Guiding policy and practice to address mental disorders in conflict settings
Authors: Cristiane S Duarte, M Claire Greene
Journal: The Lancet (2019)

The number of armed conflicts reached an all-time high in 2016, with 53 ongoing conflicts in 37 countries and 12% of the world's population living in an active conflict zone.1Bahgat K Dupuy K Ostby G Rustad SA Strand H Wig T Children and armed conflict: what existing data can tell us. PRIO, Oslo2018Google Scholar Mental health problems are one profound consequence of conflict, and quantification of their burden is a crucial first step. Indeed, despite the inherent challenges in collecting relevant data, stakeholders have advocated for documenting the prevalence and burden of mental health problems in conflict settings as a priority in global mental health research.2Tol WA Patel V Tomlinson M et al.Relevance or excellence? Setting research priorities for mental health and psychosocial support in humanitarian settings.Harv Rev Psychiatry. 2012; 20: 25-36Crossref PubMed Scopus (44) Google Scholar In The Lancet, Fiona Charlson and colleagues3Charlson F van Ommeren M Flaxman A Cornett J Whiteford H Saxena S New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis.Lancet. 2019; (published online June 11.)http://dx.doi.org/10.1016/S0140-6736(19)30934-1Summary Full Text Full Text PDF PubMed Scopus (387) Google Scholar aimed to improve estimates of the burden of mental health problems in conflict settings first by synthesising prevalence estimates of mental disorders in conflict-affected populations globally. These prevalence estimates were based on 129 studies (430 estimates from 39 countries) conducted within 10 years of a major conflict. Exceptions are prevalence estimates for schizophrenia and bipolar disorder, which, because of the shortage of studies, were based exclusively on the global mean estimates from Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016. Next, for depression and anxiety disorders, the authors were able to estimate the burden in conflict settings by using age-adjusted prevalence weighted by predetermined disability,4Vos T Flaxman AD Naghavi M et al.Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2163-2196Summary Full Text Full Text PDF PubMed Scopus (5551) Google Scholar resulting in years lived with disability (YLDs). Post-traumatic stress disorder-associated burden was derived exclusively from prevalence estimates, as disability weights for post-traumatic stress disorder (until recently considered a type of anxiety disorder) were not available from GBD 2016. There are several strengths of the approach taken by Charlson and colleagues. The study avoids the common limitation of restricting focus to one type of disorder (post-traumatic stress disorder). Also included are other anxiety, depressive, schizophrenic, and bipolar disorders, as advocated by the scientific and practitioner communities, when the goal is to provide support in acute and protracted emergencies.5Tol WA Barbui C Galappatti A et al.Mental health and psychosocial support in humanitarian settings: linking practice and research.Lancet. 2011; 378: 1581-1591Summary Full Text Full Text PDF PubMed Scopus (310) Google Scholar In addition, the authors should be commended for framing their results with the clear intention of informing practice, by considering comorbidities and describing prevalence estimates by disorder severity (mild, moderate, or severe). This strategy is of high clinical and public health relevance, and consistent with practice guidelines.6WHOUnited Nations High Commissioner for RefugeesmhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies. World Health Organization, Geneva2015Google Scholar Although these estimates make a crucial contribution to our knowledge of the burden of mental disorder in conflict-affected populations, limitations exist. First, cultural variation in case definition, changes in diagnostic criteria, and measurement variability might have affected prevalence estimates. Such contextual7de Jong JT Komproe IH Van Ommeren M et al.Lifetime events and posttraumatic stress disorder in 4 postconflict settings.JAMA. 2001; 286: 555-562Crossref PubMed Scopus (558) Google Scholar and methodological8Dohrenwend BP Turner JB Turse NA Adams BG Koenen KC Marshall R The psychological risks of Vietnam for U.S. veterans: a revisit with new data and methods.Science. 2006; 313: 979-982Crossref PubMed Scopus (553) Google Scholar heterogeneity has been evident in the wide variation in prevalence estimates of psychiatric disorders found across existing studies, usually of non-representative samples, comprising individuals exposed to a wide range of traumatic events.9Steel 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: 537-549Crossref PubMed Scopus (1307) Google Scholar Second, the scarcity of data in conflict settings forces exclusive reliance on GBD 2016 estimates (eg, of schizophrenia and bipolar disorder) or even exclusion of important aspects (eg, alcohol use disorder). Finally, even if methodological problems could be resolved and uniformly pristine prevalence data were available, limitations would still apply to estimates of burden. In this case, the disability weights used to derive YLDs, although improved,10Gabbe BJ Lyons RA Simpson PM et al.Disability weights based on patient-reported data from a multinational injury cohort.Bull World Health Organ. 2016; 94 (16C): 806Crossref PubMed Scopus (29) Google Scholar are based on a proxy: GBD 2016 disability weights. Such weights might not reflect mental disorder-related disability in conflict settings as those probably differ11Lahiri S van Ommeren M Roberts B The influence of humanitarian crises on social functioning among civilians in low- and middle-income countries: a systematic review.Glob Public Health. 2017; 12: 1461-1478Crossref PubMed Scopus (7) Google Scholar from disability in non-conflict contexts. The suboptimal nature of the available data needs to be weighed against the demand by policy makers for information about these complex conditions. Of ultimate importance is clarity when reporting by indicating exactly what data are used for each estimation. The next meaningful steps require investing in strategies that improve the accuracy of local estimates by considering sources of variation relevant to conflict settings. Systematically incorporating information about context-specific exposures and supporting culturally meaningful measurement of disorders and disability might considerably improve the accuracy and local relevance of the estimates produced. A more distant goal, but one of high impact, is to incorporate information about resilience.12Galatzer-Levy IR Huang SH Bonanno GA Trajectories of resilience and dysfunction following potential trauma: a review and statistical evaluation.Clin Psychol Rev. 2018; 63: 41-55Crossref PubMed Scopus (304) Google Scholar Individuals who stay disorder-free in extreme adversity can teach us powerful lessons about how best to alleviate burden in conflict settings. The many challenges inherent to generating information capable of guiding policy in the absence of reliable data need to be balanced against the alarming need suggested by current estimates: the prevalence of mental disorders (depression, anxiety, post-traumatic stress disorder, bipolar disorder, and schizophrenia) was 22·1% (95% uncertainty interval 18·8–25·7) at any point in time in the conflict-affected populations assessed and the burden is substantial. Work towards producing more accurate estimates needs to continue. Improved estimates can guide strategic implementation of services and more effective allocation of scarce resources. Notwithstanding its limitations, current estimates warrant greater investment in prevention and treatment of mental disorders in conflict-affected populations.2Tol WA Patel V Tomlinson M et al.Relevance or excellence? Setting research priorities for mental health and psychosocial support in humanitarian settings.Harv Rev Psychiatry. 2012; 20: 25-36Crossref PubMed Scopus (44) Google Scholar CSD and MCG report grants from the US National Institutes of Health. New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysisThe burden of mental disorders is high in conflict-affected populations. Given the large numbers of people in need and the humanitarian imperative to reduce suffering, there is an urgent need to implement scalable mental health interventions to address this burden. Full-Text PDF Open Access