[Prishtina-E] JAMA: Mental Health, Social Functioning, and Attitudes of Kosovar Albanians Following the War in Kosovo (Vol. 284 No. 5, August 2, 2000)

[Uk Lushi]

>JAMA - Journal of the American Medical Association
>Vol. 284 No. 5, August 2, 2000
>
>Mental Health, Social Functioning, and Attitudes of Kosovar Albanians
>Following the War in Kosovo
>
>Barbara Lopes Cardozo, MD, MPH; Alfredo Vergara, PhD; Ferid Agani, MD;
>Carol A. Gotway, PhD
>
>Context
>The 1998-1999 war in Kosovo had a direct impact on large numbers of
>civilians. The mental health consequences of the conflict are not known.
>
>Objectives
>To establish the prevalence of psychiatric morbidity associated with the
>war in Kosovo, to assess social functioning, and to identify vulnerable
>populations among ethnic Albanians in Kosovo.
>
>Design, Setting, and Participants
>Cross-sectional cluster sample survey conducted from August to October
>1999 among 1358 Kosovar Albanians aged 15 years or older in 558 randomly
>selected households across Kosovo.
>
>Main Outcome Measures
>Nonspecific psychiatric morbidity, posttraumatic stress disorder (PTSD)
>symptoms, and social functioning using the General Health Questionnaire
>28 (GHQ-28), Harvard Trauma Questionnaire, and the Medical Outcomes
>Study Short-Form 20 (MOS-20), respectively; feelings of hatred and a
>desire for revenge among persons surveyed as addressed by additional
>questions.
>
>Results
>Of the respondents, 17.1% (95% confidence interval [CI], 13.2%-21.0%)
>reported symptoms that met Diagnostic and Statistical Manual of Mental
>Disorders, Fourth Edition criteria for PTSD; total mean score on the
>GHQ-28 was 11.1 (95% CI, 9.9-12.4). Respondents reported a high
>prevalence of traumatic events. There was a significant linear decrease
>in mental health status and social functioning with increasing amount of
>traumatic events (P.02 for all 3 survey tools). Populations at increased
>risk for psychiatric morbidity as measured by GHQ-28 scores were those
>aged 65 years or older (P = .006), those with previous psychiatric
>illnesses or chronic health conditions (P<.001 for both), and those who
>had been internally displaced (P = .009). Populations at risk for poorer
>social functioning were living in rural areas (P = .001), were
>unemployed (P = .046) or had a chronic illness (P = .01). Respondents
>scored highest on the physical functioning and role functioning
>subscales of the MOS-20 and lowest on the mental health and social
>functioning subscales. Eighty-nine percent of men and 90% of women
>reported having strong feelings of hatred toward Serbs. Fifty-one
>percent of men and 43% of women reported strong feelings of revenge; 44%
>of men and 33% of women stated that they would act on these feelings.
>
>Conclusions
>Mental health problems and impaired social functioning related to the
>recent war are important issues that need to be addressed to return the
>Kosovo region to a stable and productive environment.
>
>JAMA. 2000;284:569-577
>
>
>In late February 1998, clashes in Kosovo between Serbian police forces
>and members of the Kosovo Liberation Army intensified.1 Serbian forces
>burned homes and killed dozens of ethnic Albanians in these raids. As a
>result of the fighting, thousands of ethnic Albanians were displaced
>from their homes in Kosovo; many took refuge with host families, while a
>smaller proportion (several thousands) fled to the hills and forests.1
>By the time North Atlantic Treaty Organization (NATO) operations began
>against Serbia on March 24, 1999, about 260,000 people had been
>displaced within Kosovo and 199,000 had fled to other countries.2 It is
>estimated that as result of this conflict, more than 800,000 people
>became refugees in neighboring countries (mainly Albania, Montenegro,
>and the former Yugoslav Republic of Macedonia), as well as secondary
>countries of asylum in Europe, the United States, and elsewhere. On June
>9, 1999, an agreement between NATO and Serbia was reached, and the
>following day NATO halted its bombing campaign.
>      As the Serbian troops began to pull out of Kosovo, the nearly
>750,000 Albanians from Kosovo who had been living in refugee camps in
>Albania, Macedonia, and Montenegro began to return to Kosovo.2 On their
>return, the displaced Albanians had to come to terms with the
>destruction of their homes and property, missing family members, and the
>traumatic experiences of violence, rape, and persecution. The full
>psychological impact of such emergency situations is a neglected issue.3
>However, recent epidemiological studies in Bosnia4 and studies among
>Cambodian refugees living on the Thai border5 and in the United States
>have shown that psychiatric morbidity is much higher in populations that
>have experienced war, persecution, and mass violence.6, 7
>      To estimate the prevalence of psychiatric morbidity and to identify
>specific vulnerable populations, the Centers for Disease Control and
>Prevention (CDC) and the Institute of Mental Health and Recovery in
>Kosovo, in collaboration with Doctors of the World, conducted a mental
>health survey among ethnic Albanians in Kosovo from August 20 to October
>7, 1999. The survey focused on the period of August 1998 through August
>1999, when most of the intense violence took place.
>
>
>METHODS
>
>Survey Design
>
>Assuming a true prevalence of 20% of mental health-related problems8 and
>a cluster sample design effect of 2, we estimated that a minimum of 1135
>adults aged 15 years or older would be required for a 95% confidence
>interval (CI) to detect a prevalence between 15% and 25%. On the basis
>of available household size and age distribution, we estimated that a
>minimum of 504 households would need to be surveyed. The number of
>households targeted was increased to 600 to compensate for refusals and
>absent adults and to obtain estimates for various subgroups of the
>population.
>      We conducted a 2-stage, 30-cluster sample survey using the 1991
>Kosovo census as a primary sampling frame. Because these data did not
>reflect population movements before and during the ethnic conflict,
>additional data sources were used to adjust the 1991 population figures.
>These sources were village surveys from the United Nations High
>Commissioner for Refugees and food distribution population estimates
>from Action Against Hunger (a nongovernmental organization), both
>reflecting information collected during the weeks before our survey. The
>primary sampling frame consisted of all villages and cities listed in
>the 1991 census, excluding those that were predominantly populated by
>Serbs (70% Serb population) and those that had a population of less than
>100 Albanian inhabitants. The sampling frame was stratified into urban
>(cities with a population >10,000) and rural areas. Using this sampling
>frame, we estimated the total ethnic Albanian population in Kosovo to be
>1.6 million. With probability proportional to population size, we
>selected 15 clusters from the rural and 15 from the urban frame in the
>first sampling stage. In the second stage of sampling, 20 households
>were randomly selected within each chosen cluster (20 households from
>each of 30 clusters for a total of 600 households) using an appropriate
>method designed for the Expanded Programme on Immunization and adapted
>to the particular field conditions.9
>      Identification of cluster samples differed for urban centers and
>rural villages. No maps were available for the villages, and many
>villages were spread out over a large geographic area. We drew maps of
>each cluster, which were then divided into segments of approximately
>equal populations. We then randomly chose a single segment by first
>numbering all segments and then blindly drawing a segment number from a
>bag containing all numbers. In the cities, Kosovo Force (KFOR) offices
>usually had aerial or other maps available. In these cases, we
>superimposed a grid to partition the map into neighborhoods. The
>neighborhoods were numbered, and then a number was blindly chosen to
>randomly select a neighborhood for our survey.
>      After a segment or neighborhood was chosen, the first household to
>be surveyed was chosen randomly as follows. Households were mapped and
>numbered in a random direction from the center to the edge of the
>segment, chosen by spinning a bottle. The first household was chosen by
>blindly drawing a number from a bag using the same method described
>above. The next house was selected to be the closest house to the left,
>as the interviewer exited the house just surveyed. This process was
>repeated until 20 households were surveyed, or until the team leader
>decided it was time to leave for security reasons.
>      We interviewed all adult members of the household present. To
>ensure as much privacy as possible, we encouraged people to complete the
>questionnaires in separate rooms, and men and women interviewers paired
>up with same-sex interviewees to help them complete the questionnaires.
>A security curfew at dusk imposed by KFOR prevented interview teams from
>coming back to survey adults not present during the day. Because of the
>ongoing threat of land mines, KFOR considered access to some remote
>houses unsafe. These homes had to be excluded from our sample and
>replaced by the closest accessible household.
>      Native Kosovar Albanian survey team members had 3 days of training
>on general survey objectives, safety precautions, procedures for proper
>household selection (including randomly selecting the first household
>and handling special situations), and interviewing techniques
>(understanding the questionnaires and addressing sensitive topics). All
>members of the survey team were closely supervised for the first 2 days,
>and they continued to receive daily supervision and instruction until
>the survey was completed. Interviewers were instructed to refer
>participants who appeared to be in obvious distress to community mental
>health services where available. A list of these services was procured
>from the nongovernmental organization coordinating office at the United
>Nations Mission in Kosovo.
>      The study protocol was reviewed by a CDC institutional review board
>representative and informed consent was obtained verbally from all
>participants (with communication occurring in the potential
>participant's native language). The study protocol was also reviewed by
>Doctors of the World for ethical considerations.
>
>Screening Tools
>
>All instruments used in this survey were designed as self-report
>questionnaires, but because of a high percentage of illiteracy,
>especially in rural areas, questionnaires frequently had to be read
>aloud. Because of the need for expediency in collecting data,
>interviewers were instructed to read the questionnaires only to those
>who were illiterate, and to provide assistance if needed to those who
>completed the questionnaire themselves. We used 3 screening tools to
>assess mental health problems and social dysfunction: the General Health
>Questionnaire-28 (GHQ-28),10, 11 the Harvard Trauma Questionnaire
>(HTQ),12 and the Medical Outcomes Study 20 (MOS-20).13 We chose these
>instruments to obtain information on common, nonspecific psychiatric
>problems, to gather information on specific psychiatric syndromes such
>as posttraumatic stress disorder (PTSD) and related traumatic events,
>and to get a broad understanding of the level of social functioning and
>disability in this population.
>      The GHQ-28 is used as a community screening tool and for the
>detection of nonspecific psychiatric disorders among individuals in
>primary care settings.11 A higher mean score on the GHQ-28 represents
>poorer mental health status (score range, 0-28). The GHQ-28 is composed
>of 4 subscales (score range, 1-7): somatization, anxiety, social
>dysfunction, and depression. The HTQ combines the measurement of trauma
>events (part I) and symptoms of PTSD (part II), selected from the
>Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).14 We
>defined the occurrence of PTSD symptoms according to a scoring algorithm
>proposed by the Harvard Refugee Trauma Group,4, 12 on the basis of
>DSM-IV diagnostic criteria. The MOS-20 consists of 20 items on 6
>different scales that assess physical functioning, bodily pain, role
>functioning, social functioning, mental health, and self-perceived
>general health status. We scored the MOS-20 as recommended in the user's
>manual; each raw score was transformed to fit a 0-to-100 scale using a
>standard formula,13, 15 with the higher scores on this scale
>representing better functioning. All 3 tools have been extensively
>validated in many countries and cultures and in many disease
>settings.16-18
>      To assess the effect of broadly defined demographic characteristics
>on mental health status, we collected demographic information including
>age, sex, education level, and marital status. We added additional
>questions specific to the Kosovar Albanian population on feelings of
>hatred and a desire for revenge. All questionnaires were translated into
>Albanian and back-translated to English to ensure cultural
>appropriateness of the instrument and accuracy of the translation. A
>team of Albanian translators including a psychiatrist, a psychologist,
>and a primary care physician from the Institute for Mental Health and
>Recovery did the translation and adaptation of the screening tools.
>
>Data Analysis
>
>We adjusted prevalence estimates and CIs for cluster sampling and
>stratification using Epi Info version 6.4.19 Regression analyses were
>performed using SUDAAN, release 7.5.2 (Research Triangle Institute,
>Research Triangle Park, NC). For continuous variables, we used
>multivariate linear regression models to assess the effects of exposure
>on outcome and multivariate logistic regression models to analyze
>dichotomous outcomes. When the exposure variable had more than 2 levels
>(eg, displacement), we made multiple comparisons of the responses
>between pairs of the different levels using single df contrasts. When
>the exposure variable had a natural ordering (eg, age, education, number
>of traumatic events), we did a test for linear trend. All P values were
>derived from adjusted Wald F tests based on these regression models, and
>P<.05 was considered statistically significant. All analyses were
>adjusted for stratification and the clustered design, and were weighted
>to account for unequal selection probabilities among the individual
>respondents.
>
>
>RESULTS
>
>Characteristics of Survey Participants
>
>A total of 558 households, consisting of 1358 adults aged 15 years or
>older, were included in the survey (mean [SD] household size for all
>ages, 7.3 [3.5] persons). This is smaller than the target number of 600
>households since logistical and time constraints prevented the
>completion of 20 surveys in some villages. However, 558 households is
>still greater than the 504 households deemed needed from sample size
>calculations.
>      Demographic characteristics are summarized in Table 1. Of the
>adults surveyed, 62.3% were women, 55.8% lived in a rural area, 59.5%
>had completed only primary school or less, 67.3% were married, and only
>15.1% were currently employed. Nearly 41% of participants reported
>having a chronic illness (diagnosis by a medical professional of
>hypertension, diabetes, cardiovascular disease, kidney disease, asthma,
>epilepsy, cancer, or major injury such as loss of a limb), and 1.7%
>reported having received a diagnosis by a physician of a previous mental
>illness, such as schizophrenia or bipolar disorder, before the conflict.
>      The exposure to traumatic events, including displacement, is
>summarized in Table 2. High percentages of respondents reported having
>personally experienced traumatic events. For example, 66.6% reported
>being deprived of water and food, 66.5% reported being in a combat
>situation, and 61.6% reported being close to death. Furthermore, 39.4%
>of participants reported experiencing 8 or more of the traumatic events
>listed; 56.2% had fled to another country as refugees during the past
>year, 25.6% had been internally displaced within Kosovo, and only 18.2%
>remained in their homes during the war. In all analyses, the traumatic
>events were equally weighted since we had no resources for in-depth
>questioning needed to provide additional information.
>
>Mental Health and Social Functioning
>
>Estimated mean scores on the GHQ-28 and the MOS-20 and the prevalence of
>PTSD symptoms from the HTQ are shown in Table 3, along with 95% CIs
>adjusted for stratification and cluster design effects. These figures
>represent estimates of the population indicator measured by each test
>for the adult Albanian population living in Kosovo at the time of this
>survey.
>      For the GHQ-28, the estimated mean total score based on a possible
>28 questions was 11.1 (95% CI, 9.9-12.4). A higher mean score signifies
>a greater number of symptoms. The mean scores for somatic symptoms and
>for anxiety and insomnia were higher compared with the mean scores for
>social dysfunction and depression.
>      The estimated MOS-20 mean scores are shown on a scale of 1 to 100,
>with a higher score representing better functioning. In general,
>respondents tended to score highest on physical functioning and role
>functioning and lowest on the mental health and social functioning
>components (Table 3). We compared scores on the MOS-20 with scores of a
>US general population14, 20, 21 (data for the Albanian Kosovo population
>before the conflict are not available). The mean scores for mental
>health (29.6) and social functioning (29.5) were strikingly lower for
>the Kosovar Albanians than for the US population (74.7 and 83.3,
>respectively). However, there were no great differences between the 2
>populations in the measures of general health, physical functioning,
>bodily pain, and role functioning. The estimated prevalence of PTSD
>symptoms in this population of Kosovar Albanians was 17.1% (95% CI,
>13.2%-21.0%).
>
>Feelings of Hatred and Revenge
>
>Questions regarding hatred toward the Serbs and desire for revenge
>revealed that high percentages of both men and women (>88% among each)
>had strong feelings of hatred, defined as a response of "extreme hatred"
>(men, 60% [n = 288]; women, 55% [n = 464]) or "a lot of hatred" (men,
>29% [n = 142]; women, 35% [n = 271]). The proportions of people having
>strong feelings of revenge were lower (> 43% for both men and women),
>but still very high. Strong feelings of revenge were defined as a
>response of feeling revenge "all the time" (men, 35% [n = 159]; women,
>23% [n = 192]) or "a lot of the time" (men, 16% [n = 92]; women, 20% [n
>= 166]). Of those men and women who had feelings of revenge ("all the
>time," "a lot of the time," or "sometimes"), 44.2% of men (n = 177) and
>33.3% of women (n = 197) said they would definitely act on those
>feelings, and only 17.3% of men (n = 71) and 26.2% of women (n = 184)
>said they would not act on those feelings.
>
>Univariate Statistical Analysis
>
>Table 4 summarizes the univariate analysis of the effect of selected
>demographic factors and exposure to trauma on the mental health and
>social functioning outcomes. We present the results of the GHQ-28 total
>score, estimated prevalence of PTSD symptoms, and MOS-20 social function
>scale as outcome measures in relation to various demographic and trauma
>experience measures. P<.05 was considered significant for univariate and
>multivariate analyses. Being older, being currently unemployed, being
>widowed, having little education, reporting a previously diagnosed
>psychiatric illness, and reporting a previous diagnosis of a chronic
>health condition were associated in this analysis with a high (eg,
>worse) GHQ-28 score, indicating nonspecific psychiatric morbidity.
>Similarly, living in a rural setting, being currently unemployed, being
>older, having little education, and reporting having received a
>diagnosis of a chronic health condition were associated with a low (eg,
>worse) social functioning score. Finally, HTQ results indicate that
>being female and having received a diagnosis of a chronic health
>condition were associated with PTSD symptoms.
>      Most traumatic event variables (forced separation from family,
>murder of family or friend, and increasing number of traumatic events)
>but not rape were associated with a worse score in the 3 measured mental
>health outcomes, with the exception of forced separation for social
>functioning. The association between rape and psychiatric morbidity and
>social functioning may be difficult to observe here because of the
>relatively small number of reported rape cases.
>
>Multivariate Statistical Analyses
>
>Since we had identified 2 different groups of explanatory variables,
>demographic and exposure, we treated these differently using a
>multivariate analysis. First, the effect of each demographic variable on
>the mental health outcomes was adjusted for all other variables, both
>demographic and exposure (Table 5).
>      Subpopulations at risk (statistically significant as measured by
>the multivariate analyses) for psychiatric morbidity as measured by
>GHQ-28 scores were those aged 65 years or older, those with previous
>psychiatric illnesses, and those with self-reported chronic health
>problems. In the multivariate analysis, employment, location, sex,
>marital status, and education were not statistically significant risk
>factors for psychiatric morbidity. Subpopulations at risk for poor
>social functioning, as measured by the MOS-20, were people living in
>rural areas, those currently unemployed, and those with chronic health
>problems. There was no significant decrease in social functioning with
>increasing age or education status when adjusted for all other
>variables. Women and persons with a previous psychiatric illness had a
>significantly higher estimated prevalence of PTSD symptoms.
>      To analyze the effect of exposure variables on mental health
>outcomes, we performed a second multivariate analysis for which all P
>values for the relationship between each exposure variable and each
>outcome measure were adjusted for all demographic variables, previous
>psychiatric illness, and chronic health condition (Table 6). People who
>were internally displaced tended to have higher total GHQ-28 scores than
>refugees (P = .03) or those who did not move (P = .009). However, there
>was no significant difference in the total GHQ-28 scores between
>refugees and those who did not move (P = .50), and the displacement
>seemed to have no effect on significance for MOS-20 social functioning
>scores or the prevalence of PTSD symptoms, when adjusted for the effects
>of the demographic variables.
>      There was a significant linear increase in total GHQ-28 scores
>(P<.001), a significant linear decrease in MOS-20 social functioning
>scores (P = .02), and a significant linear increase in the prevalence of
>PTSD symptoms (P<.001) with increasing numbers of trauma events (Table
>6). Specific traumatic events seemed to be closely related to specific
>mental health conditions. People experiencing forced separation from
>family or murder of a family member or friends had significantly higher
>total GHQ-28 scores and significantly higher prevalence of PTSD symptoms
>than people without these experiences. People experiencing murder of a
>family member or friend also had significantly lower MOS-20 social
>functioning scores.
>      A rape experience seemed to have no effect on GHQ-28 scores, MOS-20
>social functioning, or prevalence of PTSD symptoms, although, as stated
>earlier, a relationship may be difficult to observe due to the
>relatively small number of reported rape cases.
>
>
>COMMENT
>
>There was a high prevalence of traumatic events (Table 2) among the
>Kosovar Albanians, and large numbers appear to have experienced multiple
>traumas. Higher levels of PTSD symptoms, an increase in nonspecific
>mental morbidity as measured by the GHQ-28, and a decrease in social
>functioning were associated with higher levels of cumulative trauma.
>These relationships remained even after adjusting for the effects of
>demographic variables, previous psychiatric illness, and other chronic
>health conditions. Our results are consistent with those of other
>studies.22-24 Although the 4 subscales of the GHQ-28 provide information
>on types of symptoms, they have not been designed to make a psychiatric
>diagnosis. They do, however, give information on the mean scores for
>somatic, anxiety, social dysfunction, and severe depression symptoms
>(Table 3). It has been shown in other studies that the 4 subscales are
>not independent from each another.11 In our study, the mean scores for
>somatic symptoms and anxiety and insomnia were higher than those for
>social dysfunction and severe depression. It is possible that in this
>culture depression is more likely to be expressed as somatic and anxiety
>symptoms. Alternatively, despite the traumatic events experienced by
>many people by the time of the survey, there may have been a genuine
>sense of hope and optimism because the war had ended, and people were
>rebuilding their homes, lives, and country.
>      The optimal threshold score to determine prevalence of psychiatric
>morbidity from the GHQ-28 has not been established for this population.
>Although we found that the GHQ-28 was well accepted and easy to
>administer, the interpretation of the results for prevalence estimates
>is not straightforward unless an optimal cutoff score is established for
>the specific population. Goldberg et al25 have suggested that a mean
>score will provide a rough guide to the best threshold; however, this
>would always result in a general psychiatric morbidity prevalence of
>approximately 50%. Adopting a similar method with a conservative cutoff
>score of 11/12 out of 28 (so that those answering positively to 12
>questions would be considered a "case"), we found an estimated
>prevalence of nonspecific psychiatric morbidity of 43%. In studies of
>general populations in 15 different countries, the highest cutoff score
>found was 6/7.26-28 However, no cutoff scores have been published for
>refugee populations or those recently exposed to war, where it is likely
>that the prevalence of nonspecific psychiatric morbidity is much higher
>than in general populations.
>      A similar type of cutoff score is needed to estimate the prevalence
>of psychiatric morbidity using the MOS-20 in refugee populations. In the
>US population, a cutoff score of 52 (range, 0-100) was established based
>on studies of the relationship between mental health and clinical
>measures of the probability of any psychiatric disorder.13 Using the
>same cutoff score for the Kosovo population would result in an estimated
>prevalence of psychiatric disorder of 83.5% vs 13.2% in the US
>population.20 Further clinical validation of the GHQ-28 and the MOS-20
>is under way to establish the best thresholds for the Kosovar
>population. The estimated prevalence of PTSD symptoms (17.1%) is
>somewhat lower than the reported PTSD figures (26.3%) for Bosnian
>refugees living in Croatia.4
>      The findings from the GHQ-28, MOS-20, and HTQ confirm earlier
>anecdotal reports that while the general health status of the Kosovo
>population remained fairly stable, mental problems related to the war
>situation are common. This is in line with other findings in refugee
>camps and war/conflict situations.3-7 No baseline general mental health
>status data from before the war are available for Kosovo. However, in
>our survey, self-reporting of previous mental illness (1.7%) correlated
>with findings in other populations.29
>      We identified several subpopulations at risk for poor mental health
>status and social functioning and we also attempted to identify
>mitigating factors. In general, Kosovar Albanians younger than 35 years
>old, in good physical health, and without previous psychiatric illness
>appear to have been protected from war-related psychiatric morbidity.
>Future research will have to determine whether there are other
>protective factors that could be influenced by policy (eg, adequate
>housing, social and community support). Social functioning was
>significantly lower among the population in rural areas; however,
>location did not seem to have the same effect on general mental health.
>It is possible that the extensive disruption of the civic infrastructure
>in the rural areas made it harder to function socially than in cities,
>but closer family ties in these areas mitigated mental health problems.
>Not unexpectedly, people with previous psychiatric illness had worse
>mental health outcomes, including higher levels of PTSD symptoms, than
>did those without such illness. Similarly, indication of a previously
>diagnosed chronic health condition was associated with general
>psychiatric morbidity and social functioning but not PTSD.
>      As measured by the GHQ-28 scores, people who were internally
>displaced had worse mental health status than did refugees and those who
>never moved. In fact, a subsequent analysis revealed that on the
>average, those who did not move experienced a mean (SE) of 5.36 (0.53)
>traumatic events, while refugees experienced an average of 6.87 (0.33)
>and those internally displaced an average of 8.02 (0.56). This
>difference was statistically significant (P = .01). Virtually all people
>who were internally displaced were being persecuted, and as a result of
>this suffered continuous trauma. People who became refugees faced
>similar traumatic events, but usually of shorter duration because they
>were able to escape to other countries. It can be hypothesized that
>people who never moved away from their homes were able to stay because
>they happened to be in relatively safer areas and thus experienced less
>trauma.
>      There are a number of limitations to this study. Women were
>overrepresented in our sample probably because they were more likely to
>be at home during the daytime (data from other sources30 indicate that
>the male-female ratio in Kosovo is close to 1). People who were employed
>during the time of the survey were less likely to be home during the
>day. Because of security curfews it was not possible to return to homes
>and interview those who were absent during the day. There is a
>possibility that some people who were the most stressed, because they
>were living in the most dangerous areas, were excluded from our study.
>However, if at all, this exclusion happened very seldom and would have
>resulted in underreporting of mental morbidity. Our study might be
>somewhat limited in statistical power since resources were available to
>sample only 30 clusters. However, the potential reduction in statistical
>power may have been moderated by the use of a stratified design.
>      Because no structured clinical interviews were performed, it is
>unclear to what extent self-reported symptoms of PTSD and nonspecific
>psychiatric morbidity, in the HTQ and the GHQ-28 respectively, would
>match clinical diagnosis. It is possible that cross-cultural differences
>could have influenced the results of this study. Even though the
>screening instruments used were created and validated in developed
>nations similar to Kosovo, the instruments were not specifically
>validated for this society. However, the GHQ-28 has proven to be a
>reliable instrument in a wide variety of cultures. The HTQ traumatic
>events section was specifically adapted for the Kosovo situation.
>      Although not traditionally part of a mental health survey, the
>questions regarding feelings of hatred and a desire for revenge give a
>poignant picture of all-too-common emotions in this setting. These
>findings underscore the challenge faced by the interim government of the
>United Nations Mission in Kosovo as it to seeks to establish
>reconciliation among different ethnic groups.
>
>
>CONCLUSIONS
>
>Whether measured by the prevalence of nonspecific psychiatric morbidity
>(43%), social dysfunction, or prevalence of PTSD symptoms (17.1%), our
>study demonstrates the severity of mental health problems among Kosovar
>Albanians.
>      When we conducted this survey the war had just ended. The wounds of
>war were still fresh, including the events that had shaken the lives of
>hundreds of thousands of people. Violence and acts of revenge continue
>in Kosovo. On the basis of the results of our survey, these incidents
>are not surprising. Mental health problems related to the psychological
>trauma of war and conflict situations are a major public health concern.
>The high rates of poor mental health status among those internally
>displaced and refugees who have returned to Kosovo also raises concern
>for the mental health status of those who remain in countries of asylum
>and resettlement.
>      Until the psychological and social effects of the war and
>persecution in Kosovo are evaluated over time, we must exercise caution
>in basing future predictions on the results of our survey. Follow-up
>studies and monitoring of mental health problems to determine long-term
>effects of multiple, prolonged, and severe traumatic events among the
>Kosovar Albanian population will provide more accurate data for policy
>recommendations.
>
>
>Author/Article Information
>
>Author Affiliations: National Center for Environmental Health,
>International Emergency and Refugee Health Branch (Dr Lopes Cardozo),
>National Center for Infectious Diseases, Division of Quarantine (Dr
>Vergara), and National Center for Environmental Health, Environmental
>Hazards and Health Effects (Dr Gotway), Centers for Disease Control and
>Prevention, Atlanta, Ga; and Institute for Mental Health and Recovery,
>Pristina, Kosovo (Dr Agani).
>
>Corresponding Author and Reprints: Barbara Lopes Cardozo, MD, MPH,
>National Center for Environmental Health, Centers for Disease Control
>and Prevention, 4770 Buford Hwy NE, Mailstop F-48, Atlanta, GA 30341
>(e-mail: bhc8 at cdc.gov).
>
>Funding/Support: This study was supported by funds from the Centers for
>Disease Control and Prevention.
>
>Acknowledgment: We acknowledge the enormous contribution and logistic
>support of Doctors of the World, in particular Supriya Madhavan, who
>provided us with invaluable insights into the Kosovo situation. We also
>acknowledge the contributions of the interviewers, many of whom
>themselves had been refugees or internally displaced during the war, who
>made the data collection possible. We also acknowledge the contribution
>of mental health staff from the Institute of Mental Health and Recovery
>in Pristina, Kosovo. The Harvard Program in Refugee Trauma gave us
>invaluable advice, particularly by Richard Mollica, MD, MAR; James
>Lavelle, MSW; and Keith McInnes, MS, who shared their extensive clinical
>and research expertise in this field.
>
>
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>© 2000 American Medical Association. All rights reserved.
>

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