پیش بینی پریشانی روانی در گروگان های جنگ لبنان

A cross-sectional study addressed the experience of Lebanese hostages of war in Lebanon. It specifically assessed the prevalence of general distress and its relationship to captivity-related factors and selected psychosocial variables. Trained field researchers using standard measurements interviewed 118 Lebanese hostages released from Khiam prison, an Israeli detention center in Lebanon. Questionnaires administered included the GHQ-12 and the Harvard Trauma Questionnaire. Individuals were detained for 3.4 years on average, and 86% were tortured. Psychological distress was present in 42.1% of the sample compared to 27.8% among the control group. In the multivariate analysis, the significant predictors for distress were: years of education and increase in religiosity after release. In conclusion, even after 2 years of release, more than one-third of the Lebanese hostages released from Khiam prison were found to have psychological distress. Caregivers need to pay special attention to the mental health of hostages of war. The paper discusses the meaning and implications of the factors predicting resilience and vulnerability in this particular population.

The health status of prisoners of war (POW) has been a constant concern to physicians after World Wars I and II and subsequently, with special interest in their psychological aspects, during the Korean and Vietnamese campaigns. War imprisonment is among the many atrocities that the Lebanese population endured in the past 20 years, especially as a result of the conflict with Israel. Hundreds of Lebanese were detained in the Khiam Detention Center in South Lebanon and many others were held prisoners in Israel. The Khiam prison was run by the South Lebanese Army, a militia allied to Israel. Most prisoners were detained without charge or trial and many of those tried were kept beyond the expiry of their sentences, and so were hostages. They were subject to different forms of torture and ill treatment described in many reliable reports (Amnesty International, 1997). In 1995, 14 persons were reported to have died in prisons because of physical torture. In the mid-1990s, Israel released many of the detainees, and the remaining hostages in Khiam Detention Centre were liberated with the withdrawal of the Israeli Armed Forces from South Lebanon in May 2000. The released hostages were welcomed like heroes. The government and some political parties attended to part of their financial needs. However, there was little interest shown in their mental health needs. Multiple observations and informal reports described the psychological impairment. The present study examines psychosocial and captivity-related variables that might be associated with psychological impairment. Literature review The most closely related literature to hostages of war comes from the research on prisoners of war. The available literature on POWs documents the impact of captivity on their physical and mental health (Gold et al., 2000; Neria, Solomon, & Dikel, 1998), often with long-lasting effects (Dent, Tennant, & Goulston, 1987; Sutker, Winstead, Galina, & Allain, 1991). One of the most prominent psychiatric disorders consequent to war trauma is post-traumatic stress disorder (PTSD), a seminal concept developed in the Vietnam War. The reported prevalence of PTSD in POWs is as high as 88% (Sutker & Allain, 1996). Depression, anxiety disorders, and alcohol and substance abuse are also frequently reported in prisoners subjected to harsh conditions in times of war or violent social conflict (Allodi, 1994; Bleich, Koslowsky, Dolev, & Lorer, 1997; Engdahl, Dikel, Eberly, & Blank (1997) and Engdahl, Dikel, Eberly, & Blank (1998); Genefke & Vesti, 1998; Maercker & Schutzwohl, 1997; O’Toole, Marshall, Schureck, & Dobson, 1998). A Medline search yielded few articles on distress among prisoners (Easton & Turner, 1991; Gold et al., 2000). Other studies report altered personality and somatoform symptoms ( Genefke & Vesti, 1998), and higher mortality among POW than non-POW veterans ( Guest & Venn, 1992). On the other hand, with all the deleterious effects of captivity cited above, some studies document that POWs do experience emotional growth and good psychological health in the years following the ordeal, or simply no difference in psychosocial status from the general population or other war veteran groups ( Kirn, 1989; Nice, Garland, Hilton, Baggett, & Mitchell, 1996; Gale, Braidwood, Winter, & Martyn, 1999). The extent of psychiatric problems experienced by POWs varies according to several environmental and personal factors. Higher education and younger age at time of capture seem to protect against mental health problems (Gold et al., 2000). There exists a positive relationship between young age and PTSD in those who face combat duty (Elder, Shanahan, & Clipp, 1994). Other socio-demographic determinants include marital and employment status. The unmarried, unemployed, and retired POWs are more likely to develop depression (Dent et al., 1987). Loss of financial independence and lack of accommodation were associated with psychological symptoms in British individuals taken as hostages in the Gulf War in 1990 (Easton & Turner, 1991). Traumatic experiences during imprisonment are strong predictors of psychological problems manifested later on. Severity and duration of torture are directly related to psychological distress, even after 40 years of captivity (Gold et al., 2000). Basoglu, Paker, Ozmen, Tasdemir, and Dahin (1994) showed that perceived severity, rather than objective severity of torture, is associated with mental health problems. Social support at homecoming is negatively related to psychiatric problems (Neria et al., 1998; Engdahl et al., 1997). Allodi (1998) observed a positive effect on the health of torture victims when public attitude was welcoming and a network of social support was accessible to the victim and his/her family. Furthermore, ideological and political commitment alleviates the development of psychological distress (Genefke & Vesti, 1998); a strong belief in a cause may protect the core of the personality of POWs (Eitinger & Weisaeth, 1998). The design of this study is based on the assumption that the experience of captivity is a main determinant of the hostages’ mental health status and psychosocial functioning. Other intervening and independent variables are of a demographic and psychosocial nature. The objectives of this study were to assess general distress in Lebanese hostages and investigate its relationship to trauma experienced during captivity, other captivity related factors, selected demographic, psychosocial, and illness factors. Methods The population under study consisted of a cross-sectional sample of Lebanese hostages released from the Khiam prison between 1990 and 1996. The sampling frame was a list of 195 released hostages provided by the non-governmental organization with the name Follow-Up Committee for the Support of Lebanese Detainees in Israeli Prisons. The list included name, year and place of birth, and father's and mother's names of each hostage. A random sample of 92 subjects was initially drawn from the list, and the selected individuals were contacted by the Follow-Up Committee. Forty released prisoners showed up for the interview, providing an initial response of 43%. To improve on the response rate, the rest of those on the original list were added to the sample and efforts were made to contact them through the unions and political parties to which these individuals were affiliated. The final study sample consisted of 118 hostages, thus providing a 60.5% response rate of those listed. The distribution of the final sample obtained by gender, and age is similar to the distribution of the total released population (N: 195). Ninety community controls chosen from the same place of residence as that of the hostages, within + or −5 years of age, and who had never experienced detention, were selected. Data collection took place over a three-month period. The interviewers were a family practitioner, a registered nurse and a sociologist, all experienced in interviewing techniques and trained in the administration of the study's questionnaire. The purpose of the study was explained in general terms to all respondents, and an informed consent form was signed by them. The study received approval from the Ethics and Research Committee at the researchers’ university. Measurements Distress, the main outcome variable, was assessed using the Arabic translation of the GHQ-12 (General Health Questionnaire). This instrument is a short version of the 60-item GHQ developed by Goldberg in 1972 to study psychiatric distress in primary care and community settings ( Goldberg, 1978). It has been used in Arabic speaking countries and found to be a valid psychiatric screening instrument in primary health care ( El-Rufaie & Daradkeh, 1996). The psychometric properties were as follows: sensitivity 83%, specificity 80%, and total discriminatory power 86%. Individuals who scored 3 or more on the GHQ-12 were considered either distressed or psychologically disturbed, as recommended by Goldberg. The main determinants of psychological distress were categorized into four main groups: 1. Socio-demographic variables included age, sex, education, employment, and marital status. Education was measured as the highest level of education an individual attained and then transformed into years of education to permit comparison with data obtained in other educational systems. Employment status referred to whether the individual was employed at the time of the interview. Occupational type was ranked at three different levels: professional, skilled, and unskilled. The variable on marital status was recoded into two categories, single and ever-married, since the sample contained few divorced and widowed individuals. 2. Captivity-related factors included reason and manner of arrest, age at arrest, duration of imprisonment in months, trauma experienced during imprisonment, and number of years since release from prison. Reasons for arrest were grouped into three main categories: active involvement in military action, logistic involvement, and passive involvement/suspicion of involvement. Manner of arrest was categorized into: caught in military action or other ways. Trauma experience was assessed using section I and II of the Harvard Trauma Questionnaire ( Mollica et al., 1992). The test–retest reliability of HTQ is 0.89 and inter-item correlation varies between 0.39 to 0.86 with a median of 0.62. Time since release was categorized into three groups: less than 2 years, 2–5 years and more than 5 years. 3. Psychosocial factors included life events, social support, religiosity, and political commitment. Life events were assessed by asking questions related to three domains: changes in social status in the past year and the intensity of their effect on the individual (marriage, engagement, births, divorce, death of family member); problems with family members (spouse, children, head of household, friends, and relatives); and daily problems related to work and financial situations (loss of work, searching for a job, and decrease in income). Each event was coded as 0 if it did not happen or happened with no effect, 1 if it had a positive effect and 2 if it had a negative effect. Two types of scores were computed, one for every domain of life and the other computed as an overall score; in all cases the score was the sum of relevant items. The total 13-item score ranged from 0 to 13 with a median of 4.5. The Life Events scale has been used and validated by the authors in a study on victims of a church explosion in Lebanon ( Farhood & Nourriddine, in preparation). Social Support was assessed by asking 8 closed-ended questions about the hostage's perception of change in people's views towards the prisoner after his/her release; if the prisoner has someone to rely on for emotional and psychological help; if he/she has financial support, feeling needed, respected, and appreciated by the people around him/her. Responses were 0 (not at all), 1 (rarely), 2 (often), and 3 (always). A summary measure of each individual's social support was then computed by summing responses (alpha=0.70). The scores ranged from 8 to 21 with a median value of 17. An additional open question was asked to elicit information on the type of support during detention. The answers were later grouped and the main categories were: belief in religion or in a political doctrine, availability of support outside the prison (family and friends), and personal characteristics of resilience (self-esteem, hope, belief in his/her innocence). The social support scale was constructed by the investigators of the study and was adapted from existing social support scales used in Lebanon ( Chaaya, Campbell, El Kak, Shaar & Kaddour, 2002; Farhood et al., 1993). 4. Individuals were also asked whether they had faith and/or practiced religion, and whether they were politically committed. In addition, they were asked whether there had been any change in their faith or religious practice and in their political commitment during detention and after release. 5. Illness-related variables included the presence of any chronic illness, taking psychotropic medications, change in health status after release, increased number of medical visits and current smoking and alcohol drinking habits coded 0=no and 1=yes.

Torture of prisoners of war is common. It has been practiced throughout history, and probably before a written history existed (Eitinger & Weisaeth, 1998). Amnesty International (2001) reported that torture and human rights violations during 2000 are being practiced in 149 countries and territories. . The prevalence of distress among released hostages in Lebanon presents a risk and a challenge. Resources to support the reintegration of hostages into society should be mobilized. This requires commitment from the public sector first and from the major welfare agencies. On another level, health care providers need to know more about the effect of torture and identify people at risk of having mental health problems. Taking into consideration the immediate needs of the released and others who might be released, it becomes urgent to develop and evaluate intervention strategies directed to the full rehabilitation of the ex-prisoner, in his/her family and in his/her community. This study is the first of its kind in Lebanon, and contributes to the literature on hostages and prisoners of war.