Context More than 2 decades of conflict have led to widespread human suffering
and population displacement in Afghanistan. In 2002, the Centers for Disease
Control and Prevention and other collaborating partners performed a national
population-based mental health survey in Afghanistan.
Objective To provide national estimates of mental health status of the disabled
(any restriction or lack of ability to perform an activity in the manner considered
normal for a human being) and nondisabled Afghan population aged at least
15 years.
Design, Setting, and Participants A national multistage, cluster, population-based mental health survey
of 799 adult household members (699 nondisabled and 100 disabled respondents)
aged 15 years or older conducted from July to September 2002. Fifty district-level
clusters were selected based on probability proportional to size sampling.
One village was randomly selected in each cluster and 15 households were randomly
selected in each village, yielding 750 households.
Main Outcome Measures Demographics, social functioning as measured by selected questions from
the Medical Outcomes Study 36-Item Short-Form Health Survey, depressive symptoms
measured by the Hopkins Symptoms Checklist-25, trauma events and symptoms
of posttraumatic stress disorder (PTSD) measured by the Harvard Trauma Questionnaire,
and culture-specific symptoms of mental illness and coping mechanisms.
Results A total of 407 respondents (62.0%) reported experiencing at least 4
trauma events during the previous 10 years. The most common trauma events
experienced by the respondents were lack of food and water (56.1%) for nondisabled
persons and lack of shelter (69.7%) for disabled persons. The prevalence of
respondents with symptoms of depression was 67.7% (95% confidence interval
[CI], 54.6%-80.7%) and 71.7% (95% CI, 65.0%-78.4%), and symptoms of anxiety
72.2% (95% CI, 63.8%-80.7%) and 84.6% (95% CI, 74.1%-95.0%) for nondisabled
and disabled respondents, respectively. The prevalence of symptoms of PTSD
was similar for both groups (nondisabled, 42.1%; 95% CI, 34.2%-50.1%; and
disabled, 42.2%; 95% CI, 29.2%-55.2%). Women had significantly poorer mental
health status than men did. Respondents who were disabled had significantly
lower social functioning and poorer mental health status than those who were
nondisabled. Feelings of hatred were high (84% of nondisabled and 81% of disabled
respondents). Coping mechanisms included religious and spiritual practices;
focusing on basic needs, such as higher income, better housing, and more food;
and seeking medical assistance.
Conclusions In this nationally representative survey of Afghans, prevalence rates
of symptoms of depression, anxiety, and PTSD were high. These data underscore
the need for donors and health care planners to address the current lack of
mental health care resources, facilities, and trained mental health care professionals
in Afghanistan.
More than 2 decades of war and conflict and 3 years of drought have
led to widespread human suffering and substantial population displacement
in Afghanistan. The country's infrastructure has been destroyed or degraded
and vital human resources have been depleted.
The invasion and subsequent occupation (1979-1989) of Afghanistan by
Soviet forces exposed Afghans to bombardment, executions, and the mass placement
of landmines. This conflict generated an estimated 6 million refugees and
caused an estimated 1 million deaths.1 The
period following the Soviet withdrawal until 1996 was characterized by factional
fighting among the Afghan resistance forces (mujahideen) that led to the death
of tens of thousands of civilians and displacement of more than half a million
people.1 During this period, the capital city
of Kabul was repeatedly rocketed and bombed, and tens of thousands of landmines
were laid.1
The emergence of the Taliban in 1994 resulted in extreme restrictions
on the Afghan people.1 Under the Taliban, women
were prohibited from working outside their homes unless accompanied by a close
male relative. In January 1997, the Taliban announced a policy of segregating
men and women, which further impeded women's access to health care.
Coalition and Afghan opposition military action led to the fall of the
Taliban government in December 2001,2 and the
return of an estimated 1.6 million refugees from Pakistan and Iran.3 Afghanistan is left with little capacity to support
the economic, social, or health care needs of its people. The current estimate,
as of July 2003, of the population of Afghanistan is 28.7 million.2
Mental health facilities throughout Afghanistan are nonexistent or in
poor condition. In Kabul, the main psychiatric hospital was destroyed during
the recent war.4 Three of 4 community mental
health centers in Kabul are no longer functioning and there is a shortage
of trained mental health care professionals in Afghanistan.4 Chronic
mental illness has been left unattended in Afghanistan for decades. Previous
studies have shown that 20% to 30% of a population affected by war and civil
strife develop some level of mental distress.5 To
our knowledge, the only studies that have addressed the impact of protracted
armed conflict on mental health in Afghanistan were limited to select provinces
in Afghanistan and to Afghan refugees in Pakistan.6,7
Basic mental health indicators are essential for guiding efforts to
provide mental health programs to the population. From August through October
2002, the Centers for Disease Control and Prevention (CDC), United Nations
Children's Emergency Fund (UNICEF), and Vietnam Veterans of America Foundation,
in collaboration with the Ministry of Health and the Ministry of Martyrs and
Disabled of Afghanistan, and nongovernmental organizations conducted a nationwide
population-based mortality, injury, disability, and mental health survey.
The objectives of this survey were to measure the mental health status
of Afghans and their traumatic experiences during decades of conflict, as
well as self-reported chronic mental illness and substance abuse; assess risk
and mitigating factors for mental illness; compare the mental health status
of the nondisabled and disabled populations; and develop recommendations for
mental health priorities.
The mental health survey was a multistage cluster sample survey. The
study population comprised all Afghan residents aged 15 years or older as
of August 2002. Because Afghanistan is divided into 32 provinces, 321 districts,
and more than 30 000 villages, a 3-stage cluster sampling was used in
this survey (Figure 1). The first
stage in the sampling was district. The district population frame was determined
by using data from 2 sources. First, we obtained data from UNICEF that documented
the number of children younger than 5 years who had been vaccinated for poliomyelitis
during the national immunization days in April 2002 and applied an adjustment
factor for each district to estimate the total population in each district.
Second, we combined these estimates with data from the United Nations High
Commissioner for Refugees,3 which documented
the number of refugees who had returned to each district since April 2002.
To calculate sample size, we used the limit of statistical significance α
= .05 with 95% confidence intervals (CIs), assumed a prevalence of mental
illness of 25%, and an estimated design effect of 2.5. Based on these assumptions,
a sample size of 720 would be necessary. We selected 50 clusters of 15 households
per cluster, which yielded 750 households. This sample size was adequate for
estimation of prevalence for the overall mental health status of the population.
In addition, it allowed identification of risk and mitigating factors for
mental illness, and vulnerable groups within the sample of nondisabled Afghan
individuals.
During the first stage of sampling, 50 district-level clusters were
selected using probability proportional to size method. We selected clusters
using the C-Survey software package (Department of Biostatistics and Population
Studies Faculty of Public Health, University of Indonesia, Indonesia and Fogarty
International HIV/AIDS Training Program Department of Epidemiology, School
of Public Health, University of California, Los Angeles).
For the second stage of sampling, village-level population data were
not available. Therefore, we randomly selected 1 village or neighborhood from
each of the 50 district-level clusters. If the village was inaccessible for
any reason, we substituted the nearest accessible village.
For the third sampling stage, we asked a mullah, abob, or other village
leader to provide a preexisting list of all households in each village or
to help create a list. The households were numbered and 15 households were
selected using a random number table. In villages of more than 200 to 300
households, village leaders were asked to help create a list of mosques, with
the number of subscribing households in each mosque. As in the first sampling
stage, 1 mosque was selected with the probability of selection proportional
to size: all households subscribing to this mosque were listed and 15 households
were selected as described above. We defined the term household as a group of people who normally lived under the same roof and shared
meals. If more than 1 household resided in the same dwelling, 1 household
was randomly selected.
For Kabul district, we conducted an additional sampling stage. Using
data from 1999 obtained from the Afghan Information Management Service, we
estimated the number of houses in each of the 14 subdistricts in Kabul district.
Based on the results of the first sampling stage, 4 clusters (subdistricts)
were selected from within Kabul district by using probability proportional
to size method. After we selected these 4 subdistrict clusters, we selected
individual houses using the methods described above.
From the list of household members in each of the households surveyed,
we randomly selected 1 nondisabled person aged 15 years or older and administered
the mental health questionnaire to this person by reading the instrument aloud.
In addition, if a disabled person lived in the household, he or she was also
given the mental health questionnaire. If more than 1 disabled person lived
in the household, 1 person was randomly selected from among those persons
who were disabled and aged 15 years or older.
We defined the term disability as any restriction
or lack (resulting from impairment) of ability to perform an activity in the
manner or within the range considered normal for a human being.8 Disability
summarizes many different functional limitations occurring in any population.
Such impairments, conditions, or illnesses may be permanent or transitory
in nature.9
Each survey team comprised 5 persons: a team leader who had experience
with surveys, a male and female interviewer, an Afghan interpreter, and a
driver/logistician. Each of the 12 survey teams received 5 days of training,
which included a half-day field trial.
After selecting the households, survey teams identified and attempted
to meet with the head of each household. The team explained the purpose of
the survey, reviewed the risks and benefits of participating, and obtained
consent for participation. If the head of the household or another adult member
was not available, the survey teams asked a neighbor about the whereabouts
of the occupants. If the household members had departed permanently or were
not expected to return before the survey team had to leave the village, the
household was not replaced. If household members were expected to return,
the survey team revisited the house at least twice before declaring the household
missing.
Data were collected for program purposes, as part of an assessment to
inform the development of programs to assist the population of Afghanistan.
As such, the objectives of this survey were not primarily research and formal
review by an institutional review board at CDC was not required. The data
used for analyses were anonymous (contained no personal identifiers of survey
participants). Representatives of the Afghan Ministry of Health, UNICEF, and
the International Rescue Committee approved the protocol. In each household
visited, a consent form was read and oral consent was obtained.
The mental health questionnaire was designed to provide information
on the mental health status of the population in relation to war-related psychological
trauma. We collected information using open-ended questions from key informants
about traumatic events, culture-specific attitudes and symptoms, and mental
health problems. Key informants were health care professionals, people from
different socioethnic groups, and both men and women of different age groups
that we interviewed. We used this qualitative information to adapt standard
instruments such as the trauma events scale. In addition to the standardized
screening tools mentioned, we asked a series of standard and culture-specific
questions to provide data on (1) ethnicity, using a predefined list from which
participants selected their preference; (2) mental health coping mechanisms,
as determined by the question, "Which of the following factors would help
improve your state of mind?"; (3) self-reported previous mental illness disagnosed
by a physician or health care professional; (4) substance abuse; and (5) feelings
of hatred and revenge and attitudes toward justice, as determined by 3 questions:
"Do you feel hatred about what has happened to you and your family during
the recent war?", "Do you have feelings and fantasies of taking revenge over
what has happened to you and your family?", and "If the person(s) who has/have
wronged you and you feel hatred for, would be tried and sentenced by a war
crimes tribunal or other justice system, would you still want to take revenge?"
The questionnaire included 3 standard instruments: Medical Outcomes
Study 36-Item Short-Form Health Survey (SF-36),10-12 the
Hopkins Symptom Checklist-25,13,14 and
the Harvard Trauma Questionnaire.15 We selected
4 scales from the SF-36 that assess self-perceived general health, bodily
pain, social functioning, and role-emotional functioning. We scored the selected
SF-36 questions as recommended in the user's manual; each raw score was transformed
to fit a 0-to-100 scale by using a standard formula, with the higher scores
on this scale representing better functioning.
The Hopkins Symptom Checklist-25, a screening tool used to detect the
symptoms of anxiety and depression, is composed of a 10-item subscale for
anxiety and a 15-item subscale for depression, with each item scored from
1 to 4.13 Mean cumulative symptom scores of
more than 1.75 for each subcategory have been found to be valid in predicting
clinical diagnosis of anxiety and affective disorders.14
We used an adapted version of the Harvard Trauma Questionnaire,15 which combined the measurement of trauma events (part
1) and symptoms (part 2) of posttraumatic stress disorder (PTSD) as described
in the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV).16 The
traumatic events questions of the Harvard Trauma Questionnaire (part 2) were
modified from previous versions used by the Harvard Program in Refugee Trauma
in Cambodia and Bosnia, and by the CDC in Kosovo. We used the information
from key informants to determine the most common traumatic events experienced
in Afghanistan. We defined cases meeting PTSD symptom criteria according to
a scoring algorithm proposed by the Harvard Refugee Trauma Group, on the basis
of DSM-IV diagnostic criteria.17 This
definition of PTSD requires a score of 3 or 4 on at least 1 of 4 reexperiencing
symptoms, at least 3 of 7 avoidance and numbing symptoms, and at least 2 of
5 arousal symptoms.17 Trauma event questions
were adapted for the specific events among the Afghan population, and the
first 16 questions were used from the PTSD symptoms, according to DSM-IV and derived from the Harvard Trauma Questionnaire (part 1).
Recall period for questions related to trauma events spanned 10 years, and
the previous 4 weeks were used for questions on symptoms of depression, anxiety,
and PTSD.
The questionnaires were translated into 2 local languages (Pashtun and
Dari) by field staff and back-translated by other staff not involved with
the initial translation. All instruments were piloted in 8 to 16 households
in the Kabul area to test for ambiguous phrasing, appropriateness of language,
and interview technique. The participants in the pilot test were excluded
from the study.
We entered results into Epi Info version 6.04 (CDC, Atlanta, Ga). After
data were entered from the survey instrument into the electronic database,
all identifiers were removed from the electronic database. We calculated prevalence
rates for the characteristics described and basic frequencies using Epi Info
version 2002 C sample (CDC). Multivariate analyses were performed by using
the SUDAAN software version 8.0 (Research Triangle Institute, Research Triangle
Park, NC) to account for the complex sampling design. All presented data were
adjusted for clustering and assigned a weighting factor. Bonferroni adjustment
was performed for comparing traumatic events of disabled and nondisabled persons,
with P<.002 considered statistically significant
for this analysis.
We used multivariate linear regression to assess the effect of demographic,
occupational, and exposure variables on continuous outcome variables, such
as the SF-36 scales. Multivariate logistic regression was used for the dichotomous
variables, depression, anxiety, and PTSD. We performed statistical comparisons
using Wald F tests from multivariate linear regression for continuous variables
and Wald χ2 tests from multivariate logistic regression for
dichotomous variables. P<.05 was considered statistically
significant for these analyses.
The demographic variables used in the multivariate regression models
were selected based on results from previous studies.5 Other
variables were included in the model based on their relative importance in
this study. All regression models were based on partial, not sequential analysis.
A total of 799 persons completed the mental health survey, of whom 100
were disabled. One cluster of 50 total clusters was not accessible because
of security reasons. In some clusters, less than 15 households were present
because of the small size of some villages. Only 4 households (0.5%) refused
to participate in the survey (Figure 1).
We sampled more women than men among nondisabled respondents and more men
than women among disabled respondents (Table 1). Most people in both groups were in the younger age category
(15-34 years) and married. All participants were Muslim. Most participants
reported not having sufficient food and most reported no regular employment.
Disabled respondents were mainly Tajik and half of these respondents had no
education. However, we found no statistically significant differences in the
demographic characteristics between nondisabled and disabled respondents.
The weighted prevalence of self-reported mental illness diagnosed previously
by a physician or health care professional was 19.3% (n = 144) for nondisabled
respondents and 32.4% (n = 25) for disabled respondents. No respondents reported
alcohol use. Diazepam (0.7% [n = 10] in nondisabled group; 0.2% [n = 2] in
disabled group) and sniffing glue (4.2% [n = 20] in nondisabled group; 10.8%
[n = 5] in disabled group) were the most commonly reported drugs used.
A total of 49 participants (7%) experienced at least 11 trauma events;
250 participants (38%) experienced 0-3 trauma events; 231 (35%) experienced
4-7 trauma events; 127 (19%) experienced 8-11 trauma events; and 49 (7%) experienced
12-16 trauma events. The most common trauma events experienced by nondisabled
respondents were lack of food and water (56.1%), ill health without access
to medical care (54.9%), the need to flee suddenly (44.1%), lack of shelter
(44.1%), lost property or belongings (41.4%), and experiencing shelling or
rocket attacks (40.8%) (Table 2).
Approximately one third of nondisabled respondents reported experiencing bombardments
by Coalition forces (34.9%), beatings by Taliban or other groups (32.4%),
and living in refugee camps (31.2%).
Disabled respondents most commonly reported lack of shelter (69.7%),
ill health without access to medical care (67.3%), bombardments by Coalition
forces (62.6%), shelling or rocket attacks (61.6%), serious injury due to
knife/gunshot or fighting (60.8%), lack of food or water (58.9%), and need
to flee suddenly (55.8%). Nearly one third of disabled respondents experienced
lost property or belongings (32.5%) and beatings by Taliban or other groups
(31.2%). Most respondents (407 [62.0%]) had experienced multiple traumatic
events (≥4 trauma events during the previous 10 years). Trauma events for
nondisabled respondents differed statistically from those of disabled respondents
for experiencing imprisonment, shelling or rocket attacks, and need to flee
suddenly (Table 2).
Mental health coping mechanisms varied among nondisabled and disabled
respondents (Table 3). Among nondisabled
respondents, reading the Koran or praying (36.9%), more income (27.6%), and
talking to family or friends (8.5%) were reported as coping mechanisms. Among
disabled respondents, reading the Koran or praying (21.1%), more income (41.3%),
medical assistance (14.0%), and talking to family or friends (5.4%) were the
most frequently reported coping mechanisms. Overall coping mechanisms for
nondisabled respondents differed statistically from those of disabled respondents
(P = .04).
Both disabled and nondisabled respondents commonly reported feelings
of hatred. Among nondisabled respondents, 84% reported "a lot" of or "extreme"
hatred, 14% reported feelings of revenge, and 14% reported wanting to act
on their feelings of revenge. Eighty-six percent of nondisabled participants
reported not wanting to take revenge if the people who had wronged them and
toward whom they felt hatred were tried and sentenced by a war crimes tribunal
or other justice system. Among disabled respondents, 81% of participants reported
"a lot" of or "extreme" hatred, 20% reported a desire for revenge, and 27%
reported wanting to act on this desire. Sixty-five percent of disabled respondents
did not want to take revenge if a justice system tried the people who had
wronged them.
Multivariate Statistical Analyses
We compared mean scores of general health, bodily pain, social functioning,
and role-emotional functioning scales of the SF-36 for nondisabled and disabled
respondents (Table 4). All outcomes
were adjusted for demographic characteristics. Disabled respondents had significantly
lower health perception, reported more bodily pain, had lower social functioning,
and had lower role-emotional functioning than did nondisabled respondents.
The prevalence of symptoms of anxiety was significantly higher for disabled
respondents (84.6%; 95% CI, 74.1%-95.0%) than for nondisabled respondents
(72.2%; 95% CI, 63.8%-80.7%; P = .004). The prevalence
of symptoms of depression did not differ among groups: 71.7% (95% CI, 65.0%-78.4%)
for disabled and 67.7% (95% CI, 54.6%-80.7%) for nondisabled respondents.
The prevalence of PTSD symptom criteria was similar for both disabled and
nondisabled respondents (42.2% and 42.1%, respectively).
In addition, we compared mean scores of the general health, social functioning,
bodily pain, and role-emotional functioning scales of the SF-36 of nondisabled
respondents to the US reference population.11 Higher
scores represent better functioning. For nondisabled and disabled persons,
the mean scores for general health (39.2 and 29.3), social functioning (57.2
and 46.4), bodily pain (49.0 and 37.9), and role-emotional functioning (56.7
and 41.6), respectively, were substantially lower for the adult population
in Afghanistan than for the US reference population mean scores (72.0, 83.3,
75.2, and 81.3, respectively).11
We analyzed the association between selected demographic factors, traumatic
events experienced, coping mechanisms, and feelings of hatred, and the social
functioning and mental health outcomes for nondisabled and disabled respondents.
For nondisabled respondents (Table 5),
female sex was associated with lower prevalence of social functioning and
higher prevalences of symptoms of depression, anxiety, and PTSD. Older respondents
had significantly poorer social functioning and higher levels of depression
symptoms. Respondents with little or no education had symptoms of anxiety
more often than did respondents with higher levels of education. History of
mental illness was associated with higher prevalences of symptoms of depression
and symptom criteria for PTSD.
Among nondisabled respondents, multiple trauma events were associated
with poorer social functioning and higher levels of anxiety symptoms. Landmine
injuries were associated with a higher prevalence of anxiety symptoms and
the murder of family or friend was associated with poorer social functioning.
Religious or spiritual practices such as reading the Koran or engaging in
traditional ceremonies were associated with lower anxiety. Those respondents
who focused on covering basic needs, such as more income, better housing,
and more food, were less likely to have symptoms of depression and PTSD.
For disabled respondents (Table 6), the prevalences of symptoms of depression and symptom criteria
for PTSD were higher for women than men. History of mental illness was associated
with poorer social functioning and higher prevalences of symptoms of depression,
anxiety, and PTSD. In addition, older respondents were more likely than younger
respondents to have symptoms of anxiety; lack of a regular income was associated
with anxiety and PTSD among disabled respondents. Married respondents were
more likely than single respondents to have symptom criteria for PTSD. Less
education correlated with higher prevalences of symptoms of depression (P = .01) and anxiety (P = .004).
Among disabled respondents, multiple trauma events were associated with
poorer social functioning. Engagement in religious practices was associated
with less depression symptoms. Respondents who sought medical assistance and
who focused on covering basic needs were less likely to have symptoms of anxiety.
Disabled respondents who had feelings of extreme hatred were more likely to
have poorer social functioning but less likely to have depression symptoms.
This population-based mental health survey revealed high prevalence
of exposure to trauma events and mental health symptoms among the conflict-affected
population of Afghanistan in 2002. Prevalences of symptoms of depression and
anxiety and symptom criteria for PTSD were high even when compared with those
symptoms of other communities traumatized by war and conflict,5 and
were higher for women than for men. In comparison, we previously reported
PTSD symptom rates of 17% and nonspecific psychiatric morbidity of 43% shortly
after the end of the war in Kosovo.5 In this
study, social functioning was lower among disabled respondents than among
nondisabled respondents. Not unexpectedly, social functioning was lower in
the surveyed population in Afghanistan than in a US reference population.12
The significantly higher prevalences for symptoms of depression, anxiety,
and PTSD, and lower social functioning for women than men is not surprising
given the restrictions placed on women, especially during the Taliban regime.
Although the end of the Taliban regime improved women's liberties, many restrictions
remain. Studies among women conducted by the Physicians for Human Rights during
the Taliban regime in 1 province in Afghanistan also showed high rates for
self-reported symptoms of PTSD, depression, and anxiety.6,7
Not unexpectedly, respondents who reported previous mental illness had
worse mental health outcomes, including higher levels of symptom criteria
for PTSD and symptoms of depression. Disabled respondents also had lower social
functioning and higher levels of anxiety symptoms if a psychiatric illness
previously had been diagnosed. These results are consistent with findings
in other mental health surveys in postwar settings.5
In this study, 62% of Afghan respondents have experienced multiple trauma
events. Multiple trauma events were associated with decreased social functioning
and higher rates of anxiety symptoms for nondisabled respondents. Lower social
functioning associated with multiple trauma events also was observed in a
mental health study conducted in postwar Kosovo, while higher rates of symptoms
of depression and PTSD were associated with trauma events among Cambodian
refugees.5,17 However, we did
not find a significant association between trauma events and symptom criteria
for PTSD in this survey as was found in these other studies. This is surprising
in view of the high prevalence of both PTSD symptoms as well as having experienced
multiple trauma events. Extreme poverty and concerns for day-to-day survival
caused by economic hardship commonly causes stress. In Afghanistan, socioeconomic
factors may have been more important risk factors than traumatic events for
PTSD.
Lack of a regular income was associated with higher rates of symptoms
of anxiety and symptom criteria for PTSD among disabled but not among nondisabled
respondents. Economic hardship may affect disabled persons differently; lack
of resources for persons with disabilities can cause additional hardship and
may be more difficult to resolve than for people without disabilities.
It became clear during interviews with key informants that the questions
regarding alcohol and substance use were considered inappropriate in this
Muslim culture, which forbids the use of these substances. Substance abuse
was therefore probably underreported in this study because of cultural and
religious taboos and the fear of legal ramifications. Use of alcohol, heroin,
cocaine, or marijuana was not reported by any of the participants. Some of
the participants reported using diazepam and sniffing glue. Some Islamic societies,
like Afghanistan, forbid the use of substances that impair thinking and consciousness.18 However, anecdotal information and reports describe
the use of amphetamines and marijuana and an increase of opium production
in Afghanistan.19,20 Reporting
use of diazepam may be less of a taboo than reporting use of other substances
because it is often prescribed by health care practitioners and therefore
accepted as a medical treatment.
Feelings of hatred were commonly reported by these Afghan respondents
and prevalence levels (81%-84%) were similar to those levels observed in a
postwar mental health survey in Kosovo in 1999.5,21 As
in previous studies in war-affected countries, feelings of hatred and revenge
may partially explain continued cycles of violence.21 However,
in Afghanistan, a desire for revenge was less common than in Kosovo and a
substantial number of respondents reported that revenge would not be necessary
if a justice system existed. Establishment (or reestablishment) of a justice
system may be essential for postwar societies to decrease feelings of hatred
and revenge.
We identified several subpopulations with higher risk for poor mental
health status and attempted to identify resilience factors. Afghan men in
general, men and women younger than 35 years, and people who had no history
of previous mental illness, had a high school education, engaged in religious
or spiritual practices as coping mechanisms, and believed that covering basic
needs was important appear to have been protected from war-related psychiatric
morbidity. In general, women in Afghanistan were at higher risk for psychiatric
morbidity and lower social functioning. Religious or spiritual practices were
important coping mechanisms and protected against anxiety symptoms among nondisabled
respondents, and depression symptoms among disabled respondents. Results were
similar in a study of Cambodian refugees in the Thailand-Cambodian border
camps conducted during the 1980s and 1990s; refugees who engaged in indigenous
religious practices were less likely than those refugees who did not to have
PTSD.22 Such protective effects of religious
practices were also observed among Bhutanese refugees in Nepal and survivors
of torture23 and among Tibetan refugees residing
in India.24
Our study had several limitations. No village-level population data
were available before the survey began. However, population data were adjusted
with weighting factors after data collection using population estimates for
surveyed villages. No nationwide baseline data existed on the mental health
outcomes for the Afghanistan population, but a survey conducted by the Physicians
for Human Rights among Afghan women in parts of Afghanistan and in refugee
camps in Pakistan also showed high rates of symptoms of depression.6,7 Cross-cultural differences could have
influenced the results of this study; the instruments were not specifically
validated for this society. Nevertheless, in other postwar populations, these
instruments have proven to have reliable internal consistency. Care was taken
with translation and back-translation of the instruments, and Harvard Trauma
Events Scale was adapted for the specific trauma events in Afghanistan. Because
no structured clinical interviews were performed, the extent to which self-reported
symptoms of PTSD, depression, and anxiety would match clinical diagnosis is
unclear. Finally, for persons who were disabled, we did not collect information
on whether the disability was permanent or temporary. Although it is possible
that there are differences in outcomes among persons with differing durations
of disability, the proportion of persons whose disability was temporary was
likely to be small. Future assessments should examine these proportions and
whether there are differences in outcomes based on duration of disability.
Our survey demonstrates a high prevalence of exposure to trauma and
the magnitude of mental health problems among Afghan individuals in postwar
Afghanistan. Prevalences of symptoms of depression, anxiety, and PTSD were
high, even when compared with other communities traumatized by war and conflict.
Women and disabled respondents had significantly poorer mental health status
than men and nondisabled respondents. These data underscore the need for donors
and health care planners to address the current lack of mental health care
resources, facilities, and trained mental health care professionals in Afghanistan.
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