William G. Axinn, PhD; Ronny Bruffaerts, PhD; Timothy L. Kessler, AB; Rochelle Frounfelker, ScD; Sergio Aguilar-Gaxiola, MD, PhD; Jordi Alonso, MD, PhD; Brendan Bunting, PhD; José Miguel Caldas-de-Almeida, MD, PhD; Graça Cardoso, MD, PhD; Stephanie Chardoul, BA; Wai Tat Chiu, AM; Alfredo Cía, MD; Oye Gureje, MD, DSc; Elie G. Karam, MD; Viviane Kovess-Masfety, MD, PhD; Maria V. Petukhova, PhD; Marina Piazza, ScD; José Posada-Villa, MD; Nancy A. Sampson, BA; Kate M. Scott, PhD; Juan Carlos Stagnaro, MD, PhD; Dan J. Stein, MD, PhD; Yolanda Torres, MPH; David R. Williams, MPH, PhD; Ronald C. Kessler, PhD

IMPORTANCE Understanding the association of civil violence with mental disorders is important for
developing effective postconflict recovery policies.
OBJECTIVE To estimate the association between exposure to civil violence and the subsequent
onset and persistence of common mental disorders (in the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition [DSM-IV]) in representative surveys of civilians from countries that
have experienced civil violence since World War II.
DESIGN, SETTING, AND PARTICIPANTS This study used data from cross-sectional World Health
Organization World Mental Health (WMH) surveys administered to households between February 5,
2001, and January 5, 2022, in 7 countries that experienced periods of civil violence after World War
II (Argentina, Colombia, Lebanon, Nigeria, Northern Ireland, Peru, and South Africa). Data from
respondents in other WMH surveys who immigrated from countries with civil violence in Africa and
Latin America were also included. Representative samples comprised adults (aged 18 years) from
eligible countries. Data analysis was performed from February 10 to 13, 2023.
EXPOSURES Exposure was defined as a self-report of having been a civilian in a war zone or region
of terror. Related stressors (being displaced, witnessing atrocities, or being a combatant) were also
assessed. Exposures occurred a median of 21 (IQR, 12-30) years before the interview.
MAIN OUTCOMES AND MEASURES The main outcome was the retrospectively reported lifetime
prevalence and 12-month persistence (estimated by calculating 12-month prevalence among lifetime
cases) of DSM-IV anxiety, mood, and externalizing (alcohol use, illicit drug use, or intermittent
explosive) disorders.
RESULTS This study included 18 212 respondents from 7 countries. Of these individuals, 2096
reported that they were exposed to civil violence (56.5% were men; median age, 40 [IQR, 30-52]
years) and 16 116 were not exposed (45.2% were men; median age, 35 [IQR, 26-48] years).
Respondents who reported being exposed to civil violence had a significantly elevated onset risk of
anxiety (risk ratio [RR], 1.8 [95% CI, 1.5-2.1]), mood (RR, 1.5 [95% CI, 1.3-1.7]), and externalizing (RR,
1.6 [95% CI, 1.3-1.9]) disorders. Combatants additionally had a significantly elevated onset risk of
anxiety disorders (RR, 2.0 [95% CI, 1.3-3.1]) and refugees had an increased onset risk of mood (RR, 1.5
[95% CI, 1.1-2.0]) and externalizing (RR, 1.6 [95% CI, 1.0-2.4]) disorders. Elevated disorder onset risks
persisted for more than 2 decades if conflicts persisted but not after either termination of hostilities or emigration. Persistence (ie, 12-month prevalence among respondents with lifetime prevalence of
the disorder), in comparison, was generally not associated with exposure.
CONCLUSIONS In this survey study of exposure to civil violence, exposure was associated with an
elevated risk of mental disorders among civilians for many years after initial exposure. These findings
suggest that policy makers should recognize these associations when projecting future mental
disorder treatment needs in countries experiencing civil violence and among affected migrants.

: Mood disorders, Anxiety disorders, Adult-onset, War exposure, Childhood adversities, Trauma, Family malfunctioning.