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Richard F. Mollica, MD, MAR; Keith McInnes, MS; Narcisa Sarajli, MD, PhD; James Lavelle, MSW; Iris Sarajli, MD; Michael P. Massagli, PhD

JAMA. 1999;282:433-439.

Context  The relationship between psychiatric symptoms and disability in refugee survivors of mass violence is not known.

Objective  To determine if risk factors, such as demographics, trauma, health status, and psychiatric illness, are associated with disability in Bosnian refugees.

Design, Setting, and Participants  Cross-sectional survey conducted in 1996 of Bosnian refugee adults living in a camp established by the Croatian government near the city of Varadin. One adult aged 18 years or older was randomly selected from each of 573 camp families; 534 (93%) agreed to participate (mean age, 50 years; 41% male).

Main Outcome Measures  Culturally validated measures for depression and posttraumatic stress disorder (PTSD) included the Hopkins Symptom Checklist 25 and the Harvard Trauma Questionnaire, respectively. Disability measures included the Medical Outcomes Study Short-Form 20, a physical functioning scale based on World Health Organization criteria, and self-reports of socioeconomic activity, levels of physical energy, and perceived health status.

Results  Respondents reported a mean (SD) of 6.5 (4.7) unduplicated trauma events; 18% (n=95) had experienced 1 or more torture events. While 55.2% reported no psychiatric symptoms, 39.2% and 26.3% reported symptoms that meet DSM-IV criteria for depression and PTSD, respectively; 20.6% reported symptoms comorbid for both disorders. A total of 25.5% reported having a disability. Refugees who reported symptoms comorbid for both depression and PTSD were associated with an increased risk for disability compared with asymptomatic refugees (unadjusted odds ratio [OR], 5.02; 95% confidence interval [CI], 3.05-8.26; adjusted OR, 2.06; 95% CI, 1.10-3.86). Older age, cumulative trauma, and chronic medical illness were also associated with disability.

Conclusions  In a population of Bosnian refugees who had recently fled from the war in Bosnia and Herzegovina, psychiatric comorbidity was associated with disability independent of the effects of age, trauma, and health status.

Author Affiliations: Harvard Program in Refugee Trauma, Harvard Medical School, Boston, Mass (Dr Mollica, and Messrs McInnes and Lavelle); Ruke (Drs N. Sarajli and I. Sarajli); University of Zagreb Medical School (Dr N. Sarajli), Zagreb, Croatia; and the Picker Institute, Boston, Mass (Dr Massagli).

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