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Prevalence and associated factors of mental health disorders among internally displaced persons in Gaza

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Ahmed Hassan Albelbeisi1, Alireza Hajizadeh2, Amroo M Al-Zeer3, Jalal Saeidpour2 and Edris Kakemam4

1College of Health Professions, Israa University, Gaza, State of Palestine. 2Health Information Management Research Center, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran. 3Minstry of Health, Gaza Strip, State of Palestine. 4Non-communicable Diseases Research Center, Research Institute for Prevention of Non-communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Islamic Republic of Iran (Correspondence to Edris Kakemam: edriskakemam@gmail.com)

Abstract

Background: War and political instability continue in the Gaza Strip, and little is known about the impact on the prevalence of depression, anxiety and stress.

Aim: To assess the prevalence of depression, anxiety and stress and analyse the potential factors associated with them among internally displaced persons in the Gaza Strip.

Methods: This cross-sectional, descriptive survey used a structured self-administered questionnaire to collect data from internally displaced persons aged ≥ 18 years in Deir al-Balah and South Gaza between 15 June and 15 August 2024. It used the Arabic version of the Depression, Anxiety and Stress Scale - 21 Items to investigate symptom severity for depression, anxiety and stress within one week before the survey. Data analysis was performed using SPSS version 26.0.

Results: Prevalence of depression, anxiety and stress were 99.5%, 99.7% and 93.7%, respectively. Participants aged >40 years had a significantly higher likelihood of experiencing mental health disorder (P < 0.05). Majority of the participants (89.8%) were forced to change their shelter at least 2 times. Those who were forcefully displaced for more than 4 times had a significantly higher likelihood of experiencing mental health disorder (P < 0.05).

Conclusion: We found a high prevalence of depression, anxiety and stress among internally displaced persons in the Gaza Strip, particularly among those living in tents and those frequently forced to change their shelter. These findings support the urgent need for effective interventions to prevent and control these disorders among affected families in Gaza and similar conflict zones.

Keywords: depression, anxiety, stress, mental health, internally displaced persons, war, Gaza

Citation: Albelbeisi AH, Hajizadeh A, Al-Zeer AM, Saeidpour J, Kakemam E. Prevalence and associated factors of mental health disorders among internally displaced persons in Gaza. East Mediterr Health J. 2025;31(2):81–88. https://doi.org/10.26719/2025.31.2.81.

Received: 13/10/2024; Accepted: 08/01/2025

Copyright: © Authors 2025; Licensee: World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

Between 1990 and 2019, the burden of mental disorders increased slightly in the Middle East and North Africa (MENA) Region (1). Mental health conditions such as stress, anxiety, depression, post-traumatic stress disorder and obsessive-compulsive disorder can affect the social and psychological lives of people (2). A significant burden of mental health is borne by populations exposed to the effects of war and forced migration (3-5). Gaza Strip is a portion of the Occupied Palestinian Territory characterised by high population density, with more than 2 million residents, of which 70% are registered refugees (6). Since 2007, Gaza Strip has been under blockade and this has impacted all aspects of the population’s life; more than half of the population suffers from poverty, with majority depending on aids (7). Gaza Strip has been subject to repeated violence and escalation for decades and is in a permanent state of complex humanitarian emergency (8).

Most of the people living in the State of Palestine have faced a variety of social and psychological shocks due to the unstable living environment (9). Among the challenges facing Gazans are the disruption of economic activities, looting of humanitarian supplies and the psychological warfare waged by the Israeli occupiers, which has caused social and health problems for the people (10).

Internal displacement is the sudden transition to an unexpected situation for which people are not mentally prepared, and it triggers a range of disturbing emotions such as fear, anxiety, longing, hopelessness, and depression (11). Displaced people face disruptions to various aspects of their lives when they are forced to leave their homes or shelters (12). A wide range of mental symptoms such as depression, anxiety, post-traumatic stress disorder (PTSD), bipolar disorder or schizophrenia have been observed in 22% of populations affected by conflict globally (8).

Military incursions, arrests, land confiscations, house evictions and demolitions, bodily injury, loss of loved ones, exposure to immediate danger to life, and injury are some of the many problems resulting from Israel's more than 75 years war against the people of Gaza (13,14). Since the beginning of the current war between Israel and Hamas on 7 October 2023, there has been a significant increase in the level of violence, with unprecedented number of airstrikes in Gaza (15). It is estimated that around 1.9 million people – about 9 in 10 of Gaza’s population – have been displaced internally. Residents do not have enough access to water, food, fuel, and medicine. Their homes have been destroyed with families torn apart. Many families have been displaced multiple times and have lost homes, family members and loved ones (16).

A worrying number of internally displaced persons (IDPs) face significant physical and mental health problems that necessitate urgent interventions. A 2023 study among Sudanese IDPs shows that 45% of IDPs have experienced poor physical health, and depression (18%), PTSD (20%) and anxiety (14%) were prevalent among adults (17). A systematic review reported PTSD ranging from 12.3% in Central Sudan to 85.5% in Nigeria (18). Psychological distress, insecurity and mental suffering among Gaza residents are associated with poor health-related quality of life, as a consequence of the war (19). In a systematic review and meta-analysis, Ahmed et al reported a 23.7% prevalence of PTSD symptoms and 25.3% depressive features among war-affected civilians (20). Ronzani et al reported that 58% of adults in the State of Palestine had symptoms of depression, and the highest prevalence (71%) in Gaza (15).

Study objectives

To date, there is limited knowledge and very few studies about depression, anxiety and stress due to the 2023 war in the Gaza Strip. Therefore, our aim in this cross-sectional study was to assess the prevalence of depression, anxiety and stress and investigate its related factors among IDPs in the Gaza Strip due to the 2023 war.

Methods

Data collection

This cross-sectional, descriptive survey used a structured questionnaire to collect data from IDPs aged ≥ 18 years residing in the southern governorates (Deir al-Balah and South Gaza) of Gaza Strip between 15 June and 15 August 2024. Gaza Strip is divided into 3 regions: North Gaza Governorates, Deir al-Balah (middle area) Governorate and South Gaza. Before data collection, participants were informed by a researcher about the aim of the study and the methods of data gathering. IDPs aged less than 18 years and individuals living in their own houses during the study period were excluded.

Using the standard Cochran’s sample size formula, a minimum sample size of 384 was estimated, with a 5% margin of error and a 95% confidence level (21). A convenience sampling method was used. We included all the 400 respondents who completed the questionnaire. Six nurses helped to recruit the participants from the different governorates.

The data were collected using a self-administered questionnaire, which contained questions on demography, depression, anxiety, and stress. The demography-related variables included gender, age, shelter type, frequency of displacement, total family size, and family income. The Arabic version of the Depression, Anxiety and Stress Scale - 21 Items (DASS-21) was used to investigate symptom severity for depression, anxiety and stress within one week before the survey (22). Each subscale included 7 items, rated on a Likert scale 0 (“did not apply to me at all”) to 3 (“applied to me very much or most of the time”). The scores of depression, anxiety and stress were calculated by summing the scores of relevant items for each subcase, multiplied by 2, based on the instructions (22). Overall, higher scores indicated a higher severity of each dimension. The scores were categorized as “normal”, “mild”, “moderate”, “severe”, and “extremely severe” for each subscale (22). Table 1 presents the classification of DASS severity scores, with cutoff scores >9 indicating depression, >7 indicating anxiety, and >14 indicating stress.

Data analysis

Data processing and analysis were performed using SPSS version 26.0. The demographic characteristics of the participants were described using frequencies (n) and percentages (%). The scores of depression, anxiety and stress were presented using means and standard deviation (SD). Before testing the hypotheses, the Kolmogorov–Smirnov and Shapiro–Wilk tests were performed to assess the normality of variables. Therefore, the parametric tests including independent samples t-test and one-way analysis of variance (ANOVA) followed by the Bonferroni post-hoc test were used to compare the differences in mental health scores among participants with different sample groups. A multiple linear regression was conducted to identify the factors that associated with depression, anxiety and stress as the continuous outcomes. Statistically significant independent variables in univariate analyses were included in multiple linear model analyses. P < 0.05 was considered statistically significant.

Ethics considerations

Due to the war and conflict situation, there is no ethics review board in Gaza, therefore, we could not obtain an ethics code for the study. However, the trained data collectors (nurses) informed participants about the aim of the study and the data-gathering method, and assured them of data confidentiality and voluntary involvement. The participants signed written informed consent to officially confirm their participation.

Results

Characteristics of the study population

More than half of the 400 participants (56.5%) were female and 62.7% were aged ≤30 years. All of the participants were considered IDPs and lived either in tents (54.0%) or a school shelter (46.0%). The majority (89.8%) were forced to change their shelter at least 2 times.

Prevalence of depression, anxiety and stress

The mean depression score was 30.67 (SD = 4.36), mean anxiety score was 30.65 (SD = 9.09), and mean stress score was 31.24 (SD = 9.05). Prevalence of depression was 99.5% (398/400) and 14.3% were considered severe depression and 69.5% considered extreme depression cases (Figure 1). Regarding the prevalence of anxiety, 399 (99.7%) respondents met the diagnostic criteria for anxiety symptoms, with severe and extremely severe depressive symptoms reported in 20 (5.0%) and 350 (87.5%) respondents, respectively. Regarding the prevalence of stress, 375 (93.7%) of respondents met the diagnostic criteria for stress symptoms, 44.8% and 32.3% had extremely severe and severe symptoms of stress, respectively.

Comparing mental health disorders according to the characteristics of participants

There were statistically significant differences in depression, anxiety and stress mean scores between participants of different age groups, shelter types and according to the frequency of displacement. Regarding depression, anxiety and stress, the highest mean scores were registered among participants aged >40 years living in tents and displaced >4 times.

Factors associated with depression, anxiety and stress

Participants aged >40 years had a significantly higher likelihood of experiencing depression, anxiety, and stress (for depression: β = -4.50; 95% CI= -7.35 to -1.66; for anxiety: β = -3.37; 95% CI= -0.75 to -6.70; for stress: β = -3.28; 95% CI = -6.06 to -0.50) than those aged 30–40 years (Table 4). Those who were forcefully displaced >4 times had a significantly higher likelihood of experiencing depression (β = -4.98;95% CI = -7.03 to -2.92), (β = -6.39; 95% CI = - 9.67 to -3.10) than those displaced 2–4 times, and 1 time, respectively. They had a significantly higher likelihood of experiencing anxiety (β = -4.93; 95% CI = -7.08 to -2.78), (β = -6.68; 95% CI = - 10.11 to -3.25) than those displaced 2–4 times, and 1 time, respectively. For stress cases, participants who were forcefully displaced >4 times had a significantly higher likelihood of experiencing stress (β = -4.945; 95% CI = -6.46 to -2.45), β = -5.74; 95% CI = - 8.95 to -2.54) than those displaced 2–4 times, and 1 time, respectively.

Discussion

Mental health disorder is one of the common psychologically distressing symptoms, and it may seriously affect the psychological adjustment and quality of life of people. To the best of our knowledge, this is the first attempt to provide data on the mental health problems of IDPs in the Gaza Strip, during the 2023 war. Our study found that a considerable proportion of IDPs were afflicted with depression (99.5%), anxiety (99.7%) and stress (93.7%) during the war. Results of multivariable linear regression analyses indicated that mental health disorders were more prevalent among those living in tents and among those frequently forced to change their shelter.

The level of hostilities and infrastructure destruction during the current war in Gaza has been unprecedented, and our results prove that due to these hostilities, the level of stress, suffering and other mental health problems is very high. A 2017 study showed that 21.9% of children in Gaza had anxiety and 50.6% had depression (23). Compared to the 2007 war (the second uprising or intifada), our study showed that the prevalence of mental disorders has increased. A 2007 study showed that 68.9% of 229 participants had PTSD, 40.0% had moderate or severe depression, 94.9% had severe anxiety levels, and 69.9% had adverse coping responses (24).

The results of our study regarding the prevalence of stress, depression and anxiety among refugees in the Gaza Strip are comparable with war situations and among similar refugees in other countries. A study that investigated the prevalence and factors associated with common mental disorders among internally displaced people due to armed conflict in Cabo Delgado, Mozambique, reported 74.3% PTSD, 63.8% depression and 40.0% anxiety (25). The results of this study are comparable with studies before 2023 when the intensity of the war in the Gaza Strip was low. A study among patients with type 2 diabetes in Gaza in 2018 showed that 27% of participants were positive for depression (26). Another study reported alarming rates of severe depression (73%), anxiety (60%) and insomnia (65%) among Palestinian migrant women living in camps during the war in Gaza in 2024, which calls for urgent mitigation measures (27).

The attacks of the Israeli forces started on 7 October 2023 and it has caused the death of many health workers in Gaza and put the healthcare system on the verge of collapse. Children are a vulnerable demographic group. Those who are exposed to violence, loss of relatives, deprivation of food and lack of water often have increased mental health and psychosocial needs, with psychological consequences such as developmental issues, anxiety and stress (28).

The results of our research are similar to the results of WHO study on mental health in the West Bank and Gaza in 2023, which showed that more than half of the adult population were positive for depression (58%), and the levels of depression symptoms were different in the different regions: 71% positive in Gaza and 50% in the West Bank (29). Ukraine is also a war-torn country, and a 2023 research has shown that the level of depression and anxiety was relatively low, while stress and resilience were relatively high among war-affected Ukrainians. Those directly exposed to military action, physical violence or extreme human suffering had higher levels of anxiety, depression, stress, and trauma-related symptoms, with the experience of war varying by gender, age and living condition (30).

A 2019 review of adult IDPs and refugees affected by armed conflict found post-traumatic stress disorder (3–88%), depression (5–80%) and anxiety disorders (1–81%) to have the highest prevalence, with high variability (31). Similar to the results of our study, the mental health situation in the Syrian war was poor, as levels of post-traumatic stress disorder ranged from 16 to 84%, depression from 11 to 49%, and anxiety disorder from 49 to 55% (32). The high prevalence of depression, anxiety and stress among IDPs in the Gaza Strip, particularly among those living in tents and frequently forced to change their shelter is a serious humanitarian situation which impacts every aspect of life, according to the international reports at least 5% of the Gaza population had been killed, severely injured or missing due to the war (33).

The results of the linear regression analysis in our study showed that participants aged>40 years who had moved frequently were more likely to experience mental health disorders. Similar to these findings, a report has shown that the prevalence of symptoms of war-related mental health conditions and the association with displacement were significant in the Jaffna District of post-war Sri Lanka (34). The overall prevalence of PTSD, anxiety and depression symptoms was 7.0, 32.6 and 22.2%, respectively. Such high prevalence in situations of war is significantly related to displacement status and exposure to trauma (34).

During the last decade, Syria has experienced war conditions similar to that of Gaza Strip, and the results of a 2020 review showed prevalence of 43.0% post-traumatic stress, 40.9% depression and 26.6% anxiety among adult Syrian refugees (35). Comparing research results from other countries with our results, it is clear how severe the consequences of the war that started in October 2023 in the Gaza Strip have been, and that the prevalence of mental disorders among refugees is about 100%. Syrian refugees have a situation similar to Gaza Strip refugees, where the high prevalence of mental disorders, including emotional distress (84.6%), depression (85.7%) and anxiety (76.5%) was reported in 2024 (36). Of course, different countries have reported high prevalence of mental illness among refugees and asylum seekers. A 2020 systematic review and meta-analysis among 15 countries showed that the prevalence of PTSD was 31.46%, depression 31.5%, anxiety disorders 11%, and psychosis 1.51% among refugees and asylum seekers (37).

Limitations of the study

This study had several limitations. Firstly, we used convenience sampling method to recruit the study participants, thus limiting generalization of the results. Secondly, we collected the data using a self-administered questionnaire, which may have led to recall bias, social desirability and reporting errors. Voluntary participation and anonymity were adopted to mitigate the risk of reporting errors. Thirdly, because of the difficulty of contacting and reaching the IDPs in North Gaza Governorate, the study did not include North Gaza Governorate. Fourthly, the small sample size compared to the total number of IDPs in the Gaza Strip may have affected the generalizability of the study findings.

Suggestions for future research

There is limited research on the psychological problems among specific populations such as refugees and the displaced, pregnant women, children, and the elderly, which needs to be addressed in future research. There is a need for more consistent and detailed methodological research on the mental health of war refugees in the Gaza Strip, who have been settled there for a long time, to reveal the long-term consequences of mental disorders. National and international organizations should support studies that will provide more evidence on the prevalence of mental disorders in the Gaza Strip during the current war.

Conclusion

This study highlights a high prevalence of depression, anxiety and stress among IDPs in the Gaza Strip, particularly among those living in tents and those frequently forced to change their shelters. These results support the urgent need for effective interventions that will prevent and control such disorders among affected families in conflict zones. Given the mental disasters caused by the current war, we propose interventions that embrace community and family support, focused support (individual counselling), specialized services specifically for vulnerable groups, as well as psychosocial support and recreational activities for children, adolescents and adults. There is a unique situation in the Gaza Strip that puts more burden on the residents regarding various types of mental disasters. As an additional humanitarian plea, the authors call for peace and protection for all civilians, with a special emphasis on the most vulnerable, to alleviate the suffering of the people of Gaza.

Acknowledgements

The authors thank the study participants for agreeing to participate in the study.

Funding: None.

Competing interests: None declared.

Prévalence et facteurs associés aux troubles mentaux chez les personnes déplacées à l'intérieur de la bande de Gaza

Résumé

Contexte : La guerre et l’instabilité politique persistent dans la bande de Gaza, et peu d’informations sont disponibles sur l'impact de ces événements sur la prévalence de la dépression, de l'anxiété et du stress.

Objectifs : Évaluer la prévalence de la dépression, de l'anxiété et du stress, et analyser les facteurs potentiels associés à ces troubles chez les personnes déplacées à l'intérieur de la bande de Gaza.

Méthodes : La présente étude descriptive transversale a eu recours à un questionnaire structuré auto-administré pour recueillir les données de personnes déplacées âgées de 18 ans et plus à Deir Al-Balah et au sud de la bande de Gaza entre le 15 juin et le 15 août 2024. L ’étude a utilisé la version arabe de l’ échelle de dépression, d’anxiété et de stress à 21 items pour étudier la sévérité des symptômes de dépression, d’anxiété et de stress durant la semaine ayant précédé l'étude. L’ analyse des données a été réalisée à l'aide du logiciel SPSS version 26.0.

Résultats : La prévalence de la dépression, de l'anxiété et du stress étaient respectivement de 99,5 %, 99,7 % et 93,7 %. Les participants âgés de plus de 40 ans avaient une probabilité significativement plus élevée de souffrir de troubles mentaux (p < 0,05). La majorité des participants (89,8 %) ont été contraints de changer de refuge au moins deux fois. Ceux qui ont été déplacés de force plus de quatre fois présentaient un taux bien plus important d'être affectés par ces troubles (p < 0,05).

Conclusion : Nous avons observé une forte prévalence de la dépression, de l'anxiété et du stress chez les personnes déplacées à l'intérieur de la bande de Gaza, en particulier parmi celles vivant dans des tentes et celles souvent forcées de changer de refuge. Ces résultats soulignent l'urgence de mettre en place des interventions efficaces pour prévenir et maîtriser ces troubles parmi les familles affectées à Gaza et dans d’autres zones de conflit similaires.

معدل انتشار اضطرابات الصحة النفسية بين النازحين داخليًا في غزة والعوامل المرتبطة بها

أحمد حسن البلیسي، علی رضا حاجي زاده، عمرو الزیر، جلال سعیدپور، إدریس کاکه مم

الخلاصة

الخلفية: لا تزال نيران الحرب وعدم الاستقرار السياسي مستعرة في قطاع غزة، ولا يُعرف سوى قدرٌ ضئيل من المعلومات عن تأثير ذلك على معدل انتشار الاكتئاب والقلق والإجهاد النفسي.

الأهداف: هدفت هذه الدراسة الى تقييم معدل انتشار الاكتئاب والقلق والإجهاد النفسي وتحليل العوامل المحتملة المرتبطة بهذه المشكلات في صفوف النازحين داخليًا في قطاع غزة.

طرق البحث: أُجريت هذه الدراسة الوصفية المُقطعية على 400 نازح داخلي تبلغ أعمارهم 18 عامًا فأكثر خلال الفترة من 15 يونيو/حزيران إلى 15 أغسطس/آب 2024. وقد جُمعت البيانات عبر استبيان يملؤه المستجيبون بأنفسهم، وباستخدام النسخة العربية من مقياس الاكتئاب والقلق والإجهاد النفسي (DASS-21). وخضعت البيانات للتحليل باستخدام الإصدار 26.0 من برمجية SPSS، استنادًا إلى إحصاءات وصفية وإحصاءات استنتاجية، منها اختبار «تي» للعينات المستقلة، وتحليل التباين الأحادي الاتجاه، والانحدار الخطي المتعدد.

النتائج: بلغ معدل انتشار الاكتئاب 99.5% والقلق 99.7% والإجهاد النفسي 93.7%. وكان المشاركون الذين تزيد أعمارهم على 40 عامًا أكثر عُرضة للإصابة باضطراب الصحة النفسية (قيمة الاحتمال < 0.05). واضطر معظم المشاركين (89.8%) إلى تغيير مأواهم مرتين على أقل تقدير. في حين كان النازحون قسرًا لأكثر من 4 مرات أكثر عُرضة للإصابة باضطراب الصحة النفسية (قيمة الاحتمال < 0.05).

الاستنتاجات: تبين لنا ارتفاع معدل انتشار الاكتئاب والقلق والإجهاد النفسي بين النازحين داخليًا في قطاع غزة، لا سيما بين النازحين الذين يتخذون من الخيام مأوى لهم والنازحين الذين يضطرون إلى تغيير مأواهم باستمرار. وتدعم هذه الاستنتاجات الحاجة المُلحَّة إلى تدخلات فعَّالة للوقاية من هذه الاضطرابات ومكافحتها بين الأسر المتضررة في غزة ومناطق النزاع المشابهة.

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