Israel's mental health system has entered a period of transition. A major reform in the provision of mental health services is in the process of being implemented. The main targets of the reform are: a) the proper allocation of resources between hospital and community and, consequently, the shift of focus from inpatient care toward community care; and b) the inclusion of mental health services in the insurance coverage of general health. The reform mirrors developments in the treatment and care of people with mental disorders, but is intended also to deal with the severe budgetary shortages common to health delivery systems all over the world, requesting more efficient and effective provision of care.

Historical Overview

Historically, the development of the mental health system has been based on a nationwide network of psychiatric hospitals established in the early years of the state. This was perhaps the only possible and immediate response to the problem created by the large number of people with mental disorders who arrived with the mass immigration, many of them Holocaust survivors. Providing immediate shelter became an urgent policy issue, while the process of developing a community care system was secondary (Aviram 1981).
The focus on hospital treatment was also influenced by the then prevailing medical model approach and orientation toward curative medicine with an emphasis on acute states. Consequently, there was a reluctance to deal with rehabilitation and supportive care of people with chronic disorders. Most of the latter ultimately ended up in institutions, which were similar to boarding houses. The increase in beds reached its peak in the late '60s and '70s (2.4 beds per 1000 population). In the '80s, the bed rates gradually started to decline following the community-oriented reorganization of the mental health services in the '70s, which called for the delivery of comprehensive mental health services in geographically defined catchment areas (Tramer 1975). This reorganization was undoubtedly influenced by the American model of community mental health centers. Several community mental health centers were established (Miller 1977). This development was followed in the eighties by the implementation of several rehabilitation projects (Levy & Davidson 1988).

Inpatient Care

Psychiatric inpatient care is provided in psychiatric hospitals and psychiatric units in general hospitals. The latter comprise only about 3.5 percent of the total number of psychiatric beds, compared to 20 percent in the US (Witkin et al 1998). During the last 15 years, in spite of a substantial increase in the general population, the number of patient facilities, as well as the number of psychiatric beds has declined. The rate of beds decreased to 0.84 beds per 1000. The main reduction was in long-term-care beds. However, Israel does not have a significant problem with homelessness even among the more severe mentally ill patients, partly also because of the preparedness of hospitals to extend inpatient care until community accommodation is found.

Outpatient Services

Israel has a fairly impressive public outpatient mental health service system. The estimated rate of outpatients in care per year of the ambulatory mental health services is 19 per 1000 population, the rate of outpatient visits is 180 per 1000. This means that, on average, an outpatient makes about 10 visits a year (Levinson et al 1996). Outpatient services provide medication and discussion therapies (Lerner et al 1993, 1996), but are not as active in linking patients with community resources as in the case management model. A gradual increase in the number of new referrals was observed during the years 1998-2001 (Mental Health in Israel - Statistical Annual 2002), partly as a result of the terrorism acts to which the Israeli population has been exposed (Landau 2003).
This was already preceded by a previous increase in demand during the '90s, following the mass emigration from the former Soviet Union (almost 900,000 immigrants). These immigrants not only created a quantitative increase in demand, they created new challenges for the services, coming from a different cultural background and having language difficulties (Zilber & Lerner 1996).
Another issue of concern is the discrepancy in the utilization of outpatient services between children and adults. Although children (not including the 0-4 age group, who do not use these services) make up 25 percent of the total population, their representation among the outpatients is only 12 percent (Lerner 2000). It seems the needs of this population are unmet. There are also discrepancies in the provision of services between the peripheral areas in the north and south of the country compared to the center. There also exist unmet needs in the predominantly Arab communities because of understaffed services. The national fight against addiction, including promotional and preventive activities, is under the responsibility of an autonomous council. However, the services, such as methadone supply are under the Ministry of Health and are buttressed by the welfare system, but are still insufficient.

Services in Times of Emergency

The unstable security situation has led the country to devote considerable efforts to helping the civilian population overcome war and terrorism-related stress. During the second Intifada that began in late September 2000, the health authorities organized a network of mental health services that are provided, as early as possible, in the emergency rooms and in ad hoc wards in all general hospitals that receive casualties. Following first-aid treatment, everyone is offered some psychological intervention, inlcuding an explanation of the nature of psychotrauma, provision of emotional support, and information about psychological and social security assistance if needed.

Mental Health Rehabilitation Services

Israel can be considered a welfare state, which takes responsibility for the care of weak populations. The National Insurance Institute provides a broad range of benefits. Accordingly, the mentally disabled are entitled to social benefits like disability allowance and financial help for renting apartments (Aviram 1996). However, until recently, rehabilitation and vocational programs for patients with chronic disorders lagged seriously behind the expansion of the ambulatory clinics. An important development in 2000 was the passage of the Rehabilitation of the Mentally Disabled Act, following the initiative and effort of Knesset member Tamar Godzansky. According to this law, every disabled patient is entitled to a basket of rehabilitation services tailored according to individual needs. The government has been mandated to allocate an additional budget to meet these needs (hostels, sheltered apartments, rehabilitation units, social clubs, dental care, etc.) during the next five years. Hospitalized patients who do not need inpatient services will be gradually released into the community. This will lead to a further reduction of bed rates (to a target of 0.5 beds per 1000 population).

Insurance Coverage

Mental health services are provided by the state free of charge (Lerner et al 1993), although they are not included in the coverage of the general health insurance program. Thus, the provision of inpatient and outpatient services for mental health patients was carved out from general medical care. Every resident is entitled to receive care for mental problems without having to be insured, since this is the responsibility of the state. Yet, the availability and accessibility of these services are not based on legislation, nor are there firm regulations. Gaps in the provision of services are thus found in the community services, which are rather insufficient in the periphery, in the Arab sector and even in some cities (Feinson et al 1992).

Health Reform

In 1994, the National Health Insurance Act was approved. This law provides all Israeli residents with mandatory health insurance, which requires payment of a health tax. Mental health was to be included in the general service package, thus becoming part of the general health insurance. This reform had two main objectives: l) by including mental health services in the legislation, the provision of these services was to be mandatory, according to explicit rules, and not dependent on changing government policies; 2) since mental health services were to be integrated into overall medical care, it might contribute to reducing the stigma and thus legitimize getting help for mental health problems. This reform is still pending. The government has promised not to cut the budget for mental health following the reduction in beds, but to transfer the saved funds to the ambulatory services. The four national health maintenance organizations are reluctant to assume responsibility because of an anticipated surge in demand for ambulatory care without additional budget, since the provision of care will be mandatory by legislation.

The Way Ahead

Psychiatric reform is progressing, although not at the speed and depth wished by many. Mental hospitals still remain the center of care, command an unusual amount of power and authority, and consume most of the mental health budget. A large proportion of their personnel, although less fearful of community-based care then years ago, remains ambivalent at best with regards to the psychiatric reform. In order to advance the process of shifting the focus from hospital based care to community based care, there is a need for a wider reorientation and education of the professional community. More attention should be paid to issues like preventive programs, cooperation with primary care services and guidance of representatives of communal institutions like the educational system on topics related to mental health (Hershko & Ophir 1993). A positive step in furthering mental health care is the development of consumer and family organizations during the last years. These organizations are active in both advocacy and mutual support. Their representatives are members in the national councils and have a strong voice in the efforts leading to the transfer of mental health care to mental health organizations (Alperovitch 2003).

References
Alperovitch, S., (2003). The consumer movement in mental health care - editorial. Israel Journal Psychiatry Relat. Sci. 39: 159-164.
Aviram, U. (1981). Facilitating deinstitutionalization: A comparative analysis. International Journal of Social Psychiatry, 27: 23-32.
Aviram, U. (1996). Mental health services in Israel at a crossroads. International Journal of Law and Psychiatry, 19: 327-372.
Bleich, A., Gelkopf, M., & Solomon, Z. (2003). Exposure to terrorism, stress-related mental health symptoms and coping behaviors among a nationally representative sample in Israel. JAMA. 290: 612-620
Feinson, M., Propper, M., & Handelsman, M. (1992). Utilization of public ambulatory mental health services in Israel. Jerusalem: JCD - Brookdale Institute.
Hershko, S. & Ophir, M. (1993). Community mental health services in Israel: Current status and future trends. Israel Journal Psychiatry Relat. Sci. 30:142-149
Lerner, Y., Zilber, N. & Wittman, L. (1993). Utilization pattern of community mental health services by newly referred patients. Social Psychiatry & Psychiatric Epidemiology. 28:17-22.
Lerner, Y., Levinson, D., Feinson, M.C. & Popper, M. (1996). Patterns of service utilization of the mental health outpatient population in Israel. Harefuah. 131:236-241 (in Hebrew).
Lerner, Y. (2000). Predication of ambulatory mental health service utilization - Policy paper. Ministry of Health, Mental Health Services. Jerusalem (in Hebrew).
Levinson, D., Popper, M., Lerner, Y., Feinson, M.C. & Mark, M. (1996). Utilization of ambulatory mental health services: rates and patterns. Ministry of Health, Mental Health Services, Department of Information and Evaluation & Falk Institute. Jerusalem (in Hebrew).
Levy, A., & Devidson, S. (1988). Community psychiatric rehabilitation in Israel. Sihot, 2:202-209 (in Hebrew).
Miller, L. (1977). Community intervention and the historical background of community mental health in Israel. Israel Annals of Psychiatry and Related Disciplines, 15:300-319.
Ministry of Health, Mental Health Services, Department of Information and Evaluation. (2002). Mental health in Israel. Statistical Annual 2002, Jerusalem.
Tramer, L. (1975). A proposal for the reorganization of the mental health services system: A comprehensive integrated plan. Public Health, 18: 1-12 (in Hebrew).
Witkin, M.J., Atay, J.E., Manderscheid, R.W., et al (1998). Highlights of organized mental health services in 1994, in Mental Health United States 1998, Manderscheid, R.W. & Henderson M.J., eds. DHHS Pub. No. (SMA) 99-3285. Washington DC.
Zilber, N.& Lerner, Y. (1996). Psychological distress among recent immigrants from the former Soviet Union to Israel: I. Mediating factors. Psychological Medicine, 26: 493-501.