Almost two-thirds of low-income countries exist in fragile and conflict-affected contexts, characterized by intense conflict with institutional and social weaknesses. By the end of last year, 123.2 million individuals were displaced against their will due to persecution, warfare, violence, or violations of human rights. Approximately 400 million individuals will reside in fragile nations within the next decade (1). The psychological impact of war is one of the most prevalent and significant effects of this human-made disaster. The disorder first came to attention in the 1860s during the American Civil War under the name Soldier's Heart or Da Costa's syndrome (2). It was then examined in greater detail in other wars and has been given various names throughout history. It is now classified under the heading of Trauma and Stress-Related Disorders, which includes posttraumatic stress disorder, acute stress disorder, and adjustment disorders (3). Psychological factors can not only cause disorders related to psychological stress but also, in interaction with biological factors, can cause various psychosomatic disorders (4).A famous example related to combat stress is Persian Gulf War Syndrome, also known as Chronic Multisymptom Illness, where, although there is a large body of evidence in favor of biological causative factors, some experts believe that the unexplained set of symptoms associated with this syndrome may result from an interaction between biological and psychological factors (5).
The prevalence of these effects is directly related to the severity of the trauma and the availability and speed of access to psychological support (6). It has a significant impact on mental health and can lead to long-term distress and impaired interpersonal relationships, affecting various aspects of life such as familial, social, educational, and occupational functioning (7). The impact of severe trauma, including war trauma — which is always considered one of the most significant types of traumas — on humans is not limited to the injured individual. There is now increasing evidence that the adverse effects of trauma can be passed on to future generations (8, 9).
According to the World Health Organization, one of the most authoritative studies, which analyzed 129 studies, found that more than 20 percent of people living in conflict-affected zones suffer from a major psychiatric disorder, and about 10 percent of them suffer from a moderate to severe psychiatric disorder (10). This figure has been reported to be up to 85 percent in war-wounded individuals (11).
Immediate treatment of traumatized individuals plays a significant role in preventing these consequences. Various measures have been recommended in this regard and have evolved over time with the increasing experience of mental health professionals. The common point of all these measures is the urgency of their implementation. "Debriefing" was probably the first preventive measure employed in this field, encompassing a wide range of philosophies and techniques (12, 13). After debriefing, other psychosocial interventions such as crisis counseling and psychoeducation were introduced in this context (14). One of the latest measures being taken in this area is "Psychological First Aid," which was introduced in 2006 and is emphasized by the International Federation of Red Cross and Red Crescent Societies. Adequate evidence for psychological first aid is broadly supported by available objective observations and expert opinion, with a lot of evidence indicating its effectiveness (15, 16).
The experience of the eight-year war between Iraq and Iran showed us how neglecting the psychiatric consequences of war can impose dire consequences on society for years to come (11, 17). There is no doubt that providing relief to populations affected by war should be considered a priority for mental health care.
The findings of a recent meta-analysis emphasize that mental health in times of conflict is an important public health issue that cannot be ignored, and that appropriate aid made available to at-risk populations can reduce the prevalence of psychological problems during disasters (18). The experience of the recent Israeli government attack on Lebanon highlights the critical importance of including mental health in disaster response plans (19). This is why the World Health Organization and some other United Nations-related entities recently established a task force working group to develop “mental health and psychosocial support in emergencies” (20).
In the midst of emergencies, mental health care cannot be separated from physical and social needs, as people often face multifaceted stressors, including displacement, trauma, and misery. The experiences of Lebanese mental health professionals show that in war situations where limited resources are available, flexibility and simple, practical interventions, as well as the integration of mental health care with the physical needs of affected populations, are needed to increase the provision of care in these settings (19).
Physicians must be prepared to effectively manage these challenges. Specialized training is essential to ensure they are prepared to do so. This training should include core skills such as resource management, adaptation of therapeutic interventions, and psychological first aid.
Given the preventive importance of these interventions, it is suggested that psychological first aid training be included in the general medical education curriculum. Furthermore, as the experience of Lebanese professionals has shown, residency programs for mental health professionals should offer skills such as emergency decision-making, collaboration with non-mental health professionals, and compliance with ethical standards. Lay mental health workers, who often play a key role in the initial response to emergencies, should also receive basic training, including basic psychological interventions and awareness of when to refer cases to intensive care (19). These measures can also be applied in situations unrelated to war, such as natural disasters or widespread diseases like the COVID-19 pandemic.
Unfortunately, in the recent Israeli-American war against Iran, we witnessed that the Iranian Ministry of Health, Treatment, and Medical Education not only failed to take action in this regard but, instead of emphasizing training in psychological emergencies for intervention in the war crisis, took the step of closing the psychiatric internship for medical students who could have taken effective preventive measures in these sensitive and critical circumstances.
