Mental health amidst chronic crises: the case of Arab countries from the Middle East

Abstract

Introduction

For decades, Arab countries in the Middle East—particularly Palestine, Lebanon, and Syria—have faced overlapping armed conflicts, political instability, economic collapse, and large-scale displacement. These protracted and compounding crises expose populations to cumulative trauma, leading to a higher prevalence of mental health disorders and long-term cognitive-emotional repercussions. In such contexts, social determinants—including poverty, insecurity, and systemic neglect—interact with trauma exposure to shape vulnerability and resilience in complex ways. The region is a critical ground for trauma and mental health research, offering insights into the effects of chronically stressful environments on both vulnerability factors and adaptive processes.

Methods

This scoping review synthesizes peer-reviewed literature published between 2014 and 2024, focusing on the mental health impact of regional conflicts in Lebanon, Palestine, and Syria—countries marked by some of the highest levels of war-related trauma exposure. Drawing from five major databases, it highlights studies examining both psychiatric disorders (e.g., PTSD, major depression) and broader cognitive-affective disruptions in individuals not meeting diagnostic criteria but exposed to chronic adversity.

Results

Findings reveal two central patterns: first, a heightened and persistent prevalence of psychiatric conditions in contexts of multi-crisis exposure, often exacerbated by systemic instability and poor access to care; second, growing documentation of emotion and cognition alterations among individuals considered “healthy,” underscoring repercussions of trauma beyond disease. Despite these burdens, mental health systems remain underfunded, fragmented, and poorly integrated into broader health and social frameworks. Large-scale longitudinal studies and culturally grounded approaches remain limited across the region.

Conclusion

Mental health infrastructures in the Middle East must evolve beyond reactive, externally driven models and toward resilient, context-sensitive systems rooted in local realities. This requires increased investment in trauma-focused longitudinal research, regionally adapted tools for assessment and care, and policy mechanisms that directly translate research insights into scalable social and governmental responses. The region’s complexity makes it an essential lens for global trauma research, demanding both attention and sustained support.

Introduction

Multiple crises took place, most of which are still ongoing in Arab countries from the Middle East. Originally, we intended to use the word “war”, or even “conflict” instead of “crisis” in the first sentence of this review. Unfortunately, the binary conceptualization of "war" and "post-war" is not as clear-cut in the studied region; past and present are often intertwined and form a magma of everlasting catastrophe. As for the word “conflict”, it seems restricted to violent and tactical events and does not embrace regional financial or societal crises. By selecting the word crisis, we also touch upon the complexity of this region, as krisis etymologically means “decisive point”; in such, “chronic crises” means that every moment is, constantly, a decisive one, with the weight, pressure and stress that can spring from such a situation, as opposed to punctual exposure to adversities, followed by secure periods and spaces. Indeed, every time the Middle East attempts to recover from a crisis, it undergoes new waves of intense violence and terror attacks. The most recent examples include the ongoing 12+ year war in Syria; the accumulation of multiple crises in Lebanon since 2019, culminating in the Beirut port explosion of August 4, 2020; and the genocide in Gaza beginning in October 2023, marking over 75 years of continuous violence and mass atrocities in occupied Palestine. As the populations grapple with mounting crises, the field offers a unique opportunity to explore the impact of cumulative trauma, both on individuals and as a collective experience, and to study social determinants that exacerbate or protect from the development of mental health illnesses in such context. In turn, researchers in the sector could and should leverage their data to better assist individuals in the region with reintegrating into their communities and daily activities, or at least in adapting to the ever-changing sociopolitical landscape [101], where instability remains the only constant. Results could also shed light on other global multi-crisis contexts, given the growing prevalence of collective trauma experiences globally in recent years, whether at a pandemic, financial, or security level [11, 86].

Mental health studies in the Middle East are scarce, both due to lack of funds, but also as a reflection of political and economic priorities that shape research funding agendas. In contrast to comparatively well-funded fields such as HIV, fertility control, and pharmaceutical research, mental health research in conflict-affected Arab countries remains structurally under-supported. This is particularly alarming given the fact that, despite the scarcity, available data indicates that regional conflicts are associated with increased propensity to develop anxiety and mood disorders [23, 57]. This finding is consistent with previous data from other wars and conflicts [53] including results from the World Mental Health Survey Initiative, which highlights the association between exposure to civil violence and an elevated risk of mental disorders among civilians for many years after initial exposure [7, 41]. While these alterations are reversible in a healthy, stable, and peaceful post-conflict context, that alleviates the stress and reduces the persistency of disease over time [20, 29, 60, 91], data suggests that the unstable middle eastern context characterized by continuous exposure to political violence, repetitive displacement, and prolonged socio-professional limitations, slows the healing process and exacerbates the persistency of psychiatric disorders on the long run [18, 20, 37, 48, 60]. Furthermore, in addition to having a strong impact on the propensity to develop certain mental health disorders, the ongoing multi-crisis context, with its chronic stress, violence and uncertainty, revives traumas, sustains fears, and prolongs the feeling of insecurity beyond disease, on a more nuanced continuum. This results in cognitivo-affective alterations, i.e. intertwined modifications in both cognitive processes (such as thinking and memory) and affective experiences (such as emotions and attitudes) with one influencing the other, not only in diagnosed subjects but also in “resilient”, “apparently healthy” individuals from the general population [13, 26, 56, 78, 97].

Here we review the literature on mental health and trauma amidst middle eastern conflicts, emphasizing why these large at-risk populations should be studied, especially at this specific, acute phase. The first part of our work focuses on mental health disorders with increased propensity in middle eastern multi-crisis contexts (i.e., PTSD and mood disorders), whereas the second part more broadly explores cognitivo-affective particularities in the region, with attempts to link chronic stress to collective traits in a generally “healthy” population, in which mental health conditions have been far from optimal for a long while, and are bound to further deteriorate [65]. Based on our review, we call for increased investment in mental health and trauma research in the region, and emphasize the necessity to build large-scale longitudinal studies that encompass different time points, as wars and crises unfold over time. We also stress the importance of including technology-driven translations of the results into societal and governmental solutions.

Methods

Our paper is a scoping review as it assesses the potential scope of available literature on the topic of prolonged cumulative trauma in Arab countries from the Middle East, and has the purpose to identify existing gaps and suggest directions for further research [82]. Two elements were key:

1. The date, because multi-crisis contexts evolved significantly across the years. We chose to focus on the literature from the past ten years, from 2014 to 2024, as they were highly tumultuous in several countries from the region, and were met by a particularly scarce number of reviews.

2. Geographical delimitation. Not all Arab countries commonly grouped under the term “Middle East” have experienced comparable forms or intensities of crisis. Although the region comprises 13 Arab countries (Bahrain, Egypt, Iraq, Jordan, Kuwait, Lebanon, Oman, Palestine, Qatar, Saudi Arabia, Syria, United Arab Emirates, and Yemen), this review does not treat them as a homogeneous unit. We initially screened literature from all 13 countries; however, inclusion was restricted to countries characterized by chronic exposure to cumulative and overlapping collective adversities—including armed conflict, political instability, economic collapse, and large-scale displacement—over the past decade. On this basis, the review focuses on Lebanon, Palestine, and Syria, which share sustained, multi-layered war-related trauma exposure across multiple generations. While Jordan is culturally and geographically part of the Levant, its historical trajectory does not reflect the same degree of prolonged, overlapping crises and was therefore excluded on methodological rather than cultural grounds.

We systematically searched the following electronic databases: PsycINFO, PubMed, PubMed Central, Scopus and Web of Science for studies on either mental health or cognitive-affective repercussions of chronic multi-crisis. The search covered publications from January 2014 to December 2024, a period selected to capture the most recent decade of intensified and overlapping crises in the region, during which armed conflict, political instability, economic collapse, and mass displacement escalated substantially, while remaining under-synthesized in existing reviews.

Search terms combined mental health and cognitivo-affective keywords (mental health; psychiatric disorders; PTSD; major depressive disorder; depression; cognitive alterations; memory impairments; emotion dysregulation; trauma exposure) with geographic identifiers (Middle East; Arab countries; Levant; Lebanon; Syria; Palestine). We conducted this scoping review according to the methods described by Arksey and O’Malley [6].

Inclusion criteria were: (1) original quantitative or mixed-methods peer-reviewed studies; (2) focus on populations exposed to conflict-related or structurally driven crises in the targeted countries; and (3) outcomes related to mental health disorders or cognitive-affective functioning. Exclusion criteria included studies focusing primarily on COVID-19, medical comorbidities (e.g., cancer, epilepsy), substance use disorders unrelated to trauma exposure, or populations outside the defined geographic scope.

All records were screened in two stages (title/abstract, then full text) for relevance to the review objectives. As this study followed a scoping review methodology, no formal risk-of-bias assessment was conducted; instead, studies were evaluated for conceptual relevance, population characteristics, exposure type, and outcome alignment. We scanned all articles but only selected the ones directly related to a crisis context specific to the region. The selection process and final sample are reported in accordance with PRISMA-ScR guidelines, with a detailed flow diagram presented in Fig. 1. This approach was chosen to map the breadth of available evidence, identify gaps, and inform future research directions rather than to estimate pooled effect sizes.

Fig. 1.

PRISMA Extension for Scoping Reviews (PRISMA-ScR): flow diagram

Part I—Cumulative trauma exposure and mental health disorders

The aftermath of wars is associated with higher lifetime risks of developing mood and anxiety disorders as shown by the World Mental Health Survey Initiative [41]. What happens though when the aftermath of war is yet another conflict? In this first part, we review the literature on the two main mental health disorders associated with the chronic middle eastern multi-crisis context [37]: PTSD and Major Depression.

PTSD

Based on a pool of systemic reviews [3, 57], prevalence of PTSD is particularly high in the Middle East, ranging from 15 to 40% depending on the countries and the year of publication, against a 6.8% lifetime prevalence in the USA according to the National Comorbidity Survey of the NIH. This rate should of course be interpreted with caution given the challenge in conceptualizing and measuring PTSD in a background of continuous and cumulative trauma.

Exposure to combats appears to be a major cause of PTSD in the region [28], affecting both people who remain in the countries where war traumas occur [3, 38, 39, 54], and people who flee their countries, including displaced Iraqi [51], Palestinian [3, 35, 60], or Syrian refugees [5, 75, 85], both children [83] and adults [70], as well as American soldiers deployed in middle eastern war zones [19].

A large body of work on these different middle eastern populations confirm previous PTSD research on attention-biases towards or away from threat [50], the maintenance of a sense of threat beyond exposure [20], and diminished positive affect [40]. What is most interesting however, are the specificities observed in populations facing cumulative rather than punctual trauma in the region.

Contextual and structural determinants of PTSD severity in chronic conflict settings

A review of twenty-four studies in Palestine (both Gaza and the West Bank) highlights the complex interplay of several environmental factors, including living under occupation, inconsistent availability of medication, and fragmental mental health services, in the symptomatology and persistency of PTSD in the country [60]. While the overall prevalence of PTSD in Palestine is at 36% according to Agbaria et al.’s systemic review in 2021, studies conducted on punctual events and sub-populations indicate a drastic increase in this rate, as it is the case with injured participants of the Great March of Return that was associated with a 95.4% PTSD prevalence [2]. Similarly, in Lebanon, 11 PTSD risk factors were identified in a civilian population one year after the 2006 War in South Lebanon, in a research paper published in 2013, within the 10-year window of our review: gender, education level, marital and employment status, village of residence, social support, exposure to trauma, loss of resources, physical illness, tranquillizer use, substance use, financial problems [38]. These findings underscore the need for primary prevention addressing the impact of chronic violence under war or occupation and the establishment of a multidisciplinary mental health care system to address the substantial challenges due to cumulative political violence, and to tailor these approaches to the different subgroups of individuals [83].

Cumulative trauma exposure across post-displacement populations

A questionnaire-based study on Syrian refugees in Norway further shows that cumulative exposure to traumatic experiences increases not only the risk of developing PTSD, but also its duration and intensity [70]. This is in line with a study on Sudanese refugees demonstrating how avoidance behavior, emotional reactivity and overall PTSD severity were proportionally linked to the level and the duration of trauma exposure on the long term [21]. In such, it would be interesting to compare the longitudinal results of Syrian, Iraqi, and Sudanese refugees in stable countries such as Sweden [83], Norway [70], or Turkey [43, 51] to refugees regionally relocated to other unstable, uncertain multi-crisis contexts such as Lebanon [75] or Palestine [3]. Although first analyses suggest that the relocation in “stable” countries favors healing [70], more direct comparisons, and more data on mental health in the Middle East are needed to draw significant findings.

Acute traumatic events as compounding stressors within chronic crisis contexts

Although the regional landscape is characterized with the chronicity of crises, exposure to specific events can act as turning points. Indeed, a growing body of research studied the psychological effects of the Beirut Port blast on survivors’ mental health [31]. Results showed that nearly two-thirds showed symptoms of PTSD, reflecting the event’s profound psychological toll [4]. PTSD was more prevalent among women and those with depressive symptoms or prior psychiatric vulnerability [4, 16, 32, 34]. The impact of the blast was also investigated in specific populations, including healthcare providers [16, 45] and university students [32, 34], both of whom demonstrated high levels of stress, PTSD symptoms, and maladaptive coping mechanisms [16, 32, 34, 45]. Some studies also revealed that the Beirut Port blast impacted sense of coherence—defined as the ability to perceive life as comprehensible, manageable, and meaningful—and mentalizing capacities, both of which are key resilience factors [17, 93]. These findings suggest possible disruptions in underlying brain structures involved in emotion regulation and adaptive coping, particularly the prefrontal cortex and amygdala [17, 93]. In other words, even in chronic crisis contexts, it remains essential to examine the specific impact of each traumatic event, recognizing their potential to act as distinct and compounding adversities.

Intergenerational transmission of continuous trauma

Another interesting particularity that comes out of trauma research in the region focuses on intergenerational effects of chronic war trauma [71, 76, 77, 94]. For instance, a study exploring a family approach to trauma, as opposed to the more conventionally researched individual response, identified four family types based on attachment, parenting, and sibling relations. The largest type reflected secure attachment and optimal relationships, while the smallest exhibited insecurity and problematic relationships. In between, families with discrepant experiences or moderate security and neutral relationships emerged [77]. Further analyses of how these family types differed concerning war trauma revealed that the family type characterized by insecurity and negative relationships showed the highest levels of war trauma, with an increase in children’s internalizing and externalizing symptoms, as well as cognitive dysfunctions [77]. The findings highlight the importance of a family systems approach to mental health interventions in war-affected children and suggest tailoring treatments to unique family attachment patterns. The same research group had also shown that, out of three possible trajectories for trauma exposed children with PTSD (recovery, resistance and increased symptoms), fathers’ attachment security was associated with the resistant trajectory [76], reflecting the paternal role in life threat and in Arab cultures [76], a result that is consistent with previous findings where the father’s past war trauma showed negative association with attachment security, but positive association with the child’s mental health problems [71]. As for mother-child transmissions, a study on Palestinian mothers and their infants living in the Gaza strip indicates a protective role for high posttraumatic growth (i.e. one of the rare beneficial gains of war atrocities [61]) and positive posttraumatic cognitions (i.e. capacity to make sense and reconstruct new meanings [27]) on their infants’ stress levels and general mental health [30].

In summary, PTSD studies in middle eastern populations reveal that, in addition to internal traits (coping styles for examples), contextual factors such as instability, uncertainty and the extent to which individuals feel they can control events around them, can help predict the development and long-term prognostic of PTSD. In addition, intergenerational factors must be taken into account as the adverse impact of war trauma is not limited to those who experience it directly, but is passed on to future generations through multiple mechanisms [94].

Mood disorders (MD)

The most common mood disorder in the Middle East is major depression (MDD), with a particularly high rate compared to other countries and regions worldwide, although numbers vary widely across studies depending on factors such as country and time of measurement [8, 66, 68, 80, 81]. In the Lebanese population for instance, war exposure increased the risk of developing first onset mood disorders by three [54] and by four in Syrian refugees [9]. Similarly, almost 50% of Syrian refugees living in a Greek refugee camp [74] and 50% of Palestinians living in the West Bank and Gaza strip [8, 10] had a MDD in cross-sectional surveys. Depression-PTSD comorbidity is also more frequent in the Middle East with numbers ranging from 9 to 17% [39, 69], heightening the burden of mental illness, lowering psychosocial functioning, and corroborating the increasingly complex necessitation for treatment [18]. Finally, the region exhibits high rates of maternal [87] and post-partum [64] depression, both locally and among the displaced, highlighting intergenerational effects and the necessity for family-based interventions [63].

As per international classification criteria [58], MDD in individuals from the Middle East is characterized by sad mood, apathy, fatigue, combined with sleep, concentration, and psychomotor problems [10]. However, as we focus on regional specificities, individual differences, and contextual influences such as sociodemographic factors appear to serve as antecedents of symptom exacerbation or resilience [98]. More recently, home demolition or “domicide”, and urban landscape reshaping were added as risk factors in a review encompassing nine studies in Palestine [59]. Similar and additional factors were further identified across a multitude of studies.

For instance, Syrian refugees in Germany have less maladaptive coping and less MDD symptoms than Syrian refugees in Turkey [98], demonstrating the role of maladaptive coping in increasing vulnerability, and highlighting the importance of a healthy context for optimal healing of depression. Another interesting example is the comparison of Syrian refugees living in Turkey as opposed to a population of Syrians internally displaced [92]. Results reveal that, while both MDD and PTSD are highly prevalent in both populations, PTSD is more common in the internally displaced population and MDD is more prevalent among Syrian refugees in Turkey [92]. This underscores the significance of the resettlement locus and the conditions necessary for a population to transition from PTSD to MDD. It also means that both screening tools and effective treatment options should be differently selected depending on the context in which depressed and traumatized individuals live post-conflict.

Finally, the literature underscores the importance of post-migration factors, such as providing healthcare services, education, and employment opportunities in post-conflict zones; not only for their substantive value, but also for the sense of stability and optimism for the future they offer, ultimately alleviating pervasive symptoms of PTSD, mood disorders, and anxiety [36, 91]. The literature more broadly indicates that resilience itself is very dependent on the social context post-trauma [12, 48]. Unfortunately, little can be done in Middle Eastern countries where prolonged uncertainty and extreme violence prevent the establishment of safe environments conducive to healing. This underscores the imperative to undertake additional large-scale, longitudinal studies on these highly vulnerable populations. Such studies are essential for accurately portraying the evolution of each community’s mental health over time and examining the interplay between new traumas and existing ones. The overarching goal is to provide tailored treatment interventions accordingly.

Part II—Cognitivo-affective alterations beyond disease

As described earlier, the Middle East’s multi-crisis context is characterized by prolonged violence, chronic stress, and constant uncertainty, all of which have a wide spectrum of affections on mental health and the human brain beyond disease (). In this second part, we review publications on cognitivo-affective dysregulations associated with regional warfare, placing particular emphasis on memory alterations, which emerged as the most extensively documented change.

The term cognitivo-affective impact refers to intertwined alterations in cognitive processes and affective functioning that emerge in response to chronic stress and cumulative trauma, even in the absence of a diagnosable psychiatric disorder. It encompasses changes in cognitive domains such as attention, memory, executive functioning, and decision-making, alongside affective alterations including emotion regulation difficulties, negative affective bias, heightened threat sensitivity, blunted positive affect, and persistent feelings of insecurity or vigilance.

A wide range of cognitivo-affective dysregulations

Longitudinal studies on military personnel deployed in Iraq suggest that even in the absence of psychiatric disorders, conflicts can alter cognition and behavioral performance [20]. Another longitudinal study, on war-exposed civilians in Lebanon [37] also reveals that, while PTSD prevalence decreases in the long term after trauma exposure, negative cognition and low mood remain and are reinforced by socio-economic repercussions [37]. Similarly, large scale studies in youth showed 64.9% of Syrian school children in Idleb had a social, behavioral, or emotional dysfunction ranging from low/abnormal socialization and educational decline to emotional issues and bullying/aggressivity [79]. Additionally, 8–13-year-olds from Gaza demonstrated between 2.5- and 17-times higher point prevalence of cognitive and emotion dysfunctions (such as social problems, attention and memory deficits, aggression, etc.) compared to estimates from the U.S. population [29]. A similar large-scale study on 11–17-year-old Palestinians from Gaza indicate that cumulative exposure to violence increases the propensity of developing emotional and behavioral problems on the long run [35]. Interestingly, another large-scale study on Syrian refugees relocated to Jordan and Lebanon showed that long term cognitivo-affective impact of chronic trauma exposure did not require a previous PTSD diagnosis [55]. As a matter of fact, there are no significant differences between young individuals with PTSD and those who do not meet PTSD criteria: all children and adolescents with high levels of exposure to war-related trauma are more likely to suffer from adverse consequences such as emotion dysregulation [55].

Additionally, direct trauma exposure is not even necessary to induce emotion dysregulation in chronic multi-crisis contexts. Indeed, the impact can happen more implicitly, namely via intergenerational transmission. For instance, a study exploring the impact of paternal trauma exposure (fathers having lived the 1975–1990 Lebanese civil war) on their offspring (now adults who haven’t experienced the civil war) reveals that fathers’ traumatic experience of war influences emotion regulation strategy and alexithymia levels in their offspring (longitudinal studies needed to provide further information and subgroups as well as potential therapeutic indications) [33].

The chronic multi-crisis context can thus alter cognition and emotion on the long run beyond disease, even in the absence of diagnosis and direct exposure to trauma, confirming in humans what had already been shown in an animal model of chronic unpredictable stress [62].

Focus on memory alterations and the Living in History effect

The most documented cognitivo-affective alterations in the middle eastern context are related to memory. In times of conflict, chronic stress can impair memory by reducing its episodic retrieval [84], encoding, and retention [96], or by decreasing detail recollection accuracy [42] and spatial memory recognition [62].

Research indicates similar alterations in Middle Eastern populations. One extensively documented impact of regional conflicts on memory concerns autobiographical memories, specifically the Living in History (LiH) effect—the extent to which historical events reorganize autobiographical memory [99, 100]. A study comparing two Lebanese populations, a Beiruti population that lived in the epicenter of the civil war (1975–1990), and an indirectly exposed population, revealed a significantly stronger LiH effect in the Beirut sample and a significant yet weaker LiH effect in the indirectly exposed sample [99]. The study further demonstrated that reported personal experiences of war exposure predicted the strength of the LiH effect. These results suggest that both collective transitions and publicly motivated individual transitions play a role in the organization of autobiographical memory [100]. Another study on Palestinian children from Gaza, seeking to identify contents of early memories in children living in war conditions, revealed that about 30% of participants recalled traumatic events or accidents, and that these war traumas were further associated with less positive emotional tone and with more specific memories [73]. Aligned with autobiographical reconstructions, sense of coherence, defined as the global mindset to interpret the world and emerging stressors as comprehensible and manageable, has been linked to reduced stress following trauma exposure [17, 95]. In other words, cumulative trauma exposure, whether direct or indirect, is reshaping autobiographical memories of individuals in the region, and sense of coherence could play a protective role in the long run [72].

Other documented memory alterations associated with cumulative trauma exposure in the region concern emotional memory. In a working memory task with emotional distraction performed on Syrian refugee adolescents in Istanbul, Turkiye, high (vs. low) trauma individuals were less performant at remembering spatial locations of a cue, although both groups performed at very low levels [67]. Furthermore, individuals in both groups, not only the high trauma one, had a bias toward interpreting the emotional distraction faces as more negative [67], indicating that memory-related cognitivo-affective alterations were present even in the absence of proper diagnosis.

As previously stated, healthy environments increase the possibility of healing and decrease long term cognitive repercussions in trauma exposed individuals. Unfortunately, even when individuals from warzones in the Middle East manage to seek refuge in Western countries, they are often asked to recount very precise and painful memories as part of excessively long administrative processes [24]. In other words, even if they find themselves physically in safer, more stable environments, migrants are still not given space to cope with trauma and heal. In addition, a feasibility study on Syrian children refugees in Sweden reports elevated daily rates of intrusive memories (average of two per day) associated with concentration disruption [47], despite the fact that kids participating to the study were in safe environments. Of note, a study exploring the impact of war and displacement on executive functions in 12 to 18 year old Syrian refugees did not find any significant association between trauma exposure and executive functions [25]; this result however comes with important limitations, mostly the fact that the studied population had been displaced to safe environments for an average of three years at the time of testing, as well as the fact that the RACER tasks (Rapid Assessment of Cognitive and Emotional Regulation) used do not represent the entirety of adolescents’ executive functions [25].

In summary, there is a need not only to conduct more research on cognitivo-affective repercussions in regions experiencing chronic crises but also to investigate similar phenomena in refugees from these regions who are relocated to presumably safer environments in the West in order to better address their cognitive needs and ultimately improve their integration.

Discussion

This scoping review covered mental health and cognitive repercussions of the undergoing chronic multi-crisis context in levant countries in the past 10 years.

While the first part of the review shows that PTSD and depression are highly prevalent and exacerbated by chronic stressors—raising questions about the suitability of Western-derived diagnostic frameworks for chronic crisis settings—the second part reveals subclinical cognitivo-affective alterations, including autobiographical memory changes in undiagnosed individuals, and highlights the need for longitudinal research across other cognitive domains in these large at-risk populations.

Effectively, such research should (1) be ethically grounded and culturally adapted beyond replicating Western assessment models and (2) translate context-sensitive evidence into scalable therapeutic interventions and public health strategies centered on resilience.

Both points are discussed below.

Cultural specificities and relevant theoretical frameworks

Understanding mental health in contexts of chronic crisis in Arab societies exposed to chronic adversities requires theoretical frameworks that move beyond the application of Western psychiatric categories [49, 52]. A growing body of culturally grounded work emphasizes that trauma in the region is not only individual and event-based, but also collective, structural, and politically mediated. Such studies exploring how prolonged occupation, structural violence, and historical erasure shape mental suffering in Arab populations, challenge the adequacy of PTSD and major depressive disorder as standalone diagnostic lenses in contexts where threat, loss, and humiliation are continuous rather than episodic [52, 60]. The conceptualization of trauma as a lived condition embedded in social and political realities highlights phenomena such as moral injury, continuous traumatic stress, and the pathologization of resistance, thereby situating individual distress within collective histories and power asymmetries [44]. Complementing this perspective, Suad Joseph’s work foregrounds the relational and moral dimensions of subjectivity in Arab societies, emphasizing how kinship, family obligation, and communal belonging shape experiences of suffering, resilience, and care [49, 90]. From this viewpoint, psychological distress cannot be fully understood without accounting for interdependence, social roles, and the ethical injuries produced by prolonged instability and dispossession. Together, these frameworks underscore the necessity of context-sensitive approaches that reconceptualize trauma as cumulative, relational, and structurally sustained, rather than as an individual pathology detached from its sociopolitical environment. Integrating such culturally relevant theories strengthens the interpretation of both psychiatric disorders and cognitivo-affective alterations observed in the region and helps avoid reproducing Western-centric models that inadequately capture the lived realities of populations exposed to chronic, multi-generational crises.

“Resilience”, recovery, and adaptation in chronic crisis contexts

Resilience has emerged as a central but contested concept in trauma research, particularly in settings characterized by prolonged and recurrent adversity. Contemporary work by Bonanno and colleagues challenges deficit-based models of trauma by demonstrating the heterogeneity of post-trauma trajectories, including resilience, recovery, delayed distress, and chronic dysfunction, rather than a single dominant pathological outcome [14, 15, 46]. Importantly, resilience in this framework is not conceived as invulnerability, but as the capacity to maintain or regain functional adaptation over time through learning, flexibility, and context-dependent adjustment [14]. This perspective is especially relevant in chronic crisis contexts, where individuals and communities are repeatedly exposed to stressors and where recovery processes are iterative rather than linear.

Extending this view, Taleb’s concept of antifragility offers a complementary lens to understand adaptation under sustained uncertainty [88, 89]. Antifragility refers to systems that do not merely resist shocks but may reorganize and develop adaptive capacities through exposure to variability. While originally formulated in complex systems theory, this concept resonates with empirical observations in mental health, where certain coping strategies, meaning-making processes, and social practices emerge precisely through repeated exposure to adversity. However, benefits from stress remain bounded and context-dependent, and prolonged exposure can equally if not mostly result in cumulative harm.

In Arab, Levantine and particularly Palestinian contexts, the notion of “sumud” (steadfastness) captures a culturally embedded form of resilience that emphasizes continuity of everyday life, relational anchoring, and moral persistence rather than individual performance or symptom absence [1, 22]. Unlike Western resilience frameworks that often foreground individual adaptation, sumud reflects a collective, relational, and politically situated process, illustrating how resilience, recovery, and endurance are shaped by social meaning, historical continuity, and communal ties [22]. Integrating these perspectives allows for a more nuanced understanding of resilience in chronic crisis settings—one that acknowledges adaptation and learning without obscuring structural violence or minimizing psychological cost.

Limitations

First, a limitation of this review relates to the temporal scope of the literature examined. Although the review covered the period from 2014 to 2024 (a timeframe that includes the COVID-19 pandemic) studies specifically focused on COVID-19 were excluded. Given that the pandemic occurred alongside ongoing political, economic, and conflict-related crises in the region, its exclusion limits the ability to fully capture the compounded effects of concurrent global and regional stressors on mental health.

Second, defining inclusion and exclusion criteria in the Middle Eastern context remains inherently challenging. Countries in the region differ in their exposure to armed conflict, political instability, economic collapse, displacement, and duration of chronic adversity, making it difficult to draw clear methodological boundaries. As a result, decisions regarding country selection, types of exposure, and levels of chronicity may have influenced the composition of the reviewed literature.

Third, this review did not incorporate comparative analyses with other populations exposed to sustained, multi-generational trauma (e.g., Rohingya, Rwandan, or Cambodian populations). Although such comparisons may offer valuable insights, original data allowing methodologically coherent and non-arbitrary cross-regional comparisons were not consistently available. Given the scoping nature of this review, we therefore prioritized contextual specificity and internal coherence over breadth, which may limit generalizability but strengthens relevance to conflict-affected settings in the region.

Conclusion

This scoping review synthesizes evidence from the past decade showing that chronic, overlapping crises in Middle Eastern contexts are associated with high and persistent rates of PTSD and depression, as well as subclinical cognitivo-affective alterations that extend beyond diagnostic categories. Notably, these effects are shaped by continuous exposure to instability and uncertainty, and are observed even among individuals without formal diagnoses, underscoring the limits of Western-derived nosological models in chronic crisis settings. Future research should prioritize ethically grounded, longitudinal, and context-sensitive approaches—integrating culturally adapted assessment tools and translating findings into scalable psychosocial, digital, and public health interventions.

Author contributions

LJB did the literature review and wrote the paper. YA, NK, CK, participated in writing the first draft. RK, RI, FZ, CM, EB, SR and MA revised the manuscript.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

We did not analyze any primary or secondary quantitative data, and therefore, the concern of data availability is not relevant.

Declarations

Ethics and consent to participate

Not applicable.

Consent to publish

Not applicable.

Competing interest

The authors declare no competing interests.