Skip to main content
    • Aa
    • Aa

Course of post-traumatic stress disorder following war in the Balkans: 1-year follow-up study

  • S. Priebe (a1), J. Gavrilovic (a1), S. Bremner (a2), D. Ajdukovic (a3), T. Franciskovic (a4), G. Neri (a5), A. Kucukalic (a6), D. Lecic-Tosevski (a7), N. Morina (a8), M. Popovski (a9), M. Schützwohl (a10), M. Bogic (a1) and A. Matanov (a1)...

Prevalence rates of post-traumatic stress disorder (PTSD) following the experience of war have been shown to be high. However, little is known about the course of the disorder in people who remained in the area of conflict and in refugees.


We studied a representative sample of 522 adults with war-related PTSD in five Balkan countries and 215 compatriot refugees in three Western European countries. They were assessed on average 8 years after the war and reinterviewed 1 year later. We established change in PTSD symptoms, measured on the Impact of Events Scale – Revised (IES-R), and factors associated with more or less favourable outcomes.


During the 1-year period, symptoms decreased substantially in both Balkan residents and in refugees. The differences were significant for IES-R total scores and for the three subscales of intrusions, avoidance and hyperarousal. In multivariable regressions adjusting for the level of baseline symptoms, co-morbidity with depression predicted less favourable symptom change in Balkan residents. More pre-war traumatic events and the use of mental health services within the follow-up period were associated with less improvement in refugees.


Several years after the war, people with PTSD reported significant symptom improvement that might indicate a fluctuating course over time. Co-morbid depression may have to be targeted in the treatment of people who remained in the post-conflict regions whereas the use of mental health services seems to be linked to the persistence of symptoms among refugees.

Corresponding author
*Address for correspondence: Professor S. Priebe, Unit for Social and Community Psychiatry, Newham Centre for Mental Health, London E13 8SP, UK. (Email:
Linked references
Hide All

This list contains references from the content that can be linked to their source. For a full set of references and notes please see the PDF or HTML where available.

M Bogic , D Ajdukovic , S Bremner , T Franciskovic , GM Galeazzi , A Kucukalic , D Lecic-Tosevski , N Morina , M Popovski , M Schützwohl , D Wang , S Priebe (2012). Factors associated with mental disorders in long-settled war refugees: refugees from the former Yugoslavia in Germany, Italy and the UK. British Journal of Psychiatry 200, 216223.

N Breslau , HD Chilcoat , RC Kessler , GC Davis (1999). Previous exposure to trauma and PTSD effects of subsequent trauma: results from the Detroit Area Survey of Trauma. American Journal of Psychiatry 156, 902907.

N Breslau , RC Kessler , HD Chilcoat , LR Schultz , GC Davis , P Andreski (1998). Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Archives of General Psychiatry 55, 626632.

N Breslau , EL Peterson , LR Schultz (2008). A second look at prior trauma and the posttraumatic stress disorder effects of subsequent trauma: a prospective epidemiological study. Archives of General Psychiatry 65, 431437.

BL Cardozo , R Kaiser , CA Gotway , F Agani (2003). Mental health, social functioning, and feelings of hatred and revenge of Kosovar Albanians one year after the war in Kosovo. Journal of Traumatic Stress 16, 351360.

JT de Jong , IH Komproe , M Van Ommeren , M El Masri , M Araya , N Khaled , W van de Put , D Somasundaram (2001). Lifetime events and posttraumatic stress disorder in 4 post-conflict settings. Journal of the American Medical Association 286, 555562.

B Drozdek (1997). Follow-up study of concentration camp survivors from Bosnia-Herzegovina: three years later. Journal of Nervous and Mental Disease 185, 690694.

JF Etter , TV Perneger (2000). Snowball sampling by mail: application to a survey of smokers in the general population. International Journal of Epidemiology 29, 4348.

A Eytan , A Guthmiller , S Durieux-Paillard , L Loutan , M Gex-Fabry (2011). Mental and physical health of Kosovar Albanians in their place of origin: a post-war 6-year follow-up study. Social Psychiatry and Psychiatric Epidemiology 46, 953963.

M Fazel , J Wheeler , J Danesh (2005). Prevalence of serious mental disorder in 7000 refugees resettled in Western countries: a systematic review. Lancet 365, 13091314.

NT Fear , M Jones , D Murphy , L Hull , AC Iversen , B Coker , L Machell , J Sundin , C Woodhead , N Jones , N Greenberg , S Landau , C Dandeker , RJ Rona , M Hotopf , S Wessely (2010). What are the consequences of deployment to Iraq and Afghanistan on the mental health of the UK armed forces? A cohort study. Lancet 375, 17831797.

EB Foa , LA Zoellner , NC Feeny , EA Hembree , J Alvarez-Conrad (2002). Does imaginal exposure exacerbate PTSD symptoms? Journal of Consulting and Clinical Psychology 70, 10221028.

T Franciskovic , Z Tovilovic , Z Sukovic , A Stevanović , D Ajduković , R Kraljević , M Bogić , S Priebe (2008). Health care and community-based interventions for war-traumatized people in Croatia: community-based study of service use and mental health. Croatian Medical Journal 49, 483490.

AK Goenjian , AM Steinberg , LM Najarian , LA Fairbanks , M Tashjian , RS Pynoos (2000). Prospective study of posttraumatic stress, anxiety, and depressive reactions after earthquake and political violence. American Journal of Psychiatry 157, 911916.

E Hauff , P Vaglum (1994). Chronic posttraumatic stress disorder in Vietnamese refugees: a prospective community study of prevalence, course, psychopathology, and stressors. Journal of Nervous and Mental Disease 182, 8590.

M Hotopf , L Hull , NT Fear , T Browne , O Horn , A Iversen , M Jones , D Murphy , D Bland , M Earnshaw , N Greenberg , JH Hughes , AR Tate , C Dandeker , R Rona , S Wessely (2006). The health of UK military personnel who deployed to the 2003 Iraq war: a cohort study. Lancet 367, 17311741.

F Hume , D Summerfield (1994). After the war in Nicaragua: a psychosocial study of war wounded ex-combatants. Medicine and War 10, 425.

N Kadri , M Agoub , S El Gnaoui , KM Alami , T Hergueta , D Moussaoui (2005). Moroccan colloquial Arabic version of the Mini-International Neuropsychiatric Interview (MINI): qualitative and quantitative validation. European Psychiatry 20, 193195.

RC Kessler , A Sonnega , E Bromet , M Hughes , CB Nelson (1995). Posttraumatic stress disorder in the National Comorbidity Study. Archives of General Psychiatry 52, 10481060.

G Kivling-Boden , E Sundbom (2002). The relationship between post-traumatic symptoms and life in exile in a clinical group of refugees from the former Yugoslavia. Acta Psychiatrica Scandinavica 105, 461468.

KC Koenen , JM Stellman , SD Stellman , JF Sommer Jr. (2003). Risk factors for course of posttraumatic stress disorder among Vietnam veterans: a 14-year follow-up of American Legionnaires. Journal of Consulting and Clinical Psychology 71, 980986.

D Koren , I Arnon , E Klein (2001). Long term course of chronic posttraumatic stress disorder in traffic accident victims: a three-year prospective follow-up study. Behaviour Research and Therapy 39, 14491458.

B Lie (2002). A 3-year follow-up study of psychosocial functioning and general symptoms in settled refugees. Acta Psychiatrica Scandinavica 106, 415425.

RF Mollica , N Sarajlic , M Chernoff , J Lavelle , IV Sarajlic , MP Massagli (2001). Longitudinal study of psychiatric symptoms, disability, mortality, and emigration among Bosnian refugees. Journal of the American Medical Association 286, 546554.

N Morina , HF Böhme , D Ajdukovic , M Bogic , T Frančišković , GM Galeazzi , A Kucukalic , D Lečić-Toševski , M Popovski , M Schützwohl , U Stangier , S Priebe (2010). The structure of posttraumatic stress symptoms in survivors of war: a confirmatory factor analysis of the Impact of Event Scale – Revised. Journal of Anxiety Disorders 24, 606611.

N Morina , JD Ford (2008). Complex sequelae of psychological trauma among Kosovar civilian war victims. International Journal of Social Psychiatry 54, 425436.

A Nickerson , RA Bryant , D Silove , Z Steel (2011). A critical review of psychological treatments of posttraumatic stress disorder in refugees. Clinical Psychology Review 31, 399417.

T Otsubo , K Tanaka , R Koda , J Shinoda , N Sano , S Tanaka , H Aoyama , M Mimura , K Kamijima (2005). Reliability and validity of Japanese version of the Mini-International Neuropsychiatric Interview. Psychiatry and Clinical Neurosciences 59, 517526.

A Perkonigg , H Pfister , MB Stein , M Höfler , R Lieb , A Maercker , H-U Wittchen (2005). Longitudinal course of posttraumatic stress disorder and posttraumatic stress disorder symptoms in a community sample of adolescents and young adults. American Journal of Psychiatry 162, 13201327.

S Priebe , M Bogic , D Ajdukovic , T Frančišković , GM Galeazzi , A Kucukalic , D Lečić-Toševski , N Morina , M Popovski , D Wang , M Schützwohl (2010 a). Mental disorders following war in the Balkans: a community based study on long-term outcomes in 5 countries. Archives of General Psychiatry 67, 518528.

S Priebe , M Bogic , R Ashcroft , T Frančišković , GM Galeazzi , A Kucukalic , D Lečić-Toševski , N Morina , M Popovski , M Roughton , M Schützwohl , D Ajduković (2010 b). Experience of human rights violations and subsequent mental disorders: a study following the war in the Balkans. Social Science and Medicine 71, 21702177.

S Priebe , P Huxley , S Knight , S Evans (1999). Application and results of the Manchester Short Assessment of Quality of Life (MANSA). International Journal of Social Psychiatry 45, 712.

S Priebe , J Jankovic Gavrilovic , A Matanov , T Frančišković , G Knezevic , D Ljubotina , AB Mehmedbasic , M Schützwohl (2010 c). Treatment outcomes and costs at specialized centers for the treatment of PTSD after the war in former Yugoslavia. Psychiatric Services 61, 598604.

S Priebe , A Matanov , J Jankovic Gavrilovic , P McCrone , D Ljubotina , G Knezević , A Kucukalić , T Francisković , M Schützwohl (2009). Consequences of untreated posttraumatic stress disorder following war in former Yugoslavia: morbidity, subjective quality of life, and care costs. Croatian Medical Journal 50, 465475.

S Priebe , R McCabe , U Junghan , T Kallert , M Ruggeri , M Slade , U Reininghaus (2011). Association between symptoms and quality of life in patients with schizophrenia: a pooled analysis of changes over time. Schizophrenia Research 133, 1721.

S Priebe , S Watzke , L Hansson , T Burns (2008). Objective Social Outcomes Index (SIX): a method to summarise objective indicators of social outcomes in mental health care. Acta Psychiatrica Scandinavica 118, 5763.

G Roth , S Ekblad , H Agren (2006). A longitudinal study of PTSD in a sample of adult mass-evacuated Kosovars, some of whom returned to their home country. European Psychiatry 21, 152159.

P Roy-Byrne , L Arguelles , ME Vitek , J Goldberg , TM Keane , WR True , RK Pitman (2004). Persistence and change of PTSD symptomatology: a longitudinal co-twin control analysis of the Vietnam Era Twin Registry. Social Psychiatry and Psychiatric Epidemiology 39, 681685.

A Shlosberg , RD Strous (2005). Long-term follow-up (32 years) of PTSD in Israeli Yom Kippur War veterans. Journal of Nervous and Mental Disease 193, 693696.

Z Solomon , M Mikulincer (2006). Trajectories of PTSD: a 20-year longitudinal study. American Journal of Psychiatry 163, 659666.

TC Smith , MAK Ryan , DL Wingard , DJ Slymen , JF Sallis , D Kritz-Silverstein (2008). New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: prospective population based US military cohort study. British Medical Journal 336, 366371.

CY Su , KY Tsai , FH Chou , WW Ho , R Liu , WK Lin (2010). A three-year follow-up study of the psychosocial predictors of delayed and unresolved post-traumatic stress disorder in Taiwan Chi-Chi earthquake survivors. Psychiatry and Clinical Neurosciences 64, 239248.

D Summerfield (1999). A critique of seven assumptions behind psychological trauma programmes in war-affected areas. Social Science and Medicine 48, 14491462.

S Weine , D Vojvoda , D Becker , TH McGlashan , E Hodzic , D Laub , L Hyman , M Sawyer , S Lazrove (1998). PTSD symptoms in Bosnian refugees 1 year after resettlement in the United States. American Journal of Psychiatry 155, 562564.

C Zlotnick , M Warshaw , TM Shea , J Allsworth , T Pearlstein , MB Keller (1999). Chronicity in posttraumatic stress disorder (PTSD) and predictors of course of comorbid PTSD in patients with anxiety disorders. Journal of Traumatic Stress 12, 89100.

Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Psychological Medicine
  • ISSN: 0033-2917
  • EISSN: 1469-8978
  • URL: /core/journals/psychological-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score