Journal of ISSN: 2373-6445JPCPY

Psychology & Clinical Psychiatry
Research Article
Volume 5 Issue 2 - 2016
Post-Traumatic Stress Disorder in the Aftermath of Wars, Conflicts and Terrorism: Co-Relation between Countries GDP and Prevalence of PTSD
Muhammad Gul1* and Rafey Faruqui A2,3
1South Staffordshire & Shropshire Healthcare NHS Foundation Trust, England
2St Andrew's Academic Centre, Kings College London, England
3Department of Neuropsychiatry, University of Birmingham, England
Received: July 02, 2015 | Published: January 28, 2016
*Corresponding author: Muhammad Gul, South Staffordshire & Shropshire Healthcare NHS Foundation Trust, England, UK, Email:
Citation: Gul M, Rafey FA (2016) Post-Traumatic Stress Disorder in the Aftermath of Wars, Conflicts and Terrorism: Co-Relation between Countries GDP and Prevalence of PTSD. J Psychol Clin Psychiatry 5(2): 00275. DOI: 10.15406/jpcpy.2016.05.00275

Abstract

Background: An estimated 1.6 trillion dollars per year is spent on defence, and as much as three times more people are killed by human made disasters, the reported prevalence of post-traumatic stress disorder among population exposed to human-made disasters varied across different countries. The global cost of mental illness is 2.5 trillion dollars, accounting for 37% of health loss years.

Aim: Our aim was to investigate the prevalence of post-traumatic stress disorder across different region in population exposed to human-made disasters including war, conflicts and terrorist attacks. Another aim of our study was to investigate the correlation between prevalence of post-traumatic stress disorder and economic performance indicators of individual countries, and percentage of GDP spend on health care.

Method: The study was conducted in two stages. In stage 1 we conducted systematic literature search to establish prevalence of PTSD reported in context of human-made disasters from different countries. In stage we gathered economic performance reports and health care expenditure of respective countries. SPSS was used to identify any correlation between prevalence of PTSD, countries GDP, and percentage of GDP spend on health care expenditure.

Results: The review identifies large variation in the prevalence of post-traumatic disorder in population exposed to human-made disasters, with prevalence estimates from 0.6 to 73%. It has been found that countries with poor socioeconomic structure and lower spending on health care expenditures were seen with high prevalence of post-traumatic stress disorder.

Conclusion: Difference in prevalence of PTSD can be explained by gender, marital status, and educational background of the participants and time of the study after exposure to traumatic event. But countries socioeconomic status and per capita GPD health care expenditure were found to be significantly correlated with the difference in prevalence of PTSD in population exposed to human-made disasters.

Keywords: Human-made disasters; Conflicts; Wars; Mental illness; PTSD; Cost of mental illness

Introduction

CS: Cross Sectional Survey; LS: Longitudinal Survey; CC: Case Control; T: Time of Assessment; TA: Terrorists Attack; QPTS: Questionnaire for Post-Traumatic Stress; HADS: Hospital Anxiety & Depression Scale; HRQL-P: Health Quality of Life –Persian; SF-36: Short Form Health Survey; PTSD Scale: Post-Traumatic Stress Disorder Scale; RW-Rate: Return to Work Rate; THQ: Trauma History Questionnaire; DSM-IV ASD: DSM-IV Acute Stress Disorder; SF-8HS: Short Form Health Survey; PDEQ: Peritraumatic Dissociative Experience Questionnaire; ZSDS: Zung Self Rating Depression Scale; PCL-S 20: Post Traumatic Stress Disorder Check List, Stressor Specific Version; PSS-SR: Post-Traumatic Self Report Scale; PTSS: PTSD Total Severity Scale; HTQ: Harvard Trauma Questionnaire; GHQ-28: General Health Questionnaire -28; SCL-90-R: Symptom Check List -90 Revised; TE-CL: Traumatic Event Symptom Check List; MINI-INPI: MINI International Neuropsychiatric Review; PHQ: Patient Health Questionnaire; IES: Impact of Event Scale; EQLS: Eurohis Quality of Life Scale; CAPS: Clinician Administered PTSD Scale; PCL: PTSD Check list; GECL: Gaza Traumatic Event Check List; CRIES: Children Revised Impact of Event Scale; RCMAS-36: Revised Children Manifest Anxiety Scale; SDQ: Strength & Difficulty Questionnaire; TMAS: Taylor Manifest Anxiety Scale; MOS-20: Medical Outcomes Study Short Form; COR-E: Conservation of Resources Evaluation; PSQI: Pittsburgh Sleep Quality Index; D-HSCL-25: Depression Sub-scale Hopkins Symptoms Check List 25; BDI: Brief Depression Inventory; BSI: Brief Symptoms Inventory; PWBS: Psychological Well Being Scale; MSAQL: Manchester Short Assessment of Quality of Life; PTSD-CL-Civ: PTSD Check list Civilian Version; LSC: Life Stressor Check List –Revised; AAQ: Acceptance and Action Questionnaire; MOSS-S: Medical Outcome Study –Social Support Scale; MCRI: Mood Coping Responses Inventory; MSC-PTSD: Mississippi Scale for Combat Related PTSD; PPS: Police Perception Survey; PSI: Post Traumatic Inventory; DES-11: Dissociative Experience Scale

Background

It has been estimated that human made disaster kills as much as three time more people, than those killed by natural disaster [IFRC World Disaster Report]. There are more than 61 countries in the world that are at war, either with other countries or with separatist, militia, guerrilla and anarchic groups. In Africa there are 24 countries and 83 separatist groups fighting, mainly in Algeria, Libya, Nigeria, Somalia and Sudan. In Asia, there are more than 16 countries involved in fighting, which involve more than 79 militia and anarchic group, mainly in Afghanistan, Pakistan and Burma. In Middle East more than 8 countries and 78 separatist and other groups are involved in conflict, mainly in Iraq, Israel, Syria, Turkey and Yemen. According to one estimates, in the Eastern Mediterranean region of World Health Organization , more than 80% of the population is either in conflict situation or has had experienced one or more such situation in the last quarter of the 20th century [1].
Since 1980 there have been more than 39 major wars and since 1970 there have been more than 98,000 Terrorist Attacks in the World [National Consortium for Study and Response to Terrorism].In the last 100 years we have lost more than 187 million people due to war, conflicts and terrorism, which would have been equivalent to more than 10 % of World Population in 1913 [2].

An estimated 1.6 trillion dollars per year is spent on defence, which is equivalent to 2.6 % of World GDP, an amount of 236$ per person in the world. These conflicts, wars and act of terrorism cause significant damage to both physical and social environment of a community, are resulting in human losses, damage to properties, and disintegration of any society, with massive displacement of native population. The mental health consequences of these disasters are enormous requiring careful evaluation of community needs, identification of vulnerable groups, implementation of service provision programmes and work on prevention of secondary handicap and further morbidity. Currently the global cost of mental illness is 2.5 trillion dollars, with a predicting increase to 6 trillion dollars by 2030 [3]. Mental Illness is the leading cause of disability adjusted life year [DALY], accounting for 37% of healthy loss years [4].

Massive collective distress distinguishes the victims of disaster from those suffering as a result of individual trauma, which may replicate some of the same stresses carried by disaster traumas [5]. Mass traumatic events, particularly terrorist attacks are associated with greater mental health effects in the population [6].

Globally an estimated 10% of population exposed to traumatic events in a conflict situation develop serious mental health problems notably depression, anxiety and PTSD, with another 10 % developing behavioural difficulties leaving them with reduced level of function (WHO 2002).

Prevalence of mental health problems among population exposed to human-made disaster is reported to be varied in different studies ranging from 5% to more than 50% in some epidemiological studies. An accurate estimate of true prevalence is important in planning, assessment, and intervention stages of a community’s health response to such situations.

Aims and Objectives

We conducted a mixed methods study including a systematic review of medical literature to investigate the prevalence of posttraumatic stress disorder attributed to human made disaster. We also reviewed economic performance indicator of countries reporting prevalence data in order to understand association between adverse economic performance and reported prevalence of mental health difficulties. We hypothesized that countries with higher prevalence of posttraumatic stress disorder were performing poorly in economic performance and that higher prevalence of illness was associated with additional economic adversity suffered by the population at large, possibly through an association with poor provision of appropriate healthcare input and intervention to deal with mental health consequences of human made disaster.

Methods

We conducted this study in two stages. In first stage we conducted systematic literature search to establish a clear picture of PTSD prevalence reported in the context of human made disasters from different countries. The second stage of the study gathered economic performance reports and health expenditure data from these countries. Statistical Package for Social Sciences (SPSS) was used to calculate correlations between prevalence of PTSD, Gross Domestic Product (GDP-per capita), and Health Expenditure figures calculated as proportion of GDP of each country.

Literature Search

Four data bases, PubMed, MEDLINE, and EMBASE & Psych INFO were systematically searched for psychiatric morbidity, man-made disaster, terrorism, conflicts and Wars. In addition, references of available studies were examined to identify further studies.

Pub Med [Medline] [Searched 19th January 2012] Years 1960 - 2012
(("psychiatry"[MeSH Terms] OR "psychiatry"[All Fields] OR "psychiatric"[All Fields]) AND ("epidemiology"[Subheading] OR "epidemiology"[All Fields] OR "morbidity"[All Fields] OR "morbidity"[MeSH Terms])) AND ((("men"[MeSH Terms] OR "men"[All Fields] OR "male"[MeSH Terms] OR "male"[All Fields]) AND ("disasters"[MeSH Terms] OR "disasters"[All Fields] OR "disaster"[All Fields])) OR ("conflict (psychology)"[MeSH Terms] OR ("conflict"[All Fields] AND "(psychology)"[All Fields]) OR "conflict (psychology)"[All Fields] OR "conflicts"[All Fields]) OR ("war"[MeSH Terms] OR "war"[All Fields]) OR ("terrorism"[MeSH Terms] OR "terrorism"[All Fields]
EMBASE, Psych Info [Searched 14th January 2012]
Years 1960 – 2012
Psychiatric morbidity AND man-made disaster OR Terrorism OR War OR Conflict

Box 1: Search Strategy for Identifying PTSD Prevalence Studies

(a) Study Selection

Identified papers were examined against the inclusion criteria for the studies. Selected papers were then examined in detail.

  1. Primary Research
  2. In a geographically defined population exposed to war, conflicts and terrorism.
  3. Case Control, Cross Sectional and longitudinal studies.
  4. Use validated instruments or DSM-IV or ICD-10 based criteria for diagnoses of psychiatric morbidity, mainly Post- traumatic Stress Disorder.
  5. Includes individual above 18 years.
  6. Paper published in Peer reviewed English Journals or Conference Presentation.
  7. Studies that includes prevalence data.

Box 2: Inclusion Criteria

  1. General Population or Population not exposed to conflicts, wars or terrorism.
  2. Studies of population exposed to natural disaster.
  3. Studies that only includes children and adolescent.
  4. Studies among the military personal, military veteran.
  5. Studies published in other languages

Box 3: Exclusion Criteria

(b) Data Extraction

Method, design of study, sample size, time of assessment since exposure to traumatic events, population characteristics mainly gender distribution; marital status and education were selected using the carefully designed data extraction sheet (Figure 1).

Results

Literature search identified 2041 papers inclusive of duplicates. After exclusion through comparison of titles and abstracts against the inclusion criteria, 121 papers were selected for detailed examination. 24 papers were identified, and further 14 papers were identified from the bibliography of these studies, thus 38 papers were finally selected, which gave prevalence estimates for post-traumatic stress disorder amongst the populations exposed to wars, conflicts, or terrorism.

Studies included participants from more than 20 countries across Asia, Africa, Europe and America. The study sample sizes ranged from 32 to 28,962. Only 15 studies [38%] reported the prevalence rate by gender distribution. And only 5 studies (13%) reported the prevalence data by marital status and participant’s educational background. Many studies didn’t comment on selection criteria, refusal rate, interviewers background, number of traumas, previous psychiatric history or any other physical or mental health problem, socioeconomic status and family or close friends loses to these traumatic events.

  1. Table 1: Summary of Studies Assessing PTSD in population exposed to war, conflicts & terrorism.
  2. Table 1: summarizes PTSD prevalence data from different countries. The table provides prevalence range where multiple studies are reported from individual countries.
  3. Table 2 breaks down prevalence data on the basis of gender and Table 3 provides further overview of prevalence of PTSD sub-dividing study populations on the basis of marital status, and educational background.
  4. Table 2: Studies explaining the variation in prevalence of PTSD by gender.
  5. Table 3: Prevalence of PTSD & participants’ marital status and education background.
  6. Table 4: Prevalence of PTSD and Countries GDP.

We collected countries’ GDP data and health expenditure data as a proportion of GDP from United States of America Government website that was freely accessible as a useful source of information.

We calculated Correlations between prevalence of PTSD, GDP (per capita income) and countries health expenditure (as % of GDP). We used Pearson Correlations Test using SPSS in order to test the study hypothesis.

The test provided confirmation of study hypothesis. GDP (per capita income) and Healthcare Expenditure (as % of GDP) were negatively correlated with prevalence of PTSD. We used statistical analysis conducting statistical testing using prevalence figures reported from different countries. Where more than one study reported prevalence figures from a country we used the lower figure for our hypothesis testing. Pearson correlation coefficient was -.569 (P<0.01) for GDP-per capita income and PTSD prevalence. Pearson correlation coefficient was -.496 (P<0.05) for Healthcare Expenditure and PTSD prevalence.

Figure 1: Search Flow Diagram.

S. No

 

Study Author &
Location

 

Study Design &
Time of
Assessment

 

Sample Size/
Trauma
Group

 

Outcome
Measures

 

Prevalence
of PTSD

1

Maya Tuchner et al. Israel

C.S
2 years after the
T.A

35 T.A

PTSD scale
SF-36
R-W Rate

39%

2

Louise Jehel et al.
France

L.S
T1= 6 Months
T2= 32 Months

32 T.A

QPTSIES

 
T1=38.5%
T2=25%

3

Goran Arbanas et al.
Croatia

L.S
T1= after the
war
T2-= after 10
years

T1= 272
T2= 85
War

Clinical
Diagnostic
Criteria

T2= 73%

4

Laura DiGrande et al.
USA

C.S
2-3 years after
the T.A

3271 T.A

PCL-S 20

15%

5

Noam Shussman et al.
Israel

C.C
2001-2004
(0n going
conflict)

46 T.As

PTSD Scale
PSS-SR
PTSS

52.20%

5

Laila Farhood et al.
Lebanon

C.S
Lived in area of
conflict for 2
years

257 War

 

HTQ
GHQ-28

29.30%

6

Miro Klaric et al.
Bosnia & HZ

C.C
After the end of
war in 2000

367 War

 

HTQ
SCD-90-R

28.30%

7

Nexhmedine Morina et. al.
Kosovo

C.S
8 years after the
war

 

 

163 War

 

 

TE-CL, PHQ
MINI-INPI, IES
GHQ-28, EQLS

 

29.40%

 

8

Judith Cukor et al.
USA

C.S
10-34 months
after the T.A

2960 T.A

 

CAPS
PCL

 

8%

9

Jenannne Mager Stellman et al.
USA

C.S
10-61 months
after the T.A

10.132 T.A

PCL
PHQ
CAGE

 

11.90%

10

A.A Thabet et al.
Gaza

C.S
On-going
Conflict

200 War

GECL, CRIES-13
RCMAS-36 ,SDQ
GTC, PCL .TMAS

60%

11

Carol S North et al.
USA

L.S
T1= 6 months
post disaster.
T2= after 7 years

113 T.A

 

DIS-DS
DSM-IV

 

T1=41%
T2=26%

12

Katie J Campion et al.
Israel

C.S
On-going
Conflict

1001 War

CORE-E
PSQI
PTSD-SC

5.50%

 

13

Khalid A Mufti et al.
Afghanistan

C. S
On-going
Conflict

1301 War

SS-I
MINI-INPI

 

 53%

14

Nexhmedine Morina et al.
Kosovo

C. S
T1 = 8-9 years
after war

81 War

MINI-INPI,BDI ,
PTSD-S, BSI ,
PWBS, MSAQL

 

69.10%

 

15

 

Ann-Charlotte
Hermansson et al.
Iran, Iraq, Lebanon,
Somalia, Colombia,
El Salvador

C.S
T1= 8 years after
exposure to war

 

       44 War

HSCL-2,PTSD-S
WBS , ADL
SCHEME,
Bathel Index

 

 50%

 

 

16

Carmela Vazquez et al.
Spain

C.S
T1= 25 says
after the T.A

503 T.A

IR-DSM-IV ,
PTS-DSM-IV
PTSD-CL-Civ

 

13.30%

 

17

Todd B Kashdan et al.
Kosovo

C. S
T1= 7 years after
the war

174 War

MINI-INPI ,BSI
DSM-IV & ICD-
A.A.Q

 

26.40%

 

     18

Bayard Roberts et al.
Sudan

C.S
On-going
Conflict

1242 War

HTQ HSCL-25

 

36%

 

19

Phuong N .Pharm et al.
Rwanda

C.S
T1= 8 year after
genocide

2091 War

PCL-C CAPS

24.80%

 

20

Megan A Perrin et al.
USA

C.S
T1= 2-3 years
after the T.A

28,962 TA

PCL-C

14.40%

 

21

Pierre Verger et al.
France

C.S
T1= 2 years after
TA

196 TA

Computer
Assisted
Interview

 

31.30%

 

 

     22

 

 

 

Stefan Preibe et al.
Balkan Region [BH, Croatia, Kosovo, Macedonia,
Serbia]

 

C. S T1= 5-15 years
after the war ,&
still living in area
of conflict

 

 

3313 War

 

 

 

Self-
Administered
Interview

 

 

BH: 35.4%
Croatia:
18%
Kosovo:
18.20%
Macedonia:
10.60%
Serbia:
18.80%

 

23

Carol S North et al.
USA

C.S
T1= 6 months
after TA

182 T.A

 

DI-DS

 


34.30%

24

Barbara Lopes Cardozo et al.
Afghanistan

C.C
On-going
Conflict

799 War

SF-36 ,HSCL-25 HTQ
Open Ended Qs

42.10%

25

Laila F Farhood et al.
Lebanon

C.S
T1= One year
after T.A

33 T.A

CAPS-1 BDI

 

39.40%

 

26

Vivian Khamis
Palestine

C.S On-going
Conflict

120 War

 

DSM-III-R

 

50%

 

      27

 

 

Yori Gidron et al.
Israel

C.S
T1= Few days
after the T.A

149 T.A

PTSD-like
Symptoms
based Qs.

10.10%

28

Jennifer Ahern et al.
Kosovo

C.S
T1= 2 years
after the war

306 War

MOSS-S
HTQ

14.10%

29

Harvey-Lintz et al.
USA

C.S After 1997 LA
Civil Unrest
/Riots

141 Civil Unrest

MCRI
MSC-PTSD
PPS

17%

30

Lucien Abenhaim et al.
France

C. S
T1= months
after 1987 T.A

254 T.A

Self-
administered
Qs

18.10%

31

Eve Bernstein Carlson
et al.
Cambodia

C.S
T1= Settled
Refugees in
USA 1983-1985

50 War /Armed
Conflict

PSI
PTSD-CL
DES
HSCL-25

40%

32

Jessica Cardenas et al.USA

C.S T1= 1-2 years
after TA

305 T.A

SR-PTSD &
MDD Qs
Based on DSM-
IV Criteria

5.90%

33

Patrick A .Palmieri et al. Israel

C.S
T1=Soon after
escalation of
rocket attacks

1200 War

COR-E PTSD-S

7.20%

34

Willem F. Scholte et al. Afghanistan

C.S
T1= on going
conflict

1011 War /T.A

HTQ
HSCL-25

20.40%

35

Joop T.VM de jong et al.
Algeria ,Cambodia, Ethiopia,
Palestine

C.S T1= Ongoing Conflict

Algeria :653
Cambodia :610
Ethiopia :1200 Palestine:585
War/ Armed
Conflict

Using the
Composite
International Diagnostic
Review
[CIDI] Version
2.1

Algeria :37%
Cambodia
:28.4% Ethiopia :15.8%
Palestine:17.8%

36

Galea S et al.
USA

L.S
T1=1 month
T2=4 month
T3=6 month

T1=1008
T2= 2001
T3=2752
T.A

SCID-DSM III R

T1= 7.5%
T2= 0.6 %

37

Galea S et al.
USA

C.S
T1= 5- 8 weeks
after TA

988
TA

DSM-IV based
PTSD SCALE

8.80%

38

Barbara Lopes Cardozo
et al.
Kosovo

C.S
T1= 12 months
After War

1358 War

GHQ-28
HTQ
MOS-20

17%

Table 1: Summary of Studies Assessing PTSD in population exposed to war, conflicts & terrorism.

Study Author / Location

Male[%]: Female[%]

Male

Female

Total Prevalence

& Statistical Analysis

Louise Jehel et al.
France

47 % : 53 %

25%

75%

38%

(df [1]P value 0.003)

Goran Arbanas
Croatia

12% : 88%

36%

20%

73%

(NA)

Laura Di Grande et al.
USA

58.8% : 41.2%

9.90%

22.40%

15%

(OR [ 2.63])

Laila Farhood et al.
Lebanon

46% : 54%

20.95%

36.60%

29.30%

( P Value < 0.0067)

Nexhmedine Morina et al. Kosovo

39.3% : 607%

28.10%

30.30%

29.40%

( X2 090 , df =1 )

Jenannne Mager Stellman

et al. USA

87% : 13%

10.90%

12.10%

11.90%

( N.S )

Carmela Vazquez et al. Spain

33% : 67%

11.30%

14.40%

13.30%

(N.S)

Phuong N .Pharm et al. Rwanda

48.5%: 51.5%

19.60%

29.70%

24.85

( OR F:M ; 1.73[95%

CI ;1.41-2.12])

Pierre Verger et al.
France

46.4% : 54%

23.10%

38.10%

31.30%

( OR M:F :2.54 [ 95%

CI; 1.22-5.57])

Carol S North et al. USA

51.6% : 48.4%

23%

45%

34%

(X2=9.44; P Value;

0.002)

Barbara Lopes Cardozo

et al.

Kosovo

37.7% : 62.3%

12%

19.67%

17%

( P Value < 0.01 )

Barbara Lopes Cardozo et

al.

Afghanistan

37% : 63%

32.14%

48.30%

42.10%

( P Value < 0.001 )

Lucien Abenhaim et al. France

51% : 49 %

16.90%

19.3% `

18.10%

(N.S)

Jessica Cardenas et al.USA

25% : 74%

1.30%

4.60%

5.90%

( P Value < 0.01 )

Patrick A. Palmieri et al. Isarael

48.3% : 51.8%

4.30%

9.90%

7.20%

(Fisher exact test P

Value < 0.001).

Table 2: Studies explaining the variation in prevalence of PTSD by gender.

Study Author & Location

Marital Status (PTSD %)

Education (PTSD %)

Laura DiGrande et al.

Married= 11.8%

H.S= 60%

USA

Divorced =25.4%

College =11.5%

Widow= 21.4%

Postgraduate=8%

Jenannne Mager Stellman et al. USA

Single=11.6%

H.S= 17.2%

Married =10.2%

> H.S =12.2%

Separated=14.6%

College=9.6%

Widow=13%

Graduate College=8.8%

>G. College =10.7%

P Value < 0.001

P Value < 0.001

Barbara Lopes Cardozo et al. Kosovo

Married =16.49%

< Pr.Education= 21.29%

Single=15.14%

Pr.Education=15.99%

Divorced=10..48%

Secondary School =15.8%

Widow=30.96%

University = 11.01%

Barbara Lopes Cardozo et al.

 

Married =42.43%

No Education= 75.6%

Afghanistan

Widow =41.47%

Pr.Education=18%

Single=43.19%

H.S=6.5%

Pierre Verger et al.
France

Married or in

Low Education : 30.8%

relationship=25.4%

High Education : 31.8%

Living Alone =44.8%

OR :2.29 [95% CI 1.09-4.72]

Table 3: Prevalence of PTSD & participants’ marital status and education background.

Countries
Prevalence Range (%)
GDP ( per capita Income)**
Heath Care Expenditure (% of GDP )***
Afghanistan
20% to 53%
1000$
7.4
Algeria
37%
7200$
5.8
Bosnia
28.% to 35%
8200$
10.8
Herzegovina Cambodia
40%
2300$
5.9
Croatia
18.2%-73 %
18,300$
7.8
E Salvador
50%
7600$
6.4
Ethiopia
11.50%
1100$
4.3
France
18% to 25%
35000$
11.7
Gaza
185 to 50 %
2900$
NA
Israel
5.5 % to 52 %
31,000
7.6
Kosovo
14% to 69%
6400$
NA
Lebanon
29% to 39 %
15,600$
8.1
Macedonia
10.60%
10,400$
6.9
Rwanda
25%
1300$
9
Spain
13.30%
30,600$
9.7
Serbia
18.80%
10,700$
9.9
Somalia
50%
600$
5.9
Sudan
36%
3000$
7.3
United States of America
0.6 % to 34 %
48,000$
16.2

Table 4: Prevalence o PTSD and Countries GDP.

**Source: CIA World Fact-book. *** World Bank Data

Results

The review found a large amount of variation in the prevalence of post-traumatic disorder in population exposed to human made disasters that includes wars, conflicts and terrorism (Table 1). The prevalence estimates have been from 0.6 to 73 %. Although no statistical analysis was done, it was noted that most of the studies with smaller sample size yields high prevalence rate [7-10]. The research period to estimate the prevalence is again debatable in these studies, as some of the studies [11-13] reported their initial time of assessment from as early as few days to few weeks for probably diagnoses of post-traumatic stress disorder. On the other hand, some of the studies carried their initial assessment almost a decade after the population exposure to massive and collective traumatic events [14-17]. Some variation in the prevalence rate can be explained as studies were carried out in areas where the population remain exposed to these traumatic events and continue to live in these areas of conflict [18-23]. Having experienced a single traumatic event and remain living in conflict zone with continuous exposure to multiple traumatic events, fear of life with minimal social support may be seen as another factor for some of the variation in the prevalence.

Some studies [2,3,5,8,10,12,14,21,24-28] commented on prevalence of PTSD in population exposed to human-made disasters into male and female groups (Table 2). Some of the studies found significant statistical variation in prevalence of PTSD in male and female, with female more likely to suffer from PTSD after exposure to traumatic events.

Few studies [2,6,21,24,27] reported the prevalence of PTSD according to participant’s marital status and education background (Table 3). It has been noted that being married or in relationship and have a higher education were protective factors against PTSD.

We also try to understand the variation in prevalence of PTSD in different regions and countries by their socioeconomic structure and health care expenditure (Table 4). Countries with poor socioeconomic structure lower GDP and lower spending on health care expenditure was seen with high prevalence of post-traumatic stress disorder [29-32].

Large degree of variation in prevalence of post-traumatic stress disorder was found, so funnel plot to exclude publication bias was not considered. In some of the studies, time since the traumatic event was not documented [33-36]. There may be some selection bias because papers not likely to generate significant clinical interest, paper with smaller studies, with un-remarkable results or published in languages other than English, may not have been identified in the searches or published. There were few studies from Afghanistan, none from Iraq & Pakistan, Yemen ,some parts of Russia, countries going through significant civil unrest, and have been victim of significant numbers of terrorist attacks on general population [37-39]. Another limitation of the review would be that most of the studies didn’t comment on participants’ previous history of mental health illness or whether any efforts were made to ensure that assessment of incidence were carried out among population group with no previous exposure to traumatic events [40,41].

Discussion

This review will contribute in explaining some of the variation in prevalence data of serious mental health problem among population exposed to human-made disasters. Some of the variation can be explained by difference in prevalence by gender, marital status and education of the participants, socio-economic status which was noted to have large regional variation. Other explanation could be access to better therapeutic services and early intervention in some part of the world and less awareness of mental health illness in other parts of the World. Another important factor would be exposure to multiple traumatic events both at individual and community level. One substantial factor would be population migration due to conflicts, wars and terrorist attacks, which also cause significant socio-economic disruption to the society. It is also likely that population with better coping strategies to collective traumas may remain in the area of conflict or on the other hand those with significantly reduced level of functioning , or poor economic status never able to move out of the conflict zone, which may skewed the prevalence data in either direction.

References

  1. World Health Organization (2005) Resolution on health action in crises and disaster. Geneva.
  2. Eric Hoobsbwn (2002) The Guardian News Paper.
  3. Bloom DE, Cafiero ET, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, et al. (2011) The Global Economic Burden of Non-communicable Diseases. World Economic Forum, Geneva.
  4. World Health Organization (WHO 2011a) Global status report on non-communicable diseases 2010. Geneva.
  5. Kinston W, Rosser R (1974) Disaster Effects on Mental and Physical State. J Psychosom Res 18(6): 437-456.
  6. Norris FH, Friedman MJ, Watson PJ (2002) 60,000 disaster victims speak, part II Summary and implication of the disaster mental health research. Psychiatry 65(3): 240-60.
  7. Thabet AA, Abu Tawahina A, El Sarraj E, Vostanis P (2008) Exposure to War Trauma and PTSD among Parents and Children in the Gaza Strip. Eur Child Adolesc Psychiatry 17(4): 191-199.
  8. Hermansson AC, Timpka T, Thyberg M (2002) The Mental Health of War Wounded Refugees; An 8 Year Follow-up. J Nerv Ment Dis 190(6): 374-380.
  9. Harvey-Lintz, Terri, Tidwell, Romeria (1997) Effects of the 1992 Los Angeles Civil Unrest; Post Traumatic Stress Disorder Symptomology Among Law Enforcement Officers; Social Science Journal 34(2).
  10.  Klaric M, Klarić B, Stevanović A, Grković J, Jonovska S (2007) Psychological Consequences of War Trauma and Post-war Social Stressors in Women in Bosnia and Herzegovina. Croat Med J 48(2): 167-176.
  11.  Perrin MA, DiGrande L, Wheeler K, Thorpe L, Farfel M, et al. (2007) Differences in PTSD prevalence and associated risk factors among World Trade Center disaster rescue and recovery workers. Am J Psychiatry 164(9): 1385-1394.
  12. Laure DiGrande, Yuval Neria, Robert Brackbill M, Paul Pulliam, Sandro Galea (2010) Long Term Posttraumatic Stress Symptoms Among 3271 Civilian Survivors of the September 11, 2001, Terrorist Attacks on the World Trade Center. American Journal of Epidemiology.
  13. National Consortium for Study of Terrorism and Response to Terrorism.
  14. Lopes Cardozo B, Vergara A, Agani F, Gotway CA (2000) Mental Health, Social Functioning, and Attitudes of Kosovar Albanians Following the War in Kosovo. JAMA 284(5): 569-577.
  15. Arbanas G (2010) Patient with Combat-related And War related Posttraumatic Stress Disorder 10 years after Diagnosis. Croat Med J 51(3): 209-214.
  16.  Ahern J, Galea S, Fernandez WG, Koci B, Waldman R, et al. (2004) Gender, Social Support, Posttraumatic Stress in Postwar Kosovo. J Nerv Ment Dis 192(11): 762-770.
  17. Mufti KA, Naeem F, Ayub M, Saifi F, Haroon A, et al. (2005) Psychiatric Problems in an Afghan Village. J Ayub Med Coll Abbottabad 17(3): 19-20.
  18. Roberts B, Damundu EY, Lomoro O, Sondorp E (2009) Post-Conflict Mental Health Needs; A cross Sectional survey of Trauma, depression, and associated factors in Juba, Southern Sudan. BMC Psychiatry 9: 7.
  19. Carlson EB, Rosser-Hogan R (1991) Trauma Experiences, Post-Traumatic stress, Dissociation, and Depression in Cambodian Refugees. Am J Psychiatry 148(11): 1548-1551.
  20. Galea S, Resnick H, Ahern J, Gold J, Bucuvalas M, et al. (2002) Posttraumatic stress disorder in Manhattan, New York City, after the September 11th terrorist attacks. J Urban Health 79(3): 340-353.
  21. DiGrande L, Neria Y, Brackbill RM, Pulliam P, Galea S (2010) Long Term Posttraumatic Stress Symptoms Amomg 3271 Civilian Survivors of the September 11, 2001, Terrorist Attacks on the World Trade Center. Am J Epidemiol 173(3): 271-281.
  22. Farhood LF, Noureddine SN (2003) PTSD, Depression and Health Status in Lebanese Civilian Exposed to a Church Explosion. Int J Psychiatry Med 33(1): 39-53.
  23. Morina N, Ford JD, Risch AK, Morina B, Stangier U (2010) Somatic Distress among Kosovar Civilian War Survivors: Relationship to Truama Exposure and the Mediating Role of Experiental Avoidance. Soc Psychiatry Epidemiol 45(12): 1167-1177.
  24. Cardozo BL, Bilukha OO, Crawford CA, Shaikh I, Wolfe MI (2004) Mental Health & Social Functioning and Disability in Post War Afghanistan. JAMA 292(5): 57-84.  
  25. Jenannne Mager Stellman, Rebecca P Smith, Craig L Katz, Vansh Sharma, Dennis S Charney, et al. (2008) Enduring Mental Health Morbidity and Social Function Impairment in World Trade Center Rescue, Recovery, And Clean-up Workers. The Psychological Dimension of and Environmental Health Disaster; Enviromental Health Perspectives, Enviromental Medicine 116(9).
  26. de Jong JT, Komproe IH, Van Ommeren M (2003) Common Mental Disorders in post conflict settings. Lancet 361(9375): 2128-2130.
  27.  Chipman KJ, Palmieri PA, Canetti D, Johnson RJ, Hobfoll SE (2011) Predictors of Posttraumatic Stress related impairment in victims of terrorism and on-going conflict in Israel. Anxiety Stress Coping 24(3): 255-271.
  28. Tuchner M, Meiner Z, Parush S, Hartman-Maeir A (2010) Health Related Quality of Life Two Years After Injury Due to Terrorism. Isr J Psychiatry Relat Sci 47(4): 269-275.
  29. Shussman N, Mintz A, Zamir G, Shalev A, Gazala MA, et al. (2011) Posttraumatic Stress Disorder in Hospitalized Terroist Bombing Attack Victims. J Trauma 70(6): 1546-1550.
  30. Farhood L, Dimassi H, Lehtinen T (2006) Exposure to War-Related Traumatic Events, Prevalence of PTSD and General Psychiatric Morbidity in a Civilian Population From Southern Lebanon. J Transcult Nurs 17(4): 333-340.
  31. Kashdan TB, Morina N, Priebe S (2009) Post-Traumatic stress Disorder, Social Anxiety Disorder, and Depression in Survivors of Kosovo War: Experimental Avoidance as a contributor to distress and quality of life. J Anxiety Disord 23(2): 185-196.
  32. Pham PN, Weinstein HM, Longman T (2004) Trauma and PTSD Symptoms in Rwanda Implications for Attitudes Toward Justice and Reconciliation. JAMA 292(5): 602-612.
  33. Verger P, Dab W, Lamping DL, Loze JY, Deschaseaux-Voinet C, et al. (2004) The Psychological Impact of Terrorism; An Epidemiologic Study of Posttraumatic Stress Disorder and Associated Factors in Victims of the 1995-1996 Bombings in France. Am J Psychiatry 161(8): 1384-1389.
  34. North CS, Nixon SJ, Shariat S, Mallonee S, McMillen JC, et al. (1999) Psychiatric Disorders Among Survivors of the Oklahoma City Bombing. JAMA 282(8): 755-762.
  35. Vivian Khamis (1993) Post-Traumatic Stress Disorder Among the Injured of the Intifida. Journal of Traumatic Stress Volume 6(4).
  36. Gidron Y, Kaplan Y, Velt A, Shalem R (2004) Prevalence and Moderators of Terror-Related Post-Traumatic Stress Disorder Symptoms in Israeli Citizens. Isr Med Assoc J 6(7): 387-391.
  37. Abenhaim L, Dab W, Salmi LR (1992) Study of Civilian Victims of Terrorist Attacks [France 1982-1987]. J Clin Epidemiol 45(2): 103-109.
  38. Cardenas J, Williams K, Wilson JP, Fanouraki G, Singh A (2003) PTSD, Major Depressive Symptoms, and Substance Abuse Following September 11, 2001, in a Midwestern University Population. Int J Emerg Ment Health 5(1): 15-28.
  39. Palmieri PA, Canetti-Nisim D, Galea S, Johnson RJ, Hobfoll SE (2009) The Psychological Impact of the Israel-Hezbollah War on Jews and Arabs in Israel: The Impact of Risk and Resilience Factors. Soc Sci Med PMC 67(8): 1208-1216.
  40. Scholte WF, Olff M, Ventevogel P, de Vries GJ, Jansveld E, et al. (2004) Mental Health Symptoms Following War and Repression in Eastern Afghanistan. JAMA 292(5): 585-593.
  41. Galea S, Vlahov D, Resnick H, Ahern J, Susser E, et al. (2003) Trends of probable post-traumatic stress disorder in New York City after the September 11 terrorist attacks. Am J Epidemiol 158(6): 514-524.
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