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
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
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).
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.
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
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
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
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).
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).
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
Alperovitch, S., (2003). The consumer movement in mental health
care - editorial. Israel Journal Psychiatry Relat. Sci. 39:
Aviram, U. (1981). Facilitating deinstitutionalization: A
comparative analysis. International Journal of Social Psychiatry,
Aviram, U. (1996). Mental health services in Israel at a
crossroads. International Journal of Law and Psychiatry, 19:
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.
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.
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
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.