Changes in psychological distress during conflict escalation in an adult population-based cohort in the Gaza Strip (2020-2025): a longitudinal analysis.

Abstract

The Gaza Strip has experienced prolonged conflict and blockade, straining infrastructure, basic services, and daily life. These chronic stressors pose a severe threat to mental health. The escalation to war in October 2023 led to widespread displacement, destruction, and loss of life. While cross-sectional studies before the war suggest high psychological distress, longitudinal data documenting the temporal course of mental health during conflict escalation are lacking. This study uses longitudinal data from 677 adults (aged at least 40 years) who participated in three self-report household surveys (2020, 2023, 2025) in the Gaza Strip. The three surveys were carried out in the governorates of Gaza, North Gaza, and Rafah, and responses were gathered from March 18 to July 15, 2020; January 24 to March 7, 2023; and January 12-28, 2025, respectively. The primary endpoint, mental health status, was assessed in all three survey rounds using the 12-item General Health Questionnaire (GHQ-12). Items were scored dichotomously (0/1), resulting in a total GHQ-12 score ranging from 0 to 12, with higher scores indicating greater psychological distress. We applied a conservative threshold of GHQ-12 score >6 for defining high psychological distress, consistent with previous studies in the Gaza Strip. Descriptive analyses documented temporal changes in GHQ-12 scores and items. A mixed-effects logistic regression model estimated the association between survey year and high psychological distress, adjusting for socio-demographic variables. A total of 677 participants took part in all three surveys (from 2980 in 2020 and 1547 in 2023). In 2020, 49%, 31%, and 20% of the 677 retained participants lived in Gaza, North Gaza, and Rafah governorates, respectively. 51% (n = 347) of the participants were women, and the majority (70%) were aged 40-59 years. High psychological distress (GHQ-12 score >6) increased from 19.5% in 2020 and 17.4% in 2023 to 67.2% in 2025. Adjusted models showed 12 times higher odds of psychological distress in 2025 compared with 2020 (OR = 12.45; 95% CI: 9.01-17.20). This increase did not differ across socio-demographic subgroups, although older adults and those with secondary or higher education were less likely to exhibit high psychological distress. While our study cannot establish causality, the recent tripling of severe psychological distress evolved from a background of an exceedingly high mental health burden before October 2023. Our findings underscore the relevance of providing long-term psychosocial and mental health services, including strengthening resilience, to prevent long-term consequences for the current and next generations in Gaza and other conflict-affected populations. Future research should examine the long-term mental health trajectories and resilience, including intergenerational impacts. UK's Department for International Development, Medical Research Council, Economic and Social Research Council, Wellcome Trust, Gaza Resilience Program of the International Committee of the Red Cross, and Department of Epidemiology and Public Health, Swiss TPH.