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Unconfirmed death as a predictor of psychological morbidity in family

members of disappeared persons

Article in Psychological Medicine · December 2018

DOI: 10.1017/S0033291718003793

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 Psychological Medicine Unconfirmed death as a predictor of
cambridge.org/psm
psychological morbidity in family members of
disappeared persons
Amila Isuru1, S. N. Hewage2, Padmakumara Bandumithra3 and S. S. Williams4
Original Article
1
Cite this article: Isuru A, Hewage SN, University Psychiatry Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka; 2Independent Statistician,
Bandumithra P, Williams SS (2018). Colombo, Sri Lanka; 3District General Hospital, Hambantota, Sri Lanka and 4Department of Psychiatry, Faculty of
Unconfirmed death as a predictor of Medicine, University of Kelaniya, Ragama, Sri Lanka
psychological morbidity in family members of
disappeared persons. Psychological Medicine
Abstract
1–8. https://doi.org/10.1017/
S0033291718003793 Background. The 2004 tsunami, the civil conflict until 2009 and the youth insurrection in the
late 1980s in Sri Lanka resulted in many persons being classified as ‘missing’ as they disap-
Received: 15 July 2018
Revised: 15 November 2018
peared and were unaccounted for. Our aim was to compare the prevalence of major depressive
Accepted: 20 November 2018 disorder (MDD) and prolonged grief disorder (PGD) in families of disappeared individuals,
who eventually received the mortal remains and those who did not.
Key words: Method. An ethically approved cross sectional study was conducted in a purposively selected
Ambiguous loss; civil conflict; depression;
sample after informed consent. Information on the circumstances of the family member going
grief; missing individuals; natural disasters;
post-traumatic stress disorder; prolonged grief missing was gathered. Culturally adapted versions of the General Health Questionnaire and
disorder; psychological morbidity the Beck Depression Scale were administered. Those who screened positive were assessed
by a psychiatrist on Diagnostic and Statistical Manual of Mental Disorders-5 criteria to arrive
Author for correspondence: at a diagnosis.
Amila Isuru,
E-mail:[email protected] Results. Of 391 cases of disappearances studied, MDD (17.5% v. 6%) and PGD (22% v. 7%)
were significantly higher in those who did not eventually receive the mortal remains of the
disappeared person. Among those who did not receive the mortal remains, being unsure
whether the disappeared person was dead or alive was highly predictive of MDD and PGD.
Mothers and wives, older family members and those with a family history of mental illness
were more vulnerable.
Conclusions. Family members of missing individuals unsure whether their loved one was
alive or dead have higher psychological morbidity in the form of MDD and PGD.

Introduction
Ambiguous loss when loved ones go missing
When someone is lost without verification, the family members are left in a state of uncer-
tainty, vacillating between hope and despair and they do not come to an acceptance of
death even after many years (Boss, 2002). Continued disbelief of the death of a loved one pre-
vents initiation of the normal grief process resulting in high psychological morbidity (Kersting
et al., 2011). Besides the ambiguity of the fate of their loved one, family members have to con-
tend with financial, social and legal ramifications arising from the disappearance of the loved
one (Crettol and La Rosa, 2006). The family members often embark on a desperate pursuit of
evidence to establish whether their relatives are alive or dead.
There are but a handful of studies which have studied this phenomenon of ambiguous loss
resulting from persons going missing. Civil wars, terrorism and natural disasters across the
globe render many families bereft of their loved ones classified as ‘missing’ (Barakovic
et al., 2014). A study compared the prevalence of post-traumatic stress disorder (PTSD) in
wives of missing individuals with unconfirmed death and confirmed death in Bosnia and
Herzegovina. This study showed greater PTSD among wives who did not have an opportunity
to see the mortal remains of their husbands (Powell et al., 2010).

Ambiguous loss in Sri Lanka

Sri Lanka has suffered three decades of ethnic conflict, the late 1980s youth insurrection, and
the tsunami disaster in 2004 which left a large number of individuals unaccounted for. The
Presidential Commission on missing persons in Sri Lanka has received more than 20 000 com-
© Cambridge University Press 2018 plaints about missing individuals including more than 5000 missing from government forces
(ICRC,. 2016). The Sri Lankan parliament in response to this issue has passed a law on a statu-
tory office of Missing Persons in August 2016 which has become operational in 2018. People in
southern Sri Lanka have experienced the above described three calamities which have resulted
in thousands of missing persons. It is important to understand the extent of psychological

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 2 Amila Isuru et al.

morbidity the family members of these missing persons endure. It Psychometric instruments
is known that persons who experience grief can progress to pro-
General health questionnaire-30 (GHQ-30)
longed grief disorder (PGD), major depressive disorder (MDD)
GHQ-30 displays adequate validity for screening psychiatric dis-
and PTSD) (Boelen et al., 2010; Boelen, 2013). Although the lit-
orders (Jackson, 2007). It has been validated and widely used in
erature on normal grief and abnormal grief reactions following
the Sri Lankan Sinhala speaking population with a sensitivity of
the death of a loved one is extensively described, the grief follow-
67.5% and specificity of 80% at the score of 5/6 (Abeysena et al.,
ing a loved one going missing is not adequately described or
2012). Individuals who scored six or more were further evaluated
documented.
for MDD, PGD and PTSD. When rating the GHQ-30, we used
the scoring system of allocating marks: 0, 1, 2 and 3 for the four
responses in each item. Therefore, the possible scores for the
Aims of the study GHQ-30 raged from 0 to 90.
The objective of this study was to compare the rates of PGD,
MDD and PTSD among family members of those classified as Beck depression inventory-II (BDI-II)
missing and ascertain whether those who did not receive confirm- BDI has been the most commonly used self-rating depression
ation of their death subsequently had higher psychological mor- screening tool and rating scale with 21 items which has good psy-
bidity. We also looked at their belief as to whether the missing chometric properties and has shown discriminant validity in many
individual was still alive or dead and its effect on the outcome. cultures (Steer et al., 1999). BDI-II has been validated to use
among Sinhalese speaking Sri Lankan individuals and found
to have both sensitivity and specificity of 94 at a cut off score
Methods of 16 (Rodrigo et al., 2015).
Participant recruitment and assessment
This is a cross sectional study involving family members of indi- Post-traumatic stress symptom scale-self-report version (PSS-SR)
viduals in Sri Lanka who went missing in the tsunami disaster in PTSD was screened by a self-administered PSS-SR (Foa et al.,
2004, the late 1980s youth insurrection and while serving in the 1993). PSS-SR has been previously used in Sinhalese speaking
military during the civil conflict. populations (Hollifield et al., 2008; Wijesinghe et al., 2015). The
The missing, as referred to in this research paper are indivi- self-administered version of the PSS-SR has satisfactory internal
duals unaccounted for as a result of the 2004 tsunami, the consistency, high test–retest reliability and good concurrent valid-
armed conflict in late 1980s and the separatist war in the north ity (Foa et al., 1993).
of Sri Lanka. The study however was conducted in the south of
Sri Lanka and those who went missing in the south in relation DSM-5 criteria
to the war in the north were mainly military personnel and not DSM-5 criteria were used to make a psychiatric diagnosis. MDD
civilians. Purposive sampling was done due to the sensitive nature included all categories under DSM-5 category 296. PGD is diag-
of the research. We approached two groups of respondents, 223 nosed when severe persistent grief reaction occurs following a loss
family members of missing individuals and 168 family members of a loved one (Prigerson, 2004). It corresponds to the diagnostic
who had lost family members due to the above situations but had criteria of persistent complex bereavement disorder in DSM-5
confirmation of the death of their loved one. The study was con- which gives three comprehensive diagnostic categories; separation
ducted in Galle, Matara and Hambantota districts in the southern distress, reactive distress to the death and social identity disruption
province of Sri Lanka. The families were identified through the with clinically significant distress or impairment in functional level.
district secretariat office and the village civil service official PTSD was diagnosed on criteria on 309.81 (American Psychiatric
known as the Grama Niladhari. Some families did not volunteer Association; American Psychiatric Association, DSM-5 Task
to divulge information due to understandable reasons such as Force, 2013).
security issues and stigma. Hence, a snow balling sampling
method was used. The family members were visited by the
researchers and interviewed after informed consent. In each fam-
Statistical analysis
ily, the first family member who volunteered to participate was
interviewed. If the interviewee had lost more than one family Descriptive statistics for variables that were of the nominal data
member, they were asked to specify whose death was most diffi- type were calculated and shown as frequencies and percentages.
cult to cope with and to base their answers with reference to that Variables related to age were considered as continuous data and
person. Interviews were carried out by a doctor trained in psych- described using mean and standard deviation. Calculations related
iatry. The interview included a questionnaire on the socio- to GHQ scores were also done considering it to approximate con-
demographic background and the circumstances involving the tinuous data, as the range of the scale was relatively high. In the
missing or dead individual. All the interviewees were screened process of identifying the independent predictors of depression
using culturally adapted and validated versions of the General and PGD multiple logistic regression analysis was performed.
Health Questionnaire, Beck Depression Scale and Post- This included an initial calculation of unadjusted odds ratios
Traumatic Stress Symptom Scale self-report version (PSS-SR). (ORs) for all potential predictor variables followed by arriving
Those who screened positive on the above scales were assessed at the final model with significant independent predictors.
clinically on Diagnostic and Statistical Manual of Mental Disorders Adequacy of the final fitted model was assessed with Hosmer
(DSM)-5 criteria by a psychiatrist blind to interviewee status, to diag- and Lemeshow goodness of fit test. Type-I error of 0.05 was con-
nose MDD, PGD and PTSD. Thus each of these three diagnoses was sidered in all significance calculations and all analyses were per-
mutually exclusive. formed using the IBM SPSS statistical package.

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 Psychological Medicine 3

Ethical considerations Psychiatric morbidity in the family members of the missing

Ethical approval for the study was granted by the Ethical Review The assessment of mental health status of the interviewees showed
Committee of the Faculty of Medicine, University of Kelaniya, that 49 (12.5%) had MDD, 62 (15.9%) had PGD and three (0.8%)
Sri Lanka. Written informed consent was obtained from all parti- had PTSD. A total of 114 (29.3%) had psychiatric morbidity as
cipants. The psychological status of the persons interviewed could each diagnosis was mutually exclusive and confirmed clinically.
be fragile. When these incidents are probed into, these individuals While the overall mean GHQ-30 score for the sample was
may be re-traumatised. Nevertheless, skilful and sensitive interviews 15.41, there were significant differences in the mean scores be-
can sometimes be helpful (Nelson et al., 2013). Subjects may benefit tween those without psychiatric morbidity [6.47; 95% confidence
from talking openly about their experiences. Emotional distress was interval (CI) 5.82–7.11], those with PGD (25.52; 95% CI 23.94–
monitored during the interview and the interviewer stopped con- 27.10) and those with MDD (51.65; 95% CI 44.71–58.60). Even
versation immediately if participants did not want to continue to though the GHQ-30 score for responders with PTSD was rela-
talk about their experiences. It was made clear that at any point tively high (40.00), as there were only three individuals with the
the interviewee could terminate the interview without any negative diagnosis, it was not significantly different from the other diag-
consequences. nostic categories (95% CI 3.92–76.08). Due to the low number
Interviewees found to have any psychological morbidity were of cases with PTSD, those three responders were excluded from
referred to local mental health teams for assessment and treatment. further analyses in the study. Table 2 provides details of
GHQ-30 scores in the study sample.
Results
Demographic characteristics of participants Major depressive disorder (MDD) and its predictors
The study included 391 cases of disappearances with an immedi- In the analysis of factors associated with depression, cases with
ate family member of each missing person being the responder for depression (n = 49) and those without any diagnosed psychiatric
the interview. Of the interviewees, 275 (70.3%) were females and illness (n = 277) were taken into consideration, while excluding
164 (41.9%) were mothers of the disappeared person. They had a the responders with PGD or PTSD. The potential predictors for
mean age of 57.6 (S.D. = 14.8) years, with the youngest and oldest depression in the sample were initially screened using simple
being 18 and 89 years, respectively. At the time of their family logistic regression. The significance of the obtained coefficient (and
member’s disappearance, the interviewees ranged from being thus the unadjusted OR) was used in assessing the relationship of
just 2 years to 72 years in age (mean = 38.2, S.D. = 13.8). the predictor variable with the presence or absence of depression.
Variables under consideration included those related to the inter-
viewee, the person that had gone missing and the disappearance
Characteristics of the missing person
itself. Except for the age-related variables and duration since dis-
Of the 391 cases of disappearances, 248 (63.4%) were related to appearance, all other variables were categorical in nature.
civil conflicts in Sri Lanka, while the remainder were due to the All the factors except for age of the person that had gone missing
2004 Indian Ocean Tsunami. According to the year of disappear- were found to be significantly related to the interviewed family mem-
ance, 2004 (the year of the tsunami) had the highest number of ber having depression (Table 3). Some of the more salient points
disappearances. This was followed by the period around 1989, include the 19 times higher odds of having depression in those
when Sri Lanka faced a violent youth insurrection. Overall, with a past history of mental illness and 18 times higher odds for
75.2% of the disappeared individuals in the sample were male. those with a family history of mental illness. But, it must be stressed
Those that had gone missing in the tsunami however were mostly that these are values obtained without controlling for the other vari-
females (64.3%) while those who had gone missing during the ables. When the circumstance of the disappearance was related to a
civil conflict were almost all male (98.0%). The average age of civil conflict, the interviewees had 3.5 times the odds of suffering
the persons that had gone missing (at the time of disappearance) from depression than when it was related to the tsunami.
in this sample was 28.54 (S.D. = 15.67) years. When performing The unadjusted odds also showed that when the missing person
sub-analysis of age of the disappeared, based on the circumstance is a male, the responding family member was at a higher risk of
of the disappearance, it was seen that those related to civil conflict depression than when the missing person was female. On the other
were mostly restricted to the young adult age group while those hand, female responders were more likely to have depression than
related to the tsunami were much more widely spread. males. This is also depicted by the finding that mothers and wives
The death of 168 (43.0%) of the cases had been later confirmed of the disappeared were affected significantly more than the other
by the remains being found and identified as the missing person. family members of the disappeared. As interviewees’ relationship
Families of the remaining 223 (57.0%) in the study are yet to to the missing individual contained within itself the gender of the
receive any confirmation related to the status of their loved one. interviewee, the variable; gender of the interviewee, was omitted
While 50.3% (72) of those who had disappeared following the from subsequent multiple logistic regression analyses. Similarly,
tsunami were confirmed to have died, this was the case for only the variable that specified whether the death of the missing person
38.7% (96) of the disappearances related to civil conflicts. was confirmed or not was excluded since it was contained within
Among those that have not obtained confirmation of death; the variable interviewee’s belief about the status of the missing indi-
when inquired about their general belief about the present status vidual. Yet, the finding that when a disappeared person’s death is
of the loved one that had gone missing, about 44% of the intervie- not confirmed, it is associated with a higher depression rate among
wees were unsure if he or she had died or was still alive. Almost a their immediate family members should be highlighted.
similar proportion was confident that the person had died, while a To identify the independent variables associated with depres-
small number was living with the strong belief that their family sion, among family members of those who had gone missing, bin-
member was still alive somewhere (Table 1). ary logistic regression analysis was performed. We used the

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 4 Amila Isuru et al.

Table 1. Interviewee’s psychiatric diagnosis according to circumstance of disappearance of family member and status of death confirmation

Circumstance of disappearance

Tsunami Civil conflict Total

Confirmation of death of the Confirmation of death of the Confirmation of death of the

missing person missing person missing person

Psychiatric Not confirmed Death confirmed Not confirmed Death confirmed Not confirmed Death confirmed
diagnosis Frequency (%) Frequency (%) Frequency (%) Frequency (%) Frequency (%) Frequency (%)

Depression 5 (7.0) 3 (4.2) 34 (22.4) 7 (7.3) 39 (17.5) 10 (6.0)

PGD 16 (22.5) 6 (8.3) 34 (22.4) 6 (6.2) 50 (22.4) 12 (7.1)
PTSD 0 (0.0) 0 (0.0) 3 (2.0) 0 (0.0) 3 (1.3) 0 (0.0)
No psychiatric 50 (70.4) 63 (87.5) 81 (53.3) 83 (86.5) 131 (58.7) 146 (86.9)
diagnosis
Total 71 (100.0) 72 (100.0) 152 (100.0) 96 (100.0) 223 (100.0) 168 (100.0)

Table 2. General Health Questionnaire-30 score according to psychiatric diagnosis

Psychiatric diagnosis Number of cases Median Mean (S.D.) S.E. 95% CI

No morbidity 277 5.00 6.47 (5.43) 0.33 5.82–7.11

PGD 62 27.00 25.52 (6.22) 0.79 23.94–27.10
MDD 49 61.00 51.65 (24.18) 3.46 44.71–58.60
PTSD 3 39.00 40.00 (14.53) 8.39 3.92–76.08
Total 391 6.00 15.41 (18.51) 0.94 13.57–17.25

predictor variables mentioned above and the backward elimin- When considering unadjusted ORs, interviewee-related vari-
ation method to arrive at the final model. Only three variables ables of past history and family history of mental illness did not
turned out to be significant, and the final model with these vari- become statistically significant. Two variables related to the
ables (and the constant term) showed a good fit using the Hosmer missing person, gender and age at disappearance, were also non-
and Lemeshow test (χ2 = 10.51, p = 0.162). significant along with the variable: circumstance of disappearance.
The three variables that independently predicted depression in As in the case of MDD, family members of individuals that had
the responders of the study were: interviewee’s relationship to gone missing show a significantly higher rate of PGD when there
missing individual, family history of mental illness and intervie- has not been confirmation of death (Table 5).
wee’s belief about the status of the missing individual. Mothers When calculating independent predictors of PGD, binary logistic
and wives had significantly higher odds of depression relative to regression analysis with stepwise method was used. The final model
siblings and offspring of the disappeared persons. Fathers and had four variables (Table 6), showing an adequate model fit with
husbands were not at a significantly higher risk. Having a family the Hosmer and Lemeshow test (χ2 = 8.63, p = 0.374). The variables
history of mental illness placed the responders at almost 30 times identified as independent predictors of prolonged grief are: inter-
the odds of having depression compared with those that did not viewee’s relationship to the missing individual, circumstance of
report such a family history. Relative to those who had their loved disappearance, present age of interviewee and interviewee’s belief
one’s death confirmed following the disappearance, the family about the status of the missing family member. Mothers had signifi-
members that were unsure if the individual is living or not, had cantly higher odds of having PGD relative to siblings and offspring.
10.49 (95% CI 4.24–25.95) times greater odds of being diagnosed Fathers, wives, and husbands did not show a significant OR relative
with depression. If they were of the belief that the individual had to siblings and offspring. Further, older individuals were at higher
died following the disappearance, the OR comes down to 5.10 odds of showing PGD compared with younger ones. For each
(95% CI 1.98–13.16). Interestingly, if the belief is that the person year in increase of age, the odds of PGD increased by 5% (95%
is still alive, the adjusted odds for depression are not significantly CI 2% to 8%) with the other variables kept constant.
different from those that had confirmation of death (Table 4). When the disappearance was related to the tsunami, the family
members had 2.73 (95% CI 1.21–6.14) times higher odds of show-
ing PGD compared with when the disappearance was linked to
Prolonged grief disorder (PGD) and its predictors
civil conflict. It is interesting to note that odds of PGD were
The factors associated with PGD were assessed using those with higher when related to civil conflict when unadjusted for other
PGD (n = 62) and those without a psychiatric diagnosis (n = variables, even though being statistically non-significant. Yet, in
277), while excluding individuals with MDD and PTSD. The the final model, not only has this variable become significant,
same sets of variables used above for MDD were applied. but also, the order of impact had reversed.

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 Psychological Medicine 5

Table 3. Unadjusted ORs for the variables predicting depression among family members of the disappeared

Unadjusted Statistical
Variable OR 95% CI significance

Gender of interviewee (in relation to male)

Female 3.92 1.61–9.54 0.003
Interviewee’s relationship to missing individual (in relation to sibling or offspring) 0.001
Mother 9.36 2.76–31.80 <0.001
Father 2.38 0.46–12.34 0.300
Wife 10.63 2.83–39.93 <0.001
Husband 4.43 0.68–28.89 0.120
Age of interviewee at present 1.04 1.01–1.06 0.001
Age of the disappeared individual at the time of disappearance in years 1.03 1.01–1.05 0.011
Past history of mental illness (in relation to No)
Yes 19.19 3.75–98.14 <0.001
Family history of mental illness (in relation to No)
Yes 18.00 1.83–176.79 0.013
Gender of missing individual (in relation to Female)
Male 2.76 1.13–6.74 0.026
Age of the missing individual at the time of disappearance 0.99 0.97–1.01 0.391
Duration since disappearance 1.05 1.01–1.10 0.028
Circumstance of disappearance (in relation to tsunami)
Civil conflict 3.53 1.60–7.82 0.002
Confirmation of death (in relation to death having been confirmed)
Not confirmed 4.35 2.09–9.05 <0.001
Interviewee’s belief about the status of the missing individual (in relation to death having <0.001
been confirmed)
Firmly believe to be dead 3.10 1.31–7.33 0.010
Unsure if dead or alive 7.14 3.17–16.09 <0.001
Firmly believe to be living 1.62 0.33–8.00 0.552

Table 4. Adjusted ORs for the variables in the final model for depression

Adjusted Statistical
Variable OR 95% CI significance

Interviewee’s relationship to missing individual (in relation to sibling or offspring) <0.001

Mother 18.02 4.72–68.73 <0.001
Father 3.73 0.66–21.07 0.136
Wife 9.29 2.27–38.00 0.002
Husband 6.59 0.91–47.78 0.062
Family history of mental illness (in relation to No)
Yes 29.80 2.08–426.09 0.012
Interviewee’s belief about the status of the missing individual (in relation to death having been <0.001
confirmed)
Firmly believe to be dead 5.10 1.98–13.16 0.001
Unsure if dead or alive 10.49 4.24–25.95 <0.001
Firmly believe to be living 3.36 0.61–18.61 0.166
Constant 0.18 0.22

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 6 Amila Isuru et al.

Table 5. Unadjusted ORs for the variables predicting PGD among family members of the disappeared

Unadjusted Statistical
Variable OR 95% CI significance

Gender of interviewee (in relation to Male)

Female 2.54 1.26–5.09 0.009
Interviewee’s relationship to missing individual (in relation to sibling or offspring) 0.002
Mother 5.26 2.24–12.37 <0.001
Father 2.73 0.92–8.03 0.069
Wife 3.04 1.02–9.00 0.045
Husband 0.95 0.11–8.31 0.962
Age of interviewee at present 1.05 1.03–1.07 <0.001
Age of the disappeared individual at the time of disappearance in years 1.04 1.02–1.06 <0.001
Past history of mental illness (in relation to No)
Yes 4.58 0.63–33.19 0.132
Family history of mental illness (in relation to no)
Yes 4.52 0.28–73.34 0.288
Gender of missing individual (in relation to female)
Male 1.32 0.69–2.53 0.403
Age of the missing individual at the time of disappearance 0.99 0.97–1.00 0.143
Duration since disappearance 1.03 0.99–1.07 0.128
Circumstance of disappearance (in relation to tsunami)
Civil conflict 1.25 0.71–2.22 0.441
Confirmation of death (in relation to death having been confirmed)
Not confirmed 4.64 2.37–9.10 <0.001
Interviewee’s belief about the status of the missing individual (in relation to death having <0.001
been confirmed)
Firmly believe to be dead 2.40 1.04–5.53 0.041
Unsure if dead or alive 6.73 3.15–14.38 <0.001
Firmly believe to be living 7.44 2.87–19.29 <0.001

Table 6. Adjusted ORs for the variables in the final model for PGD

Unadjusted Statistical
Variable OR 95% CI significance

Interviewee’s relationship to missing individual (in relation to sibling or offspring) 0.010

Mother 4.69 1.65–13.29 0.004
Father 2.27 0.62–8.25 0.214
Wife 1.81 0.56–5.84 0.321
Husband 0.37 0.04–3.87 0.405
Age of interviewee at present 1.05 1.02–1.08 0.002
Circumstance of disappearance (in relation to civil conflict)
Tsunami 2.73 1.21–6.14 0.015
Interviewee’s belief about the status of the missing individual (in relation to death having <0.001
been confirmed)
Firmly believe to be dead 3.61 1.46–8.89 0.005
Unsure if dead or alive 13.98 5.78–33.78 <0.001
Firmly believe to be living 12.98 4.29–39.30 <0.001

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 Psychological Medicine 7

When considering the belief about the missing person being We are not sure whether the duration since the loss too had an
dead or not; compared with family members that have found the impact on MDD or PGD. The tsunami was in 2004 – around 12
remains, those who were ambivalent about the status had almost years prior to the interview while the civil conflict ranged from
14 times greater odds of having PGD. If they were strong believ- 1989 to 2009 and a large proportion had gone missing during
ers that the person was still alive, the odds of PGD are about 13 the early period, nearly 25 years before. Statistically we only
times higher. But, if the belief is that the missing loved one is found a marginal significance with a longer duration being asso-
dead, the OR dropped to 3.6. In contrast to MDD, all three ciated with MDD.
types of beliefs would put the person at a higher risk of PGD. MDD and PGD can be differentiated in terms of mood, course
However, it was considerably less when they believed that the of the illness, response to treatment and the degree of preoccupa-
person was dead. tion about the deceased (Tsai et al., 2018). The clinical interviews
conducted in our study established the three mutually exclusive
categories of MDD, PGD and PTSD. However there are research-
Discussion ers who raise concern about the overlapping symptoms in these
three disorders (Bryant, 2014).
Main findings
It is noteworthy that even after 20 years of their loved one gone
This study is one of few empirical studies that illustrate the greater missing only a little more than two-fifths of the interviewees
psychological morbidity in terms of MDD and PGD in the next of believed that their loved one was dead. The majority of the rest
kin who had not received the mortal remains of their loved one in were ambivalent and nearly one-sixth firmly believed they were liv-
comparison with those who subsequently found the body follow- ing. Thus the majority were living in limbo, constantly searching
ing their disappearance in tragic circumstances. The study also for the missing person and unable to achieve closure and move on.
highlights for the first time, the nature of the loved one’s belief
as to whether the missing person was dead or alive and the higher
psychological morbidity in relation to the ambivalent or still liv- Strengths and limitations
ing belief. The belief that the missing person was dead enabled This is the first study to compare the prevalence of MDD and
better outcomes and confirms the role of closure for families of PGD between family members of missing individuals and those
missing persons. who have confirmed the death by seeing the mortal remains of
Mothers and wives seem particularly vulnerable as are those their loved one. We also highlight the importance of the belief
with a history of mental disorder or a family history of mental dis- as to whether the missing person was dead or alive and the greater
order. This finding is consistent with the study done by Steve risk of MDD and PGD in those who were unsure. Another
et al., where the severity of depression and PTSD symptoms strength is that the psychiatric diagnoses were confirmed by a
was significantly higher in wives of missing husbands in Bosnia psychiatrist in each of the participants using DSM-5 criteria.
and Herzegovina (Powell et al., 2010). South Asian women espe- Purposive sampling due to the complicated and sensitive
cially have greater psychological morbidity as shown in a study nature of the study may be considered a weakness. Families
from Pakistan (Basharat et al., 2014). Living without a verification were often reluctant to reveal information due to safety issues
of the death of a loved one can be considered a mental health risk and the re-traumatisation involved in recalling suppressed painful
factor. First, families of missing individual have to endure differ- memories.
ent profiles of stressors compared with those with confirmed It should be noted that there may have been other losses and
death. Second, they do not have an opportunity to grieve in a stressful events which may have cumulatively affected the psycho-
funeral ritual with family and friends. Third, with the disappear- logical morbidity. These factors could be potential confounders
ance of the loved one, numerous complex emotional and psycho- and this study does not identify causation.
social issues arise and there is no social, religious or political There is also a possibility that the researcher could have been
structure in place to deliver the support the families of missing perceived as someone who could deliver assistance or compensa-
individuals’ need (Powell et al., 2010). tion to the interviewees. This could lead to exaggeration of the
Our findings in relation to whether the civil conflict or the tsu- impact of the disappearance. Some families were involved in
nami was more of a risk for morbidity, was inconclusive. More socio-political activities to determine the truth or seek justice
MDD is experienced by family members of those who went miss- with regard to the missing individual.
ing during the civil conflict in comparison with those who went
missing in the tsunami. As always, man-made trauma is more dif-
ficult to come to terms with unlike natural disasters which are Implications
often conceived as ‘acts of god’. Also the tsunami involved shared
In the context of wars, terrorism and natural disasters globally,
grief among communities and mass rituals to grieve the loss were
many families have to contend with the sad phenomena of their
conducted. These factors may have mitigated the impact of the
family members going ‘missing’ without confirmation of their
loss (Beder, 2002). In contrast, loss during the civil conflict is
death. The disappearance of the person leads to uncertainty and
more personal and isolated and the victim is often made to
inhibits the normal grieving process that occurs following the
seem guilty in the socio-political context.
death of a person. The families need to be supported by psycho-
However, the risk of PGD was higher in contrast to MDD in
logical services to prevent, identify early and treat the associated
the families who had lost their loved ones in the tsunami com-
psychological morbidity. The governments and greater civil society
pared with those who had gone missing during the civil conflict.
need to enable mechanisms that facilitate closure for these families.
It is noteworthy that we looked at the risks of PGD after having
excluded the persons with MDD. This shows that although the Acknowledgements. The authors are grateful to Tanya McLaven, Deputy
risk of MDD was less in those affected by the tsunami, they Librarian, University Hospital Leicester, UK for the comprehensive literature
were still at risk of PGD. review.

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 8 Amila Isuru et al.

Author contribution. All four authors were involved in conception and Crettol M and La Rosa A (2006) The missing and transitional justice: the right
design, or analysis and interpretation of data drafting the article or revising to know and the fight against impunity. International Review of the Red
it critically for important intellectual content and final approval of the version Cross 88, 355.
to be published. Foa E, Riggs D, Dancu C and Rothbaum B (1993) Reliability and validity of a
brief instrument for assessing post-traumatic stress disorder. Journal of
Conflict of interest. None. Traumatic Stress 6, 459–473.
Hollifield M, Hewage C, Gunawardena C, Kodituwakku P, Bopagoda K and
Ethical standards. The authors assert that all procedures contributing to
Weerarathnege K (2008) Symptoms and coping in Sri Lanka 20–21 months
this work comply with the ethical standards of the relevant national and insti- after the 2004 tsunami. British Journal of Psychiatry 192, 39–44.
tutional committees on human experimentation and with the Helsinki
ICRC (2016) Living with uncertainty needs of the families of missing persons in
Declaration of 1975, as revised in 2008. Sri Lanka. ICRC, viewed 11 November 2018. Available at http://www.icrc.
org/en/document/sri-lanka-families-missing-persons.
Author ORCIDs. Amila Isuru 0000-0003-3113-1209; S.N. Hewage, 0000-
0002-8459-4840; S.S.Williams, 0000-0001-7764-5550 Jackson C (2007) The General Health Questionnaire (GHQ). Occupational
Medicine 57, 79.
Kersting A, Brähler E, Glaesmer H and Wagner B (2011) Prevalence of com-
References plicated grief in a representative population-based sample. Journal of
Abeysena C, Jayawardana P and Peiris U (2012) Factor structure and reliabil- Affective Disorders 131, 339–343.
ity of the 30-item Sinhala version of General Health Questionnaire (GHQ). Nelson JA, Onwuegbuzie AJ, Wines LA and Frels RK (2013) The therapeutic
Asian Journal of Psychiatry 5, 150–153. interview process in qualitative research studies. The Qualitative Report 18,
American Psychiatric Association, DSM-5 Task Force (2013) Diagnostic and 1–17. Available at http://nsuworks.nova.edu/tqr/vol18/iss40/1.
Statistical Manual of Mental Disorders: DSM-5™, 5th Edn. Arlington, VA, Powell S, Butollo W and Hagl M (2010) Missing or killed. European
USA: American Psychiatric Publishing, Inc. http://dx.doi.org/10.1176/appi. Psychologist 15, 185–192.
books.97808904255962013. Prigerson HG (2004) Complicated grief. Bereavement Care 23, 38–40.
Baraković D, Avdibegović E and Sinanović O (2014) Posttraumatic stress dis- Rodrigo A, Kuruppuarachchi K and Pathmeswaran A (2015) Validation of
order in women with war missing family members. Psychiatria Danubina the Beck depression inventory II among the Sinhalese speaking population
26, 340–346. in Sri Lanka. Sri Lanka Journal of Psychiatry 6, 20. doi: 10.4038/
Basharat A, Zubair A and Mujeeb A (2014) Psychological distress and coping sljpsyc.v6i2.8076.
strategies among families of missing persons in Pakistan. Journal of the Steer RA, Ball R, Ranieri WF and Beck AT (1999) Dimensions of the Beck
Indian Academy of Applied Psychology 40, 211. depression inventory-II in clinically depressed outpatients. Journal of
Beder J (2002) Mourning the unfound: how we can help. Families in Society: Clinical Psychology 55, 117–128.
The Journal of Contemporary Social Services 83, 400–403. Tsai W‐I, Kuo S‐C, Wen F‐H, Prigerson HG and Tang ST (2018) Prolonged
Boelen P (2013) Symptoms of prolonged grief, depression, and adult separ- grief disorder and depression are distinct for caregivers across their first
ation anxiety: distinctiveness and correlates. Psychiatry Research 207, 68–72. bereavement year. Psycho‐Oncology 27, 1027–1034.
Boelen P, van de Schoot R, van den Hout M, de Keijser J and van den Bout J Wijesinghe C, Williams S, Kasturiratne A, Dolawaththa N, Wimalaratne P,
(2010) Prolonged grief disorder, depression, and posttraumatic stress disorder Wijewickrema B, Jayamanne S, Isbister G, Dawson A, Lalloo D and de
are distinguishable syndromes. Journal of Affective Disorders 125, 374–378. Silva H (2015) A randomized controlled trial of a brief intervention for
Boss P (2002) Ambiguous loss in families of the missing. The Lancet 360, 39–40. delayed psychological effects in snakebite victims. PLOS Neglected
Bryant RA (2014) Prolonged grief. Current Opinion in Psychiatry 27, 21–26. Tropical Diseases 9, e0003989.

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