CASE STUDY: BOSNIA AND
HERZEGOVINA (BiH)
Harvard Program in Refugee Trauma (HPRT)
Richard F. Mollica MD, MAR
Michael P. Massagli, PhD
James Lavelle, LICSW
Aida Kapetanović, MD
Social and Health
Indicators
1981
1991
2000
4,124,256
4,395,643
3,683,665
Refugees
-
-
643,250
Displaced Persons
-
-
501,000
Employed:
Unemployed
-
3.17:1
1:1
190
299
174
Population
Monthly Income
in US$
Major Objectives of World Bank-HPRT Project in
BiH Middle Bosnian Canton (Travnik)
 Mental health training and technical assistance to
primary care providers (PCPs)
 Create network of PCPs skilled in mental health and
trauma-related disorders
 Develop with cantonal MOH mental health services
integrated at all levels, including CBRs
 Integrate results into BiH health reform
 Prepare Lessons Learned for dissemination
throughout BiH
ASSOCIATION BETWEEN PSYCHIATRIC STATUS AND
DISABILITY, BOSNIAN REFUGEES, 1996 (N=533)
60
Total %
Disabled %
50
Percent
40
30
20
10
0
Asym
SOURCE: JAMA v282:437, 1999
PTSD Alone
Dep
Both
Persistence of Mental Health
Symptoms Over 3 Years
Refugee cohort (n=378) - mental health status
70
Percent
60
50
asym ptom atic
40
depression
30
PTSD
20
depression and PTSD
10
0
1996
1999
Survey Year
Change in Symptom Status 1996-1999
90.0
80.0
Percent
70.0
60.0
Asymptomatic - 1999
50.0
Depression
40.0
PTSD
30.0
Depression and PTSD
20.0
10.0
0.0
A (n=209)
D (n=70)
PTSD (n=20)
1996 symptom status
D & PTSD
(n=78)
Effect of Trauma, 1996
Distribution of mental health symptoms - 1996
70
60
Percent
50
asym ptom atic
40
depression
30
PTSD
depression and PTSD
20
10
0
0-2
3-5
6 or more
Number of trauma events
Effect of Trauma, 1999
Distribution of mental health symptoms - 1999
70
60
Percent
50
asym ptom atic
40
depression
30
PTSD
depression and PTSD
20
10
0
0-2
3-5
6 or more
Number of trauma events
THE MENTAL HEALTH COST
OF MASS VIOLENCE
0
50
SERIOUS MENTAL ILLNESS
PSYCH. INCAPACITATION
SERIOUS FAMIILY CONFLICT
CLNICAL DEPRESSION/PTSD
FEAR OF GOVERNMENT
SEEKING JUSTICE/REVENGE
PHYS, MENTAL EXHAUSTION
DEMORALIZATION
Percentage of General Population
SOURCE: Scientific American, v282, June 2000:54-57
100
Percent
Feeling No Trust in Others, Past Week
60
50
40
30
20
10
0
ym
s
a
Not at all
A little
Quite a bit
Extrem ely Often
o
pt
m
ic
at
de
e
pr
s
on
si
SD
T
P
d
r
ep
e
n
io
s
s
d
an
SD
T
P
Symptom Status, 1999 (378 refugees)
2001 Living Standards Measurement Survey
(LSMS) in BiH (N=12,954)
 23% report depressive symptoms consistent
with DSM-IV diagnosis of major depression
 6% report reexperiencing trauma symptoms
 15% report limitations in physical functioning
 Women 2x more depression, PTSD, functional
limitations than men
Primary Health Care Patients: Middle
Bosnian Canton, 2003 (N=184)
SCID = Structured Clinical Interview for DSM-IV
32% psychiatric diagnosis (DSMIV/SCID)
•
16% major depression
• 10% Generalized Anxiety Disorder
• 3% PTSD only
• 3% Dysthymia; other
Providers Needs Assessment: 2000
 40% (30-80%) of patients have mental health problems
 65% of PCPs are not able to make DSM-IV (ICD-10)
diagnoses
 PCPs reported very low confidence in treatment of
mental health crises
 PCPs reported almost no confidence or very low
confidence in treatment of different groups of traumatized
patients
Providers Needs Assessment: 2000 (cont’d)
 33% of PCPs didn’t know about CBRs
 54% of PCPs never referred patients to CBRs
 30% of those who did refer never received feedback
from the CBR
EDUCATION
105 PCPs and psychiatrists trained
Curriculum completed:
1) Trauma Story
2) Psychosocial interviewing skills
3) Screening Instruments
4) Identification and management of the most common psychiatric
disorders: mood disorders, neurotic stress-related and
somatoform disorders, substance abuse, organic mental
disorders, psychosis
5) Identification and management of disability
6) Management skills/health reform
ON-SITE VISITS/SUPERVISION
Case-Oriented
Goals:
 To sustain the knowledge
 To improve relations between PCPs and mental health
professionals
 To prevent burnout
Level of Trauma Experienced by PCPs and
PCPs’ Families
80%
PCP
70%
PCP's Family
60%
50%
40%
30%
20%
10%
0%
None
Mild War
Trauma
Moderate War
Trauma
Severe War
Trauma
Extreme War
Trauma
PCPs’ Confidence in Eliciting and Listening to Trauma
Stories: Pre-training vs. Post-training
6
Pre-training
Post-training
Mean confidence
5
4
3
2
1
0
Eliciting Trauma Story
Listening to Trauma
Story
Listening to Emotional
Suffering
PCPs’ Confidence in Diagnosing Certain Medical and
Psychiatric Problems: Pre-training vs. Post-training
6
Pre-training
Post-training
Mean confidence
5
4
3
2
1
0
Somatic Symptoms
Caused by Trauma
Mental Health
Problems
Depression
PTSD
MENTAL HEALTH SERVICES: OPTIMAL MODEL
Community
Police
Primary Health
Care
General Hospital
In-patient
Mental Hospital
Criminally Insane
Emergency Room
General Hospital
MENTAL HEALTH SERVICES IN BOSNIA
Community
Primary Health
Care
Psychiatric Hospital
Community
Rehabilitation
Centers
MENTAL HEALTH SERVICES IN BOSNIA
Community
Primary
Health
Care
Community
Rehabilitation
Centers
General Hospital
In-patient
FRAMEWORK FOR MENTAL HEALTH RECOVERY
I. Policy/Legislation
VI. Linkage to
Economic Development/
Human Rights
II. Financing
RECOVERY
V. Role of
International Agencies
III. Science-Based
Mental Health Services
IV. Multi-Disciplinary
Education
BiH Mental Health (MH) Case Study
I.
Policy/Legislation
•
MH integrated into health reform
•
LSMS MH data integrated into BiH
health statistics
•
Future role of CBRs
BiH Mental Health (MH) Case Study
II.
Financing
•
Sustainable financing of MH in PHC
•
Psychiatry – PHC linkage
•
Job training and social services in
PHC/CBRs
•
Cost-effective MH training and services
BiH Mental Health (MH) Case Study
III. Science-Based MH Services
HPRT Model:
•
Needs assessment
•
Implementation of field-tested
curriculum
•
On-site supervision
•
Monitoring assessment and feedback
BiH Mental Health (MH) Case Study
IV. Multi-Disciplinary Education
•
“Pedagogy of Trauma” in BiH medical
schools
•
Integration into family medicine
•
CME
BiH Mental Health (MH) Case Study
V.
Role of International Agencies
•
Coordination/collaboration among BiH
MOH – UN – NGO – donors –
universities
BiH Mental Health (MH) Case Study
VI. Linkage to Economic Development (ED)
and Human Rights (HR)
•
•
•
•
Violence-induced trauma has negative impact
on MH
Both provider and patient exposed to violence
MH has negative impact on social capital and
physical functioning
Undiagnosed and untreated MH problems place
significant burden on health care system
Harvard Program in Refugee Trauma
22 Putnam Avenue
Cambridge, MA 02139
http://www.hprt-cambridge.org