Findings From the World Mental Health Surveys of Civil Violence Exposure and Its Association With Subsequent Onset and Persistence of Mental Disorders

Abstract

ImportanceUnderstanding the association of civil violence with mental disorders is important for developing effective postconflict recovery policies.ObjectiveTo estimate the association between exposure to civil violence and the subsequent onset and persistence of common mental disorders (in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV]) in representative surveys of civilians from countries that have experienced civil violence since World War II.Design, Setting, and ParticipantsThis study used data from cross-sectional World Health Organization World Mental Health (WMH) surveys administered to households between February 5, 2001, and January 5, 2022, in 7 countries that experienced periods of civil violence after World War II (Argentina, Colombia, Lebanon, Nigeria, Northern Ireland, Peru, and South Africa). Data from respondents in other WMH surveys who immigrated from countries with civil violence in Africa and Latin America were also included. Representative samples comprised adults (aged ≥18 years) from eligible countries. Data analysis was performed from February 10 to 13, 2023.ExposuresExposure was defined as a self-report of having been a civilian in a war zone or region of terror. Related stressors (being displaced, witnessing atrocities, or being a combatant) were also assessed. Exposures occurred a median of 21 (IQR, 12-30) years before the interview.Main Outcomes and MeasuresThe main outcome was the retrospectively reported lifetime prevalence and 12-month persistence (estimated by calculating 12-month prevalence among lifetime cases) of DSM-IV anxiety, mood, and externalizing (alcohol use, illicit drug use, or intermittent explosive) disorders.ResultsThis study included 18 212 respondents from 7 countries. Of these individuals, 2096 reported that they were exposed to civil violence (56.5% were men; median age, 40 [IQR, 30-52] years) and 16 116 were not exposed (45.2% were men; median age, 35 [IQR, 26-48] years). Respondents who reported being exposed to civil violence had a significantly elevated onset risk of anxiety (risk ratio [RR], 1.8 [95% CI, 1.5-2.1]), mood (RR, 1.5 [95% CI, 1.3-1.7]), and externalizing (RR, 1.6 [95% CI, 1.3-1.9]) disorders. Combatants additionally had a significantly elevated onset risk of anxiety disorders (RR, 2.0 [95% CI, 1.3-3.1]) and refugees had an increased onset risk of mood (RR, 1.5 [95% CI, 1.1-2.0]) and externalizing (RR, 1.6 [95% CI, 1.0-2.4]) disorders. Elevated disorder onset risks persisted for more than 2 decades if conflicts persisted but not after either termination of hostilities or emigration. Persistence (ie, 12-month prevalence among respondents with lifetime prevalence of the disorder), in comparison, was generally not associated with exposure.ConclusionsIn this survey study of exposure to civil violence, exposure was associated with an elevated risk of mental disorders among civilians for many years after initial exposure. These findings suggest that policy makers should recognize these associations when projecting future mental disorder treatment needs in countries experiencing civil violence and among affected migrants.

Exposure to Adversity and its Impact on Later Life Cognitive, Mental, and Physical Health

“…Our findings on how exposure to violence in combat and the experience of assault are associated with health outcomes complement existing research. For example, Axinn et al (2023) found, that exposure to civil violence in 7 countries that experienced civil violence since WWII, was associated with a higher risk of mental disorders in the long term [28].…”

“…Our findings on how exposure to violence in combat and the experience of assault are associated with health outcomes complement existing research. For example, Axinn et al (2023) found, that exposure to civil violence in 7 countries that experienced civil violence since WWII, was associated with a higher risk of mental disorders in the long term [ 28 ]. Similarly, in a study of U.S.-based WWII and Korean War veterans, Elder and Chipp (1989) found that heavy combat veterans were at higher risk for emotional and behavioral problems, compared with noncombat and light combat veterans [ 8 ].…”

“…As people enter adulthood, their experiences and exposures to new adverse events can also have long-term impacts. Exposure to adversity across the life course has the potential to profoundly impact cognitive, mental, and physical health [8,9,[25][26][27][28][29]. For example, having a close relative who is addicted to drugs or alcohol has been found to have lasting effects on an individual's emotional well-being, often through stress and family strain [30,31].…”

DataSheet1.pdf

“…Our findings on how exposure to violence in combat and the experience of assault are associated with health outcomes complement existing research. For example, Axinn et al (2023) found, that exposure to civil violence in 7 countries that experienced civil violence since WWII, was associated with a higher risk of mental disorders in the long term [28].…”

“…As people enter adulthood, their experiences and exposures to new adverse events can also have long-term impacts. Exposure to adversity across the life course has the potential to profoundly impact cognitive, mental, and physical health [8,9,[25][26][27][28][29]. For example, having a close relative who is addicted to drugs or alcohol has been found to have lasting effects on an individual's emotional well-being, often through stress and family strain [30,31].…”