress associated with PTSS or psychological dis- (2018) [52] Great East Japan pletion of de- (K10) tress. Earthquake ployment Radiation anxiety was higher for people who utilized internet sources for information about the nuclear disaster and lower for peo- Nakayama et al. ple who utilized local broadcast TV. Radia- Fukushima residents 868 August 2016 Radiation anxiety (2019) [15] tion anxiety was lower for people who trusted government sources of information and higher for people who trusted citizen groups. 169,175 (71,100 in Janu- Prevalence of PTSS for men was 18.6% in Fukushima residents January 2012, Psychological dis- Oe, Fujii et al. ary 2012, 53,162 in Janu- 2012, 16.3% in 2013, and 15.0% in 2013. Prev- living in evacuation January 2013, tress (K6), PTSS (2016) [53] ary 2013, 44,913 in Feb- alence of PTSS for women was 24.9% in 2012, zones February 2014 (PCL) ruary 2014) 19.9% in 2013, and 18.1% in 2014. Fukushima residents living in areas that Psychological dis- Higher psychological distress was associated Oe, Maeda et al. were considered com- 2011, 2012, 12,371 tress (K6), radiation with greater radiation risk perception and (2016) [54] plete evacuation 2013 risk perception poor social support. zones for three years after the disaster Fukushima residents living in areas that Four trajectories of PTSS were demonstrated: Oe et al. (2017) were considered com- 2011, 2012, PTSS (PCL), radia- PTSS trajectories: chronic (8.1%), resistant 12,371 [55] plete evacuation 2013 tion risk perception (54.9%), recovered (19.3%), and non-recov- zones for three years ered (17.7%). after the disaster Use of public relations information from local 225 (156 forced evacu- Orui et al. (2020) August–Octo- government was associated with lower anxi- Fukushima residents ees, 69 voluntary evacu- Radiation anxiety [16] ber 2016 ety for forced evacuees, but not voluntary ees) evacuees. Male suicide rates in evacuation areas in- Vital statistics from creased immediately after the nuclear disas- the Ministry of ter, then increased again four years after the March 2009– Orui et al. (2018) Health, Labour, and Monthly suicide disaster. Overall, suicide rates decreased for n/a December [56] Welfare on suicide rate males 50–69 years, but increased for males rates in Japan during younger than 30 and 70 and older. Female su- the study period icide rates declined during the first year and then increased over the next three years. Psychological dis- 16% reported psychological distress, 29.7% Rubin et al. (2012) British nationals in Ja- December tress (GHQ-12), an- reported anxiety, and 30.4% reported anger. [57] pan 2011 ger (STAXI-2), anxi- Utilizing low credibility sources was associ- ety (STAI) ated with greater distress, anger, and anxiety. Male dentists who conducted disaster Psychological dis- Greater psychological distress was associated Shigemura et al. September-De- victim identification 49 tress (GHQ-12), with younger age and property loss. PTSS (2018) [58] cember 2011 (DVI) in Fukushima PTSS (IES-R) was associated with extensive property loss. after the 2011 disaster Fukushima nuclear For both plants, PTSS was highly associated power plant workers Shigemura et al. 1411 (831 from Daiichi, May–June with peritraumatic distress. Experiencing dis- at TEPCO Daiichi (af- PTSS (IES-R) (2014) [59] 580 from Daini) 2011 crimination and the presence of a pre-exist- fected reactor) and ing illness were also associated with PTSS. Daini (intact reactor) Systematic review of Rates of psychological distress ranged from studies on the psycho- Shigemura et al. Psychological dis- 8.3 to 65.1%. Rates of depressive symptoms logical consequences 79 studies August 2019 (2020) [10] tress, PTSS, anxiety ranged from 12 to 52.0%. Rates of PTSS of the Fukushima dis- ranged from 10.5 to 62.6%. aster Behav. Sci. 2021, 11, 113 9 of 20 Utilizing rumours as a source of information Sugimoto et al. about the disaster increased radiation anxi- Fukushima residents 969 June–July 2011 Radiation anxiety (2013) [17] ety. Attending a seminar on radiation re- duced radiation anxiety. Systematic review of studies on risk per- ception and anxiety Radiation anxiety is associated with de- Takebayashi et al. regarding radiation mographics, disaster-related stressors, 24 studies May 2017 Radiation anxiety (2017) [12] among people living trusted information, and radiation-related in Japan after the 2011 stressors. Fukushima nuclear disaster Fukushima nuclear Experiencing discrimination at time one pre- power plant workers May–June Psychological dis- dicted higher psychological distress and Tanisho et al. 968 (571 from Daiichi, at TEPCO Daiichi (af- 2011, May– tress (K6), PTSS PTSS at time two. Higher PTSS at time one (2016) [60] 397 from Daini) fected reactor) and June 2012 (IES-R) predicted higher PTSS at time two. PTSS was Daini (intact reactor) associated with older age. Systematic review of Radiation risk perception was associated Emotional and be- studies on the emo- with immediate health effects and fear of fu- havioural conse- Terayama et al. tional and behav- ture health effects. Survivors of nuclear disas- 61 studies August 2019 quences of the Fu- (2020) [11] ioural consequences ters experience lower well-being, greater dis- kushima nuclear of the 2011 Fuku- crimination, and have an increased rate of su- disaster shima nuclear disaster icide. Fukushima residents of Iitate village and Soma city who under- Tsubokura et al. Depressive symp- 12% of participants met criteria for depres- went annual health 564 May 2011 (2014) [61] toms (PHQ-9) sion. evaluations in the year before and the year after the disaster 59.4% of participants had symptoms con- Fukushima evacuees sistent with a diagnosis of PTSD. Predictors Tsujiuchi et al. March–April living in Saitama pre- 350 PTSS (IES-R) of PTSD included chronic physical and men- (2016) [62] 2012 fecture tal illness, lost jobs, and limited social sup- port. Abbreviations: ASD, Acute Stress Disorder; BCL, Basic Checklist; BJSQ, Brief Job Stress Questionnaire; CD-RISC, Connor- Davidson Resilience Scale; CES-D, Center for Epidemiologic Studies Depression Scale; CIDI, Composite International Di- agnostic Interview; GHQ-12, General Health Questionnaire-12; HAI, Health Anxiety Index; ICD-10, International Classi- fication of Diseases, 10th edition; IES-R, Impact of Event Scale-Revised; K6, Kessler 6-Item Psychological Distress Scale; K10, Kessler 10-Item Psychological Distress Scale; MDE, major depressive episode; MINI, Mini-International Neuropsy- chiatric Interview; n/a, not available; PCL, PTSD Checklist; PHQ-9, Patient Health Questionnaire-9; PTSD, post-traumatic stress disorder; PTSS, post-traumatic stress symptoms; SEA, Spence–Essau Anxiety Questionnaire; STAI, State-Trait Anx- iety Inventory; STAXI, State-Trait Anger Expression Inventory; STAXI-2, State-Trait Anger Expression Inventory 2; TEPCO, Tokyo Electric Power Company; WHO-5, World Health Organization-Five Well-Being Index; ZSDS, Zung Self- Rating Depression Scale. 4. Discussion The literature on the mental health consequences of nuclear disasters revealed in- creased prevalence of PTSD, depression, and anxiety. Each of these conditions has associ- ated risk factors and will be discussed in turn. Vulnerable populations and protective fac- tors will be identified because this can help policymakers know where to first allocate services in the aftermath of a nuclear disaster. Although there has been a limited amount of research on interventions aimed at mitigating psychological distress after a nuclear dis- aster, three interventions with modestly positive outlines will be discussed. Population- level interventions, such as radiation countermeasures and media strategies, are outlined. Technology-based supports, such as supportive text messages, that have been successful in the aftermath of other disasters are discussed. Significant limitations are discussed and suggestions for future research are provided. Behav. Sci. 2021, 11, 113 10 of 20 5. Key Mental Health Disorders and Associated Risk Factors 5.1. Post-Traumatic Stress Disorder (PTSD) Stress often peaks during disaster-related events, remains high for a period of time afterwards, and then, gradually decreases [22,26,35,53,55,60]. Lasting symptoms of stress can include hypervigilance, avoidance of reminders of the event, flashbacks, and night- mares. These symptoms may bother people for years after the traumatic incident. PTSD symptomatology rates range from 33.2 to 59.4% in the first year after experiencing a nu- clear accident [44,62]. Not everyone who lives through a nuclear disaster is affected the same way. There are individual variables and disaster-related variables that play a role in the psychological outcomes. Individual variables, such as social isolation [62] and having a pre-existing physical or mental illness [59,62], were associated with higher levels of PTSD. People who experienced discrimination or slurs in the aftermath of a nuclear disaster had higher levels of post-traumatic stress [59,60] and a more prolonged course of post-traumatic stress re- sponse symptoms [35]. Concern about livelihood and lost jobs were also associated with PTSD [62]. Disaster-related variables, such as witnessing the plant exploding and experiencing life-threatening danger, were associated with a more prolonged course of post-traumatic stress response symptoms [35]. Higher levels of stress experienced at the time of the nu- clear disaster, or in the immediate aftermath of the disaster, have been linked to higher levels of stress a year after the disaster [59,60]. Greater exposure to radiation was associated with greater PTSD symptoms both in the year after the accident and 18 years after the accident [25]. Even if there is no actual radiation exposure, living next to a nuclear reactor that has been experiencing problems leads to higher levels of stress than living next to a normally functioning nuclear plant [1,2]. People required to evacuate their homes due to a nuclear disaster are at a higher risk of developing post-traumatic stress response symptoms [35] and are more likely to fit the criteria for a formal PTSD diagnosis [20,21,53]. Evacuees face the compounded risk of greater exposure to radiation due to their location, the stressors of relocation [20], and fear of future nuclear events. 5.2. Depression and Suicidality Depression is also more prevalent in the aftermath of a nuclear disaster. Studies have found that 21.1–66.8% of people experience depressive symptoms [37,44] and 7.1–23% of people meet criteria for a full diagnosis of depression [7,47,61] in the first year after a nu- clear accident. Disaster-related stressors that were associated with greater depressive symptoms were having to evacuate one’s home due to a nuclear disaster [20,42], income reduction, and home water incursion [47]. People with a history of psychiatric illness are also more likely to screen positive for depression in the aftermath of a nuclear disaster [4,31]. Proximity to the nuclear plant and radiation exposure are associated with depression. Those who lived closest to the nuclear reactor reported greater levels of depressive symp- toms [37] and had higher rates of depression [61]. Clean-up workers in Chernobyl who experienced acute radiation sickness (ARS) were more likely to experience depressive symptoms than clean-up workers who did not experience ARS [19]. More specifically, a more significant received dose of external radiation exposure was associated with more depressive symptoms, a formal diagnosis of depression, and the severity of the depression [19]. More Chernobyl clean-up workers experienced depression and suicidal ideation af- ter the accident than a control group of non-clean-up workers from the same area, and this pattern was consistent even 18 years after the incident [25]. Suicidal ideation is often discussed in the context of depression but has been less studied in the nuclear disaster literature. One study found that two years after the Fuku- shima nuclear accident, 8.9% of public employees were considered to have a “suicide risk” Behav. Sci. 2021, 11, 113 11 of 20 [49]. Chernobyl workers were more likely to report suicidal ideation than a similar group of non-clean-up workers from the Chernobyl area, with rates of 9.2% and 4.1%, respec- tively [25]. In addition to increased suicidal ideation, rates of suicide attempts and deaths by suicide were also impacted by the nuclear disaster. The risk of non-fatal suicide attempt via high mortality means (jumping from a significant height, hanging, or stabbing) was significantly higher for four months after the disaster and then decreased to baseline [29]. Rates of completed suicide were affected on a more long-term scale. Men from Estonia who participated in the Chernobyl clean-up had an increased risk of death by suicide compared to a control group from Estonia, but no increase in overall mortality rate 17 years after the accident [27]. In Fukushima, female suicide rates started increasing 1.5 years after the nuclear disaster and male suicide rates started increasing 2.5 years after the accident, although they had initially increased for a brief period immediately after the accident before returning to baseline [56]. For men, changes in suicide rate differed based on age group [56]. Suicide rates decreased for men 50–69 and increased for men younger than 30 and 70 and older [56]. 5.3. Anxiety Disorders In addition to anxiety-related to post-traumatic stress disorder and its associated symptoms, nuclear disasters can contribute to other types of anxiety. This can include generalized anxiety disorder, health anxiety, and non-specific anxious symptomatology. Anxiety surrounding radiation exposure and future health consequences from radiation exposure is a large focus of research on anxiety and nuclear disasters. Damage to one’s home from the nuclear disaster and having to evacuate one's home after the disaster are associated with more significant anxiety [13,21,42,57]. People evacu- ated to temporary housing had higher rates of generalized anxiety disorder [42]. Radia- tion anxiety was also shown to be higher in evacuees than non-evacuees [13,21,42]. Anxiety in the aftermath of a nuclear disaster differs from other disasters because of the ongoing threats to health that radiation exposure holds. Rather than the disaster being a discrete stressor, the stress is ongoing due to potential future risks from radiation expo- sure. Common concerns from radiation exposure are thyroid cancer and other types of cancer, concern about the next generation, food contamination, soil contamination, and genetic effects [43,51]. Those who perceive the risk of radiation exposure as higher have greater levels of psychological distress [4,13,21,46,50,57]. As time passes from the nuclear accident, concern about radiation decreases [32,43]. 6. Protective Factors and Vulnerable Populations Research has demonstrated several protective features for those who experience ac- cidental radiation exposure. Resilience is a protective factor for depression and PTSD after a nuclear disaster [44]. Laughter has been shown to be a protective factor for Fukushima evacuees, as it is associated with improved psychological health [53] and lower percep- tions of genetic risk [50]. Research has found that medical students who volunteered in the Fukushima relief efforts did not have detrimental mental health effects [28]. This could relate to a self-selection bias, because those who volunteer for post-disaster relief work may be less likely to experience mental health concerns [28], but it could also relate to volunteers’ satisfaction from being able to help in a traumatic situation rather than feeling helpless. Social support is also a significant protective factor for those who experience a nu- clear disaster [3,48,53]. For elderly people forced to evacuate to rental living conditions from the Fukushima disaster, engagement in social activities was a protective factor against the development of depression [45]. Greater social support reduced the likelihood of a diagnosis of major depressive disorder or generalized anxiety disorder after a nuclear disaster [7]. Behav. Sci. 2021, 11, 113 12 of 20 Certain vulnerable populations have been identified in the aftermath of a nuclear disaster. Although research has shown impact on areas near and far to the disaster loca- tion [38], people living closest to the reactor are disproportionally affected by a nuclear disaster [22,24]. People who are forced to evacuate their homes due to a nuclear disaster have higher levels of distress [13,20,21,26,32,35,42]. This could be due to multiple mecha- nisms, as evacuees are more likely to have had actual radiation exposure but are also more likely to suffer social consequences such as isolation and lost employment. People with pre-existing psychiatric conditions should also be considered as a group to monitor closely after a nuclear disaster [4]. Demographic variables, such as age and gender, may also affect how people are im- pacted by nuclear disasters. Most research indicates that women are at higher risk for PTSD [52,53], depression [42,45], and anxiety [57]. Other research has shown no associa- tion between gender and PTSD [62] or depression [47]. Older age tends to be associated with greater risk of adverse outcomes after living through a nuclear disaster [23,52,55,60], although not all research has shown this result [47,62]. Research has shown that older age is associated with a greater likelihood of PTSD [52,55,60], depression [45], and anxiety [33]. Although symptoms of depression and PTSD improved over time for all participants, they improved at a slower rate for people 55 and older [23]. Older age is also associated with other factors that predispose people to worse outcomes after a nuclear disaster. Many people emigrated out of the Soviet Union after the Chernobyl nuclear disaster and re- search has shown that immigrants aged 65 and older had more difficulty establishing so- cial supports, finding employment, and learning the language [23]. Older decontamina- tion workers were more likely to work in an unfamiliar environment and in inadequate working conditions [33]. All of these factors may predispose older adults to worse psy- chological outcomes. In contrast, one study found that younger people (age 20–39) had higher levels of depression than middle-aged and older adults [47]. Another study showed that age was not associated with an increased likelihood of a PTSD diagnosis in either direction [62]. 7. Comparison of Three Nuclear Disasters The Three Mile Island incident, the Chernobyl nuclear disaster, and the Fukushima nuclear disaster are the three largest and most well-studied nuclear disasters in history. Despite all three disasters involving the release of radioactive material, the events had many differences. The Three Mile Island incident was a level 5 nuclear disaster on the International Nuclear Event Scale, indicating an accident with wider consequences, whereas Chernobyl and Fukushima were both level 7 nuclear disasters, indicating a major accident. Three Mile Island residents were not exposed to levels of radiation high enough to cause physical damage and had only a brief and voluntary evacuation warning [4]. No deaths have been attributed to the Three Mile Island incident [1]. In contrast, the Cherno- byl nuclear disaster had both deaths from acute radiation exposure and delayed deaths from radiation exposure [8]. The Fukushima nuclear disaster caused no deaths from acute radiation [8], but deaths did occur in the context of the larger disaster, the Tohoku earth- quake and tsunami. Fukushima had a much smaller evacuation zone than Chernobyl, more successful decontamination efforts, and significantly less health effects secondary to radiation exposure [8]. Despite both being level 7 nuclear disasters, some of the differences in outcome could be reasonably attributed to learning from the mistakes of Chernobyl. All three of the nuclear disasters are associated with adverse psychological outcomes. Each of the nuclear disasters were associated with increased symptoms of PTSD [1,2,25,34] and depression [25,27,45] when compared to a control group. Suicidal ideation, attempts, and completed suicides increased in the aftermath of Chernobyl and Fukushima [25,27]. The rates of psychological sequelae are not comparable between disasters for multiple reasons. First, much of the research on the Chernobyl nuclear disaster was conducted 11– 18 years after the accident. Second, the types of control groups used in the research varied between disasters. For the Three Mile Island incident, researchers compared the residents Behav. Sci. 2021, 11, 113 13 of 20 of Three Mile Island with people who lived near normally functioning nuclear plants [1,2]. The studies on Chernobyl use decontamination workers sent to Chernobyl from other countries compared to people from the same country who were not deployed [25,27]. The studies on Fukushima compare the rates of illnesses and symptoms in the same commu- nity pre- and post-nuclear disaster [29,34]. Certain factors made people more susceptible to experiencing adverse psychological outcomes in the aftermath of a nuclear disaster. Lack of social support was associated with adverse psychological outcomes for all three nuclear disasters [3,7,23,33,45,48,62]. Certain risk factors were unique to Chernobyl and Fukushima, given that the Three Mile Island nuclear incident did not release large quantities of radiation, require decontamination workers, or have a mandatory evacuation for residents [1]. For Chernobyl and Fukushima, living closer to the reactor, engaging in work with radiation exposure, and having to evac- uate one’s home were risk factors for PTSD and depression [19–22,24,31,42]. One might hypothesize that Fukushima would have unique risk factors or outcomes compared to the other two nuclear disasters because of the co-occurring earthquake and tsunami, but the literature did not reflect this. The only significant risk factor that was found in Fukushima, but not the other nuclear disasters, was experiencing discrimination [59,60]. The Chernobyl nuclear disaster was caused by human error, whereas the nuclear meltdown in Fukushima was secondary to a natural disaster, yet nuclear plant workers in Fukushima still faced discrimination [59,60]. Discrimination was not a variable in the studies on Chernobyl or Three Mile Island included in this review. Only studies on the Fukushima nuclear disaster addressed protective factors and psychological interventions. This may reflect the large number of years that passed between Chernobyl and Fukushima and the advances in mental health research and treatment that occurred in that period. 8. Individual-Level Interventions Aimed at Mitigating Psychological Distress People who experience nuclear disasters are more likely to struggle with lasting post- traumatic stress, depression, and anxiety. Measures and programs aimed towards miti- gating the physical consequences of radiation exposure have been well-studied, but re- search on programs to improve psychological outcomes after a nuclear disaster has been scarce. Despite the availability of community mental health supports after a disaster, rates of service utilization have been low. In psychiatric patients, experiencing the Three Mile Island accident did not increase inpatient or outpatient service use [3]. Despite the risk of severe mental health sequelae, only 6% of nuclear plant workers from Fukushima had more than three mental health visits in the three years after the disaster [35]. Although research is limited due to the low number of nuclear disasters that have occurred in history, specific psychological interventions have been shown to be helpful in mitigating some of the negative mental health consequences of living through a nuclear disaster. These cognitive interventions include mindfulness training, behavioural activa- tion, and cognitive reappraisal training [30,36,41]. A cross-sectional study based on online self-report questionnaires found that mindfulness has been associated with lower health anxiety and psychological distress, but not radiation risk perception [41]. This indicates that although people still perceive the same risks from radiation exposure, mindfulness training may decrease somatic symptoms by increasing one’s awareness of bodily sensa- tions [41]. A randomized control trial of a two-session behavioural activation intervention was shown to have a small but significant impact on life satisfaction and livelihood, and a more intensive program could potentially have greater efficacy [36]. Learning to suc- cessfully use cognitive reappraisal skills to reduce negative emotions and thoughts asso- ciated with disaster-related pictures is associated with fewer symptoms of depression and PTSD in a correlational self-report study [30]. If people are able to re-evaluate how they think about the traumatic event, they may be able to reduce emotional reactivity, which is associated with poorer functioning [30]. Those who tend to benefit most from cognitive interventions are educated, employed, and have multiple children [36]. These three psy- chological interventions were studied in the aftermath of the Fukushima nuclear disaster Behav. Sci. 2021, 11, 113 14 of 20 and provide a basis for types of interventions that could be implemented in the aftermath of future nuclear disasters. 9. Population-Based Interventions, Public Policy, and Practice Interventions 9.1. Trust in Experts and Sources of Information Where people seek information post-nuclear disaster and which sources of infor- mation are considered the most trustworthy can have an impact on mental health seque- lae. After the Fukushima nuclear disaster, the Japanese government and the Tokyo Elec- tric Power Company (TEPCO) were rated as low in credibility [43,57]. People who utilized the government as their main source of information had higher levels of anxiety [57]. Peo- ple who reported a loss of faith in experts after a nuclear disaster had higher levels of psychological distress [5], anxiety, and depression [51]. People tended to rate mass media information sources as more reliable than government information [17], and thus, local media was utilized as a source of information more often than public relations information from the local government [16]. Improving the credibility of government information and reducing uncertainty is essential for mitigating the psychological impact of radiologic dis- asters [57]. Policies aimed towards bolstering trust in media and government sources of information may be beneficial. Online sources of information have been examined for their associations with mental health sequelae. Some studies have found that utilizing internet sites and blogs as sources of information was associated with higher radiation anxiety [15]. Other studies found no evidence that social media was associated with anxiety about radiation risk [17]. This may indicate that anxiety is related to the type of information utilized online rather than the online form of media itself. In-person sources have also been investigated for perceptions of trustworthiness. People rated information from family physicians and lectures held by radiation experts as the most reliable sources of information, more than any of the media or government sources [43]. Researchers suggested that this finding could be because these people are considered experts in the field of health and radiation or because in-person communica- tion may have a greater impact on perceived trustworthiness than mass media communi- cations [43]. Participation in a seminar on radiation health led to decreased anxiety about radiation risk [17]. Other in-person sources of information, such as citizen groups, word of mouth, and rumours, were associated with higher anxiety [15,17]. This indicates that it is likely the source of information rather than the in-person nature of the communication that is key to reducing psychological distress. 9.2. Radiation Countermeasures Radiation countermeasures are measures implemented at the population level after a nuclear disaster to help mitigate the negative health implications of radiation exposure. The first radiation countermeasure implemented after a nuclear disaster is deploying de- contamination workers to the areas with the highest radiation levels. When people evalu- ated the decontamination efforts of their town as successful, they reported lower radiation anxiety [14]. Unfortunately, the decontamination workers themselves face higher levels of radiation exposure and more significant psychological consequences, including PTSD, depression, and anxiety [19,25,27,33]. Specific measures must be taken to try to reduce the psychological impact of this type of work. Interventions such as training sessions, self- study materials, and wearing a mask have not been shown to decrease anxiety in decon- tamination workers [33]. This points to a critical area of future research. In addition to widespread decontamination work, other radiation countermeasures are implemented to try to limit the negative impact of radiation on community members. Tools to measure an individual's current level of radiation include whole-body counts, which are a measure of internal radiation, and individual dosimeters, which are a measure Behav. Sci. 2021, 11, 113 15 of 20 of external radiation [15]. Although aimed at preventing further radiation exposure, utili- zation of these particular radiation countermeasures was associated with higher levels of anxiety [15,51]. Attending explanatory meetings about radiation and paying close atten- tion to radiation levels in food were also associated with higher levels of anxiety [15,51]. This increase in anxiety could be due to the countermeasures making the thought of radi- ation toxicity more salient in people's minds, or it could be a selection bias that people who are already more anxious about radiation seek out and utilize these countermeasures. Although the aim of these countermeasures is to improve both physical and mental health, they instead might point us to a group of people who would benefit from further psychological interventions to reduce their distress. An important area of future research could focus on how to implement these types of community-wide programs without an increase in anxiety from participation in the radiation countermeasures. 9.3. Technology-Based Population Supports Technology is ubiquitous in most developed countries today and may provide an effective way to reach people struggling with mental health concerns after living through a disaster. Research has shown that mobile phone-based population interventions are a cost-effective and valuable way to provide accessible psychological support [63–71]. These types of programs have been shown to decrease stress, depression, anxiety, and alcohol abuse [64,66,67,69–71]. A randomized control trial on psychiatric patients from Dublin in 2011 with dual diagnoses of depression and alcohol use disorder showed sig- nificantly reduced depressive symptoms and significantly greater abstinence from alcohol in the intervention group that received daily supportive text messages for three months compared to a control group that did not receive these messages [67]. Subsequent research found similar initial results but no lasting benefits six months after the cessation of the daily messages [70]. This type of mobile intervention has also been studied in remote populations. A mo- bile support program was effective in reducing depressive symptoms in Fort McMurry, Alberta, Canada, during the severe wildfires of 2016 [69]. This randomized control trial found that Fort McMurry residents diagnosed with Major Depressive Disorder who were assigned to the intervention group and received twice-daily supportive text messages for three months reported significantly lower depression scores on the Beck Depression In- ventory than the control group (20.8 vs. 24.9) [69]. This program came to be known as Text4Mood, and this program was recognized as a mental health innovation by the Men- tal Health Innovations Network [71]. These types of mobile health interventions are useful in underserviced and remote areas where access to mental health services may be scarce or costly. More recently, a similar program called Text4Hope has been developed and studied in Alberta, Canada. The goal of this program is to reduce psychological distress related to the COVID-19 pandemic and to promote resilience [63–66,68,71]. Text4Hope was created based on the Text4Mood mobile support program and provides subscribers with daily messages based on cognitive behavioural therapy [65]. The program was launched in March 2020, and within one week of launch, 32,805 Alberta residents had signed up for Text4Hope, indicating widespread uptake [63]. Demographic data indicate that people who self-subscribe to this program are mostly female (88%) and have an average age of 44.58 [71]. The average overall satisfaction with this program on a scale of 0–10 was 8.55 [71]. Most participants reported that the daily texts helped them cope with stress (77.1%), helped them cope with anxiety (75.8%), helped them feel connected to a support system (81%), helped them cope with COVID-related stressors (74%), and improved their mental well-being (75.6%). Two studies looking at stress measured with the Perceived Stress Scale-10 (PSS-10), anxiety measured with the General Anxiety Disorder Scale 7 (GAD-7), and depression measured with the Patient Health Questionnaire (PHQ-9) found de- creased scores on all three scales in the intervention group who received the daily sup- Behav. Sci. 2021, 11, 113 16 of 20 portive messages compared to the control group [64,66]. Although these types of techno- logically based interventions have not been studied in prior nuclear disasters, they could be extremely useful to implement in the aftermath of a nuclear disaster, as they are able to be delivered remotely and would be accessible to those forced to evacuate because of the disaster. 10. Limitations There were several limitations of this review. First, the majority of the studies used self-rating questionnaires to investigate symptoms of PTSD, depression, and anxiety, which are inferior to a clinical diagnosis [53]. Second, the most heavily studied nuclear disaster is the Fukushima nuclear disaster of 2011, which occurred in the wake of the Tohoku earthquake and tsunami, meaning that many people in the area experienced the stress of more than one type of disaster. Although this paper excluded studies that focused solely on the tsunami or earthquake, the effects of these disasters could not be controlled for and may have impacted those who experienced the nuclear disaster. Third, there are some limitations that are inherent to studying nuclear disasters, including both the diffi- culty finding ‘healthy controls’ sharing the same situation and the challenges in doing a pre–post design. Fourth, none of the reviewed literature addressed the role of pharmacol- ogy in the treatment of psychiatric conditions associated with nuclear disasters. Fifth, there are limitations inherent to qualitative narrative reviews. Narrative reviews are more subjective than systematic reviews. We attempted to mitigate this bias by outlining our search strategy and clearly stating our study inclusion criteria. Given the qualitive nature of this review, the goal was not to analyze the selected studies, but to synthesize the avail- able literature. A relatively small sample size of 59 studies was included in this review. We chose to exclude manual searching to prioritize transparency in our study selection, but this may have limited the sample size by inadvertently excluding gray literature. Sixth, the studies addressing radiation exposure level did not use actual radiation meas- urements. They instead approximated higher or lower radiation exposure groups based on location of residence [22–24,31], evacuee status [13,16,26,49], or employment [19,23,25,26,33,52,59]. The lack of research on individual doses of radiation exposure and mental health outcomes makes it difficult to determine whether the symptoms are from the physiological impact radiation has on the brain or from the significant stress surround- ing the event, which is also highest for those living the closest to the reactor, those required to evacuate, and those working in the highest risk jobs, such as nuclear plant workers at the time of the accident and decontamination workers after the accident. 11. Conclusions and Future Research This review summarizes the adverse psychological outcomes associated with living through a nuclear disaster. The synthesis of studies from Three Mile Island, Chernobyl, and Fukushima nuclear disasters, indicate that survivors have higher levels of PTSD, de- pression, and anxiety than people who did not experience a nuclear disaster. Certain groups are disproportionally impacted by mental health sequelae after a nuclear disaster, including evacuees and those living in closest proximity to the nuclear reactor. Although the rates of each of these psychiatric conditions decrease over time since the nuclear inci- dent, the significant impact these have on individuals and society should not be over- looked. There are psychological interventions that have shown modest benefit in reducing the adverse psychological outcomes of nuclear disasters, including mindfulness training, behavioral activation, and cognitive reappraisal training. Research into these types of in- terventions in the aftermath of a nuclear disaster has been scarce; thus, further research in this area would be beneficial prior to the next large-scale nuclear disaster. Government- level interventions providing the public with credible sources of information in the after- math of a nuclear disaster reduce fear surrounding radiation exposure. Although neces- sary, some of the measures that are put in place to mitigate the risk of radiation exposure Behav. Sci. 2021, 11, 113 17 of 20 in affected areas actually raise levels of mental health distress. Research could be carried out to see if there are any effective strategies to mitigate the rise in psychological distress due to the necessary radiation countermeasures. Suggestions for future research include technology-based interventions, such as mobile support programs, which are cost-effec- tive strategies to reach large populations in geographically distributed areas. Author Contributions: Conceptualization, V.I.O.A. and C.L.; methodology, C.L.; writing—original draft preparation, C.L.; writing—review and editing, V.I.O.A.; supervision, V.I.O.A. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Institutional Review Board Statement: Not applicable. Informed Consent Statement: Not applicable. 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JMIR MHealth UHealth 2021, 9, e24184, doi:10.2196/24184. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Behavioral Sciences Multidisciplinary Digital Publishing Institute http://www.deepdyve.com/lp/multidisciplinary-digital-publishing-institute/social-and-mental-health-impact-of-nuclear-disaster-in-survivors-a-UtdDVasd0h

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Abstract

Review Social and Mental Health Impact of Nuclear Disaster in Survivors: A Narrative Review Caley Longmuir * and Vincent I. O. Agyapong Department of Psychiatry, University of Alberta, Edmonton, AB T6G 2R3, Canada; agyapong@ualberta.ca * Correspondence: clongmui@ualberta.ca Abstract: This narrative review synthesizes the literature on the psychological consequences of the Three Mile Island nuclear accident of 1979, the Chernobyl nuclear disaster of 1986, and the Fuku- shima nuclear disaster of 2011. A search was conducted on OVID for studies in English from 1966 to 2020. Fifty-nine studies were included. Living through a nuclear disaster is associated with higher levels of PTSD, depression, and anxiety. Decontamination workers, those living in closest proximity to the reactor, and evacuees experience higher rates of mental health problems after a nuclear dis- aster. Those with greater psychological resilience and social supports experience lower rates of psy- chological distress. Individual-level interventions, such as mindfulness training, behavioral activa- tion, and cognitive reappraisal training, have shown modest benefits on improving psychological wellbeing. At the population level, many of the measures in place aimed at reducing exposure to radiation actually increase individuals’ anxiety. Technology-based supports have been studied in other types of natural disasters and it may be beneficial to look at mobile-based interventions for future nuclear disasters. Keywords: radioactive hazard release; nuclear disaster; anxiety; depression; post-traumatic stress disorder; psychological resilience; community mental health services; health policy; post-disaster Citation: Longmuir, C.; interventions Agyapong, V.I.O. Social and Mental Health Impact of Nuclear Disaster in Survivors: A Narrative Review. Behav. Sci. 2021, 11, 113. https:// 1. Introduction doi.org/10.3390/bs11080113 Although nuclear disasters have been relatively uncommon throughout history, their psychological impact is long-lasting and widespread. This paper will describe the seque- Academic Editor: Gianluca Serafini lae of mental health conditions related to nuclear disasters that led to actual or threat of radiation exposure. This paper includes data from the Three Mile Island accident of 1979, Received: 11 May 2021 Accepted: 20 August 2021 the Chernobyl disaster of 1986, and the Fukushima Daiichi nuclear disaster of 2011. This Published: 23 August 2021 paper will not include exposure to radiation from medical means or nuclear warfare. Research on the psychological impact of nuclear disasters began in the aftermath of Publisher’s Note: MDPI stays neu- the Three Mile Island accident, which occurred in Pennsylvania in 1979. This was a level tral with regard to jurisdictional 5 nuclear disaster on the International Nuclear Event Scale (INES). In the initial period claims in published maps and institu- after the accident, Three Mile Island residents received contradictory information about tional affiliations. radiation exposure and an evacuation advisory was released for pregnant women and families with young children [1]. Although a radiation leak did occur from the plant, there has been no evidence to suggest that any residents of Three Mile Island were exposed to high enough levels of radiation to cause physiological consequences [1]. Nonetheless, the Copyright: © 2021 by the authors. Li- threat of radiation exposure still contributed to mental health distress in the residents of censee MDPI, Basel, Switzerland. Three Mile Island [1–7]. This article is an open access article The Chernobyl disaster was the first level 7 nuclear disaster in history and remains distributed under the terms and con- the biggest nuclear disaster to date. Despite the magnitude of this disaster, research on ditions of the Creative Commons At- the Chernobyl nuclear disaster is limited as research coming out of the Soviet Union dur- tribution (CC BY) license (http://crea- ing this time period was restricted. Research on the physiological consequences of the tivecommons.org/licenses/by/4.0/). Behav. Sci. 2021, 11, 113. https://doi.org/10.3390/bs11080113 www.mdpi.com/journal/behavsci Behav. Sci. 2021, 11, 113 2 of 20 Chernobyl nuclear disaster indicates several thousand thyroid cancer cases directly at- tributable to the disaster, increased prevalence of leukemia among decontamination workers, and 134 confirmed cases of acute radiation syndrome [8]. Approximately 50 peo- ple died as a result of high levels of acute radiation [8]. Research in the area of nuclear disasters proliferated exponentially in the aftermath of the Fukushima nuclear disaster of 2011. The Fukushima nuclear disaster was triggered by the Tohoku earthquake and tsunami. The earthquake, with a magnitude of 9.0, trig- gered an automatic shutdown of reactors and the subsequent tsunami flooded the nuclear power plant, which damaged the cooling system [8]. As with the Chernobyl nuclear dis- aster, the Fukushima nuclear disaster was classified as a level 7 nuclear disaster, but the evacuation area around the plant was much smaller and the health effects have been sig- nificantly lower [8]. Unlike Chernobyl, there were no deaths from acute radiation effects in Fukushima and no cases of acute radiation syndrome [8]. Despite this, 116,000 people had to be evacuated and many elderly and hospitalized people lost their lives in the evac- uation process [9]. Though nuclear accidents are uncommon, they lead to serious physical and mental health issues. There is a large breadth of literature on the physical consequences of nuclear disasters and radiation exposure, but psychological sequelae have been less widely stud- ied until recently. Research on the mental health consequences of the Fukushima nuclear disaster has recently been summarized by a two-part systematic review [10,11] and a sys- tematic qualitative review [12]. These articles summarize the psychological consequences of nuclear disasters, including increased levels of general psychological distress, depres- sive symptoms, post-traumatic stress symptoms [10], and radiation anxiety [12], as well as behavioral consequences, such as increased suicide rates [11]. There have been no re- views to date on the mental health consequences of nuclear disasters that include studies from multiple nuclear accidents. For the purposes of this review, radiation anxiety will be defined as health anxiety due to perceived radiation exposure, actual radiation exposure, or potential for radiation exposure in the future. This definition is based on previous re- search [10,11,13–17] and includes concern about current health status, delayed health ef- fects, and genetic effects on offspring and future generations. This paper aims to outline the impact of nuclear disasters on mental health. The types of psychological sequelae that most commonly occur after living through a nuclear disas- ter, including symptoms of post-traumatic stress disorder, depression, and anxiety, will be reviewed and the risk factors and protective factors surrounding the development of these conditions will be described. Specific groups of people, such as plant workers, clean- up workers, and those residing closest to the nuclear reactor, will be discussed, as they have an increased risk of exposure to radioactive material. Recommendations for future research, as well as policies and programs to mitigate the risk of development of mental health conditions post-nuclear disaster and to increase protective factors, will be ad- dressed. 2. Methods 2.1. Search Strategy A literature search of the MEDLINE database through OVID was conducted by one author (C.L.) in December 2020. The search used the MeSH terms “radioactive hazard release”, “nuclear reactors”, “radiation injuries”, “anxiety disorders”, “anxiety”, “depres- sive disorder”, “depression”, “dysthymic disorder”, “depression, reactive”, “adjustment disorders”, “suicide”, and “stress disorders, post-traumatic”. The stages of the literature search are presented in Figure 1. This search strategy yielded 287 research articles. Behav. Sci. 2021, 11, 113 3 of 20 Figure 1. Flow diagram of article selection process, based on Page et al. (2020) [18]. 2.2. Inclusion and Exclusion Criteria This review includes articles published in English between 1966 and 2020. We only included articles with a study population of adults who lived through a nuclear disaster. This excluded 11 studies on children, eight on animals, and two on people who did not experience a nuclear disaster firsthand. Thirty-four articles were excluded because of pub- lication type. Editorials, letters to the editor, policy papers, case reports, news articles, conference presentations, and research studies that were purely qualitative in nature were excluded. For inclusion in this review, the source of radiation in the study had to be from a nuclear disaster. This excluded 64 articles that pertained to radiation exposure from on- cology treatments, medical imaging, and other types of medical radiation. We excluded three studies on radiation secondary to the atomic bombings of Hiroshima and Nagasaki in 1945 and one study on a radioactive contamination accident secondary to stolen radio- therapy equipment in Goiania in 1987. Four articles were excluding for studying micro- wave radiation, tanning beds, or mobile phone radiation. We defined the outcome measures as “psychological consequences”, including, but not limited to, psychiatric diagnoses such as PTSD, depression, or anxiety, or clinically significant symptoms pertaining to these diagnoses. Two articles were excluded because they only studied acute stress in the peritraumatic period and did not address any other psychological consequences. We excluded studies with primarily physiological conse- quences as their outcomes. We also excluded studies that had “general psychological dis- tress” as their only outcome measure pertaining to mental health. This further limited the search by 26 papers. After applying the inclusion and exclusion criteria to the search re- sults, 59 studies were included in this review. Behav. Sci. 2021, 11, 113 4 of 20 3. Results Tables 1–3 summarize the key literature on the psychological consequences of nu- clear disasters. Table 1. Studies assessing psychological consequences of the Three Mile Island nuclear disaster. Reference/ Nuclear Sample Final Sample Size Study Period Outcomes Key Findings Disaster 121 (38 in TMI group, 32 Stress (psychologi- Residents of TMI exhibited more symptoms Residents of Three Mile in undamaged nuclear Baum et al. cal, behavioural, of stress (self-report, performance, and cate- Island and three control plant group, 24 in coal August 1980 (1983) [2] and biochemical cholamine levels) than the other three groups plant group, 27 in no measures) groups. plant group) Rates of psychiatric conditions did not in- Psychiatric patients December Mental health diag- 215 (151 from Three crease after the TMI accident. Greater psy- Bromet et al. treated in the six months 1979–January noses (SADS-L), Mile Island, 64 from chological distress was associated with lower (1982) [3] prior to the Three Mile 1980, March– general psychologi- comparison area) social support and perceiving the reactor as Island accident April 1980 cal distress (GSI) dangerous. Residents living within 5 Stress (psychologi- miles of Three Mile Is- cal, behavioral, and Residents of TMI exhibited more symptoms Davidson and 87 (52 in TMI group, 35 land and a control group January 1984 biochemical of stress (self-report, performance, and cate- Baum (1986) [1] in control group) of residents living at least measures), PTSS cholamine levels) and greater PTSS. 80 miles from TMI (IES) December 361 (257 who lived 1979, March Married women who de- within 10 miles of the 1980, Septem- Levels of psychological symptoms were simi- livered a child between Subclinical psycho- Dew et al. TMI facility, 104 who ber 1981, Sep- lar between groups at all timepoints. Pres- January 1978 and March logical sympto- (1987) [4] lived near a plant that tember 1982, ence of a pre-existing psychiatric diagnosis 1979 who experienced a matology (SCL-90) experienced widespread September predicted enduring distress in both groups. community-wide stressor layoffs) 1983 (layoff group only) Prince-Embury Residents of Three Mile Psychological symptoms were chronically el- November Psychological symp- and Rooney Island at the time of the 108 evated for residents who remained at TMI af- 1985 toms (SCL-90-R) (1988) [5] reactor restart in 1985 ter the 1979 accident. Residents of Three Mile A lowering of psychological symptoms oc- Prince-Embury Island at the time of the November Psychological symp- curred between 1985 and 1989 despite in- and Rooney reactor restart in 1985 64 1985, June toms (SCL-90-R) creased lack of control, less faith in experts, (1995) [6] still living in the area in 1989 and increased fear of developing cancer. Mothers from two semi- 436 (312 from Three Women with worse social support were more Solomon (1985) March–April Psychiatric disorder rural regions of Pennsyl- Mile Island, 124 from likely to develop a psychiatric disorder fol- [7] 1980 (SADS-L) vania (TMI and control) the control area) lowing the TMI nuclear accident. Abbreviations: GSI, Global Severity Index; IES, Impact of Event Scale; PTSS, post-traumatic stress symptoms; SADS-L, Schedule for Affective Disorders and Schizophrenia-Lifetime version; SCL-90, Symptom Checklist-90; SCL-90-R, Symp- tom Checklist-90-Revised; TMI, Three Mile Island. Table 2. Studies assessing psychological consequences of the Chernobyl nuclear disaster. Reference/ Nuclear Sample Final Sample Size Study Period Outcomes Key Findings Disaster Workers who experienced ARS reported Abramenko et Male clean-up Depressive 59 1986 more depressive symptoms than those who al. (2017) [19] workers symptoms did not. PTSD (IES-R), MDE Mothers with 797 (254 evacuees, 239 neigh- Evacuees reported more negative risk per- Adams et al. (CIDI), general psy- small children in borhood controls, 203 popula- 2005–2006 ceptions and poorer overall well-being than (2011) [20] chological distress Kyiv, Ukraine tion-based controls) the two control groups. (SCL-90) Evacuees had worse health, more Chernobyl- Mothers with Perceived health, Bromet et al. 600 (300 evacuees, 300 con- February–May related illness, higher Chernobyl-related small children in Chernobyl-related (2002) [21] trols) 1997 stress, and greater rates of PTSD (18% of Kyiv, Ukraine stress, PTSD (IES) evacuees vs. 9.7% of controls). Behav. Sci. 2021, 11, 113 5 of 20 Immigrants from the Common- 520 (87 from high-exposure PTSS (IES), depres- At eight years after the accident, the exposure Cwikel et al. wealth of Inde- areas, 217 from low-exposure sion (CES-D), soma- group had higher rates of PTSS, depressive 1993–1996 (1997) [22] pendent States areas, and 216 from compari- tization (SCL-90), symptoms, somatization, and anxiety than (CIS) living in Is- son areas) anxiety (SCL-90 the comparison group. rael Immigrants from PTSS (IES), depres- the Common- 520 (87 from high-exposure Rates of somatization, depressive symptoms, Cwikel and Ro- sive symptoms wealth of areas, 217 from low-exposure and PTSS symptoms improved at a slower zovski (1998) 1993–1996 (CES-D), somatiza- Independent States areas, and 216 from compari- rate for immigrants who were 55 and older [23] tion (SCL-90), anxi- (CIS) living in Is- son areas) compared to younger immigrants. ety (SCL-90 rael Participants who lived closer to the reactor Russian immi- Depression (BDI), Foster (2002) had higher levels of anxiety and PTSS 15 grants residing in 261 2001 anxiety (BAI), PTSS [24] years after the accident than those who lived New York City (MISS PTSD) further away. Depressive disor- Male clean-up ders, anxiety disor- Clean-up workers were more likely than con- workers sent to March–De- ders, alcohol abuse, trols to experience depression (18.0% vs. Chernobyl be- 692 (295 clean-up workers, cember 2002, and intermittent ex- 13.1%) and suicidal ideation (9.2% vs. 4.1%) Loganovsky et tween 1986 and 397 geographically matched December plosive disorder after the Chernobyl accident. Eighteen years al. (2008) [25] 1990 and geo- controls) 2003–June (CIDI), PTSD (IES), after the accident, rates of depression and graphically 2004 somatization (SCL- PTSD were still elevated in the clean-up matched controls 90), suicidal idea- workers compared to the control group. tion 241 (34 Chernobyl clean-up workers with PTSD and ARS, Radiation PTSD, Radiation PTSD includes “flashforward” 81 Chernobyl clean-up work- neurological defi- phenomena, somatoform disorders, and neu- Patients with PTSD ers with PTSD without ARS, cits, cognitive func- rocognitive deficits. Structural brain changes Loganovsky et and population 76 Chernobyl evacuees with 2011–2012 tions, neurophysio- were demonstrated in Chernobyl clean-up al. (2013) [26] controls PTSD, 28 Afghanistan war logic studies (EEG workers, and changes in bioelectrical brain veterans with PTSD, and 22 and carotid and cer- activity were demonstrated in Chernobyl sur- healthy controls without ebral ultrasounds) vivors with PTSD. PTSD) Men from Estonia who participated Compared to population rates, clean-up Rahu et al. in the Chernobyl 4786 1992–2002 Mortality workers had increased risk of suicide, but no (2006) [27] clean-up between elevated mortality risk. 1986 and 1991 Abbreviations: ARS, acute radiation sickness; BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; CES-D, Cen- ter for Epidemiologic Studies Depression Scale; CIDI, Composite International Diagnostic Interview; IES, Impact of Event Scale; IES-R, Impact of Event Scale-Revised; MDE, major depressive episode; MISS PTSD, Mississippi PTSD Scale; PTSD, post-traumatic stress disorder; PTSS, post-traumatic stress symptoms; SCL-90, Symptom Checklist-90. Table 3. Studies assessing psychological consequences of the Fukushima nuclear disaster. Reference/ Nuclear Sample Final Sample Size Study Period Outcomes Key Findings Disaster Post-traumatic growth, psychologi- Higher post-traumatic growth in volunteers Anderson et al. Fukushima Medical 494 (132 volunteers, 362 July 2014 cal distress (confu- than non-volunteers, but no difference in dis- (2016) [28] University students non-volunteers) sion, anger, and tressing symptoms. sadness) Clinical records of all March 2010– The risk of suicide attempt by high-mortality patients who visited Aoki et al. (2014) 981 (493 in control year, March 2011, Non-fatal suicide at- means was elevated for four months after the the Ohta Nishinouchi [29] 488 in study year) March 2011– tempts disaster. There was no change in rates of low medical center in the March 2012 lethality attempts. study period Psychological func- Cavanagh et al. Members of the U.S. tioning (PTSS, de- Self-reported use of cognitive reappraisal 120 July 2011 (2014) [30] Embassy in Tokyo pressive symptoms, was not related to psychological functioning, and life satisfaction) Behav. Sci. 2021, 11, 113 6 of 20 but demonstrated success using cognitive re- appraisal techniques was associated with fewer symptoms of depression and PTSS. Women living in Fu- kushima who regis- Depressive symp- 28% of women reported depressive symp- Goto et al. (2015) August 2010– tered their pregnan- 8196 toms (two-item toms. Living close to the reactor was associ- [31] July 2011 cies in a one-year pe- screening measure) ated with greater depressive symptoms. riod Women living in Fu- August 2011– 25% of mothers reported depressive symp- kushima who regis- Depressive symp- Goto et al. (2017) 13,109 (6686 in 2012, July 2012, Au- toms in 2012, and 24% reported depressive tered their pregnan- toms (two-item [32] 6423 in 2013) gust 2012–July symptoms in 2013. Higher radiation concern cies in a two-year pe- screening measure) 2013 was associated with depressive symptoms. riod 44.7% of decontamination workers reported Hidaka et al. Fukushima decontam- August–Octo- radiation anxiety. Socially isolated workers 512 Radiation anxiety (2016) [33] ination workers ber 2013 reported more anxiety over radiation expo- sure. March–June New patients in Fuku- Diagnosis of ASD, Increased incidence of new patients with 2010, March– Hori et al. (2016) shima outpatient psy- 2504 (771 in 2010, 1000 in PTSD, adjustment ASD and PTSD in 2011 and decreased inci- June 2011, [34] chiatry clinics in a 2011, 733 in 2012) disorder and de- dence of new patients with depression. These March–June three-month period pression (ICD-10) results returned to pre-disaster levels in 2012. May–June Fukushima nuclear 2011, May– power plant workers Psychological Dis- Post-traumatic stress response symptoms de- Ikeda et al. (2017) 1417 (1053 from Daiichi, June 2012, No- at TEPCO Daiichi (af- tress (K6), PTSS creased over time but remained elevated [35] 707 from Daini) vember 2013, fected reactor) and (IES-R) three years after the nuclear disaster. November Daini (intact reactor) Psychological dis- Behavioural activation was associated with tress (K6), physical lower psychological distress and less physi- Mothers with pre- 37 (18 in behavioural ac- August 2014, symptoms (BJSQ), cal symptoms at the one-month follow-up, Imamura et al. school children in Fu- tivation intervention September radiation anxiety, but not at three months. Behavioural activa- (2016) [36] kushima city and sur- group, 19 in control 2014, Novem- positive well-being tion was associated with higher life satisfac- rounding areas group) ber 2014 (liveliness and life tion and increased liveliness at the three- satisfaction) month follow-up. Women who received Maternal and Child 60,860 (16,001 in 2011, Depressive symp- 27% of mothers reported depressive symp- Ishii et al. (2017) Health Handbooks 14,516 in 2011, 15,218 in 2011–2014 toms (two-item toms in 2011, 26% in 2012, 25% in 2013, and [37] from municipal of- 2013, 14,516 in 2014) screening measure) 23% in 2014. fices in Fukushima from 2011 to 2014 Tokyo undergraduates had the most signifi- Trauma response cant traumatic response immediately after Undergraduates from 435 (106 from Fuku- September– (IES-R), depressive the earthquake. Fukushima undergraduates Ishikawa at al. universities in Fuku- shima, 176 from Tokyo, December symptoms (CES-D), had the highest levels of anger. Kyoto under- (2015) [38] shima, Tokyo, and 153 from Kyoto) 2013 anger (STAXI), anxi- graduates had more anxiety and depressive Kyoto ety (SEA) symptoms 2.5 years after the nuclear disaster than immediately after the accident. 46.5% of female college students reported de- Depressive symp- pressive symptoms. Higher radiation risk Ito et al. (2018) Female college stu- December toms (WHO-5), ra- 288 perception predicted reduced reproductive [39] dents 2015 diation risk percep- confidence, which was ultimately associated tion with increased depressive symptoms. 91.6% of decontamination workers reported at least one type of anxiety. Job security was Kakamu et al. Radiation decontami- August–Octo- 531 Type of anxiety the most common type of anxiety (41.8%) (2019) [40] nation workers ber 2013 and working hours was the least common (6.0%). Greater health anxiety was associated with Residents of Fuku- Health anxiety Kashiwazaki et al. 832 (416 from Fuku- more psychological distress. Mindfulness shima and Tokyo August 2018 (HAI), psychologi- (2020) [41] shima, 416 on Tokyo) was associated with lower health anxiety and aged 20–59 years cal distress (K6) less psychological distress. Behav. Sci. 2021, 11, 113 7 of 20 Adults living in tem- MDE, manic or hy- porary housing for The shelter group had a higher incidence of pomanic episode, three years after the 1941 (1089 in shelter new mood and anxiety disorders in the first Kawakami et al. June–August GAD, panic disor- nuclear disaster and a group, 852 in control year after the disaster, but not in subsequent (2020) [42] 2014 der, PTSD, and alco- control group of resi- group) years. The remission rate for mood and anxi- hol use disorder dents from non-disas- ety disorders was lower in the shelter group. (CIDI) ter areas of East Japan Citizens living in Fukushima were more anx- ious than those living outside Fukushima. Citizens, doctors, and September– Medical students who recently studied radia- Kohzaki et al. medical students in- 2487 (1557 in 2011, 930 in October 2011; Radiation anxiety tion biology were less anxious than the other (2015) [43] side and outside Fu- 2013) August–No- groups. All three groups reported dissatisfac- kushima vember 2013 tion with the government and TEPCO after the nuclear accident. PTSS (IES-R), de- 53.5% reported symptoms of PTSD, and Kukihara et al. Evacuees from Hirono 241 (116 men, 125 December pressive symptoms 66.8% reported symptoms of depression. Re- (2014) [44] Town women) 2011 (ZSDS), resilience silience was shown to be a protective factor (CD-RISC) for PTSD, depression, and general health. In elderly evacuees who did not report a de- pressive tendency at baseline, 37.2% had a Elderly evacuees Kuroda et al. May 2010, Depressive ten- depressive tendency at the second survey. without a baseline de- 438 (2017) [45] May 2013 dency (BCL) Depressive tendency was associated with fe- pressive tendency male sex, older age, and less engagement in social activities. Kuroda, Iwasa, Radiation anxiety, Higher health literacy was associated with Orui, Moriyama, 777 (606 from non-evac- August–Octo- discrimination and lower radiation anxiety in both areas and as- Nakayama, and Fukushima residents uation areas, 171 from ber 2016 prejudice based on sociated with lower discrimination and prej- Yasumura (2018) evacuation areas) radiation exposure udice in the evacuation areas. [13] 23.0% of participants reported anxiety and 12.0% engaged in radiation risk-averse be- Anxiety, radiation Kusama et al. haviours. Those with higher socioeconomic Residents of Japan 10,000 March 2012 risk-averse behav- (2018) [46] status felt less anxious, but engaged in more iours risk-averse behaviours than those with lower socioeconomic status. 23% of female participants and 17% of male Residents from Hira- December Lebowitz (2016) 466 (351 female, 115 participants met criteria for depression. The kata, Japan, and Otsu, 2011–March Depression (CES-D) [47] male) strongest predictors of depression were prop- Japan 2012 erty damage and younger age. Residents from Hira- December Relational satisfaction from both providing Lebowitz (2017) 466 (351 female, 115 kata, Japan, and Otsu, 2011–March Depression (CES-D) and receiving social support buffers against [48] male) Japan 2012 depression. 168 (92 from Town A where evacuation re- Fukushima public strictions were lifted employees working in Depression, PTSD, 17.9% of public employees met criteria for Maeda et al. (2016) several months after the March–Octo- two coastal towns that and suicide risk depression, and 4.8% met criteria for PTSD. [49] accident, 76 from Town ber 2013 were initially evacu- (MINI) 8.9% screened positive for suicide risk. B where evacuation or- ated ders remained at time of study) Radiation anxiety, Higher evaluation of the town’s decontami- Murakami et al. Residents of Maru- perceptions of radi- 174 March 2015 nation efforts was associated with a reduc- (2017) [14] mori Town, Japan ation risk, well-be- tion in radiation anxiety. ing Frequency of laugh- Laughing more frequently was associated Murakami, Hi- ter, mental health with lower radiation anxiety in the absence of rosaki et al. (2018) Fukushima evacuees 34.312 2011–2012 distress (K6), radia- mental health distress, but not in the pres- [50] tion anxiety ence of mental health distress. Certain radiation countermeasures were as- Murakami, Take- Fukushima Radiation anxiety, sociated with lower well-being (thyroid bayashi et al. 1023 August 2016 residents well-being exam, food inspection, explanatory meet- (2018) [51] ings), but the basic survey was associated Behav. Sci. 2021, 11, 113 8 of 20 with greater well-being. The thyroid exam is associated with less radiation anxiety. Japan Ground Self- 1, 6, and 12 Defense Force person- months post- PTSS (IES-R), psy- Duties with radiation exposure risk were not Nagamine et al. nel deployed to the 56,753 mission com- chological distress associated with PTSS or psychological dis- (2018) [52] Great East Japan pletion of de- (K10) tress. Earthquake ployment Radiation anxiety was higher for people who utilized internet sources for information about the nuclear disaster and lower for peo- Nakayama et al. ple who utilized local broadcast TV. Radia- Fukushima residents 868 August 2016 Radiation anxiety (2019) [15] tion anxiety was lower for people who trusted government sources of information and higher for people who trusted citizen groups. 169,175 (71,100 in Janu- Prevalence of PTSS for men was 18.6% in Fukushima residents January 2012, Psychological dis- Oe, Fujii et al. ary 2012, 53,162 in Janu- 2012, 16.3% in 2013, and 15.0% in 2013. Prev- living in evacuation January 2013, tress (K6), PTSS (2016) [53] ary 2013, 44,913 in Feb- alence of PTSS for women was 24.9% in 2012, zones February 2014 (PCL) ruary 2014) 19.9% in 2013, and 18.1% in 2014. Fukushima residents living in areas that Psychological dis- Higher psychological distress was associated Oe, Maeda et al. were considered com- 2011, 2012, 12,371 tress (K6), radiation with greater radiation risk perception and (2016) [54] plete evacuation 2013 risk perception poor social support. zones for three years after the disaster Fukushima residents living in areas that Four trajectories of PTSS were demonstrated: Oe et al. (2017) were considered com- 2011, 2012, PTSS (PCL), radia- PTSS trajectories: chronic (8.1%), resistant 12,371 [55] plete evacuation 2013 tion risk perception (54.9%), recovered (19.3%), and non-recov- zones for three years ered (17.7%). after the disaster Use of public relations information from local 225 (156 forced evacu- Orui et al. (2020) August–Octo- government was associated with lower anxi- Fukushima residents ees, 69 voluntary evacu- Radiation anxiety [16] ber 2016 ety for forced evacuees, but not voluntary ees) evacuees. Male suicide rates in evacuation areas in- Vital statistics from creased immediately after the nuclear disas- the Ministry of ter, then increased again four years after the March 2009– Orui et al. (2018) Health, Labour, and Monthly suicide disaster. Overall, suicide rates decreased for n/a December [56] Welfare on suicide rate males 50–69 years, but increased for males rates in Japan during younger than 30 and 70 and older. Female su- the study period icide rates declined during the first year and then increased over the next three years. Psychological dis- 16% reported psychological distress, 29.7% Rubin et al. (2012) British nationals in Ja- December tress (GHQ-12), an- reported anxiety, and 30.4% reported anger. [57] pan 2011 ger (STAXI-2), anxi- Utilizing low credibility sources was associ- ety (STAI) ated with greater distress, anger, and anxiety. Male dentists who conducted disaster Psychological dis- Greater psychological distress was associated Shigemura et al. September-De- victim identification 49 tress (GHQ-12), with younger age and property loss. PTSS (2018) [58] cember 2011 (DVI) in Fukushima PTSS (IES-R) was associated with extensive property loss. after the 2011 disaster Fukushima nuclear For both plants, PTSS was highly associated power plant workers Shigemura et al. 1411 (831 from Daiichi, May–June with peritraumatic distress. Experiencing dis- at TEPCO Daiichi (af- PTSS (IES-R) (2014) [59] 580 from Daini) 2011 crimination and the presence of a pre-exist- fected reactor) and ing illness were also associated with PTSS. Daini (intact reactor) Systematic review of Rates of psychological distress ranged from studies on the psycho- Shigemura et al. Psychological dis- 8.3 to 65.1%. Rates of depressive symptoms logical consequences 79 studies August 2019 (2020) [10] tress, PTSS, anxiety ranged from 12 to 52.0%. Rates of PTSS of the Fukushima dis- ranged from 10.5 to 62.6%. aster Behav. Sci. 2021, 11, 113 9 of 20 Utilizing rumours as a source of information Sugimoto et al. about the disaster increased radiation anxi- Fukushima residents 969 June–July 2011 Radiation anxiety (2013) [17] ety. Attending a seminar on radiation re- duced radiation anxiety. Systematic review of studies on risk per- ception and anxiety Radiation anxiety is associated with de- Takebayashi et al. regarding radiation mographics, disaster-related stressors, 24 studies May 2017 Radiation anxiety (2017) [12] among people living trusted information, and radiation-related in Japan after the 2011 stressors. Fukushima nuclear disaster Fukushima nuclear Experiencing discrimination at time one pre- power plant workers May–June Psychological dis- dicted higher psychological distress and Tanisho et al. 968 (571 from Daiichi, at TEPCO Daiichi (af- 2011, May– tress (K6), PTSS PTSS at time two. Higher PTSS at time one (2016) [60] 397 from Daini) fected reactor) and June 2012 (IES-R) predicted higher PTSS at time two. PTSS was Daini (intact reactor) associated with older age. Systematic review of Radiation risk perception was associated Emotional and be- studies on the emo- with immediate health effects and fear of fu- havioural conse- Terayama et al. tional and behav- ture health effects. Survivors of nuclear disas- 61 studies August 2019 quences of the Fu- (2020) [11] ioural consequences ters experience lower well-being, greater dis- kushima nuclear of the 2011 Fuku- crimination, and have an increased rate of su- disaster shima nuclear disaster icide. Fukushima residents of Iitate village and Soma city who under- Tsubokura et al. Depressive symp- 12% of participants met criteria for depres- went annual health 564 May 2011 (2014) [61] toms (PHQ-9) sion. evaluations in the year before and the year after the disaster 59.4% of participants had symptoms con- Fukushima evacuees sistent with a diagnosis of PTSD. Predictors Tsujiuchi et al. March–April living in Saitama pre- 350 PTSS (IES-R) of PTSD included chronic physical and men- (2016) [62] 2012 fecture tal illness, lost jobs, and limited social sup- port. Abbreviations: ASD, Acute Stress Disorder; BCL, Basic Checklist; BJSQ, Brief Job Stress Questionnaire; CD-RISC, Connor- Davidson Resilience Scale; CES-D, Center for Epidemiologic Studies Depression Scale; CIDI, Composite International Di- agnostic Interview; GHQ-12, General Health Questionnaire-12; HAI, Health Anxiety Index; ICD-10, International Classi- fication of Diseases, 10th edition; IES-R, Impact of Event Scale-Revised; K6, Kessler 6-Item Psychological Distress Scale; K10, Kessler 10-Item Psychological Distress Scale; MDE, major depressive episode; MINI, Mini-International Neuropsy- chiatric Interview; n/a, not available; PCL, PTSD Checklist; PHQ-9, Patient Health Questionnaire-9; PTSD, post-traumatic stress disorder; PTSS, post-traumatic stress symptoms; SEA, Spence–Essau Anxiety Questionnaire; STAI, State-Trait Anx- iety Inventory; STAXI, State-Trait Anger Expression Inventory; STAXI-2, State-Trait Anger Expression Inventory 2; TEPCO, Tokyo Electric Power Company; WHO-5, World Health Organization-Five Well-Being Index; ZSDS, Zung Self- Rating Depression Scale. 4. Discussion The literature on the mental health consequences of nuclear disasters revealed in- creased prevalence of PTSD, depression, and anxiety. Each of these conditions has associ- ated risk factors and will be discussed in turn. Vulnerable populations and protective fac- tors will be identified because this can help policymakers know where to first allocate services in the aftermath of a nuclear disaster. Although there has been a limited amount of research on interventions aimed at mitigating psychological distress after a nuclear dis- aster, three interventions with modestly positive outlines will be discussed. Population- level interventions, such as radiation countermeasures and media strategies, are outlined. Technology-based supports, such as supportive text messages, that have been successful in the aftermath of other disasters are discussed. Significant limitations are discussed and suggestions for future research are provided. Behav. Sci. 2021, 11, 113 10 of 20 5. Key Mental Health Disorders and Associated Risk Factors 5.1. Post-Traumatic Stress Disorder (PTSD) Stress often peaks during disaster-related events, remains high for a period of time afterwards, and then, gradually decreases [22,26,35,53,55,60]. Lasting symptoms of stress can include hypervigilance, avoidance of reminders of the event, flashbacks, and night- mares. These symptoms may bother people for years after the traumatic incident. PTSD symptomatology rates range from 33.2 to 59.4% in the first year after experiencing a nu- clear accident [44,62]. Not everyone who lives through a nuclear disaster is affected the same way. There are individual variables and disaster-related variables that play a role in the psychological outcomes. Individual variables, such as social isolation [62] and having a pre-existing physical or mental illness [59,62], were associated with higher levels of PTSD. People who experienced discrimination or slurs in the aftermath of a nuclear disaster had higher levels of post-traumatic stress [59,60] and a more prolonged course of post-traumatic stress re- sponse symptoms [35]. Concern about livelihood and lost jobs were also associated with PTSD [62]. Disaster-related variables, such as witnessing the plant exploding and experiencing life-threatening danger, were associated with a more prolonged course of post-traumatic stress response symptoms [35]. Higher levels of stress experienced at the time of the nu- clear disaster, or in the immediate aftermath of the disaster, have been linked to higher levels of stress a year after the disaster [59,60]. Greater exposure to radiation was associated with greater PTSD symptoms both in the year after the accident and 18 years after the accident [25]. Even if there is no actual radiation exposure, living next to a nuclear reactor that has been experiencing problems leads to higher levels of stress than living next to a normally functioning nuclear plant [1,2]. People required to evacuate their homes due to a nuclear disaster are at a higher risk of developing post-traumatic stress response symptoms [35] and are more likely to fit the criteria for a formal PTSD diagnosis [20,21,53]. Evacuees face the compounded risk of greater exposure to radiation due to their location, the stressors of relocation [20], and fear of future nuclear events. 5.2. Depression and Suicidality Depression is also more prevalent in the aftermath of a nuclear disaster. Studies have found that 21.1–66.8% of people experience depressive symptoms [37,44] and 7.1–23% of people meet criteria for a full diagnosis of depression [7,47,61] in the first year after a nu- clear accident. Disaster-related stressors that were associated with greater depressive symptoms were having to evacuate one’s home due to a nuclear disaster [20,42], income reduction, and home water incursion [47]. People with a history of psychiatric illness are also more likely to screen positive for depression in the aftermath of a nuclear disaster [4,31]. Proximity to the nuclear plant and radiation exposure are associated with depression. Those who lived closest to the nuclear reactor reported greater levels of depressive symp- toms [37] and had higher rates of depression [61]. Clean-up workers in Chernobyl who experienced acute radiation sickness (ARS) were more likely to experience depressive symptoms than clean-up workers who did not experience ARS [19]. More specifically, a more significant received dose of external radiation exposure was associated with more depressive symptoms, a formal diagnosis of depression, and the severity of the depression [19]. More Chernobyl clean-up workers experienced depression and suicidal ideation af- ter the accident than a control group of non-clean-up workers from the same area, and this pattern was consistent even 18 years after the incident [25]. Suicidal ideation is often discussed in the context of depression but has been less studied in the nuclear disaster literature. One study found that two years after the Fuku- shima nuclear accident, 8.9% of public employees were considered to have a “suicide risk” Behav. Sci. 2021, 11, 113 11 of 20 [49]. Chernobyl workers were more likely to report suicidal ideation than a similar group of non-clean-up workers from the Chernobyl area, with rates of 9.2% and 4.1%, respec- tively [25]. In addition to increased suicidal ideation, rates of suicide attempts and deaths by suicide were also impacted by the nuclear disaster. The risk of non-fatal suicide attempt via high mortality means (jumping from a significant height, hanging, or stabbing) was significantly higher for four months after the disaster and then decreased to baseline [29]. Rates of completed suicide were affected on a more long-term scale. Men from Estonia who participated in the Chernobyl clean-up had an increased risk of death by suicide compared to a control group from Estonia, but no increase in overall mortality rate 17 years after the accident [27]. In Fukushima, female suicide rates started increasing 1.5 years after the nuclear disaster and male suicide rates started increasing 2.5 years after the accident, although they had initially increased for a brief period immediately after the accident before returning to baseline [56]. For men, changes in suicide rate differed based on age group [56]. Suicide rates decreased for men 50–69 and increased for men younger than 30 and 70 and older [56]. 5.3. Anxiety Disorders In addition to anxiety-related to post-traumatic stress disorder and its associated symptoms, nuclear disasters can contribute to other types of anxiety. This can include generalized anxiety disorder, health anxiety, and non-specific anxious symptomatology. Anxiety surrounding radiation exposure and future health consequences from radiation exposure is a large focus of research on anxiety and nuclear disasters. Damage to one’s home from the nuclear disaster and having to evacuate one's home after the disaster are associated with more significant anxiety [13,21,42,57]. People evacu- ated to temporary housing had higher rates of generalized anxiety disorder [42]. Radia- tion anxiety was also shown to be higher in evacuees than non-evacuees [13,21,42]. Anxiety in the aftermath of a nuclear disaster differs from other disasters because of the ongoing threats to health that radiation exposure holds. Rather than the disaster being a discrete stressor, the stress is ongoing due to potential future risks from radiation expo- sure. Common concerns from radiation exposure are thyroid cancer and other types of cancer, concern about the next generation, food contamination, soil contamination, and genetic effects [43,51]. Those who perceive the risk of radiation exposure as higher have greater levels of psychological distress [4,13,21,46,50,57]. As time passes from the nuclear accident, concern about radiation decreases [32,43]. 6. Protective Factors and Vulnerable Populations Research has demonstrated several protective features for those who experience ac- cidental radiation exposure. Resilience is a protective factor for depression and PTSD after a nuclear disaster [44]. Laughter has been shown to be a protective factor for Fukushima evacuees, as it is associated with improved psychological health [53] and lower percep- tions of genetic risk [50]. Research has found that medical students who volunteered in the Fukushima relief efforts did not have detrimental mental health effects [28]. This could relate to a self-selection bias, because those who volunteer for post-disaster relief work may be less likely to experience mental health concerns [28], but it could also relate to volunteers’ satisfaction from being able to help in a traumatic situation rather than feeling helpless. Social support is also a significant protective factor for those who experience a nu- clear disaster [3,48,53]. For elderly people forced to evacuate to rental living conditions from the Fukushima disaster, engagement in social activities was a protective factor against the development of depression [45]. Greater social support reduced the likelihood of a diagnosis of major depressive disorder or generalized anxiety disorder after a nuclear disaster [7]. Behav. Sci. 2021, 11, 113 12 of 20 Certain vulnerable populations have been identified in the aftermath of a nuclear disaster. Although research has shown impact on areas near and far to the disaster loca- tion [38], people living closest to the reactor are disproportionally affected by a nuclear disaster [22,24]. People who are forced to evacuate their homes due to a nuclear disaster have higher levels of distress [13,20,21,26,32,35,42]. This could be due to multiple mecha- nisms, as evacuees are more likely to have had actual radiation exposure but are also more likely to suffer social consequences such as isolation and lost employment. People with pre-existing psychiatric conditions should also be considered as a group to monitor closely after a nuclear disaster [4]. Demographic variables, such as age and gender, may also affect how people are im- pacted by nuclear disasters. Most research indicates that women are at higher risk for PTSD [52,53], depression [42,45], and anxiety [57]. Other research has shown no associa- tion between gender and PTSD [62] or depression [47]. Older age tends to be associated with greater risk of adverse outcomes after living through a nuclear disaster [23,52,55,60], although not all research has shown this result [47,62]. Research has shown that older age is associated with a greater likelihood of PTSD [52,55,60], depression [45], and anxiety [33]. Although symptoms of depression and PTSD improved over time for all participants, they improved at a slower rate for people 55 and older [23]. Older age is also associated with other factors that predispose people to worse outcomes after a nuclear disaster. Many people emigrated out of the Soviet Union after the Chernobyl nuclear disaster and re- search has shown that immigrants aged 65 and older had more difficulty establishing so- cial supports, finding employment, and learning the language [23]. Older decontamina- tion workers were more likely to work in an unfamiliar environment and in inadequate working conditions [33]. All of these factors may predispose older adults to worse psy- chological outcomes. In contrast, one study found that younger people (age 20–39) had higher levels of depression than middle-aged and older adults [47]. Another study showed that age was not associated with an increased likelihood of a PTSD diagnosis in either direction [62]. 7. Comparison of Three Nuclear Disasters The Three Mile Island incident, the Chernobyl nuclear disaster, and the Fukushima nuclear disaster are the three largest and most well-studied nuclear disasters in history. Despite all three disasters involving the release of radioactive material, the events had many differences. The Three Mile Island incident was a level 5 nuclear disaster on the International Nuclear Event Scale, indicating an accident with wider consequences, whereas Chernobyl and Fukushima were both level 7 nuclear disasters, indicating a major accident. Three Mile Island residents were not exposed to levels of radiation high enough to cause physical damage and had only a brief and voluntary evacuation warning [4]. No deaths have been attributed to the Three Mile Island incident [1]. In contrast, the Cherno- byl nuclear disaster had both deaths from acute radiation exposure and delayed deaths from radiation exposure [8]. The Fukushima nuclear disaster caused no deaths from acute radiation [8], but deaths did occur in the context of the larger disaster, the Tohoku earth- quake and tsunami. Fukushima had a much smaller evacuation zone than Chernobyl, more successful decontamination efforts, and significantly less health effects secondary to radiation exposure [8]. Despite both being level 7 nuclear disasters, some of the differences in outcome could be reasonably attributed to learning from the mistakes of Chernobyl. All three of the nuclear disasters are associated with adverse psychological outcomes. Each of the nuclear disasters were associated with increased symptoms of PTSD [1,2,25,34] and depression [25,27,45] when compared to a control group. Suicidal ideation, attempts, and completed suicides increased in the aftermath of Chernobyl and Fukushima [25,27]. The rates of psychological sequelae are not comparable between disasters for multiple reasons. First, much of the research on the Chernobyl nuclear disaster was conducted 11– 18 years after the accident. Second, the types of control groups used in the research varied between disasters. For the Three Mile Island incident, researchers compared the residents Behav. Sci. 2021, 11, 113 13 of 20 of Three Mile Island with people who lived near normally functioning nuclear plants [1,2]. The studies on Chernobyl use decontamination workers sent to Chernobyl from other countries compared to people from the same country who were not deployed [25,27]. The studies on Fukushima compare the rates of illnesses and symptoms in the same commu- nity pre- and post-nuclear disaster [29,34]. Certain factors made people more susceptible to experiencing adverse psychological outcomes in the aftermath of a nuclear disaster. Lack of social support was associated with adverse psychological outcomes for all three nuclear disasters [3,7,23,33,45,48,62]. Certain risk factors were unique to Chernobyl and Fukushima, given that the Three Mile Island nuclear incident did not release large quantities of radiation, require decontamination workers, or have a mandatory evacuation for residents [1]. For Chernobyl and Fukushima, living closer to the reactor, engaging in work with radiation exposure, and having to evac- uate one’s home were risk factors for PTSD and depression [19–22,24,31,42]. One might hypothesize that Fukushima would have unique risk factors or outcomes compared to the other two nuclear disasters because of the co-occurring earthquake and tsunami, but the literature did not reflect this. The only significant risk factor that was found in Fukushima, but not the other nuclear disasters, was experiencing discrimination [59,60]. The Chernobyl nuclear disaster was caused by human error, whereas the nuclear meltdown in Fukushima was secondary to a natural disaster, yet nuclear plant workers in Fukushima still faced discrimination [59,60]. Discrimination was not a variable in the studies on Chernobyl or Three Mile Island included in this review. Only studies on the Fukushima nuclear disaster addressed protective factors and psychological interventions. This may reflect the large number of years that passed between Chernobyl and Fukushima and the advances in mental health research and treatment that occurred in that period. 8. Individual-Level Interventions Aimed at Mitigating Psychological Distress People who experience nuclear disasters are more likely to struggle with lasting post- traumatic stress, depression, and anxiety. Measures and programs aimed towards miti- gating the physical consequences of radiation exposure have been well-studied, but re- search on programs to improve psychological outcomes after a nuclear disaster has been scarce. Despite the availability of community mental health supports after a disaster, rates of service utilization have been low. In psychiatric patients, experiencing the Three Mile Island accident did not increase inpatient or outpatient service use [3]. Despite the risk of severe mental health sequelae, only 6% of nuclear plant workers from Fukushima had more than three mental health visits in the three years after the disaster [35]. Although research is limited due to the low number of nuclear disasters that have occurred in history, specific psychological interventions have been shown to be helpful in mitigating some of the negative mental health consequences of living through a nuclear disaster. These cognitive interventions include mindfulness training, behavioural activa- tion, and cognitive reappraisal training [30,36,41]. A cross-sectional study based on online self-report questionnaires found that mindfulness has been associated with lower health anxiety and psychological distress, but not radiation risk perception [41]. This indicates that although people still perceive the same risks from radiation exposure, mindfulness training may decrease somatic symptoms by increasing one’s awareness of bodily sensa- tions [41]. A randomized control trial of a two-session behavioural activation intervention was shown to have a small but significant impact on life satisfaction and livelihood, and a more intensive program could potentially have greater efficacy [36]. Learning to suc- cessfully use cognitive reappraisal skills to reduce negative emotions and thoughts asso- ciated with disaster-related pictures is associated with fewer symptoms of depression and PTSD in a correlational self-report study [30]. If people are able to re-evaluate how they think about the traumatic event, they may be able to reduce emotional reactivity, which is associated with poorer functioning [30]. Those who tend to benefit most from cognitive interventions are educated, employed, and have multiple children [36]. These three psy- chological interventions were studied in the aftermath of the Fukushima nuclear disaster Behav. Sci. 2021, 11, 113 14 of 20 and provide a basis for types of interventions that could be implemented in the aftermath of future nuclear disasters. 9. Population-Based Interventions, Public Policy, and Practice Interventions 9.1. Trust in Experts and Sources of Information Where people seek information post-nuclear disaster and which sources of infor- mation are considered the most trustworthy can have an impact on mental health seque- lae. After the Fukushima nuclear disaster, the Japanese government and the Tokyo Elec- tric Power Company (TEPCO) were rated as low in credibility [43,57]. People who utilized the government as their main source of information had higher levels of anxiety [57]. Peo- ple who reported a loss of faith in experts after a nuclear disaster had higher levels of psychological distress [5], anxiety, and depression [51]. People tended to rate mass media information sources as more reliable than government information [17], and thus, local media was utilized as a source of information more often than public relations information from the local government [16]. Improving the credibility of government information and reducing uncertainty is essential for mitigating the psychological impact of radiologic dis- asters [57]. Policies aimed towards bolstering trust in media and government sources of information may be beneficial. Online sources of information have been examined for their associations with mental health sequelae. Some studies have found that utilizing internet sites and blogs as sources of information was associated with higher radiation anxiety [15]. Other studies found no evidence that social media was associated with anxiety about radiation risk [17]. This may indicate that anxiety is related to the type of information utilized online rather than the online form of media itself. In-person sources have also been investigated for perceptions of trustworthiness. People rated information from family physicians and lectures held by radiation experts as the most reliable sources of information, more than any of the media or government sources [43]. Researchers suggested that this finding could be because these people are considered experts in the field of health and radiation or because in-person communica- tion may have a greater impact on perceived trustworthiness than mass media communi- cations [43]. Participation in a seminar on radiation health led to decreased anxiety about radiation risk [17]. Other in-person sources of information, such as citizen groups, word of mouth, and rumours, were associated with higher anxiety [15,17]. This indicates that it is likely the source of information rather than the in-person nature of the communication that is key to reducing psychological distress. 9.2. Radiation Countermeasures Radiation countermeasures are measures implemented at the population level after a nuclear disaster to help mitigate the negative health implications of radiation exposure. The first radiation countermeasure implemented after a nuclear disaster is deploying de- contamination workers to the areas with the highest radiation levels. When people evalu- ated the decontamination efforts of their town as successful, they reported lower radiation anxiety [14]. Unfortunately, the decontamination workers themselves face higher levels of radiation exposure and more significant psychological consequences, including PTSD, depression, and anxiety [19,25,27,33]. Specific measures must be taken to try to reduce the psychological impact of this type of work. Interventions such as training sessions, self- study materials, and wearing a mask have not been shown to decrease anxiety in decon- tamination workers [33]. This points to a critical area of future research. In addition to widespread decontamination work, other radiation countermeasures are implemented to try to limit the negative impact of radiation on community members. Tools to measure an individual's current level of radiation include whole-body counts, which are a measure of internal radiation, and individual dosimeters, which are a measure Behav. Sci. 2021, 11, 113 15 of 20 of external radiation [15]. Although aimed at preventing further radiation exposure, utili- zation of these particular radiation countermeasures was associated with higher levels of anxiety [15,51]. Attending explanatory meetings about radiation and paying close atten- tion to radiation levels in food were also associated with higher levels of anxiety [15,51]. This increase in anxiety could be due to the countermeasures making the thought of radi- ation toxicity more salient in people's minds, or it could be a selection bias that people who are already more anxious about radiation seek out and utilize these countermeasures. Although the aim of these countermeasures is to improve both physical and mental health, they instead might point us to a group of people who would benefit from further psychological interventions to reduce their distress. An important area of future research could focus on how to implement these types of community-wide programs without an increase in anxiety from participation in the radiation countermeasures. 9.3. Technology-Based Population Supports Technology is ubiquitous in most developed countries today and may provide an effective way to reach people struggling with mental health concerns after living through a disaster. Research has shown that mobile phone-based population interventions are a cost-effective and valuable way to provide accessible psychological support [63–71]. These types of programs have been shown to decrease stress, depression, anxiety, and alcohol abuse [64,66,67,69–71]. A randomized control trial on psychiatric patients from Dublin in 2011 with dual diagnoses of depression and alcohol use disorder showed sig- nificantly reduced depressive symptoms and significantly greater abstinence from alcohol in the intervention group that received daily supportive text messages for three months compared to a control group that did not receive these messages [67]. Subsequent research found similar initial results but no lasting benefits six months after the cessation of the daily messages [70]. This type of mobile intervention has also been studied in remote populations. A mo- bile support program was effective in reducing depressive symptoms in Fort McMurry, Alberta, Canada, during the severe wildfires of 2016 [69]. This randomized control trial found that Fort McMurry residents diagnosed with Major Depressive Disorder who were assigned to the intervention group and received twice-daily supportive text messages for three months reported significantly lower depression scores on the Beck Depression In- ventory than the control group (20.8 vs. 24.9) [69]. This program came to be known as Text4Mood, and this program was recognized as a mental health innovation by the Men- tal Health Innovations Network [71]. These types of mobile health interventions are useful in underserviced and remote areas where access to mental health services may be scarce or costly. More recently, a similar program called Text4Hope has been developed and studied in Alberta, Canada. The goal of this program is to reduce psychological distress related to the COVID-19 pandemic and to promote resilience [63–66,68,71]. Text4Hope was created based on the Text4Mood mobile support program and provides subscribers with daily messages based on cognitive behavioural therapy [65]. The program was launched in March 2020, and within one week of launch, 32,805 Alberta residents had signed up for Text4Hope, indicating widespread uptake [63]. Demographic data indicate that people who self-subscribe to this program are mostly female (88%) and have an average age of 44.58 [71]. The average overall satisfaction with this program on a scale of 0–10 was 8.55 [71]. Most participants reported that the daily texts helped them cope with stress (77.1%), helped them cope with anxiety (75.8%), helped them feel connected to a support system (81%), helped them cope with COVID-related stressors (74%), and improved their mental well-being (75.6%). Two studies looking at stress measured with the Perceived Stress Scale-10 (PSS-10), anxiety measured with the General Anxiety Disorder Scale 7 (GAD-7), and depression measured with the Patient Health Questionnaire (PHQ-9) found de- creased scores on all three scales in the intervention group who received the daily sup- Behav. Sci. 2021, 11, 113 16 of 20 portive messages compared to the control group [64,66]. Although these types of techno- logically based interventions have not been studied in prior nuclear disasters, they could be extremely useful to implement in the aftermath of a nuclear disaster, as they are able to be delivered remotely and would be accessible to those forced to evacuate because of the disaster. 10. Limitations There were several limitations of this review. First, the majority of the studies used self-rating questionnaires to investigate symptoms of PTSD, depression, and anxiety, which are inferior to a clinical diagnosis [53]. Second, the most heavily studied nuclear disaster is the Fukushima nuclear disaster of 2011, which occurred in the wake of the Tohoku earthquake and tsunami, meaning that many people in the area experienced the stress of more than one type of disaster. Although this paper excluded studies that focused solely on the tsunami or earthquake, the effects of these disasters could not be controlled for and may have impacted those who experienced the nuclear disaster. Third, there are some limitations that are inherent to studying nuclear disasters, including both the diffi- culty finding ‘healthy controls’ sharing the same situation and the challenges in doing a pre–post design. Fourth, none of the reviewed literature addressed the role of pharmacol- ogy in the treatment of psychiatric conditions associated with nuclear disasters. Fifth, there are limitations inherent to qualitative narrative reviews. Narrative reviews are more subjective than systematic reviews. We attempted to mitigate this bias by outlining our search strategy and clearly stating our study inclusion criteria. Given the qualitive nature of this review, the goal was not to analyze the selected studies, but to synthesize the avail- able literature. A relatively small sample size of 59 studies was included in this review. We chose to exclude manual searching to prioritize transparency in our study selection, but this may have limited the sample size by inadvertently excluding gray literature. Sixth, the studies addressing radiation exposure level did not use actual radiation meas- urements. They instead approximated higher or lower radiation exposure groups based on location of residence [22–24,31], evacuee status [13,16,26,49], or employment [19,23,25,26,33,52,59]. The lack of research on individual doses of radiation exposure and mental health outcomes makes it difficult to determine whether the symptoms are from the physiological impact radiation has on the brain or from the significant stress surround- ing the event, which is also highest for those living the closest to the reactor, those required to evacuate, and those working in the highest risk jobs, such as nuclear plant workers at the time of the accident and decontamination workers after the accident. 11. Conclusions and Future Research This review summarizes the adverse psychological outcomes associated with living through a nuclear disaster. The synthesis of studies from Three Mile Island, Chernobyl, and Fukushima nuclear disasters, indicate that survivors have higher levels of PTSD, de- pression, and anxiety than people who did not experience a nuclear disaster. Certain groups are disproportionally impacted by mental health sequelae after a nuclear disaster, including evacuees and those living in closest proximity to the nuclear reactor. Although the rates of each of these psychiatric conditions decrease over time since the nuclear inci- dent, the significant impact these have on individuals and society should not be over- looked. There are psychological interventions that have shown modest benefit in reducing the adverse psychological outcomes of nuclear disasters, including mindfulness training, behavioral activation, and cognitive reappraisal training. Research into these types of in- terventions in the aftermath of a nuclear disaster has been scarce; thus, further research in this area would be beneficial prior to the next large-scale nuclear disaster. Government- level interventions providing the public with credible sources of information in the after- math of a nuclear disaster reduce fear surrounding radiation exposure. Although neces- sary, some of the measures that are put in place to mitigate the risk of radiation exposure Behav. Sci. 2021, 11, 113 17 of 20 in affected areas actually raise levels of mental health distress. Research could be carried out to see if there are any effective strategies to mitigate the rise in psychological distress due to the necessary radiation countermeasures. Suggestions for future research include technology-based interventions, such as mobile support programs, which are cost-effec- tive strategies to reach large populations in geographically distributed areas. Author Contributions: Conceptualization, V.I.O.A. and C.L.; methodology, C.L.; writing—original draft preparation, C.L.; writing—review and editing, V.I.O.A.; supervision, V.I.O.A. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Institutional Review Board Statement: Not applicable. Informed Consent Statement: Not applicable. 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Behavioral Sciences – Multidisciplinary Digital Publishing Institute

Published: Aug 23, 2021

Keywords: radioactive hazard release; nuclear disaster; anxiety; depression; post-traumatic stress disorder; psychological resilience; community mental health services; health policy; post-disaster interventions

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Social and Mental Health Impact of Nuclear Disaster in Survivors: A Narrative Review

Social and Mental Health Impact of Nuclear Disaster in Survivors: A Narrative Review

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Social and Mental Health Impact of Nuclear Disaster in Survivors: A Narrative Review

Social and Mental Health Impact of Nuclear Disaster in Survivors: A Narrative Review

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