Afghan mental health and psychosocial well-being: thematic review of four decades of research and interventions

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Abstract

Background

Four decades of war, political upheaval, economic deprivation and forced displacement have profoundly affected both in-country and refugee Afghan populations.

Aims

We reviewed literature on mental health and psychosocial well-being, to assess the current evidence and describe mental healthcare systems, including government programmes and community-based interventions.

Method

In 2022, we conducted a systematic search in Google Scholar, PTSDpubs, PubMed and PsycINFO, and a hand search of grey literature ( N = 214 papers). We identified the main factors driving the epidemiology of mental health problems, culturally salient understandings of psychological distress, coping strategies and help-seeking behaviours, and interventions for mental health and psychosocial support.

Results

Mental health problems and psychological distress show higher risks for women, ethnic minorities, people with disabilities and youth. Issues of suicidality and drug use are emerging problems that are understudied. Afghans use specific vocabulary to convey psychological distress, drawing on culturally relevant concepts of body–mind relationships. Coping strategies are largely embedded in one's faith and family. Over the past two decades, concerted efforts were made to integrate mental health into the nation's healthcare system, train cadres of psychosocial counsellors, and develop community-based psychosocial initiatives with the help of non-governmental organisations. A small but growing body of research is emerging around psychological interventions adapted to Afghan contexts and culture.

Conclusions

We make four recommendations to promote health equity and sustainable systems of care. Interventions must build cultural relevance, invest in community-based psychosocial support and evidence-based psychological interventions, maintain core mental health services at logical points of access and foster integrated systems of care.

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Most cited references 273

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Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

(2022)

Summary Background The mental disorders included in the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 were depressive disorders, anxiety disorders, bipolar disorder, schizophrenia, autism spectrum disorders, conduct disorder, attention-deficit hyperactivity disorder, eating disorders, idiopathic developmental intellectual disability, and a residual category of other mental disorders. We aimed to measure the global, regional, and national prevalence, disability-adjusted life-years (DALYS), years lived with disability (YLDs), and years of life lost (YLLs) for mental disorders from 1990 to 2019. Methods In this study, we assessed prevalence and burden estimates from GBD 2019 for 12 mental disorders, males and females, 23 age groups, 204 countries and territories, between 1990 and 2019. DALYs were estimated as the sum of YLDs and YLLs to premature mortality. We systematically reviewed PsycINFO, Embase, PubMed, and the Global Health Data Exchange to obtain data on prevalence, incidence, remission, duration, severity, and excess mortality for each mental disorder. These data informed a Bayesian meta-regression analysis to estimate prevalence by disorder, age, sex, year, and location. Prevalence was multiplied by corresponding disability weights to estimate YLDs. Cause-specific deaths were compiled from mortality surveillance databases. The Cause of Death Ensemble modelling strategy was used to estimate death rate by age, sex, year, and location. The death rates were multiplied by the years of life expected to be remaining at death based on a normative life expectancy to estimate YLLs. Deaths and YLLs could be calculated only for anorexia nervosa and bulimia nervosa, since these were the only mental disorders identified as underlying causes of death in GBD 2019. Findings Between 1990 and 2019, the global number of DALYs due to mental disorders increased from 80·8 million (95% uncertainty interval [UI] 59·5–105·9) to 125·3 million (93·0–163·2), and the proportion of global DALYs attributed to mental disorders increased from 3·1% (95% UI 2·4–3·9) to 4·9% (3·9–6·1). Age-standardised DALY rates remained largely consistent between 1990 (1581·2 DALYs [1170·9–2061·4] per 100 000 people) and 2019 (1566·2 DALYs [1160·1–2042·8] per 100 000 people). YLDs contributed to most of the mental disorder burden, with 125·3 million YLDs (95% UI 93·0–163·2; 14·6% [12·2–16·8] of global YLDs) in 2019 attributable to mental disorders. Eating disorders accounted for 17 361·5 YLLs (95% UI 15 518·5–21 459·8). Globally, the age-standardised DALY rate for mental disorders was 1426·5 (95% UI 1056·4–1869·5) per 100 000 population among males and 1703·3 (1261·5–2237·8) per 100 000 population among females. Age-standardised DALY rates were highest in Australasia, Tropical Latin America, and high-income North America. Interpretation GBD 2019 showed that mental disorders remained among the top ten leading causes of burden worldwide, with no evidence of global reduction in the burden since 1990. The estimated YLLs for mental disorders were extremely low and do not reflect premature mortality in individuals with mental disorders. Research to establish causal pathways between mental disorders and other fatal health outcomes is recommended so that this may be addressed within the GBD study. To reduce the burden of mental disorders, coordinated delivery of effective prevention and treatment programmes by governments and the global health community is imperative. Funding Bill & Melinda Gates Foundation, Australian National Health and Medical Research Council, Queensland Department of Health, Australia.

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Mental health, social functioning, and disability in postwar Afghanistan.

Mitchell Wolfe, Barbara Lopes Cardozo, Mark Anderson … (2004)

More than 2 decades of conflict have led to widespread human suffering and population displacement in Afghanistan. In 2002, the Centers for Disease Control and Prevention and other collaborating partners performed a national population-based mental health survey in Afghanistan. To provide national estimates of mental health status of the disabled (any restriction or lack of ability to perform an activity in the manner considered normal for a human being) and nondisabled Afghan population aged at least 15 years. A national multistage, cluster, population-based mental health survey of 799 adult household members (699 nondisabled and 100 disabled respondents) aged 15 years or older conducted from July to September 2002. Fifty district-level clusters were selected based on probability proportional to size sampling. One village was randomly selected in each cluster and 15 households were randomly selected in each village, yielding 750 households. Demographics, social functioning as measured by selected questions from the Medical Outcomes Study 36-Item Short-Form Health Survey, depressive symptoms measured by the Hopkins Symptoms Checklist-25, trauma events and symptoms of posttraumatic stress disorder (PTSD) measured by the Harvard Trauma Questionnaire, and culture-specific symptoms of mental illness and coping mechanisms. A total of 407 respondents (62.0%) reported experiencing at least 4 trauma events during the previous 10 years. The most common trauma events experienced by the respondents were lack of food and water (56.1%) for nondisabled persons and lack of shelter (69.7%) for disabled persons. The prevalence of respondents with symptoms of depression was 67.7% (95% confidence interval [CI], 54.6%-80.7%) and 71.7% (95% CI, 65.0%-78.4%), and symptoms of anxiety 72.2% (95% CI, 63.8%-80.7%) and 84.6% (95% CI, 74.1%-95.0%) for nondisabled and disabled respondents, respectively. The prevalence of symptoms of PTSD was similar for both groups (nondisabled, 42.1%; 95% CI, 34.2%-50.1%; and disabled, 42.2%; 95% CI, 29.2%-55.2%). Women had significantly poorer mental health status than men did. Respondents who were disabled had significantly lower social functioning and poorer mental health status than those who were nondisabled. Feelings of hatred were high (84% of nondisabled and 81% of disabled respondents). Coping mechanisms included religious and spiritual practices; focusing on basic needs, such as higher income, better housing, and more food; and seeking medical assistance. In this nationally representative survey of Afghans, prevalence rates of symptoms of depression, anxiety, and PTSD were high. These data underscore the need for donors and health care planners to address the current lack of mental health care resources, facilities, and trained mental health care professionals in Afghanistan.

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Mental health symptoms following war and repression in eastern Afghanistan.

Robert G J Vries, Willem F Scholte, Barbara Lopes Cardozo … (2004)

Decades of armed conflict, suppression, and displacement resulted in a high prevalence of mental health symptoms throughout Afghanistan. Its Eastern province of Nangarhar is part of the region that originated the Taliban movement. This may have had a distinct impact on the living circumstances and mental health condition of the province's population. To determine the rate of exposure to traumatic events; estimate prevalence rates of symptoms of posttraumatic stress disorder (PTSD), depression, and anxiety; identify resources used for emotional support and risk factors for mental health symptoms; and assess the present coverage of basic needs in Nangarhar province, Afghanistan. A cross-sectional multicluster sample survey of 1011 respondents aged 15 years or older, conducted in Nangarhar province during January and March 2003; 362 households were represented with a mean of 2.8 respondents per household (72% participation rate). Posttraumatic stress disorder symptoms and traumatic events using the Harvard Trauma Questionnaire; depression and general anxiety symptoms using the Hopkins Symptom Checklist; and resources for emotional support through a locally informed questionnaire. During the past 10 years, 432 respondents (43.7%) experienced between 8 and 10 traumatic events; 141 respondents (14.1%) experienced 11 or more. High rates of symptoms of depression were reported by 391 respondents (38.5%); anxiety, 524 (51.8%); and PTSD, 207 (20.4%). Symptoms were more prevalent in women than in men (depression: odds ratio [OR], 7.3 [95% confidence interval [CI], 5.4-9.8]; anxiety: OR, 12.8 [95% CI, 9.0-18.1]; PTSD: OR, 5.8 [95% CI, 3.8-8.9]). Higher rates of symptoms were associated with higher numbers of traumas experienced. The main resources for emotional support were religion and family. Medical care was reported to be insufficient by 228 respondents (22.6%). In this survey of inhabitants of Nangarhar province, Afghanistan, prevalence rates of having experienced multiple traumatic events and having symptoms of anxiety, depression, and PTSD were high. These findings suggest that mental health symptoms in this region should be addressed at the population and primary health care level.

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Author and article information

Journal

Journal ID (nlm-ta): BJPsych Open

Journal ID (iso-abbrev): BJPsych Open

Journal ID (publisher-id): BJO

Title: BJPsych Open

Publisher: Cambridge University Press (Cambridge, UK )

ISSN (Electronic): 2056-4724

Publication date (Electronic, collection): July 2023

Publication date (Electronic): 10 July 2023

Volume: 9

Issue: 4

Electronic Location Identifier: e125

Affiliations

[1]School of Behavioral Health, Loma Linda University , California, USA

[2]Jackson Institute for Global Affairs and Department of Anthropology, Yale University , Connecticut, USA

[3]School of Education, Simon Fraser University , Canada

[4]Department of Counselling, Faculty of Psychology and Educational Sciences, Kabul University , Afghanistan

[5]World Health Organization , Kabul, Afghanistan

[6]Jalalabad Regional Management Office, Swedish Committee for Afghanistan , Jalalabad, Afghanistan

[7]Migration Health Unit, International Organization for Migration , Kabul, Afghanistan

[8]Child Protection Section, UNICEF , Kabul, Afghanistan

[9]Action Against Hunger , Kabul, Afghanistan

[10]Mental Health and Psychosocial Support Unit, International Medical Corps , Kabul, Afghanistan

[11]Independent Public Health Expert , Kabul, Afghanistan

[12]Mental Health and Peacebuilding Program, International Assistance Mission , Herat, Afghanistan

[13]Kabul Mental Health Hospital Support Project, HealthNet TPO , Kabul, Afghanistan

[14]Mental Health and Psychosocial Support Unit, HealthNet TPO , Kabul, Afghanistan

[15]Department of Psychology, Bard College , New York, USA

[16]Faculty of Humanities and Social Sciences, Helmut-Schmidt University , Germany

[17]Independent Mental Health Specialist , Geneva, Switzerland

[18]Department of Ipso Academy and Quality Management, International Psychosocial Organisation , Konstanz, Germany

[19]Behrawan Research and Psychology Services Organization , Kabul, Afghanistan

[20]HealthNet TPO , Amsterdam, The Netherlands

[21]Silberman School of Social Work, The City University of New York , New York, USA

[22]Prevention Treatment and Rehabilitation Section, United Nations Office on Drugs and Crime , Vienna, Austria

[23]Department of Psychosocial Science, Faculty of Psychology, University of Bergen , Norway

[24]Faculty of Education, University of British Columbia , Canada

[25]International Psychosocial Organisation , Konstanz, Germany

[26]Focusing Initiatives International , Corvallis, Oregon, USA

[27]Brown School, Washington University in St Louis , Missouri, USA

[28]Mental Health and Psychosocial Support Unit, Première Urgence – Aide Médicale Internationale , Kabul, Afghanistan

[29]School of Psychiatry, University of New South Wales , Australia

[30]Public Health Section, United Nations High Commissioner for Refugees , Geneva, Switzerland

Author notes

Correspondence: Peter Ventevogel. Email: ventevog@ 123456unhcr.org

Author information

Jean-Francois Trani https://orcid.org/0000-0002-9187-0946

Peter Ventevogel https://orcid.org/0000-0002-3567-8861

Article

Publisher Item ID: S2056472423005021

DOI: 10.1192/bjo.2023.502

PMC ID: 10375890

PubMed ID: 37424447

SO-VID: 340eeefa-862f-488b-96ac-2002e8151e50

License:

This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.

History

Date received : 22 August 2022

Date revision received : 23 December 2022

Date accepted : 20 January 2023

Page count

Tables: 3, References: 235, Pages: 18

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Afghan mental health and psychosocial well-being: thematic review of four decades of research and interventions

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Most cited references 273

Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Mental health, social functioning, and disability in postwar Afghanistan.

Mental health symptoms following war and repression in eastern Afghanistan.

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