Mediating effect of intolerance of uncertainty between fear of war and mental health in adults during the Israel-Palestine war of 2023

Abstract

Background

The Israel-Palestine war of 2023 has exposed many individuals to prolonged fear and uncertainty, contributing to significant psychological and behavioral consequences. Fear of war has been shown to exacerbate negative mental health outcomes such as anxiety, depression, aggression and suicidal ideation and reduce overall wellbeing. Intolerance of uncertainty is a trait characterized by difficulty coping with ambiguous situations. It was regarded as a potential mediator in the association between fear of war and these outcomes. Therefore, this study’s aim is to investigate the mediating effect of intolerance of uncertainty between fear of war and mental health including anxiety, depression, aggression, suicidal ideation and wellbeing in adults during the Israel-Palestine war of 2023.

Methods

This study employs a cross-sectional design; it included a total of 484 Lebanese participants. A snowball sampling method via Google forms was employed by the research team to collect data. They were assessed with self-reported measures using The War-related Media Exposure Scale (WarMES), the Buss Perry Aggression Questionnaire—Short Form (BPAQ-SF), Columbia-Suicide Severity Rating Scale (C-SSRS), Intolerance of Uncertainty Scale (IUS) and The World Health Organization 5-item Well-Being Index (WHO-5).

Results

Higher fear of war was significantly associated with more inhibitory and prospective anxiety. More prospective anxiety and inhibitory anxiety were significantly associated with more aggression, higher suicidal ideation, higher depression, lower wellbeing and higher anxiety. Fear of war was directly associated with depression, anxiety and lower wellbeing. Whereas the results did not show a direct association with aggression and suicidal ideation. The mediation analysis revealed that inhibitory anxiety and prospective anxiety fully mediated the relation between fear of war and aggression and partially mediated the relation between fear of war and depression, anxiety and wellbeing. Whereas the association between fear of war and suicidal ideation was fully mediated by prospective anxiety but not by inhibitory anxiety.

Conclusion

Understanding the role of intolerance of uncertainty is crucial to developing interventions aimed to reduce mental health challenges in populations affected by conflict.

Introduction

Wars can result in detrimental consequences. Conflict affected populations, suffer from death, injuries, malnutrition and family separation which contribute to long term physical and psychological effects [1]. Therefore, being exposed to long periods of violence and assault can result in trauma related disorders, including post-traumatic stress disorder (PTSD) and other psychological conditions [2]. The World Health Organization (WHO) disclosed that in situations of warfare, 10% of people exposed to distressing incidents will face profound psychological issues, while 10% will develop behavior that will interfere with their capacity to function properly [3].

Exposure to war and mental health

One example of behavioral manifestations resulting from exposure to a traumatic event such as war, is aggression [4]. Aggression is generally known as the intention to harm someone who does not wish to be harmed [5]. Aggression can take many forms such as physical, verbal or sexual and a combination of one or more occurs rather often [6]. More particularly, aggression in the setting of war can be attributed to the brutality and violence that is witnessed, alongside media and press that incite public sentiment toward hatred and hostility against the opposing party [7]. Numerous studies have demonstrated that exposure to violence often leads to greater interpersonal aggression or violent behavior in many individuals [4, 7, 8].

As mentioned earlier, war significantly impacts mental health, leading to a set of psychological and psychiatric issues, one of which is depression [9]. Major depressive disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), is defined by a range of symptoms, including depressed mood, decline in interest in activities, insomnia, difficulty maintaining focus and sense of unworthiness [10]. A national multistage, cluster, population-based survey of 799 individualsaged 15 years and older, exposed to traumatic events caused by the war in Afghanistan in 2002, determined that the occurrence of symptoms of depression in respondents was 67.7% [11]. Another study done in Cambodia known for its extensive history of conflict, showcased by the civil war in the 1960s [12], found that 55% of participants had symptoms of depression [13]. Moreover, war exposure and a history of previous major depression were the main predictors for current depression in a study done in 1998 after the Lebanese civil war [14]. In contrast, in populations not affected by war, such as the United states of America, the 12-month and lifetime prevalence of DSM-5 major depressive disorder (MDD) in a representative sample of 36,309 U.S. adults were 10.4% and 20.6%, respectively [15].

Another mental health issue that is endured consequently to distressing events is anxiety [16]. Anxiety is an intense, often overwhelming sense of dread or unease about real or imagined future events [17]. It is one of the most experienced psychological effects during and after wartime [18]. Not only does it affect residents of the country at war, but it also impacts neighboring countries and those with loved ones in the conflict zone [18]. A study done about psychological strain of the Russian-Ukrainian war in 2022 among young adults found that 34% of the participants showed moderate to severe levels of anxiety [19]. Similarly, Cardozo et al., in a study done in 2002, reported high prevalence rates for symptoms of anxiety at 72% in Afghan citizens [11]. An additional significant concern that also warrants attention is the issue of suicidal ideation. Suicidal ideation refers to thoughts and consideration about ending one’s life [20]. It is strongly associated with a history of psychological disorders such as depression [21], anxiety [22] and Post-Traumatic Stress Disorder (PTSD) [23]. Given that warfare survivors tend to develop these mental disorders frequently, it is only logical that previous studies found high rates of suicidal ideation among war affected individuals [24, 25]. Furthermore, a study carried-out in southwestern Croatia revealed a 30% increase in suicide rate between the year 1991 and 1995 in comparison to the pre-war period from 1986 to 1990 [26].

Moreover, during military conflicts, major disruption and distress negatively influenced well-being [27]. Wellbeing is a state of mind that provides individuals with life satisfaction and happiness [28] and influenced by many factors, including physical health, emotional stability, economic security, and access to resources and opportunities [27]. Thus, a study done on Syrians affected by armed conflict showed a decline in mental and psychological wellbeing [29].

Fear of war

Fear of war by definition is the personal awareness and anticipation of suffering the consequences of war, whether directly through exposure to violence and conflict or indirectly through the extended repercussions of war, for instance economic instability, displacement, or emotional distress [30].

Fear of war can be triggered by thoughts, images or even discussions related such as watching the news [31]. It is not only experienced by those directly involved in conflict but also by individuals living in countries where the likelihood of war is high [31]. In fact, fear of war development is multifactorial, encompassing early childhood experiences, mental health conditions, and environmental factors [32]. However, limited information was available on the consequences of fear of war [31].

Boehnke and Schwartz showed an association between fear of war and trait anxiety, whereas no association was found with negative affect on mental health [31]. Conversely, other studies found an association between fear of war, anxiety and depression [33–35], which can exacerbate feelings of hopelessness and despair, consequently increasing the risk of suicidal ideation [21, 36]. Furthermore, the literature highlighted the association between fear of war and aggression [37]. In fact, fear can trigger a heightened state of arousal that leads to aggressive behavior, where the instinct for self-preservation is perceived as aggression [38]. Additionally, the fear of war can significantly affect well-being, as persistent emotional strain often negatively influences physical and mental health [39].

Moreover, fear of major threats, specifically war, can drive people to prefer certainty and predictability to regain a sense of control and to manage their fears [40]. Thus, fear of war was found to be correlated with the onset of intolerance of uncertainty as well as future anxiety [40].

Intolerance of uncertainty, fear of war and mental health

Intolerance of uncertainty describes a cognitive and emotional difficulty in handling and accepting ambiguous and unpredictable situations [41]. Carleton, Norton, and Asmundson (2007) recognized two factors of intolerance of uncertainty: inhibitory and prospective anxiety [42]. Inhibitory anxiety signifies paralysis or inaction when confronted with uncertainty whereas prospective anxiety refers to anxiety in anticipation of the uncertain [43].

The literature shows that intolerance of uncertainty is correlated with many psychological issues, namely anxiety [44] and depression [45, 46]. Conversely, more intolerance of uncertainty was associated with lower psychological well-being [47]. In addition, research showed a link between intolerance of uncertainty and increased aggression, suggesting that discomfort with unpredictability can fuel aggressive behaviors [48]. Furthermore, intolerance of uncertainty is associated with higher risk of suicide [49].

Since fear of war was shown to heighten intolerance of uncertainty [40] which in turn exacerbated symptoms of aggression [48], depression [45, 46], anxiety [44], suicidal ideation [49] and wellbeing [47], therefore, we hypothesize that intolerance of uncertainty might mediate the association between fear of war and psychological outcomes (aggression, depression, anxiety, suicidal ideation, and wellbeing).

The present study

Recent decades have witnessed their fair share of conflicts; this has been particularly evident in the Middle East [50]. Notably, the Israeli Palestinian conflict that dates back to 1947 with the most recent clash being on October 7, 2023, when a group of Palestinian militants carried out a cross-border assault [51]. In response, Israel declared war on Hamas and initiated extensive military operations in the Gaza Strip. The Israeli Defense Forces (IDF) conducted airstrikes and ground invasions targeting Hamas infrastructure and leadership. These operations led to significant destruction in Gaza and a substantial loss of life [51].

This conflict sparked increased regional tensions across the Middle East, with hostilities extending to Lebanon, where Israeli forces targeted Hezbollah positions [52], as well as to Yemen, where Houthi rebels launched missiles toward Israel [53], and impacting neighboring countries such as Egypt, Syria, and Jordan [51].

Abumbe et al, [54]. These countries have previously endured wars and hardship subjecting their citizens to stressful situations resulting in considerable damage and lasting psychological effects [55]. Although experiencing catastrophes is a universal occurrence, post-trauma responses were proven to vary considerably cross-culturally [56]. Middle Eastern countries including Iraq, Lebanon, Syria, Jordan and Egypt were found to have high burden of mental illnesses with a high prevalence ranging between 15,6% and 35,5% [57]. Therefore, this research can offer valuable perspectives into the unique challenges faced by these populations.

Unfortunately, few studies have investigated the psychological outcomes of the current situation among Middle Easterners, specifically on the topic of fear of war and its psychological implications. Furthermore, limited research explores other psychological and behavioral outcomes such as aggression and suicidal ideation. Moreover, most of the studies conducted were focused on specific demographic groups such as children [58] and military personnel [59], hence, more research is needed on adults in this field.

In addition, no studies were found that examined a mediating effect of intolerance of uncertainty between fear of war and mental health outcomes specifically in this context. Consequently, this study’s aim is to investigate the mediating effect of intolerance of uncertainty between fear of war and aggression, depression, anxiety, suicidal ideation and wellbeing in adults during the Israeli-Palestinian war of 2023.

Methods

Study design and procedure

The ethics committee of the School of Pharmacy at the Lebanese International University granted this study approval to proceed on ethical grounds (approval code: 2024ERC-024-LIUSOP). This study was undertaken from March till April 2024. The research team got in touch with participants who they know (convenient sampling); those who consented to participate were requested to distribute the Google form link to other adults they knew, thereby applying the snowball sampling method. The inclusion requirements state that individuals must be residents and citizens of Lebanon, aged above 18 years. To prevent any participant from completing the survey multiple times, we reviewed Internet Protocol (IP) addresses. At the start of the survey link, we included an introductory paragraph outlining the objectives of the study and assuring partakers that their responses would remain anonymous and confidential. After finishing the digital consent part, partakers were then inquired to fill out the items in the questionnaire. The items are presented in a disordered sequence to mitigate any potential order effects. The questions were addressed by the participants freely and without compensation.

Minimal sample size calculation

A minimal sample of 413 was deemed necessary using the formula suggested by Fritz and MacKinnon [60] to estimate the sample size: $n=\frac{L}{f2}+k+1$, where f = 0.14 for small effect size, L = 7.85 for an α error of 5% and power β = 80%, and k = 11 variables to be entered in the model.

Measures

The questionnaire is in Arabic, the official language in Lebanon. Starting with an informed consent, which confirmed the participants' readiness to fill out the survey at their own discretion. The first section also included a brief overview of the study along with important instructions for the questionnaire. The questionnaire includes the following:

Socio-demographic information: questions about the age, sex and parental situation of the participants. We calculated the Household Crowding Index (HCI) by dividing the total number of residents by the total number of rooms in the household [61]. The socioeconomic status (SES) of the family is represented by this measure, hence a greater HCI indicates a lesser SES. We additionally added questions regarding psychological problems, smoking, alcohol and cannabis use.

The War-related Media Exposure Scale (WarMES) Validated in Arabic [62], this scale is comprised of 9 items; these items are scored on Five-point scale ranging from 0”None” to 4 “More than 5 h per day” [62]. Respondents were asked to report how many times they engaged with every kind of war-related content over the past two weeks (e.g., “Threats of attacks against the civilian population”, “Victims crying or terrorized”) on Television, newspapers, radio or the Internet (e.g., TV programs, Instagram, Facebook, Tik Tok, breaking news, music videos) [62]. The scale yielded excellent psychometric properties (Cronbach’s alpha = 0.96).

Buss-Perry Aggression Questionnaire -Short Form (BPAQ-SF) Validated in Lebanon [63], this questionnaire consists of 12 items such as “I have trouble controlling my temper”, “I can’t help getting into arguments when people disagree with me”, and “I have threatened people I know”. It yields four scales: one for physical aggression, one for verbal aggression, one for hostility, and one for anger. The score is based on a 5-point Likert scale, 1 being “extremely uncharacteristic of me” and 5 “extremely characteristic of me”. More severe aggressive behavior is reflected by a higher score [64] (Cronbach’s alpha = 0.94).

The Patient Health Questionnaire–9 (PHQ-9) Validated in Arabic [65], it is comprised of 9 items used to assess depression intensity over the past two weeks [66]. These items represent the criteria for diagnosis of depressive disorder as mentioned in the Diagnostic and Statistical Manual of Mental Disorders [66]. The items are scored on a 3-point Likert scale from 0 “absence of symptom” to 3 “presence of symptom nearly every day”. Higher scores indicate more severe depression (Cronbach’s alpha = 0.91).

Generalized Anxiety Disorder (GAD-7) Anxiety is evaluated by this questionnaire during the previous two weeks [67]. It includes seven items for example “Becoming easily annoyed or irritable” on a four-point Likert scale that ranges from 0 “Not at all” to 3 “Nearly every day”. Greater symptom severity is indicated by a higher score. Scores between 0 and 4 indicated no anxiety, between 5 and 9 mild anxiety, 10 and 14 moderate anxiety, and 15 or more severe anxiety symptoms. It is validated among Lebanese Arabic-speaking population [68] (Cronbach’s alpha = 0.97).

Columbia-Suicide Severity Rating Scale (C-SSRS) It is a scale composed of 5 items that are used to evaluate behavior and suicidal ideation [69]. The first 5 questions analyze behavior in the last month, and the 6th question asses it in the past 3 months and over the respondent’s lifetime. Giving a positive response to one or more of the 5 questions reflects suicidal ideation [69]. This scale has been validated in Lebanon [70] (Cronbach’s alpha = 0.74).

Intolerance of Uncertainty Scale (IUS-12): This is a shorter version of the IUS-27 [42]. It has been validated in Arabic [71]. 12 items are included in this scale and are scored on a Likert scale: 1 “Not at all characteristic of me” to 5 “Very characteristic of me” [42] This scale comprises two subscales: inhibitory anxiety and prospective anxiety, where greater scores indicate greater levels of anxiety [42] (Cronbach’s alpha values = 0.91 for prospective anxiety and 0.91 for inhibitory anxiety).

The World Health Organization 5-item Well-Being Index (WHO-5) This scale comprises five statements that evaluate self-perceived psychological well-being [72] on a 5-point Likert scale with 5”all of time” to 0”none of time” [72].Absence of well-being is reflected by a total score of 0 and a maximum well-being by a total score of 25 [72]. To obtain a percentage 0 = worst to 100 = best; original scores are then multiplied by 4. It has been validated in Arabic among young adults without clinical conditions from six Arab countries [73] (Cronbach’s alpha = 0.94).

Statistical analysis

The SPSS software v.25 was used for the statistical analysis. We did not have any missing values in our database. The aggression/depression/anxiety/wellbeing scores were considered normally distributed since the skewness and kurtosis values varied between −1 and + 1 [74]. To know which variables should be included in the mediation model, we conducted a bivariate analysis; the Student’s t was used to compare a continuous variable and a dichotomous one, one-way ANOVA test to compare a continuous variable and a categorical one, and the Pearson test to correlate two continuous variables.

The suicidal ideation score was not normally distributed, as well as its LOG transformation. Consequently, the score was categorized into the absence or presence of suicidal ideation. The Chi-squared test was employed to compare two means, while the Student’s t-test was used to compare a continuous variable with a dichotomous one.

The mediation analysis was conducted using PROCESS MACRO (an SPSS add-on) v3.4 model 4, with the number of bootstrap samples set at 5000 and 95% confidence interval [75]; four pathways derived from this analysis: pathway A from the independent variable to the mediator, pathway B from the mediator to the dependent variable, Pathways C and C’ indicating the total and direct effects from the independent to the dependent variable. Results of the mediation analyses were adjusted over all variables that showed a p < 0.25 in the bivariate analysis. We considered the mediation analysis to be significant if the Boot Confidence Interval did not pass by zero. P < 0.05 was deemed statistically significant.

Results

Sociodemographic and other characteristics of the sample

Four hundred eighty-four participants participated in this study, with a mean age of 27.74 ± 11.17 years and 68.4% females. Other descriptive statistics can be found in Table 1.

Table 1.

Sociodemographic and other characteristics of the sample (N = 484)

Variable	N (%)
Sex
Male	153 (31.6%)
Female	331 (68.4%)
Parental situation
Together	453 (93.6%)
Divorced	31 (6.4%)
Smoking
No	297 (61.4%)
Yes	187 (38.6%)
Alcohol
No	428 (88.4%)
Yes	56 (11.6%)
Cannabis use
No	467 (96.5%)
Yes	17 (3.5%)
Psychological problems
No	451 (93.2%)
Yes	33 (6.8%)
Suicidal ideation
No	414 (85.5%)
Yes	70 (14.5%)

	Mean ± SD
Age (years)	27.74 ± 11.17
Household crowding index	1.12 ± .47
Aggression	26.97 ± 11.34
Depression	9.09 ± 6.43
Anxiety	18.62 ± 12.15
Suicide	0.25 ± .75
Wellbeing	15.48 ± 5.58
Fear of war	36.31 ± 13.57
Prospective anxiety	19.48 ± 6.49
Inhibitory anxiety	12.87 ± 4.74

Bivariate analysis of factors associated with depression, aggression, anxiety and wellbeing

The Student’s t test results showed that a higher mean depression score was significantly found in females vs males (9.85 ± 6.69 vs 7.45 ± 5.51; p < 0.001) and in participants with psychological problems (14.55 ± 6.49 vs 8.69 ± 6.25; p < 0.001) (Table 2). Moreover, a higher mean anxiety score was significantly found in females vs males (19.80 ± 12.28 vs 16.07 ± 11.48; p = 0.001), in those who have never used cannabis (18.78 ± 12.24 vs 14.29 ± 8.31; p = 0.046) and in those with psychological problems (24.45 ± 12.88 vs 18.19 ± 11.99; p = 0.004) (Table 3). A higher wellbeing score was markedly found in males and in participants who do not have psychological problems compared to those who do (15.74 ± 5.52 vs 11.94 ± 5.33; p < 0.001) (Table 3). Moreover, more fear of war was significantly associated with more aggression (r = 0.16), depression (r = 0.27), anxiety (r = 0.35), prospective (r = 0.36) and inhibitory (r = 0.32) anxiety, and lower wellbeing aggression (r = −0.31). Finally, a higher household crowding index was significantly associated with lower wellbeing (r = −0.12) and higher prospective (r = 0.13) and inhibitory (r = 0.11) anxiety and fear of war (r = 0.18) (Table 4).

Table 2.

Bivariate analyses of factors associated with depression and aggression

	Depression					Aggression
Variable	Mean ± SD	T	df	p	Effect size	Mean ± SD	t	df	p	Effect size
Gender		−3.86	482	< 0.001	0.378		0.22	482	0.829	0.021
Male	7.45 ± 5.51					27.14 ± 10.93
Female	9.85 ± 6.69					26.90 ± 11.53
Parental situation		1.48	482	0.139	0.275		−1.47	482	0.141	0.273
Together	8.98 ± 6.41					26.77 ± 11.35
Divorced	10.74 ± 6.67					29.87 ± 10.82
Smoking		−1.46	482	0.145	0.136		−0.87	482	0.383	0.081
No	8.75 ± 6.37					26.62 ± 11.25
Yes	9.63 ± 6.52					27.54 ± 11.47
Alcohol		−1.13	482	0.260	0.160		0.26	482	0.798	0.036
No	8.97 ± 6.45					27.02 ± 11.43
Yes	10.00 ± 6.31					26.61 ± 10.72
Cannabis use		−0.71	482	0.479	0.175		−0.75	482	0.454	0.185
No	9.05 ± 6.47					26.90 ± 11.37
Yes	10.18 ± 5.46					29.00 ± 10.40
Psychological problems		−5.18	482	< 0.001	0.934		−1.43	482	0.153	0.258
No	8.69 ± 6.25					26.77 ± 11.39
Yes	14.55 ± 6.49					29.70 ± 10.38

Numbers in bold indicate significant p values

Table 3.

Bivariate analyses of factors associated with anxiety and wellbeing

	Anxiety					Wellbeing
Variable	Mean ± SD	T	df	p	Effect size	Mean ± SD	t	df	p	Effect size
Gender		−3.26	482	0.001	0.310		3.39	482	0.001	0.331
Male	16.07 ± 11.48					16.73 ± 5.09
Female	19.80 ± 12.28					14.90 ± 5.71
Parental situation		−0.79	482	0.429	0.147		1.03	482	0.304	0.191
Together	18.51 ± 12.05					15.55 ± 5.54
Divorced	20.29 ± 13.54					14.48 ± 6.17
Smoking		1.08	482	0.283	0.100		0.72	482	0.473	0.067
No	19.09 ± 12.36					15.63 ± 5.40
Yes	17.87 ± 11.80					15.25 ± 5.87
Alcohol		0.34	482	0.737	0.048		1.17	482	0.243	0.166
No	18.69 ± 12.29					15.59 ± 5.59
Yes	18.11 ± 11.03					14.66 ± 5.50
Cannabis use		2.14	482	0.046	0.370		0.14	482	0.888	0.035
No	18.78 ± 12.24				0.519	15.49 ± 5.63
Yes	14.29 ± 8.31					15.29 ± 4.16
Psychological problems		−2.88	482	0.004			3.83	482	< .001	0.690
No	18.19 ± 11.99					15.74 ± 5.52
Yes	24.45 ± 12.88					11.94 ± 5.33

Numbers in bold indicate significant p values

Table 4.

Correlations of continuous variables

	1	2	3	4	5	6	7	8
1. Aggression	1
2. Depression	0.46***	1
3. Anxiety	0.46***	0.43***	1
4. Wellbeing	−0.44***	−0.49***	−0.44***	1
5. Prospective anxiety	0.29***	0.41***	0.43***	−0.37***	1
6. Inhibitory anxiety	0.28***	0.45***	0.36***	−0.27***	0.78***	1
7. Fear of war	0.16***	0.27***	0.35***	−0.31***	0.36***	0.32***	1
8. Age	−0.05	−0.12*	−0.11*	0.08	−0.05	−0.03	0.03	1
9. Household crowding index	0.05	0.09	0.04	−0.12**	0.13**	0.11*	0.18***	−0.09*

^*p < 0.05; **p < 0.01; ***p < 0.001. Numbers refer to Pearson correlation coefficients Numbers in bold indicate significant p values

Mediation analysis

All assumptions were met before performing the mediation analysis; (1) the dependent, independent and mediator variables are all continuous, (2) the data did not show multicollinearity, and (3) the variables followed a normal distribution. The mediation analysis taking aggression as the dependent variable, was adjusted over the following covariates: psychological problems and parental situation. The results of the mediation analysis showed that prospective anxiety (indirect effect: Beta = 0.08; Boot SE = 0.02; Boot CI 0.04; 0.11) and inhibitory anxiety (indirect effect: Beta = 0.07; Boot SE = 0.02; Boot CI 0.04; 0.10) fully mediated the relation between fear of war and aggression. Higher fear of war was significantly associated with more prospective anxiety/inhibitory anxiety, whereas more prospective anxiety/inhibitory anxiety were significantly associated with more aggression. Fear of war was not directly associated with aggression (Figs. 1 and 2).

Fig. 1.

(a) Relation between fear of war and prospective anxiety (R² = 0.139); (b) Relation between prospective anxiety and aggression (R² = 0.092); (c) Total effect of fear of war on aggression (R² = 0.032); (c’) Direct effect of fear of war on aggression. Numbers are displayed as regression coefficients (standard error). ***p < 0.001. Solid lines represent significant associations and dashed lines represent non-significant associations

Fig. 2.

(a) Relation between fear of war and inhibitory anxiety (R² = 0.106); (b) Relation between inhibitory anxiety and aggression (R² = 0.086); (c) Total effect of fear of war on aggression (R² = 0.032); (c’) Direct effect of fear of war on aggression. Numbers are displayed as regression coefficients (standard error). ***p < 0.001. Solid lines represent significant associations and dashed lines represent non-significant associations

The mediation analysis taking depression as the dependent variable, was adjusted over the following covariates: sex, parental situation, smoking, psychological problems, age and household crowding index. The results of the mediation analysis showed that prospective anxiety (indirect effect: Beta = 0.05; Boot SE = 0.01; Boot CI 0.03; 0.07) and inhibitory anxiety (indirect effect: Beta = 0.06; Boot SE = 0.01; Boot CI 0.04; 0.08) partially mediated the relation between fear of war and depression. Higher fear of war was significantly associated with more prospective anxiety/inhibitory anxiety, whereas more prospective anxiety/inhibitory anxiety were significantly associated with more depression. Higher fear of war was directly associated with depression (Figs. 3 and 4).

Fig. 3.

(a) Relation between fear of war and prospective anxiety (R² = 0.145); (b) Relation between prospective anxiety and depression (R² = 0.092); (c) Total effect of fear of war on depression (R.² = 0.032); (c’) Direct effect of fear of war on depression. Numbers are displayed as regression coefficients (standard error). **p < 0.01; ***p < 0.001

Fig. 4.

(a) Relation between fear of war and inhibitory anxiety (R² = 0.110); (b) Relation between inhibitory anxiety and depression (R² = 0.290); (c) Total effect of fear of war on depression (R.² = 0.152); (c’) Direct effect of fear of war on depression. Numbers are displayed as regression coefficients (standard error). *p < 0.05; ***p < 0.001

The mediation analysis taking anxiety as the dependent variable, was adjusted over the following covariates: sex, psychological problems, age and ever cannabis use. The results of the mediation analysis showed that prospective anxiety (indirect effect: Beta = 0.10; Boot SE = 0.02; Boot CI 0.07; 0.15) and inhibitory anxiety (indirect effect: Beta = 0.08; Boot SE = 0.02; Boot CI 0.05; 0.12) partially mediated the relation between fear of war and anxiety. Higher fear of war was significantly associated with more prospective anxiety/inhibitory anxiety, whereas more prospective anxiety/inhibitory anxiety were significantly associated with more anxiety. Higher fear of war was directly associated with higher anxiety (Figs. 5 and 6).

Fig. 5.

(a) Relation between fear of war and prospective anxiety (R² = 0.143); (b) Relation between prospective anxiety and anxiety (R² = 0.245); (c) Total effect of fear of war on anxiety (R.² = 0.149); (c’) Direct effect of fear of war on anxiety. Numbers are displayed as regression coefficients (standard error). ***p < 0.001

Fig. 6.

(a) Relation between fear of war and inhibitory anxiety (R² = 0.110); (b) Relation between inhibitory anxiety and anxiety (R² = 0.218); (c) Total effect of fear of war on anxiety (R.² = 0.149); (c’) Direct effect of fear of war on anxiety. Numbers are displayed as regression coefficients (standard error). ***p < 0.001

The mediation analysis taking wellbeing as the dependent variable, was adjusted over the following covariates: sex, alcohol drinking, psychological problems, age and household crowding index. The results of the mediation analysis showed that prospective anxiety (indirect effect: Beta = -0.04; Boot SE = 0.01; Boot CI -0.06; -0.02) and inhibitory anxiety (indirect effect: Beta = -0.02; Boot SE = 0.01; Boot CI -0.04; -0.01) partially mediated the relation between fear of war and wellbeing. Higher fear of war was significantly associated with more prospective anxiety/inhibitory anxiety, whereas more prospective anxiety/inhibitory anxiety were significantly associated with lower wellbeing. Higher fear of war was directly associated with lower wellbeing (Figs. 7 and 8).

Fig. 7.

(a) Relation between fear of war and prospective anxiety (R² = 0.148); (b) Relation between prospective anxiety and wellbeing (R² = 0.203); (c) Total effect of fear of war on wellbeing (R.² = 0.137); (c’) Direct effect of fear of war on wellbeing. Numbers are displayed as regression coefficients (standard error). ***p < 0.001

Fig. 8.

(a) Relation between fear of war and inhibitory anxiety (R² = 0.105); (b) Relation between inhibitory anxiety and wellbeing (R² = 0.166); (c) Total effect of fear of war on wellbeing (R.² = 0.137); (c’) Direct effect of fear of war on wellbeing. Numbers are displayed as regression coefficients (standard error). ***p < 0.001

Bivariate analysis of factors associated with suicidal ideation

A higher percentage of participants with suicidal ideation were females and had psychological problems. A lower mean age and higher mean prospective and inhibitory anxiety scores were found in participants with suicidal ideation (Table 5).

Table 5.

Bivariate analysis of factors associated with suicidal ideation

Variable	Absence of suicidal ideation	Presence of suicidal ideation	t / X2	df	p
Sex			3.93	1	0.048
Male	138 (90.2%)	15 (9.8%)
Female	276 (83.4%)	55 (16.6%)
Parental situation			0.64	1	0.428
Together	389 (85.9%)	64 (14.1%)
Divorced	25 (80.6%)	6 (19.4%)
Smoking			0.27	1	0.604
No	256 (86.2%)	41 (13.8%)
Yes	158 (84.5%)	29 (15.5%)
Alcohol			0.002	1	0.968
No	366 (85.5%)	62 (14.5%)
Yes	48 (85.7%)	8 (14.3%)
Cannabis use			0.14	1	0.723
No	400 (85.7%)	67 (14.3%)
Yes	14 (82.4%)	3 (17.6%)
Psychological problems			33.14	1	< 0.001
No	397 (88.0%)	54 (12.0%)
Yes	17 (51.5%)	16 (48.5%)
Age	28.22 ± 11.48	24.84 ± 8.68	2.86	482	0.005
Household crowding index	1.12 ± .47	1.09 ± .52	0.46	478	0.648
Fear of war	36.14 ± 13.63	37.30 ± 13.24	−0.66	482	0.508
Prospective anxiety	19.15 ± 6.56	21.41 ± 5.73	−2.72	482	0.007
Inhibitory anxiety	12.67 ± 4.67	14.04 ± 4.97	−2.25	482	0.025

Numbers in bold indicate significant p values

The mediation analysis taking suicidal ideation as the dependent variable, was adjusted over the following covariates: sex, psychological problems, and age. The results of the mediation analysis showed that prospective anxiety (indirect effect: Beta = 0.01; Boot SE = 0.004; Boot CI 0.001; 0.02), but not inhibitory anxiety (indirect effect: Beta = 0.01; Boot SE = 0.004; Boot CI -0.001; 0.02), fully mediated the relation between fear of war and suicidal ideation. Higher fear of war was significantly associated with more prospective anxiety, whereas more prospective anxiety was significantly associated with more suicidal ideation. Higher fear of war was not directly associated with suicidal ideation (Fig. 9).

Fig. 9.

(a) Relation between fear of war and prospective anxiety (R² = 0.143); (b) Relation between prospective anxiety and suicidal ideation (R² = 0.129); (c’) Direct effect of fear of war on suicidal ideation (R.² = 0.129). Numbers are displayed as regression coefficients (standard error). ***p < 0.001

Discussion

After a thorough review of previous literature, this study to the best of our knowledge is the first study to assess the mediating role of intolerance of uncertainty between fear of war and aggression, depression, anxiety, suicidal ideation and wellbeing in adults during the Israeli-Palestinian war of 2023. Results reveal that prospective and inhibitory anxiety partially mediated the association between fear of war and depression, fear of war and anxiety, and fear of war and wellbeing, while they fully mediated the association between fear of war and aggression. Moreover, prospective anxiety fully mediated the association between fear of war and suicidal ideation, however, inhibitory anxiety did not play a mediating role in this association.

The relationship between fear of war & mental health

We found that more fear of war was significantly associated with more depression, anxiety and lower wellbeing. This is in line with current literature, reinforcing the idea that fearing a distressing event such as war plays a significant role in negatively influencing mental health [33–35, 39]. Devastation and disruption produced by war have major psychological and social repercussions, one of which is fear, particularly fear of war [1, 31]. The possibility of loss, displacement and violence generates a deep sense of threat which keeps the individual in a state of hypervigilance. Although this response is manageable in the short term, prolonged periods of war will eventually lead to chronic stress, which in turn will lead to anxiety and depression. As evidenced by the Israel-Palestine conflict, additional key factors play a role in heightening sensitivity towards traumatic events such as generational trauma, which is a phenomenon where the psychological effects of past trauma are passed down from one generation to the next [76]. Children born into such environments may grow up hearing stories of suffering, loss, and fear from their parents or grandparents, which not only shapes their worldview but also predisposes them to experience similar fears and anxieties [77].

However, this study demonstrates that fear of war was not directly associated with aggression nor suicidal ideation, which means that developing fear of war does not explain an individual’s aggressive behavior and thoughts of suicide without the effect of intolerance of uncertainty. Furthermore, extreme psychological outcomes such as suicidal ideation and aggression often require interaction with additional variables. For example, economic and environmental stressors, such as poverty or displacement, can exacerbate the psychological impact of fear, Heightening the risk of aggressive behavior and suicidal tendencies [78]. Similarly, culture and society shape how fear is perceived and expressed, determining whether it is externalized as aggression or internalized as despair [79]. Without these interacting factors, fear of war alone may not be sufficient to trigger suicidal ideation or aggressive behaviors.

Fear of war and intolerance of uncertainty

Regarding fear of war and intolerance of uncertainty, this study revealed a positive association between fear of war and prospective/inhibitory anxiety; which is in line with prior findings that fear of major threats such as war can heighten excessive worry about future events and fear of taking actions when facing uncertainty [40]. This can be attributed to the cautiousness and inhibition people exposed to war develop, fearing that any action could lead to disastrous consequences, thus fueling intolerance of the uncertain.

The relationship between prospective/inhibitory anxiety and mental health

On one hand, prospective and inhibitory anxiety were shown to be significantly associated with higher rates of aggression. This is consistent with previous literature [48], which explains that feeling constant anxiety about the future and internal restraint results in more vigilance and hyper-awareness of potential dangers causing a heightened state of alertness leading to stress which can be translated into aggressive behavior [80].

On the other hand, greater levels of prospective and inhibitory anxiety were significantly associated with higher levels of depression. This lines up with previous studies [45, 46], in that they both demonstrate the same underlying concept, meaning that the inability to accept and manage unknown outcomes can lead to constant worry and stress which contributes to the development of depressive symptoms [81].

Moreover, greater prospective anxiety and inhibitory anxiety were significantly associated with more anxiety. Similar results were observed in numerous previous studies [44]. This stems from the perception of uncertainty as a threat that creates fear and discomfort. As a result, individuals might experience excessive worrying and overthinking [82]. In addition, more prospective anxiety and inhibitory anxiety were significantly associated with lower wellbeing. Previous studies also showed that intolerance of the uncertain significantly contributes to lower wellbeing [47], given that ongoing worry and fear limit emotional resilience and prevent individuals from fully engaging in life, resulting in diminished overall quality of life [83].

When it comes to suicidal ideation, more prospective anxiety is significantly associated with more suicidal ideation while inhibitory anxiety is not significantly associated with suicidal ideation. As expected, since inhibitory anxiety restricts a person’s actions and behaviors whereas prospective anxiety creates a persistent state of stress and hopelessness often leading to developing suicidal thoughts [84]. Former research established the association between intolerance of uncertainty and suicidal ideation [49]. However, no studies have specifically examined how its subtypes, prospective and inhibitory anxiety, contribute to this relationship.

Mediation analysis

Prospective anxiety and inhibitory anxiety partially mediated the association between fear of war and several psychological aspects: depression, anxiety, and well-being. This means that when fear of war is present, these two forms of anxiety intervene in the development of these problems, but they only partially explain this relationship. This makes sense, because fear of war stems from anticipated threat that pushes to a state of heightened vigilance [85]. In addition, inhibitory anxiety, linked to the inability to act in the face of the threat, also plays a role by increasing stress levels, which can worsen depression, anxiety or reduce well-being [86].

However, the association between fear of war and aggression is completely mediated by these forms of anxiety, which means that they fully explain this link. This makes sense because fear of war is associated with increased intolerance of uncertainty but not directly with aggression.

Anxiety, whether prospective or inhibitory, can create intense emotional tension, which sometimes manifests as aggression in response to this frustration and feeling of helplessness [87].

As previously mentioned, fear of war was not directly associated with suicidal ideation, however, it was linked to increased intolerance of uncertainty. The mediation analysis demonstrated that prospective anxiety fully mediated the relationship between fear of war and suicidal ideation. This is consistent because prospective anxiety, which involves fear of what might happen in the future, can lead an individual to consider hopeless outcomes, such as suicide, to escape this constant anticipation of danger. Conversely, inhibitory anxiety did not play a mediating role in this case, probably because blocking action does not directly lead to suicidal thoughts in the same way that prolonged fear of the future does [88].

Clinical implications

These findings suggest that interventions to reduce intolerance of uncertainty might play a crucial role in managing the negative effects of fear of war on mental health. By helping individuals tolerate uncertainty, it is possible to decrease symptoms of anxiety and depression, along with aggressive behavior and suicidal ideation. Mental health professionals could integrate uncertainty management strategies into their therapeutic approaches to improve the well-being of people exposed to war contexts. For example, developing specific programs based on Cognitive Behavioral Therapy (CBT) to help individuals manage their intolerance to uncertainty. These programs could include techniques to change negative beliefs and thoughts related to uncertainty, to reduce the impact that fear of war has on mental health. Another example is setting up psychosocial support groups which can help address the effects of fear of war. These groups can provide a safe space to discuss uncertainty and its impacts, while also providing coping strategies to improve individuals' resilience and well-being.

Limitations

Several limitations must be considered. The research design employed a cross-sectional approach, that hinders the formation of causal associations between variables. Subsequent studies could benefit from longitudinal designs for an improved comprehension of temporal dynamics. Information bias is evident, which is common in all cross-sectional studies, as participants are inclined to exaggerate or minimize the severity of their symptoms. The snowball sampling method may have led to an overrepresentation of certain groups (e.g., younger, more educated participants), which could have influenced the association between the variables and the results of the mediation analysis. In addition, the sample might not be representative of the general population due to selection bias, as some individuals may have refused to participate in the survey.Furthermore, other factors, such as previous mental health conditions, cultural influences and proximity to conflict zones, were not measured and could have influenced the results. Finally, participants were not inquired about whether they had been treated or diagnosed by a physician for depression or anxiety.

Conclusion

In conclusion, exposure to war results in a series of outcomes, one of which is fear of war. Psychological and behavioral implications such as aggression, depression, anxiety, suicidal ideation, and wellbeing are profoundly influenced by the fear of war. Our findings demonstrate an exacerbation of these psychological issues by fear of war, with intolerance of uncertainty serving as an important mediator in these associations. These results emphasize the importance of addressing intolerance of uncertainty in both research and clinical settings. Longitudinal studies are essential to gain more insight into the long-lasting effects of intolerance of uncertainty and fear of war on mental health, providing valuable insights into changes over time. Additionally, Future perspective studies are essential to investigate how intolerance of uncertainty and fear of war shape mental health challenges, offering theoretical frameworks for intervention.

Author contributions

FFR, SO and SH designed the study; YN drafted the manuscript; SH carried out the analysis and interpreted the results; FS, MD and DM collected the data. FFR, SH and SO reviewed the paper for intellectual content; all authors reviewed the final manuscript and gave their consent.

Funding

None.

Data availability

All data generated or analyzed during this study are not publicly available due the restrictions from the ethics committee, but are available upon a reasonable request from the corresponding author (SH).

Declarations

Ethics approval and consent to participate

Ethics approval for this study was obtained from the ethics committee of the School of Pharmacy at the Lebanese International University (2024ERC-024-LIUSOP). Written informed consent was obtained from all subjects; the online submission of the soft copy was considered equivalent to receiving a written informed consent. All methods were performed in accordance with the relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.