Dean Ajduković

Psychological well-being of refugee children.

Two groups of refugee families participated in a program aimed at preventing childrens mental health problems. The program attempted to gain insight into the character and scope of problems of refugee families and to develop and implement a spectrum of interventions that would meet their specific psychological needs. Data about the family situation and the psychosocial adaptation of refugee children to displacement was gathered during detailed structured interviews with the mothers, while the study families were accommodated either in a shelter or with host families. A considerable range of stress-related reactions among displaced children were identified (e.g., sleeping and eating disorders, separation fears, and withdrawal or aggression). Refugee children exhibited a significantly higher incidence of stress reactions if their mothers had difficulty coping with the stress of displacement. The findings also indicated that children in the collective shelter were at greater mental health risk than their peers housed with host families.

Mental Disorders Following War in the Balkans: A Study in 5 Countries

CONTEXT War experience may affect mental health. However, no community-based study has assessed mental disorders several years after war using consistent random sampling of war-affected people across several Western countries. OBJECTIVES To assess current prevalence rates of mental disorders in an adult population who were directly exposed to war in the Balkans and who still live in the area of conflict, and to identify factors associated with the occurrence of different types of mental disorders. DESIGN, SETTING, AND PARTICIPANTS War-affected community samples in Bosnia-Herzegovina, Croatia, Kosovo, the Republic of Macedonia, and Serbia were recruited through a random-walk technique. MAIN OUTCOME MEASURE Prevalence rates of mood, anxiety, and substance use disorders were assessed using the Mini-International Neuropsychiatric Interview. RESULTS Between 637 and 727 interviewees were assessed in each country (N = 3313). The prevalence rates were 15.6% to 41.8% for anxiety disorders, 12.1% to 47.6% for mood disorders, and 0.6% to 9.0% for substance use disorders. In multivariable analyses across countries, older age, female sex, having more potentially traumatic experiences during and after the war, and unemployment were associated with higher rates of mood and anxiety disorders. In addition, mood disorders were correlated with lower educational level and having more potentially traumatic experiences before the war. Male sex and not living with a partner were the only factors associated with higher rates of substance use disorders. Most of these associations did not significantly differ among countries. CONCLUSIONS Several years after the end of the war, the prevalence rates of mental disorders among war-affected people vary across countries but are generally high. War experiences appear to be linked to anxiety and mood disorders but not substance use disorders. Long-term policies to meet the mental health needs of war-affected populations are required.

Factors associated with mental disorders in long-settled war refugees: refugees from the former Yugoslavia in Germany, Italy and the UK

BACKGROUND Prevalence rates of mental disorders are frequently increased in long-settled war refugees. However, substantial variation in prevalence rates across studies and countries remain unexplained. AIMS To test whether the same sociodemographic characteristics, war experiences and post-migration stressors are associated with mental disorders in similar refugee groups resettled in different countries. METHOD Mental disorders were assessed in war-affected refugees from the former Yugoslavia in Germany, Italy and the UK. Sociodemographic, war-related and post-migration characteristics were tested for their association with different disorders. RESULTS A total of 854 war refugees were assessed (≥ 255 per country). Prevalence rates of mental disorders varied substantially across countries. A lower level of education, more traumatic experiences during and after the war, more migration-related stress, a temporary residence permit and not feeling accepted were independently associated with higher rates of mood and anxiety disorders. Mood disorders were also associated with older age, female gender and being unemployed, and anxiety disorders with the absence of combat experience. Higher rates of post-traumatic stress disorder (PTSD) were associated with older age, a lower level of education, more traumatic experiences during and after the war, absence of combat experience, more migration-related stress, and a temporary residence permit. Only younger age, male gender and not living with a partner were associated with substance use disorders. The associations did not differ significantly across the countries. War-related factors explained more variance in rates of PTSD, and post-migration factors in the rates of mood, anxiety and substance use disorder. CONCLUSIONS Sociodemographic characteristics, war experiences and post-migration stressors are independently associated with mental disorders in long-settled war refugees. The risk factors vary for different disorders, but are consistent across host countries for the same disorders.

My Neighbor, My Enemy: Attitudes toward justice and social reconstruction in Bosnia and Herzegovina and Croatia

In this study we examined the factors that may contribute to or prevent the rebuilding of war-torn societies, based on two surveys of attitudes and beliefs of the inhabitants of three cities – Vukovar, Mostar and Prijedor – in 2000 and 2002. The main goals of our study were: to investigate some of the underlying attitudes and beliefs of the population of Mostar, Prijedor and Vukovar toward the rebuilding of community and reconciliation. The total sample of the survey consisted of 1624 participants, divided equally among national groups in each city. The questionnaire consisted of 68 items and contained three scales and questions about attitudes toward nationalism and xenophobia, other national groups, reconciliation, the ICTY and war crimes, as well as questions about prior experience with members of the other national groups, traumatic experiences during the war and demographic data. The results suggest that authoritarianism, nationalism and ethnocentrism may be the most important obstacles to the process of reconciliation among ethnic groups in target communities. An important finding is that the level of traumatic experience by itself is not a significant predictor of reconciliation. However, when combined with negative experience with opposing group trauma becomes a serious obstacle. The relationship between trauma and the attitudes towards ICTY trials is even less clear, and the role of the ICTY in promoting reconciliation is far from being perceived as accomplished.

Social Contexts of Trauma and Healing

The social contexts in which the mass trauma of thousands of people occur and in which their recovery should progress have qualities that distinguish it in important ways from individualised trauma in which a person is a victim of a violent attack, rape or a traffic accident. Organised violence, such as wars, oppression by dictatorships and massive terrorist attacks are extreme cases in which hundreds or thousands of people are exposed to trauma in a short period of time. As such, it has multiple consequences that extend beyond the affected individuals and the symptoms they suffer. Although the symptoms may be similar, the social contexts in which individual victimisation and exposure to organised violence happen are very different. The social milieu in which the survivors of individual trauma and survivors of mass trauma are embedded is likewise different, with important consequences for recovery. Understanding the social context of the trauma helps create the right social intervention for healing at social and personal levels.

Experience of human rights violations and subsequent mental disorders - a study following the war in the Balkans.

War experiences are associated with substantially increased rates of mental disorders, particularly Post-Traumatic Stress Disorder (PTSD) and Major Depression (MD). There is limited evidence on what type of war experiences have particularly strong associations with subsequent mental disorders. Our objective was to investigate the association of violations of human rights, as indicated in the 4th Geneva Convention, and other stressful war experiences with rates of PTSD and MD and symptom levels of intrusion, avoidance and hyperarousal. In 2005/6, human rights violations and other war experiences, PTSD, post-traumatic stress symptoms and MD were assessed in war affected community samples in five Balkan countries (Bosnia-Herzegovina, Croatia, Kosovo, Macedonia, and Serbia) and refugees in three Western European countries (Germany, Italy, United Kingdom). The main outcome measures were the MINI International Neuropsychiatric Interview and the Impact of Event Scale-Revised. In total 3313 participants in the Balkans and 854 refugees were assessed. Participants reported on average 2.3 rights violations and 2.3 other stressful war experiences. 22.8% of the participants were diagnosed with current PTSD and also 22.8% had MD. Most war experiences significantly increased the risk for both PTSD and MD. When the number of rights violations and other stressful experiences were considered in one model, both were significantly associated with higher risks for PTSD and were significantly associated with higher levels of intrusion, avoidance and hyperarousal. However, only the number of violations, and not of other stressful experiences, significantly increased the risk for MD. We conclude that different types of war experiences are associated with increased prevalence rates of PTSD and MD more than 5 years later. As compared to other stressful experiences, the experience of human rights violations similarly increases the risk of PTSD, but appears more important for MD.

Caught between the ethnic sides: Children growing up in a divided post-war community:

The war-related process of disintegration of a highly integrated and multi-ethnic community is described using a series of studies done in the city of Vukovar (Croatia) as a case example. After analyzing the key points of the community social breakdown , the three roots of ongoing ethnic division are explored: the feelings of being betrayed by important others at life-important situations; massive suffering and traumatization; and lack of compassion and acknowledgment of the victimhood. These also influence the inner dynamic of the divided community in which the strong social norm is not to cross the ethnic lines in public. When the schools became divided after the war so that the Serb and Croat children started going to separate schools, opportunity to meet each other across the ethnic lines became and remained severely limited. The implications for children that grow up in an ethnically divided community are documented in a study of childrens and parental inter-ethnic attitudes and behaviors. The study included 1,671 students aged 12 to 16 and their parents. It showed that the children had more out-group biases and negative attitudes, and were more likely to choose discriminative behaviors towards their peers from the ether ethnic group. Consequences for the future community inter-ethnic relations in the post-war societies and life limitations the children face are discussed.

Long-term impact of war on healthcare costs: an eight-country study.

Objective Exposure to war can negatively affect health and may impact on healthcare costs. Estimating these costs and identifying their predictors is important for appropriate service planning. We aimed to measure use of health services in an adult population who had experienced war in the former-Yugoslavia on average 8 years previously, and to identify characteristics associated with the use and costs of healthcare. Method War-affected community samples in Bosnia-Herzegovina, Croatia, Kosovo, FYR Macedonia, and Serbia were recruited through a random walk technique. Refugees in Germany, Italy and the UK were contacted through registers, organisations and networking. Current service use was measured for the previous three months and combined with unit costs for each country for the year 2006/7. A two-part approach was used, to identify predictors of service use with a multiple logistic regression model and predictors of cost with a generalised linear regression model. Results 3,313 participants were interviewed in Balkan countries and 854 refugees in Western European countries. In the Balkan countries, traumatic events and mental health status were related to greater service use while in Western countries these associations were not found. Participants in Balkan countries with post traumatic stress disorder (PTSD) had costs that were 63% higher (p = 0.005) than those without PTSD. Distress experienced during the most traumatic war event was associated with higher costs (p = 0.013). In Western European countries costs were 76% higher if non-PTSD anxiety disorders were present (0.027) and 63% higher for mood disorders (p = 0.006). Conclusions War experiences and their effects on mental health are associated with increased health care costs even many years later, especially for those who stayed in the area of conflict. Focussing on the mental health impact of war is important for many reasons including those of an economic nature.

My Neighbor, My Enemy: Trust and betrayal in war

In 2002 we set out the study to examine how loss of trust and feeling of betrayal among the participants influenced openness to social reconstruction and readiness for reconciliation after the war and the return of Vukovar to Croatian authority. We conducted an interview study of forty-eight Croat and Serb residents of the city, from three age categories and three levels of education. A major criterion for recruiting a person for the study was that he/she must have had close friends from the other ethnic group before the war and that their relationship has been severed or seriously threatened due to war. Our study shows that distrust and betrayal have paralyzed ethnic relations in Vukovar. A way to move forward could be to create a community-based programs that targeted those former friends who are willing, at the minimum, to meet and talk. Such a program could help former friends, and possibly groups of old friends and acquaintances, by providing them with a safe environment where the risk of emotional rejection would be minimal. Key to the success of the program would be the extent to which both sides would be willing to acknowledge and apologize for past crimes committed in their name, even if the scale of such abuses vary greatly. Any program developed in Vukovar to help re-unite former friends and acquaintances will need to emphasize the need for participants to recognize and respect the losses suffered my members of the other group. Along these lines, an intervention program aimed at facilitating dialogue between former friends and other community members could go a long way toward helping Vukovar on the path to recovery.

Co-occurrence of major depressive episode and posttraumatic stress disorder among survivors of war: how is it different from either condition alone?

OBJECTIVE Major depressive episode (MDE) and posttraumatic stress disorder (PTSD) have been shown to be the most common mental disorders following traumatic war experiences and have been found to frequently co-occur. This study, designed as a randomized cross-sectional interview survey, aimed to identify whether the co-occurence of MDE and PTSD following exposure to war-related experiences is associated with different demographics, exposure to previous traumatic events, and clinical characteristics than either condition alone. METHOD After a random-walk technique was used to randomly select participants, face-to-face interviews were conducted among war-affected community samples in 5 Balkan countries (N = 3,313) in the years 2006 and 2007. The mean age of participants was 42.3 years, and all participants had experienced potentially traumatic events during war in the countries of the former Yugoslavia. Current prevalence rates of MDE and PTSD and suicide risk were assessed using the Mini-International Neuropsychiatric Interview. Levels of general psychological distress, posttraumatic stress, and quality of life were assessed with self-reports. RESULTS 30.5% of the sample met DSM-IV diagnostic criteria for either MDE or PTSD, and 9.1% had both disorders. Participants with concomitant MDE and PTSD reported significantly higher numbers of prewar and postwar traumatic events than participants with PTSD only and higher numbers of war-related events than those with MDE only (all P values < .001). Participants with both MDE and PTSD had significantly higher levels of general psychological and posttraumatic stress symptoms, a higher suicide risk, and lower levels of quality of life than participants with either condition alone (all P values < .001). CONCLUSIONS Concomitant MDE and PTSD are associated with the experience of different traumatic events and are characterized by more general psychological distress than either condition alone. The assessment of concomitant MDE and PTSD can facilitate better identification of individuals with severe psychopathology and poor quality of life. People with co-occurrence of MDE and PTSD may require specific health care programs following war.