Over the past two weeks, mental health services have been inundated with thousands of calls for help, and increasing numbers of persons suffering from anxiety have turned to hospitals. The rise in the demand for mental health services in the wake of the missile attacks and other acts of hostility within the country added to the increase in mental health ailments already in evidence following the COVID pandemic.

The first line of defense against the epidemic was, of course, the public health system. However, while most attention was focused on prevention, on the special coronavirus departments set up in hospitals and on vaccinations, one aspect of the epidemic remained at the margins of public attention: its impact on mental health.

The upward trend of the incidence of depression, tension and anxiety, the increased use of medications (tranquillizers, anti-depressants and sleeping pills), and the recourse to narcotics and alcohol, are expected to increase further still. During the COVID crisis, Israel allocated the negligible sum of NIS 10 million to mental health needs connected with the pandemic. The lack of attention to the issue of mental health, when added to the inadequate mental health services in Israel prior to the pandemic, are expected to have an especially negative affect on low-income people who lack the resources to pay out of pocket for treatment and medications.

Public mental health services were lacking even before the pandemic. Thus, for example, under-staffing of mental health professionals at all endpoints led to long waiting times for treatment. To cope with this situation, many persons requesting mental health services were referred by health funds to external (private) professionals, with whom the health funds have service contracts. These involve direct out-of-pocket payments. Now, with the pandemic on the wane, the same under-funded and under-staffed system needs to cope with a sharp increase in mental health disorders surfacing in its wake.

Studies have shown that people living in poverty are more in need of mental health services than those with higher incomes. One can describe the situation as having a snowball effect: poverty leads to mental distress, which leads to additional poverty. The pandemic, and the resulting unemployment, had a particularly adverse effect on people living in poverty or near poverty.

HOW DID WE get to this point? The answer is that the health funds have not been up to the task. In 2015, responsibility for mental health care was transferred from the Health Ministry to the health funds, accompanied by a budget of millions of shekels and a commitment on the part of the health funds to adhere to certain benchmarks. However, a report published on the eve of the outbreak of the pandemic by the State Comptroller’s Office found that while the budget allotted for mental health services was based on the assumption that 4% of adult insured persons and 2% of insured minors would be receiving mental health services, only 3.1% of adults and 1.6% of minors in the largest health fund actually received such services in 2017. The rates were especially low among Arab citizens and ultra-Orthodox Jews.

One of the obstacles to accessibility to mental health services for Arab citizens, ultra-Orthodox Jews and residents of Israel’s geographic periphery, according to the report, is the unequal distribution of mental health clinics. “Thus, for example, in the towns of Yeruham, Netivot and Mitzpe Ramon there are no psychotherapy services, and patients need to travel dozens of kilometers, often accompanied by family members, to receive treatment in another locality. In contrast, most of the localities in [the central area of] Gush Dan benefit from many clinics.”

Another assumption of the reform was that 1.5% of the budget for mental health services would come from user fees. In fact, user fees covered only 5% of the costs in one health fund and 6% in another. The health funds referred a high percentage of patients to external professionals, whose user charges are higher than those of professionals working directly for the health funds. Not surprisingly, 65% of patients referred to external professionals came from the most affluent localities. Thus, the neediest were the least likely to receive help in real time. This situation needs to be changed.

// The article published originally in the Jerusalem Post