Research reportComorbidity of PTSD and depression: associations with trauma exposure, symptom severity and functional impairment in Bosnian refugees resettled in Australia
Introduction
Epidemiological studies have documented high rates of posttraumatic stress disorder (PTSD) in refugees and war-affected populations (Carlson and Rosser-Hogan, 1994, Cheung, 1994). With 21 million people displaced to various regions of the world (United Nations High Commissioners for Refugees, 2002), mostly in resource-poor countries, the dilemma for mental health professionals is how to select those refugees with PTSD who are in greatest need of treatment, particularly since natural remission of posttraumatic symptoms appears to be a common outcome (Steel et al., 2002). PTSD commonly occurs together with depression, with a recent epidemiological study undertaken in a Bosnian refugee camp revealing that 26% of that population manifested such comorbidity (Mollica et al., 1999). The present report focusing on Bosnian refugees explore whether those with comorbidity represent a high risk group for longer-term disability, and whether a specific pattern of traumatic antecedents leads to this particular clinical picture.
The war in Bosnia-Herzegovina displaced 2 million people (Mollica et al., 1999), many of whom were exposed to a campaign of ethnic cleansing in which gross human rights violations, torture and execution were common (Weine et al., 1995). According to the United Nations Economic and Social Council (1994), of the survivors, about half were forced to flee from their homes. Many refugees were accommodated in overpopulated refugee camps where hygiene was poor and shortages of food, water and fuel were endemic (Arcel et al., 1995). Others were detained in concentration camps (Arcel et al., 1995, Ryn, 1997) where human rights violations were widespread (Weine, 1999).
Australia has received a substantial number of Bosnian refugee families (Barrett et al., 2000) but, as yet, there is scant information available about the trauma experiences of this group. Anecdotal evidence (Silove, 1994) suggests that the reasons for fleeing, the traumas experienced, and the levels of psychiatric morbidity suffered by Bosnian refugees may be diverse. Hence, it is important to identify those trauma-affected subgroups that may still need interventions as a consequence of impairments in their psychosocial functioning.
Evidence is emerging from both the general trauma literature and the field of refugee mental health that those suffering from comorbid PTSD and depression may stand out as a group with substantial levels of psychosocial impairment, at least in the short-term. Comorbidity has been documented in a diversity of trauma-affected populations (Blank, 1994, Bleich et al., 1986, McGorry, 1995, Mellman et al., 1992, Sierles et al., 1983, Skodol et al., 1996) with the extent of the diagnostic overlap varying from 21% in Bosnian refugees (Mollica et al., 1999) to 45% in survivors of civilian violence (Shalev et al., 1998). Comorbidity in refugees appears to be clinically important in relation to the intensity of PTSD symptoms, with Karam (1997) reporting a three- to fivefold greater severity of overall symptoms compared to those with PTSD alone, findings that have been mirrored in other studies amongst refugees (Moore and Boehnlein, 1991) as well as amongst combatants (Skodol et al., 1996).
Comorbidity also appears to increase the level of impairment in social and occupational functioning at least in the short-term (Koren et al., 1999, Mollica et al., 1999, Mintz et al., 1992, Shalev et al., 1998). In a large-scale epidemiological survey in a Bosnian refugee camp, Mollica et al. (1999) reported that the comorbid group was five times more likely to manifest functional impairment compared to those diagnosed with PTSD alone. This study was conducted in the immediate aftermath of the war, so that the long-term impact of comorbidity on psychosocial functioning in Bosnian refugees remains unknown.
As yet, the mechanisms linking PTSD and depression remain unclear, although the frequency with which comorbidity is observed suggests that the association is not simply coincidental (Bleich et al., 1997, Mollica et al., 1999, Skodol et al., 1996, Shalev et al., 1998). Some authorities have suggested that PTSD is a more severe variant of reactive depression (Davidson et al., 1993). Other data tend to indicate that PTSD usually is the primary disorder, with comorbid depression developing as a secondary reaction (Bleich et al., 1997). An alternative hypothesis is that the antecedents of depression and PTSD are relatively independent (Skodol et al., 1996) reflecting the multiple challenges posed by complex trauma events (Silove, 1999). In particular, there is some evidence to suggest that exposure to physical abuse and threat to life are more likely to lead to PTSD (Green et al., 1993, Hauff and Vaglum, 1994), whereas loss of close attachments increases vulnerability to depression (Kroll et al., 1989, Westermeyer et al., 1983). For example, Carlson and Rosser-Hogan (1994), in their study of 50 Cambodian refugees, reported that separation from family members, loneliness and loss of loved ones were associated with depression, whereas severity of trauma, closeness to death and threat to survival predicted PTSD.
Refugees and war survivors commonly are exposed to multiple, sequential stressful events involving threat to life as well as loss. In some situations, such as witnessing the murder of family members, both loss and threat events occur simultaneously (Silove, 1999). Hence, it is possible that these overlapping but distinguishable stresses, namely traumatic loss and life threat may trigger distinctive but co-occurring symptom complexes of depression and PTSD. In a preliminary report based on the present sample (Momartin et al., in press.) we have found that life threat was specifically associated with risk of PTSD. In the present report, we sought to build on that earlier analysis to investigate the traumatic antecedents associated with comorbidity. We also aimed to extend the findings of Mollica et al. (1999) by investigating whether comorbidity in Bosnian refugees was associated with greater severity of symptoms and with higher levels of psychosocial impairment in the longer term.
Section snippets
Sample
One hundred and twenty six Bosnian Muslim refugees (hereafter Bosnian refugees) were recruited from the larger Bosnian community residing in Sydney, Australia. Although several ethnic groups experienced trauma during the war, most victims of ethnic cleansing were from Muslim backgrounds (Arcel et al., 1995, Weine et al., 1995, Weine, 1999) so that the focus of recruitment was restricted to this subgroup.
Random epidemiological sampling was not feasible given the absence of a central register of
Results
The sample consisted of 77 females (61%) and 49 (39%) males. The mean age was 47 years (range 18 to 88). Seventy-seven percent were married and 29% had at least one child. Eighty-seven percent of the sample had completed high school and 13% had completed a university course. Sixty-two percent had previously been employed in factory or sales work and 14% were professionals. In Australia, 96% were unemployed. Seventy-four percent of the sample spoke little or no English. Ninety-two percent of the
Discussion
Prior to drawing inferences from the present study, several limitations need to be considered. Retrospective reports of trauma by refugees could be biased or inaccurate. Recent research has indicated, however, that refugees remain consistent in their reports of the more extreme past traumas (Miller et al., 2002) such as the categories inquired into in the present study. The sample size was modest and the method of recruitment was not random. Hence, the rates of disorder observed, although
Conclusions
In summary, the present study suggests that comorbid PTSD and depression, an outcome of exposure to traumatic loss and life threat, is associated with a high risk of persisting disability in refugees. If it is true that those with pure PTSD are at no greater risk of psychosocial disability compared to refugees with no psychiatric diagnosis, this finding raises serious questions about the usefulness of the present classification of traumatic stress disorders. In particular, the results raise
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