Abstract
BackgroundThere is growing recognition of the psychological impact of adversity associated with armed conflict on exposed civilian populations. Yet there is a paucity of evidence on the value of mental health programs in these contexts, and of the chronology of psychological sequelae, especially in prolonged conflicts with repeated cycles of extreme violence. Here, we describe changes in the psychological profile of new patients in a mental health program after the military offensive Cast Lead, in the context of the prolonged armed conflict involving the Gaza Strip.MethodsThis study analyses routinely collected program data from a Médecins Sans Frontières mental health program in the Gaza Strip spanning 2007–2011. Data consist of socio-demographic as well as clinical baseline and follow-up data on new patients entering the program. Comparisons were made through Chi square and Fisher’s exact tests, univariate and multivariate logistic and linear regression.ResultsPTSD, depression and other anxiety disorders were the most frequent psychopathologies, with 21% having multiple diagnoses. With a median of nine sessions, clinical improvement was recorded for 83% (1122/1357), and more common for those with separation anxiety, acute and posttraumatic disorders as principal diagnosis (855/1005), compared to depression (141/183, p<0.01). Noted changes proximal to Operation Cast Lead were: a doubling in patient case load with a broader socio-economic background, shorter interval from an identified traumatic event to seeking care, and a rise in diagnoses of acute and posttraumatic stress disorders. Sustained changes included: high case load, more distal triggering events, and increase in diagnoses of other anxiety disorders (especially for children 15 years and younger) and depression (especially for patients 16 years and older).ConclusionEvolving changes in patient volume, diagnoses and recall period to triggering events suggest a lengthy and durable effect of an intensified exposure to violence in a context of prolonged conflict. Our findings suggest that mental health related humanitarian relief in protracted conflicts might need to prepare for an increase in patients with changing profiles over an extended period following an acute flare-up in violence.
Highlights
There is growing recognition of the psychological impact of adversity associated with armed conflict on exposed civilian populations
The present operational review aims to update this description through 2011 and explore potential changes in diagnoses, severity and treatment outcomes potentially associated with the intensification of the conflict during Cast Lead. This exploratory analysis was intended as descriptive and hypothesis generating. This analysis draws from routinely collected information from the patient database of the Médecins Sans Frontières/Doctors without Borders (MSF) mental health program in Gaza Strip for files opened between 2007 and the program’s closure in 2011
Privacy and confidentiality of patients were ensured during the treatment and after the conduct of the analysis. This analysis met the criteria for review of program monitoring data and for exemption from the MSF Ethics Review Board. This analysis included 1357 evaluable of 1377 (98.5%) MSF mental health clinic patients whose treatment started between January 2007 through July 2011
Summary
There is growing recognition of the psychological impact of adversity associated with armed conflict on exposed civilian populations. Shelling during the military offensive Operation Cast Lead (OCL) from 27 December 2008 to 18 January 2009, resulted in between 1,166-1,417 deaths, including 300 children, many more injured, and the destruction of homes and infrastructure, massive displacement and financial loss in the Gaza Strip. This intense, prolonged bombardment and military occupation exposed the community to the conflict to an unprecedented degree, adding economic and psychological stressors while disrupting existing social support networks [13,14,15]
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