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Common mental disorders in postconflict


settings

Article in The Lancet July 2003


DOI: 10.1016/S0140-6736(03)13692-6 Source: PubMed

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RESEARCH LETTERS

Contributors Algeria, periurban area exposed to large massacres, n=653),


D Guha-Sapir identified the principal theme and message of the paper, southeast Asia (low, modal, and relatively high income
designed the methods, and wrote the text. W G van Panhuis compiled data,
communities in Cambodia, exposed to decades of violence
did statistical calculations, and did the literature search.
including autogenocide, n=610), east Africa (Ethiopia,
Conflict of interest statement community of Eritrean refugees living in temporary shelters,
None declared. n=1200), and the Middle East (Gaza in Palestine, long-term
Acknowledgments refugee population exposed to ongoing violence, assessed
There was no specific funding source for this study. between the first and second Intifada, n=585).
1 Paquet C, Van Soest M. Mortality and malnutrition among Rwandan We assessed lifetime mental disorder (Diagnostic and
refugees in Zare. Lancet 1994; 344: 82324. Statistical Manual of Mental Disorders, fourth edition [DSM-IV])
2 Moore PS, Marfin AA, Quenemoen LE, et al. Mortality rates in with the composite international diagnostic interview (CIDI),
displaced and resident populations of central Somalia during 1992
famine. Lancet 1993; 341: 93538. version 2.1. We focused on four categories: mood disorder,
3 Shears P, Berry AM, Murphy R, Nabil MA. Epidemiological assessment somatoform disorder, post-traumatic stress disorder (PTSD),
of health and nutrition of Ethiopian refugees in emergency camps in and (other) anxiety disorder. We defined having a common
Sudan, 1985. BMJ 1987; 295: 31418. disorder as fulfilling criteria for at least one of the four
4 Gessner BD. Mortality rates, causes of death, and health status among categories. In our analyses, mood disorder includes dysthymia
displaced and resident populations of Kabul, Afghanistan. JAMA 1994;
272: 38285. and major depressive disorder; somatoform disorder includes
5 Assefa F, Jabarkhil MZ, Salama P, Spiegel P. Malnutrition and mortality somatisation disorder, conversion disorder, hypochondriasis,
in Kohistan District, Afghanistan, April 2001. JAMA 2001; 286: and pain disorder; and anxiety disorder encompasses panic
272327. disorder, agoraphobia, and social and specific phobia. Verbal
World Health Organization Collaborating Centre for Research on the rather than written informed consent was obtained because of
Epidemiology of Disasters (CRED), School of Public Health, Catholic illiteracy and fear of signing forms. Ethics approval was
University of Louvain, 1200 Brussels, Belgium (Prof D Guha-Sapir PhD, obtained from local programme directors, their boards, and
W G van Panhuis MSc) local authorities.
Correspondence to: Prof Debarati Guha-Sapir We classed participants as having experienced violence
(e-mail: sapir@epid.ucl.ac.be) associated with armed conflict if they reported experience of
at least one of 17 assessed conflict-related events. We applied
multivariate ANOVA in all groups to test whether general
profiles of disorders and comorbidity differed between those
Common mental disorders in who had and had not experienced violence. Covariates were
sex, age, marital status, and education; Wilks was the
postconflict settings criterion. We calculated risk ratios for each country to assess
the relation of violent experience with presence of each of the
Joop T V M de Jong, Ivan H Komproe, Mark Van Ommeren
four categories of disorder. We calculated odds ratios using
Research into postconflict psychiatric sequelae in low-income multiple logistic regression analyses, adjusting for potential
countries has been focused largely on symptoms rather than bias associated with demographic differences. We entered
on full psychiatric diagnostic assessment. We assessed 3048 sex, age, marital status, and education in step one, and
respondents from postconflict communities in Algeria, violence associated with armed conflict in step two. Since
Cambodia, Ethiopia, and Palestine with the aim of establishing odds ratios result in overestimation of relative risk in studies
the prevalence of mood disorder, somatoform disorder, post- with frequent outcomes, we converted the adjusted odds
traumatic stress disorder (PTSD), and other anxiety disorders. ratios into risk ratios.3 We repeated these regression analyses
PTSD and other anxiety disorders were the most frequent to calculate the relation between violent experience and
problems. In three countries, PTSD was the most likely disorder comorbidity. The pattern of results did not change if
in individuals exposed to violence associated with armed interactions between violence and demographic data were
conflict, but such violence was a common risk factor for various assessed (interactions were not significant [data not
disorders and comorbidity combinations in different settings. reported]).
In three countries, anxiety disorder was reported most in people Sociodemographic characteristics varied across groups.2
who had not been exposed to such violence. Experience of There were more women than men in groups from all
violence associated with armed conflict was associated with countries apart from Algeria. Mean ages were: Algeria,
higher rates of disorder that ranged from a risk ratio of 210 35 years (SD 11; range 1760); Cambodia, 36 years (13;
(95% CI 138285) for anxiety in Algeria to 1003 (5261665) 1665); Ethiopia, 34 years (10; 1660); and Palestine, 32
for PTSD in Palestine. Postconflict mental health programmes (12; 1660). Distributions of marital status, number of
should address a range of common disorders beyond PTSD. children, education, and religion also varied across groups.2
Frequency of exposure to violence differed between
Lancet 2003; 361: 212830 countries (Algeria 92%, Cambodia 81%, Ethiopia 79%,
Postconflict psychiatric research in low-income countries has Palestine 59%; all 2 comparisons between pairs of
been based largely on non-representative samples and focused samples were significant [p<005]). Within countries, few
on symptoms rather than on full psychiatric diagnostic sociodemographic differences were associated with violent
assessment.1 Consequently, data for the prevalence of experience. In Algeria, Cambodia, and Palestine respondents
diagnosed common mental disorders in postconflict com- exposed to conflict violence were older than those not
munities is scarce. We did population-based epidemiological exposed (p<005 for all t tests). In Algeria and Palestine,
surveys with broad psychiatric diagnostic assessment in more men than women reported experiencing violence (all
Algeria, Cambodia, Ethiopia, and Palestine. We aimed to 2 tests p<005). In Cambodia, respondents who had
assess the prevalence of common mental disorders in these experienced violence were less educated than non-exposed
four samples and analyse the effect of violence associated with people (2 test p=0002).
armed conflict on prevalence and comorbidity rates. PTSD and anxiety disorder were the two most frequently
Details of methods, including multistep random sampling reported problems in all groups (table 1). Among respondents
and instrument translation procedures, have been described.2 exposed to violence, PTSD was most frequently reported
Participants came from North Africa (Gouvernorat dAlgiers, (apart from in Cambodia). In respondents not exposed to

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RESEARCH LETTERS

n PTSD Mood disorder Anxiety disorder Somatoform disorder Any common disorder
Algeria
Total group 653 374% (337411) 227% (195259) 372% (335409) 83% (62104) 605% (567643)
Without ACAV 53 132% (41223) 151% (55247) 226% (113339) 38% (0089) 396% (264528)
With ACAV 600 395% (356434) 233% (199267) 385% (346424) 87% (64109) 623% (584662)
Risk ratio (95% CI) 314 (180467)* 163 (085276) 210 (138285) 293 (075921) 178 (143206)*
Cambodia
Total group 610 284% (248320) 115% (90140) 400% (361439) 16% (0626) 534% (494574)
Without ACAV 116 69% (23115) 43% (0680) 302% (218386) 17% (0041) 353% (266440)
With ACAV 494 334% (292376) 132% (102162) 423% (389467) 16% (0527) 577% (533621)
Risk ratio (95% CI) 352 (179612)* 178 (069428) 123 (087328) 045 (008257) 141 (106175)
Ethiopia
Total group 1200 158% (137178) 52% (3965) 96% (79113) 27% (1836) 236% (212260)
Without ACAV 256 39% (1563) 08% (0019) 31% (1052) 04% (0012) 78% (45111)
With ACAV 944 190% (165215) 58% (4373) 113% (93133) 33% (2244) 278% (249307)
Risk ratio (95% CI) 453 (248771)* 606 (1512190) 316 (151628) 228 (0>1000) 333 (219478)*
Palestine
Total group 585 178% (147209) 94% (70118) 135% (107163) 53% (3571) 291% (254328)
Without ACAV 238 29% (0850) 29% (0850) 84% (49119) 25% (0545) 126% (84168)
With ACAV 347 280% (233327) 133% (97169) 170% (131209) 72% (4599) 403% (351455)
Risk ratio (95% CI) 1003 (5261665)* 453 (206913)* 258 (158396) 407 (164924) 356 (264453)*
Data are percentage and 95% CI except where indicated. Risk ratios were adjusted for potential bias associated with differences between individuals with and without
ACAV on sex, age, marital status, and education. *p<0001. p=0001. p=002. p=0003. p>01.
Table 1: DSM-IV disorders in people with and without exposure to armed-conflict-associated violence (ACAV)

violence, anxiety disorder was most reported (apart from in comorbidity in all groups. We have previously reported that in
Ethiopia). Somatoform disorders were consistently least postconflict settings, PTSD is not only associated with
reported. Overall, reported rates were lowest in Ethiopia and experience of conflict violence, but also with a range of other
highest in Algeria. stressors (eg, quality of camps, daily difficulties).2 Therefore,
Violent experience was associated with disorder in all groups mental health programmes with a narrow focus on violence
(multivariate ANOVA all F tests, p<001). Rates of disorder associated with armed conflict or PTSD are probably not
tended to be significantly higher in people who had covering the full range of determinants and burden of common
experienced violence (table 1). The largest risk ratios were for mental disorders in postconflict settings. Postconflict
PTSD, ranging from 1003 in Palestine to 314 in Algeria. For programmes should address a wide range of problems and
mood disorder, risk ratios were 606 and 453 in Ethiopia and disorders. Our results differ from the 15% PTSD and 55%
Palestine, respectively, and not significant in Algeria and depression rates reported in Cambodian refugees living in
Cambodia. For anxiety disorder, risk ratio ranged from 210 to camps in Thailand.4 Different measures might account for the
316 in Ethiopia, Algeria, and Palestine and was not significant discrepancy. The low rates of mental disorder we noted in
in Cambodia. For somatoform disorder, the risk ratio was Ethiopia agree with findings of a CIDI survey in the general
significant only in Palestine. The risk ratio for reporting any Ethiopian population.5 The low rates of DSM-IV somatoform
common disorder ranged between 14 in Cambodia and 36 in disorders reported in our study contrast with the high rates of
Palestine. The International Statistical Classification of Diseases and Related
Comorbidity at 1 year was defined as occurrence of at least Health Problems, tenth revision (ICD-10) persistent somatoform
two categories of disorder within a 1-year interval, and was pain disorder reported in Bhutanese refugees.1 CIDI criteria
uncommon in people not exposed to violence. In all settings show that the threshold for somatoform disorder is much
apart from Cambodia, in people exposed to violence, the most higher for DSM-IV disorders than for ICD-10 persistent
frequent comorbidities at 1 year were PTSD with anxiety somatoform pain disorder.
disorder and PTSD with mood disorder. Comorbidity of three There are some limitations to our results. Although we did
disorders was rare, but PTSD with mood disorder and anxiety random sampling, the selection of catchment areas was not
disorder was the most frequent combination. No participant random.2 Our study is based on the unverified assumption that
had comorbidity of four disorders at 1 year. DSM-IV disorders have diagnostic validity across cultures.
Violent experience was not associated with comorbidity of Data collection involved recall of events and associated
two disorders, apart from in Gaza (multivariate ANOVA F test symptoms. Moreover, our groups differed with respect to age
p=0003). The risk ratio for the association between violence and sex as well as ethnic background. Although we adjusted
and 1-year comorbidity of PTSD and mood disorder was for sociodemographic differences, the effects of age and sex on
1359 in Palestine, 659 in Algeria, and not significant in prevalence might be considerable. Furthermore, although we
Cambodia or Ethiopia (table 2). The risk ratio for the used the same methods across sites, we did not control for
association between violence and 1-year comorbidity of PTSD cultural differences in response styles. Finally, we did not
with anxiety disorder was 1001 and 795 in Ethiopia and assess all common mental disorders. Inclusion of alcohol
Algeria, respectively, and not significant in Cambodia or dependence, a common disorder in certain cultures, would
Palestine. With respect to 1-year comorbidities of PTSD with have strengthened the study.
somatoform disorder and mood disorder with somatoform Because of our interest in the effect of violence associated
disorder, risk ratios were only significant in Palestine (about with armed conflict, we split the group into people with and
nine-fold for both analyses). 1-year comorbidity of mood without exposure to conflict-related events. Although this
disorder with anxiety, 1-year comorbidity of anxiety with approach causes loss of information, it was essential to
somatoform disorder, and 1-year comorbidity of three generate the prevalence rates of interest. We did not address
disorders were not related to exposure to violence in any group. whether different events or clusters of events are of equal
Our results show that common mental disorders are weight, which is an important, yet unexplored research topic.
frequent in areas where most of the worlds survivors of armed We included a range of common mental disorders and large,
conflict live. Exposure to violence associated with armed random community samples from understudied populations in
conflict was a potent risk factor for various disorders and four countries, and our interviewers used uniform full

THE LANCET Vol 361 June 21, 2003 www.thelancet.com 2129

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RESEARCH LETTERS

Algeria Cambodia Ethiopia Palestine


PTSD mood
Total group 107% (83131) 57% (3975) 18% (1126) 31% (1745)
Without ACAV 19% (0056) 09% (0026) 0% 04% (0012)
With ACAV 115% (89141) 69% (4791) 23% (1333) 49% (2672)
Risk ratio (95% CI) 659 (1012702) 330 (0432151)** 1359 (1807826)*
PTSD anxiety
Total group 126% (101152) 79% (58100) 35% (2545) 29% (1543)
Without ACAV 19% (0056) 17% (0041) 04% (0012) 0%
With ACAV 135% (108162) 93% (67119) 43% (3056) 49% (2672)
Risk ratio (95% CI) 795 (1242983) 325 (0761214)** 1001 (1425850)
PTSD somatoform
Total group 37% (2352) 05% (0011) 08% (0313) 20% (0931)
Without ACAV 0% 0% 0% 04% (0012)
With ACAV 40% (2456) 06% (0013) 11% (0418) 32% (1451)
Risk ratio (95% CI) 907 (1116031)
Mood anxiety
Total group 76% (5696) 69% (4989) 13% (0719) 15% (0525)
Without ACAV 19% (0056) 17% (0041) 0% 04% (0012)
With ACAV 82% (60104) 81% (57105) 17% (0925) 23% (0739)
Risk ratio (95% CI) 441 (0612126)** 251 (057981)** 608 (0714463)||
Mood somatoform
Total group 29% (1642) 05% (0011) 06% (0210) 19% (0830)
Without ACAV 0% 0% 0% 04% (0012)
With ACAV 32% (1846) 06% (0013) 08% (0214) 29% (1147)
Risk ratio (95% CI) 920 (1136077)
Anxiety somatoform
Total group 37% (2352) 08% (0115) 08% (0313) 17% (0728)
Without ACAV 0% 09% (0026) 0% 08% (0019)
With ACAV 40% (2456) 08% (0016) 11% (0418) 23% (0739)
Risk ratio (95% CI) 029 (002399)** 393 (0781811)||
PTSD mood anxiety
Total group 48% (3264) 36% (2151) 08% (0313) 07% (0014)
Without ACAV 0% 0% 0% 0%
With ACAV 52% (3470) 45% (2763) 10% (0416) 12% (0124)
Risk ratio (95% CI)
PTSD mood somatoform
Total group 23% (1235) 02% (0006) 03% (0006) 07% (0014)
Without ACAV 0% 0% 0% 0%
With ACAV 25% (1338) 02% (0006) 04% (0008) 12% (0124)
Risk ratio (95% CI)
PTSD anxiety somatoform
Total group 20% (0931) 03% (0007) 05% (0109) 07% (0014)
Without ACAV 0% 0% 0% 0%
With ACAV 22% (1034) 04% (0010) 06% (0111) 12% (0124)
Risk ratio (95% CI)
Data are percentage and 95% CI except where indicated. Risk ratios were adjusted for potential bias associated with differences between individuals with and without
ACAV on sex, age, marital status, and education. Not all risk ratios could be calculated because some rates of comorbidity were zero. *p=0012. p=002. p=003.
p=004. p=005. ||p=009. **p>01.
Table 2: 1-year comorbid categories of DSM-IV disorder in people with and without experience of armed-conflict-associated
violence (ACAV)

psychiatric diagnostic methods and were familiar with local 1 Van Ommeren M, de Jong JTVM, Sharma B, Komproe I, Thapa S,
contexts. Such research, paired with theoretical investigations Cardea E. Psychiatric disorders among tortured Bhutanese refugees
in Nepal. Arch Gen Psychiatry 2001; 58: 47582.
into response styles and transcultural validity issues, could be
2 de Jong JTVM, Komproe IH, Van Ommeren M, et al. Lifetime events
used to assess fully the distribution of common mental and posttraumatic stress disorder in 4 post-conflict settings. JAMA
disorders in postconflict settings. 2001; 286: 55562.
3 Zhang J, Yu KF. Whats the relative risk?: a method of correcting the
Contributors
odds ratio in cohort studies of common outcomes. JAMA 1998; 280:
J T V M de Jong and I H Komproe were responsible for study design,
169091.
supervision, data collection, and writing the report. I H Komproe
analysed data. M Van Ommeren contributed to study design and writing 4 Mollica RF, Donelan K, Tor S, et al. The effect of trauma and
and editing of the report. confinement on functional health and mental health status of
Cambodians living in Thailand-Cambodia border camps. JAMA
Conflict of interest statement 1993; 270: 58186.
None declared. 5 Kebede D, Alem A. Major mental disorders in Addis Ababa, Ethiopia.
Acta Psychiatr Scand 1999; 100 (suppl): 1829.
Acknowledgments
We acknowledge the large contribution to data collection by local staff in Transcultural Psychosocial Organisation (TPO), WHO Collaborating
Algeria (Socit Algerienne de Recherche en Psychologie-TPO: Centre for Refugees and Ethnic Minorities, Keizersgracht 329,
Mustafa El Masri, Noureddine Khaled), Cambodia (TPO, Cambodia: 1016 EE Amsterdam, Netherlands (Prof J T V M de Jong MD,
Willem van de Put, Daya Somasundaram), Ethiopia (TPO Ethiopia:
I H Komproe PhD, M Van Ommeren PhD); and Vrije Universiteit,
Mesfin Araya), and Palestine (Gaza Community Mental Health
Programme: Mustafa El Masri, Samir Quota). This study was supported Amsterdam (Prof J T V M de Jong, I H Komproe)
by a grant (WW049002) from the Dutch Ministry of Foreign Affairs, the
Hague. The sponsors of the study had no role in study design, data Correspondence to: Dr Ivan H Komproe
collection, data analysis, data interpretation, or writing of the report. (e-mail: ikomproe.tpo@pom.nl)

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