in the Shadow
The Next Battlefront is Mental Health
Treatments have stopped, departments have shut down, calls to helplines have tripled. This is only the beginning of a big mental health crisis with double the number of Israelis suffering from depression and anxiety.
April 12, 2020
Afew days ago, the Eran hotline, which offers emotional first aid, received a call from a man who said he was suffering from depression due to traumatic life events. The current coronavirus crisis has aggravated his mental state. The man shared his anxieties with the hotline volunteer. He talked about the loneliness, the overwhelming despair, the travel restrictions that make him more stressed and agitated, and the sleepless nights. So far, nothing out of the ordinary for this hotline. But at one point in the conversation, the man shared the fact that he had already attempted suicide in the past and that she would be the last person he would talk to before taking his own life. The volunteer listened and tried to calm him down; at the same time, she called emergency responders who located the caller and managed to stop him committing suicide.
"He is not the only one," said Dr. Shiri Daniels, the professional director of ERAN. According to Daniels, the number of calls to Eran has recently tripled, from 500 on a regular day to around 1,500 daily calls. In the last week alone, 12 calls were from people on the verge of suicide who were rescued at the last moment. "We opened a coronavirus hotline, but most of the conversations deal with the same issues we are always dealing with. It's just that in a crisis like this, these usual distresses don't go away; instead they get worse. Problems with anxiety, relationships, income, parenting, fears of death and loss – people are expressing severe mental distress."
"In the media, they talk about the coronavirus all day long, but this whole month, I haven't seen one report addressing the terrible harm that we people with mental illness are suffering," said Sigalit Malka. She gets treatment at a community clinic and participates in a weekly support group. "All treatments have been halted, and no alternative channels have been established, not even via Zoom," she said. "The group's moderators do call to check how we are dealing with the situation, but I find it very difficult to cope without the group."
Dr. Shiri Daniels, ERAN (emotional first aid services): "We opened a coronavirus hotline, but most of the conversations deal with the same issues we are always dealing with. It's just that in a crisis like this, these usual distresses don't go away; instead they get worse. Problems with anxiety, relationships, income, parenting, fears of death and loss – people are expressing severe mental distress."
Malka said that she considers herself lucky for being able to maintain her work routine. She works at a supermarket, loves her job, and feels proud to be a essential worker at a time like this. "But I think about my friends from the support group – some aren’t working, some are parents to small children– and they are lost in small apartments and can’t go out."
Malka describes the frustration she hears from the doctors who are unable to provide her and her friends with the treatment they need and refers to other problems that often remain under the radar. "For example, medication is rationed," she said. "Pharmacists won’t give us certain medication, claiming they need to save them for everyone. Stress from the lockdown caused many people to buy medication in large quantities, so now the pharmacies are hoarding them." Also troubling her is that her friends who receive disability benefits are therefore not eligible for unemployment benefits. "People with mental illness fall through the cracks and no one takes any notice," she said.
"The government must provide an answer for 250,000 people with mental illness who are in isolation and suffering severe reactions," said Oren Helman. He is a senior vice president at Israel Electric Corporation and the founder of the Sicuy Shaveh, an organization which promotes the integration of people with disabilities in society and in the job market. "They are suffering severely because they are afraid to leave the house to go shopping or for other needs, even for treatment, most of which has been completely stopped. Some of them become unstable; some suffer anxiety and may harm themselves. But the damage is long־term. Once the crisis subsides, they will suffer post־trauma. They won't die of coronavirus, but they could die because of coronavirus if they are not provided with a unique response."
There won't be enough mental health professionals
The Israel Psychiatric Association has warned of an imminent tsunami, explaining that we are now experiencing a pandemic preceding a mental health pandemic. Depression, post־trauma, and suicidal thoughts are more frequent after crises and not during. The association estimated that 10% of the Israeli population will develop depression, post־trauma, and anxiety as a direct result of the coronavirus pandemic; one of 10 people will join the one of 10 people who had already sought treatment for depression or anxiety even before the pandemic. In other words, the number of people in need of mental help treatment will double.
"The next battlefront will be mental health," said Dr. Tsvi Fischel, chair of the Israel Psychiatric Association. "We know from research done after the SARS pandemic, after the tsunami in Japan, and in other cases, that suicidal thoughts decline because people are focused on the external threat. It increases sharply once the threat goes away, sometimes even three years later. The coronavirus crisis is a situation we have never seen before."
Oren Helman, Sicuy Shaveh (an organization for the integration of people with disabilities in society and in the job market): "The government must provide an answer for 250,000 people with mental illness who are in isolation and suffering severe reactions. The damage is long־term. Once the crisis subsides, they will suffer from post־trauma. They won't die of coronavirus, but they could die because of coronavirus if they are not provided with a unique response."
In a discussion of the Knesset Covid–19 Committee on the issue of mental health which took place before Passover, Fischel presented an estimation that the coronavirus crisis will cost around NIS 2.9 billion in additional support for the country's mental health services. "It will be a pandemic after the pandemic, we will have to offer treatments on a scale we have never seen before, and so I say let's get ahead of this," he said. "Today, we are short of ventilators? In a year’s time, we will be short on mental health professionals to treat people."
Unlike other emergencies in Israel's past, such as wars, during which the authorities recorded a decrease in suicides, now there is no such decrease. According to Fischel, "the fact that there is no decrease like in other times of emergency is worrying because we expect to see a subsequent increase. That is far more than in past crises."
Dr. Gil Zalsman, chair of the National Council for Suicide Prevention, also warns of what is coming. In that same Knesset discussion, he estimated a dramatic increase in the rates of suicide among the elderly due to the coronavirus crisis. "I want to focus on the elderly population, which already comprises the highest suicide rates in Israel," he said to the members of the Covid–19 Committee headed by MK Ofer Shelah. "Among the general population, there are six suicides to every 100,000 people; among the elderly, however, it is 19 to every 100,000 people."
"The lockdown has serious psychological consequences that could last years. It might lead to anxiety and depression, especially among older people who are under lockdown at home for months. At the moment, there is a huge and all־compassying thing that people haven't caught on to. Suicide kills 550 people each year. The coronavirus has not even killed 100 people yet."
Zalsman indicated another population which is at double the risk of the general population: doctors themselves. As a rule, doctors experience a much higher emotional burden than the average person, but after periods of crisis, this could be manifested in mental distress. This is because, in addition to the intense workload and exhaustion, when there are no medical solutions, doctors must make almost immoral decisions, namely, who to treat and who not to treat. This moral erosion is something many have trouble living with – the realization that they did not "do everything they could, only what was possible."
"They are at the highest risk of infection, them and their families too," Fischel said. "When a person goes to study medicine, they don’t take into consideration the personal risk and the risk to their family."
The poorest system in the system
The psychiatric system currently treats 4,000 hospitalized people across 11 mental health facilities and psychiatric wards in general hospitals. The system has undergone certain reforms in recent years and has an annual budget of NIS 1.3 billion, but it is still a shaky system that has been neglected for years with a deficit of at least 100 positions in the various departments. "If we are talking about how impoverished Israel's health system is, its mental health system is even poorer," Fischel said. "Until now, excellent professionals have made up for the shortages, but this cannot carry on as there are no reserves and we need immediate help."
Community clinics and hospital outpatient clinics have been closed since almost the beginning of the crisis, alongside other hospital departments and clinics. The closed psychiatric units have become very worrying for the medical teams who, seeing what has happened in nursing homes, are very afraid of mass infection, as Doron Avigad recently described in an article published in Shomrim. "The psychiatric hospitals are far more dangerous than any nursing home because there are patients with psychotic conditions who are unable to follow instructions such as frequent handwashing, keeping a distance, or avoiding touching their faces," Fischel said.
"All treatments have been halted and no alternative channels have been established, not even via Zoom," said Sigalit, who gets treatment at a community clinic. "The group's moderators do call to check how we are coping with the situation, but I find it very difficult to cope without the group. Those suffering from mental illness fall between the cracks and no one takes any notice."
But putting the psychiatric units into lockdown comes at a huge cost: deterioration of the patients’ mental state. They cannot meet their family or friends, not even in the case of young patients in the child and adolescent department. "The patients understand and accept the situation, but the families are struggling. We are working to keep a balance, but we understand this is a situation in which we as doctors cannot do everything we would like," Fischel said.
Vered Bar is a lawyer working for Bizchut, an organization that promotes the rights of people with disabilities in Israel, and is responsible for the field of psychiatric hospitalization. In recent weeks, she has sent several letters to the Ministry of Health addressing the lockdown of facilities and the cancelation of visits. "The Ministry of Health directive at the beginning of the crisis mandated a reduction in visits. Every patient was entitled to one regular visitor. But what actually happened was that the departments stopped all visits – adolescents aren’t seeing their parents. Not everyone has cell phones and, anyhow, video calls don’t suit everyone," she said.
Bar tells of several incidents of violence, both self־inflicted and toward others, which ended with patients being restrained. These incidents, she said, were caused by patients’ frustrations over the lockdown. "I don’t take the coronavirus lightly," she said. "But the rights of patients have disappeared. There are other ways to allow visits with buffering, protective gear, or in the open air."
One of the most disturbing cases took place in LeTzidech, a mental health day center in Beer Yaakov, which closed down to make space for the treatment of coronavirus patients. This is not the only mental health facility to close; in Beer Sheva, a psychiatric unit closed and patients were sent home or relocated. But LeTzidech is the only facility treating women who have suffered sexual abuse. When the center closed, the women were relocated to another psychiatric facility which treats both men and women and where the medical staff do not specialize in treating victims of sexual abuse. Bar is holding a letter from one of the patients, Miriam Goldberg, who wrote: "Maybe only when they count the number of suicide victims will someone at the Ministry of Health wake up and realize that while attempting to save the lives (of corona patients), they have harmed the lives of victims of sexual abuse."
One of the problems that Bar highlights is the release of many patients home to be treated in community clinics, which has been done to reduce the number of mental health patients in hospitals. "They were sent home without a clear understanding of what treatment they need," she said; many patients simply went home alone to self־isolation without receiving the necessary therapeutic support. "There is immense chaos," Bar said. "And we, the various aid organizations, are trying to help and to find solutions because, at the moment, the Ministry of Health is capable of hearing only one voice and that is the immediate treatment of the coronavirus."