Our research examines the relationship between socio-demographic characteristics, social determinants, and mental health conditions in a heterogeneous group of patients without access to regular health services, who attended three humanitarian clinics in Germany in 2021.
The most prevalent MHCs in our study population were severe stress and adjustment disorders/PTSD followed by depression, alcohol-related disorders, anxiety disorders, somatoform and sleep disorders. When examining socio-demographic characteristics, our findings showed a high proportion of MHCs in patients originating from non-EU countries, and among refugees, undocumented migrants, persons with no health coverage and persons living in insecure housing.
A 2014 German health survey on twelve-month prevalence rates in the general population showed a high prevalence (37%) of MHCs in younger adults (18–34 years old) 19. This tends to align with our study findings, since the age group 20–39 years old was significantly associated with increased odds of MHCs.
Depression, anxiety, suicidal behaviour, and substance misuse have been reported as the predominant mental health diagnoses in young people20–22. Altered mental health in the young adult population has been linked to decreased social activities, low social support, increased family pressure, exposure to abuse and discrimination, strong feelings of social isolation, lack of financial reserve and multi-morbidity 22–24. Our results tend to confirm these findings, since a high proportion of young participants faced severe stress and adjustment disorders (19.2%), and reported feelings of depression (54.8%), a lack of interest in daily activities (55.1%) and a lack of psychological support when needed from a trusted friend or family member (44.3%) on most days of the week.
Migration
According to the International Organization for Migration (IOM) migrants in high-income countries suffer high rates of mental health conditions25. A migrant´s pre-migration peri-migration and post-migration exposures, including social, economic, environmental, political, and cultural context, are important factors determining their health status and health seeking behaviours 26. According to a randomized controlled trial on mental health services provided to migrants following settlement in high-income countries, refugees and migrants represent a priority population with unique mental needs25.
The majority (79.9%) of patients attending the humanitarian clinics for the first time in 2021 had a migrant background, with roughly half of them originating from EU countries other than Germany, and the other half from non-EU countries. Originating from a non-EU country was the only factor significantly associated with higher odds of suffering from a MHC in our analysis, although the significant association waned when adjusting for other socio-demographic factors. The “healthy migrant effect” is a well-known phenomenon and suggests that recent migrants tend to be healthier than the host country population due to a variety of pre-selection filters27. However, their health tends to worsen over time and eventually matches that of the general population in the host country26.
In our study we screened only a subgroup of the migrant population in Germany, which can be characterized as urban, and which eventually sought healthcare at a humanitarian clinic, and therefore, we cannot infer on prevalence in the overall background migrant population. However, we could show that among individuals with perceived health needs and who sought care at the clinics, a large share showed signs of mental health needs or were already diagnosed with a mental health condition. It can be assumed that in studies on migrants that are based on cross-sectional baseline screening, MHCs can often be overlooked, as they tend to surface at a later stage after arrival in a host country and clinical manifestations often wax and wane over time.
Despite Germany receiving immigrants for many decades, the German integration policy is generally considered exclusionist28. The entitlement to health services as a feature of basic human rights has been criticized as not fully respected in Germany29–31. One example of legislation that may be considered non-inclusive is the Asylum Seekers Benefit Act, which only entitles asylum seekers to health services in emergency cases or for acute and painful conditions during the first 18 months of their stay, which has received criticism from the United Nations (UN)32. Furthermore, Article 87 of the Residence Act [Aufenthaltsgesetz] requires every state institution in Germany to report migrants who cannot provide a valid residence permit, to the police or migration authorities. As a result, contact to official institutions for any purpose, including claiming basic human rights such as health care, can result in deportation and prevents undocumented migrants from seeking the services they require.
Housing Situation
The pathways linking a person’s living environment, housing and mental health are multidimensional and very complex33. The majority of the patients with MHCs in our study fell into a classification of homelessness. MHCs both precede and are a consequence of homelessness and persons experiencing homelessness (PEH) suffer a substantial burden of mental health conditions34,35. A systematic review by Ayano et al. reported a 6.5 times higher prevalence of depressive symptoms in PEH than in the general population36.
Homelessness is associated with experiences of previous domestic violence, sexual assault, childhood traumatic experiences and social isolation, which likely contribute to the high prevalence of MHCs in this population37. Furthermore, PEH often suffer high rates of physical co-morbidities, which may lead to deteriorating mental health36.
Health Care Insurance Coverage
A lack of healthcare insurance coverage may negatively affect health38,39. A 2015 report on health reforms in the United States shows that uninsured adults are far more likely to defer, renounce or not receive healthcare at all, as compared to individuals covered by insurance40. This can lead to a lack of, or late diagnosis of preventable or chronic conditions, which can worsen over time and result in a high risk of morbidity and mortality. Our study demonstrates that a large proportion of participants suffering from MHCs had no statutory or private health insurance. Similarly, a study documenting the role of insurance in healthcare access among persons with MHCs in 1999–2010 in the United States, reported that people with MHCs were more likely to be uninsured than people without MHCs.41
Despite the exclusionism that has characterized the German immigration policy over decades, regular immigrants, and their families – irrespective of their nationality – are entitled to membership in the statutory health insurance when they are employed or recipients of social welfare. However, many members of this subgroup do not exert their entitlements 18,28.
Barriers to Health Care Services
The most commonly reported barrier to accessing regular healthcare services in our study population was costs of health services, also among persons suffering from MHCs. Affordability of health services has been reported as one of the major barriers to access in previous studies undertaken in Europe, South Africa, and the US42–44. However, health insurance coverage is only one dimension in the barrier complex with regard to healthcare45,46.
Barriers can be conceptually grouped into 5 categories, which reflect the affordability, approachability, availability, acceptability, and appropriateness47–50. Our data covers in principle the categories affordability (cost) and approachability (bureaucracy, language). Our findings demonstrate that the majority of patients with MHCs were below the threshold poverty line (95.6%), reflected by “high healthcare costs” as the most frequently reported barrier. Furthermore, almost half of the patients (47.5%) required an interpreter which is provided by the services of the organization running the clinics, but which is mostly not well established in regular health services.
Mental health-related stigma is a multidimensional problem, which imposes a great burden on those affected42. Stigma plays an important role in influencing patients’ perceptions and, in some cases, can initiate or exacerbate mental health conditions51. Behavior can be distorted by cultural perceptions of illness and its management, resulting in variation between self-perceived and observed morbidity52,53. It can be assumed that access to mental health care is even more limited by perceptions of stigma and anticipated discrimination which may result in poor health-seeking behaviour.
Limitations
Several limitations must be taken into account when interpreting the results of this study. The setting of three humanitarian clinics and a mobile unit run by a single non-governmental organization in three major German cities is prone to selection bias. External validity may be hampered, for example, when extrapolation is intended towards people without access to regular health services in rural or non-metropolitan areas and to even more marginalized populations who do not seek healthcare services.
In addition, during the course of data collection, we cannot exclude a certain degree of social desirability bias when marginalized individuals talk to healthcare workers, about their living conditions for example. This may also have been the cause to missing data, which lead to changing denominators in the analyses. Moreover, patients are not systematically screened for MHCs, and not all clinics have a designated mental health professional making the diagnosis. The focus of consultations, especially at first visit, is also often on the patient's somatic complaints, and on trust building, and initial stabilization. MHCs are therefore probably more prevalent than what is documented by the healthcare professionals at the clinics.
Strengths
We were able to analyse a substantial dataset on a neglected and difficult to reach population in Germany, one that has limited access to healthcare services. We are convinced that even in the light of the stated limitations, our results are important for social and health science researchers as well as decision makers and agents of healthcare interventions, as we can provide baseline information on mental health needs in this particular population.