A Mental Health Profile of 900 Newly Arrived Refugees in Denmark Using ICD-10 Diagnoses

Round 1

Reviewer 1 Report

This manuscript addresses an important and under-research issue which has been caused by the refugee crisis in Europe. There are many merits of this study, such as a large sample size and high participation rate. However, this manuscript can be improved greatly if the following conceptual and methodological issues can be addressed or clarified.

1. More studies relevant to this study on the following topics should be reviewed: (a) Mental health of refugee and its demographic correlates; (2) comparisons of prevalence of mental health problems between refugee and general public; (3) Utilization of mental health service by refugee. Some studies in Discussion can be moved to Introduction as literature review.
2. It is better to divide the section “Materials and Methods” into several subsections, such as research design, measurement, and data collection, for easy reading. More details of the assessment tool should be described, such as the screening questionnaire for PTSD systems, the ICD-10 diagnosis and the UN geo scheme. In Line 108-109, it is indicated “If PTSD symptoms were severe, the refugee was referred directly to……” How to define severe PTSD symptoms? Is there any cut-off point for severe PTSD symptoms for the screening questionnaire for PTSD systems?
3. In Results, the presentation of findings seems a little bit messy. It would be better to combine section 3.1 “Diagnoses and region” and 3.4 “Differences within the diagnoses” to present the findings on regional differences on mental health symptoms and diagnosis.
4. What are the differences between psychiatric diagnosis and observational diagnosis? Some elaborations would be helpful.
5. The “attendance” needs more clarification. Does it mean attendance for receiving diagnosis or receiving mental health care/treatment after diagnosis? Inconsistencies were identified throughout the manuscript. In Line 150, “87% of the participants who attended care at the DOP were given a psychiatric diagnosis.” In Line 311-312, “In the study by Savin et al, 37% of the referred attended mental health services afterwards, whereas in the current study this was 89%”. It is also inconsistent with the statement that “we do not know if the participants finished a planned treatment regimen or dropped out”(Line343-344).
6. In acculturation research, it has been consistently shown that length of residence in host country is a significant factor related to adaption outcomes. Thus, it would be better if the authors could compare mental health symptoms and diagnosis between refugee group with difference length of residence in Denmark.
7. In Results, it would be better to present the x² result first, which is missing in the current presentation. In the Tables, percentage of each subgroups in total participants should be included for easy comparison. What does “DZ diagnosis” refer to in Table 4?
8. In Line 321-322, the “overrepresentation” and “underrepresentation” of the subgroups on what variables should be stated for clarity. No explanation of this finding was found.
9. In Line 335-336, more elaborations on the reasons of “cultural expression and handling of mental health problems” should be added to explain the findings.
10. English editing is needed for this manuscript.

Author Response

We would like to thank the reviewers for all their comments to the paper.

They have improved the manuscript, by making it clearer and more concise as well as develop and expand important results.

Please find our point-by-point response to each comment in the attached document.

Author Response File: Author Response.pdf

Reviewer 2 Report

This is an interesting study regarding screening for mental disorders in resettled refugees in Denmark.

Some additional information on the health care system entitlements for migrants and refugees in Denmark would be useful especially with regards to long-term treatment requirements as in the case of mental disorder diagnoses.

A short reference on how many refugees/migrants were in total resettled during the study period in Denmark would be useful to give a sense of magnitude of the study sample

Was family history of mental health illness considered in the analysis?

In Table 1 please add percentages next to the count of participants in brackets

What information was considered with regards to the basic demographic and personal history data of the study participants?

It would be interesting to see the distribution of the diagnosed refugees by sex and other variables of interest e.g. family status, number of children, employment history in addition to age

How do the authors explain the regional differences in the prevalence of mental health diagnoses in the study population? Some explanations presented in Lines 333-334 are very vague.

Lines 336-337 “In the analysis, we found no difference between the route of arrival and getting a psychiatric diagnosis. This shows that being a family reunified poses the same risk as having arrived as a refugee through an asylum centre or UNHCR”.

For this statement of no difference have the authors taken into account other variables in addition to the route of arrival? If so which? If not, I think the following statement of the “same risk” is poorly explained and should be rephrased.

Some editing in terms of language is necessary as in the following lines in the text:

…refugees often have other comorbidities which also 55 ASSOCIATE with higher prevalence line 56

WITH regards to age line 217

IN total line 258

Author Response

We would like to thank the reviewers for all their comments to the paper.

They have improved the manuscript, by making it clearer and more concise as well as develop and expand important results.

Please find our point-by-point response to each comment in the attached document

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

I am fine with the revision.

Author Response

Please see attachment 

Author Response File: Author Response.docx

Reviewer 2 Report

Thank you very much for addressing the comments. As a final touch, I would suggest to  include the variables for which information is available from the health assessment database in the Methods section i.e. age, gender, length of education, country of origin and route of arrival, as well as information from the interview (familiar dispositions, family status, number of children, employment history, religion, and ethnicity) clarifying this is missing for some participants and that it has not yet been entered into the
database. 

Also, I would suggest to the authors to include a remark in the Limitations section about the fact that family history of mental illness was not available for the study participants, as this is a potential confounder in the observed assications.

Author Response

Please see attachment