This study provides evidence that war-related loss of the father during childhood or adolescence uniquely contributes to distress and disability into adulthood over and above the experience of other war-related trauma. Results demonstrate that war survivors whose fathers had been killed during the war were significantly more likely to suffer from MDE, PTSD, and Panic Disorder as compared to non-bereaved war survivors. Accordingly, the majority of bereaved war survivors met criteria for either MDE or an anxiety disorder a full decade after the war. Additionally, one third of the bereaved participants met criteria for PGD while reporting that these symptoms caused persistent dysfunction in social, occupational, or other important areas of functioning. Among bereaved participants, the presence of PGD was associated with a higher prevalence rate of MDE or an anxiety disorder. Finally, survivors of war with PGD were significantly more likely to report current suicide risk than bereaved participants without PGD and to also report higher scores of somatic complaints and general health distress.
Given the lack of research on long-term effects of bereavement in childhood or adolescence as well as the lack of bereavement-related findings outside North America and Western Europe, the current study provides novel information on long-term sequelae of the violent death of the father during childhood or adolescence. The results are strengthened by the fact that both groups of participants were survivors of war and were recruited in exactly the same localities. Additional strengths of the study are that the interviewers were well trained with a relevant professional background and were familiar with the studied locations. Nevertheless, the study has a few limitations. Participants were recruited in only four municipalities and this might reduce the generalization of findings to other areas of war-related bereavement. Further, due to the cross-sectional format of the study, only point prevalence rates of the disorders were assessed and no definite conclusions on causal associations between the measured variables can be made. The reporting of traumatic experiences might have been influenced by recall bias with people with more current symptoms reporting more traumatic experiences 
. Additionally, we did not assess whether fathers were killed as combatants or as civilians and neither did we assess whether participants were exposed to the killing of their father. Future studies need to investigate whether the role of the father during the war and experience of the killing of the father impact levels of dysfunction and distress following parental loss. Bereaved and non-bereaved participants were recruited in different ways (i.e., using a list provided by the communal authorities vs. a random sampling procedure), which might have lead to higher rates of mental disorders among bereaved participants than in the sample using random sampling. Furthermore, all interviewers were female and thus not matched to the gender of participants, which might have influenced reporting of sexual abuse. However, sexual abuse is more likely to have occurred among women than men and female participants were in fact interviewed by female interviewers. Moreover, prior studies with survivors of war in Kosovo have also reported extremely low rates of sexual abuse 
indicating that report of sexual abuse might be strongly influenced by cultural stigma rather than gender of the interviewer. Future research needs to address these methodological approaches.
The results are consistent with other studies suggesting that war-related experiences can be associated with long-term psychiatric sequelae 
. A large-scale study with adults (mean age 39.4) conducted in Kosovo seven years after the war found a prevalence rate of MDE of 37.3% and a rate of PTSD of 18.2% 
. The prevalence rate of MDE was higher in the Priebe et al. study than in both groups of the current survey. However, the study by Priebe et al. revealed that younger survivors of war reported lower rates of MDE than older participants and this might explain our finding of a lower prevalence rate of MDE in our younger sample. The higher prevalence rate of PTSD in our study, also as compared to Priebe et al. (40% vs. 18.2%), and the prevalence rate of PGD of 34.6% indicate that war-related traumatic events in conjunction with the killing of the father during childhood or adolescence are more likely to be associated with PTSD and PGD than MDE. These high prevalence rates are consistent with another study conducted seven years after the war among bereaved survivors of the Kosovo war (mean age 40.6) 
. In this study by Morina et al., the prevalence rate of PTSD was 55% and that of PGD was 38.3%.
The fact that no participant reported any substance abuse disorder might appear surprising as research in other countries shows that people with a history of traumatic experiences report high rates of substance abuse disorders 
. Yet, prior research in Kosovo has reported very low prevalence rates for substance abuse disorders. In the survey by Priebe et al. 
, the prevalence rate for substance dependence or abuse was 0.9% and the rate for alcohol dependency or abuse was 1.8%. Alcohol is little consumed in the areas where we recruited study participants that are inhabited exclusively by Muslim Kosovars. The fact that no positive cases with any substance abuse disorder were reported might further be explained by the strong stigmatization of people with substance abuse or dependency due to both religious and cultural factors in Kosovo. Fear of stigmatization might have led some study participants to conceal their substance abuse or dependency. It remains for future studies to clarify this issue.
Apart from higher prevalence rates of mental disorders, bereaved participants reported significantly lower education and a significantly higher unemployment rate. Lower education might be a consequence of the killing of the father. It might be a direct consequence of the absence of the father and the resultant need to take care of the family, which would leave less time and energy for pursuing education. It might also be a result of emotional difficulties related to the violent loss of the father in conjunction with other war-related experiences. Additionally, loosing the father often meant loosing the main, and mostly the only, breadwinner in the family. Finally, it is also likely to be a consequence of the absence of a father figure to support the child in pursuing education. Unemployment, on the other hand, might partly be due to a lower education. It is also likely that the higher unemployment rate among the bereaved group was associated with higher scores of adverse mental health 
The syndrome of PGD proved to be a good indicator of vulnerable bereaved individuals. As compared to bereaved individuals without PGD, those with PGD reported significantly higher prevalence rates of either MDE or any anxiety disorder, suicide risk, and higher scores of somatic complaints as well as general health distress. Additionally, PGD was uniquely associated with higher suicide risk, general health distress, and somatic complaints after controlling for war-related traumatic events, socio-demographic variable, and MDE and PTSD. These data are consistent with the literature on PGD 
and thus support the proposal to include PGD in the next versions of the DSM and ICD.
In general, our findings demonstrate that the killing of the father during childhood and adolescence and the experience of other war-related events are associated with adverse health complaints and dysfunction during young adulthood. More importantly, while taking into account socio-demographic and war-related characteristics, the results yielded that war-related killing of the father can exacerbate the effects of other war-related traumatic experiences. The outcomes of the study highlight the need for long-term policies to meet the special mental health needs of bereaved war survivors.