World Psychiatry. 2006 Feb; 5(1): 25–30.
PMCID: PMC1472271
PMID: 16757987
R. SRINIVASA MURTHY1 and RASHMI LAKSHMINARAYANA2
Author information Copyright and License information PMC Disclaimer
See commentary "Terrorism and its effects on mental health" onpage35.
See commentary "The tragedy of war" onpage36.
See commentary "The population health argument against war" onpage31.
See commentary "War and mental disorders in Africa" onpage38.
See commentary "How to prevent turning trauma into a disaster?" onpage32.
See commentary "Mental health consequences of war: gender specific issues" onpage33.
See commentary "Building and translating evidence into smart policy: continuingresearch needs for informing post-war mental health policy" onpage34.
Abstract
Among the consequences of war, the impact on the mental health of the civilianpopulation is one of the most significant. Studies of the general populationshow a definite increase in the incidence and prevalence of mental disorders.Women are more affected than men. Other vulnerable groups are children, theelderly and the disabled. Prevalence rates are associated with the degreeof trauma, and the availability of physical and emotional support. The useof cultural and religious coping strategies is frequent in developing countries.
Keywords: War, mental health, vulnerable groups, coping strategies
The year 2005 is significant in understanding the relationship betweenwar and mental health. This is the 30th anniversary of the end of the Vietnamwar and of the start of the war in Lebanon. Every day the media bring thehorrors of the ongoing "war" situation in Iraq. Some recent quotations fromthe media depict the impact of war on mental health: "We are living in a stateof constant fear" (in Iraq); "War takes a toll on Iraqi mental health"; "Wartrauma leaves physical mark"; "War is hell... it has an impact on the peoplewho take part that never heals"; "War is terrible and beyond the understandingand experience of most people"; "A generation has grown up knowing only war".
Wars have had an important part in psychiatric history in a number of ways.It was the psychological impact of the world wars in the form of shell shockthat supported the effectiveness of psychological interventions during thefirst half of the 20th century. It was the recognition of a proportion ofthe population not suitable for army recruitment during the Second World Warthat spurred the setting up of the National Institute of Mental Health inUSA. The differences in the presentation of the psychological symptoms amongthe officers and the soldiers opened up new ways of understanding the psychiatricreactions to stress.
During the last year, a large number of books and documents have addressedthe effects of war on mental health. They include the WPA book "Disastersand mental health" (1); the World Bankreport "Mental health and conflicts - Conceptual framework and approaches"(2); the United Nations (UN) book "Traumainterventions in war and peace: prevention, practice and policy" (3); the United Nations Children's Fund (UNICEF) document "Thestate of the world's children - Childhood under threat" (4); the book "Trauma and the role of mental health in postconflictrecovery" (5) and a chapter on "Warand mental health in Africa" in the WPA book "Essentials of clinical psychiatryfor sub-Saharan Africa" (6).
Though there have not been any world wars since the Second World War, therehave been wars and conflicts throughout the last 60 years. For example, inthe 22 countries of the Eastern Mediterranean region of the World Health Organization(WHO), over 80% of the population either is in a conflict situation or hasexperienced such a situation in the last quarter of century (7).
War has a catastrophic effect on the health and well being of nations.Studies have shown that conflict situations cause more mortality and disabilitythan any major disease. War destroys communities and families and often disruptsthe development of the social and economic fabric of nations. The effectsof war include long-term physical and psychological harm to children and adults,as well as reduction in material and human capital. Death as a result of warsis simply the "tip of the iceberg". Other consequences, besides death, arenot well documented. They include endemic poverty, malnutrition, disability,economic/ social decline and psychosocial illness, to mention only a few.Only through a greater understanding of conflicts and the myriad of mentalhealth problems that arise from them, coherent and effective strategies fordealing with such problems can be developed.
The importance that the WHO attributes to dealing with the psychologicaltraumas of war was highlighted by the resolution of the World Health Assemblyin May 2005, which urged member states "to strengthen action to protect childrenfrom and in armed conflict" and the resolution of the WHO Executive Boardin January 2005, which urged "support for implementation of programmes torepair the psychological damage of war, conflict and natural disasters" (8).
The WHO estimated that, in the situations of armed conflicts throughoutthe world, "10% of the people who experience traumatic events will have seriousmental health problems and another 10% will develop behavior that will hindertheir ability to function effectively. The most common conditions are depression,anxiety and psychosomatic problems such as insomnia, or back and stomach aches"(9).
This paper briefly reviews the evidence from published literature aboutthe impact of war on the mental health of the general population, the refugees,the soldiers and specific vulnerable groups. For the purpose of this paper,the term "war" is used to include both wars waged between countries (e.g.,the Iraq-Kuwait war) and conflicts within countries (e.g., Sri Lanka). Thereview presents data concerning some major wars/conflicts (the countries involvedare considered in alphabetic order) and then briefly outlines the risk factorsemerging from the literature.
IMPACT OF WAR ON MENTAL HEALTH
Afghanistan
More than two decades of conflict have led to widespread human sufferingand population displacement in Afghanistan. Two studies from this countryare significant in terms of both their scope and their findings.
The first study (10) used a nationalmultistage, cluster, population based survey including 799 adult householdmembers aged 15 years and above. Sixty-two percent of respondents reportedexperiencing at least four trauma events during the previous ten years. Symptomsof depression were found in 67.7% of respondents, symptoms of anxiety in 72.2%,and post-traumatic stress disorder (PTSD) in 42%. The disabled and women hada poorer mental health status, and there was a significant relationship betweenthe mental health status and traumatic events. Coping strategies includedreligious and spiritual practices.
The second study (11), using a crosssectionalmulticluster sample, was conducted in the Nangarhar province of Afghanistan,to estimate the prevalence of psychiatric symptoms, identify resources usedfor emotional support and risk factors, and assess the present coverage ofbasic needs. About 1011 respondents aged 15 years and above formed the sample.Nearly half of the population had experienced traumatic events. Symptoms ofdepression were observed in 38.5% of respondents, symptoms of anxiety in 51.8%and PTSD in 20.4%. High rates of symptoms were associated with higher numbersof traumatic events experienced. Women had higher rates than men. The mainsources of emotional support were religion and family.
The Balkans
The conflict in the Balkans is probably one of the most widely studied(12-14)in recent years. Mental health of survivors of both sides was examined (15).
An initial study (16) among Bosnianrefugees demonstrated an association between psychiatric disorders (depressionand PTSD) and disability. A threeyear follow-up study on the same group concludedthat former Bosnian refugees who remained living in the region continued toexhibit psychiatric disorders and disability after initial assessment (17).
A cross-sectional cluster sample survey among Kosovar Albanians aged 15years or older found that 17.1% (95% CI 13.2%-21.0%) reported symptoms ofPTSD (18). There was a significantlinear decrease in mental health status and social functioning with increasingamount of traumatic events in those aged 65 years or older, and with previouspsychiatric illnesses or chronic health conditions. Internally displaced peoplewere at increased risk of psychiatric morbidity. Men (89%) and women (90%)expressed strong feelings of hatred towards the Serbs, with 44% of men and33% of women stating that they would act on these feelings.
In a study of the mental health and nutritional status among the Serbianethnic minority in Kosovo, the General Health Questionnaire (GHQ)-28 scoresin the subcategories of social dysfunction and severe depression were high,with women and those living alone or in small family units being more proneto psychiatric morbidity (19). In acommunity sample of 2,796 children aged between 9 and 14 years, high levelsof post-traumatic symptoms and grief symptoms were reported (20). This was related to the amount and type of exposure.Girls reported more distress than boys.
Cambodia
Cambodia has had a long history of violence, highlighted by the civil warin the 1960s, culminating with the "Khmer Rouge" rule that destroyed the socialfabric of the society. Studies have found that refugees had high levels ofpsychiatric symptomatology after 10 years (21).
A household survey of 993 adults from Site 2, the largest Cambodian displaced-persons camp on the Thailand- Cambodia border, found that more than 80% feltdepressed and had a number of somatic complaints despite good access to medicalservices (22). Approximately 55% and15% had symptom scores that correlated with Western criteria for depressionand PTSD, respectively. However, despite high reported levels of trauma andsymptoms, social and work functioning were well preserved in the majorityof respondents. Cumulative trauma continued to affect psychiatric symptomlevels a decade after the original trauma events (23).This study also reported that there was support for the diagnostic validityof PTSD criteria, with the notable exception of avoidance. The inclusion ofdissociative symptoms increased the cultural sensitivity of PTSD. Psychiatrichistory and current physical illness were found to be risk factors for PTSD(24).
Changes in the structure of the society have led to a breakdown of theexisting protective networks such as the village chief and the elders in thevillage, especially for women (25).Traditional healers (monks, mediums, traditional birth attendants), who playedan important role in maintaining the mental health of communities in the past,have lost their designated positions in the community following the conflict(26).
Twenty-seven Cambodian young people, who were severely traumatized at ages8 to 12, were followed up 3 years after a baseline evaluation. A structuredinterview and self-rating scales showed that PTSD was still highly prevalent(48%) and that depression was present in 41% (27).
Chechnya
The human rights abuses in the Chechen population have been well documented(28). A report on a small number ofChechen asylum seekers in the UK adds to the evidence on the abuses and relatedpsychological fallouts (29). Psychosocialissues were explored in a survey conducted in settlements housing displacedpeople (n=256) (30,31). Two thirds of respondents agreed with the statementthat the conflict has triggered mental disturbance or feelings of being upset.Nearly all respondents indicated that they had family members having difficultyin coping with their disturbance or upset feelings. Coping strategies usedwere praying, talking, keeping busy, and seeking the support of family members.
Iraq
Iraq has been at war at numerous times in history: a series of coups inthe 1960s, the Iran-Iraq war (1980-1988), the anti-Kurdish Al-Anfal campaignwithin the country (1986-1989), the Iraqi invasion of Kuwait resulting inthe Gulf war (1991), and the conflict starting in 2003. The UN-imposed economicsanctions following the Gulf war have had a profound impact on the healthof Iraqis. The human rights abuses have also been recorded (32).
There are few studies on the impact of these conflicts on mental health.A study on 45 Kurdish families in two camps reported that PTSD was presentin 87% of children and 60% of their caregivers (33).A study on 84 Iraqi male refugees found that poor social support was a strongerpredictor of depressive morbidity than trauma factors (34). During the last three years of occupation by foreignforces, there have been many news reports about the mental health of the population,but no systematic study.
Israel
Israel has been in a situation of conflict for over four decades. A largenumber of systematic studies have been undertaken in different populationgroups. A recent study (35) found that76.7% of subjects exposed to war-related trauma had at least one traumaticstress-related symptom, while 9.4% met the criteria for acute stress disorder.The most common coping mechanisms were active information search about lovedones and social support. Another study (36)reported that, twenty years after the war with Lebanon, an initial combatstress reaction, PTSD-related chronic diseases and physical symptoms wereassociated with a greater engagement in risk behaviours.
Lebanon
Lebanon has been ravaged by a civil war (1975-1990) and by an Israeli invasionin 1978 and 1982. The mental health impact of these conflicts has been studiedextensively.
A random sample of 658 people aged between 18 and 65 years was randomlyselected from four Lebanese communities exposed to war (37). The lifetime prevalence of DSM-III-R major depressionvaried across the communities from 16.3% to 41.9%. Exposure to war and a priorhistory of major depression were the main predictors for current depression.
The correlation between mother's distress and child's mental health wasexplored in a study in Beirut (38).The level of perceived negative impact of war-related events was found tobe strongly associated with higher levels of depressive symptomatology amongmothers. The level of depressive symptomatology in the mother was found tobe the best predictor of her child's reported morbidity. In a study carriedout in 224 Lebanese children (10-16 years), the number of traumatic experiencesrelated to war was positively correlated to PTSD symptoms, with various typesof war traumas being differentially related to the symptoms (39).
A cross-sectional study conducted among 118 Lebanese hostages of war (40) found that psychological distress waspresent in 42.1% of the sample compared to 27.8% among the control group.Significant predictors for distress were years of education and increase inreligiosity after release.
Palestine
During the last decade a large number of studies have reported high levelsof psychosocial problems among children and adolescents, women, refugees andprisoners in Palestine.
A study conducted by the Gaza Community Mental Health Programme among childrenaged 10-19 years (41) revealed that32.7% suffered from PTSD symptoms requiring psychological intervention, 49.2%from moderate PTSD symptoms, 15.6% from mild PTSD symptoms, and only 2.5%had no symptoms. Boys had higher rates (58%) than girls (42%), and childrenliving in camps suffered more than children living in towns (84.1% and 15.8%respectively).
A study on Palestinian perceptions of their living conditions during theSecond Intifada (42) found that 46%of parents reported aggressive behaviour among their children, 38% noted badschool results, 27% reported bed wetting, while 39% stated that their childrensuffered from nightmares. The study also revealed that more refugee (53%)than non-refugee (41%) children behaved aggressively. Thirty-eight percentof the respondents said that shooting was the main influence, 34% stated thatit was violence on TV, 7% cited confinement at home and 11% reported thatit was the arrest and beating of relatives and neighbours. Seventy percentof refugees and non-refugees stated that they had not received any psychologicalsupport for the problems of their children.
In a series of studies during the last 10 years from the Gaza CommunityMental Health Centre (43), the mostprevalent types of trauma exposure for children were witnessing funerals (95%),witness to shooting (83%), seeing injured or dead strangers (67%) and familymember injured or killed (62%). Among children living in the area of bombardments,54% suffered from severe, 33.5% from moderate and 11% from mild or doubtfullevels of PTSD. Girls were more vulnerable.
Rwanda
The physical and mental health problems of the survivors of the genocidein Rwanda have been well documented (44).In a recent community based study examining 2091 subjects (45), 24.8% met symptom criteria for PTSD, with the adjustedodds ratio of meeting PTSD symptom criteria for each additional traumaticevent being 1.43. Respondents who met PTSD criteria were less likely to havepositive attitudes towards the Rwandan national trials, suggesting that theeffects of trauma need to be considered if reconciliation has to be successful.There have been reports on the state of health among the large numbers ofrefugees (500,000-800,000 in five days) who fled to Goma, Zaire followingthe capture of the capital Kigali, but none of them has considered the mentalhealth dimension.
Sri Lanka
The conflict between the majority Sinhala and minority Tamil populationin Sri Lanka has been ongoing for nearly 30 years. One of the first studiesthat looked into the psychological effects of the conflict on the civilianpopulation was an epidemiological survey (46),which reported that only 6% of the study population had not experienced anywar stresses. Psychosocial sequelae were seen in 64% of the population, includingsomatization (41%), PTSD (27%), anxiety disorder (26%), major depression (25%),alcohol and drug misuse (15%), and functional disability (18%). The breakdownof the Tamil society led to women taking on more responsibilities, which inturn made them more vulnerable to stress (47).Children and adolescents had higher mental health morbidity (48).
Somalia
A study carried out in ex-combatants in Somalia found high psychiatricmorbidity and use of khat (49). A UNICEFstudy found evidence of psychological effects of the prolonged conflict situationin a high proportion of a sample of 10,000 children (50). There is near total disruption of the mental healthservices in the country.
Uganda
Sudanese refugees fled into northern Uganda in two major waves in 1988and 1994. Symptoms of PTSD and depression were found to be highly prevalentamong Sudanese children living in the refugee camps (51). Refugees had higher rates of individual psychopathologythan the general population, and it was observed that the cumulative stressgrew as the years in exile progressed. The consequences of long-term exilewere still present 5-15 years later, with an increase in the rates of suicideand alcohol use.
RISK FACTORS
From the large amount of studies reviewed, some broad risk factors andassociations can be drawn.
Women have an increased vulnerability to the psychological consequencesof war. There is evidence of a high correlation between mothers' and children'sdistress in a war situation. It is now known that maternal depression in theprenatal and postnatal period predicts poorer growth in a communitybased sampleof infants. Social support and traditional birth attendants have a major rolein promoting maternal psychosocial well being in war-affected regions. Theassociation between gender- based violence and common mental disorders iswell known. Despite their vulnerability, women's resilience under stress andits role in sustaining their families has been recognized.
There is consistent evidence of higher rates of trauma-related psychologicalproblems in children. The most impressive reports are those from Palestine.Of the different age groups, the most vulnerable are the adolescents.
The direct correlation between the degree of trauma and the amount of thepsychological problems is consistent across a number of studies. The greaterthe exposure to trauma - both physical and psychological - the more pronouncedare the symptoms.
Subsequent life events and their association with the occurrence of psychiatricproblems have important implications for fast and complete rehabilitationas a way of minimizing the ill effects of the conflict situations.
Studies are consistent in showing the value of both physical support andpsychological support in minimizing the effects of war-related traumas, aswell as the role of religion and cultural practices as ways of coping withthe conflict situations.
CONCLUSIONS
The occurrence of a wide variety of psychological symptoms and syndromesin the populations in conflict situations is widely documented by availableresearch. However, research also provides evidence about the resilience ofmore than half of the population in the face of the worst trauma in war situations.There is no doubt that the populations in war and conflict situations shouldreceive mental health care as part of the total relief, rehabilitation andreconstruction processes. As happened in the first half of the 20th century,when war gave a big push to the developing concepts of mental health, thestudy of the psychological consequences of the wars of the current centurycould add new understandings and solutions to mental health problems of generalpopulations.
A number of issues have emerged from the extensive literature on the prevalenceand pattern of mental health effects of war and conflict situations. Are thepsychological effects and their manifestation universal? What should be thedefinition of a case requiring intervention? How should psychological effectsbe measured? What is the long-term course of stress-related symptoms and syndromes?(52). All these issues need to be addressedby future studies.
It is important to report that the WHO and some other UN-related bodieshave recently created a task force to develop "mental health and psychosocialsupport in emergency settings" (53- 55), which is expected to complete its activityin one year.
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