War is a major cause of disability-adjusted life years lost in the global burden of disease, and it has a devastating direct effect on human lives (1, 2), including a range of “cognitive, emotional, physical, and behavioral responses” (3). Severe consequences to mental health can stem from witnessing the murders of family members, being recruited as a child soldier, and becoming a victim of sexual assaults, among others (4, 5).

Research has pointed to an increased prevalence of mood disorder, substance abuse, and posttraumatic stress disorder (PTSD) in both civilian and military populations after wars (6, 7). One study of more than 1,000 civilians in eastern Afghanistan revealed that symptoms of anxiety, depression, and PTSD were experienced by approximately 25% to 50% of respondents (8). For military personnel, suicides are a major concern (9).

At the University of Toronto, no didactic teaching in the curriculum is specifically devoted to the effects of war on mental health, and no rotations are in military hospitals. Although evaluating and treating PTSD is taught as a general topic, assessing a patient traumatized by war is not formally taught. Nevertheless, Canada is a world leader in the resettlement of refugees (10) and active in various global conflicts. It would seem likely that residents encounter patients who have been affected by war.

Thus, we created and administered a survey to psychiatric residents at the University of Toronto, Canada’s largest psychiatric residency program, which trains more than 30% of Canadian psychiatrists, to explore the following questions: Do residents believe that psychiatrists have a role in the lives of those affected by war and, if so, what role? Do residents encounter patients affected by war, and what is their comfort level with these encounters? What, if anything, do residents want to learn more about with respect to war and mental health?

A literature search was conducted with PubMed and Ovid using the key words psychiatry residents, psychiatrists, war, conflict zones, attitudes, learning needs, clinical needs, and clinical experiences. The tables of contents were hand searched for several journals known to publish on conflict and war-related topics, such as Medicine, Conflict and Survival, Croation Medical Journal, Lancet, British Medical Journal, and JAMA. A new survey was created based on this background reading and the aforementioned questions.

Survey development began in January 2007 and experts in psychiatry, peace education, and the study of war, including professors at McMaster University’s Peace Studies program, were consulted. Pilot testing involved three nonpsychiatric residents, two senior psychiatric residents who did not participate in the survey, and a nonresident, and the structure of the survey and clarity of the questions were revised according to their suggestions. The project was approved by the University of Toronto ethics committee.

The survey contained 27 questions in multiple-choice, Likert-scale, and open-ended format: six on demographics, 11 on attitudes about the psychiatrist’s role related to war, five on residents’ exposure to war and mental health issues and patients, and five on sources of information for international news, which are not discussed in this article. The survey is available upon request.

An administrative assistant e-mailed all 118 residents in the psychiatry department an explanation of the project and a consent form emphasizing that participation would be voluntary and confidential, with no academic consequences for not participating. At the bottom of the e-mail was a link to the survey. The e-mail was sent three times to all residents over 6 weeks.

For multiple-choice items, we calculated the percentage of participants who selected each response option. For open-ended items, we coded for themes within responses and grouped answers according to those themes based on a consensus of all three authors.

Of 118 residents, 54 started the survey and 52 completed it, for a response rate of 44% (n=52). The majority of respondents were 26–30 years old. The distribution of residents in each of the postgraduate years (PGY) was 30% PGY-1, 10% PGY-2, 30% PGY-3, 15% PGY-4, and 15% PGY-5. Nearly all residents had completed both high school and medical school in North America, except for three respondents who had completed high school in Asia.

Close to 75% of respondents (n=35) strongly agreed that learning about the effects of war on mental health is relevant to all physicians’ training, regardless of where one is trained or plans to practice. More importantly, more than 85% of respondents (n=43) believed that learning about war and mental health was relevant to all psychiatric residents’ training.

Most residents agreed that psychiatrists can play a role with respect to war, with 85% (n=44) reporting that psychiatrists have a role in war zones sometimes or frequently and 15% (n=7) reporting that psychiatrists always have a role. No resident responded that psychiatrists never have a role in war zones. In an open-ended question, residents were asked to elaborate on which specific roles, if any, psychiatrists could play in war zones. Themes generated from the responses included primarily advocacy and the mental health treatment of civilians and soldiers.

Respondents were also asked how psychiatrists could address international conflict other than by being present in sites of war. This question yielded 42 open-ended responses. Themes generated included advocacy, mediation, and refugee and military health. Residents raised an important nuance with respect to the role of psychiatrists in war, specifically that direct psychiatric interventions in war zones might be inappropriate or even harmful because of conflict with the social, cultural, or political environment of the victims of war or that a psychiatrist might cause more conflict by providing mental health services to one group affected by the conflict and not others or even direct harm through inappropriate debriefing of victims. This finding was not explored in detail but will be addressed in our future research.

Residents were asked about their clinical experiences related to war. More than 75% of respondents (n=38) had seen or cared for a patient who was traumatized by war. As training level increased, so did the proportion of residents who had encountered these patients. Furthermore, residents were asked how they would rank their level of preparedness for these encounters. No resident felt completely prepared, 50% felt somewhat prepared (n=25), and 30% felt not at all prepared (n=15). Those who responded “not at all prepared” were in PGY-1–4; no PGY-5 resident chose this option.

At the end of the survey, residents were asked to specify what they would like to learn about war and mental health during residency. Across all five training years, the top three topics were clinical management of patients affected by wars (80%, n=41), resources to help patients affected by wars (75%, n=37), and an approach to interviewing these patients (70%, n=3). Only five of 49 residents who answered this question chose the option “I would not like to learn about anything in this area.”

Of the 52 residents who participated in the survey, close to 90% (n=44) wished to learn more about the mental health effects of war. More than 70% of respondents (n=38) had encountered patients traumatized by war, yet none felt completely prepared to handle these patients. Our findings have implications for educational planning during residency and raise questions regarding what types of educational experiences would help residents acquire comfort with patients traumatized by war. Our next step will be to determine the skills needed by residents to develop clinical competency in this area, which, in addition to the results of this study, will help serve as a basis for developing a curriculum. We also hope to gather information about obstacles that residents experience in treating these patients.

It seems clear that residents believe psychiatrists have a role both in and outside of war zones, through mediation, as consultants, through the prevention of war, through lobbying, and as treatment providers for refugees and soldiers. Future studies might examine refugee and war-exposed populations and compare their opinions about the role of psychiatrists in treating individuals traumatized by war with the results of this survey. Finally, we would like to explore the degree to which residents who have an interest in this area would benefit from guided exploration of the controversies and dilemmas that exist regarding intervening in war zones.

A primary limitation of this research was the response rate of 44% (n=52). The study was conducted at only one school, which raises issues of generalizability of the findings to other Canadian settings or beyond Canada. Another limitation was that residents may have responded in a “socially desirable” manner, despite the assurance of confidentiality. However, the chance to express views through the open-ended questions appeared to give residents the opportunity to share their candid opinions; this provides the basis for further qualitative research.

Overall, the survey demonstrated that residents are interested in learning about war and mental health and that they believe this has direct relevance to their current and future training as psychiatrists. Further qualitative analysis examining the emergent themes using interviews and focus groups with residents will elaborate their perceptions related to war and mental health.

The authors wish to thank Drs. Neil Arya, Joanna Santa-Barbara, Graeme MacQueen, Glendon Tait, Andrea Waddell, and Ms. Irene Ly for their assistance on this project. At the time of submission, the authors reported no competing interests.