Mental Health During the Israel-Hamas War: A National Longitudinal Survey – Findings from Three Time Points

Background

The ongoing Israel-Hamas War and the extensive scope of both personal and national trauma have significantly increased the need for mental health services. To provide care that is tailored to the needs of the population, it is essential to assess the mental health status of the public and examine trends over time.

Objectives

1. To assess the prevalence of symptoms of depression, anxiety, and post-trauma at three time points since the onset of the Israel-Hamas War, identify trends in the rates of prevalence, and evaluate levels of functional impairment among those above clinical thresholds for these symptoms.

2. To Identify the factors associated with the development of severe symptoms or their disappearance.

1. To examine patterns of seeking and receiving mental health treatment over time.

Methodology

An online self-administered survey of a representative sample of 2,000 panel members of a large internet panel survey company in Israel, as well as a purposive sample of 686 panel members residing in frontline communities in northern and southern Israel. The data were collected at three time points:

• December 2023–January 2024 (n = 2,688)
• April–May 2024 (n = 1,746; repeat respondents)
• September–October 2024 (n = 1,766; repeat respondents)

The survey included validated instruments to assess symptoms of PTSD (PCL-5), depression (PHQ-9), anxiety (GAD-7), and functional impairment (WSAS – measured only at the third time point). Additional questions addressed exposure to war-related events, history of mental health challenges, perceived coping ability, patterns of seeking and receiving treatment, and demographic background. To ensure the sample’s representativeness, survey data were weighted by age, gender, residential area, and population group.

Findings

In January 2024, 41% of respondents met the clinical threshold for at least one symptom domain (anxiety, depression, or PTSD). This rate declined to 32% in May but rose again to 35% in October. Most of those who met the clinical threshold in January had not returned to baseline levels by October: 69% of those with clinical-level depression symptoms, 65% with PTSD symptoms, and 52% with anxiety symptoms remained above the threshold at the third time point. Moreover, 25% of respondents who had not met a clinical threshold in previous waves became new cases in the third measurement.

Across all three time points, higher rates of above threshold symptoms were found among individuals personally exposed to war-related events, those who reported low coping ability, and Arab respondents (compared to Jewish respondents). The gap in post-traumatic symptom rates between Arabs and Jews remained significant even after adjusting for age, gender, and income quintile.  However, after adjustment, no significant differences were found between Arabs and Jews in depression or anxiety symptom rates.

Multivariate analyses indicated that women, young adults, Arabs with low income, individuals personally exposed to the October 7th attacks, those exposed to distressing media content, and respondents with a prior history of mental health issues were at greater risk of crossing the clinical threshold. However, low perceived coping ability was the strongest predictor of crossing the clinical threshold (OR = 5.5), symptom worsening (OR = 2.6), and non-recovery (OR = 2.7).Overall, 19% of respondents reported significant impairment in daily functioning due to their mental health. This rate was markedly higher among those above clinical thresholds (48%) compared to those below (4%).

Between the first and third time points, the percentage of those receiving treatment increased from 14% to 18%, particularly among those above clinical thresholds (from 23% to 34%). Concurrently, there was a decline in the percentage of respondents who reported needing but not receiving treatment due to not seeking care or being on waiting lists (from 18% to 15%, and from 35% to 30% among those above the clinical thresholds). Overall, 26% of respondents reported receiving some form of mental health care during the first year of the war; this rate was higher (44%) among those with above clinical threshold level symptoms.

Among those who felt the need for treatment but did not seek it, 44% cited accessibility barriers (waiting times, distance, or cost) as the main reason – despite the availability of free care through the health plans. Another 35% reported not wanting care from the formal health system or having received help from outside the system.

Conclusions and Recommendations

1. Despite the overall decline in above threshold symptom rates, the demand for mental health services has increased. The system must prepare for growing treatment needs regardless of screening thresholds, including greater investment in recruiting therapists to the public health system (given that cost is still perceived as a barrier).
2. It is recommended to further develop tiered care models in community settings, integrating family physicians and resilience coaches, and to proactively engage populations with low help-seeking tendencies.
3. It is recommended to design proactive outreach and support programs for at-risk populations unlikely to recover spontaneously, especially those who were personally exposed to high-intensity war-related events.
4. It is recommended to further characterize individuals with above threshold symptoms who perceive a need for treatment but do not seek care (the primary group), as well as those who attempt to access services but are unsuccessful (a smaller group). Deeper exploration of the barriers to seeking help should guide the development of tailored interventions.
5. It is recommended to explore the continued use of broad self-report screening on mental health status, coping ability, and perceived need for care, and to encourage medical staff to initiate conversations about mental well-being.
6. It is recommended to consider a long-term resilience-building effort for populations with limited support networks, and to explore further screening and in-depth assessment among high-risk groups, such as Arabs and young women.

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