Three weeks after a 11 March earthquake and tsunami left more than 27,500 people dead or missing, shock and awe at sheer destruction can give way to despondency and depression as the gravity of the survivors' loss sets in.
"For a lot of people who up until this point have been able to ignore reality and what actually happened, as they get back on their feet they realise that, for instance, their house is gone, or their children are dead, and they're being forced to confront these facts," said volunteer Dr Toru Hosada.
Uncertainty about what to do
"A lot of them are extremely uncertain as to what they can do," he said during rounds at a shelter in the shattered port city of Yamada in Iwate prefecture.
A tour of some 150 km (90 miles) of the devastated coast of northern Japan showed brisk efforts to house, feed and bathe thousands of people made homeless by the wave - but worries that "kokoro no care" (mental health treatment) was coming too slowly.
"Many people cannot sleep well at night as they are afraid of earthquakes. They have lost many things so they are psychologically hurt," Dr Keiichiro Kubota said.
The difficulty of comforting survivors is compounded by the more than 350 aftershocks recorded since 11 March.
"I am sleeping with my regular clothes on. I am always feeling an earthquake. Even when a car passes by, I think it's an earthquake," said Toshie Fukuda, 64, a survivor in Rikuzentakata, one of the cities hit hardest by the tsunami.
At the main disaster evacuee centre in Rikuzentakata, a junior high school, the psychological counselling centre is a curtained-off four square metre corner of a classroom.
"Do you suffer from headaches, stomach aches, diarrhoea? Are you easily agitated and unable to sleep? Do you have no appetite, suffer nightmares about the disaster, or lack your normal energy? Are you irritated by the smallest sound, unable to stop crying and unable to relax?" reads a clinic poster.
"These feelings are not at all unusual - they are the normal reaction of people who have received a severe shock," the poster said. "Talk to a specialist to lighten your burden."
'Seized by sadness'
In the school gymnasium downstairs from the clinic, where tsunami evacuees sleep and eat as they wait for new living arrangements, a young man suddenly vomits near the doorway.
"We are all stressed out here," says fellow evacuee Yukio Kudo, a 55-year-old high school teacher who lost his wife and one of his three sons when the tsunami obliterated his town.
"Although I'm generally in good health, I'm pretty sure that I have post traumatic stress disorder," he said. "Sometimes I'm clearheaded and positive, but other times I'm seized by sadness - and denial that I am now a homeless widower who just had my teenaged son cremated."
Kudo said he is cheered by the kindness of young volunteers who check on him daily but adds: "when I knock on the door of the psychological counselling room, I never find anyone there."
Cho Chow-mun of the Hong Kong aid organisation Social Workers Without Borders says both trauma and shortages of trained psychological experts were common features of the earthquake in China's Sichuan province in 2008 and the Indian ocean tsunami in 2004.
"Although elderly people are more stable, if there are deaths in the family, they will blame themselves. Women, if they lose their children, will have a lot of guilt and self-blame too," she said.
Mental health not getting attention
Dr Satoshi Takada, a paediatrician at Japan's Kobe University who treated children in the aftermath of the 1995 Kobe earthquake, said children's mental health did not get the attention it deserved after that disaster, which killed 6,000 people.
"Children are more susceptible to physical problems due to the mental stress," he said.
For the next three months, it is critical to make sure people in the disaster zone have regular access to counselling, while the government must offer clear information on new living quarters and work to reopen schools to allow children to resume a normal life, Cho and other experts said.
Schools in the tsunami-torn coast of north-eastern Japan will soon open for the school year on schedule or with slight delays.
Junichi Onodera, a principal at a kindergarten in Kesennuma that lost students and has children who lost their parents, says his teachers are well aware of the psychological challenge as a new crop of children begin school on April 12.
"The children look all bright-eyed and bubbly, but their emotional pain is heavy," he said.
"I can't really urge them 'keep your chin up and persevere' and things like that. Instead I keep my words forward-looking and tell them to study hard for a bright future," said Onodera. (Reuters Health/March 2011)
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