In 2004, Dr Derrick Silove from the University of New South Wales in Sydney, Australia, and colleagues conducted a survey to estimate the prevalence of common mental disorders among 1022 adults (600 from a rural village and 422 from an urban district) in Timor Leste four years after the end of a long-running and violent war against Indonesian occupation, and again in 2010-11, following a period of prolonged internal conflict.
Interviewers used the Harvard Trauma Questionnaire to assess 16 symptoms of PTSD and the Kessler-10 questionnaire to measure depression and anxiety. The researchers also examined whether poverty, ongoing community conflict, and persisting feelings of injustice contributed to mental illness.
Over the 6 years of follow-up, rates of PTSD increased seven fold (2.3% in 2004 to 16.7% in 2010) and rates of severe distress increased almost three times (5.6% to 15.9%).
"Given that potentially traumatic events were rarer during the internal conflict than during the principal conflict, it seems likely that the effects of recurrent episodes of communal violence on the morale, sense of communal cohesion, and security of the population created a general underlying vulnerability to psychological distress", explains lead author Dr Derrick Silove.
Interestingly, PTSD was not only linked with experience of violent conflict but also with a range of other stressors. In particular, persisting preoccupations with injustice during two or three periods (the principal conflict 1975-99, internal conflict 2006-7, or the present 2008-10) was linked with a quadrupling of risk for PTSD, which the authors suggest could have been related to the unsatisfactory truth and reconciliation process that followed independence, together with ongoing human rights abuses.
According to Dr Silove, "Our findings suggest that a period of internal conflict can result in a major escalation in mental disorders in post-conflict countries. Mental health services should be enhanced in these settings to meet these increased needs. Our experiences highlight the importance of preventing communal violence, alleviating poverty, and addressing past and ongoing injustices in post-conflict communities to help avert both recurring violence and prevent an increase in mental disorders."
Writing in a linked Comment, Madelyn Hsiao-Rei Hicks from the University of Massachusetts Medical School, USA, discusses the value of culturally informed research that integrates relevant experiences, sociocultural factors, and political aspects of study populations. She adds, "A further advance would be if studies used in-depth interviews with the probability-sampled respondents of the epidemiological survey. Such interviews would produce detailed information on which to base moderately generalisable and acceptable methods of engagement, treatment, and social healing... For example, if epidemiologists studying conflict-affected populations returned to their survey respondents to explore specific means for achieving justice and reconciliation, a range of informed options could be generated for social reconstitution to prevent the future distress, symptoms, and disability, which Silove and colleagues have shown result from persistent conflict and perceived injustice."