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 inareas affected by conflict face several obstacles. Worldwide, mental illnesscontributes substantially to the burden of disease, yet funding for appropriatemental health services remains inadequate with constraints in funding andskills being particularly severe in low income countries.

Building consensus about mental healthneeds in conflict-affected countries has become urgent, particularly inrelation to PTSD. People suffer from PTSD following exposure to life threateningsituations. Symptoms include nightmares and flashbacks, avoidance of socialinteraction, withdrawal from family and usual activities, phobias of situationsthat remind the person of the trauma, and extreme anxiety. Do all persons withthat 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 problemin developing countries.
• The re-establishment of safety and security can allow fornatural recovery.
• Local systems of healing and traditional cultures may beeffective in healing psychological wounds.
• Standard treatments for PTSD devised in the developed world,such as cognitive behaviour therapy, require specialist skills or expensivemedications (such as sertraline) and may be difficult to access in othercountries.
• Other severe mental health problems such as psychosis, severedepression, organic disorders (delirium, brain injury, dementia), andepilepsy need attention.

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

Trauma interventions need to occur at theright time.  Rushing in to provide traumatherapies or awareness programs soon after the conflict has ended is notneeded.  However, services should bealerted to the likelihood that some people with acute stress reactions, andlater, chronic and disabling PTSD, will need attention.

Poor countries affected by conflict cannotafford or sustain multiple specialist agencies dealing with various aspects ofmental health.  Mental health activitiesneed to be integrated and coordinated under one authority, usually the Ministryof Health. The highest priority is for the establishment of a network ofcommunity-based mental health services that are capable of dealing with a widerange of problems, including severe mental illness and severe or chronictraumatic stress disorders. These services need to interact with other areas ofthe health sector, traditional care systems and other services. In keeping withexperience worldwide, developing and maintaining the necessary mental healthskills is an incremental task requiring extensive in-service mentoring.