Elsevier

Comprehensive Psychiatry

Volume 45, Issue 6, November–December 2004, Pages 475-482
Comprehensive Psychiatry

Complicated grief in Bosnian refugees: Associations with posttraumatic stress disorder and depression

https://doi.org/10.1016/j.comppsych.2004.07.013Get rights and content

Abstract

Complicated grief is likely to be common among refugee populations exposed to war trauma. However, there have been few studies investigating the traumatic antecedents and correlates of complicated grief in refugees, and the relationship of that symptom pattern with other common disorders such as posttraumatic stress disorder (PTSD) and depression. We studied Bosnian refugees recruited from a community center in Sydney, Australia, with the sample being supplemented by a snowball method (N = 126; response rate, 86%). Measures included a trauma inventory, the Clinician Administered PTSD Scale (CAPS), the depression module of the Structured Clinical Interview (SCID), and the Core Bereavement Items (CBI). A dimension of traumatic loss derived from the trauma inventory was a specific predictor of complicated grief, with exposure to human rights violations being associated with images of the traumatic events surrounding the lost person. There was no link between PTSD and grief other than for a low-order association with the PTSD intrusion dimension. In contrast, depression was strongly associated with grief and its subscales. Only the subgroup with comorbid grief and depression reported higher levels of traumatic loss. The results suggest that complicated grief in refugees can become persistent and associated with depression. While PTSD and grief share common symptoms of intrusion, the two symptom domains are sufficiently distinct to warrant independent assessment of grief in refugee populations.

Section snippets

Sample

One hundred twenty-six Bosnian Muslim refugees (hereafter referred to as Bosnian refugees) were recruited from the larger Bosnian community residing in Sydney, Australia. Although several ethnic groups experienced trauma during the war, most survivors of ethnic cleansing were from the Muslim group.6, 28, 29

Random epidemiologic sampling was not feasible given the absence of a central register of refugees in Australia and the wide geographic distribution of Bosnian refugees in Sydney. Telephone

Demographic characteristics

The sample consisted of 77 women (61%) and 49 men (39%). The mean age was 47 (range, 18 to 88) years. Seventy-seven percent were married and 92% had at least one child. Eighty-seven percent had completed high school and 13% held a university degree. Sixty-two percent had been employed in factory or sales work in Bosnia and 14% were professionals. Ninety-six percent were unemployed in Australia and 74% spoke little or no English. Subjects originated from 25 different cities and villages across

Discussion

The range of traumas experienced and the types of disorders identified were consistent with those reported in studies of Bosnian refugees in other settings.5, 8, 50, 51 Limitations of the study included the modest sample size and the nonrandom selection of subjects. It seems that our community center snowball sampling technique yielded a group with high levels of psychopathology. The rate of PTSD of 63% was broadly in keeping with the findings of previous studies undertaken among high-risk

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