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Civilians in World War II and DSM-IV mental disorders: results from the World Mental Health Survey Initiative

Social Psychiatry and Psychiatric Epidemiology volume 53, pages 207–219 (2018)Cite this article

Abstract

Purpose

Understanding the effects of war on mental disorders is important for developing effective post-conflict recovery policies and programs. The current study uses cross-sectional, retrospectively reported data collected as part of the World Mental Health (WMH) Survey Initiative to examine the associations of being a civilian in a war zone/region of terror in World War II with a range of DSM-IV mental disorders.

Methods

Adults (n = 3370) who lived in countries directly involved in World War II in Europe and Japan were administered structured diagnostic interviews of lifetime DSM-IV mental disorders. The associations of war-related traumas with subsequent disorder onset-persistence were assessed with discrete-time survival analysis (lifetime prevalence) and conditional logistic regression (12-month prevalence).

Results

Respondents who were civilians in a war zone/region of terror had higher lifetime risks than other respondents of major depressive disorder (MDD; OR 1.5, 95% CI 1.1, 1.9) and anxiety disorder (OR 1.5, 95% CI 1.1, 2.0). The association of war exposure with MDD was strongest in the early years after the war, whereas the association with anxiety disorders increased over time. Among lifetime cases, war exposure was associated with lower past year risk of anxiety disorders (OR 0.4, 95% CI 0.2, 0.7).

Conclusions

Exposure to war in World War II was associated with higher lifetime risk of some mental disorders. Whether comparable patterns will be found among civilians living through more recent wars remains to be seen, but should be recognized as a possibility by those projecting future needs for treatment of mental disorders.

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Acknowledgements

The WHO World Mental Health Survey collaborators are Sergio Aguilar-Gaxiola, MD, PhD, Ali Al-Hamzawi, MD, Mohammed Salih Al-Kaisy, MD, Jordi Alonso, MD, PhD, Laura Helena Andrade, MD, PhD, Corina Benjet, PhD, Guilherme Borges, ScD, Evelyn J. Bromet, PhD, Ronny Bruffaerts, PhD, Brendan Bunting, PhD, Jose Miguel Caldas de Almeida, MD, PhD, Graca Cardoso, MD, PhD, Alfredo H. Cia, MD, Somnath Chatterji, MD, Louisa Degenhardt, PhD, Giovanni de Girolamo, MD, Peter de Jonge, PhD, Koen Demyttenaere, MD, PhD, John Fayyad, MD, Silvia Florescu, MD, PhD, Oye Gureje, PhD, DSc, FRCPsych, Josep Maria Haro, MD, PhD, Yanling He, MD, Hristo Hinkov, MD, Chi-yi Hu, PhD, MD, Yueqin Huang, MD, MPH, PhD, Aimee Nasser Karam, PhD, Elie G. Karam, MD, Norito Kawakami, MD, DMSc, Ronald C. Kessler, PhD, Andrzej Kiejna, MD, PhD, Viviane Kovess-Masfety, MD, PhD, Sing Lee, MB,BS, Jean-Pierre Lepine, MD, Daphna Levinson, PhD, John McGrath, PhD, Maria Elena Medina-Mora, PhD, Jacek Moskalewicz, DrPH, Fernando Navarro-Mateu, MD, PhD, Beth-Ellen Pennell, MA, Marina Piazza, MPH, ScD, Jose Posada-Villa, MD, Kate M. Scott, PhD, Tim Slade, PhD, Juan Carlos Stagnaro, MD, PhD, Dan J. Stein, FRCPC, PhD, Margreet ten Have, PhD, Yolanda Torres, MPH, Dra.HC, Maria Carmen Viana, MD, PhD, Harvey Whiteford, PhD, David R. Williams, MPH, PhD, Bogdan Wojtyniak, ScD. The World Health Organization World Mental Health (WMH) Survey Initiative is supported by the National Institute of Mental Health (NIMH; R01 MH070884 and R01 MH093612-01), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the US Public Health Service (R13-MH066849, R01-MH069864, and R01 DA016558), the Fogarty International Center (FIRCA R03-TW006481), the Pan American Health Organization, Eli Lilly and Company, Ortho-McNeil Pharmaceutical, Inc., GlaxoSmithKline, and Bristol-Myers Squibb. We thank the staff of the WMH Data Collection and Data Analysis Coordination Centres for assistance with instrumentation, fieldwork, and consultation on data analysis. The ESEMeD project is funded by the European Commission (Contracts QLG5-1999-01042; SANCO 2004123, and EAHC 20081308), the Piedmont Region (Italy), other local agencies and by an unrestricted educational grant from GlaxoSmithKline. The World Mental Health Japan (WMHJ) Survey is supported by the Grant for Research on Psychiatric and Neurological Diseases and Mental Health (H13-SHOGAI-023, H14-TOKUBETSU-026, H16-KOKORO-013, H25-SEISHIN-IPPAN-006) from the Japan Ministry of Health, Labour and Welfare. The Romania WMH study projects “Policies in Mental Health Area” and “National Study regarding Mental Health and Services Use” were carried out by National School of Public Health and Health Services Management (former National Institute for Research and Development in Health), with technical support of Metro Media Transilvania, the National Institute of Statistics-National Centre for Training in Statistics, SC. Cheyenne Services SRL, Statistics Netherlands and were funded by Ministry of Public Health (former Ministry of Health) with supplemental support of Eli Lilly Romania SRL. The Ukraine Comorbid Mental Disorders during Periods of Social Disruption (CMDPSD) study is funded by the US National Institute of Mental Health (RO1-MH61905). Dr. Stephen E. Gilman’s work was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. None of the funders had any role in the design, analysis, interpretation of results, or preparation of this paper. The views and opinions expressed in this report are those of the authors and should not be construed to represent the views of the World Health Organization, other sponsoring organizations, agencies, or governments. A complete list of all within-country and cross-national WMH publications can be found at http://www.hcp.med.harvard.edu/wmh/.

Author information

Affiliations

  1. Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA

    Rochelle Frounfelker & Stephen E. Gilman

  2. SHERPA Research Centre, CIUSS Centre-Ouest de l-ile de Montreal, Montreal, QC, Canada

    Rochelle Frounfelker

  3. McGill University Health Centre Research Institute, Montreal, QC, Canada

    Rochelle Frounfelker

  4. Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA

    Stephen E. Gilman

  5. Health Behavior Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA

    Stephen E. Gilman

  6. Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Stephen E. Gilman

  7. Research Program on Children and Adversity, Boston College School of Social Work, Chestnut Hill, MA, USA

    Theresa S. Betancourt

  8. Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA

    Theresa S. Betancourt

  9. Center for Reducing Health Disparities, UC Davis Health System, Sacramento, CA, USA

    Sergio Aguilar-Gaxiola

  10. Health Services Research Unit, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain

    Jordi Alonso

  11. Pompeu Fabra University (UPF), Barcelona, Spain

    Jordi Alonso

  12. CIBER en Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain

    Jordi Alonso

  13. Department of Psychiatry, Stony Brook University School of Medicine, Stony Brook, NY, USA

    Evelyn J. Bromet

  14. Universitair Psychiatrisch Centrum-Katholieke Universiteit Leuven (UPC-KUL), Campus Gasthuisberg, Leuven, Belgium

    Ronny Bruffaerts

  15. Unit of Epidemiological and Evaluation Psychiatry, IRCCS-St. John of God Clinical Research Centre, Brescia, Italy

    Giovanni de Girolamo

  16. Ukrainian Psychiatric Association, Kiev, Ukraine

    Semyon Gluzman

  17. Department of Psychiatry, University College Hospital, Ibadan, Nigeria

    Oye Gureje

  18. Department of Psychiatry and Clinical Psychology, Faculty of Medicine, St George Hospital University Medical Center, Balamand University, Beirut, Lebanon

    Elie G. Karam

  19. Institute for Development, Research, Advocacy and Applied Care (IDRAAC), Beirut, Lebanon

    Elie G. Karam

  20. Department of Psychiatry, Chinese University of Hong Kong, Tai Po, Hong Kong

    Sing Lee

  21. INSERM UMR-S 1144, Hôpital Lariboisière- Fernand Widal, Assistance Publique Hôpitaux de Paris, Universités Paris Descartes-Paris Diderot, Paris, France

    Jean-Pierre Lépine

  22. Center for Cognitive Behavior Therapy and Training, Tokyo, Japan

    Yutaka Ono

  23. Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA

    Beth-Ellen Pennell

  24. National School of Public Health, Management and Professional Development, Bucharest, Romania

    Daniela G. Popovici

  25. Trimbos-Instituut, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands

    Margreet ten Have

  26. Department of Health Care Policy, Harvard Medical School, Boston, MA, USA

    Ronald C. Kessler

Authors
  1. Rochelle Frounfelker
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  2. Stephen E. Gilman
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  3. Theresa S. Betancourt
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  4. Sergio Aguilar-Gaxiola
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  5. Jordi Alonso
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  6. Evelyn J. Bromet
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  7. Ronny Bruffaerts
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  8. Giovanni de Girolamo
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  9. Semyon Gluzman
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  10. Oye Gureje
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  11. Elie G. Karam
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  12. Sing Lee
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  13. Jean-Pierre Lépine
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  14. Yutaka Ono
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  15. Beth-Ellen Pennell
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  16. Daniela G. Popovici
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  17. Margreet ten Have
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  18. Ronald C. Kessler
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Consortia

On behalf of the WHO World Mental Health Survey Collaborators

  • Sergio Aguilar-Gaxiola
  • , Ali Al-Hamzawi
  • , Mohammed Salih Al-Kaisy
  • , Jordi Alonso
  • , Laura Helena Andrade
  • , Corina Benjet
  • , Guilherme Borges
  • , Evelyn J. Bromet
  • , Ronny Bruffaerts
  • , Brendan Bunting
  • , Jose Miguel Caldas de Almeida
  • , Graca Cardoso
  • , Alfredo H. Cia
  • , Somnath Chatterji
  • , Louisa Degenhardt
  • , Giovanni de Girolamo
  • , Peter de Jonge
  • , Koen Demyttenaere
  • , John Fayyad
  • , Silvia Florescu
  • , Oye Gureje
  • , Josep Maria Haro
  • , Yanling He
  • , Hristo Hinkov
  • , Chi-yi Hu
  • , Yueqin Huang
  • , Aimee Nasser Karam
  • , Elie G. Karam
  • , Norito Kawakami
  • , Ronald C. Kessler
  • , Andrzej Kiejna
  • , Viviane Kovess-Masfety
  • , Sing Lee
  • , Jean-Pierre Lepine
  • , Daphna Levinson
  • , John McGrath
  • , Maria Elena Medina-Mora
  • , Jacek Moskalewicz
  • , Fernando Navarro-Mateu
  • , Beth-Ellen Pennell
  • , Marina Piazza
  • , Jose Posada-Villa
  • , Kate M. Scott
  • , Tim Slade
  • , Juan Carlos Stagnaro
  • , Dan J. Stein
  • , Margreet ten Have
  • , Yolanda Torres
  • , Maria Carmen Viana
  • , Harvey Whiteford
  • , David R. Williams
  •  & Bogdan Wojtyniak

Corresponding author

Correspondence to Ronald C. Kessler.

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Conflict of interest

In the past 3 years, Dr. Kessler received support for his epidemiological studies from Sanofi Aventis; was a consultant for Johnson & Johnson Wellness and Prevention, Shire, Takeda; and served on an advisory board for the Johnson & Johnson Services Inc. Lake Nona Life Project. Kessler is a co-owner of DataStat, Inc., a market research firm that carries out healthcare research.

Additional information

The members of the WHO World Mental Health Survey Collaborators are listed in acknowledgements.

Appendix

Appendix

See Table 6.

Table 6 Changes over time in the multivariate associations of being a civilian in a war zone/region of terror and war traumas with subsequent first onset of major depression and anxiety disorders among people who were alive during WWII
Full size table

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Frounfelker, R., Gilman, S.E., Betancourt, T.S. et al. Civilians in World War II and DSM-IV mental disorders: results from the World Mental Health Survey Initiative. Soc Psychiatry Psychiatr Epidemiol 53, 207–219 (2018). https://doi.org/10.1007/s00127-017-1452-3

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  • DOI: https://doi.org/10.1007/s00127-017-1452-3

Keywords

  • Civilians in war
  • World War II
  • Major depressive disorder
  • Anxiety disorders