BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-017214 on 18 August 2017. Downloaded from Posttraumatic stress disorder in adult victims of cluster munitions: A 10-year longitudinal study ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2017-017214 Article Type: Research Date Submitted by the Author: 07-Apr-2017 Complete List of Authors: Fares, Jawad; Lebanese University, Neuroscience Research Center, Faculty of Medical Sciences; American University of Beirut Faculty of Medicine Gebeily, Souheil; Lebanese University , Neuroscience Research Center, Faculty of Medical Sciences; Lebanese University , Department of Neurology, Faculty of Medical Sciences Saad, Mohamad; University of Washington School of Medicine Harati, Hayat; Lebanese University , Neuroscience Research Center, Faculty of Medical Sciences Nabha, Sanaa; Lebanese University, Neuroscience Research Center, Faculty of Medical Sciences Said, Najwane; Lebanese University , Neuroscience Research Center, Faculty of Medical Sciences Kanso, Mohamad; American University of Beirut Medical Center, Department of Emergency Medicine; Lebanese University , Neuroscience Research Center, Faculty of Medical Sciences http://bmjopen.bmj.com/ Abdel Rassoul, Ronza; INSERM U1141, Hôpital Robert Debré; Lebanese University , Neuroscience Research Center, Faculty of Medical Sciences Fares, Youssef; Lebanese University, Neuroscience Research Center, Faculty of Medical Sciences; Lebanese University, Department of Neurosurgery, Faculty of Medical Sciences <b>Primary Subject Neurology Heading</b>: on September 27, 2021 by guest. Protected copyright. Secondary Subject Heading: Mental health, Public health, Global health Posttraumatic stress disorder, PTSD, cluster munitions, cluster bombs, Keywords: Lebanon, Adults For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 33 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-017214 on 18 August 2017. Downloaded from 1 2 3 4 Original Article 5 6 7 Posttraumatic stress disorder in adult victims of 8 9 cluster munitions: A 10-year longitudinal study 10 11 12 13 Jawad Fares1,2*, Souheil Gebeily1,3, Mohamad Saad1,4, Hayat Harati1, Sanaa Nabha1, 14 1 1,5 1,6 1,7 15 NajwaneFor Said , Mohamad peer Kanso review, Ronza Abdel Rassoul only, Youssef Fares * 16 17 18 19 1. Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, 20 21 Beirut, Lebanon 22 2. Faculty of Medicine, American University of Beirut, Beirut, Lebanon 23 3. Department of Neurology, Faculty of Medical Sciences, Lebanese University, Beirut, 24 Lebanon 25 26 4. Division of Statistical Genetics, Department of Biostatistics, University of Washington, 27 Seattle, WA 98195, USA 28 5. Department of Emergency Medicine, American University of Beirut Medical Center, 29 Beirut, Lebanon 30 31 6. UMR 1141, Hôpital Robert Debré, Institut National de la Santé et de la Recherche 32 Médicale, 75019 Paris, France 33 7. Department of Neurosurgery, Faculty of Medical Sciences, Lebanese University, Beirut, 34 http://bmjopen.bmj.com/ Lebanon 35 36 37 *Corresponding Authors 38 39 Jawad Fares 40 Email: [email protected] 41 42 on September 27, 2021 by guest. Protected copyright. 43 Youssef Fares 44 Email: [email protected] 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 33 BMJ Open: first published as 10.1136/bmjopen-2017-017214 on 18 August 2017. Downloaded from 1 2 3 4 ABSTRACT 5 6 7 Objective: This study aims to explore the short-term and long-term prevalence and effects of 8 9 Posttraumatic Stress Disorder (PTSD) among victims of cluster munitions. 10 11 12 Design and Setting: A prospective 10-year longitudinal study that took place in Lebanon. 13 14 15 Participants:For The 244 Lebanese peer civilian victimsreview of sub-munition onlyblasts, who were injured in 16 17 2006 and over 18 years old, were interviewed. Included were 239 participants (N=239) who had 18 19 20 been diagnosed with PTSD according to the DSM-5 and the PTSD Checklist - Civilian Version 21 22 (PCL) in 2006; participants were present for the 10-year follow up. 23 24 25 Main Outcome Measures: The PTSD prevalence rates of participants in 2006 and 2016 were 26 27 compared. The analysis of the demographical data pertained to the association of long-term PTSD 28 29 with other variables was performed. P-values <0.05 were considered statistically significant for 30 31 all analyses (95% CI). 32 33 34 http://bmjopen.bmj.com/ 35 Results: All the 244 civilians injured by cluster munitions in 2006 responded, and were present 36 37 for long-term follow up in 2016. The prevalence of PTSD decreased significantly from 98% to 38 39 43% after ten years (p<0.001). A lower long-term prevalence was significantly associated with 40 41 the male sex (p<0.001), family support (p<0.001), and religion (p<0.001). Hospitalization 42 on September 27, 2021 by guest. Protected copyright. 43 (p=0.005) and severe functional impairment (p<0.001) post-trauma were significantly associated 44 45 46 with increased prevalence of long-term PTSD. Symptoms of negative cognition and mood were 47 48 more common in the long run. In addition, job instability was the most frequent socioeconomic 49 50 repercussion among the participants (88%). 51 52 53 Conclusions: Psychological symptoms, especially PTSD, remain high in war-affected 54 55 populations many years after the war, and this is particularly evident for Lebanese civilians that 56 57 were victimized by cluster munitions. Screening programs and psychological interventions need 58 59 60 1 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 33 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-017214 on 18 August 2017. Downloaded from 1 2 3 to be implemented in vulnerable populations exposed to war traumas. Officials and public health 4 5 6 advocates should consider the socioeconomic implications, and help raise awareness against the 7 8 harm induced by cluster munitions and similar weaponry. 9 10 11 12 13 14 STRENGTHS AND LIMITATIONS OF THE STUDY 15 For peer review only 16 - This is the first longitudinal study to analyze PTSD in victims of cluster munition 17 18 explosions, which helps in better understanding the course and prognosis of PTSD in 19 20 21 these individuals. 22 23 - The DSM-5 criteria for PTSD was adopted, and higher cut-off scores of the PCL were 24 25 used to aid in the diagnosis and minimize false positives. 26 27 - Functional impairment was measured using the Fares Scale of injuries due to cluster 28 29 munitions, which makes it easier to determine the true effects of cluster munitions and 30 31 project on the mental health service needs. 32 33 34 - More demographical data on health and socioeconomic outcomes could have been http://bmjopen.bmj.com/ 35 36 collected. 37 38 - The female sample size of our study may have contributed to the lack of significant 39 40 differences in some of the outcomes. 41 42 on September 27, 2021 by guest. Protected copyright. 43 KEYWORDS: 44 45 Posttraumatic stress disorder; PTSD; Cluster munitions; Cluster bombs; Adults; Lebanon 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 33 BMJ Open: first published as 10.1136/bmjopen-2017-017214 on 18 August 2017. Downloaded from 1 2 3 INTRODUCTION 4 5 6 As long as human beings have engaged in combat, there have often been extraordinarily 7 8 9 damaging psychiatric injuries among those who survive. The 2006 Israeli-Lebanese conflict have 10 11 resulted in a large cohort of Lebanese civilian personnel exposed to combat related psychological 12 13 trauma as well as biomechanical trauma, including proximity to blast events. Cluster munitions 14 15 are weapons thatFor scatter smallerpeer sub-munitions review intended to kill oronly mutilate on impact (Figure 1). 16 17 They have been used by the Israeli forces in the south of Lebanon and are now scattered over 18 19 wide rural areas affecting its inhabitants (Figure 2). 20 21 22 Many states perceive cluster munitions as a main military equity that increases the efficiency of 23 24 25 suppressing, killing or destroying multiple targets within a specified area. However, often, when 26 27 they have been used near populated areas, civilians have died or got injured, either as a direct 28 29 result of the attack and its area effect, or as a result of post-conflict unexploded sub-munitions. 30 31 While all types of ordnances fail to function at some rate, the failure rate for cluster munitions is 32 33 striking. http://bmjopen.bmj.com/ 34 35 36 Due to their easily "pickable" nature, sub-munitions can inflict various injuries. Biomechanical 37 38 1-8 injuries resulting from cluster munitions have been discussed in a series of research articles; 39 40 41 psychological tribulations remain to be explored. Posttraumatic stress disorder (PTSD) is a 42 on September 27, 2021 by guest. Protected copyright. 43 psychiatric disorder that affects 7–8% of the general population at some point during their 44 45 lifetime;9 however, the prevalence is much higher among certain subgroups, including active duty 46 47 military personnel, and veterans and civilians exposed to blasts, war-related injuries and, in this 48 49 case, injuries due to cluster munitions. 50 51 52 War experiences can affect mental health; however, large-scale studies that focus on the short- 53 54 term and long-term impact are rare. Such information may help screening programs in targeting 55 56 57 high-risk populations and raise awareness against the harm induced by cluster munitions and 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 33 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-017214 on 18 August 2017.