BMJ  2007;334:1121-1122 (2 June), doi:10.1136/bmj.39225.539803.80

Editorials

Mental health consequences of long term conflict

Survivors of chronic trauma need good mental health services and much more

Between 1969 and 2001, 3524 people were killed in civil disturbances in Northern Ireland. The annual death rate peaked at 479 in a population of 1.6 million. Deaths and injuries were unequally distributed, with people in working class urban communities and those living close to the Irish border being most at risk. Lessons can be learnt from such conflict, not only about the management of single episodes of psychological trauma but also about the effects of long term, violent divisions in society on mental health.

One of the aims of terrorism is to change attitudes and behaviours. This can lead to mental health problems in people who are targeted and in others. Problems include post-traumatic stress disorder, anxiety, depression, substance misuse, and (rarely) precipitation of psychosis. Post-traumatic stress disorder can be treated by psychological treatments such as trauma focused cognitive behaviour therapy¹ or antidepressants.² In this week's BMJ, a randomised controlled trial by Duffy and colleagues assesses the effectiveness of cognitive behaviour therapy in 58 people with chronic post-traumatic stress disorder associated with the conflict in Northern Ireland.³ It found that 12 weeks of cognitive therapy significantly reduced the severity of post-traumatic stress disorder (mean difference on the post-traumatic stress diagnostic scale 9.6, 95% confidence interval 3.6 to 15.6) and depression (mean difference on the Beck depression inventory 10.1, 4.8 to 15.3), compared with being on a waiting list. The authors note that response to treatment diminishes with time since the trauma and is poorer in people with a high level of depression at intake.³ The trial is the first to study cognitive behaviour therapy in the context of terrorism and other civil conflict and shows its efficacy.

Evidence from single traumatic events such as the 2001 terrorist attack on the Twin Towers in New York,⁴ the 2004 Madrid train bombings,⁵ and the 2005 London transport bombings⁶ shows that most people directly affected do not develop serious psychiatric ill health. Where psychiatric ill health does follow it subsides relatively quickly, with or without specific treatment. Characteristics that affect reactions to trauma include previous exposure to trauma, availability of family support, and religious faith, but severe reactions are difficult to predict.⁶

At a time when the setting aside of armed conflict in Northern Ireland has been associated with considerable political and economic developments, it might be expected that mental wellbeing would improve. However, mental health consequences of continued social divisions, residual violence, long term effects of conflict, and people's difficulty in adapting to change persist.

The Northern Ireland health and social wellbeing survey (2001),⁷ completed three years after the ceasefire, found that 21% of people over 16 who had been affected by the conflict reported scores consistent with the presence of mental ill health. People who said they had been affected greatly were almost twice as likely to show signs of a possible mental health problem (34%) than those who said they had been affected only a little (18%).

In contrast to patterns elsewhere in Europe, suicide rates have risen in Northern Ireland, particularly among young socially marginalised men in areas closely identified with civil conflict.⁸ Experience in Israel indicates that conflict leads to high use of primary care and other services,⁹ and indeed Northern Ireland has higher rates of consultation and prescription for a wide range of physical and mental ill health than elsewhere in the United Kingdom.

My experience is that people who have been active in violent conflict may cope well with the emotional consequences of what has been done to them and what they have done to others, as long as "the struggle" seems reasonable and justified.¹⁰ As the purpose of violent conflict becomes less clear, high rates of substance misuse, breakdown in relationships, and mood disorder follow, and the risk of suicide increases. The onset of frank psychiatric illness after chronic trauma may be delayed by many years. The mental health consequences for participants in civil conflict mirror those seen in military personnel after war.¹¹

It is important to be sensitive about language when developing services for people affected by violence. The victim in one section of the community may be viewed as a perpetrator in another. The divisions between combatant and non-combatant may be unclear. Treatment services must be non-judgmental, person centred, and needs led.

Clearly, health services alone cannot meet the needs of people affected by violence. The Bamford review (www.rmhldni.gov.uk/) of services in Northern Ireland considered policy and service provision for the province. It strongly advocated a whole systems approach to mental wellbeing, including teaching skills to increase resilience to trauma in schools while promoting mental health through workplaces, faith communities, arts facilities, and leisure services. Treatment services for mental ill health will be insufficient the meet people's needs unless the context in which these needs arises is also considered. As yet government has been unable to secure the funding or workforce resources necessary to tackle the problem.

Policy makers and service planners throughout the world face challenges in prioritising services after conflict. It is tempting to believe that mental health needs diminish with the end of conflict. As international attention is diverted from the scene of conflict, society's response to those affected must not be restricted to mental health services.

Belfast Crisis Response and Home Treatment Service, Belfast BT14 6AG

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Competing interests: GM is chairman of the voluntary Northern Ireland Association for Mental Health, a body that receives government funding for mental health promotion and educational activities.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

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2. National Institute for Health and Clinical Excellence. Post-traumatic stress disorder (PTSD): the management of PTSD in adults and children in primary and secondary care. Clinical guideline 26. London: NICE, 2005. www.nice.org.uk/pdf/CG026quickrefguide.pdf
3. Duffy M, Gillespie K, Clark DM. Post-traumatic stress disorder in the context of terrorism and other civil conflict in Northern Ireland: randomised controlled trial. BMJ 2007 doi: 10.1136/bmj.39021.846852.BE[Abstract/Free Full Text]
4. DeLisiI L, Maurizio A, Yost M, Papparozzi C, Fulchino C, Katz C, et al. A survey of New Yorkers after the September 11 2001 terrorist attacks. Am J Psychiatry 2003;160:780-3.[Abstract/Free Full Text]
5. Miguel-Tobal JJ, Cano-Vindel A, Gonzalez-Ordi H, Iruarrizaga I, Rudenstine S, Vlahov D, et al. PTSD and depression after the Madrid March 11 train bombings. J Trauma Stress 2006;19:69-80.[CrossRef][ISI][Medline]
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7. Northern Ireland Statistics and Research Agency. Northern Ireland health and social wellbeing survey 2001. 2002. www.nisra.gov.uk/whatsnew/wellbeing/Mental%20health%20and%20wellbeing%20bulletin%20report.pdf
8. Investing for Health (Northern Ireland). Section 75 analysis of suicide and self harm in Northern Ireland (2000-2005).http://www.investingforhealthni.gov.uk/documents/Suicide-Self-Harm-Assess.pdf
9. Leva I, Novikov I, Grinshpoon A, Rosenblum J, Ponizovsky A. Health services utilisation in Jerusalem under terrorism. Am J Psychiatry 2006;163:1355-61.[Abstract/Free Full Text]
10. Mikulincer M. Trajectories of PTSD; a 20 year longitudinal study. Am J Psychiatry 2006;163:659-66.[Abstract/Free Full Text]
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