Dear Editor,
On 13 June 2025, Israel initiated a hybrid warfare attack on Iran under the pretext of countering its nuclear program. This invasion resulted in hundreds of civilian casualties and targeted critical national infrastructure (1). This letter describes our experience as psychiatry residents at Roozbeh Hospital, a major academic center in downtown Tehran, navigating this battlefield-like environment to provide care for mentally ill patients. The hospital's proximity to highly sensitive political, military, and security centers, which were primary targets, placed it at extreme risk.
The attack commenced in the early morning without warning. As war was considered an unlikely scenario, the hospital's emergency preparedness plans focused on other crises, leaving us completely unprepared for such an event. Despite its location in a high-risk area, critical safety infrastructure, such as fortified shelters, was absent. The onset of hostilities during a multi-day public holiday exacerbated the crisis, as many staff were on vacation. Transportation restrictions impeded their return, forcing a skeleton crew to manage a surge in responsibilities under perilous conditions. Commuting itself became a life-threatening risk, tragically highlighted by the civilian attack in Tajrish square, Tehran, Iran on 15 June (2).
The psychological toll on our vulnerable patient population was severe; many experienced exacerbations of anxiety, restlessness, and other symptoms. Treatment adherence was disrupted, leading to a concerning rise in discharges against medical advice among symptomatic and unstable patients. The constant sound of explosions and the palpable danger made routine care impossible. Some staff felt compelled to leave without official permission due to the intolerable risk. Consequently, both inpatient stability and outpatient follow-up services were severely compromised. Although the hospital had telemedicine systems (e.g., websites, hotlines), these platforms had not been robustly implemented or popularized before the conflict. Widespread internet and telecommunications outages then crippled this last resort for remote care, leaving patients completely isolated and without guidance.
This experience underscores critical lessons for global mental health systems. Evidence from previous humanitarian crises recommends several strategies to mitigate such impacts. First, comprehensive emergency plans must specifically include scenarios of war and armed conflict, as advised by the World Health Organization (3). These plans must integrate infrastructural safeguards (e.g., shelters, backup power) with human resource strategies, such as maintaining a mobilizable reserve staff (1). Second, telepsychiatry platforms must be strengthened and familiarized with patients proactively to ensure continuity of care, a lesson learned during the COVID-19 pandemic (4). However, as we witnessed, conflicts can destroy digital infrastructure, necessitating redundant, low-tech communication plans. Third, community-based and family-focused interventions can reduce relapse rates in conflict zones; training families in basic psychoeducation and crisis management can extend care beyond the hospital walls (5). Finally, implementing psychological support systems for healthcare staff is non-negotiable for sustaining the workforce during prolonged stress (6).
In conclusion, the June 2025 attack exposed dangerous gaps in our preparedness. We urge psychiatric institutions worldwide, particularly those in geopolitically sensitive areas, to adopt and rehearse these evidence-based strategies to safeguard our patients and personnel against the devastating and unpredictable nature of modern warfare.
