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March 7, 2001

Mental Health Challenges in Postwar Kosova

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JAMA. 2001;285(9):1217. doi:10.1001/jama.285.9.1217-JMS0307-7-1

The humanitarian crisis in Kosova in 1999 has exposed the strengths and weaknesses of Kosova's mental health system. In this article I examine existing professional and social structures in Kosova, show how these structures reflect the needs of the population, and suggest ways of meeting those needs.

Twenty thousand patients with chronic psychiatric conditions and approximately 500 000 people with signs and symptoms of posttraumatic stress disorder present an extraordinary burden for the fragile, antiquated, and overly centralized mental health services of Kosova.1 Currently, there is 1 psychiatrist per 100 000 inhabitants, 1 psychiatric nurse per 35 000 inhabitants, 1 psychologist per 400 000 inhabitants, and 1 psychiatric social worker per 2 000 000 inhabitants.2 These dramatic conditions are exacerbated by insufficient long-term institutional resources, community-based mental health structures, and other support services for people with chronic mental illness.

The mental health system in Kosova continues to rely on extremely motivated mental health professionals, the strong Kosovar family unit, traditional healers in the society, and the qualified international mental health community. These are the cornerstones of the future mental health system and the resources that concerned health professionals must draw upon to work for the future of the Kosovar mental health system.

With these strengths and weaknesses in mind, members of the Kosovar mental health community started a Task Force for a Strategic Plan for Mental Health Reform in Kosova, under the auspices of the World Health Organization (WHO) Mental Health Unit and with support from mental health professionals from the University of Illinois at Chicago. Inspired by US practices and the WHO encouragement of mental health reforms, the role of the Task Force has been to implement a plan that will be grounded in evidence-based medicine while remaining culturally rooted in Kosovar society. The Task Force recognizes that the core of the future mental health system in Kosova must be community-based and family-oriented, with measures to ensure the dignity, integrity, and autonomy of the mentally ill person.

Acknowledging that the mental health system has historically been overly centralized and almost entirely based in the city of Prishtina, Task Force professionals are working toward providing locally based services, particularly by cooperating with local family physicians, traditional healers, and other community resources. Not only does this relieve some of the burden on limited medical resources, but it also encourages patients to develop support structures that will most benefit them and enlists local resources to identify the patients who most require treatment.

The Task Force has especially focused on integrating the family unit into treatment programs, including programs that are based on individual therapy. When coming to the clinics, patients usually arrive with several family members; the family provides a social support structure that practitioners must not ignore in the development of programs and interventions.

Reforms to the infrastructure, especially in education, legal and medical institutions, and human resources, are also essential. The immediate challenge is to respond to the very acute mental health needs of the population in the short term, while making nonlimiting decisions that will contribute to a positive direction for the future. Two collaborative projects between international and Kosovar organizations demonstrate how this challenge might be met. One is "Healing the Wounds of the War," a project developed by the Institute for Mental Health Recovery of Kosova (IMHRK) in cooperation with the Mind and Body Center, Washington, DC. The second is an interuniversity project, Kosovar Family Professional Educational Collaborative, that includes the University of Prishtina, IMHRK, the University of Illinois at Chicago, the University of Chicago-affiliated Chicago Center for Family Health, the American Family Therapy Academy, and the International Trauma Studies Program of New York University.

The collaboration between Kosovar and US mental health professionals in these partner organizations has been successful for 2 reasons. First, these projects recognize the potential of local professionals, as well as local social structures, to bring about improvements in mental health; second, these projects attempt to combine short-term training programs with the enhancement of long-term professional skills. As a result, these projects have focused on the capacities of Kosovar mental health professionals as the future leaders and implementers of the mental health system in Kosova. In turn, the local professionals have been able to focus on the creation of community-based mental health services, operating under the auspices of the emerging state mental health system.

This is a historic opportunity to establish a modern system of mental health services after the crisis of 1999 and decades of oppression in Kosova.3 The results so far have been encouraging, especially with regard to the restitution of the morale of the Kosovar mental health community. The effects on the everyday work in the clinic are also becoming apparent, as mental health providers begin to see more efficient work and better clinical results.

Lopes Cardozo  BVergara  AAgani  FGotway  CA Mental health, social functioning, and attitudes of Kosovar Albanians following the war in Kosovo. JAMA. 2000;284569- 577Article
United States International Development Agency, Kosovo crisis fact sheet. Available at: http://www.info.usaid.gov/hum_response/ofda/situation.html. Accessed June 28, 2000
Jones  L Letter from Kosovo: coping with Serbian repression in an Albanian population. BMJ. 1993;307112- 114Article