Research Article: Exposure to War as a Risk Factor for Mental Disorders

Date Published: April 1, 2008

Publisher: Public Library of Science

Author(s): David M Benedek, Robert J Ursano

Abstract: The authors discuss a new study on the prevalence of mental disorders in Lebanon.

Partial Text: While large-scale national psychiatric epidemiologic studies have been conducted in Western industrialized nations [1–3], studies in the Arab world have generally been limited to smaller populations [4–6]. In addition, while exposure to war as a risk factor for the development of mental disorders in military populations has previously been described [7,8], the effect of war upon first onset of a range of mental disorders in civilian populations at a national level has not been explored.

In this issue of PLoS Medicine, Elie Karam and colleagues use the WHO CIDI to address questions of lifetime prevalence, age of onset, and treatment delay for mental disorders in a nationally representative population survey of Lebanon [16]. They also examine individual and cumulative war exposure as risk factors for the development of mental disorders. One hundred and sixteen trained interviewers administered the Arabic version of the CIDI 3.0 to a randomly selected non-institutionalized adult (age ≥18 years) family member (n = 2,187) in households across 342 geographical area segments of Lebanon. For all (n = 1,031) respondents who met lifetime criteria for any core mental disorder (and for a probability sample of those who did not), a secondary assessment of risk factors was conducted. Marital status, education, and war exposure were used as time-variant variables in the analysis, using discrete-time survival analysis to estimate the probability of the first onset of a disorder at each year of life up to and including age 74 years.

The lifetime prevalence of any DSM-IV mental disorder varies greatly across the World Health Organization’s World Mental Health surveys, from 47.4% for the US to 12.0% for Nigeria. The interquartile range (25th–75th percentiles) for this prevalence across these surveys was 18.1%–36.1% [17], and thus the lifetime prevalence for Lebanon (25.8%) lies within this range. Similarly, the projected lifetime risk of about one-third (32.9%) for one or more of the DSM-IV disorders in Lebanon is between the range of 17%–69% found in other World Mental Health surveys, although perhaps low compared to other nations with sectarian violence.

Given that this study was based on retrospective self-reports, the findings on the history of psychiatric disorder, age of onset, onset of treatment, and war exposure must be interpreted in light of the potential for recall bias. In addition, the low rates of some war exposure types (and/or low rates of specific disorders) lead to the confidence intervals on a number of the findings being quite wide. Thus the odds ratios may be subject to wide variation in future studies. Real-time health surveillance and prospective longitudinal studies—as are currently being conducted in the US in the wake of Hurricanes Katrina and Rita—may help to confirm or refute these findings. Health surveillance for mental disorders, as is done for other public health concerns, can bring real-time information to health planning and delivery of services.



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