Journal of Affective Disorders 80 (2004) 231 238

www.elsevier.com/locate/jad

Research report

Comorbidity of PTSD and depression: associations with trauma

exposure, symptom severity and functional impairment in Bosnian
refugees resettled in Australia
Shakeh Momartin *, Derrick Silove, Vijaya Manicavasagar, Zachary Steel
School of Psychiatry, University of New South Wales, Centre for Population Mental Health Research, Sydney, NSW 2150, Australia
Received 8 November 2002; received in revised form 2 May 2003; accepted 6 May 2003

Abstract
Background: Posttraumatic stress disorder (PTSD) is common in refugees but its association with longer-term psychosocial
dysfunction remains unclear. We examined whether a subgroup of refugees with comorbid PTSD and depression were at
particularly high risk of disability. We also investigated whether specific trauma experiences were linked to this comorbid
pattern. Methods: Consecutive Bosnians (and one or two compatriots nominated by them) were recruited from a community
centre, yielding a total sample of 126 participants (response rate 86%). Measures included a trauma inventory, the Clinician
Administered PTSD Scale (CAPS) (Blake et al., 1995) and the depression module of the Structured Clinical Interview (SCID)
(First et al., 1997). Results: Three diagnostic groupings emerged: normals (n = 39), pure PTSD (n = 29), and comorbid PTSD
and depression (n = 58). Of four trauma dimensions derived from principle components analysis (human rights violations,
dispossession and eviction, life threat and traumatic loss), life threat alone was associated with pure PTSD, with life threat and
traumatic loss both being associated with comorbidity. Compared to normals and those with pure PTSD, the comorbid group
manifested more severe PTSD symptoms as well as higher levels of disability on all indices (global dysfunction: odds
ratio = 5.0, P < 0.001, distress: odds ratio = 6.0, P < 0.001, social impairment: odds ratio 5.9, P < 0.001, and occupational
disability: odds ratio 5.0, P < 0.001). Limitations: Recruitment was not random, the sample size was modest, and trauma event
endorsement was based on retrospective accounts. Conclusions: The combination of life threat and traumatic loss may be
particularly undermining to the psychological well-being of refugees and consequent comorbidity of PTSD and depression may
be associated with longer-term psychosocial dysfunction. The findings raise the question whether the comorbid pattern
identified should be given more recognition as a core posttraumatic affective disorder.
D 2003 Elsevier B.V. All rights reserved.
Keywords: Comorbidity; Trauma; PTSD and depression; Bosnian refugees

1. Introduction
* Corresponding author. Tel.: +61-4-1307-1333; fax: +61-29635-0302.
E-mail address: shakeh.momartin@swsahs.nsw.gov.au
(S. Momartin).
0165-0327/$ - see front matter D 2003 Elsevier B.V. All rights reserved.
doi:10.1016/S0165-0327(03)00131-9

Epidemiological studies have documented high

rates of posttraumatic stress disorder (PTSD) in refugees and war-affected populations (Carlson and
Rosser-Hogan, 1994; Cheung, 1994). With 21 million

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S. Momartin et al. / Journal of Affective Disorders 80 (2004) 231238

people displaced to various regions of the world

(United Nations High Commissioners for Refugees,
2002), mostly in resource-poor countries, the dilemma
for mental health professionals is how to select those
refugees with PTSD who are in greatest need of
treatment, particularly since natural remission of posttraumatic symptoms appears to be a common outcome
(Steel et al., 2002). PTSD commonly occurs together
with depression, with a recent epidemiological study
undertaken in a Bosnian refugee camp revealing that
26% of that population manifested such comorbidity
(Mollica et al., 1999). The present report focusing on
Bosnian refugees explore whether those with comorbidity represent a high risk group for longer-term
disability, and whether a specific pattern of traumatic
antecedents leads to this particular clinical picture.
The war in Bosnia-Herzegovina displaced 2 million people (Mollica et al., 1999), many of whom
were exposed to a campaign of ethnic cleansing in
which gross human rights violations, torture and
execution were common (Weine et al., 1995). According to the United Nations Economic and Social
Council (1994), of the survivors, about half were
forced to flee from their homes. Many refugees were
accommodated in overpopulated refugee camps where
hygiene was poor and shortages of food, water and
fuel were endemic (Arcel et al., 1995). Others were
detained in concentration camps (Arcel et al., 1995;
Ryn, 1997) where human rights violations were widespread (Weine, 1999).
Australia has received a substantial number of
Bosnian refugee families (Barrett et al., 2000) but,
as yet, there is scant information available about the
trauma experiences of this group. Anecdotal evidence
(Silove, 1994) suggests that the reasons for fleeing,
the traumas experienced, and the levels of psychiatric
morbidity suffered by Bosnian refugees may be diverse. Hence, it is important to identify those traumaaffected subgroups that may still need interventions as
a consequence of impairments in their psychosocial
functioning.
Evidence is emerging from both the general trauma
literature and the field of refugee mental health that
those suffering from comorbid PTSD and depression
may stand out as a group with substantial levels of
psychosocial impairment, at least in the short-term.
Comorbidity has been documented in a diversity of
trauma-affected populations (Blank, 1994; Bleich et

al., 1986; McGorry, 1995; Mellman et al., 1992;

Sierles et al., 1983; Skodol et al., 1996) with the
extent of the diagnostic overlap varying from 21% in
Bosnian refugees (Mollica et al., 1999) to 45% in
survivors of civilian violence (Shalev et al., 1998).
Comorbidity in refugees appears to be clinically
important in relation to the intensity of PTSD symptoms, with Karam (1997) reporting a three- to fivefold
greater severity of overall symptoms compared to
those with PTSD alone, findings that have been
mirrored in other studies amongst refugees (Moore
and Boehnlein, 1991) as well as amongst combatants
(Skodol et al., 1996).
Comorbidity also appears to increase the level of
impairment in social and occupational functioning at
least in the short-term (Koren et al., 1999; Mollica
et al., 1999; Mintz et al., 1992; Shalev et al., 1998).
In a large-scale epidemiological survey in a Bosnian
refugee camp, Mollica et al. (1999) reported that the
comorbid group was five times more likely to
manifest functional impairment compared to those
diagnosed with PTSD alone. This study was conducted in the immediate aftermath of the war, so
that the long-term impact of comorbidity on psychosocial functioning in Bosnian refugees remains
unknown.
As yet, the mechanisms linking PTSD and depression remain unclear, although the frequency with
which comorbidity is observed suggests that the
association is not simply coincidental (Bleich et al.,
1997; Mollica et al., 1999; Skodol et al., 1996; Shalev
et al., 1998). Some authorities have suggested that
PTSD is a more severe variant of reactive depression
(Davidson et al., 1993). Other data tend to indicate
that PTSD usually is the primary disorder, with
comorbid depression developing as a secondary reaction (Bleich et al., 1997). An alternative hypothesis is
that the antecedents of depression and PTSD are
relatively independent (Skodol et al., 1996) reflecting
the multiple challenges posed by complex trauma
events (Silove, 1999). In particular, there is some
evidence to suggest that exposure to physical abuse
and threat to life are more likely to lead to PTSD
(Green et al., 1993; Hauff and Vaglum, 1994), whereas loss of close attachments increases vulnerability to
depression (Kroll et al., 1989; Westermeyer et al.,
1983). For example, Carlson and Rosser-Hogan
(1994), in their study of 50 Cambodian refugees,

S. Momartin et al. / Journal of Affective Disorders 80 (2004) 231238

reported that separation from family members, loneliness and loss of loved ones were associated with
depression, whereas severity of trauma, closeness to
death and threat to survival predicted PTSD.
Refugees and war survivors commonly are exposed to multiple, sequential stressful events involving threat to life as well as loss. In some situations,
such as witnessing the murder of family members,
both loss and threat events occur simultaneously
(Silove, 1999). Hence, it is possible that these overlapping but distinguishable stresses, namely traumatic
loss and life threat may trigger distinctive but cooccurring symptom complexes of depression and
PTSD. In a preliminary report based on the present
sample (Momartin et al., in press.) we have found that
life threat was specifically associated with risk of
PTSD. In the present report, we sought to build on
that earlier analysis to investigate the traumatic antecedents associated with comorbidity. We also aimed to
extend the findings of Mollica et al. (1999) by
investigating whether comorbidity in Bosnian refugees was associated with greater severity of symptoms
and with higher levels of psychosocial impairment in
the longer term.

2. Methods
2.1. Sample
One hundred and twenty six Bosnian Muslim
refugees (hereafter Bosnian refugees) were recruited
from the larger Bosnian community residing in Sydney, Australia. Although several ethnic groups experienced trauma during the war, most victims of ethnic
cleansing were from Muslim backgrounds (Arcel et
al., 1995; Weine et al., 1995; Weine, 1999) so that the
focus of recruitment was restricted to this subgroup.
Random epidemiological sampling was not feasible given the absence of a central register of refugees
in Australia and the geographical distribution of the
target community in Sydney. Telephone directories
would not readily distinguish Bosnian Muslim names
from the larger group of other immigrants and refugees from the former Yugoslavia living in Sydney.
Hence recruitment was pursued with the help of a
Bosnian Resource Centre that provided practical assistance to all newly arrived refugees. The centre

233

provided a list of 52 consecutive Bosnian clients of

whom 48 agreed to participate. In order to obtain
additional participants, a snowball technique (Faugier and Sargeant, 1997; Hendricks and Blanken,
1992) was utilized whereby each consecutive recruit
was asked to provide the name of one or two other
unrelated Bosnian refugees. Of the 84 persons identified by the snowball method, 78 agreed to participate, yielding an overall sample of 126 with a
response rate of 86%.
Demographic information collected included age,
gender, marital status, number of children, educational
and employment background, present employment
status in Australia, present educational pursuits and
duration of resettlement.
Thirty-one trauma items were derived from a
comprehensive literature review (e.g., Mollica et al.,
1999; Weine et al., 1998), consultations with Bosnian
community workers and exploratory pilot interviews
with Bosnian refugees. A clinical coding system was
developed to rate the level of exposure to each
traumatic event on a five-point scale, where 0
indicated no and 4 severe exposure. The coding
system was refined in consultation with an expert
committee consisting of experienced refugee mental
health professionals who reached a consensus on
anchor points for severity for each identified experience of trauma. In the first phase of the interview,
participants were asked to relay their experiences
during and after the war. This information then was
supplemented by systematic questioning and clarification according to the 31 specified trauma items.
In a previous analysis of the data (Momartin et al.,
2002), principle components analysis (PCA) was used
to extract dimensions of trauma from the 31 trauma
items. Four components emerged with Eigenvalues
greater than 1.0, together accounting for 55% of the
total variance. The four components each accounted
for 31, 10, 8 and 6% of the variance, respectively. The
four components were labelled as follows:
Dimension 1Human rights violations, including
incarceration in a concentration camp, being tortured
by beating, burning and electric shock, or being
forced to witness others being tortured.
Dimension 2Dispossession and eviction, which
included being forced out of the city or home, being
evicted from the country, losing all belongings and
being dismissed from jobs.

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S. Momartin et al. / Journal of Affective Disorders 80 (2004) 231238

Dimension 3Threat to life, including experiences

such as proximity to death, exposure to killing, continuous threat of harm, critical shortages of food and
water, and absence of medical help when severely ill.
Dimension 4Traumatic loss of family which
included forced separations and/or witnessing the
killing of a close family member.
An intercorrelation matrix yielded low to moderate
associations amongst the four dimensions with the
highest correlation emerging between human rights
violations and threat to life (factors 3 and 1), (r = 0.36,
P < 0.001), followed by threat to life and dispossession and eviction (factors 2 and 3) (r = 0.25, P < 0.01),
and human rights violations and dispossession and
eviction (factors 2 and 1) (r = 0.20, P < 0.05).
PTSD was assessed by the Clinician Administered
PTSD Scale (CAPS) for DSM-IV (Blake et al., 1995).
The CAPS is a structured clinical interview that
allows a diagnosis of PTSD to be made using the
criteria and decision-tree specified by DSM-IV. Kappa
coefficients in previous studies have ranged from 0.85
to 0.87 for the three symptom subdomains of PTSD
with a coefficient of 0.94 being reported for the whole
measure (Blake, 1994). The CAPS also includes an
overall symptom severity rating and an assessment of
global, social, occupational and personal impairment.
A cut-off score of 2 or greater for any of these
disability items indicates severe functional impairment. Comparison of the functional impairment scale
with independent measures of disability such as Short
Form Health Survey (SF-36) (Ware and Sherbourne,
1992) and the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) (Endicott et al.,
1993), has provided support for the validity of this
component of the measure (Rapaport et al., 2002).
The CAPS increasingly is being translated into different languages and has been applied effectively to
diverse refugee and ethnic populations (Schnyder and
Moergeli, 2002; Hirihata et al., 2002; Yehuda et al.,
1996; Malekzaie et al., 1996). The measure was
translated and back-translated using a standard approach (Bontempo, 1993). Attention was given not
only to the linguistic equivalence of the measure but
also to the idiomatic expressions used by Bosnians to
ensure that the appropriate meaning of items was
conveyed. The measure was translated and backtranslated using a standard approach (Bontempo,
1993).

The presence of Major Depression Disorder and

Dysthymia were assessed using the Structured Clinical
Interview for the DSM-IV (SCID) (First et al., 1997).
The SCID is a semi-structured interview for assessing
DSM-IV Axis I diagnosis (American Psychiatric Association, 1994). Interviews were conducted in participants own homes with the assistance of an
experienced health care interpreter. All participants
were provided with an information sheet explaining
the aims of the study and they agreed to sign consent
forms approved by the Ethics Committee of the
University of Sydney.

3. Results
The sample consisted of 77 females (61%) and 49
(39%) males. The mean age was 47 years (range 18 to
88). Seventy-seven percent were married and 29%
had at least one child. Eighty-seven percent of the
sample had completed high school and 13% had
completed a university course. Sixty-two percent
had previously been employed in factory or sales
work and 14% were professionals. In Australia, 96%
were unemployed. Seventy-four percent of the sample
spoke little or no English. Ninety-two percent of the
subjects had resided in Australia for less than 5 years.
Subjects originated from 25 different cities around
Bosnia-Herzegovina. All subjects were authorized
refugees with permanent residency status in Australia.
The average time since exposure to the most severe
traumatic experience (the anchor point for assessing
PTSD) was 5 years.
The numbers of subjects with any past psychiatric
disorder was low (n = 5) so that this potential predictor
was not included in future analyses. Because of
comorbidity between dysthymia and major depressive
disorder, the two categories were combined to form
the depression group (n = 58). Fifty subjects (40%)
were diagnosed with comorbid depression and PTSD,
29 with a single diagnosis of PTSD (1% mild, 18%
moderate, 25% severe and 19% extreme PTSD) and
39 had no diagnosis. Only eight had a single diagnosis
of depression so that this subgroup was not included
in further analyses. There were no differences
amongst the comorbid group, those with PTSD and
normals in relation to demographic characteristics
such as gender, employment status, educational back-

S. Momartin et al. / Journal of Affective Disorders 80 (2004) 231238

ground, marital status, number of children and length

of stay in Australia.
In univariate analyses, the only trauma dimension
associated with pure PTSD was threat to life (t = 2.5;
df = 74; P<0.01). In contrast, all four dimensions,
human rights violations (t = 3.31 df = 87; P < 0.001),
dispossessions and eviction (t = 3.0; df = 87; P < 0.01),
threat to life (t = 4.9; df = 87; P < 0.001), and traumatic
loss (t = 3.4; df=87; P < 0.001) were reported more
frequently by the comorbid group.
To control for covariance amongst trauma
dimensions, logistic regression analysis was applied
(Table 1).
For pure PTSD (n = 29), threat to life (factor 3)
emerged as the only significant predictor [B = 0.65,
Exp(B) = 2.0, P < 0.01], whereas for the comorbid
group, threat to life [B = 0.86, Exp(B) = 2.3, P < 0.01],
and traumatic loss [B = 1.6, Exp(B) = 4.7, P<0.01] both
yielded significant associations. The high odds ratio
(4.7) for traumatic loss was noteworthy.
The relationship of diagnostic groupings to symptom severity, recorded by the CAPS, was explored
next. Those with comorbidity had higher rates of
severe or extreme PTSD (n = 48; 56%), than those
with PTSD alone (n = 28; 36%) (Pearson Chisquare = 4.5, df = 1, P < 0.05).
All subjects had been rated on PTSD symptoms and
levels of associated disability irrespective of whether
they reached DSM-IV diagnostic threshold for the
disorder. This allowed the group without any diagnosis
to be used as the reference point to assess disability in
relation to the pure PTSD and comorbid subgroups,
respectively. Logistic regression analysis showed no
differences between normals and the pure PTSD
groups according to the global functional scale or its
three subscales. In contrast, compared to normals, the
comorbid group manifested high levels of global func-

235

tional impairment (B = 1.5, P < 0.001, odds ratio =5.0),

distress (B = 1.8, odds ratio = 6.0, P < 0.001); as well as
social (B = 1.8, odds ratio = 5.9, P < 0.001) and occupational impairment (B = 1.6, odds ratio = 5.0,
P < 0.001). These distinctions persisted on all indices
when the comorbid group was compared directly with
the pure PTSD group (global functional impairment
B = 1.2, P < 0.001, odds ratio = 3.0; overall distress
B = 1.5, odds ratio = 3.2, P < 0.001; social impairment
B = 1.3, odds ratio = 3.5, P < 0.001; and occupational
impairment B = 1.2, odds ratio = 3.2, P < 0.01).

4. Discussion
Prior to drawing inferences from the present study,
several limitations need to be considered. Retrospective reports of trauma by refugees could be biased or
inaccurate. Recent research has indicated, however,
that refugees remain consistent in their reports of the
more extreme past traumas (Miller et al., 2002) such as
the categories inquired into in the present study. The
sample size was modest and the method of recruitment
was not random. Hence, the rates of disorder observed,
although similar to those identified amongst convenient samples of Bosnian refugees studied elsewhere
(Weine et al., 1998), cannot be regarded as an indication of the prevalence of trauma-related affective
disturbances in the general Bosnian refugee community living in Australia. The pattern of comorbidity that
emerged, however, the key index of interest in the
present analysis, was consistent with a growing body
of studies in the trauma field (Blanchard et al.,
1996a,b; Bleich et al., 1997; Mollica et al., 1999;
Shalev et al., 1998; Sierles et al., 1983; Skodol et al.,
1996). Moreover, questions still remain about the
validity of applying western criteria for PTSD across

Table 1
Logistic regression analysis comparing trauma dimensions with affective categories

Human rights violations Odds ratio

Dispossession and eviction Odds ratio
Threat to life Odds ratio
Traumatic loss Odds ratio
* P<0.05, ** P<0.01, *** P<0.001.

Pure PTSD
(n = 29)

Comorbid group
(n = 50)

0.82
1.0
2.0**
1.8

1.2
1.6
2.3**
4.7***

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S. Momartin et al. / Journal of Affective Disorders 80 (2004) 231238

cultures (Summerfield, 1999) although there is growing evidence that the clinical pattern can be identified
across ethnic groups such as the Bosnians (Mollica et
al., 1999). As indicated, the CAPS has been increasingly translated into various languages spanning a
wide range of cultures. It is also noteworthy that the
pattern of comorbidity identified in the present study
coincide with that found amongst Anglophone societies, providing an indirect index of the construct
validity of the Bosnian version of the CAPS (Yehuda
et al., 1996; Blanchard et al., 1996a,b).
Analysis of the traumatic antecedents indicated that
Threat to Life was the sole predictor of pure PTSD,
hence supporting the DSM-IV definition of a traumatic event leading to that disorder. However, both
threat to life (odds ratio = 2.3) and traumatic loss
(odds ratio = 4.7) were associated with comorbid
PTSD and depression. These associations support
those found in previous research (Goenjian et al.,
1994; Morris et al., 1993; Skodol et al., 1996; Shalev
et al., 1998), suggesting that the pathways to depression and PTSD may by somewhat distinct, with
different traumatic events leading to each. Threat of
death and proximity to danger appear most salient to
developing PTSD symptoms whereas the traumatic
loss of loved ones, especially immediate family members, appears to be linked more closely to risk of
depression (Silove, 1999; Miller et al., 2002).
Demographic variables did not differ across the
derived diagnostic categories. Although this finding is
at variance with studies in the general traumatology
literature in which greater female vulnerability to
PTSD has emerged (Fullerton et al., 2001), the data
are consistent with other studies undertaken amongst
Bosnian refugees. For example, a study conducted by
Thulesius and Hakannson (1999) of 206 Bosnian
survivors of trauma resettled in Sweden, showed no
gender differences in rates of PTSD or depression.
Moreover, Mollica et al. (1999), in an epidemiological
sample of 534 Bosnian survivors of war, found that
gender did not influence rates of trauma-related psychiatric disorder.
An important question is whether comorbidity has
any clinical significance compared to a diagnosis of
PTSD alone. Fifty-six percent of those with comorbidity compared to 36% of those with pure PTSD, fell
into the most severe symptom categories of PTSD
according to the CAPS. Other researchers have found

similar results (Skodol et al., 1996; Moore and

Boehnlein, 1991; Parkes, 1985). It is possible that
comorbidity in itself leads to more severe overall
symptoms or, alternatively, that the particular constellation of trauma exposure identified (traumatic loss
and life threat) generates both comorbidity as well as
increased intensity of symptoms. Only longitudinal
studies will be capable of examining these possible
pathways more definitively.
Those with PTSD had no greater level of functional impairment than those without a diagnosis. This
finding is noteworthy given claims by some critics
that PTSD symptoms may represent a normative
reaction in those exposed to major abuses (Summerfield, 1999). In contrast, comorbidity was strongly
associated with global psychosocial impairment
(B = 1.5, odds ratio = 5.0, P < 0.001), and with the
subscales of distress (B = 1.8, odds ratio = 6.0), social
impairment (B = 1.8, odds ratio = 5.9, P < 0.001), and
occupational disability (B = 1.6, odds ratio 5.0,
P < 0.001). This distinction remained when the
comorbid group was compared directly with the pure
PTSD group.
The present results are remarkably similar to those
reported by Mollica et al. (1999) based on their
epidemiological study of 534 Bosnian survivors living
in a refugee camp in Croatia. In the refugee camp
study, 20% of those with pure PTSD (23% in our
sample) had significant levels of functional impairment, compared to 46% with comorbidity (40% in our
study). The pattern of psychosocial impairment in the
comorbid groups across the two studies (odds ratio for
Australian study = 5.0, refugee camp = 5.02) is striking given the differences in sampling and measures
used. In both studies, there was no difference in
functional impairment between those with pure PTSD
and those without a psychiatric diagnosis.
The importance of the present findings becomes
even more evident when the timeframe across the two
studies is considered. Mollica et al. (1999) conducted
their study in 1996, the year after the Bosnian war
ended. The present study was conducted 5 years on
average after participants had been exposed to war
events. The similarity of the results across the two
studies suggests therefore that the functional impairment and disability associated with comorbidity following refugee trauma may persist over extended
periods of time.

S. Momartin et al. / Journal of Affective Disorders 80 (2004) 231238

5. Conclusions
In summary, the present study suggests that comorbid PTSD and depression, an outcome of exposure to
traumatic loss and life threat, is associated with a high
risk of persisting disability in refugees. If it is true that
those with pure PTSD are at no greater risk of
psychosocial disability compared to refugees with no
psychiatric diagnosis, this finding raises serious questions about the usefulness of the present classification
of traumatic stress disorders. In particular, the results
raise further questions as to whether symptoms of
PTSD on their own are disabling. It may be that a
wider constellation of traumatic stress symptoms that
include elements of PTSD and depression define a
broader posttraumatic affective syndrome that is specifically associated with risk of long-term disability.
From a practical perspective, refugee screening
programs might benefit from focusing on the key
trauma constellations (life threat and traumatic loss)
and symptom combinations (depression and PTSD)
identified herein when selecting refugees for early
psychosocial intervention programs aimed at reducing risk of long-term morbidity and psychosocial
dysfunction.

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