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FIELD REPORT
Year : 2023 | Volume
: 21
| Issue : 1 | Page : 9-13
Posttraumatic Stress Disorder among University Students of Mosul, Iraq: An After Effect of War Atrocities
Maha Sulaiman Younis1, Amina Saad Abdullah2, S.M. Yasir Arafat3
1 Professor of Psychiatry, College of Medicine, University of Baghdad, Baghdad, Iraq
2 Psychiatric Registrar, Mosul General Hospital, Candidate of the Arab Board for Health Specializations, Mosul, Iraq
3 Assistant Professor, Department of Psychiatry, Enam Medical College and Hospital, Dhaka, Bangladesh
Correspondence Address:
MD, MPH S.M. Yasir Arafat
Department of Psychiatry, Enam Medical College and Hospital, Dhaka 1340
Bangladesh
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/intv.intv_16_21
People in Mosul, Iraq faced many acts of violence between 2014 and 2017 when the city was seized by the terrorist group of Islamic State of Iraq and Syria (ISIS). We aimed to determine the prevalence of symptoms of posttraumatic stress disorder (PTSD) among university students in Mosul. This cross-sectional study was conducted between the period of 15 April and 29 December 2020. Data were collected from 305 university students by face-to-face interview. The Iraqi modified version of the Harvard Trauma Questionnaire was used to assess the prevalence and degree of PTSD symptoms. The mean age of the participants was 21.46 ± 2.76 years; 224 (73.4%) of the students were females and 259 (84.9%) were single. 12% of the students met the threshold criteria for symptoms of PTSD. Symptoms were associated with the type of injury and frequency of traumatic events experienced. This lower rate than expected for those who had been exposed to life-threatening and violent war warrants further studies to identify the attributing factors and preventive measures.
Keywords: Iraq, Mosul, PTSD, university students, war
What Happened in Mosul?
Mosul is Iraq’s second-largest city, measuring 180 km2 with 1.683 million city inhabitants (Iraq Ministry of Planning, 2019). The vast majority of the inhabitants are Arab Sunnis with some ethnic and religious minorities. It is geographically divided into two parts according to their location on the Tigris River: “left bank” (east side) and the “right bank” (west side) (UN-Habitat, 2016). People living in Mosul city and its suburbs were subjected to a tide of Islamic radicalism in response to the US military occupation in March 2003. The doctrine of Islamic fundamentalists was fuelled by the sectarian, nonprofessional attitudes of the Iraqi forces, leading to frequent infringements to city dynamics, cultural values and human rights. In June 2014, an estimated 1500 fighters of the Levant Islamic State of Iraq and Syria (ISIS) seized control of Mosul, imposing tyrannical and brutal governance of the city for 29 months (Fox et al., 2018). An estimated 1 million people decamped during the period of ISIS control and 1.5 million stayed behind the military campaign to drive ISIS from Mosul on 17 October 2016, in which 30,000 Iraqi military troops, police and security forces, and popular militants, along with 1700 US soldiers, composed the Coalition Task Force (Fox et al., 2018; Human Rights Watch, 2017). The coalition of Mosul city was subjected to massive bombardment specially the densely populated old city (West side), leading to the total destruction and obliteration of whole neighbourhoods in which an estimated 4000 civilians were buried under the wreckage including women and children and a loss of a total of 11,000 lives (O’Driscoll, 2016). The battle against ISIS ended on 29 June 2017 with major damage to almost all civil buildings, particularly on the West side and the displacement of 1.2 million persons constituting 37.5% of Iraq’s internally displaced persons (Lafta et al., 2018a). Mortality rate was much higher during the 9 months of the military liberation of Mosul than during the 29 months of exclusive ISIS control. The death rate was higher in West Mosul where house-to-house fighting along with aerial and artillery attacks were more intense and had a greater population density (Lafta et al., 2018b). The battle against ISIS attracted global attention and the concerns of the international humanitarian agencies considering it as the most extensive urban conflict since the Second World War (Human Rights Watch, 2017; O’Driscoll, 2016). People in Mosul city witnessed terrorism since the US-led invasion in March 2003 and endured extreme affects of war till 2017 (Lafta et al., 2018b). Survivors of such atrocities are expected to experience mental illnesses in different presentations, including posttraumatic stress disorder (PTSD).
Although some humanitarian groups and NGOs such as Medicine Sans Frontier and International Committee of the Red Cross invested in field health care units, psychiatric care was fundamentally lacking as serious physical injuries were prioritised and surgical facilities provided during and following the battle in 2017 (Garber et al., 2020).
What is Posttraumatic Stress Disorder?
PTSD is a constellation of symptoms as a response to experiencing or witnessing traumas outside normal experience invoking feelings of fear and being in danger such as natural or man-made disasters, bombardment, explosions and being tortured, kidnapped, deadly accidents and systematized violence. The term ‘PTSD’ was classified as a psychiatric disorder in 1980 (Bell, 1994). It affects traumatised people in different degrees, where some manage to recover from the early symptoms in weeks, while others suffer for a long time from severe disabling symptoms needing psychiatric intervention. PTSD can be classified into three main groups − intrusive symptoms, avoidance/numbing symptoms and arousal symptoms. Although such traumas affect large groups of people, some factors increase vulnerability to developing the disorder. These include childhood trauma, personality disorder, female gender, genetic susceptibility, inadequate family or social support and having a mental disorder. Other factors such as high school achievements, higher socioeconomic status, family and social support are considered protective factors (Ahmed, 2007; Mahdi, 2014).
Against this background, we aimed to assess the prevalence of PTSD symptoms, type of exposed trauma and association with sociodemographic variables among university students representing a homogenous nonclinical population sample.
MethodStudy Setting
The Iraq government established Mosul University in April 1967 in the East bank of the city. Its campus includes 23 colleges with around 51,926 students and 5,158 post graduate students. The College of Medicine, the first college of the university, was founded in 1959 and is located in the West bank (Wikipedia, 2022). During 2014–2017, the central university library was ravaged with some other college buildings. Partially damaged buildings were reconstructed by the beginning of 2018 to accommodate students and restart academic activities. We chose students attending the College of Medicine and College of Engineering for this study. They were located inside the university campus during the period of 15 April and 20 December 2020.
Data Collection and Ethical Approval
The Research and Ethical Committee of the Arab Council for Medical Specializations/Iraq office approved the research proposal (order/231/12-2-2020). The second author obtained formal approval from the Dean’s office to enter classrooms at the university and meet the students shortly after finishing their lectures. They contacted a total of 400 students, providing a full explanation about the study and seeking their verbal consent. The students’ participation was voluntary. Students were assured that no personal data or identities would be released in any way. The Research and Ethical Committee of the Arab Council for Medical Specializations/Iraq office approved the research proposal (order/231/12-2-2020).
Study Tools
Two tools were used for this study. The first collected sociodemographic data including age, gender, marital status, socioeconomic status and housing. The second was the Harvard Trauma Questionnaire (HTQ). This is a self-report checklist (the Arabic version) and further modified into the Iraqi version to conform with cultural norms and the incidence of war and violence (Al-Shawi, 2018; Harvard Program in Refugee Trauma, 2006). It documents symptoms related to the experience of traumatic events. Its validity and reliability in measuring the symptoms associated with PTSD has been demonstrated in many settings. The checklist includes questions related to the type of the traumatic events experienced by the respondent (such as intimidation and threat, house raid, damage to property, arrest imprisonment, inaccessible health care and witnessing torture or killing). It also includes questions depicting the types of violence experienced by the participants (killing or serious injury, receiving threats, intimidation, kidnapping for ransom and house raids). Respondents could be exposed to such traumas occurring to others related to them. These persons were categorised into: 1–first-degree relatives (son and daughter, parent, sibling, grandparents and spouse); 2–second-degree relatives (uncle, aunt and cousin); 3–friend and acquaintances. The scale contains 42 questions measuring the frequency and intensity of distressing symptoms caused by the trauma. These questions measure the symptoms of a reaction to trauma within a 4-point Likert severity scale (1 = no symptoms, 2 = sometimes, 3 = frequent, 4 = most of the times). The first 16 items follows the Diagnostic and Statistical Manual for Mental Disorders (DSM- IV) criteria and the remaining items specify distress related to forcibly conflict-affected communities. A score >2.5 was considered significant for meeting symptoms criteria of PTSD based on instrument standard (Bell, 1994). The interviewer registered the responses of participants.
Statistical Analysis
Data was collated in Microsoft Excel, cleaned and imported into IBM SPSS version 24 for statistical analysis. Tables and graphs were compiled to display descriptive statistics. Two independent sample T-tests were used to identify the significance of differences between means and the Chi-square test was used to determine the association between related categorical variables. A p-value less than 0.05 was considered a discriminative point for significance. Statistical analysis was completed by the academic statistician in the Department of Community Medicine, Mosul University. A Likert scale was used to determine the severity of PTSD symptoms where high scores indicated more severe symptoms.
ResultsA total of 305 university students participated in the study with a response rate of 76%. The mean age of the participants was 21.46 ± 2.76 years; 224 (73%) of the participants were females, and 259 (84%) were single ([Table 1]). 38 students (12%) had scores fulfilling PTSD criteria according to the HTQ scale. 138 (45%), 121 (40%) and 46 (15%) had mild, moderate and severe symptoms respectively. Respondents were affected by several types of traumatic experiences such as damaged property (31%), house raids (29%), witnessing killing or torture (20%), intimidation and threat (19%), inaccessible health care (19%) and arrest or imprisonment (3%; [Figure 1]). There was no significant association between PTSD symptoms and any sociodemographic variables. The association between PTSD and type of trauma was tested and indicated that house raids (P = .028), intimidation or receiving threat (P = .048) and inaccessible health care (P = .011) were predictors of meeting PTSD symptom criteria ([Table 2]). There was no significant association between having PTSD and the relationship of the victims to the participants.
Table 2 The Association between Posttraumatic Stress Disorder and Type of Trauma event experienced Discussion People in Mosul city and its provinces endured massive atrocities from 9 June 2014 to 10 July 2017. The post-conflict situation and security issues in Mosul city were the main obstacle in data collection. The authors therefore chose university students as a convenience sample representing the general population. The sociodemographic profile of respondents was primarily that of single, healthy, educated youth, predominantly females and more than half of them had decent living conditions and adequate income. Such characteristics may reflect the “fortunate portion” of society who did not lose their houses or had to leave schooling to make a living.
The low prevalence of those scoring above the PTSD symptom threshold (12%) is a surprising finding in the light of their long experience of war. It is lower than many other similar studies, suggesting a complex interaction of various factors such as sociodemographic backgrounds, personality characteristics, Islamic faith in destiny, passage of time, and social and family support. It was observed through the clinical experience of the psychiatrists working in Iraq that people affected by PTSD tend to cope well and develop posttraumatic growth and resilience in most of the cases. Individuals with other disorders (depression and anxiety) developed in response to a trauma usually seek psychiatric help and receive treatments (Kamil et al., 2014; Khaleel & Al-Doori, 2019).
The sociodemographic characteristics described above may have contributed to the low prevalence rate of those scoring above the threshhold in the current study. The passage of time may alleviate the severity of their psychological response to trauma (Al-Shawi, 2017; Kamil et al., 2014). This rate is similar to what Zubair et al. (2019) found in a similar sample. However, it is lower than the study findings conducted by Khaleel and Al-Doori (2019) where 44.7% of secondary students in Mosul city had PTSD. It is also lower than 22.9% found by Al-Shawi et al. (2013) in a similar study. Our rate is comparable to the finding in the Al-Jawadi and Abdul-Rhman (2007) study.
Additionally, the variations of findings are related to methods followed in the study and the time when it was conducted. We attribute the relatively low prevalence to the protective effects of youth, education and good socioeconomic status against PTSD. The nonrepresentative sample and low sample size might produce such a low prevalence of PTSD symptoms among the participants. Around third of the participants experienced profound or partial damage to their properties: homes or commercial building and house raids by Iraqi and coalition task forces. In contrast, no significant association was found between PTSD and sociodemographic variables (Mahdi et al., 2014). However, these variations are to be expected due to the complex interplay of the traumas and development of PTSD and its severity and family support, and the influence of social and religious values (Al-Shawi, 2018).
Our study indicates a higher number of women scoring above the symptom threshold for PTSD criteria than men. This may reflect the extent to which violence markedly affects women’s mental health in many degrees and different clinical presentations or may complicate existing mental disorders and impede the treatment process due to violence-related logistic difficulties (Lafta & Merza, 2021). The massive air strikes experienced by civilians killed and injured thousands of women and children turning the city’s neighbourhoods into a frontline. In addition to these war atrocities, women living in Mosul shouldered family responsibilities when their male family members were killed or injured, increasing their vulnerability to develop PTSD or other mental illness as manifested by Younis and Lafta (2021) in their recent review.
Developing symptoms of PTSD after witnessing traumatic events was not influenced by the degree of kinship as the participants show comparable rates whether the affected person was a close family member or friends and acquaintances. The association was not statistically significant, which may also be attributed to the massive size of war-related traumas and the interconnected nature of Mosul society (Abdulrazaq & Stansfield, 2016; Boloorani et al., 2021).
Limitations of the Study
Many factors limited this study: lack of official statistics regarding the size of the city’s destruction, the death toll, the number of migrants and forcibly displaced families, and the number of seriously injured civilians. The circumstances of the cornonavirus disease 2019 pandemic lockdown led to student absences or irregular attendance of students which caused difficulties in the sample collection process. A sizable proportion of students refused to participate or declined, which limited the number. The challenges in transportation caused by the destruction of city bridges also resulted in a time lag for a scheduled visit to Mosul University for data collection (Boloorani et al., 2021). Additionally, we used approximate categories for the socioeconomic status of respondents that may raise the concern for subjective bias. Therefore, a prudential judgment is warranted in terms of generalising the study results.
ConclusionThe study suggested that 12% of university students reported levels of symptoms associated with a diagnosis of PTSD. This finding was lower than expected against the backdrop of the massive destruction of the city and the high rate of fatalities from 2014 to 2017 in Mosul. A judicious approach should be considered, when considering the study findings and further studies are warranted to identify the attributing factors and preventive measures.
Authors’ contribution
MSY: Conception, design, data analysis, writing, revision and approval. ASA: Conception, design, data collection and analysis, and approval. SMYA: Writing, critical review, revision and approval.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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