A study shown in the August 3 theme issue on violence and human rights of JAMA reported that residents of Sri Lanka who were seeking refuge in neighboring countries or secure areas of their own country during the Sri Lankan civil war (1983 to 2009) have a higher occurrence of war-related mental health conditions including depression, anxiety and PTSD.

Almost 2.7 million people worldwide live as refugees in foreign countries or safe areas in their home country (internal displacement). The 26-year Sri Lankan war claimed 100,000 lives and displaced 800,000 people. The Jaffna District of Sri Lanka, situated in the far north of the country estimates that 23% of the population had been internally displaced by July 2009. Even though overall patterns of psychiatric morbidity among individuals affected by conflict have been documented, the psychological effect of forced displacement of people remaining within their national borders is lesser-known.

Farah Husain, D.M.D., M.P.H., of the Centers for Disease Control and Prevention, Atlanta, and team carried out a health survey among residents of Jaffna District to evaluate the connection between displacement status and occurrence of common war-related mental health conditions.

The survey included 1,517 Jaffna households, including 2 internally displacement camps and was conducted between July and September 2009, with a response rate of 92% (1,448 respondents of which 1,409 were eligible).

The time period of the individual displacements was broken down into 2% of participants (n = 80) who were currently displaced, 29.5% (n = 539) who were recently resettled, and 68.5% (n = 790) who were long-term residents. 31.8% of individuals (376) experienced no trauma events; 44% (578) reported experiencing 1 to 4 events; 20.2% (336) experienced 5 to 9 events and 4% (72) experienced 10 or more events. The overall occurrence of PTSD was 7.0%, with 32.6% suffering from anxiety and 22.2% experiencing depression symptoms.

Once the researchers adjusted for variables, they discovered that the likelihood for developing symptoms of depression, anxiety, and PTSD was substantially higher among displaced camp-based individuals compared with long-term residents and that chance of developing PTSD symptoms among recently resettled individuals was higher than that of long-term residents.

Whilst female respondents were more likely to report symptoms of anxiety and depression, those of older age were associated with PTSD, anxiety, and depression symptoms. In addition, the authors discovered that displacement was no longer associated with mental health symptoms after controlling for trauma exposure.

The investigators wrote:

“Although the association between displacement status and symptoms of PTSD, depression, and anxiety was no longer significant after adjusting for trauma exposure in this study, the act of being displaced and the daily stressors associated with it may be considered traumatic in themselves and may be an indicator or proxy for recent trauma as well. Therefore, the relationship between displacement status and mental health symptoms may be driven by the underlying trauma events displaced persons have experienced, events that likely caused them to leave their homes.”

Research suggests that interventions in Sri Lanka should target the most vulnerable populations, mainly those living in displacement camps.

The authors wrote:

“Internally displaced persons outnumber refugees globally and initiatives addressing mental health needs, such as those developed by the Inter-Agency Standing Committee, should be considered. In Jaffna District, interventions should include support from family, friends, religious leaders, and traditional counselors.

Finally, a longitudinal study of displaced populations would help determine how the intensity of events, the time since events, and other factors, such as coping skills, affect mental health symptoms. In this way, stakeholders could begin to understand the short- and long-term mental health implications of armed conflict and traumatic events associated with displacement.”

Written by Petra Rattue