Skip to main content
×
×
Home

Information:

  • Access
  • Cited by 8
  • Cited by
    This article has been cited by the following publications. This list is generated based on data provided by CrossRef.

    Steinert, C. Bumke, P. J. Hollekamp, R. L. Larisch, A. Leichsenring, F. Mattheß, H. Sek, S. Sodemann, U. Stingl, M. Ret, T. Vojtová, H. Wöller, W. and Kruse, J. 2017. Resource activation for treating post-traumatic stress disorder, co-morbid symptoms and impaired functioning: a randomized controlled trial in Cambodia. Psychological Medicine, Vol. 47, Issue. 03, p. 553.

    Jefee-Bahloul, Hussam Bajbouj, Malek Alabdullah, Jihad Hassan, Ghayda and Barkil-Oteo, Andres 2016. Mental health in Europe's Syrian refugee crisis. The Lancet Psychiatry, Vol. 3, Issue. 4, p. 315.

    Silove, Derrick Ivancic, Lorraine Rees, Susan Bateman-Steel, Catherine and Steel, Zachary 2014. Clustering of symptoms of mental disorder in the medium-term following conflict: An epidemiological study in Timor-Leste. Psychiatry Research, Vol. 219, Issue. 2, p. 341.

    Silove, Derrick Liddell, Belinda Rees, Susan Chey, Tien Nickerson, Angela Tam, Natalino Zwi, Anthony B Brooks, Robert Sila, Lazaro Lelan and Steel, Zachary 2014. Effects of recurrent violence on post-traumatic stress disorder and severe distress in conflict-affected Timor-Leste: a 6-year longitudinal study. The Lancet Global Health, Vol. 2, Issue. 5, p. e293.

    Jensen, Tine K Skårdalsmo, Envor M and Fjermestad, Krister W 2014. Development of mental health problems - a follow-up study of unaccompanied refugee minors. Child and Adolescent Psychiatry and Mental Health, Vol. 8, Issue. 1, p. 29.

    Jefee-Bahloul, Hussam 2014. Use of telepsychiatry in areas of conflict: the Syrian refugee crisis as an example. Journal of Telemedicine and Telecare, Vol. 20, Issue. 3, p. 167.

    Ventevogel, Peter Jordans, Mark Reis, Ria and de Jong, Joop 2013. Madness or sadness? Local concepts of mental illness in four conflict-affected African communities. Conflict and Health, Vol. 7, Issue. 1, p. 3.

    Nakimuli-Mpungu, Etheldreda Alderman, Stephen Kinyanda, Eugene Allden, Kathleen Betancourt, Theresa S. Alderman, Jeffrey S. Pavia, Alison Okello, James Nakku, Juliet Adaku, Alex and Musisi, Seggane 2013. Implementation and Scale-Up of Psycho-Trauma Centers in a Post-Conflict Area: A Case Study of a Private–Public Partnership in Northern Uganda. PLoS Medicine, Vol. 10, Issue. 4, p. e1001427.

    ×

Actions:

      • Send article to Kindle

        To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

        Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

        Find out more about the Kindle Personal Document Service.

        Do conflict-affected societies need psychiatrists?
        Available formats
        ×
        Send article to Dropbox

        To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

        Do conflict-affected societies need psychiatrists?
        Available formats
        ×
        Send article to Google Drive

        To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

        Do conflict-affected societies need psychiatrists?
        Available formats
        ×
Export citation

Abstract

Symptoms of post-traumatic stress disorder (PTSD), anxiety and depression are prevalent among post-conflict populations worldwide but controversy about the cultural meaning of these symptoms, particularly in relation to PTSD, adds to the challenge for psychiatry in mounting appropriate intervention programmes. Accumulating scientific evidence assists in guiding the focus and scope of emergency mental health programmes, initiatives that can become the vanguard of mental health development and reform for countries recovering from conflict.

The paper by Kohrt et al 1 exemplifies the advances that have been made in epidemiological research in the field of post-conflict mental health. Although a large body of research has revealed consistent associations between war-related trauma and mental disorders such as post-traumatic stress disorder (PTSD) and depression, 2 the majority of studies have been cross-sectional in design, thereby limiting the causal inferences that can be drawn. The novelty of the study of Kohrt et al 1 is that it recorded data before and after a period of conflict; of interest is that anxiety increased after war exposure but high levels of depression remained constant, being closely related to persisting conditions of poverty. The study provides a clear reminder of the inextricable link between the global challenges of mass conflict and poverty and common mental disorders that make a major contribution to the global burden of disease.

Consensus and challenges

The high prevalence of mental disorder in conflict-affected countries poses a major dilemma for psychiatry in devising appropriate responses, especially given that most of these societies have very low resources in mental health. Adding to the challenge is the ongoing controversy about the status of PTSD and the legitimacy of applying Western-derived trauma-focused therapies across diverse cultural settings, a debate that continues to divide leaders in the field. 3 Yet organisations such as the World Health Organization (WHO), the United Nations High Commissioner for Refugees and the World Psychiatric Association, working with non-governmental organisations and other partners, have managed to forge a consensus about the core principles of policy and practice that should be applied in the post-conflict mental health field. 46 Perhaps sensibly, this consensus has been reached largely by ignoring the thorny issue of PTSD.

Scientific evidence concerning trauma and PTSD

There now is a large body of epidemiological research that allows us to begin answering some of the controversial issues about PTSD in conflict-affected countries. Studies show that PTSD can be detected across a wide range of cultural settings even though the prevalence of the disorder varies substantially across countries. 2 Some of this variation is attributable to the research methodologies employed; larger, random samples using structured clinical interviews yield much lower rates of PTSD than smaller, non-random studies applying self-report questionnaires. 2 There also is overwhelming evidence that the quantum and type of trauma exposure are key factors in determining prevalence rates of PTSD across studies. 2 In particular, the impact on mental health of exposure to human rights trauma such as torture, rape and other forms of interpersonal abuse is more severe and long-lasting than that of accidents and natural disasters.

Culture is commonly invoked to explain differences in PTSD rates across countries but it may be that the particularities of the historical context and the social impact of conflict are at least as relevant. For example, studies among Cambodians have yielded consistently higher rates of PTSD compared with the Vietnamese, even though the wars in these neighbouring countries occurred during the same time epochs. 2 In Cambodia, the Khmer Rouge transformed the whole country into a virtual concentration camp, destroying existing institutions and social networks and making it all but impossible to avoid exposure to multiple threats and abuses, whereas in Vietnam, the war had a patchy geographical impact so that substantial sectors of the population were spared direct exposure to violence and associated disruptions of social structures and networks. 7

The timing of studies following the peak period of conflict has emerged as an important predictor of PTSD prevalence rates across countries. 2 Stress symptoms tend to be high in the midst of conflict and in the immediate aftermath – in that sense, symptom levels provide an accurate barometer of the level of communal terror and arousal in the acute phase. Fortunately, time is a good healer for the population as a whole, 2 as long as the recovery environment is stable and supportive – sadly, conditions that rarely pertain in the immediate post-conflict phase in the contemporary world.

From science to policy

These and other scientific observations help to shape the core principles that guide contemporary mental health programmes in low-income, post-conflict countries. There is a consensus across the field of psychiatric traumatology that early debriefing of entire populations exposed to disasters is ineffective and may be damaging to some survivors. 8 In the immediate post-conflict phase, the best treatment is social – that is, creating conditions of safety, stability and socioeconomic development that will hasten natural recovery for the majority of the population. An important qualification, however, is that there will be a minority of survivors who have experienced overwhelming levels of violence and abuse and who will continue to experience a chronic form of PTSD, commonly comorbid with other disorders such as depression. These problems often become evident at the very point that international aid programmes begin to wind down.

Importantly, there is accumulating evidence that culturally adapted trauma-focused cognitive–behavioural therapy can be applied effectively across cultures, even though these interventions are seldom used. 6 Further trials are needed to examine why the uptake of these treatments is so low, what the effective components of these therapies are, who will benefit most from these interventions, the contraindications to exposing some survivors to memories of abuse such as torture, and the psychological impact on non-professional therapists (often survivors themselves) of listening repeatedly to harrowing accounts of violence. Standards need to be established for training therapists, assessing their competency and providing adequate ongoing supervision.

Range of disorders and cultural expressions of distress

Although PTSD remains central to work in post-conflict settings, the overweening preoccupation with that single diagnostic category has had the undesirable effect of diverting attention from a range of other psychiatric disorders including depression, various subtypes of anxiety (including separation anxiety), explosive forms of anger and other impulse control problems, prolonged grief, somatoform complaints, substance and alcohol misuse, personality change and head injury. It is remarkable too how little research has been conducted among persons with psychotic illnesses in the post-conflict field, a gap that has only begun to be addressed recently. For example, a study in post-conflict Timor Leste found that psychotic disorders are at least as common and disabling in that setting as in high-income countries. 9

Epidemiological studies also have been remiss in ignoring cultural expressions of distress among conflict-affected populations. For example, a study among a large sample of war-affected Vietnamese found that an indigenously derived measure of anxiety, depression and somatic symptoms identified three times the number of cases of mental disorder as the widely used Composite International Diagnostic Instrument. 7 The lesson seems to be clear: a sole reliance on international measures of psychiatric disorder may lead to an underestimate of the need for services in post-conflict societies. A key challenge for future epidemiological research is to explore further the bridging points between the universal (etic) and the local (emic) representations of emotional responses to trauma and abuse, an enterprise that requires a painstaking methodological approach. 10

Principles guiding emergency programmes

How do these considerations guide us in designing mental health programmes for low-income, conflict-affected countries, particularly in the early post-conflict phase? Given the multiplicity of psychiatric problems that can be triggered by trauma and conflict, it does not make sense to prioritise a single diagnosis such as PTSD. The key criterion for priority attention should be the level of social vulnerability – that is, the extent to which the presence of mental disorder is undermining the capacity of the individual, and indirectly the family, to survive and adapt in the precarious conditions that prevail in post-conflict environments. 11 From a practical perspective, this means that priority should be given to those with mental disorder who are suicidal or a threat to others, who are disruptive to families and communities, and/or who are so disabled that they cannot care for themselves or their dependents. 11

There now is a legacy of work in establishing family-focused, community-based mental health services in post-conflict settings, low-cost programmes that require little in the way of technology or infrastructure to initiate. 11 A forthcoming publication by WHO will provide a series of case examples that will illustrate the application of these models across diverse post-conflict settings around the world. 12 These vanguard programmes can act as the catalyst for the reform of mental health services as conflict-affected countries enter the phase of reconstruction. 4 By highlighting the effectiveness of a community-focused approach, emergency programmes can help steer policies and practices away from previously entrenched custodial care models often inherited from the colonial period. In that way, the convulsion of conflict, although always destructive and never desirable, can bring in its wake an impetus towards mental health system reform and development, a transformation that can have a lasting impact on the society for years to come. 4

Controversy is inevitable in a field that spans the domains of human rights, international politics, conflict theory, transcultural psychiatry and psychiatric traumatology. There may be some legitimacy in the concern that culturally naive psychiatrists can become the unwitting stalking horses of neocolonial designs, colonising minds rather than territory. At the same time, those who argue for a ‘hands-off’ approach to psychiatric intervention in conflict-affected societies are at risk of over-arguing their case. The stark reality is that there are significant numbers of conflict survivors worldwide who receive no effective support or treatment for their severe mental disorders. In my experience, these people and their families are desperately concerned with obtaining relief from their suffering – and much less interested in the ideological debates that are current in the Western-dominated literature.

References

1 Kohrt, BA, Hruschka, DJ, Worthman, CM, Kunz, RD, Baldwin, JL, Upadhaya, N, et al. Political violence and mental health in Nepal: prospective study. Br J Psychiatry 2012; 201: 268–75.
2 Steel, Z, Chey, T, Silove, D, Marnane, C, Bryant, RA, van Ommeren, M. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA 2009; 302: 537–49.
3 Summerfield, D. How scientifically valid is the knowledge base of global mental health? BMJ 2008; 336: 992–4.
4 Inter-Agency Standing Committee. IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Inter-Agency Standing Committee, 2007.
5 Mezzich, J, Saraceno, B. The WPA-WHO Joint Statement on the Role of Psychiatrists in Disasters Response. World Psychiatry 2007; 6: 12.
6 Tol, WA, Barbui, C, Galappatti, A, Silove, D, Betancourt, TS, Souza, R, et al. Mental health and psychosocial support in humanitarian settings: Linking practice and research. Lancet 2011; 378: 1581–91.
7 Steel, Z, Silove, D, Giao, NM, Phan, TTB, Chey, T, Whelan, A, et al. International and indigenous diagnoses of mental disorder among Vietnamese living in Vietnam and Australia. Br J Psychiatry 2009; 194: 326–33.
8 McNally, R, Bryant, R, Ehlers, A. Does early psychological intervention promote recovery from posttraumatic stress? Psychol Sci Public Interest 2003; 4: 4579.
9 Silove, D, Bateman, CR, Brooks, RT, Fonseca, AZ, Steel, Z, Rodger, J, et al. Estimating clinically relevant mental disorders in a rural and an urban setting in postconflict Timor Leste. Arch Gen Psychiatry 2008; 65: 1205–12.
10 van Ommeren, M. Validity issues in transcultural epidemiology. Br J Psychiatry 2003; 182: 376–8.
11 Silove, D, Manicavasagar, V, Baker, K, Mausiri, M, De Carvalho, F, Soares, A, et al. Indices of social risk among first attenders of an emergency mental health service in post-conflict East Timor: an exploratory investigation. Aust N Z J Psychiatry 2004; 38: 929–32.
12 World Health Organization. Building Back Better: Sustainable Mental Health Care After Disaster. WHO, in press.