Nexhmedin Morina

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.

Post-traumatic stress disorder, social anxiety disorder, and depression in survivors of the Kosovo War: experiential avoidance as a contributor to distress and quality of life.

Few studies have been conducted on psychological disorders other than post-traumatic stress disorder (PTSD) in war survivors. The aim of this study was to examine PTSD, social anxiety disorder (SAD), and major depressive disorder (MDD) and their associations with distress and quality of life in 174 Albanian civilian survivors of the Kosovo War. This included testing of conceptual models suggesting that experiential avoidance might influence associations between anxiety and mood disorders with psychological functioning. Each of the three psychiatric disorders was associated with greater experiential avoidance and psychological distress, and lower quality of life. Being a refugee was associated with a higher likelihood of having SAD and MDD. We found evidence for experiential avoidance as a partial mediator of the respective effects of SAD and PTSD on quality of life; experiential avoidance did not mediate the effects of disorders on global distress. We also found support for a moderation model showing that only war survivors without SAD and low experiential avoidance reported elevated quality of life; people with either SAD or excessive reliance on experiential avoidance reported compromised, low quality of life. This is the third independent study, each using a different methodology, to find empirical support for this moderation model [Kashdan, T. B., & Breen, W. E. (2008). Social anxiety and positive emotions: a prospective examination of a self-regulatory model with tendencies to suppress or express emotions as a moderating variable. Behavior Therapy, 39, 1-12; Kashdan, T. B., & Steger, M. F. (2006). Expanding the topography of social anxiety: an experience sampling assessment of positive emotions and events, and emotion suppression. Psychological Science, 17, 120-128]. Overall, we provided initial evidence for the importance of addressing PTSD, SAD, MDD, and experiential avoidance in primarily civilian war survivors.

The efficacy of metacognitive therapy for anxiety and depression: a meta-analytic review

Metacognitive therapy (MCT) is a relatively new approach to treating mental disorders. The aim of the current meta‐analysis was to examine the efficacy of MCT in patients with mental disorders.

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.

Remission from Post-Traumatic Stress Disorder in adults : A systematic review and meta-analysis of long term outcome studies

Posttraumatic stress disorder (PTSD) is a frequent mental disorder associated with significant distress and high costs. We conducted the first systematic review and meta-analysis on spontaneous long-term remission rates, i. e., without specific treatment. Data sources were searches of databases, hand searches, and contact with authors. Remission estimates were obtained from observational prospective studies of PTSD without specific treatment. Remission was defined as the actual percentage of PTSD cases at baseline who are non-cases after a minimum of ten months. Forty-two studies with a total of 81,642 participants were included. The mean observation period was 40 months. Across all studies, an average of 44.0% of individuals with PTSD at baseline were non-cases at follow-up. Remission varied between 8 and 89%. In studies with the baseline within the first five months following trauma the remission rate was 51.7% as compared to 36.9% in studies with the baseline later than five months following trauma. Publications on PTSD related to natural disaster reported the highest mean of remission rate (60.0%), whereas those on PTSD related to physical disease reported the lowest mean of remission rate from PTSD (31.4%). When publications on natural disaster were used as a reference group, the only type of traumatic events to differ from natural disaster was physical disease. No other measured predictors were associated with remission from PTSD. Long-term remission from PTSD without specific treatment varies widely and is higher in studies with the baseline within five months following trauma.

Meta-analysis of psychological treatments for posttraumatic stress disorder in adult survivors of childhood abuse.

Posttraumatic stress disorder (PTSD) is highly prevalent in adult survivors of childhood sexual and/or physical abuse. However, intervention studies focusing on this group of patients are underrepresented in earlier meta-analyses on the efficacy of PTSD treatments. The current meta-analysis exclusively focused on studies evaluating the efficacy of psychological interventions for PTSD in adult survivors of childhood abuse. Sixteen randomized controlled trials meeting inclusion criteria could be identified that were subdivided into trauma-focused cognitive behavior therapy (CBT), non-trauma-focused CBT, eye movement desensitization and reprocessing, and other treatments (interpersonal, emotion-focused). Results showed that psychological interventions are efficacious for PTSD in adult survivors of childhood abuse, with an aggregated uncontrolled effect size of g=1.24 (pre- vs. post-treatment), and aggregated controlled effect sizes of g=0.72 (post-treatment, comparison to waitlist control conditions) and g=0.50 (post-treatment, comparison with TAU/placebo control conditions), respectively. Effect sizes remained stable at follow-up. As the heterogeneity between studies was large, we examined the influence of two a priori specified moderator variables on treatment efficacy. Results showed that trauma-focused treatments were more efficacious than non-trauma-focused interventions, and that treatments including individual sessions yielded larger effect sizes than pure group treatments. As a whole, the findings are in line with earlier meta-analyses showing that the best effects can be achieved with individual trauma-focused treatments.

Prolonged Grief Disorder, Depression, and Posttraumatic Stress Disorder Among Bereaved Kosovar Civilian War Survivors: a Preliminary Investigation

Background: This study aimed at examining diagnostic concordance between Prolonged Grief Disorder (PGD), Major Depressive Disorder (MDD), and Posttraumatic Stress Disorder (PTSD) among bereaved war survivors who had lost relatives due to war-related violence. Method: We investigated the rates of PGD and its association with PTSD and MDD among 60 bereaved people who had lost first-degree relatives due to war-related violence seven years ago and had also experienced other war-related events. Results: The results indicated that 38.3% of the sample fulfilled the criteria for PGD, 55.0% for PTSD, and 38.3% for MDD. Thirty per cent of the participants without PTSD and 21.6% of those without MDD met criteria for PGD. Women were more likely to have PGD than men. The immediate threat to life was significantly associated with an elevated risk for PTSD and MDD, but not PGD. Conclusion: The findings suggest that many cases of PGD would be missed by an exclusive focus on PTSD among bereaved war survivors.

Can virtual reality exposure therapy gains be generalized to real-life? : A meta-analysis of studies applying behavioral assessments

In virtual reality exposure therapy (VRET), patients are exposed to virtual environments that resemble feared real-life situations. The aim of the current study was to assess the extent to which VRET gains can be observed in real-life situations. We conducted a meta-analysis of clinical trials applying VRET to specific phobias and measuring treatment outcome by means of behavioral laboratory tests or recordings of behavioral activities in real-life. Data sources were searches of databases (Medline, PsycInfo, and Cochrane). We included in total 14 clinical trials on specific phobias. Results revealed that patients undergoing VRET did significantly better on behavioral assessments following treatment than before treatment, with an aggregated uncontrolled effect size of g = 1.23. Furthermore, patients undergoing VRET performed better on behavioral assessments at post-treatment than patients on wait-list (g = 1.41). Additionally, results of behavioral assessment at post-treatment and at follow-up revealed no significant differences between VRET and exposure in vivo (g = -0.09 and 0.53, respectively). Finally, behavioral measurement effect sizes were similar to those calculated from self-report measures. The findings demonstrate that VRET can produce significant behavior change in real-life situations and support its application in treating specific phobias.

Complex Sequelae of Psychological Trauma Among Kosovar Civilian War Victims

Aims: The impact of war trauma on civilians may include, but also extend beyond, post-traumatic stress disorder (PTSD) to include complex sequelae such as those described by the syndrome of Disorders of Extreme Stress Not Otherwise Specified (DESNOS). Methods: In the present study, 102 civilian war victims were interviewed in Kosovo, assessing traumatic life events, PTSD, DESNOS, and depression. Results: Full DESNOS rarely occurred (2% prevalence), however, clinically significant DESNOS symptoms of somatization, altered relationships, and altered systems of meaning were reported by between 24—42% of respondents. Although DESNOS symptoms were correlated with PTSD symptoms, DESNOS symptoms were associated with poorer overall psychological functioning, self-evaluations, satisfaction with life, and social support independent of the effects of PTSD. Conclusion: The findings suggest that DESNOS warrants attention in addition to PTSD in the assessment and treatment of civilians who have been exposed to war and genocide.

War and bereavement: Consequences for mental and physical distress

Background Little is known about the long-term impact of the killing of a parent in childhood or adolescence during war on distress and disability in young adulthood. This study assessed current prevalence rates of mental disorders and levels of dysfunction among young adults who had lost their father due to war-related violence in childhood or adolescence. Methods 179 bereaved young adults and 175 non-bereaved young adults were interviewed a decade after experiencing the war in Kosovo. Prevalence rates of Major Depressive Episode (MDE), anxiety, and substance use disorders, and current suicide risk were assessed using the Mini–International Neuropsychiatric Interview. The syndrome of Prolonged Grief Disorder (PGD) was assessed with the Prolonged Grief Disorder Interview (PG-13). Somatic symptoms were measured with the Patient Health Questionnaire. General health distress was assessed with the General Health Questionnaire. Findings Bereaved participants were significantly more likely to suffer from either MDE or any anxiety disorder than non-bereaved participants (58.7% vs. 40%). Among bereaved participants, 39.7% met criteria for Post-Traumatic Stress Disorder, 34.6% for PGD, and 22.3% for MDE. Bereaved participants with PGD were more likely to suffer from MDE, any anxiety disorder, or current suicide risk than bereaved participants without PGD. Furthermore, these participants reported significantly greater physical distress than bereaved participants without PGD. Conclusion War-related loss during middle childhood and adolescence presents significant risk for adverse mental health and dysfunction in young adulthood in addition to exposure to other war-related traumatic events. Furthermore, the syndrome of PGD can help to identify those with the greatest degree of distress and dysfunction.