One in four war refugees in Bosnia and Herzegovina may be disabled by psychiatric disorders, according to a pair of Harvard studies.
Psychiatric researchers at the Harvard Medical School and the Harvard Program in Refugee Trauma said worldwide humanitarian aid to Bosnia and other countries devastated by war could fail without mental health assistance.
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"Little funding has been put in this area because, in general, people haven't felt the importance of knowing the impact of violence and the disabilities involved. Most of the support is humanitarian assistance," said Richard Mollica, lead author of the study and associate professor of psychiatry at Harvard Medical School.
Many disabilities were found to stem from emotional trauma, which kept individuals from working or otherwise leading productive lives. Even given financial and other types of aid, mental health problems could cause economic and social problems and thwart recovery, researcher said.
The study results appear in the 4 August Journal of the American Medical Association.
"When there's a significant percentage [of people] who are functionally disabled, then you have a very difficult recovery process," said Mollica. And showing that people are functionally disabled due to war trauma is key to shifting the focus of aid programs.
"The first thing we had to do was measure trauma and the cultural meaning of trauma. Next, we had to ask 'what is the psychological impact?'" Mollica said. "Finally, we had to say, so what, they are emotionally distressed, so what? Emotional suffering is a normal response to violence."
Since a study of Cambodian refugees was completed in 1990, Mollica's group has worked toward identifying physical and social disabilities due to trauma.
"Once you find disability, it's hard to ignore the emotional suffering," Mollica said.
The 534 study subjects were randomly chosen from families living in a refugee camp in Varazdin, Croatia, in 1996, almost a year after the Dayton Peace Accord ended the war.
The Bosnians were 41 percent male and 59 percent female, with a mean age of 50 years. Almost half the sample had been physically disabled, while almost a quarter were widowed.
The study showed that refugees with symptoms for both major depression and post-traumatic stress disorder were five times more likely to be disabled than those who reported no psychiatric symptoms.
Ninety-four percent of the refugees studied said they had been exposed to war-related violence. They were most likely to have been confined at home, forced to hide from snipers, or to have encountered shelling or grenade attacks.
Eighteen percent of the refugees were tortured, which included being forced to stand for long periods of time, submitted to a mock execution, or confined to very small spaces, such as boxes or sacks. Refugees who suffered three to five traumatic events were more than twice as likely to suffer disabilities than were those who experienced less than two.
On the other hand, people who sustained six or more traumatic happenings -- many of them soldiers -- were less likely to have been disabled than those who met with between three and five traumatic incidents.
Researchers believe that soldiers' military training and commitment to defend their country and family may have helped them cope with trauma.
The survey also revealed that elderly refugees were more than three times more likely than their younger counterparts to be functionally disabled due to psychiatric disorders.
Two years ago, the World Bank's annual report announced that 60 states had been devastated by mass violence, according to Mollica. Traditional models for developing countries, the report said, don't seem to apply in a country in which the entire infrastructure is damaged by war.
"Business people say they need a new model because there's not enough money. This is a step towards a new model," Mollica said. "If you go back in time, mental health issues have always been ignored."
Few studies of this kind have been done, Mollica said, and more studies are needed to provide the appropriate aid to war-torn countries.
"These studies are rare because it's been very difficult to interview and study civilians and refugees and take a survey of mass violence because of the sites themselves," Mollica said. "Almost all studies have been done in countries after resettlement."
Researchers also face the challenge of deciphering cultural differences in behavior.
"All of the cultural measures have to be evaluated appropriately and validated," Mollica said. "They have their own meaning of trauma and symptoms."
The Harvard group is continuing to follow this group of refugees as they move back to their homes, to study the long-term effects of wartime trauma.
"There's an assumption that the impact of violence is like pulling a rubber band. It gets stretched, then you let go and it snaps back to normalcy," Mollica said.
"But this kind of data doesn't support that model. The rubber band doesn't go back to normal."
