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It is a positive development that researchers dealing with conflict-affected populations have become mindful of the complex interplay of contributing factors concerning the development and perpetuation of mental health disorders, and their role in the transmission and perpetuation of violence. For instance, it has become common to integrate multiple contextual, intra-, and inter-individual factors using conceptual frameworks (e.g., adaptations of Bronfenbrenner’s socio-ecological model) and longitudinal research strategies (e.g Amone-P’olak et al., 2013).

Despite the encouraging advances in crisis mental health in the last two decades, the vast majority of studies have focused on disorders like posttraumatic stress disorder (PTSD) and depression. While being recognized in epidemiological studies with military samples that consistently find elevated rates of substance use disorders (SUDs) in personnel with war-zone exposure (for a review see Kelsall et al., 2015), the study of SUDs has largely been neglected in war-affected civilian populations.

This is all the more unfortunate because the mismatch between the scale of the problem and the availability of services is larger for SUDs than any other mental health disorder in war-affected societies. Alcohol is certainly the most widely used substance in this context, because it is usually legal and readily available even in regions with ongoing conflict. Per capita alcohol consumption among those drinking (≥15 years of age) worldwide is highest for Southeast Asian (50.2g of pure ethanol/day) and African (42.4g of pure ethanol/day) regions. These regions include the majority of countries containing the world’s 46 highly violent conflicts (HIIK, 2015) and host the largest numbers of internally displaced persons and refugees (IDMC, 2015).

Knowledge about alcohol use disorder (AUD) prevalence and possible links to trauma and other psychopathologies among conflict-affected civilian populations is still limited (for reviews in displaced populations see Ezard, 2012 and Weaver & Roberts, 2010). Studies in conflict-affected civilian populations have reported high rates of hazardous, harmful, or dependent alcohol use in northern Ugandan [46,0% (Ertl, Saile, Neuner, & Catani, 2016); 32,4% (Roberts, Felix Ocaka, Browne, Oyok, & Sondorp, 2011)] and Georgian [27.8% (Roberts et al., 2014)] conflict-affected men. Like in military and non-crisis-affected civilian samples, alcohol-related symptoms are linked to trauma-exposure in all studies. What is more, childhood maltreatment (specifically emotional abuse) was found to be an important predictor of current alcohol-related problems above an beyond more recent traumatic experiences (Ertl et al., 2016).

Although other hypotheses explaining the link consistently found between trauma and alcohol use have been proposed (for an overview see Haller & Chassin, 2014) there is converging evidence that this link may be best explained by self-medication as a coping strategy to deal with trauma symptoms (e.g., Bremner, Southwick, Darnell, & Charney, 1996; Haller & Chassin, 2014; Ouimette, Coolhart, Funderburk, Wade, & Brown, 2007). Resorting to psychoactive substances as “medication” seems pragmatic, especially in contexts where other means to alleviate trauma-related symptoms are not available. We recently tested the self-medication hypothesis in a war-affected region of Uganda. Results imply that alcohol consumption fulfilled its expected purpose for non-treatment-seeking men: alleviating psychopathological symptoms in light of severe traumatization (Ertl et al., 2016).

This may further complicate treatment motivation, perpetuating consumption and a gradual deterioration of physical health. Beyond these consequences, the lasting losses in social and economic status and productivity do not only affect the individual, but contribute to the persistence of poverty, educational alienation, and stigmatization of the drinkers’ families (e.g., Navarro, Doran, & Shakeshaft, 2010).

Equally alarming, studies show that alcohol abuse seems to be one of the most important driving factors in the transmission of violence across contexts and social relationships—from war-violence to community-violence and from being a victim of war or intimate partner violence (IPV) to being a perpetrator of violence against children (e.g. Arseneault, Moffitt, Caspi, Taylor, & Silva, 2000; Saile, Ertl, Neuner, & Catani, 2014). IPV and violence against children is generally elevated in (post-)conflict areas compared to politically stable settings (e.g., Crombach & Bambonyé, 2015; Saile, Neuner, Ertl, & Catani, 2013). Recent studies in post-conflict populations have used a multi-informant approach assessing children and their guardians simultaneously. Controlling for traumatic experiences and psychopathologies within the examined dyads and triads, alcohol-related symptoms of Sri Lankan as well as Ugandan men were significant predictors of IPV and violence against children (Saile et al., 2014, 2013; Sriskandarajah, Neuner, & Catani, 2015).

Therefore it seems logical that interventions targeting alcohol may not only reduce AUD and other psychopathologies in affected individuals, but may have the potential to break cycles of violence because IPV and violence against children may reduce (i.e., factors contributing to the development of mental health disorders and SUDs in partners and children may cease). The enforcement of common alcohol policies like drinking and driving regulations, raising drinking age, alcohol taxation, and advertisement bans may be the most cost-effective interventions. However, there is not enough research on these interventions’ impacts on alcohol consumption as well as potential causes (e.g., symptoms of mental health disorders) and consequences (e.g. IPV, child maltreatment, poverty) of alcohol abuse.

Another argument for prioritizing the scale-up of alcohol-related interventions in conflict-affected regions is that individuals who show signs of substance abuse are usually excluded from treatments targeting mental health disorders like PTSD. Trials including patients with a PTSD and AUD comorbidity are limited by extremely high dropout rates, high treatment costs, and unconfident therapists who fear that alcohol consumption will increase as the result of treatment (e.g. Riggs, Rukstalis, Volpicelli, Kalmanson, & Foa, 2003).

Therapeutic interventions targeting alcohol abuse—whether inpatient or outpatient, short- or long-term, delivered individually or in groups, implemented by mental health professionals or lay personnel—are lacking in war-affected societies and low and middle-income countries. The few programs that do exist have barely been scientifically evaluated, as reviews jointly state (e.g. Benegal, Chand, & Obot, 2009; van Ginneken et al., 2013). Although some studies started to evaluate the impact of alcohol-modules integrated in batterer intervention programs (Satyanarayana et al., 2016; Stuart et al., 2013), there is not enough evidence concerning the effects of exclusively alcohol-focused interventions on IPV (Wilson, Graham, & Taft, 2014), let alone violence against children.

Governments, humanitarian agencies, and public health systems should start to prioritize addressing the causes and consequences of AUD. It is likely that investments on all three levels of alcohol-policy, prevention, and intervention can make a huge difference. Measures should be well-orchestrated and accompanied by rigorous research. Resulting knowledge about valid screening methods and effective and efficient prevention and intervention strategies needs to be disseminated. If AUD in crisis-affected contexts is successfully addressed, chances are that individual and family physical and mental health will improve as well as functionality. Investment in counteracting AUD will ultimately produce cost savings and foster reconstruction and economic uptrends for families as well as societies at large. Most importantly, gaining control over AUD may contribute to ending cycles of violence in conflict-ridden contexts.

About the Author

Verena Ertl, PhD, is a postdoctoral researcher in the Department of Psychology at Bielefeld University, Germany. Her research revolves around epidemiological and intervention research in crisis-affected populations and survivors of interpersonal trauma. She is also a licensed psychotherapist and is interested in combining research and practice in the development, implementation and evaluation of pragmatic mental health interventions in low and middle-income countries. Dr. Ertl is the current vice president of vivo international (www.vivo.org), an alliance that works to overcome and prevent traumatic stress and its consequences within the individual, the family as well as the community, safeguarding the rights and dignity of people affected by violence and conflict.


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