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Mental disorders, disability and treatment gap in a protracted refugee setting

  • Augusto E. Llosa (a1), Zeina Ghantous (a2), Renato Souza (a3), Fabio Forgione (a2), Pierre Bastin (a2), Alison Jones (a2), Annick Antierens (a2), Andrei Slavuckij (a2) and Rebecca F. Grais (a1)...

Studies have shown high levels of distress and mental disorder among people living in refugee camps, yet none has confirmed diagnosis through clinical reappraisal.


To estimate the prevalence of mental disorders, related disability and treatment gap in adult refugees living in the Burj el-Barajneh camp.


Randomly selected participants were screened by household representative (n = 748) and individual (n = 315) interviews; clinical reappraisal was performed on a subset (n = 194) of 326 selected participants. Weighted prevalence estimates and 95% confidence intervals were calculated.


The prevalence of current mental disorders was 19.4% (95% CI 12.6–26.2); depression was the most common diagnosis (8.3%, 95% CI 4.4–12.2) and multiple diagnoses were common (42%) among the 88 persons with mental disorder. Lifetime prevalence of psychosis was 3.3% (95% CI 1.0–5.5). Mental disorders were associated with moderate to severe dysfunction (odds ratio = 8.8, 95% CI 4.5–17.4). The treatment gap was 96% (95% CI 92–100).


A range of mental disorders and associated disability are common in this long-term refugee setting. Combined with an important treatment gap, findings support the current consensus-based policy to prioritise availability of mental health treatment in refugee camps, especially for the most severe and disabling conditions.

Corresponding author
Dr Augusto Llosa, Department of Epidemiology and Population Health, Epicentre, 8 Rue Saint Sabin, Paris 75011, France. Email:
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See editorial, pp. 176–177, this issue.

The study was funded by Médecins Sans Frontières.

Declaration of interest


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Mental disorders, disability and treatment gap in a protracted refugee setting

  • Augusto E. Llosa (a1), Zeina Ghantous (a2), Renato Souza (a3), Fabio Forgione (a2), Pierre Bastin (a2), Alison Jones (a2), Annick Antierens (a2), Andrei Slavuckij (a2) and Rebecca F. Grais (a1)...
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Refugees' Mental Health, What Do We Really Know?

Mustafa Alachkar, Doctor
28 March 2014

I read with great interest Llosa et al's paper on mental disorders, disability and treatment gap in Burj el-Barajneh camp for Palestinian refugees in Lebanon.1The study provides a significant contribution to the limited literature available in the area of refugees' mental health and especially in settings where refugees have settled in their host environments for a longtime as is the case for the Palestinian refugees in Lebanon.

I welcome especially the focus on the treatment gap and the link thatthe paper makes between that and the cultural factors affecting how mentalhealth is perceived in the Arab society. These cultural factors, along with lack of trust amongst refugees in non-governmental organisations (NGOs) to deliver culturally sensitive healthcare might have contributed to the high non-participation rate.

The study shows that of 88 persons in phase 2 with a psychiatric diagnosis, 5 (6%) had received psychological or psychiatric care, corresponding to an adjusted treatment gap of 96%. It's unclear whether 'psychological or psychiatric care' was defined narrowly as care received by approved mental health professionals from within MSF or includes non-specific support received from general practitioners, community support programmes or religious figures. The treatment gap might therefore be lower if these available services were to be considered part of psychological or psychiatric care. Furthermore, the numbers on which the 96% treatment gap was based remains too small to detect a meaningful result.

Personality disorders were not assessed in the study and it was suggested that 'where present these conditions would coexist with assesseddisorders.' I believe that this assumption is not justified as, although comorbidity of personality disorder with axis I disorders is high, the evidence suggests that the prevalence of personality disorder is as high as 6% of the world population with no consistent variation across countries2 and 6.2% in Lebanon itself3 and MSF's own research show that the prevalence of personality disorder in Palestinian refugee camps in Lebanon is as high as 10% 4. Moreover, personality disorders are associated with significant morbidity and dysfunction and high costs to health care services. I believe therefore that excluding personality disorders from the study is a major limitation.

Another noteworthy point relates to the relatively low prevalence of PTSD in the study population. In a large meta-analysis, the prevalence of this condition was reported to be around 9% in refugees and 17.3% in humanitarian settings5 as opposed to 2.2% in the current study. This mightreflect reporting bias, but might also be related to the validity of the diagnosis of PTSD across different cultures.

With growing numbers of Syrian refugees in Lebanon, similar studies of the prevalence of mental disorders, especially trauma related psychological disorders, are desperately needed.

References:1 Llosa AE, Ghantous Z, Souza R, Forgione F, Bastin P, Jones A, et al. Mental disorders, disability and treatment gap in a protracted refugee settings. British Journal of Psychiatry 2014, 204: 208-213. 2 Tyrer P, Mulder R, Crawford M, Newton-Howes G, Simonsen Erik, Ndetei D,et al. Personality disorder: a new global perspective. World Psychiatry 2010; 9: 56-603 Huang Y, Kotov R, de Girolamo G, Preti A, Angermeyer M, Benjet C, et al.DSM-IV personality disorders in the WHO World Mental Health surveys. British Journal of Psychiatry 2009; 195: 46-53.4 Forgione F. Mental health in Palestinian camps in Lebanon, Forced Migration Review, 2012; 40, Refugee Studies Centre, University of Oxford.5 Tol WA, Barbui C, Galappatti A, Silove D, Betancourt TS, Souza R, et al.Mental health and psychosocial support in humanitarian settings: linking practice and research. Lancet; 2011; 378: 1581-91.

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Conflict of interest: None declared

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