Context Evidence is emerging that psychiatric disorders are common in populations
affected by mass violence. Previously, we found associations among depression,
posttraumatic stress disorder (PTSD), and disability in a Bosnian refugee
Objective To investigate whether previously observed associations continue over
time and are associated with mortality emigration to another region.
Design, Setting, and Participants Three-year follow-up study conducted in 1999 among 534 adult Bosnian
refugees originally living in a refugee camp in Croatia. At follow-up, 376
(70.4%) remained living in the region, 39 (7.3%) were deceased, 114 (21.3%)
had emigrated, and 5 (1%) were lost to follow-up. Those still living in the
region and the families of the deceased were reinterviewed (77.7% of the original
Main Outcome Measures Depression and PTSD diagnoses, based on Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria and measured by the Hopkins Symptom Checklist-25 and
the Harvard Trauma Questionnaire, respectively; disability, measured by the
Medical Outcomes Study Short-Form 20; and cause of death, determined by family
interviews with review of death certificates, if available.
Results In 1999, 45% of the original respondents who met the DSM-IV criteria for depression, PTSD, or both
continued to have these disorders and 16% of respondents who were asymptomatic
in 1996 developed 1 or both disorders. Forty-six percent of those who initially
met disability criteria remained disabled. Log-linear analysis revealed that
disability and psychiatric disorder were related at both times. Male sex,
isolation from family, and older age were associated with increased mortality
after adjusting for demographic characteristics, trauma history, and health
status (for male sex, adjusted odds ratio [OR], 2.63; 95% confidence interval
[CI], 1.17-5.92; living alone, OR, 2.40; 95% CI, 1.07-5.38; and each 10-year
increase in age, OR, 1.91; 95% CI, 1.34-2.71). Depression was associated with
higher mortality in unadjusted analysis but was not after statistical adjustment
(unadjusted OR, 3.12; 95% CI, 1.55-6.26; adjusted OR, 1.85; 95% CI, 0.82-4.16).
Posttraumatic stress disorder was not associated with mortality or emigration.
Spending less than 12 months in the refugee camp (OR, 11.30; 95% CI, 6.55-19.50),
experiencing 6 or more trauma events (OR, 3.34; 95% CI, 1.89-5.91), having
higher education (OR, 1.90; 95% CI, 1.10-3.29), and not having an observed
handicap (OR, 0.11; 95% CI, 0.02-0.52) were associated with higher likelihood
of emigration. Depression was not associated with emigration status.
Conclusions Former Bosnian refugees who remained living in the region continued
to exhibit psychiatric disorder and disability 3 years after initial assessment.
Social isolation, male sex, and older age were associated with mortality.
Healthier, better educated refugees were more likely to emigrate. Further
research is necessary to understand the associations among depression, emigration
status, and mortality over time.