23 January 2020
A new study by the World Health Organization (WHO) shows that people in conflict settings are approximately three times more likely to have depression, anxiety disorder, post-traumatic stress disorder, bipolar disorder or schizophrenia.
Researchers updated the WHO’s 10-year-old estimates for prevalence rates of mental disorders in conflict-affected settings using more modern tools of statistical analysis, and by reviewing a wider range of previous research. The statistics were gathered through a close search and review of different mental health research conducted in conflict areas, including 45 new studies published over a four-year period.
The results of the review indicate that approximately one in five people in post-conflict settings had been diagnosed with one of these disorders, compared to a global average of one in 14.
The researchers found there was a higher prevalence of severe mental disorders than was previously estimated, with a current estimate of 5.1 percent, compared to the previously estimated 3 to 4 percent. They also found a higher prevalence of mild to moderate mental disorders. The estimates of years living with disability per 1,000 for depression and post-traumatic stress disorder were five times higher than the global burden of disease estimate.
These findings are essential for action plans and a closer look at conflict settings. According to Samah Jabr, psychiatrist and director of the Mental Health Unit at the Palestinian Ministry of Health, “the results can help us understand the increased mental health burden and its relationship to war and violence.”
The stigma and mental health culture, as well as the nature of conflict affect diagnosis and the reporting of data in an emergency setting.
For example, Jabr explains that the psychiatric definition of trauma does not accommodate political settings where humiliation, objectification, forced helplessness, and daily exposure to toxic stress are daily realities. The review of cultural variations then is not only essential at a contextual level but from a clinical perspective.
“We attempted to control for contextual differences where possible by testing a range of variables such as intensity of trauma exposure, time since conflict, political terror scale rating and world region — significantly associated variables were incorporated into our models,” says Fiona Charlson, the study’s first author and a researcher at the Queensland Centre for Mental Health Research, in Australia. However, conflict settings strongly vary. “Fully accounting for cultural and contextual variations is extremely challenging and was a limitation of our study,” she adds.
Defining what was considered conflict was essential for the research. For this review, conflict was defined as, “the existence of opposing forces and stipulate a violence threshold described in terms of number of deaths [and] level of state terror according to state-perpetrated human rights violations.” Natural disasters and disease outbreaks, such as Ebola, were not included in the study.
The researchers used the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD) criteria, as well as variables known to be associated with prevalence (such as exposure to trauma) as a reference for the disorders and their diagnostic traits to measure the prevalence rates.
The research reviewed criteria such as age, comorbidity, years living with disability (YLD) and the severity of the disorder. The DSM and ICD were updated repeatedly within the time of the study, between the year 2000 to 2017. Due to cultural variations and changes in diagnostic criteria, the study advises a revision of anxiety and post-traumatic stress disorder prevalence.
What do we do with the numbers?
In May 2012, the World Health Assembly adopted a resolution to implement a global mental health action plan. Prevalence rates of mental disorders are essential in the goals the action plan set to carry out. According to the WHO document, the plan “is global in its scope and is designed to provide guidance for national action plans. It addresses, for all resource settings, the response of social and other relevant sectors, as well as promotion and prevention strategies.”
The findings shed light on the increased mental health burden and its relationship to war and violent context, Jabr argues. They also make a compelling case for global humanitarian, development, health, and mental health communities to prioritize development of mental health services in conflict and post-conflict settings.
In Palestine for example, Jabr says the study “motivates us to further integrate mental health in school setting where we can find a third of the Palestinian population, and in primary health care that is accessible to most people.” She adds that it also rings the alarm bell about human rights and political oppression, a root cause for this increased incidence of mental disorders.
It is important to acknowledge that despite its importance, the study is limited by its basis on published research, not readily available in many countries, especially those undergoing conflict. Jaber says there is a shortage of comprehensive mental health research in Palestine, for example. “We have therefore a long way to go before we can draw reliable conclusions about mental health in our community. Until that time, we should examine with a critical eye the results of epidemiological surveys conducted under emergency conditions,” she says.