Background

Throughout the world several million people are affected by war every year. Posttraumatic stress disorder (PTSD) is a frequent consequence of war experience, although exact rates vary. Many people with serious and distressing levels of war-related PTSD do not receive psychiatric or psychological care despite the existence of evidence based treatments. Not much is known about their long term outcomes and barriers to care they may encounter in different contexts.

People with ongoing PTSD pose a challenge to health care services in war-affected regions, and there has been some debate on the most effective way to treat them. One approach is to establish specialized treatment centres where people with PTSD receive psychiatric treatment from experts who are both clinically qualified and familiar with the local context. However, questions arise about what outcomes the centres achieve in practice, which patients are likely to benefit more or less, and how much treatment costs. So far, there is little research evidence that can be used to answer these questions.

With this background, the STOP study was carried out between 2002 and 2006 to assess mental health outcomes of individuals who suffered from war-related post-traumatic stress but have not received or sought treatment, and to explore barriers they encountered. We also assessed outcomes of patients with war-related PTSD cared for in specialised treatment centres in post-conflict regions. The study was conducted in three countries affected by war in the early 90s: Bosnia-Herzegovina, Croatia, and Serbia, but also Germany and the UK as the countries with high number of refugees from this area.

Research questions

• What are the barriers to care in people suffering from posttraumatic stress who have not sought and not received treatment?
• What are long-term mental health outcomes in people suffering from posttraumatic stress who have not sought and not received treatment, and what kind of coping strategies they use?
• What outcomes in changes of symptoms, treatment satisfaction, social functioning and quality of life are to be expected in different sub-groups of patients who received care in specialised PTSD treatment centres?
• What baseline characteristics and treatment components are consistently associated with a more favourable outcome across treatment centres?
• What are the treatment and support costs for patients suffering from posttraumatic stress and how are costs linked to outcome?

Research activities

• In a cross-sectional study we assessed mental health outcomes, coping strategies and barriers to treatment in 264 individuals who had suffered from PTSD following the war in former Yugoslavia but have never sought or received psychiatric and psychological treatment. Participants included both refugees in Germany and the United Kingdom and those who stayed in post-war regions of Croatia, Serbia and Bosnia and Herzegovina.
• An observational study was conducted in four specialized PTSD treatment centres in Serbia, Croatia, and Bosnia-Herzegovina. Clinical outcomes, quality of life, social functioning and treatment costs were assessed in 426 consecutive adult patients with war-related PTSD. They were assessed prior to the beginning of treatment, after three and after 12 months.

Conclusion

• People with untreated war-related PTSD have a high risk of still being affected by PTSD a decade after the traumatic event. Their quality of life is relatively low, and they generate considerable care costs. More traumatic events, older age and lower education were associated with suffering from long-term PTSD.  While most participants, for a variety reasons, did not want to seek psychiatric treatment, a significant number, particularly in Western European countries, felt prevented from receiving treatment.
• The recovery rate among patients treated in specialised centers for war-related PTSD several years after the war was poor (14%), and symptom improvements were small. The recovery rate was not linked to service costs. Improving recovery rates might require different treatment methods or different service models.

Staff

• Prof. Stefan Priebe
• Aleksandra Matanov

Associated papers

Priebe S, Jankovic Gavrilovic J, Matanov A, Franciskovic T, Knezevic G, Ljubotina D, Mehmedbasic A, , Schutzwohl M, McCrone P (2010) Treatment Outcomes and Costs at Specialized Centers for the Treatment of PTSD After the War in Former Yugoslavia. Psychiatric Services, 61:598-604.

Priebe S, Matanov A, Jankovic Gavrilovic J, McCrone P, Ljubotina D, Knezevic G, Kucukalic A, Franciskovic T, Schutzwohl M (2009) Consequences of untreated posttraumatic stress disorder following war in former Yugoslavia: Morbidity, subjective quality of life, and care costs. Croatian Medical Journal, 50: 465-475.

Jankovic Gavrilovic J, Vidakovic I, Matanov A, Schutzwohl M, Ljubotina D, Lecic-Tosevski D, Priebe S (2011) Reasons for not receiving treatment in people with posttraumatic stress disorder following war. Journal of Nervous and Mental Disease, 199 (2):100-105.

Ljubotina D, Pantic Z, Franciskovic T, Mladic M, Priebe S (2007) Treatment Outcomes and Perception of Social Acknowledgment in WarVeterans: Follow-up Study. Croatian Medical Journal, 48:157-66.

Funder

European Commission: Framework Programme 5