This analysis included 1357 evaluable of 1377 (98.5%) MSF mental health clinic patients whose treatment started between January 2007 through July 2011. On average during this period, 25 patients each month started treatment; highest monthly averages were noted in the two years following OCL. Patients’ age ranged from three to 70 years, with a median of 13 and inter-quartile range (IQR) = 9–24 years; 63% (n=738) were 15 years of age or younger and 55% were female. From 2007 through 2011 the proportion of patients 15 years and younger increased, OR = 0.73 (95% CI = 0.66-0.80), as did, among those at least 16 years of age, the proportion of women, OR = 1.37 (1.25-1.50) (Table
Patient socio-demographic and referral characteristics by year of entry into the MSF program
The majority (93%) of patients were rated as having high (n=822) or medium (n=441) socio-economic needs during the intake interview. Overall, the proportion of those with high socio-economic needs increased over time, OR 1.18 (1.08-1.30), except briefly after the war in 2009 when there was a greater proportion of new patients with medium to low socioeconomic needs compared to both 2008, OR = 1.19 (0.84-1.69), and 2010, OR= 1.44 (1.08-1.92) (Table
The majority of patients were referred by community/family (45%), MSF social workers (34%) or other institutions (11%). Community/family and self referrals increased over time compared to those from MSF social workers and other institutions, OR = 1.74 (1.57-1.92). This trend was most pronounced in 2009 following the war but continued in 2010 and 2011. (Table
Of 1357 patients seen in this period, 1305 (96%) expressed that they were exposed to conflict related violence. Overall, 1137 (84%) considered Israeli Defense Forces (IDF) the source of exposure with this proportion significantly increasing from 72-74% in 2007 and 2008 respectively to 92% in 2009 (χ2 = 49.4, p<0.001).
Information on traumatic life events was available for 1352 patients, of which 1263 (93%) reported at least one. On average patients 15 years and younger, reported one event per three life-years (0.33 per year) and those older than 15 reported one per decade lived (0.11 per year) (ß = 0.22, p<0.001) (Table
). Adjusted for age, new patients were more likely to report a greater number of traumatic events after OCL (ß=1.0, p<0.001).
Traumatic life events by age category for MSF patients, 2007-2011
For those with a stated triggering event (n=1295) the median delay to care was 7–12 months, and significantly longer for those 15 years and younger (ß= 0.33, p<0.001). Following OCL, in 2009 the median delay declined from 7–12 months to 3–6 months (ß = −0.41, p<0.001) and only 1% of patients did not identify an event associated with seeking psychological support. Delay significantly rose again in 2010 (ß= 1.1, p<0.001) with the majority of patients in 2010 (74%) and 2011 (59%) attributing a triggering event more than a year earlier, to the OCL time or before it (Figure
Time from triggering event to therapy by year for new patients in the MSF mental health treatment program in Gaza Strip, January 2007-July 2011.
Most common baseline symptoms noted in the younger age group were distress or anxiety followed by inhibition or withdrawal. For adults these were sadness or crying followed by distress or anxiety. One or two patients’ main complaints were reported at first visit. Most frequent for children were fear, sleep disturbance, bed-wetting and aggressiveness; for patients older than 15 years these were sleep disturbance, sadness, intrusive memories and anxiety (Table
). After OCL, statistically significant increases (Fishers exact test) were noted in bed-wetting (p<0.05), sleep disturbance (p<0.05), and hyperactivity (p=0.001) among the younger patients, and in grief (p<0.01) and avoidance (p<0.05) for the older age group.
Baseline clinical expression and main complaints of MSF program patients by age category, 2007-2011
Anxiety disorders accounted for 83% (705/846) of diagnoses of patients 15 years and younger; depression and developmental disorders accounted for 6%. Compared to 2007–2008, the proportion of those diagnosed with PTSD rose in 2009, OR= 1.53 (1.03-2.27); and of other anxiety disorders in 2010, OR=1.85(1.17-2.90). Compared to 2008, intra-year trends in 2009 were a rise in diagnoses of acute stress disorder (ASD) first quarter, OR=5.38 (1.04-28.6); PTSD second quarter, OR=13.48 (4.6-39.3). Compared to the first six months of 2009, diagnoses of other anxiety disorders and depression increased in the second half of the year, OR=4.97 (2.29-10.80), in addition to communication disorders, attention deficit disorder and separation anxiety, albeit at lower frequencies. In 2010 and 2011 the proportion of new pediatric patients with PTSD and other anxiety disorders rose again to levels similar to before OCL.
Among patients older than 15, the most common diagnoses were PTSD, depression, other anxiety disorders, and ASD. Primary diagnoses of PTSD and ASD were more common in men OR = 1.98 (1.38-2.84) while depression and other anxiety disorders were more common in women OR= 1.91(1.34-2.72). In the first half of 2009, diagnoses of ASD and PTSD increased compared to the previous year, OR=2.70 (1.40-5.19). Compared to this period, in the second half of 2009 these two diagnoses proportionally decreased while depression and other anxiety disorders became more common, OR=4.97 (2.29-10.80). Patient diagnoses by age-group and year are shown in Tables
Main diagnosis for patients 15 years of age and younger by year of entry to MSF program
Main diagnosis for patients 16 years of age and older by year of entry to MSF program
One fifth of patients (284/1357) had more than one diagnosed psychopathology. PTSD as primary or secondary diagnosis (n=157) most commonly coexisted with depression (84/157, 54%) or other anxiety disorder (23/157, 15%); the next most common were depression (n=146) with other anxiety disorders (29/146, 20%).
Baseline severity was recorded for 1286 of 1357 patients (Table
). Patients older than 15 years were more likely to be considered severe at baseline, OR = 2.40 (1.89-3.03), while moderate baseline severity was more common after OCL, OR =2.06 (1.60-2.66). In a multivariate model (n=1263) including age, traumatic events, time to care, referral source, treatment location, and time period, variables associated with high baseline severity were: age>15 years, OR = 1.61 (1.23-2.10); greater number of traumatic events, OR = 1.33 (1.22-1.45); shorter time interval between the triggering event and seeking care OR= 0.79 (0.72-0.87); and being referred by a MSF or other health staff, OR= 2.22 (1.69-2.91); having home sessions was borderline significant, OR=1.32 (1.00-1.74); and pre/post OCL period (2007–2008 vs. 2009–2011) were not predictors of high baseline severity, OR =0.83 (0.62-1.12).
Baseline severity level by age group and year of entry to MSF program
The median number of sessions for the period 2007–2011 was 9 (IQR=6-12), peaking in 2009 for patients older than 15 years and 2010 for those 15 years and younger. A multivariate model (n=1251) showed that adults, ß = 1.05, p <0.001; higher baseline severity, ß = 0.73, p <0.001; and the post OCL years (2009–2011), ß = 1.19, p <0.001 were all positively associated with greater number of sessions. Most patients (821/1332, 61%) received individual therapy, though children and younger adolescents were more likely than older adolescents and adults to receive family or dyad therapy (χ2 = 269.2, p<0.001). No significant association between number of sessions or therapy type and time period was noted.
Most patients either improved (n=1059, 78%) or had resolved the issue for which treatment was sought (n=63, 5%); 141 (10%) remained unchanged and 2 (1%) had worsened; therapeutic outcome information was not available for 92 (7%). Greatest proportion of improvements were noted in 2009–2010 (87-88% compared to 74-77% in other years), but in multivariate models including age, baseline severity and time period, no statistically significant associations were found with improvement or recovery and time period. Of the 14 patients diagnosed with ASD in 2009, 13 (93%) showed improvement or complete resolution. Of 169 with PTSD as the principal diagnosis the same year, 221 (91%) showed improvement or resolution; 11 (5%) showed no change and 10 (4%) were not evaluable. As a whole, those with anxiety disorders (ASD, PTSD, separation anxiety or other anxiety disorders) as principal diagnosis showed improvement (855/1005, 85%) more often than those with depression as principal diagnosis (141/183, 77%) (Fisher’s exact, p<0.01).
The majority of patients (n=1008, 74%) ended sessions by mutual agreement with the therapist; 52 (4%) were externally referred, mostly to local institutions, psychologists or psychiatrists for specialized care; 194 (14%) defaulted or were missing end of therapy information in the database. Symptoms persisted for 20% (266/1357) of patients, most notably: fear, anxiety or worrying (n=64), sadness (n=34), and enuresis (n=46).