Survey Finds Iraqi Minds Resilient Despite War

In 2006, as the Iraq conflict raged on, a group of government-led interviewers started knocking on doors across the country. They entered people’s homes and asked them hundreds of questions. How much do you weigh? Are you afraid of lightning? Did you ever go through a period when you felt empty?

Answering the interviewers’ queries, many Iraqis said they had been exposed to combat, bombings and shootings. Some of them said they had seen kidnappings, killings and mutilated bodies. A large number of them had experienced what the questionnaires framed as war-related traumas.

Two years later, after 4,332 such interviews were conducted and analyzed, Iraq got the results of the first nationwide survey on mental health ever done in that country. The study may also be unique because it was carried out as the battles churned. “This is probably the first survey of its kind,” said Somnath Chatterji, a World Health Organization researcher who took part in the study.

Conducting the survey in the face of sectarian violence and combat was a “big challenge,” said Chatterji. The Iraqi government and the WHO had to put together an unusually large group of interviewers because no one wanted to tread in unfamiliar neighborhoods. Despite this safeguard, many interviewers could not access some of the most violent areas. At least two of them were kidnapped and later released during the fieldwork, said Chatterji.

The survey found that almost 20 percent of Iraqi adults have suffered a mental disorder in their lifetime, a rate that is lower than what researchers expected to find among a population under the strain of war.

“It’s a very resilient population,” said Ronald Kessler, HMS professor of health care policy and codirector of the World Mental Health Surveys, a WHO program that encourages governments around the world to carry out studies like the one in Iraq.

The results, released on March 7 by the Iraqi government and the WHO, also unveiled disquieting facts. It estimated that only 10 percent of those who suffer depression, posttraumatic stress disorder or any other mental condition are being treated. The main reason is the healthcare system has collapsed after years of conflict. “There’s an enormous level of unmet need,” said Kessler.

Many studies have screened the impacts of traumatic experiences among U.S. troops, but virtually nothing is known about the mental health of the Iraqi people.

“This is an amazing study done in difficult conditions that brings the first light to a difficult topic,” said Robert Ursano, chair of the Department of Psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, who was not involved in the research.

About one in two respondents reported feeling significantly distressed, said Chatterji, but only 18.8 percent showed signs of a diagnosable mental disorder. The most common condition was major depressive disorder, and the most prevalent disease group was the one linked to anxiety, including panic and phobias.

“The vast majority of people have maintained their emotional equilibrium despite the terrible stresses that they’re under,” said Kessler.

Although researchers have many theories to account for this resilience, there is no scientific explanation for it. A similar resilience was found last year in a WHO survey carried out in Lebanon, another war-torn country. The prevalence of mental disease in Iraq and Lebanon was higher than in other developing countries like Nigeria or China but lower than in industrialized nations like the United States, where mental disease rates are relatively high.

“There is still a lot we need to learn, especially in non-Western industrialized countries,” said HSPH professor of public health David Williams, not an author on the Iraqi study. He led a WHO survey in South Africa that found around 30 percent of the population had suffered a mental disorder.

One possible explanation is that people living amid extreme poverty, war, violence and personal loss are hardened by a shattered environment and get used to the possibility of terrible things happening to them or their relatives. “It’s not that they love their loved ones less,” said Kessler. ”It’s just the way they are in the world is a way that protects them psychologically.”

At least part of the low mental disease rates found in the study may also be due to how the survey was designed. In a paper published online in World Psychiatry, Kessler and colleagues explain that the rates of mental disorder were probably underestimated because they focused on people over 18 living inside the country. The study left out those whose mental wounds tend to be deeper in times of war, like young people and refugees, researchers said.

“The best estimate is that half of all lifetime cases of mental disorders have their onset by age 14,” said Farris Tuma, who runs the Trauma Research Program at the National Institute of Mental Health and was not involved in the study. This factor is especially important in Iraq, where almost 40 percent of the population is under 14. As the population ages, the rate of mental disorders is likely to go higher, he said.
Similarly, the estimated 4 million refugees who were displaced by the war either inside or outside Iraq would probably have raised the prevalence rates of some disorders if included, said Ursano.

The WHO survey was intended to help the Iraqi Minister of Health, Saleh Al Hassnawi, a psychiatrist, and other government officials take the first steps toward reconstructing the battered mental healthcare system in Iraq. “There is an urgent need to develop these services so that people can get the care they need,” said Chatterji.

The task will include building new facilities and bringing members of the workforce back to Iraq, because many medical professionals have fled the country, said Kessler. It will also involve healing the war’s invisible wounds. “You don’t need to just reconstruct buildings, you also have to reconstruct people’s minds and their lives,” he said.

Conflict Disclosure: Kessler has been a consultant for GlaxoSmithKline Inc., Kaiser Permanente, Pfizer Inc., Sanofi-Aventis, Shire Pharmaceuticals and Wyeth-Ayerst; has served on advisory boards for Eli Lilly & Company and Wyeth-Ayerst; and has had research support for his epidemiological studies from Bristol-Myers Squibb, Eli Lilly & Company, GlaxoSmithKline, Johnson & Johnson Pharmaceuticals, Ortho-McNeil Pharmaceuticals Inc., Pfizer Inc. and Sanofi-Aventis.

Funding Sources: Preparation of the paper was supported by the National Institute of Mental Health. The survey was supported by the World Bank and WHO; the content of the work is the responsibility solely of the authors