Wrote the paper: FC. Helped develop the concept and methodology, and derived the estimates: FC. Developed the methodology and assisted with statistical modelling: ZS. Contributed to manuscript development: ZS LD DS CM HW. Developed the concept and contributed to methodology development: LD. Carried out statistical analysis: TC. Oversaw the study design and development: HW.
The authors have declared that no competing interests exist.
Mental disorders are likely to be elevated in the Libyan population during the post-conflict period. We estimated cases of severe PTSD and depression and related health service requirements using modelling from existing epidemiological data and current recommended mental health service targets in low and middle income countries (LMIC’s).
Post-conflict prevalence estimates were derived from models based on a previously conducted systematic review and meta-regression analysis of mental health among populations living in conflict. Political terror ratings and intensity of exposure to traumatic events were used in predictive models. Prevalence of severe cases was applied to chosen populations along with uncertainty ranges. Six populations deemed to be affected by the conflict were chosen for modelling: Misrata (population of 444,812), Benghazi (pop. 674,094), Zintan (pop. 40,000), displaced people within Tripoli/Zlitan (pop. 49,000), displaced people within Misrata (pop. 25,000) and Ras Jdir camps (pop. 3,700). Proposed targets for service coverage, resource utilisation and full-time equivalent staffing for management of severe cases of major depression and post-traumatic stress disorder (PTSD) are based on a published model for LMIC’s.
Severe PTSD prevalence in populations exposed to a high level of political terror and traumatic events was estimated at 12.4% (95%CI 8.5–16.7) and was 19.8% (95%CI 14.0–26.3) for severe depression. Across all six populations (total population 1,236,600), the conflict could be associated with 123,200 (71,600–182,400) cases of severe PTSD and 228,100 (134,000–344,200) cases of severe depression; 50% of PTSD cases were estimated to co-occur with severe depression. Based upon service coverage targets, approximately 154 full-time equivalent staff would be required to respond to these cases sufficiently which is substantially below the current level of resource estimates for these regions.
This is the first attempt to predict the mental health burden and consequent service response needs of such a conflict, and is crucially timed for Libya.
International attention has focused on the civil conflict in Libya following anti-government protests starting in February 2011 which led to the fall of the regime led by Muammar Gaddafi. The events in Libya were associated with widespread violence and NATO military intervention under United Nations Security Council resolution 1973 adopted on 17 March 2011.
Evidence indicates that exposure to conflict-related potentially traumatic events (PTE) will lead to an elevation in the prevalence of mental disorders, including depression and post-traumatic stress disorder (PTSD), among exposed sections of the Libyan population.
The increased prevalence of mental disorders in combination with the limited health resources available in low- and middle-income countries (LMIC’s) highlights the need for health service planning to focus on the subgroup of severe cases that are most likely to benefit from access to treatment.
Studies that have been undertaken in post-conflict settings provide valuable datasets allowing us to estimate the prevalence of mental disorder in conflict zones. The present study represents the first attempt to draw on existing datasets to estimate the increase in numbers of people with mental disorders using a contemporary conflict exposed setting. We also apply a benchmark model of target setting
Our findings aim to be of assistance to conflict and post-conflict countries, including Libya, and the international health and humanitarian community in meeting the challenges of post-conflict reconstruction.
This paper aims to:
derive best-estimates for depression and PTSD prevalence in conflict-affected Libyan populations based on the factors known to influence the prevalence of these disorders;
estimate the number of severe cases and comorbidity between these disorders for given populations;
describe the mental health service requirements that would be needed in Libya to meet the needs of this population during the post-conflict period and compare this with the current service capacity in Libya.
Post-conflict prevalence estimates have been derived from models based on a previously conducted systematic review and meta-regression. The methodology has been described in detail elsewhere.
Data extraction included methodological characteristics that were likely to affect prevalence rates, including study sample size and sampling method, and substantive study population characteristics, such as sociodemographic characteristics, place of survey, exposure to torture and other PTE’s, PTS score, residency status, and time since the cessation of major hostilities.
The PTS provides two separate measures of the political terror experienced in a country during a given year based on independent qualitative narrative reports produced by the United States Department of State and Amnesty International. It is considered the most comprehensive and most accurate index of its type and hence was chosen in favour of other potential measures of political terror within a population.
A strong dose-response association between exposure to PTE and both PTSD and depression has been reported across a wide number of individual surveys undertaken in the post-conflict literature
Meta-regression models were calculated in SAS version 9.1.3
When choosing the most appropriate model for estimating prevalence in a given population, the rating on the political terror scale; intensity of exposure to traumatic events (PTE adversity ratio) and time in years since the cessation of major hostilities were selected as stratifying variables as they are standardised measures with high utility that had been identified as the most significant predictors of global prevalence
Model stratification was conducted according to ‘moderate’ (PTS <4) and ‘high’ (PTS ≥4) political terror, and ‘moderate’ (PTE adversity ratio <0.3) and ‘high’ (PTE adversity ratio ≥0.3) trauma. PTS and PTE adversity ratio cut-off points were derived from the thresholds associated with elevated risk for mental disorder identified in the full sample meta-regression analysis. The reference group to which all other models were compared was the moderate trauma and moderate political terror scenario. In addition, we have modelled the time effect of 3 years since the end of the conflict representing the projected notional end of the acute post-conflict phase.
Populations in areas documented as high conflict or who have fled such areas were deemed the most likely to experience higher levels of exposure to PTE’s and ongoing risk of conflict related mental disorder. Six populations were identified as being profoundly affected by the conflict, based on assessments of documented reports from multiple humanitarian actor websites and other sources deemed as credible
Misrata (medium intensity conflict): the former opposition-controlled city of Misrata has been highlighted as a conflict zone
Benghazi (medium intensity conflict): Benghazi was the main focus of the demonstrations against Colonel Gaddafi's rule with numerous reports of government troops opening fire on civilians resulting in substantial deaths
Tripoli/Zlitan (high intensity conflict): Tripoli and displacement sites in former government controlled areas near Misrata (Zlitan and Al Khums) and the Nafusa Mountain area of Gharian have been highlighted by the United Nations High Commissioner for Refugees (UNHCR) as populations affected by widespread conflict
Misrata displaced (high intensity conflict): within Misrata city itself there is a population displaced from their homes as a direct result of the state of terror
Zintan (high intensity conflict): is the largest town in the Nafusa Mountains of western Libya which has suffered frequent rocket attacks affecting civilian homes and public areas. Most of its population fled and many live as refugees in Tunisia
Ras Jdir (high intensity conflict): refugee camps on the border of Libya and Tunisia which largely hold migrant workers waiting for repatriation have been overloaded with those fleeing the violence in Libya. Camps are severely over capacity and conditions are very poor.
Population size estimates were obtained preferentially from government and other official websites, such as those provided by the United Nations (UN); however unofficial websites were accepted where other sources were lacking. In the absence of a publicly available official population estimate but where we were able to identify multiple unofficial sources we took the average. The total population of Libya is 6,730,000.
Numbers needing treatment and mental health service requirements in this paper are based on the estimated number of severe cases as these individuals are most likely to experience the highest levels of ongoing psychiatric disability. Severity proportions were based on data for affective and anxiety disorders recorded by the World Mental Health Survey (WMHS) Collaboration with anxiety disorder accepted as a proxy for PTSD. Severity ratings within the WMHS collaboration were derived from the Sheehan Disability Scale (SDS)
The proportion of PTSD cases comorbid with depression derived from general population and post conflict settings was estimated at 50%.
Models of mental health service requirements for depression are taken from mental health cost-effectiveness studies for LMIC’s._ENREF_14 Chisholm and colleagues have estimated resources required to scale-up delivery of an essential mental healthcare package for treatment of four mental disorders (schizophrenia, bipolar disorder, depression and hazardous alcohol use) over a 10-year period.
As there is currently no published mental health service requirement model for PTSD or comorbid PTSD/depression, the model was adapted to cover all cases we have estimated in our paper. Service types for PTSD were limited to treatment within the primary healthcare and psychosocial therapy setting in accordance with guidelines for the management of PTSD.
Clinician resources for day care services, outpatient/primary care visits, long-stay inpatients and acute inpatients were computed separately for each of the six populations. Full-time equivalent (FTE) is a unit to measure employed persons or students in a way that makes them comparable although they may work or study a different number of hours per week. FTE for primary healthcare and outpatient services were estimated based on the following algorithm;
The total numbers of FTE staff for each level of service in each population were apportioned across health worker types.
To assess the gap in mental health service requirements based on estimates derived from the meta-regression models reported herein and the resource capacity in Libya we draw on data recording mental health resources in Libya compiled by WHO during 2005.
The results of the meta-regression models for PTS, PTE adversity ratio and time since conflict are presented in
Overall, the model in which included variables PTS and PTE adversity ratio accounted for the largest proportion of inter-study variability in PTSD prevalence rates (35.3%); 17.0% variance was explained by the methodological variables and a further 18.3% from the substantive variables (PTS and PTE adversity ratio). According to this model, PTSD prevalence amongst populations with a high level of political terror and a high level of PTE exposure was estimated to be 41.3% (95%CI 28.3–55.6). Lower levels of exposure to trauma (PTE adversity ratio <0.3) would equate to a prevalence of 32.3% (95%CI 18.2–50.6) (
Odds ratio (95%CI) |
Total case prevalenceestimate (%) (95%CI) | Severely impaired case prevalence estimate (%) (95%CI) | |
|
|||
Moderate trauma | 2.16 (1.01–4.64) |
32.3 (18.2–50.6) | 9.7 (5.5–15.2) |
High trauma | 3.18 (1.79–5.68) |
41.3 (28.3–55.6) | 12.4 (8.5–16.7) |
|
|||
Moderate trauma | 2.61 (1.22–5.56) |
34.5 (19.8–52.9) | 18.3 (10.5–28.0) |
High trauma | 2.95 (1.79–4.87) |
37.3 (26.5–49.6) | 19.8 (14.0–26.3) |
Abbreviations: PTSD = Post-traumatic stress disorder; Low political terror = PTS <4; High political terror = PTS ≥4; Moderate trauma = PTE adversity ratio <0.3; High trauma = PTE adversity ratio ≥0.3;
reference category = moderate trauma*low political terror;
All substantive predictor models are adjusted for significant methodological predictors (sample size and type of measure);
Statistically significant OR compared to reference group.
Based on the pooled PTSD disability ratings from the World Mental Health Survey studies, 30.0% (95%CI 27.0–33.0) of PTSD cases fell into the severe disability range.
Population | Severely impaired caseprevalence estimate (%) (95%CI) | Total population | Estimated number of severely impaired cases (95%CI) |
|
|||
Moderate trauma settings | |||
Misrata |
9.7 (5.5–15.2) | 444,812 | 43,100 (24,500–67,600) |
Benghazi |
9.7 (5.5–15.2) | 674,094 | 65,400 (37,100–102,500) |
High trauma settings | |||
Tripoli/Zlitan |
12.4 (8.5–16.7) | 49,000 | 6,100 (4,200–8,200) |
Misrata displaced |
12.4 (8.5–16.7) | 25,000 | 3,100 (2,100–4,200) |
Zintan |
12.4 (8.5–16.7) | 40,000 | 5,000 (3,400–6,700) |
Ras Jdir camps |
12.4 (8.5–16.7) | 3,700 | 500 (300–600) |
Total | 1,236,606 | 123,200 (71,600–182,400) | |
|
|||
Moderate trauma settings | |||
Misrata |
18.3 (10.5–28.0) | 444,812 | 81,400 (46,700–124,500) |
Benghazi |
18.3 (10.5–28.0) | 674,094 | 123,400 (70,800–188,700) |
High trauma settings | |||
Tripoli/Zlitan |
19.8 (14.0–26.3) | 49,000 | 9,700 (6,900–12,900) |
Misrata displaced |
19.8 (14.0–26.3) | 25,000 | 5,000 (3,500–6,600) |
Zintan |
19.8 (14.0–26.3) | 40,000 | 7,900 (5,600–10,500) |
Ras Jdir camps |
19.8 (14.0–26.3) | 3,700 | 700 (500–1,000) |
Total | 1,236,606 | 228,100 (134,000–344,200) |
PTSD = Post-traumatic stress disorder; Moderate trauma = PTE adversity ratio <0.3; High trauma = PTE adversity ratio ≥0.3.
The meta-regression model that included PTS and the PTE adversity ratio accounted for 62.0% of overall inter-study variance. 46.5% was accounted for by the methodological model with 15.5% accounted for by PTS and PTE adversity. Depression estimates were high for all political terror categories, 34.5% (95%CI 19.8–52.9) and 37.3% (95%CI 26.5–49.6) for moderate and high trauma respectively (
Findings from WMHS studies used as the basis for the current analysis indicate that 53.0% (95%CI 46.0–60.0) of depression cases had disability scores within the severe category.
Taken across the six regions, the predictive models estimate a post-conflict total of 123,200 (71,600–182,400) cases of severe PTSD and 228,100 (134,000–344,200) cases of severe depression in an exposed population of approximately 1.24 million persons (
Applying a comorbidity estimate of 50% to the current projections would identify 61,600 of the PTSD cases as being comorbid with major depression leading to an estimate of non-comorbid depression and PTSD cases of 43,300 and 61,600, respectively.
We also used the meta-analytic models to estimate prevalence within post-conflict settings of 3 or more years since the cessation of major hostilities, in which a more stable, low trauma environment may have had an opportunity to develop. The model yields an estimate of PTSD prevalence of 5.0% (95%CI 3.2–7.7) when considering only the more severely impaired and 9.0% (95%CI 5.9–13.0) for severe depression (
Odds ratio (95%CI) | Total case prevalenceestimate (%) (95%CI) | Severely impaired case prevalence estimate (%) (95%CI) | |
|
|||
Moderate trauma |
1.00 | 16.8 (10.7–25.6) | 5.0 (3.2–7.7) |
High trauma | 1.55 (0.77–3.13) | 23.9 (13.5–38.8) | 7.2 (4.1–11.6) |
|
|||
Moderate trauma |
1.00 | 16.9 (11.2–24.6) | 9.0 (5.9–13.0) |
High trauma | 2.93 (1.54–5.60) |
37.3 (23.8–53.2) | 19.8 (12.6–28.2) |
Abbreviations: PTSD = Post-traumatic stress disorder;
reference category;
All substantive predictor models are adjusted for significant methodological predictors (sample size and type of measure); Moderate trauma = PTE adversity ratio <0.3; High trauma = PTE adversity ratio ≥0.3;
Statistically significant OR compared to reference group.
Population | Severely impaired caseprevalence estimate (%) (95%CI) | Total population | Estimated number of severelyimpaired cases (95%CI) |
|
|||
Moderate trauma settings | |||
Misrata |
5.0 (3.2–7.7) | 444,812 | 22,400 (14,300–34,200) |
Benghazi |
5.0 (3.2–7.7) | 674,094 | 34,000 (21,700–51,800) |
High trauma settings | |||
Tripoli/Zlitan |
7.2 (4.1–11.6) | 49,000 | 3,500 (2,000–5,700) |
Misrata displaced |
7.2 (4.1–11.6) | 25,000 | 1,800 (1,000–2,900) |
Zintan |
7.2 (4.1–11.6) | 40,000 | 2,900 (1,600–4,700) |
Ras Jdir camps |
7.2 (4.1–11.6) | 3,700 | 300 (50–400) |
Total | 1,236,606 | 64,800 (40,600–99,600) | |
|
|||
Moderate trauma settings | |||
Misrata |
9.0 (5.9–13.0) | 444,812 | 39,800 (26,400–58,000) |
Benghazi |
9.0 (5.9–13.0) | 674,094 | 60,000 (40,000–87,900) |
High trauma settings | |||
Tripoli/Zlitan |
19.8 (12.6–28.2) | 49,000 | 9,700 (6,200–13,800) |
Misrata displaced |
19.8 (12.6–28.2) | 25,000 | 4,900 (3,200–7,000) |
Zintan |
19.8 (12.6–28.2) | 40,000 | 7,900 (5,000–11,300) |
Ras Jdir camps |
19.8 (12.6–28.2) | 3,700 | 700 (500–1,000) |
Total | 1,236,606 | 123,500 (81,300–179,100) |
PTSD = Post-traumatic stress disorder; Moderate trauma = PTE adversity ratio <0.3; High trauma = PTE adversity ratio ≥0.3.
Based on the coverage target of 33% for major depression identified by Chisholm
The service coverage model proposed by Chisholm
Depression alone(n = 43,300) | PTSD alone (n = 61,600) | Comorbid (n = 61,600) | |
|
|||
Community residential (long-stay) |
0.5 | - | 1 |
Community psychiatric (acute care) |
2 | - | 4 |
Day care services |
1 | - | 1 |
Hospital out-patient service |
20 | - | 20 |
Primary healthcare – treatment |
30 | 10 | 40 |
Psychosocial treatment |
20 | 20 | 20 |
|
|||
Community residential (long-stay) |
217 | 0 | 616 |
Community psychiatric (acute care) |
866 | 0 | 2464 |
Day care services |
433 | 0 | 616 |
Hospital out-patient service |
8660 | 0 | 12320 |
Primary healthcare – treatment |
12990 | 6160 | 24640 |
Psychosocial treatment |
8660 | 12320 | 12320 |
Adapted from Bruckner 2011
Service coverage: percentage of patients in the population who are expected to use the service or resource over the course of 1 year.
Based on severe cases estimated for a state of high political terror.
Inpatient and residential service.
Outpatient and day care service.
For the six populations we estimate a need of 154 FTE, or 12.5 FTE per 100,000 of population for meeting the service coverage targets for severe depression and PTSD. This comprises 28 medical staff, 59 nurses and 68 psychosocial care providers (see
Resource and workforce information for Libya was only available for a period 4 years prior to the conflict.
Population | Medical | Nurses | Psychosocial care providers | Total FTE | |
Misrata | 444,812 | 10 | 21 | 24 | 54 |
Benghazi | 674,094 | 15 | 31 | 36 | 82 |
Tripoli | 49,000 | 1 | 3 | 3 | 7 |
Misrata displaced | 25,000 | 1 | 1 | 2 | 4 |
Zintan | 40,000 | 1 | 2 | 3 | 6 |
Ras Jdir | 3,700 | 0 | 0 | 0 | 0 |
Total | 1,236,606 | 28 | 59 | 68 | 154 |
Adapted from Chisholm 2007
Based on severe cases estimated for a state of high political terror.
This is the first study to model the prevalence of selected mental disorders following country-level conflict. In doing so, we draw systematically upon the existing epidemiological research undertaken amongst displaced and conflict-affected populations, published over the past three decades. We have presented the estimated prevalence of depression and PTSD according to levels of population-level political terror, trauma exposure and recency of conflict as they are estimated to have affected six population groups during 2011–2012 Libyan conflict. The statistical modelling reported herein suggest a substantial mental health burden associated with political terror and exposure to traumatic events, reflected in the number of cases of PTSD and depression for exposed populations.
In line with global epidemiological data, depression prevalence is consistently higher than PTSD prevalence across all models. In terms of time effects, our findings demonstrate an overall trend for PTSD prevalence to drop markedly with time since the end of a conflict whilst a reduction in depression prevalence is much more reliant on a reduction in trauma exposure.
Population prevalence estimates of PTSD and depression derived for six population groups identified from areas affected by periods of intense conflict or mass displacement were in the 30% to 40% range within the post-conflict period. These estimates accord with findings from parallel fields of research. A recent systematic review examining major depressive disorder following terrorist attacks suggested that the risk ranges between 20 and 30% in directly affected victims.
For the purposes of service planning, we further refined these prevalence estimates by focusing only on those cases that were most likely to be associated with severe levels of impairment by integrating the severity proportions of affective and anxiety disorders recorded by the World Mental Health Surveys. Using this information, severe cases of PTSD were estimated at 9.7%–12.4% and severe depression at 18.3%–19.8% during the immediate post-conflict period. Interpolating these estimates to the 1.24 million Libyans within six population groups identified as being affected by exposure to war trauma and conflict indicates that 123,400 people are likely to have severe PTSD and 228,100 severe depression. Not surprisingly, based upon current WHO estimates,
The results of the systematic review and meta-regression that form the basis of the current projections indicate that it is not mass conflict in general but rather the population level of exposure to torture, potentially traumatic events and political terror that are the substantive determinants of PTSD and depression prevalence. For this reason, we have limited the attempt to calculate conflict-related mental health projections to those population groups and geographic regions for which there is some information about the extent of trauma exposure.
For the same reasons, we have not attempted to model the conflict related rates for PTSD and depression for the whole of Libya, as the current body of psychiatric epidemiological research has primarily involved small to medium sized population studies of directly affected populations. It is not clear to what extent these estimates can be scaled up to provide prevalence estimates at a national level.
There is increasing recognition of the importance of responding in a timely manner to population-level mental health problems following conflict.
The ability for resource poor and disrupted health systems to meet population needs is invariably difficult and we have elected to only model severe cases of depression and PTSD. It is recognized this may represent an underestimation of overall need, particularly with regard to psychosocial services for less severe cases. This, combined with the fact that the service requirement model used was developed in countries with much lower prevalence rates than exhibited in our estimates for post-conflict Libya, means our predictions may be conservative; and the actual number of persons requiring service utilisation may be higher.
It is typical for a health system to deteriorate during times of war, with infrastructure becoming degraded and health staff fleeing areas most in need of health services. This would result in even fewer available mental health resources than the WHO pre-conflict estimate for Libya. We have not considered the entire spectrum of mental disorders in our estimations, but rather focused on disorders known to be largely affected by conflict. A comprehensive mental health service would have additional requirements to accommodate the full range of mental disorders.
The importance of Libya returning to a state of peace and stability and a positive post-conflict recovery trajectory for the mental health of the population cannot be overstated. Reducing political terror and trauma is crucial in stabilising prevalence of PTSD and depression.
It was not the aim of this paper to explore specific forms of treatment interventions or program design, however, the mhGAP action programme
The modelling in this study drew on an existing, heterogeneous body of epidemiological research from conflict-affected countries around the world. One limitation is the challenge of validation of instruments for use in post-conflict environments. The variability in prevalence rates found in psychiatric epidemiology following complex emergencies is partially attributable to differences in context, methodology, and exposure to risk factors which have been identified in previously published work.
It is also important to highlight that measurement errors within the PTS have been demonstrated revealing estimates to be conservatively biased by an absolute order of roughly two.
The modelling process was not able to include torture as a variable despite it’s known significance as a risk factor for mental disorders in post-conflict settings
It has been necessary to apply surrogate measures in the absence of data for a number of other key areas; ‘affective disorders’ has been used as a proxy for depression in establishing comorbidity rates and ‘anxiety disorder’ severity proportions have been used for PTSD. A lack of statistical power and limitations in carrying out subgroup analysis in the meta-regression modelling necessarily means differences between countries or regions is forfeited and the influence of other environmental
Population data for affected Libyan regions is also difficult to ascertain in some cases. Without a public domain for verifying official Libyan census data we relied on various web sources to derive best estimates of numbers of people living in areas exposed to the highest levels of violence and trauma. There is no a priori reason to expect that we have either under- or overestimated population sizes, but it is a source of uncertainty.
The need for epidemiological estimates of mental disorders in conflict and post-conflict regions is essential for more effective program prioritisation and planning. Research is needed to fill knowledge gaps and enhance what we have presented in this paper. High quality epidemiological studies from developing and conflict/post-conflict countries are required in order to obtain more accurate baseline prevalence estimates, more statistical power in modelling prevalence estimates, and a better understanding of how cultural and environmental aspects affect modelling. The potential for applying these models, adapted as necessary, to forecasting prevalence estimates in other conflict-affected populations is ready for exploration. It is hoped that with further research and refining of methodologies the modelling will provide even more useful and accurate projections.
The findings presented in this paper highlight the potential magnitude of the post-conflict mental health need in Libya, a model that can also be applied to other countries experiencing such conflict. Mental health problems are already surfacing, according to reports from mental health teams on the ground.
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We gratefully acknowledge contributions and comments throughout the preparation of this paper from Mark van Ommeren, Dan Chisholm, Holly Erskine, Amanda Baxter, and Alize Ferrari.