NZNTV

Study. After mass conflicts, countries are at increased risk of recurrent episodes of communal violence and upheavals that adversely affect social, economic, and political development.  However, no studies have assessed the effect of repeated communal violence on mental health of citizens in these settings.

Generally, symptoms of post-traumatic stress remain high in the period soon after mass conflict (up to 3 years), with a gradual improvement in mental health in the years afterwards. Recurrent conflict might increase the prevalence of mental disorders for several reasons. Repeated exposure to trauma increases the risk of post-traumatic stress disorder and other common forms of mental distress in a well established dose-effect relationship. Furthermore, the nature of the conflict—and what it means to the affected citizens, for example, a sense of persistent injustice—might be instrumental in determining mental health responses.

Timor-Leste exemplifies a country that has had recurrent conflicts that differ in their characteristics and implications for the society as a whole. The Indonesian occupation (1975—99) leading up to the humanitarian crisis of 1999 was associated with extreme trauma and human rights violations, including torture, murder, and mass displacement. Yet our study of a rural village and an urban district in 2004 yielded low prevalence of post-traumatic stress disorder and severe distress compared with other post-conflict settings, which we tentatively attributed to the general sense of optimism that followed national independence in 2002.

A period of internal violence occurred in 2006—07, involving warring factions from within the country. Tensions persisted even after the UN contained the violence, with members of opposing groups continuing to live side by side in the same villages. Observers noted that the internal conflict had a detrimental effect on the society as a whole, undermining the sense of optimism that had followed independence. The loss of community cohesion and continuing feelings of insecurity after the internal conflict might have created a general vulnerability to mental disorders in the community as a whole.

Persistent feelings of injustice related to human rights violations might be an important factor leading to mental disorders in post-conflict populations. We anticipate that successive periods of conflict in Timor-Leste in which human rights traumas were common would lead to a mounting sense of injustice among survivor populations, particularly because most of the perpetrators have not been brought to account.

Debate continues as to the relative importance of poverty and psychological trauma in shaping adverse mental health outcomes in people living in post-conflict settings. Poverty and trauma might exert different effects on mental health outcomes—eg, poverty is associated with symptoms of depression, whereas trauma is associate with post-traumatic stress disorder. Establishing how each of these determinants contributes to mental health is important for the development of strategies for prevention and intervention of mental health disorders.

We did this study to test several related hypotheses: first, that post-traumatic stress disorder and severe distress would be more common after the period of internal conflict in Timor-Leste compared with baseline. Second, that these mental disorders would be associated with wide-ranging psychosocial disabilities. Third, that post-traumatic stress disorder would be linked to potentially traumatic events related to violence and ongoing tensions, whereas ongoing poverty would be most relevant to severe distress (including symptoms of depression). And finally, that distressing preoccupations with injustice spanning several historical periods would be associated with mental health symptoms.

Follow the whole study here: http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(14)70196-2/fulltext