Mental health of refugees: the case of Albania.
Authors: Anastas Suli, Ariel Como
Journal: World Psychiatry (2002)

The war in Kosova, as shown by the media, started in March 1999, but a 'hidden' war was going on since the period September-October 1998. That was the time of the first expulsion of Albanian people from Kosova: 3500-4000 refugees settled in villages of Albania. Most of them had been exposed to such atrocities as systematic rape; torture; systematic killing of men; forced separation from family members; disappearance of male family members; witnessing of shelling and killing of relatives and others; plundering, burning or destruction of property and land; and the destruction of their social and cultural community.

We carried out a study assessing the prevalence of post-traumatic stress disorder (PTSD) in a sample of 840 Kosova refugees who settled in a village of Albania during the autumn/winter period 1998/1999. They were 392 males and 448 females within the age range of 14-81 years. They were approached by a postgraduate resident in psychiatry and a non-professional worker (herself a refugee) by the outreach method, and gave their informed consent to be interviewed. No inclusion criteria were used except for the age range. Data collection was made during a threemonth period (Spring 1999) and was concluded just before the massive displacement of Kosova people occurring during that year.

We recorded war-related trauma exposure by an ad-hoc questionnaire. The occurrence of PTSD was tested by the Penn Inventory for Posttraumatic Stress Disorder (1). This is a 26-item scale detecting the re-experiencing, avoidance and arousal symptomatology required by the DSM-III-R criteria for PTSD, which has been found to be quite reliable in terms of both internal consistency (alpha=0.94) and stability over a 5-day interval (r=0.96). Using a score of 35 as the cut-off, the scale has showed a sensitivity of 0.90 and a specificity of 1.0 (2). The scale was translated into Albanian by a senior psychiatrist, and the translation was approved by a group of mental health experts. It is normally a self-administered interview, but since many of our refugees were not accostumed to papers, in our study the scale was administered by a group of trained professionals and para-professionals.

Physical torture through beating using mili- tary means was reported by 50.5% of the interviewed people; destruction of property by 79.2%; robbing by 19%; imprisoning by 17.2%; killing of a loved one by 49%; sexual violence by 2.2% (information given in the standard interview); disappearance of a family member by 32.6%. 14% of the interviewed people had been seriously injured.

Using the cut-off score of 35 of the abovementioned scale, the prevalence of PTSD was 59%. It was 66.5% in women and 50.2% in men. The prevalence according to age groups was the following: 14-25 years of age: 47.6%; 26-45 years: 61.1%; 46-65 years: 67.9%; above 65 years: 76.9%.

These data are difficult to compare with those available in the literature. In a study of Croatian prisoners of war tortured in Serbian detemption camps, the prevalence of PTSD was 34% (3). On the other hand, a recent study of Bosnian refugees resettled in the United States reports a prevalence of 65% (4). It is important to emphasize that our sample consisted of people who survived a polyvalent traumatic situation, but who where still 'within' the trauma, since the 'real' war and the massive expulsion of Kosova inhabitants were just coming.

Despite the extent of the traumatic event and the enormous psychological distress, we have observed tremendous courage and fight for survival in this population. After the NATO declared Kosova as a place without war, the displaced persons massively started returning to their homes, despite the persistent claims by the international community that the place was not safe enough. In less than one month, around 1 million of them came back home in search for their lost identity and social status. Reports from the after-war period show that their adaptation abilities were high, although no information is available on their mental health status.

The exodus and the period of stay of Kosova people in Albania caused a change in the perception of mental health issues in this country: in a very short time the media were filled with comments and ideas (although very often superficial and simplistic) on possible assistance to this vulnerable group, as it never happened in the past. As a consequence, the social and state structures became more open to mental health problems in general and the atmosphere became more favorable to the reform needed in the mental health care system.