This course proposes an overview of current global health challenges drawing on the insights of several academic disciplines including medicine, public health, law, economics, social sciences and humanities. This interdisciplinary approach will guide the student into seven critical topics in global health.
Mental Health and Conflict by Ariel Eytan
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來自 University of Geneva 的課程
全球健康：跨学科概述
135 個評分
從本節課中
Emerging Trends in Global Health: Non-Communicable Diseases and Disability
In this module we consider the rise of non-communicable (NCDs) diseases across countries, along with mental disorders and disability.
與講師見面
Rafael Ruiz De CastañedaInstitute of Global Health - Faculty of Medicine
University of Geneva
Antoine FlahaultProfessor of Public Health and Director of the Institute of Global Health (Faculty of Medicine, University of Geneva) and co-Director of Centre Virchow-Villermé (Université Paris Descartes)
University of Geneva and Université Paris Descartes – Sorbonne Paris Cité
[MUSIC]
Hello, everyone.
The title of this presentation is Mental Health and Conflicts.
We will discuss this topic using disaster psychiatry as our model of reference.
Disaster psychiatry addresses the mental health consequences of extreme situations,
including conflict and war.
Disaster situations can be categorized as follows.
We have natural disasters, non-intentional human made disasters,
intentional human made disasters, and quite often nowadays,
in fact, mixed natural and human disasters.
For example, when an earthquake occurs in an area with high density population and
poorer construction buildings, this is the case of such a mixed disaster.
Now let's talk about conflicts and
what about the frequency of conflicts worldwide?
It is estimated that since the Second World War,
22 interstate conflicts occurred with 3 to 8 million
deaths as a consequence of these but there were many more civil conflicts.
It is estimated 240, causing up to 10 million direct
battle deaths, 25 million indirect deaths,
and the forced displacements of more than 40 million individuals.
Interestingly, inter-ethnic tensions are at the origin
of most of these civil conflicts.
Now we will examine conflicts and mental health, and the interface between the two.
Who is concerned by this topic?
Veterans of war, of course, refugees or asylum seekers
in host countries, refugees in refugee camps,
internally displaced persons and general civilian populations.
What are the individual responses to disaster?
There is first distress with basic and strong emotions like sadness,
despair, or maybe desire for revenge and anger.
There are health risk behaviors such as increased smoking or
alcohol drinking, and full blown mental disorders.
Of course, those three coexist and
interact, and you can have the presence of distress, health risk behaviors,
mental disorders, at some point, in the same individual.
It is also of interest to note that intentional traumatic events
have worse outcomes than non-intentional ones.
We mentioned mental disorders as a consequence of trauma.
Which are these trauma related disorders?
The most permanent ones are post traumatic stress disorder,
or PTSD, which was extensively studied, and so
was major depression or so called major depressive episode.
But we also observe acute stress disorders that is occurring quite quickly,
shortly, after the events, substance use disorders,
anxiety disorders and various kinds of somatizations.
Let us say here that comorbidities are the rule rather than the exception.
That means that it is common to find the presence of two or
more of these mental disorders.
They are comorbidities but
there is also some symptom overlap between the categories.
Let's say, for example, not being able to enjoy every day life or
not being able to function properly in every day life
can be encountered both in PTSD and major depression.
So we have the two phenomena, comorbidities and
symptom overlap between disorders.
The time frame is also important to remember.
There are immediate and short-term consequences of
disaster occurring hours up to days or weeks after the event.
But also long term consequences of disaster, which can occur maybe or
you can have still symptoms of PTSD, for example, decades after the war.
Some situations are in themselves long-lasting,
such as ongoing war,
as opposed to sporadic events such as a terrorist attack.
It is also relevant to know that both sporadic events and
long-lasting situations may have long-lasting consequences
on mental health but we won't observe,
like in a physical injury, direct immediate signs of the problem.
These consequences may not be quickly or immediately apparent.
One has to remain attentive to what can occur later on.
Now let us focus on the current issues of this
presentation that is full blown mental disorders as mentioned,
long-lasting intentional human made situation, war and conflict,
and general civilian populations, internally displaced persons and refugees.
Here you can see the prevalence rates of
PTSD and depression and also the co-morbidity rates.
This comes from a systematic review of the literature
which was published in 2009 and as you see,
there are huge differences in prevalence rates.
This is due to the fact that various studies were conducted in different
cultural settings and also using different questionnaires and methodologies.
So, it splits really these values.
What are the symptoms of these two mental disorders?
Obviously, for PTSD, you need
to identify the exposure to a potentially traumatic event.
Once you have this, there are a number of symptoms like persistent remembering and
re-experiencing of the events, avoidance of reminders effects,
poor recall for events at time of stressor that is amnesia.
Persistent symptoms of increased psychological sensitivity and
arousal, such as insomnia or startle response.
For symptoms of depression, there is low mood, feeling low, sad or
unhappy, fatigue with pronounced loss of energy,
lack of interest and pleasure for the usually pleasurable things of life.
Other symptoms such as suicide ideation or somatic anxiety,
also known as hypochondria, sleep and appetite disturbances.
In order to have a diagnosis of depression,
these symptoms have to be present for, at least, two weeks and almost everyday,
otherwise, it's difficult to differentiate it from normal, usual sadness.
Now let us look at the risk factors for
mental health for civilians in war.
Too often, professionals consider that troubles start with the conflicts.
And maybe pre-existing factors can be overtaken but in fact,
it's also important to investigate what was the situation before the war started.
For example, you can find familial and social factors of vulnerability,
pre-existing symptoms of a mental disorder,
or exaggerated personality traits.
During the conflict, there are several risk factors also,
of course, like severity and duration of the conflict,
personal loss or bereavement, life threats or physical injury,
forced separation from close relatives, loss of property
and a lack of security in the neighborhood at the neighborhood level.
Regarding past conflict factors,
there are a number of stresses which can exist at this
stage like forced displacement as a consequence of the war.
Lack of financial support, lack of structures and, for
example, lack of access to healthcare
due to lack of hospitals and so this is an important issue.
Poverty at various levels and persisting interethnic tensions,
which is quite often observed even after
peace was officially settled.
Now when talking about PTSD or
depression, we use a Western model
which may not be relevant in all cultural settings, of course.
This creates tension between on one side,
a medical model with Western psychiatric diagnostic categories.
We use questionnaires to elicit the diagnosis.
Then we prescribe a medication and we use psychotherapy but on the other hand,
there can be sociocultural factors such as institutional cohesion,
justice, need for reconciliation, etc.
Also, individuals use other types of help such
as consultations with traditional healers,
for example, or spiritual support.
So inevitably, this creates tensions between cultural
factors and our medical model and when we
meet individuals from different cultures.
This is an example I took from a mission we made
in Kosovo, a couple of years after the end of the war.
It is important to wonder, is the intervention I bring or
our tools relevant for this population, or not?
These populations may have very different needs than those we
expect from a theoretical point of view using Western psychiatric categories.
This brings us to the topic of interventions.
What are the possible interventions from
institutional perceptive or individual ones?
It is important to increase resilience, psychological and
social resources, that is in the population.
Support not only the individual but also the family.
Encourage community solidarity, and traditional methods of support.
It is also useful to integrate mental health skills of caring for
the population with general services.
This in order to reduce barriers to access to care.
Also to focus on long-term rather than on short-term measures.
In conclusion, some also attitudes or interventions should be,
I think, avoided, like imposing a medical model when it
is inappropriate, disregarding local resources.
Being in competition between institutions and
bringing massive support on the short-term but
disengage on the mid-term and long-term.
[MUSIC]
