Background

Stressful experiences occurring in war situations may lead to short-term and long-term mental disorders. A common feature of these disorders is posttraumatic stress disorder (PTSD); however, other problems such as depression, phobias, and addictive behaviour also frequently follow traumatic experiences. Despite significant publications on the epidemiology of PTSD in the community, systematic studies on long-term outcomes are rare and little is known about: a) the frequency of mental disorders in populations that have been exposed to war related stressful events ten or more years after the war, b) the social outcomes in these populations, and c) the predictors of more or less positive long-term outcomes.

Randomised controlled trials have provided evidence that specific psychological treatments, such as trauma focused cognitive-behavioural work and exposure, can be effective in alleviating symptoms of PTSD and preventing relapse. However, it has been argued that providing such treatments to people with war-related mental health distress - in particular refugees - is less important than offering them social and material support to rebuild their lives. This debate is of obvious relevance for health and social policies, but there has been hardly any systematic studies addressing the issue.

Treatment of people with posttraumatic stress is less successful once the symptoms have lasted for several years and become chronic. This patient group poses a special challenge to social and health services. Because of the lack of research evidence on what factors, if any, influence symptoms and quality of life in these patients, effective care is difficult to plan and deliver. As a consequence, the often severely distressed and persistently suffering patients are not only excluded from research studies, but also from receiving targeted interventions.

Against this background, the CONNECT study was carried out between 2003 and 2007, to assess mental health outcomes in people who experienced potentially traumatic events during the war in former Yugoslavia in the early 90s. This was the largest community-based epidemiological study assessing people directly exposed to war  that has been conducted several years after the war, included both civilians and refugees, and used consistent methods across eight countries: Croatia, Bosnia and Herzegovina, Serbia, Kosovo, FYR Macedonia, Germany, Italy and the United Kingdom.

Research questions

• What proportion of individuals who were directly exposed to stressful war-related events and who still live in a post-conflict area have mental disorders?
• What are the factors associated with the occurrence of different types of mental disorders in individuals who still live in post-conflict areas?
• What proportion of refugees who relocated to the Western countries have mental disorders?
• What are the factors associated with the occurrence of different types of mental disorders in refugees relocated to Western countries?
• What are the clinical and social outcomes, as well as health care costs of people with long-term war-related PTSD?
• What are the factors influencing change in people with long-term PTSD?
• What are the subjective health outcomes and costs of using health services and community based interventions in people with long-term PTSD?

Research activities

• 3313 participants from war-affected communities in Bosnia-Herzegovina, Croatia, Kosovo, the Republic of Macedonia, and Serbia were recruited and assessed with a structured psychiatric questionnaire. The use of health care services and community interventions was also recorded.
• 854 refugees based in Germany, Italy and the United Kingdom were assessed with a structured psychiatric questionnaire and their use of health care services and community interventions was recorded.
• A sub-sample of 522 participants with persistent PTSD were followed for one year and factors associated with change were assessed.

Conclusion

• Several years after the end of the war, the proportion of ar-affected people with mental disorders varies across countries but is generally high. War experiences and unemployment after war appear to be linked to anxiety and mood disorders but not substance use disorders.
• Sociodemographic characteristics, war experiences and postmigration stressors are independently associated with mental disorders in long-settled war refugees. The risk factors vary for different disorders, but are consistent across countries for the same disorders.
• Individuals with persistent PTSD reported significant symptom improvement after one year that might indicate a fluctuating course over time. Depression may have to be targeted in the treatment of people who remained in the post-conflict regions. The use of mental health services seems to be linked to the persistence of symptoms among refugees.

Staff

• Marija Bogic
• Ksenia Yeels
• Ljubica Ivanovic
• Arlinda Cerga
• Almir Kula

Associated papers

Priebe S, Bogic M, Ajdukovic D, Bremner S, Franciskovic T, Galeazzi GM, Kucukalic A, Lecic-Tosevski D, Morina N, Popovski M, Wang D, Schutzwohl M (2010) Mental disorders following war in the Balkans. Archives of General Psychiatry; 67: 518-28.

Bogic M, Ajdukovic D, Bremner S, Franciskovic T, Galeazzi GM, Kucukalic A, Lecic-Tosevski D, Morina N, Popovski M, Schutzwohl M, Wang D, Priebe S (2012) Factors associated with mental disorders in long-term settled war refugees: refugees from the former Yugoslavia in Germany, Italy, and the UK. The British Journal of Psychiatry; 200: 216-23.

Priebe S, Jankovic Gavrilovic J, Bremner S, Ajdukovic D, Franciskovic T, Neri G, Kucukalic A, Lecic-Tosevski D, Morina N, Popovski M, Schutzwohl M, Bogic M, Matanov A (2013) Course of post-traumatic stress disorder following war in the Balkans: 1-year follow-up study. Psychological Medicine; 43:1837- 47.

Priebe S, Bogic M, Ashcroft R, Franciskovic T, Galeazzi GM, Kucukalic A, Lecic-Tosevski D, Morina N, Popovski M, Roughton M, Schutzwohl M, Ajdukovic D (2010) Experience of human rights violations and subsequent mental disorders - a study following the war in the Balkans. Social Science and Medicine; 71: 2170-7.

Sabes-Figuera R, McCrone P, Bogic M, Ajdukovic D, Franciskovic T, Colombini N, Kucukalic A, Lecic-Tosevski D, Morina N, Popovski M, Wang D, Schutzwohl M, Priebe S (2012) Long-term impact of war on healthcare costs: an eight-country study. PLoS One; 7(1):e29603 doi: 10.1371/journal.pone.0029603.

Priebe S, Jankovic Gavrilovic J, Bremner S, Ajdukovic D, Franciskovic T, Galeazzi GM, Kucukalic A, Lecic-Tosevski D, Morina N, Popovski M, Schutzwohl M, Bogic M (2013) Psychological symptoms as long-term consequences of war experiences. Psychopathology; 46: 45-54.

Ajdukovic D, Ajdukovic D, Bogic M, Franciskovic T, Galeazzi GM, Kucukalic A, Lecic-Tosevski D, Schutzwohl M, Priebe S. (2013). Recovery from posttraumatic stress symptoms: a qualitative study of attributions in survivors of war. PLoS One 8(8):e70579, doi: 10.1371/journal.pone.0070579.

Funder

European Commission: Framework Programme 6