Mental health consequences of war: A brief review of research findings

Abstract

Among the consequences of war, the impact on the mental health of the civilian population is one of the most significant. Studies of the general population show a definite increase in the incidence and prevalence of mental disorders. Women are more affected than men. Other vulnerable groups are children, the elderly and the disabled. Prevalence rates are associated with the degree of trauma, and the availability of physical and emotional support. The use of cultural and religious coping strategies is frequent in developing countries.

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The year 2005 is significant in under-
standing the relationship between war
and mental health. This is the 30th
anniversary of the end of the Vietnam
war and of the start of the war in
Lebanon. Every day the media bring
the horrors of the ongoing “war” situa-
tion in Iraq. Some recent quotations
from the media depict the impact of
war on mental health: “We are living in
a state of constant fear” (in Iraq); “War
takes a toll on Iraqi mental health”;
“War trauma leaves physical mark”;
“War is hell… it has an impact on the
people who take part that never heals”;
“War is terrible and beyond the under-
standing and experience of most peo-
ple”; “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 shock
that supported the effectiveness of psy-
chological interventions during the first
half of the 20th century. It was the
recognition of a proportion of the pop-
ulation not suitable for army recruit-
ment during the Second World War
that spurred the setting up of the
National Institute of Mental Health in
USA. The differences in the presenta-
tion of the psychological symptoms
among the officers and the soldiers
opened up new ways of understanding
the psychiatric reactions to stress.
During the last year, a large number
of books and documents have ad-
dressed the effects of war on mental
health. They include the WPA book
“Disasters and mental health” (1); the
World Bank report “Mental health and
conflicts – Conceptual framework and
approaches” (2); the United Nations
(UN) book “Trauma interventions in
war and peace: prevention, practice and
policy” (3); the United Nations Chil-
dren’s Fund (UNICEF) document “The
state of the world’s children – Child-
hood under threat” (4); the book “Trau-
ma and the role of mental health in post-
conflict recovery” (5) and a chapter on
“War and mental health in Africa” in the
WPA book “Essentials of clinical psy-
chiatry for sub-Saharan Africa” (6).
Though there have not been any
world wars since the Second World War,
there have been wars and conflicts
throughout the last 60 years. For exam-
ple, in the 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 has experienced such a situ-
ation in the last quarter of century (7).
War has a catastrophic effect on the
health and well being of nations. Stud-
ies have shown that conflict situations
cause more mortality and disability than
any major disease. War destroys com-
munities and families and often disrupts
the development of the social and eco-
nomic fabric of nations. The effects of
war include long-term physical and psy-
chological harm to children and adults,
as well as reduction in material and
FORUM: MENTAL HEALTH CONSEQUENCES OF WAR
Mental health consequences of war:
a brief review of research findings
Among the consequences of war, the impact on the mental health of the civilian population is one of the most significant. Studies of the
general population show a definite increase in the incidence and prevalence of mental disorders. Women are more affected than men.
Other vulnerable groups are children, the elderly and the disabled. Prevalence rates are associated with the degree of trauma, and the
availability of physical and emotional support. The use of cultural and religious coping strategies is frequent in developing countries.
Key words: War, mental health, vulnerable groups, coping strategies
R. SRINIVASA MURTHY
1
, RASHMI LAKSHMINARAYANA
2
1
Regional Office for the Eastern Mediterranean, World Health Organization, Post Box 7608,
Abdul Razak Al Sanhouri Street, Naser City, Cairo 11371, Egypt
2
London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
human capital. Death as a result of wars
is simply the “tip of the iceberg”. Other
consequences, besides death, are not
well documented. They include endem-
ic poverty, malnutrition, disability, eco-
nomic/social decline and psychosocial
illness, to mention only a few. Only
through a greater understanding of con-
flicts and the myriad of mental health
problems that arise from them, coherent
and effective strategies for dealing with
such problems can be developed.
The importance that the WHO attrib-
utes to dealing with the psychological
traumas of war was highlighted by the
resolution of the World Health Assem-
bly in May 2005, which urged member
states “to strengthen action to protect
children from and in armed conflict”
and the resolution of the WHO Execu-
tive Board in January 2005, which urged
“support for implementation of pro-
grammes to repair the psychological
damage of war, conflict and natural dis-
asters” (8).
The WHO estimated that, in the sit-
uations of armed conflicts throughout
the world, “10% of the people who
experience traumatic events will have
serious mental health problems and
another 10% will develop behavior
that will hinder their ability to function
effectively. The most common condi-
tions are depression, anxiety and psy-
chosomatic problems such as insom-
nia, or back and stomach aches” (9).
This paper briefly reviews the evi-
dence from published literature about
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26
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February 2006
the 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). The
review presents data concerning some
major wars/conflicts (the countries
involved are considered in alphabetic
order) and then briefly outlines the risk
factors emerging from the literature.
IMPACT OF WAR ON MENTAL
HEALTH
Afghanistan
More than two decades of conflict
have led to widespread human suffer-
ing and population displacement in
Afghanistan. Two studies from this
country are significant in terms of both
their scope and their findings.
The first study (10) used a national
multistage, cluster, population based
survey including 799 adult household
members aged 15 years and above.
Sixty-two percent of respondents report-
ed experiencing at least four trauma
events during the previous ten years.
Symptoms of depression were found in
67.7% of respondents, symptoms of
anxiety in 72.2%, and post-traumatic
stress disorder (PTSD) in 42%. The dis-
abled and women had a poorer mental
health status, and there was a significant
relationship between the mental health
status and traumatic events. Coping
strategies included religious and spiritu-
al practices.
The second study (11), using a cross-
sectional multicluster sample, was con-
ducted in the Nangarhar province of
Afghanistan, to estimate the prevalence
of psychiatric symptoms, identify re-
sources used for emotional support and
risk factors, and assess the present cov-
erage of basic needs. About 1011 res-
pondents aged 15 years and above
formed the sample. Nearly half of the
population had experienced traumatic
events. Symptoms of depression 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 numbers of
traumatic events experienced. Women
had higher rates than men. The main
sources of emotional support were reli-
gion and family.
The Balkans
The conflict in the Balkans is proba-
bly one of the most widely studied (12-
14) in recent years. Mental health of sur-
vivors of both sides was examined (15).
An initial study (16) among Bosnian
refugees demonstrated an association
between psychiatric disorders (depres-
sion and PTSD) and disability. A three-
year follow-up study on the same group
concluded that former Bosnian re-
fugees who remained living in the
region continued to exhibit psychiatric
disorders and disability after initial
assessment (17).
A cross-sectional cluster sample sur-
vey among Kosovar Albanians aged 15
years or older found that 17.1% (95%
CI 13.2%-21.0%) reported symptoms
of PTSD (18). There was a significant
linear decrease in mental health status
and social functioning with increasing
amount of traumatic events in those
aged 65 years or older, and with previ-
ous psychiatric illnesses or chronic
health conditions. Internally displaced
people were at increased risk of psychi-
atric morbidity. Men (89%) and women
(90%) expressed strong feelings of
hatred towards the Serbs, with 44% of
men and 33% of women stating that
they would act on these feelings.
In a study of the mental health and
nutritional status among the Serbian
ethnic minority in Kosovo, the General
Health Questionnaire (GHQ)-28 scores
in the subcategories of social dysfunc-
tion and severe depression were high,
with women and those living alone or in
small family units being more prone to
psychiatric morbidity (19). In a commu-
nity sample of 2,796 children aged
between 9 and 14 years, high levels of
post-traumatic symptoms and grief
symptoms were reported (20). This was
related to the amount and type of expo-
sure. Girls reported more distress than
boys.
Cambodia
Cambodia has had a long history of
violence, highlighted by the civil war
in the 1960s, culminating with the
“Khmer Rouge” rule that destroyed
the social fabric of the society. Studies
have found that refugees had high lev-
els of psychiatric symptomatology
after 10 years (21).
A household survey of 993 adults
from Site 2, the largest Cambodian dis-
placed-persons camp on the Thailand-
Cambodia border, found that more
than 80% felt depressed and had a
number of somatic complaints despite
good access to medical services (22).
Approximately 55% and 15% had
symptom scores that correlated with
Western criteria for depression and
PTSD, respectively. However, despite
high reported levels of trauma and
symptoms, social and work functioning
were well preserved in the majority of
respondents. Cumulative trauma con-
tinued to affect psychiatric symptom
levels a decade after the original trauma
events (23). This study also reported
that there was support for the diagnos-
tic validity of PTSD criteria, with the
notable exception of avoidance. The
inclusion of dissociative symptoms
increased the cultural sensitivity of
PTSD. Psychiatric history and current
physical illness were found to be risk
factors for PTSD (24).
Changes in the structure of the soci-
ety have led to a breakdown of the
existing protective networks such as
the village chief and the elders in the
village, especially for women (25). Tra-
ditional healers (monks, mediums, tra-
ditional birth attendants), who played
an important role in maintaining the
mental health of communities in the
past, have lost their designated posi-
tions in the community following the
conflict (26).
Twenty-seven Cambodian young
people, who were severely traumatized
at ages 8 to 12, were followed up 3
years after a baseline evaluation. A
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27
structured interview and self-rating
scales showed that PTSD was still high-
ly 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 of Chechen asylum seekers in
the UK adds to the evidence on the
abuses and related psychological fallouts
(29). Psychosocial issues were explored
in a survey conducted in settlements
housing displaced people (n=256) (30,31).
Two thirds of respondents agreed with
the statement that the conflict has trig-
gered mental disturbance or feelings of
being upset. Nearly all respondents indi-
cated that they had family members hav-
ing difficulty in coping with their distur-
bance or upset feelings. Coping strate-
gies used were 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 in the
1960s, the Iran-Iraq war (1980-1988),
the anti-Kurdish Al-Anfal campaign
within the country (1986-1989), the
Iraqi invasion of Kuwait resulting in the
Gulf war (1991), and the conflict starting
in 2003. The UN-imposed economic
sanctions following the Gulf war have
had a profound impact on the health of
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 present in 87%
of children and 60% of their caregivers
(33). A study on 84 Iraqi male refugees
found that poor social support was a
stronger predictor of depressive morbid-
ity than trauma factors (34). During the
last three years of occupation by foreign
forces, 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 con-
flict for over four decades. A large num-
ber of systematic studies have been
undertaken in different population
groups. A recent study (35) found that
76.7% of subjects exposed to war-relat-
ed trauma had at least one traumatic
stress-related symptom, while 9.4% met
the criteria for acute stress disorder. The
most common coping mechanisms were
active information search about loved
ones and social support. Another study
(36) reported that, twenty years after the
war with Lebanon, an initial combat
stress reaction, PTSD-related chronic
diseases and physical symptoms were
associated with a greater engagement in
risk behaviours.
Lebanon
Lebanon has been ravaged by a civil
war (1975-1990) and by an Israeli inva-
sion in 1978 and 1982. The mental
health impact of these conflicts has been
studied extensively.
A random sample of 658 people aged
between 18 and 65 years was randomly
selected from four Lebanese communi-
ties exposed to war (37). The lifetime
prevalence of DSM-III-R major depres-
sion varied across the communities
from 16.3% to 41.9%. Exposure to war
and a prior history of major depression
were the main predictors for current
depression.
The correlation between mother’s
distress and child’s mental health was
explored in a study in Beirut (38). The
level of perceived negative impact of
war-related events was found to be
strongly associated with higher levels of
depressive symptomatology among mo-
thers. The level of depressive symptoma-
tology in the mother was found to be the
best predictor of her child’s reported
morbidity. In a study carried out in 224
Lebanese children (10-16 years), the
number of traumatic experiences related
to war was positively correlated to PTSD
symptoms, with various types of 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
was present in 42.1% of the sample
compared to 27.8% among the control
group. Significant predictors for distress
were years of education and increase in
religiosity after release.
Palestine
During the last decade a large num-
ber of studies have reported high levels
of psychosocial problems among chil-
dren and adolescents, women, refugees
and prisoners in Palestine.
A study conducted by the Gaza Com-
munity Mental Health Programme
among children aged 10-19 years (41)
revealed that 32.7% suffered from PTSD
symptoms requiring psychological inter-
vention, 49.2% from moderate PTSD
symptoms, 15.6% from mild PTSD
symptoms, and only 2.5% had no symp-
toms. Boys had higher rates (58%) than
girls (42%), and children living 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 the Sec-
ond Intifada (42) found that 46% of par-
ents reported aggressive behaviour
among their children, 38% noted bad
school results, 27% reported bed wet-
ting, while 39% stated that their children
suffered from nightmares. The study also
revealed that more refugee (53%) than
non-refugee (41%) children behaved
aggressively. Thirty-eight percent of the
respondents said that shooting was the
main influence, 34% stated that it was
violence on TV, 7% cited confinement at
home and 11% reported that it was the
arrest and beating of relatives and neigh-
bours. Seventy percent of refugees and
non-refugees stated that they had not
received any psychological support for
the problems of their children.
In a series of studies during the last 10
years from the Gaza Community Mental
Health Centre (43), the most prevalent
types of trauma exposure for children
were witnessing funerals (95%), witness
to shooting (83%), seeing injured or
dead strangers (67%) and family mem-
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ber injured or killed (62%). Among chil-
dren living in the area of bombardments,
54% suffered from severe, 33.5% from
moderate and 11% from mild or doubt-
ful levels of PTSD. Girls were more vul-
nerable.
Rwanda
The physical and mental health prob-
lems of the survivors of the genocide in
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
adjusted odds ratio of meeting PTSD
symptom criteria for each additional
traumatic event being 1.43. Respon-
dents who met PTSD criteria were less
likely to have positive attitudes towards
the Rwandan national trials, suggesting
that the effects of trauma need to be con-
sidered if reconciliation has to be suc-
cessful. There have been reports on the
state of health among the large numbers
of refugees (500,000-800,000 in five
days) who fled to Goma, Zaire following
the capture of the capital Kigali, but
none of them has considered the mental
health dimension.
Sri Lanka
The conflict between the majority
Sinhala and minority Tamil population
in Sri Lanka has been ongoing for near-
ly 30 years. One of the first studies that
looked into the psychological effects of
the conflict on the civilian population
was an epidemiological survey (46),
which reported that only 6% of the
study population had not experienced
any war stresses. Psychosocial sequelae
were seen in 64% of the population,
including somatization (41%), PTSD
(27%), anxiety disorder (26%), major
depression (25%), alcohol and drug
misuse (15%), and functional disability
(18%). The breakdown of the Tamil
society led to women taking on more
responsibilities, which in turn 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 psychiatric mor-
bidity and use of khat (49). A UNICEF
study found evidence of psychological
effects of the prolonged conflict situa-
tion in a high proportion of a sample of
10,000 children (50). There is near total
disruption of the mental health services
in the country.
Uganda
Sudanese refugees fled into northern
Uganda in two major waves in 1988
and 1994. Symptoms of PTSD and
depression were found to be highly
prevalent among Sudanese children liv-
ing in the refugee camps (51). Refugees
had higher rates of individual psy-
chopathology than the general popula-
tion, and it was observed that the
cumulative stress grew as the years in
exile progressed. The consequences of
long-term exile were still present 5-15
years later, with an increase in the rates
of suicide and alcohol use.
RISK FACTORS
From the large amount of studies
reviewed, some broad risk factors and
associations can be drawn.
Women have an increased vulnera-
bility to the psychological consequen-
ces of war. There is evidence of a high
correlation between mothers’ and chil-
dren’s distress in a war situation. It is
now known that maternal depression in
the prenatal and postnatal period pre-
dicts poorer growth in a community-
based sample of infants. Social support
and traditional birth attendants have a
major role in promoting maternal psy-
chosocial well being in war-affected
regions. The association between gen-
der-based violence and common mental
disorders is well known. Despite their
vulnerability, women’s resilience under
stress and its role in sustaining their
families has been recognized.
There is consistent evidence of high-
er rates of trauma-related psychological
problems in children. The most impres-
sive reports are those from Palestine. Of
the different age groups, the most vul-
nerable are the adolescents.
The direct correlation between the
degree of trauma and the amount of the
psychological problems is consistent
across a number of studies. The greater
the exposure to trauma – both physical
and psychological – the more pro-
nounced are the symptoms.
Subsequent life events and their
association with the occurrence of psy-
chiatric problems have important impli-
cations for fast and complete rehabilita-
tion as a way of minimizing the ill
effects of the conflict situations.
Studies are consistent in showing
the value of both physical support and
psychological support in minimizing
the effects of war-related traumas, as
well as the role of religion and cultural
practices as ways of coping with the
conflict situations.
CONCLUSIONS
The occurrence of a wide variety of
psychological symptoms and syndromes
in the populations in conflict situations
is widely documented by available
research. However, research also pro-
vides evidence about the resilience of
more than half of the population in the
face of the worst trauma in war situa-
tions. There is no doubt that the popula-
tions in war and conflict situations
should receive mental health care as part
of the total relief, rehabilitation and
reconstruction processes. As happened
in the first half of the 20th century, when
war gave a big push to the developing
concepts of mental health, the study of
the psychological consequences of the
wars of the current century could add
new understandings and solutions to
mental health problems of general pop-
ulations.
A number of issues have emerged
from the extensive literature on the
prevalence and pattern of mental health
effects of war and conflict situations. Are
the psychological effects and their mani-
festation universal? What should be the
definition of a case requiring interven-
IMP. 25-30 2-02-2006 9:33 Pagina 28

29
tion? How should psychological effects
be measured? What is the long-term
course of stress-related symptoms and
syndromes? (52). All these issues need
to be addressed by future studies.
It is important to report that the
WHO and some other UN-related bod-
ies have recently created a task force to
develop “mental health and psychoso-
cial support in emergency settings” (53-
55), which is expected to complete its
activity in one year.
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