The unprecedented terror attacks carried out by Hamas on October 7th, 2023, victimizing Jewish and Arab Israelis alike, were characterized by a scope and magnitude not formerly known to Israeli citizens. Although the number of casualties from the October 7th events is still being updated, at least 1200 were reported dead, including over 400 participants in an outdoor rave party, 240 kidnapped, including children and babies, and many thousands injured (Rubin and Morris, 2023). Evidence collected since October 7th reveal numerous acts of rape, mutilation and torture committed by the terrorists, some of which were live-broadcasted on social media. While current estimates about the mental health sequelae of this attack are yet to be reported, reports from previous massive terror attacks, globally, have demonstrated significant levels of posttraumatic stress disorder (PTSD), depression and anxiety, as well as elevated use and misuse of addictive substances and prescription medications (Kerridge et al., 2014; Neria et al., 2011). In the New York area, which suffered a loss of 2977 people during the 9/11 terror attack, the prevalence of PTSD was reported to be 11.2% four to eight weeks after the attacks (Schlenger et al., 2002) and 7.5% at five to eight weeks post-9/11 (Galea et al., 2002). Prevalence rates of PTSD after the Madrid 2004 train bombing, in which 193 fatalities were reported, were 2.3% (Neria et al., 2008).

Studies suggest that there are several vulnerable populations which are at higher risk to develop anxiety, depression, and PTSD after exposure to imminent threat (Neria et al., 2008; Schlenger et al., 2002). Female sex, younger age, and belonging to an ethnic minority were found to increase vulnerability to develop PTSD after exposure to threat (Adams and Boscarino, 2006; DiGrande et al., 2008; Galea et al., 2002; Schlenger et al., 2002). Factors related to the severity of exposure, such as being directly exposed to terror attacks (Berninger et al., 2010) or alternatively exposure to terror via media or social networks (Neria et al., 2009; Silver et al., 2002) have also been demonstrated to increase risk for PTSD symptoms.

Some of the individuals afflicted by distress following exposure to traumatic events might also develop harmful behaviors, such as increased use and misuse of substances (Kerridge et al., 2014). Previous studies focusing on consequences of the 9/11 attack in the New York area indicated an increase in prevalence of alcohol and tobacco use (Pfefferbaum et al., 2008; Vlahov et al., 2006) as well as increase in the use of prescription medication (Druss and Marcus, 2004). During the COVID-19 pandemic, a mixed trend was observed concerning the increase in alcohol consumption, with some studies indicating an increase and others a decrease (Acharya and Dhakal, 2022), yet clearer evidence were observed in other substances, pointing to an increase in use (Roberts et al., 2021). Finally, recent evidence from the Russia-Ukraine war indicate a reported 10%–19% increase in the use of tobacco, alcohol, pain relievers and sedatives (Kurapov et al., 2023). A meta-analysis indicated that after controlling for type of incident, level of exposure and time since the event, 7%–14% of the population may report an increase in alcohol use in the two years following a terror event (DiMaggio et al., 2009). A recent meta-analysis indicated that 6% of adults increased their alcohol consumption following exposure to a terror attack, with greater risk reported for individuals who were highly exposed to the attack (Sanz et al., 2023). Unadjusted prevalence of increase in cigarette smoking and mixed drug use following a terror event was reported to be 6.8% and 16.3%, respectively (DiMaggio et al., 2009).

To prepare the mental health system for the upcoming rise in mental health needs, it is imperative to assess the extent of mental effects while identifying at-risk groups likely to suffer from PTSD symptomatology. In this study we aimed to bridge this gap in scientific and practical knowledge, by focusing on prevalence and predictors of PTSD, distress and the use of addictive substances following the massive terror attacks in Israel. Specifically, we explored whether demographic and sociodemographic characteristics, the level of exposure to terror attacks, and the cumulative effects of being exposed to several potentially traumatizing events, are predictive of anxiety, depression and PTSD levels. Sensitivity analysis explored rates of PTSD, distress and increase in substance use among Israeli Arabs.