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Received: 3 February 2022 Revised: 10 September 2022 Accepted: 11 September 2022

DOI: 10.1002/jts.22893

RESEARCH ARTICLE

Posttraumatic stress response following the loss of

significant close others in the Great East Japan Earthquake:
Fukushima Health Management Survey

Mayumi Harigane1,2 Satomi Nakajima3 Yui Takebayashi1,4

Masaharu Maeda1,4 Hironori Nakano1,5 Seiji Yasumura1,2 Hirooki Yabe6
Tetsuya Ohira1,5 Kenji Kamiya1,7 Mental Health Group of the Fukushima Health
Management Survey*1
1 Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Fukushima, Japan
2 Department of Public Health, School of Medicine, Fukushima Medical University, Fukushima, Japan
3 Faculty of Human Sciences, Musashino University, Tokyo, Japan
4 Department of Disaster Psychiatry, School of Medicine, Fukushima Medical University, Fukushima, Japan
5 Department of Epidemiology, School of Medicine, Fukushima Medical University, Fukushima, Japan
6 Department of Neuropsychiatry, School of Medicine, Fukushima Medical University, Fukushima, Japan
7 Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan

Correspondence
Mayumi Harigane, Radiation Medical Abstract
Science Center for the Fukushima Health During the Great East Japan Earthquake, many people experienced the loss of
Management Survey, Fukushima Medical
University, 1 Hikarigaoka, Fukushima family and friends, among other traumatic events. This study sought to clarify
City, 960–1295, Japan. the impact of the loss of significant close others on posttraumatic stress symp-
Email: harigane@fmu.ac.jp
toms (PTSS), as well as the factors associated with PTSS, among individuals
Funding information who experienced the loss of significant close others (i.e., bereaved group). Self-
Ministry of the Environment, administered questionnaires were mailed to men and women (N = 180,604)
Government of Japan
aged 16 years and older living in municipalities that included evacuated areas
surrounding the Tokyo Electric Power Company’s Fukushima Daiichi Nuclear
Power Station, which was significantly damaged following an earthquake and
tsunami in March 2011, causing subsequent radiation leakage; this mailing
yielded a 40.7% response rate, with 57,388 valid responses, in 2012. We used the
Posttraumatic Stress Disorder Checklist–Specific (PCL-S) to measure PTSS as the
outcome variable. Loss of significant close others in the disaster and respondents’
relationship with the deceased constituted the explanatory variables. Basic char-
acteristics and disaster-related factors were the confounding variables. Data were
analyzed using chi-square tests and logistic regression analyses. The bereaved
group showed more severe PTSS than the nonbereaved group, aOR = 1.58, 95%

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the
original work is properly cited.
© 2022 ReedGroup Ltd. Journal of Traumatic Stress published by Wiley Periodicals LLC on behalf of International Society for Traumatic Stress Studies.

J. Trauma. Stress. 2022;1–15. wileyonlinelibrary.com/journal/jts 1

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2 HARIGANE et al.

CI [1.50, 1.67]. The risk of developing PTSS increased if the deceased was a respon-
dent’s spouse, aOR = 1.67, 95% CI [1.22, 2.29]; child, 1.51 [1.01, 2.25]; or friend, 1.33
[1.16, 1.53]. Individuals who lose significant close others, including both family
and friends, in disasters require close mental health care and, if necessary, should
be referred for psychiatric treatment.

Natural hazards cause deaths and disappearances world-
wide each year. In Japan, 22,192 people died or went miss-
ing due to the Great East Japan Earthquake in March 2011
(National Police Agency, 2021; Reconstruction Agency,
2020), which left an estimated 100,000 bereaved people
in its aftermath (Takahashi, 2012). Previous research has
shown that the loss of loved ones can affect mental and
physical health (Stroebe et al., 2007).
Losing a significant other can have various mental
health outcomes, such as depression, posttraumatic stress
symptoms (PTSS), sleep- and alcohol-related problems,
and suicidal ideation (Stroebe et al., 2007; Zisook et al.,
2014). The term bereavement refers to “the objective situ-
ation of having lost someone significant” (Stroebe et al.,
2001, p. 6) and is associated with depression and major
depressive disorder (MDD; Raphael et al., 2004; Zisook
et al., 1994; Zisook & Shuchter, 1993). When examining
the association between depressive symptoms and syn-
dromes and spousal bereavement in late life, Zisook and
Shuchter (1993) found that the prevalence of major depres-
sive syndrome was 24% when assessed 2 months after
the death of a spouse and 14% at 25 months. In addition,
researchers have observed associations between bereave-
ment and PTSS or posttraumatic stress disorder (PTSD;
Kaltman & Bonanno, 2003; Murphy et al., 2003; Onrust &
Cuijpers, 2006; Raphael et al., 2004; Zisook et al., 1998). In
their systematic review, Onrust and Cuijpers (2006) found
a PTSD prevalence of 11.8% PTSD among widowed indi-
viduals, with the prevalence rate decreasing with the time
elapsed since the loss. The literature also demonstrates
associations between bereavement and sleep problems
(Byrne & Raphael, 1997; Chen et al., 1999; Hardison et al.,
2010), alcohol-related problems (Pilling et al., 2012; Zisook
et al., 1990), and suicidal ideation (Byrne & Raphael, 1997;
Latham & Prigerson, 2004; Range & Knott, 2010; Rosen-
gard & Folkman, 1997; Segal & Roy, 2001; Stroebe et al.,
2005).
Factors related to mental health after bereavement
include the cause of death (Kaltman & Bonanno, 2003;
Lundin, 1984) and the bereaved individual’s age (Stroebe
et al., 2001), gender (Stroebe et al., 2001), level of social
support (Okabayashi et al., 2004; van der Houwen et al.,
2010), and relationship to the deceased (Lundin, 1984). Par-
ticularly, the loss of a significant other due to a disaster
may put the survivor at higher risk for mental health prob-
lems, particularly when the individual has experienced
multiple disaster-related losses. Generally, disasters are
unexpected and involve mass fatalities. Grief reactions are
likely among survivors and often continue for a long period
postdisaster. Furthermore, disasters cause losses not only
to human life but also to homes, relationships, and com-
munities (Ito et al., 2012; Shear et al., 2011). Such traumatic
events can complicate the grieving process for the bereaved
(Nakajima et al., 2012) and cause complicated grief, which
often activates intense PTSS (Ito et al., 2012).
PTSD occurs more frequently in the context of postdis-
aster mental health, especially after a large-scale disaster
(Galea et al., 2005; Neria et al., 2008). Studies on the
psychological problems among survivors of the Great
East Japan Earthquake showed that one of the most fre-
quent psychiatric symptoms was the development of PTSS
(Maeda & Oe, 2017; Matsumoto et al., 2016). Moreover,
the process of grief among affected people who survive
compound disasters, such as the 2011 Fukushima disas-
ter, could be more complicated due to evacuations and
long-term displacement or ambiguous loss situations as a
result of a prolonged relief process (Maeda et al., 2019).
Following bereavement, PTSS have been reported to pre-
cede grief response (Beck et al., 1996; Kaltman & Bonanno,
2003). Therefore, following disasters, the timely identifica-
tion of PTSS and initiation of intervention for individuals
who have experienced the loss of significant and close oth-
ers are critical for preventing subsequent mental health
deterioration.
In general, nuclear disasters force residents to evacuate
their residential areas due to the possible physical effects
of radioactive materials. Evacuation from an affected area
could facilitate avoiding trauma-related cues, reducing
the opportunity for habituation and, thus, preventing
improvement in PTSS. Accordingly, it is possible that the
degree of change from one’s predisaster lifestyle is a risk
factor for the development of PTSS after experiencing the
loss of significant others in a nuclear disaster. This could
encompass changes in living environment, lifestyle, and
social relationships. Losing a spouse, child, or children,
with whom the bereaved has likely had substantial con-
tact in their daily lives, is also likely a risk factor for
PTSS following a nuclear disaster. Similarly, losing friends

POSTTRAUMATIC RESPONSE AFTER DISASTER-RELATED LOSS
represents a risk factor for PTSS following a nuclear disas-
ter, particularly in communities with a high percentage of
homeownership and strong neighborhood ties, such as the
current sample.
Therefore, this study aimed to clarify the association
between the loss of significant and close others and PTSS
in compound disasters and examine the risk factors asso-
ciated with PTSS by focusing on the relationship between
the bereaved and the deceased. We hypothesized that par-
ticipants who experienced the loss of a significant or close
other during the disaster (i.e., bereaved group) would have
a higher risk of reporting PTSS even after adjusting for
other disaster-related factors. In addition, we expected that
among individuals in the bereaved group, the risk would
vary depending on the participant’s relationship with the
deceased and whether they lost a spouse, child, or friend.
METHOD
Participants
This research was conducted as part of the Mental Health
and Lifestyle Survey. This detailed survey forms part of
the Fukushima Health Management Survey, conducted in
2012, within the year following the Great East Japan Earth-
quake. The survey aimed to monitor the health of and
provide appropriate care to residents who were displaced
by the Fukushima Nuclear Disaster. The survey comprises
basic assessments to estimate levels of external radiation
exposure among all 2,050,000 residents, as well as four
detailed surveys: thyroid ultrasound examination, compre-
hensive health check, mental health and lifestyle survey,
and pregnancy and birth survey. Details of the protocol
of this research are described elsewhere (Yasumura et al.,
2012).
The Mental Health and Lifestyle Survey aimed to ascer-
tain the mental and physical problems of residents who
have faced difficulties in the aftermath of the earthquake
and subsequent nuclear accident, with the goal of pro-
viding these individuals with proper health, medical, and
welfare services. The survey also aimed to preserve the
accumulated knowledge on better mental health care
during an emergency or natural hazard for posterity (Min-
istry of the Environment Government of Japan, 2018).
Self-administered questionnaires were mailed to target
participants in 12 municipalities, including the evacua-
tion zones designated by the Japanese government (Hirono
Town, Naraha Town, Tomioka Town, Kawauchi Village,
Okuma Town, Futaba Town, Namie Town, Katsurao Vil-
lage, Iitate Village, Minamisoma City, Tamura City, and
Kawamata Town) and radiation hotspots (i.e., places asso-
ciated with high levels of radiation) in Date City, beginning
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3
on January 18, 2012, which was approximately 10 months
after the earthquake. The present study was conducted
using cross-sectional data from respondents who were 16
years of age or older in 2011. Details regarding the data
used in this research are described elsewhere (Iwasa et al.,
2016; Kunii et al., 2016; Nagai et al., 2016; Oe et al., 2016;
Suzuki et al., 2015, 2017; Ueda et al., 2016; Yabe et al., 2014;
Yasumura et al., 2012).
The present sample included residents of the target areas
who were at least 16 years old on April 1, 2011. These
individuals lived in the areas surrounding the TEPCO
Daiichi Nuclear Power Station that became evacuation
zones following the nuclear accident. We targeted 180,604
residents; by October 31, 2012, a total of 73,569 individu-
als had responded, with a response rate of 40.7%. When
blank responses and duplicate answers (n = 139), nonprin-
cipal answers (i.e., questionnaires filled out by a proxy;
n = 9,244), no data for the explanatory variable (n =
1,833), and no data for the outcome variables (n = 4,965)
were excluded, 57,388 unique respondents were left, with
a response rate of 31.8%, as shown in Figure 1. Although
this was a self-administered survey, questionnaires were
sometimes completed by a proxy (e.g., parents complet-
ing questionnaires for children who were away, family
members completing questionnaires for individuals with
cognitive or motor disabilities, and family members and
staff completing surveys for elderly adults who had under-
gone institutionalization or hospitalization). However, the
scales used are not meant to accept surrogate answers as
an outcome variable; thus, nonprincipal responses were
excluded.
Procedure
Self-administered questionnaires from January 18, 2012,
to February 16, 2012, and we analyzed responses that
had been returned by October 31, 2012. No compensation
was paid to the respondents. Potential participants were
informed in writing that their responses would never be
published in a way that would identify them. In addition,
we assumed that the return of a questionnaire indicated a
respondent’s consent to participate in the study. We con-
ducted the survey with the approval of the Fukushima
Medical University Ethics Committee (2020-239).
Measures
PTSS
The presence and severity of PTSS constituted the out-
come variable. We measured PTSS using the translated,

4 HARIGANE et al.
F I G U R E 1 Flow of participant selection
Note: PCL-S = Posttraumatic Stress Disorder Checklist–Specific.
standardized Japanese version of the PTSD–Specific Ver-
sion (PCL-S; Weathers et al., 1993). This questionnaire aims
to assess PTSS stemming from a specific traumatic expe-
rience, with 17 items related to three symptom domains
outlined in the Diagnostic and Statistical Manual of Mental
Disorders (fourth ed.; American Psychiatric Association,
1994): reexperiencing, avoidance and numbing, and hyper-
arousal. Item scores are scored on a 5-point Likert scale
ranging from 1 (not at all) to 5 (extremely), with higher
scores indicating more severe PTSS (rage: 17–85). If an
item was missing, we substituted the average value of the
remaining 16 items and used this value in the analyses;
however, questionnaires with two or more missing items
were excluded from the analyses. In the present sample,
Cronbach’s alpha for the PCL-S was .95.
Earthquake-related loss
Loss of significant and close others due to the earthquake
and the respondent’s relationship to the deceased (i.e., par-
ent, spouse, child, sibling, friend, other) constituted the
explanatory variables. Responses to the question, “Did you
lose someone important or close to you in the disaster?”
were coded as 1 for “yes” and 0 for “no.” Individuals who
answered “yes” were categorized as the bereaved group,
and those who answered “no” were categorized as the non-
bereaved group. We also asked respondents about their
relationship with the deceased, allowing a free response.
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Based on previous studies (d’Epinay et al., 2010), we cat-
egorized responses as parents, spouses, children, siblings,
and friends; responses that did not apply to these categories
were classified as “others.” In addition, if there was no
response or the respondent answered in such a way that
we could not classify the answer into one of these cate-
gories, the response was coded as 0. As there were cases
in which the respondent listed more than one relation-
ship, we classified the relationships as dummy variables.
One researcher classified the initial free description, and
another researcher confirmed the classification. The two
researchers then discussed the classified items and reclas-
sified them as needed. Respondents who did not answer
the items concerning the loss of significant and close others
were excluded from the analysis.
Confounding variables
The confounding variables were gender (men, women),
age group (16–49 years, 50–64 years, and over 65 years;
Kunii et al., 2016; Ueda et al., 2016), educational attain-
ment (ranging from 1 [elementary or junior high school]to
4 [university or graduate school]), changes in work due to
the disaster, the place of residence at the time of the sur-
vey (inside or outside Fukushima prefecture), residential
type at the time of the survey (evacuation shelter, tempo-
rary housing, rental housing or apartment, relative’s home,
own home, other), house damage due to the disaster (more

POSTTRAUMATIC RESPONSE AFTER DISASTER-RELATED LOSS
than half-collapse or less than half-collapse), experience
of the tsunami and/or nuclear power plant accident, and
radiation risk perception (i.e., genetic impact).
Data analysis
Posttraumatic stress response (PCL-S) was the outcome
variable, with the cutoff point set to 44 points according
to the recommendation for diagnostic efficiency used in
other studies (Blanchard et al., 1996; Cukor et al., 2011; Oe
et al., 2016). We classified the respondents operationally
into the “high risk” or “low risk” groups, identifying
high-risk individuals as targets for the intervention and
associated factors. We conducted chi-square tests on the
outcome, explanatory variables, and confounding vari-
ables. In addition, we conducted logistic regression anal-
yses on the extent to which the presence or absence of
the loss of significant and close others predicted PTSS.
We also carried out logistic regression analyses to deter-
mine whether and to what extent losing a parent, spouse,
child, sibling, friend, or other significant person predicted
PTSS. In Model 1, we did not adjust the logistic regression
analyses; Model 2 analyses were adjusted for gender, age,
educational attainment, history of mental illness, changes
in work, place of residence, type of occupation at the time
of survey administration, damage to the home as a result
of the disaster, tsunami experience, nuclear accident expe-
rience, and perception of radiation risk. All analyses were
conducted using SPSS (Version 28.0).
RESULTS
Respondent characteristics and PTSS
In total, 31,977 respondents were women (55.7%), and the
average participant age was 53.6 years (SD = 17.5). Regard-
ing educational attainment, 13,138 respondents (22.9%) had
an elementary or junior high school education, and 44,250
(77.1%) had a high school, vocational college, junior col-
lege, university, or graduate school education. A total
of 2,729 respondents (4.7%) had a history of mental ill-
ness. Additionally, 27,098 (47.2%) respondents reported
changes in their work situation after the Great East
Japan Earthquake. Among disaster-related factors, 46,086
(80.3%) people were living in Fukushima prefecture at the
time of the survey. There were 5,584 (9.7%) people liv-
ing in evacuation shelters or temporary housing, and the
earthquake partially damaged the homes of 8,406 (14.6%)
respondents. Additionally, 11,551 (20.1%) respondents expe-
rienced the tsunami, whereas 30,178 (52.6%) experienced
the nuclear accident. Lastly, 32,737 (57.0%) respondents
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5
thought that radiation contamination (i.e., genetic impact)
was likely or very likely. The mean PCL-S score was 32.7
(SD = 14.6), with 12,010 (20.9%) individuals scoring 44 or
higher, indicating a high level of PTSS.
Association between loss of significant and
close others and PTSS (univariate analysis)
Among participants who experienced the loss of a signif-
icant or close other, 32.7% of individuals were classified
as having a high risk for PTSS; in the nonbereaved group,
18.1% of participants were classified as high risk. This was
statistically significant, χ2 (1, N = 57,388) = 1,165.7, p <
.001, as shown in Table 1. Compared with the nonbereaved
group, the bereaved group included significantly more
women, χ2 (1, N = 57,388) = 28.1, p < .001; elderly people,
χ2 (2, N = 57,388) = 148.6, p < .001; individuals with a high-
school education, χ2 (3, N = 57,388) = 132.1, p < .001; people
with a history of mental illness, χ2 (1, N = 57,388) = 54.7, p <
.001; and people with no change in work due to the disaster,
χ2 (1, N = 57,388) = 767.3, p < .001. In addition, the bereaved
group included more people who were evacuated outside
the prefecture, χ2 (1, N = 57,388) = 69.4, p < .001; were liv-
ing in shelters or temporary housing, χ2 (1, N = 57,388) =
75.9, p < .001; had their homes damaged by the earthquake,
χ2 (1, N = 57,388) = 821.6, p < .001; and had experienced
the tsunami, χ2 (1, N = 57,388) = 2,722.7, p < .001. The
nuclear accident appeared to traumatize individuals in the
bereaved group more intensely, and they affirmed the pos-
sibility of negative health effects from radiation at a higher
rate, χ2 (1, N = 57,388) = 1,118.3, p < .001, than those in the
nonbereaved group, χ2 (1, N = 57,388) = 414.3, p < .001.
Multivariate analysis of the association
between the loss of significant and close
others and PTSS
As the results of the multiple logistic regression analysis in
Table 2 show, the loss of significant and close others was
significantly associated with PTSS. In Model 1, when PCL-
S was the outcome measure, participants in the bereaved
group were 2.20 times more likely to experience PTSS, 95%
CI [2.10, 2.30], p < .001, than those in the nonbereaved
group. The value fell to 1.58 times more likely, 95% CI [1.50,
1.67], p < .001, in Model 2. According to Model 2, the group
with high levels of PTSS included more participants who
were women, adjusted odds ratio (aOR) = 1.52, 95% [1.45,
1.59], p < .001; were elderly, aOR = 1.15 [1.09, 1.21], p < .001,
1.60 [1.51, 1.70], p < .001; had an elementary or junior high
school education, aOR = 0.79 [0.74, 0.83], p < .001, 0.74
[0.69, 0.80], p < .001, 0.64 [0.58, 0.70], p < .001; reported a
 6

TA B L E 1 Associations between posttraumatic stress symptom (PTSS) severity and possible confounding factors following postdisaster loss for the total sample and by loss experience
group
Bereaved (n = Non bereaved (n
Variable Total (N = 57,388) 11,257) = 46,131) Effect Size
M SD M SD M SD df χ2 V ϕ
Age (years)a 53.6 17.5 55.4 17.0 53.1 17.6
b
PCL-S score 32.7 14.6 38.0 16.0 31.4 14.0
n n % n %
PCL-S score 57,388 1 1,165.67 0.143
≥ 44 12,010 3,677 32.7 8,33 18.1
< 44 45,378 7,580 67.3 37,798 81.9
Gender 57,388 1 28.11 0.022
Men 25,411 4,734 42.1 20,677 44.8
Women 31,977 6,523 57.9 25,454 55.2
Age range (years) 57,388 2 148.60 0.051
16–49 22,040 3,769 33.5 18,271 39.6
50–64 years old 18,698 3,877 34.4 14,821 32.1
≥ 65 16,650 3,611 32.1 13,039 28.3
Educational attainment 57,388 3 132.14 0.048
c
Elementary school or junior high school 13,138 2,314 20.6 10,824 23.5
High school 28,858 6,170 54.8 22,688 49.2
Vocational or junior college 10,212 1,935 17.2 8,277 17.9
University or graduate school 5,180 838 7.4 4,342 9.4
History of mental illness 57,388 1 54.67 0.031
Yes 2,729 685 6.1 2,044 4.4
Noc 54,659 10,572 93.9 44,087 95.6
Change of work 57,388 1 767.27 -0.116
Yes 27,098 4,000 35.5 23,098 50.1
Noc 30,290 7,257 64.5 23,033 49.9
(Continues)
HARIGANE et al.

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 TA B L E 1 (Continued)
n n % n %
Disaster-related factors
Residential area 57,388 1 69.35 0.035
Fukushima prefecture 46,086 8,725 77.5 37,361 81.0
Other prefectures 11,302 2,532 22.5 8,770 19.0
Living arrangement 57,388 1 75.93 0.036
Shelter, temporary housing 5,584 1,341 11.9 4,243 9.2
Rented house/apartment, relatives’ home, own home, or 51,804 9,916 88.1 41,888 90.8
POSTTRAUMATIC RESPONSE AFTER DISASTER-RELATED LOSS

otherc
Home damage 57,388 1 821.63 0.120
Partial collapse or more 8,406 2,613 23.2 5,793 12.6
Less than partial collapsec 48,982 8,644 76.8 40,338 87.4
Experience of the tsunami 57,388 1 2,722.74 0.218
Yes 11,551 4,256 37.8 7,295 15.8
Noc 45,837 7,001 62.2 38,836 84.2
Experience of the power plant accidentd 57,388 1 1,118.28 0.140
Yes 30,178 7,508 66.7 22,670 49.1
Noc 27,210 3,749 33.3 23,461 50.9
Perception of radiation risk (genetic impact) 57,388 1 414.29 0.085
Likely or very likely 32,737 7,380 65.6 25,357 55.0
Unlikely or very unlikelyc 24,651 3,877 34.4 20,774 45.0
Note: PCL-C = Posttraumatic Stress Disorders Checklist–Civilian Version.
a
Total: Mdn = 56 years, interquartile range (IQR) = 39–67; Bereaved: Mdn = 59 years, IQR = 43–68; Nonbereaved: Mdn = 56 years, IQR = 39–67.
b
Total: Mdn = 29, IQR = 21–40; Bereaved: Mdn = 35, IQR = 25–48; Nonbereaved: Mdn = 27, IQR = 20–38.
c
Including missing values.
d
Defined as hearing a hydrogen explosion from the nuclear power plant.
7

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8 HARIGANE et al.

TA B L E 2 Logistic regression analysis of the associations between bereavement and high levels of posttraumatic stress symptomsa
Model 2
Variable a OR 95% CI p
Loss experience (Ref.: nonbereaved)
Bereaved 1.58 [1.50, 1.67] <.001
Gender (Ref.: Men)
Women 1.52 [1.45, 1.59] <.001
Age (Ref.: 16–49 years)
50–64 years 1.15 [1.09, 1.21] <.001
≥65 years 1.60 [1.51, 1.70] <.001
c
Educational attainment (Ref.: Elementary school or junior high school )
High school 0.79 [0.74, 0.83] <.001
Vocational or junior college 0.74 [0.69, 0.80] <.001
University or graduate school 0.64 [0.58, 0.70] <.001
History of mental illness (Ref.: No historyc )
Yes 4.80 [4.40, 5.22] <.001
c
Change of work (Ref.: No )
Yes 0.64 <.001
Residential area (Ref.: Fukushima prefecture) [0.61, 0.67]
Other prefectures 1.26 [1.19, 1.33] <.001
c
Living arrangement (Ref.: Rented house/apartment, relative’s home, own home, other )
Shelter, temporary housing 1.08 [1.01, 1.16] .035
c
Home damage (Ref.: Less than partial collapse )
Partial collapse and worse 1.37 [1.30, 1.46] <.001
c
Tsunami experience (Ref.: No )
Yes 1.34 [1.27, 1.41] <.001
d c
Nuclear power plant accident experience (Ref.: No )
Yes 1.84 [1.75, 1.92] <.001
c
Perception of radiation risk (genetic impact) (Ref.: Unlikely or very unlikely )
Likely or very likely 2.92 [2.78, 3.07] <.001
Note: N = 57,388. OR = odds ratio; aOR = adjusted odds ratio. In Model 1, when PCL-S was the outcome measure, participants in the bereaved group were 2.20
times more likely to experience PTSS, 95% CI [2.10, 2.30], p < .001, than those in the nonbereaved group.
a
Defined as a Posttraumatic Stress Disorder Checklist–Civilian Version score of 44 or higher.
b
Adjusted for gender, age, educational attainment, history of mental illness, change of work, residential area, living arrangement, home damage, experience of
the tsunami, experience of the nuclear power plant accident, and perception of radiation risk (i.e., genetic impact).
c
Including missing values.
d
Defined as hearing a hydrogen explosion from the nuclear power plant.

history of mental illness, aOR = 4.80 [4.40, 5.22], p < .001;
had no change in work due to the earthquake, aOR = 0.64
[0.61, 0.67], p < .001; were living outside the prefecture at
the time of the survey, aOR = 1.26 [1.19, 1.33], p < .001; were
living in shelters or temporary housing, aOR = 1.08 [1.01,
1.16], p = .035; had a home that was at least partially dam-
aged by the earthquake, aOR = 1.37 [1.30, 1.46], p < .001;
had experienced the tsunami, aOR = 1.34 [1.27, 1.41], p <
.001; had experienced the nuclear accident directly, aOR
= 1.84 [1.75, 1.92], p < .001; and had a high perception of
radiation risk, aOR = 2.92 [2.78, 3.07], p < .001.
Risk factors for PTSS among participants in
the bereaved group
Table 3 shows the results of the comparisons between one’s
relationship with the deceased, socioeconomic factors, and
disaster-related factors with regard to the PCL-S. Individ-
uals in the high-risk group more frequently reported that
they had lost a spouse, χ2 (1, N = 10,432) = 23.7, p < .001;
child, χ2 (1, N = 10,432) = 8.2, p < .004, sibling, χ2 (1, N =
10,432) = 7.15, p < .008; and friend, χ2 (1, N = 10,432) =
42.7, p < .001, than those who scored lower on the PCL-
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POSTTRAUMATIC RESPONSE AFTER DISASTER-RELATED LOSS 9

TA B L E 3 Associations between relationship to the deceased and posttraumatic stress symptoms (PTSS), by PTSS severity
Total High-risk Low-risk
Variable (N = 10,432) (n = 3,343) (n = 7,089) Effect size
n n % n % df χ2 p V ϕ
Relationship to the deceased
Loss of parent(s) 10,432
Noa 9,571 3,106 92.9 6,465 91.2 1 8.80 .003 -0.029
Yes 861 237 7.1 624 8.8
Loss of spouse 10,432
Noa 10,209 3,238 96.9 6,971 98.3 1 23.67 < .001 0.048
Yes 223 105 3.1 118 1.7
Loss of child/children 10,432
Noa 10,312 3,290 98.4 7,022 99.1 1 8.19 .004 0.028
Yes 120 53 1.6 67 0.9
Loss of sibling(s) 10,432
Noa 9,756 3,095 92.6 6,661 94.0 1 7.15 .008 0.026
Yes 676 248 7.4 428 6.0
Loss of friend(s) 10,432
Noa 8,387 2,564 76.7 5,823 82.1 1 42.72 < .001 0.064
Yes 2,045 779 23.3 1,266 17.9
Loss of other relation(s) 10,432
Noa 2,458 873 26.1 1,585 22.4 1 17.79 < .001 -0.041
Yes 7,974 2,470 73.9 5,504 77.6
Background characteristics
Gender 10,432
Men 4,330 1,159 34.7 3,171 44.7 1 94.73 < .001 0.095
Women 6,102 2,184 65.3 3,918 55.3
Age (years) 10,432
16–49 3,522 980 29.3 2,542 35.9 2 107.55 < .001 0.102
50–64 3,632 1,087 32.5 2,545 35.9
≥ 65 3,278 1,276 38.2 2,002 28.2
Educational attainment 10,432
Elementary school or junior high schoola 2,055 797 23.8 1,258 17.7 3 85.35 < .001 0.090
High school 5,757 1,813 54.2 3,944 55.6
Vocational or junior college 1,818 560 16.8 1,258 17.7
University or graduate school 802 173 5.2 629 8.9
History of mental illness 10,432
Yes 625 438 13.1 187 2.6 1 441.65 < .001 0.206
a
No 9,807 2,905 86.9 6,902 97.4
Change in work 10,432
Yes 3,695 1,003 30.0 2,692 38.0 1 63.11 < .001 -0.078
Noa 6,737 2,340 70.0 4,397 62.0
Disaster-related factors
Residential area 10,432
Fukushima prefecture 8,078 2,507 75.0 5,571 78.6 1 16.79 < .001 0.040
(Continues)
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10 HARIGANE et al.

TA B L E 3 (Continued)
Variable Total High-risk Low-risk Effect size
(N = 10,432) (n = 3,343) (n = 7,089)
n n % n % df χ2 p V ϕ
Other prefectures 2,354 836 25.0 1,518 21.4
Living arrangements 10,432
Shelter, temporary housing 1,230 408 12.2 822 11.6 1 0.81 0.368 0.009
Rented house/apartment, relative’s home, 9,202 2,935 87.8 6,267 88.4
own home, othera
Home damage 10,432
Partial collapse and worse 2,409 889 26.6 1,520 21.4 1 33.94 < .001 0.057
Less than partial collapsea 8,023 2,454 73.4 5,569 78.6
Tsunami experience 10,432
Yes 3,968 1,445 43.2 2,523 35.6 1 56.18 < .001 0.073
a
No 6,464 1,898 56.8 4,566 64.4
Nuclear power plant accident experienceb 10,432
Yes 6,956 2,544 76.1 4,412 62.2 1 196.47 < .001 0.137
a
No 3,476 799 23.9 2,677 37.8
Perception of radiation risk (genetic impact)
Likely or very likely 6,856 2,671 79.9 4,185 59.0 1 438.92 < .001 0.205
Unlikely or very unlikelya 3,576 672 20.1 2,904 41.0
Note: N = 10,432. Participants were characterized as high risk if they scored 44 or higher on the Posttraumatic Stress Disorder Checklist–Civilian Version and as
low risk if their score was below 44.
Chi-square tests were used, with respective effect size tests of phi and Cramer’s V.
a
Including missing values.
b
Defined as hearing a hydrogen explosion from the nuclear power plant.

S. In terms of socioeconomic factors, the high-risk group
included more women, χ2 (1, N = 10,432) = 94.7, p < .001;
elderly individuals, χ2 (1, N = 10,432) = 107.6, p < .001;
people who had an elementary and junior high school edu-
cation, χ2 (1, N = 10,432) = 85.4, p < .001; those with a
history of mental illness, χ2 (1, N = 10,432) = 441.7, p < .001;
and those who had no change in work due to the earth-
quake, χ2 (1, N = 10,432) = 63.1, p < .001, than the other
groups. For disaster-related factors, the high-risk group
included more people who were living outside the prefec-
ture at the time of survey, χ2 (1, N = 10,432) = 16.8, p <
.001; individuals whose homes were at least partially dam-
aged by the earthquake, χ2 (1, N = 10,432) = 33.9, p < .001;
those experienced the tsunami directly, χ2 (1, N = 10,432)
= 56.2, p < .001; those who experienced the nuclear acci-
dent directly, χ2 (1, N = 10,432) = 196.5, p < .001; and those
who reported a high perception of radiation risk, χ2 (1, N =
10,432) = 438.9, p < .001.
ship to the deceased and risk factors and PTSS. As shown
in Table 4, in Model 1, when PCL-S was the outcome,
bereaved individuals were 1.92, more likely to experience
PTSS when they lost their spouse, 95% CI [1.47, 2.50], p <
.001; 1.69 more likely when they lost a child, 95% CI [1.17,
2.43], p = .005; 1.25 more likely when they lost a sibling, 95%
CI [1.06, 1.47], p = .008; and 1.40 times more likely, [1.26,
1.55], p < .001, after the loss of a friend, compared with non-
bereaved individuals. These individuals were 0.79, 95% CI
[0.68, 0.92], p = .003, and 0.81, [0.74, 0.90], p < .001, times
less likely, respectively, to experience PTSS after losing a
parent or a someone characterized as “other.” In Model 2,
the values for spouse, adjusted odds ratio (aOR) = 1.67, 95%
CI [1.22, 2.29], p = .001; child, aOR = 1.51, [1.01, 2.25], p =
.046; sibling, aOR = 1.07, [0.89, 1.29], p = .481; and friend,
aOR = 1.33 [1.16, 1.53], p < .001, decreased, whereas the val-
ues for parent, aOR = 0.87, 95% CI [0.71, 1.06], p = .165; and
other relation, aOR = 0.97, [0.84, 1.13], p = .716, increased.

Correlations between relationship with the DISCUSSION

deceased and among the bereaved group
This study investigated the possibility of an association
The multiple logistic regression analysis of the bereaved between PTSS and the loss of significant and close others
group examined the correlations between one’s relation- in the Great East Japan Earthquake. We found that the loss
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POSTTRAUMATIC RESPONSE AFTER DISASTER-RELATED LOSS 11

TA B L E 4 Logistic regression analysis of the associations between relationship to the deceased and high levels of posttraumatic stress
symptomsa
Model 1 Model 2
Variable OR 95% CI p a OR 95% CI p
Loss of parent(s) (Ref.: No)
Yes 0.79 [0.68, 0.92] .003 0.87 [0.71, 1.06] .165
Loss of spouse (Ref.: No)
Yes 1.92 [1.47, 2.50] <.001 1.67 [1.22, 2.29] .001
Loss of child/children (Ref.: No)
Yes 1.69 [1.17, 2.43] .005 1.51 [1.01, 2.25] .046
Loss of sibling(s) (Ref.: No)
Yes 1.25 [1.06, 1.47] .008 1.07 [0.89, 1.29] .481
Loss of friend(s) (Ref.: No)
Yes 1.40 [1.26, 1.55] <.001 1.33 [1.16, 1.53] <.001
Loss of other relation(s) (Ref.:
No)
Yes 0.81 [0.74, 0.90] <.001 0.97 [0.84, 1.13] .716
Note: N = 10,432. OR = odds ratio, CI = confidence interval; aOR = adjusted odds ratio.
a
Defined as a Posttraumatic Stress Disorder Checklist–Civilian Version score of 44 or higher.
b
Adjusted for gender, age, educational attainment, history of mental illness, change of work, residential area, living arrangement, home damage, experience of
the tsunami, experience of the nuclear power plant accident, and perception of radiation risk (i.e., genetic impact).

of a loved one was related to higher levels of PTSS. Further-
more, we observed that bereaved individuals were at risk of
suffering from PTSS not only when they reported losing a
spouse, child, or sibling but also when they described the
deceased as a friend.
Consistent with previous research, the bereaved group
displayed signs of deteriorated mental health (Goenjian
et al., 2001; Johannesson et al., 2009; Kaltman & Bonanno,
2003), likely due to the significance of the psychological
impact of the loss itself. In addition, bereaved partic-
ipants who were female, older, and had a history of
mental illness had a higher risk of developing PTSS. Pre-
vious studies have reported associations between PTSS
and both female gender and a history of mental illness
(Breslau, 2009; Johannesson et al., 2009; Johannesson,
Lundin, Hultman, et al., 2011; Olff et al., 2007); although
the results in previous studies regarding age have been
inconsistent (Bonanno et al., 1999; Bonanno & Keltner,
1997; Tang et al., 2017), in the present study, older age
was shown to be a possible risk factor for higher levels
of PTSS. Further, experiencing multiple losses, such as
evacuation outside the prefecture and the loss of a house,
may also affect the mental health of bereaved individuals.
Consistent with previous studies, PTSS severity tended to
increase among the bereaved group (Tang et al., 2017). The
Great East Japan Earthquake was a complex disaster, and
individuals in the bereaved group experienced disaster-
related events in addition to loss; the present findings
suggest that the loss of significant and close others affects
the development and severity of PTSS even after control-
ling for other disaster-related experiences. Furthermore,
respondents who closely experienced the disaster were
more likely to suffer from psychiatric symptoms, includ-
ing PTSS, stemming from circumstances that accompanied
the disaster. It is likely that the loss of significant and close
others due to the Great East Japan Earthquake was par-
ticularly traumatic for residents because of the disaster’s
violence and the violence of the subsequent tsunami and
nuclear accident.
Among bereaved participants, an individual’s relation-
ship with the deceased person was significantly related to
PTSS even after adjusting for other disaster-related fac-
tors. Previous studies have identified the loss of children
and spouses, in particular, as risk factors for posttraumatic
stress responses (Johannesson, Lundin, Fröjd, et al., 2011;
Kristensen et al., 2009; Sakaguchi, 2001; Sanders, 1980),
and the present findings corroborate this result. In addi-
tion, the loss of friends also proved to be a risk factor for
PTSS in this study. This echoes the results reported by Sklar
and Hartley (1990) suggesting that surviving friends grieve,
often quite deeply, but are unlikely to share their grief with
others. This study consisted of open-ended interviews with
and essays by college students and a constructed support
group with participants. In the present study, we asked
respondents if they had lost someone close in the dis-
aster, then prompted them to describe their relationship
with the deceased using a free response format. There-
fore, we assumed that responses of “friend” indicated that
the individual was a close friend. Previous studies have
shown that the depth and closeness of the relationship

12
between the deceased and the respondent have a signifi-
cant impact on mental health (Mitchell et al., 2004; Shear
et al., 2006). Thus, when asking about the loss of a friend,
it may be necessary to use the term “close friend” rather
than simply “friend.” Residential areas with a high rate of
owner-occupied houses tend to have high bonding social
capital (DiPasquale & Glaeser, 1999; Qin & Tanaka, 2017).
As many of the target areas for the present study have a
high level of home ownership, many of the target partic-
ipants likely had strong ties with their neighbors before
evacuation. Thus, responses of “friend” may have included
people with whom the respondent was particularly close,
similar to family. In other words, as shown in Shear et al.’s
(2011) study of Hurricane Katrina survivors, the loss of
close friends may have had a more negative impact on
mental health because it led to the loss of community net-
works. In addition, previous studies have shown family
and community connections to play a role in the recovery
from traumatic loss following a catastrophe (Walsh, 2007).
We found a relatively low risk of PTSS among individ-
uals who described the deceased as a parent or sibling
compared with a spouse, child or children, or friend. This
may be because the respondents in this study were 16 years
of age or older and were unlikely to live with their parents
or siblings; therefore, they may have less contact with them
compared to their spouse, children, or close friends.
Broadly, the risk of mental health deterioration was
found to increase with the loss of a loved one, although
it also appeared to be dependent upon the type of relation-
ship between the bereaved and the deceased. With regard
to the nuclear disaster, the present findings indicate that
risk factors for PTSS among the bereaved included losing
a spouse, child or children, or friend. Compared to natural
hazard evacuees, nuclear hazard evacuees tend to evacu-
ate farther and longer, and their postevacuation life may
have less in common with the daily life they used to lead
with the deceased, preventing them from experiencing nat-
ural trauma reminders in their daily life. Furthermore,
the self-stigma and fear of discrimination from local res-
idents after evacuation from a nuclear hazard may cause
some people to avoid conversations about where they came
from and what their experiences were like (Harigane &
Yasumura, 2022). Therefore, specialists who provide sup-
port for bereaved evacuees who have experienced nuclear
hazards may need to conduct assessments with aware-
ness of the possibility that avoidance behaviors may exist
about which the intervention targets themselves may not
be aware.
The study had several limitations. First, the cross-
sectional design prevented us from clarifying casual
causal associations. Second, for the question regarding the
respondent’s relationship with the deceased, the open-
response format instead of distinct response options for
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HARIGANE et al.
parent, spouse, child, or friend, presents a possibility of
lost data concerning relationships. Nonetheless, as noted,
if respondents were asked about their relationship with
the deceased in closed questions, the loss of people who
were not “important” close others would be included as
well, and it is possible that the results regarding the loss of
friends and PTSS would not have emerged. Third, we could
not confirm the cause of death, which previous research
has taken into account when evaluating risk factors affect-
ing mental health among bereaved individuals (Kaltman
& Bonanno, 2003; Lundin, 1984). Fourth, we were only
able to examine the influence of losing significant and
close others on mental health in terms of PTSS. Because
this study included people who had not experienced the
loss of significant and close others, and to avoid increas-
ing the respondent burden with more questions on the
survey, we were unable to assess complicated grief. It is
worth noting that the results of this study are not repre-
sentative of grief reactions following bereavement. Fifth,
the response rate was only around 40%, possibly because
of the lack of incentives to respond, the lack of reminders
to encourage responses, and the fact that the survey was
sent less than 1 year after the Great East Japan Earth-
quake, when evacuees were repeatedly evacuating and
relocating.
The study also had several strengths. It was a complete
survey targeting more than 100,000 residents forced to
evacuate because of the nuclear accident during the Great
East Japan Earthquake. We sought to clarify the associa-
tions between losing significant and close others after a
complex disaster and PTSS, including after adjusting for
confounding factors. It also sought to clarify the intri-
cacies of the association between bereaved individuals’
relationship with the deceased and the PTSS.
This study examined the association between the expe-
rience of losing significant and close others during the
Great East Japan Earthquake and PTSS among bereaved
individuals, as well as the risk factors for PTSS. Previ-
ous research has demonstrated that mental health suffers
among the bereaved, with an elevated risk of deteriora-
tion when the deceased was a spouse, child, or friend. The
findings suggest an elevated risk of deteriorating mental
health, regardless of other disaster-related factors in these
individuals. In particular, people who experience the loss
of a spouse, child or children, or close friend may exhibit
PTSS, suggesting the need to monitor mental health.
O P E N P R AC T I C E S S TAT E M E N T
The datasets analyzed during the present study are not
publicly available because the data of the Fukushima
Health Management Survey belongs to the government of
Fukushima prefecture and can only be used within that
organization.

POSTTRAUMATIC RESPONSE AFTER DISASTER-RELATED LOSS
AU T H O R N OT E
This study was funded by the National Health Fund for
Children and Adults Affected by the Nuclear Incident. The
funding source had no involvement in the study design,
data collection, analysis, interpretation of the data, writ-
ing of the report, or decision to submit the article for
publication. The authors declare no known conflicts of
interest.
The authors wish to thank the chairpersons, other expert
committee members, advisors, and staff of the Fukushima
Health Management Survey Group and the following
members of the Mental Health Group of the Fukushima
Health Management Survey: Masaharu Maeda, Atsushi
Takahashi, Maho Momoi, Saori Goto, Tetsuya Ohira,
Mitsuaki Hosoya, Michio Shimabukuro, Hirooki Yabe,
Tomoaki Tamaki, Kanae Takese, Itaru Miura, Hajime
Iwasa, Shuntaro Itagaki, Mayumi Harigane, and Naoko
Horikoshi.
ORCID
Mayumi Harigane https://orcid.org/0000-0001-7755-
1888
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How to cite this article: Harigane, M., Nakajima,
S., Takebayashi, Y., Maeda, M., Nakano, H.,
Yasumura, S., Yabe, H., Ohira, T., & Kamiya, K.,
Mental Health Group of the Fukushima Health
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response following the loss of significant close
others in the Great East Japan Earthquake:
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https://doi.org/10.1002/jts.22893