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Cited by 60Posttraumatic Stress Disorder ResearchMigration, Health and TraumaHealth and Conflict Studies

Commentary: Explaining enormous variations in rates of disorder in trauma-focused psychiatric epidemiology after major emergencies

Rodin, D., van Ommeren, M.·2009·International Journal of Epidemiology
DOI 10.1093/ije/dyp203
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Abstract

There has been a surge of interest in the last 20 years in the mental health effects of conflict and other major disasters in low- and middle-income countries (LAMIC). In particular, post-traumatic stress disorder (PTSD) and major depression have received substantial attention. It has become evident that there are large, unexplained variations in prevalence rates identified through trauma-focused psychiatric epidemiology in such settings. For example, Mollica et al.'s1 classic study found prevalence rates of PTSD of 15% among genocide-exposed Cambodians, while Neugebauer et al.'s2 sophisticated report in this issue of the Journal identifies rates of 53–62% of PTSD in genocide-exposed Rwandans. The wide variation in the prevalence rates in studies of PTSD and depression may be attributable to differences in context, methodology or both. Discussion sections of reports often highlight only a few factors that could explain the size of obtained rates. Although peer review helps shape discussion sections, authors usually have enormous discretion in deciding what factors to report. Readers are left with the challenge of tracking all reported and unreported methodological and contextual factors that could explain a study's results. We have developed a scheme that may help to systematically identify factors influencing the size of observed prevalence rates of disorders in populations affected by major emergencies in LAMIC. The scheme may prove useful for readers and journal peer reviewers alike. The scheme, which we will apply below to Neugebauer et al.'s2 study, was built as follows. We searched the following medical, psychiatry and speciality journal websites: American Journal of Psychiatry; Archives of General Psychiatry; British Journal of Psychiatry; British Medical Journal; Culture Medicine and Psychiatry; JAMA, Journal of Traumatic Stress, Lancet, Psychological Medicine; Social Science and Medicine; and Transcultural Psychiatry for studies published after 1998 with data collected on depression or PTSD among civilians after major emergencies in LAMIC (references available upon request). Of 43 studies, 11 (26%) pertained to major natural disasters and 32 (74%) pertained to major human-made disasters (e.g. war). All articles were original contributions, and 40 (93%) made comments explaining the magnitude of findings in the articles’ discussion sections. In addition, we reviewed editorials, commentaries and letters to the editor linked to the identified articles. We thematically analysed discussion sections of all papers. We categorized authors’ explanations for observed rates as (i) either methodological or contextual in nature and (ii) explaining either relatively higher or lower observed rates. In addition, we categorized some explanations as (iii) reflecting general methodological limitations causing uncertainty in the validity of the study, with unknown impact on the magnitude of observed rates. Table 1 provides an overview of the explanations for relatively high or low rates ascribed in these studies. Schematic overview of possible influences on uncertainty in observed prevalence rates (with ratings applied to the Neugebauer et al.2 study) Sampling problems Over-sampling of severely affected areas (1) Over-sampling of likely high risk demographic groups (e.g. women) (1) Socially desirable over-reporting (acquiescence) Expectations raised by the way the overall survey and its questions are framed (3) Interviewer's own expectations (3) Help-seeking behaviour among respondents (3) Measures cover life-time prevalence (1) Measures not fully re-validated for specific emergency-affected context To-be-expected distress (e.g. ongoing experiences of loss and misery) not necessarily consistently distinguished from symptoms of mental disorder (4) Reality-based fears (e.g. due to risk of exposure to ongoing further violence) not necessarily consistently distinguished from symptoms of mental disorder (4) Sampling problems Small sample size Non-probability sampling (3) Low response rates (1) Unreported or low reliability: Internal consistency (1) Test–retest reliability (3) Inter-rater reliability (3) Use of incorrect diagnostic criteria (5) Uncertainty whether translation is adequate (1) Unknown or weak criterion validity of exposure measures (1) Unknown or weak criterion validity of outcome measures (3) Uncertainty whether measures concepts are culturally valid (2) Sampling problems Over sampling of less affected areas (1) Under-sampling of likely high-risk groups (1) Underreporting due to problems in recall (1) Socially under-desirable reporting (social stigma) Declarations of anonymity/confidentiality not persuasive. (3) Lack of privacy in interview settings (3) Measures cover point prevalence (1) Trauma-induced mental disorder expressed in other or more ways than measured (e.g. other disorders) (5) High rates of pre-existing mental health disorders (3) Dose–response phenomena High pre-existing exposure to conflict or

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  • A combination of methodological and contextual factors has contributed to very high variability in prevalence rates in epidemiological studies of conflict-affected populations.

    “First, a combination of methodological (e.g., sampling problems, use of measures that do not distinguish between normal psychological distress and mental disorder, and lack of cultural validation) and contextual factors (e.g., not accounting for pre-existing mental health conditions) have contributed to a very high variability in prevalence rates [10].”

    From Mental health and psychosocial support for South Sudanese refugees in northern Uganda: a needs and resource assessment (2016) · cites this paper as [10]

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Authors
Rodin, D., & van Ommeren, M.
Affiliations
University of Toronto (CA)
ORCID
Rodin, D.
Venue
International Journal of Epidemiology
Publisher
Oxford University Press (OUP)
Published
2009-05-04
Volume
38
Issue
4
Pages
1045-1048
ISSN
  • 0300-5771 (ISSN-L)
  • 1464-3685
DOI
10.1093/ije/dyp203
OpenAlex
W2130789467
Cited by
60
References
13
Citations by year
2026: 1 · 2025: 1 · 2024: 3 · 2023: 4 · 2022: 2 · 2021: 3 · 2020: 3 · 2019: 2 · 2018: 4 · 2017: 6 · 2016: 2 · 2015: 1 · 2014: 8 · 2013: 7 · 2012: 5
Type
journal article
Language
en
Open access
closed
Locations
  • International Journal of Epidemiology (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
  • Social Sciences › Psychology › Clinical Psychology › Migration, Health and Trauma
  • Health Sciences › Health Professions › General Health Professions › Health and Conflict Studies
Keywords
post-traumatic stress disorder, major depressive disorder, major disasters, low- and middle-income countries, prevalence rates, discussion section, methodological factors, contextual factors, natural disasters, genocide, civilian mental health, peer review, Cambodia
MeSH terms
Homicide, Humans, Research Design, Stress Disorders, Post-Traumatic, Violence, Prevalence

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