Mental Health in Gaza: The Need for Culturally and Contextually Responsive Models

Dear Editor,

I was interested to read the article by Aldabbour et al, entitled “The Psychological Toll of War and Forced Displacement in Gaza: A Study on Anxiety, PTSD, and Depression”. ¹ The authors have made an important and timely contribution in drawing attention to the alarming burden of psychiatric comorbidities in the internally displaced population in Gaza. Their findings not only emphasize the emotional ruin senseless conflict can inflict, but also provoke questions about the sufficiency of diagnosis and of the most appropriate therapy when war occurs.

Although precise instruments like the GAD-7, PHQ-9, PCL-5, etc are necessary, I suggest a broader diagnostic lens for more thorough assessment that may extend beyond traditional PTSD framings. As Aldabbour et al, ¹ themselves point out, PTSD might not be well suited to capture the chronic and cumulative character of trauma in places affected by conflict, such as in Gaza, where people are exposed to continued violence, displacement and existential insecurity. The diagnostic criteria assume a safe return after trauma—which is almost impossible in a drawn-out war zone.

The addition of CPTSD-ICD-11 to CPTSD-DSM-V (or of CTSD to these disorders), as suggested by Palestinian clinicians, could represent more culture-relative and context-relative nosological classes. CPTSD's focus on affective dysregulation and interpersonal difficulties, as well as its sustained focus on the relationship and on-going emotional ruptures found among ongoing conflict survivors. ² CTSD, on the other hand, disputes the time-based assumptions implicit in Western psychiatric nosology that reads trauma as a post-hoc syndrome rather than a condition in and out of time. ³

Moreover, although the authors point to torture and military detention as the most significant drivers of depression and PTSD, the study perhaps would be enhanced by a more robust examination of moral injury—a phenomenon gaining increased notice in war literature. Moral injury refers to the psychological, spiritual, and existential distress that occurs when deeply held values and beliefs are transgressed by experiences of betrayal, humiliation, or helplessness. ⁴ In Gaza, where one entire community after another is experiencing loss upon loss, expulsion after expulsion, and the perceived inaction of the global community, moral injury may be a critical if underexplored aspect of mental suffering.

These authors justifiably advocate for scalable mental health interventions, but they remain silent on culturally adapted care models. In resource-starved war zones, traditional Western psychotherapy may not have as wide a berth and be taken up. Community-based interventions that center on local cultural, religious and social practices—such as narrative exposure therapy, peer-based resilience programs, or community rituals of mourning and resistance—provide alternative ways for trauma survivors to recover, which are not only more accessible, but also more contextually meaningful.

In summary, this paper argues powerfully for an immediate mental health response in Gaza. I respectfully propose that further research be built on their work to include alternative diagnostic frames of reference (eg, CPTSD and CTSD), other constructs such as moral injury concept, and culture-centered care models. ⁵ Which is another way of saying, this will help make mental health interventions truly evidence-based as well as contextually responsive and ethically attuned to the lived realities of those suffering from the traumatising effects of chronic war.