Systematic review links higher psychological distress to cumulative conflict trauma, socioeconomic disadvantage, gender and childhood bereavement; authors call for expanded community-based mental-health services
SRINAGAR: A systematic review of 16 studies published between 2006 and 2025 has found substantial levels of post-traumatic stress disorder (PTSD) among civilians in Jammu and Kashmir, with estimates in community-based adult studies ranging from 15.9 per cent to 24.5 per cent in the review’s summary, while other studies using different diagnostic methods reported lower figures.
The review found that the burden of trauma-related distress was associated with cumulative exposure to conflict-related events, socioeconomic disadvantage, gender, serious injuries and the loss of family members during childhood. It also found that PTSD frequently co-occurred with depression and anxiety, with symptoms reported years after exposure in some populations. The authors caution that differences in study populations, screening instruments and diagnostic methods prevent the findings from being interpreted as a single, definitive prevalence rate for the entire population.
Published in Frontiers in Psychiatry on September 15, 2026, the paper, Post-Traumatic Stress Disorder among civilians in Kashmir: a systematic review, was authored by Tamkeen Sakeena, Aneeza Pervez and Cecilie Lolansen. Sakeena and Lolansen are affiliated with the School of Psychology at the University of Nottingham, United Kingdom, while Pervez is a Clare Hall Fellow at the Faculty of Education, University of Cambridge, United Kingdom.
The review synthesised quantitative research examining the prevalence, risk factors and correlates of PTSD among civilians in Jammu and Kashmir, focusing on the relationship between armed-conflict exposure and psychological distress. The researchers searched four academic databases and assessed the available literature using established systematic-review procedures.
Of 192 records initially identified through database searches, 16 studies met the final eligibility criteria and were included in the synthesis. The researchers did not conduct a statistical meta-analysis because the studies differed substantially in their populations, research designs, sample sizes and methods of assessing PTSD. Instead, they used a structured narrative synthesis to identify recurring patterns across the evidence.
Community Studies
The review found that estimates of PTSD varied considerably according to the population studied and the method used to assess symptoms.
A large population-based survey involving 5,428 adults in the Kashmir Valley reported that 19 per cent met the screening threshold for probable PTSD using the Harvard Trauma Questionnaire. Another community survey of 671 adults reported a lifetime PTSD prevalence of 15.9 per cent.
A separate population-based study involving 3,137 adults, including 572 people exposed to childhood trauma, found that 24.4 per cent of the trauma-exposed group met the study’s criteria for PTSD in adulthood.
The review also included a study of 3,400 adults that reported a PTSD prevalence of 3.76 per cent using a different assessment approach. The authors emphasised that such differences illustrate why prevalence estimates cannot be directly compared without accounting for the diagnostic criteria, screening thresholds and characteristics of the populations examined.
The burden was particularly pronounced in some high-exposure groups. Among college students aged 19 to 24 in northern Kashmir, 49.8 per cent met the screening threshold for probable PTSD in a study involving 797 participants. The finding was based on a self-report questionnaire and should not be interpreted as a clinically confirmed diagnosis for nearly half of all young people in the region.
Among 76 orphaned children assessed in a clinical study, 40.6 per cent were reported to have PTSD. A study of 16 people who had undergone amputations following conflict-related injuries reported a PTSD prevalence of 66 per cent. Meanwhile, 85.1 per cent of 469 patients seeking treatment for PTSD met the criteria for chronic PTSD.
The researchers cautioned that figures from clinical and treatment-seeking populations reflect groups already selected for particular experiences or symptoms and cannot be generalised to the wider population.
Trauma Exposure
One of the principal patterns identified in the review was an association between cumulative exposure to traumatic events and higher PTSD prevalence or symptom severity.
In the large population-based survey of 5,428 adults, the likelihood of probable PTSD increased with the number of conflict-related traumatic experiences reported. A similar pattern was observed among college students, among whom greater cumulative exposure was associated with a higher proportion meeting the screening threshold for probable PTSD.
The studies examined a range of experiences, including witnessing violence, exposure to crossfire, displacement, bereavement, conflict-related injuries and other traumatic events.
The review also found higher PTSD prevalence or symptom severity among women and people experiencing socioeconomic disadvantage. Lower socioeconomic position and unemployment were associated with poorer mental-health outcomes in some community samples.
Children exposed to conflict-related family loss emerged as another vulnerable group. Research involving children who had lost parents during the conflict reported high levels of PTSD and other psychiatric conditions. A study of children exposed to terrorist violence also found higher levels of withdrawal, somatic complaints and anxiety or depressive symptoms than among matched controls.
The authors noted that these findings identify recurring associations rather than establishing that any single factor independently causes PTSD. The predominantly cross-sectional nature of the available research limits conclusions about causal relationships.
Lasting Symptoms
The review found evidence that trauma-related symptoms may continue long after the original exposure, although the authors said the available research was insufficient to establish precise patterns of onset, remission and recurrence.
In the study examining childhood trauma and adult psychiatric outcomes, 24.4 per cent of trauma-exposed participants met the criteria for PTSD in adulthood, with symptoms reported to have persisted beyond ten years after the initial trauma.
Clinical studies also documented chronic PTSD among adults seeking treatment, including individuals reporting trauma exposure years earlier. Among children exposed to conflict, studies reported symptoms such as nightmares, sleep disturbance, avoidance, hyperarousal and emotional or behavioural difficulties.
The review further found that the psychological consequences of conflict extended beyond people directly exposed to violence. A study involving 337 healthcare professionals reported moderate secondary traumatic stress associated with occupational exposure to others’ traumatic experiences. Another study of 221 first-degree relatives of people with PTSD found that 62 per cent met the criteria for at least one psychiatric disorder.
Depression and anxiety were frequently reported alongside PTSD, while some studies also identified substance use and difficulties with coping. The authors said these overlapping conditions pointed to a broader pattern of psychological and social distress rather than an isolated psychiatric disorder.
Continuing Threat
The review interprets the findings in the context of prolonged conflict and continuing insecurity in Jammu and Kashmir. Rather than viewing trauma exclusively as the consequence of isolated past events, the researchers draw on the concept of “continuous traumatic stress”, which describes psychological responses in circumstances where danger remains realistic and may recur.
The paper also uses a psychosocial framework that considers the relationship between direct exposure to traumatic events and the daily stressors associated with conflict, including financial and family pressures and poor physical health.
A study examining daily stressors found that they partially mediated the relationship between cumulative traumatic exposure and symptoms of PTSD, depression and anxiety. However, the mediation effects were small, providing limited support for the proposition that everyday stressors alone explain the relationship between conflict exposure and psychological distress.
The authors therefore emphasise the importance of considering both direct traumatic experiences and the wider social and economic conditions in which people live.
The review also highlights the importance of culturally informed mental-health assessment. Research cited in the paper found that psychological distress in local communities was often described through terms such as pareshani, referring to distress associated with the prevailing situation, and ghabrahat, commonly used to describe feelings of anxiety or agitation.
The authors argue that standardised diagnostic instruments remain important but may not fully capture the ways people understand and communicate their experiences. They recommend combining locally grounded qualitative research with validated diagnostic assessments to improve the accuracy and relevance of future studies.
Mental-Health Services
The researchers argue that the scale of psychological distress identified in the literature requires approaches that extend beyond conventional specialist-led psychiatric services.
The paper states that “the scale of need for psychiatric care in Kashmir exceeds capacity”, and recommends exploring community-based and task-shared interventions to expand access to support.
Under such approaches, appropriately trained community health workers and primary-care staff could provide elements of trauma-informed care under specialist supervision. The authors also identify tele-psychiatry and stepped-care models as potential ways of extending services in settings with limited specialist resources.
Schools are highlighted as important sites for psychosocial interventions, particularly for children and adolescents affected by bereavement, displacement and continuing insecurity. The paper also calls for targeted support for healthcare professionals and caregivers who may experience secondary traumatic stress.
The researchers stress that these approaches require appropriate training, supervision and further evaluation rather than assuming that low-intensity interventions can replace specialist care in all cases.
Research Gaps
The authors identify substantial limitations in the existing evidence. Most of the included studies were cross-sectional, making it difficult to establish causal relationships or determine how symptoms develop and change over time. Several studies also relied on retrospective accounts of traumatic experiences, which may be affected by recall bias.
The review was restricted to English-language publications and four databases, and did not include a systematic search of grey literature or all regional South Asian research indexes. The quality of the included studies also varied, with some smaller clinical studies relying on limited or non-representative samples.
The researchers call for longitudinal studies that follow participants over time, more consistent assessment methods, locally validated screening thresholds and mixed-method research that incorporates people’s lived experiences.
They also caution that the review covers civilians in the Jammu and Kashmir setting defined by the study’s inclusion criteria and should not be assumed to represent populations across the entire wider Kashmir region.
The authors conclude that PTSD represents a substantial and continuing mental-health concern among civilians exposed to prolonged conflict. They argue that improving the evidence base and expanding access to culturally informed, appropriately supervised mental-health care are essential to addressing the burden identified across the reviewed studies.
