BOSTON, MA—Bosnian refugees traumatized by mass violence in the war in the Balkans continue to exhibit high levels of mental illnesses such as depression and posttraumatic stress disorder, according to a unique study appearing in this month’s issue of the Journal of the American Medical Association.
"We found that people who face mass violence or torture cannot be expected to snap back to good mental health on their own," says Richard Mollica, MD, Harvard Medical School associate professor of psychiatry and director of the Harvard Program in Refugee Trauma. "This study reveals the importance of incorporating long-term mental health initiatives into recovery efforts, especially for the elderly and disabled who appear at greater risk of mortality."
This longitudinal study, which began with a baseline assessment in 1996, followed the mental health impact of the Bosnian war on individuals in a refugee camp in Croatia. Most of them have now returned to Bosnia, though some have resettled elsewhere; this is the first longitudinal study that focuses on refugees who remain in the conflict region.
The initial 1996 survey of 534 refugees found that 209 (39.2 percent) suffered from major depression. One hundred twenty-nine (26.3 percent) had posttraumatic stress disorder (PTSD). Forty-eight (9.6 percent) had an observable physical handicap (such as blindness, deafness, or the loss of a limb, and 135 (25.5 percent) were disabled in their daily physical functioning. Study participants had experienced an average of 6.5 unduplicated traumatic events; 18 percent experienced one or more torture events.
Three hundred and seventy six (70.4 percent) of the initial interviewees remained in the region and participated in the 1999 follow-up study. Thirty-nine (7.3 percent) of the original group had died, 114 (21.3 percent) had emigrated, and five people chose not to participate in the reinterviews.
In the follow up study, 105 (45 percent) of 237 respondents who originally had depression and/or PTSD maintained the symptoms of these disorders, and 63 (46 percent) of 136 who had been disabled remained so. Forty-eight (16 percent) of those who were originally asymptomatic developed a mental health disorder.
The rate of unrecovered depression remained two to four times higher among these refugees than in the general population.
The survey showed that elderly refugees who were depressed in 1996 had three times the risk of death than those without depression. This finding was not statistically conclusive after controlling for other factors associated with premature death (e.g. living alone, male sex, older age), but the authors still consider this finding to have major clinical and public health importance.
The new survey also found that the refugees who emigrated were more traumatized, highly educated, and reported fewer health and mental health problems than those who remained in the region. "The emigration findings suggest that a ‘mental health drain’ is occurring as healthier, more educated refugees are not returning to Bosnia and are resettling in other countries," says Mollica.
The authors conclude that these findings reveal the serious chronic mental health impact of mass violence. In particular, depression and PTSD when it is present with depression were unremitting, disabling, and potentially associated with premature death. If these findings are generalized to the hundreds of thousands of other Bosnian refugees returning home, immediate attention must be given to reducing mental health disability at the local level. Local citizens may not be able to wait years for long-term macro-solutions to reduce unemployment and improve post-war adaptation.
The study was supported by a grant from the National Institutes of Mental Health.
Journal
JAMA