Of recent, Europe has been experiencing one of the most significant influxes of migrants/refugees in its history [1–3]. Pushed by civil wars, terror and pulled by the desire for a better life, people have continued to flee the Middle East, central Asia and Africa, crossing into Europe. During 2015, over one million people arrived by sea to Europe. The main push factors have included ongoing conflicts in Syria, Iraq and Afghanistan and poverty, human rights abuses and worsening security in countries like Pakistan, Eritrea, Iran, and Somalia [2].

The influx into Europe in 2015 largely occurred through the Balkan corridor. The main branch of this corridor starts in Turkey, passes through Greece into the Former Yugoslav Republic of Macedonia (FYROM) and from there to Serbia, Hungary, Croatia and Slovenia - depending on border closures - and finally into Austria, Germany and beyond (Fig. 1). European countries found themselves unprepared or unwilling to cope with the influx. Despite humanitarian and legal obligations of Europe to treat migrants/refugees with dignity and provide safe havens and asylum [4], what followed was the institution of restrictive migration policies which were often characterized by the building of razor wire border fences and border closures along the Balkan route [5] (Table 1).

Date	Country	Closure
December 2013	Bulgaria	Builds fence with Turkey making migrants/refugees take the sea route from Turkey to Greece
14th Sept 2015	Austria	Border controls with Hungary
15th September 2015	Hungary	Builds a 175 km fence with Serbia and starts arrestations
16th October 2015	Hungary	Closes border with Croatia forcing people through Slovenia
28th October 2015	Austria	Border fence with Slovenia
11th November	Slovenia	Builds a fence on its border with Croatia
18th November 2015	Slovenia, followed by Croatia, Serbia and Macedonia	Decides to only allow Syrians, Afghans and Iraq national to enter their borders.
February 2016	Macedonia	37 km fence built on the Greek-Macedonian border
February 2016	Countries along the Western Balkan route	Decides to only allow entry on humanitarian grounds to Syrians and Iraqis.

As part of its emergency and humanitarian interventions, Médecins sans Frontierès (MSF) offered mobile mental health clinics for migrants/refugees who transited through Serbia on their journey to European countries. Anecdotal reports from these MSF teams suggested that Balkan border closures were associated with violent events (including intentional physical violence) perpetrated against migrants/refugees [6]. Since MSF clinics routinely record such data [7], there was an opportunity for deeper assessment of the situation. Although a number of studies including a systematic review have assessed the association of potentially traumatic events with depression and Post-Traumatic Stress Disorder (PTSD) [8–11], a PubMed search revealed no studies that focused on violent events encountered by migrants/refugees during their journeys. Getting a better handle on individuals who experience violent events including physical trauma would be useful to guide mental health care. In addition, such information would help assess if the obligation of States “to protect” under International and refugee law is being respected [4] and if not, allow advocacy for corrective measures.

Among migrants/refugees who received mental health care, we thus aimed to assess the prevalence and patterns of traumatic events encountered along their Balkan journey to Europe. Specific objectives were to report on: a) characteristics of individuals attending mental health clinics and their presenting symptoms, b) the pattern of traumatic events including violence, c) physical traumas caused by acts of violence and c) trends in violent events in relation to border closures. In addition, we highlight a few narratives of anonymized testimonies of intentional violence against migrants/refugees.

This is one of the first studies assessing traumatic events including violence experienced by vulnerable migrants/refugees who presented for mental health care along the Balkan route to Europe. Border closures in Balkan countries were associated with a considerable decline in arrivals but, conversely, with an increase in violence. Nearly one-in-three migrants/refugees had experienced violent events with State authorities being the perpetrators in over half of such events. The sustained level of violence perpetrated by State authorities (including physical trauma inflicted on women and children) over a considerable period of time (one year of data collection) suggests a “systematic and organized nature” of the violence.

These findings herald serious short-comings in the obligation of Balkan States to provide humane treatment and protection according to the principles and provisions of international and refugee laws [4]. As member States of the United Nations recently gathered in New York for a summit (on 19^th September 2016) to agree on a “coordinated and humane approach” to the migrant and refugee issue, these data provide a sobering reality check of the considerable gap between rhetoric and action that needs to be bridged [15].

The study strengths are that recording of traumatic events (including violence) were done according to standardized guidelines, multiple sites were included and data were encoded by trained and experienced psychologists. In addition every psychologist was accompanied by a cultural mediator(s) who spoke the languages of the migrants/refugees and were from similar cultural backgrounds. The use of cultural mediators is crucial as it enhanced dialogue, trust and trans-cultural understanding, and has been recommended as a way to bridge ethno-cultural barriers of communication [9, 16]. We also used a triangulation design for linking quantitative and qualitative information and reporting was in accordance with STROBE guidelines [17].

There are some study limitations. First, data on traumatic events came from interviews conducted through mobile mental health clinics. As many individuals may not have had access to such clinics, we may have under-reported the real situation. Selection bias is very likely. Population based surveys would be the best way of determining the actual prevalence of traumatic events. Second, and understandably, there were variations in the numbers of individuals attending mental health clinics by month. To assess trends, we thus standardized violent events by 100 mental health consultations. Finally, as it is difficult to differentiate between migrants and refugees in transit situations, we considered them as one group “migrants/refugees”. This does not affect the relevance of the study findings as countries should in any case, recognize the human rights of migrants and refugees regardless of legal status.

Notably, this study has a number of policy and practice implications. First, almost four in ten individuals seeking mental health care reported having experienced one or more traumatic events (including violence and traumas) during their journey along the Balkan route. A considerable proportion of such events were perpetrated by authorities (police, border control guards) of European states. This justifies offering mental health care as an integral package of basic medical services at both transit stations and at the destination countries of migrants/refugees. Second, European countries seem to have purposefully introduced a “fortress approach” to blocking entry of migrants/refugees. By so doing, these countries have distanced themselves from their international obligations and have aggravated the predicament of those fleeing hardship. A paradigm shift that fosters a “reception approach” designed to better address the humanitarian and protection needs of vulnerable people is urgently needed.

The lack of alternatives for people to migrate and seek asylum in an organized manner, including policies of refoulement [18], push people into the hands of smugglers and make the migratory journeys more dangerous. This sort of treatment also exposes them to kidnappings for ransom, as well as to violence and abuse by organized crime gangs and/or State authorities. We thus call for access to borders and “safe passage” through the swift provision of safe and legal channels for people seeking asylum and for migrants. This may include making wider use of legal entry schemes, such as for example family reunification, humanitarian visas (albeit for restricted time periods), simplified visa requirements, migration pathways, resettlement and relocation.

Finally, the migrants/refugees journey until Serbia lasted between one and four months. This may in part, be explained by the fact that the EU’s response to large movements of migrants/refugees at Europe’s external borders has largely relied on the first country of entry rule [19]. In addition, border closures in Balkan countries might have imposed long stays in the country of first entry and make travel more arduous, lengthy and expensive.

Anecdotal evidence from MSF psychologists suggests that due to long stays and traumatic events, the initial acute reaction of distress experienced by migrants/refugees gradually turns to more complex mental health disorders/psychopathology, which is difficult to manage. Of particular concern are Post Traumatic Stress Disorder (PTSD), major depression and anxiety disorders which have been described in a number of conflict contexts [8, 10, 16]. As MSF mental health services are currently restricted to providing psychological first aid (a short term psychological intervention) and fostering coping mechanisms for acute reactions, ways of expanding the mental health package needs to be considered. Ensuring continuity of care for a dynamic migrant population will also be important. These issues merit further research.

In conclusion, we have highlighted violent events experienced by migrants/refugees which have been largely perpetrated by State authorities in Europe. In essence there is “a crisis of protection and safe passage” which needs to change towards one of respect for the principles and provisions of international human rights and refugee law.