Consequences of Untreated Posttraumatic Stress Disorder Following War in Former Yugoslavia: Morbidity,Subjective Quality of Life,and Care Costs

Aim

To assess long-term mental health outcomes in people who suffer from war-related posttraumatic stress disorder (PTSD) but do not receive appropriate treatment.

Methods

We interviewed 264 subjects from former Yugoslavia, who lived in Croatia, Serbia, Germany, and the United Kingdom. All of them had suffered from PTSD at some point following the war, but never received psychiatric or psychological treatment. The interviews took place on average 10.7 ± 3.0 years after the war-related trauma. Outcomes were current PTSD on the Clinician Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders-IV, subjective quality of life (SQOL) on the Manchester Short Assessment of Quality of Life, and care costs. Socio-demographic characteristics, the level of traumatic war-events, and aspects of the post-war situation were tested for association with outcomes.

Results

Current PTSD was diagnosed in 83.7% of participants, the mean SQOL score was 4.0 ± 0.9, and mean care costs in the last 3 months exceeded €1100 in each center. Older age, more traumatic war-events, lower education, and living in post-conflict countries were associated with higher rates of current PTSD. Older age, combat experience, more traumatic war-events, being unemployed, living alone, being housed in collective accommodation, and current PTSD were independently associated with lower SQOL. Older age and living in Germany were linked to higher costs of formal care.

Conclusion

People with untreated war-related PTSD have a high risk of still having PTSD a decade after the traumatic event. Their SQOL is relatively low, and they generate considerable care costs. Factors that have been reported as influencing the occurrence of PTSD also appear relevant for recovery from PTSD. Current PTSD may impair SQOL independently of social factors.Posttraumatic stress disorder (PTSD) is one of the most frequently reported mental health consequences of exposure to war experience, although studies on both refugees and war veterans yielded inconsistent findings on the exact prevalence rates (1-5). Some evidence suggests that a higher degree of exposure to both war-related traumatic events and the pressures of the post-migration environment can lead to higher rates of PTSD over many years (6-9). Evidence based treatments for PTSD exist and are – at least to some extent – available in most post conflict contexts in the Western world. In such contexts, it can be assumed that a significant number of people with war-related PTSD receive treatment from psychiatrists or psychologists or are prescribed anti-depressants by their general practitioner.For various reasons, however, many people with serious and distressing levels of PTSD following war do not receive psychiatric or psychological treatment (10), and not much is known about their long term outcomes. It is not clear whether most of them recover from PTSD without treatment or the symptoms are likely to take a persistent course. Another question is what their subjective quality of life (SQOL) is, and what costs of formal and informal care they generate. Finally, it is not clear what factors are associated with more or less favorable outcomes in such populations, and whether current PTSD is associated with poorer SQOL.The present study addressed these questions and assessed long term outcomes in people who suffered from PTSD at some point of time following the war in former Yugoslavia in the 1990s, but never received psychiatric or psychological treatment in either primary or secondary care. Current PTSD, SQOL, and care costs were assessed as outcomes in refugees in Western Europe and in people who stayed in the area of conflict. Socio-demographic characteristics, the level of exposure to war stressors, and aspects of the post-war situation were tested for their association with more or less favorable outcomes.