Mental health of people without access to health services: a retrospective study of patients attending a humanitarian clinic network in Germany in 2021

Abstract Background: Germany has a statutory health insurance system. However, a substantial part of the population still suffers from limited access to regular health services. While humanitarian organizations are partially filling this gap, people without regular access show a high prevalence of mental health conditions (MHCs). This study investigates the prevalence and social determinants of MHCs in patients attending the clinics of a humanitarian health network in three major cities in Germany, as well as potential barriers to healthcare access in this population. Methods: We performed a descriptive, retrospective study of adults attending the outpatient clinics of the humanitarian organization Ärzte der Welt, in Berlin, Hamburg and Munich, in 2021. Medico-administrative data was collected using a digital questionnaire at first presentation to the clinics. We report the prevalence of both subjective and diagnosed MHCs and the perceived barriers to healthcare access in this population. We performed a logistic regression analysis to identify the socio-demographic factors associated with high risk of MHCs. Results: Our study population consisted of 1,071 first presenters to the clinics in 2021. The median age at presentation was 32 years and 57.2% of the population were male. 81.8% experienced a form of homelessness, 40% originated from non-EU countries and only 12.4% had regular statutory health insurance. 101 (9.4%) patients had a mental health diagnosis. In addition, 128 (11.9%) patients reported feeling depressed, 99 (9.2%) reported a lack of interest in daily activities, and 134 (12.5%) lacked emotional support in situations of need on most days. The most reported barrier to accessing health services was high health expenses, reported by 61.3% of patients. In the bivariate analysis we found significant associations for MHCs with age, insurance status and region of origin. Conclusions: People without access to regular health services have a high need for mental health services. As a chronic condition, this is even more difficult to manage outside of regular services, where humanitarian clinics are only filling the gap in serving basic health needs.