Research report War-related trauma exposure and multiple risk behaviors among school-going adolescents in Northern Uganda: The mediating role of depression symptoms James Okello a,b,n , Etheldreda Nakimuli-Mpungu a , Seggane Musisi a , Eric Broekaert c , Ilse Derluyn d a Department of Psychiatry, Makerere University College of Health Sciences, Centre for Children in Vulnerable Situations, Uganda b Gulu University, Department of Psychiatry, Gulu, Uganda c Department of Orthopedagogics, Ghent University, Belgium d Department of Social Welfare Studies, Centre for Children in Vulnerable Situations, Ghent University, Belgium article info Article history: Received 20 June 2013 Accepted 31 July 2013 Keywords: Trauma Depression Risk behavior War Adolescents abstract Background: The relationship between war-related trauma exposure, depressive symptoms and multiple risk behaviors among adolescents is less clear in sub-Saharan Africa. Methods: We analyzed data collected from a sample of school-going adolescents four years postwar. Participants completed interviews assessing various risk behaviors defined by the Youth Self Report (YSR) and a sexual risk behavior survey, and were screened for post-traumatic stress, anxiety and depression symptoms based on the Impact of Events Scale Revised (IESR) and Hopkins Symptom Checklist for Adolescents (HSCL-37A) respectively. Multivariate logistic regression was used to assess factors independently associated with multiple risk behaviors. The logistic regression model of Baron and Kenny (1986) was used to evaluate the mediating role of depression in the relationship between stressful war events and multiple risk behaviors. Results: Of 551 participants, 139 (25%) reported multiple (three or more) risk behaviors in the past year. In the multivariate analyses, depression symptoms remained uniquely associated with multiple risk behavior after adjusting for potential confounders including socio-demographic characteristics, war-related trauma exposure variables, anxiety and post-traumatic stress symptoms. In mediation analysis, depression symptoms mediated the associations between stressful war events and multiple risk behaviors. Limitations: The psychometric properties of the questionnaires used in this study are not well estab- lished in war affected African samples thus ethno cultural variation may decrease the validity of our measures. Conclusions: Adolescents with depression may be at a greater risk of increased engagement in multiple risk behaviors. Culturally sensitive and integrated interventions to treat and prevent depression among adolescents in post-conflict settings are urgently needed. & 2013 Elsevier B.V. All rights reserved. 1. Introduction Most studies of post-war adolescents have focused on estimat- ing prevalence rates of posttraumatic stress disorder (PTSD), depression, and anxiety symptoms (Amone-P'olak et al., 2007; Bayer et al., 2007; Klasen et al., 2010). More recently, researchers have started to investigate the association between war exposure and risk behaviors such as aggression, suicidality, and substance abuse and how these behaviors relate to intrafamilial adversity and war-related experiences (Klasen et al., 2010; Kolltveit et al., 2012; Panter-Brick et al., 2011; Schiff et al., 2012). For example, cross-sectional studies in Ugandan former child soldiers found a high rate of aggression (Weierstall et al., 2012; Klasen et al., 2010), with increased rates for those exposed to both war and intra- familial violence (Klasen et al., 2010). Similarly, a study among Isreali adolescents found exposure to recurrent threats was asso- ciated with high rates of self-reported aggression (Pat-Horenczyk et al., 2007). Other studies have documented substance abuse and risk-taking behaviors following exposure to war (Franic et al., 2011; Schiff et al., 2012). An increased likelihood of exposure to intrafamilial adversity in longstanding conflicts such as in Uganda and Afghanistan suggests that some children may be exposed to a high cumulative burden of Contents lists available at ScienceDirect journal homepage: www.elsevier.com/locate/jad Journal of Affective Disorders 0165-0327/$ - see front matter & 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jad.2013.07.030 n Corresponding author at: Gulu Regional Referral Mental health Unit, P.O. Box 160, Gulu, Uganda. Tel.: þ256 774 782166. E-mail address: drokellojames@gmail.com (J. Okello). Please cite this article as: Okello, J., et al., War-related trauma exposure and multiple risk behaviors among school-going adolescents in Northern.... Journal of Affective Disorders (2013), http://dx.doi.org/10.1016/j.jad.2013.07.030i Journal of Affective Disorders ∎ (∎∎∎∎) ∎∎∎–∎∎∎