International Journal of Culture and Mental Health Vol. 1, No.

2, December 2008, 105116

Screening for PTSD and depression in Bosnia and Herzegovina: validating the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist
Lilijana Oruca, Aida Kapetanovicb, Naris Pojskicc, Kate Mileyb, Sharon Forstbauerb, Richard F. Mollicab,d and David C. Henderson*b,d
a Psychiatric Clinic, Clinical Centre, University of Sarajevo, Bosnia and Herzegovina; bHarvard Program in Refugee Trauma, Bosnia and Herzegovina; cLaboratory for Bioinformatics and Biostatistics, INGEB, University of Sarajevo, Bosnia and Herzegovina; dHarvard Medical School, Boston, Massachusetts, USA

(Received 7 March 2008; nal version received 9 September 2008)

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This study aimed to test the validity of the Harvard Trauma Questionnaire (HTQ) and the Hopkins Symptom Checklist-25 (HSCL-25) in screening for post-traumatic stress disorder (PTSD) and major depressive disorder (MDD), respectively, in primary healthcare centers in Bosnia and Herzegovina. Validating interviews were conducted with 180 randomly selected primary care patients in Middle Bosnia. Statistical analysis performed to assess diagnostic accuracy, sensitivity and specificity of the diagnostic materials revealed an optimal cut-off points of 2.06 on the HTQ for the diagnosis of PTSD and 1.8 on the HSCL-25 for the diagnosis of MDD. The HTQ and HSCL-25 are accurate and useful for identifying PTSD and MDD in primary care centers in Bosnia and Herzegovina. Keywords: major depressive disorder; post-traumatic stress disorder; primary healthcare; instrument validation; Bosnia and Herzegovina

Introduction Human rights violations associated with political instability, war, genocide and cultural persecution have been recognized as extremely damaging events to the mental health of conflict populations. Several studies have been conducted to confirm the increased rate of psychiatric morbidity among such populations, particularly post-traumatic stress disorder (PTSD) and major depressive disorder (MDD) (Durieux-Paillard, Whitaker-Clinch, Bovier, & Eytan, 2006; Hollifield et al., 2002; Marshall, Schell, Elliott, Berthold, & Chun, 2005; Mollica, 2000; Mollica et al., 2001). In 2006, the United Nations High Commissioner on Refugees reported nearly 40 million refugees, internally displaced persons, asylum seekers, stateless persons and other persons of concern (UNHCR, 2007). As this number continues to grow, the associated psychiatric morbidity in conflict populations grows in kind. It has been estimated that PTSD and depression will be observed at rates of at least 1/3 and 2/3, respectively, in refugee and conflict populations (Steel, Silove, Phan, & Bauman, 2002). It is estimated that during the war in Bosnia and Herzegovina (B&H) (1992)1995) over 250,000 citizens died, 200,000 were wounded and more than 2.6 million became refugees or internally displaced persons (Mollica et al., 1999; UNHCR, 2006). Accordingly, the war in
*Corresponding author. Email: dchenderson@partners.org.
ISSN 1754-2863 print/ISSN 1754-2871 online # 2008 Taylor & Francis DOI: 10.1080/17542860802456620 http://www.informaworld.com

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B&H caused a significant increase in trauma-related psychiatric symptoms (Mollica et al., 1999). Recent studies have observed varying rates of depression and PTSD in Bosnian refugee populations. Mollica et al. (1999) reported that 39.2% of Bosnian refugees in Croatia suffered from depression and 26.3% from PTSD. Three years later, a follow-up study found that 45% of those originally diagnosed with PTSD or depression remained affected, while an additional 16% of the study population developed at least one disorder, confirming the chronic nature of PTSD and depression in post-conflict populations (Mollica et al., 2001). Worldwide reports suggest that traumatized civilians with mental health problems primarily seek help from their primary healthcare providers (Bramsen & van der Ploeg, 1999; Lang, Laffaye, Satz, Dresselhaus, & Stein, 2003). Recent studies, for example, reveal that PTSD is an important mental health diagnosis in primary healthcare settings serving general populations (Stein, McQuaid, Pedrelli, Lenox, & McCahill, 2000; Taubman-BenAri, Rabinowitz, Feldman, & Vaturi, 2001) as well as those caring for patients from highly traumatized communities (Carey, Stein, Zungu-Dirwayi, & Seedat, 2003). Yet only a small percentage of PTSD patients are identified and treated (Carey, Stein, Zungu-Dirwayi, & Seedat, 2003; Kimerling & Calhoun, 1994). One obstacle for primary healthcare professionals in diagnosing and treating mental health disease in areas of conflict and mass violence is the lack of appropriate diagnostic instruments. In an analysis of 125 screening instruments intended for refugee populations, only 12 were found to be developed specifically for such populations (Hollifield et al., 2002). Diagnostic instruments must be developed in respect to the culture, language, history and trauma-related circumstances of the population. The chronic nature, severity and associated disability of untreated PTSD and MDD stress the importance of appropriate mental health diagnoses and care (Marshall et al., 2006; Mollica et al., 2001; Steel, Silove, Phan, & Bauman, 2002; Thapa, Van Ommeren, Sharma, de Jong, & Hauff, 2003). The introduction of culturally valid screening instruments into primary healthcare would, therefore, significantly increase the ability of primary care practitioners to diagnosis and reduce psychiatric morbidity in those patients who had been exposed to violence, as is the general condition in B&H. The Harvard Trauma Questionnaire (HTQ) and the Hopkins Check List-25 (HSCL25) are screening instruments widely used for assessment of PTSD and MDD in various populations and cultural settings (Mollica et al., 1992; Mollica, Wyshak, de Marneffe, Khuon, & Lavelle, 1987; Smith et al., 1997). These instruments have been previously translated and adapted for the B&H population by the Harvard Program in Refugee Trauma (Mollica, McDonald, Massagli, & Silove, 2004). The ability of the HTQ and the HSCL-25 to predict disorder depends on factors that vary greatly within different populations, cultures and settings. It is critical that the psychometric properties of screening instruments be established in each unique cultural and linguistic group as well as in each clinical setting. This includes establishing specific diagnostic cut-off points for identifying individuals who are check-list-positive for the disorder and may have the disease. In addition to cultural effects on the instrument, with patients from different cultures possibly emphasizing different symptoms for a given mental health diagnosis, a spectrum effect may occur influencing cut-off points to lower as the setting shifts from a psychiatric clinic to a primary healthcare setting to a community sample. The aim of this study was to establish the validity of the PTSD sub-scale of the HTQ and the depression sub-scale of the HSCL-25 in a primary care setting in B&H. In fulfilling this aim, the prevalence and types of trauma exposure in the Bosnian community were also examined. This validation study is especially valuable because it is one of the first in a

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primary healthcare setting; the most common healthcare environment where emotionally distressed traumatized people seek treatment (Ransohoff & Feinstein, 1978). It is the authors goal that once validated the HTQ and the HSCL-25 can be widely disseminated throughout the primary healthcare system of B&H. Methods Study population The study population consisted of 180 primary healthcare patients, ages 19 to 65. They were randomly selected among 3,468 patients who asked for primary care services in their local health care centers during the period of one week in May 2002. Research was conducted in six municipalities (total population approximately 142,000 inhabitants) in the central area of B&H, with the following ethnic structure: 61.7% Bosnians, 36.2% Croats and 1.9% Serbs. The research team consisted exclusively of Bosnian staff, including two senior psychiatrists, a general practitioner and a psychologist. Validating interviews took place in the local community health centers. Selected patients were invited by the health center staff to participate. They were then interviewed by a research team in the local language. The Research and Ethics Committee of the University of Sarajevo (i.e. IRB approval) approved this research and all interviewed persons signed written informed consent. Patients already diagnosed with psychotic and cognitive deficit disorders were excluded from the study. Illiterate persons were also excluded from the study sample. After these exclusion criteria were applied, the primary healthcare patient pool consisted of 2,241 patients. Between the registration and interviewing process three patients died, two had brain strokes, five permanently left the area and 34 refused to be interviewed. The interviewing procedures took 90 minutes per patient. Each patient was interviewed twice, first by a general practitioner or psychologist (using a questionnaire containing the HSCL25 and the HTQ) and immediately after, by a psychiatrist employing the Structured Clinical Interview for Axis I DSM IV disorders (SCID: First, Spitzer, Gibbon, & Williams, 1997).

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Measures Current psychiatric diagnoses for PTSD and MDD were established by two Bosnian psychiatrists employing SCID. Semantic equivalence of SCID was achieved by double blind translation from English to Bosnian/Croat language and vice versa. The HSCL is a well-known and widely-used screening instrument originally developed for non-traumatized populations (Parloff, Kelman, & Frank, 1954) and later adapted for use in traumatized populations by Mollica et al. (1987). The HSCL-25 consists of 25 questions divided into two sections: 10 anxiety and 15 depression items. The 15 items of the HSCL-25 depression subscale (items 1125) are consistent with the DSM-IV diagnosis of major depression. A cut-off value of ]1.75 is generally used for a diagnosis of major depression according to this instrument. The HTQ inquires about a variety of trauma events and those emotional symptoms uniquely associated with trauma. The HTQ consists of four sections: trauma events, personal description of ones most traumatic experience, head injury and trauma symptoms. The trauma symptom section has 40 symptom items. The first 16 items were derived from DSM-IV criteria for PTSD. These symptoms include dimensions of

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re-experiencing, avoidance and arousal symptomatology. The DSM-IV PTSD score is calculated from the first 16 items. The higher the scores on the DSM-IV PTSD items, the more likely it is that the respondent will have a PTSD diagnosis. An interview with a PTSD score and/or a total score of ]2.5 is generally considered checklist-positive for PTSD (Mollica et al., 1992). The cut-off score of 2.5 has been the standard for several versions of the HTQ, including the Indochinese, Vietnamese, Cambodian, Japanese and Tibetan translations (Choi, Mericle, & Harachi, 2006; Ichikawa, Nakahara, & Wakai, 2006; Lhewa, Banu, Rosenfeld, & Keller, 2007; Mollica et al., 1992; Silove et al., 2007). The HTQ and the HSCL-25 respondents were asked whether they were bothered by each symptom in the past two weeks and rated on a 4-point Likert scale: not at all (1), a little (2), quite often (3) and extremely often (4). Scores for each respondent were totaled and then divided by the number of items to derive the cut-off score used as a threshold for indicating these individuals with the possible disorder. Validity was established by comparing the resulting diagnoses using the HTQ and the HSCL-25 to the diagnosis of PTSD and MDD made in the Bosnian language using a Bosnian psychiatrist administered SCID. Statistical analysis Receiver Operating Characteristic (ROC) analysis was applied in order to assess the criterion validity of the 15-item depression subscale of the HSCL-25 and the 16-symptomitem subscale of the HTQ for PTSD in a primary healthcare setting in B&H. The area under the curve (AUC) was estimated in order to gain diagnostic accuracy of the instruments without consideration of their sensitivity and specificity (Hsiao, Bartko, & Potter, 1989). In order to estimate the strength of the relationship between SCID MDD diagnosis and the HSCL-25 results, as well as between SCID PTSD diagnosis and the HTQ results, calculation of effect size was used. Harvard Trauma Questionnaire results were compared between SCID PTSD diagnosed and not-diagnosed groups. The same approach was used for comparing HSCL-25 results between SCID MDD diagnosed and not-diagnosed groups. In order to study the properties of the measurement scales and the items that they consist of, reliability analysis using Cronbachs a was performed. Point biserial correlation methods were used to analyze the relationship between SCID MDD diagnosis and the HSCL-25 results (15 items) as well as between SCID PTSD diagnosis and the HTQ results (16 items). Inter-rater agreement (Kappa) was implemented for comparative analyses of two independent screening groups of the same individuals using SCID. In order to understand the relationship between the number of different trauma events and the HTQ cut-off scores, Pearson Correlation Coefficients were calculated. All statistical analyses are considered significant at a p value of B0.05. Results Of the remaining 2,197 eligible subjects, 180 adults were randomly selected for the interview; of these, 116 (64.4%) were women. The mean age for all surveyed was 48913 (95%CI 045.749.4). General demographic characteristics of the study sample are presented in Table 1. This sample of respondents was highly traumatized by the recent war in B&H. The majority of participants experienced war caused displacement: 75 (41.9%) were locally

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Table 1. General demographic characteristics of B&H primary healthcare patients (n 0180). n (%) 34 (18.7) 78 (43.4) 68 (37.9) 134 25 15 6 74 38 63 5 (74.2) (13.7) (8.2) (3.7) (41.2) (21.1) (35) (2.8)

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Demographic variable Age 2034 3454 5565 Marital status Married Widowed Single Separated or divorced Education Did not complete primary education Primary education Secondary education Higher education Employment status Employed Unemployed Ethnicity Bosnian Croat Bosnian Bosnian Serb Other

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117 (65) 63 (35) 82 85 6 7 (45.6) (47.2) (3.4) (3.8)

displaced from their homes, 17 (9.5%) resettled from other parts of the country and 84 (46.9%) never moved from their place of living during the war. The mean number of unduplicated trauma events reported by respondents was 7.5395.4. At least one traumatic event was experienced by 174 (96.7%) participants, as categorized in the HTQ. All but four (2.2%) interviewed experienced a trauma event, 2.2% experienced one trauma event, 45% experienced between two and six events and 50% experienced more than six trauma events. The six most frequently experienced traumatic events were: combat situation (e.g. shelling and grenade attacks) (89.4%), forced evacuation under dangerous conditions (80.6%), exposure to unrelenting sniper fire (62.1%), murder or death due to violence of another family member or friend (57.9%), confinement to home because of danger outside (55.6%) and serious physical injury of a family member or friend due to a combat situation (49.4%). Frequency of occurrence of specific trauma events can be found in Table 2. In order to evaluate the SCID diagnosis, two psychiatrists performed the diagnosis of PTSD and MDD independently using SCID interviews in two screening groups of the same individuals (n 020). Inter-rater (Kappa) analyses showed perfect agreement between outcome results (K 01.0, SD 00.0). Agreement between psychologist and general practitioner ratings on the HSCL-25 and the HTQ was 98 and 96%, respectively. The effect size analysis show a strong relationship between HTQ scores and SCID PTSD diagnosis (Cohens d 03.32, 95%CI 02.703.39), as well as between HSCL-25 scores and SCID MDD diagnosis (Cohens d 02.49, 95%CI 02.072.92). The ROC analysis for the HSCL-25 depression scale produced an AUC index of 0.944, reflecting a high level of concordance between the two measures. The total HSCL-25 score did not show better diagnostic accuracy of the scale in detection of MDD when compared with the use of the 15-item depression subscale. These results are supported by the fact that the AUC for the depression subscale alone was 0.944 (SD 00.025, 95%CI 00.9000.973),

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Frequency of trauma event type experienced in B&H sample population. Occurrence rate n (%) 96 (53.3) 35 (19.7) 28 (15.8) 88 (49.4) 161 (89.4) 9 (5.3) 110 (62.1) 141 (80.6) 10 (5.6) 1 (0.6) 1 (0.6) 2 (1.1) 11 (6.2) 13 (7.3) 16 (8.9) 3 (1.7) 13 (7.5) 103 (57.9) 39 (21.7) 8 (4.5) 10 (5.6) 6 (3.4) 4 (2.2) Trauma event Present while someone searched your home Forced to sing songs you did not want to sing Someone was forced to betray you Confined to home because of danger outside Prevented from burying someone Forced to desecrate/destroy bodies or graves Forced to harm family member/ friend Forced to physically harm someone Forced to destroy property or possessions Forced to betray family member or friend Forced to betray unrelated party Forced labor Extortion or robbery Brainwashing Disappearance or kidnapping of spouse Disappearance or kidnapping of child Disappearance or kidnapping of other family member or friend Serious physical injury of family member or friend due to combat situation or landmine Witness beatings to head or body Witness torture Witness killing or murder Witness rape or sexual abuse Other frightening or life threatening situation Occurrence rate n (%) 23 (12.9) 2 (1.1) 7 (3.9) 100 (55.6) 21 (11.7) 2 (1.1) 2 (1.1) 2 (1.1) 3 (1.7) 6 (3.4) 5 (2.8) 5 (2.8) 20 (11.2) 9 (5.0) 4 (2.4) 1 (0.6) 16 (9.5) 84 (49.4) 20 (11.2) 19 (10.6) 49 (27.2) 2 (1.1) 51 (28.8)

Trauma event Lack of shelter Lack of food or water Ill health without access to medical care Confiscation or destruction of property Combat situation Used as a human shield Exposure to frequent & unrelenting sniper fire Forced evacuation under dangerous conditions Beating to the body Rape Other sexual abuse or sexual humiliation Knifing or axing Torture Serious physical injury from combat Imprisonment Murder or death of spouse due to violence Murder or death of son or daughter due to violence Murder or death of other family member or friend due to violence Forced to hide Kidnapped Other forced separation from family members Forced to find and bury bodies Forced isolation from others

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while for combined depression and anxiety symptoms the AUC was 0.913 (SD 00.030, 95%CI 00.8620.950). Cronbachs a was used as a comparison method to study the properties of measurement of the HSCL-25 scales (15-item depression subscale) and showed a high degree of reliability (a 00.8676). For the HSCL-25, the cut-off point that maximizes sensitivity and specificity at the level point of the curve is 1.8 (Figure 1) with a sensitivity of 93.2%, specificity of 91.2%, a PPV of 77.4 and a NPV of 97.6 (Table 3a). Using a cut-off score of 1.8 on the HSCL-25, 18 (10%) false positive and three (1.7%) false negative cases were recorded. Point biserial correlation analyses show a statistically significant relationship between SCID MDD diagnosis and MDD diagnosis using the

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Figure 1. ROC curve for HSCL-25 for major depressive disorder (subscale and total scale): criterion based on SCID diagnosis.

HSCL-25 (r 00.7444, p B0.0001, 95%CI for r 00.67120.8032), demonstrating the measures accuracy in MDD diagnosis for this population. The ROC analyses for the HTQ show very good diagnostic accuracy (AUC 0 0.981, SD 0 0.024, 95%CI 00.9490.995). A cut-off score of 2.06 maximized sensitivity (100%) and specificity (93.9%), with a PPV and a NPV of 61.5 and 100, respectively (Table 3b). A cut-off score of 2.0 for the HTQ was considered a suitable cut-off point in order to maximize utility for screening in the primary healthcare setting (Table 3b, Figure 2). Cronbachs a estimation for the HTQ shows strong reliability (a 00.8881). Using a cut-off score of 2.00, no cases were recorded as a false negative and 11 (6.1%) cases were recorded as a false positive. Point biserial correlation analyses showed a statistically significant
Table 3a. Cut-off scores: sensitivity, specicity, positive and negative predictive values of HSCL-25 (depression subscale) for primary healthcare settings in B&H. Diagnostic measure HSCL-25 Cut-off score 0 1.00  1.00  1.25  1.50  1.75 *  1.80  2.00  2.25  2.50  2.75  3.00 Sensitivity (95%CI) 100.0 97.7 97.7 95.5 93.2 93.2 65.9 54.5 20.5 2.3 0.0 (91.9100.0) (87.999.6) (87.999.6) (84.599.3) (81.398.5) (81.398.5) (50.179.5) (38.969.6) (9.835.3) (0.412.1) (0.08.1) Specificity (95%CI) 0.0 11.8 41.9 71.3 86.6 91.2 97.8 97.8 100.0 100.0 100.0 (0.02.7) (6.918.4) (33.550.7) (62.978.7) (79.992.0) (85.195.4) (93.799.5) (93.799.5) (97.3100.0) (97.300.0) (97.300.0) PPV 24.4 26.4 35.2 51.9 69.5 77.4 90.6 88.9 100.0 100.0 100.0 NPV 94.1 98.3 98.0 97.5 97.6 89.9 86.9 79.5 76.0 75.6

Note: *Cut-off on the ROC curve that maximizes both sensitivity and specificity.

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Table 3b. Cut-off scores: sensitivity, specicity, positive and negative predictive values of HTQ for primary healthcare settings in B&H. Diagnostic measure HTQ Cut-off Score 0 1.00  1.00  1.25  1.50  1.75  2.00 *  2.06  2.25  2.50  2.75  3.00 Sensitivity (95%CI) 100.0 100.0 100.0 100.0 100.0 100.0 100.0 75.0 37.5 18.8 0.0 (79.2100.0) (79.2100.0) (79.2100.0) (79.2100.0) (79.2100.0) (79.2100.0) (79.2100.0) (47.692.6) (15.364.5) (4.345.7) (0.020.8) Specificity (95%CI) 0.0 6.7 36.0 64.0 83.5 93.3 93.9 97.6 98.2 99.4 100.0 (0.02.2) (3.411.7) (28.643.8) (56.271.4) (77.088.9) (88.396.6) (89.197.0) (93.999.3) (94.799.6) (96.699.9) (97.8100.0) PPV 8.9 9.5 13.2 21.3 37.2 59.3 61.5 75.0 66.7 75.0 100.0 NPV 100.0 100.0 100.0 100.0 100.0 100.0 97.6 94.2 92.6 91.1

Note: *Cut-off on the ROC curve that maximizes both sensitivity and specificity.
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relationship between the SCID diagnosis and the HTQ PTSD screening measures (r 00.6587, p B0.0001, 95%CI for r 00.56700.7342), demonstrating the HTQs accuracy in PTSD diagnosis in this population. The sensitivity, specificity, PPV and NPV at various cut-off points for the HTQ and the HSCL-25 are shown in Table 3a and 3b. Discussion To the best of our knowledge, this is the first study to validate the HSCL-25 and the HTQ in a primary healthcare population in B&H. The criterion validity of the HTQ and the HSCL-25 in screening for PTSD and depression, respectively, among primary healthcare

Figure 2.

ROC curve for HTQ (PTSD 16 items): criterion based on SCID diagnosis of PTSD.

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patients in B&H is confirmed by the study results. The subscales of the HTQ and the HSCL-25 based upon DSM-IV criteria show excellent diagnostic accuracy. When applied to the B&H primary healthcare population, the clinically derived HTQ cut-off score of 2.50 suggested by Mollica et al. (1992) revealed a sensitivity and specificity of 37.5 and 98%, respectively. This HTQ cut-off score needs to be replaced by a cut-off score of around 2.06, with 2.00 as having the optimum utility for usability in the B& H population. With this cut-off score, which maximizes sensitivity and specificity at 100 and 93.9%, respectively, no cases were recorded as a false negative, while 11 cases would be classified as a false positive. The occurrence of people labeled positive by the instrument but who do not have the disease is offset by the fact that no truly positive cases would be missed. This is an ideal situation in primary healthcare where no harm occurs to a false positive and the primary care physician can conduct a more intensive examination of the patient, possibly with a psychiatric referral to confirm the diagnosis. Internal consistency is an indicator of how responses to a set of questions correlate to each other. The minimum alpha coefficient recommended for screening instruments is 0.7 (70%) (Coons et al., 1998). Cronbachs a reliability test for the HTQ (16 items PTSD) indicates that this screening instrument is 89% reliable, which shows very good internal consistency in a B&H primary care setting. A positive correlation between diagnosis using SCID and the cut-off scores for the HTQ is evident, reflecting the validity of the HTQ as a PTSD screening instrument in a B&H primary healthcare setting. The maximum accuracy of the HSCL-25 with a cut-off score of 1.8 for the 15-item subscale is similar to the score of 1.75 that was previously observed and proposed in different Indochinese communities and clinic populations (Hinton et al., 1994; Mollica et al., 1987; Smith et al., 1997). At a cut-off of 1.8 the HSCL-25 has a maximum sensitivity and specificity of 93.2 and 91.2%, respectively. In our study sample (n 0180) there were 18 false positives and three false negatives. Using this cut-off only 6.8% of patients with MDD would be missed. Again, similar to the HTQ, a PPV and a NPV of 77.4 and 97.6%, respectively, is very acceptable in the primary healthcare setting. These results suggest excellent psychometric properties for the primary healthcare settings, demonstrating the reliability and usefulness of the HTQ and the HSCL-25, with their respective cut-off scores, for diagnosing PTSD and MDD in B&H. Mass violence from war, ethnic cleansing and genocide has a major impact on the mental health of affected civilian populations (Goldfeld, Mollica, Pesavento, & Faraone, 1988; Mollica, 2000). Bosnia and Herzegovina follows this pattern. Prevalence rates of trauma exposure as high as 96.7% were observed in this study population. Similarly, a 94% prevalence rate of trauma experience was observed in a population of Bosnian refugees living in Croatia. Accordingly, the population exhibited a 40% rate of MDD symptoms and a 26% rate of PTSD symptoms. This data is in line with reports of high prevalence of symptoms of PTSD and MDD in refugees from additional studies (Drozdek, 1997; Favaro, Maiorani, Colombo, & Santonastaso, 1999; Mollica et al., 2001; Thulesius & Hakansson, 1999). The World Health Organization (WHO) has strongly supported the role of mental health in primary healthcare (WHO, 2001). However, there has been little discussion of the feasibility of achieving this in conflict/post-conflict societies. A recent study (Carey, Stein, Zungu-Dirwayi, & Seedat, 2003) in a South African primary healthcare center serving an urban Xhosa population revealed that, in spite of high rates of trauma exposure (94%), PTSD (19.9%) and depression (37%) in the study population, no diagnoses were made by clinicians (0%). The lack of clinician ability to identify trauma-related psychopathology in conflict areas needs to be addressed in order to provide traumatized persons with the

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mental healthcare they need. Creating culturally accurate diagnostic materials for the primary healthcare setting is a crucial step towards providing such care. Due to the lack of a simple screen for identifying PTSD and depression in the B&H primary healthcare setting, this study was conducted to establish the psychometric properties of the HSCL-25 and the HTQ before introducing them into B&H nationally. The HTQ and the HSCL-25 were specifically designed to be adapted to different cultural groups and different settings, such as psychiatric clinics, primary healthcare and community settings. In their review of the use of screening instruments in traumatized refugee populations, Hollifield et al. (2002) have demonstrated the importance of testing instruments in specific populations where the psychometric properties of an instrument may vary depending on the cultural manifestation of symptoms (i.e. different emphasis in different cultural groups), prevalence of the measured disorder and the heterogeneity of the population (homogenous clinic population versus diverse community group). The developers of the HSCL-25 and the HTQ for use in traumatized populations have been sensitive to these issues (Hollifield et al., 2002; Mollica, McDonald, Massagli, & Silove, 2004). Additional validation studies for the HTQ and the HSCL are needed in several other cultural settings in which their implementation and utilization would be beneficial to the given population. This study is an important step in the development of simple screening instruments for diagnosing PTSD and MDD in highly traumatized populations. These instruments, with their respective diagnostic cut-off points, can now be widely disseminated in primary healthcare settings throughout B&H, facilitating the treatment of thousands of patients whose psychiatric illness may be currently missed by their primary healthcare providers. The next task of this study will be to describe the degree of trauma, prevalence of PTSD and MDD, service utilization and associated risk factors existing in this study population and the implications of these findings for the identification and treatment of traumarelated psychiatric illness in B&H.

Limitations This study used randomized sampling techniques and highly trained B&H psychiatric professionals to conduct the study minimizing the biases of poor sampling and culturally inadequate interviewing. Although the study has only been conducted in one region of B&H, the results suggest that the instruments and related cut-off points may be utilized in other B&H primary healthcare settings to identify probable cases of PTSD and MDD. Notes on contributors
Lilijana Oruc, MD is psychiatrist at the Psychiatric Clinic, Clinical Centre, University of Sarajevo, Bosnia and Herzegonia. Aida Kapetanovic, MD is the director of the Harvard Program in Refugee Trauma, Bosnia and Herzegonia. Naris Pojskic, Ph.D. is a statistician at the Clinical Centre, University of Sarajevo, Bosnia and Herzegonia. Kate Miley is research assistant at the Harvard Program in Refugee Trauma at Massachusetts General Hospital. Sharon Forstbauer is a research assistant at the Harvard Program in Refugee Trauma at Massachusetts General Hospital. Richard Mollica, MD is the Director of the Harvard Program in Refugee Trauma at Massachusetts General Hospital, and Professor of Psychiatry at Harvard Medical School. David Henderson, MD is the Medical Director of the Harvard Program in Refugee Trauma at Massachusetts General Hospital, and Associate Professor of Psychiatry at Harvard Medical School.

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