Hi, my name is Barbara Lopes Cardozo. I'm the assistant professor in the School of Medicine Department of Psychiatry and Behavioral Sciences. As well as the assistant professor in the Hooper Department of Global Health, the Rollins School of Public Health at Emory University. I spend more than 30 years working in humanitarian emergencies and as a psychiatrists, I currently work at the Centers for Disease Control and prevention. Or mental health in countries affected by war, violent conflict, and natural disasters around the globe. And before all that I worked for doctors without borders in Warsaw Poland, an organization I helped to start in the Netherlands. Today I'm going to share with you why mental health is so important in humanitarian emergencies and post conflict settings, and what we can do to reduce the negative psychological consequences. The World Health Organization estimates that more than 450 million people suffer from mental health disorder worldwide. Numerous studies and surveys have found that mental illness is increased in populations who have been affected by war and conflict. There are several mental illnesses and psychological problems that can be caused by the trauma and stress of war. The most common ones are depression, anxiety and acute or post traumatic stress disorder or also called PTSD. As you may know, people with a chronic mental illness such as schizophrenia and bipolar illness usually fair better in stable, predictable living conditions. Which is not the case in war and conflict settings. So exacerbations of preexisting mental disorder may also occur. There are many elements that may contribute to psychological trauma. It's not just the war itself, but the experience with long term persecution, with becoming a refugee. Or having to hide in your own country, experiencing the anxiety and uncertainty of separation from family members. And of course, the terribly difficult experiences of witnessing and being a victim of extreme violence and rape, and a return to burnt homes and destroyed property. I would like to give you some examples of mental health surveys that the CDC and other organizations like the Harvard Program in Refugee Trauma have conducted over the years. In all these surveys, we have found that there was an increase in the prevalence of mental illness related to war and conflict compared to a more stable situation like in the United States. For example among Cambodian refugees who were living in refugee camps in Thailand, they found prevalences of depression as high as 68% and PTSD 37%. And in Kosovo, shortly after the end of the conflict in 1999, we found levels of PTSD of 17% and in 2000, the PTSD prevalence was 25%. In 2002 in Afghanistan the CDC found 42% of PTSD and 68% of depression among the general Afghan population. And then you compare these figures to the United States, surveys there have found PTSD levels of 7-8% and a lifetime depression prevalence of 6%. Just keep in mind that because of cross cultural differences, it is not possible to make direct comparisons. If and when using validated instruments to measure mental illness across cultures. Symptoms of PTSD, depression and anxiety, may vary across cultures. This is usually less the case with more severe mental illnesses like schizophrenia. If not treated or addressed, psychological wounds of war may persist for many years and have transgenerational effects. This has been most clearly shown in Holocaust survivors who's children, and even grandchildren were still suffering the negative psychological consequences. Because of the traumatic experience their parents, and their grandparents had suffered. We have also seen the feelings of hatred and a desire to take revenge which may be related to symptoms of mental illness like PTSD may lead to continue cycles of violence. In Kosovo, after the end of the conflict, 85% of men and women reported having feelings of hatred. And in Afghanistan we have seen similar high levels of feelings of hatred and a desire to take revenge after the fall of the Taliban. Survivors of natural disasters are also at high risk to develop PTSD, emotional distress, anxiety and depression. Some examples of natural disasters are the earthquake in Armenia, volcano eruption in Armero, Columbia. The tsunami in southeast Asia, Hurricane Katrina in the US, and the earthquake in Haiti and Nepal recently. In 2007 initiated by the World's Health Organization, the Inter-Agency Standing Committee Guidelines for Mental Health and Psychosocial Support in Emergency Settings, were established and reflect the insights of numerous agencies and practitioners worldwide. According to the Sphere Handbook in 2011, there is now wide spread acceptance, that mental health services are part of the minimum package of care in disaster, and guidelines exist to guide the implementation. However, despite the progress that has been made in creating consensus, regarding standards of care, the scientific basis for mental health and psychosocial intervention and humanitarian settings is still weak. Because until now very few randomized control trials or outcome evaluations of mental health interventions, and complex emergencies have been conducted. Results of this evaluation have been mixed. A systematic review published in the concludes that the most commonly used mental health and psychosocial interventions in humanitarian emergencies have little evidence to back them up. Some examples of psychological interventions during the emergency phase mentioned in these guidelines are establishing services, through the primary health care system to address urgent psychiatric problems. Ensuring the availability of essential psychotropic medications at health facilities, organizing outreach and non-intrusive psychological support or psychological first aid. At the later time during the so called reconsolidation phase or impulse conflict settings and more time and resources are available. Psychological interventions could include some of the following, training and supervision of primary healthcare workers in basic mental health knowledge. And skills and education of aid workers and community leaders in basic life psychological skills. And also here to ensure the continuation of medication of psychiatric patients, and the facilitation and creation of community based health help support groups can also be useful. To avoid some of the confusion and the fussiness of the term psychosocial used by many but which is not very clearly defined, some like to separate out the term psychological from social. Some examples of recommended social interventions post emergencies are encouraging income generating projects if poverty is an issue, organizing recreational activities and schooling for children. And who are the main players involved in mental health and psycho-social programming and emergencies? First of all the Ministry of Health and mental health professionals and institutions and universities in the country. Several international non governmental organizations and Medecins Sans Frontiers MSF, International Medical Corps, The Transcultural Psychosocial Organization and of course local NGOs. Now which UN organizations are involved in mental health and emergencies? The United Nation High Commission for Refugees. UNICEF is a focus on child protection and psychosocial support. The International Organization for Migration. And the World Health Organization. In summary, there's a high burden of mental illness around the world and even higher in humanitarian emergencies, and what are some of the risks factors, traumatic events, and multiple stressors. They exist a variety of tools to asses mental health with challenges with validation and cross cultural issues remain. Intervention guidelines exist, but still need more evidence that they are effective, and work the way they're supposed to, and also that they do no harm. We talked about the main players, but keep in mind that mental health in emergencies is still a relatively new field. And finally to quote Prince and Vikram Patel and others, there can be no health without mental health.