Study site, period and sample
The night clinic of MMS provided emergency medical care in Moria camp from January to April 2018. During this period the camp population size fluctuated between 5,560 and 6,429 people.10 An anonymized database was provided by MMS, comprising routinely collected information on 1,206 clinical consultations with 937 unique visitors. For some patients, relevant data were missing, meaning that the final sample comprised 857 consultations from 635 unique patients.
Data
Apart from medical data (problem, diagnosis, and treatment), information had been documented on patients’ sex, age, country of origin, and length of stay in the camp at the time of consultation.
Categorization of raw medical data was done in retrospect by the first author of this article. ‘Acute mental health crisis’ was chosen as the indicator of an exacerbated mental health condition. The reason for investigating exacerbations rather than the actual disorders themselves (i.e., depression, anxiety, PTSD, psychosis, substance abuse) is threefold. First, the setting of the clinic (see Box 1) did not allow standard psychiatric interviewing. Second, few of the volunteer medical staff were qualified to adequately differentiate between the underlying psychiatric disorders in patients presenting an acute crisis. Lastly, the association between the presentation rate of acute mental health crises at the clinic and the incidence of such crises in the camp is likely to be stronger than the association between the presentation rate of general mental health problems at the clinic and the prevalence of such problems in the camp. To clarify, given the nature (emergency) and opening hours of the clinic, the larger part of patients with non-urgent mental health problems were expected to stay at their designated living space within the camp, whereas patients with serious suicide attempts, significant self-harm, and severe panic/agitation/dissociation/psychosis tended to be brought to the clinic by bystanders if they would not come on their own accord.
Case definition
‘Acute mental health crisis’ was operationalized as a concept encompassing three conditions: a) self-harm as constituted by a non-accidental self-inflicted wound, the majority being skin cutting; b) a suicide attempt as constituted by an action with suicidal intent, in which either the seriousness of the intent or the resulting injuries warranted immediate referral to (in-hospital) specialized care; c) a severe state of panic and/or agitation and/or dissociation and/or psychosis as constituted by anxiety, nervous agitation, undirected aggression, alienation or disturbed reality testing, causing disturbed behavior resistant to non-invasive treatment (i.e., adequate psychological approach, relaxation and grounding techniques, or/and oral psychotropic medication) and thus requiring intra-muscular psychotropic medication. The additional criterion ‘resistant to non-invasive treatment’ was added to differentiate between relatively mild or possibly self-limiting crises and more serious cases. E.g., three patients presenting with an acute psychosis who accepted oral medication were not included in the sample.
Data analysis
Main demographic and displacement characteristics were described, as well as a general overview of the mental health consultations. Logistic regression was conducted with duration of stay as an independent variable, and the manifestation of any of the conditions covered by this study’s case definition as dependent variables (value of one if present, zero otherwise). The regression also included country of origin as displacement characteristic and, as prevalence rates of mental health disorders vary with gender11 and are non-linear through individuals’ lifespan,12,13 also gender, age, and age squared as sociodemographic characteristics.