In 1998 the Serbian Kosovars waged a war of ethnic cleansing against the Albanian Kosovars. In June 1999 the war came to an end. At this point, Albanian Kosovars had to come to terms with experiences of being targets of violence and persecution, mourning dead or missing family members, and the destruction of their homes and property. However, the defeated Serbian Kosovars didn’t fare a whole lot better: Some were killed in reprisal attacks, and others experienced assault, forced eviction, threats, arson, crop burning, and the cutting of phone lines.

Two groups of scientists have now studied the mental health impact of the war in Kosovo and reported their results in the August 2 Journal of the American Medical Association. Not surprisingly, the war unleashed major mental health damage on the victimized Albanian Kosovars. Moreover, it caused mental health difficulties for the defeated Serbian Kosovars as well.

In an interview with Psychiatric News, S. Arshad Husain, M.D., professor and chief of the Section of Child and Adolescent Psychiatry at the University of Missouri in Columbia and director of the university’s International Center for Psychosocial Trauma, said that he found the JAMA studies to be "very good research done by people used to doing research." And in an editorial accompanying the reports, Joseph Westermeyer, M.D., a psychiatrist with the Veterans Affairs Medical Center in Minneapolis, describes both studies as "laudable investigations."

Westermeyer found them praiseworthy, he explained, because compared with previous investigations about the effects of war on mental health, they have broken new ground in several areas. For one, they were conducted shortly after the war instead of at a later date, thus offering insights into the more immediate mental health consequences of armed conflict rather than into those occurring later.

"Of greatest importance," Westermeyer writes, "these investigations have demonstrated that rapid assessments based on valid and reliable research methods can be conducted under the difficult circumstances associated with war and armed conflict."

What’s more, one of the studies dealt with a taboo subject that others have not broached—the mental health impact of war on the aggressors rather than on the victims. And one of the studies addressed the feelings of hatred and revenge that can result from war—a domain that has been largely neglected.

In the first study, Barbara Cardozo, M.D., Alfredo Vergara, Ph.D., and Carol Gotway, Ph.D., of the Centers for Disease Control and Prevention in Atlanta, along with Ferid Agani, M.D., of the Institute for Mental Health and Recovery in Pristina, Kosovo, conducted a mental health survey among Albanian Kosovars from August 20, 1999, to October 7, 1999. Members of 558 households in both urban and rural areas were surveyed.

The researchers used three questionnaires to evaluate posttraumatic stress disorder, general psychiatric problems, and social functioning in the persons surveyed. All three questionnaires had been found, in a number of countries, to be competent tools for measuring travel-related mental health problems. They were the Harvard Trauma Questionnaire, the General Health Questionnaire 28, and the Medical Outcomes Study Short-Form 20. The researchers added additional questions specific to the Albanian Kosovar population on feelings of hatred and a desire for revenge. All questionnaires were translated into Albanian and back-translated into English to ensure cultural appropriateness 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 in Pristina, did the translating.

Respondents reported having experienced a high incidence of traumatic events. Some two-thirds, for instance, reported having experienced a lack of food or water, a combat situation, or being close to death. Over half reported having fled to another country as refugees during the war, while 48 percent reported having been beaten, incarcerated, verbally abused, witnessing a loved one suffering these abuses, or being forced to choose the victim of a violent act among one’s family’s members. About one-fourth reported having witnessed the murder of a family member or friend. Thus, not surprisingly, 17 percent of the respondents met DSM-IV criteria for posttraumatic stress disorder, and certain traumatic events such as forced separation from one’s family or the murder of a family member or friend seemed to have particularly predisposed those surveyed to the disorder.

As for the psychiatric symptoms experienced by those surveyed, anxiety and insomnia predominated over social dysfunction and symptoms of severe depression. These findings, the researchers believe, may have been due to the fact that by the time the survey was conducted, the war had ended, and many may have felt relatively optimistic about the future. In any event, populations at increased risk for psychiatric problems were persons aged 65 or older, those with previous psychiatric illnesses or chronic health conditions, and those who had been internally displaced and often persecuted (as opposed to those who had fled the country and returned once the war ended).

Eighty-nine percent of the men and 90 percent of the women surveyed reported having strong feelings of hatred toward the Serbians. Fifty-one percent of the men and 43 percent of the women reported strong feelings of revenge; 44 percent of men and 33 percent of women stated that they would act on these feelings.

In fact, the hate and desire for revenge found to prevail among female Albanian Kosovars, Husain maintained, was one of the most interesting findings to emerge from the studies. And he said that he thinks that he knows the reason: There are still a lot of male Albanian Kosovars missing—they may be in concentration camps in Serbia or dead—and the uncertainty about their fates has fueled frustration, rage, and desperation among their wives.

Whether or not he is right about why female Albanian Kosovars are so keen on revenge, he pointed out, this situation in Kosovo differs from that in Bosnia-Herzegovina, where women scarred by the war of 1992-95 subsequently taught their children not to think of revenge. "And I think they were successful," Husain added, "at least in the population we interviewed".

The second study about the mental health consequences of the Kosovo war was conducted by Peter Saloma, M.D., and Paul Spiegel, M.D., of the Centers for Disease Control and Prevention; Marci Van Dyke of the International Rescue Committee in Pristina, Kosovo; and Laura Phelps and Caroline Wilkinson of Action Against Hunger in Pristina.

From the end of September 1999 to the end of October 1999, Saloma and his colleagues administered the General Health Questionnaire 28—one of the three questionnaires that Cardozo and her team had given the Albanian Kosovars—to some 200 Serbian Kosovars in about 200 households. After Saloma and his colleagues analyzed the results of the questionnaire, they compared the results with those that Cardozo and her team had gotten with their evaluation of the Albanian Kosovars.

The 28 questions on the GHQ questionnaire have to do with somatic symptoms, anxiety, depression, and social dysfunction. A higher score signifies a greater number of psychiatric symptoms. The total mean GHQ score for the Serbian Kosovars, the researchers found, was not only as high as that of the Albanian Kosovars, but even somewhat higher, and especially in the domains of depression and social dysfunction.

Given that Serbian Kosovars had been the aggressors, not the victims, Saloma and his colleagues pointed out that they find these results somewhat surprising. None-theless, they noted, the Serbian Kosovars’ particularly high level of psychological distress might have reflected that while the war was over for the Albanian Kosovars, it was in a sense just beginning for them—the defeated, the disgraced, the people in retreat.