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New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis

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Background: Existing WHO estimates of the prevalence of mental disorders in emergency settings are more than a decade old and do not reflect modern methods to gather existing data and derive estimates. We sought to update WHO estimates for the prevalence of mental disorders in conflict-affected settings and calculate the burden per 1000 population. Methods: In this systematic review and meta-analysis, we updated a previous systematic review by searching MEDLINE (PubMed), PsycINFO, and Embase for studies published between Jan 1, 2000, and Aug 9, 2017, on the prevalence of depression, anxiety disorder, post-traumatic stress disorder, bipolar disorder, and schizophrenia. We also searched the grey literature, such as government reports, conference proceedings, and dissertations, to source additional data, and we searched datasets from existing literature reviews of the global prevalence of depression and anxiety and reference lists from the studies that were identified. We applied the Guidelines for Accurate and Transparent Health Estimates Reporting and used Bayesian meta-regression techniques that adjust for predictors of mental disorders to calculate new point prevalence estimates with 95% uncertainty intervals (UIs) in settings that had experienced conflict less than 10 years previously. Findings: We estimated that the prevalence of mental disorders (depression, anxiety, post-traumatic stress disorder, bipolar disorder, and schizophrenia) was 22·1% (95% UI 18·8-25·7) at any point in time in the conflict-affected populations assessed. The mean comorbidity-adjusted, age-standardised point prevalence was 13·0% (95% UI 10·3-16·2) for mild forms of depression, anxiety, and post-traumatic stress disorder and 4·0% (95% UI 2·9-5·5) for moderate forms. The mean comorbidity-adjusted, age-standardised point prevalence for severe disorders (schizophrenia, bipolar disorder, severe depression, severe anxiety, and severe post-traumatic stress disorder) was 5·1% (95% UI 4·0-6·5). As only two studies provided epidemiological data for psychosis in conflict-affected populations, existing Global Burden of Disease Study estimates for schizophrenia and bipolar disorder were applied in these estimates for conflict-affected populations. Interpretation: The burden of mental disorders is high in conflict-affected populations. Given the large numbers of people in need and the humanitarian imperative to reduce suffering, there is an urgent need to implement scalable mental health interventions to address this burden. Funding: WHO; Queensland Department of Health, Australia; and Bill & Melinda Gates Foundation.
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New WHO prevalence estimates of mental disorders in
conflict settings: a systematic review and meta-analysis
Fiona Charlson, Mark van Ommeren, Abraham Flaxman, Joseph Cornett, Harvey Whiteford, Shekhar Saxena
Summary
Background Existing WHO estimates of the prevalence of mental disorders in emergency settings are more than a
decade old and do not reflect modern methods to gather existing data and derive estimates. We sought to update
WHO estimates for the prevalence of mental disorders in conflict-aected settings and calculate the burden per
1000 population.
Methods In this systematic review and meta-analysis, we updated a previous systematic review by searching MEDLINE
(PubMed), PsycINFO, and Embase for studies published between Jan 1, 2000, and Aug 9, 2017, on the prevalence of
depression, anxiety disorder, post-traumatic stress disorder, bipolar disorder, and schizophrenia. We also searched the
grey literature, such as government reports, conference proceedings, and dissertations, to source additional data, and
we searched datasets from existing literature reviews of the global prevalence of depression and anxiety and reference
lists from the studies that were identified. We applied the Guidelines for Accurate and Transparent Health Estimates
Reporting and used Bayesian meta-regression techniques that adjust for predictors of mental disorders to calculate
new point prevalence estimates with 95% uncertainty intervals (UIs) in settings that had experienced conflict less
than 10 years previously.
Findings We estimated that the prevalence of mental disorders (depression, anxiety, post-traumatic stress disorder,
bipolar disorder, and schizophrenia) was 22·1% (95% UI 18·8–25·7) at any point in time in the conflict-aected
populations assessed. The mean comorbidity-adjusted, age-standardised point prevalence was 13·0% (95% UI
10·3–16·2) for mild forms of depression, anxiety, and post-traumatic stress disorder and 4·0% (95% UI 2·9–5·5) for
moderate forms. The mean comorbidity-adjusted, age-standardised point prevalence for severe disorders
(schizophrenia, bipolar disorder, severe depression, severe anxiety, and severe post-traumatic stress disorder) was
5·1% (95% UI 4·0–6·5). As only two studies provided epidemiological data for psychosis in conflict-aected
populations, existing Global Burden of Disease Study estimates for schizophrenia and bipolar disorder were applied
in these estimates for conflict-aected populations.
Interpretation The burden of mental disorders is high in conflict-aected populations. Given the large numbers of
people in need and the humanitarian imperative to reduce suering, there is an urgent need to implement scalable
mental health interventions to address this burden.
Funding WHO; Queensland Department of Health, Australia; and Bill & Melinda Gates Foundation.
Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.
Introduction
Currently, there are major conflict-induced humanitarian
crises in numerous countries, including Afghanistan,
Iraq, Nigeria, Somalia, South Sudan, Syria, and Yemen.
UN estimates suggest that more than 68·6 million people
worldwide have been forcibly dis placed by violence and
conflict, the highest number of people aected since
World War 2.1 This increase in people aected by conflict
coincides with a growing interest in mental health, as
exemplified by the recently approved 10-year extension of
the Mental Health Action Plan by 194 WHO member
states.2 Interest is especially high in the mental health of
people aected by humanitarian emergencies.3
In 2005, WHO estimated the prevalence of mental
disorders among people aected by humanitarian
emergencies.4 These estimates have been frequently
repeated in policy documents,3,5,6 news media,7 and
appeals and funding proposals for help for people living
through the world’s worst crises. WHO emphasised that
these estim ates represented averages across emergency
settings and that observed prevalence estimates would
vary by aected population and assessment method.4
However, WHO’s 2005 estimates were not based on
applicable systematic reviews of evidence.
Epidemiological studies in conflict settings typically
present varying results, making their interpretation
dicult,8 and their statistical heterogeneity is extremely
high.9,10 We sought to update WHO estimates of the
prevalence of mental disorders in conflict-aected
populations by updating systematic literature reviews for
post-traumatic stress disorder and depression, searching
for a wider range of disorders, and applying Bayesian
meta-regression techniques while adjusting for predictors
of mental disorders in conflict settings. Natural disasters
Lancet 2019; 394: 240–48
Published Online
June 11, 2019
http://dx.doi.org/10.1016/
S0140-6736(19)30934-1
See Comment page 192
Policy and Epidemiology
Group, Queensland Centre for
Mental Health Research
(F Charlson PhD, J Cornett BS,
Prof H Whiteford PhD), and
School of Public Health,
University of Queensland
(F Charlson, Prof H Whiteford),
QLD, Australia; Institute for
Health Metrics and Evaluation,
University of Washington,
Seattle, WA, USA (F Charlson,
A Flaxman PhD, H Whiteford);
Department of Mental Health
and Substance Abuse, WHO,
Geneva, Switzerland
(M van Ommeren PhD); and
T H Chan School of Public
Health, Harvard University,
Boston, MA, USA (S Saxena MD)
Correspondence to:
Dr Mark van Ommeren,
Department of Mental Health
and Substance Abuse, WHO,
Geneva 1211, Switzerland
vanommerenm@who.int
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and public health emergencies, such as the Ebola
virus outbreak, were outside the scope of this study.
Previous research has identified dierent mental health
consequences across these emergency settings11,12 (conflict
probably has more severe consequences), and our
selectivity was designed to limit heterogeneity within our
dataset. Our approach was in line with current WHO and
Inter-Agency Standing Committee humanitarian policies
and tools that include a broad multidisorder perspect-
ive.2,3,13,14 Furthermore, we aimed to estimate disease
burden in terms of years lived with disability (YLDs) per
1000 people aected by conflict.
Methods
Overview
For this systematic review and meta-analysis, we followed
the Guidelines for Accurate and Transparent Health
Estimates Reporting (GATHER) statement15 and used
methodologies developed for the Global Burden of
Diseases, Injuries, and Risk Factors Study (GBD) 2016.16
We refer to the generic term conflict as a substitute for
armed conflict and war. Current concepts and defi nitions
of conflict were extracted by searching peace and conflict
databases, organisation websites, and pub lished reports.
The relevance and usefulness of current concepts and
definitions of conflict were assessed to determine the
most appropriate database for our context. A critique of
the usefulness of each database identified five potentially
appropriate conflict databases. The Uppsala Conflict
Data Program,17 the Correlates of War project,18 the
Integrated Network for Societal Conflict Research Major
Episodes of Political Violence,19 and the Heidelberg
Institute for International Conflict Research Conflict
Barometer20 describe conflict as the existence of opposing
forces and stipulate a violence threshold described in
terms of number of deaths. The Political Terror Scale21
reports level of state terror according to state-perpetrated
human rights violations. We then did a quantitative
assessment of concordance between these five databases
using the kappa (κ) statistic.22 On the basis of the
assessments of usefulness and concordance, we elected
to use both the Uppsala Conflict Data Program and
Political Terror Scale databases. Further details of this
process can be found in the appendix and online.23
We based our dataset on a previous systematic review,10
which included studies published between 1980 and 2013
(search details in the appendix). We updated this review
by searching MEDLINE (PubMed), PsycINFO, and
Embase for studies published between Jan 1, 2000, and
Aug 9, 2017, to identify sources for the prevalence
Research in context
Evidence before this study
In 2005, in response to the Asian tsunami, WHO estimated
the prevalence of mental disorders among people affected by
humanitarian emergencies. These estimates were repeated in
policy documents, news media, and appeals and funding
proposals, but they did not have confidence intervals and
were not based on systematic reviews of evidence. We
searched MEDLINE (PubMed), PsycINFO, and Embase, to
identify studies published from Jan 1, 2000, to Aug 9, 2017,
to identify sources for the prevalence of post-traumatic stress
disorder, depression, and anxiety disorders using the
Diagnostic and Statistical Manual of Mental Disorders (DSM)
or the International Classification of Diseases (ICD) criteria
and variables known to be associated with prevalence (such
as exposure to trauma) to guide a predictor analysis. We used
the search string ((((((((“Warfare”[MESH]) OR “Warfare and
Armed Conflicts”[MESH]) OR “Torture”[MESH]) OR “Ethnic
Violence”[MESH]) OR “Exposure to Violence”[MESH]) OR
“Mass Casualty Incidents”[MESH]) OR “Civil
Disorders”[MESH])) AND (((((“Anxiety Disorders”[MESH]) OR
“Mood Disorders”[MESH]) OR “Trauma and Stressor Related
Disorders”[MESH]) OR “Stress, Psychological”[MESH]) OR
“Neurotic Disorders”[MESH]) AND
((((“Epidemiology”[MESH] OR “epidemiology” [Subheading])
OR “Prevalence”[MESH]) OR “Psychiatric Status Rating
Scales”[MESH])) for PubMed, and adapted it for the other
online databases. No language restriction was applied. We
also did a grey literature search using Google Scholar, datasets
from existing literature reviews, and reference lists from
studies identified.
Added value of this study
In this systematic review and meta-analysis, we updated WHO’s
2005 estimates for the prevalence of mental disorders in
conflict-affected low-income and middle-income settings,
focusing on depression, anxiety disorder, post-traumatic stress
disorder, bipolar disorder, and schizophrenia in settings that had
experienced conflict in the preceding 10 years. We estimated
that more than one in five people (22·1%) in post-conflict
settings has depression, anxiety disorder, post-traumatic stress
disorder, bipolar disorder, or schizophrenia and that almost one
in ten people (9·1%)in post-conflict settings has a moderate of
severe mental disorder at any point in time.
Implications of all the available evidence
Given that the prevalence of mental disorders was found to be
very high, there is a need to make available sustainable mental
health care in conflict-affected countries. This will require a
focus on investment in leadership and governance for mental
health; integrated and responsive mental health and social
care services in community-based settings; strategies for
promotion and prevention in mental health; and information
systems, evidence, and research for mental health in
conflict-affected countries. The well established links between
mental health, individual functioning, and country
development underscore the imperative to prioritise mental
health care in countries affected by conflict.
See Online for appendix
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of post-traumatic stress disorder, depression, anxiety
disorders, schizophrenia, and bipolar disorder diagnosed
using the Diagnostic and Statistical Manual of Mental
Disorders (DSM) or the International Classification of
Diseases (ICD) criteria, and for variables known to be
associated with prevalence (such as exposure to trauma)
to guide a predictor analysis. No language restriction
was applied. We also searched the grey literature, such
as government reports, conference proceedings, and
dissertations, to source additional data. Sources included
Google search engines (eg, Google Scholar) and ProQuest
digital dissertations. Additionally, we searched datasets
from existing literature reviews of the global prevalence
of depression and anxiety24,25 and reference lists from the
studies that were identified. All grey-literature sources
identified were in English. We sought data on the
prevalence of schizophrenia and bipolar disorder in
conflict-aected populations from existing systematic
reviews.26,27
We included study samples that were representative of
the general conflict-aected population, defined as being
within a described geographical location and having
been in a state of conflict within 10 years preceding data
collection, as documented by the Uppsala Conflict Data
Program database.17 We only included studies of partici-
pants residing in their country of origin, or displaced
or resettled in a neighbouring low-income or middle-
income country; populations resettled in a high-income
country were excluded because there is evidence that the
hetero geneity might be considerable because of exposure
to external and environmental factors during the
resettling process.9 We included studies that reported
point or past-year prevalence estimates from either
cross-sectional or longitudinal population-based surveys.
Figure 1: Map of number of depression studies, 1980–2017
1
2
4
6
8
Depression datapoints
Figure 2: Map of number of any anxiety studies, 1980–2017
1
2
3
4
Any anxiety datapoints
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Survey instru ments had to map to DSM or ICD
diagnostic criteria. A complete list of inclusion and
exclusion criteria can be found in the appendix.
Two of the authors (FC and JC) were responsible for the
searches and data extraction. Identified data sources were
reviewed by both authors and, if a consensus was not
reached, a third author (HW).
Data analysis
Data were extracted into a standardised excel template.
Duplicate data from the same study samples and reported
in multiple studies were identified and removed. We used
a Bayesian meta-regression model and the adaptive
Metropolis Markov-chain Monte Carlo method to draw
samples from the posterior distribution of all model
parameters simultaneously, with the modelling software
package DisMod-MR 1.0.16,28 To explain between-study
variability in prevalence, we included a range of study-level
and war-related covariates that had previously been
shown to have significant associations with mental
disorder prevalence.10 We reported age-standardised point
estimates based on the means of functions of these
parameter draws, and uncertainty intervals (UIs)
corresponding to the 2·5–97·5 percentile values. The UI
provides an upper and lower bound that the model predicts
to contain the true value with 95% certainty. Details on
covariate selection can be found in the appendix.
We conducted quality assessment at the time of data
extraction through our inclusion and exclusion criteria.
To adjust for comorbidities and severity splits in
depression, anxiety, and post-traumatic stress disorder,
we applied the prevalence of 41·6% (95% UI 39·8–43·4)
of indi viduals with depressive disorder who also had
comorbid anxiety, as previously identified from the
literature.29 Distributions of depression and anxiety
severity were taken from GBD 2016,16 which considers
several health states within a particular disease that are
reflective of dierent levels of functional impairment
(ie, none, mild, moderate, or severe) once disability
attributable to comorbid disorders is portioned out.30
In the absence of severity splits for post-traumatic
stress disorder, we relied on severity distributions for
anxiety disorders. More detail on GBD severity splits and
disability weights can be found in the appendix.
Figure 3: Map of number of post-traumatic stress disorder studies, 1980–2017
1
5
10
15
18
Post-traumatic stress
disorder datapoints
Depression Any anxiety disorder
(including post-traumatic
stress disorder)
Post-traumatic stress
disorder
Severe disorder 1·1% (0·3–2·2) 2·8% (1·8–4·0) 2·0% (1·1–3·2)
Moderate disorder 1·8% (1·2–2·6) 4·1% (2·9–5·6) 2·9% (1·7–4·4)
Mild disorder 6·4% (4·4–8·6) 8·5% (6·2–11·1) 6·1% (3·5–9·1)
Disorder without
functional impairment
1·4% (0·9–2·0) 6·2% (4·6–7·9) 4·4% (2·7–6·5)
Total 10·8% (8·1–14·2) 21·7% (16·7–28·3) 15·3% (9·9–23·5)
All severity splits taken from Global Burden of Diseases, Injuries, and Risk Factors Study 2016. Disorder without
functional impairment indicates cases with disability weight equal to zero once disability attributable to comorbid
disorders is portioned out.
Table 2: Age-standardised point prevalence with 95% uncertainty intervals, unadjusted for comorbidity
Point prevalence
(95% uncertainty
interval)
Severe disorder (severe anxiety, severe
post-traumatic stress disorder, severe
depression, schizophrenia, and bipolar disorder)
5·1% (4·0–6·5)
Moderate disorder (moderate anxiety,
moderate post-traumatic stress disorder, and
moderate depression)
4·0% (2·9–5·5)
Mild disorder (mild anxiety, mild post-traumatic
stress disorder, and mild depression)
13·0% (10·3–16·2)
Total 22·1% (18·8–25·7)
Table 1: Point prevalence estimates for mental disorders in
conflict-affected populations, adjusted for comorbidity
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YLDs were derived by multiplying the number of
prevalent cases associated with each disorder by their
associated GBD disability weight. In place of GBD
prevalence estimates, we used prevalence estimates of
conflict-aected population mental disorder (derived as
described previously) as a primary input for YLD
estimation. Post-traumatic stress disorder was concep-
tualised as an anxiety disorder until the most recent
version of DSM (fifth edition) and, accordingly, was not
assessed as a separate disorder in GBD 2016, so we did not
calculate burden of disease estimates for post-traumatic
stress disorder. In our analyses, we considered all prevalent
cases of schizophrenia and bipolar disorder as severe. We
used Monte Carlo simulation–modelling techniques to
present 95% UIs around estimates reflecting the main
sources of sampling uncertainty in the calculations using
Ersatz software, version 1.2.31 More detailed information
on GBD burden of disease estimation can be found
elsewhere.16,32
Role of the funding source
WHO provided funding for this study and had a role in
study design, data inter pretation, and writing of the
report. The other funders had no role in study design,
data collection, data analysis, data interpretation, or
writing of the report. The corresponding author had
full access to all the data in the study and had final
responsibility for the decision to submit for publication.
Results
We identified 129 studies published between Jan 1, 1980,
and Aug 9, 2017, providing 96 studies with prevalence
estimates for post-traumatic stress disorder, 70 studies
with prevalence estimates for depression, and 38 studies
with prevalence estimates for any anxiety disorder
(appendix); 51 of these were studies published between
Jan 1, 2000, and Aug 9, 2017. 39 countries were represented
in the dataset; 34 had data for depression, 34 had data for
post-traumatic stress disorder, and 25 had data for anxiety
(figures 1–3; appendix).
We estimated that the prevalence of mental disorders
(depression, anxiety, post-traumatic stress disorder,
bipolar disorder, and schizophrenia) was 22·1%
(95% UI 18·8–25·7) at any point in time in the conflict-
aected populations assessed (table 1). Age-standardised
prevalence for depression, post-traumatic stress dis-
order, and anxiety disorders was elevated in conflict-
aected populations compared with global mean
prevalence (10·8% [95% UI 8·1–14·2] for depression,
15·3% [9·9–23·5] for post-traumatic stress disorder, and
21·7% [16·7–28·3] for any anxiety disorders; table 2).
The mild forms of all three disorders were the most
prevalent. Adjusting for comorbidity between depression
and anxiety, the mean, combined age-standardised
preva lence of mild, moderate, and severe depression,
post-traumatic stress disorder, and any anxiety disorders
was 21·2% [95% UI 17·7–24·7] in conflict-aected
popula tions (table 3). The mean comorbidity-adjusted,
age-stand ardised point prevalence was 13·0% (95% UI
10·3–16·2) for mild forms of depression, anxiety, and
post-traumatic stress disorder and 4·0% (95% UI
2·9–5·5) for moderate forms. The mean comorbidity-
adjusted, age-standardised point prevalence for severe
disorders (schizophrenia, bipolar disorder, severe
depression, severe anxiety, and severe post-traumatic
stress disorder) was 5·1% (95% UI 4·0–6·5). By
aggregating the prevalence of mental dis orders in
conflict-aected populations by severity, we estimated
Depression
(without comorbid
anxiety disorder)
Any anxiety disorder
(without comorbid
depression)
Any anxiety
disorder with
comorbid
depression*
Total
Severe disorder 0·6% (0·2–1·3) 3·3% (2·1–4·7) 0·4% (0·1–1·0) 4·3% (3·1–5·6)
Moderate disorder 1·1% (0·7–1·5) 2·2% (1·3–3·3) 0·8% (0·5–1·1) 4·0% (2·9–5·5)
Mild disorder 3·7% (2·6–5·1) 6·8% (4·4–9·6) 2·6% (1·9–3·6) 13·0% (10·3–16·2)
Total 5·3% (4·0–6·9) 12·1% (9·4–15·4) 3·8% (2·8–4·9) 21·2% (17·7–24·7)
Estimates of any anxiety disorder include post-traumatic stress disorder. Totals might not equal sum of parts due to
rounding. *Applying a rate of 41·6% (95% uncertainty interval 39·8–43·4) of depression cases with comorbid anxiety.
Global Burden of Diseases, Injuries, and Risk Factors Study 2016 severity splits applied.
Table 3: Age-standardised point prevalence with 95% uncertainty intervals, adjusted for comorbidity
Figure 4: Age-specific prevalence (mean) of depression and any anxiety and
post-traumatic stress disorder in conflict-affected populations, 2016
GBD 2016=Global Burden of Diseases, Injuries, and Risk Factors Study 2016.
0
10
20
30
40
50
60
70
80
90
100
Prevalence (%)
0 10 20 30 40 50 60 70
0
10
20
30
40
50
60
70
80
90
100
Prevalence (%)
Age (years)
Depression in conflict
Depression GBD 2016
Anxiety in conflict
Anxiety GBD 2016
Post-traumatic stress disorder in conflict
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that at any point in time about 9% of the conflict-aected
population has moderate to severe mental disorders
(schizophrenia, bipolar dis order, moderate to severe
anxiety, moderate to severe post-traumatic stress
disorder, and moderate to severe depression; table 1).
We only identified two studies that provided epi-
demiological estimates for psychosis in conflict-aected
populations. A cross-sectional study of an internally
displaced population in South Darfur reported a pre-
valence of schizophrenia of 4·1%,33 and a general
population survey in Timor-Leste reported a schizophrenia
point prevalence of 0·34%.34 We did not identify any
studies that reported epidemiological estimates for bipolar
disorder in conflict-aected populations. This small
number of studies precluded pooling of estimates, and
we conservatively defaulted to global mean prevalence
estimates as derived by GDB 2016 for schizophrenia
(0·3% [95% UI 0·2–0·3]) and bipolar disorder
(0·6% [0·5–0·7]).35 Therefore, we were unable to take into
account any increase in psychosis or bipolar disorder
prevalence in populations aected by conflict.
In conflict settings, trends of depression and anxiety
prevalence increased with age. Mean prevalence of post-
traumatic stress disorder declined in the older age groups,
although there are large ranges of uncertainty surrounding
these estimates (figure 4). Our data suggest prevalence of
depression, post-traumatic stress disorder, or any anxiety
disorder is higher in women than in men, although this
finding was only significant for depression (appendix).
Examination of covariate coecients in our modelling
showed that symptom scales significantly overestimate
prevalence by about 1·5 to 2 times in conflict-aected
populations as compared with diagnostic tools in all
three disorder models (appendix).
Heterogeneity in our datasets was large. The median
value of the negative binomial model overdispersion
parameter calculated by DisMod-MR was 1·2 for anxiety,
0·95 for post-traumatic stress disorder, and 0·96 for
depression (where zero is completely uninformative, and
infinity is a Poisson distribution).
Age-specific YLDs in conflict-aected populations
showed elevated and significant dierences across most
age groups compared with estimated global YLDs in
GBD 2016 (figure 5). We estimated age-standardised
YLDs for depression in conflict-aected populations at a
rate of 24·8 YLDs per 1000 population (95% UI
16·4–36·0), in contrast to the GBD 2016 global age-
standardised estimate of 4·6 YLDs per 1000 population
(3·2–6·2). Age-standardised estimates of YLDs for any
anxiety disorder in conflict-aected populations were
23·2 YLDs per 1000 population (95% UI 17·0–29·9), as
compared with the GBD 2016 estimates of 3·5 YLDs per
1000 population (2·5–4·8).
Discussion
By updating our previous systematic review on
depression and post-traumatic stress disorder10 to include
more recent data and data on schizophrenia, bipolar, and
anxiety disorders, we identified an additional 45 studies
published over a 4-year period; this reflects a substantial
increase in psychiatric epidemiological research taking
place in conflict-aected contexts.
We estimated that approximately one in five people in
post-conflict settings has depression, anxiety disorder,
post-traumatic stress disorder, bipolar dis order, or
schizophrenia. This finding is in contrast to data from
GBD 2016,16 which suggest a mean global prevalence of
one in 14. Our empirically derived estimates show higher
prevalence of severe mental disorders than the previous
WHO estimates (about 5·1% point prevalence in current
estimate compared with 3–4% 12-month prevalence in
previous estimates) and higher prevalence of mild to
moderate mental disorders (approximately 17% point
prevalence in the revised estimates, compared with
15–20% 12-month prevalence in previous estimates). Our
estimates of YLDs per 1000 people for depression and
post-traumatic stress disorder were more than five times
higher than the existing global mean burden of disease
Figure 5: Age-specific years lived with disability (YLDs) per 1000 population (95% uncertainty interval) of
depression and any anxiety in conflict-affected populations, 2016
GBD 2016=Global Burden of Diseases, Injuries, and Risk Factors Study 2016.
0
10
20
30
40
50
60
70
80
90
100
YLDs per 1000 population
0–9 10–19 20–29 30–39 40–49 50–59 60–69 ≥70
0
10
20
30
40
50
60
70
80
90
100
YLDs per 1000 population
Age group (years)
Depression in conflict
Major depression GBD 2016
Anxiety in conflict
Anxiety GBD 2016
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estimates. One previous study10 reported an age-
standardised pooled prevalence of 7·6% for depression
and 12·9% for post-traumatic stress disorder.
A useful finding from our study for field researchers
who use self-report or symptom-based measures to
ascertain mental disorder prevalence estimates is that
these instruments were shown to significantly over-
estimate the prevalence of depression, post-traumatic
stress disorder, and anxiety by 1·5 to 2 times. Most of
these instruments do not assess clinical significance
or function, and hence can overestimate prevalence of
disorders compared with diagnostic instruments.
Our study methodology has several strengths. By
contrast with previously published reviews, we applied
more stringent inclusion and exclusion criteria to our
literature search, optimised search strategies, and used
updated statistical methods.9,36 We sought to address
heterogeneity in epidemiological studies by use of
Bayesians approaches to allow for a more consistent set
of estimates. We made separate estimates for mild,
moderate, and severe mental disorders. Although the
clinical significance of mild mental disorders in
emergencies can be contested,8 the clinical needs of
people with severe mental disorders are too often
neglected.37 An important limitation in this study was the
raw data. Even with relatively strict inclusion criteria,
there was considerable heterogeneity in the mental
disorder datasets and their reported estimates, which
created large uncertainty around the predicted estimates.
This heterogeneity stemmed partly from dierences
across study designs—an issue inherent to psychiatric
epidemiology, particularly research following major
emergencies8—and partly from the myriad of factors that
aect the experience and expression of mental distress in
these settings. Many studies failed to report a robust
process of translation, cultural adaptation, or validity
testing of their instruments. However, a key strength
of the DisMod-MR approach is how it addresses
heterogeneity through adjustments to the data, which
allowed us to create a robust epidemiological profile of
mental disorders in conflict-aected populations.
Although not unique to the field of psychiatric epi-
demiology, issues related to the case definitions of mental
disorders warrant consideration in the context of the
settings represented in our study. Although reliable
systems of classification (DSM and ICD) make it possible
to determine prevalence estimates and, therefore, to guide
decisions about the development of services, these models
of mental disorders assume universality and might not
be the most useful way to describe the experience
and expression of psychological distress in many of
the contexts captured in our study.38 Further to the concept
of cultural variation are issues presented by shifts in
diagnostic criteria. Data included our study are pre-
dominantly based on DSM-IV; no studies using DSM-5
were identified. It is apparent that epidemiological
research, at least in this context, is yet to move on to most
recent version of DSM. In the event of such a transition, it
might be prudent to revise anxiety and post-traumatic
stress disorder prevalence and YLD estimates.
We only identified two studies on schizophrenia and
found no studies on bipolar disorder in conflict-aected
populations—too few to pool estimates using meta-
regression methods, especially given that one of the
studies estimated a ten times higher prevalence estimate
than the GBD 2016 prevalence estimate of schizophrenia.33
Therefore, we conservatively defaulted to global mean
prevalence estimates as derived by GDB 2016.16 The
estimates for psychosis we report here might thus be
underestimates and do not take into account the studies
we had to exclude from our systematic search that suggest
an increase in psychoses in populations aected by
conflict.39 Because of the paucity of data, we had to use
several assumptions and proxy inputs—such as a
comorbidity adjustment informed by a single study from a
conflict-aected population and the proxy use of GBD 2016
disability weights—which should be considered when
interpreting our findings, until more and better-quality
epidemiological data become available. Furthermore, the
study did not include comorbid disorders, such as alcohol
use disorders and epilepsy, which are frequently addressed
within mental health programmes.14
Nonetheless, our study identified the sustained
presence of high prevalence of mental disorders in
conflict-aected countries, making a compelling case for
global humanitarian, development, health, and mental
health communities to prioritise development of mental
health services in conflict and post-conflict settings.
Evidence for building systems for mental health care
after conflict shows that emergencies, which can
generate political interest and funding for mental health,
can be a catalyst for the meaningful development of
mental health care.3 A review of lessons learned from
such work in ten countries showed that focusing on
system-wide reform to address both new-onset and pre-
existing mental disorders is crucial.3 Practical guidance
for management of disorders that should be scaled up in
conflict-aected coun tries already exists. WHO and UN
High Commissioner for Refugees have designed the
mhGAP Humanitarian Intervention Guide,14 which
addresses the assessment and management of moderate
and severe mental disorders in non-specialised health-
care settings, such as general hospitals and primary
health care. Moreover, a variety of packages designed to
address multiple mental disorders, such as Problem
Management Plus, Common Elements Treatment
Approach and Self-Help Plus, have been used with
promising results among conflict-aected Pakistanis,
Burmese refugees, and South Sudanese refugees.40–42 It
should be noted that there is wide consensus that mental
health and psychosocial support for aected populations
should go beyond psychological and medical treatments
for mental disorders, and that such support should
include psychosocial intervention that strengthens
Articles
www.thelancet.com Vol 394 July 20, 2019
247
community self-help and support13 and advocacy for
security and protection and for adequate humanitarian
aid, including basic health services and livelihood
support.
Our findings highlight the need to prioritise conflict-
aected countries for implementation of the WHO
Mental Health Action Plan.2 This will require a focus on
investment in leadership and governance for mental
health, and the development of integrated, responsive
mental health and social care services in community-
based settings. Strategies for promotion and prevention
in mental health, and building and strengthening of
information systems, evidence, and research for mental
health in conflict-aected countries, are also needed.
These services could be initiated with short-term
emergency funds that are often available during crises.
Demonstration projects can provide proof of concept and
attract the further support and funds necessary for system
development to reduce the burden of mental disorders
among people aected by war and other conflict.3
Our study shows that the impact of conflict on people’s
mental health is higher than previous estimates suggest.
Mental health care must be prioritised in countries aected
by conflict, not least for the well established links between
mental health, functioning, and country development.
Contributors
FC and JC undertook the systematic review and data collection. FC and
AF undertook statistical analyses and modelling. FC, HW, and AF were
responsible for study design. FC, AF, MvO, and SS were responsible for
interpretation of results. All authors were responsible for writing and
editing of the manuscript.
Declaration of interests
We declare no competing interests.
Acknowledgments
We thank Dan Chisholm (WHO, Geneva, Switzerland), Domenico Giacco
(Queen Mary University of London, UK), Derrick Silove (University of
New South Wales, Sydney, Australia), and Peter Ventevogel (United
Nations High Commissioner for Refugees, Geneva, Switzerland) for
comments on an earlier version of this manuscript. The authors alone are
responsible for the views expressed in this Article and they do not
necessarily represent the views, decisions, or policies of the institutions
with which they are aliated.
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... During the last years, several studies have examined the prevalence of mental disorders in refugees and asylum seekers. However, the resulting prevalence rates in this population present great variability (Fazel et al., 2005;Porter and Haslam, 2005;Bogic et al., 2015;Foo et al., 2018;Morina et al., 2018;Charlson et al., 2019;Blackmore et al., 2020), ranging from 5% (Fazel et al., 2005) to 80% (Bogic et al., 2015) for depression, from 4% (Charlson et al., 2019) to 88% (Morina et al., 2018) for PTSD, and from 1.5% (Blackmore et al., 2020) to 2% (Fazel et al., 2005) for psychosis. A systematic review on the prevalence of serious mental disorders in refugees resettled in high-income western countries reported weighted average rates of 5% for major depressive disorder (MDD), 9% for posttraumatic stress disorder (PTSD) and 2% for psychotic disorders (Fazel et al., 2005). ...
... During the last years, several studies have examined the prevalence of mental disorders in refugees and asylum seekers. However, the resulting prevalence rates in this population present great variability (Fazel et al., 2005;Porter and Haslam, 2005;Bogic et al., 2015;Foo et al., 2018;Morina et al., 2018;Charlson et al., 2019;Blackmore et al., 2020), ranging from 5% (Fazel et al., 2005) to 80% (Bogic et al., 2015) for depression, from 4% (Charlson et al., 2019) to 88% (Morina et al., 2018) for PTSD, and from 1.5% (Blackmore et al., 2020) to 2% (Fazel et al., 2005) for psychosis. A systematic review on the prevalence of serious mental disorders in refugees resettled in high-income western countries reported weighted average rates of 5% for major depressive disorder (MDD), 9% for posttraumatic stress disorder (PTSD) and 2% for psychotic disorders (Fazel et al., 2005). ...
... A meta-analysis among refugees and asylum seekers residing outside their country of origin reported a prevalence of 31.5% for PTSD, of 31.5% for depression, and 1.5% for psychosis (Blackmore et al., 2020). Another meta-analysis that examined the prevalence of mental disorders in conflict settings showed estimated rates of 22.1% for any mental disorder (13% for depression and 4% for PTSD) (Charlson et al., 2019). The variability across studies could be explained by differences in the origins and background of the analysed populations, the sample size, the sampling methods, and the diagnostic tools used (e.g. ...
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Background Studies have identified high rates of mental disorders in refugees, but most used self-report measures of psychiatric symptoms. In this study, we examined the percentages of adult refugees and asylum seekers meeting diagnostic criteria for major depressive disorder (MDD), post-traumatic stress disorder, bipolar disorder (BPD), and psychosis. Methods A systematic literature search in three databases was conducted. We included studies examining the prevalence of MDD, post-traumatic stress disorder, BPD, and psychosis in adult refugees according to a clinical diagnosis. To estimate the pooled prevalence rates, we performed a meta-analysis using the Meta-prop package in Stata (PROSPERO: CRD42018111778). Results We identified 7048 records and 40 studies (11 053 participants) were included. The estimated pooled prevalence rates were 32% (95% CI 26–39%; I ² = 99%) for MDD, 31% (95% CI 25–38%; I ² = 99.5%) for post-traumatic stress disorder, 5% (95% CI 2–9%; I ² = 97.7%) for BPD, and 1% (95% CI 1–2%; I ² = 0.00%) for psychosis. Subgroup analyses showed significantly higher prevalence rates of MDD in studies conducted in low-middle income countries (47%; 95% CI 38–57%, p = 0.001) than high-income countries studies (28%; 95% CI 22–33%), and in studies which used the Mini-International Neuropsychiatric Interview (37%; 95% CI 28–46% p = 0.05) compared to other diagnostic interviews (26%; 95% CI 20–33%). Studies among convenience samples reported significant ( p = 0.001) higher prevalence rates of MDD (35%; 95% CI 23–46%) and PTSD (34%; 95% CI 22–47%) than studies among probability-based samples (MDD: 30%; 95% CI 21–39%; PTSD: 28%; 95% 19–37%). Conclusions This meta-analysis has shown a markedly high prevalence of mental disorders among refugees. Our results underline the devastating effects of war and violence, and the necessity to provide mental health intervention to address mental disorders among refugees. The results should be cautiously interpreted due to the high heterogeneity.
... By the end of 2020, over 80 million people were forcibly displaced due to persecution, conflict, violence, human rights violations, and other emergencies globally [1]. Displaced populations face increased exposure to potentially traumatic events and ongoing adversity that increase their risk of mental health and psychosocial problems [2][3][4]. The evidence supporting the effectiveness of mental health and psychosocial support (MHPSS) programs in humanitarian settings has grown over the past few decades [5,6]. ...
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Background Community- and strengths-based psychosocial interventions are central to mental health and psychosocial support guidelines, but rigorous evidence regarding the effectiveness of these interventions is limited. The complexity and variability that is inherent to many community-based psychosocial interventions requires innovative strategies in order to facilitate the comparability and synthesis across research studies without compromising the fit and appropriateness of interventions to specific study populations and context. Entre Nosotras is a community-based psychosocial intervention developed for migrant and host community women that is designed to be flexible enough to enable integration of external intervention components and adaptable to diverse study contexts and populations. This protocol describes a study that aims to evaluate the appropriateness, acceptability, and feasibility of integrating a standardized stress management intervention into Entre Nosotras. Methods This study will evaluate the appropriateness, acceptability, feasibility, and safety of intervention and research procedures for a cluster randomized comparative effectiveness trial conducted in Ecuador and Panamá with migrant and host community women. In this feasibility trial, we will allocate communities nested within the three study sites to the integrated Entre Nosotras + stress management intervention versus Entre Nosotras alone through stratified randomization. Migrant and host community women residing in these study communities who report low to moderate levels of distress will be allocated to the intervention condition that their community is assigned (n = 220 total). We will collect quantitative measures of psychosocial wellbeing, psychological distress, coping, social support, and functioning from study participants. We will collect quantitative measures of fidelity and facilitator competencies through observation and facilitator self-assessment. Data on appropriateness, acceptability, feasibility, and safety will be gathered from participants and facilitators through quantitative assessments at 0, 5, and 10 weeks post-enrollment and qualitative interviews conducted with all facilitators and a subset of 70 study participants during the post-intervention follow-up period. Discussion Results from this feasibility trial will determine whether a multi-site cluster randomized comparative effectiveness trial of an adaptable community-based psychosocial intervention for migrant and host community women is relevant, acceptable, and feasible. Trial registration ClinicalTrials.gov identifier: NCT05130944. Registered November 23, 2021—retrospectively registered.
... Thereby, it addresses a research gap pointed out in a recent umbrella review (Uphoff et al., 2019). Also the focus on transdiagnostic psychosocial interventions goes beyond previous reviews in the field and might be of particular relevance in a population at risk of a broad range of mental disorders (Blackmore et al., 2020;Charlson et al., 2019;Morina, Akhtar, et al., 2018;Morina, Stam, et al., 2018). Moreover, interventions included in the present review were more homogeneous than in previous reviews that included interventions ranging from low-dose mental health promotion to high-dose treatment of mental disorders (e.g., Nocon et al., 2017;Tribe et al., 2014;Turrini et al., 2019;Uphoff et al., 2019). ...
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People forced to leave their homes, such as refugees and internally displaced persons, are exposed to various stressors during their forced displacement, putting them at risk for mental disorders. In view of the Russian military offensive in Ukraine, this review aimed at summarizing the evidence on the efficacy of transdiagnostic psychosocial interventions to promote mental health and/or to prevent mental symptoms in forcibly displaced persons of all ages. Four electronic databases and reference lists were searched for randomized controlled trials on interventions in this population from inception to March 11, 2022. Thirty-six studies were eligible, 32 were included in random-effects multilevel meta-analyses. Results on mental symptoms, M(SMD)=0.26, p=.075, and positive mental health indicators like wellbeing, M(SMD)=0.41, p=.182, provided no evidence for an effect favoring transdiagnostic interventions over control conditions in children/adolescents and adults. After excluding studies at risk of bias, meta-analyses on adult samples provided evidence for a small effect on mental symptoms and positive mental health, while analyses on children/adolescents yielded unchanged results. Heterogeneity was considerable, and certainty of evidence was very low. Future research should combine the imperative of humanitarian aid in face of major crises with studying forcibly displaced persons’ diverse needs to improve future interventions.
... 12,27 SCCM was tailored to simultaneously overcome several obstacles by offering a set of culturally-sensitive psychological interventions. Although conflict exposure can result in a wide range of psychiatric disorders (depression, PTSD, anxiety and psychosis), 39 we followed a diagnostic approach in our study focusing on depressive symptoms, which are highly prevalent among refugee groups in Germany. 12 While Germany's mental health care system is relatively robust and well-organized, it still has shortcomings, such as an ineffective allocation of existing psychotherapeutic resources, fragmentation and lack of coordinated care, and a scarcity of available flexible and integrative treatment models. ...
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... Climate change-related events have been associated with psychological distress, poor mental health (particularly among those with pre-existing mental health conditions), higher mortality among people with mental health conditions and higher suicide rates (Charlson et al., 2021). The mental health and wellbeing needs of populations experiencing climate change impacts within humanitarian crises are likely to be particularly high, with an estimated one in five people living in conflict-affected settings already meeting criteria for probable mental health conditions (Charlson et al., 2019) in addition to substantial increases in psychosocial distress. ...
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... A recent global study conducted by the World Health Organization (WHO) sought to estimate the prevalence of mental disorders in 39 conflict-affected LMIC settings, including the MENA region. Their results indicated that more than 1 in 5 individuals in post-conflict settings has depression, anxiety disorder, post-traumatic stress disorder, bipolar disorder, or schizophrenia, with 1 in 10 people having moderate or severe mental disorder [12]. Another study conducted in Lebanon estimated that 1 in 4 Syrian refugees are at risk of developing depression, with women being disproportionately affected by it [13]. ...
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Background Given the magnitude and frequency of conflicts in the MENA region along with their devastating impact on health responses and outcomes, there exists a strong need to invest in contextualized, innovative, and accessible capacity building approaches to enhance leadership and skills in global health. The MENA region suffers from limited (1) continued educational and career progression opportunities, (2) gender balance, and (3) skill-mix among its health workforce, which require significant attention. Main text The Global Health Institute at the American University of Beirut incepted the Academy division to develop and implement various global health capacity building (GHCB) initiatives to address those challenges in fragile settings across low-and middle-income countries in the MENA region. These initiatives play a strategic role in this context, especially given their focus on being accessible through employing innovative learning modalities. However, there exists a dearth of evidence-based knowledge on best practices and recommendations to optimize the design, implementation, and evaluation of GHCB in fragile settings in the MENA region. The present paper describes the development of the evaluation of capacity building program (eCAP), implemented under the Academy division, to assess the effectiveness of its initiatives. eCAP is composed of 3 phases: (1) a situational assessment, followed by (2) production of multiple case studies, and finally (3) a meta-assessment leading to model development. The goal of eCAP is not only to inform the Academy’s operations, but also to synthesize produced knowledge into the formation of an evidence-based, scalable, and replicable model for GHCB in fragile settings. Conclusion eCAP is an important initiative for researchers, educators, and practitioners interested in GHCB in fragile settings. Several lessons can be learned from the outcomes it has yielded so far in its first two phases of implementation, ranging from the situational assessment to the production of evaluation case studies, which are expanded on in the manuscript along with pertinent challenges.
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Background Most displaced people with mental disorders in low- and middle-income countries do not receive effective care, and their access to care has deteriorated during the Coronavirus Disease 2019 (COVID-19) pandemic. Digital mental health interventions are scalable when digital access is adequate, and they can be safely delivered during the COVID-19 pandemic. We examined whether a new WHO-guided digital mental health intervention, Step-by-Step, in which participants were supported by a nonspecialist helper, was effective in reducing depression among displaced people in Lebanon. Methods and findings We conducted a single-blind, 2-arm pragmatic randomized clinical trial, comparing guided Step-by-Step with enhanced care as usual (ECAU) among displaced Syrians suffering from depression and impaired functioning in Lebanon. Primary outcomes were depression (Patient Health Questionnaire, PHQ-9) and impaired functioning (WHO Disability Assessment Schedule-12, WHODAS) at posttreatment. Secondary outcomes included subjective well-being, anxiety, post-traumatic stress, and self-described problems. A total of 569 displaced people from Syria with depression (PHQ-9 ≥ 10) and impaired functioning (WHODAS > 16) were randomized to Step-by-Step ( N = 283; lost to follow-up: N = 167) or ECAU ( N = 286; lost to follow-up: 133). Participants were considered to be lost to follow-up when they did not fill in the outcome measures at posttest or follow-up. Recruitment started on December 9, 2019 and was completed on July 9, 2020. The last follow-up assessments were collected in December 2020. The study team had access to the online platform, where they could see treatment arm assignment for each participant. All questionnaires were completed by participants online. Intention-to-treat (ITT) analyses showed intervention effects on depression (standardized mean differences [SMDs]: 0.48; 95% CI: 0.26; 0.70; p < 0.001), impaired functioning (SMD: 0.35; 95% CI: 0.14; 0.56; p < 0.001), post-traumatic stress (SMD: 0.36; 95% CI: 0.16; 0.56; p < 0.001), anxiety (SMD: 0.46; 95% CI: 0.24; 0.68; p < 0.001), subjective well-being (SMD: 0.47; 95% CI: 0.26; 0.68; p < 0.001), and self-identified personal problems (SMD: 0.49; 95% CI 0.28; 0.70; p < 0.001). Significant effects on all outcomes were maintained at 3 months follow-up. During the trial, one serious adverse event occurred, unrelated to the intervention. The main limitation of the current trial is the high dropout rate. Conclusions In this study, we found that a guided, digital intervention was effective in reducing depression in displaced people in Lebanon. The guided WHO Step-by-Step intervention we examined should be made available to communities of displaced people that have digital access. Trial registration ClinicalTrials.gov NCT03720769 .
Chapter
Although the vast majority of research into posttraumatic mental health, including posttraumatic stress disorder (PTSD), emerges from western nations, most of the world’s population exposed to trauma and adversity live in non-western countries. People living in low- and middle-income countries (LMICs) are more likely to be exposed to a range of difficult live events and not surprisingly experience higher rates of mental disorders. This chapter reviews the current knowledge about mental health, and particularly posttraumatic mental health, in LMICs. It commences with a review of the prevalence of disorders in LMICs, outlines some of the major risk factors for disorders, and discusses current evidence pertaining to treatment initiatives. The chapter also focuses on the major challenges facing the field of mental health in balancing the need to address mental health problems in LMICs with the ongoing reality that LMICs have limited resources to allocate to mental health programs. The chapter outlines the role of scalable, task-shifting approaches that have implemented mental health non-specialists to deliver programs in settings where there is a large gap between mental health needs and treatment delivery.
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Introduction In recent years, clinical studies have shown that perinatal pain could increase the risk of postpartum depression, while such a conclusion appears controversial. Therefore, we conducted this systematic review and meta-analysis to explore the association between perinatal pain and postpartum depression, and to evaluate the effectiveness of epidural labor analgesia in reducing the risk of postpartum depression. Methods PubMed, Web of Science, Embase and Cochrane Library were searched from inception to Jan 30th, 2022. The effect size of the meta-analysis was calculated using odds ratio and 95 % confidence interval. Statistical analysis was performed using Stata 15.0 software. Results There were 19 studies included with a total of 96,378 patients. Among the included studies, 10 investigated the association between perinatal pain and the risk of postpartum depression, and 9 reported that between labor analgesia and the risk of postpartum depression. The results of meta-analysis showed that perinatal pain increased the risk of postpartum depression [OR = 1.43, 95% CI (1.23, 1.67), p<0.05], and epidural analgesia could reduce the risk of postpartum depression [OR = 0.42, 95% CI (0.33, 0.55), p < 0.05]. Limitations Source of heterogeneity in the association between perinatal pain and PPD could not be identified due to the limitations of the original studies. There were mainly cohort studies included in the assessment for effectiveness of epidural analgesia in reducing the incidence of postpartum pain. Therefore, we look forward to more RCTs to confirm our results. Conclusion Perinatal pain is one of the risk factors for postpartum depression, and epidural analgesia could reduce the risk of PPD. This result might provide guidance for clinical practice. However, psychological health counseling should be combined with epidural analgesia for perinatal pain to reduce the risk of PPD.
Article
Refugees can experience elevated levels of psychological distress upon resettlement, although disparate outcomes over time are expected. The current study modeled trajectories of changes in distress over a 5-year period among resettled refugees and sought to explicate post-settlement factors that influence distress over time. A large-scale sample of refugees resettled in Australia (N = 2,399) were tracked over a 5-year period, completing measures of psychological distress at each wave and initial risk and protective factors immediately after resettlement. A latent class growth analysis conducted on distress found four unique classes characterised by (1) resilient levels of distress, (2) consistent clinical distress, (3) recovering levels of distress, and (4) deteriorating distress. Lower perceived discrimination and greater positive context of reception predicted membership to the resilient group and differentiated the recovering and deteriorating groups. Further, lower ingroup social support predicted membership to the clinically distressed group relative to all others. We conclude by echoing calls to strengthen community support for refugees and promote ingroup ties, particularly among those who are the most vulnerable.
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Background: Protracted armed conflicts not only shape political, legal, and socio-economic structures, but also have a lasting impact on people's human migration. In 2017, the United Nations High Commissioner for Refugees reported an unprecedented number of 65.6 million individuals who were displaced worldwide as a result of armed conflicts. To date, however, little is known about these people's mental health status. Therefore, we conducted a systematic review of the prevalence of psychiatric disorders among forcibly displaced populations in settings of armed conflicts. Methods: We undertook a database search using Medline, PsycINFO, PILOTS, and the Cochrane Library, using the following keywords and their appropriate synonyms to identify relevant articles for possible inclusion: “mental health,” “refugees,” “internally displaced people,” “survey,” and “war.” This search was limited to original articles, systematic reviews, and meta-analyses published after 1980. We reviewed studies with prevalence rates of common psychiatric disorders—mood and anxiety disorders, psychotic disorders, personality disorders, substance abuse, and suicidality—among adult internally displaced persons (IDPs) and refugees afflicted by armed conflicts. Results: The search initially yielded 915 articles. Of these references 38 studies were eligible and provided data for a total of 39,518 adult IDPs and refugees from 21 countries. The highest prevalence were for reported for post-traumatic stress disorder (3–88%), depression (5–80%), and anxiety disorders (1–81%) with large variation. Only 12 original articles reported about other mental disorders. Conclusions: These results show a substantial lack of data concerning the wider extent of psychiatric disability among people living in protracted displacement situations. Ambitious assessment programs are needed to support the implementation of sustainable global mental health policies in war-torn countries. Finally, there is an urgent need for large-scale interventions that address psychiatric disorders in refugees and internally displaced persons after displacement.
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Background Exposure to armed conflict and forced displacement constitute significant risks for mental health. Existing evidence-based psychological interventions have limitations for scaling-up in low-resource humanitarian settings. The WHO has developed a guided self-help intervention, Self Help Plus (SH+), which is brief, implemented by non-specialists, and designed to be delivered to people with and without specific mental disorders. This paper outlines the study protocol for an evaluation of the SH+ intervention in northern Uganda, with South Sudanese refugee women. Methods A two-arm, single-blind cluster-randomised controlled trial will be conducted in 14 villages in Rhino Camp refugee settlement, with at least 588 women experiencing psychological distress. Villages will be randomly assigned to receive either SH+ with enhanced usual care (EUC), or EUC alone. SH+ is a five-session guided self-help intervention delivered in workshops with audio-recorded materials and accompanying pictorial guide. The primary outcome is reduction in overall psychological distress over time, with 3 months post-treatment as the primary end-point. Secondary outcomes are self-defined psychosocial concerns, depression and post-traumatic stress disorder symptoms, hazardous alcohol use, feelings of anger, interethnic relations, psychological flexibility, functional impairment and subjective wellbeing. Psychological flexibility is a hypothesised mediator, and past trauma history and intervention attendance will be explored as potential moderators. Discussion This trial will provide important information on the effectiveness of a scalable, guided self-help intervention for improving psychological health and wellbeing among people affected by adversity. Trial Registration ISRCTN50148022; registered 13/03/2017.
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Introduction: The global burden of disease (GBD) studies have derived detailed and comparable epidemiological and burden of disease estimates for schizophrenia. We report GBD 2016 estimates of schizophrenia prevalence and burden of disease with disaggregation by age, sex, year, and for all countries. Method: We conducted a systematic review to identify studies reporting the prevalence, incidence, remission, and/or excess mortality associated with schizophrenia. Reported estimates which met our inclusion criteria were entered into a Bayesian meta-regression tool used in GBD 2016 to derive prevalence for 20 age groups, 7 super-regions, 21 regions, and 195 countries and territories. Burden of disease estimates were derived for acute and residual states of schizophrenia by multiplying the age-, sex-, year-, and location-specific prevalence by 2 disability weights representative of the disability experienced during these states. Findings: The systematic review found a total of 129 individual data sources. The global age-standardized point prevalence of schizophrenia in 2016 was estimated to be 0.28% (95% uncertainty interval [UI]: 0.24-0.31). No sex differences were observed in prevalence. Age-standardized point prevalence rates did not vary widely across countries or regions. Globally, prevalent cases rose from 13.1 (95% UI: 11.6-14.8) million in 1990 to 20.9 (95% UI: 18.5-23.4) million cases in 2016. Schizophrenia contributes 13.4 (95% UI: 9.9-16.7) million years of life lived with disability to burden of disease globally. Conclusion: Although schizophrenia is a low prevalence disorder, the burden of disease is substantial. Our modeling suggests that significant population growth and aging has led to a large and increasing disease burden attributable to schizophrenia, particularly for middle income countries.
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Background: As mortality rates decline, life expectancy increases, and populations age, non-fatal outcomes of diseases and injuries are becoming a larger component of the global burden of disease. The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of prevalence, incidence, and years lived with disability (YLDs) for 328 causes in 195 countries and territories from 1990 to 2016. Methods: We estimated prevalence and incidence for 328 diseases and injuries and 2982 sequelae, their non-fatal consequences. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between incidence, prevalence, remission, and cause of death rates for each condition. For some causes, we used alternative modelling strategies if incidence or prevalence needed to be derived from other data. YLDs were estimated as the product of prevalence and a disability weight for all mutually exclusive sequelae, corrected for comorbidity and aggregated to cause level. We updated the Socio-demographic Index (SDI), a summary indicator of income per capita, years of schooling, and total fertility rate. GBD 2016 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER). Findings: Globally, low back pain, migraine, age-related and other hearing loss, iron-deficiency anaemia, and major depressive disorder were the five leading causes of YLDs in 2016, contributing 57·6 million (95% uncertainty interval [UI] 40·8–75·9 million [7·2%, 6·0–8·3]), 45·1 million (29·0–62·8 million [5·6%, 4·0–7·2]), 36·3 million (25·3–50·9 million [4·5%, 3·8–5·3]), 34·7 million (23·0–49·6 million [4·3%, 3·5–5·2]), and 34·1 million (23·5–46·0 million [4·2%, 3·2–5·3]) of total YLDs, respectively. Age-standardised rates of YLDs for all causes combined decreased between 1990 and 2016 by 2·7% (95% UI 2·3–3·1). Despite mostly stagnant age-standardised rates, the absolute number of YLDs from non-communicable diseases has been growing rapidly across all SDI quintiles, partly because of population growth, but also the ageing of populations. The largest absolute increases in total numbers of YLDs globally were between the ages of 40 and 69 years. Age-standardised YLD rates for all conditions combined were 10·4% (95% UI 9·0–11·8) higher in women than in men. Iron-deficiency anaemia, migraine, Alzheimer's disease and other dementias, major depressive disorder, anxiety, and all musculoskeletal disorders apart from gout were the main conditions contributing to higher YLD rates in women. Men had higher age-standardised rates of substance use disorders, diabetes, cardiovascular diseases, cancers, and all injuries apart from sexual violence. Globally, we noted much less geographical variation in disability than has been documented for premature mortality. In 2016, there was a less than two times difference in age-standardised YLD rates for all causes between the location with the lowest rate (China, 9201 YLDs per 100 000, 95% UI 6862–11943) and highest rate (Yemen, 14 774 YLDs per 100 000, 11 018–19 228). Interpretation: The decrease in death rates since 1990 for most causes has not been matched by a similar decline in age-standardised YLD rates. For many large causes, YLD rates have either been stagnant or have increased for some causes, such as diabetes. As populations are ageing, and the prevalence of disabling disease generally increases steeply with age, health systems will face increasing demand for services that are generally costlier than the interventions that have led to declines in mortality in childhood or for the major causes of mortality in adults. Up-to-date information about the trends of disease and how this varies between countries is essential to plan for an adequate health-system response.
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Despite significant research examining mental health in conflict-affected populations we do not yet have a comprehensive epidemiological model of how mental disorders are distributed, or which factors influence the epidemiology in these populations. We aim to derive prevalence estimates specific for region, age and sex of major depression, and PTSD in the general populations of areas exposed to conflict, whilst controlling for an extensive range of covariates. Methods A systematic review was conducted to identify epidemiological estimates of depression and PTSD in conflict-affected populations and potential predictors. We analyse data using Bayesian meta-regression techniques. Results We identified 83 studies and a list of 34 potential predictors. The age-standardised pooled prevalence of PTSD was 12.9% (95% UI 6.9–22.9), and major depression 7.6% (95% UI 5.1–10.9) – markedly lower than estimated in previous research but over two-times higher than the mean prevalence estimated by the Global Burden of Disease Study [3.7% (95% UI 3.0–4.5) and 3.5% (95% UI 2.9–4.2) for anxiety disorders and MDD, respectively]. The age-patterns reveal sharp prevalence inclines in the childhood years. A number of ecological variables demonstrated associations with prevalence of both disorders. Symptom scales were shown to significantly overestimate prevalence of both disorders. Finding suggests higher prevalence of both disorders in females. Conclusion This study provides, for the first time, age-specific estimates of PTSD and depression prevalence adjusted for an extensive range of covariates and is a significant advancement on our current understanding of the epidemiology in conflict-affected populations.
Article
Background: Existing studies of mental health interventions in low-resource settings have employed highly structured interventions delivered by non-professionals that typically do not vary by client. Given high comorbidity among mental health problems and implementation challenges with scaling up multiple structured evidence-based treatments (EBTs), a transdiagnostic treatment could provide an additional option for approaching community-based treatment of mental health problems. Our objective was to test such an approach specifically designed for flexible treatments of varying and comorbid disorders among trauma survivors in a low-resource setting.
Article
Objectives: Little is known about the psychological trauma experienced by children and young adults (CYAs) following displacement after natural disasters vs migration from conflict zones. In both instances, the decision to leave is usually cast by the family, and the life of CYAs is suddenly disrupted by external circumstances. Study design: An anonymous survey. Methods: The same survey instrument, provided by the National Child Traumatic Stress Network (NCTSN), was used to survey self-reported health needs among CYAs during the aftermath of Hurricane Katrina (Health Survey for Children and Adolescents After Katrina) in October 2005-February 2006 and again during the peak of refugee arrivals in Berlin between October 2015 and March 2016. A weighted index to measure cumulative exposure to traumatic stresses during migration was developed along with an unweighted psychological impact score based on the 22-item NCTS psychological impact questionnaire. Spearman's correlation coefficient (rho) was used to assess the correlation between age and the two psychological impact indices. The two-tailed t-test was used to investigate differences in trauma experienced and psychological impact by gender. Logistic regression was used to investigate differences in types of traumatic stress experienced and psychological impact among CYAs displaced because of Hurricane Katrina and those seeking asylum in Berlin. Results: The Katrina cohort included a total of 1133 CYAs, the Berlin cohort, a total of 405 CYAs. The median age in the Katrina cohort was 6.73 years (standard deviation [SD] 5.67, range 0-24; 50.13% males) compared with 17.64 years (SD, range 0-24; 83% males) in the Berlin cohort. Comparative analyses were adjusted to age and gender and revealed significant differences between the two cohorts, both with regards to the amount of trauma experienced and the psychological impact. A statistically significant and moderate positive correlation was observed between trauma experienced and psychological impact of migration in the refugee population (rho = 0.4955, P < 0.001); the correlation was less pronounced but still significant in the Katrina cohort (rho = 0.0942, P = 0.0015). Free-text responses revealed that in addition to common concerns about health, housing and safety, refugees were also pre-occupied with language acquisition and the adaptation to a new culture. Conclusions: The observed differences in the experience and the consequences of trauma in displaced CYAs warrant additional investigation. It was replicated that human-made disaster seems to show more traumatising potential than natural disaster. Stakeholders need to be aware of the potential medium and long-term consequences of migration/evacuation and allocate resources accordingly.
Article
Importance: The mental health consequences of conflict and violence are wide-ranging and pervasive. Scalable interventions to address a range of mental health problems are needed. Objective: To test the effectiveness of a multicomponent behavioral intervention delivered by lay health workers to adults with psychological distress in primary care settings. Design, setting, and participants: A randomized clinical trial was conducted from November 1, 2014, through January 28, 2016, in 3 primary care centers in Peshawar, Pakistan, that included 346 adult primary care attendees with high levels of both psychological distress and functional impairment according to the 12-item General Health Questionnaire and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Interventions: Lay health workers administered 5 weekly 90-minute individual sessions that included empirically supported strategies of problem solving, behavioral activation, strengthening social support, and stress management. The control was enhanced usual care. Main outcomes and measures: Primary outcomes, anxiety and depression symptoms, were independently measured at 3 months with the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes were posttraumatic stress symptoms (Posttraumatic Stress Disorder Checklist for DSM-5), functional impairment (WHODAS 2.0), progress on problems for which the person sought help (Psychological Outcome Profiles), and symptoms of depressive disorder (9-item Patient Health Questionnaire). Results: Among 346 patients (mean [SD] age, 33.0 [11.8] years; 78.9% women), 172 were randomly assigned to the intervention and 174 to enhanced usual care; among them, 146 and 160 completed the study, respectively. At baseline, the intervention and control groups had similar mean (SD) HADS scores on symptoms of anxiety (14.16 [3.17] vs 13.64 [3.20]; adjusted mean difference [AMD], 0.52; 95% CI, -0.22 to 1.27) and depression (12.67 [3.27] vs 12.49 [3.34]; AMD, 0.17, 95% CI, -0.54 to 0.89). After 3 months of treatment, the intervention group had significantly lower mean (SD) HADS scores than the control group for anxiety (7.25 [3.63] vs 10.03 [3.87]; AMD, -2.77; 95% CI, -3.56 to -1.98) and depression (6.30 [3.40] vs 9.27 [3.56]; AMD, -2.98; 95% CI, -3.74 to -2.22). At 3 months, there were also significant differences in scores of posttraumatic stress (AMD, -5.86; 95% CI, -8.53 to -3.19), functional impairment (AMD, -4.17; 95% CI, -5.84 to -2.51), problems for which the person sought help (AMD, -1.58; 95% CI, -2.40 to -0.77), and symptoms of depressive disorder (AMD, -3.41; 95% CI, -4.49 to -2.34). Conclusions and relevance: Among adults impaired by psychological distress in a conflict-affected area, lay health worker administration of a brief multicomponent intervention based on established behavioral strategies, compared with enhanced usual care, resulted in clinically significant reductions in anxiety and depressive symptoms at 3 months. Trial registration: anzctr.org.au Identifier: ACTRN12614001235695.
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Measurements of health indicators are rarely available for every population and period of interest, and available data may not be comparable. The Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) define best reporting practices for studies that calculate health estimates for multiple populations (in time or space) using multiple information sources. Health estimates that fall within the scope of GATHER include all quantitative population-level estimates (including global, regional, national, or subnational estimates) of health indicators, including indicators of health status, incidence and prevalence of diseases, injuries, and disability and functioning; and indicators of health determinants, including health behaviours and health exposures. GATHER comprises a checklist of 18 items that are essential for best reporting practice. A more detailed explanation and elaboration document, describing the interpretation and rationale of each reporting item along with examples of good reporting, is available on the GATHER website.