Mental Health of Migrants in Morocco: A Decade-Long Pilot Study of Psychiatric Hospitalization Trends 2013–2023

Abstract

Objectives: Migrants are at greater risk of psychiatric hospitalization. This study aims to improve care for migrants hospitalized in psychiatric wards in Morocco by studying comprehensive clinical and epidemiological characteristics, focusing on potential risk factors to guide mental health intervention efforts. Methods: The present retrospective multicenter study retrieved sociodemographic, clinical data, and patient records of migrants admitted to a large Moroccan psychiatric hospital in the Rabat region between 2013 and 2023 in order to delineate characteristics and risk factors for psychiatric hospitalizations. Descriptive and univariable analyses were conducted using chi-square, Fisher’s exact, and Mann–Whitney tests, and multivariable logistic regression analyses were performed by Jamovi 2.3.28.0 software to predict rehospitalization. Results: A total of 102 patient files were analyzed. Of these, 72.5% were single men, 27.5% had mental health problems prior to migration, 23.5% had attempted suicide, and 88.2% had negative insight. Some 94.86% were hospitalized against their will, 73.5% were diagnosed with psychosis, and only 2 were diagnosed with a stress-related disorder. Some 34.3% were hospitalized. Factors significantly associated with hospitalized were divorced family status, presence of psychotic pathology, and number of family members between five and nine with OR = 5.28, CI [1.04–26.68], p = 0.044; OR = 5.95, CI [2.02–17.44], p = 0.001; and OR = 6.02, CI [1.71–21.11], p = 0.005, respectively. Shorter length of stay in Morocco, unemployment, asylum seekers, and use of restraints were more frequent in hospitalized patients. Conclusions: Identifying at-risk migrants and setting up culturally appropriate, trauma-informed services can reduce the number of hospital admissions and boost the training and awareness of healthcare professionals in this area.

1. Introduction

International migration is a constantly growing phenomenon, transforming demographic, social, and health dynamics on a global scale. According to the United Nations’ 2024 projection, there were around 281 million foreign migrants in the globe in 2022, accounting for roughly 3.6% of the total population [1]. This is approximately double the number reported 2000 [1]. Morocco, due to its proximity to Spain and Europe, has become a key destination for immigrants, particularly from Sub-Saharan African countries [2].

The migration process carries considerable risks of emotional discomfort and mental problems at all three stages: preparation, migration, and post-migration. Migration poses challenges that negatively impact quality of life and health [3]. This is most evident in the mental health domain.

According to a systematic review, mental illnesses such as depression, anxiety, stress, and post-traumatic stress disorder (PTSD) are prevalent and higher among migrants in the Middle East and North Africa (MENA) region than elsewhere in the world [4]. Several studies reported that immigrants in Morocco had a low health-related quality of life, with the mental health component being the most noticeable [2,5]. Depression and anxiety are the most commonly diagnosed mental diseases among migrants. PTSD is more prevalent among immigrants and asylum seekers. Migration is a significant risk factor for schizophrenia and psychotic illnesses [6].

Migrants hospitalized in psychiatry often present severe and acute disorders. In Italy, a study revealed that migrants had a higher frequency of substance use disorders and self-aggressive behavior than natives [7]. In addition, migrants are more likely to be involuntarily hospitalized and to present more pronounced negative symptoms during follow-up [8]. This reality has significant consequences for healthcare systems, notably in psychiatry, where migrants might have different epidemiological profiles due to socio-cultural, economic, environmental, and political variables. Migrants hospitalized in psychiatry are a distinct group whose treatment requirements and clinical features must be investigated in order to better tailor mental health therapies [9]. The frequency of mental diseases among migrants varies depending on several factors, including country of origin, length of stay, migratory status, and cultural differences in the perception and treatment of mental illness [10].

Given the particular difficulties that these demographic faces, research on the epidemiology of migrants admitted to psychiatric hospitals is essential. Whether they are refugees, asylum seekers, or economic immigrants, migrants frequently have different mental health profiles than the general population. This is due to a variety of circumstances, including stress associated with migration, past trauma, and unstable living situations in the host nation. In light of this, we see that our nation lacks epidemiological research on mental illnesses. As far as we are aware, no epidemiological study has hitherto examined the hospitalization of migrants in a psychiatric hospital in Morocco. In this context, the primary objective of our study was to examine the trends, frequency, and factors associated with psychiatric hospitalization of migrants in Morocco over a ten-year period. Our specific objectives were to determine the characteristics of psychiatric admissions for migrant workers and asylum applicants and to examine the epidemiology of these hospitalizations. Clinical characteristics of migrants admitted to psychiatric care at the Arrazi in Sale Hospital (HAS) of the Ibn Sina University Hospital (CHUIS) in Rabat were assessed to identify risk factors for mental disorders and a common indirect indicator of acute exacerbations of severe mental illness.

Transparency and Openness: We report how we determined data inclusion and exclusion criteria, all study manipulations and measures. The final study data are available from the corresponding author on reasonable request. Data were analyzed using Jamovi 2.3.28.0 software.

Preregistration: The study was not preregistered.

Ethical approval: Ethical and regulatory aspects were taken into consideration before starting this study, in particular the submission of the protocol to the Biomedical Research Ethics Committee, Faculty of Medicine and Pharmacy, Mohamed V University in Rabat, Morocco (ethical approval no. 52/24 issued on the 14 February 2024) in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments or comparable standards. The protocol underwent institutional review by the CHUIS Research Division. Throughout the study and data analysis, anonymity was preserved by not including any identifiable information (such as surnames or first names).

2. Methods

2.1. Setting of the Study

The Rabat-Sale-Kenitra (RSK) region is 18,194 km² with a population of 5 million 133.000, accounting for 2.56% of the national population [11]. In the space of just a few decades, it has become a highly attractive area, particularly its coastal region. It is the focal point for the majority of the Kingdom’s demographic, economic, administrative, and cultural activity. This development is essentially due to the administrative importance of Rabat as the Moroccan capital, its status as a university city, and its role as a communications hub. It is the first Moroccan region to welcome asylum seekers and refugees [12].

HAS is a psychiatric establishment specializing in the care and prevention of mental health conditions under the Dahir of 30 April 1959. It was not until 1989 that it became one of the 10 university hospitals under the management of CHUIS. The HAS serves the population of the RSK region and remains a national reference for certain disciplines, such as Adult and Child Psychiatry, Care and Prevention of Drug Addiction, School Mental Hygiene, Reception and Guidance of Troubled Adolescents, and Geriatrics.

2.2. Type and Population of Study

This research is an observational and exhaustive study of the medical records of all migrants hospitalized in the psychiatric wards under the jurisdiction of the HAS of the CHUIS between 1 January 2013 and 31 December 2023. Initial data extraction identified 102 patients. A leakage study was performed to identify missing subjects by checking the list of patients registered in the information systems of the CHUIS statistics and archives department. The study sample consisted of 102 patients. Specifically, we examined migrant patients who had been discharged between 2013 and 2023, and there were 137 cumulative hospitalizations during the study period.

2.3. Study Eligibility Criteria

2.3.1. Inclusion Criteria

Subjects included in this study met the following criteria:

-

Age: Patients aged 18 and over.

-

Status: Migrant, refugee, asylum seekers, or immigrant.

-

Period of hospitalization: Patients hospitalized between 2013 and 2023.

-

Psychiatric diagnosis: Patients diagnosed with a psychiatric disorder according to DSM-5 or ICD-10.

2.3.2. Exclusion Criteria

Subjects excluded from this study based on the following criteria:

-

Migrant patients hospitalized outside the period 2013–2023.

-

Moroccan patient hospitalized in the same period 2013–2023.

-

Tourist or minor patient.

2.3.3. Data Collection

This study was carried out with the authorization of the CHUIS management in order to access the HAS archives.

This was achieved in collaboration with the Public Health Department at the Faculty of Medicine and Pharmacy in Rabat.

A standardized evaluation form was created to include all necessary sections for HAS patient hospitalization records.

2.4. Measures

First, the patient record numbers of migrants hospitalized between 2013 and 2023 were collected from the computer registers of the HAS Archives and Statistics Unit. Then, information on the patient’s journey and hospitalization was extracted from each patient record. Data were rendered anonymous. For each participant, we collected the following information:

-

Socio-economic and demographic variables: Age, sex, country of origin, place of residence, family situation, presence of family members in Morocco (spouse, children), educational level, employment, religious affiliation, economic class, method of payment.

-

Migration-related variables: Reason for immigration, status and situation, languages spoken, Morocco as a leading immigration destination, total number of years of immigration.

-

Clinical data: Admission (type, accompanied or alone, accepted or not); date of admission and discharge; Referring agencies, including courts or welfare services, general hospitals, volunteer psychiatric clinics, self-referrals, referrals from family or friends, and humanitarian aid organizations; hospitalization department; inpatient duration; pathway to care; insight; any suicide attempt; restraints/seclusion; symptoms of psychiatric disorders before migration; personal history (medical, psychiatric, and gynecological for women); family history; discharge diagnosis (according to the International Classification of Diseases, CIM-10) [13].

Psychiatric diagnoses were grouped according to the following categories: (F00–F09) Organic brain disorders; (F10–F19) Drug and alcohol use disorders; (F20–F29) Psychotic disorders (including schizophrenia); (F30–F39) Affective disorders; (F43) Stress-related disorders, specifically adjustment disorder; (Z03, Z04) Observation for suspected mental and behavioral disorder and examination for clinical evaluation including as per request by a legal entity [14]. In cases of multiple diagnoses, the principal discharge diagnosis was recorded as the one most directly associated with the cause of admission, as defined by the attending psychiatrist.

2.5. Management and Statistical Analysis

The Public Health Medicine Department of the Faculty of Medicine and Pharmacy in Rabat entered and analyzed the data and then carried out a descriptive analysis of the validated data.

Numbers and percentages were used to express qualitative variables, and quantitative variables were expressed as median with the inter-quartile range because the distribution of the variable was asymmetric (non-Gaussian).

Depending on the test circumstances, the chi-square, Fisher’s exact, and Mann–Whitney tests were used for univariate analysis. The study employed logistic regression analysis to evaluate the independent impact of family status, family members, psychiatric disorders before immigration, and psychotic spectrum disorder on rehospitalization of migrants in psychiatry. Variables were included in the multivariable model based on statistical significance in univariable analysis (p < 0.05) and prior evidence of clinical relevance.

The list of explanatory variables was compiled based on the results of the univariate analysis and the relevance of the variables. A difference was considered statistically significant if the p-value was less than 0.05. Associations were expressed as odds ratios (ORs) with a 95% confidence interval. Data analysis was performed using the Jamovi 2.3.28.0 statistical software package.

3. Results

3.1. Demographic and Clinical Characteristics

Table 1. Sociodemographic and clinical characteristics of migrants hospitalized at the Arrazi Psychiatric Hospital of Rabat’s Ibn Sina University Hospital (2013–2023) (n = 102).

Variable	N (%)
Age at admission (in year) a	31 [25–42]
Gender
Men	74 (72.5)
Women	28 (27.5)
Continent of origin
Africa	97 (95.0)
America	2 (1.9)
Asia	3 (2.9)
City of residence in Morocco
Rabat	55 (53.9)
Salé	20 (19.6)
Kénitra	12 (11.8)
Other outside RSK b region	15 (14.9)
Religion
Christianity	19 (18.6)
Islam	13 (12.7)
Judaism	1 (1.0)
Undeclared	69 (67.6)
Family status
Single	76 (74.5)
Married	16 (15.7)
Divorced	9 (8.8)
Widower	1 (1.0)
Education
Uneducated	43 (42.2)
University	30 (29.4)
Secondary	16 (15.7)
Primary	11 (10.8)
Undeclared	2 (2.0)
Employed in Morocco	16 (15.7)
Family members
1–4	86 (84.3)
5–9	16 (15.7)
Economic class
Average	68 (66.7)
Poor	18 (17.6)
Rich	16 (15.7)
Total number of years of migration a	5 [3–7]
Reasons for migration
Economic	32 (31.4)
Educational	4 (3.9)
Policies	17 (16.7)
Social	49 (48.0)
Status and situation
Migrant	87 (85.3)
Refugee	8 (7.8)
Asylum seekers	2 (2.0)
Immigrant	5 (4.9)
Irregular	15 (14.7)
Regular	87 (85.3)
Pre-migration psychiatric disorder	28 (27.5)
Acceptance of hospitalization on admission	9 (5.14)
Type of admission
Consultation center	27 (26.5)
CHU Transfer	2 (2.0)
Private doctor	3 (2.9)
Police requisition	7 (6.9)
Urgent case	63 (61.8)
Insight
Negative	90 (88.2)
Positive	12 (11.8)
Restraint/isolation during hospitalization	41 (40.6)
Suicide attempt	24 (23.5)
Psychoactive substance abuse	29 (28.4)
Physical comorbidity	10 (9.8)
Units for difficult patients (UDP)	70 (68.6)
Days in hospital (index hospitalization) a	30.5 [23.3–46.8]
Discharge diagnosis
Affective disorder	13 (12.7)
Examination requested by authority	7 (6.9)
Organic mental disorder	1 (1.0)
Psychotic spectrum disorder	75 (73.5)
Stress-related disorder	2 (2.0)
Substance-induced disorder	4 (3.9)
Rehospitalization	35 (34.3)

^a Expressed as median [Q25–Q75], ^b RSK: Rabat-Salé-Kénitra.

shows the demographic and clinical characteristics of the participants. We analyzed data from 102 migrant patients hospitalized at the Arrazi Psychiatric Hospital in Rabat between 2013 and 2023.

The median age of this population was 31 years [25–42]. The majority were men 74 (72.5), and 97 (95.0) were of African origin. More than ¾ were single.

The most frequent type of admission was classified as urgent in 63 of patients (61.8), and the median length of hospital stay was 30.5 [23.3–46.8]. In addition, 74 patients (72.5) among this population did not suffer from any mental disorder prior to their migration.

With regard to insight, 90 (88.2) had a negative insight regarding their mental disorder. In total, 78 (76.5) of them had already made at least one suicide attempt, and 73 (71.6) had no substance abuse.

The number of admissions varied over the years, with a peak in 2013 (n = 23), followed by fluctuations likely influenced by changes in admission policies, migration flows, or healthcare accessibility.

3.2. Demographic and Clinical Characteristics Associated with Rehospitalization

Table 2. Frequency of sociodemographic and clinical variables associated with rehospitalization of migrants at the Ar-Razi Psychiatric Hospital of the Ibn Sina University Hospital Center in Rabat for the period 2013–2023 (n = 102).

Variables	Rehospitalization		p Value
	No	Yes
Gender a			0.113
Man	52 (70.3)	22 (29.7)
Women	15 (53.6)	13 (46.4)
Age b	30.0 [25.0–37.5]	35.0 [26.0–43.5]	0.126
Family status a			0.079
Divorced	3 (33.3)	6 (66.7)
Married	9 (56.3)	7 (43.8)
Single	54 (71.1)	22 (28.9)
Type of admission a			0.615
Consultation center	19 (70.4)	8 (29.6)
CHU Transfer	2 (100.0)	0 (0.0)
Private doctor	2 (66.7)	1 (33.3)
Police requisition	3 (42.9)	4 (57.1)
Urgent case	41 (65.1)	22 (34.9)
Restraint/isolation during hospitalization a	24 (58.5)	17 (41.5)	0.234
Family members a			0.044
1–4	60 (69.8)	26 (30.2)
5–9	7 (43.8)	9 (56.3)
Reasons for migration a			0.096
Economic	25 (78.1)	7 (21.9)
Education	4 (100.0)	0 (0.0)
Policies	9 (52.9)	8 (47.1)
Social	29 (59.2)	20 (40.8)
Insight a			0.331
Negative	61 (67.8)	29 (32.2)
Positive	6 (50.0)	6 (50.0)
Pre-migration psychiatric disorder a	12 (42.9)	16 (57.1)	0.003
Suicide attempt a	15 (62.5)	9 (37.5)	0.707
Units for difficult patients (UDP) a	49 (70.0)	21 (30.0)	0.175
Discharge diagnosis a			0.262
Affective disorder	9 (69.2)	4 (30.8)
Examination requested by authority	3 (42.9)	4 (57.1)
Organic mental disorder	1 (100.0)	0 (0.0)
Psychotic spectrum disorder	52 (69.3)	23 (30.7)
Stress-related disorder	1 (50.0)	1 (50.0)
Substance-induced disorder	1 (25.0)	3 (75.0)

^a Expressed as n (%), ^b Expressed as median [Q25–Q75].

shows the frequency of social and clinical characteristics (gender, age, family status, type of admission, restraint/isolation during hospitalization, family members, reasons for migration, insight, pre-migration psychiatric disorder, any suicide attempt, units for difficult patients (UDP), and discharge diagnosis) in relation to hospitalized migrants; this difference is statistically significant for family members and pre-migration psychiatric disorder. Rehospitalization was present in 46.4% of women, 66.7% of divorced subjects, 57.1% of those admitted by police decision, 56.3% of migrants with five to nine family members, and 57.1% of migrants with pre-migration psychiatric disorder.

3.3. Univariable and Multivariable Analysis of Rehospitalization

Table 3. Risk factors affecting rehospitalization of the migrant population at the Arrazi Psychiatric Hospital of Rabat’s Ibn Sina University Hospital (2013–2023) (n = 102).

Variable	Univariable Analysis			Multivariable Analysis
	OR	IC	p Value	OR	IC	p Value
Family membersa
5–9–1–4	2.96	[0.99–8.82]	0.050	6.02	[1.71–21.11]	0.005
Pre-migration psychiatric disordera
Yes–No	3.86	[1.55–9.61]	0.004	5.95	[2.02–17.44]	0.001
Family statusa,c
Divorced–Single	4.90	[1.12–21.39]	0.034	5.28	[1.04–26.68]	0.044
Ageb	1.03	[0.99–1.06]	0.092
Gendera
Women–Man	2.04	[0.83–5.01]	0.116
Psychotic spectrum disordera
Yes–No	0.55	[0.22–1.37]	0.199	0.38	[0.12–1.14]	0.085

^a Expressed as n (%), ^b Expressed as median [Q25–Q75], ^c We collapsed categories for statistical power.

presents the univariable analysis results. A number of family members between five and nine was a risk factor for rehospitalization of patients with an OR = 2.96 and CI [0.99–8.82] at the limit of significance. The presence of a psychiatric pathology prior to migration increased the risk by 3.86 with a CI [1.55–9.61]. Divorce status increased the risk by 4.90 with CI [1.12–21.39]. Age was a risk factor that multiplied the risk by 1.03, CI [0.99–1.06], but the result was not significant at p = 0.09. Female gender increased the risk of rehospitalization by 2.04, but not significantly at p = 0.11.

In multivariable analysis, adjusting for the presence of psychotic pathology, family status, history of psychiatric pathology prior to migration, and number of family members, family status divorce only, presence of psychotic pathology, and number of family members between five and nine were risk factors for rehospitalization with OR = 5.28, CI [1.04–26.68], p = 0.044; OR = 5.95, CI [2.02–17.44], p = 0.001; and OR = 6.02, CI [1.71–21.11], p = 0.005, respectively.

4. Discussion

This study aimed to describe the characteristics of psychiatric hospitalizations among migrants, refugees, and asylum seekers living in Morocco and to identify the risk factors associated with rehospitalization. The composition of the target population is similar to that of the migrant population (originating from the Democratic Republic of Congo (DRC) with 53.8%, Côte d’Ivoire (53.6%), and lowest among those from Guinea (27.6%), Mali (29.9%), and Central Africa (32.8%)) [15] who live mainly in the hospital’s catchment area.

4.1. Hospitalization Characteristics

The high frequency of psychotic spectrum diseases upon discharge, including schizophrenia (73.5%), is one of the study’s intriguing results. Affective illness was identified in 12.7% of cases, whereas stress-related disorders (adjustment disorder) were diagnosed in just two instances (2.0%), despite the fact that 27.5% of the sample reported having a mental disease before migrating. This finding is consistent with other research showing that migration is a risk factor for schizophrenia [16] and for an increased prevalence of psychotic disorders among migrants [17]. Immigrants with nonpsychotic issues may not be referred for hospitalization. In rare cases, refugees may struggle to distinguish between PTSD and psychotic symptoms. PTSD symptoms such as fear, flashbacks, and dissociation may be misinterpreted as psychosis, especially among refugees perceiving their environment as threatening [18].

As shown in Figure 1, the number of psychiatric hospitalizations among migrants fluctuated over the 11 years, with a notably high number of admissions in 2013 (n = 23), followed by a sharp decline in the subsequent years. After reaching a low point in 2015 (n = 4), hospitalizations gradually increased again, peaking modestly in 2019 (n = 14). These variations may reflect changes in migration dynamics, institutional policies, referral practices, or access to psychiatric care for undocumented or uninsured populations. The relatively low and inconsistent admission numbers also highlight the systemic underrepresentation of migrant populations in formal psychiatric care pathways, possibly due to social, legal, or cultural barriers.

Nonetheless, the use of coercive treatment—that is, forcible hospitalizations and restraints—may be explained by the nature of psychotic spectrum disorders and severe clinical symptoms that allow for the hospitalization of uninsured migrants. According to the data, the sample’s share of restraint usage (40.6% for all hospitalizations, and much higher among hospitalized patients), and the percentage of involuntary hospitalizations (94.86%). It is important to note that, in the absence of a comparison group, the data on restraint use in this study should be interpreted solely as descriptive. No inference can be made regarding whether migrants are more or less likely to be subjected to coercive measures than other populations.

In contrast to the indigenous population, the justification of perceived risk, such as unpredictability or danger, is frequently used to support involuntary admissions of migrant patients (especially in Denmark), asylum seekers, and refugees in mental health facilities. In a retrospective cohort study based on a Danish registry, refugees (n = 29) and immigrants (n = 33) had higher forced admission rates than sick Danish (n = 133) (refugees, RR: 1.82, 95% CI: 1.45–2.29; immigrants, RR: 1.14, 95% CI: 0.83–1.56), especially among male refugees (RR: 2.00, 95% CI: 1.53–2.61) [19], Asylum seekers’ acute hospitalizations in Norway, however, were compared to those of other immigrants and local patients [20], and the number of forced admissions for asylum seekers was minimal. In London’s mental inpatient hospitals, the likelihood of detaining refugees and asylum seekers was no higher than that of non-refugees [21]. These disparities can be ascribed to superior health, welfare, and social rights for refugees and asylum seekers in certain nations, along with better access to mental and primary health care.

The high percentage of coercive measures used on migrants may also be explained by the fact that cultural differences in how distress is expressed, a lack of care that is tailored to the culture, and a lack of natural social support networks all lead to higher rates of illness severity and, consequently, emergency referrals [22]. Mental health practitioners’ lack of cultural competency causes communication and cultural barriers with migrant patients (for example, different idioms of distress). This can lead to misunderstandings, misinterpretations, and an overall overestimation of the risk of violence and unpredictable behavior [23]. Coercive measures alone can cause resistance to obtaining mental health care, thus increasing the risk of involuntary hospitalization and further coercive interventions [24]. In addition, migrants’ pathways to specialized mental health services are more complex [22,23] and can lead to a worsening of the disease and consequent referrals to emergency services.

A high percentage of patients (88.2%) had a negative insight into their mental disorder, which could indicate a lack of awareness and understanding of mental illness in this population. This aligns with studies indicating migrants often lack awareness of mental disorders and available health services [25]. Moreover, the significant proportion of patients who have attempted suicide (23.5%) is alarming and calls for special preventive attention. Studies show that migrants have an increased risk of suicide attempts due to social isolation, lack of family support, and traumatic experiences before and during migration [26].

Although 71.6% of patients had no documented primary diagnosis of a substance use disorder, this does not exclude the presence of substance use as a comorbid or unreported condition. Due to the lack of systematic screening or recording of comorbidities in our dataset, the prevalence of substance use in this population is likely underestimated. A study by Joye et al. [27] examined the links among depression, substance abuse, and suicide risk in adolescents, noting that substance use is frequently employed as a coping mechanism in response to chronic stress or trauma.

However, as only the primary discharge diagnosis was recorded in our dataset, comorbid stress-related or trauma-related conditions—including PTSD—may have been underreported or undetected.

Involuntary psychiatric hospitalization practices vary considerably across countries. In many European systems, such as France and the United Kingdom, involuntary admission is governed by legal frameworks that require judicial authorization or external review, multidisciplinary medical assessments, and strict adherence to legal criteria—typically the presence of a severe mental disorder and imminent risk to self or others, or lack of capacity to consent [28,29]. By contrast, the Moroccan framework, guided by Law 71-16 modifying Law 15-86 on mental health, allows physicians to initiate involuntary hospitalization on clinical grounds without immediate judicial oversight, especially in emergencies. In practice, this discretion is more frequently exercised when patients are undocumented or lack social or financial support [30].

Migrants in Morocco may therefore be disproportionately subjected to coercive measures, not only due to clinical severity, but also as a result of structural factors such as the absence of universal health coverage, limited access to community-based mental health services, and under-resourced psychiatric facilities. These systemic constraints may partially explain the exceptionally high rate of involuntary hospitalizations observed in our study. Comparative findings from Denmark and France, where asylum seekers and refugees also show elevated rates of forced admission, support this hypothesis [31,32].

4.2. Risk Factors for Rehospitalization

In the multivariable logistic regression model, two variables emerged as statistically significant predictors of psychiatric rehospitalization:

• The number of family members in the household;
• The presence of a psychiatric disorder before migration.

These findings are consistent with previous research, which has identified family-related stress and psychiatric history as key risk factors for recurrence in migrant populations [33,34,35].

While other variables, such as female gender, divorce, suicide attempts, or negative illness perception, appeared more frequent in the hospitalized group in the bivariate analysis, none of them reached statistical significance in the multivariate model. For example, women had slightly higher rates of rehospitalization, which may reflect gender-specific stressors such as caregiving roles or gender-based violence [36]. Divorced participants showed higher unadjusted rates of recurrence, possibly linked to social isolation or financial vulnerability [37]. In addition, migrants with a history of psychiatric disorders prior to migration were more likely to be hospitalized. This finding is in line with a study conducted in 2022, which found that migrants with a history of mental disorders prior to migration had a significantly higher risk of rehospitalization [34]. Migrants living in large families (five to nine members) show an increased risk of rehospitalization in this study. Large families may be associated with higher stress levels due to increased responsibilities and limited resources [35].

Patients with a negative perception of their mental state exhibited a higher rehospitalization rate (32.2%) compared to those with a positive perception (50.0%); however, this difference was not statistically significant (p = 0.331). A negative perception may reflect a deficiency in understanding and accepting the illness, which can impede symptom management and elevate the risk of recurrence. In addition, patients who attempted suicide were slightly more likely to be hospitalized (37.5%) than those who did not attempt suicide (33.3%). Suicide attempts are often a sign of the severity of mental illness and the need for continued treatment.

In the analysis, there was a strong link between rehospitalization and the presence of a psychiatric condition prior to migration. It should be mentioned that 57.1 percent of the research group reported having a psychiatric disease in their home country, during migration, or in Morocco. However, a closer study of the patient files revealed that, most of the time, patients were not asked explicitly about any traumatic experiences they had while migrating, and when they did, it was typically on their own initiative.

Although no cases of post-traumatic stress disorder (PTSD) were diagnosed in our sample, either as a primary or comorbid condition, this may reflect an under recognition of trauma-related symptoms due to the absence of specific assessment of traumatic exposure [38]. The underreporting of mental health issues before migration is well documented in the literature, often attributed to factors such as stigma, cultural taboos, lack of awareness about psychiatric conditions, language barriers, and fear of legal or social consequences [39]. While some patients in our study reported a history of pre-migration psychiatric symptoms, our data do not allow for a statistical association between geographic origin and prior mental health status. Therefore, any potential link between the region of origin (e.g., sub-Saharan Africa) and pre-migration psychiatric history should be interpreted with caution [40].

When active, focused questions were asked about mental health status before migration, several participants reported having experienced adverse events such as trauma, sexual assault, or starvation. However, the limited reporting of pre-migration mental disorders in clinical records may reflect patients’ reluctance to disclose such experiences, as highlighted in previous studies [41]. Some descriptive patterns in our data suggest that patients in the rehospitalization group were more frequently of African origin, had shorter stays in Morocco, and faced social vulnerability such as unemployment or lack of support networks. However, none of these factors reached statistical significance in the multivariable analysis. Therefore, while these elements may constitute psychosocial stressors potentially contributing to mental health deterioration, our data do not allow us to conclude that they are independent predictors of rehospitalization.

The hypothesis that underdiagnosis of pre-migration conditions or limited cultural competence among hospital staff might influence clinical pathways remains speculative and should be explored in future qualitative or mixed-methods studies. Similarly, although coercive measures (such as involuntary hospitalization and use of restraints) were more frequent among the rehospitalized group, their predictive value did not persist after adjustment for covariates in the multivariate model.

Similarly, the high proportion of patients with poor insight into their mental disorder may reflect not only clinical severity, but also cultural and linguistic factors that influence how symptoms are perceived, labeled, and disclosed. Variations in health beliefs, mistrust in formal psychiatric systems, or stigma surrounding mental illness may contribute to limited awareness or denial of symptoms.

These observations should thus be interpreted with caution and framed as hypotheses for future investigation, rather than confirmed findings from the present dataset.

In another multivariable model including psychotic spectrum disorder, this variable failed to attain statistical significance. This may be due to the ceiling effect of the high overall prevalence of this variable in the group.

Although psychotic spectrum disorders were highly prevalent in our sample, this variable did not emerge as a statistically significant predictor of rehospitalization in the multivariable model (OR = 0.38, p = 0.085). This may be due to a ceiling effect, given the high overall prevalence of psychotic disorders among hospitalized migrants, which reduces its discriminative value. Therefore, it should not be interpreted as an independent risk factor based on our data.

5. Conclusions

In summary, among migrants to Morocco, a substantial proportion of mental hospitalizations were involuntary. Variables linked with less resources and more exposure to past trauma predicted rehospitalization. It is critical to be concerned about mental health and the avoidance of hospitalization in this vulnerable population. Migrants, like everyone else, have the right to the highest standard of medical care. Furthermore, psychiatric hospitalization for migrants is typically the result of severe psychosis, suicidality, or hostility toward others. Preventing acute exacerbations lowers the public health risk for both native and migrant populations.

Improving migrants’ knowledge of mental health care and giving them the right training, together with trauma-informed and culturally sensitive therapies relevant to the difficulties of migration, are essential to reducing the likelihood of rehospitalization. Additionally, it is necessary to provide therapeutic continuity between inpatient and outpatient programs, particularly in the absence of reliable social support networks. The study’s conclusions highlight how crucial it is to provide migrants with more equitable community-hospital care in order to reduce hospitalization rates. Therefore, giving migrants regular access to community-based mental health care helps the host population, medical professionals, and migrant patients.

These findings have important implications for mental health policy and clinical practice. Given the high prevalence of severe psychiatric disorders and the disproportionate use of coercive measures among migrants, there is a pressing need to enhance healthcare staff training in trauma-informed care, intercultural communication, and the management of vulnerable populations. Policies promoting cultural competence, community outreach, and access to psychosocial support could help reduce barriers to care, improve diagnostic accuracy, and ultimately decrease the risk of rehospitalization in migrant populations.

5.1. Limitations

This study has a few limitations. First, the limited sample size is one of the primary drawbacks. The limited sample size can be attributed to the overall policy’s restrictions on these groups as well as the migrants’ ignorance about the program. Patients’ internal barriers, such as mistrust, fear of sharing information, mental health illiteracy, and stigmatization, may account for incomplete data. Clinical staff’s lack of cultural competence, such as their understanding of the political and cultural context and issues pertinent to migrant populations, may also be a contributing factor [42]. Furthermore, the study only looked at the migrant population and was based on data from a single hospital, without comparing it to Moroccan patients. Despite this, the majority of Moroccan migrants reside in the Rabat-Sale-Kenitra region, which is the hospital’s catchment area. A potential limitation lies in the shorter observation window for patients hospitalized closer to 2023, which may underestimate their risk of rehospitalization.

5.2. Future Directions

To address the dynamic features of migration and mental health, the current study will need to be extended throughout time. The challenges faced by health professionals while caring for migrants in psychiatric settings should be investigated. Furthermore, local studies of culturally appropriate treatment programs that may be adopted to assist mental health among Moroccan migrants would benefit international initiatives.

5.3. Note

In Morocco, a court may impose involuntary hospitalization. A court order is issued when a person is suspected of having committed an offence/public order disturbance or is under arrest by the police, or when an indictment has been served against him/her and the judge has issued an order for psychiatric examination or inpatient observation in order to assess whether the person’s mental state is related to his/her actions or whether the person’s current mental state does not permit the proper conduct of a trial. Depending on the psychiatric assessment, the judge will decide whether the person’s mental state requires involuntary hospitalization. The King’s Public Prosecutor is authorized to issue an involuntary hospitalization order under specific conditions: the person is in a psychotic state; because of this psychotic state, the person presents a danger to himself or to others; and the person has refused to be hospitalized voluntarily (Dahir n 1-88-285 of 21 chaoual 1878 (30 April 1959) relating to the prevention and treatment of mental illness and the protection of the mentally ill [43].