Depression, anxiety and somatization in women with war missing family members.

INTRODUCTION: During the war circumstances, women and children are exposed to multiple traumatic experiences, one of which is an violent disappearance of a family member. GOAL: The aim of this research was to establish the presence of symptoms of depression, anxiety and somatization in women in Bosnia and Herzegovina who have sought their war missing family members for 15 to 18 years. SUBJECTS AND METHODS: The research was based on a sample of 120 women with war missing family member and 40 women without a war missing family member as a control group. For assessment of depression, anxiety and symptoms of somatization the self-rating Beck Depression Inventory (BDI), Hamilton Anxiety Rating Scale (HAM-A), Somatic Symptoms Index (SSI) questionnaire and a general questionnaire on the sociodemographic data and data on war missing family members were used.
RESULTS: A significantly higher intensity of symptoms of depression (p<0.001), anxiety (p<0.001) and somatization (p = 0.013) was present in women with, in comparison to women without a missing family member. In comparison of the kinship with the missing family members, statistically significantly higher intensity of symptoms of depression, anxiety and somatization was in women with a missing child (p<0.001) in comparison to other missing family members.
CONCLUSION: A prolonged period of seeking, waiting and uncertainty of what happened in the war with the missing family member presents for those women a prolonged suffering manifested through depression, anxiety and symptoms of somatization.

INTRODUCTION

War conflicts and disasters leave a number of consequences for the population of the affected area, and one of them is also the forced disappearance of persons. It is estimated that during the war in the former Yugoslavia (1991 – 1998) there are over 30.000 missing persons (1). Reports state that in July 1995, only in Srebrenica, there were about 7.000 missing and killed men (2). Data from conflict affected countries suggest that there is greater number of men among disappeared persons than women (3, 4). During the war conflicts in Bosnia and Herzegovina about 91.7% men and about 8.1% women disappeared (5). Several reports suggest that the experience of a missing family member has a negative influence on the survivor’s psychological and somatic health (6, 7). Boss (8) particularly emphasized the specificity of the loss in person disappearance, marking it as an ambiguous loss. Ambiguous loss is, in fact, the standard theory of understanding the impact of the situation in which one member of the family is a subject to ambiguity (9). Several authors have found that the family members of the disappeared person show feelings of helplessness, depression, anxiety, somatization and conflicting relations (9, 10, 11). In Bosnia and Herzegovina, 18 years after the war, the surviving members of the family are still searching for their missing family members (12). Therefore, the goal of this research was to analyze the intensity of symptoms of anxiety, depression and somatization in women who have a war missing family member and to establish the existence of difference in their intensity in relation to the kinship with the missing family member. For the needs of this research we used a definition of a “missing person” and a definition of a “family member of a missing person” in accordance to the Law on Missing Persons in Bosnia and Herzegovina from 2004 (Official Gazette, no. 50/04, Article 2). Under this law, a missing person is a person whose family does not have any news and/or is reported on the basis of reliable information as a missing person as a result of the armed conflict that took place on the territory of the former Yugoslavia. Family member of a missing person is a child born in or out of wedlock, an adopted child, as well as stepchild supported by the missing person, marital or common-law partner, parents (stepfather, stepmother), adoptive parents, brother or sister of a missing person, previously supported by the missing person.

SUBJECTS AND METHODS

The total sample consisted of 160 women aged 18 to 65 who lived during the war in Bosnia and Herzegovina and who were displaced from their place of residence. The sample was divided in two groups: a group of 120 women with, and a group of 40 women without war missing family members. The research was conducted in the period between April 2010 and May 2011 in the area of District Brčko, Tuzla Canton and Sarajevo Canton, Bosnia and Herzegovina. The research included women who met the general criteria of inclusion and who gave their informed consent to participate in a research. General criteria for inclusion were: that women were not impaired in intellectual development, that they had preserved the ability of understanding and comprehension of the questions, that they did not undergo a psychiatric treatment before the war, that lived in Bosnia and Herzegovina during the war and that they had an experience of exile. For a group of women with a war missing family member, besides the general criteria for inclusion, there was a criterion of having one close member of the family missing: a son/daughter, husband, father/mother and brother/sister. We did not include in the research women who have more war missing family members. The sample of women with a war missing family member was formed out of female members of associations of families of the missing. After preliminary selection of 157 women who a voluntarily agreed to participate in the research, 138 women met the criteria for inclusion. During the research, eight of them gave up. The sample of women with a war missing family member was stratified according to the kinship with the missing member by including an equal number of women whose husband, father/mother, brother/sister and son/daughter were missing. Questionnaires on data about the missing family member were divided in four groups according to the kinship with the missing member. By counting the sample of 130 women, we found that 30 women had a missing brother, 32 a missing father, 35 a missing husband and 33 a missing son. Not one of the women had a missing female member of the family. The final sample of 120 women was formed by including the first 30 women from each group. A group of women without a war missing family members consisted of 40 women from a general population coming from the area of District Brčko, who met the general criteria for inclusion and gave their informed consent. This group was formed by using a method of a “snowball” sample.

For the purposes of this research, we used a general questionnaire which contained data on age, family status, marital status, education, vocation, employment, financial status, somatic and mental disorders, alcohol and nicotine, and data on a missing family member. To assess depression, we used Beck Depression Inventory (BDI-I) (13). The scale has 21 questions with four options for answers scaled from 0 to 3. Assessment of the state refers to the previous week and the day when it is applied. Severity of the disorder is numerically marked with: 0 – 9 considered normal; 10 – 15 mild depressed state; 16 – 19 mild to moderate state of depression; 20 – 29 moderate to severe state of depression; and 30 – 63 severe depression. For the assessment of anxiety, we used Hamilton Anxiety Rating Scale (HAM-A) (14). HAM-A is comprised of 14 items. Each item is scored on scale of 0 (not present) to 4 (severe), with a total score range of 0–56, where a score < 17 indicates mild severity, 18 – 24 mild to moderate severity, and 25 – 30 moderate to severe scale has a good. Somatic Symptom Index (SSI) (15) is a self-report questionnaire for assessment of the severity of somatic symptoms. It is comprised of 26 items to assess somatic symptoms, physical sensations and overall health. The subject is offered a list of symptoms with numbers which mark the severity caused by the symptoms of distress: 1 – not at all, 2 – a little bit, 3 – moderate, 4 – quite a bit, and 5 – a great deal. The total score is ranged from 26 to 130. The minimum score ranges up to 52, moderate to high is 53 – 104 and extremely high from 105 to 130. The results were analyzed using descriptive statistics from the calculation of the average value and standard deviation. To test the difference between groups, we used X2- test, non-parametric Mann Whitney-U test, and Pearson’s correlation test. For statistical analysis of data we used SPSS for Windows 10.0 (SPSS Inc., Chicago, IL, USA).

RESULTS

The average age of women in the total sample was 47.1±14.0, and there was no significant difference between the groups (P = 0.073). It is significant that in comparison to women without missing member more women with a war missing family member did not return to their pre-war place of residence (p<0.001) and were widows (p = 0.001), without education (p<0.001), living in the countryside (p<0.001). Also, a significantly higher number of these women had someone close to them who was wounded (p = 0.036) or killed in the war (p<0.001). However, a significantly higher number of women without missing family member smoke (p = 0.003) and consume alcohol (p = 0.001). There was no significant difference between these two groups of women in seeking psychiatric help after the war, but a significantly higher number of women with a war missing family member used sedatives self-initiatively (p = 0.012) (Table 1). When asked how much the life changed after the war, more women with a war missing family member than women without a missing family member reported completely (102/120 vs 8/40), while more women without missing family member responded fairly (20/40 vs 16/120) and slightly (10/40 vs 2/120). Women with a war missing family member had a significantly higher mean value of symptoms of depression (p<0.001), anxiety (p<0.001) and somatization (p = 0.014) in comparison to women without missing family members. By using a non-parametric Mann-Whitney test, it was established higher average value of symptoms of depression were in women who had a son missing, than in women with a missing father, brother and husband (p<0.001); women with a missing husband and women with a missing father (p<0.001); and between women who had a missing brother and women with a missing father (p = 0.005). No significant difference was found in average value of symptoms of depression between women with a missing husband and women with a missing brother (Table 2).

Table 1

Demographic characteristics of the sample (N = 160)

Table 2

Mean and standard deviation of symptoms of depression, anxiety and somatisation in a group of women with a war missing family member in relation to kinship with the missing and women without a war missing family member M – mean, SD – Standard deviation, *Kruskal Wallis Test; † Mann-Whitney U-test, p<0.001; ‡ Mann-Whitney U-test, p<0.001; ρ Mann-Whitney U-test, p=0.005; ¶Mann-Whitney U-test, z =–2.64, p=0.008; § Mann-Whitney U test, z =–3.33, P = 0.001; **Mann-Whitney U test, z =–2.39, P = 0.017; ‡‡ Mann-Whitney U test: Z = -3.24, P = 0.001

In average values of symptoms of anxiety there were significant difference in women with a missing son than in women with a missing brother (p = 0.008) and women with a missing husband (p = 0.001). There was no significant difference in average value of symptoms of anxiety between women with a missing husband and women with a missing brother, and between women with a missing father and women with a missing brother (Table 2). Women with a missing son had a significantly higher average value of symptoms of somatization than women with a missing son (p = 0.027), brother (p = 0.033) and father (p = 0.001), while there was no significant difference between women with a missing husband and women with a missing brother (Table 2). In relation to the level of depression, anxiety and somatization, 57 (47.5%) women with a war missing family member suffered from a serious depression, 48 (40.0%) moderate to serious anxiety, while 61 (50.8%) women had a moderate to high level of somatic symptoms (Table 3). The most common somatic complains in women with war missing family member were myalgia (50 or 41.7%), malaise and dizziness (62 or 51.7%), visual disturbance (57 or 47.5%), a feeling of prostration, weakness and fatigue (75 or 62.5%), changes of heat and cold (57 or 47.5%), feeling that their physical health is not as good as in their acquaintances, headache (57 or 47.5%), not feeling good most of the time (83 or 69.2%), feeling of heaviness in arms and legs (79 or 65.8%), back pain (62 or 51.7%). The correlation between the intensity of somatic symptoms and symptoms of depression was statistically significant (r = 0.183, p = 0.021) as well as symptoms of anxiety (r = 0.410, p<0.001). Also, there was a significant correlation between the intensity of symptoms of depression and the age of women in the total sample (r = 0.596, p<0.001), symptoms of anxiety and the age of women (r = 0.531, p<0.001), and intensity of symptoms of anxiety and depression (r = 0.698, p<0.001).

Table 3

Level of depression, anxiety and somatic symptoms in women with a missing family member in relation to kinship with the missing and women without a missing family member. BDI – Beck Depression Inventory, HAM-A- Hamilton Anxiety Scale, SSI – Somatic Symptom Inventory. * X2 = 38.533, df = 1, p<0.001; † X2 = 22.533, df = 1, p<0.001; ‡ X2 = 5.637, df = 1, p = 0.018

DISCUSSION

In this research, we found that women with a war missing family member are more depressed, anxious and they show a higher intensity of somatic symptoms than women without a war missing family members. Also, we found that, in comparison of kinships with a missing family member, symptoms of depression, anxiety and somatic symptoms are shown at the maximum intensity in women with a missing son, approximately equal in women with a missing husband and son, and at the minimum intensity in women with a missing father. The presence of symptoms of depression, anxiety and somatization in women with a forced missing member of family similar to our results was in research of Schaal et al. (16) in Ruanda, and in Robins’ (9) research conducted in Nepal. Boss (8) states that many members of the family of missing experience feelings of helplessness, depression and anxiety, conflicts in relationships and somatization. Furthermore, she considers that these adverse effects occur due to ambiguity of loss, which is confusing because the person cannot anticipate the situation, and have an idea whether or not the missing member will return. Perez-Sales et al. (6), in a research conducted in Chile amongst women who have sought a missing member of the family for over 20 years, found in 9.7 % symptoms of pathological grief, in 29.4 % symptoms of depression and in 31.1% diagnosed mood disorders. In persons with an experience of a missing member, anxiety occurs as a symptom of traumatization, and as a symptom of depression, but also as a anxious disorder, and most commonly in a form of generalized anxiety and a mixed anxiety-depressive disorder (6). Somatic symptoms are often closely related to traumatic and stressful events (17). In this research, 50.8% of women with a missing family member had a moderate to high intensity of somatic symptoms, and Robins (9) states that 27% of Nepal women with an experience of a missing member complained on chronic somatic symptoms. Also, in our research we found that women with a missing son show a higher intensity of symptoms of depression, anxiety and somatization than women who have some other family member missing. The disappearance of a child, the lack of information about what happened lead towards an excessive search for information, which may result in the neglect of other family members or can lead towards a development of mental and somatic disorders (9). With the death of a child, or a certain loss, parents go through the grieving process which, depending on the circumstances of the death of a child, may grow into a form of a pathological grief. However, in a situation of an ambiguous loss, the process of grief cannot begin. In addition, we found that the disappearance of a husband was a significant source of emotional suffering. In situations where a woman has an experience of disappearance of a husband, then some of her basic human rights are affected, especially those referring to her status. Women may experience emotional suffering due to an ambiguous loss, which can stem from the fact that they have no knowledge about the husband or possibility to mourn the loss of a loved one, or grief. Research suggests a frequent occurrence of pathological grief and a severe depressive disorder in this group of women (19, 20).

Several research show that the loss of a husband may result in a more intense reaction of pain than in any other kind of loss (20-22). A high level of depression and suicidal ideations were also found by Powell et al. (23) in a group of 56 women from Bosnia and Herzegovina who had an experience of a war missing husband. Schaal et al. (16), in a research conducted among 194 widows from Ruanda, 13 years after the genocide 48% of them had a depression, 41.7% anxiety disorder and 49% posttraumatic stress disorder. Results of research conducted in Nepal (9) among women with a twelve-year long experience of disappearance of the son and husbands, as well, indicate presence of symptoms of anxiety and depression. Results of our research indicate that symptoms of depression, anxiety and somatization in relation to kinship were the highest in women with a missing son, then husband and somewhat lower in women with a missing brother but with no significant difference in comparison to women with a missing father. Anxiety, depression and somatization in this group of women can be explained as a reaction to a changed role and status of a Bosnian woman after the confrontation with taking over the family and social role that her husband, father, brother or son previously had (24). In this research, we did not examine this aspect which a violent disappearance has of woman, but we did found that majority of women with a war missing family member did not return to their pre-war place of residence. Also, we found that more women with a missing family member than women without a missing family member stated that their life has changed completely after the war.

There are several limitations to this research. One of the limitations is in the methodological approach and stratification of women in subgroups with a relatively small sample size, and in choice of women over the age of 45. The age itself may be one of the risk factors for depression, anxiety and somatization, but in this research we attempted to minimise this risk factor by choosing the control group of the approximately same age. Furthermore, the limitation of this research was also contained in the fact that in the group of women with a missing family member, there were some other losses which refer to a multiple traumatization in comparison with the group of women without a war missing family member.

CONCLUSION

Results of this research once more imply that forced disappearance of a close person has an adverse effect on mental health of surviving members of the family. Forced disappearance of a son, husband, brother and father, along with a long-term search for information about the missing, prolonged waiting and hope for a possible return of the missing can make a woman more vulnerable for developing depression, anxiety disorders or cause chronic somatic complaints. Results clearly confirm fact that the disappearance of a close and loved person may be accompanied by the appearance of a number of psychological, somatic and behavioral problems in women. Forced disappearance of a family member leads to changes in life of the survivors and as a response to mentioned changes may be associated with psychological problems.