Traumatic Stress Clinic, London
London
University of Manchester, Manchester, UK
Tirana Health Authority, Tirana, Albania
Institute of Psychiatry, London, UK
Correspondence: Dr Stuart W. Turner, Traumatic Stress Clinic, Camden and Islington Mental Health and Social Care Trust, 73 Charlotte Street, London WIT 4PL, UK. Tel: 020 7530 3666; fax: 020 7530 3677; e-mail: s.turner{at}traumaclinic.org.uk
Declaration of interest This work was undertaken with funding from the National Health Service (NHS) Executive London, Research and Development Programme. The views expressed in this publication are those of the authors and not necessarily those of the NHS Executive or the Department of Health.
See editorial, pp.
376378, this issue.
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ABSTRACT |
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Aims To determine the prevalence of mental health problems in this group.
Method A sample of 842 adults was surveyed. All were asked to complete self-report questionnaires (translated into Kosovan Albanian). A subset of 120 participants were later interviewed in Albanian using the Clinician Administered PTSD (post-traumatic stress disorder) Scale and a depression interview.
Results The study yielded estimates of prevalence of PTSD and depression. Self-report measures appear to overestimate the prevalence of these disorders. Just under half of the group surveyed had a diagnosis of PTSD and less than one-fifth had a major depressive disorder.
Conclusions These results may be taken as a sign of the resilience of many who survived this conflict but they also imply that there is still a substantial need for good health and social care in a significant proportion. Psychosocial interventions are likely to be an important part of the treatment programme.
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INTRODUCTION |
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METHOD |
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Self-report measures
A questionnaire pack was developed using Kosovan Albanian forms (developed
for this study) of the War Trauma Questionnaire
(Macksoud, 1992), the Beck
Depression Inventory (BDI; Beck,
1996), the Beck Anxiety Inventory (BAI;
Beck, 1987), the 28-item
General Health Questionnaire (GHQ28;
Goldberg & Hillier, 1979) and the Post-traumatic Diagnostic Scale (PDS;
Foa et al, 1997). Each
measure was translated and then back-translated to ensure that it was a
reasonable equivalent of the original. Where necessary, the self-report
questionnaires were read aloud (in Albanian) to respondents.
Interview validation
A subgroup of people who had completed the questionnaires were approached
subsequently and interview assessments were undertaken (February 2000 to June
2000). All interviews were conducted in Albanian by one of us (L.S.) using the
Clinician Administered PTSD (post-traumatic stress disorder) Scale (CAPS) for
DSMIV (Blake et al,
1997) and a symptom list for major depressive disorder as defined
in the DSMIV (American Psychiatric
Association, 1994). The interview subgroup was recruited from five
of the reception centres. As many refugees as possible were included from each
of these centres. The reception centres were selected on the basis that they
included people with a broad range of scores in the self-report survey, so
that sensitivity and specificity analyses could be undertaken.
Statistical analyses
Statistical analyses were undertaken using the Statistical Package for the
Social Sciences, version 9 for Windows.
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RESULTS |
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General Health Questionnaire
The mean total score on the translated GHQ28 (using the GHQ scoring
method of 0, 0, 1, 1) was 10.37 (s.d.=8.47; n=715). The currently
recommended cut-off point for a positive result is a total score of 7 or more
(Goldberg et al,
1997). Using this criterion, 428 (59.9%) were above threshold
(n=715). In a previous report
(Easton & Turner, 1991) a
much more conservative threshold has been suggested for traumatised people,
with a cut-off between 12 and 13 (Turner
& Lee, 1998). Even using this approach, 278 (38.9%) were still
above the threshold for caseness.
The 28-item version of the GHQ yields sub-scale scores in four domains: (A) somatic symptoms, (B) anxiety and insomnia, (C) social dysfunction and (D) severe depression. We were fortuitously able to compare our data on the GHQ and its sub-scales with a recently published large survey of Kosovan Albanians who had stayed in Kosovo, or who had been displaced to nearby countries and had quickly returned to live in Kosovo (Lopes Cardozo et al, 2000). The total GHQ28 scores from the different samples were similar, but there were interesting differences in the detailed sub-scale scores (Table 2). Those who had remained in or who had already returned to Kosovo reported higher levels of somatic symptoms as well as anxiety and insomnia (sub-scales A and B). On the other hand, levels of social dysfunction and severe depression (substantially to do with suicidal thinking) were higher in the refugee sample in the UK (sub-scales C and D).
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Beck Depression Inventory
The mean score on the translated version of the BDI was 18.89 (s.d.=14.18;
n=617). Comparison with the severity ranges for the standardised
(English) BDI revealed that 238 (38.6%) were below threshold (minimal
symptoms, scores 0 to 13); 109 (17.7%) were in the mild range (scores 14 to
19); 134 (21.7%) were in the moderate range (scores 20 to 28); and 136 (22.0%)
were in the severe range (scores 29 and above). Using these thresholds, 61.4%
have a score indicating possible depression and 43.7% have scores in the
moderate or severe range.
Beck Anxiety Inventory
The mean score on the translated version of the BAI was 14.09 (s.d.=14.50;
n=645). Again, it is possible to apply ranges to these scores from
the standardised (English) scale: 278 (43.1%) had scores between 0 and 7, said
to reflect minimal anxiety; 147 (22.8%) had scores in the mild range (8 to
15); 103 (16.0%) had scores in the moderate range (16 to 25); and 117 (18.1%)
had scores in the severe range (26 and above). Using these thresholds, 56.9%
have a score indicative of possible anxiety and 34.1% have a score suggesting
moderate or severe anxiety.
Post-traumatic Diagnostic Scale
The response to the translated version of the PDS (which was towards the
end of the questionnaire pack) was lower than for the other measures. The data
were scored so that if some but not all items for a given criterion had been
marked, then the criterion was included in the analyses. If all the items had
been omitted, the criterion was shown as a missing variable. This approach was
intended to take account of occasional missing items. The missing values were
scored as negative. The effect of this is to reduce the likelihood of
achieving diagnosis since individual criteria will be included as negative
where, had all the items been marked, the threshold might have been
reached.
There was a particularly low response rate to items that dealt with impact of trauma at the time or with duration of symptoms. Only 360 participants gave valid returns to all six criteria. Of these, 234 (65.0%) met the requirements for a probable diagnosis of PTSD based on the (English language) standardised thresholds in this self-report measure. However, in view of the low response rate, a number of other analyses were undertaken. First, criterion A, which deals with history of trauma, was omitted from all analyses (reasonable in view of the information scores elsewhere). With this approach, the valid sample size rose to 457. Of these, 310 (67.8%) were scored as positive. Finally, the symptom criteria (B, C and D) alone were analysed. Here, the sample size rose again, to 639. Of these, 452 (70.7%) were scored as positive. Similar percentages were found therefore, regardless of scoring method.
It has been suggested that the original threshold for scoring the PDS may be too generous, and a more conservative threshold has been proposed (Brewin et al, 1999). Each of the symptom items is rated by frequency. A threshold of once a week or less/once in a while is sufficient for inclusion using the standard scoring approach (Foa et al, 1997). Taking a higher standard and requiring that symptoms meet the higher threshold of being present at least two to four times a week/half the time lowers the predicted prevalence of PTSD. In this case, using the symptom criteria (B, C and D), only 32.1% scored as positive.
Relationships between questionnaires, age, gender, trauma and current
separation
There were significant correlations between age and all scales: GHQ
(=0.36, n=689, P<0.001) and PDS total severity score
(
=0.26, n=555, P<0.001). There was no significant
association with gender.
A cumulative variable (exposure to violence) was constructed by summating
the main trauma items in the War Trauma Questionnaire. As expected, exposure
to violence was significantly and positively correlated with GHQ (=0.30,
n=715, P<0.001), BDI total score (
=0.32,
n=617, P<0.0010, BAI total score (
=0.24,
n=0.001) and PDS total severity score (
=0.33, n=575,
P<0.001). There was also a positive relationship between age and
exposure to violence (
=0.26, n=555, P<0.001).
A categorical variable was constructed on the basis of family separation (present or absent). Significant differences (Table 3) were found for age (MannWhitney U=45 738; P<0.001), GHQ (U=40962; P<0.001), BDI (U=30 379; P<0.001), BAI (U=35 213; P<0.001) and PDS (U=24 880; P<0.001). Those with family separations were older and had higher scores on measures of psychopathology.
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Characteristics of the interview subsample
Interviews were undertaken with 120 participants who had already completed
the questionnaires. This subgroup was composed of 64 women and 56 men, with a
mean age of 37.1 years (s.d.=14.7). There was no significant difference in age
or gender between those who were and were not interviewed. Comparison rates of
caseness derived from the screening questionnaires have been calculated for
this subgroup and are shown in Table
4, where they may be compared with the rates in the whole
sample.
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Relationships between questionnaire and clinical diagnosis
Using the standard cut-off criteria on the CAPS interview, 46 (39%;
n=118) had a diagnosis of PTSD. The mean CAPS score in this sample
was 48.6 (s.d.=21.6; n=120). Using the criteria of DSMIV and
applying these at interview, 19 participants (16%; n=120) met the
criteria for a major depressive episode. Examining comorbidity, we found that
all but one of the 19 participants with major depressive disorder also had
PTSD; on the other hand, only 18 of the 46 with PTSD also had a major
depressive disorder. Using standard scoring criteria, in the same subset,
questionnaire measures gave much higher estimates than did the interviews:
GHQ28 caseness 52%, BDI depression 58%, BAI anxiety 61% and PDS/PTSD
54%.
In the whole sample, the questionnaire data gave the following percentages:
GHQ28 caseness 60%, BDI depression 61%, BAI anxiety 57% and PDS/PTSD
71%. The subset interviewed was not a random sample of the whole group. The
greatest difference in results is in relation to the PTSD scores (PDS scores
of 54% v. 71%). This suggests that the prevalence of PTSD in the
whole sample would be greater than in the interview subset (PTSD diagnosed in
38%). Adjusting the results on this basis, the proportion of people with an
interview diagnosis of PTSD in the whole sample would be expected to be just
below 50% ().
This is therefore the best estimate of PTSD diagnosis in the whole sample,
based on questionnaire data, adjusted on the basis of an interview validation
exercise in a subset.
Sensitivities and specificities for each of the screening questionnaires at two levels of severity are shown in Table 4 in summary form.
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DISCUSSION |
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Most surveys of refugees have focused on PTSD and depression, probably because these are easier to measure. Large-scale community surveys generally rely on questionnaire (self-report) measures. Of 534 Bosnian refugees living in Croatia (Mollica et al, 1999), 39% were reported as having a probable diagnosis of depression and 26% of PTSD defined according to DSMIV. In 993 Cambodian refugees living in Thailand (Mollica et al, 1998) the corresponding rates were 68% for depression and 37% for PTSD. Thus in general, high rates of PTSD and depression are reported. Interview-based studies tend to present lower figures for the prevalence of these diagnoses (e.g. Hondius et al, 2000). In the UK, Van Velsen et al (1996) in an interview survey of a mixed group of refugees in London reported 35% with depression (major depressive disorder using DSMIIIR; American Psychiatric Association, 1987) and 52% with PTSD, but this was in a group of people specifically referred for specialist psychiatric assessment.
The study reported here demonstrates that a substantial proportion of recently arrived adult refugees have clinically significant mental health problems. We have demonstrated that about half of the total refugees sampled had evidence of PTSD, many with a comorbid major depressive disorder. The time course of PTSD (e.g. Kessler et al, 1995) is such that some members of this recently arrived refugee community would still be in the natural recovery phase, and the prevalence of PTSD would probably diminish somewhat over the subsequent year or so, leaving a core group with a chronic persistent condition. This may be taken as a sign of the resilience of many who survived this conflict, but it also implies that there is still a substantial need for health care in a proportion.
Validity of self-report measures
This study demonstrates that care is required in extrapolating from
self-report measures, using standard scoring approaches, at least in refugee
samples. The validity of the self-report questionnaire approach has already
been considered by Smith Fawzi et al
(1997) in a sample of former
Vietnamese political prisoners. They found serious problems in seeking to rely
on previous standardisation data. They concluded that future community
based studies conducted among refugee populations should include a validation
sub-study in order to ascertain the most appropriate cut-off score for each
individual context. We agree with this conclusion.
In our survey, more consistent results were obtained using higher thresholds for the self-report measures, but even so the estimated prevalence of depression remained high. This is an important issue, not least because of the tendency of some to reject the diagnostic paradigm in refugee populations. It is just as important not to overstate the prevalence of psychiatric disorders and the need for treatment services as it is to avoid understatements of need. This is especially important when there is a need to prioritise resources between community development work designed to help the whole refugee community and treatment services, designed to help the most traumatised subgroups. These are complementary approaches, but are sometimes unfortunately seen as being in opposition.
Comparison between UK and Kosovo data
We were able to compare our data with the results of a large survey of
Kosovan Albanians in Kosovo carried out at about the same time
(Lopes Cardozo et al,
2000). The total GHQ28 scores from the different samples
were similar but there were interesting differences in the detailed subscale
scores (see Table 2). These
results have face validity. They suggest that Kosovan Albanians who were in
Kosovo were probably more frightened. On the other hand, those who found
themselves in the UK, although objectively safer at least for the time
being experienced greater levels of alienation and isolation as well
as feelings of despair.
Pro- and post-migration factors
A substantial body of evidence points to the link between (for example)
PTSD and the degree of trauma exposure in refugees (Mollica et al,
1998,
1999;
Shrestha et al,
1998). However, it also appears that there is a cumulative effect,
with both pre-migration trauma exposure and post-migration factors being
implicated in overall psychiatric morbidity. For example, in the UK, Van
Velsen et al (1996)
reported a significant relationship between levels of depression and current
social context (including poor accommodation, isolation and lack of family
reunion). Gorst-Unsworth & Goldenberg
(1998), in a sample of 84
Iraqi men in London, reported a significant relationship between social
factors in exile and the severity both of PTSD and depression; they reported
that poor social support was a stronger predictor of depression than were
trauma factors. Finally, Steel et al
(1999), in an Australian
sample of Tamil refugees, reported that pre-migration factors accounted for
20% and post-migration factors 14% of the variance in post-traumatic symptoms.
So PTSD and depression, often comorbid, appear to have complex relationships
with pre-migration violence and post-migration social difficulties. In the
present sample, although the measures are more limited, there were
demonstrable effects both of prior traumatisation (experience of violence) and
of current difficulty (family separation).
Clinical implications
This study demonstrates the resilience of many Kosovan refugees coming to
the UK. None the less, a substantial proportion did have evidence of serious
psychological difficulties. Newly arrived refugees not only need community
support, but also many will have significant mental health problems and will
need access to effective treatment services. Screening questionnaires are
likely to be helpful, but the thresholds need careful clinical validation. It
is probable that mental health problems will constitute the greatest health
burden in refugee communities. One of the implications of the study reported
here is that family separation is related to severity of distress. There is
scope for using psychosocial interventions, especially to reduce levels of
depression. These approaches are likely to be synergistic with individual
treatment services for those with the more severe psychological reactions to
these experiences.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSMIV). Washington, DC: APA.
Beck, A. T. (1987) Beck Anxiety Inventory. New York: Psychological Corporation.
Beck, A. T. (1996) Beck Depression Inventory. New York: Psychological Corporation.
Blake, D. D., Weathers, F. W., Nagy, L. M., et al (1997) Clinician Administered PTSD Scale for DSMIV. Current and Lifetime Diagnostic Version. White River Junction, VT: US National Center for Post Traumatic Stress Disorder.
Brewin, C. R., Andrews, B., Rose, S., et al
(1999) Acute stress disorder and posttraumatic stress
disorder in victims of violent crime. American Journal of
Psychiatry, 156,
360-366.
Easton, J. A. & Turner, S. W. (1991) Detention of British citizens as hostages in the Gulf health, psychological, and family consequences. BMJ, 303, 1231-1234.[Medline]
Foa, E. B., Cashman, L., Jaycox, L. H., et al (1997) The validation of a self-report measure of posttraumatic stress disorder: the Posttraumatic Diagnostic Scale. Psychological Assessment, 9, 445-451.[CrossRef]
Goldberg, D. P. & Hillier, V. F. (1979) A scaled version of the General Health Questionnaire. Psychological Medicine, 9, 139-145.[Medline]
Goldberg, D. P., Gater, R., Sartorius, N., et al (1997) The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychological Medicine, 27, 191-197.[CrossRef][Medline]
Gorst-Unsworth, C. & Goldenberg, E. (1998) Psychological sequelae of torture and organised violence suffered by refugees from Iraq. Trauma-related factors compared with social factors in exile. British Journal of Psychiatry, 172, 90-94.[Abstract]
Hondius, A. J. K., Van Willigen, L. H. M., Kleijn, W. C., et al (2000) Health problems among Latin-American and middle-eastern refugees in the Netherlands: relations with violence exposure and ongoing sociopsychological strain. Journal of Traumatic Stress, 13, 619-634.[CrossRef][Medline]
Kessler, R. C., Sonnega, A., Bromet, E. J., et al (1995) Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060.[Abstract]
Lopes Cardozo, B., Vergara, A., Agani, F., et al (2000) Mental health, social functioning, and attitudes of Kosovar Albanians following the war in Kosovo. JAMA, 284, 577.
Macksoud, M. S. (1992) Assessing war trauma in children: a case study of Lebanese children. Journal of Refugee Studies, 5, 1-15.
Mollica, R. F., Mclnnes, K., Poole, C., et al (1998) Doseeffect relationships of trauma to symptoms of depression and post-traumatic stress disorder among Cambodian survivors of mass violence. British Journal of Psychiatry, 173, 482-488.[Abstract]
Mollica, R. F., Mclnnes, K., Sarajlic, N., et al
(1999) Disability associated with psychiatric comorbidity and
health status in Bosnian refugees living in Croatia.
JAMA, 282,
433-439.
Shrestha, N. M., Sharma, B., Van Ommeren, M., et al
(1998) Impact of torture on refugees displaced within the
developing world: symptomatology among Bhutanese refugees in Nepal.
JAMA, 280,
443-448.
Smith Fawzi, M. C., Murphy, E., Pham, T., et al (1997) The validity of screening for post-traumatic stress disorder and major depression among Vietnamese former political prisoners. Acta Psychiatrica Scandinavica, 95, 87-93.[Medline]
Steel, Z., Silove, D. M., Bird, K., et al (1999) Pathways from war trauma to posttraumatic stress symptoms among Tamil asylum seekers, refugees, and immigrants. Journal of Traumatic Stress, 12, 421-435.[Medline]
Turner, S. W. & Gorst-Unsworth, C. (1990) Psychological sequelae of torture. A descriptive model. British Journal of Psychiatry, 157, 475-480.[Medline]
Turner, S. W. & Lee, D. (1998) Measures in Post Traumatic Stress Disorder: A Practitioner's Guide. Windsor: NFER-Nelson.
Van Velsen, C., Gorst-Unsworth, C. & Turner, S. W. (1996) Survivors of torture and organized violence demography and diagnosis. Journal of Traumatic Stress, 9, 181-193.[Medline]
Received for publication August 28, 2001. Revision received August 12, 2002. Accepted for publication September 4, 2002.
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