Building and translating evidence into smart policy: continuing research needs for informing post-war mental health policy

Murthy and Lakshminarayana's review of research findings on the mental health (MH) consequences of war and armed conflict (hereafter referred to as war) provides an outline of how far the knowledge base has grown in the last 30 years, and also highlights how much further it has yet to go.

While the studies cited provide a snapshot of war's psychological impact, there is less empirical information available to guide policymaker and clinician decisions about how best to address the MH needs of individuals directly and indirectly affected by war. Such information is sorely needed, however, as the resources available to address MH needs in the aftermath of war are often limited, both in terms of adequate numbers of individuals prepared to approach MH issues and funding for MH services. As a result, difficult decisions must often be made regarding the priority of addressing MH needs during post-war reconstruction versus other priorities, including providing physical health care and services to meet public health needs, fostering economic redevelopment, maintaining security, and establishing safe and adequate housing (1). Decisions must also be made regarding what MH services should be provided, to whom they should be provided, who should be providing them, and within what time frame. While there are ethical and logistical challenges in gathering these data in the immediate aftermath of war, we will list below some of the research questions which should be addressed to ensure that scarce resources are used in a manner most likely to reduce psychiatric or psychological morbidity.

How should we identify individuals who require interventions, and when should such interventions be delivered?In the aftermath of other community-wide traumas (e.g., natural disasters, community violence, etc.), psychological or emotional symptoms often diminish over time or change in frequency, nature, and severity for many exposed individuals (2,3). In addition, symptomatic individuals are not always impaired (4). These findings, however, are from populations exposed to events that are less pervasive and traumatic than war. A better understanding of the longitudinal and developmental effects of exposure to war would improve the ability to target interventions to those individuals most in need, when they need it. Optimally meeting exposed individuals' MH needs requires careful consideration of when and how to best commit resources, and in some cases may require policymakers to weigh the pros and cons of acute interventions to address the most pressing needs vs. longer term strategies to address the broad range of persistent and impairing MH problems that may result from exposure to war.

How should we choose and implement effective interventions? Further work is needed to develop and deliver interventions that best address the MH needs of individuals exposed to war. Expert consensus groups have recommended core elements that should exist in these MH interventions (5). These include addressing the individual's trauma in the context of his family, community, and society (6), addressing cultural influences on exposed individuals experiences (7), and realizing that the appropriate interventions in the context of ongoing conflict and its immediate aftermath may differ from those in subsequent periods (5). While there is an increasing evidence base of effective interventions for traumatized individuals (8), there remains a paucity of empirical data to guide clinicians and policymakers with respect to the optimal content of interventions to be provided to individuals exposed to war.

How and where should MH services be provided if the health care system has been degraded? Clinicians and policymakers must consider how best to meet the MH needs of individuals within the environment that exists in a post-conflict community. This may be especially challenging since the capacity for MH care is often degraded during conflict (9), and in many conflict ridden or impoverished countries the system for providing MH care was often limited prior to war.

We have made tremendous progress in our understanding of the psychological impact of war on exposed individuals. The challenge of the coming decades is enhancing our ability to make more informed decisions about how to best address the psychological needs of these individuals.