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Table of Contents
ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 1  |  Page : 13-22

Capturing the essential: Revising the mental health categories in UNHCR’s Refugee Health Information System


1 MD, PhD, Public Health Section, United Nations High Commissioner for Refugees, Geneva, Switzerland
2 MSc, PhD (cand.), Department of Population Health, London School of Hygiene & Tropical Medicine; Centre for Global Mental Health, London, UK
3 MD, MPH, Public Health Section, United Nations High Commissioner for Refugees, Geneva, Switzerland
4 PhD, MPH, Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA

Date of Web Publication28-Jun-2019

Correspondence Address:
Peter Ventevogel
PhD, Public Health Section, United Nations High Commissioner for Refugees, Rue de Montbrillant 94, 1202 Geneva
Switzerland
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INTV.INTV_66_18

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  Abstract 


The Refugee Health Information System (RHIS) for humanitarian settings was developed by the United Nations High Commissioner for Refugees (UNHCR) in 2004. As of 2009, it contained seven categories related to mental, neurological and substance use (MNS) conditions: epilepsy/seizure, alcohol/substance use disorder, mental retardation/intellectual disability, psychotic disorder, severe emotional disorder, medically unexplained somatic complaint and other psychological complaint. During a recent overhaul of the RHIS, the MNS categories were revisited. This article describes the revision process and provides insights into how and why changes were made. Two rounds of consultations involving 34 expert reviewers in humanitarian mental health led to nine case definitions for MNS conditions in the new integrated RHIS (iRHIS): epilepsy/seizure, alcohol/substance use disorder; intellectual disability/developmental disorder; psychotic disorder (including mania); delirium/dementia; depression or other emotional disorder; other emotional complaint; medically unexplained somatic complaint; and self-harm/suicide. The use of additional specifiers enables dedicated mental health professionals in humanitarian settings to document a more refined diagnosis with a total of 22 different categories that made the system compatible with the modules of the Mental Health Gap Action Programme, without additional complexity.



Key implications for practice

  • The new iRHIS contains nine broad categories for MNS problems, reflecting consensus among humanitarian mental health practitioners.
  • iRHIS allows health workers in refugee settings to more accurately classify patients with MNS problems.
  • Specialized mental health workers in refugee settings can use additional specifiers in iRHIS to categorise their patients more precisely.

Keywords: classification, health information system, monitoring, primary healthcare, refugees


How to cite this article:
Ventevogel P, Ryan GK, Kahi V, Kane JC. Capturing the essential: Revising the mental health categories in UNHCR’s Refugee Health Information System. Intervention 2019;17:13-22

How to cite this URL:
Ventevogel P, Ryan GK, Kahi V, Kane JC. Capturing the essential: Revising the mental health categories in UNHCR’s Refugee Health Information System. Intervention [serial online] 2019 [cited 2019 Nov 19];17:13-22. Available from: http://www.interventionjournal.org/text.asp?2019/17/1/13/255362




  Introduction Top


Worldwide, health facilities in more than 135 refugee camps use the Refugee Health Information System (RHIS) for primary healthcare. Development of this system by the United Nations High Commissioner for Refugees (UNHCR) and its partners started in 2004 and was prompted by the need for standardised data collection and reporting tools in refugee camps that could inform evidence-based policy formulation, surveillance and better management of health programmes for refugees (Haskew, Spiegel, Tomczyk, Cornier, & Hering, 2010). Humanitarian health programmes are often initiated in challenging and remote environments in response to sudden cross-border movements of large populations. Refugees and other displaced populations are unique groups with specific health needs that are induced or exacerbated by the emergency situation (Ager et al., 2014; Spiegel, Checchi, Colombo, & Paik, 2010).

With regard to mental health issues, the situation is particularly complex. Compared to host populations, refugees have greater mental health needs, with higher levels of mental, neurological and substance use (MNS) disorders and elevated levels of non-pathological reactive emotional distress (Silove, Ventevogel, & Rees, 2017; van Ommeren, Saxena, & Saraceno, 2005). Specialized human resources for mental health in emergency settings are scarce, which reinforces the need to integrate mental health services within existing general healthcare settings (Ventevogel, van Ommeren, Schilperoord, & Saxena, 2015; Weissbecker, Hanna, El Shazly, Gao, & Ventevogel, 2019). It is important to properly document how many and which kind of MNS conditions are identified and treated in refugee health settings. For the advancement of mental health services outside specialized facilities, it is necessary to collect routine data on mental health service use and diagnosis in general health facilities, something that few low and middle-income countries (LMICs) currently do (Lora, Lesage, Pathare, & Levav, 2017; Ryan, De Silva, Terver, Ochi, & Eaton, 2015). Therefore, in 2009, seven categories for MNS conditions [see [Table 1]] were added to the RHIS (https://his.unhcr.org) after a consultative process with the World Health Organization and experts in humanitarian mental health from non-governmental organisations. These categories were specifically developed to capture essential data necessary to monitor mental health conditions in refugee camps and other humanitarian settings.
Table 1 Mental, neurological, substance use disorders in the 2009 system

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These categories were purposely broadly defined so they could be used by non-specialists working in general health settings. Over the years, the seven categories have been used in refugee camps (Kane, Ventevogel, Spiegel, Bass, van Ommeren, & Tol, 2014) and have become the standard for mental health reporting in humanitarian settings in general; they have also been included in various widely used toolkits and manuals (International Medical Corps, 2018; United Nations High Commissioner for Refugees, 2013; World Health Organization & United Nations High Commissioner for Refugees, 2012, 2015).

In 2017 and 2018, the RHIS system was revised as it had various limitations that hampered the analysis of routine data to improve programming. During the revision process, the UNHCR’s Public Health Section decided to also evaluate whether the mental health categories needed to be adapted to enhance their utility, and make them more compatible with the Mental Health Gap Action Programme (mhGAP) of the World Health Organization (2008) that aims to reduce the treatment gap for MNS conditions. The main tool of the mhGAP is the intervention guide (World Health Organization, 2010, (2016)) that is widely used for capacity building of general health workers in identification and management of MNS disorders (Humayun, Haq, Khan, Azad, Khan, & Weissbecker, 2017; Keynejad, Dua, Barbui, & Thornicroft, 2018). UNHCR promotes the use of the mhGAP Humanitarian Intervention Guide (HIG), which is a version that is adapted for emergency contexts (Ventevogel et al., 2015; World Health Organization & United Nations High Commissioner for Refugees, 2015). Over the years, UNHCR has supported capacity building using the mhGAP-HIG,1 particularly in Africa, and has trained almost 1000 staff from its health partners in identifying and treating MNS disorders (Echeverri, Le Roy, Worku, & Ventevogel, 2018). However, the RHIS categories for MNS disorders were developed before the mhGAP intervention guide (IG) and HIG were published and hence did not correspond exactly with them, which some staff trained in mhGAP found confusing.

Although there was a clear need to adapt the RHIS categories to the mhGAP, UNHCR’s public health section was at the same time cognizant of the need to maintain a high level of consistency with the earlier case definitions to ensure that future data could be meaningfully compared with retrospective data to explore long-term patterns in service utilization and regional trends.

This article describes the revision process of the MNS categories in the new ‘integrated RHIS’ (iRHIS).2 It documents the main changes in the case definitions for MNS conditions and provides insights into why changes were made. As such, the article documents a critical advancement in refining the major mental health information system being used in humanitarian settings.


  Materials and methods Top


In 2015, UNHCR invited fifteen external experts in mental health in humanitarian settings to provide comments on the current seven mental health categories in the RHIS. These experts were chosen because of their familiarity with mental health programmes in refugee settings. The responses were anonymised (R1–R15) and ordered. Based on these responses, the Senior Mental Health Officer (PV) made a proposal for changes to the classification system. In February 2016, this proposal was then sent out to thirty-five reviewers (the fifteen experts from the first round plus twenty additional experts, representing the main partners for Mental Health and Psychosocial Support (MHPSS) of UNHCR and the agencies represented in the Inter-Agency Standing Committee (IASC) Reference Group for MHPSS in Emergencies. One reviewer did not respond due to time constraints. The final sample consisted of thirty-four expert reviewers. All these reviewers had experience in mental healthcare in humanitarian settings and came from diverse backgrounds (eighteen different nationalities, ten reviewers came from low and middle income countries (LMIC)) and represented a wide range of affiliations: United Nations organisations (4×), non-governmental organisations (12×), independent MHPSS consultants (10×), academics (6×) and other (2×).

The responses of the reviewers were anonymised and subsequently manually coded by two independent coders (GR and JK) who were blind to the identity of the respondents. Upon completion, the two coders compared their coding and resolved all disagreements without further need for resolution by a third coder. For each of the seven MNS categories covered in the proposal, responses were entered into a matrix divided into three columns: ‘agree with proposed category and wording’, ‘agree with proposed category but revise wording’ and ‘revise proposed category and wording’. This allowed the UNHCR Senior Mental Health Officer to take into consideration the level of agreement among reviewers, as well as their specific recommendations on the revised proposal for each MNS category. The revised proposal was discussed with the health information specialists in the Public Health Section of UNHCR to ensure consistency with the overall revision process of the iRHIS. See [Figure 1] for a flow chart of the revision process.
Figure 1 Flow chart of the revision process

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  Description of major changes Top


The new iRHIS has several new features. First, data can be entered through either tablets, computers or android phones and is stored in the cloud. Second, it allows to select multiple categories for a single patient at a single consultation to register comorbidity. This is an important feature because despite the high level of co-occurrence of various MNS and physical disorders, routine health information systems (HIS) in LMIC are not able to capture comorbidity (Kane et al., 2018). Third, the new iRHIS makes it possible to differentiate between new cases and revisits. Fourth, UNHCR also revised the age categories to report diseases in line with the practice of many Ministries of Health in refugee hosting countries. Earlier, UNHCR used to segregate its data into under-five and over five categories, in addition to gender information. In the new revisions, additional age categories were added including under five, five to seventeen years, eighteen to fifty-nine and over sixty years. In addition to these changes, there were also changes related to the use of new technology. For example, new iRHIS allows data entry for individual cases with aggregation/reporting done electronically. To improve action by front-line clinicians using modern technologies, the new system can automatically generate alerts and has a simple interactive dashboard for information analytics to assist decision-making by local healthcare providers, who are frequently left out of the data management loop.

Also new in the iRHIS are case definitions for MNS with optional specifiers that can be used by specialists, such as dedicated mental health workers. For example, the category ‘psychotic disorder (including mania)’ can be used by general health workers, whereas dedicated mental health workers who need more sophisticated sub-categorisation can add specifiers for variants such as acute psychosis, chronic psychosis or manic psychosis. The option to add specifiers is open only to healthcare staff with a more specialized training in mental health, such as psychiatric nurses, psychiatric clinical officers or others who work in a dedicated mental health outpatient unit. This allows providers to make specific diagnoses that are commensurate with their own training, which will improve both data quality and patient care.

The new system includes a major technological change from the old technology that worked with paper-based tally sheets that were manually entered in a Microsoft Excel-based data file that was subsequently uploaded for compilation and analysis at central level. The new system is much more user-friendly: the health provider can directly enter data (online or offline) using tablets or personal computers with cloud-based data storage and analysis. Paper data collection will initially be retained as a back-up, with aggregate data entry possible into the application. By using modern technology, UNHCR and its partners envisage to improve data accuracy, timeliness, data analysis which will ultimately improve evidence-based decision-making in humanitarian emergencies.


  Results of the review process for MNS categories Top


This section describes the new case definitions and presents the rationale for the changes that were made.

Epilepsy/seizure

In many LMICs, particularly in sub-Saharan Africa, care for people with epilepsy constitutes an important part of the work in the mental health sector (Birbeck, 2010). Epilepsy is one of the most often diagnosed MNS disorders in LMICs, and in African refugee settings often forms the single largest group of patients in MNS programmes (Kane et al., 2014; Mateen, Carone, Haskew, & Spiegel, 2012). The ‘old’ case definition in the RHIS 2009 for ‘epilepsy/seizures’ was

‘A person with epilepsy has at least two episodes of seizures not provoked by any apparent cause such as fever, infection, injury or alcohol withdrawal. These episodes are characterized by loss of consciousness with shaking of the limbs and sometimes associated with physical injuries, bowel/bladder incontinence and tongue biting’.

During revisions, four reviewers suggested a total of four revisions. One reviewer suggested differentiation between ‘convulsive seizures’ and ‘epilepsy’. However, there is no clear algorithm for different forms of epilepsy in the mhGAP IG, HIG and the IG-2.0. We considered adding specifiers: one for the most commonly diagnosed form of epilepsy (generalized epilepsy with tonic–clonic seizures) and another for all other forms of epilepsy including localization-related (focal or partial) epilepsy and ‘absences’. Ultimately, based on consultation with WHO’s Department of Mental Health and Substance Abuse, the decision was made not to add specifiers for epilepsy because of the limited diagnostic and therapeutic utility of such distinctions for healthcare staff who are not specialized in neurology.

Two reviewers suggested adding more common symptoms such as presence of frothing. However, frothing is not considered a defining symptom of an epileptic seizure and was therefore not included. Two other reviewers suggested distinguishing clearly between epilepsy and conversion/dissociative disorder. Distinguishing between epilepsy and pseudo-seizure is very important in clinical practice, and thus, a sentence was added in the case-definition.

The new case definition is shown in [Table 2].
Table 2 iRHIS 2018 case definition: epilepsy/seizures

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Alcohol or other substance use disorder

The case definition in the RHIS 2009 for ‘alcohol or other substance use disorder’ was:

‘A person with this disorder seeks to consume alcohol or other addictive substances and has difficulties controlling consumption. Personal relationships, work performance and physical health often deteriorate. The person continues consuming alcohol or other addictive substances despite these problems’.

In the revision rounds, five reviewers suggested five revisions. Two reviewers suggested the need to differentiate between alcohol and other substances. This suggestion was adopted by adding specifiers for different substances, which will allow for a more detailed description of people with substance use disorder and their treatment. The suggestion to include locally appropriate examples of commonly abused substances in the case definition was accepted by adding a specifier for ‘other’ that can be locally defined. However, a global health information system cannot include specific local terms. Relevant local terms for substances of abuse should be discussed during the training of health workers. Given the high level of benzodiazepine abuse and other prescription drugs, a specifier for this group was added.

This led to a new case definition for ‘alcohol or other substance use disorder’ [see [Table 3]].
Table 3 iRHIS 2018 case definition: alcohol or other substance use disorder

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Intellectual disability and developmental disorder

The case definition in the RHIS 2009 for ‘intellectual disability’ was:

The person has very low intelligence, causing problems in daily living. As a child, this person is slow in learning to speak. As an adult, the person can work if tasks are simple. Rarely will this person be able to live independently or look after oneself and/or children without support from others. When severe, the person may have difficulties speaking and understanding others and may require constant assistance’.

This category prompted eighteen suggestions by a total of twenty-one reviewers. According to multiple reviewers, the term developmental disorders should be made clear in the title of the category. A strong argument is that developmental disorders such as autism are not necessarily accompanied by intellectual impairments. To allow for a better documentation of developmental disorders in emergency settings, specifiers were added for specialized health workers to differentiate between ‘intellectual disability’ and ‘other developmental disorder including autism’.

The suggestion to add hyperactivity in this category was rejected because hyperactivity has a profoundly different symptomatology and aetiology than developmental disorder and can better be classified in ‘psychological complaint’. The suggestion to add a separate category for ‘childhood and adolescent disorders’ was not adopted because developmental disorders and intellectual disability are not limited to children and adolescents. Moreover, children and adolescents with depression should be categorized in the appropriate categories and not grouped together as ‘child and adolescent mental disorder’. Suggestions to use specialist terms such as ‘pervasive developmental disorders’ or ‘autism spectrum disorders’ were not followed, as the framework must be easy to use by non-specialists.

The revision process led to a new case definition for ‘intellectual disability and developmental disorders’ as shown in [Table 4].
Table 4 iRHIS 2018 case definition: intellectual disability and developmental disorders

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Psychotic disorder (including mania)

The case definition in the RHIS 2009 for ‘psychotic disorder (including mania)’ was:

The person may hear or see things that are not there or strongly believe things that are not true. They may talk to themselves, their speech may be confused or incoherent, and their appearance unusual. They may neglect themselves. Alternatively, they may go through periods of being extremely happy, irritable, energetic, talkative, and reckless. The person’s behaviour is considered “crazy”/highly bizarre by other people from the same culture. This category includes acute psychosis, chronic psychosis, mania and delirium’.

Eleven reviewers proposed a total of ten revisions in two revision rounds. One proposal was to limit this category to non-affective psychosis and put all bipolar disorders under severe emotional disorders. To keep consistency with the mhGAP HIG classification, this suggestion was not accepted. In clinical presentation, manic states and non-affective psychotic states are often difficult to distinguish for non-specialized health workers. For dedicated mental health workers, a specifier was added for ‘bipolar disorder (mania)’. For dedicated mental health workers, it is also relevant to differentiate between various psychotic syndromes, and hence, specifiers were added for acute and chronic psychosis (with a duration of psychotic symptoms of three months as the cut-off point in accordance with mhGAP IG). See [Table 5] for the final case definition of ‘psychotic disorder (including bipolar disorder)’.
Table 5 iRHIS 2018 case definition: psychotic disorder (including bipolar disorder)

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In the revision rounds, there was discussion as to whether ‘delirium’ should be classified under ‘psychotic disorder’, which was the case in the RHIS 2009. Several reviewers suggested combining ‘delirium’ with ‘dementia’ in a separate category. This suggestion was accepted [see [Table 6]].
Table 6 iRHIS 2018 case definition: dementia or delirium

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Dementia or delirium

This category did not exist in the 2009 version of RHIS. Given the increased global relevance of dementia, particularly in middle-income countries, and its inclusion in mhGAP, it is logical to add this category. There would be two ways to do this: (1) to add a separate category, or (2) to add it to the definition of ‘psychotic disorder including mania’, which would then have to be renamed as ‘severe mental disorders including psychosis, mania and dementia’. As the treatment of psychotic disorders is fundamentally different from that of dementia, its inclusion in the psychosis category may have caused confusion and even led to the use of antipsychotics in dementia, which is usually not recommended.

In round two, various reviewers made suggestions to simplify the definition, emphasising diagnoses based on interviews by non-specialists, such as not recognising people they know, getting lost on a familiar route, getting confused with time/dates.

There were diverging opinions about whether to merge ‘dementia’ with ‘delirium’ (a brief and self-limiting condition, as opposed to dementia, which is slow but progressive). However, by adding a specifier specialists would be able to classify them separately. See [Table 6] for the case definition of the new iRHIS category ‘dementia or delirium’.

Depression or other emotional disorder

The case definition in the RHIS 2009 for ‘severe emotional disorder, including moderate-severe depression’ was:

This person’s daily normal functioning is markedly impaired for more than two weeks due to (a) overwhelming sadness/apathy and/or (b) exaggerated, uncontrollable anxiety/fear. Personal relationships, appetite, sleep and concentration are often affected. The person may complain of severe fatigue and be socially withdrawn, often staying in bed for much of the day. Suicidal thinking is common. This category includes people with moderate-severe depression and disabling forms of anxiety disorders and posttraumatic stress disorder (characterized by re-experiencing, avoidance and hyper-arousal). Presentations of milder forms of these disorders are classified as ‘other psychological complaint’.

This category prompted a wide range of diverging suggestions: five suggestions by twelve reviewers in round one and sixteen suggestions by twenty-eight reviewers in round two. The category is transdiagnostic (covering various disorders that in professional classification systems such as the International Classification of Diseases (ICD) and Diagnostic and Statistical Manual (DSM) are kept apart, such as depression, posttraumatic stress disorder and anxiety disorders), and it has a severity criterion which excludes the milder variants of these disorders. This last element is important because in acute humanitarian emergencies many people have adaptive and transient emotional symptoms − related to loss, grief and acute stress factors − that should not be confounded with a frank mental disorder (Cavallera, Jones, Weisbecker, & Ventevogel, 2019; Silove et al., 2017). In round one, six reviewers explicitly expressed that they wanted one comprehensive category that included depression, anxiety and posttraumatic stress disorder (PTSD), because these conditions often co-occur and may be difficult to distinguish for primary care providers, whereas treatment principles in primary care are largely similar. Four reviewers in round one expressed the opposite sentiment and proposed to create separate categories for depression and another for anxiety and/or stress-related disorders. Two reviewers proposed to include bipolar disorder in this category. Three reviewers suggested to include self-harm and suicide under ‘Severe emotional disorders’. In the proposal that was put forward to round two, a single category for emotional disorder was retained.

Seven reviewers in round two suggested creating a separate category for depression and consequently another for different emotional disorders. The advantage is that this would be consistent with the modules in mhGAP IG and HIG. This suggestion was not adopted because it may be difficult for primary care clinicians to make a distinction between the various common mental disorders that often have overlapping symptom presentations. Two reviewers suggested to use the term ‘common mental disorders’, as opposed to ‘severe mental disorders’ (psychosis, bipolar disorder), as a concept to refer to mild and moderate forms of depression, anxiety and stress-related disorders. However, the term ‘common mental disorders’ causes confusion in many settings and is not generally accepted. We, therefore, prefer the more specific term ‘emotional disorders’.

The category was reworded into ‘moderate-severe emotional disorder’ instead of ‘severe emotional disorder’. This makes the case definition more compatible with the module for depression in mhGAP (that includes moderate-to-severe depression). The phrasing of ‘disabling anxiety’ was changed to ‘severe anxiety’.

In the specifiers, detailed information about depression and posttraumatic stress disorder was given in line with the diagnostic criteria from the mhGAP modules. A separate category for suicide attempt/self-harm was created (see below) that can be used in addition to the other categories. See [Table 7] for the iRHIS case definition of ‘moderate-severe emotional disorder/depression’.
Table 7 iRHIS 2018 case definition: moderate–severe emotional disorder/depression

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Other psychological complaint

The RHIS 2009 contained the following case definition for ‘other psychological complaint’:

‘This category covers complaints related to emotions (e.g., depressed mood, anxiety), thoughts (e.g., ruminating, poor concentration) or behaviour (e.g., inactivity, aggression, avoidance)’.

‘The person tends to be able to function in most day-to-day, normal activities. The complaint may be a symptom of a less severe emotional disorder (for example mild forms of depression, of anxiety disorder or of posttraumatic stress disorder) or may represent normal distress (i.e., no disorder). Inclusion criteria: This category should only be applied if (a) if the person is requesting help for the complaint and (b) if the person is not positive for any of the above five categories’.

In round one, only three out of fifteen reviewers explicitly wanted to keep the category as it is. One reviewer referred to the study by Kane et al. (2014) that found that in ninety refugee camps, these types of visits accounted for 9.6% of all visits. The majority of reviewers (nine) proposed to delete the category. Several reviewers proposed to merge it with ‘other psychological complaints’.

For round two, a proposal was put forward that merged all ‘other emotional complaints’ with ‘unexplained somatic complaints’ into a new category, ‘mild emotional complaint’, that would cover sub-threshold complaints related to emotions (e.g. depressed mood, anxiety, fear), thoughts (e.g. ruminating, poor concentration) behaviour (e.g. inactivity, aggression, avoidance), and any somatic/physical complaint that does not have an apparent organic cause. In round two, only eight expert reviewers agreed with this new definition, and six proposed substantial revisions, whereas eleven disagreed with the new wording. There were great objections to the term ‘mild emotional disorders/complaints’, because grief and acute stress, though not pathological, are certainly not necessarily perceived as ‘mild’. Others suggested that dissociative conditions should be a specifier given the high prevalence of such problems in many humanitarian settings (de Jong & Reis, 2013; van Duijl, Nijenhuis, Komproe, Gernaat, & de Jong, 2010; van Ommeren et al., 2001).

Ultimately two separate categories were maintained, as they were in the 2009 RHIS: one for ‘other psychological complaint’ and one for ‘medically unexplained somatic complaint’ (see below). In the case definition for ‘other psychological complaint’, explicit reference was made to the categories in the mhGAP HIG modules that would be included in this category, such as acute stress reactions and grief reactions. Both can be normal reactions to overwhelming circumstances and events, whereas they can cause great suffering. Explicit reference was also made to other psychological complaints such as dissociation and behavioural problems. Correspondingly, four specifiers were made for dedicated mental health workers (see [Table 8]).
Table 8 iRHIS 2018 case definition: other psychological complaint

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Medically unexplained somatic complaint

In the 2009 version of the RHIS, the category ‘medically unexplained somatic complaint’ was defined as follows:

The category covers any somatic/physical complaint that does not have an apparent organic cause. Inclusion criteria: This category should only be applied (a) after conducting necessary physical examinations, (b) if the person is not positive for any of the above six categories and (c) if the person is requesting help for the complaint’.

As discussed above, this category was retained (see [Table 9]).
Table 9 iRHIS 2018 case definition: medically unexplained somatic complaint

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Self-harm (including suicide attempt)

This category did not exist in the 2009 version of RHIS. Three reviewers commented ‘suicidality’ should be added as a specifier and another commented that ‘suicide/self-harm’ should be a separate category. From various refugee operations such as in Thailand, Nepal and Jordan, UNHCR received requests to register suicide attempts and self-harm in the RHIS. Given the potentially lethal consequences and the huge psychosocial consequences for the person, family and helpers, it is important to monitor the incidence of such events. Moreover, suicide is one of the two specific mental health indicators in the sustainable development goals (United Nations General Assembly, 2015), which makes it even more important to collect data on suicide and suicide attempts in humanitarian settings. There are several ways to do this, for example by adding categories for self-harm and suicide attempts (with ‘intent to die’ as the differentiating criterion). In practice, it is not always easy to differentiate. The mhGAP IG 2.0 and HIG have one single module for self-harm/suicide, and the definition used in the IG and HIG is that ‘self-harm is intentional self-inflicted poisoning or injury to oneself, which may or may not have a fatal intent or outcome’. Therefore, one case definition was used to indicate all forms of self-harm (defined as intentional self-inflicted poisoning or injury), which may or may not have a fatal intent or outcome (see [Table 10]).
Table 10 iRHIS 2018 case definition: self-harm (including suicide attempt)

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  Discussion and conclusion Top


Many humanitarian mental health programmes have weak and inconsistent monitoring and evaluation systems across organisations (Augustinavicius, Greene, Lakin, & Tol, 2018; Bangpan, Dickson, Felix, & Chiumento, 2017). UNHCR’s new iRHIS can generate detailed and comparable data about utilization of services for MNS conditions across settings in various countries longitudinally. This is a critical aspect for improving mental health systems in humanitarian settings and needs to be embedded in a series of activities for capacity building and system changes around the integration of mental health within general health settings (International Medical Corps, 2018). The new case definitions in the iRHIS constitute a balance between continuity and change. The number of categories increased from seven to nine, which allows a more sophisticated categorisation without making the system overtly complicated. Comparison with the ‘old’ MNS categories will still be possible.

Major changes involve the addition of separate categories for organic psychiatric conditions such as dementia and delirium, and for self-harm and suicide attempts. The users of the iRHIS, including healthcare staff in refugee health facilities, can use the MNS categories to make a diagnosis in a person seen during a consultation. The new system is compatible with the modules of the mhGAP, which will make uptake and use easier: users of the system will typically have received a basic introduction to mental healthcare, for example through a training based on the mhGAP HIG.

This iRHIS will provide more refined data around MNS conditions. Such data can be used for more precise analysis, while maintaining sufficient continuity with the earlier version of the RHIS. The addition of specifiers for use by dedicated mental health professionals allows them to document more detailed diagnoses, with a total of twenty-two different categories to be used. As such, the new iRHIS paves the way for a next phase of professionalisation of mental health and psychosocial support in humanitarian settings. The iRHIS is currently being introduced in the countries where UNHCR used the old RHIS. After a transitional period in which the old and new system will be used simultaneously, the new system will be fully operational in 2019.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

1The mhGAP-HIG is a practitioner’s guide for the clinical management of mental, neurological and substance use conditions in humanitarian emergencies.

2Other disease categories were also revised, including communicable diseases, non-communicable diseases, injuries and notifiable disease, with the respective case definitions updated and where possible, links were made with the International Classification of Diseases (ICD)-10 categories. These changes are not discussed in this article. See website of World Health Organization for more information on the ICD: http://www.who.int/classifications/icd/en/.



 
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