Kosovan Mental Health

ORIGINAL CONTRIBUTION

Mental Health, Social Functioning,and Attitudes of Kosovar AlbaniansFollowing the War in KosovoBarbara Lopes Cardozo, MD, MPHAlfredo Vergara, PhDFerid Agani, MDCarol A. Gotway, PhD

IN LATE FEBRUARY 1998, CLASHES IN

Kosovo between Serbian policeforces and members of the KosovoLiberation Army intensified.1 Ser-

bian forces burned homes and killeddozens of ethnic Albanians in these raids.As a result of the fighting, thousands ofethnic Albanians were displaced fromtheir homes in Kosovo; many took ref-uge with host families, while a smallerproportion(several thousands) fled to thehills and forests.1 By the time North At-lantic Treaty Organization (NATO) op-erations began against Serbia on March24, 1999, about 260000 people had beendisplaced within Kosovo and 199000had fled to other countries.2 It is esti-mated that as result of this conflict, morethan 800000 people became refugees inneighboring countries (mainly Alba-nia, Montenegro, and the former Yugo-slav Republic of Macedonia), as well assecondary countries of asylum in Eu-rope, the United States, and elsewhere.On June 9, 1999, an agreement be-tween NATO and Serbia was reached,and the following day NATO halted itsbombing campaign.

As the Serbian troops began to pullout of Kosovo, the nearly 750000 Al-banians from Kosovo who had been liv-

ing in refugee camps in Albania, Mace-donia, and Montenegro began to returnto Kosovo.2 On their return, the dis-placed Albanians had to come to terms

with the destruction of their homes andproperty, missing family members, andthe traumatic experiences of violence,rape, and persecution. The full psycho-

Author Affiliations are listed at the end of this article.Corresponding Author and Reprints: BarbaraLopes Cardozo, MD, MPH, National Center for

Environmental Health, Centers for Disease Controland Prevention, 4770 Buford Hwy NE, MailstopF-48, Atlanta, GA 30341 (e-mail: [email protected]).

Context The 1998-1999 war in Kosovo had a direct impact on large numbers of ci-vilians. The mental health consequences of the conflict are not known.

Objectives To establish the prevalence of psychiatric morbidity associated with thewar in Kosovo, to assess social functioning, and to identify vulnerable populations amongethnic Albanians in Kosovo.

Design, Setting, and Participants Cross-sectional cluster sample survey con-ducted from August to October 1999 among 1358 Kosovar Albanians aged 15 yearsor older in 558 randomly selected households across Kosovo.

Main Outcome Measures Nonspecific psychiatric morbidity, posttraumatic stressdisorder (PTSD) symptoms, and social functioning using the General Health Ques-tionnaire 28 (GHQ-28), Harvard Trauma Questionnaire, and the Medical OutcomesStudy Short-Form 20 (MOS-20), respectively; feelings of hatred and a desire for re-venge among persons surveyed as addressed by additional questions.

Results Of the respondents, 17.1% (95% confidence interval [CI], 13.2%-21.0%)reported symptoms that met Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition criteria for PTSD; total mean score on the GHQ-28 was 11.1 (95% CI,9.9-12.4). Respondents reported a high prevalence of traumatic events. There was asignificant linear decrease in mental health status and social functioning with increas-ing amount of traumatic events (P#.02 for all 3 survey tools). Populations at in-creased risk for psychiatric morbidity as measured by GHQ-28 scores were those aged65 years or older (P=.006), those with previous psychiatric illnesses or chronic healthconditions (P,.001 for both), and those who had been internally displaced (P=.009).Populations at risk for poorer social functioning were living in rural areas (P=.001),were unemployed (P=.046) or had a chronic illness (P=.01). Respondents scored high-est on the physical functioning and role functioning subscales of the MOS-20 and low-est on the mental health and social functioning subscales. Eighty-nine percent of menand 90% of women reported having strong feelings of hatred toward Serbs. Fifty-one percent of men and 43% of women reported strong feelings of revenge; 44% ofmen and 33% of women stated that they would act on these feelings.

Conclusions Mental health problems and impaired social functioning related to therecent war are important issues that need to be addressed to return the Kosovo re-gion to a stable and productive environment.JAMA. 2000;284:569-577 www.jama.com

See also pp 578 and 615.

©2000 American Medical Association. All rights reserved. (Reprinted) JAMA, August 2, 2000—Vol 284, No. 5 569

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logical impact of such emergency situ-ations is a neglected issue.3 However, re-cent epidemiological studies in Bosnia4

and studies among Cambodian refu-gees living on the Thai border5 and inthe United States have shown that psy-chiatric morbidity is much higher inpopulations that have experienced war,persecution, and mass violence.6,7

To estimate the prevalence of psy-chiatric morbidity and to identify spe-cific vulnerable populations, the Cen-ters for Disease Control and Prevention(CDC) and the Institute of MentalHealth and Recovery in Kosovo, in col-laboration with Doctors of the World,conducted a mental health surveyamong ethnic Albanians in Kosovo fromAugust 20 to October 7, 1999. The sur-vey focused on the period of August1998 through August 1999, when mostof the intense violence took place.

METHODSSurvey Design

Assuming a true prevalence of 20% ofmental health–related problems8 and acluster sample design effect of 2, we es-timated that a minimum of 1135 adultsaged 15 years or older would be re-quired for a 95% confidence interval(CI) to detect a prevalence between 15%and 25%. On the basis of availablehousehold size and age distribution, weestimated that a minimum of 504households would need to be sur-veyed. The number of households tar-geted was increased to 600 to compen-sate for refusals and absent adults andto obtain estimates for various sub-groups of the population.

We conducted a 2-stage, 30-clustersample survey using the 1991 Kosovocensus as a primary sampling frame. Be-cause these data did not reflect popula-tion movements before and during theethnic conflict, additional data sourceswere used to adjust the 1991 popula-tion figures. These sources were villagesurveys from the United Nations HighCommissioner for Refugees and fooddistribution population estimates fromAction Against Hunger (a nongovern-mental organization), both reflecting in-formation collected during the weeks be-

fore our survey. The primary samplingframe consisted of all villages and citieslisted in the 1991 census, excludingthose that were predominantly popu-lated by Serbs ($70% Serb popula-tion) and those that had a population ofless than 100 Albanian inhabitants. Thesampling frame was stratified into ur-ban (cities with a population .10000)and rural areas. Using this samplingframe, we estimated the total ethnic Al-banian population in Kosovo to be 1.6million. With probability proportionalto population size, we selected 15 clus-ters from the rural and 15 from the ur-ban frame in the first sampling stage. Inthe second stage of sampling, 20 house-holds were randomly selected withineach chosen cluster (20 households fromeach of 30 clusters for a total of 600households) using an appropriatemethod designed for the Expanded Pro-gramme on Immunization and adaptedto the particular field conditions.9

Identification of cluster samples dif-fered for urban centers and rural vil-lages. No maps were available for the vil-lages, and many villages were spread outover a large geographic area. We drewmaps of each cluster, which were thendivided into segments of approximatelyequal populations. We then randomlychose a single segment by first number-ing all segments and then blindly draw-ing a segment number from a bag con-tainingallnumbers. In thecities,KosovoForce (KFOR) offices usually had aerialor other maps available. In these cases,we superimposed a grid to partition themap into neighborhoods. The neighbor-hoods were numbered, and then a num-berwasblindlychosentorandomlyselecta neighborhood for our survey.

After a segment or neighborhood waschosen, the first household to be sur-veyed was chosen randomly as follows.Households were mapped and num-bered in a random direction from thecenter to the edge of the segment, cho-sen by spinning a bottle. The first house-hold was chosen by blindly drawing anumber from a bag using the samemethod described above. The next housewas selected to be the closest house tothe left, as the interviewer exited the

house just surveyed. This process was re-peated until 20 households were sur-veyed, or until the team leader decidedit was time to leave for security reasons.

We interviewed all adult members ofthe household present. To ensure asmuch privacy as possible, we encour-aged people to complete the question-naires in separate rooms, and men andwomen interviewers paired up withsame-sex interviewees to help themcomplete the questionnaires. A secu-rity curfew at dusk imposed by KFORprevented interview teams from com-ing back to survey adults not presentduring the day. Because of the ongo-ing threat of land mines, KFOR con-sidered access to some remote housesunsafe. These homes had to be ex-cluded from our sample and replacedby the closest accessible household.

Native Kosovar Albanian survey teammembers had 3 days of training on gen-eral survey objectives, safety precau-tions, procedures for proper house-hold selection (including randomlyselecting the first household and han-dling special situations), and interview-ing techniques (understanding the ques-tionnaires and addressing sensitivetopics). All members of the survey teamwere closely supervised for the first 2days, and they continued to receive dailysupervision and instruction until the sur-vey was completed. Interviewers wereinstructed to refer participants who ap-peared to be in obvious distress to com-munity mental health services whereavailable. A list of these services was pro-cured from the nongovernmental orga-nization coordinating office at the UnitedNations Mission in Kosovo.

The study protocol was reviewed bya CDC institutional review board rep-resentative and informed consent wasobtained verbally from all participants(with communication occurring in thepotential participant’s native language).The study protocol was also reviewedby Doctors of the World for ethical con-siderations.

Screening ToolsAll instruments used in this surveywere designed as self-report question-

MENTAL HEALTH FOLLOWING THE WAR IN KOSOVO

570 JAMA, August 2, 2000—Vol 284, No. 5 (Reprinted) ©2000 American Medical Association. All rights reserved.



naires, but because of a high percent-age of illiteracy, especially in ruralareas, questionnaires frequently hadto be read aloud. Because of the needfor expediency in collecting data,interviewers were instructed to readthe questionnaires only to those whowere illiterate, and to provide assis-tance if needed to those who com-pleted the questionnaire themselves.We used 3 screening tools to assessmental health problems and socialdysfunction: the General HealthQuestionnaire-28 (GHQ-28),10,11 theHarvard Trauma Questionnaire(HTQ),12 and the Medical OutcomesStudy 20 (MOS-20).13 We chose theseinstruments to obtain information oncommon, nonspecific psychiatricproblems, to gather information onspecific psychiatric syndromes such asposttraumatic stress disorder (PTSD)and related traumatic events, and toget a broad understanding of the levelof social functioning and disability inthis population.

The GHQ-28 is used as a commu-nity screening tool and for the detec-tion of nonspecific psychiatric disor-ders among individuals in primary caresettings.11 A higher mean score on theGHQ-28 represents poorer mentalhealth status (score range, 0-28). TheGHQ-28 is composed of 4 subscales(score range, 1-7): somatization, anxi-ety, social dysfunction, and depres-sion. The HTQ combines the measure-ment of trauma events (part I) andsymptoms of PTSD (part II), selectedfrom the Diagnostic and StatisticalManual of Mental Disorders (DSM-IV).14

We defined the occurrence of PTSDsymptoms according to a scoring algo-rithm proposed by the Harvard Refu-gee Trauma Group,4,12 on the basis ofDSM-IV diagnostic criteria. TheMOS-20 consists of 20 items on 6 dif-ferent scales that assess physical func-tioning, bodily pain, role functioning,social functioning, mental health, andself-perceived general health status. Wescored the MOS-20 as recommended inthe user’s manual; each raw score wastransformed to fit a 0-to-100 scale us-ing a standard formula,13,15 with the

higher scores on this scale represent-ing better functioning. All 3 tools havebeen extensively validated in manycountries and cultures and in many dis-ease settings.16-18

To assess the effect of broadly de-fined demographic characteristics onmental health status, we collected de-mographic information including age,sex, education level, and marital sta-tus. We added additional questions spe-cific to the Kosovar Albanian popula-tion on feelings of hatred and a desirefor revenge. All questionnaires weretranslated into Albanian and back-translated to English to ensure cul-tural appropriateness of the instru-ment and accuracy of the translation.A team of Albanian translators includ-ing a psychiatrist, a psychologist, anda primary care physician from the In-stitute for Mental Health and Recov-ery did the translation and adaptationof the screening tools.

Data AnalysisWe adjusted prevalence estimates andCIs for cluster sampling and stratifica-tion using Epi Info version 6.4.19 Re-gression analyses were performed us-ing SUDAAN, release 7.5.2 (ResearchTriangle Institute, Research TrianglePark, NC). For continuous variables, weused multivariate linear regressionmodels to assess the effects of expo-sure on outcome and multivariatelogistic regression models to analyzedichotomous outcomes. When the ex-posure variable had more than 2 lev-els (eg, displacement), we made mul-tiple comparisons of the responsesbetween pairs of the different levels us-ing single df contrasts. When the ex-posure variable had a natural ordering(eg, age, education, number of trau-matic events), we did a test for lineartrend. All P values were derived fromadjusted Wald F tests based on theseregression models, and P,.05 was con-sidered statistically significant. Allanalyses were adjusted for stratifica-tion and the clustered design, and wereweighted to account for unequal selec-tion probabilities among the indi-vidual respondents.

RESULTSCharacteristics ofSurvey ParticipantsA total of 558 households, consisting of1358 adults aged 15 years or older, wereincluded in the survey (mean [SD]household size for all ages, 7.3 [3.5]persons). This is smaller than the tar-get number of 600 households since lo-gistical and time constraints preventedthe completion of 20 surveys in some vil-lages. However, 558 households is stillgreater than the 504 households deemedneeded from sample size calculations.

Demographic characteristics are sum-marized in TABLE 1. Of the adults sur-

Table 1. Sample Characteristics of KosovarAlbanian Respondents (N = 1358)

CharacteristicNo. of

Respondents*Proportion,

%

LocationRural 758 55.8

Urban 600 44.2

SexFemale 825 62.3

Male 499 37.7

Age, y15-34 609 45.3

35-54 459 34.1

55-64 147 10.9

$65 130 9.7

Marital statusMarried 906 67.3

Divorced 31 2.3

Single 319 23.7

Widowed 91 6.8

EducationLess than

primary313 23.3

Primary 485 36.2

Secondary 377 28.1

Some university 166 12.4

Currently employedYes 202 15.1

No 1134 84.9

Previous psychiatricillness†

Yes 23 1.7

No 1302 98.3

Chronic healthproblems‡

Yes 551 40.6

No 807 59.4

*Excludes missing data or “unknown” responses.†Diagnosed by a physician before the conflict.‡Diagnosed by a medical professional before the con-

flict. Includes hypertension, diabetes, cardiovasculardisease, kidney disease, asthma, epilepsy, cancer, ormajor injury such as loss of a limb.





veyed, 62.3% were women, 55.8% livedinaruralarea,59.5%hadcompletedonlyprimary school or less, 67.3% were mar-ried, and only 15.1% were currentlyemployed. Nearly 41% of participantsreported having a chronic illness (diag-nosis by a medical professional of hyper-tension, diabetes, cardiovascular dis-ease, kidney disease, asthma, epilepsy,cancer, or major injury such as loss of alimb),and1.7%reportedhavingreceiveda diagnosis by a physician of a previousmental illness, such as schizophrenia orbipolar disorder, before the conflict.

The exposure to traumatic events, in-cluding displacement, is summarized inTABLE2.Highpercentagesofrespondentsreported having personally experiencedtraumaticevents.Forexample,66.6%re-portedbeingdeprivedofwaterandfood,66.5% reported being in a combat situ-ation, and 61.6% reported being close todeath.Furthermore,39.4%ofparticipantsreported experiencing 8 or more of thetraumatic events listed; 56.2% had fledtoanothercountryasrefugeesduringthepastyear,25.6%hadbeen internallydis-placed within Kosovo, and only 18.2%remained in theirhomesduring thewar.Inall analyses, the traumaticeventswereequally weighted since we had no re-sources for in-depthquestioningneededto provide additional information.

Mental Health andSocial FunctioningEstimated mean scores on the GHQ-28and the MOS-20 and the prevalence ofPTSD symptoms from the HTQ areshown in TABLE 3, along with 95% CIsadjusted for stratification and cluster de-sign effects. These figures represent es-timates of the population indicator mea-sured by each test for the adult Albanianpopulation living in Kosovo at the timeof this survey.

For the GHQ-28, the estimated meantotal score based on a possible 28 ques-tions was 11.1 (95% CI, 9.9-12.4). Ahigher mean score signifies a greaternumber of symptoms. The mean scoresfor somatic symptoms and for anxietyand insomnia were higher comparedwith the mean scores for social dys-function and depression.

The estimated MOS-20 mean scoresare shown on a scale of 1 to 100, with ahigher score representing better func-tioning. In general, respondents tendedto score highest on physical function-ing and role functioning and lowest onthe mental health and social function-ing components (Table 3). We com-pared scores on the MOS-20 with scoresof a US general population14,20,21 (data forthe Albanian Kosovo population beforethe conflict are not available). The meanscores formentalhealth(29.6)andsocialfunctioning (29.5) were strikingly lowerfor the Kosovar Albanians than forthe US population (74.7 and 83.3,respectively). However, there were nogreat differences between the 2 popula-tions in the measures of general health,physical functioning, bodily pain, androle functioning. The estimated preva-lence of PTSD symptoms in this popu-lation of Kosovar Albanians was 17.1%(95% CI, 13.2%-21.0%).

Feelings of Hatred and RevengeQuestions regarding hatred toward theSerbs and desire for revenge revealed thathigh percentages of both men andwomen (.88% among each) had strongfeelings of hatred, defined as a responseof “extreme hatred” (men, 60% [n=288];women, 55% [n=464]) or “a lot of ha-tred” (men, 29% [n=142]; women, 35%[n=271]). The proportions of peoplehaving strong feelings of revenge werelower (. 43% for both men and wom-en), but still very high. Strong feelingsof revenge were defined as a response offeeling revenge “all the time” (men, 35%[n=159]; women, 23% [n=192]) or “alot of the time” (men, 16% [n=92];women, 20% [n=166]). Of those menand women who had feelings of re-venge (“all the time,” “a lot of the time,”or “sometimes”), 44.2% of men (n=177)and 33.3% of women (n=197) said theywould definitely act on those feelings,and only 17.3% of men (n=71) and26.2% of women (n=184) said theywould not act on those feelings.

Univariate Statistical AnalysisTABLE 4 summarizes the univar-iate analysis of the effect of selected

Table 2. Kosovar Albanians ReportingTrauma Exposure, August 1998–August1999 (N = 1358)

Trauma Experiences No. (%)

Lack of food or water 904 (66.6)Combat situation 903 (66.5)Forced isolation 870 (64.1)Being close to death 837 (61.6)Lack of shelter 778 (57.3)Torture/abuse* 664 (48.9)Ill health without access to

medical care646 (47.6)

Forced separation from familymembers

568 (41.8)

Family member or respondentinvolved in fighting duringthe war

470 (34.6)

Murder of family or friend 359 (26.4)Witness murder of stranger(s) 324 (23.9)Unnatural death of family

or friend298 (21.9)

Lost or kidnapped 240 (17.7)Serious injury 202 (14.9)Imprisonment 131 (9.6)Rape† 60 (4.4)Trauma events, No.

0-3 293 (21.6)4-7 529 (39.0)8-11 374 (27.5)12-16 162 (11.9)

Displacement during the conflict‡Did not move 231 (18.2)Internally displaced 326 (25.6)Refugee 715 (56.2)

*Torture/abuse was not defined for the participant. It wasinterpretedbroadly, includingverbalabusebyarmedforces,intimidation, beatings, incarceration, witnessing a lovedone suffering these abuses, and being forced to choosethe victim of a violent act among one’s family members.

†Rape was identified in women only.‡Data available from only 1272 respondents.

Table 3. Estimated Mean Scoreson GHQ-28 and MOS-20 and EstimatedPTSD Prevalence in Kosovar AlbanianPopulation*

Mental HealthStatus Measure(Score Range)

Mean(95% Confidence

Interval)

GHQ-28 (1-7 For All Subscales)

Somatic symptoms 3.9 (3.4-4.3)Anxiety and insomnia 4.2 (3.7-4.7)Social dysfunction 2.2 (2.0-2.5)Symptoms of severe

depression0.9 (0.7-1.1)

Total (0-28) 11.1† (9.9-12.4)

MOS-20 (0-100 For All Subscales)

General health perception 54.7 (50.2-59.1)Mental health status 29.6 (24.9-34.4)Bodily pain 57.0 (52.8-61.1)Physical function status 77.3 (74.9-79.7)Social functioning 29.5 (25.5-33.6)Role functioning 77.5 (74.9-80.1)

HTQ-Symptoms

Total PTSD prevalence, % 17.1 (13.2-21.0)

*GHQ-28 indicates General Health Questionnaire-2810,11; MOS-20, Medical Outcomes Study13; PTSD,posttraumatic stress disorder; and HTQ, Harvard TraumaQuestionnaire.12 See the “Methods” section for a de-scription of each screening tool.

†Numbers have been rounded.





Table 4. Univariate Analysis of Effects of Demographic and Exposure Variables on GHQ-28 and MOS-20 Social Functioning Mean Scoresand Prevalence of PTSD*

Variable

GHQ-28 (Scale, 0-28)MOS-20 Social Functioning

(Scale, 0-100) PTSD Symptoms

Mean (SE)P

Value Mean (SE)P

Value % (SE)P

Value

LocationUrban 10.50 (0.61)

.4140.60 (2.70)

,.00113.16 (2.17)

.11Rural 11.42 (0.92) 24.08 (2.31) 19.02 (2.76)

SexMale 10.80 (0.74)

.3529.10 (3.51)

.8012.01 (1.85)

.01Female 11.34 (0.65) 30.24 (2.46) 19.67 (2.67)

Current employmentYes 9.14 (0.71)

,.00136.70 (3.72)

.00612.49 (3.44)

.20No 11.46 (0.66) 28.20 (1.84) 18.00 (2.29)

Age, y15-34 8.33 (0.72)

,.001 (linear)

33.83 (2.32)

.03 (linear)

13.22 (1.74).01

35-54 12.64 (0.66) 26.63 (2.35) 21.44 (3.44) .67 for all(linear)55-64 14.24 (0.69) 24.99 (2.99) 17.81 (2.89)

$65 14.68 (0.76) 25.67 (3.87) 16.30 (4.69)

Marital statusMarried 12.03 (0.63)

,.001

28.90 (2.29)

.43

16.49 (2.28)

.48Divorced 6.37 (1.63) 32.79 (4.95) 10.48 (6.94)

Widowed 14.78 (1.24) 18.21 (3.60) 30.96 (5.32)

Single 7.69 (0.68) 34.39 (2.31) 15.14 (2.21)

EducationLess than primary 14.06 (0.61)

,.001 (linear)

24.37 (2.73)

.03 (linear)

21.29 (3.73)

.11 (linear)Primary 10.51 (0.77) 28.82 (2.54) 15.99 (2.42)

Secondary 10.10 (0.66) 32.47 (3.74) 15.84 (1.69)

Some university 8.88 (0.60) 37.19 (4.33) 11.01 (4.25)

Previous psychiatric illnessYes 20.72 (1.80)

,.00120.08 (6.48)

.2035.92 (12.63)

.15†No 10.95 (0.65) 29.56 (2.02) 16.81 (2.05)

Chronic health conditionYes 14.49 (0.37)

,.00124.44 (2.10)

,.00121.51 (2.67)

.003No 8.62 (0.78) 33.30 (2.25) 13.95 (1.90)

DisplacementRefugee (R) 10.68 (0.81) R vs I: .03 28.45 (1.66) R vs I: .75 16.64 (2.70) R vs I: .12

Internally displaced (I) 13.05 (0.78) R vs D: .66 26.72 (5.20) R vs D: .009 21.97 (2.55) R vs D: .19

Did not move (D) 10.26 (0.66) I vs D: .007 36.60 (3.03) I vs D: .12 11.88 (2.37) I vs D: .004

RapeYes 11.03 (1.30)

.9326.71 (5.21)

.5521.62 (6.91)

.49No 11.12 (0.62) 29.67 (2.06) 16.92 (2.02)

Forced separationYes 12.22 (0.81)

.00227.36 (2.20)

.2022.69 (3.50)

.01No 10.30 (0.62) 31.17 (2.69) 13.09 (1.76)

Murder of family or friendYes 13.66 (0.49)

,.00121.92 (3.66)

.00525.48 (3.41)

.002No 10.16 (0.70) 32.42 (1.73) 13.97 (1.82)

Trauma events, No.0-3 9.28 (0.57)

,.001 (linear)

42.14 (3.34)

,.001 (linear)

13.40 (2.57)

,.001 (linear)4-7 9.37 (0.77) 32.49 (2.62) 10.03 (2.15)

8-11 12.43 (0.83) 23.17 (2.31) 22.16 (3.66)

12-16 16.11 (0.63) 15.66 (4.60) 32.55 (5.69)

*GHQ-28 indicates General Health Questionnaire-2810,11; MOS-20, Medical Outcomes Study13; and PTSD, posttraumatic stress disorder. See the “Methods” section for a descrip-tion of each screening tool. P values are derived from Wald F tests (df = 28) for the difference between each group, or a linear trend.

†Only 23 people in “yes” category.





demographic factors and exposure totrauma on the mental health and socialfunctioning outcomes. We present theresults of the GHQ-28 total score, esti-mated prevalence of PTSD symptoms,andMOS-20social functionscale asout-come measures in relation to variousdemographic and trauma experiencemeasures. P,.05 was considered sig-nificant for univariate and multivari-ate analyses. Being older, being cur-rently unemployed, being widowed,having little education, reporting a pre-viously diagnosed psychiatric illness,and reporting a previous diagnosis of achronic health condition were associ-ated in this analysis with a high (eg,worse) GHQ-28 score, indicating non-

specific psychiatric morbidity. Simi-larly, living in a rural setting, being cur-rently unemployed, being older, havinglittle education, and reporting havingreceived a diagnosis of a chronic healthcondition were associated with a low(eg, worse) social functioning score.Finally, HTQ results indicate that beingfemale and having received a diagno-sis of a chronic health condition wereassociated with PTSD symptoms.

Most traumatic event variables (forcedseparation from family, murder of fam-ily or friend, and increasing number oftraumatic events) but not rape were as-sociated with a worse score in the 3 mea-sured mental health outcomes, with theexception of forced separation for so-

cial functioning. The association be-tweenrapeandpsychiatricmorbidityandsocial functioning may be difficult to ob-serve here because of the relatively smallnumber of reported rape cases.

Multivariate Statistical AnalysesSince we had identified 2 different groupsof explanatory variables, demographicand exposure, we treated these differ-ently using a multivariate analysis. First,the effect of each demographic variableon the mental health outcomes was ad-justed for all other variables, both de-mographic and exposure (TABLE 5).

Subpopulations at risk (statisticallysignificant as measured by the multi-variate analyses) for psychiatric mor-

Table 5. Demographic Variables Affecting Mental Health Outcomes, Adjusted for All Variables*

Variable

GHQ-28(Scale, 0-28)

MOS-20 Social Functioning(Scale, 0-100) PTSD Symptoms

Adjusted Mean(SE)

PValue

Adjusted Mean(SE)

PValue

OR(95% CI)

PValue

LocationUrban 12.19 (0.56)

.0637.03 (2.37)

.0011.00

.74Rural 10.54 (0.55) 25.85 (1.72) 1.10 (0.63-1.92)

SexMale 10.96 (0.45)

.4728.95 (3.31)

.821.00

.02Female 11.20 (0.45) 30.10 (2.28) 1.93 (1.09-3.41)

Current employmentYes 10.11 (0.79)

.15†35.64 (4.07)

.0460.97 (0.43-2.17)

.94No 11.28 (0.40) 28.57 (1.23) 1.00

Age, y15-34 9.64 (0.56) 31.85 (2.32) 0.78 (0.40-1.54)

35-54 12.22 (0.42).006 (linear)

26.85 (1.62).91 (linear)†

1.76 (0.91-3.38).39 (linear)

55-64 12.03 (0.72) 27.56 (2.61) 1.00

$65 12.37 (0.61) 32.14 (3.74) 0.67 (0.30-1.48)

Marital statusMarried 11.29 (0.46) 29.97 (1.69) 0.68 (0.37-1.24)

Divorced 8.11 (0.83).08†

27.34 (6.42).14

0.50 (0.08-3.22).07

Widowed 12.60 (1.33) 21.23 (3.47) 1.62 (0.85-3.07)

Single 10.41 (0.48) 31.62 (2.11) 1.00

EducationLess than primary 11.22 (0.40) 31.20 (2.41) 0.78 (0.39-1.53)

Primary 10.65 (0.57).70 (linear)†

31.19 (2.26).50 (linear)†

0.63 (0.39-1.01).92 (linear)

Secondary 11.84 (0.53) 26.75 (2.61) 1.00

Some university 10.51 (0.57) 28.28 (4.51) 0.70 (0.27-1.87)

Previous psychiatric illnessYes 18.00 (1.00)

,.00127.17 (6.94)

.732.87 (1.22-6.76)

.02‡No 10.98 (0.38) 29.72 (1.45) 1.00

Chronic health conditionYes 13.33 (0.28)

,.00126.51 (1.91)

.011.44 (0.89-2.33)

.13No 9.40 (0.61) 32.11 (1.60) 1.00

*GHQ-28 indicates General Health Questionnaire-2810,11; MOS-20, Medical Outcomes Study13; PTSD, posttraumatic stress disorder; OR, odds ratio; and CI, confidence interval.See the “Methods” section for a description of each screening tool.

†Indicates change to not significant from univariate analysis.‡Indicates change to significant from univariate analysis.





bidity as measured by GHQ-28 scoreswere those aged 65 years or older, thosewith previous psychiatric illnesses, andthose with self-reported chronic healthproblems. In the multivariate analysis,employment, location, sex, marital sta-tus, and education were not statisti-cally significant risk factors for psychi-atric morbidity. Subpopulations at riskfor poor social functioning, as mea-sured by the MOS-20, were people liv-ing in rural areas, those currently un-employed, and those with chronic healthproblems. There was no significant de-crease in social functioning with increas-ing age or education status when ad-justed for all other variables. Women andpersons with a previous psychiatric ill-ness had a significantly higher esti-mated prevalence of PTSD symptoms.

To analyze the effect of exposure vari-ablesonmentalhealthoutcomes,weper-formedasecondmultivariateanalysis forwhich all P values for the relationshipbetweeneachexposurevariableandeachoutcome measure were adjusted for alldemographic variables, previous psy-chiatric illness, and chronic health con-dition(TABLE 6).Peoplewhowere inter-

nally displaced tended to have highertotal GHQ-28 scores than refugees(P=.03) or those who did not move(P=.009). However, there was no sig-nificant difference in the total GHQ-28scores between refugees and those whodid not move (P=.50), and the displace-ment seemed to have no effect on sig-nificance for MOS-20 social function-ing scores or the prevalence of PTSDsymptoms, when adjusted for the effectsof the demographic variables.

There was a significant linear in-crease in total GHQ-28 scores (P,.001),a significant linear decrease in MOS-20social functioning scores (P=.02), and asignificant linear increase in the preva-lence of PTSD symptoms (P,.001) withincreasing numbers of trauma events(Table 6). Specific traumatic eventsseemed to be closely related to specificmental health conditions. People expe-riencing forced separation from familyor murder of a family member or friendshad significantly higher total GHQ-28scores and significantly higher preva-lence of PTSD symptoms than peoplewithout these experiences. People expe-riencing murder of a family member or

friend also had significantly lowerMOS-20 social functioning scores.

A rape experience seemed to have noeffect on GHQ-28 scores, MOS-20 so-cial functioning, or prevalence of PTSDsymptoms, although, as stated earlier,a relationship may be difficult to ob-serve due to the relatively small num-ber of reported rape cases.

COMMENTThere was a high prevalence of trau-matic events (Table 2) among the Kos-ovar Albanians, and large numbers ap-pear to have experienced multipletraumas. Higher levels of PTSD symp-toms, an increase in nonspecific mentalmorbidity as measured by the GHQ-28,and a decrease in social functioning wereassociated with higher levels of cumu-lative trauma. These relationships re-mained even after adjusting for the ef-fects of demographic variables, previouspsychiatric illness, and other chronichealth conditions. Our results are con-sistent with those of other studies.22-24 Al-though the 4 subscales of the GHQ-28provide information on types of symp-toms, they have not been designed to

Table 6. Exposure Variables Affecting Mental Health Outcomes, Adjusted for All Demographic Variables*

Variable

GHQ-28 (Scale, 0-28)MOS-20 Social Functioning

(Scale, 0-100) PTSD Symptoms

Adjusted Mean(SE)

PValue

Adjusted Mean(SE)

PValue

OR(95% CI)

PValue

DisplacementRefugee (R) 10.71 (0.59) R vs I: .03 28.99 (1.62) R vs I: .80 1.30 (0.64-2.66) R vs I: .58

Internally displaced (I) 12.80 (0.71) R vs D: .50 30.15 (4.34) R vs D: .20† 1.52 (0.68-3.36) R vs D: .46

Did not move (D) 10.24 (0.60) I vs D: .009 31.51 (1.71) I vs D: .77 1.00 I vs D: .29†

Rape (HTQ)Yes 11.83 (1.09)

.4025.48 (4.86)

.351.68 (0.69-4.08)

.24No 11.01 (0.50) 30.01 (1.46) 1.00

Forced separation (HTQ)Yes 12.16 (0.59)

,.00130.35 (2.15)

.722.10 (1.38-3.20)

.001No 10.23 (0.51) 29.40 (1.81) 1.00

Murder of family or friend (HTQ)Yes 13.58 (0.35)

,.00124.64 (3.45)

.0472.09 (1.29-3.38)

.004No 10.12 (0.60) 31.74 (1.14) 1.00

Trauma events, No.0-3 9.22 (0.46)

,.001 (linear)

37.59 (3.01)

.02 (linear)

1.00

,.001 (linear)4-7 9.32 (0.67) 32.19 (2.26) 0.65 (0.32-1.31)

8-11 12.49 (0.57) 25.64 (2.06) 1.49 (0.82-2.69)

12-16 15.87 (0.63) 20.07 (4.96) 3.54 (1.98-6.35)

*GHQ-28 indicates General Health Questionnaire-2810,11; MOS-20, Medical Outcomes Study13; PTSD, posttraumatic stress disorder; OR, odds ratio; and CI, confidence interval.See the “Methods” section for a description of each screening tool. All P values are adjusted for location, sex, current employment status, age, marital status, education, indi-cation of previous psychiatric illness, and indication of chronic illness.

†Indicates change to not significant from univariate analysis.





make a psychiatric diagnosis. They do,however, give information on the meanscores for somatic, anxiety, social dys-function, and severe depression symp-toms (Table 3). It has been shown inother studies that the 4 subscales are notindependent from each another.11 In ourstudy, the mean scores for somatic symp-toms and anxiety and insomnia werehigher than those for social dysfunc-tion and severe depression. It is pos-sible that in this culture depression ismore likely to be expressed as somaticand anxiety symptoms. Alternatively, de-spite the traumatic events experiencedby many people by the time of the sur-vey, there may have been a genuine senseof hope and optimism because the warhad ended, and people were rebuildingtheir homes, lives, and country.

The optimal threshold score to de-termine prevalence of psychiatric mor-bidity from the GHQ-28 has not beenestablished for this population. Al-though we found that the GHQ-28 waswell accepted and easy to administer, theinterpretation of the results for preva-lence estimates is not straightforward un-less an optimal cutoff score is estab-lished for the specific population.Goldberg et al25 have suggested that amean score will provide a rough guideto the best threshold; however, thiswould always result in a general psychi-atric morbidity prevalence of approxi-mately 50%. Adopting a similar methodwith a conservative cutoff score of 11/12out of 28 (so that those answering posi-tively to 12 questions would be consid-ered a “case”), we found an estimatedprevalence of nonspecific psychiatricmorbidity of 43%. In studies of generalpopulations in 15 different countries, thehighest cutoff score found was 6/7.26-28

However, no cutoff scores have beenpublished for refugee populations orthose recently exposed to war, where itis likely that the prevalence of nonspe-cific psychiatric morbidity is muchhigher than in general populations.

A similar type of cutoff score is neededto estimate the prevalence of psychiat-ric morbidity using the MOS-20 in refu-gee populations. In the US population,a cutoff score of 52 (range, 0-100) was

established based on studies of the rela-tionshipbetweenmentalhealthandclini-cal measures of the probability of anypsychiatric disorder.13 Using the samecutoff score for the Kosovo populationwould result in an estimated preva-lence of psychiatric disorder of 83.5% vs13.2% in the US population.20 Furtherclinical validation of the GHQ-28 and theMOS-20 is under way to establish thebest thresholds for the Kosovar popula-tion. The estimated prevalence of PTSDsymptoms (17.1%) is somewhat lowerthan the reported PTSD figures (26.3%)for Bosnian refugees living in Croatia.4

The findings from the GHQ-28, MOS-20, and HTQ confirm earlier anecdotalreports that while the general health sta-tus of the Kosovo population remainedfairly stable, mental problems related tothe war situation are common. This isin line with other findings in refugeecamps and war/conflict situations.3-7 Nobaseline general mental health statusdata from before the war are availablefor Kosovo. However, in our survey, self-reporting of previous mental illness(1.7%) correlated with findings in otherpopulations.29

We identified several subpopula-tions at risk for poor mental health sta-tus and social functioning and we alsoattempted to identify mitigating fac-tors. In general, Kosovar Albaniansyounger than 35 years old, in good physi-cal health, and without previous psychi-atric illness appear to have been pro-tected from war-related psychiatricmorbidity. Future research will have todetermine whether there are other pro-tective factors that could be influencedby policy (eg, adequate housing, socialand community support). Social func-tioningwassignificantly loweramongthepopulation in rural areas; however, lo-cation did not seem to have the same ef-fect on general mental health. It is pos-sible that the extensive disruption of thecivic infrastructure in the rural areasmade it harder to function socially thanin cities, but closer family ties in theseareas mitigated mental health prob-lems. Not unexpectedly, people with pre-vious psychiatric illness had worse men-tal health outcomes, including higher

levels of PTSD symptoms, than did thosewithout such illness. Similarly, indica-tion of a previously diagnosed chronichealthconditionwasassociatedwithgen-eral psychiatric morbidity and socialfunctioning but not PTSD.

As measured by the GHQ-28 scores,peoplewhowere internallydisplacedhadworse mental health status than did refu-gees and those who never moved. In fact,a subsequentanalysis revealed thaton theaverage, those who did not move expe-rienced a mean (SE) of 5.36 (0.53) trau-matic events, while refugees experi-enced an average of 6.87 (0.33) and thoseinternally displaced an average of 8.02(0.56). This difference was statisticallysignificant (P=.01). Virtually all peoplewho were internally displaced were be-ing persecuted, and as a result of this suf-fered continuous trauma. People who be-came refugees faced similar traumaticevents, but usually of shorter durationbecause they were able to escape to othercountries. It can be hypothesized thatpeoplewhonevermovedaway fromtheirhomes were able to stay because theyhappened to be in relatively safer areasand thus experienced less trauma.

There are a number of limitations tothis study. Women were overrepre-sented in our sample probably becausethey were more likely to be at home dur-ing the daytime (data from othersources30 indicate that the male-femaleratio in Kosovo is close to 1). People whowere employed during the time of thesurvey were less likely to be home dur-ing the day. Because of security cur-fews it was not possible to return tohomes and interview those who were ab-sent during the day. There is a possibil-ity that some people who were the moststressed, because they were living in themost dangerous areas, were excludedfrom our study. However, if at all, thisexclusion happened very seldom andwould have resulted in underreportingof mental morbidity. Our study mightbe somewhat limited in statistical powersince resources were available to sampleonly 30 clusters. However, the poten-tial reduction in statistical power mayhave been moderated by the use of astratified design.





Because no structured clinical inter-views were performed, it is unclear towhat extent self-reported symptoms ofPTSD and nonspecific psychiatric mor-bidity, in the HTQ and the GHQ-28 re-spectively, would match clinical diag-nosis. It is possible that cross-culturaldifferences could have influenced theresults of this study. Even though thescreening instruments used were cre-ated and validated in developed na-tions similar to Kosovo, the instru-ments were not specifically validated forthis society. However, the GHQ-28 hasproven to be a reliable instrument in awide variety of cultures. The HTQ trau-matic events section was specificallyadapted for the Kosovo situation.

Although not traditionally part of amental health survey, the questions re-garding feelings of hatred and a desire forrevenge give a poignant picture of all-too-common emotions in this setting.These findings underscore the chal-lenge faced by the interim governmentof the United Nations Mission in Kosovoas it to seeks to establish reconciliationamong different ethnic groups.

CONCLUSIONS

Whether measured by the prevalence ofnonspecific psychiatric morbidity (43%),socialdysfunction,orprevalenceofPTSDsymptoms (17.1%), our study demon-strates the severity of mental health prob-lems among Kosovar Albanians.

When we conducted this survey thewar had just ended. The wounds of warwere still fresh, including the events thathad shaken the lives of hundreds ofthousands of people. Violence and actsof revenge continue in Kosovo. On thebasis of the results of our survey, theseincidents are not surprising. Mentalhealth problems related to the psycho-logical trauma of war and conflict situ-ations are a major public health con-cern. The high rates of poor mentalhealth status among those internallydisplaced and refugees who have re-turned to Kosovo also raises concern forthe mental health status of those whoremain in countries of asylum and re-settlement.

Until the psychological and social ef-fects of the war and persecution inKosovo are evaluated over time, wemust exercise caution in basing futurepredictions on the results of our sur-vey. Follow-up studies and monitor-ing of mental health problems to de-termine long-term effects of multiple,prolonged, and severe traumatic eventsamong the Kosovar Albanian popula-tion will provide more accurate data forpolicy recommendations.

Author Affiliations: National Center for Environmen-tal Health, International Emergency and Refugee HealthBranch (Dr Lopes Cardozo), National Center for In-fectious Diseases, Division of Quarantine (Dr Ver-gara), and National Center for Environmental Health,Environmental Hazards and Health Effects (Dr Got-way), Centers for Disease Control and Prevention, At-lanta, Ga; and Institute for Mental Health and Recov-ery, Pristina, Kosovo (Dr Agani).Funding/Support: This study was supported by fundsfrom the Centers for Disease Control and Prevention.Acknowledgment: We acknowledge the enormouscontribution and logistic support of Doctors of the World,in particular Supriya Madhavan, who provided us withinvaluable insights into the Kosovo situation. We alsoacknowledge the contributions of the interviewers, manyof whom themselves had been refugees or internallydisplaced during the war, who made the data collec-tion possible. We also acknowledge the contributionof mental health staff from the Institute of Mental Healthand Recovery in Pristina, Kosovo. The Harvard Pro-gram in Refugee Trauma gave us invaluable advice, par-ticularly by Richard Mollica, MD, MAR; James Lavelle,MSW; and Keith McInnes, MS, who shared their ex-tensive clinical and research expertise in this field.

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Kosovan Mental Health