The war between Israel and Hamas that broke out on Saturday, October 7, has had a profound impact on Israel, affecting not only the general population but also psychiatric patients and the professionals who treat them. This article describes the response to this challenging situation.

Psychiatric In-Patient Treatment

Israel’s severe psychiatric patients are primarily served by a network of standalone psychiatric hospitals positioned across the country, with a total of approximately 3300 beds. Although some of these facilities are partially fortified against missile attacks, most remain vulnerable. Hospitals situated near the borders face potential casualties from missile attacks, as they lack protection against bombs; a missile landed in one of them with no casualties. Approximately 160 psychiatric patients have been evacuated from one of these hospitals near the border to hospitals situated more centrally.

During times of acute stress, such as the 1991 Gulf War and the beginning of the COVID-19 pandemic, patients with severe psychiatric disorders such as schizophrenia, schizoaffective disorder, and severe bipolar disorder tend to partially and temporarily improve in their positive symptoms.

In addition, family members living with these patients are aware of the danger of missiles falling on psychiatric hospitals and are willing to put up with disruptive behaviors. This leads to a short-term decrease in psychiatric emergency room visits and psychiatric admissions, and enables many patients to remain at home.

In parallel, psychiatric hospitals have discharged patients whenever possible, thus minimizing the risk of mass casualties in the event of an attack on a psychiatric facility. However, experience indicates that this situation is temporary, as, over time, patients can worsen clinically and/or families lose their patience, causing psychiatric emergency visits and hospitalizations to revert to their usual rates. At this point, these rates of psychiatric emergency visits, admissions, and occupancy rates remain low—but if the war continues, a gradual increase in these rates is expected.

Psychiatric Outpatient Treatment

Many patients prefer to stay at home and do not attend outpatient visits. Remote telephone and video treatments were developed and well utilized during the COVID-19 pandemic. As time went by after the pandemic, most patients and mental health professionals preferred to go back to face-to-face meetings. In this time of war, many outpatient visits are performed utilizing these remote technologies.

Wounded Soldiers and Civilians

Wounded soldiers and civilians are being treated in general hospitals, mostly in the south and center of the country. Some of the wounded have symptoms of acute stress disorder and are being treated by psychological and psychiatric consultants. Many of the family members of these patients also suffer from anxiety and depressive symptoms and are being treated as well.

Staff

Psychiatric staff members are not immune to the anxiety gripping the general population during the conflict. Many of them have family members serving in the military, either in their mandatory service (ages 18 to 21 years) or in the reserves. Some have had family members or close friends killed or held in captivity in Gaza. The closure of schools has forced staff members with young children to juggle work and childcare responsibilities, often requiring remote work arrangements.

A significant number of the medical—particularly nursing—staff are Arabs, and there have been incidents of racist comments directed against them, both in the psychiatric wards and in the surgical and orthopedic wards. A small minority of Arab staff members have voiced or posted support of Hamas, which also contributes to the complexity of this issue.

On the second day of the war, groups of racist right-wing fascists entered hospitals where they thought Palestinian terrorists were being treated, threatened Arab staff members, and caused major disruptions. In fact, the terrorists received emergency treatment and were then transferred to the prison services.

Psychological Support

Thousands of Israelis living near the Israeli-Gaza border have been evacuated and are displaced, staying in hotels around the country. Many of these individuals were in the settlements that were attacked. They have had their homes destroyed, they have lost loved ones, and/or they have relatives who were kidnapped.

Many therapists have volunteered to help these individuals—some more, and others less, professionally trained. The Israeli Ministry of Health is now organizing these efforts, sending staff members from psychiatric hospitals and outpatient clinics to offer support to these individuals.

Another group with special mental health needs in this situation are Israel Defense Force veterans with preexisting posttraumatic stress disorder (PTSD), of whom there are approximately 6500 in the country. These patients need increased availability of their psychiatrists and psychologists.

Many are chronically symptomatic, and the news reports with often graphic TV coverage often causes worsening of their symptoms. Being closed in the house with the family and children, feeling incompetent and powerless to defend them, and being incapable of joining the troops in combat renders these individuals even more restless and impatient. Others become remote and distanced, some become suicidal. Their families, often dysfunctional at baseline, worsen and become disarrayed.

Psychological Support for the General Population

The broader population in Israel is experiencing high levels of tension, given the significant mobilization of reservists and the grim realities faced by those who have lost loved ones, have experienced injuries, or have family members who are being held hostage in the Gaza Strip.

To address this growing psychological distress, multiple psychiatric and psychological organizations have swiftly organized to provide support. Hospitals, HMOs, and the Israeli military have established mental health hotlines, where individuals in distress can seek assistance. These hotlines typically screen callers and may offer short-term psychotherapy, often remotely.

One of us (NN) has taken proactive steps to address the emerging trauma, offering a 4-session psychoeducation (PE) course, a well-established method for preventing acute stress disorder from evolving into PTSD. One of the patient groups particularly in need of this treatment is the survivors of the Nova Music Festival, in which thousands of young people participated and 260 were killed,¹ with many of the survivors suffering from acute stress disorder.

Concerns Regarding the Residents of Gaza

Gaza is under siege, with minimal or no supply of food, water, and electricity. Israeli jets continuously bombard Gaza, causing the deaths of Hamas members, but also of many civilians, and there are 50,000 pregnant women in Gaza not receiving medical care. Hospitals are overflowing, and hundreds of thousands are displaced. Many Israelis are very concerned and upset about this situation.

Concluding Thoughts

The ongoing conflict in Israel has had far-reaching psychological and psychiatric implications for psychiatric patients, mental health professionals, and the general population. As the situation remains uncertain, the mental health community is committed to providing support and innovative solutions to help individuals cope with the immediate and long-term consequences of this challenging period.

As the war evolves, there will be many more injured, both physically and emotionally, who, together with their family members, will need help. We will need funding to train therapists and psychiatrists, administer these treatments, and accompany these efforts with research. Readers interested in supporting these efforts can make a tax-deductible donation at https://give.afsmc.org/give/525518/#!/donation/checkout, specifying that the donation is to support the mental health war effort. In addition, please send an email to Dr Weiser, the corresponding author, with the receipt of the donation so that we can follow-up. Thank you very much.

Dr Weiser, Dr Nacasch, Dr Caspi, and Dr Polliack are affiliated with the Drora and Pinchas Zachai Division of Psychiatry at Sheba Medical Center in Ramat Gan, Israel. Dr Weiser is also a professor of psychiatry at the Tel Aviv University School of Medicine.

Reference

1. Cohen R. Slaughter at a festival of peace and love leaves Israel transformed. The New York Times. October 15, 2023. Accessed October 15, 2023. https://www.nytimes.com/2023/10/15/world/middleeast/israel-music-festival-massacre.html