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Persistence of PTSD and Quality of Life

in Refugees

The CONNECT study

Lara Drožđek 10001287 Masterthesis Clinical psychology 5628 woorden University of Amsterdam Supervisor: A. Noordhof Februari 2015

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Aims: To examine the persistence of PTSD, and to identify factors which may influence the quality of life (QoL) in refugees from ex-Yugoslavia. Method: 215 refugees with war-related PTSD were assessed approximately 8 years after the war, and reinterviewed 1year later. PTSD and Depression were measured with the M.I.N.I., hostility with the BSI hostility

subscale, and QoL with the MANSA. Post-migration stressors were assessed with a structured interview. Results: Very little variance in persistent PTSD could be explained by the study’s variables. Only hostility had a significant predictive value. Also, hostility mediated the relationship between PTSD persistence and QoL. Conclusion: In treatment of persistent PTSD it may be useful to pay attention to comorbid depression symptoms and to hostility.

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Content

Persistence of PTSD and quality of life in refugees………...4

Depression………...5

Hostility………...6

Post-migration stressors………..8

Method………..10

Sampling techniques and participants……….10

Procedures and measures………10

Statistical analysis………...13

Results………...14

Participant characteristics………...14

Prediction analysis………..14

Mediationanalysis………...15

Testing alternative hypotheses………17

Discussion……….20

References……….24

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Persistence of PTSD and Quality of Life in Refugees The civil war in ex-Yugoslavia, between 1991 and 1995, has exposed civilian

populations to various severely traumatic experiences (Priebe et al., 2013), and has created an influx of refugees to other countries. Exposure to traumatic experiences may lead to the development of mental health problems, such as Posttraumatic Stress Disorder (PTSD). A review of 25 surveys stated that refugees resettled in western countries are about ten times more likely to have PTSD than age-matched general populations in those countries (Fazel et al., 2005). Moreover, there is much evidence for substantial persistence in the course of PTSD. Various studies found that refugees still experience PTSD symptoms many years after the war has ended (Lie, 2002; Mollica et al., 2001; Roth, Ekblad, & Agren, 2006). Also, studies on the course of PTSD found an increase in PTSD symptoms over time in refugees (Lie, 2002; Roth, Ekblad, & Agren, 2006), indicating severity and chronicity of the disease (Lie, 2002). Furthermore, being a refugee, as well as suffering from symptoms of PTSD has been associated with substantially reduced QoL (Akinyemi, Owoaje, Ige, & Popoola, 2012) even many years upon exposure to traumatic experiences (Matanov et al., 2013). PTSD seems to be an important predictor for poor QoL in refugees (Cozijn, 2012), both from acute and prolonged perspectives (Johansen, Wahl, Eilertsen, Weisaeth, & Hanestad, 2007; Huijts, Kleijn, van Emmerik, Noordhof, & Smith, 2012; d’Ardenne, Capuzzo, Fakhoury, Jankovic-Gavrilovic, & Priebe, 2005).

The aim of the current study is to examine the persistence of PTSD, and to identify factors which may influence the quality of life (QoL) in refugees from ex-Yugoslavia, years after the war has ended.

While the high prevalence of persistent PTSD, as well as it’s detrimental impact on the QoL, are well-established (Priebe et al., 2004; Quilty, van Ameringen, Mancini, Oakman, & Farvolden, 2003), mediators of the relationship between PTSD and QoL and moderators of

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PTSD have been studied less thoroughly. Such studies may help to understand which refugees are most vulnerable to persistent PTSD and which factors contribute to the impact of trauma on the QoL. Knowledge of various factors that may influence PTSD persistence will help tailoring mental help assistance to refugees and may therewith impact the level of PTSD symptoms on the long-term. In that manner, their QoL may be improved too.

In the current study we focus on three possible factors, which have been identified as correlates of PTSD and QoL in earlier studies.

Depression

The first factor that may contribute to the impact of trauma is depression. The reason for considering depression as a relevant factor is because comorbidity with PTSD is

particularly high (Ikin, Creamer, Sim, & McKenzie, 2010; Taft, Resick, Watkins, & Panuzio, 2009). War experiences seem to result in higher risks for both PTSD and depression (Priebe et al., 2010), and are likely to be the most common mental health problems among refugees (Fazel, Wheeler, & Danesh, 2005). Comorbidity between PTSD and depression has been associated with greater symptom severity of PTSD and less improvement in PTSD symptoms 8 years after the war in ex-Yugoslavia (Priebe et al., 2013). Moreover, individuals with PTSD and comorbid depression appeared to have poorer treatments outcomes than individuals with PTSD alone (Resick, 2001, cited in Nishith, Nixon, & Resick, 2005).

Hopelessness is often present in individuals suffering from depression (Zhang & Li, 2013). Hopelessness is defined as a state in which an individual holds negative expectations toward oneself and the future , expectations that highly valued outcomes will not occur, and he/she sees no opportunities about changing the likelihood of occurrence of these outcomes (Alloy, Abramson, Metalsky, & Hartlage, 1988). The treatment of PTSD is known to be negatively influenced by feelings of hopelessness (Shamseddeen et al., 2011; Geraghty, Wood, & Hyland, 2010; Wilkinson, Dubicka, Kelvin, Roberts, & Goodyer, 2009; Cheavens, Feldman,

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Woodward, & Snyder, 2006; Curry et al., 2006). It is possible that feelings of hopelessness may interfere with the client’s motivation during treatment, which may hinder the healing process of PTSD symptoms. As a result, depression is expected to increase the chance for persistence of PTSD.

Concerning the influence of PTSD on the QoL, comorbidity of PTSD and depression has been associated with a poorer QoL compared to having one of these diagnoses (Morina et al., 2013; Ikin et al., 2010; d’Ardenne et al., 2005). That is, as mentioned before, PTSD seems to be an important predictor for a poorer QoL in refugees. Secondly, PTSD symptoms seem to predict depression (Asmundson, Stein, Mccreary, 2002). Thirdly, previous studies have found associations between depression and QoL (Ghazinour, Richter, Eisemann, 2004), even after 15 months (Boelen, & Prigerson, 2007).

As found before, the QoL of individuals with PTSD is already significantly reduced. Moreover, it is plausible that the PTSD symptoms, such as constant preoccupation with traumatic experiences, disturbed sleep, nightmares, avoidance of triggers for traumatic memories, and hypervigilance may also lead to development of co-morbid depressive

symptoms. These are - feeling down all the time, feeling worthless, having diminished interest for activities, eating problems, and concentration problems. When depression co-exists with PTSD, it is reasonable to expect that the QoL in these individuals will be even lower than in those diagnosed with PTSD alone.

Therefore, it is expected that depression will play a mediating role in the relationship between the persistence of PTSD and QoL. More specifically, the persistence of PTSD will result in a poorer QoL, PTSD will amplify depression, and depression will decrease the QoL.

Hostility

The second factor concerned, is hostility. Research suggested that hostility is more pronounced in individuals who have experienced war-trauma than in those who have not

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(Klaric, Klaric, Stevanovic, Grkovic, & Jonovska, 2007). People who are high in trait hostility do not trust others, hold negative beliefs about human nature, and tend to interpret the

disagreeable behavior of others as aggressive and intentionally directed at the self (Smith, 1992). Furthermore, hostility was not only shown to be positively associated with PTSD (Orth & Wieland, 2006;Butterfield, Forneris, Feldman, & Beckham 2000; Beckham et al., 2002; Jakupcak, &Tull, 2005), but also predicted PTSD symptoms on both short and longer terms (Wikman, Bhattacharyya, Perkins-Porras, & Steptoe, 2008).

The contribution of hostility to the persistence of PTSD may be explained through the concept of forgiveness (Snyder, & Heinze, 2005). According to these authors ‘’forgiveness is a

process whereby the prior linkage to the transgressor or event is transformed and one no longer perceives an active and ongoing mental negative connection to that transgressing person or event’’ (p. 415). Individuals who are unable to forgive the perpetrators, remain hostile and stuck in their victim identities. This disables them to work through their traumatic experiences and to lower their PTSD symptoms. Therefore, hostility is expected to increase the chance for persistence of PTSD.

Concerning the influence of PTSD on the QoL, PTSD in combination with higher levels of hostility have been associated with a poorer QoL compared to PTSD in combination with lower levels of hostility (Cozijn, 2012; Ouimette, Cronkite, Prins, & Moos, 2004). On one hand, PTSD seems to predict a poorer QoL, and PTSD seems to predict hostility (Snyder, & Heinze, 2005). On the other hand, hostility seems to contribute to a poorer QoL (Julkunen, & Ahlström, 2006).

This may be explained in the following way. As mentioned before, the QoL of individuals with PTSD is already significantly reduced. People with war trauma may have an elevated hostility trait because they have been submitted to man-made violence. People high in hostility trait tend to act aggressively, although often in a subtle manner (Smith, 1992). This

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could be a reaction to their negative feelings towards others as they may want protect

themselves from the perceived threats by feeling hostile. Building on this momentum, people who experience high levels of hostility appear to have a less social contacts and emotional relationships than people who experience less hostility (Sörgaard et al., 2001). It is therefore possible to assume that experiencing hostility, on top of the PTSD symptoms will result in a poorer QoL than when suffering from PTSD alone.

Consequently, it is expected that hostility will play a mediating role in the relationship between the persistence of PTSD and the QoL. More specifically, the persistence of PTSD will result in a poorer QoL, PTSD will amplify hostility, and hostility will decrease the QoL.

Post-migration stressors

The final factor considered, are post-migration stressors. Some studies suggested that post-migration experiences are important in predicting psychological well-being in refugees (Steel et al., 2009; Davidson, Murray, & Schweitzer, 2008) even decades after resettlement (Ryan, Benson, & Dooley, 2008). In particular, post-migration stressors have been found to be associated with higher rates of PTSD (Bogic et al., 2012), and greater severity of PTSD symptoms in refugees (Priebe et al., 2013).

Suffering from PTSD may make it more difficult for people to deal with post-migration stressors (Silove, Sinnerbrink, Field, Manicavasagar, & Steel, 1997). At the same time, it is possible that ongoing PTSD is maintained by post-migration stressors (Lie, 2002). Moreover, it can be hypothesized that post-migration stressors may add up to the stress of PTSD,

impeding individuals to overcome their PTSD complaints (Silove, Sinnerbrink, Field,

Manicavasagar, & Steel, 1997). Therefore, post-migration stressors are expected to play a role in the persistence of PTSD.

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As previously mentioned, the prevalence of persistent PTSD and its impact on the QoL are well-established (Priebe et al., 2004; Quilty, van Ameringen, Mancini, Oakman, &

Farvolden, 2003). However, mediators of the relationship between PTSD and QoL and moderators of PTSD have been studied less thoroughly.

This follow-up study was conducted in regard to factors which may influence the persistence of PTSD, and to identify mediators which may influence the QoL in refugees years after the exposure to war trauma. The first aim of this study was to examine whether depression, hostility and post-migration stressors would influence the persistence of PTSD. The following hypotheses were formulated (figure 1).

H1.1: Depression at time 1 will increase the chance for persistence of PTSD. H1.2: Hostility at time 1 will increase the chance for persistence of PTSD.

H1.3: Post-migration stressors at time 1 will increase the chance for persistence of PTSD.

Figure 1. Prediction model. Influence of depression, hostility and post-migration stressors at

time 1 on the persistence of PTSD

The second aim of this study was to examine whether depression and hostility would each play a mediating role in the relationship between PTSD and QoL. First, it was expected that PTSD would result in a poorer QoL. Secondly, it was expected that PTSD would amplify depression and hostility variables independently. Thirdly, it was expected that these two variables would decrease the QoL. Finally, depression and hostility were expected to mediate the relationship between PTSD and QoL. This leads us to the following hypotheses.

H2.1: Depression will mediate the relationship between PTSD and QoL. H2.2: Hostility will mediate the relationship between PTSD and QoL.

T2 PTSD persistence T1 Depression Hostility Post-migration stressors 9

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Figure 2. Mediation model, with depression and hostility at time 2 as the mediating variables

in the relationship between PTSD persistence and QoL at time 2.

Method

Sampling Techniques and Participants

At time 1, our sample consisted of a total of 283 refugees with PTSD. At time 2, 215 refugees (76%) with PTSD were reinterviewed. Sixty-eight participants could not be

contacted or have declined to participate in the follow-up. The refugees are all originating from the former Yugoslavia and are currently living in Italy, Germany and the United

Kingdom (UK). These three countries were in the 1990s depicted as the ones with the highest numbers of immigrants in Western Europe (Bogic et al., 2012). Refugees were identified through data registers, community organizations and snowballing. Inclusion criteria were: born within the territory of former Yugoslavia; age between 18 and 65 years; experience of at least 1 war-related potentially traumatic event; no severe learning difficulties, and no organic mental impairment; experience of the last war-related event at the age of 16 or older.

Procedures and Measures

All participants in the current sample completed three questionnaires and one

interview. These assessments were conducted face-to-face between 2005 and 2006 (time 1), and within a follow-up 1 year later (time 2). So, all measures used in this study were

completed twice by these participants. All interviewers were bilingual (language of the host country and Croatian/Bosnian/Serbian/Albanian). All of them were trained in the assessment

T2 PTSD persistence T2 QoL T2 Depression Hostility 10

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method. Written informed consent was obtained from all the participants prior to the

interview. The study has been approved by the relevant ethic committee. Sociodemographic characteristics were obtained with a brief structured questionnaire.

Mini-International Neuropsychiatric Interview (M.I.N.I.). The MINI was used to examine the presence of PTSD and depression. This interview is based on the Fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric

Association, 2000), with published translations for the languages used in this study

(Ackenheil, Stotz-Ingenlath, Dietz-Bauer, & Vossen, 1999, Morina, 2006; Rossi et al. 2004, Sheehan et al., 2000). The participants were interviewed and had to answer each of the questions with either ‘yes’ or ‘no’. For example, a question assessing PTSD was ‘Have you ever experienced or witnessed or had to deal with an extremely traumatic event that included actual or threatened death or serious injury to you or someone else?’. A question assessing depression was ‘Have you been consistently depressed or down, most of the day, nearly every day, for the past 2 weeks?’ In general, high validity and reliability of the MINI have been shown across various cultures (Sheehan et al., 1997; 1998; Kadri et al., 2005; Otsubo et al., 2005). However, even though the Albanian version of the MINI has been developed in collaboration with the original authors of the MINI, the validity of the Albanian version remains unknown (Kashdan, Morina, & Priebe, 2009). Regardless, the MINI seemed to be a successful tool in identifying mental disorders in war-affected populations (Morina, & Ford 2008; Mufti et al., 2007). The mean rating agreement among interviewers for diagnostic measurements using the MINI assessing 251 items was 90.2% (Priebe, Bogic, Ajdukovic, Franciskovic,& Galeazzi, 2010).

Brief Symptom Inventory (BSI). The BSI scale was used to measure self-reported psychological symptoms during the past week over nine specific dimensions of

psychopathology. The original authors reported good test-retest reliability for all the BSI

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subscales (.68-.91) (Kashdan et al., 2009). Moreover, research showed that BSI has a good reliability and validity (Meachen, Hanks, Millis, & Rapport, 2008).

The hostility subscale of the BSI was particularly in our interest.This scale was used to measure self-reported hostility during the past week. This subscale consists of 5 items assessing levels of annoyance, argumentativeness, violent urges and temper outbursts. Answers were provided on a 5-point Likert scale, ranging from 0 (‘not at all’) to 4

(‘extremely’). The total scores ranged from 0 (no clinically relevant hostility) to 20 (high level of hostility). An example of the items was “During the past 7 days, how much were you distressed by temper outbursts that you could not control?” This scale showed a high internal consistency in the refugee sample (α=.78) (Henninger, 2014). Also, research showed good support for the construct validity of the hostility subscale (Derogatis, 1993, cited in Jakupcak et al., 2007). Substantial correlations between the hostility scale of the BSI and the hostility scale of the BPRS (r=.49) have also been found (Morlan, & Tan, 1998).

Post-migration stressors. Participants were asked questions about various post-migration stressors (separation from family, difficulties in obtaining a work permit or work in own profession, financial difficulties, inadequate accommodation, difficulties in accessing medical care) and the aspects of cultural adaptation, resulting in a cumulative score of the number of stressors experienced (ranging from 0-6). The self-perceived level of acceptance by the host country and the command of the language of host country were assessed using single Likert-type items (ranging from 1 ‘not at all’ to 5 ‘entirely’). Whether the interviewees had a temporary or permanent legal status in the country of residence, was also assessed. This method has been successfully used in the previous CONNECT studies with the same aim (Bogic et al., 2012; Priebe et al., 2013).

Manchester Short Assessment of Quality of Life (MANSA). The MANSA was used to examine the subjective indicators of the QoL. This interview contains 12 questions which

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assesses subjective QoL including social relationships, family relationships, work, financial situation, living situation, leisure, sex life, personal safety, mental and physical health. The answers were provided on a scale, ranging from 1 (couldn’t be worse) to 7 (couldn’t be better). The total scores ranged from 12 to 84. An example of the items was ‘How satisfied are you with your life as a whole today?’ The MANSA is based on the concept of the QoL, which applies to all populations (Matanov et al., 2013). Therefore it was also applicable in the present sample. High internal consistency (α=.85) of the MANSA has been found for the same sample of ex-Yugoslavian refugees as used in the present study (Cozijn, 2012).

Furthermore, convergent validity with the AAQ (Acceptance and Action Questionnaire) and the BSI has been found (Morina, 2007). Moreover, research suggests a good convergent validity of the MANSA with general life satisfaction (Eklund, & Sandqvist, 2006).

Statistical analysis

Statistical analyses were performed using IBM SPSS Statistics version 20.0. To test the first group of hypotheses (1.1-1.3), separate logistic regression analyses examined associations between predictor variables (depression, hostility, post-migration stressors) and PTSD. Multicollinearity among potential predictor variables was assessed using the variance inflation factor statistic. A variance inflation factor exceeding 10 for a variable was regarded as indicating multicollinearity (Myers, 1990, cited in Field, 2009). For the second group of hypotheses (2.1-2.2), separate linear regression models with QoL as a dependent variable for PTSD examined the mediation. A formal test of mediation (Baron & Kenny, 1986) was used to assess whether each of the mediator variables (depression, hostility) added significant variance to predicting the QoL. In the first step of this mediation test a correlation between PTSD and QoL was examined. Subsequently, correlations between PTSD and each mediator variable were assessed. In the third step, effects of each mediator variable on the QoL were examined. The final step of the mediation examined whether the relationship between PTSD

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and QoL was mediated by depression and hostility. Therefore, the effect of PTSD on the QoL, upon controlling for the mediator variables, had to be 0.

Results Participant characteristics

The sample at time 2 consisted of 215 refugees with PTSD, with mean age of 44.8 years. In this sample were 124 females (57.7%). They experienced 6.8 different traumatic war events, and 136 refugees were diagnosed with comorbid depression. Most refugees (21.4%) migrated in 1993 to one of the three Western countries, and have experienced on average 2.6 migration stressors. Table 1 shows the sociodemographic data, war participation and country of origin per country of migration at the follow-up.

Table 1

Sociodemographic data, war participation and country of origin at follow-up

Total (n=215 ) Germany (n=114) UK (n=61) Italy (n=40) Females, n (%) 124 (57.7) 72 (63.2) 29 (47.5) 23 (57.5)

Age, years: mean (s.d.) 44.8 (10.3) 44.36 (9.79) 48.62 (8.97) 40.8 (11.46) Active participation in the war, n (%) 30 (14%) 18 (15.8) 5 (8.2) 7 (17.5) Country of origin, n (%)

Bosnia and Hercegovina Kosovo

Serbia and Montenegro Croatia Macedonia Yugoslavia SFRJ 139 (64.7) 42 (19.5) 16 (7.4) 11 (5.1) 4 (1.9) 2 (.9) 1 (.5) 86 (75.4) 12 (10.5) 9 (7.9) 2 (1.8) 2 (1.8) 2 (1.8) 1 (.9) 39 (63.9) 19 (31.2) - 2 (3.3) 1 (1.6) - - 14 (35.0) 11 (27.5) 7 (17.5) 7 (17.5) 1 (2.5) - - Predictor analysis

Three separate logistic regressions were conducted with PTSD persistence as the dependent variable and depression, hostility and post-migration stressors at time 1 as the independent variables. Only hostility predicted PTSD persistence significantly (β=.08, Wald=5.26, p=.02). Neither depression (β=.41, Wald=1.91, p=.17), nor post-migration stressors (β=.02, Wald=.07, p=.80) seemed to predict PTSD persistence. Table 2 shows the odds ratio and it’s confidence interval.

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Table 2

Odds ratio and confidence interval for each predictor variable

95% Cl for Odds ratio

Lower Odds Ratio Upper Included Depression .84 1.51 2.70 Hostility 1.01 1.08 1.15 Post-migration stressors .88 1.02 1.19 Note. R²= .009¹; .03²; .00³ (Cox & Snell), .01³; .04²; .00³ (Nagelkerke).

Model X²= 1.90, p=.17³; X²= 5.63, p=.02²; X²= .07, p=.80³ Note. ¹ Depression, ² hostility, ³ post-migration stressors

Mediation analysis

Mediational analyses were carried out with QoL at time 2 as the dependent variable, PTSD persistence as the independent variable, and depression and hostility at time 2 as the potential mediating variables. A significant moderate effect of PTSD persistence on QoL was found (β=-.27, t=-3.73, p<.01). So having PTSD at time 2 decreases the QoL at time 2. Subsequently, an analysis was carried out to establish if depression mediated the relationship between PTSD persistence and QoL (Figure 3). Unexpectedly, no significant effect of PTSD persistence on depression at time 2 was found (β=-.60, Wald=3.17, p=.08), resulting in no certainty about this relationship. However, an effect of depression at time 2 on QoL at time 2 was found (β=-.19, t=-2.58, p<.05).

Considering these results, further analyses were done in order to explore the possible mediating effect of depression in the relationship between PTSD persistence and QoL. The association between PTSD persistence and QoL remained significant, adding to the finding that depression doesn’t play a mediating role in this relationship.

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Figure 3. Mediational model between PTSD persistence, depression and QoL

*p<0.05, **p<0.01

Note. Beta values before and after inclusion of the mediator variable

A second mediational analysis was carried out in order to explore whether hostility mediated the relationship between PTSD persistence and QoL (Figure 4). In fact, PTSD persistence did predict hostility at time 2 (β=.29, t=4.43, p<.01). Also, hostility did predict the QoL at time 2 (β=-.48, t=-7.42, p<.01). This suggests that suffering from PTSD increases hostility, which in turn decreases the QoL. After inclusion of hostility as a mediator, the association between PTSD persistence and QoL became non-significant (β=-.13, t=-1.90, p=.06). The attenuation of this association was significant (Sobel Z= -3.80, p<.01). This confirms the existence of a mediating relationship, suggesting that hostility may account for the association between PTSD persistence and QoL.

Figure4. Mediational model between PTSD persistence, hostility and QoL

*p<0.05, **p<0.01

Note. Beta values before and after inclusion of the mediator variable

-.60 -.19 * -.27 ** (-.25)** T2 PTSD persistence T2 QoL T2 Depression -.27** (-.13) -.48 ** T2 PTSD persistence T2 QoL .29 ** T2 Hostility 16

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Testing alternative hypotheses

Since previous research found PTSD with depression to be associated with greater PTSD severity and less improvement in PTSD symptoms 8 years later (Priebe at al., 2013; Priebe et al., 2013), it was surprising that in the current study no effect of depression on PTSD persistence was found. Therefore we were wondering if the way depression was assessed could account for our unexpected finding. A separate logistic regression with PTSD persistence as the dependent variable and depression at time 1, measured with BSI, as the independent variable was conducted. In this case, depression did predict PTSD persistence significantly (β=.44, Wald=8.55, p<.01). Secondly, since post-migration stressors are important in predicting psychological well-being in refugees (Steel et al., 2009; Davidson, Murray, & Schweitzer, 2008), it was assumed that in case that they don’t predict PTSD persistence, they may predict depression. A logistic regression with depression at time 2 as the dependent variable and post-migration stressors at time 1 as the independent variable was conducted. An effect of post-migration stressors on depression was found (β=-.32,

Wald=13.83, p<.01).

Upon establishing a possible mediating effect of hostility in the relationship between PTSD persistence and QoL, we tested several alternatives to the hypothesis that hostility is indeed a specific mediator. First, we tested whether the mediating effect was specific to hostility, or alternatively whether all BSI-scales would show a similar effect. Therefore, mediational analyses were carried out with QoL at time 2 as the dependent variable, PTSD persistence as the independent variable, and each of the nine subscales of the BSI at time 2 as potential mediating variables (figure 5). As mentioned before, PTSD persistence predicted the QoL (β=-.27, t=-3.73, p<.01). Separate linear regressions showed that PTSD persistence predicted a significant increase on each subscale, and that all scores on every subscale of the BSI predicted a significant decrease in the QoL (table 3). This means that suffering from

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PTSD, increases scores on every subscale of the BSI, which in turn decreases the QoL. After inclusion of all the subscales as mediators, only the Depression subscale made the relationship between PTSD persistence and QoL non-significant (β=-.03, t=-.39, p=.70). The attenuation of this association was significant (Sobel Z= -5.61, p<.01). Given that the resulting

association between PTSD and QoL attenuated to non-significance indicates full mediation. We can conclude that hostility indeed plays a mediating role in the relationship between PTSD persistence and QoL. However, once depression, measured with the BSI, is included in the model, the mediating role of hostility disappears.

Figure 5. Mediational model between PTSD persistence, BSI subscales and QoL

*p<0.05, **p<0.01

Note. Beta values before and after inclusion of the mediator variable

Table 3

Beta’s and p-values per step, per BSI subscale

Step 1 PTSD → subscale Step 2 Subscale → QoL Step 3 Mediation (Subscale→QoL) Step 4 Sobel Z Anxiety 0.41 (p<.01) -0.45 (p<.01) 0.09 (p=.54) - Depression 0.42 (p<.01) -0.61 (p<.01) -0.49 (p>.01) -5.62 (p<.01) Hostility 0.29 (p<.01) -0.48 (p<.01) -0.16 (p=.10) - Interpersonal sensitivity 0.28 (p<.01) -0.52 (p<.01) -0.04 (p=.75) - Obsessive-compulsive 0.42 (p<.01) -0.54 (p<.01) -0.18 (p=.22) - Paranoid ideation 0.25 (p<.01) -0.55 (p<.01) -0.19 (p=.07) - Phobia 0.36 (p<.01) -0.43 (p<.01) 0.16 (p=.22) - Psychoticism 0.32 (p<.01) -0.53 (p<.01) 0.17 (p=.22) - Somatization 0.33 (p<.01) -0.45 (p<.01) -0.01 (p=.90) - -.27** (-.03) ** T2 BSI subscales T2 QoL T2 PTSD persistence ** 18

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Second, we controlled for a possible confound in the association between PTSD persistence and hostility at time 2, that is hostility at time 1. A linear regression analysis was carried out with hostility at time 2 as the dependent variable and PTSD persistence and hostility at time 1 as the independent variables. As mentioned before, the association between PTSD persistence and hostility at time 2 was significant (β=.29, t=4.43, p<.01). After controlling for this

confound, this association remained significant (β=.23, t=3.65, p<.01). This result strengthens the finding that PTSD persistence predicts hostility. Finally, we tested an alternative mediating pathway within the model linked to our second

hypothesis. This was to investigate whether this pathway would provide a better framework for the relationships between PTSD persistence, hostility and QoL. Therefore we included hostility at time 2 as the dependent variable, PTSD persistence as the independent variable and QoL at time 2 as the potential mediator in our mediation (figure 6). As mentioned before, PTSD persistence predicted hostility at time 2 (β=.29, t=4.43, p<.01), as well as QoL at time 2 (β=-.27, 3.73, p<.01). Furthermore, QoL at time 2 predicted hostility at time 2 (β=-.48, t=-7.42, p<.01). After inclusion of the mediator in the model, a slight drop in significance in the relationship between PTSD persistence and hostility at time 2 was found (β=.18, t=2.79, p<.01), suggesting a partial mediation (Sobel Z= 3.33, p<.01). This suggests that having PTSD results in a lower QoL, and leads to higher hostility. Our original model however, suggested a full mediation. We can conclude that our original model provides a more adequate framework for the relationships between the variables.

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Figure 6. Mediational model between PTSD persistence, QoL and hostility

*p<0.05, **p<0.01

Note. Beta values before and after inclusion of the mediator variable

Discussion

The first aim of this study was to identify predictors of PTSD persistence in refugees. It was found that very little variance in persistent PTSD could be explained by the study’s variables and that only hostility had a significant, albeit weak, predictive value. This means that the effect of hostility on PTSD persistence has to be questioned. The second aim was to identify mediators of the relationship between persistent PTSD and QoL. Again, only hostility was found to serve as a potential mediator in this relationship.

Next, no predictive value of depression on PTSD persistence was found. This unexpected finding may be explained through the way depression was assessed. Depression was initially assessed with the MINI, which is an interview-based measure. No effect of depression on PTSD persistence was found. Later on, in our exploratory analyses, depression was examined with the BSI, which is a self-report measure. When assessed with the BSI depression did predict PTSD persistence. One possible explanation for this finding is that factors such as social desirability or unwillingness to complain may be more of an influence in case of when an interview based measure is used compared to a self-report measure. No predictive value of post-migration stressors on PTSD persistence was found either. This is surprising since post-migration stressors have been consistently related to PTSD

-.27 ** .29** (.18)** -.48 ** T2 PTSD persistence T2 Hostility T2 QoL 20

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symptomatology among refugees (Miller, & Rasmussen, 2010). On the other hand, research also suggests that war exposure tends to be more strongly related to PTSD than

post-migration stressors, while post-post-migration stressors are stronger predictors of depression than war exposure (Miller et al., 2002; Montgomery, 2008; Steel et al., 1999; Montgomery, 2008). Consequently, our exploratory analyses found an effect of post-migration stressors on

depression.

The exploratory analyses also provided us with more insight with regard to our mediational models. As expected, hostility was found to play a mediating role in the relationship between PTSD persistence and QoL. Results relating to the alternative hypotheses mostly supported this finding. Also, our original model provided a more adequate framework for the

relationships between PTSD persistence, hostility and QoL, than the alternative model. However, the exploratory analyses showed that all BSI scales have a mediating effect, indicating that the effect of hostility may be nonspecific.

Concerning our last hypothesis, the findings unexpectedly suggested that depression doesn’t play a mediating role in the relationship between PTSD persistence and QoL. This finding may also be due to the way depression was assessed. Again, when depression was assessed with the BSI, it did mediate the relationship between PTSD persistence and QoL.

This research has several strengths and limitations. The CONNECT study is, in our knowledge, the largest community-based prospective study so far, which has focused on the course of PTSD in war-affected populations. Although one cannot infer causality from the present study, due to the observational design, the results may suggest directions regarding causality because of the study’s longitudinal design. Moreover, it is one of the few studies which focused on the long term relationship between hostility and PTSD.

However, the sample was not completely representative for a refugee population. The reason for this is the unavailability of detailed population data, legislation, and research regulations

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in the participating countries (Priebe et al., 2013). This phenomenon is common among research studying refugee groups. Also, there is an overlap in methodology. The scores of the QoL, as well as of hostility were based on subjective reports. Since every person has its own style of responding, correlations between the two variables due to method are inevitable. Furthermore, with regard to the association between BSI-Depression and subjective QoL it appears that these scales may tap into similar experiences of dissatisfaction with life.

Therefore, the associations between these self-reported scales found in this study may result from methodological rather than substantive reasons.

The findings of this study prudently suggest an effect of depression, when measured with the BSI, on PTSD persistence. In clinical practice, interventions aiming at targeting PTSD symptoms may be combined with those lowering depression symptoms. This combination of treatment focuses may lead to improvement of both PTSD and depression symptoms, in comparison with treatment approaches focusing on only one of these

conditions. The combined approach may also result in a better QoL in refugees. Also, it may be important for clinicians to have knowledge of the, albeit weak, but maintaining effect of hostility on PTSD persistence and, subsequently, on the QoL. Clinicians should therefore be aware of the possible negative influence of hostility on the therapeutic relationship and the PTSD symptoms, and develop strategies to deal with hostile clients.

Based on this study’s findings, the following suggestions for future research can be formulated. Firstly, it may be useful to compare the validities of the MINI and the BSI

Depression subscale. In that manner, it may come apparent which of these two measurements provides a more accurate view of the levels of experienced depression. Next, it may be interesting to explore whether hostility has an effect on depression symptoms in refugees. And to establish which of the two diagnoses, PTSD or depression, are more influenced by hostility.At last, the relationship between hostility and post-migration stressors in refugees

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may also be a topic of future research. A higher level of hostility may predict higher levels of post-migration stressors, and this may, in turn, contribute to a higher hostility level. In other words, when a refugee has hostile feelings towards people from the host country, he or she may less likely become accepted and respected by them. This in turn, may make it harder for a refugee to make friends, get a job and to integrate, resulting in a higher level of experienced post-migration stressors. Furthermore, when a refugee feels he/she is not accepted in the host country, his or her hostile feelings may further increase. And so the cycle goes on.

In conclusion, persistent PTSD in refugees is a complex condition. In treatment it may be useful to pay attention to both PTSD and comorbid depression symptoms and to a lesser extent to hostility.

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