Description and Predictive Factors of Individual
Outcomes in a Refugee Camp Based Mental Health
Intervention (Beirut, Lebanon)
Pierre Bastin1*, Mathieu Bastard2, Ludovic Rossel1, Pablo Melgar1, Alison Jones1, Annick Antierens1
1Me ´decins sans Frontie `res, Geneva, Switzerland, 2Epicentre, Paris, France
Background: There is little evidence on the effectiveness of services for the care of people with mental disorders among
refugee populations. Me ´decins sans Frontie `res (MSF) has established a mental health centre in a mixed urban-refugee
population in Beirut to respond to the significant burden of mental health problems. Patients received comprehensive care
through a multidisciplinary team. A cohort of people with common and severe mental disorders has been analysed
between December 2008 and June 2011 to evaluate individual outcomes of treatment in terms of functionality.
Methods: All patients diagnosed with mental disorders were included in the study. The Global Assessment of Functioning
(GAF) and the Self Reporting Questionnaire–20 items (SRQ 20) were used as tools for baseline assessment, monitoring and
evaluation of patients. Predictors of evolution of SRQ20 and GAF over visits were explored using a linear mixed model.
Results: Up to June 2011, 1144 patients were followed, 63.7% of them Lebanese, 31.8% Palestinians and 1.2% Iraqis.
Females represented 64.2% of the patient population. Mean age was 39.2 years (28.5–46.5). The most frequent primary
diagnoses were depressive disorders (28.8%), anxiety disorders (15.6%) and psychosis (11.5%). A lower baseline SRQ20
score/higher baseline GAF score (indicators of severity), being diagnosed with anxiety (compared to being diagnosed with
depression or psychosis) and a higher level of education were associated with better outcomes.
Discussion: In this MSF program, we observed a significant decrease of SRQ20 individual scores and a significant increase of
individual GAF scores. This corresponded to an improvement in the functionality of our patients. Analysis of the predictors
of this positive evolution indicates that we need to adapt our model for the more severe and less educated patients. It also
makes us reflect on the length of the individual follow-up. Further research could include a qualitative evaluation of the
intervention. Results of this study have been presented at the World Congress of the World Federation for Mental Health in
Cape Town, October 2011.
Citation: Bastin P, Bastard M, Rossel L, Melgar P, Jones A, et al. (2013) Description and Predictive Factors of Individual Outcomes in a Refugee Camp Based Mental
Health Intervention (Beirut, Lebanon). PLoS ONE 8(1): e54107. doi:10.1371/journal.pone.0054107
Editor: Richard Fielding, The University of Hong Kong, Hong Kong
Received June 8, 2012; Accepted December 10, 2012; Published January 17, 2013
Copyright: ? 2013 Bastin et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The authors have no support or funding to report.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: firstname.lastname@example.org
An estimated 450 million people worldwide have a mental
disorder, 85% of them living in low and middle income countries.
At any given time, approximately 10% of adults are experiencing a
current mental disorder, and 25% will develop one at some point
during their lifetime [1,2]. Effective treatments are available for a
range of mental disorders; medication and psychological inter-
ventions. In most countries, especially those with low- and middle-
income economies, there is an enormous gap between those who
need mental health care, on one hand, and those who receive care,
on the other hand. The causes of mental health disorders are
widespread and understandable. Difficult socio-economic condi-
tions are associated with significantly higher levels of mental health
problems and mental illness , especially in protracted refugee
A middle income country with a population of 4.35 million,
Lebanon has experienced multiple wars, internal conflicts, and a
long period of instability. Internal and external displacement has
occurred through the years and, today, among the refugee
population, around 400 000 are Palestinians. The country has a
heavily privatized and fragmented health system. Uncovered
medical needs are found in mental health , geriatric care, and
production and use. The context has the characteristics of middle
income countries; access to technicity (or technology), but with
important inequalities.In termsofprevalence ofmental disorders, a
national epidemiological psychiatric survey in the Lebanese
population had shown that 17% (SE: 1.6) of those interviewed met
criteria for at least one DSMIV/CIDI disorder . For the
Palestinian population, a prevalence study made in the camp of
Burj-el-Barajneh during the summer of 2010, revealed 29% (CI:
19%–39%) diagnosed with a mental disorder. The study also
showed important levels of associated disability, enormous treat-
PLOS ONE | www.plosone.org1January 2013 | Volume 8 | Issue 1 | e54107
ment gaps and unavailability of mental health services (unpublished
Me ´decins sans Frontie `res Switzerland (MSF) has established a
community mental health centre in Burj-el-Barajneh, working in
close collaboration with Primary Health Care (PHC) services for
Palestinian and Lebanese populations . The centre was opened
on December 18, 2008, aiming at a progressive integration of the
mental health activities inside United Nations Relief and Works
Agency (UNRWA) health services and a Palestinian Red Crescent
Society (PRCS) hospital.
There is little evidence on the effectiveness of services for care of
people with common and severe mental disorders among refugee
populations . The objective of this study was to describe the
individual outcomes of patients in terms of functionality and to
identify potential predictors of these outcomes.
The MSF project welcomes any adult (.18 years) in the
community regardless of nationality, religion or beliefs. Each
patient coming for treatment to the center was asked to answer the
questionnaires included in the patient file.
In Burj-el-Barajneh, a suburban area in South West Beirut,
there are Palestinians from the camp as well as Lebanese and other
refugees (Iraqi). We estimate a general population of 20 000
people living in the camp and 200 000 people around the camp
(Burj-el-Barajneh area).The centre is located just outside the camp.
Patients came to the center either by their own initiative or were
referred by family or friends (thanks to our Community Health
Workers network), another organisation, the UNRWA clinic, their
general practitioner or our social workers (SW). On arrival, patient
was first seen by a MSF psychiatric nurse who evaluated the
indication and decided whether the patient should go to the
psychologist first or directly to the psychiatrist. The nurse also
checked the general health status. MSF psychologist then decided
on the setting needed: individual, couple, family, group or art
therapy. Finally, MSF psychiatrist saw the patient, if necessary, for
confirmation of diagnosis and provision of psychotropic medica-
tion. All the diagnosis were done following the International
Classification of Diseases (ICD-10).Some speech and self-help
groups as well as relaxation sessions were also organised in the
centre, animated by MSF SW or Community health workers
(CHW). When indicated, a SW assessment and intervention was
performed (home visits). Patients were followed-up every 2 weeks
(sometimes weekly) by the psychologist and every month by the
psychiatrist. If needed, patients could also come to the center for
All patients coming to the centre, UNRWA clinic and PRCS
hospital between December 2008 and June 2011 were included in
At first visit and during follow-up consultations, two function-
ality questionnaires were passed. The first one was the Self
Reporting Questionnaire–20 items (SRQ 20), based on patient’s
statement. This instrument was designed by the World Health
Organization to screen for psychiatric disturbance in primary
health care settings, especially in developing countries . The
score ranges from 0 to 20, scoring 1 for a positive answer and 0 for
a negative answer. Examples of questions are: ‘‘Do you feel
nervous, tense or worried?’’, ‘‘Do you find it difficult to enjoy your
daily activities?’’, or ‘‘Has the thought of ending your life been on
your mind?’’ The second questionnaire was the Global Assessment
of Functioning (GAF) , based on clinical evaluation. This
instrument considers the client’s psychological, social, and
occupational functioning on a hypothetical continuum (1–100) of
mental health-illness, in intervals of 10. For example, the interval
61–70 means: ‘‘Some mild symptoms (e.g., depressed mood and
mild insomnia) OR some difficulty in social, occupational, or
school functioning (e.g. occasional truancy, or theft within the
household), but generally functioning pretty well, has some
meaningful interpersonal relationships’’. The GAF was routinely
evaluated by the psychologist at each consultation and the SRQ20
was performed monthly. Both scales have been translated in
Arabic and translated back in English.
Closing date of the database was June 30, 2011. Baseline
characteristics of the patients were recorded for all the patients
included in the study and for specific subgroups of the cohort.
Categorical variables were summarized using counts and percent-
ages, and continuous variables were summarized using median
and interquartile range (IQR).
We estimated the median evolution of SRQ20 and GAF over
time. Differences between scores at first visit and at last visit were
reported and tested using Wilcoxon rank sum test. We explored
potential predictors of SRQ20 and GAF scores using random-
linear mixed models. Factors included in univariate analysis were
age, gender, nationality, level of education, employment and
marital status, having access to several services (electricity, water,
heating), score at first consultation, diagnosis at first consultation,
medical coverage, personal and financial support, and period of
inclusion in the programme. Multivariate analysis was then
performed using a backward approach.
All analyses were performed with Stata 10 software (Stata
Corporation, College Station, TX). The threshold P-value to
include factors in an initial model was 0.4 and 0.05 for all other
This retrospective analysis was performed from an anonymized
database. All patients gave their oral consent before answering the
questionnaires which had been previously sent for approval to the
local political and religious authorities. The World Medical
Association’s Declaration of Helsinki was respected. This study
has met the Medecins Sans Frontieres’ Ethics Review Board-
approved criteria for analysis of routinely-collected program data.
A total of 1144 patients were included in the study. Baseline
characteristics of the patients are presented in Table 1. Among the
1144 patients, 729 (63.7%) were Lebanese, 364 (31.8%) were
Palestinians and 14 (1.2%) were Iraqi refugees. The proportion of
Palestinians included in our program increased from 26.5% for the
period December 2008 – May 2009 to 33.3% for the period
December 2010 – June 2011. Among the 1144 patients, 734 were
women (64.2%). The proportion of males included in our program
increased from 34.4% for the period December 2008 – May 2009
to 41.7% for the period June 2010 – November 2010.The median
age of all patients was 39 years [IQR 28.5–46.5]. The distribution
of inclusions in the programme was as follows: 151 patients have
been included for the period December 2008 – May 2009, 173 for
the period June 2009 – November 2009, 255 for the period
December 2009 – May 2010, 180 for the period June 2010 –
November 2010, and 385 for the period December 2010 – June
2011. About 57.3% of the patients were under 40 while 32.6%
Outcomes in a Refugee Mental Health Intervention
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belonged to the age category 41–60. Looking at the references:
46% were referred to the centre by family or neighbours, 12% by
another organization, 10.4% by our direct partner UNRWA,
9.8% from home visits and 6.1% by their medical doctor. In terms
of primary diagnosis, 28.8% of the patients were identified as
suffering from depression, 16% from anxiety and 12% from
psychosis. In Table 1, we also displayed baseline characteristics of
the patients included in the analysis of SRQ20 and GAF evolution.
A total of 526 patients (46%) had at least 2 measures of GAF and
38.5% had at least 2 measures for SRQ 20.There is no evidence
for strong differences in baseline characteristics between patients
included in the different analyses and the overall cohort.
Patients with at least 2 measures for SRQ20 were followed up
for a median of 8 months (IQR 3–16) and attended a median of 4
visits (IQR 2–7). The median SRQ20 score at baseline was 13
[IQR, 10–16]. A drastic decrease was observed directly after the
first visit and the SQR20 tended to stabilize at a median of 6 after
the fifth visit (Figure 1). The median SRQ20 score at last visit for
each patient was 7 [IQR 4–12] and was significantly lower than at
first visit (Wilcoxon test p,0.001).
We presented in Table 2 the factors associated with the
evolution of SRQ20 over time. A higher baseline score was
associated with a higher score over time while an older age was
associated with a lower score over time. Compared to patients
diagnosed with depression, those diagnosed with anxiety had a
lower SRQ20 score over time. Finally, a higher level of education
was also associated with a lower SRQ20 score over time.
Patients with at least 2 measures for GAF were followed up for a
median of 11 months (IQR 3–18) and attended a median of 5 visits
(IQR 3–9). The median GAF score at baseline was 6 [IQR, 5–6].
A small increase was observed during second and third visit before
stabilizing at a median of 7 (Figure 2). The median GAF score at
last visit for each patient was 6 [IQR 6–8] and was significantly
higher than at first visit (Wilcoxon test p,0.001). We have used a
non parametric test (the Wilcoxon rank sum test) to compare the
distribution of the GAF between baseline score and score at last
visit. This means that at baseline, only 25% of patients had a GAF
score $6, while at last visit, 75% of patients had a GAF score $6.
We presented in Table 3 the factors associated with the evolution
of GAF over time. Having a baseline GAF score $5, being
diagnosed with anxiety compared to depression, and having a
Table 1. Baseline characteristics of patients included in the Burj-el Barajneh cohort between December 2008 and June 2011.
At least two GAF
At least two SRQ20 measurements
Nationality, n (%)
Lebanese 729 (63.7)399 (75.8)331 (75.0)
Palestinian364 (31.8) 113 (21.5)97 (22.0)
Iraqi 14 (1.2)4 (0.8)3 (0.7)
Other 32 (2.8)10 (1.9)10 (2.3)
Missing 5 (0.4)0 (0.0)0 (0.0)
Gender, n (%)
Men 410 (35.8) 192 (36.5)126 (28.6)
Women734 (64.2) 334 (63.5) 315 (71.4)
Age (years), n (%)
Median [IQR] 39.2 [28.5–46.5]39.6 [30.5–48.2] 40.0 [30.6–48.4]
18–40 655 (57.3)273 (51.9)223 (50.6)
41–60 373 (32.6)201 (38.2) 173 (39.2)
.60 97 (8.5)44 (8.4)38 (8.6)
Missing 19 (1.6)8 (1.5)7 (1.6)
Reference, n (%)
Family526 (46.0)272 (51.7)218 (49.4)
NGO137 (12.0)58 (11.0)51 (11.6)
UNRWA119 (10.4)48 (9.1) 43 (9.8)
Home visit112 (9.8)21 (4.0) 18 (4.1)
GP 70 (6.1)44 (8.4)36 (8.2)
Other120 (10.5)61 (11.6)56 (12.6)
Missing60 (5.2)22 (4.2) 19 (4.3)
Diagnosis, n (%)
Depression329 (28.8)198 (37.6)207 (46.9)
Anxiety178 (15.6)114 (21.7) 117 (26.5)
Psychosis 132 (11.5) 91 (17.3)21 (4.8)
Other 215 (18.8)121 (23.0)93 (21.1)
Missing290 (25.3)2 (0.4)3 (0.7)
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higher level of education was significantly associated with a higher
GAF score over time. Patients diagnosed with psychosis had a
lower score GAF over time than those diagnosed with depression.
In this MSF program, we observed a decrease of SRQ20
individual scores and an increase of individual GAF scores. This
corresponded to an improvement in the functionality of our
patients, indicating the success of treatments.
Treating mental disorders as early as possible, holistically and
close to person’s home and community leads to the best health
outcomes . Primary care offers unparalled opportunities for
prevention of mental disorders and mental health promotion, for
family and community education, and for collaboration with other
We observed a progressive increase of inclusion over time,
proportionate to the acceptance and information about the centre,
thanks to ‘‘word of mouth’’ as well as the services’ promotion
made by our CHWs. Collaboration with other organizations
(including UNRWA) becomes relatively effective in referring
patients to the center and the camp’s clinics. The work performed
by the CHWs and SWs inside the patients’ homes also brought
patients to our services. Referrals from external doctors remained
Figure 1. Evolution of SRQ20 score over visits to the centre for patients included in the Burj-el Barajneh cohort between December
2008 and June 2011.
Table 2. Predictors of the evolution of SRQ20 scores over time for patients included in the Burj-el Barajneh cohort between
December 2008 and June 2011.
Predictors Adjusted coefficient* (95% CI)
Baseline SRQ20 score (1 unit increases)0.33 (0.26; 0.41)
Age per 10 unit increases (years)
20.46 (20.72; 2 0.20)
20.99 (21.75; 20.23)
20.15 (21.33; 1.02)
20.69 (22.27; 0.90)
20.86 (22.20; 0.48)
Level of education
21.85 (23.15; 20.54)
22.86 (24.22; 21.49)
*adjusted for gender, time of follow-up and period of inclusion.
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We observed a progressive increase in the proportion of males
coming to our services, as contacts with the religious authorities
Most of our patients were Lebanese, which is not surprising
given the centre’s location and the density of population in Burj-el-
Barajneh. We estimate that, even if a prevalence study were not
performed there, the needs and gaps regarding mental health
services would be almost identical (deprived area, with a lot of
displaced population) to those found inside the camp.
The proportion of Palestinians coming to the services has risen
while those services were progressively integrated in the camp
Evolutions of both scales can be considered as satisfying. As the
cut-off score for SRQ 20 was arbitrarily set at 7 (based on WHO
document  and other field observations), we could consider
our intervention brought most of the patients under this line.
Stabilization around 6 is, in this sense, a very good result.
After several visits we no longer observed an effect. This could
be the stabilization phase, corresponding to the maintenance
treatment of chronic patients, but this could also questions the
necessity to perform more than 6 to 8 consultations.
Being unable to test for all possible predictors, we used other
studies as a base to examine which predictors to explore . Our
intervention appears better adapted to patients suffering from
anxiety than to those with severe disorders like psychosis. The
baseline score is also a predictor of evolution over time tending to
show we do better with less severe cases. A big and progressive
effect was observed for the educational level as a predictor of a
favourable evolution. This leads us to think we should increase our
attention and adapt our interventions to severe mental disorders
(SMD) and less educated patients.
Patient file which included both scales was tested beforehand on
healthy volunteers. Those scales have been chosen in agreement
with the clinicians of the project. We are considering keeping only
one of the instruments for monitoring of future projects. We would
prefer to opt for SRQ even if it is not adapted to severe (psychotic)
patients, nor always supported to follow patients’ evolution (as a
monitoring tool). The narrow distribution of GAF (between
intervals 50 to 80) and the inter-rater problems of reliability create
more limitations in the use of GAF only. Another problem faced
here with the GAF is that we do not observe any further changes
after 3 visits.
Some colleagues from other MSF sections use 1–10 Likert
scales, complaint and functionality rating (patient and clinician
point of view), which are very practical, but with the disadvantage
of being not yet standardized tools .
Figure 2. Evolution of GAF score over visits to the centre for patients included in the Burj-el Barajneh cohort between December
2008 and June 2011.
Table 3. Predictors of the evolution of GAF scores over time
for patients included in the Burj-el Barajneh cohort between
December 2008 and June 2011.
Baseline GAF score
$5 0.54 (0.36; 0.72)
Anxiety 0.25 (0.01; 0.48)
Personality disorder0.00 (20.37; 0.38)
20.49 (20.76; 20.22)
Bipolar disorder 0.14 (20.24; 0.42)
Level of education
Primary0.50 (0.15; 0.85)
University0.71 (0.34; 1.08)
*adjusted for age, gender, time of follow-up and period of inclusion.
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For common mental disorders (CMD) there would be other Download full-text
possibilities such as the depression and anxiety stress scale (DASS)
while for psychosis we could consider using an adaption of the
positive and negative syndrome scale (PANSS) or the brief
psychiatric rating scale (BPRS). Actually we may have to use
different instruments for CMD and SMD.
Our study presents several limitations. First, a moderate
proportion of patients have comparative measures (38.5% for
SRQ20 and 46% for GAF). As in each cohort, we probably have a
selection bias. The patients remaining in the programme (and for
whom we have comparative measures) are the ones doing better.
We have tried to collect a lot of information through the patient
file on top of SRQ 20 and GAF (a questionnaire on health
behavior, the Self Functioning questionnaire with 12 items, the
Harvard Trauma Scale, and the Trauma Scale Questionnaire). It
is certainly one of the reasons why the questionnaires were not
always filled. From this experience we believe that the project
team’s efforts in collecting information can be sustained for a
limited period of time (pilot or research project) but that this
information should be limited to the minimum needed for effective
monitoring of a regular project and should also be timely analyzed
at field level.
The aim of this study was to describe individual outcomes of
patients and to identify potential predictors of these outcomes in a
refugee camp based mental health intervention. We believe that
the efficacy of our treatment model has been demonstrated by the
positive individual outcomes we got in terms of functionality.
Analysis of predictors of this positive evolution shows that we need
to adapt our model for the more severe and less educated patients.
It also makes us reflect on the length of the individual follow-up.
Those results must be taken into consideration in our other
interventions, with limitations due to the context. This study
provides evidence that SRQ20 can be used as a baseline and
monitoring tool but that the use of GAF for the same purpose is
A further and deeper analysis of the data collected would be
needed, especially regarding the link between socio-economic
determinants and patients’ outcomes. We do indeed consider
social determinants of mental health as predictors of mental health
conditions (in protracted refugee situations in general). Advocating
for better socio-economic conditions for the refugee populations is
also part of our work.
Further research could also include a qualitative evaluation of
Conceived and designed the experiments: PB LR. Performed the
experiments: PB PM AJ. Analyzed the data: PB MB LR. Contributed
reagents/materials/analysis tools: PB MB AA. Wrote the paper: PB MB
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