During the conflict in 2008, the people of Gaza were subjected to intense psychological stress, derived from stringent restrictions on access to services, exposure to death and injury, entrapment in areas of continual violence, experiencing and witnessing injury and death, patchy access to humanitarian assistance, and forced dislocation and loss. Many who fled areas of violence, returned to find their homes and businesses destroyed. It is projected that the lack of basic services, shelter and livelihood capacity have exacerbated the already substantial mental health problems.
The situation in Gaza is unique in regards to the combined psychological impact of nearly two years of tight blockade, continued conflict and insecurity, and the recent war which has affected the capacity of the health and social service systems to meet the needs of the most vulnerable. Interventions in humanitarian situations often focus on psychological distress related to crises and conflict, while the needs of people with more long standing and severe mental health problems are often neglected. Yet, this group of people is often the most vulnerable and the most under-served by existing health services.
It has been estimated by the World Health Organization that severe mental disorders (SMIs) such as schizophrenia and bipolar disorder affect about one percent of the population. Given the population of Gaza is about 1.5 million, it is expected that approximately 15,000 persons are affected. Patients with SMIs are at increased risk during conflict and continued instability and many patients have difficulty accessing appropriate care.
People suffering from severe mental illness in Gaza are highly vulnerable and dependent on the ability of their family to care for them. With lack of adequate services to address these problems and a marked social stigma, many patients are confined at home and kept out of sight by their families.
Now, with the support of the European Commission Humanitarian Aid (ECHO), International Medical Corps has set up a program to reach people with severe mental illness and provide comprehensive case management services that take into account the complex needs of patients and their families. International Medical Corps also supports the provision of rehabilitation and recovery services to patients with SMIs, including occupational therapy.
Below is a selection of case studies taken from this program.
Waleed is married with 5 children and he worked as a mechanic when one of his friends was almost killed in 2006. He started feeling sad and depressed and his condition worsened during the war of 2009. He felt more and more hopeless and he stopped going to work and began neglecting his daily activities. He began isolating himself from others and eventually even refused to leave his room.
The International Medical Corps case management team supervised by our psychiatrist visited Waleed and after a comprehensive assessment diagnosed severe depression. International Medical Corps prescribed some medication and talked to Waleed and his family about ways to cope with his condition. Within a few weeks, he started talking with his family again and he started taking care of his appearance and hygiene. His family felt relieved when they saw how Waleed was improving. After a few months, he went back to work and was able to start supporting his family again.
Ameena, a married woman with eight children suffered from compulsions to destroy her property and had obsessive thoughts about harming others. Her neighbors were worried she could hurt her children. She had suffered from this for several years but her symptoms had become worse after she witnessed the deaths of some of her neighbors during the conflict. She was extremely distressed by her symptoms and had attempted suicide three times. The International Medical Corps team conducted a comprehensive assessment, diagnosing Obsessive Compulsive Disorder (OCD), prescribed medication, and offered support.
International Medical Corps also talked with her and her family about how to deal with OCD symptoms and about taking medication as prescribed. After two weeks, she started to show some improvement in her symptoms. Our case management team observed that Ameena developed a better relationship with her children, hugged them frequently, and had more positive interactions with her husband, who supported her in her recovery. Her children reported that they were not afraid of her anymore and her family thanked International Medical Corps for the intervention. She also started working in a small shop.
Ahmed, a middle-aged man, married with 4 children, was visited by International Medical Corps after his family had reported concerns about his strange behavior. His symptoms had started 18 years ago and had gotten worse over time. He was very suspicious that others were watching him and he was frequently aggressive and destroyed property. His speech was often incoherent and didn’t make sense to his family and he stopped taking care of himself. He became more and more isolated, he stopped leaving the house or going to family events. He sometimes laughed to himself in a loud voice.
His family became ashamed and did not leave the house together with him anymore. The International Medical Corps case management team diagnosed him with schizophrenia and talked to him and his family about the need for regular medication. An International Medical Corps community health worker also taught Ahmed self-care skills and helped him to manage his symptoms and interact with his family in positive ways. After a few weeks, symptoms improved, he was able to talk to close family members about his delusions and reminded them about medication timing. A few weeks later, Ahmed started to attend family events again and his wife reported significant improvement in his daily functioning.
Zaira is 60 years old and had lived with her brother and sister in law with their extended family since she started experiencing symptoms about 40 years ago. She would see things on the wall, she heard voices, and she often became agitated and aggressive. She also used bad language and her family was afraid of her and did not let her leave the house. They were worried that others would see her strange behaviour and they felt ashamed. Her family had cared for her in their house, giving her food and basic needs for living but they did not know how to help her.
The International Medical Corps case management team diagnosed her with schizophrenia and talked to the family about medication and how to help Zaira cope with this illness. The family appreciated visits from the case management team and reported that she was improving continuously.
After several weeks, Zaira sat and talked together with the family when the International Medical Corps team visited, something she had not been able to do in a very long time. Zaira stopped seeing things and using bad language, she started helping with housework and playing with the children in her family. Her family had never thought that Zaira would improve and they expressed gratitude to the International Medical Corps case management team.
International Medical Corps plans to continue helping patients with mental illness and their families and the funding from ECHO has made it possible to not only provide services but to also train community mental health workers in the provision of services for individuals with mental illness. This project is also laying the groundwork for longer-term capacity building in Gaza.
(All names have been changed).