 |
|
Disability Associated With Psychiatric Comorbidity and Health Status in Bosnian Refugees Living in Croatia
Richard F. Mollica, MD, MAR;
Keith McInnes, MS;
Narcisa Sarajli , MD, PhD;
James Lavelle, MSW;
Iris Sarajli, MD;
Michael P. Massagli, PhD
JAMA. 1999;282:433-439.
ABSTRACT
| |
Context The relationship between psychiatric symptoms and disability in refugee survivors of mass violence is not known.
Objective To determine if risk factors, such as demographics, trauma, health status, and psychiatric illness, are associated with disability in Bosnian refugees.
Design, Setting, and Participants Cross-sectional survey conducted in 1996 of Bosnian refugee adults living in a camp established by the Croatian government near the city of Vara din. One adult aged 18 years or older was randomly selected from each of 573 camp families; 534 (93%) agreed to participate (mean age, 50 years; 41% male).
Main Outcome Measures Culturally validated measures for depression and posttraumatic stress disorder (PTSD) included the Hopkins Symptom Checklist 25 and the Harvard Trauma Questionnaire, respectively. Disability measures included the Medical Outcomes Study Short-Form 20, a physical functioning scale based on World Health Organization criteria, and self-reports of socioeconomic activity, levels of physical energy, and perceived health status.
Results Respondents reported a mean (SD) of 6.5 (4.7) unduplicated trauma events; 18% (n=95) had experienced 1 or more torture events. While 55.2% reported no psychiatric symptoms, 39.2% and 26.3% reported symptoms that meet DSM-IV criteria for depression and PTSD, respectively; 20.6% reported symptoms comorbid for both disorders. A total of 25.5% reported having a disability. Refugees who reported symptoms comorbid for both depression and PTSD were associated with an increased risk for disability compared with asymptomatic refugees (unadjusted odds ratio [OR], 5.02; 95% confidence interval [CI], 3.05-8.26; adjusted OR, 2.06; 95% CI, 1.10-3.86). Older age, cumulative trauma, and chronic medical illness were also associated with disability.
Conclusions In a population of Bosnian refugees who had recently fled from the war in Bosnia and Herzegovina, psychiatric comorbidity was associated with disability independent of the effects of age, trauma, and health status.
INTRODUCTION
The recent war in Bosnia and Herzegovina that ended with the signing of the Dayton Peace Accord in 1995 has had a catastrophic effect on local populations residing in this region. For example, it is estimated that the war caused more than 250,000 deaths, created more than 2 million refugees and internally displaced persons, and wounded 200,000 in Bosnia and Herzegovina alone.1-2 Recent epidemiologic studies have revealed that the psychiatric morbidity associated with mass violence in civilian and refugee populations is elevated when compared with nontraumatized communities.3 In our previous report on Cambodian refugees living on the Thai border, approximately 68% of refugees displayed symptoms of major depression and 37% showed symptoms associated with the diagnosis of posttraumatic stress disorder (PTSD).4 These results were anticipated by clinical studies of Cambodian refugees resettled in the United States that revealed high rates of depression and PTSD.5-8 Currently, clinical reports of Bosnian refugees in treatment show similar findings for depressive symptoms with rates ranging from 14% to 21%9-10 and for PTSD symptoms with rates ranging from 18% to 53%.9-12 Because no epidemiologic studies of refugee communities from the Balkans have been reported to date, the degree of impact this recent war has had on the psychiatric morbidity of Bosnian refugees is unknown.
The relationship between psychiatric distress and disability in communities devastated by mass violence has received little attention, despite the widespread knowledge that mental illness is a leading cause of disability worldwide.13 In traditional populations, psychiatric disorders, especially depression, are associated with physical impairment,14 social role impairment,15 and loss of productivity.16 Cross-national investigations of primary health care patients have revealed that high rates of disability associated with common psychiatric disorders, such as depression, occur independently of the presence of medical illnesses.17 While these studies did not focus on nations in conflict, they suggest that the relationship between psychiatric illness and disability in postconflict societies should be at least as strong as in nontraumatized communities and developing nations.
In this study, conducted in February and March, 1996, we surveyed a population of Bosnian refugees living in a refugee camp in Croatia to assess the following: (1) degree of disability associated with trauma and other risk factors, (2) relationship between psychiatric symptoms (depression and PTSD) and disability, and (3) relationship between chronic medical illnesses and disability.
METHODS
In 1992 the Croatian government established a number of refugee camps, including the Varadin camp in northeastern Croatia. At approximately the same time, a private social service agency, Ruke, based in Croatia, began providing counseling and other social services to the Varadin camp residents. In the fall of 1995, Ruke and the Harvard Program in Refugee Trauma conducted a key informant survey of 100 human service and Croatian government workers serving the Varadin camp.18 That survey (available from the authors on request) provided the background data for the design and implementation of the current study.
We conducted a census of the 573 families, totaling 1275 people, living in the Varadin camp as of February 1, 1996. One adult respondent 18 years of age or older was randomly selected from each family from a list of all adult family members. Of the target sample of 573 adults, 534 (93%) agreed to participate in the study. Nonrespondents were somewhat older (mean [SD] age, 58.6 [17.9] years) than respondents (50.4 [16.14] years; (t565=- 2.83; P=.005) but did not differ significantly by sex ( 21=1.36; P=.24).
Interviews were conducted by Ruke's professional staff of local psychiatrists and by paraprofessionals who were Bosnian refugees living in the Varadin camp and trained by Ruke staff members. The interviews were conducted in Bosnian and took an average of 90 minutes. Before the interviews, each respondent was read, in Bosnian, a letter of informed consent to sign that indicated the voluntary nature of participation and guaranteed strict confidentiality of responses. Informed consent procedures and study design were approved by the Human Subjects Committee of the Harvard School of Public Health. Interviewers received 4 days of training, including review of the questionnaire and practice interviews with refugees (Varadin camp residents who met the criteria for selection but were not enrolled in the study sample). Quality assurance procedures assessed interrater reliability until there was 100% concordance among the interviewers.
The survey questionnaire was adapted for this study from the key informant survey.18 Translation was done by the Ruke team to construct the final questionnaire by means of the standard methods of cross-cultural research.19-20 The study's questionnaire focused on risk factors and outcomes associated with the respondent's refugee experience. Risk factors evaluated included demographics (sex, age, marital status, and education), length of time in the camp, family size, health (self-perception of health, handicaps, and chronic conditions), economic and social resources, work status, prisoner-of-war (POW) status, traumatic life experiences before and after leaving home, and torture experience. Outcomes included functional disability, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) symptoms of major depression and PTSD, health status, and work. The anticipated repatriation needs of the respondents were also assessed.
The trauma history was derived from the Bosnian version of the Harvard Trauma Questionnaire (HTQ).21 Measures of cumulative trauma were constructed from responses to questions about trauma events, before and after leaving home (the refugee experience), related to the conflict. Affirmative responses were summed for 38 trauma events and 19 torture events. The torture experiences conformed to international definitions of torture.22
Two interview schedules were used to measure psychological symptoms: a 25-item section of the Hopkins Symptom Checklist (HSCL-25)23 and a 30-item section of the HTQ.21 The HSCL-25 includes a 15-item scale of depressive symptoms, while the HTQ contains a scale made up of 16 of the 17 diagnostic criteria for PTSD in DSM-III-R and DSM-IV. For both schedules, respondents were asked whether they were bothered by each symptom "not at all" (1), "a little" (2), "quite a bit" (3), or "extremely" (4) in the past week. In our sample, Cronbach  ,24 a measure of internal-consistency reliability, was estimated at .89 for both the depression scale and the PTSD scales.
Both instruments have been widely translated and used in a number of studies among diverse cultural groups25-30 and validated against clinical diagnoses.21, 23, 31-32 Since the cutoff points for psychiatric diagnosis have not yet been established in a Bosnian refugee population, an algorithm method was selected that replicated the DSM-IV criteria for major depression (HSCL-25) and PTSD (HTQ).33-34 The algorithm method correlated well with standard cutoff points for the HSCL-25 and HTQ for PTSD and depression, respectively (results available from authors on request), and was more conservative in classifying respondents as symptomatic.
Functional disability was measured using the physical functioning scale of the Medical Outcomes Study 20-Item Short-Form Health Survey (MOS SF-20), which has been tested for its reliability and validity in a large number of disease settings, countries, and languages.35-37 Our survey questionnaire also contained other measures of disability, including a World Health Organization (WHO) physical functioning scale,38 a measure of perceived energy level,25 and a measure of self-perceived health.39 The physical functioning scale of the MOS SF-20 correlated highly with the WHO scale (r=0.78, P<.001), and moderately high with energy level (r=- 0.62, P<.001) and self-perceived health (r=-0.58, P<.001). Cronbach was estimated at .80 for the 6-item physical functioning scale of the MOS SF-20.
Since cutoff points have not been established for this population for the HSCL-25 and HTQ PTSD scales, another method of establishing caseness was used.40 To be classified as symptomatic for depression a respondent required a positive response (score of 3 or 4) on either depressed mood or diminished interest/pleasure, and at least 4 of the following 6 DSM-IV criterion A symptoms: significant weight loss or change in appetite, insomnia or hypersomnia, fatigue or loss of energy, feeling of worthlessness, diminished ability to think or concentrate, and recurrent thoughts of death. The criterion A symptom, "observable psychomotor agitation or retardation" was omitted because of the inability to conduct physical examinations in this study.
For PTSD the algorithm for caseness included a positive response (3 or 4 on the HTQ) on at least 1 of the 4 reexperiencing symptoms (criterion B), at least 3 of the 7 avoidance and numbing symptoms (criterion C), and at least 2 of the 5 arousal symptoms (criterion D). Criterion A (exposure to traumatic event) was deemed to have been met by all respondents due to their flight from home and refugee status.
The physical functioning scale of the MOS SF-2036 was used to measure disability. The 6 items measure limitations in physical functioning due to health and are measured on a 3-point scale (1, limited for more than 3 months; 2, limited for 3 months or less; and 3, not limited at all). The item responses were summed and then transformed linearly to a 0 through 100 scale with 0 indicating the poorest physical functioning and 100 indicating no limitations in physical functioning.36
For the logistic regression analysis it was necessary to create a dichotomous variable from the 100-point functional impairment scale. The cutoff point of 50 was selected as a conservative estimate of functional disability. Stewart et al,36 in a study of a US population using the same MOS SF-20, defined poor physical functioning as being limited on 1 or more items on the 6-item scale, which is equal to a score of 91.7 on the 100-point scale. In our sample, this same cutoff point (91.7) would result in 65% of respondents being classified as functionally impaired; we chose instead a more stringent cutoff point of 50 in order to examine the highly physically impaired individuals who, by most professional and clinical standards, unequivocally would be classified as functionally impaired or disabled.
Bivariate relationships between disability and characteristics of interest were examined using logistic regression. These analyses produced relative odds, that is, the likelihood of being disabled given the presence of a certain characteristic compared with not having the characteristic. Later, multivariate logistic regression was performed to produce odds ratios (ORs) that control for the presence of all the other variables in the model. An estimated pseudo-R2 statistic was calculated to assess the degree to which the hypothesized model fit the observed data. We estimated F ratios and 2 values for categories of trauma. All analyses were performed with SAS statistical analysis software, version 6.11.41
RESULTS
The sample was 41% male and 59% female. The mean age was 50 years. Nearly half of the sample (48%) were married, with 22% widowed. A relatively large proportion of the sample was poorly educated, with 37% not having completed primary school. Self-identified ethnicity was 60% Bosnian Muslim, 23% Bosnian Croat, 11% Croat, and 6% other (Serb, Gypsy, and Bosnian unspecified).
The mean (SD) number of unduplicated trauma events reported by respondents was 6.5 (4.7). All but 31 respondents reported at least 1 event; 18% (95/534) reported experiencing 1 or more of the 19 torture events.
The 5 most frequently experienced trauma events were being present during shelling or grenade attacks (83%), hiding from snipers (75%), hiding outdoors (63%), being confined to home (51%), and being present while one's home was searched (37%). Other frequently reported traumas were being threatened or humiliated (34%), witnessing sexual abuse (33%), lacking food or water (28%), having a family member injured from violence (28%), witnessing violence to family member (28%), and being ill but having no access to medical care (23%). Roughly 17% of the sample reported the death, due to violence, of a family member: death of a child accounted for 3.4% of such deaths and other family members, 13.1%.
The most commonly reported torture events were forced standing (58%); being placed in sack, box, or other small space (36%); mock execution (34%); forced witnessing of torture (31%); and blows to the ears (28%).
Table 1 provides the results of the logistic regression models, with disability as the outcome variable and the demographic and other personal characteristics as the uncontrolled (univariate) predictors. In this sample, the scores on the MOS SF-20 ranged from 0 to 100, with a mean (SD) of 74 (26.6) and a median of 83. When we set a cutoff point of 50 on the physical functioning scale of the MOS SF-20, 25.5% of respondents were classified as disabled. As is shown in Table 1, sex, length of camp time, cumulative trauma, POW status, and experience of torture were not associated with increased risk for disability. Older age, being widowed or never married, lack of education, physical handicaps, and having 2 or more chronic conditions were associated with risk for disability. Having 3 or more family members in camp, earning an income while in camp, and reporting good to excellent health status were associated with a decreased risk for disability.
|
|
|
|
Table 1. Associations Between Personal Characteristics and Disability, Varadin Refugee Camps, Croatia, 1996*
|
|
|
In Table 2 the odds of being disabled according to psychiatric status is assessed. In this sample 39.2% of respondents reported symptoms of depression (18.6% reported depression alone) and 26.3% reported symptoms of PTSD (5.6% reported PTSD alone); 20.6% reported symptoms comorbid for depression and PTSD. The odds for disability increased progressively with the addition of psychiatric symptoms. Respondents who met the criteria for depressive symptoms were 3.75 times more likely to report disability than asymptomatic respondents (95% confidence interval [CI], 2.23-6.31). In this analysis, the association between disability and PTSD alone became insignificant. Those who reported symptoms for both depression and PTSD were 5 times more likely to report disability than those who reported no psychiatric symptoms (95% CI, 3.05-8.26).
Table 3 presents the results of the multivariate logistic regression, controlling for sex, marital status, education, length of time in refugee camp, number of family members in camp, income earning in camp, POW status, medical conditions, and torture. In this analysis, the association between disability and depression became insignificant. However, the association between disability and symptoms comorbid for both depression and PTSD symptoms remained (OR=2.06; 95% CI, 1.10-3.86).
|
|
|
|
Table 3. Multivariate Logistic Regression Modeling Disability With Psychiatric Status, Demographic Characteristics, and Personal Risk Factors (n = 503)*
|
|
|
Analysis of cumulative trauma revealed that at 3 to 5 traumatic events the probability of disability was 2.36 times the probability for respondents with 0 to 2 events (95% CI, 1.14-4.86). Surprisingly, the fitted odds of impairment for persons with 6 or more events is not statistically different than the odds of impairment for persons with 0 to 2 events (P=.88).
Perceived health, physical handicap, and age continued to be important variables in explaining the variation in disability, although the magnitude of the relationship was no longer as great as in the previous univariate analyses. Persons aged 65 years and older were 3.6 times as likely to be disabled as young adults aged 18 to 34 years (95% CI, 1.03-12.53).
COMMENT
In this study, 94% of refugee respondents reported having been exposed to war-related violence with a mean (SD) experience of 6.5 (4.7) events. The most common trauma events were warfare and refugee experiences, including shelling and grenade explosions, exposure to sniper fire, and hiding. Torture was experienced by 18% of respondents. Even with conservative measurement, almost 40% of respondents reported symptoms of depression and 26% reported symptoms of PTSD. Of the refugee respondents, 25.5% reported having a significant disability.
Our data suggest that the following risk factors are associated with disability in this population: psychiatric symptoms, trauma, age, handicaps, and perceived health status. The impact of trauma, such as torture22, 45-46 and the refugee experience,26, 47-48 on psychiatric symptoms has received considerable attention by previous investigators. While cumulative trauma was initially associated with disability in this population, after 5 trauma events the association was no longer significant. Our measure of trauma is based on an unweighted self-report of having experienced a possible range of trauma and/or torture events. Since the psychological and biological responses to specific types of traumas experienced by refugees are poorly understood, our instruments have avoided a priori weightings of individual events. In previous studies of Cambodian refugees, our data have revealed significant dose-effect relationships between cumulative trauma and psychiatric symptoms.4, 47
The apparent lack of a consistent dose-effect response in the present study might be due to the higher cumulative trauma experienced by younger soldiers who, through their training, were better prepared to cope with traumatic events.49 Therefore, we hypothesize that respondents with 6 or more trauma events may be different from less traumatized respondents in ways that are not captured by other control variables. Specifically, they may represent a disproportionate number of combatants. While direct inquiry about combat status was considered too sensitive for this sample of Bosnians living in the territory of Croatia, a country that had been at war with Bosnia and Herzegovina approximately 12 months before the interviews, an analysis of the characteristics of respondents in the different trauma categories was conducted. It indicated that those with 6 or more events were more likely to be male, younger, have POW experience, and have been tortured than their counterparts reporting fewer trauma events). This suggests that persons with 6 or more events disproportionately represent combatants. Military training and the belief that one is protecting country and family may have a protective effect, so that even though the number of traumas may be higher, the psychiatric symptoms are not more elevated than in less traumatized refugee respondents.45, 50-51
Demographic characteristics of the disabled indicate that age is associated with disability in this population.52 In previous refugee investigations, the relative youth of the refugee population, especially in developing nations, has not provided an opportunity for the important association of age to be demonstrated.25 In the Bosnian context, hundreds of thousands of elderly have been displaced. These results raise questions about the physical and psychological abilities of older people to adapt to their ongoing traumatizing life situation after repatriation.11, 52 The association between disability and being widowed or never married,12 lack of education, and absence of family members is consistent with previous studies revealing the lack of resiliency of these groups when coping with extreme environments.53-54 The negative impact of poor physical health status and chronic medical conditions, including handicap, on disability is evident. While there appears to be a beneficial effect on disability status associated with economic activity, the actual value of working is unknown since it is confounded with other variables such as age and education.
This study documents high comorbidity of the 2 major psychiatric disorders investigated in this Bosnian refugee population, major depression and PTSD. This finding has been well established in clinical reports of resettled refugee patients,6, 8 other traumatized special clinical populations such as POWs,55 in community studies of PTSD in the general population,56-58 and in veteran groups.59-60 Our results support the ubiquitousness of comorbid psychiatric illness in traumatized refugees. This conclusion led us to explore the hypothesis that psychiatric comorbidity was associated with higher levels of disability than that found in asymptomatic refugees or those with single diagnoses. Our analyses revealed that disability levels were markedly increased among Bosnian refugees comorbid with symptoms of PTSD and depression. Furthermore, our analyses reveal that psychiatric illness is not an epiphenomenon of medical illness in relationship to disability. Our multivariate analysis reveals that self-reported symptoms of PTSD and depression are associated with disability independent of poor physical health. These results in a refugee population are similar to the results of the WHO collaborative study of primary health care patients in nonconflict societies.17
A number of limitations need to be noted. The classification of respondents into diagnostic categories was affected by the lack of validation with clinical diagnoses that has been achieved with the screening instruments in other refugee populations.31, 50 Because neither clinical interviews nor structured clinical interviews were included in the study it is unclear to what extent the rates of self-reported symptoms of PTSD and depression cited here would match clinical diagnoses. For this reason, rather than using a predetermined cutoff point for the instruments, a multidimensional classification algorithm, based on DSM-IV, was used. Our follow-up study, now in progress, includes structured clinical interview for the DSM-IV diagnoses to validate cutoff points and case definitions.
Currently there exists no criterion standard to validate disability measures in refugee populations. For example, we do not know the baseline functional status of Bosnia and Herzegovina citizens before the war, and we do not know how functioning changes as individuals adapt to their new refugee situation. Because of these limitations we used multiple measures of disability, which, in our study, were shown to be highly intercorrelated. We also selected a conservative cutoff point on the physical functioning scale of the MOS SF-20 relative to US-based norms established by the Medical Outcomes Study.61 What remains undetermined, however, is how many more respondents would have been classified as disabled if less stringent criteria were used based on a criterion standard or structured clinical rating scale.
The majority of the variables are based on self-reported data such as measures of trauma, physical functioning, and health status. Physical examinations were not conducted. The only health-related measure that could be independently verified was physical handicap status. The accuracy of reporting of trauma events by refugees has been extensively reviewed in previous reports.27, 62 The validity and reliability of the disability measure used in our analyses have been evaluated against objective assessments supporting the feasibility of using self-report disability scales in refugee populations such as the one we describe.37
Furthermore, the 3 disability measures used in this study are not highly correlated with psychiatric symptoms, suggesting that disability and psychiatric symptoms are separate constructs. Von Korff et al37 arrived at similar conclusions while investigating the association of the MOS survey short form disability questions to depressive symptoms as measured by the General Health Questionnaire.63
Finally, we are in the process of conducting a prospective study of this sample of Bosnian refugees returning home because cross-sectional data cannot show how risk factors such as torture, trauma events, and demographic status (eg, age) interact with psychiatric symptoms and disability, respectively, over time.
AUTHOR INFORMATION
| |
Funding/Support: This study was supported by grant MH57806-02 from the National Institute of Mental Health, Bethesda, Md, and by cooperative agreement DHR-0016-A-00-5055-00 between the US Agency for International Development, Washington, DC, and Harvard University, Cambridge, Mass.
Acknowledgment: We acknowledge the enormous contribution of the Ruke professionals and interviewers, many themselves refugees, who made the data collection possible: Merjema Pa ali , MD; Vesna Dominis, MD; Nevenka Veri; Sanja Zeli; Saida Cerimagi; Nezira Huzejrovi; Nihada Islamovi; Sena Serdar; and Na a Mulabdi. We also acknowledge the additional contribution of social workers employed in the refugee camps: Andrea Bobek, Maja Ani, Kristina Jakopovi, Josip Marjanovi, and Melanija Hasnak.
Corresponding Author and Reprints: Richard F. Mollica, MD, MAR, Harvard Program in Refugee Trauma, 8 Story St, Third Floor, Cambridge, MA 02138 (e-mail: rmollica{at}hprt.harvard.edu).
Author Affiliations: Harvard Program in Refugee Trauma, Harvard Medical School, Boston, Mass (Dr Mollica, and Messrs McInnes and Lavelle); Ruke (Drs N. Sarajli and I. Sarajli); University of Zagreb Medical School (Dr N. Sarajli), Zagreb, Croatia; and the Picker Institute, Boston, Mass (Dr Massagli).
REFERENCES
1. World Bank Group. The World Bank Group Countries: Bosnia and Herzegovina. 1998. Available at: http://www.worldbank.org/html/extdr/offrep/eca/ba2.htm. Accessed March 25, 1999.
2. US Committee for Refugees. World Refugee Statistics: World Refugee Survey 1997. Washington, DC: Immigration and Refugee Services of America; 1997.
3. DeGirolamo G, McFarlane AC. The epidemiology of PTSD. In: Marsella AJ, Friedman MJ, Gerrity ET, Scurfield RM, eds. Ethnocultural Aspects of Posttraumatic Stress Disorder. Washington, DC: American Psychological Association; 1996:33-85.
4. Mollica RF, Poole C, Tor S. Symptoms, functioning and health problems in a massively traumatized population. In: Dohrenwend BP, ed. Adversity, Stress and Psychopathology. New York, NY: Oxford University Press; 1998:34-51.
5. Carlson EB, Rosser-Hogan R. Trauma experiences, posttraumatic stress, dissociation, and depression in Cambodian refugees. Am J Psychiatry. 1991;148:1548-1551.
FREE FULL TEXT
6. Mollica RF, Wyshak G, Lavelle J. The psychosocial impact of war trauma and torture on Southeast Asian refugees. Am J Psychiatry. 1987;144:1567-1572.
FREE FULL TEXT
7. Kroll J, Habenicht M, Mackenzie T, et al. Depression and posttraumatic stress disorder in Southeast Asian refugees. Am J Psychiatry. 1989;146:1592-1597.
FREE FULL TEXT
8. Kinzie DJ, Boehnlein J, Leung P, Moore L, Riley C, Smith B. The prevalence of posttraumatic stress disorder and its clinical significance among Southeast Asian refugees. Am J Psychiatry. 1990;147:913-917.
FREE FULL TEXT
9. Favaro A, Maiorani M, Colombo G, Santonastaso P. Traumatic experiences, posttraumatic stress disorder and dissociative symptoms in a group of refugees from former Yugoslavia. J Nerv Ment Dis. 1999;187:306-308.
FULL TEXT
|
ISI
| PUBMED
10. Thulesius H, Hakansson A. Screening for posttraumatic stress disorder symptoms among Bosnian refugees. J Trauma Stress. 1999;12:167-174.
FULL TEXT
|
ISI
| PUBMED
11. Drozdek B. Follow-up study of concentration camp survivors from Bosnia-Herzegovina: three years later. J Nerv Ment Dis. 1997;185:690-694.
FULL TEXT
|
ISI
| PUBMED
12. Dahl S, Mutapcic A, Schei B. Traumatic events and predictive factors for posttraumatic symptoms in displaced Bosnian women in a war zone. J Trauma Stress. 1998;11:137-145.
FULL TEXT
|
ISI
| PUBMED
13. Murray CJL, Lopez AD. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability From Diseases, Injuries and Risk Factors in 1990 and Projected to 2020. Cambridge, Mass: Harvard University Press; 1996.
14. Wells KB, Golding JM, Burnam MA. Psychiatric disorder and limitations in physical functioning in a sample of the Los Angeles general population. Am J Psychiatry. 1988;145:712-717.
FREE FULL TEXT
15. Hurry J, Sturt E. Social performance in a population sample: relation to psychiatric symptoms. In: Wing JK, Bebbington P, Robins LN, eds. What is a Case? London, England: Grant McIntyre; 1981:202-213.
16. Mintz J, Mintz LI, Arruda MJ, Hwang SS. Treatments of depression and the functional capacity to work. Arch Gen Psychiatry. 1992;49:761-768.
FREE FULL TEXT
17. Ormel J, Von Korff M, Ustun B, Pini S, Korten A, Oldehinkel T. Common mental disorders and disability across cultures. JAMA. 1994;272:1741-1748.
FREE FULL TEXT
18. Harvard Program in Refugee Trauma. Major Findings of Ruke Phase I. Cambridge, Mass: Harvard Program in Refugee Trauma; 1996.
19. Flaherty JA, Gaviria FM, Pathak D, Mitchell T, Wintrob R, Richman JA. Developing instruments for cross-cultural psychiatric research. J Nerv Ment Dis. 1988;176:257-263.
ISI
| PUBMED
20. Westermeyer J. Psychiatric diagnosis across cultural boundaries. Am J Psychiatry. 1985;142:798-805.
FREE FULL TEXT
21. Mollica RF, Caspi-Yavin Y, Bollini P, Truong T, Tor S, Lavelle J. The Harvard Trauma Questionaire. J Nerv Ment Dis. 1992;180:111-116.
ISI
| PUBMED
22. Rasmussen OV. Medical aspects of torture. Dan Med Bull. 1984;37:1-88.
23. Mollica RF, Wyshak G, Khoun F, Lavelle J. Indochinese versions of the Hopkins Symptom Checklist-25. Am J Psychiatry. 1987;144:497-500.
FREE FULL TEXT
24. Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika. 1951;16:297-334.
FULL TEXT
|
ISI
25. Mollica RF, Donelan K, Tor S, et al. The effect of trauma and confinement on functional health and mental health status of Cambodians living in Thailand-Cambodia border camps. JAMA. 1993;270:581-586.
FREE FULL TEXT
26. Shrestha NM, Sharma B, Ommermen MV, et al. Impact of torture on refugees displaced within the developing world. JAMA. 1998;280:443-448.
FREE FULL TEXT
27. Mollica RF, Caspi-Yavin Y. Measuring torture and torture-related symptoms. Psychol Assess. 1991;3:1-7.
28. Rasekh Z, Bauer HM, Manos MM, Iacopino V. Women's health and human rights in Afghanistan. JAMA. 1998;280:449-455.
FREE FULL TEXT
29. Gorst-Unsworth C, Goldenberg E. Psychological sequelae of torture and organised violence suffered by refugees from Iraq. Br J Psychiatry. 1998;172:90-94.
FREE FULL TEXT
30. Sinnerbrink I, Silove D, Field A, Steel Z, Manicavasagar V. Compounding of premigration trauma and postmigration stress in asylum seekers. J Psychol. 1997;131:463-470.
ISI
| PUBMED
31. Fawzi MCS, Murphy E, Pham T, Lin L, Poole C, Mollica RF. The validity of screening for posttraumatic stress disorder and major depression among Vietnamese former political prisoners. Acta Psychiatr Scand. 1997;95:87-93.
ISI
| PUBMED
32. Caspi-Yavin Y. The Psychiatric and Functional Impact of Refugee Trauma. Boston, Mass: Harvard University Press; 1995.
33. Mellinger G, Balter M, Uhlenhuth E, Cisin I, Manheimer D, Rickels K. Evaluating a household survey measure of psychic distress. Psychol Med. 1983;13:607-622.
ISI
| PUBMED
34. Uhlenhuth E, Balter M, Mellinger G, Cisin I, Clinthorne J. Symptom checklist syndromes in the general population. Arch Gen Psychiatry. 1983;40:1167-1173.
FREE FULL TEXT
35. Ware JE Jr, Sherbourne CD. The MOS 36-item short form health survey (SF-36), I: conceptual framework and item selection. Med Care. 1992;30:473-483.
ISI
| PUBMED
36. Stewart AL, Hays RD, Ware JE Jr. The MOS Short-form General Health Survey: reliability and validity in a patient population. Med Care. 1988;26:724-732.
ISI
| PUBMED
37. Von Korff M, Ustun TB, Ormel J, Kaplan I, Simon GE. Self-report disability in an international primary care study of psychological illness. J Clin Epidemiol. 1996;49:297-303.
FULL TEXT
|
ISI
| PUBMED
38. World Health Organization. International Classification of Impairments, Disabilities, and Handicaps. Geneva, Switzerland: World Health Organization; 1980.
39. Idler EL, Kasl S. Health perceptions and survival: do global evaluations of health status really predict mortality? J Gerontol. 1991;2:55-65.
40. Mollica RF, Caspi-Yavin Y, Lavelle J, et al. The Harvard Trauma Questionnaire (HTQ) Manual: Cambodian, Laotian, and Vietnamese versions. Torture Quarterly: Journal on Rehabilitation of Torture Victims and Prevention of Torture. 1996;(suppl 1):19-42.
41. SAS/STAT. User's Guide. 4th ed. Version 6.11. Cary, NC: SAS Institute Inc; 1989.
42. Lemeshow S, Hosmer DW. A review of goodness-of-fit statistics for use in the development of logistic regression models. Am J Epidemiol. 1982;115:92-106.
FREE FULL TEXT
43. Bleich A, Koslowski M, Dolev A, Lorer B. PTSD and depression: an analysis of comorbidity. Br J Psychiatry. 1997;170:479-482.
FREE FULL TEXT
44. Solomon Z, Neria Y, Ohry A, Waysman M, Ginsburg K. PTSD among Israeli former prisoners of war and soldiers with combat stress reaction: a longitudinal study. Am J Psychiatry. 1994;151:554-559.
ABSTRACT
45. Basoglu M, Paker M, Ozmen E, Tasdemir O, Sahin D. Factors related to long-term traumatic stress responses in survivors of torture in Turkey. JAMA. 1994;272:357-363.
FREE FULL TEXT
46. Goldfeld A, Mollica RF, Pesavento B, Faraone S. The physical and psychological sequelae of torture. JAMA. 1988;259:2725-2729.
FREE FULL TEXT
47. Mollica RF, Poole C, Tor S. The dose-effect relationships of trauma to symptoms of depression and posttraumatic stress disorder among Cambodian survivors of mass violence. Br J Psychiatry. 1998;173:482-488.
FREE FULL TEXT
48. Weine SM, Becker DF, McGlashan TH, et al. Psychiatric consequences of "ethnic cleansing." Am J Psychiatry. 1995;152:536-542.
FREE FULL TEXT
49. Jankovic S, Stivicevic V, Dodig G, Biocic M, Stajner I, Primorac D. Psychological characteristics of wounded and disabled Croatian war veterans. Mil Med. 1998;163:331-336.
ISI
| PUBMED
50. Mollica RF, McInnes K, Pham T, Fawzi MCS, Murphy E, Lin L. Dose-effect relationships between torture and psychiatric symptoms in Vietnamese ex-political detainees and a comparison group. J Nerv Ment Dis. 1998;186:543-553.
FULL TEXT
|
ISI
| PUBMED
51. Holtz T. Refugee trauma versus torture trauma. J Nerv Ment Dis. 1998;186:24-34.
FULL TEXT
|
ISI
| PUBMED
52. Havelka M, Lucanin JD, Lucanin D. Psychological reactions to war stressors among elderly displaced persons in Croatia. Croat Med J. 1995;36:262-265.
53. Jenkins JH. Not without a trace. Psychiatry. 1997;60:40-43.
ISI
| PUBMED
54. Reynell J. Political Pawns: Refugees on the Thai-Kampuchean Border. Oxford, England: Refugee Studies Program; 1989.
55. Engdahl B, Dikel TN, Eberly R, Blank A. Comorbidity and course of psychiatric disorders in a community sample of former prisoners of war. Am J Psychiatry. 1998;155:1740-1745.
FREE FULL TEXT
56. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the Natinoal Comorbidity Survey. Arch Gen Psychiatry. 1995;52:1048-1060.
FREE FULL TEXT
57. Helzer JE, Robins LN, McEvoy L. Post-traumatic stress disorder in the general population. N Engl J Med. 1987;317:1630-1634.
ABSTRACT
58. Davidson JRT, Hughes D, Blazer DG. Post-traumatic stress disorder in the community: an epidemiological study. Psychol Med. 1991;21:713-721.
ISI
| PUBMED
59. Kulka RA, Schlenger WE, Fairbank JA, et al. National Vietnam Veterans Readjustment Study (NVVRS): Description, Current Status, and Initial PTSD Prevalence Estimates. Final Report. Washington, DC: Veterans Affairs; 1988.
60. Skodol AE, Schwartz S, Dohrenwend BP, Levav I, Shrout PE, Reiff M. PTSD symptoms and comorbid mental disorders in Israeli war veterans. Br J Psychiatry. 1996;169:717-725.
FREE FULL TEXT
61. Ware JE Jr, Snow KK, Kosinski M, Grandek B. SF-36 Health Survey. Boston, Mass: The Health Institute, New England Medical Center; 1993.
62. Willis GB. Methodological issues in the use of survey questionnaires to assess the health effects of torture. J Nerv Ment Dis. 1998;186:283-289.
FULL TEXT
|
ISI
| PUBMED
63. Goldberg D, Williams P. A User's Guide to the General Health Questionnaire. Windsor, England: NFEF/Nelson; 1988.
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
RELATED LETTERS
Mental Health Among Bosnian Refugees
James C. Coyne, Ashraf Kagee, Arsad A. Karcic, and Edin Karcic
JAMA. 2000;283(1):55-56.
EXTRACT
| FULL TEXT
Factors Associated With Poor Mental Health Among Guatemalan Refugees Living in Mexico 20 Years After Civil Conflict
Miriam Sabin, Barbara Lopes Cardozo, Larry Nackerud, Reinhard Kaiser, and Luis Varese
JAMA. 2003;290(5):635-642.
ABSTRACT
| FULL TEXT
RELATED ARTICLES
War and Health: From Solferino to Kosovo—The Evolving Role of Physicians
Vincent Iacopino and Ronald J. Waldman
JAMA. 1999;282(5):479-481.
EXTRACT
| FULL TEXT
August 4, 1999
JAMA. 1999;282(5):497-498.
EXTRACT
| FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Post-traumatic stress reactions among Rwandan children and adolescents in the early aftermath of genocide
Neugebauer et al.
Int J Epidemiol 2009;38:1033-1045.
ABSTRACT
| FULL TEXT
Increased gender-based violence among women internally displaced in Mississippi 2 years post-Hurricane Katrina.
Anastario et al.
dmphp 2009;3:18-26.
ABSTRACT
| FULL TEXT
Factors associated with the health status of internally displaced persons in northern Uganda
Roberts et al.
J. Epidemiol. Community Health 2009;63:227-232.
ABSTRACT
| FULL TEXT
Estimating Clinically Relevant Mental Disorders in a Rural and an Urban Setting in Postconflict Timor Leste
Silove et al.
Arch Gen Psychiatry 2008;65:1205-1212.
ABSTRACT
| FULL TEXT
Complex Sequelae of Psychological Trauma Among Kosovar Civilian War Victims
Morina and Ford
Int J Soc Psychiatry 2008;54:425-436.
ABSTRACT
Difficulties and Coping Strategies of Sudanese Refugees: A Qualitative Approach
Khawaja et al.
Transcultural Psychiatry 2008;45:489-512.
ABSTRACT
Posttraumatic Stress Disorder Following Ethnoreligious Conflict in Jos, Nigeria
Obilom and Thacher
J Interpers Violence 2008;23:1108-1119.
ABSTRACT
Prevalence of Posttraumatic Stress Disorder in a Coastal Fishing Village in Tamil Nadu, India, After the December 2004 Tsunami
Kumar et al.
AJPH 2007;97:99-101.
ABSTRACT
| FULL TEXT
Mental health problems among adults in tsunami-affected areas in southern Thailand.
van Griensven et al.
JAMA 2006;296:537-548.
ABSTRACT
| FULL TEXT
Psychological Distress among Recent Russian Immigrants in the United States
Hoffmann et al.
Int J Soc Psychiatry 2006;52:29-40.
ABSTRACT
Post-Traumatic Stress Symptoms, Language Acquisition, and Self-Sufficiency: A Study of Bosnian Refugees
Corvo and Peterson
Journal of Social Work 2005;5:205-219.
ABSTRACT
The Impact of Comorbid Posttraumatic Stress Disorder on Short-Term Clinical Outcome in Hospitalized Patients With Depression
Holtzheimer et al.
Am. J. Psychiatry 2005;162:970-976.
ABSTRACT
| FULL TEXT
The Making and Breaking of Yugoslavia and Its Impact on Health
Kunitz
AJPH 2004;94:1894-1904.
ABSTRACT
| FULL TEXT
Burden of Medical Illness in Women With Depression and Posttraumatic Stress Disorder
Frayne et al.
Arch Intern Med 2004;164:1306-1312.
ABSTRACT
| FULL TEXT
Household Survey of Psychiatric Morbidity in Cambodia
Dubois et al.
Int J Soc Psychiatry 2004;50:174-185.
ABSTRACT
War on the Couch: The Emotionology of the New International Security Paradigm
Pupavac
European Journal of Social Theory 2004;7:149-170.
ABSTRACT
The psychological and social situation of repatriated and exiled refugees: a longitudinal, comparative study
Lie
Scand J Public Health 2004;32:179-187.
ABSTRACT
The Mandinka Nosological System in the Context of Post-Trauma Syndromes
Fox
Transcultural Psychiatry 2003;40:488-506.
ABSTRACT
Psychiatric Disability Among Tortured Bhutanese Refugees in Nepal
Thapa et al.
Am. J. Psychiatry 2003;160:2032-2037.
ABSTRACT
| FULL TEXT
Factors Associated With Poor Mental Health Among Guatemalan Refugees Living in Mexico 20 Years After Civil Conflict
Sabin et al.
JAMA 2003;290:635-642.
ABSTRACT
| FULL TEXT
Group Interpersonal Psychotherapy for Depression in Rural Uganda: A Randomized Controlled Trial
Bolton et al.
JAMA 2003;289:3117-3124.
ABSTRACT
| FULL TEXT
Mental health of Kosovan Albanian refugees in the UK
TURNER et al.
Br. J. Psychiatry 2003;182:444-448.
ABSTRACT
| FULL TEXT
Towards a Researcher-Advocacy Model for Asylum Seekers: A Pilot Study Amongst East Timorese Living in Australia
Silove et al.
Transcultural Psychiatry 2002;39:452-468.
ABSTRACT
A 46-Year-Old Man With Anxiety and Nightmares After a Motor Vehicle Collision
Stein
JAMA 2002;288:1513-1521.
FULL TEXT
Unforeseen Consequences of Terrorism: Medically Unexplained Symptoms in a Time of Fear
Hassett and Sigal
Arch Intern Med 2002;162:1809-1813.
FULL TEXT
Measuring Trauma and Health Status in Refugees: A Critical Review
Hollifield et al.
JAMA 2002;288:611-621.
ABSTRACT
| FULL TEXT
Torture Assessment and Treatment: The Wraparound Approach
Kira
Traumatology 2002;8:54-86.
ABSTRACT
Predicting Posttraumatic Distress in Hospitalized Trauma Survivors With Acute Injuries
Zatzick et al.
Am. J. Psychiatry 2002;159:941-946.
ABSTRACT
| FULL TEXT
Discrepancies in autobiographical memories--- implications for the assessment of asylum seekers: repeated interviews study
Herlihy et al.
BMJ 2002;324:324-327.
ABSTRACT
| FULL TEXT
Posttraumatic Stress, Problem Drinking, and Functional Outcomes After Injury
Zatzick et al.
Arch Surg 2002;137:200-205.
ABSTRACT
| FULL TEXT
Longitudinal Study of Psychiatric Symptoms, Disability, Mortality, and Emigration Among Bosnian Refugees
Mollica et al.
JAMA 2001;286:546-554.
ABSTRACT
| FULL TEXT
Lifetime Events and Posttraumatic Stress Disorder in 4 Postconflict Settings
de Jong et al.
JAMA 2001;286:555-562.
ABSTRACT
| FULL TEXT
Traumatic Life Events in Primary Care Patients: A Study in an Ethnically Diverse Sample
Holman et al.
Arch Fam Med 2000;9:802-810.
ABSTRACT
| FULL TEXT
Social, Cultural, and Clinical Dimensions of Traumatic Experiences of Primary Care Patients
Palinkas
Arch Fam Med 2000;9:812-813.
FULL TEXT
The Not-So-Silent Marks of Torture
Moreno and Grodin
JAMA 2000;284:538-538.
FULL TEXT
Health Care of Torture Survivors
Piwowarczyk et al.
JAMA 2000;284:539-541.
FULL TEXT
Mental Health, Social Functioning, and Attitudes of Kosovar Albanians Following the War in Kosovo
Cardozo et al.
JAMA 2000;284:569-577.
ABSTRACT
| FULL TEXT
Mental Health and Nutritional Status Among the Adult Serbian Minority in Kosovo
Salama et al.
JAMA 2000;284:578-584.
ABSTRACT
| FULL TEXT
Policies of Deterrence and the Mental Health of Asylum Seekers
Silove et al.
JAMA 2000;284:604-611.
ABSTRACT
| FULL TEXT
Psychiatric help for survivors of torture
Turner
Adv. Psychiatr. Treat. 2000;6:295-303.
FULL TEXT
Mental Health Among Bosnian Refugees
Coyne et al.
JAMA 2000;283:55-56.
FULL TEXT
Health and human rights in contemporary humanitarian crises: is Kosovo more important than Sierra Leone?
Salama et al.
BMJ 1999;319:1569-1571.
FULL TEXT
War and Health: From Solferino to Kosovo--The Evolving Role of Physicians
Iacopino and Waldman
JAMA 1999;282:479-481.
FULL TEXT
What Can We Do About Violence?
Cole and Flanagin
JAMA 1999;282:481-483.
FULL TEXT
|
din Refugee Camps, Croatia, 1996 (n = 533)*