Sudan’s long history of conflict

The current war must be understood in the context of Sudan’s long history of political turmoil. Armed conflict has been a recurring reality for decades, with profound implications for the population’s mental health. The Second Sudanese Civil War (1983–2005) claimed over 2 million lives and displaced millions more. ⁴ The 2003 Darfur conflict drew international condemnation for atrocities, yet it persisted for years with limited global attention. The separation of South Sudan in 2011 marked a major geopolitical split, which led to a rise in the mental health burden in both countries as instability and violence continued. ^{Reference Ali, Saeed and Sultan5} What distinguish the current conflict are not only its severity but also its geographical expansion, reaching the capital, Khartoum, and other major cities and causing mass displacement. These repeated cycles of conflict have created a population uniquely vulnerable to trauma, where decades of insecurity have compounded the mental health burden. ^{Reference Shoib, Osman Elmahi, Siddiqui, Abdalrheem Altamih, Swed and Sharif Ahmed1}

Pre-war mental health system

Despite ongoing instability, Sudan made significant, albeit uneven, progress in mental health care before April 2023. These advancements deserve recognition so that the current crisis is understood within the context of what is at risk and what needs rebuilding.

Before the war, Sudan’s health system was underfunded, fragmented and characterised by critical workforce shortages and disparities in access and quality of care. ^{Reference Shoib, Osman Elmahi, Siddiqui, Abdalrheem Altamih, Swed and Sharif Ahmed1} Mental health services were highly centralised, with most psychiatric hospitals, out-patient clinics and specialist staff concentrated in Khartoum. Rural areas were largely unserved. Sudan had one of the lowest psychiatrist-to-population ratios globally. Many trained professionals emigrated due to limited resources and poor working conditions.

Nevertheless, targeted initiatives signalled a shift towards a public health approach. The WHO’s Mental Health Gap Action Programme (mhGAP) was introduced to train non-specialists in recognising and managing common mental disorders. Non-governmental organisation (NGO)-supported psychosocial interventions reached schools and community settings, expanding care beyond hospital walls. ^{Reference Ali, Saeed and Hughes6} The pre-war period demonstrated that modest investment and coordinated planning could improve access. This progress is now at risk of being completely reversed.

The current conflict: scope and human toll

Since April 2023 the war has escalated into one of the fastest-growing humanitarian crises worldwide. By early 2025 an estimated 30 million people, over two-thirds of Sudan’s population, required humanitarian assistance. Public services have collapsed, food and fuel prices have soared and communicable disease outbreaks have spread across most states. ^{Reference Mohammed, Altamih, Elgailani, Khalid, Alhassan and Ibrahim7}

Nearly 13 million people were forcibly displaced, including more than 3 million refugees in neighbouring countries and over 8 million internally displaced. Civilian infrastructure has been repeatedly targeted, and casualty estimates suggest that deaths may exceed 150 000. ⁴

Epidemiology of mental disorders in crises

Although Sudan-specific epidemiological data remain limited, available studies indicate a substantial burden of mental disorders in conflict-affected populations. ^{Reference Charlson, van Ommeren, Flaxman, Cornett, Whiteford and Saxena2} Emerging findings from internally displaced communities are particularly concerning. A study among older internally displaced persons in Darfur found that 75% had non-psychotic psychiatric disorders. ^{Reference Musa and Hamid8} Internally displaced people consistently demonstrate a greater prevalence of mental illnesses. ^{Reference Shoib, Osman Elmahi, Siddiqui, Abdalrheem Altamih, Swed and Sharif Ahmed1}

Emergency mental health response and systemic challenges

The IASC’s Guidelines on Mental Health and Psychosocial Support in Emergency Settings (2007) remains the primary global framework guiding mental health response in crisis zones. ⁹ These guidelines promote a layered system of care, ranging from basic services (e.g. food, shelter) and community support to focused, non-specialised supports (e.g. psychological first aid) and specialised psychiatric services. In Sudan, this approach is being implemented through multi-sector coordination among United Nations agencies, NGOs and community-based groups.

Multiple emergency psychosocial support services have been launched. In Chad, for example, which hosts over 1 million Sudanese refugees, mental healthcare has been integrated into primary health services in several camps through NGO-led training for nurses and community health workers. ¹⁰ Within Sudan, the Sudanese Red Crescent’s strong volunteer network has continued delivering community-based health and psychosocial services despite extreme insecurity. ¹¹ Another example is the network of emergency response rooms (ERRs): local, often volunteer-run, coordination hubs organising food distribution, medical referrals and psychosocial support. ¹² These efforts demonstrate that, even amid systemic collapse, structured and culturally grounded interventions are possible.

Several systemic barriers continue to impede effective mental health response. The displacement and destruction of facilities have further worsened the shortage of a trained workforce. Deep-rooted stigma discourages many from seeking help. High illiteracy rates and the absence of reliable surveillance data constrain planning. Infrastructure collapse, including power outages, internet shutdowns and shortages of psychotropic medications, has severely limited service delivery. Finally, funding instability compounds these challenges. These barriers highlight the fragility of Sudan’s mental health system and the urgent need for sustained, coordinated intervention.

This profile has limitations. Reliable epidemiological data during active conflict are scarce, and casualty and displacement figures are derived largely from humanitarian reporting rather than from independently verified national surveillance. Additionally, as a narrative synthesis rather than a systematic review, source selection was guided by relevance and recency rather than predefined inclusion criteria. These constraints reflect the realities of documenting an ongoing emergency.

Call to action

Preventing a generational mental health crisis in Sudan requires immediate emergency measures and long-term system rebuilding. In the short term, mental health services must be fully integrated into humanitarian responses in line with the IASC framework. Before 2023, meeting population needs would have required more than quadrupling Sudan’s mental health specialist workforce; rapid training using the mhGAP model can expand the pool of non-specialist providers, and scaling up of initiatives such as ERR and Red Crescent programmes can extend care to populations otherwise beyond reach.

In the longer term, rebuilding infrastructure is a priority. Anti-stigma campaigns tailored to Sudan’s cultural and religious contexts are also essential. Sustained funding is required, ensuring that mental health is not sidelined once the acute phase of the conflict subsides. Beyond immediate morbidity, prolonged exposure to conflict carries potential long-term and intergenerational consequences. Evidence from other conflict- and famine-affected settings demonstrates associations among prenatal stress, early-life adversity and increased risk of later depression, anxiety disorders and psychosis. These findings suggest that the mental health consequences of the current war may extend well beyond the present crisis, reinforcing the urgency of early and sustained intervention. ^{Reference Khoodoruth and Khoodoruth13,Reference Rabayaa and Rabaya14}

The question remains, however: is there a realistic means of delivering appropriate mental healthcare to such an immense and traumatised civilian population when the nation’s infrastructure is being razed to the ground, crimes against humanity are being systematically perpetrated and foreign actors stand to profit from Sudan’s natural resources? This question is intended to underscore the structural constraints within which mental health services must operate during active conflict. Although clinical frameworks such as the IASC guidelines provide a blueprint for layered intervention, their effectiveness ultimately depends on minimum conditions of security, governance and sustained international engagement. Without these enabling conditions, even well-designed humanitarian responses risk remaining fragmented and insufficient relative to the scale of need. ^{Reference Patel, Saxena, Lund, Thornicroft, Baingana and Bolton15}

Without a multilateral peace agreement supported by international peacekeeping forces, the humanitarian suffering will continue. Meanwhile, Sudanese health workers and communities, who have demonstrated extraordinary resilience and courage in the face of overwhelming violence, will continue confronting a humanitarian catastrophe with profoundly inadequate resources. Addressing Sudan’s mental health crisis is not only a clinical imperative but an ethical one.