Exposure to trauma and mental health symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD) are prevalent among people in Afghanistan but, often go untreated because of lack of resources and mental health care professionals, according to two studies in the August 4 issue of JAMA, the Journal of the American Medical Association, a theme issue on Violence and Human Rights.
According to background information: "More than two decades of war and conflict and three years of drought have led to widespread human suffering and substantial population displacement in Afghanistan. The country's infrastructure has been destroyed or degraded and vital human resources have been depleted." The researchers note that mental health facilities in Afghanistan are non-existent or in poor condition.
Barbara Lopes Cardozo, M.D., M.P.H., from the Centers for Disease Control and Prevention, Atlanta, and colleagues, conducted a nationally representative survey of 799 Afghan adult household members (699 nondisabled and 100 disabled respondents) aged 15 years or older from July to September 2002 to assess respondents exposure to trauma during the previous 10 years, mental health symptoms, resources for emotional support, and disability. The researchers defined the term disability "as any restriction or lack (resulting from impairment) of ability to perform an activity in the manner or within the range considered normal for a human being."
"A total of 407 respondents (62 percent) reported experiencing at least four trauma events during the past 10 years," the authors found. "The most common trauma events experienced by the respondents were lack of food and water (56.1 percent) for nondisabled persons and lack of shelter (69.7 percent) for disabled persons.
The prevalence of respondents with symptoms of depression was 67.7 percent and 71.7 percent, and symptoms of anxiety 72.2 percent and 84.6 percent for nondisabled and disabled respondents, respectively. The prevalence of symptoms of PTSD was similar for both groups (nondisabled, 42.1 percent and disabled, 42.2 percent). Women had significantly poorer mental health status than men did. Respondents who were disabled had significantly lower social functioning and poorer mental health status than those who were nondisabled. Feelings of hatred were high (84 percent of nondisabled and 81 percent of disabled respondents). Coping mechanisms included religious and spiritual practices; focusing on basic needs, such as higher income, better housing, and more food; and seeking medical assistance."
In conclusion, the authors write: "Our survey demonstrates a high prevalence of exposure to trauma and the magnitude of mental health problems among Afghan individuals in post-war Afghanistan. Prevalences of symptoms of depression, anxiety, and PTSD were high, even when compared with other communities traumatized by war and conflict. Women and disabled respondents had significantly poorer mental health status than men and nondisabled respondents. These data underscore the need for donors and health care planners to address the current lack of mental care resources, facilities, and trained mental health care professionals in Afghanistan." (JAMA. 2004; 292:575-584. Available post-embargo at JAMA.com)
Editor's Note: This study was supported by the Centers for Disease Control and Prevention.
Mental Health Symptoms Following War and Repression in Eastern Afghanistan
Another study in the JAMA theme issue on Violence and Human Rights reports on a mental health survey of residents from the Nangarhar province in the Eastern part of Afghanistan the region in which the Taliban movement originated.
Willem F. Scholte, M.D., from the University of Amsterdam, the Netherlands, and colleagues, surveyed 1,011 respondents aged 15 years or older during January and March 2003 to determine the rate of exposure to traumatic events; estimate the prevalence of symptoms of depression, anxiety, and PTSD; identify resources used for emotional support and risk factors for mental health symptoms; and assess the present coverage of basic needs in Nangarhar province.
"During the past 10 years, 432 respondents (43.7 percent) experienced between 8 and 10 traumatic events; 141 respondents (14.1 percent) experienced 11 or more. High rates of symptoms of depression were reported by 391 respondents (38.5 percent); anxiety, 524 (51.8 percent); and PTSD, 207 (20.4 percent)," the authors report. Symptoms were more prevalent in women than men. "The main resources for emotional support were religion and family. Medical care was reported to be insufficient by 228 respondents (22.6 percent)."
"Among the population of Nangarhar province, Afghanistan, many have experienced traumatic events during a long history of armed conflict, repression, and insufficiency of needs. Mental health symptoms are highly prevalent, especially in those who experienced multiple traumas and in women. The capacity of primary health care workers to raise awareness of basic options for support or treatment and to address mental health needs should be strengthened," the authors conclude. (JAMA. 2004; 292:585-593. Available post-embargo at JAMA.com)
Editor's Note: This study was funded by a grant from the Centers for Disease Control and Prevention, Department of Health and Human Services.
Editorial: Mental Health in Postwar Afghanistan
In an accompanying editorial, Paul Bolton, M.B.B.S., M.P.H., M.Sc., and Theresa Stichick Betancourt, Sc.D., M.A., from Boston University, Boston, write: "These studies add to a growing literature on the devastating impact of war on the mental health of civilian populations and to the sparse medical literature on Afghanistan since the Taliban era."
"The 2 epidemiological studies of mental health in Afghanistan published in this issue of JAMA provide a useful and interesting assessment of the postwar mental health symptoms in Afghanistan. There are some concerns about the assessment instruments used and whether generalizations about clinical disorders and specific medical treatment can be made. However, these studies provide an initial indicator of psychosocial approaches that might be effective and worthy of future study." (JAMA. 2004; 292: 626-628. Available post-embargo at JAMA.com).
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