Prioritising mental health care in war-torn countries

Armed conflict has affected over a billion people worldwide in the last 50 years, with most survivors living in low income countries. Mental distress is common during and after periods of mass conflict, but the number of people who require clinical treatment needs closer scrutiny, especially in relation to post-traumatic stress disorder (PTSD). In particular, the needs of those with severe mental disorder demands further attention.

Advocates for mental health services in areas affected by conflict face several obstacles. Worldwide, mental illness contributes substantially to the burden of disease, yet funding for appropriate mental health services remains inadequate with constraints in funding and skills being particularly severe in low income countries.

Building consensus about mental health needs in conflict-affected countries has become urgent, particularly in relation to PTSD. People suffer from PTSD following exposure to life threatening situations. Symptoms include nightmares and flashbacks, avoidance of social interaction, withdrawal from family and usual activities, phobias of situations that remind the person of the trauma, and extreme anxiety. Do all persons with that reaction need treatment? Reservations include:

• During and after conflict, many people experience trauma, and 'symptoms' of PTSD are very common soon after exposure.
• PTSD symptoms may not be disabling or seen as a major problem in developing countries.
• The re-establishment of safety and security can allow for natural recovery.
• Local systems of healing and traditional cultures may be effective in healing psychological wounds.
• Standard treatments for PTSD devised in the developed world, such as cognitive behaviour therapy, require specialist skills or expensive medications (such as sertraline) and may be difficult to access in other countries.
• Other severe mental health problems such as psychosis, severe depression, organic disorders (delirium, brain injury, dementia), and epilepsy need attention.

There is emerging evidence from studies amongst Vietnamese refugees and in East Timor to suggest that PTSD-type symptoms may recover of their own accord if the political and social situation is stabilised. Mass psychological interventions (debriefing) are not necessary, nor are such broad-based strategies affordable and feasible in many countries affected by conflict. The best 'therapy' is sound social policy aimed at building peace, supporting the reunion of families and communities, promoting justice, providing opportunities for work, and re-establishing institutions that bring meaning and coherence to political, religious, spiritual and social life.

Trauma interventions need to occur at the right time. Rushing in to provide trauma therapies or awareness programmes soon after the conflict has ended is not needed. However, services should be alerted to the likelihood that some people with acute stress reactions, and later, chronic and disabling PTSD, will need attention.

Poor countries affected by conflict cannot afford or sustain multiple specialist agencies dealing with various aspects of mental health. Mental health activities need to be integrated and coordinated under one authority, usually the Ministry of Health. The highest priority is for the establishment of a network of community-based mental health services that are capable of dealing with a wide range of problems, including severe mental illness and severe or chronic traumatic stress disorders. These services need to interact with other areas of the health sector, traditional care systems and other services. In keeping with experience worldwide, developing and maintaining the necessary mental health skills is an incremental task requiring extensive in-service mentoring.

Derrick Silove
School of Psychiatry
Level 6, Parkes Building East
Prince of Wales Hospital
Randwick
New South Wales
Australia
d.silove@unsw.edu.au

See also

'The psychosocial effects of torture, mass human rights violations, and refugee trauma: toward an integrated conceptual framework', Journal of Nervous and Mental Disease 187: 200-207 by D. Silove, 1999

'Long-term effect of psychological trauma on the mental health of Vietnamese refugees resettled in Australia: a population-based study', The Lancet 360: 1056-1062 by Z. Steel et al, 2002

'Mental health in the aftermath of disasters: consensus and controversy', Journal of Nervous and Mental Disease 191: 611-615 by M.G. Weiss et al, 2003

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