Mental Health of Migrants in Morocco: A Decade-Long Pilot Study of Psychiatric Hospitalization Trends 2013–2023
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsOverall, this study has promise in filling a gap in predictors of rehospitalization for migrants in a Moroccan region, which might offer insights more generally. Some items to consider:
- Clarify in the text that the sample only included those were discharged from the original hospitalization during the period of analysis. If some were not, this would seem to introduce bias.
- Discuss any potential bias in that those hospitalized late in the time period had less time to be rehospitalized by the end of the study period.
- As there is only one discharge diagnosis given, specify how was it prioritized considering it is quite likely that some individuals had multiple discharge diagnoses.
- The selection of the factors in the multivariate model (at line 190) could be better specified.
- The text at line 204 could better be described that the most common admission type was urgent case as it was unclear as written.
- Clarify why family status was collapsed in Table 3.
- The discussion on hospitalization characteristics (section 4.1.) often implied that the study was able to analyze predictors of hospitalization when the sample does not so allow as there is no comparison to non-hospitalized migrants.
- Some of the comparisons in section 4.1. are not substantiated as it unknown if there is really a fair comparison (e.g., comparing the use of restraints in this sample versus among Moroccan patients in a prior study or comparators in the paragraph beginning at line 267). Indeed, this article seems to more appropriately be about rehospitalizations than initial hospitalizations, so potentially Section 4.1. should itself be reduced in favor of more discussion of Section 4.2. which appears to be the focus of the study with comparison groups.
- The sentence at line 267 was unclear what “argument” is being referenced.
- Line 300 discusses no history of substance abuse when the study actually is far more limited to a small subset that would qualify as psychoactive substance abuse. There is also conflation in line 335 about PTSD (unsubstantiated) when the actually variable was stress-related disorders, which a prior description mentioned adjustment disorders.
- It is unclear what the empirical support is for the statement at line 344, which cannot be derived from the quantitative analysis.
- Section 4.2. curiously focuses more on bivariate results between individual factors and rehospitalization that the multivariate model. The section seems to mix and mingle statistically significant and nonsignificant factors, which means that nonsignificant factors could be read as more important than this study can support.
- It was not clear where some of the predictors for rehospitalization discussed in Section 4.2. derived from this study (e.g., hospital nursing staff’s lack of experience, higher prevalence of those from African origin in the rehospitalization group, shorter stay in Morocco, and unemployment. One wonders if some of these derive from the initial hospitalization statistics.
Author Response
Please see the attachment.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
Comments and Suggestions for AuthorsThe manuscript presents a valuable retrospective multicenter study on psychiatric hospitalization trends among migrants in Morocco over a 10-year period. This is a highly relevant and timely contribution, given the lack of epidemiological research in the MENA region on this topic. The study benefits from a solid methodological approach, a clear presentation of data, and a well-contextualized discussion of its findings.
However, some limitations need to be addressed.
The manuscript would benefit greatly from professional English language editing. Several sections contain unclear or grammatically incorrect phrases (e.g., line 161: "Morocco is the leading immigration country where no" – needs rephrasing).
Interpretation of Multivariate Analysis:
In Table 3, the odds ratio for “psychotic spectrum disorder” is <1 in the multivariable model (OR = 0.38, p = 0.085), which contradicts the narrative in the discussion suggesting it is a risk factor for re-hospitalization. Please clarify this apparent inconsistency.
Legal and Ethical Context:
The section on involuntary hospitalizations is highly informative. A brief comparative insight into involuntary admission policies in other contexts (e.g., European systems) would enrich the discussion and highlight the uniqueness of the Moroccan system.
Please standardize the use of abbreviations (e.g., CHUIS, HAS) and define them at first mention.
Figures and tables are well-structured, but including a visual timeline or graph showing annual trends in hospitalizations could enhance data visualization.
Consider a short paragraph on implications for policy and practice in the Conclusions section, particularly concerning healthcare staff training and cultural competence.
Author Response
Please see the attachment.
Author Response File: Author Response.pdf
Round 2
Reviewer 1 Report
Comments and Suggestions for AuthorsSome of the discussions on the psychiatric diagnoses are not necessarily accurate as they ignore that only the primary discharge diagnosis was included. For example, at lines 301-303 it indicates few were diagnosis with stress-related disordered; however, many might have had a comorbidity of a stress disorder whereby another disorder was deemed to be primary. Then there is no support in this study for the prevalence of PTSD (cf. line 516) due to the primary diagnosis issue.
Lines 323-325 seem to mixing up different contexts and do not represent complete sentence(s) - perhaps some wording or sentences were unintentionally removed?
The reader may wonder about the discussion of the use of restraints while hospitalized as being outside the scope of the purposes of the study (and also an inherent difficulty where there is no real comparison group in data presented).
It is curious why the argument that the need for restraints could be culturally based would not also theoretically apply to the negative insight attribution at line 401.
The discussion at line 409 could still be improved whereby the initial statement is still not accurate as there is no variable that is related only to substance abuse.
Author Response
Please see the attachment
Author Response File: Author Response.pdf
Reviewer 2 Report
Comments and Suggestions for AuthorsCongrats!
Author Response
Dear Reviewer,
Thank you very much for your encouraging feedback and for acknowledging the improvements made to the manuscript following your initial suggestions. Your thoughtful and constructive comments were highly valuable in refining the scientific clarity, structure, and integrity of the work. We truly appreciate the time and expertise you devoted to the review process.
With sincere appreciation,
Dr. Meryem Zabarra (on behalf of all co-authors)
