Subjective quality of life in war-affected populations.

BACKGROUND: Exposure to traumatic war events may lead to a reduction in quality of life for many years. Research suggests that these impairments may be associated with posttraumatic stress symptoms; however, wars also have a profound impact on social conditions. Systematic studies utilising subjective quality of life (SQOL) measures are particularly rare and research in post-conflict settings is scarce. Whether social factors independently affect SQOL after war in addition to symptoms has not been explored in large scale studies. METHOD: War-affected community samples were recruited through a random-walk technique in five Balkan countries and through registers and networking in three Western European countries. The interviews were carried out on average 8 years after the war in the Balkans. SQOL was assessed on Manchester Short Assessment of Quality of Life--MANSA. We explored the impact of war events, posttraumatic stress symptoms and post-war environment on SQOL. RESULTS: We interviewed 3313 Balkan residents and 854 refugees in Western Europe. The MANSA mean score was 4.8 (SD = 0.9) for the Balkan sample and 4.7 (SD = 0.9) for refugees. In both samples participants were explicitly dissatisfied with their employment and financial situation. Posttraumatic stress symptoms had a strong negative impact on SQOL. Traumatic war events were directly linked with lower SQOL in Balkan residents. The post-war environment influenced SQOL in both groups: unemployment was associated with lower SQOL and recent contacts with friends with higher SQOL. Experiencing more migration-related stressors was linked to poorer SQOL in refugees. CONCLUSION: Both posttraumatic stress symptoms and aspects of the post-war environment independently influence SQOL in war-affected populations. Aid programmes to improve wellbeing following the traumatic war events should include both treatment of posttraumatic symptoms and social interventions.

The utilization and perceived usefulness of health care and other support services by people exposed to traumatic events related to the war in the Balkans.

OBJECTIVE: To explore which health care and other support services people exposed to traumatic events related to the war use, how helpful they perceive them in the course of their post-war adaptation and whether utilization and perceived usefulness depend on the mental health status of participants. METHODS: A community sample of 3304 adults exposed to at least one war-related traumatic event was randomly selected in different regions in the former Yugoslavia. A specifically designed instrument, the Matrix for the Assessment of Community and Healthcare Services, was used to record service utilization and their perceived usefulness. The mental health status of participants was assessed using the Mini International Neuropsychiatric Interview. RESULTS: Primary health care was the most frequently used type of service (80.5%). Services providing help with leisure activities, social support and social contacts were perceived as most helpful. Participants with current post-traumatic stress disorder used all types of health care services and employment support services significantly more often than participants without mental disorders and participants with other mental disorders. They were more satisfied with primary health care services than participants without mental disorders and less satisfied with financial and material support services as compared to participants with other mental disorders. CONCLUSIONS: The frequency of utilization of different types of services varies greatly in war affected communities. Medical services are widely used and therefore have a central role in the care provision following a war. Services providing help with leisure activities and social support are most appreciated and may be more widely established.

Co-occurrence of major depressive episode and posttraumatic stress disorder among survivors of war: how is it different from either condition alone?

OBJECTIVE: Major depressive episode (MDE) and posttraumatic stress disorder (PTSD) have been shown to be the most common mental disorders following traumatic war experiences and have been found to frequently co-occur. This study, designed as a randomized cross-sectional interview survey, aimed to identify whether the co-occurence of MDE and PTSD following exposure to war-related experiences is associated with different demographics, exposure to previous traumatic events, and clinical characteristics than either condition alone. METHOD: After a random-walk technique was used to randomly select participants, face-to-face interviews were conducted among war-affected community samples in 5 Balkan countries (N = 3,313) in the years 2006 and 2007. The mean age of participants was 42.3 years, and all participants had experienced potentially traumatic events during war in the countries of the former Yugoslavia. Current prevalence rates of MDE and PTSD and suicide risk were assessed using the Mini-International Neuropsychiatric Interview. Levels of general psychological distress, posttraumatic stress, and quality of life were assessed with self-reports. RESULTS: 30.5% of the sample met DSM-IV diagnostic criteria for either MDE or PTSD, and 9.1% had both disorders. Participants with concomitant MDE and PTSD reported significantly higher numbers of prewar and postwar traumatic events than participants with PTSD only and higher numbers of war-related events than those with MDE only (all P values < .001). Participants with both MDE and PTSD had significantly higher levels of general psychological and posttraumatic stress symptoms, a higher suicide risk, and lower levels of quality of life than participants with either condition alone (all P values < .001). CONCLUSIONS: Concomitant MDE and PTSD are associated with the experience of different traumatic events and are characterized by more general psychological distress than either condition alone. The assessment of concomitant MDE and PTSD can facilitate better identification of individuals with severe psychopathology and poor quality of life. People with co-occurrence of MDE and PTSD may require specific health care programs following war.

Psychological symptoms as long-term consequences of war experiences.

BACKGROUND/AIMS: War experiences can affect mental health, but large-scale studies on the long-term impact are rare. We aimed to assess long-term mental health consequences of war in both people who stayed in the conflict area and refugees. METHOD: On average 8 years after the war in former Yugoslavia, participants were recruited by probabilistic sampling in 5 Balkan countries and by registers and networking in 3 Western European countries. General psychological symptoms were assessed on the Brief Symptom Inventory and posttraumatic stress symptoms on the Impact of Event Scale-Revised. RESULTS: We assessed 3,313 interviewees in the Balkans and 854 refugees. Paranoid ideation and anxiety were the severest psychological symptoms in both samples. In multivariable regressions, older age, various specific war experiences and more traumatic experiences after the war were all associated with higher levels of both general psychological and posttraumatic stress symptoms in both samples. Additionally, a greater number of migration stressors and having only temporary legal status in the host country were associated with greater severity of symptoms in refugees. CONCLUSIONS: Psychological symptoms remain high in war-affected populations many years after the war, and this is particularly evident for refugees. Traumatic war experiences still predict higher symptom levels even when the findings have been adjusted for the influence of other factors.

Long-term impact of war on healthcare costs: an eight-country study.

OBJECTIVE: Exposure to war can negatively affect health and may impact on healthcare costs. Estimating these costs and identifying their predictors is important for appropriate service planning. We aimed to measure use of health services in an adult population who had experienced war in the former-Yugoslavia on average 8 years previously, and to identify characteristics associated with the use and costs of healthcare. METHOD: War-affected community samples in Bosnia-Herzegovina, Croatia, Kosovo, FYR Macedonia, and Serbia were recruited through a random walk technique. Refugees in Germany, Italy and the UK were contacted through registers, organisations and networking. Current service use was measured for the previous three months and combined with unit costs for each country for the year 2006/7. A two-part approach was used, to identify predictors of service use with a multiple logistic regression model and predictors of cost with a generalised linear regression model. RESULTS: 3,313 participants were interviewed in Balkan countries and 854 refugees in Western European countries. In the Balkan countries, traumatic events and mental health status were related to greater service use while in Western countries these associations were not found. Participants in Balkan countries with post traumatic stress disorder (PTSD) had costs that were 63% higher (p = 0.005) than those without PTSD. Distress experienced during the most traumatic war event was associated with higher costs (p = 0.013). In Western European countries costs were 76% higher if non-PTSD anxiety disorders were present (0.027) and 63% higher for mood disorders (p = 0.006). CONCLUSIONS: War experiences and their effects on mental health are associated with increased health care costs even many years later, especially for those who stayed in the area of conflict. Focussing on the mental health impact of war is important for many reasons including those of an economic nature.

Factors associated with mental disorders in long-settled war refugees: refugees from the former Yugoslavia in Germany, Italy and the UK.

BACKGROUND: Prevalence rates of mental disorders are frequently increased in long-settled war refugees. However, substantial variation in prevalence rates across studies and countries remain unexplained. AIMS: To test whether the same sociodemographic characteristics, war experiences and post-migration stressors are associated with mental disorders in similar refugee groups resettled in different countries. METHOD: Mental disorders were assessed in war-affected refugees from the former Yugoslavia in Germany, Italy and the UK. Sociodemographic, war-related and post-migration characteristics were tested for their association with different disorders. RESULTS: A total of 854 war refugees were assessed (≥ 255 per country). Prevalence rates of mental disorders varied substantially across countries. A lower level of education, more traumatic experiences during and after the war, more migration-related stress, a temporary residence permit and not feeling accepted were independently associated with higher rates of mood and anxiety disorders. Mood disorders were also associated with older age, female gender and being unemployed, and anxiety disorders with the absence of combat experience. Higher rates of post-traumatic stress disorder (PTSD) were associated with older age, a lower level of education, more traumatic experiences during and after the war, absence of combat experience, more migration-related stress, and a temporary residence permit. Only younger age, male gender and not living with a partner were associated with substance use disorders. The associations did not differ significantly across the countries. War-related factors explained more variance in rates of PTSD, and post-migration factors in the rates of mood, anxiety and substance use disorder. CONCLUSIONS: Sociodemographic characteristics, war experiences and post-migration stressors are independently associated with mental disorders in long-settled war refugees. The risk factors vary for different disorders, but are consistent across host countries for the same disorders.

Experience of human rights violations and subsequent mental disorders - a study following the war in the Balkans.

War experiences are associated with substantially increased rates of mental disorders, particularly Post-Traumatic Stress Disorder (PTSD) and Major Depression (MD). There is limited evidence on what type of war experiences have particularly strong associations with subsequent mental disorders. Our objective was to investigate the association of violations of human rights, as indicated in the 4th Geneva Convention, and other stressful war experiences with rates of PTSD and MD and symptom levels of intrusion, avoidance and hyperarousal. In 2005/6, human rights violations and other war experiences, PTSD, post-traumatic stress symptoms and MD were assessed in war affected community samples in five Balkan countries (Bosnia-Herzegovina, Croatia, Kosovo, Macedonia, and Serbia) and refugees in three Western European countries (Germany, Italy, United Kingdom). The main outcome measures were the MINI International Neuropsychiatric Interview and the Impact of Event Scale-Revised. In total 3313 participants in the Balkans and 854 refugees were assessed. Participants reported on average 2.3 rights violations and 2.3 other stressful war experiences. 22.8% of the participants were diagnosed with current PTSD and also 22.8% had MD. Most war experiences significantly increased the risk for both PTSD and MD. When the number of rights violations and other stressful experiences were considered in one model, both were significantly associated with higher risks for PTSD and were significantly associated with higher levels of intrusion, avoidance and hyperarousal. However, only the number of violations, and not of other stressful experiences, significantly increased the risk for MD. We conclude that different types of war experiences are associated with increased prevalence rates of PTSD and MD more than 5 years later. As compared to other stressful experiences, the experience of human rights violations similarly increases the risk of PTSD, but appears more important for MD.

The structure of post-traumatic stress symptoms in survivors of war: confirmatory factor analyses of the Impact of Event Scale--revised.

The study aimed at establishing the factor structure of the Impact of Event Scale-Revised (IES-R) in survivors of war. A total sample of 4167 participants with potentially traumatic experiences during the war in Ex-Yugoslavia was split into three samples: two independent samples of people who stayed in the area of conflict and one sample of refugees to Western European countries. Alternative models with three, four, and five factors of post-traumatic symptoms were tested in one sample. The other samples were used for cross-validation. Results indicated that the model of best fit had five factors, i.e., intrusion, avoidance, hyperarousal, numbing, and sleep disturbance. Model superiority was cross-validated in the two other samples. These findings suggest a five-factor model of post-traumatic stress symptoms in war survivors with numbing and sleep disturbance as separate factors in addition to intrusion, avoidance and hyperarousal.

Mental disorders following war in the Balkans: a study in 5 countries.

CONTEXT: War experience may affect mental health. However, no community-based study has assessed mental disorders several years after war using consistent random sampling of war-affected people across several Western countries. OBJECTIVES: To assess current prevalence rates of mental disorders in an adult population who were directly exposed to war in the Balkans and who still live in the area of conflict, and to identify factors associated with the occurrence of different types of mental disorders. DESIGN, SETTING, AND PARTICIPANTS: War-affected community samples in Bosnia-Herzegovina, Croatia, Kosovo, the Republic of Macedonia, and Serbia were recruited through a random-walk technique. MAIN OUTCOME MEASURE: Prevalence rates of mood, anxiety, and substance use disorders were assessed using the Mini-International Neuropsychiatric Interview. RESULTS: Between 637 and 727 interviewees were assessed in each country (N = 3313). The prevalence rates were 15.6% to 41.8% for anxiety disorders, 12.1% to 47.6% for mood disorders, and 0.6% to 9.0% for substance use disorders. In multivariable analyses across countries, older age, female sex, having more potentially traumatic experiences during and after the war, and unemployment were associated with higher rates of mood and anxiety disorders. In addition, mood disorders were correlated with lower educational level and having more potentially traumatic experiences before the war. Male sex and not living with a partner were the only factors associated with higher rates of substance use disorders. Most of these associations did not significantly differ among countries. CONCLUSIONS: Several years after the end of the war, the prevalence rates of mental disorders among war-affected people vary across countries but are generally high. War experiences appear to be linked to anxiety and mood disorders but not substance use disorders. Long-term policies to meet the mental health needs of war-affected populations are required.