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Terrorism & psychiatric morbidity
Mental health and Suicide Terrorism
Impact of terrorism on mental health in developing countries.
How do people cope with PTSD and grief in Insurgent areas of developing world
Terrorism and Mental Health in Sri Lanka
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AADIL JAN SHAH, Doctor Psychiatry Gwent Health Care NHS Trust, OVAIS WADOO,Sheffield Care NHSTrust
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aadilshah{at}gmail.com AADIL JAN SHAH, et al.
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I read the article “Mental health following terrorist attacks” & was very impressed the way authors,Matthew.G Whalley et.al have structured it.They have very well reflected the consequences of the terrorist attacks to general population & direct victims.Though there are not many studies done on children hit by terrorism,the authors have efficiently incorporated them in both the groups. It is worth mentioning about one of the terrorism hit places called Kashmir in India & how it has affected the mental health of the people there. Kashmir was hit by terrorism in 1989 & since then almost every day there is an act of terrorism affecting the common man. As per the records of the psychiatric hospital in Srinagar (Capital City),there were only 1,700 cases of mental illness registered in 1989, but this has gone up to 60,000 by 2004. Women and children are the most vulnerable. In the Kashmir valley in 1990, there were on average 6-patients per day attending the Out Patient Department (OPD) of the psychiatric hospital. By 1994 this number had gone up to 59 patients per day and by 1999, there were more than100- patients per day. In 2002, on average 200 patients attended the OPD.A study done by Margoob revealed that there are significant number of children having mental health problems in Kashmir,He reported that 66.67% of children suffering from PTSD belonged to the age group of 12 – 16years. The above figures gives us an idea how terrorism can affect the mental health of the people leading to conditions like PTSD & Depression. As terrorism is increasing I agree with the `screen & treat` approach suggested by the authors and there is a need to use techniques like “EMDR” which has shown good results with PTSD. References An ECHO-funded survey, “State of Mental Health in Urban Kashmir” (January 2006) Matthew G.Whalley,Chris R.Brewin The British Journal Of Psychiatry(2007)190:94-96 Margoob MA, The Pattern of child psychiatric disorders in Kashmir. JK Practitioner 1996: 3: 4, 233-236. Source: Actionaid, 11/2005. |
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Emad Salib, Consultant Psychiatrist Peasley Cross Hospital, St helens, Naghma Malik, Mark Theophanous, Frances Lindon
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esalib{at}hotmail.com Emad Salib, et al.
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We read this review with interest. Whilst the paper is well referenced, the authors appear to have ignored an important aspect of mental health in relation to suicide terrorism, which is suicide and self harm in the population after the terrorist attacks. Psychological impact of terrorism on affected population varies. Some people develop well-recognized psychiatric disorders such as depression or post-traumatic stress disorder, higher levels of general anxiety or stress related symptoms. Others who may not report psychiatric symptoms could show considerable changes in their behaviour (Greiger et al 2003) or their feelings about the future (Bleich et al 2003). The effect of suicide terrorism on suicide has been reported in a number of studies since 2001. Two studies came from countries not directly affected by September 11th. Salib (2003) reported a brief but significant reduction in suicide in England & Wales while De Lange and Neelman (2004) found an increase in suicide and self-harm in the Netherlands in the weeks following September 11th attacks in USA. Starkman (2006) reported a 49% increase in number of people making harmful suicide attempt over 12 months following September 11th. Lester (2006) reported that lethality of suicide attacks in Israel between 1983 to 1999 was negatively associated with the suicide rate. It is important that prospective studies examine the long term effect of suicide terrorism on suicidality of the surviving victims of suicide terrorism, particularly those with history of deliberate self harm. References: Bleich A, Gelkopf M, Solomon Z (2003 Exposure to terrorism, stress- related mental health symptoms, and coping behaviors among a nationally representative sample in Israel. JAMA 2003;2003: 612-20. De Lange AW., Neeleman J (2004) The effect of September 11 terrorst attacks on suicide and Deliberate Self harm: a time trend study Suicide Life Threat Behav (2004) 34(4): 439-47 Grieger TA, Fullerton CS, Ursano RJ, Reeves JJ (2003 . Acute stress disorder, alcohol use, and perception of safety among hospital staff after the sniper attacks. Psychiatr Serv 2003;54: 1383-7. Lester D (2006) Suicide attacks in Israel and suicide rate. Percept Mot Skills 102(1) 104 Salib E (2003) Effect of September 11th 2001 on suicide and homicide in England and Wales (2003) British Journal of Psychiatry 183, 207-212 Starkman MN (2006) the terrorist attack of September 11 2001 as psychological toxin:increase in suicide attempts J Nerv Ment Dis 194(7):547-50 |
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Dilum T A Jayawickrama, Senior House Officer in Psychiatry, Princess of Wales Hospital, Bridgend.
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dilumthushara{at}hotmail.com Dilum T A Jayawickrama
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It was interesting to see this article. My focus is on terrorist attacks in developing countries. When I was medical student attending to the accident and emergency unit in Sri Lanka I have witnessed many terrorist attacks in Colombo. Especially in 1996 when one terrorist group bombed the Central Bank of Sri Lanka. Impact was horrific where more than 1000 casualties with over 200 deaths. There was initial shock, anger and grief. I have seen father’s caring their dead children to the casualty department asking for help. My observation is that in developing countries people have not brought mental illness into the surface compared to people in developed countries. There are few reasons for that. Main reason is the stigma attached with mental illness. Majority of the people living in South East Asia still think that mental illness is associated stigma. They like to keep mental illness as a secret within the close family unit. Due to the fear of isolation from the society they are reluctant to take any professional help. Other main reason is that there is a significant family support during the hour of crisis. People shred their differences and get together to help each other by giving advice, support and encouragement to come out of the crisis. These reasons by no means minimise significant trauma that some people went through during the terrorist attacks. It is clear that mental health services are not developed to cater to victims of a major terrorist attack in some developing countries than in developed countries especially when you take into account the lack of mental health services during the time of natural disaster’s like tsunami. I could not find any studies that indicate prevalence of psychiatric conditions associated with terrorist attacks in Sri Lanka which may also indicate a need for further research in this area in this part of the world. References: David A. Alexander, Early mental health intervention after disasters, Advances in Psychiatric Treatment (2005) 11: 12-18. Caroline Ryan , Tsunami boost for mental health care, BBC News website, 22 December 2005 |
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Ravimal Galappaththi, Staff Grade Psychiatrist, Pilgrim Hospital, Boston,UK none
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ravimalg{at}hotmail.com Ravimal Galappaththi
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I read this paper with great interest, having understood that impact of terrorism on mental health is becoming a key issue around the world. I had an enriching experience as a medical officer in mental health in rural Sri Lanka including insurgent areas. I shift my emphasis to traditional healing and religious rituals on alliviating mental health problems among people affected by terrorism. PTSD, stress reaction and grief by far the commonest brief psychotic episodes are not uncommon. I recall a soldider who lost his collegues in claimo (land) mine blast, who became convinced that he was possessed by several of his diseased collegues. He spoke in a different voice and behaved similar to his dead collegues. This was almost like different personalities in one person, and symptoms did not respond to antipsychotics or other forms of psychaitric treatment. He later took several sessions of native treatment and underwent ritualistic traditional healing, which indeed benifited him. Similarly, In the aftermarth of the tsunami disaster and death following terrorist attacks, culturaly acceptable catharsis and religious rituals have been used to resolve grief and PTSD. Rural indigenious communities of developing countries have done this for centuries. Sri Lanka, in particular psychiatric services do not even encounter 8% of psychiatric disease burden and , rural people have a greater reluctance to engage with services. However western style mental health services, if sensitive can incorporate the local belief systems, and culturally sensitive techniques to effectively communicate and convince clients. Social dysfunction can be minimised should timely intervention be done however needs greater rapport prior to therapeutic process. On the otherhand epecialist psychology services may only be needed for complex problems and local clergy, respected community figures does an excellent job. It is assumed that stigma of mental illness is higer in developing countries, however it could also be argued that due to family cohesiveness, mutual support systems and holystic attitude, stigma may even be less. Also in high insurgent areas people may have a “psychological prepairdness” so even in the wake of a disaster distressing symptoms might be less. Literature is scarce on these areas and I do feel culturally sensitive research is needed to evaluate above aspects in developing countries. References 1) Different disasters different needs, Diyanath Samarasinghe, Thematic paper, International Psychiatry, vol. 3, No. 3, July 2006 2) Natural disasters and their aftermath, Shobha Singh, Correspondence, International Psychiatry, vol. 4, No. 2,April 2007 3) Research on the Mental Health Effects of Terrorism, Carol S. North, MD,MPE; Betty Pfefferbaum, MD,JD, JAMA. 2002;288:633-636. |
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Prof. K.A.L.A. Kuruppuarachchi MD,FRCPsych(UK), Professor of Psychiatry Faculty of Medicine, University of Kelaniya,Ragama,Sri Lanka, Dr. L.T.Wijeratne MD , Lecturer in Psychiatry, Faculty of Medicine,University of Kelaniya,Ragama,Sri Lanka
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lalithkuruppu{at}lycos.com Prof. K.A.L.A. Kuruppuarachchi MD,FRCPsych(UK), et al.
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The article on “Mental Health following Terrorist attacks” by Matthew.G Whalley et.al was read with interest. Exposure to natural or manmade disaster is a common phenomenon in many developing countries. Sri Lanka is a country where people experience such disasters frequently. Natural disasters such as floods following heavy rainfalls, has led to deaths and displacement even in the capital city of Colombo. The tsunami was one of the most devastating natural disasters. In addition, over the past twenty three years, people are exposed repeatedly to bomb blasts and other manmade disasters related to war. Although no data is available regarding its prevalence in Sri Lanka, following a disaster of any kind, clinicians encounter a whole range of psychiatric problems. However one needs to also take note of the many protective factors that exist in our part of the world, which clearly reduces the burden on psychiatric services. Helpful, closely knit families and the support from community and religious leaders are such factors. When planning for services too it is necessary to identify these protective factors. The efficacy of spiritually augmented cognitive behaviour therapy has been highlighted by Russel F D’Souza and Angelo Rodrigo. It is more readily accepted by the community and similar forms of psychotherapy have been used effectively on tsunami victims in Sri Lanka. As highlighted by Matthew.G Whalley et.al, children are a very vulnerable group where this kind of repeated disasters are concerned. They find it difficult to grasp the concepts involved. The absence of properly developed child psychiatric services is a problem of significant magnitude in developing countries. Various incidents related to these disasters are also highlighted indiscriminately in the media, exposing the people further. Kuruppuarachchi et al have reported case histories of children who developed PTSD after watching violent TV programmes in Sri Lanka. Raising awareness among the media personnel regarding this aspect is also important. Having lived most part of their lives with the war, most people now accept it as a part of their lives. However, a change in their attitude is seen from time to time when the nature of the terrorist attacks change. For instance in Sri Lanka, the recently introduced air raids is a novel experience to people and the reaction was observed to be different. It has also been highlighted by the World Health Organization that preparedness for disasters can help minimize the harmful effects. The clinician should be aware of these factors when increasing community services for the vulnerable populations. References: D’Souza R. F. , Rodrigo A., ( 2004) Spiritually augmented cognitive behavioural therapy. Australasian Psychiatry 12(2), 148 – 152 Kuruppuarachchi K. A. L. A., Williams S. S. , Gadambanathan T. ( 2000) Post-traumatic stress disorder after watching violent scenes on television. Ceylon Medical Journal, volume 45, No. 4, 177 - 8 Whalley M. G. , Brewin C. R. (2007) Mental Health following terrorist attacks. British Journal of Psychiatry 190: 94-96 World Health Organization (2005) Mental Health and Psychosocial Relief Efforts after the Tsunami in South-East Asia . World Health Organization, Regional Office for South-East Asia, New Delhi |
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