Naturalistic Study of Posttraumatic Stress Disorder Among Israeli Civilians Exposed to Wartime Attacks

Although violent conflict is a global problem, the state of Israel represents a unique situation. It has experienced decades of ongoing wartime attacks, dating back to its independence in 1948. The major waves of attacks between 2009 and 2015 consisted of the 2012 and 2014 Gaza wars, during which Hamas launched rockets directly at Israeli civilians, and the 2015 “stabbing intifada” (9). Since the 1970s, Israel has recognized and supported people who have been directly affected by wartime attacks via a unique case management approach to identify and track such individuals (10–12). Within 24 hours after a wartime attack, specially trained social workers contact the people affected and their families and remain available to provide advice, training, and guidance for mostly psychological problems. Survivors are closely followed up during their rehabilitation process. Medical treatment, including mental health care, is available in public hospitals or through four health maintenance organizations that provide Israel’s hospital, clinic, and outpatient services. These services are reimbursed after approval by the National Insurance Institute (NII), which also provides support services for rehabilitation, job loss support, and grief counseling.

Since the second Lebanon war (in 2006), Israel has operated a special outpatient support system dedicated to stress management and behavioral health. The service is free, available throughout the country, and offers a specific number of sessions (usually 12). As Bodas et al. (10) have reported, the treatment begins with a general assessment of the patient’s condition, according to protocols developed by Dr. Ilan Kutz. After patient assessment, a wide array of psychotherapy methods can be used for patients diagnosed as having PTSD, including cognitive-behavioral therapy, somatic experiencing, and eye movement desensitization and reprocessing. Pharmaceutical interventions are avoided, except in cases of extreme distress, and even then, benzodiazepines are not prescribed (10). Afterward, a patient who remains injured or disabled can file a claim with the NII for damages (a lump-sum payment or a disability pension). The type and level of disability is assessed by medical commissions composed of national insurance physicians. During this assessment, psychiatrists determine whether the patient continues to be affected by PTSD and by subsequent impaired functioning in daily life activities. Complementary to this support, the NII provides other services and monetary aids to survivors and grieving families.

We conducted the current study by using data from a national administrative database of all civilians who experienced wartime attacks to determine the level of Israeli civilian exposure to such attacks, prevalence of PTSD and physical injuries after such exposure, and associated medical costs over a recent 7-year period. Our study may benefit other countries as well, because it is the first look at the impact of violent conflict on medical costs and the cost-effectiveness of using an early treatment approach to reduce the long-term effects on survivors of wartime attacks.

We retrospectively examined administrative data from the NII database of individuals who were exposed to wartime attacks during the period of January 1, 2009, to December 31, 2015, a period that offered the most robust available data. This database records all disability claims from a centralized, patient-based medical record. It includes details on ICD-10 principal diagnoses, associated costs for medical care from hospital and outpatient invoices, and type and level of disability for those adjudicated as disabled by the Israeli Medical Commission.

These records are updated in real time as each invoice or external medical record is received. The current analyses included all invoices coming from all health care providers through December 31, 2016. The database also includes information about individuals who have experienced ASRs and have been reimbursed for mental health services. Descriptive analyses of individuals adjudicated as disabled by PTSD (i.e., analyses of prevalence, demographic characteristics, disability, and medical costs) are provided below. All medical costs are presented in 2016 U.S. dollars (1 $U.S.=3.5 new Israeli shekels). Because these retrospective analyses were conducted with anonymous archival data, institutional review board approval and informed consent were not required.

We identified 11,476 civilians who experienced and survived wartime attacks from 2009 through 2015, stemming from 243 separate attacks on civilians (for reference, Israel’s total population was estimated to be 8,299,706 in 2017) (13). Of that group, 7,561 (65.9% of the total sample) received immediate mental health care treatment for ASRs, 1,332 (11.6%) were subsequently adjudicated as having a disability (from all causes), and 519 (4.5%) as disabled by PTSD by the Israeli Medical Commission through the end of 2016 (Table 1).

We also examined the role of an early intervention (EI) for ASR (consisting of psychological support, including telephone interviews, direct contact in the field, and structured psychotherapy sessions) (10) and physical injuries among those who did and did not develop PTSD (Table 2). Of those who received EI for ASRs, 291 were eventually adjudicated as having disability due to PTSD (3.9%), whereas among those who did not receive immediate treatment for ASRs, 228 were adjudicated as having been disabled by PTSD (5.8%). Chi-square analyses showed that individuals who received EI for ASRs were less likely to later receive a diagnosis of PTSD-related disability (p=0.001). Of those without physical injuries, 90.4% (N=7,143 of 7,906) received EI for ASR, compared with 12.7% (N=418 of 3,291) of those with physical injuries. Also, among those without physical injuries, the EI was associated with decreased PTSD rates (2.6% of those who received the EI developed PTSD, whereas 7.2% of those who did not receive the EI developed PTSD). However, for individuals with physical injuries, the PTSD rate was higher among those who received EI for ASR (30.4%) than among those who did not receive the EI (5.2%).

Finally, we examined medical costs for those disabled by PTSD or by another cause (Table 3). Individuals disabled by causes other than PTSD incurred higher average medical costs ($7,153 in U.S. dollars) than those disabled by PTSD ($1,960 in U.S. dollars). The cost of early psychological support for the 7,065 individuals manifesting ASR was $5.5 million in U.S. dollars.

The adjudicated rate of PTSD (4.5%) among Israeli civilians directly affected by wartime attacks was relatively low compared with previously reported PTSD rates among other groups of people affected by such attacks (e.g., approximately 12%−16%) (7) and among combat veterans in the United States, United Kingdom, and Australia (e.g., 1.9%−17.1%) (14). The current results based on data from a cross-sectional national administrative database revealed a PTSD rate that is approximately half the rate (9.4%) reported in an earlier epidemiological study (5) conducted >15 years ago with a nationally representative sample of Israeli civilians. This difference in study results may have been caused by differing research methods, improvements in behavioral health care in the aftermath of an attack (i.e., immediate treatment for ASRs), or other changes in science, medicine, and technology over time. The finding of low disability rates due to PTSD in this national sample is especially stark compared with the historically unprecedentedly high rates of PTSD-related disability among U.S. military veterans, for which data from 2012 (15) have indicated that 7.8% of all U.S. Iraq and Afghanistan veterans are receiving federal disability benefits for PTSD, with almost as many claims pending. The differences identified in our study may stem from cultural or systemic differences (e.g., disability incentives, secondary gain, extent of civilian experience with wartime attacks or military service, or the low suicide rate in Israel among other countries of the Organisation for Economic Co-Operation and Development) (16).

It is notable that individuals who received EI for ASRs were less likely to eventually be adjudicated as having been disabled by PTSD than those who did not receive the EI (3.9% vs. 5.8%, p<0.001). Although our study design did not permit strong causal inferences that EI for ASR reduces the eventual PTSD rate, future research may examine the efficacy and cost-effectiveness of providing a time-limited and relatively inexpensive treatment for ASR shortly after wartime attacks (17).

Our findings also revealed several meaningful associations between EI for ASR and physical injuries for those with and without PTSD (Table 2). First, those who had no physical injuries received a high level of EI for ASR. Among those without physical injuries, 90.4% received EI compared with only 12.7% of those with physical injuries. This result may be explained by medical providers attending mainly to the physical injuries, which may have reduced attention to any psychiatric symptoms. Second, only among those without physical injury was EI associated with decreased PTSD (2.6% of those who received EI developed PTSD, whereas 7.2% of those who did not receive EI developed PTSD). For those with physical injuries, the PTSD rate was higher among those who received EI for ASR (30.4%) compared with those who did not receive EI (5.2%). One possible explanation for this difference is that those who received the EI when they also had physical injuries (<4% of the entire sample) received the EI only because the severity of their psychiatric symptoms came to the attention of medical providers attending to the physical injuries.

Finally, the data showed that the total medical costs for those disabled by PTSD or by other causes were relatively low (Table 3). Primarily because of hospitalizations, medically disabled individuals without PTSD incurred higher average medical costs ($7,153 in U.S. dollars) than those disabled by PTSD ($1,960 U.S. dollars). The total cost of early psychological support for the 7,067 people with ASRs was 5.5 million in U.S. dollars, about $778 in U.S. dollars per individual treated (the cost of about five outpatient psychotherapy sessions in the United States). Other expenses (e.g., disability pension, unemployment compensation) were not included in this study.

The primary limitation of this study was its reliance on a national administrative database that was not originally developed for research purposes and therefore provides only a limited representation of people’s medical and psychiatric status, rather than on data from a prospectively designed epidemiological study. No specific statistical model was selected to control for the different groups who did or did not benefit from immediate treatment. Because of missing data, especially demographic information, we could not identify variables that may have been explained by uncontrolled group differences. On the other hand, this study provides a valuable description of existing government information on all Israeli civilians directly affected by violent conflict or war from 2009 through 2015.

Although the study design did not permit strong causal inferences, our findings suggest that providing case management, medical care, behavioral health screening, and early intervention for ASR in the wake of wartime attacks on a civilian population may reduce long-term PTSD-related disability, medical disability, and associated medical costs. Considering the aftereffects of wartime attacks as a potential public health problem may help other countries to develop similar national-level systems and approaches. Further research is needed to identify factors associated with long-term resilience and the effectiveness of various policy and treatment approaches after wartime attacks.