ORIGINAL CONTRIBUTION

Mental Health, Social Functioning,

and Attitudes of Kosovar Albanians
Following the War in Kosovo
Barbara Lopes Cardozo, MD, MPH
Alfredo Vergara, PhD

Context The 1998-1999 war in Kosovo had a direct impact on large numbers of civilians. The mental health consequences of the conflict are not known.

Ferid Agani, MD
Carol A. Gotway, PhD

Objectives To establish the prevalence of psychiatric morbidity associated with the

war in Kosovo, to assess social functioning, and to identify vulnerable populations among
ethnic Albanians in Kosovo.

Design, Setting, and Participants Cross-sectional cluster sample survey conducted from August to October 1999 among 1358 Kosovar Albanians aged 15 years
or older in 558 randomly selected households across Kosovo.

N LATE FEBRUARY

1998, CLASHES IN
Kosovo between Serbian police
forces and members of the Kosovo
Liberation Army intensified.1 Serbian forces burned homes and killed
dozens of ethnic Albanians in these raids.
As a result of the fighting, thousands of
ethnic Albanians were displaced from
their homes in Kosovo; many took refuge with host families, while a smaller
proportion (several thousands) fled to the
hills and forests.1 By the time North Atlantic Treaty Organization (NATO) operations began against Serbia on March
24, 1999, about 260000 people had been
displaced within Kosovo and 199000
had fled to other countries.2 It is estimated that as result of this conflict, more
than 800000 people became refugees in
neighboring countries (mainly Albania, Montenegro, and the former Yugoslav Republic of Macedonia), as well as
secondary countries of asylum in Europe, the United States, and elsewhere.
On June 9, 1999, an agreement between NATO and Serbia was reached,
and the following day NATO halted its
bombing campaign.
As the Serbian troops began to pull
out of Kosovo, the nearly 750000 Albanians from Kosovo who had been livSee also pp 578 and 615.

Main Outcome Measures Nonspecific psychiatric morbidity, posttraumatic stress

disorder (PTSD) symptoms, and social functioning using the General Health Questionnaire 28 (GHQ-28), Harvard Trauma Questionnaire, and the Medical Outcomes
Study Short-Form 20 (MOS-20), respectively; feelings of hatred and a desire for revenge among persons surveyed as addressed by additional questions.
Results Of the respondents, 17.1% (95% confidence interval [CI], 13.2%-21.0%)
reported symptoms that met Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition criteria for PTSD; total mean score on the GHQ-28 was 11.1 (95% CI,
9.9-12.4). Respondents reported a high prevalence of traumatic events. There was a
significant linear decrease in mental health status and social functioning with increasing amount of traumatic events (P#.02 for all 3 survey tools). Populations at increased risk for psychiatric morbidity as measured by GHQ-28 scores were those aged
65 years or older (P = .006), those with previous psychiatric illnesses or chronic health
conditions (P,.001 for both), and those who had been internally displaced (P= .009).
Populations at risk for poorer social functioning were living in rural areas (P = .001),
were unemployed (P=.046) or had a chronic illness (P=.01). Respondents scored highest on the physical functioning and role functioning subscales of the MOS-20 and lowest on the mental health and social functioning subscales. Eighty-nine percent of men
and 90% of women reported having strong feelings of hatred toward Serbs. Fiftyone percent of men and 43% of women reported strong feelings of revenge; 44% of
men and 33% of women stated that they would act on these feelings.
Conclusions Mental health problems and impaired social functioning related to the
recent war are important issues that need to be addressed to return the Kosovo region to a stable and productive environment.
www.jama.com

JAMA. 2000;284:569-577

ing in refugee camps in Albania, Macedonia, and Montenegro began to return

to Kosovo.2 On their return, the displaced Albanians had to come to terms

with the destruction of their homes and

property, missing family members, and
the traumatic experiences of violence,
rape, and persecution. The full psycho-

Author Affiliations are listed at the end of this article.

Corresponding Author and Reprints: Barbara
Lopes Cardozo, MD, MPH, National Center for

Environmental Health, Centers for Disease Control

and Prevention, 4770 Buford Hwy NE, Mailstop
F-48, Atlanta, GA 30341 (e-mail: bhc8@cdc.gov).

2000 American Medical Association. All rights reserved.

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MENTAL HEALTH FOLLOWING THE WAR IN KOSOVO

logical impact of such emergency situations is a neglected issue.3 However, recent epidemiological studies in Bosnia4
and studies among Cambodian refugees living on the Thai border5 and in
the United States have shown that psychiatric morbidity is much higher in
populations that have experienced war,
persecution, and mass violence.6,7
To estimate the prevalence of psychiatric morbidity and to identify specific vulnerable populations, the Centers for Disease Control and Prevention
(CDC) and the Institute of Mental
Health and Recovery in Kosovo, in collaboration with Doctors of the World,
conducted a mental health survey
among ethnic Albanians in Kosovo from
August 20 to October 7, 1999. The survey focused on the period of August
1998 through August 1999, when most
of the intense violence took place.
METHODS
Survey Design

Assuming a true prevalence of 20% of

mental healthrelated problems8 and a
cluster sample design effect of 2, we estimated that a minimum of 1135 adults
aged 15 years or older would be required for a 95% confidence interval
(CI) to detect a prevalence between 15%
and 25%. On the basis of available
household size and age distribution, we
estimated that a minimum of 504
households would need to be surveyed. The number of households targeted was increased to 600 to compensate for refusals and absent adults and
to obtain estimates for various subgroups of the population.
We conducted a 2-stage, 30-cluster
sample survey using the 1991 Kosovo
census as a primary sampling frame. Because these data did not reflect population movements before and during the
ethnic conflict, additional data sources
were used to adjust the 1991 population figures. These sources were village
surveys from the United Nations High
Commissioner for Refugees and food
distribution population estimates from
Action Against Hunger (a nongovernmental organization), both reflecting information collected during the weeks be570

fore our survey. The primary sampling

frame consisted of all villages and cities
listed in the 1991 census, excluding
those that were predominantly populated by Serbs ($70% Serb population) and those that had a population of
less than 100 Albanian inhabitants. The
sampling frame was stratified into urban (cities with a population .10000)
and rural areas. Using this sampling
frame, we estimated the total ethnic Albanian population in Kosovo to be 1.6
million. With probability proportional
to population size, we selected 15 clusters from the rural and 15 from the urban frame in the first sampling stage. In
the second stage of sampling, 20 households were randomly selected within
each chosen cluster (20 households from
each of 30 clusters for a total of 600
households) using an appropriate
method designed for the Expanded Programme on Immunization and adapted
to the particular field conditions.9
Identification of cluster samples differed for urban centers and rural villages. No maps were available for the villages, and many villages were spread out
over a large geographic area. We drew
maps of each cluster, which were then
divided into segments of approximately
equal populations. We then randomly
chose a single segment by first numbering all segments and then blindly drawing a segment number from a bag containing all numbers. In the cities, Kosovo
Force (KFOR) offices usually had aerial
or other maps available. In these cases,
we superimposed a grid to partition the
map into neighborhoods. The neighborhoods were numbered, and then a number was blindly chosen to randomly select
a neighborhood for our survey.
After a segment or neighborhood was
chosen, the first household to be surveyed was chosen randomly as follows.
Households were mapped and numbered in a random direction from the
center to the edge of the segment, chosen by spinning a bottle. The first household was chosen by blindly drawing a
number from a bag using the same
method described above. The next house
was selected to be the closest house to
the left, as the interviewer exited the

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house just surveyed. This process was repeated until 20 households were surveyed, or until the team leader decided
it was time to leave for security reasons.
We interviewed all adult members of
the household present. To ensure as
much privacy as possible, we encouraged people to complete the questionnaires in separate rooms, and men and
women interviewers paired up with
same-sex interviewees to help them
complete the questionnaires. A security curfew at dusk imposed by KFOR
prevented interview teams from coming back to survey adults not present
during the day. Because of the ongoing threat of land mines, KFOR considered access to some remote houses
unsafe. These homes had to be excluded from our sample and replaced
by the closest accessible household.
Native Kosovar Albanian survey team
members had 3 days of training on general survey objectives, safety precautions, procedures for proper household selection (including randomly
selecting the first household and handling special situations), and interviewing techniques (understanding the questionnaires and addressing sensitive
topics). All members of the survey team
were closely supervised for the first 2
days, and they continued to receive daily
supervision and instruction until the survey was completed. Interviewers were
instructed to refer participants who appeared to be in obvious distress to community mental health services where
available. A list of these services was procured from the nongovernmental organization coordinating office at the United
Nations Mission in Kosovo.
The study protocol was reviewed by
a CDC institutional review board representative and informed consent was
obtained verbally from all participants
(with communication occurring in the
potential participants native language).
The study protocol was also reviewed
by Doctors of the World for ethical considerations.
Screening Tools

All instruments used in this survey

were designed as self-report question-

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MENTAL HEALTH FOLLOWING THE WAR IN KOSOVO

naires, but because of a high percentage of illiteracy, especially in rural

areas, questionnaires frequently had
to be read aloud. Because of the need
for expediency in collecting data,
interviewers were instructed to read
the questionnaires only to those who
were illiterate, and to provide assistance if needed to those who completed the questionnaire themselves.
We used 3 screening tools to assess
mental health problems and social
dysfunction: the General Health
Questionnaire-28 (GHQ-28),10,11 the
Harvard Trauma Questionnaire
(HTQ),12 and the Medical Outcomes
Study 20 (MOS-20).13 We chose these
instruments to obtain information on
common, nonspecific psychiatric
problems, to gather information on
specific psychiatric syndromes such as
posttraumatic stress disorder (PTSD)
and related traumatic events, and to
get a broad understanding of the level
of social functioning and disability in
this population.
The GHQ-28 is used as a community screening tool and for the detection of nonspecific psychiatric disorders among individuals in primary care
settings.11 A higher mean score on the
GHQ-28 represents poorer mental
health status (score range, 0-28). The
GHQ-28 is composed of 4 subscales
(score range, 1-7): somatization, anxiety, social dysfunction, and depression. The HTQ combines the measurement of trauma events (part I) and
symptoms of PTSD (part II), selected
from the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV).14
We defined the occurrence of PTSD
symptoms according to a scoring algorithm proposed by the Harvard Refugee Trauma Group,4,12 on the basis of
DSM-IV diagnostic criteria. The
MOS-20 consists of 20 items on 6 different scales that assess physical functioning, bodily pain, role functioning,
social functioning, mental health, and
self-perceived general health status. We
scored the MOS-20 as recommended in
the users manual; each raw score was
transformed to fit a 0-to-100 scale using a standard formula,13,15 with the

higher scores on this scale representing better functioning. All 3 tools have
been extensively validated in many
countries and cultures and in many disease settings.16-18
To assess the effect of broadly defined demographic characteristics on
mental health status, we collected demographic information including age,
sex, education level, and marital status. We added additional questions specific to the Kosovar Albanian population on feelings of hatred and a desire
for revenge. All questionnaires were
translated into Albanian and backtranslated to English to ensure cultural appropriateness of the instrument and accuracy of the translation.
A team of Albanian translators including a psychiatrist, a psychologist, and
a primary care physician from the Institute for Mental Health and Recovery did the translation and adaptation
of the screening tools.
Data Analysis

We adjusted prevalence estimates and

CIs for cluster sampling and stratification using Epi Info version 6.4.19 Regression analyses were performed using SUDAAN, release 7.5.2 (Research
Triangle Institute, Research Triangle
Park, NC). For continuous variables, we
used multivariate linear regression
models to assess the effects of exposure on outcome and multivariate
logistic regression models to analyze
dichotomous outcomes. When the exposure variable had more than 2 levels (eg, displacement), we made multiple comparisons of the responses
between pairs of the different levels using single df contrasts. When the exposure variable had a natural ordering
(eg, age, education, number of traumatic events), we did a test for linear
trend. All P values were derived from
adjusted Wald F tests based on these
regression models, and P,.05 was considered statistically significant. All
analyses were adjusted for stratification and the clustered design, and were
weighted to account for unequal selection probabilities among the individual respondents.

2000 American Medical Association. All rights reserved.

Table 1. Sample Characteristics of Kosovar

Albanian Respondents (N = 1358)
Characteristic

No. of
Proportion,
Respondents*
%

Location
Rural
Urban

758
600

55.8
44.2

Sex
Female
Male

825
499

62.3
37.7

Age, y
15-34
35-54

609
459

45.3
34.1

55-64

147

10.9

$65

130

9.7

Marital status
Married
Divorced

906
31

67.3
2.3

Single

319

23.7

Widowed
Education
Less than
primary
Primary

91

6.8

313

23.3

485

36.2

Secondary

377

28.1

166

12.4

202
1134

15.1
84.9

23
1302

1.7
98.3

551
807

40.6
59.4

Some university
Currently employed
Yes
No
Previous psychiatric
illness
Yes
No
Chronic health
problems
Yes
No

*Excludes missing data or unknown responses.

Diagnosed by a physician before the conflict.
Diagnosed by a medical professional before the conflict. Includes hypertension, diabetes, cardiovascular
disease, kidney disease, asthma, epilepsy, cancer, or
major injury such as loss of a limb.

RESULTS
Characteristics of
Survey Participants

A total of 558 households, consisting of

1358 adults aged 15 years or older, were
included in the survey (mean [SD]
household size for all ages, 7.3 [3.5]
persons). This is smaller than the target number of 600 households since logistical and time constraints prevented
the completion of 20 surveys in some villages. However, 558 households is still
greater than the 504 households deemed
needed from sample size calculations.
Demographic characteristics are summarized in TABLE 1. Of the adults sur-

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MENTAL HEALTH FOLLOWING THE WAR IN KOSOVO

Table 2. Kosovar Albanians Reporting

Trauma Exposure, August 1998August
1999 (N = 1358)
Trauma Experiences

No. (%)

Lack of food or water

Combat situation
Forced isolation
Being close to death
Lack of shelter
Torture/abuse*
Ill health without access to
medical care
Forced separation from family
members
Family member or respondent
involved in fighting during
the war
Murder of family or friend
Witness murder of stranger(s)
Unnatural death of family
or friend
Lost or kidnapped
Serious injury
Imprisonment
Rape
Trauma events, No.
0-3
4-7
8-11
12-16
Displacement during the conflict
Did not move
Internally displaced
Refugee

904 (66.6)
903 (66.5)
870 (64.1)
837 (61.6)
778 (57.3)
664 (48.9)
646 (47.6)
568 (41.8)
470 (34.6)
359 (26.4)
324 (23.9)
298 (21.9)
240 (17.7)
202 (14.9)
131 (9.6)
60 (4.4)
293 (21.6)
529 (39.0)
374 (27.5)
162 (11.9)
231 (18.2)
326 (25.6)
715 (56.2)

*Torture/abuse was not defined for the participant. It was

interpreted broadly, including verbal abuse by armed forces,
intimidation, beatings, incarceration, witnessing a loved
one suffering these abuses, and being forced to choose
the victim of a violent act among ones family members.
Rape was identified in women only.
Data available from only 1272 respondents.

Table 3. Estimated Mean Scores

on GHQ-28 and MOS-20 and Estimated
PTSD Prevalence in Kosovar Albanian
Population*
Mental Health
Status Measure
(Score Range)

Mean
(95% Confidence
Interval)

GHQ-28 (1-7 For All Subscales)

Somatic symptoms
3.9 (3.4-4.3)
Anxiety and insomnia
4.2 (3.7-4.7)
Social dysfunction
2.2 (2.0-2.5)
Symptoms of severe
0.9 (0.7-1.1)
depression
Total (0-28)
11.1 (9.9-12.4)
MOS-20 (0-100 For All Subscales)
General health perception
54.7 (50.2-59.1)
Mental health status
29.6 (24.9-34.4)
Bodily pain
57.0 (52.8-61.1)
Physical function status
77.3 (74.9-79.7)
Social functioning
29.5 (25.5-33.6)
Role functioning
77.5 (74.9-80.1)
HTQ-Symptoms
Total PTSD prevalence, %
17.1 (13.2-21.0)
* GHQ-28 indicates General Health Questionnaire-

2810,11; MOS-20, Medical Outcomes Study13; PTSD,

posttraumatic stress disorder; and HTQ, Harvard Trauma
Questionnaire.12 See the Methods section for a description of each screening tool.
Numbers have been rounded.

572

veyed, 62.3% were women, 55.8% lived

in a rural area, 59.5% had completed only
primary school or less, 67.3% were married, and only 15.1% were currently
employed. Nearly 41% of participants
reported having a chronic illness (diagnosis by a medical professional of hypertension, diabetes, cardiovascular disease, kidney disease, asthma, epilepsy,
cancer, or major injury such as loss of a
limb), and 1.7% reported having received
a diagnosis by a physician of a previous
mental illness, such as schizophrenia or
bipolar disorder, before the conflict.
The exposure to traumatic events, including displacement, is summarized in
TABLE 2.Highpercentagesofrespondents
reported having personally experienced
traumatic events. For example, 66.6% reported being deprived of water and food,
66.5% reported being in a combat situation, and 61.6% reported being close to
death.Furthermore,39.4%ofparticipants
reported experiencing 8 or more of the
traumatic events listed; 56.2% had fled
to another country as refugees during the
past year, 25.6% had been internally displaced within Kosovo, and only 18.2%
remained in their homes during the war.
In all analyses, the traumatic events were
equally weighted since we had no resources for in-depth questioning needed
to provide additional information.
Mental Health and
Social Functioning

Estimated mean scores on the GHQ-28

and the MOS-20 and the prevalence of
PTSD symptoms from the HTQ are
shown in TABLE 3, along with 95% CIs
adjusted for stratification and cluster design effects. These figures represent estimates of the population indicator measured by each test for the adult Albanian
population living in Kosovo at the time
of this survey.
For the GHQ-28, the estimated mean
total score based on a possible 28 questions was 11.1 (95% CI, 9.9-12.4). A
higher mean score signifies a greater
number of symptoms. The mean scores
for somatic symptoms and for anxiety
and insomnia were higher compared
with the mean scores for social dysfunction and depression.

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The estimated MOS-20 mean scores

are shown on a scale of 1 to 100, with a
higher score representing better functioning. In general, respondents tended
to score highest on physical functioning and role functioning and lowest on
the mental health and social functioning components (Table 3). We compared scores on the MOS-20 with scores
of a US general population14,20,21 (data for
the Albanian Kosovo population before
the conflict are not available). The mean
scores for mental health (29.6) and social
functioning (29.5) were strikingly lower
for the Kosovar Albanians than for
the US population (74.7 and 83.3,
respectively). However, there were no
great differences between the 2 populations in the measures of general health,
physical functioning, bodily pain, and
role functioning. The estimated prevalence of PTSD symptoms in this population of Kosovar Albanians was 17.1%
(95% CI, 13.2%-21.0%).
Feelings of Hatred and Revenge

Questions regarding hatred toward the

Serbs and desire for revenge revealed that
high percentages of both men and
women (.88% among each) had strong
feelings of hatred, defined as a response
of extreme hatred (men, 60% [n=288];
women, 55% [n=464]) or a lot of hatred (men, 29% [n=142]; women, 35%
[n=271]). The proportions of people
having strong feelings of revenge were
lower (. 43% for both men and women), but still very high. Strong feelings
of revenge were defined as a response of
feeling revenge all the time (men, 35%
[n=159]; women, 23% [n=192]) or a
lot of the time (men, 16% [n = 92];
women, 20% [n=166]). Of those men
and women who had feelings of revenge (all the time, a lot of the time,
or sometimes), 44.2% of men (n=177)
and 33.3% of women (n=197) said they
would definitely act on those feelings,
and only 17.3% of men (n = 71) and
26.2% of women (n = 184) said they
would not act on those feelings.
Univariate Statistical Analysis

T ABLE 4 summarizes the univariate analysis of the effect of selected

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MENTAL HEALTH FOLLOWING THE WAR IN KOSOVO

Table 4. Univariate Analysis of Effects of Demographic and Exposure Variables on GHQ-28 and MOS-20 Social Functioning Mean Scores
and Prevalence of PTSD*
GHQ-28 (Scale, 0-28)
Variable
Location
Urban

Mean (SE)
10.50 (0.61)

Rural

11.42 (0.92)

Sex
Male

10.80 (0.74)

Female
Current employment
Yes
No

P
Value
.41

9.14 (0.71)

Mean (SE)
40.60 (2.70)
24.08 (2.31)

.35

11.34 (0.65)

11.46 (0.66)

MOS-20 Social Functioning

(Scale, 0-100)

29.10 (3.51)

P
Value
,.001

.80

30.24 (2.46)
,.001

36.70 (3.72)

PTSD Symptoms

13.16 (2.17)

12.01 (1.85)

.006

28.20 (1.84)

12.49 (3.44)

8.33 (0.72)

33.83 (2.32)

13.22 (1.74)

26.63 (2.35)

21.44 (3.44)

55-64

14.24 (0.69)

$65

14.68 (0.76)

Marital status
Married

.03 (linear)

24.99 (2.99)

17.81 (2.89)

25.67 (3.87)

16.30 (4.69)

12.03 (0.63)

28.90 (2.29)

16.49 (2.28)

Divorced

6.37 (1.63)

32.79 (4.95)

10.48 (6.94)

Widowed

14.78 (1.24)

Single

7.69 (0.68)

.43

18.21 (3.60)

30.96 (5.32)

34.39 (2.31)

15.14 (2.21)

14.06 (0.61)

24.37 (2.73)

21.29 (3.73)

Primary

10.51 (0.77)

28.82 (2.54)

15.99 (2.42)

Secondary

10.10 (0.66)

Some university
Previous psychiatric illness
Yes
No
Chronic health condition
Yes
No
Displacement
Refugee (R)

,.001 (linear)

8.88 (0.60)
20.72 (1.80)
10.95 (0.65)
14.49 (0.37)
8.62 (0.78)

,.001

,.001

.03 (linear)

32.47 (3.74)

15.84 (1.69)

37.19 (4.33)

11.01 (4.25)

20.08 (6.48)

.20

29.56 (2.02)
24.44 (2.10)
33.30 (2.25)

.20

18.00 (2.29)

12.64 (0.66)

Education
Less than primary

.01

19.67 (2.67)

35-54

,.001

.11

19.02 (2.76)

Age, y
15-34

,.001 (linear)

P
Value

% (SE)

35.92 (12.63)

.01

.67 for all

(linear)

.48

.11 (linear)

.15

16.81 (2.05)
,.001

21.51 (2.67)

.003

13.95 (1.90)

10.68 (0.81)

R vs I: .03

28.45 (1.66)

R vs I: .75

16.64 (2.70)

R vs I: .12

Internally displaced (I)

13.05 (0.78)

R vs D: .66

26.72 (5.20)

R vs D: .009

21.97 (2.55)

R vs D: .19

Did not move (D)

10.26 (0.66)

I vs D: .007

36.60 (3.03)

I vs D: .12

11.88 (2.37)

I vs D: .004

Rape
Yes
No
Forced separation
Yes
No
Murder of family or friend
Yes
No
Trauma events, No.
0-3

11.03 (1.30)

.93

11.12 (0.62)
12.22 (0.81)

.002

10.30 (0.62)
13.66 (0.49)
10.16 (0.70)

26.71 (5.21)

.55

29.67 (2.06)
27.36 (2.20)

.20

31.17 (2.69)
,.001

21.92 (3.66)

21.62 (6.91)

22.69 (3.50)

.005

32.42 (1.73)

25.48 (3.41)

42.14 (3.34)

13.40 (2.57)

9.37 (0.77)

32.49 (2.62)

10.03 (2.15)

8-11

12.43 (0.83)

12-16

16.11 (0.63)

15.66 (4.60)

.002

13.97 (1.82)

9.28 (0.57)

23.17 (2.31)

.01

13.09 (1.76)

4-7

,.001 (linear)

.49

16.92 (2.02)

,.001 (linear)

22.16 (3.66)

,.001 (linear)

32.55 (5.69)

*GHQ-28 indicates General Health Questionnaire-2810,11; MOS-20, Medical Outcomes Study13; and PTSD, posttraumatic stress disorder. See the Methods section for a description of each screening tool. P values are derived from Wald F tests (df = 28) for the difference between each group, or a linear trend.
Only 23 people in yes category.

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MENTAL HEALTH FOLLOWING THE WAR IN KOSOVO

demographic factors and exposure to

trauma on the mental health and social
functioning outcomes. We present the
results of the GHQ-28 total score, estimated prevalence of PTSD symptoms,
and MOS-20 social function scale as outcome measures in relation to various
demographic and trauma experience
measures. P,.05 was considered significant for univariate and multivariate analyses. Being older, being currently unemployed, being widowed,
having little education, reporting a previously diagnosed psychiatric illness,
and reporting a previous diagnosis of a
chronic health condition were associated in this analysis with a high (eg,
worse) GHQ-28 score, indicating non-

cial functioning. The association between rape and psychiatric morbidity and
social functioning may be difficult to observe here because of the relatively small
number of reported rape cases.

specific psychiatric morbidity. Similarly, living in a rural setting, being currently unemployed, being older, having
little education, and reporting having
received a diagnosis of a chronic health
condition were associated with a low
(eg, worse) social functioning score.
Finally, HTQ results indicate that being
female and having received a diagnosis of a chronic health condition were
associated with PTSD symptoms.
Most traumatic event variables (forced
separation from family, murder of family or friend, and increasing number of
traumatic events) but not rape were associated with a worse score in the 3 measured mental health outcomes, with the
exception of forced separation for so-

Multivariate Statistical Analyses

Since we had identified 2 different groups

of explanatory variables, demographic
and exposure, we treated these differently using a multivariate analysis. First,
the effect of each demographic variable
on the mental health outcomes was adjusted for all other variables, both demographic and exposure (TABLE 5).
Subpopulations at risk (statistically
significant as measured by the multivariate analyses) for psychiatric mor-

Table 5. Demographic Variables Affecting Mental Health Outcomes, Adjusted for All Variables*
GHQ-28
(Scale, 0-28)
Variable
Location
Urban
Rural
Sex
Male
Female
Current employment
Yes
No
Age, y
15-34
35-54

Adjusted Mean
(SE)

MOS-20 Social Functioning

(Scale, 0-100)
P
Value

12.19 (0.56)
10.54 (0.55)

.06

10.96 (0.45)
11.20 (0.45)

.47

10.11 (0.79)
11.28 (0.40)

.15

9.64 (0.56)
12.22 (0.42)

.006 (linear)

Adjusted Mean
(SE)
37.03 (2.37)
25.85 (1.72)
28.95 (3.31)
30.10 (2.28)
35.64 (4.07)
28.57 (1.23)

PTSD Symptoms

P
Value
.001

.82

.046

OR
(95% CI)
1.00
1.10 (0.63-1.92)
1.00
1.93 (1.09-3.41)
0.97 (0.43-2.17)
1.00

31.85 (2.32)

0.78 (0.40-1.54)

26.85 (1.62)

1.76 (0.91-3.38)

12.03 (0.72)

$65
Marital status
Married
Divorced

12.37 (0.61)

32.14 (3.74)

11.29 (0.46)
8.11 (0.83)

29.97 (1.69)

0.68 (0.37-1.24)

27.34 (6.42)

0.50 (0.08-3.22)

Widowed

12.60 (1.33)

Single
Education
Less than primary
Primary
Secondary
Some university
Previous psychiatric illness
Yes
No
Chronic health condition
Yes
No

.08

27.56 (2.61)

.91 (linear)

55-64

21.23 (3.47)

1.00

.14

1.62 (0.85-3.07)

31.62 (2.11)

11.22 (0.40)
10.65 (0.57)

31.20 (2.41)

0.78 (0.39-1.53)

31.19 (2.26)

0.63 (0.39-1.01)

.70 (linear)

10.51 (0.57)

26.75 (2.61)

,.001

13.33 (0.28)
9.40 (0.61)

,.001

27.17 (6.94)
29.72 (1.45)
26.51 (1.91)
32.11 (1.60)

.02

.94

.39 (linear)

.07

1.00

.50 (linear)

28.28 (4.51)

18.00 (1.00)
10.98 (0.38)

.74

0.67 (0.30-1.48)

10.41 (0.48)

11.84 (0.53)

P
Value

1.00

.92 (linear)

0.70 (0.27-1.87)
.73

.01

2.87 (1.22-6.76)
1.00
1.44 (0.89-2.33)
1.00

.02

.13

*GHQ-28 indicates General Health Questionnaire-2810,11; MOS-20, Medical Outcomes Study13; PTSD, posttraumatic stress disorder; OR, odds ratio; and CI, confidence interval.
See the Methods section for a description of each screening tool.
Indicates change to not significant from univariate analysis.
Indicates change to significant from univariate analysis.

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MENTAL HEALTH FOLLOWING THE WAR IN KOSOVO

bidity as measured by GHQ-28 scores

were those aged 65 years or older, those
with previous psychiatric illnesses, and
those with self-reported chronic health
problems. In the multivariate analysis,
employment, location, sex, marital status, and education were not statistically significant risk factors for psychiatric morbidity. Subpopulations at risk
for poor social functioning, as measured by the MOS-20, were people living in rural areas, those currently unemployed, and those with chronic health
problems. There was no significant decrease in social functioning with increasing age or education status when adjusted for all other variables. Women and
persons with a previous psychiatric illness had a significantly higher estimated prevalence of PTSD symptoms.
To analyze the effect of exposure variables on mental health outcomes, we performed a second multivariate analysis for
which all P values for the relationship
between each exposure variable and each
outcome measure were adjusted for all
demographic variables, previous psychiatric illness, and chronic health condition (TABLE 6). People who were inter-

nally displaced tended to have higher

total GHQ-28 scores than refugees
(P = .03) or those who did not move
(P=.009). However, there was no significant difference in the total GHQ-28
scores between refugees and those who
did not move (P=.50), and the displacement seemed to have no effect on significance for MOS-20 social functioning scores or the prevalence of PTSD
symptoms, when adjusted for the effects
of the demographic variables.
There was a significant linear increase in total GHQ-28 scores (P,.001),
a significant linear decrease in MOS-20
social functioning scores (P=.02), and a
significant linear increase in the prevalence of PTSD symptoms (P,.001) with
increasing numbers of trauma events
(Table 6). Specific traumatic events
seemed to be closely related to specific
mental health conditions. People experiencing forced separation from family
or murder of a family member or friends
had significantly higher total GHQ-28
scores and significantly higher prevalence of PTSD symptoms than people
without these experiences. People experiencing murder of a family member or

friend also had significantly lower

MOS-20 social functioning scores.
A rape experience seemed to have no
effect on GHQ-28 scores, MOS-20 social functioning, or prevalence of PTSD
symptoms, although, as stated earlier,
a relationship may be difficult to observe due to the relatively small number of reported rape cases.
COMMENT
There was a high prevalence of traumatic events (Table 2) among the Kosovar Albanians, and large numbers appear to have experienced multiple
traumas. Higher levels of PTSD symptoms, an increase in nonspecific mental
morbidity as measured by the GHQ-28,
and a decrease in social functioning were
associated with higher levels of cumulative trauma. These relationships remained even after adjusting for the effects of demographic variables, previous
psychiatric illness, and other chronic
health conditions. Our results are consistent with those of other studies.22-24 Although the 4 subscales of the GHQ-28
provide information on types of symptoms, they have not been designed to

Table 6. Exposure Variables Affecting Mental Health Outcomes, Adjusted for All Demographic Variables*
GHQ-28 (Scale, 0-28)
Variable
Displacement
Refugee (R)
Internally displaced (I)
Did not move (D)
Rape (HTQ)
Yes
No
Forced separation (HTQ)
Yes
No
Murder of family or friend (HTQ)
Yes
No
Trauma events, No.
0-3
4-7

Adjusted Mean
(SE)

P
Value

MOS-20 Social Functioning

(Scale, 0-100)
Adjusted Mean
(SE)

PTSD Symptoms

P
Value

OR
(95% CI)

P
Value

10.71 (0.59)
12.80 (0.71)

R vs I: .03
R vs D: .50

28.99 (1.62)
30.15 (4.34)

R vs I: .80
R vs D: .20

1.30 (0.64-2.66)
1.52 (0.68-3.36)

R vs I: .58
R vs D: .46

10.24 (0.60)

I vs D: .009

31.51 (1.71)

I vs D: .77

1.00

I vs D: .29

11.83 (1.09)
11.01 (0.50)

.40

12.16 (0.59)
10.23 (0.51)

,.001

13.58 (0.35)
10.12 (0.60)

,.001

9.22 (0.46)
9.32 (0.67)

8-11

12.49 (0.57)

12-16

15.87 (0.63)

,.001 (linear)

25.48 (4.86)
30.01 (1.46)
30.35 (2.15)
29.40 (1.81)
24.64 (3.45)
31.74 (1.14)

.35

.72

.047

1.68 (0.69-4.08)
1.00
2.10 (1.38-3.20)
1.00
2.09 (1.29-3.38)
1.00

37.59 (3.01)

1.00

32.19 (2.26)

0.65 (0.32-1.31)

25.64 (2.06)
20.07 (4.96)

.02 (linear)

1.49 (0.82-2.69)

.24

.001

.004

,.001 (linear)

3.54 (1.98-6.35)

*GHQ-28 indicates General Health Questionnaire-2810,11; MOS-20, Medical Outcomes Study13; PTSD, posttraumatic stress disorder; OR, odds ratio; and CI, confidence interval.
See the Methods section for a description of each screening tool. All P values are adjusted for location, sex, current employment status, age, marital status, education, indication of previous psychiatric illness, and indication of chronic illness.
Indicates change to not significant from univariate analysis.

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MENTAL HEALTH FOLLOWING THE WAR IN KOSOVO

make a psychiatric diagnosis. They do,

however, give information on the mean
scores for somatic, anxiety, social dysfunction, and severe depression symptoms (Table 3). It has been shown in
other studies that the 4 subscales are not
independent from each another.11 In our
study, the mean scores for somatic symptoms and anxiety and insomnia were
higher than those for social dysfunction and severe depression. It is possible that in this culture depression is
more likely to be expressed as somatic
and anxiety symptoms. Alternatively, despite the traumatic events experienced
by many people by the time of the survey, there may have been a genuine sense
of hope and optimism because the war
had ended, and people were rebuilding
their homes, lives, and country.
The optimal threshold score to determine prevalence of psychiatric morbidity from the GHQ-28 has not been
established for this population. Although we found that the GHQ-28 was
well accepted and easy to administer, the
interpretation of the results for prevalence estimates is not straightforward unless an optimal cutoff score is established for the specific population.
Goldberg et al25 have suggested that a
mean score will provide a rough guide
to the best threshold; however, this
would always result in a general psychiatric morbidity prevalence of approximately 50%. Adopting a similar method
with a conservative cutoff score of 11/12
out of 28 (so that those answering positively to 12 questions would be considered a case), we found an estimated
prevalence of nonspecific psychiatric
morbidity of 43%. In studies of general
populations in 15 different countries, the
highest cutoff score found was 6/7.26-28
However, no cutoff scores have been
published for refugee populations or
those recently exposed to war, where it
is likely that the prevalence of nonspecific psychiatric morbidity is much
higher than in general populations.
A similar type of cutoff score is needed
to estimate the prevalence of psychiatric morbidity using the MOS-20 in refugee populations. In the US population,
a cutoff score of 52 (range, 0-100) was
576

established based on studies of the relationship between mental health and clinical measures of the probability of any
psychiatric disorder.13 Using the same
cutoff score for the Kosovo population
would result in an estimated prevalence of psychiatric disorder of 83.5% vs
13.2% in the US population.20 Further
clinical validation of the GHQ-28 and the
MOS-20 is under way to establish the
best thresholds for the Kosovar population. The estimated prevalence of PTSD
symptoms (17.1%) is somewhat lower
than the reported PTSD figures (26.3%)
for Bosnian refugees living in Croatia.4
The findings from the GHQ-28, MOS20, and HTQ confirm earlier anecdotal
reports that while the general health status of the Kosovo population remained
fairly stable, mental problems related to
the war situation are common. This is
in line with other findings in refugee
camps and war/conflict situations.3-7 No
baseline general mental health status
data from before the war are available
for Kosovo. However, in our survey, selfreporting of previous mental illness
(1.7%) correlated with findings in other
populations.29
We identified several subpopulations at risk for poor mental health status and social functioning and we also
attempted to identify mitigating factors. In general, Kosovar Albanians
younger than 35 years old, in good physical health, and without previous psychiatric illness appear to have been protected from war-related psychiatric
morbidity. Future research will have to
determine whether there are other protective factors that could be influenced
by policy (eg, adequate housing, social
and community support). Social functioning was significantly lower among the
population in rural areas; however, location did not seem to have the same effect on general mental health. It is possible that the extensive disruption of the
civic infrastructure in the rural areas
made it harder to function socially than
in cities, but closer family ties in these
areas mitigated mental health problems. Not unexpectedly, people with previous psychiatric illness had worse mental health outcomes, including higher

JAMA, August 2, 2000Vol 284, No. 5 (Reprinted)

levels of PTSD symptoms, than did those

without such illness. Similarly, indication of a previously diagnosed chronic
health condition was associated with general psychiatric morbidity and social
functioning but not PTSD.
As measured by the GHQ-28 scores,
people who were internally displaced had
worse mental health status than did refugees and those who never moved. In fact,
a subsequent analysis revealed that on the
average, those who did not move experienced a mean (SE) of 5.36 (0.53) traumatic events, while refugees experienced an average of 6.87 (0.33) and those
internally displaced an average of 8.02
(0.56). This difference was statistically
significant (P=.01). Virtually all people
who were internally displaced were being persecuted, and as a result of this suffered continuous trauma. People who became refugees faced similar traumatic
events, but usually of shorter duration
because they were able to escape to other
countries. It can be hypothesized that
people who never moved away from their
homes were able to stay because they
happened to be in relatively safer areas
and thus experienced less trauma.
There are a number of limitations to
this study. Women were overrepresented in our sample probably because
they were more likely to be at home during the daytime (data from other
sources30 indicate that the male-female
ratio in Kosovo is close to 1). People who
were employed during the time of the
survey were less likely to be home during the day. Because of security curfews it was not possible to return to
homes and interview those who were absent during the day. There is a possibility that some people who were the most
stressed, because they were living in the
most dangerous areas, were excluded
from our study. However, if at all, this
exclusion happened very seldom and
would have resulted in underreporting
of mental morbidity. Our study might
be somewhat limited in statistical power
since resources were available to sample
only 30 clusters. However, the potential reduction in statistical power may
have been moderated by the use of a
stratified design.

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MENTAL HEALTH FOLLOWING THE WAR IN KOSOVO

Because no structured clinical interviews were performed, it is unclear to

what extent self-reported symptoms of
PTSD and nonspecific psychiatric morbidity, in the HTQ and the GHQ-28 respectively, would match clinical diagnosis. It is possible that cross-cultural
differences could have influenced the
results of this study. Even though the
screening instruments used were created and validated in developed nations similar to Kosovo, the instruments were not specifically validated for
this society. However, the GHQ-28 has
proven to be a reliable instrument in a
wide variety of cultures. The HTQ traumatic events section was specifically
adapted for the Kosovo situation.
Although not traditionally part of a
mental health survey, the questions regarding feelings of hatred and a desire for
revenge give a poignant picture of alltoo-common emotions in this setting.
These findings underscore the challenge faced by the interim government
of the United Nations Mission in Kosovo
as it to seeks to establish reconciliation
among different ethnic groups.
CONCLUSIONS
Whether measured by the prevalence of
nonspecific psychiatric morbidity (43%),
social dysfunction, or prevalence of PTSD
symptoms (17.1%), our study demonstrates the severity of mental health problems among Kosovar Albanians.
When we conducted this survey the
war had just ended. The wounds of war
were still fresh, including the events that
had shaken the lives of hundreds of
thousands of people. Violence and acts
of revenge continue in Kosovo. On the
basis of the results of our survey, these
incidents are not surprising. Mental
health problems related to the psychological trauma of war and conflict situations are a major public health concern. The high rates of poor mental
health status among those internally
displaced and refugees who have returned to Kosovo also raises concern for
the mental health status of those who
remain in countries of asylum and resettlement.

Until the psychological and social effects of the war and persecution in
Kosovo are evaluated over time, we
must exercise caution in basing future
predictions on the results of our survey. Follow-up studies and monitoring of mental health problems to determine long-term effects of multiple,
prolonged, and severe traumatic events
among the Kosovar Albanian population will provide more accurate data for
policy recommendations.
Author Affiliations: National Center for Environmental Health, International Emergency and Refugee Health
Branch (Dr Lopes Cardozo), National Center for Infectious Diseases, Division of Quarantine (Dr Vergara), and National Center for Environmental Health,
Environmental Hazards and Health Effects (Dr Gotway), Centers for Disease Control and Prevention, Atlanta, Ga; and Institute for Mental Health and Recovery, Pristina, Kosovo (Dr Agani).
Funding/Support: This study was supported by funds
from the Centers for Disease Control and Prevention.
Acknowledgment: We acknowledge the enormous
contribution and logistic support of Doctors of the World,
in particular Supriya Madhavan, who provided us with
invaluable insights into the Kosovo situation. We also
acknowledge the contributions of the interviewers, many
of whom themselves had been refugees or internally
displaced during the war, who made the data collection possible. We also acknowledge the contribution
of mental health staff from the Institute of Mental Health
and Recovery in Pristina, Kosovo. The Harvard Program in Refugee Trauma gave us invaluable advice, particularly by Richard Mollica, MD, MAR; James Lavelle,
MSW; and Keith McInnes, MS, who shared their extensive clinical and research expertise in this field.
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