Efforts to rebuild the country's infrastructure and economy will fail without mental health resources
BOSTON -- July 30, 1999 -- One in four Bosnian adults who fled the Bosnia and Herzegovina war may be functionally disabled due to psychiatric disorders, according to a study from Harvard Medical School and the Harvard Program in Refugee Trauma. The findings go well beyond simple depression and anxiety and, the researchers suggest, underline the need to address mental health issues when creating and implementing redevelopment programs in war-torn countries. The study is published in the August 4 Journal of the American Medical Association.
The researchers surveyed 534 adults aged 18 years or older who were randomly selected from families living in a refugee camp in Varazdin, Croatia. The survey was conducted in 1996, nearly a year after the Dayton Peace Accord ended the war. The researchers found that 25.5 percent of the respondents were functionally disabled. Refugees who reported symptoms for both major depression and posttraumatic stress disorder (PTSD) were five times more likely to report a disability than those who reported no psychiatric symptoms. After controlling for demographic characteristics and personal risk factors, such as age and exposure to traumatic events, those who reported symptoms for both major depression and PTSD were two times more likely to report a disability than those who reported no psychiatric symptoms.
Functional disability was measured using several tools, including the physical functioning scale of the Medical Outcomes Study 20-Item Short-Form Health Survey and the World Health Organization physical functioning scale.
"War and civil strife obviously affect people physically, but our study shows that there is also a mental toll that requires immediate medical treatment," explains Richard Mollica, Harvard Medical School associate professor of psychiatry and director of the Harvard Program in Refugee Trauma. "It is critical that relief and redevelopment agencies recognize this need for mental health services. Otherwise, efforts to rebuild a country's infrastructure and economy will be hindered if a significant number of the country's citizens are disabled by psychiatric disorders."
According to the survey, the five most frequently experienced traumatic events were being present during shelling or grenade attacks, hiding from snipers, hiding outdoors, being confined to home, and being present while one's home was being searched. The most commonly reported torture event were forced standing, being placed in a sack, box or other small space, mock execution, forced witnessing of torture, and blows to the ears.
Refugees who experienced three to five traumatic events were more than two times more likely to suffer disability than were those who experience two or fewer events. However, those who experienced six or more traumatic events actually had a lower risk of being disabled than did those who experienced three to five traumatic events. The researchers speculate that a disproportionate number of those who experienced six or more events probably were combatants, as they tended to be younger, male, and have prisoner of war experience. Military training might have helped these refugees to cope with traumatic experience.
The survey also revealed that people aged 65 years and older were more than three times more likely to by functionally disabled due to psychiatric disorders than adults aged 18 to 34 years. This finding counters the widely held belief that the elderly are resilient and typically able to overcome the trauma of war and displacement.
"There are, unfortunately, dozens of countries and tens of millions of people who are currently affected by mass violence," says Mollica. "I hope our study encourages government and redevelopment agencies to view refugees' mental and emotional suffering as a significant economic problem. Then, perhaps, the appropriate resources will be dedicated to treating the refugees' psychiatric disorders."
The study was funded in part by the National Institute of Mental Health and the US Agency for International Development.
Journal
JAMA