Psychological consequences of global armed conflict

Abstract

Armed conflict unvaryingly leads to a loss of life, serious violations of human rights and international law, and extensive human suffering. As technological advances change the landscape of modern armed conflict, developments are also urgently needed to ensure accessible, evidence-based care is readily available to those affected.

At the time of writing, multiple armed conflicts are currently raging across the globe, affecting areas such as Ukraine, the Middle East, North Africa and Latin America adversely impacting millions of people. Regardless of the conflicts’ location, cause or the forces involved, the devastating impact of armed conflict is largely the same. Armed conflict unvaryingly leads to a loss of life, violations of human rights and international law, and extensive human suffering. Many of the most serious human rights violations are committed during armed conflict, including recruiting children to serve in militaries, using sexual assault as a weapon of war, and obstructing civilians’ access to humanitarian aid. This editorial goes alongside the BMC special edition titled ‘psychological consequences of war and other conflicts’. The aim of this special edition was to shed light on the lasting impact of conflicts. This was done by collating a series of research papers associated from different conflicts and populations affected by war. By doing so, we aimed to further knowledge to allow researchers working within this field to be better equipped to develop interventions to support those affected by conflict.

Despite international law which states that civilians and civilian infrastructure (e.g. schools, homes, hospitals) cannot be deliberately targeted [1], time and again data has shown that civilians are systematically victimized and come to disproportionate harm during armed conflict [1]. Recent technological advancements in weapon systems, such as the rise in artificial intelligence (AI), biological weapons and use of first-person view (FBV) drones, are rapidly changing the landscape of modern warfare. Armed conflict also remains the leading driver of terrorism and radical extremism, with the majority of all terrorism-related deaths occurring in countries involved in violent conflict [1]. Extremist groups today have unprecedented access to the public via the internet and social media platforms, with advances in AI technologies facilitating the spread of misinformation, recruitment and incitement.

The implications that these developments to the modern landscape of armed conflict may have for both civilian and military personnel psychological wellbeing are not yet fully understood. Nonetheless, the psychological consequences of armed conflict have long been studied and reflect the focus of this special issue [2,3,4,5].One of the most commonly reported psychological consequences of armed conflict is posttraumatic stress disorder (PTSD). Meta-analyses estimate that 15.3–36.0% of war-affected adult populations experience PTSD as compared to 3.9–7.8% of the general population [6].

For military personnel and veterans, higher rates of PTSD have been found in those who deployed in combat roles compared to those who did not deploy [7]. Mental health problems following exposure to armed conflict are also experienced by those who serve in humanitarian aid roles and as well as media professionals. The impact of armed conflict on aid workers may be especially marked at present as recent reports show that 2024 has been the deadliest year in recent history for aid workers, with 26 Red Cross staff killed in violence and conflict [8].

The recent addition of complex PTSD (CPTSD) to the ICD-11 [9] has allowed for the exploration of the impact of prolonged trauma exposure on wellbeing, and studies indicate that both military and civilian populations exposed to armed conflict may be at elevated risk of CPTSD. This is a concern as CPTSD is associated with greater comorbidity, poorer functioning and worse treatment outcomes [10].

Civilian and military personnel may also be vulnerable to moral injury as a result of their exposure to armed conflict. Moral injury refers to the profound distress that can be experienced following events that violate ones moral or ethical code [11]. Potentially morally injurious events (PMIES) include acts of commission (e.g. military personnel kills an enemy combatant against the rules of engagement), omission (e.g. a villager witnessed an insurgent seriously injure their neighbour and felt unable to intervene), or betrayal (e.g. humanitarian aid worker was not provided with enough resources to provide adequate care to the injured). While moral injury is not a mental illness, it is significantly associated with PTSD, depression and suicidality and moral injury-related mental health difficulties can be particularly challenging for clinicians to treat [11]. No validated treatment for moral injury-related mental health difficulties currently exists, although recently developed interventions for military personnel/veterans (e.g. Restore & Rebuild) have promising findings [12].

Several risk and protective factors for mental ill health in the context of armed conflict have been identified, including the nature and intensity of trauma exposure, lower social support, lower education attainment, and poorer mental health pre-trauma [13]. For those fleeing war or mass violence, post-migration resettlement conditions are also a key factor in post-trauma adjustment. Those who receive appropriate humanitarian assistance and were able to secure paid employment in refugee camps report more positive adjustment [14]. However, all too often the resettlement experience of war-affected refugees is poor, with many reporting serious challenges with integration and accessing appropriate care [14].

Effective, evidence-based treatments for post-trauma mental health difficulties do exist. Treatments such as trauma focused cognitive behavioural therapy (TF-CBT) and eye movement desensitization and reprocessing (EMDR) are first line recommended treatments for PTSD [15]. However, much of the available evidence for these approaches comes from Western contexts. As the majority of war-affected populations reside in low- and middle-income countries (LMICs) [6], ensuring access to appropriate, affordable care is vital. Emerging low-level interventions, such as Daily Bread which provided conflict exposed families living in refugee camps with leaflets on child adjustment post-trauma included in their daily food ration packs [16] illustrate that it is possible to widely distribute post-trauma psychoeducation at relatively low cost. Social distancing restrictions during COVID-19 and advances in technology have also led to increased access to PTSD treatments delivered online or via smartphone apps. Further testing is needed of apps for PTSD before these can be recommended, but given the challenges of providing mental health treatment in low resource, war torn LMICs, such technology may fill a substantial gap in patient care in the future. That said, preventing the development of armed conflict-related mental health difficulties would be best achieved by a global commitment to peace. Although, with more than 50 armed conflicts currently underway across the globe [1], this seems like a distant goal. Perhaps more achievable is a collaborative effort of clinicians, researchers, stakeholders and policy makers working together to design accessible, effective psychological treatments that can be successfully deployed across settings to lessen the long trail of destruction that armed conflict invariably leaves.