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Gaza after the conflict: assessing mental health needs, August 2014

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28 August 2014, Jerusalem – Experience of previous conflicts in the Gaza Strip and elsewhere has shown that, as soon as the war is over, multiple organizations or institutions rush in to conduct a variety of assessments and surveys concerning mental health. The assessments may seek to inform programme planning, to support fundraising or advocacy, or to gain academic knowledge.

Most assessments take place during the first three months after the war, usually using various international tools which may not have been validated locally or within the emergency context. The majority focus on the prevalence of disorders, especially post-traumatic stress disorder (PTSD), anxiety and depression. However, these assessments rarely take into account that distress tends to be a normal manifestation in a community affected by an emergency, while in stable settings the same level of distress would more likely be a sign of pathology. This often leads to the reporting of extremely high prevalences of mental disorders in the immediate aftermath of emergencies.

Key messages

  • Make use of existing mental health data
  • Use standard mental health assessment tools
  • Consult with WHO and Health Cluster before conducting a survey.

Considerable expertise is required to conduct a survey of mental disorders in a rapid and useful manner. WHO recommends the use of a combination of quantitative and qualitative methods in order to gain an adequate understanding of the meaning and the extent of people’s reactions.

WHO and the United Nations High Commissioner for Refugees (UNHCR) have developed standards for mental health assessments in emergencies:  “Assessing mental health and psychosocial needs and resources – Toolkit for humanitarian settings” (2012)[i]. The toolkit, available also in Arabic, is consistent with the Interagency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in emergency settings (2007), the Sphere Project (2011) standards, and the work of the IASC Task Force on Needs Assessment (2012). The toolkit includes both validated instruments and appropriate indicators for measuring the severity of mental health problems as well as the level of daily functioning. WHO strongly urges all agencies involved in mental health and psychosocial assessments for the recent Gaza conflict to refer to the guidance available in the toolkit.

As substantial resources are required to conduct a reliable prevalence survey of mental disorders, the intended use of the findings should be explicitly defined. Furthermore, survey instruments for assessing the prevalence of mental disorders should not be used unless validated within the emergency context. Validation requires specific expertise and involves recalibrating the instrument using independent interviews by a psychiatrist or clinical psychologist trained in use of, for example, WHO's SCAN instrument.

Considering the high costs of time, human resources and finances needed for conducting assessments, efforts should be made to avoid asking questions for which the answers are already known or for which an answer can be found through review of existing data or needs assessments in similar situations. Assessments should be conducted only when the findings will be essential for addressing the key needs of the population and for informing mental health service development.   

Although the precise extent of current mental disorders in Gaza is not known, meta-analysis of the most robust epidemiological surveys (those using random samples and diagnostic interviews) in conflict-affected populations around the world show an average prevalence of 15.4% (30 studies) for PTSD and of 17.3 % (26 studies) for depression[ii]. This corresponds with WHO estimates of up to 20% prevalence for mental disorders in emergency-affected populations. Normal mental distress will be common in the remaining 80%.

Instead of conducting further studies to report again that a very high percentage of the population needs mental health intervention, assessments could for example focus on the response capacity of existing mental health services and on potential ways to address gaps. Also, assessments may be used to investigate the characteristics of the treatment gap, such as the adequacy and distribution of services, awareness of the population about mental health and psychosocial support, stigma attached to mental illness, and the outcomes of mainstreaming mental health and psychosocial support into health, education and social care.

Agencies intending to conduct mental health surveys are advised to contact the WHO office for West Bank and Gaza (Dr Dyaa Saymah: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ) and to coordinate with the West Bank and Gaza Health Cluster prior to embarking on a time- and resource-consuming endeavour.


[i] http://www.who.int/mental_health/resources/toolkit_mh_emergencies/en

[ii] Steel, Z. et al (2009) Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. JAMA; 302: 537–549