The association of exposure to civil violence with the subsequent onset and persistence of mental disorders: Results from the World Mental Health Surveys

Importance: Understanding the effects of civil violence on mental disorders is important for developing effective post-conflict recovery policies.
Objective: To estimate associations of civil violence with subsequent onset and persistence of common DSM-IV mental disorders in representative surveys of civilians from countries that experienced civil violence.
Design: Cross-sectional household surveys.
Setting: WHO World Mental Health (WMH) surveys administered 2002-2015 in 7 countries that experienced periods of civil violence post World War II (Argentina, Colombia, Lebanon, Nigeria, Northern Ireland, Peru, South Africa) in addition to respondents in other WMH surveys who emigrated from countries with civil violence in Africa and Latin America.
Participants: Representative samples of adults (ages 18+) from eligible countries.
Exposures: Exposure was defined as a self-report of having been a civilian in a war zone or region of terror. We also assessed related stressors (being displaced, witnessing atrocities, being a combatant). Exposures occurred a median (IQR) of 21 (12-30) years before interview.
Main outcomes: Retrospectively reported lifetime prevalence and 12-month persistence of DSM-IV anxiety, mood, and externalizing (alcohol use, illicit drug use, intermittent explosive) disorders.
Results: n=2,096 respondents were exposed to civil violence (56.4% males, median [IQR] age 40 [30-52[). n=16,116 were not exposed (45.2%, age 35 [26-48]). The exposed had significantly elevated onset risk of anxiety (Relative Risk [RR]=1.8, 95% Confidence Interval [CI]= 1.5,2.1;  21=52.5, p<0.001), mood (RR=1.5, 95% CI=1.3,1.7;  21=24.2, p<0.001), and externalizing (RR=1.6, 95% CI=1.3,1.9;  21=26.6, p<0.001) disorders. Combatants additionally had
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significantly elevated onset risk of anxiety disorders (RR=2.0, 95% CI=1.3,3.1; 21=9.5, p=0.002) and refugees of mood (RR=1.5, 95% CI=1.1,2.0; 21=8.2, p=0.004) and externalizing (RR=1.6, 95% CI=1.0,2.4; 21=4.7, p=0.031) disorders. Elevated disorder onset risks persisted for more than two decades if conflicts persisted but not after either termination of hostilities or emigration. Persistence (i.e., 12-month prevalence among lifetime cases), in comparison, was generally unrelated to exposure.
Conclusions: In this survey study of exposure to civil violence, exposure was associated with significantly elevated risk of mental disorders for many years after initial exposure. These associations should be recognized by policymakers in projecting future mental disorder treatment needs in countries experiencing civil violence and among affected migrants.