The prevalence of PTSD and major depression in the global population of adult war survivors: a meta-analytically informed estimate in absolute numbers

Figures & data

Figure 1. Forest plot depicting meta-analytic results of all representative surveys assessing PTSD in countries with a history of war between 1989 and 2015.

Table 1. Characteristics of included studies in the meta-analysis.

Publication	Country	N	PTSD assessed with	MD assessed with	Years since trauma
Ayazi, Lien, Eide, Ruom, & Hauff, 2012	Sudan	1200	NA	MINI	5
Betancourt et al., 2016	Sierre Leone	563	PSS-I	NA	NR
Canetti et al., 2010	Palestine	1196	PSS-I	NA	Ongoing
De Jong et al., 2001	Algeria	653	CIDI	NA	6
	Palestine	585	CIDI	NA	Ongoing
Eytan, Gex-Fabry, Toscani, Deroo, Loutan, Bovier, 2004	Kosovo	996	MINI	NA	2
Fodor, Pozen, Ntaganira, Sezibera, & Neugebauer, 2015	Rwanda	465	NA	MINI	NR
Johnson et al., 2008	Liberia	1661	PSS-I	NA	4
Morina & Ford, 2008	Kosovo	102	MINI	MINI	6
Morina, Stangier, & Risch, 2008	Kosovo	84	MINI	NA	6
Morina, Ford, Risch, Morina, & Stangier, 2010	Kosovo	163	MINI	MINI	8
Morina, Reschke, & Hofmann, 2011*	Kosovo	71	MINI	MINI	9
Morina, von Lersner, & Prigerson, 2011*	Kosovo	175	MINI	MINI	10
Morina & Emmelkamp, 2012*	Kosovo	106	MINI	MINI	10
Mugisha, Muyinda, Malamba, & Kinyanda, 2015	Uganda	2361	MINI	MINI	7
Munyandamutsa, Nkubamugisha, Gex-Fabry, & Eytan, 2012	Rwanda	962	MINI	MINI	14
Priebe et al., 2010	Croatia	727	MINI	MINI	13
	Kosovo	648	MINI	MINI	8
	Serbia	637	MINI	MINI	13
	Bosnia & Herzegovina	640	MINI	MINI	13
Rieder & Elbert, 2013	Rwanda	172	PSS-I	NA	16
Rugema, Mogren, Ntaganira, & Krantz, 2015	Rwanda	917	MINI	MINI	17
Schaal, Dusingizemungu, Jacob, & Elbert, 2011	Rwanda	400	PSS-I	NA	13
Somasundaram & Sivayokan, 1994	Sri Lanka	98	SIQ	SIQ	4
Veling, Hall, & Joosse, 2013	D. R. of Congo	93	CIDI	NA	ongoing
Yasan, Saka, Ozkan, & Ertem, 2009	Turkey	708	CAPS	NA	10

CAPS = Clinician-Administered PTSD Scale; CIDI = Composite International Diagnostic Interview; MD = Major Depression; MINI = MINI International Neuropsychiatric Interview; N = number of participants; NA = not applicable; NR = not reported; PSS-I = Posttraumatic Symptom Scale Interview; PTSD = Posttraumatic Stress Disorder; SIQ = Stress Impact Questionnaire. *only subsample included that met presented inclusion criteria

Table 2. Prevalence estimates of PTSD and MD in absolute numbers for countries/regions with a recent or ongoing history of war (between 1989 and 2015).

Country (plus region if war was regional)	Year (first war intensity reached within given timespan)	Year (last) war ended (within given timespan)	War survivors alive in 2015 (all ages)	Adult war survivors alive in 2015	Estimate of adult war survivors with PTSD	Lower bound 95% CI for estimate of adult war survivors with PTSD	Upper bound 95% CI for estimate of adult war survivors with PTSD	Estimate of adult war survivors with MD	Lower bound 95% CI for estimate of adult war survivors with MD	Upper bound 95% CI for estimate of adult war survivors with MD	Estimate of adult war survivors with PTSD+MD	Lower bound 95% CI for estimate of adult war survivors with PTSD+MD	Upper bound 95% CI for estimate of adult war survivors with PTSD+MD
Afghanistan	1989	2015	33,736,494	16,248,402	3,868,745	3,174,938	4,606,422	3,797,252	3,197,686	4,430,939	1,860,274	1,150,187	2,575,676
Angola	1989	2001	14,743,060	12,932,355	3,079,194	2,526,982	3,666,323	3,022,291	2,545,087	3,526,653	1,480,621	915,452	2,050,020
El Salvador	1989	1989	3,232,318	3,232,318	769,615	631,595	916,362	755,393	636,120	881,453	370,067	228,808	512,383
Ethiopia	1989	2000	58,315,113	51,037,897	12,152,123	9,972,805	14,469,244	11,927,557	10,044,258	13,918,035	5,843,310	3,612,857	8,090,462
India (5 regions)	1989	2010	76,156,270	50,263,138	11,967,653	9,821,417	14,249,600	11,746,495	9,891,786	13,706,758	5,754,608	3,558,013	7,967,648
Lebanon	1989	1990	3,308,096	3,308,096	787,658	646,402	937,845	773,102	651,033	902,118	378,743	234,173	524,395
Mozambique	1989	1991	9,825,494	9,825,494	2,339,450	1,919,902	2,785,528	2,296,218	1,933,657	2,679,412	1,124,917	695,524	1,557,525
Myanmar	1989	1995	32,949,950	32,949,950	7,845,383	6,438,420	9,341,311	7,700,403	6,484,550	8,985,451	3,772,428	2,332,452	5,223,184
Peru	1989	1992	17,036,955	17,036,955	4,056,499	3,329,021	4,829,977	3,981,536	3,352,873	4,645,978	1,950,555	1,206,007	2,700,676
Somalia	1989	2015	13,908,129	6,460,529	1,538,252	1,262,387	1,831,560	1,509,826	1,271,432	1,761,786	739,664	457,326	1,024,115
Sri Lanka	1989	2009	19,071,024	14,663,408	3,491,357	2,865,230	4,157,076	3,426,838	2,885,759	3,998,711	1,678,808	1,037,989	2,324,425
Sudan	1989	2015	38,647,803	19,999,254	4,761,822	3,907,854	5,669,789	4,673,826	3,935,853	5,453,797	2,289,707	1,415,702	3,170,256
Uganda	1989	2004	25,053,829	17,988,598	4,283,085	3,514,972	5,099,768	4,203,935	3,540,156	4,905,491	2,059,508	1,273,372	2,851,529
Kuwait	1990	1990	2,666,577	2,666,577	634,912	521,049	755,975	623,179	524,782	727,176	305,295	188,761	422,702
Liberia	1990	2003	2,922,132	2,295,826	546,636	448,604	650,867	536,535	451,819	626,072	262,848	162,516	363,931
Philippines	1990	2009	77,272,212	62,766,155	14,944,622	12,264,507	17,794,205	14,668,450	12,352,379	17,116,330	7,186,074	4,443,074	9,949,610
Iraq	1991	2015	36,115,649	19,093,017	4,546,047	3,730,776	5,412,870	4,462,038	3,757,506	5,206,666	2,185,952	1,351,551	3,026,600
Serbia	1991	1999	7,269,488	7,055,639	1,679,948	1,378,672	2,000,274	1,648,903	1,388,550	1,924,073	807,797	499,453	1,118,451
Sierra Leone	1991	1999	3,976,502	3,655,622	870,404	714,309	1,036,369	854,319	719,426	996,888	418,531	258,773	579,484
Azerbaijan	1992	1994	6,528,719	6,528,719	1,554,488	1,275,712	1,850,892	1,525,762	1,284,852	1,780,382	747,471	462,153	1,034,924
Bosnia-Herzegovina	1992	1996	2,790,591	2,790,591	664,440	545,281	791,133	652,161	549,188	760,994	319,494	197,540	442,361
Chad	1992	2006	8,814,828	6,370,163	1,516,736	1,244,730	1,805,941	1,488,707	1,253,648	1,737,143	729,318	450,929	1,009,790
Colombia	1992	2005	39,780,695	34,084,736	8,115,576	6,660,157	9,663,023	7,965,603	6,707,876	9,294,908	3,902,349	2,412,781	5,403,068
Tajikistan	1992	1996	5,027,045	5,027,045	1,196,939	982,285	1,425,167	1,174,820	989,322	1,370,875	575,545	355,853	796,881
Turkey	1992	2015	78,271,472	54,214,657	12,908,510	10,593,544	15,369,855	12,669,965	10,669,444	14,784,337	6,207,016	3,837,733	8,594,037
DR Congo	1993	2014	76,196,619	36,005,024	8,572,796	7,035,382	10,207,424	8,414,374	7,085,789	9,818,570	4,122,202	2,548,714	5,707,470
Georgia	1993	1993	2,923,312	2,923,312	696,041	571,215	828,759	683,178	575,308	797,187	334,689	206,935	463,400
Nigeria	1993	2015	181,181,744	89,657,945	21,347,557	17,519,162	25,418,027	20,953,062	17,644,684	24,449,722	10,264,905	6,346,682	14,212,462
Algeria	1994	2002	30,136,506	26,695,292	6,356,149	5,216,260	7,568,115	6,238,690	5,253,633	7,279,806	3,056,334	1,889,699	4,231,703
Ghana	1994	1994	13,464,347	13,464,347	3,205,861	2,630,933	3,817,142	3,146,618	2,649,783	3,671,727	1,541,528	953,111	2,134,351
Rwanda	1994	1994	5,677,229	5,677,229	1,351,748	1,109,331	1,609,494	1,326,768	1,117,279	1,548,180	649,984	401,878	899,947
Yemen	1994	2015	26,916,207	14,168,377	3,373,491	2,768,501	4,016,735	3,311,150	2,788,337	3,863,716	1,622,132	1,002,947	2,245,953
Burundi	1995	2003	6,572,888	4,998,535	1,190,151	976,714	1,417,085	1,168,158	983,712	1,363,100	572,280	353,835	792,361
Croatia	1995	1995	3,366,460	3,366,460	801,554	657,806	954,391	786,742	662,519	918,034	385,425	238,304	533,647
Russia (Chechnya)	1995	2004	1,395,678	1,115,147	265,517	217,900	316,144	260,610	219,461	304,101	127,673	78,939	176,772
Congo	1997	1998	2,668,374	2,570,121	611,946	502,202	728,629	600,637	505,800	700,872	294,252	181,933	407,412
Kosovo	1998	1999	1,920,079	1,555,264	370,308	303,899	440,917	363,465	306,076	424,120	178,062	110,094	246,538
Eritrea	1999	2000	2,691,877	2,497,009	594,538	487,916	707,902	583,551	491,411	680,934	285,882	176,758	395,823
Indonesia	1999	2004	205,171,722	172,620,713	41,100,992	33,730,087	48,937,972	40,341,461	33,971,756	47,073,668	19,763,282	12,219,428	27,363,613
Nepal	2002	2005	22,036,098	17,327,965	4,125,788	3,385,884	4,912,478	4,049,545	3,410,144	4,725,336	1,983,872	1,226,607	2,746,807
Pakistan	2007	2015	189,380,513	111,392,381	26,522,526	21,766,071	31,579,740	26,032,399	21,922,021	30,376,702	12,753,272	7,885,214	17,657,777
Libya	2011	2015	6,234,955	4,129,126	983,145	806,831	1,170,607	964,977	812,612	1,126,013	472,742	292,291	654,544
South Sudan	2011	2015	11,882,136	6,077,912	1,447,151	1,187,624	1,723,088	1,420,408	1,196,133	1,657,447	695,858	430,242	963,463
Syria	2011	2015	18,734,987	10,239,376	2,437,995	2,000,774	2,902,863	2,392,942	2,015,109	2,792,278	1,172,302	724,822	1,623,133
Israel	2014	2014	8,064,547	5,436,620	1,294,459	1,062,316	1,541,282	1,270,538	1,069,927	1,482,566	622,437	384,846	861,806
Ukraine (East)	2014	2015	14,530,001	11,943,661	2,843,786	2,333,791	3,386,028	2,791,234	2,350,512	3,257,036	1,367,425	845,465	1,893,294
Cameroon	2015	2015	22,834,522	11,530,588	2,745,433	2,253,077	3,268,922	2,694,698	2,269,220	3,144,391	1,320,133	816,224	1,827,814
Total			1,471,401,246	1,017,887,545	242,359,024	198,895,226	288,571,119	237,880,319	200,320,269	277,577,934	116,537,568	72,053,949	161,354,221

PTSD = Post-traumatic Stress Disorder; CI = confidence interval; MD = Major Depression. Bold country data indicates that a random sample from the general population of the respective country was available for the meta-analysis whereas normal font indicates that no such representative sample was available.

Figure 2. Forest plot depicting meta-analytic results of all representative surveys assessing MD in countries with a history of war between 1989 and 2015.

Figure 3. World map with countries and regions marked which have a history of at least one war between 1989 and 2015.

Retrieved from: https://www.amcharts.com/visited_countries/#. Regions added manually.

Ayazi, T., Lien, L., Eide, A. H., Ruom, M. M., & Hauff, E. (2012). What are the risk factors for the comorbidity of posttraumatic stress disorder and depression in a war-affected population? A cross-sectional community study in South Sudan. BioMed Central Psychiatry, 12(1), e175.

 Web of Science ®Google Scholar

Betancourt, T. S., Brennan, R. T., Vinck, P., VanderWeele, T. J., Spencer-Walters, D., Jeong, J., … Pham P. (2016). Associations between mental health and ebola-related health behaviors: A regionally representative cross-sectional survey in post-conflict Sierra Leone. Public Library of Science Medicine, 13(8), e1002073.

 Google Scholar

Canetti, D., Galea, S., Hall, B. J., Johnson, R. J., Palmieri, P. A., & Hobfoll, S. E. (2010). Exposure to prolonged socio-political conflict and the risk of PTSD and depression among Palestinians. Psychiatry, 73(3), 219–231.

 PubMed Web of Science ®Google Scholar

De Jong, J. T., Komproe, I. H., Van Ommeren, M., El Masri, M., Araya, M., Khaled, N., … Somasundaram, D. (2001). Lifetime events and posttraumatic stress disorder in 4 postconflict settings. Journal of the American Medical Association, 286(5), 555–562.

 Web of Science ®Google Scholar

Eytan, A., Gex-Fabry, M., Toscani, L., Deroo, L., Loutan, L., & Bovier, P. A. (2004). Determinants of postconflict symptoms in Albanian Kosovars. The Journal of Nervous and Mental Disease, 192(10), 664–671. doi: 00005053-200410000-00004

 Web of Science ®Google Scholar

Fodor, K. E., Pozen, J., Ntaganira, J., Sezibera, V., & Neugebauer, R. (2015). The factor structure of posttraumatic stress disorder symptoms among Rwandans exposed to the 1994 genocide: A confirmatory factor analytic study using the PCL-C. Journal of Anxiety Disorders, 32, 8–16.

 PubMed Web of Science ®Google Scholar

Johnson, K., Asher, J., Rosborough, S., Raja, A., Panjabi, R., Beadling, C., & Lawry, L. (2008). Association of combatant status and sexual violence with health and mental health outcomes in postconflict Liberia. Journal of the American Medical Association, 300(6), 676–690.

 PubMed Web of Science ®Google Scholar

Morina, N., & Ford, J. D. (2008). Complex sequelae of psychological trauma among Kosovar civilian war victims. International Journal of Social, 54(5), 425–436.

 Google Scholar

Morina, N., Stangier, U., & Risch, A. K. (2008). Experiential avoidance in civilian war survivors with current versus recovered posttraumatic stress disorder: A pilot study. Behaviour Change, 25(1), 15–22.

 Web of Science ®Google Scholar

Morina, N., Ford, J. D., Risch, A. K., Morina, B., & Stangier, U. (2010). Somatic distress among Kosovar civilian war survivors: Relationship to trauma exposure and the mediating role of experiential avoidance. Social Psychiatry and Psychiatric Epidemiology, 45(12), 1167–1177.

 Web of Science ®Google Scholar

Morina, N., Reschke, K., & Hofmann, S. G. (2011). Long-term outcomes of war-related death of family members in Kosovar civilian war survivors. Death Studies, 35(4), 365–372.

 Web of Science ®Google Scholar

Morina, N., Von Lersner, U., & Prigerson, H. G. (2011). War and bereavement: Consequences for mental and physical distress. Public Library of Science One, 6(7), e22140.

 Google Scholar

Morina, N., & Emmelkamp, P. M. (2012). Mental health outcomes of widowed and married mothers after war. British Journal of Psychiatry, 200(2), 158–159.

 Web of Science ®Google Scholar

Mugisha, J., Muyinda, H., Malamba, S., & Kinyanda, E. (2015). Major depressive disorder seven years after the conflict in northern Uganda: Burden, risk factors and impact on outcomes (The Wayo-Nero Study). BioMed Central Psychiatry, 15(1), e48.

 Web of Science ®Google Scholar

Munyandamutsa, N., Nkubamugisha, P. M., Gex-Fabry, M., & Eytan, A. (2012). Mental and physical health in Rwanda 14 years after the genocide. Social Psychiatry and Psychiatric Epidemiology, 47(11), 1753–1761.

 PubMed Web of Science ®Google Scholar

Priebe, S., Bogic, M., Ajdukovic, D., Franciskovic, T., Galeazzi, G. M., Kucukalic, A., … Schützwohl, M. (2010). Mental disorders following war in the Balkans: A study in 5 countries. Archives of General Psychiatry, 67(5), 518–528.

 Web of Science ®Google Scholar

Rieder, H., & Elbert, T. (2013). Rwanda–Lasting imprints of a genocide: Trauma, mental health and psychosocial conditions in survivors, former prisoners and their children. Conflict and Health, 7(1), e6.

 PubMedGoogle Scholar

Rugema, L., Mogren, I., Ntaganira, J., & Krantz, G. (2015). Traumatic episodes and mental health effects in young men and women in Rwanda, 17 years after the genocide. British Medical Journal Open, 5(6), e006778.

 PubMed Web of Science ®Google Scholar

Schaal, S., Dusingizemungu, J. P., Jacob, N., & Elbert, T. (2011). Rates of trauma spectrum disorders and risks of posttraumatic stress disorder in a sample of orphaned and widowed genocide survivors. European Journal of Psychotraumatology, 2(1), e6343.

 PubMed Web of Science ®Google Scholar

Somasundaram, D. J., & Sivayokan, S. (1994). War trauma in a civilian population. British Journal of Psychiatry, 165(4), 524–527.

 PubMed Web of Science ®Google Scholar

Veling, W., Hall, B. J., & Joosse, P. (2013). The association between posttraumatic stress symptoms and functional impairment during ongoing conflict in the Democratic Republic of Congo. Journal of Anxiety Disorders, 27(2), 225–230.

 PubMed Web of Science ®Google Scholar

Yasan, A., Saka, G., Ozkan, M., & Ertem, M. (2009). Trauma type, gender, and risk of PTSD in a region within an area of conflict. Journal of Traumatic Stress, 22(6), 663–666.

 PubMed Web of Science ®Google Scholar