As missile sirens wail across Israel during the ongoing conflict with Iran, psychiatric hospitals face dilemmas that extend beyond physical protection. At the Shalvata Mental Health Center in Hod HaSharon, near Tel Aviv, medical teams contend with patients who refuse to enter shelters, sometimes expressing a desire to die.
Professor Shlomo Mendelovich, director of Shalvata, describes the acute tension these moments create. Caregivers must weigh the duty to preserve life against respecting patient autonomy and ensuring staff safety.
“Sometimes a patient suffering from severe depression tells us: ‘What will happen if I don’t go to the shelter? I will die? I want to die.’ In those moments we often have only seconds to act,” Mendelovich explained.
Shalvata typically hospitalises 150–170 psychiatric patients across open, semi-secure, and closed wards. With the worsening security situation, the hospital reduced inpatient numbers to 74 by discharging those with supportive families who could return home safely. Even with fewer patients, evacuating dozens of vulnerable individuals during each alert remains a major logistical and ethical challenge.
“Sometimes staff members choose to stay behind with a patient who refuses to evacuate. When I saw that, I didn’t know whether to feel proud of their dedication or worried that they were risking their own lives,” Mendelovich said, recounting a recent incident when four patients, including one agitated individual, declined to move to the shelter.
The hospital’s underground protected space holds 45 people, including patients and staff. During alarms, around 35 patients are transferred underground, while the remaining patients are directed to protected corridors. A temporary command centre operates within the space, coordinating operations with the Ministry of Health and national emergency authorities.
Strict protocols complicate shelter arrangements. Adult and adolescent patients cannot mix, and male and female wards must remain separate. To maintain these separations, staff have erected temporary partitions underground.
Nighttime sirens present additional difficulties. Many patients take medications or sleeping pills and are disoriented upon waking.“Waking a patient who is heavily sedated, explaining the situation and helping them move quickly to a shelter is extremely difficult,” Mendelovich said.
Once in the shelter, the environment can challenge patients’ stability. Individuals accustomed to quiet, small shared rooms must adapt to crowded, noisy spaces with repeated alarms. Remarkably, staff report no increase in violence.“In fact, sometimes the opposite happens. Some patients who tend to withdraw in the wards begin helping and supporting others during the crisis,” Mendelovich said.
The emotional load on hospital teams is heavy. Command staff make split-second decisions while worrying about families elsewhere.
“Extreme situations amplify every tension. Even deciding which television channel to watch for news can become a sensitive issue when everyone is under stress,” Mendelovich said.
While global coverage often emphasises trauma surgery and physical injuries in wartime, psychiatric hospitals face distinct frontline issues. Managing severe depression, psychosis, and trauma amid repeated alerts raises profound questions of autonomy, safety, and duty. “As long as the war continues, we are adapting to a reality that changes every day,” Mendelovich said.