Psychiatric and Cognitive Effects of War in Former Yugoslavia

CONTEXT: Although impunity for those responsible for trauma is widely thought to be associated with psychological problems in survivors of political violence, no study has yet investigated this issue. OBJECTIVE: To examine the mental health and cognitive effects of war trauma and how appraisal of redress for trauma and beliefs about justice, safety, other people, war cause, and religion relate to posttraumatic stress responses in war survivors. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional survey conducted between March 2000 and July 2002 with a population-based sample of 1358 war survivors who had experienced at least 1 war-related stressor (combat, torture, internal displacement, refugee experience, siege, and/or aerial bombardment) from 4 sites in former Yugoslavia, accessed through linkage sampling. Control groups at 2 study sites were matched with survivors on sex, age, and education. MAIN OUTCOME MEASURES: Semi-structured Interview for Survivors of War, Redress for Trauma Survivors Questionnaire, Emotions and Beliefs After War questionnaire, Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). RESULTS: The mean (SD) age was 39 (12) years, 806 (59%) were men, and 339 (25%) had high school or higher level of education. Participants reported experiencing a mean of 12.6 war-related events, with 292 (22%) and 451 (33%) having current and lifetime posttraumatic stress disorder (PTSD), respectively, and 129 (10%) with current major depression. A total of 1074 (79%) of the survivors reported a sense of injustice in relation to perceived lack of redress for trauma. Perceived impunity for those held responsible for trauma was only one of the factors associated with sense of injustice. Relative to controls, survivors had stronger emotional responses to impunity, greater fear and loss of control over life, less belief in benevolence of people, greater loss of meaning in war cause, stronger faith in God, and higher rates of PTSD and depression. Fear and loss of control over life were associated with PTSD and depression (odds ratio OR, 2.91; 95% CI, 2.27-3.74 and OR, 2.30; 95% CI, 1.75-3.03, respectively), and emotional responses to impunity showed a relatively weaker association with PTSD (OR, 1.53; 95% CI, 1.16-2.02) and depression (OR, 1.39; 95% CI, 1.02-1.91). Appraisal of redress for trauma was not associated with PTSD or depression. CONCLUSIONS: PTSD and depression in war survivors appear to be independent of sense of injustice arising from perceived lack of redress for trauma. Fear of threat to safety and loss of control over life appeared to be the most important mediating factors in PTSD and depression. These findings may have important implications for reconciliation efforts in postwar countries and effective interventions for traumatized war survivors.