Reducing depressive symptoms afterthe Great East Japan
Earthquake inolder survivors through group exerciseparticipation
and regular walking:a prospective observational study
Taishi Tsuji,1 Yuri Sasaki,1 Yusuke Matsuyama,2 Yukihiro Sato,2
Jun Aida,2
Katsunori Kondo,1,3 Ichiro Kawachi4
To cite: Tsuji T, Sasaki Y,Matsuyama Y, et al.
Reducingdepressive symptoms afterthe Great East JapanEarthquake in
older survivorsthrough group exerciseparticipation and
regularwalking: a prospectiveobservational study. BMJOpen
2017;7:e013706.doi:10.1136/bmjopen-2016-013706
▸ Prepublication history andadditional material isavailable. To
view please visitthe journal
(http://dx.doi.org/10.1136/bmjopen-2016-013706).
Received 2 August 2016Revised 10 January 2017Accepted 9 February
2017
For numbered affiliations seeend of article.
Correspondence toDr Taishi Tsuji;[email protected]
ABSTRACTObjectives: Survivors of the 2011 Great East
JapanEarthquake have an increased risk of depressivesymptoms. We
sought to examine whetherparticipation in group exercise and
regular walkingcould mitigate the worsening of depressive
symptomsamong older survivors.Design: Prospective observational
study.Setting: Our baseline survey was conducted in August2010, ∼7
months prior to the Great East JapanEarthquake and tsunami, among
people aged 65 orolder residing in Iwanuma City, Japan, which
sufferedsignificant damage in the disaster. A 3-year
follow-upsurvey was conducted in 2013.Participants: 3567 older
survivors responded to thequestionnaires predisaster and
postdisaster.Primary outcome measures: Change in depressivesymptoms
was assessed using the 15-item GeriatricDepression Scale
(GDS).Results: From predisaster to postdisaster, the meanchange in
GDS score increased by 0.1 point (95% CI−0.003 to 0.207). During
the same interval, thefrequency of group exercise participation and
dailywalking time also increased by 1.9 days/year and1.3 min/day,
respectively. After adjusting for allcovariates, including personal
experiences of disaster,we found that increases in the frequency of
groupexercise participation (B=−0.139, β=−0.049, p=0.003)and daily
walking time (B=−0.087, β=−0.034,p=0.054) were associated with
lower GDS scores.Interactions between housing damage and changes
ingroup exercise participation (B=0.103, β=0.034,p=0.063) and
changes in walking habit (B=0.095,β=0.033, p=0.070) were marginally
significant,meaning that the protective effects tended to
beattenuated among survivors reporting more extensivehousing
damage.Conclusions: Participation in group exercises orregular
walking may mitigate the worsening ofdepressive symptoms among
older survivors who haveexperienced natural disaster.
INTRODUCTIONThe frequency of natural disasters such
ashurricanes, floods and earthquakes has beenincreasing worldwide.1
The experience ofdisaster presents a significant burden on
themental health of survivors.2–4 Depression inolder adults is
strongly associated with beinghouse-bound,5 which may lead to a
declinein physical and cognitive function and even-tually to
premature death.6 To clarify thefactors that contribute to mental
healthrecovery after a disaster, several postdisastersurveys have
been previously conducted.7–9
However, these studies have relied on survi-vors’ recollection
of their predisaster mentalhealth status, potentially contributing
torecall bias, that is, the experience of disastercan colour the
respondents’ assessment oftheir status ex ante. Clearly, it would
be desir-able to have predisaster information on survi-vors in
order to avoid information bias.10 Tothe best of our knowledge,
only two studiesexamining mental health status prior todisaster
events have been conducted.11 12 Bothstudies suggested that major
disaster was asso-ciated with an increase in the risk for
common
Strengths and limitations of this study
▪ The strength of this study is the unprecedentedand fortuitous
availability of information predat-ing the disaster.
▪ The study design enabled us to effectivelyaddress the problem
of recall bias that occurs inmost studies conducted in postdisaster
settings.
▪ Selection bias might have occurred because ofthe 59% response
rate to the baseline survey.
▪ The measurements rely entirely on self-reporteddata.
Tsuji T, et al. BMJ Open 2017;7:e013706.
doi:10.1136/bmjopen-2016-013706 1
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mental health disorders independently of previous mentalhealth
status and other potentially confounding factors.Furthermore, a
previous study suggested that dwellinghouse damage caused by major
disasters was associatedwith worsening depressive symptoms in older
survivors.13
Little evidence, however, is available for the prevention
ofmental health problems from a public health
interventionperspective.Physical activity, which is a modifiable
behaviour, has
the benefit of preventing or alleviating depressive symp-toms14
15 and of treating depression16 17 in older adults.It has also been
found that regular walking is by far themost prevalent physical
activity in older adults18 and hasprotective effects for
depression.19 20 Participation ingroup exercises may be
particularly effective for mentalhealth promotion in the elderly by
enhancing social par-ticipation in addition to physical activity.21
22 However, itis unclear whether the same benefits can be
alsoobtained following the experience of natural disaster.Following
the Great East Japan Earthquake on March
11, 2011, various health promotion interventions—including group
exercise programmes for older adults—were initiated in
disaster-stricken areas to address thehealth needs of survivors.23
24 Tomata and colleagues24
reported that there was no significant psychologicalbenefit from
attending group exercises once a monthamong middle-aged and older
survivors in disaster-stricken areas. Possible reasons for this
null finding wereinsufficient exercise frequency and sampling
bias24 asparticipants might have had good health, behaviour
andawareness before the disaster and might not have suf-fered much
damage as a result of the disaster.The purpose of the present study
was to examine
whether participation in group exercise and regularwalking could
mitigate the worsening of depressivesymptoms among older survivors
of the Great East JapanEarthquake after taking into account
predisaster mentalhealth status. We hypothesised that participation
ingroup exercises or regular walking may mitigate the wor-sening of
depressive symptoms among older survivorswho have experienced
natural disaster. These associa-tions, however, may differ
according to the extent ofdamage caused by the disaster.
METHODSStudy designOur longitudinal study was conducted in
Iwanuma City,a coastal municipality in the Miyagi prefecture,
Japan,located ∼80 km west of the epicentre of the Great EastJapan
Earthquake that occurred on 11 March, 2011.Iwanuma City (total
population 44 000) suffered tremen-dous damage from the earthquake
and tsunami: 180people were killed,25 and 48% (29 km2) of the land
wasinundated by seawater.26 Our study takes advantage ofthe
coincidence that Iwanuma City happened to be oneof the field sites
of the Japan Gerontological EvaluationStudy ( JAGES) Project,27 28
a nationwide, ongoing
prospective cohort study that started in 2010 to investi-gate
the social and behavioural factors associated withhealthy ageing.
As part of the baseline survey for theJAGES project cohort, we
conducted a census of alladults aged 65 years or older living in
Iwanuma City inAugust 2010, 7 months prior to the earthquake. A
3-yearfollow-up survey was conducted in November 2013,2 years and 7
months after the earthquake. Aftersending the questionnaires to all
older adults living inIwanuma City in the follow-up survey, we
visited all theresidences to collect the completed questionnaires.
Theparticipant flow chart is shown in figure 1.29
Study participants were selected for the Iwanumaproject based on
the following inclusion criteria: respon-dents from the 2010 and
2013 surveys who had no lim-itations in activities of daily living
(ADL) (ie, they couldindependently walk, bathe and visit the
toilet) at thebaseline survey in 2010.All participants gave
informed consent.
MeasurementsChange in depressive symptomsWe assessed depressive
symptoms using the 15-itemGeriatric Depression Scale (GDS)30 31 as
a continuousvariable in 2010 and 2013. The score range is 0–15
andhigher value means greater severity of depressive symp-toms.
Change in depressive symptoms calculated by sub-tracting the score
in 2010 from that in 2013.
Changes in group exercise participation and regular
dailywalkingIn predisaster and postdisaster surveys, we
ascertainedthe frequency of group exercise participation (4
days/week or more, 2–3 days/week, once a week, 1–3 time(s)/month, a
few times/year or none), as well as regulardaily walking behaviour
(
Research Grant (No. 24140701) from the Japanese Ministry of
Health, Labourand Welfare.
Disclaimer The funding sources had no role in study design, data
collectionand analysis, decision to publish or preparation of the
manuscript.
Competing interests None declared.
Ethics approval The Ethics Committee at the Graduate school of
Medicine,Chiba University, approved the study protocol.
Provenance and peer review Not commissioned; externally peer
reviewed.
Data sharing statement No additional data are available.
Open Access This is an Open Access article distributed in
accordance withthe Creative Commons Attribution Non Commercial (CC
BY-NC 4.0) license,which permits others to distribute, remix,
adapt, build upon this work non-commercially, and license their
derivative works on different terms, providedthe original work is
properly cited and the use is non-commercial. See:
http://creativecommons.org/licenses/by-nc/4.0/
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Reducing depressive symptoms after the Great East Japan
Earthquake in older survivors through group exercise participation
and regular walking: a prospective observational
studyAbstractIntroductionMethodsStudy designMeasurementsChange in
depressive symptomsChanges in group exercise participation and
regular daily walkingCovariates
Statistical analyses
ResultsDiscussionReferences