Pre-disaster family visits and post-evacuation return to Fukushima among psychiatric inpatients evacuated to out-of-area hospitals after the nuclear accident

Introduction

The Great East Japan Earthquake that occurred on March 11, 2011, caused a radioactive spill at the Fukushima Daiichi Nuclear Power Plant (FDNPP). Five hospitals (four psychiatric hospitals and one general hospital) in the Soso district of Fukushima Prefecture were close to the FDNPP and were forced to evacuate more than seven hundred psychiatric inpatients. They were mandatorily transferred to hospitals both within and outside the prefecture (Watari, 2018). The accident and subsequent evacuation caused a lot of trauma and confusion among the parties being evacuated and the receiving institutions (Igarashi et al., 2018). Previous studies have shown that evacuation status and patient background affect patient outcomes after evacuation. For example, patients’ evacuation distance (Terui et al., 2021) and time (Sawano et al., 2023) affected their mortality. Furthermore, Terui et al. (2023) found an association between certain psychiatric diagnoses and physical complications among hospitalized patients and the likelihood of returning to their hometown, Fukushima Prefecture, after evacuation. Nevertheless, there is still insufficient research on factors such as the impact of social background – including family relationships – on patients’ lives after evacuation caused by large-scale disasters. Therefore, this study examined whether family support, seen through the proxy measure of family visits to the inpatient’s former hospital, affects psychiatric patients’ return to Fukushima Prefecture after the evacuation.

Methods

Participants included 57 inpatients who were admitted to a psychiatric hospital in the Soso area and were evacuated to a hospital in Tokyo immediately after the nuclear accident. After the evacuation, between 12 December and 26 December 2018, we visited the hospital to which they were transferred in 2011 (evacuation) and collected data from their medical records using a survey sheet. If the information collected by this survey was insufficient, we visited a psychiatric clinic in which the prior hospital’s medical records of the participants were being kept. The survey specifically focused on inpatient family visits prior to the FDNPP as family support could potentially influence patients’ subsequent return to Fukushima. We defined family visits as those documented in physicians’ charts or nursing records.

After excluding one person whose return to Fukushima was unknown, five people who died at the hospital to which they were transferred, and seven people whose family member visits to the hospital from which they were transferred were unknown, forty-four people were included in the analysis.

A log-rank test was conducted to examine the relationship between post-evacuation return and pre-disaster family visits. The primary outcome of this study was return from the evacuation hospital, defined as the period between March 11, 2011, and return to Fukushima (survival time). SPSS version 27 (IBM, Armonk, NY, USA) was used for the analysis and R was used to calculate the cumulative survival curve. This study was conducted in accordance with the Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects and was approved by the Ethics Committee of Fukushima Medical University (No. 29389). An opt-out consent procedure was adopted. We posted a document in the hospital where the survey was conducted, which outlined the research purpose, participants, and methods, and described how personal data would be protected. The document also clearly stated that the participants would be guaranteed the opportunity to refuse participation.

Results

The average time to return to Fukushima was 681.8 days (standard error [SE], 163.3) among patients with family visits, and 1,027.8 days (SE, 152.0) among patients without family visits. The results of the test suggested the tendency of an association between return to Fukushima and previous family visits to the former hospital (p = .073; Figure 1). Patients who received family visits before the disaster tended to return to their hometown earlier, even if they were immediately and forcibly transferred to their new hospital. Among inpatients admitted to psychiatric hospitals, physical and mental illness as well as family cooperation were found to be possible indicators of return after evacuation.

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Figure 1.

The Kaplan-Meier curve illustrating the post-evacuation return and the difference between patients who had family visits before the evacuation and those who did not.

Discussion

A previous study showed that the return of evacuated psychiatric inpatients to their hometowns was associated with their physical and psychiatric status (Terui et al., 2023). Our results are the first to reveal that this population’s post-evacuation return is associated with their family history of visits in the hospital. We hypothesize that at least two factors might be related to the results of the current study. First, families who had frequently visited inpatients’ former hospitals had fundamentally tended to be dedicated to patients and, therefore, were able to perform constructive collaborations with staff of both the former and destination hospitals, coordinate return, and – above all – evacuate inpatients. Another possible hypothesis is that the medical staff of the hospitals where patients had been hospitalized before the evacuation had constructed in-person relationships with inpatients’ families before the FDNPP accident, and such ties were passed on to the staff of the evacuated destination hospitals.

From these hypotheses, we could consider pre-disaster family visits as a predictive factor of post-evacuation earlier returns to hometowns. Simultaneously, psychiatric practitioners’ daily efforts to construct cooperative relationships with inpatients’ families may decrease, or even prevent, evacuees’ unexpected and extended lengths of stay (LOS) at the evacuation destination. Velelekou et al. (2022) reported that social support from the families of inpatients with schizophrenia shortened the duration of hospitalization. Furthermore, a survey conducted in Japan that targeted nurses of psychiatric hospitals showed that one of the factors that helped prevent patients’ early readmission was that these nurses had established cooperative relationships with service providers and caregivers in the community, including patients’ families (Maki et al., 2021). During the management of ‘comprehensive community care systems dealing with mental disorders’ to promote psychiatric inpatients with an extended LOS in Japan, close collaboration with professionals, patients, and their families is essential (Yoshimasu et al., 2023). This study emphasizes the importance of daily clinical practices for community transition as well as support for future massive disasters and subsequent long-distance hospital evacuations.

However, this study has several limitations. First, there is potential information bias, as the survey was retrospective and record-based, and records of some patients’ occurrence of family visits might be overlooked. Second, because the target population was patients who had been evacuated to one hospital, concerns about external validity cannot be ignored (the efforts toward post-evacuation return or community transition among psychiatric patients vary from one hospital to another). Finally, our small sample size limited our ability to consider other covariates using methods such as regression model analysis.

Conclusion

Despite these limitations, this study focuses on the effects of pre-disaster family visits on the post-evacuation return of psychiatric inpatients following the FDNPP accident, suggesting that family support plays a crucial role in post-evacuation outcomes. Proactive efforts by medical staff to foster collaborative relationships with patients’ families are important not only for daily clinical practice, but also in the context of future large-scale disasters and subsequent evacuations.