Last week, Udi Kagan shared a video in which he spoke candidly about his struggles with post-traumatic stress disorder ever since 2002, when he fought in Operation Defensive Shield in the West Bank. Kagan, an Israeli actor, comedian and screenwriter, discussed the seizures he suffered since his release from military service, the shame he was afraid to talk about, his efforts to escape by using drugs and alcohol, the suicidal thoughts that plagued him – as well as the process of rehabilitation and recovery. “You’re probably asking yourselves why I’m talking about this during a standup show,” he told his audience. “Because it’s important to me. It’s so important. Because here’s the thing, guys: It’s not just me. It’s been part of every household [since October 7]. People who were there, people who saved others, people who heard it and people who lost loved ones.”

Udi Kagan's video (Hebrew)

This is not the first time that Kagan has addressed the issue of PTSD, but it was no coincidence that this particular video went viral, garnering millions of views and shares, at this particular time – just a few weeks before the second anniversary of the start of the war and days before a massive call-up of reserve soldiers, who will be drafted into active service to carry out the government’s plan to recapture Gaza City. Studies from the past few months have shown a dramatic increase in the number of Israelis suffering from PTSD and experts warn that the country is not prepared to deal with the fallout: the soldiers’ exhaustion, the public’s exposure and the polarization which only grows as the war drags on – all of these increase the risk of mental and emotional harm in the longer term, they warn.

Just three months ago, Prof. Yair Bar-Haim, director of the National Center for Traumatic Stress and Resilience at Tel Aviv University, unveiled the findings of a comprehensive study he conducted. Bar-Haim tracked 600 IDF soldiers from the day they were recruited in March 2019 and found a shocking increase in PTSD cases: from 4.4 percent at the end of their mandatory service to around 8 percent within a few months of returning to civilian life. Since the outbreak of the war on October 7, that has risen to 12.2 percent – in other words, more than 70 soldiers aged 24 or below suffer from symptoms of PTSD. In comparison, after Operation Protective Edge – the five-day conflict in the summer of 2014 – around 7.8 percent of soldiers were diagnosed with PTSD.

“In the meantime, there have been more cases. The war is still going on and still generating fresh trauma,” Bar-Haim tells Shomrim, adding with concern that the true number is even higher. “The figures I cited in May were estimates of full pathologies – that is, soldiers who are diagnosed with full-blown PTSD. There are a lot of people – soldiers and civilians alike – who are defined as being on a subclinical level, but who exhibit many of the symptoms and will also need treatment. So, in the end, there are huge numbers of people, which is beyond the capacity of the existing systems.”

The big question, of course, is how far beyond. “We are about to face a wave of PTSD diagnoses,” Bar-Haim says. “There are many people suffering from post-trauma right now, but we still have not hit the peak. Around a year or two after the war is over – if it ever ends – we will start to see that wave arriving. Originally, I predicted that there would be around 30,000 PTSD sufferers. I later amended that to around 50,000. Now I think it could be even higher.”

"Originally, I predicted that there would be around 30,000 PTSD sufferers. I later amended that to around 50,000. Now I think it could be even higher”

The stressor and the urgency | New clinics and waiting lists

In an effort to get a better understanding of the overall picture, Shomrim spoke to experts from the three main research and treatment centers in Israel: the National Center for Mental Trauma at Sheba Medical Center, The Asif Center for Post-Trauma at Tel Aviv Sourasky Medical Center and the National Center for Traumatic Stress and Resilience at Tel Aviv University. Each of these facilities treats thousands of people suffering from PTSD and, since October 7, they all say that there has been an incessant stream of new patients.

“The clinic at Sheba has been operating for almost 30 years. Throughout those years, the number of patients was static – around 1,500 patients a year were treated by our clinic. Since the start of the current war, the number has doubled and we now treat around 3,000 patients every year,” says Dr. Vlad Svetlitzky, director of Sheba’s network of trauma clinics. In order to deal with the extra demand, Sheba teamed up with the IDF Disabled Veterans Organization and the Friends of the IDF to open six additional clinics across the country, all of which focus primarily on members of the armed forces and their families. “We only opened these new clinics in January and they have already treated close to 1,000 people,” Svetlitzky says, adding that the waiting list for treatment at Sheba can be as long as two months.

Svetlitzky agrees with Bar-Haim’s assessment: “We recognize that there is a wave of PTSD on the way,” he says. “I see my patients and I see at what stage they start to fall apart: it’s the stage where you leave the framework you were in, when reserve duty ends and you return home. In the army, you were always alert; here, that’s no longer functional. You no longer have the unit and your friends and the support network isn’t as strong as it was in the army. Unfortunately, we see people getting divorced, people having difficulty at work or in their studies. In the end, when the penny finally drops, they come to see us. And it’s an ongoing process, sadly.”

“I see my patients and I see at what stage they start to fall apart. when reserve duty ends and you return home"

Dr. Oren Tene, director of the Asif Center, also says that “there has been an increase of hundreds of percent since the start of the war. The Asif Center has treated around 1,000 patients so far this year. We have taken on additional staff and also expanded the services we give, but at the moment we have reached a plateau and the waiting list is getting longer. We try to make sure that people don’t wait more than a month or two. We try very hard.”

Not only are the waiting lists getting longer, but so, too, is the war itself. The oft-repeated statistic about the 2023 Israel-Gaza war being the longest conflict in Israel’s history is borne out not only by the number of fatalities and causalities, but also in the emotional and psychological toll. Of even more concern is that this is having a direct impact on the success rate of treatment. “What makes this period – and the people seeking treatment – unique is that they have not managed to disconnect for a second from stressor – the source of their stress,” says Dr. Ophir Levy, a clinic director at the National Center for Traumatic Stress and Resilience. “We have been at war for almost two years; most of the people who come to us for treatment are in the military or are facing some kind of stressor because of the war. As a result, we are less able to have a full impact on their recovery.

“I’ll give you an example: If you come to me for treatment after you’ve been in service and, after we’ve started treating you, if you're suddenly called back into the army for another tour of duty and you go, that will obviously affect the treatment. Even if you finish your treatment and you’re called up the next day again, that will usually have a negative impact because one of the most important elements of PTSD treatment is to disconnect the patients from the source of the stress.”

Like his colleagues, Tene is also worried about the wave of diagnoses that is on the way and says that there is one factor that could impact the extent of the damage: the erosion of the national consensus over the war and its goals. “There are wars over which there is a public consensus. The October 7 war started as one of those, and who are filled with a sense of  purpose, meaning and value, when you go to war as the proud head of the family and with the community behind you, you are a lot more resilient to the potential emotional damage that could happen. When you go into the army unsettled, feeling helpless, frustrated or angry, that will have dangerous repercussions. How we experience a traumatic incident is critical when it comes to how the brain and the mind interpret that incident in retrospect. We are, in fact, deploying soldiers who are highly susceptible to PTSD. I wish I could say that we have reached the peak of the wave.”

Prolonged exposure to the stressor erodes our natural defense mechanisms, Bar-Haim adds: “This is a hugely problematic development which adds another layer of difficulty to treating the patient’s mental health. The erosion is very significant and it affects a lot of people who, if they faced one-time trauma, might not have developed the symptoms of full-blown PTSD. More and more of these people are now reaching that stage.”

"We have taken on additional staff and also expanded the services we give, but at the moment we have reached a plateau and the waiting list is getting longer"

American experience and the Israeli model | One in five soldiers

While it is impossible to predict or quantify the extent of the damage caused by the ongoing war, it is possible to learn something from the experiences of other countries. “The American forces who were deployed to Iraq and Afghanistan spent long periods of time there and served multiple tours of duty – just as is happening here,” Ben-Haim says. “At the height of those conflicts, up to 15 percent or even 19 percent of American forces suffered from PTSD. These are the statistics we have when it comes to prolonged conflicts; behind these numbers are soldiers who have full-blown PTSD. They don’t sleep, they are constantly on edge, they refrain from anything that could potentially remind them of the trauma, they have nightmares and flashbacks, intrusive memories and they see the world as a threatening place. It’s a highly debilitating disorder.”

Speaking in May at a conference about the future of Israel organized by Tel Aviv University, Limor Luria – the director of the Ministry of Defense’s Rehabilitation Department – revealed an unprecedented statistic. She stated that 47 percent of the people injured on October 7 who contacted her department for assistance were diagnosed with symptoms of PTSD and other mental health issues. She spoke about the department’s efforts to help these people and its preparations for the challenges still to come. Other experts who also addressed the conference painted a picture that was far less flattering of the military mental-health system, arguing that soldiers suffering with symptoms of PTSD were still being called up for reserve duty, including emergency call-ups, even though they were undergoing treatment.

47 percent of the people injured on October 7 who contacted her department for assistance were diagnosed with symptoms of PTSD and other mental health issues

“Since then, there has been a development of some kind, but I am still not sure whether it is being implemented efficiently on the ground,” Bar-Haim says. “The Ministry of Defense sends the IDF a report about anyone who is in the process of submitting a request to be recognized as a PTSD sufferer, to make sure that they are not sent emergency call-up papers. It may sound obvious that you don’t call up someone who is already exhibiting symptoms of PTSD, but the army is also under pressure and sometimes the soldiers themselves feel that they owe it to their colleagues in the unit and to their commanders, so they are willing to serve even though they shouldn’t.”

Levy describes one encounter he had with exactly this dilemma. “Not long ago, I was treating an officer from the Artillery Brigade at the clinic,” he says. “We started treatment and he immediately got another call-up order. He, of course, introduced the whole dilemma of his command, so I asked him: Do you think, given your condition today, that you are capable of fulfilling your duties as an officer? He replied that he didn’t think he was. So I told him to draw his own conclusions. A week later, he came back and told me that he had decided not to go to reserve duty this time. He contacted the liaison officer, who told him that it wouldn’t be a problem: Just get approval and send it to us, she told him. And that’s what happened. The army is willing to be accommodating.”

"A lot of clinics have been opened to deal with the initial stages of PTSD, because it’s a disorder that comes in stages”

According to Levy, the IDF is heavily invested in studying PTSD among its forces and, as far as possible, preventing it. “I served in an emergency unit in the army that was designed to help prevent soldiers from developing symptoms of PTSD,” he says. “There is a series of activities before an operation or a war – and certainly afterwards: from lectures to increasing awareness of the subject during routine times to sitting down with the soldiers for a debriefing after the operation. A lot of clinics have been opened to deal with the initial stages of PTSD, because it’s a disorder that comes in stages.”

Referring to the 2024 data, Levy says that “when we first opened, we had up to 60 calls in the first week. Now we are getting 20 or 30 new patients a week; at any given time, we have between 70 and 80 patients on our books – and that is our capacity. Our therapists are not employed full time, but we are growing along with the demand. We started out with a team of eight therapists and now we have 10 on every shift. The others are university professors who mainly deal with research and psychology students who are responsible for the initial intake.”

The efficiency of treatment | 50 percent success rate

Text: The fact that treatment centers have been inundated with PTSD patients has also had an impact on the staff. “Last week, one of the residents came to me and said that she couldn’t carry on. ‘You have to reduce my patient workload, I can’t do it,’ she told me. ‘I see one after another, 10 a day; I get home and I can’t fall asleep.’ That is how hard it has become,” Tene says. He agreed to the resident’s request and halved the number of patients she was assigned every day. He also admits, however, that the number of therapists at his disposal does not permit him to lose talent. “The biggest restriction – even more than money – is the issue of trained therapists and how quickly they can become exhausted.”

How is it different from dealing with patients with other mental health issues?

“There is something about listening to patients’ disaster stories, many of which can be extremely troubling and shocking. Stories about mutilated bodies and smells which can be secondary stressors that are less common in other areas.”

“The work’s tough and we're seeing a ton of patients,” says Svetlitzky. “When you are treating between eight and 10 patients a day, that’s a burden and it can even lead to situations where it affects the therapists’ mental health. We must have more instruction and team meetings to allow them to let it all out.” Moreover, he adds, eight patients is often the minimum and some therapists see 14 patients a day.

“There is a shortage of therapists,” Ber-Haim confirms. “Although Israel is in a pretty good place in terms of the OECD’s index of psychologists per capita, the government has starved the public sector of funding and many of the best therapists find their way into private practice. And you have to bear in mind that the public sector is also dealing with all kinds of pathologies. Psychiatric wards also have to deal with schizophrenia, depression, anxiety, eating disorders – all those kinds of things.”

“It’s important to understand,” says Tene, “that there is likely to be an increase in demand for mental health care across every sector of Israeli society. We know that the first people who arrived on the scene of the 9/11 attacks, thousands of first responders, are the most susceptible. At a certain stage – maybe years later – most of them developed depression rather than PTSD. It’s important to note that we are in a pretty deep hole in this respect. Budgets are flowing to the trauma treatment centers and I get calls from the directors asking me why I sent someone with depression to their clinic rather than a depression clinic. But those clinics haven’t got extra funding, aren’t getting donations and have year-long waiting lists.”

“The mental health system was in a state of collapse even before the war and the wait times were unrealistic,” says Svetlitzky, who goes on to explain how the shortfall works. “It’s a zero-sum game. You draw the top professionals from one organization to another. There are around 400 organizations which offer trauma therapy and they all draw professionals from one body to another. There’s crazy competition for quality therapists.”

All of the experts with whom Shomrim spoke agree that this issue will be on the agenda for many years to come and, as one of them put it, “we have to prepare two or three decades ahead.” All three of the centers hold seminars and conduct research to increase the pool of therapists and to improve the effectiveness of the therapy they provide. Currently, around half of their patients receive effective treatment. “For 50 percent of the patients, it’s a significant help, compared to other disorders like depression and anxiety, which have success rates of 75 to 80 percent,” Bar-Haim says. “Our intention, through intensive research over the next 10 years, is to narrow this gap and reach a situation where we have both higher efficacy of existing treatments and new treatments.”

Perhaps it’s fitting to end with another quote from Udi Kagan’s stand-up. “I want to say something positive,” he tells the audience in the final moments of his routine. “This thing grew in the darkness, in shame, in silence. When you don’t talk about it, it grows — but it dies very quickly in the light. And we are the light.” He’s right.