Three years after the NATO-led bombing campaign over Serbia and Kosovo, a high prevalence of war-related mental health problems exists among ED patients presenting for care. In our sample of 562 participants, 13.0% had symptoms of PTSD, while almost half the study sample (49.2%) had symptoms consistent with depression. Among study participants, becoming a refugee during the war and living in the remote community of Laplje Selo were predictive of PTSD. Older age, unemployment, and lower social support predicted depression.
A persistently high prevalence of PTSD following conflict situations, torture or forced migration has been frequently described [5, 9, 14–16, 21, 37–43]. For example, the prevalence of PTSD was 14% among ethnic Albanians presenting for care in the ED setting in Kosovo two years post conflict . In Serbia, one year following the NATO air attack, 11% of subjects had symptoms suggestive of PTSD. Distress at the time of the bombing raids was predictive of PTSD symptoms one year later .
Despite numerous associations with PTSD in bivariate analysis, only two factors, refugee status during the war and living in a remote isolated setting, remained important after controlling for other factors in this study. The importance of refugee status in determining mental health after conflict is consistent with the findings of others. For example, even after 20 years following civil conflict in Guatemala, 11.8% of participants had symptoms of PTSD . In that study, symptoms of PTSD were predicted by refugee status, human rights violations, and sum of traumatic events . Not surprisingly, living in the remote, isolated village of Laplje Selo was also predictive of PTSD. In a study evaluating the effects of social isolation, Mollica et al.  reported that among Bosnian refugees, PTSD was associated with isolation from family at a three-year follow up.
In our study, we found that nearly half of participants reported symptoms consistent with major depression. The high prevalence of depression in this sample is comparable with the findings by investigators in other post-conflict setting. Among a clinical sample of Bosnian refugees who had resettled in Chicago, Illinois, the prevalence of major depression was 66% . In a study of Bosnian refugees, 43% of participants who met DSM-IV criteria on original testing for major depression (alone or co-morbid with PTSD) still met criteria at three-year follow-up .
Older age, unemployment, and lower social support were predictive of major depression among respondents in this dataset. Our findings are in accord with what has been reported elsewhere [43–47]. For instance, in a study of ethnic Albanians following the war in Kosovo, individuals aged 65 years and older had higher odds of psychiatric morbidity . Among former Somali refugees resettled in the United Kingdom, suicidality and drug use were associated with unemployment prior to their migration . In a study that evaluated coping strategies among Serbian medical students, greater social support activities seemed to protect against psychological morbidity in the year following the NATO air campaign .
Among participants in our study with symptoms of PTSD, many had symptoms of major depression as well. A number of other investigators have found PTSD comorbid with depression in the post-war setting [9, 50–52]. PTSD commonly co-occurs with other psychiatric disorders, particularly with major depression. These co-existing entities are often difficult to distinguish, which leads to difficulties in diagnosis, and may be harder to manage than PTSD or depression alone .
There were a number of limitations to this study. It was designed as a cross-sectional study, where both exposure status and outcomes are determined simultaneously. Therefore, the issue of causality (that is, war-trauma had directly caused poor results on post-war mental health screening) cannot be readily established [54–56]. However, cross-sectional studies allow for rapid, cost-efficient gathering of information that generates hypotheses for further investigation. Furthermore, the findings from a cross-sectional study can help to focus attention on issues of public health importance, which can assist public health planning [54–56]. It is possible that participants drawn from a clinical setting may exaggerate the true prevalence of PTSD and depression compared to a non-clinical sample [54–56]. This study was carried out among a Serbian patient population presenting to hospitals in a post-war setting, thus generalizations beyond this setting need to incorporate additional information.
One of the major challenges to conducting post-war mental health research beyond Western Europe and North America is the paucity of established benchmark data in a given area. Although these instruments have been used extensively, normative data have yet to be determined in this setting. Therefore, it is important to emphasize that the clinical implication of screening 'positive' for depression or PTSD using the instruments in this study has yet to be fully established in Serbia.