This article is part of AOAV’s examination of the health impacts from explosive violence. The full report, Blast injury: the reverberating health from the use of explosive weapons, can be found here. The summary and key findings can be found here.
- In the conflict-affected areas of Ukraine, 40% are said to have experienced trauma resulting in stress, depression, anxiety, and post-traumatic stress disorder.
- A Humanity and Inclusion study found that 80% of people injured by explosive weapons in Syria expressed signs of high psychological distress.
- Among Ukraine’s IDPs 20% are thought to suffer from moderately severe to severe anxiety, compared to 12% of Ukraine’s general population.
- Among Lebanon’s Syrian refugees, it was reported that in many cases the psychological impacts often stem more from the reverberating consequences of explosive violence, such as displacement and poor living conditions.
The psychological impact of conflict has increasingly been the subject of research in recent years, including a focus on the mental effects of exposure to explosive weapon harm. AOAV research into the psychological harm of explosive violence found depression was particularly a lasting consequence, often having impact for generations, even impacting the children of survivors.
The longevity of such harm is also highly affected by the availability of psychological support, the living conditions of those impacted, as well as the dominant narrative of the violence in the post-conflict period.
The below section discusses some of the lasting direct and indirect psychological impacts from the use of explosive weapons in Syria and Ukraine.
In the conflict-affected areas of Ukraine, 40% of civilians were reported to have experienced trauma resulting in stress, depression, anxiety, and post-traumatic stress disorder (PTSD). However, it has also been reported that there has been an over-diagnosis of PTSD there owing to a lack of mental health services. One psychologist working for Caritas, for instance, said that, at one stage, virtually anyone who experienced the war was diagnosed with PTSD.
While things have improved since the height of the fighting, Ukrainian families still live with daily anxiety owing to the dangers the conflict continues to pose. The ongoing prevalence of shelling, landmines, IEDs and other UXO means that psychological support still remains one of the most requested forms of health assistance in the conflict-affected areas.
Such demand is problematic. There is a general lack of expertise in Ukraine in terms of addressing mental health issues. For instance, it was reported in a 2019 Humanitarian Response Plan, that 75% of Ukrainian families in the government-controlled areas living close to the contact line complained of a lack of psychological support or said they did not know where to access such support – though these issues are a salient feature of most global conflict hotspots.
When AOAV met Dr Yuriy Smal, head of the psychiatric hospital in Semenivka, in the Poltava Oblast of Ukraine, he described the impact the conflict had had in terms of common mental health complaints. Before the war, his patients had what you might expect to see in any large psychiatric unit: mood disorders (such as depression or bipolar disorder); anxiety disorders; personality disorders; psychotic disorders (such as schizophrenia); eating disorders; and substance abuse disorders. During and after the war, though, a large portion of his work involves treating those with trauma-related disorders, especially post-traumatic stress (PTSD). While he has not researched the prevalence of PTSD in his region, such a shift in focus comes as little surprise.
While his hospital has received specific government and overseas funding for repairs and construction, his overall budgets have not increased to cater for those impacted by the war. 23 psychiatrists in Dr Yuriy Smal’s team did receive further training in identifying and treating PTSD, up to what he described as ‘European standards.’ He claimed that this changed his staff’s curative approach, away from a pharmacological-centric approach to a psychotherapeutic and social rehabilitative approach.
One thing of note in many health centres in Ukraine was that the war has helped raise awareness of mental health issues and has, in certain cases, led to a change in treatment approaches and regimes, as Ukraine seeks to align itself much more with European standards and practise.
Among Syrians, including local populations, the displaced and refugees, there is a high prevalence of mental health concerns. A report by the German Federal Chamber of Psychotherapists found that around 50% of Syrian refugees living in Germany had mental health problems. The International Medical Corps (IMC), also found that among the Internal Displace Peoples (IDPs) and refugees using their facilities, over 50% had emotional disorders and over 25% of children had intellectual and developmental issues. And though these figures relate to those fleeing the conflict in general, explosive weapons are one of the most significant contributors to psychological health impacts. As AOAV’s own research has shown, 85% of refugees in Europe are fleeing explosive violence.
The deafening noise of explosive weapons and the witnessing of its surreal impact – bombs crumpling buildings and concertinaing familiar horizons – are clearly significant psychological stressors. It has been argued that continuous exposure to such visual and auditory horrors can have “the same negative outcomes as major traumatic events”. A Save the Children study examined the psychological effects of the conflict on children and found that, among Syrians interviewed, “84% of adults and almost all children said that ongoing bombing and shelling is the number one cause of psychological stress in children’s daily lives”.
For those injured by explosive weapons there is an even greater psychological toll. A Humanity and Inclusion study revealed 80% of people injured by explosive weapons expressing signs of high psychological distress. Furthermore, of those injured, 66% were unable to carry out essential daily activities due to their feelings of fear, anger, fatigue, disinterest and hopelessness.
It is also worth highlighting that before the conflict in Syria there were few health facilities dedicated to patients with mental disorders. It went from few to virtually none. Within two years of the conflict, there were only three public mental health facilities in Syria left functioning. Between late December 2012 and early January 2013, one of these facilities, the Ibn Khaldun Psychiatric Hospital, suffered severe shelling and bombardment, forcing patients and doctors to leave. Two patients were killed by snipers as they fled.
Among Ukraine’s IDPs, 20% are thought to suffer from moderately severe to severe anxiety, compared to 12% of Ukraine’s general population. While 25% of IDPs suffer from moderately severe to severe depression, compared with 15% of the general population. Only 23% of IDPs suffering anxiety or depression have received professional help. For those that did receive help, most only benefited from a one-time consultation.
While most IDPs identified positive coping mechanisms for dealing with anxiety and depression, such as talking with friends or going for a walk, 16.7% identified alcohol and smoking as a way in which to cope. Such coping mechanisms appear to vary somewhat between the sexes. Women were more likely to turn to religion and to self-prescribe medication, while men were more likely to turn to exercise, alcohol or smoking. There were also differences based on age – the elderly were more likely to turn to religion or gardening than younger generations; younger groups more likely to turn to exercise than the elderly.
Those that continue to live in the conflict-affected areas are also impacted by the isolation. In many abandoned villages, the elderly remain unable or unwilling to leave their homes. In many cases, children and grandchildren have fled to other areas and so the parents or grandparents who stay behind are left abandoned and lonely. According to the Food and Agriculture Organisation of the United Nations, a third of households have members who have migrated. The elderly are also reported to be the least likely to feel hopeful.
Gender differences in coping mechanisms should be of concern, not least because of the high prevalence of male suicide in Ukraine; Ukraine has the seventh-highest suicide rate in the world for men compared to the 81st highest for women. Alcoholism is another concern among men.
In a separate and recent study of mental health among IDPs, 32% were found to have symptoms of PTSD, while those with depression and anxiety saw similar scores to the study above (22% and 18% respectively).
The challenges for many IDPs facing mental health difficulties
is made worse by the prevalence of physical health challenges amongst that
community. One report highlighted that about half of IDPs reported
mobility difficulties, compared to 7.5% of non-IDPs interviewed,
while the likelihood of blindness/poor vision and hearing loss was also more
likely among IDPs. Blindness or poor vision among IDPs stood at 7.4%, compared
to 6.9 for non-IDPs and hearing loss was 6.1% for IDPs, compared to 2.2%
amongst the control group. Such difficulties can not only intensify isolation
and mental health issues but also increase the barriers to those seeking
support. It should be noted that the study also found that IDPs were more
likely to seek and access support compared to the general population but this
usually only occurred once without follow-up. About a quarter of respondents
were offered mental health support when they left the conflict-affected areas; only
10% received help.
Improving and making more affordable the living conditions for IDPs was identified as one of the main ways in which their mental health could be improved. Other popular suggestions included: low-cost mental health support which is easy to access; greater awareness around mental health; and IDP support groups and activities. Many professionals recognise that the problems that IDPs face require a multidisciplinary approach to address concerns such as housing and employment as well as trauma, as the everyday burdens of just living as a displaced person intensify mental health impacts.
According to Dr Leyla Akoury-Dirani, Associate Professor of Psychiatry at AUBMC in Lebanon, from her experience with Syrian refugees, often the psychological impacts stem more from the consequences of explosive violence, such as displacement and the living conditions associated with being a refugee in Lebanon, than the trauma of the impact itself.[i]
Dr Akoury-Dirani highlighted the complexities of addressing psychological health among refugees, many of whom are still in ‘survival mode’, and are therefore unable or not ready to address the trauma they experienced.
In Lebanon, where healthcare is usually expensive and where there are few psychiatrists in any case, there is a clear unmet need. Dr Akoury-Dirani explained to AOAV researchers that there are just 50 psychiatrists throughout Lebanon, including three child psychiatrists; about two-thirds of these psychiatrists reside in the capital city, Beirut.[ii] These psychiatrists struggle to address the needs of Lebanon’s own war-affected population – Dr Akoury-Dirani currently has a three-month waiting list. And many more cannot access care due to the costs and the stigma which remains associated with mental health. Few Syrian refugees could access such services.
AOAV spoke to the son of a Syrian refugee who had tried to commit suicide. His father, who suffers from diabetes, cancer and depression, is unable to afford the treatment for any of his conditions. His family had been scraping together enough to provide his diabetes medication but he felt like a burden and so tried to overdose. Fortunately, the attempt did not work but he is described as remaining catatonic.
The head of a refugee camp in Arsal said that many at the camp suffered psychologically but there was a considerable stigma and no help available. There had been other suicide attempts inside the camp. The camp head believed that almost everyone in the camp suffered from depression and echoed the statement of health professionals when he identified their current living situation in the camps, not just the trauma experienced in Syria, as a primary cause of the depression. Many, he believed, also suffer psychosomatic and other stress-related illnesses.
In one camp, it was reported that a Lebanese therapist used to visit to try to provide relief, but it was stated it became too much and they had a breakdown as they encountered “too much misery”. This case was confirmed by local NGOs.
In both Syria and Ukraine, explosive violence will leave lasting psychological harm. While there has been a growing awareness of the psychological harm from conflict, it is still one of the impacts least addressed.
Addressing the psychological harm of explosive weapons is
complex, especially as many of those impacted remain in unstable circumstances
for many years after their experience of explosive violence. While there is
awareness of the stigma still associated with mental health across the globe,
far more needs to be done to overcome these obstacles and to ensure mental
health support reaches all civilians impacted by armed violence.
[i] Interview with Dr Leyla Akoury-Dirani, Associate Professor of Psychiatry, AUBMC, January 29th 2020.
[ii] Interview with Dr Leyla Akoury-Dirani, Associate Professor of Psychiatry, AUBMC, January 29th 2020.
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