Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq Benjamin Wood Charité Universitätsmedizin Berlin & MSF Genève Ana-Maria Tijerino MSF Genève Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq Image courtesy of Pierre-Yves Bernard, MSF Media

Introduction MSF has been present in Domiz Camp since 2012 Image courtesy of theguardian.com Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq Image courtesy of bbc.com

Why integrate MH into PHC? Increase detection of mental health cases Make treatment more readily accessible Reduce stigma of MH patients Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq Image courtesy of Pierre-Yves Bernard, MSF Media

MH Integration Strategy Cases from PHC, maternity and other services Staff provide psychological first aid (PFA), counseling and brief psychotherapy for common mental health disorders Psychologist/counselor present 6 days/week at PHC clinic Medical team trained in PFA, screening, referring, and connecting with services. Referral network with DoH hospitals Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq Image courtesy of Pierre-Yves Bernard, MSF Media Trained staff (psychologists and counsellors) provide psychological first aid, counselling (when appropiate) and brief psychotherapy for common mental health disorders Community outreach strategy with active case finding of severe mental health disorders. Mental Health Promotion by community health workers. Group sessions for targeted groups eg. young single men, children with behavioural issues, pregnant women with depression risk, etc. Cases are detected at PHC consultations, maternity, and other medical services, as well as referred by other NGOs, the community outreach team, and later on, by same patients’ relatives, or by themselves. Presence of a psy/counselor at the PHC clinic 6 days per week. For emergency cases, medical team is trained in offering PFA, how to refer to hospital if necessary and how to connect with MH Services. Image courtesy of Pierre-Yves Bernard, MSF Media

MH Integration Strategy Community outreach strategy with active case finding of severe disorders Mental health promotion by community health workers Targeted group sessions Referrals by other NGOs, the community outreach team, patients’ relatives, self-referrals Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq Image courtesy of Pierre-Yves Bernard, MSF Media Trained staff (psychologists and counsellors) provide psychological first aid, counselling (when appropiate) and brief psychotherapy for common mental health disorders Community outreach strategy with active case finding of severe mental health disorders. Mental Health Promotion by community health workers. Group sessions for targeted groups eg. young single men, children with behavioural issues, pregnant women with depression risk, etc. Cases are detected at PHC consultations, maternity, and other medical services, as well as referred by other NGOs, the community outreach team, and later on, by same patients’ relatives, or by themselves. Presence of a psy/counselor at the PHC clinic 6 days per week. For emergency cases, medical team is trained in offering PFA, how to refer to hospital if necessary and how to connect with MH Services. Image courtesy of Pierre-Yves Bernard, MSF Media

Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq Image courtesy of Pierre-Yves Bernard, MSF Media

Aim Present the evolution of three functionality assessment scores Self-reporting Questionnaire (SRQ-20) Global Assessment of Functioning (GAF) Children’s Global Assessment Scale (CGAS) Determine predictive factors for these evolutions Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq

Methods Retrospective analysis of programme data collected 1/1/2013 to 30/6/2015 Patients scheduled visits every 7-15 days at mental health clinic Patients >15 years completed SRQ-20 Consultants completed GAF for patients >15 and CGAS for patients <15 Inclusion: at least two mental health clinic visits Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq Image courtesy of Pierre-Yves Bernard, MSF Media

Methods Stata 13 used to analyse data Evolution of median assessment scores tested using Wilcoxon rank-sum test & plotted according to visit number Multilevel mixed-effects linear regression model used to explore predictive factors This retrospective study met the criteria of the MSF Ethics Review Board for exemption from ethics review. Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq

Results 2 753 patient visits to the mental health clinic, amounting to 11 165 consultations 44.7% < 15yrs; 6.9% < 5yrs Median treatment length: 74 days (IQR 38-139 days; max 730 days) Diagnoses Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq *ICD-10 used as diagnostic classification

Results SRQ-20 = 6-point change GAF = 1-point change Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq SRQ-20 = 6-point change GAF = 1-point change CGAS = 2-point change

Results Frequency per visit number: 1318 1023 645 502 304 212 146 84 49 Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq

Results Frequency per visit number: 1541 1039 711 477 331 226 133 71 51 Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq

Results Frequency per visit number: 201 264 256 200 143 88 50 24 Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq

Top predictors of evolution Older age, poorer initial assessment scores, psychosis, and individual therapy were associated with poorer evolution of SRQ-20 and GAF scores Poorer initial assessment scores, autism, mental retardation and psychosis were associated with poorer evolution of CGAS scores. Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq

Top predictors of evolution SRQ-20 GAF Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq Adjusted for other predictors in table, as well as length of therapy * depression as comparison ** individial therapy as comparison Adjusted for other predictors in table, as well as length of therapy and date of first consultation * depression as comparison ** MSF community health worker as comparison *** per 1 unit incremental increase CGAS Adjusted for other predictors in table * Child behaviour disorder as comparison

Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq Image courtesy of Pierre-Yves Bernard, MSF Media

Limitations Functionality assessments need to be contextually validated as monitoring tools Lack of uniformity regarding when and how many times the assessments were completed Limited information collected about reasons for ending therapy Lack of important predictive factors Need for improved collection of precipitating factors Co-morbidities and multiple diagnoses not considered Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq 1. Rwanda 2011 – longitudinal factorial invariance, an important prerequisite for monitoring changes in severity over time; srq20 can be used to measure the effect of an intervention on mental health

Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq Image courtesy of Pierre-Yves Bernard, MSF Media

Conclusion Positive evolutions of functionality scores SRQ-20 = 6-point change GAF = 1-point change CGAS = 2-point change Could this be a portrayal of positive efficacy of the integrated mental health programme? Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq

Conclusion Severe cases and psychosis associated with poorer evolution of all three assessments Analysis also serves to strengthen Mental Health Monitoring Systems Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq