Download Armed conflict and mental health

Armed conflict and mental health
Magdalena Cerdá, DrPH
Assistant Professor
Department of Epidemiology
April 16, 2014
Intended Audience & Learning Objectives
This lecture will be most informative for someone with an
intermediate knowledge of the topic. With this in mind,
by the end of this lecture, users will be able to:
• Describe the epidemiology of armed conflict
• Understand the types of mental health problems that
arise in armed conflict
• Describe the risk factors for mental illness in a context
of armed conflict
• Identify promising prevention strategies to address
mental health in armed conflict settings
What is Collective Violence?
“The instrumental use of violence by people who
identify themselves as members of a group against
another group or set of individuals, in order to achieve
political, economic, or social objectives” (WHO, 2002).
• Examples:
– Wars/armed conflict
– Terrorism
– State-perpetrated violence (torture,
disappearances)
– Genocide (intent to destroy a particular group)
Our Focus Today
Wars and other forms of civilian armed
conflict:
• Interstate wars
• Civil wars
What Types of Armed Conflict Exist
Today?
• 32 conflicts were taking place around the
world by 2012
• Most conflicts:
– Civil conflicts: take place within countries
– Concentrated in middle- and low-income
countries
– Target local population
– Resulting in mass population displacement
Who is Affected?
• Armed combatants fighting in the
conflict
– Members of state military organizations
– Civilian combatants:
• Paramilitaries
• Guerrillas
• Child soldiers
• Civilian populations exposed to the
conflict
What Types of Mental Illness Have
Been Studied in Relation to Conflict?
• A focus on common psychiatric disorders
• Bulk of studies focus on posttraumatic stress
disorder (PTSD)
• Other disorders considered include:
– Depression
– Substance use disorders, in particular alcohol
abuse and dependence
How Prevalent is Mental Illness among
Armed Combatants?
• Prevalence of psychiatric disorders in military
populations
– PTSD: 12% to 20%:
– Depression: 3%-15%
• Prevalence of psychiatric disorders among
child soldiers:
– PTSD: 16%-34.9%
– Depression: 55%-88.2%
• No systematic data on the prevalence of
psychiatric disorders among civilian
combatants
How Prevalent is Mental Illness among
Civilians Following Conflict?
• Wide variability in rates of mental disorders
• Meta-analysis of 161 articles published on 40
countries in 1980-2009 (Steel, 2009) found:
– Prevalence of posttraumatic stress disorder (PTSD): 099%
– Prevalence of depression: 3-85.5%
– Weighted prevalence:
• PTSD: 30.6% (26.3%-35.2%)
• Depression: 30.8% (26.3%-35.6%)
• Substance Use (Kerridge et al., 2013)
– 1% + deaths from collective violence  0.14% more
disability-adjusted life years lost due to substance use
disorders
Methodological Issues that Affect
Studies of Collective Violence
• Larger prevalence estimates are found in
studies characterized by:
– Sample size: smaller samples
– Sampling design: convenience sampling
– Measurement: self-report (rather than clinical
interview) measures of disorders
• Need to draw random samples of a
population to obtain valid estimates of
prevalence
A Conceptual Framework
Civilian stressors
Combat-related
traumatic events
Mental health
status
Determinants of Postdeployment
Mental Illness among Combatants
• Combat-related traumatic events: being
under fire, attacked by civilians/insurgents,
engaging in battle, injury in battle, killing others in
battle
• Post-battle traumatic events: seeing soldiers
wounded/dead, seeing wounded/dead civilians
• Civilian stressors: divorce or break-up, losing job,
stressful legal problems, lack of adequate health
care, financial problems
Combat-Related and Post-Battle
Traumatic Events
• Consistent relationship between exposure to traumatic
events during & after combat and common psychiatric
disorders: PTSD, depression, alcohol dependence
• Bulk of research focused on PTSD; most studies of U.S.
and United Kingdom military forces
• Studies usually measure a count of exposure to different
types of traumatic combat-related and post-battle
events
• Virtually no studies on effects on paramilitary or guerrilla
forces
– A few studies conducted on former child soldiers
Example of a Study
(click title of article to link to article online--in Slide Show mode only)
Example of a Study
Objective: To describe the relationship between combat
exposures and post-traumatic stress disorder symptoms in
a large population-based military cohort
Sample: 50,184 US service members recruited for the
Millennium cohort before wars in Iraq and Afghanistan
Results:
• US service members who were deployed and reported
combat experiences—at greater odds for PTSD than those
deployed who did not report combat experiences and those
not deployed
• 7.6-8.7% of deployers reporting combat exposures reported
PTSD symptoms, while 1.4-2.1% of deployers without reported
combat exposures and 2.3-3.0% of non-deployers reported
PTSD symptoms
Civilian Stressors Experienced by
Combatants
Civilian stressors following deployment linked to an
increase in PTSD, depression & substance use disorders
• Particularly affected in the US and UK: members of reserve
forces who return home without the support of a military unit
and must enter civilian employment
• Factors that increase difficulties upon return from deployment
include: problems at home regarding children, financial
distress, job loss, and lack of employer support
• Little systematic research on the role that civilian stressors play
in mental illness among paramilitary or guerrilla members who
return home from combat
Example of a Study
(click title of article to link to article online--in Slide Show mode only)
Example of a Study
Objectives: To determine if financial hardship, job
loss, employer support & effect of deployment
absence on co-workers are associated with PTSD &
depression among reserve soldiers
Methods: Cross-sectional study of a sample of US
4034 National Guard soldiers
Results: Job loss & financial difficulties linked to PTSD
& depression
• PTSD rates of those who lost jobs or reported financial
difficulties at least twice as high compared with rates of
those who had not
• Depression rates almost three times as high among those
who lost jobs or experienced financial difficulties
Example of a Study
(click title of article to link to article online--in Slide Show mode only)
Example of a Study
Objectives: Determine risk and the protective factors related to
PTSD among former child soldiers (average age 16.6) in Sierra
Leone
Methods: Longitudinal Study of War Affected Youth in Sierra
Leone (n= 529) identified by the International Rescue Committee;
assessed war experiences, PTSD, stigma, family acceptance,
family abuse and neglect
Results:
– 36% endorsed having injured or killed someone
– 32% met the criteria for PTSD
– War experiences and post-conflict family abuse were
significantly associated with increased PTSD
– Death of a parent due to the war was significantly
associated with increased PTSD
Determinants of Post-Conflict Mental
Health among Civilians
• Exposure to combat-related traumatic
events as civilians
– Injury, death or disappearance of loved ones,
seeing dead/injured bodies, torture, physical
assault, sexual assault
• Experience of civilian stressors associated
with conflict
– Displacement, loss of housing, loss of job,
financial problems, poverty, divorce, malnutrition,
loss of social network
Combat-Related Traumatic Events
Experienced by Civilians
• Civilian experiences of torture and cumulative
exposure to traumatic events are consistently
associated with civilian rates of depression and PTSD
– Steel et al., 2009: strongest determinants of depression and PTSD
across 161 studies
• Consistent dose-response relationship between
number of traumatic events and level of psychiatric
symptoms
• Civilian responses to combat may differ from soldier
responses:
– Can shatter civilian assumptions about safety
– Civilians experience higher frequency of intrusive recollections and
less emotional numbing
Example of a Study
(click title of article to link to article online--in Slide Show mode only)
Example of a Study
Example of a Study
Objective: Determine association of displacement
due to war with symptoms of PTSD, anxiety, and
depression in postwar Jaffna District, Sri Lanka
Methods: In 2009, 1409 residents of Jaffna were
surveyed on displacement status and PTSD, anxiety
and depression
Results:
• Participants who were displaced at the time of the survey
were more likely to report PTSD symptoms and depression
compared to those individuals who had been long term
residents of the displacement camps.
• Displacement was no longer associated with mental health
conditions after controlling for trauma exposure.
Civilian Stressors Associated with
Conflict
• Armed conflict leads to the destruction of
the physical and material infrastructure &
social fabric of communities
• Given high prevalence of civilian conflicts
& absence of a State in many civilian
conflicts, civilian stressors are a particularly
important driver of post-conflict mental
health
(over)
Civilian Stressors Associated with
Conflict
• Civilian stressors following conflict have
shown strong & significant associations with
common psychiatric disorders, in particular
PTSD
• A number of studies have shown a stronger
effect of civilian stressors compared to
combat-related traumatic events on
mental illness
Example of a Study
(click title of article to link to article online--in Slide Show mode only)
Example of a Study
Objectives: What was the impact of war-related stressful life events
on health of families living during war conditions in Lebanon?
Methods: 540 families from Beirut were surveyed on indicators of
somatization, depression, other psychological symptoms,
interpersonal relations, and marital relations, war-related events,
economic hardship, reduction in social network, social class, social
support, and migration.
Results:
• Reduction in social networks associated with
increased depression among parents
• Reduction in food safety associated with increased
other psychological symptoms for the mother and adolescents
• Migrating associated with reduced depression and other psychological
symptoms among mothers
• Availability of social support was associated with reduced depression
and other psychological symptoms among fathers
How do We Address Mental Health
after Conflict?
• Prevention
• Treatment
Prevention
Four guidelines outlined by Miller and Rasmussen:
• A rapid and contextually grounded assessment of stressors
that are salient is needed before developing interventions;
Possible methods include: focus groups, free-listing, key
informant interviews
• First address the combat-related civilian stressors before
providing clinical services that target mental health
• When clinical services are indicated, services should target a
broad range of mental health conditions and not only PTSD
• It is also imperative to take into account that the
symptomology seen may not be solely due to conflict
exposure; there may be other sources of psychological
trauma
Treatment
A systematic review of 29 Randomized Control Trials
and Clinical Controlled Trials (Tol, 2011) assessed various
domains of treatment:
• Specialized services
- Narrative exposure therapy showed beneficial effects on
PTSD among Romanian, Ugandan, Sri Lankan and Rwandan
cohorts
• Focused non-special supports
- Studies assessing treatment methods such as: classroombased skills, psychoeducation, group-based trauma and
grief-focused, testimony therapy found mixed results
• Strengthening community and family support
- Studies examining the impact of increased family support
and community strength found improvements on
psychological symptoms
Treatment
Specialized service
• In a study among torture survivors in Romania,
PTSD and depression improved in those survivors
who had narrative exposure therapy. On
average, after treatment, PTSD symptoms
reduced 50% and depression symptoms by 67%
(Bichescu, 2007).
Treatment
Specialized service
• Among Sudanese refugees in Uganda, narrative exposure
therapy was more effective in reducing PTSD compared to
supportive counseling and psychoeducation. One year after
treatment, only 29% of the narrative exposure therapy
participants compared to 79% of the supportive
counseling group and
80% of the psychoeducational group
had PTSD (Nuener,
2004).
Treatment
Focused non-special supports
• In Bosnia and Herzegovina, war-affected 13–18year-olds underwent classroom-based skills and
psychoeducation intervention aimed at trauma
and loss and the related stress and grief and a
group-based trauma-focused and grief-focused
treatment.
• Both treatments improved depression and PTSD.
The group-based treatment group, showed the
greatest improvement. At the 4-month follow-up,
there was on average there was a 81% reduction
in PTSD symptoms and a 61% reduction in
depressive symptoms (Layne, 2008).
Treatment
Strengthening community and family support
• A randomized-clinical trial in northern Uganda of a
school-based intervention (structured activities
including drama, movement, music, and art), resulted
in improvements in overall wellbeing among those
children aged 7-12 year olds who received the
intervention (Ager, 2011)
• A study among 250 children from the West Bank and
150 children from Gaza, found that children among
the treatment group (structured events including:
cultural and recreational activities traditional
dancing, art work, sports, drama and puppetry) had
lower total problem scores, externalizing problem
scores, and internalizing problem scores (Loughry,
2006)
Conclusions
• Traumatic events directly related to conflict,
and civilian stressors that follow conflict, shape
post-conflict mental health among combatants
and civilians
• To address mental health consequences of
combat, need to:
– Address the stressors combatants face upon return
from deployment
– Rebuild infrastructure that was destroyed by conflict
– Provide access to treatment to combatants and
civilians particularly vulnerable to the consequences
of armed conflict
Acknowledgements
Spruha Joshi, MPH, for assistance in
reviewing and synthesizing the literature
for this presentation.