1. 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

2. Introduction MSF has been present in Domiz Camp since 2012
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Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq
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3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Results
2 753 patient visits to the mental health clinic, amounting to consultations
44.7% < 15yrs; 6.9% < 5yrs
Median treatment length: 74 days (IQR 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

11. 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

12. Results Frequency per visit number: 1318 1023 645 502 304 212 146 8449
Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq

13. Results Frequency per visit number: 1541 1039 711 477 331 226 133 7151
Benjamin Wood, MSF, Description of outcomes from the integrated mental health programme in Domiz refugee camp, Iraq

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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