Mental Health Rehabilitation in Gaza: Addressing the Impact of Ongoing War Conflict on Access and Challenges, a Systematic Review

Abstract

Objective

The ongoing conflict in Gaza, intensified since October 2023, has critically disrupted mental health services, exacerbating issues such as post-traumatic stress disorder (PTSD), anxiety, and depression among the population. This systematic review aims to identify and assess the challenges faced in mental health rehabilitation during this period.

Methods

Utilizing the Arksey & O’Malley framework and PRISMA guidelines, a comprehensive literature search was conducted across 6 databases. Studies focusing on barriers to mental health services for Gazan residents were selected, and data were extracted using the Critical Appraisal Skills Program (CASP) for quality assessment.

Results

Eight studies were included, revealing significant barriers to accessing mental health services, including extensive damage to health care infrastructure, a shortage of trained professionals, economic hardships, and a pervasive distrust in health care institutions.

Conclusions

The findings underscore the urgent need for tailored interventions and strategies to enhance access to mental health services and rebuild trust within the community. Addressing these barriers is essential for effective psychological rehabilitation and long-term recovery for the affected population in Gaza.

The impact of war and conflict on individual psychological rehabilitation and well-being is a critical area of study, particularly in regions that have experienced prolonged violence and instability. ¹ Armed conflicts disrupt not only the physical infrastructure of communities, but also the mental health of individuals, leading to a range of psychological issues such as post-traumatic stress disorder (PTSD), anxiety, and depression. ^{2 , 3} The consequences of such conflicts extend beyond immediate trauma, affecting social cohesion, economic stability, and the overall quality of life. ³ These psychological effects can persist long after the cessation of hostilities, creating a cycle of trauma that can be challenging to break. ⁴ Understanding these impacts is essential for developing effective rehabilitation strategies and mental health services to address the unique needs of affected populations. ⁵ Moreover, integrating mental health support into humanitarian responses is crucial, as it helps foster resilience and empower individuals to rebuild their lives in the aftermath of conflict. ⁶

Since the onset of the Gaza war conflict on October 7, 2023, the region has faced unprecedented levels of destruction, particularly within its health care system and mental health services. ^{7 , 8} The ongoing violence has severely compromised medical facilities, limiting access to essential health care and mental health support for the population. ⁹ Hospitals have been overwhelmed with casualties, and many clinics have been rendered inoperable due to bombings and resource shortages. ¹⁰ As resources become increasingly scarce, individuals are left without adequate psychological care, exacerbating existing mental health issues, and creating new ones. ⁹ The challenges of displacement, loss of loved ones, and chronic stress further hinder psychological rehabilitation, making it difficult for individuals to regain a sense of normalcy and well-being. ¹ In addition, the pervasive atmosphere of fear and uncertainty can lead to a breakdown of community support systems vital for recovery. ⁵ Identifying these challenges is crucial for reestablishing adequate mental health services and support systems once the conflict subsides. ¹¹ Understanding the specific barriers individuals face in accessing care will be instrumental in designing targeted interventions to promote psychological recovery after the conflict.

This literature review aims to explore the challenges faced by mental health rehabilitation in Gaza because of the ongoing war conflict. Due to the persistent nature of the conflict, there is a significant shortage of studies addressing this critical area, making it challenging to gather comprehensive data and insights. The ongoing war severely restricts research efforts, as conducting studies in such an unstable environment presents considerable obstacles, including limited resources and safety concerns.

By identifying the challenges faced in accessing mental health services and the broader implications for psychological recovery, this review seeks to provide insights that can inform future interventions and support strategies for affected populations. Ultimately, the goal is to enhance understanding of the complexities involved in psychological rehabilitation in post-conflict settings, paving the way for more effective recovery initiatives. By shedding light on the unique needs of those affected by the Gaza conflict, this review aspires to contribute to developing comprehensive mental health frameworks that can be employed in similar contexts around the world, ensuring that the psychological well-being of individuals is prioritized in the recovery process.

Method

This systematic review was carried out using the Arksey & O’Malley framework, which includes the following steps: ¹² 1) formulating the research question; 2) identifying pertinent studies; 3) selecting the studies; 4) organizing the data; and 5) compiling, summarizing, and reporting the results. Furthermore, the review followed the guidelines established in the PRISMA Statement.

The author worked alongside a health services librarian to search literature using keywords, MeSH terms, and Boolean operators. ^{13 , 14} The review searched 6 independent databases: PUBMED, OVID, WEB OF SCIENCE, CINAHL, SCOPUS, and EMBASE. Key search terms included “mental health rehabilitation,” “war conflict,” and “Gaza Strip.” The search strategy combined “mental health” with relevant synonyms, resulting in the following query: ((mental health OR mental health challenges OR mental health rehabilitation) AND (Gaza strip) AND (war conflict)). In databases like PUBMED, OVID, and CINAHL, relevant MeSH phrases were incorporated into the search, using OR operators to improve the search’s comprehensiveness. This structured approach aimed to shed light on “Mental Health Rehabilitation in the Gaza Strip: Understanding the Impact of War on Access and Barriers” through a thorough systematic review of existing literature.

Study Eligibility

The abstract screening process was conducted using specific inclusion and exclusion criteria designed to evaluate the challenges of mental health rehabilitation in the Gaza Strip following the war that began on October 7, 2023. The inclusion criteria specified that studies must focus on the barriers individuals in Gaza encounter when seeking mental health services for rehabilitation, involve participants who require such support, and be conducted in various health care environments, including hospitals and community services. The exclusion criteria eliminated studies that fell outside the review’s scope, such as those focusing on non-Gaza residents or populations other than those seeking mental health support, articles published in languages other than English, and non-peer-reviewed works such as magazines, newsletters, and conference proceedings that lacked sufficient detail for analysis. This review accepted all primary research designs and included studies published from October 2023 to August 2024, as noted in Table 1.

Table 1. Article eligibility criteria

Data Extraction

The author of this review, along with an eternal reviewer, conducted the data extraction process independently. They commenced by identifying and eliminating any duplicate records. In the second step, they assessed the studies based on their titles and abstracts. They reviewed the full texts during the third stage to verify that the studies met the inclusion criteria. If there were any disagreements between the researchers, a third independent researcher was brought in to evaluate the records and help resolve any discrepancies. The author of this review, along with the eternal reviewer, extracted critical information from each study, which included the authors, publication year, country of origin, study design and sample characteristics, research objectives, and key findings.

Ethical Considerations

This study does not need ethical approval because it relies solely on published research and does not involve human or animal interaction.

Quality Appraisal

The author of this study and one external researcher assessed the quality of the selected studies using the Critical Appraisal Skills Program (CASP), a widely recognized and user-friendly evaluation tool. ¹⁵ The CASP comprises 9 simple questions, with answers classified as “Yes,” “Might Tell,” or “No.” Each response was assigned a numerical value for a structured assessment of research quality, facilitating comparisons among reviewers: “Yes” was scored 2, “Might Tell” received a score of 1, and “No” was assigned a score of 0. If there was a discrepancy more significant than 25% between the total scores from the 2 reviewers after they individually reviewed each study, a third external reviewer was called in to perform an independent evaluation.

Data Synthesis

A narrative synthesis analysis explored “Mental Health Rehabilitation in the Gaza Strip: Understanding the Impact of War on Access and Barriers.” The theoretical framework underscored the urgent need to identify the challenges faced by individuals affected by the ongoing conflicts, particularly in the aftermath of October 7, 2023. Recognizing these obstacles is crucial for developing a safe and supportive health care environment that can improve mental well-being for those currently suffering in the Gaza Strip. Tackling these barriers may enhance reporting mechanisms and promote a culture of respect and professionalism among health care providers. The author examined whether the current literature indicates that these challenges significantly impact mental health rehabilitation for the affected population. This was followed by a comparative analysis of the included studies, focusing on their characteristics, findings, and relationships among relevant variables. The evaluation also considered the studies’ robustness and the synthesis’s methodological quality, while acknowledging any limitations and biases within the existing research.

Risk of Bias Assessment

The author of this study and one external reviewer independently evaluated the quality of the included articles using the revised Newcastle-Ottawa Scale (NOS), specifically designed for assessing nonrandomized studies. ¹⁶ When the reviewers disagreed, a third reviewer was brought in to help reach a consensus or provide a final decision. The NOS tool assesses potential bias in nonrandomized cohort studies based on 3 main categories: participant selection, group comparability, and outcome determination. ¹⁶ Each category is awarded “stars” to reflect the risk of bias, with a more significant number indicating a lower risk. A study can earn up to 1 star for each subcategory within the selection and outcome determination categories. At the same time, it may receive 2 stars in the comparability category if it considers one or more factors.

Results

An initial search of the designated databases produced 41 results. Three more documents were found through reference lists and Google searches. All relevant documents and their abstracts were exported using Endnote X8 software and reviewed in a Microsoft Word document. After removing duplicate entries, 33 abstracts were carefully evaluated. The author then screened 11 abstracts based on eligibility criteria, assessing 9 articles for full-text inclusion. In total, 8 articles were chosen for this review. Figure 1 illustrates the article selection process according to the Preferred Reporting Items for Systematic Reviews guidelines.

Figure 1. Flowchart of the literature search according to the Preferred Reporting Items for Systematic Reviews.

Characteristics of Included Studies

Table 2 summarizes the characteristics of the included studies: 1 mix methodology (12.5%), 1 systematic review (12.5%), 2 quantitative cross-sectional (25%), and 4 literature review (50%). These studies highlight significant challenges related to utilizing mental health services in Gaza during the ongoing conflict. Key challenges include damage to infrastructure, limited access to mental health resources, a shortage of trained professionals, and economic hardships, all of which impede the provision of adequate care.

Table 2. Overview of studies examining challenges to mental health rehabilitation in Gaza during the ongoing war conflict

Quality Assessment of Included Studies

According to the CASP methodology, the quality ratings for the various studies ranged from 12 to 16 out of 18 points. Overall, the studies were of moderate quality, achieving an average score of 14.13 in the quality assessment. Each study clearly defined its objectives, employed appropriate methodologies, and presented well-documented results. However, they failed to acknowledge or address potential biases and confounding factors, which could have negatively impacted the quality of the evidence ratings. Consequently, despite the research’s intention to evaluate the current level of knowledge, all related activities persisted due to the quality assessment process.

Challenges to Mental Health Rehabilitation in Gaza During the Ongoing Conflict

A summary of findings related Challenges to Mental Health Rehabilitation in Gaza During the Ongoing Conflict is outlined in Table 3. An analysis of this table reveals 6 significant themes: 1) limited access and availability of services; 2) economic hardship and poverty; 3) ongoing trauma and fear; 4) distrust in health care institutions; 5) mobility restrictions; and 6) disruption of social support networks.

Table 3. Challenges Themes in Mental Health Rehabilitation in Gaza During the Ongoing Conflict: Findings from Research Analysis

Limited Access and Availability of Services

The recent escalation of conflict in Gaza has severely damaged health care facilities, significantly hindering access to essential mental health services. A shortage of trained professionals exacerbates this issue, making rehabilitation difficult for trauma-affected individuals facing an overwhelmed health care system. ^{8 , 17 – 24}

Economic Hardship and Poverty

The ongoing conflict has intensified economic struggles in Gaza, leading to higher poverty and unemployment rates. Families prioritize basic survival needs, leaving little room for mental health concerns, which are compounded by an inability to afford necessary care. ^{8 , 18 , 19 , 23 – 26}

Ongoing Trauma and Fear

Prolonged exposure to violence has fostered a pervasive environment of trauma and anxiety among Gazans. This normalization of fear erodes coping abilities and disrupts family dynamics, amplifying the psychological impact on both adults and children. ^{19 , 20 , 24 , 25 , 27 , 28}

Distrust in Health Care Institutions

Years of conflict have bred deep distrust among Gaza residents toward health care providers, stemming from past inadequate care experiences. This skepticism discourages individuals from seeking mental health support, necessitating transparency and community engagement to rebuild trust. ^{8 , 18 , 19 , 23 – 26}

Mobility Restrictions

Mobility restrictions due to ongoing military conflict have significantly hindered access to mental health services in Gaza. Checkpoints and damaged infrastructure create formidable barriers, particularly for vulnerable populations, preventing individuals from seeking the care they need. ^{8 , 18 , 19 , 22 , 25}

Disruption of Social Support Networks

The conflict has shattered social support networks in Gaza, leading to isolation and a feeling of hopelessness among affected individuals. Reestablishing community bonds through initiatives like group therapy is essential for fostering resilience and emotional support in an increasingly challenging environment. ^{17 , 19 , 22 , 24 , 25}

Discussion

The ongoing humanitarian crisis in the Gaza Strip, exacerbated by the recent escalation of violence beginning on October 7, 2023, has significantly impacted the mental health of its residents. Over 43 665 Palestinian civilians have been killed, and more than 1 037 650 have sustained injuries, leading to an urgent mental health crisis characterized by a dramatic rise in disorders such as PTSD. ²⁹ Vulnerable populations are facing heightened mental health challenges, with studies indicating that over 75% of Gaza’s residents suffer from depression. ^{29 , 30} One report highlights that children experience increased symptoms of anxiety, disordered eating, and sleep disturbances, illustrating the profound effect of conflict on their psychological development. ^{30 , 31} The ongoing conflict has also led to widespread displacement, with over 1.5 million refugees seeking shelter. ^{29 , 32 , 33} The destruction of health care facilities—in which 35 hospitals and 69 medical centers were damaged—compounds these issues and signifies the urgent need for comprehensive mental health interventions tailored to the local context. ²¹ Proposed strategies include improving access to mental health services, deploying community-based interventions, fostering international collaboration to rebuild health care infrastructure, and advocating for a ceasefire to facilitate humanitarian aid. ²⁹ International efforts must focus on not only providing immediate aid but also addressing the long-term mental health repercussions of this protracted conflict. ²⁹

The escalation of conflict in Gaza starting on October 7, 2023 has critically impacted mental health rehabilitation by devastating the health care infrastructure. ²⁰ The destruction of facilities and the migration of trained mental health professionals due to safety concerns has significantly diminished access to vital services. ³⁴ As the health care system becomes increasingly overwhelmed, individuals experiencing trauma face substantial challenges in obtaining necessary resources, further compounding their psychological distress. ⁸ This dire situation highlights the fundamental need for increased investments and resources specifically targeting mental health rehabilitation services, as acknowledgment of mental health as a critical component of overall health is often overshadowed during conflicts. ²³ Compounding these challenges, widespread displacement has further hindered access to previously available mental health services, leaving vulnerable populations isolated. ²⁴ Families struggling to meet their basic needs often prioritize physical survival over addressing mental health concerns, exacerbating feelings of despair and hopelessness. ²¹ The interrelation between economic hardship and mental health access emerges clearly here; individuals grappling with trauma find it increasingly difficult to navigate a system that is both strained and scarce. Without appropriate interventions and support structures in place, the potential for recovery diminishes, underscoring the urgent requirement for coordinated efforts to enhance the overall mental health landscape in Gaza during these tumultuous times. ¹⁹

The economic ramifications of the conflict exacerbate these obstacles, as increased poverty limits families’ ability to afford necessary mental health care. ²² The socioeconomic collapse that accompanies prolonged military engagement forces residents to prioritize immediate survival, marginalizing mental health services even further. ^{18 , 20} In such dire circumstances, the psychological needs of the community can take a back seat, affecting individuals’ resilience and well-being. Additionally, the compounding effect of economic instability fosters an environment where mental health remains a secondary concern, obstructing pathways to achieving psychological recovery. ²³

Given these complexities, it is essential to integrate mental health support into broader economic recovery initiatives to address the interlinked challenges facing Gaza. ³⁴

Development of community-based programs that seamlessly blend mental health interventions with economic empowerment is vital for rebuilding community resilience and addressing psychological needs. Furthermore, the implementation of flexible service delivery models, such as mobile mental health units or telehealth initiatives, can help bridge existing gaps in access. ^{8 , 18} By promoting peer support groups and fostering connections within the community, residents can address the impacts of loss, trauma, and economic hardship while enhancing mental health rehabilitation efforts.

Lastly, effective mental health rehabilitation in the Gaza Strip hinges on the collaboration between local and international organizations to restore and improve essential services. ²⁵ The continuity of mental health provision during and after the conflict is crucial, as mental health issues will persist long after the cessation of violence. To achieve this, stakeholders must prioritize the establishment and maintenance of a robust mental health infrastructure that is responsive to the immediate and long-term needs of the population. ²¹ By providing comprehensive support systems, integrating mental health into humanitarian responses, and fostering a collaborative environment, the residents of Gaza can begin to reclaim their mental well-being amidst a landscape fraught with challenges.

Implication for Health Care Systems and Policymakers

The ongoing conflict in Gaza has underscored the critical need for integrated mental health services within humanitarian responses. As the psychological distress resulting from prolonged conflict continues to escalate, it is essential to adopt a comprehensive approach that prioritizes mental health alongside physical health care. This involves recognizing that the trauma experienced by individuals and communities is not just a secondary consequence of physical injuries, but a profound and pervasive issue that requires immediate attention. Addressing basic human needs—food, clean water, shelter, and safety—is fundamental for establishing a stable foundation for psychological rehabilitation. Moreover, special attention must be given to vulnerable groups, particularly children, women, and those who have lost family members or homes, to ensure that their specific challenges are adequately addressed. These groups often face unique psychological burdens, including grief, anxiety, and a sense of loss, which necessitate tailored interventions that resonate with their experiences.

In the immediate term, crisis response efforts must integrate mental health support as a core component of humanitarian aid. This means focusing on trauma-informed care for individuals affected by the conflict, providing them with the resources and support needed to process their experiences. Ensuring access to basic needs like food, clean water, and shelter will help stabilize the affected populations, allowing them to regain a sense of security. Additionally, targeted interventions should be implemented for vulnerable groups, including safe spaces for children to express their emotions and receive support, as well as specialized services for women who may face heightened risks of violence and trauma. Furthermore, it is crucial to provide support for those grieving the loss of family members or homes, offering counseling and community support to help them navigate their grief. Engaging local organizations to facilitate grassroots efforts will foster community support networks that promote resilience and healing, allowing individuals to connect and share their experiences in a supportive environment.

For long-term recovery, it is vital to invest in training programs for local mental health practitioners, ensuring that they are equipped with the skills necessary to address the complex psychological needs of the population. Establishing telehealth services can further enhance access to mental health support, particularly in areas where traditional health care infrastructure has been severely disrupted. Economic assistance and job training initiatives can help alleviate stressors contributing to mental health issues, enabling individuals to prioritize their well-being and rebuild their lives. Ongoing research is necessary to understand the evolving psychological needs of the population, informing future strategies for recovery and ensuring that interventions remain relevant and practical. Finally, developing inclusive support systems that specifically address the needs of children, women, and those who have lost loved ones will be essential for fostering a more resilient and cohesive community over time. By prioritizing these elements, we can create a comprehensive psychological rehabilitation framework that addresses immediate needs and lays the groundwork for sustained healing and recovery in the face of ongoing challenges.

Limitations and Future Recommendation

Despite the comprehensive insights provided by this systematic review, several limitations warrant consideration. The review includes only 8 studies, a notably small number, which may limit the generalizability and robustness of the findings. Furthermore, the majority of included studies are literature reviews and cross-sectional analyses, resulting in a scarcity of quantitative data due to the ongoing conflict in Gaza. This lack of quantitative research diminishes the applicability of the conclusions drawn to dynamic, real-time contexts, particularly in crisis situations. Additionally, the variability in research methodologies and quality may impact the consistency of the results.

Future research should focus on longitudinal studies that explore the long-term mental health effects of conflict, employing rigorous quantitative methods to assess the efficacy of specific interventions in diverse subpopulations. Qualitative studies investigating individual experiences and perceptions of mental health services in Gaza can provide a nuanced understanding necessary for tailoring interventions. Engaging local stakeholders in the research design and implementation will enhance the contextual relevance and sustainability of mental health interventions. Finally, enhancing collaborative efforts between international organizations and local entities will be critical in developing effective frameworks to address the complex and evolving mental health needs of affected populations.

Conclusion

In conclusion, the ongoing conflict in Gaza has profoundly impacted the mental health landscape, creating significant barriers to effective psychological rehabilitation. The destruction of health care infrastructure, compounded by economic hardship, pervasive trauma, and a deep-rooted distrust in health care institutions, has left many individuals without access to essential mental health services. The findings of this systematic review highlight the urgent need for targeted interventions and collaborative efforts that prioritize mental health within humanitarian responses. Integrating mental health support alongside immediate humanitarian aid will be crucial in fostering resilience among affected populations. Additionally, investing in local mental health practitioners and resources will ensure sustainable recovery in the long term. Ultimately, addressing the unique challenges faced by individuals in conflict-affected areas like Gaza is essential for advancing their psychological well-being and recovery.