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European Journal of Psychotraumatology logoLink to European Journal of Psychotraumatology
. 2019 Feb 22;10(1):1578637. doi: 10.1080/20008198.2019.1578637

The prevalence of PTSD and major depression in the global population of adult war survivors: a meta-analytically informed estimate in absolute numbers

La prevalencia de TEPT y Depresión Mayor en la población global de adultos sobrevivientes a la guerra: Una estimación en números absolutos meta-analíticamente informada.

成年战争幸存者全球群体中PTSD和严重抑郁症的患病率：根据元分析估计绝对数值

Thole Hilko Hoppen 1, Nexhmedin Morina 1,✉
PMCID: PMC6394282  PMID: 30834069

ABSTRACT

Background: Elevated prevalences of post-traumatic stress disorder (PTSD) and major depression (MD) have been reported in populations exposed to war. However, no global estimates of war survivors suffering from PTSD and/or MD in absolute numbers have been reported.

Objective: We made the first attempt to estimate in absolute numbers how many adult war survivors globally may suffer PTSD and/or MD, which should inform local and global mental health programmes.

Method: Drawing on the Uppsala Conflict Database, we reviewed all countries that suffered at least one war within their own territory between 1989 and 2015 (time span chosen on availability of geo-referenced data and population estimates). We then conducted a meta-analysis of current randomized epidemiological surveys on prevalence of PTSD and/or MD among war survivors. Finally, we extrapolated our results from the meta-analysis on the global population of adult war survivors by means of using general population data from the United Nations.

Results: We estimate that about 1.45 billion individuals worldwide have experienced war between 1989 and 2015 and were still alive in 2015, including one billion adults. On the basis of our meta-analysis, we estimate that about 354 million adult war survivors suffer from PTSD and/or MD. Of these, about 117 million suffer from comorbid PTSD and MD.

Conclusions: Based on the slim available evidence base, the global number of adult war survivors suffering PTSD and/or MD is vast. Most war survivors live in low-to-middle income countries with limited means to handle the enormous mental health burden. Since representative high quality data is lacking from most of these countries, our results contain a large margin of uncertainty and should be interpreted with caution.

KEYWORDS: Posttraumatic stress disorder, major depression, prevalence, war trauma, civilian war survivors, meta-analysis

HIGHLIGHTS

• We estimate that 1.45 billion people worldwide have experienced war between 1989 and 2015.• We estimate that 354 million adult war survivors globally suffer from PTSD and/or MD.• We estimate that 117 million adult war survivors globally suffer from a comorbidity of PTSD+MD.• Most war survivors live in low-to-middle income countries with limited means to handle the associated mental health burden.

1. Introduction

Posttraumatic stress disorder (PTSD) and major depression (MD) are among the leading contributors to the global disease burden according to the global burden of disease report 2010 (Whiteford, Ferrari, Degenhardt, Feigin, & Vos, 2015). According to numerous predictions, MD will be the leading contributor to the global disease burden by 2020 (Mathers & Loncar, 2006; Murray & Lopez, 1996). PTSD also leads to a substantial functional impairment due to mental and physical dysfunctions and can follow a chronic course if untreated (Kessler et al., 2009; Morina, Wicherts, Lobbrecht, & Priebe, 2014; Nemeroff et al., 2006). Accordingly, PTSD and MD need to be addressed as a public health priority (Collins et al., 2011). Since the end of the Cold War in 1989, more than half of the countries in the world have been affected by armed conflicts (Marshall & Cole, 2009). PTSD and MD are the most prevalent mental disorders in war-affected communities, and significantly more prevalent than in communities with no recent history of conflict (Priebe et al., 2010). A meta-analysis from 2009 indicated that about 30% of individuals exposed to mass conflict and displacement suffer from PTSD and/or MD (Steel et al., 2009). However, this meta-analysis relied mostly on surveys conducted with subgroups of survivors of organized violence, such as survivors of torture or refugees. Hence, no conclusions about the prevalence of PTSD and MD in the general population in countries with a recent history of war can be made. Recently, we reported a meta-analysis on prevalences of PTSD and MD in adult civilian war survivors who live in war-afflicted regions. Similar to the results of Steel et al. (2009), we found a prevalence of 26% for PTSD (k = 30 studies) and 27% for MD (k = 18 studies; Morina, Stam, Pollet, & Priebe, 2018). In the current paper, we extend this earlier work by estimating the global prevalence of PTSD and MD in adult survivors of war in absolute numbers. To the best of our knowledge, this is the first attempt to do so.

This approach should prove useful in better evaluating the current burden of PTSD and MD in war-ridden regions. Hence, this article aims at giving a global estimate of the absolute number of adult war survivors who suffer from PTSD and/or MD.

2. Materials and methods

2.1. Definition of war regions

To operationalize war and war regions, we utilized data from the Uppsala Conflict Data Program (UCDP) from the Department of Peace and Conflict Research of the Uppsala University in Sweden (Pettersson & Wallensteen, 2015; UCDP, 2018). The UCDP is a free access database on fatality statistics, geo-referenced event data, armed actor(s) and descriptions of conflict for all armed conflicts since 1946 until the previous calendar year. Data is collected globally, vigorously, comparable across cases and countries and updated annually. The year 1989 was chosen as a starting year, as the UCDP offers geo-referenced data on armed conflicts from 1989 onwards. Geo-referenced data is essential for the present review, as it makes prevalence estimates of war-related PTSD, MD or PTSD+MD more precise. The geo-referenced data of the UCDP helped us to identify how widespread each war was and, therefore, allowed for a more precise estimate of how many people had been affected by each war. In line with the UCDP, the following definition of war was utilized for the present review: ‘Armed conflict in which at least one actor is the government of a state, resulting in at least 1000 battle-related deaths in one calendar year’.

2.2. Reference estimates for extrapolation

The aims and methods of the previously published meta-analysis, on which the present work is based, were registered with the PROSPERO database (CRD42016032720, https://www.crd.york.ac.uk/prospero/). A more detailed description of methodology of the original meta-analysis can also be found in Morina et al. (2018). We reviewed available epidemiological research on prevalences of PTSD and MD in adult civilian survivors of war who stayed in war-afflicted regions by means of a systematic research and meta-analysis. We located relevant epidemiological studies conducted in war-effected countries in Medline, PsycINFO and PILOTS (PILOTS is managed by the USA National Center for PTSD). The search was conducted in September 2017 in titles, abstracts and key concepts using terms relating to PTSD, major depression, general mental health and war survivors. Studies meeting the following criteria were selected for the meta-analysis: (a) a sample size of at least 50 participants who were living in the area of former conflict at the time the survey was conducted; (b) participants had experienced war-related events within 25 years prior to conducting the survey; (c) at least 80% of the participants were older than 18 years; and (d) PTSD and/or MD was measured with a structured psychiatric interview based on the Diagnostic and Statistical Manuals of Mental Disorders or International Classification of Diseases criteria for these conditions (American Psychiatric Association [APA], 1980, 1994, 2013; World Health Organization [WHO], 1992). Surveys were excluded if the studied population were not representative of the general population (e.g. subgroup of participants who had all received mental health interventions or subgroups like combatants in armed forces or refugees). For the same reason, surveys carried out with Israeli samples were excluded as they usually involved a small group of the population who were exposed to specific terrorist attacks. If a publication reported on more than one sample because the study was carried out in more than one country or with different groups of war survivors, the samples were treated as distinct. For the purpose of the current publication, we added an additional inclusion criterion to the meta-analysis conducted by Morina et al. (2018), namely that surveys had to utilize a random sampling procedure from the general population to allow for an extrapolation on general populations. We conducted random effects meta-analyses to generate pooled prevalence estimates for depression and PTSD using MetaXL version 2.0 (EpiGear, QLD, Australia).

2.3. Population estimates

National population estimates relied on United Nations data for the year 2015 conducted by the Population Division of the Department of Economic and Social Affairs (DESA) of the United Nations Secretariat (UN, 2018). As stated above, geo-referenced data of the UCDP was utilized to analyse whether a respective war was spread out across an entire country or took place only in a certain region of a country (e.g. province). When a war was clearly regional rather than national, regional population estimates were taken from Wikipedia instead of DESA as the latter does not offer regional population estimates. Research indicates that Wikipedia is a reliable source in this respect (Anthony, Smith, & Williamson, 2009). Finally, regional population estimates taken from Wikipedia were multiplied with the percentage of individuals equal and above the age of 18, as given by the UN (2018). This last step was necessary, as the Wikipedia estimates do not include age groups whereas DESA estimates do. Our time span was limited to the year of 2015 as UN population estimates including the necessary age ranges (i.e. 0–17 and 18+) were only available for the year 2015. In line with our original aim, we first report the total population size, number of adults and number of people estimated to suffer from PTSD and/or MD for all countries listed by the UCDP as countries with a recent or ongoing history of war.

3. Results

3.1. Prevalences of MD and PTSD

Two raters independently rated the quality of the included trials. This was done by developing a scale tailored to the particular requirements for the current review following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines and based on previous literature (Sanderson, Tatt, & Higgins, 2007; Von Elm et al., 2007, 2014). As all but one study (Alhasnawi et al., 2009) reported point prevalences, only studies reporting point prevalences were entered. Overall, 24 and 15 epidemiological surveys met inclusion criteria that measured PTSD and MD, respectively. Taken together, 14,718 war survivors from 14 countries/regions (including Palestine) from three continents were assessed in epidemiological surveys focusing on PTSD and 9272 war survivors from eight countries and three continents were assessed in epidemiological surveys focusing on MD. In the surveys assessing PTSD, participation rate (i.e. study participants/potential participants) was higher than 70% in 83.3% of the samples. With regards to MD, participation rate was higher than 70% in 73.3% of the samples. All but two surveys reported that the interviewers were trained in assessing PTSD and/or MD. All instruments used to diagnose PTSD and/or MD had originally been developed in English and subsequently translated into the language of study participants. However, none of the authors reported the psychometric properties of the translated instruments used to assess PTSD and/or MD. The most frequently used diagnostic interview for both PTSD and MD was the MINI International Neuropsychiatric Interview (Sheehan et al., 1998). A basic description of the included surveys is provided in Table 1 and prevalences for all included surveys are depicted in the forest plots for PTSD and MD (see Figures 1 and 2). Utilizing a random effects model, we found that 23.81% of adult war survivors met diagnostic criteria for PTSD (95% CI, 19.54–28.35%) and 23.37% for MD (95% CI, 19.68–27.27%). Of these, 48.99% met criteria for comorbid PTSD and MD (95% CI, 30.29–67.83%). We utilized these percentages as a meta-analytically informed reference for the planned extrapolation.

Table 1.

Characteristics of included studies in the meta-analysis.

Publication Country N PTSD assessed with MD assessed with Years since trauma
Ayazi, Lien, Eide, Ruom, & Hauff, 2012 Sudan 1200 NA MINI 5
Betancourt et al., 2016 Sierre Leone 563 PSS-I NA NR
Canetti et al., 2010 Palestine 1196 PSS-I NA Ongoing
De Jong et al., 2001 Algeria 653 CIDI NA 6
  Palestine 585 CIDI NA Ongoing
Eytan, Gex-Fabry, Toscani, Deroo, Loutan, Bovier, 2004 Kosovo 996 MINI NA 2
Fodor, Pozen, Ntaganira, Sezibera, & Neugebauer, 2015 Rwanda 465 NA MINI NR
Johnson et al., 2008 Liberia 1661 PSS-I NA 4
Morina & Ford, 2008 Kosovo 102 MINI MINI 6
Morina, Stangier, & Risch, 2008 Kosovo 84 MINI NA 6
Morina, Ford, Risch, Morina, & Stangier, 2010 Kosovo 163 MINI MINI 8
Morina, Reschke, & Hofmann, 2011* Kosovo 71 MINI MINI 9
Morina, von Lersner, & Prigerson, 2011* Kosovo 175 MINI MINI 10
Morina & Emmelkamp, 2012* Kosovo 106 MINI MINI 10
Mugisha, Muyinda, Malamba, & Kinyanda, 2015 Uganda 2361 MINI MINI 7
Munyandamutsa, Nkubamugisha, Gex-Fabry, & Eytan, 2012 Rwanda 962 MINI MINI 14
Priebe et al., 2010 Croatia 727 MINI MINI 13
  Kosovo 648 MINI MINI 8
  Serbia 637 MINI MINI 13
  Bosnia & Herzegovina 640 MINI MINI 13
Rieder & Elbert, 2013 Rwanda 172 PSS-I NA 16
Rugema, Mogren, Ntaganira, & Krantz, 2015 Rwanda 917 MINI MINI 17
Schaal, Dusingizemungu, Jacob, & Elbert, 2011 Rwanda 400 PSS-I NA 13
Somasundaram & Sivayokan, 1994 Sri Lanka 98 SIQ SIQ 4
Veling, Hall, & Joosse, 2013 D. R. of Congo 93 CIDI NA ongoing
Yasan, Saka, Ozkan, & Ertem, 2009 Turkey 708 CAPS NA 10
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CAPS = Clinician-Administered PTSD Scale; CIDI = Composite International Diagnostic Interview; MD = Major Depression; MINI = MINI International Neuropsychiatric Interview; N = number of participants; NA = not applicable; NR = not reported; PSS-I = Posttraumatic Symptom Scale Interview; PTSD = Posttraumatic Stress Disorder; SIQ = Stress Impact Questionnaire. *only subsample included that met presented inclusion criteria

Figure 1.

Figure 1.

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Forest plot depicting meta-analytic results of all representative surveys assessing PTSD in countries with a history of war between 1989 and 2015.

3.2. Extrapolated prevalence estimates of global war survivors suffering MD and/or PTSD in absolute numbers

Global estimates of absolute numbers of war survivors with PTSD, MD or PTSD+MD per war-country/region are depicted in Table 2. In three countries, wars were clearly regional rather than statewide. These took place in India (five regions), the Russian Federation (one region) and Ukraine (five regions). In the case of India, war took place in the five provinces of Kashmir, Punjab, Nagaland, Assam and Manipur. The population size is distributed as follows: Punjab = 27,743,338; Nagaland = 1,980,602; Kashmir = 12,541,302; Assam = 31,169,272; Manipur = 2,721,756. Nationally, 66% of Indians were 18 years old or above in 2015. Based on this proportion, we estimated that 50,263,138 inhabitants in the given five war regions were adult war survivors in 2015. In Ukraine, warfare took place in five provinces of Eastern Ukraine, namely Donetsk (4,403,178 inhabitants), Kharkiv (2,742,180 inhabitants), Luhansk (2,272,676 inhabitants), Zaporizhia (1,791,668 inhabitants) and Dnipropetrovsk (3,320,299 inhabitants). Based on the national proportion of 82.2% adults, we estimated that 11,943,661 adult war survivors lived in the given five regions in 2015. In the Russian Federation, war took place in Chechnya with a population of 1,395,678. Based on the national proportion of 79.9% adults, we estimated 1,115,147 adult war survivors living in Chechnya in 2015. Since no population estimates were available for Kosovo in the UN database, we also took this population estimate from Wikipedia with 1,920,079 inhabitants in total and 1,555,264 adults (i.e. 81%). Overall, wars took place in the territory of 47 countries between 1989 and 2015. Figure 3 presents a world map with all countries or regions marked that have a war history during these 26 years. Presented data and estimations for countries in which at least one of the included surveys were conducted are presented with bold font whereas normal font indicates that no survey was available.

Table 2.

Prevalence estimates of PTSD and MD in absolute numbers for countries/regions with a recent or ongoing history of war (between 1989 and 2015).

Country (plus region if war was regional) Year (first war intensity reached within given timespan) Year (last) war ended (within given timespan) War survivors alive in 2015 (all ages) Adult war survivors alive in 2015 Estimate of adult war survivors with PTSD Lower bound 95% CI for estimate of adult war survivors with PTSD Upper bound 95% CI for estimate of adult war survivors with PTSD Estimate of adult war survivors with MD Lower bound 95% CI for estimate of adult war survivors with MD Upper bound 95% CI for estimate of adult war survivors with MD Estimate of adult war survivors with PTSD+MD Lower bound 95% CI for estimate of adult war survivors with PTSD+MD Upper bound 95% CI for estimate of adult war survivors with PTSD+MD
Afghanistan 1989 2015 33,736,494 16,248,402 3,868,745 3,174,938 4,606,422 3,797,252 3,197,686 4,430,939 1,860,274 1,150,187 2,575,676
Angola 1989 2001 14,743,060 12,932,355 3,079,194 2,526,982 3,666,323 3,022,291 2,545,087 3,526,653 1,480,621 915,452 2,050,020
El Salvador 1989 1989 3,232,318 3,232,318 769,615 631,595 916,362 755,393 636,120 881,453 370,067 228,808 512,383
Ethiopia 1989 2000 58,315,113 51,037,897 12,152,123 9,972,805 14,469,244 11,927,557 10,044,258 13,918,035 5,843,310 3,612,857 8,090,462
India (5 regions) 1989 2010 76,156,270 50,263,138 11,967,653 9,821,417 14,249,600 11,746,495 9,891,786 13,706,758 5,754,608 3,558,013 7,967,648
Lebanon 1989 1990 3,308,096 3,308,096 787,658 646,402 937,845 773,102 651,033 902,118 378,743 234,173 524,395
Mozambique 1989 1991 9,825,494 9,825,494 2,339,450 1,919,902 2,785,528 2,296,218 1,933,657 2,679,412 1,124,917 695,524 1,557,525
Myanmar 1989 1995 32,949,950 32,949,950 7,845,383 6,438,420 9,341,311 7,700,403 6,484,550 8,985,451 3,772,428 2,332,452 5,223,184
Peru 1989 1992 17,036,955 17,036,955 4,056,499 3,329,021 4,829,977 3,981,536 3,352,873 4,645,978 1,950,555 1,206,007 2,700,676
Somalia 1989 2015 13,908,129 6,460,529 1,538,252 1,262,387 1,831,560 1,509,826 1,271,432 1,761,786 739,664 457,326 1,024,115
Sri Lanka 1989 2009 19,071,024 14,663,408 3,491,357 2,865,230 4,157,076 3,426,838 2,885,759 3,998,711 1,678,808 1,037,989 2,324,425
Sudan 1989 2015 38,647,803 19,999,254 4,761,822 3,907,854 5,669,789 4,673,826 3,935,853 5,453,797 2,289,707 1,415,702 3,170,256
Uganda 1989 2004 25,053,829 17,988,598 4,283,085 3,514,972 5,099,768 4,203,935 3,540,156 4,905,491 2,059,508 1,273,372 2,851,529
Kuwait 1990 1990 2,666,577 2,666,577 634,912 521,049 755,975 623,179 524,782 727,176 305,295 188,761 422,702
Liberia 1990 2003 2,922,132 2,295,826 546,636 448,604 650,867 536,535 451,819 626,072 262,848 162,516 363,931
Philippines 1990 2009 77,272,212 62,766,155 14,944,622 12,264,507 17,794,205 14,668,450 12,352,379 17,116,330 7,186,074 4,443,074 9,949,610
Iraq 1991 2015 36,115,649 19,093,017 4,546,047 3,730,776 5,412,870 4,462,038 3,757,506 5,206,666 2,185,952 1,351,551 3,026,600
Serbia 1991 1999 7,269,488 7,055,639 1,679,948 1,378,672 2,000,274 1,648,903 1,388,550 1,924,073 807,797 499,453 1,118,451
Sierra Leone 1991 1999 3,976,502 3,655,622 870,404 714,309 1,036,369 854,319 719,426 996,888 418,531 258,773 579,484
Azerbaijan 1992 1994 6,528,719 6,528,719 1,554,488 1,275,712 1,850,892 1,525,762 1,284,852 1,780,382 747,471 462,153 1,034,924
Bosnia-Herzegovina 1992 1996 2,790,591 2,790,591 664,440 545,281 791,133 652,161 549,188 760,994 319,494 197,540 442,361
Chad 1992 2006 8,814,828 6,370,163 1,516,736 1,244,730 1,805,941 1,488,707 1,253,648 1,737,143 729,318 450,929 1,009,790
Colombia 1992 2005 39,780,695 34,084,736 8,115,576 6,660,157 9,663,023 7,965,603 6,707,876 9,294,908 3,902,349 2,412,781 5,403,068
Tajikistan 1992 1996 5,027,045 5,027,045 1,196,939 982,285 1,425,167 1,174,820 989,322 1,370,875 575,545 355,853 796,881
Turkey 1992 2015 78,271,472 54,214,657 12,908,510 10,593,544 15,369,855 12,669,965 10,669,444 14,784,337 6,207,016 3,837,733 8,594,037
DR Congo 1993 2014 76,196,619 36,005,024 8,572,796 7,035,382 10,207,424 8,414,374 7,085,789 9,818,570 4,122,202 2,548,714 5,707,470
Georgia 1993 1993 2,923,312 2,923,312 696,041 571,215 828,759 683,178 575,308 797,187 334,689 206,935 463,400
Nigeria 1993 2015 181,181,744 89,657,945 21,347,557 17,519,162 25,418,027 20,953,062 17,644,684 24,449,722 10,264,905 6,346,682 14,212,462
Algeria 1994 2002 30,136,506 26,695,292 6,356,149 5,216,260 7,568,115 6,238,690 5,253,633 7,279,806 3,056,334 1,889,699 4,231,703
Ghana 1994 1994 13,464,347 13,464,347 3,205,861 2,630,933 3,817,142 3,146,618 2,649,783 3,671,727 1,541,528 953,111 2,134,351
Rwanda 1994 1994 5,677,229 5,677,229 1,351,748 1,109,331 1,609,494 1,326,768 1,117,279 1,548,180 649,984 401,878 899,947
Yemen 1994 2015 26,916,207 14,168,377 3,373,491 2,768,501 4,016,735 3,311,150 2,788,337 3,863,716 1,622,132 1,002,947 2,245,953
Burundi 1995 2003 6,572,888 4,998,535 1,190,151 976,714 1,417,085 1,168,158 983,712 1,363,100 572,280 353,835 792,361
Croatia 1995 1995 3,366,460 3,366,460 801,554 657,806 954,391 786,742 662,519 918,034 385,425 238,304 533,647
Russia (Chechnya) 1995 2004 1,395,678 1,115,147 265,517 217,900 316,144 260,610 219,461 304,101 127,673 78,939 176,772
Congo 1997 1998 2,668,374 2,570,121 611,946 502,202 728,629 600,637 505,800 700,872 294,252 181,933 407,412
Kosovo 1998 1999 1,920,079 1,555,264 370,308 303,899 440,917 363,465 306,076 424,120 178,062 110,094 246,538
Eritrea 1999 2000 2,691,877 2,497,009 594,538 487,916 707,902 583,551 491,411 680,934 285,882 176,758 395,823
Indonesia 1999 2004 205,171,722 172,620,713 41,100,992 33,730,087 48,937,972 40,341,461 33,971,756 47,073,668 19,763,282 12,219,428 27,363,613
Nepal 2002 2005 22,036,098 17,327,965 4,125,788 3,385,884 4,912,478 4,049,545 3,410,144 4,725,336 1,983,872 1,226,607 2,746,807
Pakistan 2007 2015 189,380,513 111,392,381 26,522,526 21,766,071 31,579,740 26,032,399 21,922,021 30,376,702 12,753,272 7,885,214 17,657,777
Libya 2011 2015 6,234,955 4,129,126 983,145 806,831 1,170,607 964,977 812,612 1,126,013 472,742 292,291 654,544
South Sudan 2011 2015 11,882,136 6,077,912 1,447,151 1,187,624 1,723,088 1,420,408 1,196,133 1,657,447 695,858 430,242 963,463
Syria 2011 2015 18,734,987 10,239,376 2,437,995 2,000,774 2,902,863 2,392,942 2,015,109 2,792,278 1,172,302 724,822 1,623,133
Israel 2014 2014 8,064,547 5,436,620 1,294,459 1,062,316 1,541,282 1,270,538 1,069,927 1,482,566 622,437 384,846 861,806
Ukraine (East) 2014 2015 14,530,001 11,943,661 2,843,786 2,333,791 3,386,028 2,791,234 2,350,512 3,257,036 1,367,425 845,465 1,893,294
Cameroon 2015 2015 22,834,522 11,530,588 2,745,433 2,253,077 3,268,922 2,694,698 2,269,220 3,144,391 1,320,133 816,224 1,827,814
Total     1,471,401,246 1,017,887,545 242,359,024 198,895,226 288,571,119 237,880,319 200,320,269 277,577,934 116,537,568 72,053,949 161,354,221
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PTSD = Post-traumatic Stress Disorder; CI = confidence interval; MD = Major Depression. Bold country data indicates that a random sample from the general population of the respective country was available for the meta-analysis whereas normal font indicates that no such representative sample was available.

Figure 3.

Figure 3.

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World map with countries and regions marked which have a history of at least one war between 1989 and 2015.

Retrieved from: https://www.amcharts.com/visited_countries/#. Regions added manually.

For the reference year 2015, we estimate that globally 1,471,401,246 individuals were still alive who experienced war between 1989 and 2015. Of this global population estimate of war survivors, 1,017,887,545 (i.e. about 70%) were adults and the remaining 432,146,933 children and adolescents in 2015. These about 1.45 billion living estimated war survivors in 2015 represented about 19.6% of the whole world population. In other words, we estimate that a little less than one in five individuals on the planet in 2015 experienced war between 1989 and 2015. Similarly, the estimated approximately one billion adult war survivors represented about 20% of the global adult population, and the approximately 0.4 billion children about 18.9% of the global population of children and adolescents. Based on the meta-analytically informed overall prevalence of 23.81% for PTSD (95% CI, 19.54–28.35%) and 23.37% for MD (95% CI, 19.68–27.27%), about 242 million adult war survivors residing in (post-)war regions are estimated to suffer from PTSD (95% CI, 198,895,226–288,571,119) and about another 238 million adult survivors of war from MD (95% CI, 200,320,269–277,577,934). Based on the reported comorbidity rate of 48.99% (95% CI, 30.29–67.83%), about 117 million war survivors are estimated to suffer from both conditions (95% CI, 72,053,949–161,354,221), leaving about 126 million people suffering from PTSD exclusively and another approximately 121 million people suffering from MD exclusively. Accordingly, about 354 million adult war survivors are estimated to suffer from PTSD and/or MD.

4. Discussion/conclusion

From the approximate five billion adults worldwide in 2015, we estimate that about one billion, or about one in five, were residing in a country or region that has been directly affected by war between 1989 and 2015. Our findings suggest that 354 million adult war survivors suffer from PTSD and/or MD and, of these, about 117 million suffer from both conditions.

4.1. Comparison with the literature

Our findings are in line with the meta-analysis conducted by Steel et al. (2009) who reported that about 30% of populations exposed to mass conflict and displacement suffer from PTSD and/or MD. Steel et al. (2009) based their results on surveys conducted with selected populations that had undergone specific war events (e.g. torture) and most of the included samples were refugees. These results cannot directly inform estimates of mental disorders in the general population in post-war regions. Hence, the studies included in our meta-analysis are likely to better capture prevalences for whole regions with a recent war history.

4.2. Strengths and limitation

To our knowledge, this is the first publication to provide estimates of absolute numbers of war survivors with PTSD and/or MD. For this purpose, we included only surveys that applied a randomized procedure to collect data in the general population and a valid psychiatric interview to diagnose the disorders in question. However, our paper has several limitations. First, the number of the available surveys that met our inclusion criteria was rather limited. Our estimates involving 1 billion adults living in (post-)conflict regions are based on only 24 surveys assessing PTSD that included 14,718 participants from 14 countries/regions (including Palestine) and 15 surveys assessing MD that included 9272 participants from eight countries. Overall, we were able to include random samples from 14 countries/regions only (lines in bold font in Table 2). The reader will notice that only 13 lines are presented in bolt font in Table 2. This concerns the fact that Palestinians reside in several regions across several countries and hence could not be categorized. The overall slim evidence base in this field of research reminds us that our findings must be interpreted with caution until more research has been conducted.

Another major limitation of the present review concerns variability in trauma exposure on a country as well as subpopulation level. We relied on the definition of the UCDP to define war but, naturally, war is not a categorical phenomenon as the definition may imply. The duration of war as well as the intensity (e.g. number of casualties, committed war crimes, etc.) may vary considerably across countries. However, our analysis could not account for such country-based differences. Also, on a subpopulation level, different individuals may have been exposed to different war-related events. We have tried to adjust for this problem by dividing into nationwide/widespread wars and local/regional wars. However, this categorical approach can again be criticized for lacking specificity. Nevertheless, we would like to emphasize that our meta-analysis was based on surveys that utilized a random sampling procedure and were conducted in the general population. By definition, this included individuals with different levels of exposure to war-related events. Accordingly, such surveys offered mean prevalences of PTSD and depression in the general population. Furthermore, we report mean prevalences of PTSD and depression across countries and results yielded narrow confidence intervals for both PTSD and MD (i.e. 95% CI of 19.54–28.35% and 19.68–27.27%, respectively). The narrow confidence intervals point towards a similarly high prevalence across the included samples/countries despite the lack in adjusting for variability in conflict length and intensity on a country and subpopulation level. Another limitation is that samples from Kosovo and Rwanda are overrepresented in the available literature. This is crucial as the prevalences from war survivors from these countries may skew the results of the meta-analysis. A further issue to consider is that all instruments had been translated from English into the spoken language of the participants. While they possess good psychometric properties in English, none of the included surveys reported psychometric cross-validation of the translated instruments. As such, the missing psychometric validation presents a main methodological limitation in this field of research.

While PTSD is trauma-related per definition, MD is not necessarily. MD is the most prevalent mental disorder across countries (Ferrari et al., 2013). As such, the high MD prevalence reported in this paper may or may not be directly associated with exposure to and consequences of war events. While exposure to war-related events and the consequences of these events can play a causal role in the aetiology of MD, other influential variables (i.e. other pre-war and post-war stressors) may also lead to the development and maintenance of depression.

Crucially, we were not able to control for the frequency and duration of exposure to other types of trauma. Neither can we expect that frequency and duration of non-war-related trauma types are equally distributed across countries around the world. Hence, we cannot preclude the hypothesis that other trauma types may be more prevalent in countries with a recent or ongoing history of war, compared to countries without recent history of conflict, and that the increased prevalence may boil down to the exposure to different trauma types rather than the postulated war-related traumas (i.e. third variable problem). Kessler et al. (2017) concluded from their analysis of the WHO World Mental Health Surveys that the most common trauma-exposures globally are witnessing or discovering death or serious injury (35.7% of respondents) followed by traumas involving accidents (34.3% of respondents), unexpected death of a loved one (31.4% of respondents), physical violence (22.9% of respondents), intimate partner sexual violence (14% of respondents), war trauma (13.1% of respondents) and ‘other’ traumas (8.4% of respondents). As such, literature suggests that war-related traumas, globally speaking, are a rather uncommon trauma type compared to the other trauma types that people may experience. However, it should be noted that conclusions by Kessler et al. were mainly limited to data from countries without a war history between 1989 and 2015. In fact, they included data from only three of the countries that the UCDP lists as countries with a war history between 1989 and 2015, namely Colombia, Nigeria and Peru. They also reported data from Ukraine, which, however, were collected in 2002 (i.e. before the recent war had started). Hence, it remains speculative whether the pooled data analysed by Kessler et al. and their conclusions based on these data are representative for countries with a recent history of war.

Furthermore, the definition of trauma type is crucial. In their article, Kessler et al. subdivided war trauma into the following categories: combat experience, purposefully injured/killed someone, saw atrocities, being a relief worker or peacekeeper, being a civilian in war zone, being a civilian in a region of terror, and being forcefully displaced (i.e. a refugee). Arguably, this list is not exhaustive and lines between the trauma types are blurred. For instance, rape is categorized as a subcategory of ‘intimate partner or sexual violence’ in Kessler et al.’s analyses. However, war atrocities such as mass rapes show that rape in a war context may be conceptualized as war-related trauma rather than ‘intimate partner or sexual violence’ (see Kuwert et al., 2010; Silove, 1999).

Kessler et al. (2017) also report that war-trauma is associated with a higher risk of developing PTSD (3.5%) compared to, for instance, physical violence (2.8%) or accidents (2%), but associated with less risk compared to intimate partner or sexual violence (11.4%) or unexpected death of a loved one (5.4%). These data in particular suggest the possibility that the increased prevalence rates reported in the present analysis are not simply due to war-related traumas, but to other forms of traumatization, such as intimate interpersonal traumas. Again, the lacking data from countries with a recent war history in their analyses do not allow for a generalization and hence this statement remains speculative.

We would also like to stress that, apart from the degree of exposure and differences in exposure levels, the cultural and socioeconomic profile of a country relates to the risk of developing trauma-related mental health disorders and thus to country-level prevalence rates. For instance, Burri and Maercker (2014) noted that, apart from country-specific trauma rates during World War II as a significant predictor of country-level PTSD prevalence, the cultural value orientation of ‘stimulation’, which they conceptualized as a cultural orientation towards modern values, as opposed to traditional values, was related to higher country-level PTSD prevalences. Since their results are specific to European countries in the aftermath of World War II, we cannot simply translate these findings to different cultural- and war-contexts of the countries included in our analysis. Yet their findings indicate that, next to trauma exposure, culture-specific factors may also explain differences in prevalence rates. As we did not account for cultural differences, this should be regarded as another limitation of the present analysis.

On this note, Dückers, Alisic, and Brewin (2016) verified the positive relation between trauma exposure and country-level PTSD prevalence. However, paradoxically they also found a negative relationship between a country’s overall cultural and socioeconomic vulnerability to adversity and a country’s PTSD prevalence. Trauma exposure and the country’s cultural and socioeconomic vulnerability, together with the interaction between the two, explained about 75% of the variance in country-level PTSD prevalence. The population samples included in our study did not allow us to corroborate these results. It should be pointed out that, similar to Kessler et al. (2017), Dückers et al. (2016) included data mainly from middle-to-upper and high income countries and only data from six of the 47 countries with a war history between 1989 and 2015 (i.e. Nigeria, Israel, Colombia, Iraq, Lebanon and Ukraine). Again, the included data might not be representative for low-to-middle income countries (LMICs) with a recent war history and therefore conclusions from their study may not apply globally. The included surveys in our review did not enable us to control for the cultural and socioeconomic profile of a country and the relation to PTSD prevalence and persistence.

Furthermore, the included surveys did not systematically report prevalences by gender, which is another limitation in the current analysis. However, this was reported by Priebe et al. (2010) in relation to the five countries of former Yugoslavia that were surveyed in their project. The findings of this study revealed that women had higher prevalences of both PTSD and depression in four of the surveyed countries, whereas the sample from Croatia did not report any significant gender difference. Similarly, the included studies did not systematically report on the relationship between age and prevalences of PTSD and depression. Again, this was mentioned in the publication by Priebe et al. (2010) who reported that older age (i.e. defined as being older than 40 years old) was associated with higher prevalences of both PTSD and depression on all of the five surveyed countries.

4.3. Implications and conclusions

PTSD and MD in war-afflicted societies have to be prioritized as a serious global health issue. To improve estimates of mental disorders, and perhaps more importantly to assess factors associated with the maintenance of and recovery from mental disorders, randomized surveys conducted in post-war societies applying empirically validated measurements are required. Furthermore, longitudinal research is crucial to better capture the course of mental disorders, which might fluctuate over time. This notion directly relates to the extent of accuracy of our findings. Theoretically, one can expect rates of PTSD and MD to decline over time in populations with no current open conflict. However, research indicates that PTSD, if left untreated, has a rather chronic course (Morina et al., 2014). This notion is supported by the fact that 10 of the included samples were assessed at least 10 years after the respective war ended and the prevalences of PTSD and/or MD were still high (see Table 1). Kessler et al. (2017) report that war-related trauma is associated with a slower speed of PTSD-remission compared to other trauma types such as intimate partner violence, sexual violence or accidents in the first six years after traumatization, with war-related trauma victims being the subgroup with the least PTSD-remissions by far (see Figure 2 in their article). However, at about six years after traumatization, Kessler et al. report a steep increase in PTSD-remission rates resulting in better remission rates compared to physical violence, intimate partner or sexual violence, and other traumas. After about 10 years, about 90% of those initially with war-trauma-related PTSD did not meet criteria for this condition anymore. However, one limitation regarding the study by Kessler et al. is that we cannot conclude whether remission from PTSD at a certain point translates into recovery from this disorder. This conclusion might only result from longitudinal surveys with repeated measurements for a long period of time. As mentioned before, we have included 10 epidemiological surveys that were assessed at least 10 years after war exposure and yet these surveys report PTSD and MD prevalences way above 10%. One reason for this difference in figures could be different data sources. Again, Kessler et al. mainly included data from middle-to-upper and high-income countries and were only able to include data from three countries with a recent war history in their analyses. As such, their PTSD-remission curve may not apply to the war-afflicted LMICs context. There is a lack of research on the course of PTSD or depression among war survivors living in LMICs. However, a follow-up study by Priebe et al. (2013) indicates that there might be a fluctuating course of PTSD symptoms over time. In this study, about a third of 522 war survivors who had initially reported PTSD did not meet criteria for this disorder a year later. One implication is therefore that our averaged prevalence of PTSD might possibly decline over time. Besides the mentioned research implications, the findings call for more clinical efforts to develop feasible interventions in LMICs-contexts to address the large number of survivors of mass violence who are in need of mental health services (Morina, Malek, Nickerson, & Bryant, 2017).

Figure 2.

Figure 2.

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Forest plot depicting meta-analytic results of all representative surveys assessing MD in countries with a history of war between 1989 and 2015.

Based on the slim available evidence base, it is estimated that globally about 354 million adult survivors of war suffer from PTSD and/or MD, of which about 117 million are estimated to suffer from comorbid PTSD and MD. More randomized surveys with longitudinal assessments of mental health conditions in general population samples utilizing (cross-)validated measures are necessary to evaluate the accuracy of the estimates reported here. Most countries with a recent or ongoing history of war are LMICs with limited resources to handle the vast PTSD and MD burden at hand. We would like to encourage the development of feasible solutions for treatment purposes as well as international collaborations for war prevention.

Disclosure statement

No potential conflict of interest was reported by the authors.

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