Healthcare workers face unique challenges, including inadequate funding, high patient volumes, and trauma from conflict, which can lead to emotional distress and burnout (1). Additionally, healthcare workers around the world confront numerous work-related challenges that can have a significant impact on their mental health. These include heavy workloads, long shifts, fast-paced environments, a lack of proper safety measures, the continuous nature of patient care, ethical dilemmas, worries about job security, violence at work, and a lack of social support (2). Consequently, healthcare providers face conflicts in their work life due to the inherent tension between their duty of care and the demanding nature of healthcare environments (3). Burnout, depression, anxiety, sleeplessness, and other mental health problems might result from this psychological distress (4, 5). Anxiety and depression are rather common, according to research (7, 8). Anxiety affects 33–50% of healthcare professionals (6), and depression affects 26–60% (8, 9). Mental disorders profoundly affect both individuals and healthcare organizations. Previous research indicates that chronic illnesses, such as cardiovascular disease, along with physical symptoms like lethargy, dizziness, vomiting, nausea, disturbed sleep, and muscular spasms, may be caused by mental disorders (10). Also, healthcare workers who suffer from mental illnesses are more likely to have negative attitudes toward their jobs, poor judgment, and low performance (11), in addition to being more likely to quit, be absent, or have high turnover rates.

An increase in stress levels may have an effect on healthcare workers’ capacity to cope (5, 12, 13). According to Folkman et al., coping involves how people think and behave in response to stressful situations (14). Folkman and Lazarus identified two main types of coping strategies: problem-focused coping, which aims to change the current situation or find a solution to the problem, and emotion-focused coping, which deals with the emotional distress that comes with stressful situations (15). Two types of coping mechanisms are linked to improved mental health outcomes and are regarded as adaptive (16–18). Avoidant coping strategies—including drug abuse, self-distraction, behavioral disengagement, and denial—are considered maladaptive or dysfunctional (16). Since 1967, in Palestine, the West Bank and Gaza Strip have been under Israeli occupation. The Palestinian Ministry of Health (MOH), United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), non-governmental organizations (NGOs), and the private sector oversee primary, secondary, and tertiary healthcare in Palestine (19). According to the Palestinian Ministry of Health (2017), there are 81 hospitals under their authority. The West Bank (including East Jerusalem) hosts 51 of these hospitals, while Gaza hosts 30 (20). After October 7, 2023, the health status in Palestine was significantly impacted, and the healthcare system in Palestine continues to confront serious challenges as a result of conflict, political instability, and underfunding (12). Depression and post-traumatic stress disorder are common among healthcare workers since they are the first to see and treat serious injuries caused by military operations (21). Additionally, healthcare personnel encounter unique challenges such as working in an unsafe environment, insufficient resources, an excessive number of patients, and conflict-related trauma, which can result in burnout, anxiety, and depression (5, 12). Assessing the magnitude and underlying causes of depressive and anxiety symptoms in healthcare workers, along with their coping strategies, may provide a basis for formulating and executing intervention strategies for policymakers and healthcare organizations to mitigate, manage, and alleviate the impact of these symptoms. However, there has been little study on the mental health of healthcare personnel during conflict, specifically the association between depression, anxiety, and coping strategies. Therefore, the aim of this study was to assess the prevalence of depression and anxiety symptoms and to examine their associations with sociodemographic characteristics and coping strategies among healthcare workers. Additionally, it sought to determine the factors that affect the prevalence of depression and anxiety symptoms among these healthcare professionals.

The current study is a pioneer in investigating the prevalence of depression and anxiety, as well as their association with coping strategies, among Palestinian health workers in a wartime context. Our findings underscore the importance of taking mental health during conflict periods seriously as a public health concern. The findings revealed a significant prevalence of depression and anxiety among Palestinian health workers. These results are considered high in comparison to the findings of previous studies. Researchers reported that the prevalence of depression among health professionals in Uganda was 11.0%, while the prevalence of anxiety was 14.5% (22). According to Elhadi et al., 45% of emergency doctors in Libya had anxiety and depression following the civil war (23). One systematic review found that the prevalence of anxiety among healthcare professionals was 23.2%, while depression was 22.8% (24). In Ukraine, Rzońca et al. reported that anxiety and depression disorders were prevalent among physicians and paramedics during combat at 12.6% and 9%, respectively (25).

Furthermore, Lim et al. revealed that the prevalence of depression and anxiety increased during times of conflict or war by 28.9, and 30.7, respectively (26). Additionally, during the COVID-19 epidemic in the United States, Prasad et al. found that 22.7% of healthcare professionals were depressed and 69.4% were anxious (27).

Nevertheless, other studies revealed a higher prevalence than our study. For instance, a recent study in Gaza found that 93.9% of health professionals experienced depression and 96.5% experienced anxiety (21). Additionally, Wańkowicz et al. found that depression and anxiety were prevalent among healthcare workers in Poland during the COVID-19 pandemic, with 70.7% and 64.3%, respectively (28). The findings of our study may be attributed to the fact that Palestinian healthcare workers were working in a resource-limited environment, where they were confronted with significant stressors such as inadequate staffing, limited health support, and heavy responsibilities (29). In addition, practitioners’ mental health problems may be exacerbated by the ubiquitous hardships associated with armed conflicts, including poverty, malnutrition, devastation, economic and social deterioration, and pervasive feelings of sadness, fear, despair, and depression (30). To effectively manage stress and prioritize their own mental well-being, it is imperative that health personnel receive psychological interventions and treatment, particularly in high-stress contexts such as wars.

Several variables have been identified as potential causes of anxiety and depression among mental health professionals during armed conflict and hostilities in the current study. For instance, the results indicated that males were less likely to experience anxiety than females, which is consistent with the findings of other studies (24, 31). Research indicates that women exhibit a significantly higher prevalence of anxiety disorders and a higher level of anxiety sensitivity than men (32). Furthermore, women display greater emotional distress and anxious coping strategies in response to stressors than their male counterparts (32, 33). Additionally, women adopt a ruminative coping style (34). Research indicates that an increasing trajectory of anxiety arousal symptoms in women is caused by a negative cognitive style or rumination in conjunction with a stressor (35, 36). This trend was attributed by Zhang et al. to the fact that females are required to work night schedules and have contact with high-risk patients, which may exacerbate their symptoms of anxiety (37). Consequently, to address the needs of female health professionals, psychological intervention and psychotherapy are required in the workplace. Furthermore, additional research is required to investigate the cause of the elevated anxiety levels among female health workers.

The present study revealed that mental health professionals employed varied coping strategies, which might decrease or increase their levels of depression and anxiety. For instance, the current study found that mental health professionals who used self-distraction, substance use and active coping were less susceptible to depression than their counterparts who did not. This finding is consistent with the results of other studies (30, 38–40) and contradicts other studies (41). Sharif et al. reported comparable findings, indicating that participants utilized adaptive coping strategies, including substance use, self-distraction, and active coping, to manage their depression (42). Also, Wahab et al. revealed that depression was less likely to occur in correlation with active coping and self-distraction strategies (43). Further, Avants et al. found that depressed patients were more likely to rely on avoidant coping strategies and less on adaptive coping strategies (44). For instance, distraction is a passive coping strategy that involves the individual avoiding confrontation with the situation or attempting to resolve the problem (45). If the situation is unchangeable, it may be beneficial to engage in activities that provide a sense of relaxation, such as reading, exercising, or viewing television, to divert one’s attention from the distressing event (45). Furthermore, individuals with depression may be particularly susceptible to engaging in substance use as a coping mechanism to mitigate their severe, all-encompassing psychological distress (39). Research has linked efficient coping strategies, such as problem-solving, to improved mental health outcomes. However, maladaptive strategies, such as substance misuse or avoidance, can exacerbate depression (46). According to Steare et al., the persistent use of avoidant coping strategies can reduce quality of life by inducing ongoing stress (47). Additionally, individuals who use substances to alleviate negative emotions may be at increased risk of developing substance use disorders (48, 49). Our findings underscore the potential benefits of addressing depression, which is a promising target for interventions that foster adaptive coping and empowerment among health professionals who are depressed. In addition, it is important to provide psychotherapies specifically tailored to address substance use. Furthermore, additional research is required to evaluate the potential efficacy of these strategies in reducing problematic substance use among individuals with depression.

Additionally, our results indicated that the participants who employed emotional coping strategies, including acceptance and emotional support, were less likely to experience anxiety and depression, which is consistent with the findings of other studies (50–52). In contrast, Yoon et al. found that depression was negatively associated with problem-focused coping, while emotion-focused coping was positively associated with it (53, 54). Emotional support is crucial because it is regarded as a protective mechanism against life stressors and is believed to enhance health and wellness (55). Furthermore, acceptance serves as an effective psychological buffering mechanism (41). According to Stals et al., acceptance may serve as a means of coping with the bereavement process when confronted with overwhelming illness, trauma, and loss in the context of restricted resources (41). Our results may indicate that depressed participants exhibited a tendency to reduce their use of the “confrontation” coping strategy and were more likely to rely on acceptance to manage their stressors, which may have contributed to their depression and anxiety. Nevertheless, Beck et al. suggested that acceptance may exacerbate pessimistic emotions (56). Consequently, it was essential to implement coping skills training and psychological therapies in the care of professionals with depression and anxiety (56). The coping intervention has to include the reconstruction of recognition and the promotion of a positive view regarding adaptation to stress.

Finally, our research indicated that participants employing avoidant coping mechanisms (denial), emotional coping strategies (venting), and problem-solving strategies (planning) were more vulnerable to experiencing depression and anxiety than those who did not use these methods, which confirms findings from other studies (30). Avoidant coping mechanisms are frequently considered maladaptive because of their poor correlation with psychological well-being (57). Wahab et al. found that the use of maladaptive coping techniques, such as denial, correlated with a heightened probability of depression (43). In addition, Lee et al. showed that elevated utilization of emotion-focused coping strategies correlates with increased depression symptoms, particularly in relation to emotional venting and denial coping (58). Excessive venting without effective coping methods may result in rumination, reinforcing negative thought patterns and intensifying depression symptoms (59). Furthermore, denial coping often involves the suppression or disregard of negative feelings, especially those associated with depression (58). According to Bjørkløf et al., health workers risk missing out on opportunities for processing emotions, acknowledging them, and getting the help they need if they avoid or reject these feelings (60). In addition, our finding indicated that planning may exacerbate anxiety and depression. This finding stands in contrast to previous studies (50–52) that have shown planning coping as a protective factor against anxiety and depression. A potential explanation is that the presence of an excessive number of complicated and unpredictable factors in a healthcare environment can impede the planning process and, in fact, increase tension (41). Lazarus and Folkman’s transactional theory posits that the effectiveness of any coping strategy depends fundamentally on the controllability of the stressor (61). Problem-focused coping strategies, such as planning, are most effective when stressors are manageable and can be directly addressed. Nevertheless, when stressors are outside an individual’s control, problem-focused strategies may prove counterproductive (15). They may lead individuals to allocate cognitive and emotional resources to unresolvable issues, resulting in heightened exhaustion and anxiety (62). Moreover, wartime conditions impose significant, often uncontrollable pressures on healthcare professionals. Factors such as ongoing violence, unpredictable attacks, lack of resources, damage to infrastructure, and threats to personal safety are out of their control (63). Thus, sticking rigidly to a planning strategy in chaotic situations can hinder emotional adaptation, which is crucial for achieving psychological resilience during wartime. Therefore, relying on planning under these circumstances may demonstrate cognitive inflexibility and an inability to adjust coping strategies to meet situational demands, thereby suggesting a maladaptive coping approach (64). As a consequence, healthcare providers can express their emotions and investigate alternative approaches by providing education about healthy coping strategies, including the limitations of excessive venting or denial coping (65). Also, psychoeducation promotes the cultivation of healthier coping strategies and builds awareness (58). Zhang and Li emphasized the significance of offering psychological interventions such as community-based programs, internet- and mobile-mediated interventions, cognitive behavioral therapy, mindfulness meditation, trauma-informed care, and support groups for individuals affected by armed conflict (66).

This research is subject to limitations. The representativeness of the sample and the generalizability of the findings are influenced by convenience sampling and cross-sectional designs, which reduce the ability to demonstrate causal relationships and limit the generalizability of results. Additionally, the use of a self-reported questionnaire may increase the likelihood of reporting bias. It is likely that health personnel who are already employed in the impacted areas, including the Gaza Strip, do not have access to or the opportunity to use this technology, as recruiting took place using platforms such as Google Docs and WhatsApp. Consequently, the representativeness of the sample may be affected by this circumstance. In addition, there is a scarcity of research that investigates the coping strategies, anxiety, and depression of healthcare professionals during wartime. Consequently, the ability to compare our results to those of other studies is restricted. Despite these limitations, the results of the current study shed light on the psychological well-being of health professionals residing in countries that are conflict-affected. This study is a significant contribution to the current literature, as it is the first to examine the coping strategies, depression, and anxiety of Palestinian healthcare professionals during periods of political violence and armed conflict.

The findings revealed a high prevalence of depression and anxiety among health professionals during wartime and political violence. As a result, health professionals need assistance in enhancing their mental well-being through psychological support, psychotherapy, and comprehensive training in stress management.