Highly sensitive to noise due to childhood trauma, Nili is stressed when air raid sirens send her to a crowded shelter where her “internal war” overlaps with that raging outside.
The experience of Nili, whose name has been changed for this article, shows the particular vulnerability of people with mental health conditions when facing the Middle East war, triggered on February 28 by the US-Israeli attack on Iran.
With each warning siren, the same agony for the 21-year-old, who has spent nine months at the Shalvata Mental Health Center in the central city of Hod HaSharon, is run by Israel’s largest healthcare provider, Clalit Health Services.
“It’s unpleasant and unusual in a relatively small room with a lot of people you don’t know, men and women together, usually quite crowded,” he told AFP during a visit to the center.
“We are in Israel, and there is war outside. But there are also people who have been dealing with their own internal war for many years,” he added.
War anxiety is also felt strongly by Israelis living with disabilities, who number about 1.32 million people, or about 13 percent of the population, according to a 2025 report by the Central Bureau of Statistics.
For 16-year-old Rhea Azmanov, who has a cognitive disability, the uncertainty creates an additional layer of challenge.
“All children with disabilities really need routine” to give them a sense of stability and certainty, their father, Ziv Azmanov, told AFP.
“So when there is no normal routine, as in the current situation, it creates a lot of stress and anxiety.”
The Azmanov family does not have a “mamad” or reinforced room in their apartment in the city center of Raanana, and must use the shelter of their building every time the siren sounds to warn of an incoming missile.
“He is very uncomfortable. He hates crowded places. So sometimes instead of going down, we have to stand outside,” said his mother, Veena Azmanov, who noted that the noise inside the shelter, combined with the wail of sirens and the boom of missile interceptions, can elevate stress.
And for people with reduced mobility, the challenge of accessibility becomes more extreme during the war “because everything is faster”, says Yoav Braver, who leads training at Beit Issie Shapiro, one of Israel’s main centers for people with disabilities.
Braver said that public information mapping of accessible shelters is difficult to find, and even those who are confined to their homes may struggle to get there in the 90-second window provided by the longest air raid warning.
Nurses often bear a heavy burden during war, Braver said, adding that Beit Issie Shapiro has set up a hotline offering advice to professionals or family members.
“Burnout is the main problem we deal with in wartime,” he said.
– ‘Ethical dilemma’ –
For medical staff who care for psychiatric patients like Nili, and those with more severe conditions such as schizophrenia and personality disorders, a seemingly impossible choice may arise between ensuring their own safety or remaining with the most vulnerable.
Merav Agsham, head nurse of the psychiatric unit at Shalvata, describes these as daily “ethical dilemmas” when the sirens sound.
“Get out, please,” he recently asked a patient with a psychotic episode, when he was taking a shower and refused to go to the shelter.
“Eventually I went down without him,” the 38-year-old mother told AFP, but remembered that she had a lump in her throat.
“If something happens, how can I live with it? It’s my responsibility,” he said.
Agsham said that sometimes patients refuse to take shelter by insisting that there is no danger and nothing will happen to them.
Sometimes, the patient will answer “I don’t mind if a missile will come down on me, and I will die. I want to die.”
At night everything becomes more complicated, says center director Shlomo Mendlovic.
Drugged patients sleep deeply and find it difficult to wake up, while others are restrained to prevent violence.
Mendlovic said that staff must find their own balance between respecting the patient’s autonomy, choosing to stay with those in care, or ensuring their own safety.
“I would prefer that everyone go to the shelter,” he said, but added he was proud to see the dedication of the staff who chose to stay with the patients.
Uri Nitzan, director of the depression and crisis intervention ward at Shalvata, said the center prioritized dialogue, encouragement and support.
“In a moment of crisis, you can feel that … there is a good relationship,” he said.
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