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Course of post-traumatic stress disorder following war in the Balkans: 1-year follow-up study

Published online by Cambridge University Press:  29 November 2012

S. Priebe*
Affiliation:
Unit for Social and Community Psychiatry, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
J. Gavrilovic
Affiliation:
Unit for Social and Community Psychiatry, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
S. Bremner
Affiliation:
Centre for Primary Care and Public Health, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
D. Ajdukovic
Affiliation:
Faculty of Philosophy, University of Zagreb, Croatia
T. Franciskovic
Affiliation:
School of Medicine, University of Rijeka, Croatia
G. Neri
Affiliation:
Department of Psychiatry, University of Modena and Reggio Emilia, Italy
A. Kucukalic
Affiliation:
School of Medicine, University of Sarajevo, Bosnia and Herzegovina
D. Lecic-Tosevski
Affiliation:
Belgrade University School of Medicine, Belgrade, Serbia
N. Morina
Affiliation:
Department of Clinical Psychology, University of Amsterdam, The Netherlands
M. Popovski
Affiliation:
Faculty of Philosophy, University of Skopje, FYRMacedonia
M. Schützwohl
Affiliation:
Department of Psychiatry and Psychotherapy, University of Technology, Dresden, Germany
M. Bogic
Affiliation:
Unit for Social and Community Psychiatry, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
A. Matanov
Affiliation:
Unit for Social and Community Psychiatry, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
*
*Address for correspondence: Professor S. Priebe, Unit for Social and Community Psychiatry, Newham Centre for Mental Health, London E13 8SP, UK. (Email: s.priebe@qmul.ac.uk)

Abstract

Background

Prevalence rates of post-traumatic stress disorder (PTSD) following the experience of war have been shown to be high. However, little is known about the course of the disorder in people who remained in the area of conflict and in refugees.

Method

We studied a representative sample of 522 adults with war-related PTSD in five Balkan countries and 215 compatriot refugees in three Western European countries. They were assessed on average 8 years after the war and reinterviewed 1 year later. We established change in PTSD symptoms, measured on the Impact of Events Scale – Revised (IES-R), and factors associated with more or less favourable outcomes.

Results

During the 1-year period, symptoms decreased substantially in both Balkan residents and in refugees. The differences were significant for IES-R total scores and for the three subscales of intrusions, avoidance and hyperarousal. In multivariable regressions adjusting for the level of baseline symptoms, co-morbidity with depression predicted less favourable symptom change in Balkan residents. More pre-war traumatic events and the use of mental health services within the follow-up period were associated with less improvement in refugees.

Conclusions

Several years after the war, people with PTSD reported significant symptom improvement that might indicate a fluctuating course over time. Co-morbid depression may have to be targeted in the treatment of people who remained in the post-conflict regions whereas the use of mental health services seems to be linked to the persistence of symptoms among refugees.

Type
Original Articles
Copyright
Copyright © Cambridge University Press 2012 

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References

Bogic, M, Ajdukovic, D, Bremner, S, Franciskovic, T, Galeazzi, GM, Kucukalic, A, Lecic-Tosevski, D, Morina, N, Popovski, M, Schützwohl, M, Wang, D, Priebe, S (2012). Factors associated with mental disorders in long-settled war refugees: refugees from the former Yugoslavia in Germany, Italy and the UK. British Journal of Psychiatry 200, 216223.CrossRefGoogle ScholarPubMed
Breslau, N, Chilcoat, HD, Kessler, RC, Davis, GC (1999). Previous exposure to trauma and PTSD effects of subsequent trauma: results from the Detroit Area Survey of Trauma. American Journal of Psychiatry 156, 902907.CrossRefGoogle ScholarPubMed
Breslau, N, Kessler, RC, Chilcoat, HD, Schultz, LR, Davis, GC, Andreski, P (1998). Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Archives of General Psychiatry 55, 626632.CrossRefGoogle ScholarPubMed
Breslau, N, Peterson, EL, Schultz, LR (2008). A second look at prior trauma and the posttraumatic stress disorder effects of subsequent trauma: a prospective epidemiological study. Archives of General Psychiatry 65, 431437.CrossRefGoogle ScholarPubMed
Cardozo, BL, Kaiser, R, Gotway, CA, Agani, F (2003). Mental health, social functioning, and feelings of hatred and revenge of Kosovar Albanians one year after the war in Kosovo. Journal of Traumatic Stress 16, 351360.CrossRefGoogle Scholar
de Jong, JT, Komproe, IH, Van Ommeren, M, El Masri, M, Araya, M, Khaled, N, van de Put, W, Somasundaram, D (2001). Lifetime events and posttraumatic stress disorder in 4 post-conflict settings. Journal of the American Medical Association 286, 555562.CrossRefGoogle Scholar
Drozdek, B (1997). Follow-up study of concentration camp survivors from Bosnia-Herzegovina: three years later. Journal of Nervous and Mental Disease 185, 690694.CrossRefGoogle ScholarPubMed
Etter, JF, Perneger, TV (2000). Snowball sampling by mail: application to a survey of smokers in the general population. International Journal of Epidemiology 29, 4348.CrossRefGoogle ScholarPubMed
Eytan, A, Guthmiller, A, Durieux-Paillard, S, Loutan, L, Gex-Fabry, M (2011). Mental and physical health of Kosovar Albanians in their place of origin: a post-war 6-year follow-up study. Social Psychiatry and Psychiatric Epidemiology 46, 953963.CrossRefGoogle ScholarPubMed
Fazel, M, Wheeler, J, Danesh, J (2005). Prevalence of serious mental disorder in 7000 refugees resettled in Western countries: a systematic review. Lancet 365, 13091314.CrossRefGoogle ScholarPubMed
Fear, NT, Jones, M, Murphy, D, Hull, L, Iversen, AC, Coker, B, Machell, L, Sundin, J, Woodhead, C, Jones, N, Greenberg, N, Landau, S, Dandeker, C, Rona, RJ, Hotopf, M, Wessely, S (2010). What are the consequences of deployment to Iraq and Afghanistan on the mental health of the UK armed forces? A cohort study. Lancet 375, 17831797.CrossRefGoogle ScholarPubMed
Foa, EB, Zoellner, LA, Feeny, NC, Hembree, EA, Alvarez-Conrad, J (2002). Does imaginal exposure exacerbate PTSD symptoms? Journal of Consulting and Clinical Psychology 70, 10221028.CrossRefGoogle ScholarPubMed
Franciskovic, T, Tovilovic, Z, Sukovic, Z, Stevanović, A, Ajduković, D, Kraljević, R, Bogić, M, Priebe, S (2008). Health care and community-based interventions for war-traumatized people in Croatia: community-based study of service use and mental health. Croatian Medical Journal 49, 483490.CrossRefGoogle ScholarPubMed
Goenjian, AK, Steinberg, AM, Najarian, LM, Fairbanks, LA, Tashjian, M, Pynoos, RS (2000). Prospective study of posttraumatic stress, anxiety, and depressive reactions after earthquake and political violence. American Journal of Psychiatry 157, 911916.CrossRefGoogle ScholarPubMed
Hauff, E, Vaglum, P (1994). Chronic posttraumatic stress disorder in Vietnamese refugees: a prospective community study of prevalence, course, psychopathology, and stressors. Journal of Nervous and Mental Disease 182, 8590.CrossRefGoogle ScholarPubMed
Hotopf, M, Hull, L, Fear, NT, Browne, T, Horn, O, Iversen, A, Jones, M, Murphy, D, Bland, D, Earnshaw, M, Greenberg, N, Hughes, JH, Tate, AR, Dandeker, C, Rona, R, Wessely, S (2006). The health of UK military personnel who deployed to the 2003 Iraq war: a cohort study. Lancet 367, 17311741.CrossRefGoogle Scholar
Hume, F, Summerfield, D (1994). After the war in Nicaragua: a psychosocial study of war wounded ex-combatants. Medicine and War 10, 425.CrossRefGoogle ScholarPubMed
Kadri, N, Agoub, M, El Gnaoui, S, Alami, KM, Hergueta, T, Moussaoui, D (2005). Moroccan colloquial Arabic version of the Mini-International Neuropsychiatric Interview (MINI): qualitative and quantitative validation. European Psychiatry 20, 193195.CrossRefGoogle ScholarPubMed
Kessler, RC, Sonnega, A, Bromet, E, Hughes, M, Nelson, CB (1995). Posttraumatic stress disorder in the National Comorbidity Study. Archives of General Psychiatry 52, 10481060.CrossRefGoogle Scholar
Kivling-Boden, G, Sundbom, E (2002). The relationship between post-traumatic symptoms and life in exile in a clinical group of refugees from the former Yugoslavia. Acta Psychiatrica Scandinavica 105, 461468.CrossRefGoogle Scholar
Koenen, KC, Stellman, JM, Stellman, SD, Sommer, JF Jr. (2003). Risk factors for course of posttraumatic stress disorder among Vietnam veterans: a 14-year follow-up of American Legionnaires. Journal of Consulting and Clinical Psychology 71, 980986.CrossRefGoogle ScholarPubMed
Koren, D, Arnon, I, Klein, E (2001). Long term course of chronic posttraumatic stress disorder in traffic accident victims: a three-year prospective follow-up study. Behaviour Research and Therapy 39, 14491458.CrossRefGoogle ScholarPubMed
Lie, B (2002). A 3-year follow-up study of psychosocial functioning and general symptoms in settled refugees. Acta Psychiatrica Scandinavica 106, 415425.CrossRefGoogle ScholarPubMed
Mollica, RF, Sarajlic, N, Chernoff, M, Lavelle, J, Sarajlic, IV, Massagli, MP (2001). Longitudinal study of psychiatric symptoms, disability, mortality, and emigration among Bosnian refugees. Journal of the American Medical Association 286, 546554.CrossRefGoogle ScholarPubMed
Morina, N, Böhme, HF, Ajdukovic, D, Bogic, M, Frančišković, T, Galeazzi, GM, Kucukalic, A, Lečić-Toševski, D, Popovski, M, Schützwohl, M, Stangier, U, Priebe, S (2010). The structure of posttraumatic stress symptoms in survivors of war: a confirmatory factor analysis of the Impact of Event Scale – Revised. Journal of Anxiety Disorders 24, 606611.CrossRefGoogle Scholar
Morina, N, Ford, JD (2008). Complex sequelae of psychological trauma among Kosovar civilian war victims. International Journal of Social Psychiatry 54, 425436.CrossRefGoogle ScholarPubMed
Mufti, KA, Naeem, F, Chaudry, HR, Haroon, A, Saifi, F, Qureshi, SM, Dagarwal, SR (2007). Post-traumatic stress disorder among Afghan refugees following war. International Psychiatry 4, 79.CrossRefGoogle ScholarPubMed
Nickerson, A, Bryant, RA, Silove, D, Steel, Z (2011). A critical review of psychological treatments of posttraumatic stress disorder in refugees. Clinical Psychology Review 31, 399417.CrossRefGoogle ScholarPubMed
Otsubo, T, Tanaka, K, Koda, R, Shinoda, J, Sano, N, Tanaka, S, Aoyama, H, Mimura, M, Kamijima, K (2005). Reliability and validity of Japanese version of the Mini-International Neuropsychiatric Interview. Psychiatry and Clinical Neurosciences 59, 517526.CrossRefGoogle ScholarPubMed
Perkonigg, A, Pfister, H, Stein, MB, Höfler, M, Lieb, R, Maercker, A, Wittchen, H-U (2005). Longitudinal course of posttraumatic stress disorder and posttraumatic stress disorder symptoms in a community sample of adolescents and young adults. American Journal of Psychiatry 162, 13201327.CrossRefGoogle Scholar
Pitman, RK, Altman, B, Greenwald, E, Longpre, RE, Macklin, ML, Poiré, RE, Steketee, GS (1991). Psychiatric complications during flooding therapy for post-traumatic stress disorder. Journal of Clinical Psychiatry 52, 1720.Google Scholar
Priebe, S, Bogic, M, Ajdukovic, D, Frančišković, T, Galeazzi, GM, Kucukalic, A, Lečić-Toševski, D, Morina, N, Popovski, M, Wang, D, Schützwohl, M (2010 a). Mental disorders following war in the Balkans: a community based study on long-term outcomes in 5 countries. Archives of General Psychiatry 67, 518528.CrossRefGoogle Scholar
Priebe, S, Bogic, M, Ashcroft, R, Frančišković, T, Galeazzi, GM, Kucukalic, A, Lečić-Toševski, D, Morina, N, Popovski, M, Roughton, M, Schützwohl, M, Ajduković, D (2010 b). Experience of human rights violations and subsequent mental disorders: a study following the war in the Balkans. Social Science and Medicine 71, 21702177.CrossRefGoogle ScholarPubMed
Priebe, S, Huxley, P, Knight, S, Evans, S (1999). Application and results of the Manchester Short Assessment of Quality of Life (MANSA). International Journal of Social Psychiatry 45, 712.CrossRefGoogle ScholarPubMed
Priebe, S, Jankovic Gavrilovic, J, Matanov, A, Frančišković, T, Knezevic, G, Ljubotina, D, Mehmedbasic, AB, Schützwohl, M (2010 c). Treatment outcomes and costs at specialized centers for the treatment of PTSD after the war in former Yugoslavia. Psychiatric Services 61, 598604.CrossRefGoogle ScholarPubMed
Priebe, S, Jankovic Gavrilovic, J, Schuetzwohl, M, Galeazzi, GM, Lečić-Toševski, D, Ajduković, D, Frančišković, T, Kucukalic, A, Popovski, M (2004). Study of long-term clinical and social outcomes after war experiences in ex-Yugoslavia: methods of the ‘CONNECT’ project. Psychiatry Today 36, 101122.Google Scholar
Priebe, S, Matanov, A, Jankovic Gavrilovic, J, McCrone, P, Ljubotina, D, Knezević, G, Kucukalić, A, Francisković, T, Schützwohl, M (2009). Consequences of untreated posttraumatic stress disorder following war in former Yugoslavia: morbidity, subjective quality of life, and care costs. Croatian Medical Journal 50, 465475.CrossRefGoogle ScholarPubMed
Priebe, S, McCabe, R, Junghan, U, Kallert, T, Ruggeri, M, Slade, M, Reininghaus, U (2011). Association between symptoms and quality of life in patients with schizophrenia: a pooled analysis of changes over time. Schizophrenia Research 133, 1721.CrossRefGoogle ScholarPubMed
Priebe, S, Watzke, S, Hansson, L, Burns, T (2008). Objective Social Outcomes Index (SIX): a method to summarise objective indicators of social outcomes in mental health care. Acta Psychiatrica Scandinavica 118, 5763.CrossRefGoogle Scholar
Roth, G, Ekblad, S, Agren, H (2006). A longitudinal study of PTSD in a sample of adult mass-evacuated Kosovars, some of whom returned to their home country. European Psychiatry 21, 152159.CrossRefGoogle Scholar
Roy-Byrne, P, Arguelles, L, Vitek, ME, Goldberg, J, Keane, TM, True, WR, Pitman, RK (2004). Persistence and change of PTSD symptomatology: a longitudinal co-twin control analysis of the Vietnam Era Twin Registry. Social Psychiatry and Psychiatric Epidemiology 39, 681685.CrossRefGoogle ScholarPubMed
Sheehan, DV, Lecrubier, Y, Sheehan, KH, Amorim, P, Janavs, J, Weiller, E, Hergueta, T, Baker, R, Dunbar, GC (1998). The MINI-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry 59, 2233.Google ScholarPubMed
Shlosberg, A, Strous, RD (2005). Long-term follow-up (32 years) of PTSD in Israeli Yom Kippur War veterans. Journal of Nervous and Mental Disease 193, 693696.CrossRefGoogle ScholarPubMed
Solomon, Z, Mikulincer, M (2006). Trajectories of PTSD: a 20-year longitudinal study. American Journal of Psychiatry 163, 659666.CrossRefGoogle ScholarPubMed
Smith, TC, Ryan, MAK, Wingard, DL, Slymen, DJ, Sallis, JF, Kritz-Silverstein, D (2008). New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: prospective population based US military cohort study. British Medical Journal 336, 366371.CrossRefGoogle ScholarPubMed
Su, CY, Tsai, KY, Chou, FH, Ho, WW, Liu, R, Lin, WK (2010). A three-year follow-up study of the psychosocial predictors of delayed and unresolved post-traumatic stress disorder in Taiwan Chi-Chi earthquake survivors. Psychiatry and Clinical Neurosciences 64, 239248.CrossRefGoogle ScholarPubMed
Summerfield, D (1999). A critique of seven assumptions behind psychological trauma programmes in war-affected areas. Social Science and Medicine 48, 14491462.CrossRefGoogle ScholarPubMed
Weine, S, Vojvoda, D, Becker, D, McGlashan, TH, Hodzic, E, Laub, D, Hyman, L, Sawyer, M, Lazrove, S (1998). PTSD symptoms in Bosnian refugees 1 year after resettlement in the United States. American Journal of Psychiatry 155, 562564.CrossRefGoogle ScholarPubMed
Weiss, DS (2004). The Impact of Event Scale – Revised. In Assessing Psychological Trauma and PTSD (ed. Wilson, J. P. and Keane, T. M.), pp. 399411. Guilford Press: Surrey.Google Scholar
Wolfe, J, Kimerling, R (1997). Gender issues in the assessment of posttraumatic stress disorder. In Assessing Psychological Trauma and PTSD (ed. Wilson, J. P. and Keane, T. M.), pp. 192219. Guilford Press: Surrey.Google Scholar
Zlotnick, C, Warshaw, M, Shea, TM, Allsworth, J, Pearlstein, T, Keller, MB (1999). Chronicity in posttraumatic stress disorder (PTSD) and predictors of course of comorbid PTSD in patients with anxiety disorders. Journal of Traumatic Stress 12, 89100.CrossRefGoogle ScholarPubMed