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Post-traumatic stress disorder in adult victims of cluster munitions in Lebanon: a 10-year longitudinal study
  1. Jawad Fares1,2,
  2. Souheil Gebeily1,3,
  3. Mohamad Saad1,4,
  4. Hayat Harati1,
  5. Sanaa Nabha1,
  6. Najwane Said1,
  7. Mohamad Kanso1,5,
  8. Ronza Abdel Rassoul1,6,
  9. Youssef Fares1,7
  1. 1 Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
  2. 2 Faculty of Medicine, American University of Beirut, Beirut, Lebanon
  3. 3 Department of Neurology, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
  4. 4 Division of Statistical Genetics, Department of Biostatistics, University of Washington, Seattle, Washington, USA
  5. 5 Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
  6. 6 UMR 1141, Hôpital Robert Debré, Institut National de la Santé et de la Recherche Médicale, Paris, France
  7. 7 Department of Neurosurgery, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
  1. Correspondence to Dr Jawad Fares; jyf04{at} and Prof. Youssef Fares; yfares{at}


Objective This study aims to explore the short-term and long-term prevalence and effects of post-traumatic stress disorder (PTSD) among victims of cluster munitions.

Design and setting A prospective 10-year longitudinal study that took place in Lebanon.

Participants Two-hundred-and-forty-four Lebanese civilian victims of submunition blasts, who were injured in 2006 and were over 18 years old, were interviewed. Included were participants who had been diagnosed with PTSD according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) and the PTSD Checklist - Civilian Version in 2006. Interviewees were present for the 10-year follow-up.

Main outcome measures PTSD prevalence rates of participants in 2006 and 2016 were compared. Analysis of the demographical data pertaining to the association of long-term PTSD with other variables was performed. p Values <0.05 were considered statistically significant for all analyses (95% CI).

Results All the 244 civilians injured by cluster munitions in 2006 responded, and were present for long-term follow-up in 2016. The prevalence of PTSD decreased significantly from 98% to 43% after 10 years (p<0.001). A lower long-term prevalence was significantly associated with male sex (p<0.001), family support (p<0.001) and religion (p<0.001). Hospitalisation (p=0.005) and severe functional impairment (p<0.001) post-trauma were significantly associated with increased prevalence of long-term PTSD. Symptoms of negative cognition and mood were more common in the long run. In addition, job instability was the most frequent socioeconomic repercussion among the participants (88%).

Conclusions Psychological symptoms, especially PTSD, remain high in war-affected populations many years after the war; this is particularly evident for Lebanese civilians who were victimised by cluster munitions. Screening programmes and psychological interventions need to be implemented in vulnerable populations exposed to war traumas. Officials and public health advocates should consider the socioeconomic implications, and help raise awareness against the harm induced by cluster munitions and similar weaponry.

  • posttraumatic stress disorder
  • PTSD
  • cluster munitions
  • cluster bombs
  • adults
  • lebanon
  • middle east

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  • Contributors JF and YF designed the study and collected the data. JF carried out the statistical analyses and drafted the manuscript. All authors contributed to the analysis of the results. All authors critically revised the manuscript for important intellectual content. JF and YF are the primary investigators and guarantors of the study.

  • Funding This research was funded by a grant from the Central Administration of the Lebanese University, Beirut, Lebanon.

  • Competing interests None declared.

  • Patient consent Detail has been removed from these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

  • Ethics approval Institutional Review Board at the Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Supplementary material is provided.

  • Press Release Cluster munitions: a peril to global health and human rightsIt is about time that cluster munitions are banned. A 10-year longitudinal study published in BMJOpen by Fares et al. explored post-traumatic stress disorder (PTSD)in victims of cluster munitions in Lebanon. PTSD is a mental health problem that anindividual may develop after experiencing or witnessing a life-threateningevent. It affects 7%–8% of the general population at some point during theirlifetime; however, the prevalence is much higher among certain subgroups, includingcivilians exposed to blast injuries and war-related traumas.

    The 2006 Israeli-Lebanese conflict led toa large number of Lebanese civilians subjected to war-related psychological andbiomechanical traumas. Cluster munitions, explosive weapons that release oreject smaller submunitions, were extensively used by the Israeli forces insouthern Lebanon, and were dispersed over vast Lebanese lands affecting itsinhabitants.

    Participants included 244 civiliansinjured by cluster munitions in 2006. They were interviewed and present for the10-year follow-up.

    The researchers report that the prevalence of PTSD decreasedfrom 98% to 43% after 10 years. A lower long-term prevalence wassignificantly associated with male sex, family support and religion.Hospitalisation post-trauma and severe functional impairment were significantlyassociated with increased prevalence of long-term PTSD. Symptoms of negative cognition and mood weremore common in the long run, and job instability was the most frequentsocioeconomic repercussion among the participants in the long run.

    Theresearchers conclude that screening programmes and psychological interventionsneed to be implemented in vulnerable populations exposed to war traumas. Officialsand public health advocates should consider the socioeconomic implications, andhelp raise awareness against the harm induced by cluster munitions and similarweaponry. More countries should join the Convention on Cluster Munitions to banthe use of these detrimental weapons.

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