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Başoğlu M, Livanou M, Crnobarić C, et al. Psychiatric and Cognitive Effects of War in Former Yugoslavia: Association of Lack of Redress for Trauma and Posttraumatic Stress
Reactions. JAMA. 2005;294(5):580–590. doi:https://doi.org/10.1001/jama.294.5.580
Author Affiliations: Trauma Studies Unit, Institute
of Psychiatry, King’s College, University of London, London, England
(Drs Başoğlu and Livanou); Clinical Hospital Zvezdara, Department
for Psychiatry, Belgrade, Serbia and Montenegro (Dr Crnobarić); Psychotrauma
Center, Psychiatric Clinic, Medical School, University of Rijeka, Rijeka,
Croatia (Dr Frančišković); Psychiatric Clinic, University
of Sarajevo, Sarajevo, Bosnia-Herzegovina (Drs Suljić and Vranešić);
and Institute for Physical Medicine and Rehabilitation “Dr. Miroslav
Zotović,” Banja Luka, Republica Srpska, Bosnia-Herzegovina (Dr
Context Although impunity for those responsible for trauma is widely thought
to be associated with psychological problems in survivors of political violence,
no study has yet investigated this issue.
Objective To examine the mental health and cognitive effects of war trauma and
how appraisal of redress for trauma and beliefs about justice, safety, other
people, war cause, and religion relate to posttraumatic stress responses in
Design, Setting, and Participants A cross-sectional survey conducted between March 2000 and July 2002
with a population-based sample of 1358 war survivors who had experienced at
least 1 war-related stressor (combat, torture, internal displacement, refugee
experience, siege, and/or aerial bombardment) from 4 sites in former Yugoslavia,
accessed through linkage sampling. Control groups at 2 study sites were matched
with survivors on sex, age, and education.
Main Outcome Measures Semi-structured Interview for Survivors of War, Redress for Trauma Survivors
Questionnaire, Emotions and Beliefs After War questionnaire, Structured Clinical
Interview for the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV).
Results The mean (SD) age was 39 (12) years, 806 (59%) were men, and 339 (25%)
had high school or higher level of education. Participants reported experiencing
a mean of 12.6 war-related events, with 292 (22%) and 451 (33%) having current
and lifetime posttraumatic stress disorder (PTSD), respectively, and 129 (10%)
with current major depression. A total of 1074 (79%) of the survivors reported
a sense of injustice in relation to perceived lack of redress for trauma.
Perceived impunity for those held responsible for trauma was only one of the
factors associated with sense of injustice. Relative to controls, survivors
had stronger emotional responses to impunity, greater fear and loss of control
over life, less belief in benevolence of people, greater loss of meaning in
war cause, stronger faith in God, and higher rates of PTSD and depression.
Fear and loss of control over life were associated with PTSD and depression
(odds ratio [OR], 2.91; 95% CI, 2.27-3.74 and OR, 2.30; 95% CI, 1.75-3.03,
respectively), and emotional responses to impunity showed a relatively weaker
association with PTSD (OR, 1.53; 95% CI, 1.16-2.02) and depression (OR, 1.39;
95% CI, 1.02-1.91). Appraisal of redress for trauma was not associated with
PTSD or depression.
Conclusions PTSD and depression in war survivors appear to be independent of sense
of injustice arising from perceived lack of redress for trauma. Fear of threat
to safety and loss of control over life appeared to be the most important
mediating factors in PTSD and depression. These findings may have important
implications for reconciliation efforts in postwar countries and effective
interventions for traumatized war survivors.
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