A new systematic review published in Frontiers in Psychiatry brings together 68 studies from the first two years after the October 7 attacks, offering insights that extend far beyond Israel into how prolonged conflict, cumulative exposure and continuing threat can shape post-traumatic stress, anxiety, depression and addiction-related outcomes.

In the hours and days after October 7, 2023, the immediate human toll was visible. Far harder to see was what would happen inside people in the months and years that followed.

How does a society respond psychologically when a traumatic event does not simply end—when displacement, bereavement, economic insecurity, repeated threats and prolonged uncertainty continue to shape everyday life?

A new systematic review published in Frontiers in Psychiatry begins to answer that question, providing the first systematic synthesis of psychiatric outcomes across multiple symptom domains during the first two years following the October 7 attacks.

Bringing together 68 studies, the review provides a comprehensive picture of the rapidly growing research on mental health in Israel after October 7. But its implications reach beyond a single country or conflict. By examining post-traumatic stress symptoms (PTSS), anxiety, depression and addiction-related outcomes together, the researchers offer a window into a broader global question: What happens to mental health when people are not simply recovering from a traumatic event, but adapting while threat and uncertainty continue?

The study was led by Dr. Michal Cohen and Prof. Mario Mikulincer of the Israel Center for Addiction and Mental Health (ICAMH) at the Hebrew University of Jerusalem, together with PhD student Maor Daniel Levitin, affiliated with ICAMH/Hebrew University and Tel Aviv University, in collaboration with the Israel Center for Addiction (ICA).

The Story Is Not Simply “More Trauma”
One of the review’s most important conclusions is that there is no single psychological response to collective trauma.

Across the studies, people followed different trajectories. Symptoms declined over time for some, while for others psychological distress remained elevated. What appeared to matter was not simply whether someone had experienced a traumatic event, but the intensity, continuity and accumulation of exposure, alongside the broader social and personal circumstances in which that exposure occurred.

Post-traumatic stress was particularly associated with direct, cumulative and role-related exposure. While symptoms declined over time in some populations, they remained elevated among people experiencing sustained exposure or continuing strain.

Anxiety and depression were also widely documented. Direct trauma was only part of the picture. Displacement, loss, income disruption, prolonged threat, food insecurity and extensive media exposure were among the broader stressors associated with increased anxiety and depressive symptoms.

This distinction has implications well beyond Israel. In prolonged conflicts, humanitarian emergencies and other large-scale crises, psychological risk may be shaped not only by a single catastrophic event, but by what comes afterward: repeated exposure, disrupted lives, economic pressure, uncertainty and the gradual erosion of coping resources.

The picture that emerges is therefore not of an entire population responding in the same way, but of different trajectories of vulnerability and resilience. People facing bereavement, displacement, socioeconomic strain, repeated exposure or fewer psychological and social resources may experience very different outcomes from those with greater stability and support.

At the same time, the review points to something that may help protect people across cultures and crises: social connection. Greater perceived social support, particularly from friends and significant others, was associated with lower levels of post-traumatic stress symptoms.

A Critical Blind Spot: Addiction
One of the review’s most revealing findings lies not only in what the evidence shows, but in what remains largely unexplored.

Of the 68 studies included in the systematic review, only three examined addiction-related outcomes.

Two focused on substance use, and both reported post-attack increases. Increased use was associated with greater exposure severity, psychological distress and prior mental-health difficulties. Direct exposure emerged as the strongest correlate of increased substance use, while psychological distress partially mediated associations between indirect exposure and substance use.

The third study examined gambling and found a more selective pattern, with increased gambling observed primarily among men without prior gambling problems who reported greater difficulties with emotion regulation.

That gap in the evidence raises a broader question for the international research community.
Trauma does not necessarily manifest only as recognizable symptoms of post-traumatic stress, anxiety or depression. Addictive behaviors have been associated with trauma exposure and affective dysregulation and may emerge as maladaptive coping responses under sustained threat. Yet compared with PTSD, anxiety and depression, addiction-related outcomes remain comparatively understudied in research on large-scale collective trauma.

Importantly, the available evidence does not establish a generalized population-wide escalation in addiction. Instead, the limited research points toward selective, exposure- and distress-related increases.

For researchers and health systems responding to crises elsewhere, the finding highlights an important potential blind spot: if mental-health surveillance focuses primarily on PTSD, anxiety and depression, other ways of coping with prolonged distress may receive too little attention.

A Global Lesson: Identify Risk, Not Just Distress
The review points toward a broader lesson for clinicians, policymakers and health systems responding to populations living through prolonged crises: mental-health needs are unlikely to be distributed uniformly.

The findings suggest that screening and services should take into account the intensity and duration of exposure, displacement and loss, socioeconomic pressures, existing vulnerabilities, social resources and the continuing conditions in which people are living.

That matters for any health system attempting to respond to large-scale trauma. A population-wide crisis does not necessarily require an identical intervention for everyone. Understanding who is most vulnerable, why they are vulnerable and what kinds of support they need may allow limited mental-health resources to be targeted more effectively.

Because post-traumatic stress, anxiety and depression frequently co-occur, the findings also support integrated services capable of addressing overlapping mental-health needs rather than approaching each condition as an isolated problem.

And recovery cannot be measured only by whether symptom scores fall.

Anxiety and depression were also associated with reduced health-related quality of life and impaired daily functioning. For mental-health systems, the question is therefore not simply, “Are people less distressed?” It is also: Can they work? Can they care for their families? Can they participate in their communities and return to meaningful everyday roles?

When There Is No Clear “After”
The review covers research from the first two years following October 7, but the authors emphasize that the psychological story is far from complete.

Much of the existing evidence relies on screening instruments rather than comprehensive diagnostic assessments, while cross-sectional designs are common, limiting researchers’ ability to draw causal conclusions. Sustained longitudinal research will therefore be essential to distinguish temporary stress reactions from psychiatric difficulties that persist and require longer-term clinical intervention.

That distinction has significance far beyond Israel.

Traditional ideas about trauma often imply an “event” followed by an “aftermath.” But wars, displacement, terrorism and prolonged humanitarian crises do not always provide such a clear dividing line. People may be expected to recover psychologically while the conditions producing fear, uncertainty and disruption are still present.

The Israeli experience captured in this review therefore offers a case study with broader relevance: how should societies understand and respond to mental health when there is no clear “after” to the trauma?

The findings suggest that the continuity and accumulation of exposure may matter profoundly. Persistent symptoms were more frequently observed among people facing continuous threat, cumulative stressors or sustained strain. For anxiety and depression in particular, symptom persistence appeared to reflect cumulative stress load, chronic uncertainty and the erosion of coping resources rather than discrete traumatic events alone.

For countries and communities confronting war, terrorism, mass displacement, natural disasters followed by prolonged disruption, or other sustained collective crises, this distinction could influence how mental-health responses are designed—from when screening occurs and which outcomes are monitored to how vulnerable groups are identified and how long support remains available.

The review also exposes important gaps that have international relevance. Longer-term follow-up is needed; standardized diagnostic measures are needed alongside brief screening tools; functional outcomes should be measured alongside symptoms; and exposure itself needs to be assessed more systematically so researchers can distinguish the effects of exposure intensity and cumulative burden from pre-existing vulnerability.

The central lesson is therefore larger than October 7 itself: the mental-health consequences of collective trauma cannot be understood simply by asking whether people experienced a traumatic event. We must also ask how intense that exposure was, how long it continued, what accumulated around it, and what social and personal resources people had available as they tried to adapt.

Understanding those differences may be essential for designing mental-health systems capable not only of responding to the immediate psychological shock of a crisis, but of supporting people through the much longer and less visible process that follows—or, in some cases, continues.

Methodology
The researchers conducted a systematic review in accordance with PRISMA 2020 guidelines, searching four major scientific databases—PubMed, PsycINFO, Scopus and Web of Science. The review considered empirical studies of Israeli populations published between October 7, 2023 and October 7, 2025, with the database search updated through December 30, 2025.
Titles and abstracts were independently screened by two reviewers, as were potentially eligible full-text articles, and data were independently extracted and cross-checked. Risk of bias was assessed using design-specific Joanna Briggs Institute (JBI) critical appraisal tools.
The searches initially identified 4,588 records, with 68 studies ultimately meeting the inclusion criteria. Because the studies differed substantially in their populations, definitions of exposure, measurement instruments and timing of assessment—and because some reports may have drawn from overlapping samples—the researchers did not conduct a meta-analysis. Instead, they used a structured narrative synthesis to identify patterns, consistencies and differences across psychiatric outcomes, exposure characteristics and population subgroups.