Challenges of Studying PTSD in Afghanistan

Afghanistan has been in war for four decades now. Although the number of casualties, physical disabilities, and fatalities during those decades is controversial; it would be safe to assume that no Afghan family remains unaffected by the war. One could safely assume that every family has lost a loved one to the consequences of war, which in most cases had been violent death. Thus, all Afghans would meet the criteria of “exposure to a life threatening situation while being in helpless situation”. Being a closely netted society, it would be hard to imagine Afghans do not have flashbacks when there is continuous re-exposure to repeated traumas to self or close acquaintance. The rest of criteria for PTSD can also be easily satisfied and validate by the face value (ongoing wars). Very few elements could, thus, be protective factors against PTSD in all Afghans.

In spite of a substantial help from the international community, the mental health has remained unaddressed in Afghanistan and systematic studies are lacking. Therefore, the rate of PTSD in Afghans is unknown. A study by Cardozo et al.  shows the prevalence of depression to be close to 68%, prevalence of anxiety merely above 72% while prevalence of TPSD was around 42%. It would be hard to imagine that after such a rampant exposure to trauma, the prevalence of PTSD is so low. Because of continued wars and threats against healthcare providers, it is hard to study any health related outcomes in Afghanistan , especially such illnesses as mental disorders also carry stigma with them. Thus, findings that Cardozo et al. report could very well be under estimation. For instance, in the United States , the exposure to trauma that would satisfy criteria A for PTSD, is about 40% and 23% - 25% of the exposed individuals develop PTSD. From these statistics, one could expect to see at least a rate of 60% PTSD in Afghanistan .

The observed disconnect between the rate of exposure to trauma and development of PTDS in studies in Afghanistan , as expected, is complex. One can be almost certain that the rate of 40% is under-report. Being surrounded by many surviving family members could protect against development of PTSD. Strong faith could be another protective factor. Also, PTSD could be to some degrees “culturally bound” phenomena; or perhaps, Afghans are genetically less susceptible to developing PTSD. None of these or other possibilities would, however, explain the reported low rate of PTSD. Among myriads of explanations, two factors deserve special attention.

The most pressing issue, as addressed in Cardozo's paper, is need for mental healthcare facilities and research. The research on mental health (or health related issues for that matter) is practically non-existing in Afghanistan . The concept of “evidence based” medicine is translated to “practicing medicine by following a textbook (which are often time outdated)”. Although it is an improvement from “learning from mentor how to practice medicine”; this lack of understanding and investment in research in healthcare makes individualized treatment planning and strategies impossible. Had the clinicians been educated about research in clinical practice (case report, case series, observational studies etc.); a better impression of prevalence of PTSD, and for that matter, any psychiatric illness could be ascertained. 

The second concept that could explain the difference between expected and observed rate of PTSD in Afghanistan is cultural difference in presentation and self-report. In the above study, the rate of depression and anxiety were close to 70% which seems accurate even at the face value. One could imagine that perhaps the respondent did not know the difference between symptoms of PTSD, depression and anxiety. Moreover, some of the symptoms that could meet the criteria for PTSD in the developed work could be considered norm in Afghanistan . Once again, the only way to answer such questions would be development of strong academic and research infrastructure in Afghanistan .