Post-traumatic stress disorder (PTSD) in war: a comprehensive review of subtypes, risk and protective factors, and therapeutic approaches.

Background

War-related trauma is associated with substantial mental health burden, particularly post-traumatic stress disorder (PTSD) and complex PTSD (cPTSD). These presentations often co-occur with depression, anxiety, traumatic brain injury, sleep disturbance, functional impairment, and moral injury, complicating assessment and treatment. Despite growing research on trauma in conflict-affected populations, recent evidence remains uneven across active-duty personnel, veterans, civilians, refugees, internally displaced persons, and children.

Methods

Studies published in English between 2020 and November 2025 were identified by following the PRISMA 2020 guidelines and conducting systematic searches in the PubMed, Scopus, and Web of Science databases. Eligible studies examined PTSD or cPTSD outcomes, moral injury or potentially morally injurious events, functioning, comorbidities, treatment engagement, or implementation outcomes among war-affected populations. Eligible designs included randomized controlled trials, quasi-experimental studies, cohort and longitudinal studies, case-control studies, cross-sectional surveys, psychometric studies, and implementation-oriented evaluations. Risk of bias was assessed using RoB 2 for randomized trials and the Newcastle-Ottawa Scale for observational studies. Findings were synthesized narratively.

Results

Twenty-six empirical studies met the inclusion criteria. The evidence base was dominated by military and veteran samples, particularly from high-income health-system settings, limiting generalizability to civilians, refugees, asylum seekers, and internally displaced persons. Across observational studies, combat and interpersonal trauma exposure, unemployment, female sex, low social connectedness, and insomnia were associated with greater PTSD symptom burden or more symptomatic traumatic-stress profiles. Social and vocational well-being, unit cohesion, social connectedness, and sleep health were associated with more favourable outcomes, although these findings should be interpreted as associations rather than causal effects. Randomized controlled trials supported trauma-focused psychotherapies, particularly cognitive processing therapy and prolonged exposure, in veteran, active-duty, and primary-care samples. Sleep-focused augmentation and alternative approaches such as Sudarshan Kriya Yoga appeared promising but were supported by limited evidence. Implementation studies suggested that telehealth, massed, and primary-care delivery formats were feasible and acceptable, but uncontrolled designs limited conclusions about effectiveness. Psychometric evidence provided mixed support for the empirical distinction between ICD-11 PTSD and cPTSD in veteran samples. Moral injury was closely associated with PTSD and related psychological outcomes, but causal mechanisms remain unconfirmed.

Conclusions

Trauma-focused psychotherapies remain the best-supported interventions for war-related PTSD, particularly in veteran and military samples. Sleep assessment, social and vocational support, and scalable delivery models such as telehealth may improve service access and treatment planning, but stronger controlled studies are needed, especially among civilians, refugees, internally displaced persons, and children in humanitarian settings.