Psychologists' perspective of mental health in Yemen during the civil war and COVID-19: a qualitative inquiry.

In comparison to other Middle Eastern nations that are experiencing conflicts and wars, Yemen has the greatest rate of mental health issues since the war was accompanied by distressing experiences and severe chronic psychological crises. This study aims to examine the current state of psychological problems from the perspectives of psychologists and psychiatrists in light of the ongoing civil war and the COVID-19 pandemic. This study included 20 psychologists and psychiatrists in total. Semi-structured face-to-face interviews with the psychologists and psychiatrists were done between October 2021 and December 2021 and between May 2022 and June 2022. Handwritten notes and field notes were used to record the interview process. The transcripts were inductively analysed using Braun and Clarke's thematic analytic approach to get the main themes and subthemes. The four major themes that emerged from the emerging codes are the impact of war on mental health, the impact of COVID-19 on mental health, the healthcare system, and the lack of awareness about mental health. These themes reveal how the civil war and COVID-19 contributed to Yemenis' mental health issues and resulting psychological disorders. Yemenis' mental health and well-being are under several threats; thus, the government and other relevant authorities must take urgent measures to lessen the impact of mental illness on society.

Introduction

One of the most dangerous pandemics in 2020, the coronavirus, has put the entire planet in danger. Every day, tens of thousands of people pass away, and hundreds of thousands more contract an infection (Clemente-Suárez et al., 2021). The majority of nations used preventative measures to stop the pandemic’s spread, including quarantine, border closures, and proactive isolation (Devi, 2020). Even though these methods have slowed down transmission, they have a big impact on economies and communities (Nicola et al., 2020). Wherein, people’s mental health and psychological distress are directly impacted by general health, economics, and social life (Kim & Hwang, 2020).

Initial reports showed a relationship between the COVID-19 pandemic and some mental health issues like depression, anxiety, stress, alcohol consumption, future uncertainty, and eating disorders (Altena et al., 2020). Traumatic experiences that occurred during the lockdown, including the death of a loved one, depression, anxiety, insomnia, and an act of gender violence, were found to raise the demands on and concerns about short-term mental health (Petersen et al., 2020). Therefore, psychiatrists and psychologists worldwide should be aware of the mental health implications caused by COVID-19 (Clemente-Suárez et al., 2021). However, there is little information about the impact of COVID-19 on mental health in Yemen, as well as how people are coping psychologically with COVID-19 and other crises (Al-Baadani & Abbas, 2020; Al-Hamdani, 2021).

The fact that COVID-19 has spread at a time when Yemen is going through a war and a dire economic scenario makes things much worse for Yemenis. In the previous seventeen years, Yemenis have endured more than seven wars, the most recent of which is currently ongoing (Ghanm, 2021). Eighty-one per cent of Yemenis, which is equivalent to 21 million persons, are estimated by some national and international organisations to be below the poverty line. These individuals require immediate aid in the form of food, housing, and clothing. At least one youngster dies from a preventable disease as a result of the escalating war every ten minutes (Bachman, 2019). Additionally, the population’s unemployment rate has climbed from 35% at the end of 2010 to over 65% in 2018, especially among young people (Family Counselling and Development Foundation, 2018).

War and mental health in Yemen

There is no doubt that the ongoing war in Yemen has made psychological disorders worse (Family Counselling and Development Foundation, 2018). In comparison to other Middle Eastern nations that are experiencing conflicts and wars, Yemen has the greatest rate of mental health issues since it is accompanied by painful experiences and severe chronic psychological crises (Ghanm, 2021). Many people are affected psychologically by the war, and when they are exposed to further severe psychological traumas, their chances of turning these disorders into chronic psychological and mental illnesses increased (Ghanm, 2021). According to the Family Counselling and Development Foundation, Yemen experienced a 48.19% overall prevalence of psychological disorders in 2018, and there were 195 cases of mental disorders per every 1000 patients. Additionally, around 5.455.348 Yemenis were diagnosed with psychological disorders between 2014 and 2017 (Family Counselling and Development Foundation, 2018). Dr. Abdullah Abdulwahab Al-Sharabi, the head of the psychiatry department at Al-Thawra General Hospital, stated that there are no precise official statistics regarding the number of psychiatric patients; however, they receive about 40 cases of such patients in the outpatient clinic each day, or 14,000 cases annually. According to Dr. Al-Sharabi, the types of psychological disorders that these people experience range from psychosis, schizophrenia, mania, emotional disturbance, and many others (Al-Maliki, 2021).

Moreover, previous studies found that people in low-income countries, including Yemen, have been observed to suffer mental health issues like depression, anxiety, and post-traumatic disorders (Tomada & Getty, 2017). However, little research has been conducted on this topic, and it is yet uncertain what precise causes, dynamics, and effects may exist (Tomada & Getty, 2017). The World Health Organisation (WHO) has detected a shortage of information on mental health disorders in the epidemiological statistics of Yemen. As a result, it is very difficult to evaluate the general state of mental health in Yemen using psychological epidemiology data that are available internationally. Furthermore, there is little lobbying activity to improve conditions and mental health services at a time when Yemenis are seen to be in severe need of aid (Tomada & Getty, 2017).

The severity of the mental health situation in Yemen and the need for social and psychological solutions to provide emergency and specialised mental health care for the millions of Yemenis affected by war have been addressed in nearly all international publications on Yemeni mental health (Family Counselling and Development Foundation, 2018). Despite this, the ratio of psychologists to the population in Yemen is believed to be one psychologist for every half a million people, compared to a specialist for every 10,000 individuals worldwide and per 100,000 people in the Middle East (Samara et al., 2020). In addition, Yemen only has four psychiatric hospitals nationwide. The nation’s health system is in poor shape and has been made worse by the war, making it unable to meet the needs of any psychological health problems (Alhariri et al., 2021). Furthermore, the absence of competent care for those who are afflicted by mental and psychological problems causes hopelessness, anxiety, and sadness as well as an increase in domestic violence among spouses, partners, parents, and children. Furthermore, exposure to trauma can intensify emotions of dread, anger, and anxiety, which may lead to a lack of faith in efforts at reconciliation (Ghanm, 2021).

Additionally, due to the nation’s economic crisis, few people can afford basic healthcare, let alone mental health therapy. Because mental illness is usually mistaken for a demonic condition, people would prioritise their physical health over their mental health if they could visit a doctor (Ghanm, 2021; Taresh et al., 2020). Only in the most severe forms of schizophrenia, professional assistance is frequently sought after. This is also supported by Alhariri et al. (2021), who claimed that people turn to local sheikhs and traditional healers for mental health support and that mental disorder is stigmatised and taboo. Mental health patients may be referred to as “crazy,“ “insane,“ “possessed by Jinn,“ or “far from Allah” by many Yemenis. Those think that psychiatric hospitals are only for people who are out of control and that, due to the stigma attached to psychological disorders, those individuals should be isolated from society (Alhariri et al., 2021; Taresh et al., 2020).

COVID-19 and mental health in Yemen

In March 2022, WHO published a scientific brief stating that the first year of the COVID-19 pandemic has seen a startling 25% increase in the prevalence of anxiety and depression worldwide (World Health Organisation, 2021). The brief also indicated that 90% of the countries examined addressed mental health and psychological help in their response to the COVID-19 plan due to worries about the potential rise in mental health disorders. Nonetheless, the gap in mental health treatment has grown as a result of the epidemic, and outpatient mental health services have been particularly impacted (World Health Organisation, 2022). WHO general director, Dr. Tedros Adhanom Ghebreyesus stated that “The information we have now about the impact of COVID-19 on the world’s mental health is just the tip of the iceberg,“. This should serve as a wake-up call for all nations to prioritise mental health and improve their efforts to assist their societies’ mental health (World Health Organisation, 2022).

The American Psychiatric Association reported that 59% of Americans believe that COVID-19 has a significant impact on their daily life and that 62% of Americans feel anxiety symptoms as a result of the virus (Shanmugam et al., 2020). A significant contributing cause to the growth of mental health issues is the tremendous stress that the social isolation of the pandemic imposed, in addition to the restrictions on people’s ability to work, seek support from loved ones, and engage in their communities. Stressors that cause anxiety and depression include loneliness, infection dread, pain, fear of death for oneself or loved ones, sadness after a bereavement, and financial difficulties. Suicidal thoughts among workers in the healthcare industry have been connected to exhaustion (World Health Organisation, 2022).

In Yemen, on April 10, 2020, the Hadramout Governorate reported the first case of the coronavirus pandemic. Simultaneously, an increase in positive cases of COVID-19 in neighbouring countries such as Oman, Saudi Arabia, and Somalia raises concerns that more positive cases of COVID-19 may be undetected in Yemen. Because the ongoing war and Yemen’s inadequate healthcare system have made it limited for Yemenis to test for COVID-19 (Mousavi & Anjomshoa, 2020). Wherein, infrastructure has been decimated by the ongoing war, only 51% of Yemen’s healthcare centres are operational, and there are only 500 ventilators and two testing centres accessible to serve the country’s inhabitants, nearly 30 million (MedGlobal, 2020). Additionally, Yemen has insufficient testing capabilities, severe insufficient health supplies including fundamental preventive measures (MedGlobal, 2020), and few ways to monitor the spread of COVID-19, particularly given that the illness’ symptoms are similar to those of other illnesses which are already common in Yemen (Alrubaiee et al., 2020). All of these factors make Yemen a risky setting for the drastic emergence of COVID-19, which has alarmed and seriously concerned Yemenis.

It is noteworthy that Yemenis have endured a variety of stressors and damages over the past six years, and the COVID-19 outbreak has made the situation there even worse (Mousavi & Anjomshoa, 2020). There were approximately 6,587 confirmed COVID-19 cases and 1,299 death in Yemen as of May 20th, 2021, with many cases and deaths going unrecorded as a result of political connotations and a lack of testing (World Health Organisation, 2021). The shortage of health care services, worries about COVID-19 transmission, and greater social isolation have positively impacted the Yemenis’ stress levels. Because there hasn’t been much research on the mental health situation in Yemen (Taresh et al., 2020; Zaid et al., 2020), especially with the outbreak of COVID-19, this study intends to investigate the current situation of psychological problems in Yemen in light of the ongoing civil war and COVID-19 pandemic.

The impact of the ongoing war in Yemen and COVID-19 on Yemenis’ mental health has not received much attention from other studies. Even though, little is known about the mental health disorders in Yemen, to the researcher’s knowledge there are not many studies that looked at the perspectives of psychologists and psychiatrists on mental disorders in Yemen. As it is known, in mental health clinics or centres, psychologists and psychiatrists interact more with patients with mental health conditions and offer them therapy and counselling to lessen the impact of these disorders. Furthermore, these therapists have in-depth knowledge of mental health issues as well as techniques to aid people in making changes that can prevent and treat mental health issues and promote general mental health (Marszalek et al., 2021). They could therefore provide insightful information on Yemenis’ mental health throughout the conflict and the COVID-19 outbreak. In addition, as mental health professionals play an important role in mental health initiatives, the perspectives of this stakeholder group are critical for ensuring the long-term growth of mental health services (Hanafiah & Van Bortel, 2015). Psychiatrists and psychologists are considered regarded as primary or key informants of mental health as they can reach the patients and their caregivers as well as community organisations; this made them at the forefront of the target samples in the current study.

To better understand the mental health status in Yemen in light of the ongoing civil war and the COVID-19 pandemic, this qualitative study conducted semi-structured interviews to interview psychologists and psychiatric professionals. The current study adopted a qualitative method because open-ended questions used in a qualitative study give insight into the participants’ perspectives on mental health. Qualitative design can also help study the phenomena from fresh angles that have not yet been covered by theory-based research (Drawert, 2013; Silverman, 2013). In addition, qualitative approaches are the best for eliciting the opinions of individuals being studied and enabling them to speak in their voices (Palinkas, 2014; Sofaer, 1999).

Method

Design

A qualitative interpretative design was adopted because it is an appropriate tool for investigating and evaluating the interactions and perspectives of psychologists (Torne, 2016). This study, in particular, used phenomenological design to gain a thorough understanding of psychologists’ and psychiatrists’ experiences and perspectives on mental health in Yemen during the ongoing civil war and the outbreak of the COVID-19 pandemic, to provide a complete picture of Yemenis’ mental health during this critical time. In this kind of study, researchers distil the participant experiences to their essence or central significance (Moustakas, 1994). The primary objective of the phenomenological approach is to arrive at a description of the nature of a particular phenomenon. Interviews are typically conducted with a group of people who have first-hand knowledge of a situation, event, or experience (Creswell, 2013). Face-to-face semi-structured interviews with psychologists and psychiatrists were used in this design, and the researchers asked open-ended questions to investigate the mental health status in Yemen.

Participants

The psychologists and psychiatrists who work in mental health centres and clinics in Sana’a province were the study’s target population. There were 20 contestants in total, with 13 of them being female. The participants ranged in age from 28 to 46 years old; 17 were clinical psychologists and 3 were psychiatrists. A total of eight participants held bachelor’s degrees, seven held master’s degrees in clinical psychology, and five held PhDs. The years of work experience ranged from 3 to 25. Face-to-face semi-structured interviews with participants were conducted between October 2021 and December 2021and between May 2022 and June 2022. Due to the researchers’ lack of knowledge regarding mental health workers, the participants were chosen using the snowball sampling approach. Psychologists and psychiatrists were contacted via WhatsApp and email; and then, each interviewee was asked to suggest other psychologists and psychiatrists who should take part in the interviews. A letter of invitation was sent to each participant outlining the purpose of the study, the questions to be asked, and the researchers’ contact information.

Procedures

Individual face-to-face semi-structured interviews were done by the researchers to gather the data. A semi-structured interview guide with open-ended questions about the primary areas of interest related to the current study was created. Experts in psychology reviewed the guide and the open-ended questions, they agreed that the questions are suitable and in line with the purpose of the study. Prior to data collection, researchers sought approval for conducting the study from the respective clinics and centres. Moreover, before the interview, the researchers described the purpose of the study to the participants and explained that their participation is entirely voluntary. Participants were also asked to sign a consent form.

The researchers were well-versed in research ethics. Researchers asked participants for their consent to record the interviews before they took place, however, the interviewees declined to allow for audio or video recording due to a desire to maintain their privacy. The interviews were done in Arabic and handwritten notes were taken during the interviews. To ensure that researchers capture the participants’ words during the interviews, a researcher and two research assistants were involved in each interview. One of the researchers ask the interviewee and the other two writes what the participants say. After each interview, the three researchers revised the content of the transcripts to ensure that nothing is missing and refined the content while the memory is still fresh. Furthermore, if researchers were unable to achieve an agreement on the content, they returned back to the participants to confirm with them.

Data Analysis

Thematic analytic methods were utilised to inductively analyse the transcripts and provide primary themes and subthemes. The data were thematically analysed using Braun and Clarke (2006) six steps: (1) data collecting, (2) initial code generalisation, (3) searching for themes, (4) themes reviewing, (5) naming and defining the themes, and (6) reporting. For each question, line-by-line coding was used. ATLAS. ti software was used to analyse the interview transcripts. The first author reviewed the original transcripts generated from the participants’ comments for anonymity before importing the transcripts into the software. Then, the researchers loaded all of the interview transcripts into the software and made an effort to familiarise themselves with the content of the interview transcripts by reading them more than once before the analysis.

All of the researchers analysed the original transcripts repeatedly and independently to identify key codes with supporting quotations, and the resulting codes were classified under general themes relevant to the study aims. The researchers then gathered to check the generated codes and themes in order to establish the initial codes and code sequences of the transcription. Moreover, to assess agreement in the major codes and themes. Any inconsistencies were resolved through discussion between the researchers. After then, all of the researchers worked together to categorize the original codes to reach an agreement on the final themes.

To minimise bias and guarantee that the results are transparent in qualitative research, it is crucial to combine the results that the researchers have coded (Guion, 2004). Consequently, member checking and external evaluation were utilised to guarantee the validity of the study’s findings (Chan et al., 2021). Before drafting the final report, the researchers gave a summary of the themes to the participants for them to evaluate and provide feedback (member checking). Furthermore, two external readers participated in revising the emergent codes and themes from the thematic analysis to eliminate researchers’ bias and ensure the credibility of the results. Themes and codes were revised in response to the feedback of the participants and the reviewers.

Findings

The thematic analysis identified four significant themes: (1) the impact of war on mental health, (2) the impact of COVID-19 on mental health, (3) the healthcare system, and (4) The lack of mental health awareness. The sections that follow elaborate on the emerging themes. Participants were given an ID consisting of the letter P and a number, such as P1, P2, P3, and so on.

Theme 1: the impact of War on Mental Health

This theme represents the participants’ perspectives on the effects of war on Yemenis’ mental health. The war has contributed significantly to a rise in mental health problems among Yemenis, particularly among women and children. According to the responses of participants, there are four major subthemes: (1) the increase in the prevalence of mental disorders due to the ongoing war, (2) the impact of arbitrary airstrikes and bombing, (3) the impact of economic situation and poverty, and (4) the impact of displacement on the mental health of Yemenis.

Regarding the increased prevalence of psychological disorders, all participants agreed that as a result of the war, many people suffer from post-traumatic disorder, anxiety, fear, depression, panic attacks, sleep disorders, schizophrenia, death anxiety, and stress. Furthermore, despite a lack of actual data, the majority of them said that the number of persons suffering from psychological disorders had approximately tripled since the war and the COVID-19 pandemic.

According to P18, “the war has contributed to a significant increase in the prevalence of various psychological disorders, such as anxiety, depression, and death anxiety.“

In terms of the impact of airstrikes and bombings, participants reported that continuous bombing and airstrikes are the greatest sources of psychological stress among people. Because most arbitrary airstrikes and bombings occur around midnight, participants expressed concern that airstrikes could fall on their homes and kill them at any time.

P16 stated that “people can’t sleep comfortably, they wake up in horror due of the random bombardment; as a result, many people got death anxiety and sleeping disorder.”

According to P3, “many people lost their beloved ones as a result of the airstrikes and bombardment. Also, some families sent their children to battles and they were killed there, which caused victims’ families to experience sadness and post-traumatic stress disorder.”

Furthermore, children were the most affected by the arbitrary bombing, as participants stated that children are the ones that visit psychiatric clinics the most. Due to the traumatic experiences brought on by the war, despair, and anxiety, these children are experiencing behavioural issues, urinary incontinence, trouble concentrating, and stuttering. Furthermore, many children were forced to suspend their education for several years due to war escalation, while some children experienced learning issues.

According to P7, “children are at high risk of developing a variety of psychological disorders; the majority of families who seek our support complain about urinary incontinence, stuttering, trauma, difficulty concentrating in children, depression, and anxiety as a result of the fear of arbitrary airstrikes and bombing.”

Poverty and unemployment are key war outcomes that lead to mental illnesses in people. Yemen’s “long-running war”, as highlighted by participants, has significantly harmed the country’s economy and infrastructure, as well as caused major humanitarian challenges. Many workers have been laid off as a result of several companies going bankrupt. Participants reported that as a result, some people suffer from hunger, aggression, fear of the future, post-traumatic stress disorder, suicidal ideation, anxiety, and sadness.

According to P14, “many people lose their jobs, and the unemployment rate has increased, which may have a significant impact on mental health and led to an increase in stress, anxiety, depression, and many other psychological disorders among Yemenis, as many families become unable to meet basic needs of life.”

Participants agreed that, despite the overwhelming prevalence of mental illnesses in Yemen, there are just a few psychiatric clinics or hospitals in the most populous governorates.

According to P16, “people cannot easily access or afford to use mental health services or facilities. They can rarely save enough money to tackle physical illnesses and meet basic demands.”

According to P5, “war has resulted in regular exposure to many types of stressors due to food shortages, unemployment, as well as the spread of depression and anxiety, addiction, and suicide.”

Meanwhile, P11 stated that “the ongoing war has increased the prevalence of depression, post-traumatic disorder, addiction, suicide, anxiety, stress, and family violence.”

P2 explained, “Since the continuing war occurred in Yemen, people are seen on the street wearing dirty clothes; many didn’t shower or shave their hair for a very long time” People call them majnun, which means “crazy,“ since they talk to themselves and are unaware of their surroundings. These persons have schizophrenia, mania, bipolar disorder, or paranoia. This group of people existed before the war, but their numbers expanded significantly during the conflict.”

Displacement is another serious issue that has harmed people’s mental health as a result of war. Many people living in crisis zones have been internally displaced to camps in big cities and relatively safe places. Displacement had an impact on the mental health of internally displaced people (IDPs). Participants stated that IDPs were compelled to leave their homes and cities of habitual residency, which harmed their mental health in various ways.

P4 stated that “IDPs encounter a variety of pressures linked to food, shelter, education, access to healthcare, and finance, which puts them at risk of developing mental illnesses such as anxiety, post-traumatic disorder, depression, panic attack, and phobia.”

According to P13, “many individuals have lost hope and developed future anxiety; however, the situation is worse for IDPs, who believe that they have no future because they lack fundamental necessities of life.”

Furthermore, according to P17, “people become exceedingly miserable and lose the joy of living as a result of the accumulated issues and stressors they encounter every day.”

Theme 2: the impact of COVID-19 on Mental Health

This theme depicts the impact of the COVID-19 pandemic on Yemenis’ mental health. Participants agreed that Yemen’s mental health status, which is already severely compromised by numerous crises brought on by the war, has gotten worse as a result of the COVID-19 outbreak. Participants reported an increase in psychological disorders, with some people developing fears of infection and death, as well as stress, frustration, social problems, family problems, and the fear of losing loved ones.

P6 noted that “what people have experienced as a result of the ongoing war was taxing; in addition to worrying about the risks of war, the spread of the coronavirus has caused people to suffer from the fear of Coronavirus infection.”

Moreover, according to P7, “people become more concerned about the rapid spread of COVID-19, concerned about becoming infected with the COVID-19 , and concerned that they may die as a result of the coronavirus.”

According to P19, “for persons with pre-existing mental health illnesses such as obsessive-compulsive disorder, their suffering becomes more acute due to COVID-19, as guidance on increasing personal hygiene may intensify their fear of contamination and washing compulsions.”

Furthermore, the spread of COVID-19 has resulted in societal issues such as marital troubles, social disintegration, and gender-based violence. Participants also indicated a lack of psychological care and psychological education on dealing with the effects of the pandemic has increased mental disorders.

P14 stated that “because of the closure of schools and several companies, many people stayed at home, causing a lot of marital issues and violence. In addition, depression has worsened as a result of COVID-19 due to a loss of social support.”

Regarding the impact of the country’s economic status on controlling the coronavirus and reducing mental illnesses caused by the virus’s transmission, participants agree that the country lacks the resources and power to prevent the spread of COVID-19.

P8 noted that “many people are scared that the government would be unable to tackle coronavirus or any other pandemic due to economic crisis and the inability to take preventive measures to preserve people’s lives, which makes people more stressed.”

According to P13, “most individuals are poor, and they are afraid of COVID-19 infection because they cannot pay the expense of its medication.”

P10 stated that “the country is unable to purchase a vaccine that would suffice for all citizens, or at least cover the demands of those who desire to receive the vaccine.“ In addition, the WHO only donated a very small amount of vaccines to Yemen, which worries some people a lot.”

Theme 3: the Healthcare System

This theme depicts Yemen’s healthcare and mental health care systems. The statements of the participants revealed three major subthemes: (1) mental health care facilities, (2) vocational qualification of psychotherapists, and (3) the health system and epidemic control.

Yemen’s mental health facilities are highly limited and centralised in the most populous cities, as is the number of mental health workers. According to the participants, the explanation for the shortage of mental health services is that the government does not prioritise mental health care in the general health care system.

According to P9, “there is a severe shortage of centres or clinics dedicated to treating mental illnesses, even though the number of persons suffering from mental illnesses is relatively large.”

Furthermore, according to P1, “there is a lack of psychiatric treatment services in most locations of Yemen, as well as difficulty in accessing these services.”

P6 stated that “the country does not play its role in caring for the mental health sector, which is why people are unaware of the importance of mental health and the societal consequences of mental health deterioration.”

Before beginning to practise psychotherapy, psychotherapists must get a vocational qualification. However, according to the participants, the government places less emphasis on psychotherapists’ professional qualifications, and there are fewer authorised centres that can provide appropriate training for graduates who want to specialise in psychotherapy, in addition to a shortage of career opportunities.

According to P15, “there are limited hospitals and centres that can provide career opportunities for graduates; the existing psychiatric hospitals and clinics accept a relatively small number of psychiatrists and psychologists after conducting competency tests and interviews.”

According to P17, “building mental clinics for psychotherapists is a major risk compared to other medical specialities because society rejects the idea of taking patients to a psychiatrist.”

Before the war, Al-Amal Psychiatric Hospital offered a free clinical psychology diploma approved by the Ministry of Public Health and Population for 1–2 years to graduates of the Departments of Psychology and Medicine who wanted to specialise in psychotherapy. Unfortunately, due to the war, this clinical diploma was suspended for a time.

According to P20, “Recently, the clinical psychology diploma was reintroduced, but excessive tuition fees were charged to enrol in the diploma; thus, many students couldn’t offer this amount.”

Regarding the health care system and pandemic control, participants stated that Yemen’s health care system is entirely incapable of tackling the corona pandemic.

According to P12, “the country lacks hospitals and health facilities because there are only a few hospitals, most of which are private, and treatment charges in private hospitals are costly.” He also stated that “because of the war, more than half of these facilities are out of service, which causes people to be anxious about getting sick.”

According to P1, “there is a significant load on health services due to the harms produced by the war.”

According to P18, “during the first year of the pandemic outbreak, hospitals refused to accept coronavirus cases due to their fear of the virus spreading among medical professionals and hospital workers.”

Theme 4: the lack of awareness of Mental Health

This theme illustrates the lack of awareness regarding mental illnesses as well as the significance of adopting preventive measures to avoid COVID-19 infection. This theme generated several subthemes including stigma, misconceptions about mental disorders, and awareness of COVID-19 prevention efforts.

Participants stated that people perceive mental disorders as a stigma and do not prioritise their treatment. As a result, the cultural stigma associated with mental illness discourages people from seeking care, worsening the severity of these conditions.

According to P20, “the stigma connected with mental disorders causes families to hide individuals who suffer from mental illnesses and chain them in the house.”

Misconceptions about mental disorders are common in Yemeni society, according to participants, many people associate psychological disorders with superstitions and black magic.

According to P5, “some families believe that persons who suffer from mental problems are possessed by Jinn, thus they seek treatment from sheikhs or charlatans using Qur’an and traditional therapy.” He continued that “Unfortunately, some of those charlatans beat the patients hard to expel the Jinn from them, which makes it worse for the patients and causes physical agony in addition to psychological suffering.”

According to P19, “psychotherapists are considered the last option for persons who suffer from mental illnesses. Most of the individuals who seek psychotherapists’ assistance do so only after they have gone to charlatans or tried traditional therapy, which can take years, so they arrive in extremely terrible conditions. Patients are sent to psychotherapists if they have not benefited from charlatans or traditional therapy, or if they have become a danger to themselves or others, or if those around them are facing difficulties dealing with them.”

In terms of the awareness of the COVID-19 impact and the significance of adopting preventive steps to prevent the virus’s transmission, all participants agreed that many individuals are unconcerned about the virus and its effects or damages. They take no precautions to keep themselves from becoming infected with the virus. Furthermore, many people refuse to take immunizations.

P4 stated that “People in Yemen have been in denial about the existence of the coronavirus thus far and acted with extreme indifference. Furthermore, the government did not impose any mandatory preventive measures, and as a result, citizens did not commit to taking any preventive measures.”

According to P15, “most people do not practice social distancing, wear a face mask, or use hand sanitisers. Also, most of the time, a large number of people gather in congested areas such as markets.”

P10 stated, “There are many cases of COVID-19 infection and that was noticed from the number of deaths every day but because of the media discretion, especially in the north part of Yemen, as well as lack of awareness, many people do not know if they are infected with the coronavirus or they have flu, and they even do not go to hospitals to do the necessary tests.”

Discussion

The current study aimed to investigate the current situation of psychological illnesses in light of the ongoing civil war and the COVID-19 pandemic breakout from the perspectives of psychologists and psychiatrists. It has been revealed that Yemenis were subjected to a wide range of severe conditions and psychological disorders as a result of the civil war and the COVID-19 pandemic. All of the participants in this study agreed that the war and the COVID-19 pandemic led to the rise in psychological disorders and many people suffer from various mental illnesses due to the war and COVID-19, Fig. (1) presents a summary of the prevalent psychological disorders. Similarly, according to a study conducted by the Family Counselling and Development Foundation (2018), the rate of prevalence of psychological disorders in Yemen is one of the highest in the world and is relatively close to rates in nations experiencing emergencies.

Fig. 1

Prevalent psychological disorder

Regarding the impacts of war on people’s mental health, the study’s findings indicate that the ongoing civil war has increased depression, post-traumatic disorder, sleep disorders, anxiety, stress, and panic attacks, as well as death anxiety. This result was in agreement with local research by Al-Hamdani (2020). Al-Hamdani found that many persons suffer from psychological problems such as anxiety and depression, bipolar disorder, post-traumatic stress disorder, and schizophrenia as a result of traumatic occurrences (Al-Hamdani, 2020).

Furthermore, participants indicated that displacement may affect IDPs’ mental health, as traumatic events, food shortages, and the length of displacement make IDPs more susceptible to suffering mental health disorders such as depression and post-traumatic stress disorder (Dhilion, 2021). Many factors, including a lack of proper health care/finances/education, disrupted social networks, co-morbid physical conditions, pre-existing psychopathology, displacement trauma, and a pessimistic view of the future, can all contribute to an increased risk of mental illness (Siriwardhana & Stewart, 2012).

The study’s findings revealed that Yemenis’ mental health is significantly influenced by the country’s economic situation. Participants noted how financial difficulties and poverty affect Yemenis’ mental health, resulting in significant stress, anxiety, and depression (Marazziti et al., 2021). Many people have lost their jobs, and as a result of the increase in unemployment, some are suffering from hunger, violence, fear of the future, and depression. Previous research has associated financial difficulties and unemployment with mental health illnesses such as depression, psychological distress, chronic stress, and anxiety (Taylor et al., 2007; Volkos & Symvoulakis, 2021; Zissi & Stalidis, 2017). Despite all of these mental health problems, people in higher-unemployment countries were less likely to access mental health services (Silva et al., 2020).

Besides, the findings of this study suggested that the COVID-19 pandemic has aggravated the condition of phycological disorders in Yemen. This finding is in line with a large body of research indicated that the COVID-19 pandemic has highly impacted mental health. Besides, according to some studies, the majority of respondents felt depressed, followed by anxiety and stress (Wong et al., 2021; World Health Organisation, 2022). The findings of this study indicated that COVID-19 causes family conflicts and violence (Opanasenko et al., 2021) and increases mood disorders as a result of staying at home for an extended period. Similarly, Shanmugam et al. (2020) found that since the start of the COVID-19 pandemic, many people have had mild to severe anxiety and depression as a result of job loss, social isolation, and deteriorating economic conditions. According to a body of studies, COVID-19 hurts mental health (Rajkumar, 2020; Schäfer et al., 2020).

This study’s findings highlighted another critical issue: the healthcare system. The war has aggravated the country’s already inadequate healthcare system, which is now incapable of meeting the demands of this oncoming mental-health disaster. Only 51% of all health institutions are operative, healthcare personnel’s salaries are mostly unpaid, and critical medications are scarce and expensive (Alhariri et al., 2021). Because mental health is not integrated into the main health care system, many Yemenis are unable to undergo mental health therapy. According to a recent analysis, just 10% of primary health care facilities in Yemen, for example, have staff educated in the detection and treatment of mental health illnesses (Alhariri et al., 2021). Furthermore, it was shown that the severe stigma associated with mental health care discourages medical students from continuing university psychiatric degree programmes or specialised training (Tomada & Getty, 2017).

Furthermore, participants agreed that there are only four psychiatric clinics or hospitals in Yemen, which are located in the most populous governorates of Sana’a, Taiz, Aden, and Hudaydah. There are also 7 outpatient psychiatric clinics at public hospitals, 5 private psychiatric hospitals, 34 private mental health clinics, and 3 residential psychiatric treatment institutes, according to Yemen’s Ministry of Public Health and Population (Harmmal & Almoayad, 2020). Furthermore, skilled personnel are in short supply in the few available hospitals and clinics; the country has just approximately 130 trained therapists and about 59 psychiatrists (Family Counselling and Development Foundation, 2018; Harmmal & Almoayad, 2020).

Another element that emerged from the findings of this study is the lack of awareness. As previously noted, mental illness has long been associated with “myth, superstition, witchcraft, and jinn (spirits)” in Yemen, and the subject of mental illness is stigmatised and forbidden. Many Yemenis may characterise someone seeking mental health therapy as “out of the ordinary,“ “unstable,“ “possessed by a demon or jinn,“ “crazy,“ or “far from God”. Before obtaining medical treatment, many Yemenis turn to traditional medicinal or superstitions (such as witchcraft) (Alhariri et al., 2021).

Recommendations

There is a crucial need to analyse the number of psychiatric patients and types of mental disorders caused by war and COVID-19 in all Yemeni governorates so that the government and corresponding authorities can provide adequate mental health services and provide easy access to those in need. Furthermore, the Ministry of Public Health and Population should prioritise the qualification of psychotherapists through a variety of methods, including low-cost training courses for mental health experts and their assistants, as well as conducting continuous seminars, workshops, and conferences. Besides, the proper authorities and WHO should intensify awareness campaigns in developing countries, particularly in Yemen, to raise awareness about the importance of psychotherapy and warn about the dangers of referring to charlatans, as well as reduce the stigma associated with mental illnesses.

Furthermore, this study suggests that future studies should include participants from diverse backgrounds, such as family members, patients, and policymakers, in addition to psychologists and psychiatrists, to gain a more comprehensive understanding of Yemen’s mental health from various perspectives. This study suggests employing triangulation and other data collection approaches, such as focus group discussions and observations. Furthermore, this study urges future studies to apply a mixed method design, which may provide additional information regarding Yemen’s mental health. Furthermore, this study suggests that future research should find interventions to lessen the impact of mental illnesses on Yemenis.

Limitations

The current study has some limitations that should be addressed in future studies. First, participants were limited to psychologists and psychiatrists. They were selected using the snowball sample technique, and data was collected from a small sample size. Second, because the findings are contextually dependent on the participants’ perspective, they are of limited utility and should be interpreted with caution. Third, in order to protect the participants’ privacy, handwritten notes were used instead of recorded interviews. Fourth, because this is a qualitative study, the findings cannot be generalized; rather, significant contexts addressing several sources or causes of mental diseases, which might be used to influence future initiatives and policies was provided.

Conclusion

This study of 20 psychologists’ and psychiatrists’ perspectives contributed to the population’s understanding of Yemenis’ mental diseases throughout the ongoing civil war and the COVID-19 pandemic, which policymakers may use to assist at-risk people experiencing psychological hardship during the crisis. Researchers established several themes, based on the information gathered, including the influence of war on mental health, the impact of COVID-19 on mental health, the healthcare system, and the lack of mental health awareness. According to this study, the non-stop negative impact of civil war and COVID-19 may increase Yemen’s mental health disorder situation. It may be concluded that there are numerous threats to Yemenis’ mental health and well-being; consequently, the government and respective authorities must take immediate action to alleviate the impact of mental health illness on individuals.