Mevludin Hasanović

Muhammed Hasanović

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135Psychiatria Danubina, 2020; Vol. 32, No. 1, pp 135-136 Letter to Editor © Medicinska naklada - Zagreb, CroatiaHEALING INVISIBLE WOUNDS - HAVE WE DONE ENOUGH  TO HELP SUCIDAL WAR VETERANS WHO SUFFER FROM PTSD Mevludin Hasanovi1,2 & Muhammed Hasanovi31Department of Psychiatry, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina 2School of Medicine, University of Tuzla, Tuzla, Bosnia and Herzegovina 3 School of Psychology, University of Tuzla, Tuzla, Bosnia and Herzegovina*  *  *  *  *  Dear Editor, The Balkan wars had dramatic consequences for all the republics of the former Yugoslavia, and more spe-cifically Bosnia and Herzegovina (BH), where the most hostile action and violent fighting took place.  According to World Health Organization (WHO) data, about a million people commit suicide each year across the world. The Bosnian average is about 12 people per 100,000 annually, which is close to the Euro-pean average. Unfortunately, there is still no systematic approach in BH to address this problem. There is no adequate program to monitor the long-term consequen-ces of the war, especially considering that relatively few people have sought professional help. It is all down to the care of psychiatrists/neuropsychiatrists and health services in terms of providing assistance when PTSD victims decide to seek help. Over 450 people committed suicide in 2014 in Bosnia and Herzegovina, with depression and post-traumatic stress disorder (PTSD) linked to the 1990s conflict cited as some of the causes. According to police records in both Bosnian entities, 459 people committed suicide throughout the country last year - 230 in the Federation of Bosnia and Herze-govina and 229 in the Serb-dominated Republika Srpska. In more than two-thirds of cases, the victims were male. In Republika Srpska most suicides were committed in the largest city, Banja Luka, where there were 79 deaths, while the Federation city of Tuzla recorded more than 50 people taking their own lives. The most commonly used method was hanging (Džidi  2015). According the autopsy protocols of all 44 suicides committed in the Belgrade District population over a period between 1992 and 2000 by war veterans Mihailovi  et al. (2015) found that symptoms of PTSD were present in 27.3%, major depression in 9.1% and schizophrenia in 6.8% of war veterans. The majority of suicides (84.1%) were committed by recruits in the Yugoslav National Army, spending between three and eight months in the zone of war operations. Six committed suicide during the first 30 days after their war activities, while the majority of suicides occurred between five and six years after combat. The most frequent manner of suicide was the use of handguns (56.8%) and bombs (18.2%) (Mihailovi  et al. 2015). The occurrence of suicidal thoughts and behaviors is rather frequent among war veterans, particularly those suffering from posttraumatic stress disorder (PTSD). In the sample of 72 Croatian male war veterans (mean age 52.33 years) diagnosed with PTSD who was gathered at the National Center for Psycho-trauma between May and October 2014, Jakši  et al. (2015) found that tem-perament dimension Harm avoidance and character dimension Self-directedness were moderately associated with the total risk for suicide, while Persistence and Cooperativeness showed significant but weaker rela-tions. Different dimensions of suicidality were associa-ted with different personality traits. Harm Avoidance was shown to be significantly increased among the sub-group of war veterans with high suicidal risk. These fin-dings could help extend our understanding of the elevated suicide risk in war veterans with PTSD. Detection of individuals displaying high Harm Avoidance and low Self-Directedness might facilitate prevention of suicidal behaviors in this population (Jakši  et al. 2015). In the study on evaluation of the influence of PTSD and other comorbid disorders on suicidal risk among combat veterans and evaluation of the impact of psycho-social factors on the escalation of suicidal risk, on the random and representative sample of 215 Kosovo War veterans, Halimi and Halimi (2015) found that suicidal ideations were observed in 44 (20.5%) of the 215 subjects. High suicide risk was found in 31.8% veterans diagnosed with PTSD and comorbid major depressive disorder. In addition, high suicide risk was also obser-ved in the group of unemployed veterans, veterans dis-satisfied with social/economic attainment and veterans dissatisfied with living conditions. They concluded that these socioeconomic factors contributes to the deterio-ration of symptoms of major depression, PTSD and other comorbid disorders, with a direct impact of wor-sening suicidal ideations and suicidal behavior among war veterans (Halimi & Halimi 2015). Generally speaking, most suicides are connected to a psychiatric disorder – most commonly unipolar or bipo-lar depression, but PTSD especially and other social and economic reasons such as unemployment, financial and family stress can significantly influence suicide. After the indescribably difficult traumatic events, the loss of loved one in a violent manner, the everyday pain of family members can lead to a predisposition to Mevludin Hasanovi  & Muhammed Hasanovi : HEALING INVISIBLE WOUNDS - HAVE WE DONE ENOUGH TO HELP SUCIDAL WAR VETERANS WHO SUFFER FROM PTSD          Psychiatria Danubina, 2020; Vol. 32, No. 1, pp 135-136 136suicide. This predisposition can be intensified in an area which has no support and where other negative social and economic factors are present (Džidi  2015). Trans-generational transfer of trauma can also lead to many of these problems. According to police records, more than 20 minors committed suicide in 2014 year, with the reasons listed as conflict with elders, proble-matic family relations and school issues. The problem is the negative impact of parents with PTSD on children, which can be manifested on a behavioral, cognitive and psychic plane. These are mostly parents who have never been treated (Džidi  2015). In order to lower the suicide rate, BH society should educate people about, and highlight mental health issues. Education focused on the destigmatization of psychiatric disease and suicides are the first step toward lowering the number of suicides. The more society has an opportunity to publicly discuss psychiatric difficul-ties the more knowledge and understanding of these ill-nesses will increase and people will be tolerant and understanding and supportive towards those who suffer. That can lead to the early detection of symptoms and can stop people from committing suicide (Hasanovi  et al. 2006). The establishment of Mental Health Centers across BH has increased accessibility and facilitated treatment for people with mental disabilities (Avdi-begovi  et al. 2008, Sinanovi  et al. 2009). This should be talked about constantly because this is lack of care for war veterans, and their attitudes. A war veteran alone cannot help him/herself with suicidal ideations. It is a very complex trauma, and due to this, war veterans haven’t often come to our clinic looking for help; most of them have left the country and most do not even want to be psychiatric patients. It is certain that the public health system of Bosnia-Herzegovina never expected, before the war, to have to deal with such a large number of consequences of the war, on such a vast scale. The increasing shortage of resources and the lack of a multisectorial integrative approach, contribute to the “conspiracy of silence” even 25 years later, and need to be scientifically and politically discussed. Acknowledgements: None.Conflict of interest: None to declare.References 1. Avdibegovi  E, Hasanovi  M, Selimbasi  Z, Pajevi  I, Sinanovi  O: Mental health care of psychotraumatized persons in post-war Bosnia and Herzegovina – experien-ces from Tuzla Canton. Psychiatr Danub 2008; 20:474-84. PubMed PMID: 19011588 2. Džidi  D: War Traumas Influence Bosnia Suicide Rate. https://balkaninsight.com/2015/01/28/war-traumas-influence-bosnia-suicide-rate/ 2015. Approached: 02.03.2020. 3. Halimi R, Halimi H: Risk among Combat Veterans with Post-traumatic Stress Disorder: The Impact of Psychosocial Factors on the Escalation of Suicidal Risk. Noro Psikiyatr Ars 2015; 52:263-266. doi: 10.5152/npa.2015.7592. PubMed PMID: 28360721; PubMed Central PMCID: PMC53530594. Hasanovi  M, Sinanovi  O, Pajevi  I, Avdibegovi  E, Sutovi  A: Post-war mental health promotion in Bosnia-Herzegovina. Psychiatr Danub 2006; 18:74-8. PubMed PMID: 16804502 5. Jakši  N, Aukst-Margeti  B, Mar inko D, Brajkovi  L, Lon ar M, Jakovljevi  M: Temperament, character, and suicidality among Croatian war veterans with post-traumatic stress disorder. Psychiatr Danub 2015; 27:60-3. PubMed PMID: 25751432 6. Mihailovi  Z, Savi  S, Damjanjuk I, Jovanovi  A, VukoviS: Suicides among Serbian War Veterans - An Autopsy Study. Srp Arh Celok Lek 2015; 143:590-4. PubMed PMID: 26727868 7. Sinanovic O, Avdibegovic E, Hasanovic M, Pajevic I, Sutovic A, Loga S, Ceric I: The organisation of mental health services in post-war Bosnia and Herzegovina. Int Psychiatry 2009; 6:10-12. eCollection 2009 Jan. PubMed PMID: 31507971; PubMed Central PMCID: PMC6734861 Correspondence: Professor Mevludin Hasanovi , MD, PhD Department of Psychiatry, University Clinical Center Tuzla Ul. Rate Dugonji a bb, 75 000 Tuzla, Bosnia and Herzegovina E-mail: dr.mevludin.hasanovic@gmail.com

HEALING INVISIBLE WOUNDS - HAVE WE DONE ENOUGH TO HELP SUCIDAL WAR VETERANS WHO SUFFER FROM PTSD

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