Family Practice Vol. 20, No. 4, 489-491
© Oxford University Press 2003
International Health Care Research |
Post-traumatic stress disorder among family physicians in Bosnia and Herzegovina
d
a Department of Family Medicine,
b Queen’s University Family Medicine Development Program in the Balkans Region,
c Centre for Studies in Primary Care, Queen’s University, Kingston, Ontario, Canada and
d Department of Psychiatry, University of Tuzla, Bosnia and Herzegovina.
Correspondence to Ms Teresa Broers, Family Medicine Centre, 220 Bagot Street, PO Bag 8888, Kingston, Ontario, Canada; E-mail: broerst{at}post.queensu.ca
Hodgetts G, Broers T, Godwin M, Bowering E and Hasanovi M. Post-traumatic stress disorder among family physicians in Bosnia and Herzegovina. Family Practice 2003; 20: 489–491.
Received 30 September 2002; Revised 13 January 2003; Accepted 28 March 2003.
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Abstract |
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Background. The traumatic events experienced by thousands of people in Bosnia and Herzegovina during the 1992–1995 conflict may have a lasting effect on the mental health of the country, characterized by high rates of post-traumatic stress disorder (PTSD). A diagnosis of PTSD among family physicians could affect their ability to diagnose and treat patients for depression, anxiety and PTSD.
Objective. The aim of the present study was to determine the prevalence of PTSD among family medicine physicians in Bosnia and Herzegovina.
Methods. A self-administered questionnaire, including the PTSD Checklist–Civilian Version (PCL-C) which is a validated scale for PTSD screening, was distributed to family medicine residents and specialists in Bosnia and Herzegovina. The prevalence of PTSD was determined, and factors related to PTSD were considered.
Results. One hundred and thirty-three (90.5%) of the 147 physicians who were available to be surveyed completed the questionnaire. Of the 88% who had a traumatic experience during the war, 18% met the criteria for PTSD. The likelihood of meeting the criteria for PTSD was not affected by age, sex or whether the physician had worked in a field hospital during the war. However, a positive response to the question "Do you think the traumatic event you experienced during the war still affects you today?" was highly associated with the diagnosis of PTSD (odds ratio 7.26, 95% confidence interval: 1.57–33.60). Also, this question was shown to have a high degree of sensitivity and negative predictive value, and may be of use as a screening tool for ruling out the presence of PTSD after a traumatic war experience.
Keywords. Bosnia and Herzegovina, epidemiology, family medicine, post-traumatic stress disorder.
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Introduction |
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From 1992 to 1995, the people of Bosnia and Herzegovina (BiH) experienced one of the most horrific wars seen in Europe in the latter half of the 20th century, where thousands of citizens witnessed or experienced traumatic events. This has led to long-term emotional scars and mental health problems in the population, including post-traumatic stress disorder (PTSD). For doctors and nurses in particular, the combination of the hospital environment during a war and personal experiences outside of work could expose them to a greater number of traumatic stressors that subsequently could lead to PTSD. Moreover, a diagnosis of PTSD in general, and the avoidance mechanism in particular, could affect a physician’s ability to diagnose and treat patients for depression, anxiety and PTSD. Although several mental health and physical disorders are triggered by trauma, this study focuses on PTSD and seeks to determine the prevalence of PTSD among family physicians in BiH.
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Methods |
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This descriptive study used a self-administered questionnaire, the PTSD Checklist–Civilian Version (PCL-C). The PCL-C is a 17-item self-report measure of PTSD.1,2 The items correspond to the DSM-IV symptoms for PTSD and yield a total score and three symptom cluster subscale scores. Although the PCL-C has not been validated in the Bosnian-Serbo-Croat language, it has excellent internal consistency, test–retest reliability and validity in English.1,2
The PCL-C was selected for its ability to screen for PTSD without asking about the specific traumatic events that may have caused PTSD. Demographic and occupational questions were added to the questionnaire, but no sensitive questions regarding ethnic/religious background were included. The final two questions asked whether or not the respondents witnessed or experienced what they considered to be a traumatic event during the conflict, and if yes, did they think that it still affected them today. Respondents who did not live in BiH during the conflict were excluded from the final sample frame.
The questionnaire was translated into Bosnian-Serbo-Croat, back-translated into English, and pilot-tested by health professionals in BiH.
The study population included family medicine residents and graduates from the Queen’s University Family Medicine Development Program in the Balkans Region. Data collection took place in June 2002 at a series of research conferences in BiH. This study received ethics approval from the Queen’s University Human Research Ethics Board.
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Results |
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There are 224 physicians currently enrolled or who have graduated from the Family Medicine programme. A total of 147 residents and graduates were at the research conferences, and questionnaires were completed by 133 participants, for a 90.5% response rate. Of those, 118 lived in BiH at some point during the conflict.
Demographic data on the final 118 physicians surveyed showed that 82% of respondents were women, and 78% of respondents practised medicine during the conflict. Some type of traumatic event was witnessed or experienced by 102 (88%) of the 116 responding physicians; of those, 59% believed that the traumatic event still affected them in some way. Proportionally more men than women (95% versus 51%: P value <0.001) worked in field hospitals during the war, but there were no differences between men and women regarding experience of traumatic events.
Based on the PCL-C cut-off score of 50 and respecting the symptom cluster criteria, the observed prevalence rate of PTSD among those physicians who experienced or witnessed a traumatic event (n = 102) during the conflict was 18%.
No differences in age, sex or practise of medicine during the war were associated with PTSD (Table 1
). However, believing that the traumatic event experienced during the war still affected them was associated with a diagnosis of PTSD according to the PCL-C (odds ratio 7.26, 95% confidence interval: 1.57–33.60).
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Because of this strong association, we looked at the potential use of this single question as a screening test for PTSD and found a sensitivity of 89% and specificity of 48%. The positive predictive value of this question was 27%; the negative predictive value was 95%.
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Discussion |
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The 18% PTSD rate among family physicians is lower than studies that considered the Bosnian population following the Balkan conflict. Reports of PTSD rates among refugees, for example, range from 45 to 75%.3–6
Rates among health workers in conflict periods differ significantly. Of two studies that consider American nurses in Vietnam, one determined that >30% of the nurses experienced PTSD-related symptoms, while the other found that 3.3% of nurses still on active duty had PTSD nearly 20 years after the war.7,8 Moreover, health care workers who are from the country at war may experience the trauma of war differently from expatriate health care workers. A study by Shields et al. found that 22 of 25 Croatian health professionals working in post-war Croatia had some PTSD symptomatology.9 PTSD symptomatology can last for years and can affect job performance. For our study population of family physicians, this has consequent implications for the treatment of patients with mental health disorders.
Our study looked at PTSD rates among this population >6 years after the Bosnian conflict ended. PTSD symptomatology can increase over the years for some and decrease for others.5,6 Since no baseline data had been collected for this population, we cannot know whether current PTSD symptomatology for our population has improved over the years or not. We also do not know if existing PTSD symptomatology is a result of traumatic experiences from the war or of unrelated traumatic experiences. Not obtaining specific information regarding trauma is a limitation of this study. However, it was important to the authors to use a self-report screening tool and to avoid any emotional distress that could occur by asking specific questions regarding trauma. A further limitation related to the PCL-C is that, as a highly sensitive screening tool, it may lead to false positives, so the actual number of physicians with PTSD is likely to be lower than 18%.
An interesting finding was the high sensitivity (89%) and negative predictive value (95%) of the question "Do you believe that the traumatic event still affects you today?" This is the best configuration for a screening test. If the response to the question is ‘no’, then one can be fairly certain the condition does not exist. If the response is ‘yes’, the condition may or may not be present and further testing is needed. This screening question could be extremely useful in limiting the numbers of people that require more evaluation for PTSD. While we have only shown this single question to be a useful screen in family physicians in BiH, it is likely that it would be equally effective in other populations of physicians and perhaps in the general population, although this remains to be shown.
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References |
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1 Weathers FW, Litz BT, Herman DS, Huska JA, Keane TM. The PTSD checklist: reliability, validity, and diagnostic utility. Presented at the Annual Meeting of the International Society for Traumatic Stress Studies. San Antonio, TX; October 1993.
2 Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist (PCL). Behav Res Ther 1996; 34: 669–673.[CrossRef][ISI][Medline]
3 Kozaric-Kovacic D, Folnegovic-Smalc V, Skrinjaric J, Szajnberg NM, Marusic A. Rape, torture, and traumatization of Bosnian and Croatian women: psychological sequelae. Am J Orthopsychiatry 1995; 65: 428–433.[ISI][Medline]
4 Weine SM, Becker DF, McGlashan TH et al. Psychiatric consequences of ‘ethnic cleansing’: clinical assessments and trauma testimonies of newly resettled Bosnian refugees. Am J Psychiatry 1995; 152: 536–542.
5 Weine SM, Vojvoda D, Becker DF et al. PTSD symptoms in Bosnian refugees 1 year after resettlement in the United States. Am J Psychiatry 1998; 155: 562–564.
6 Mollica RF, Sarajlic N, Chernoff M, Lavelle J, Vukovic IS, Massagli MP. Longitudinal study of psychiatric symptoms, disability, mortality, and emigration among Bosnian refugees. J Am Med Assoc 2001; 286: 546–554.
7 Paul EA. Wounded healers: a summary of the Vietnam Nurse Veteran Project. Mil Med 1985; 150: 571–576.[ISI][Medline]
8 Stretch RH, Vail JD, Maloney JP. Posttraumatic stress disorder among Army Nurse Corps Vietnam veterans. J Consult Clin Psychol 1985; 53: 704–708.[CrossRef][ISI][Medline]
9 Shields J, Erdal K, Skrinjaric J, Majic G. Post-traumatic stress symptomatology among health care professionals in Croatia. Am J Orthopsychiatry 1999; 69: 529–535.[Medline]
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