Israelis are a resilient people. Despite Oct. 7, sirens, terror attacks, harrowing red alerts with missiles flying overhead, and COVID isolation, which all took tolls on our well-being, somehow we are still going about our lives, fighting, and serving our country. We are even the fifth-“happiest” country of the 143 countries ranked in the World Happiness Report, a partnership of Gallup, the Oxford Wellbeing Research Centre, and the UN Sustainable Development Solutions Network.
But for some people, happiness is a transient state that comes and goes; and for those in a never-ending battle with depression, the clouds seldom, if ever, dissipate. In writing this article, I found that our “happy” country has parents, doctors, and healthcare providers who refuse to go on record about the state of mental health in Israel.
As I write this, parents in Karnei Shomron are reeling from a teen suicide, one of several within several years, and are asking what they can do to assist their youth through the labyrinth of hormones, situational pain, and mental anguish that make youth want to give up and end their lives.
The mayor of Karnei Shomron, Yonatan Kuznitz, declined to comment, saying the feelings are too intense and raw.One Israeli doctor I interviewed refused to be quoted on the record, calling the mental health system “outrageous.”According to the World Health Organization (WHO), it is estimated that worldwide, 4.4% of 10- to 14 year olds, and 5.5% of 15 to 19 year olds experience an anxiety disorder. Depression is estimated to occur among 1.4% of adolescents aged 10-14 and 3.5% of 15 to 19 year olds, and suicide is the third-leading cause of death in older adolescents and young adults (15-29).
“Here in Israel, we are seeing more anxiety and stress since Oct. 7 among adolescents and teens than ever before,” says Yael Avraham, a social worker and manager in the trauma field at ELEM, Israel’s leading nonprofit organization dedicated to treating troubled and at-risk youth. “Our kids are more afraid. More parents are reaching out for therapy. Our clinic has become a full-time job.”
If you add bullying and social media pressure that comes with a click of their cellphones, fragile, sensitive youth, particularly those with mental illness, face a greater risk of suicide, she says.It’s a story that many do not want to talk about, but one that must be told.
Many myths about mental illness must be addressed. These include the following:
Mental illness manifests only in adults.
This is not true. There is evidence that mental illness can surface even in very young children and throughout their teenage years. Many young people who have bipolar disorder (manic depression) are initially diagnosed with ADHD, according to psychiatrists I spoke to. The problem is, that when a child is medicated with stimulants like Ritalin, in some cases the drug can have dangerous effects and can even cause psychosis.
Mental illness is not like physical illness.
This is false. What many do not realize is that mental illness is a physical illness – the result of unbalanced brain chemistry, which can become exacerbated as hormones shift in a growing child or teen.
Mental illness is a direct result of bad parenting.
False. While behavioral symptoms can be triggered by events or family issues, the most predictive factor for mental illness is often a family history of mental illness. Is it triggered by nature or nurture? Most doctors believe that mental illness is a genetic hand-me-down, like diabetes, hypertension, or any other family trait that is transmitted from one generation to the next. While external conditions can trigger the illness, the genetic predisposition must be there. In Israel, where Jews marry mostly Jews, genetic conditions are likely to be expressed more consistently.
RABBI SHALOM HAMMER, a former educator, lecturer at the IDF, and hesder yeshiva teacher, established the organization Gila’s Way (www.gilasway.com) after his daughter Gila died by suicide several years ago. He began speaking about suicide prevention just three days after getting up from his daughter’s shiva, and helping others became his life’s mission. He was brought to Karnei Shomron the night after the fifth anniversary of Gila’s death to speak to the parents and grandparents of the town, who were naturally concerned.
“You can have mental illness without suicidal ideations, and you can have suicidal ideations without having mental illness, but often they are intertwined,” he says.
“Life took a 180-degree turn for me,” he explains. “I had to somehow make sense of Gila’s death in order to help others understand the complexities and possibly save lives.”
He began by sharing Gila’s personal story. Gila’s Way, an official organization, recognized by the National Suicide Prevention Program of the Health Ministry, rose from the ashes of his despair. Gila’s suicide occurred after an incident of sexual abuse. Hammer says there has been the most aggressive rise in suicide among the ages of 16 to 24. It is all about education for prevention. “People just don’t know enough, especially parents,” Hammer explains. “Mental health is confusing, difficult, and chaotic. People become so confused when a loved one is suffering from this invisible illness.”
Gila’s Way helps parents put things in order, offering seminars, workshops, and presentations, mostly in Hebrew but also in English. It also offers consultation service to help parents navigate the confusion.
According to Avraham, there is a severe lack of child-adolescent psychiatrists in Israel, even ones who treat private paying patients. Those practicing are frequently fully booked for as much as a year. She says this is compounded by the fact that the government farms out much of the mental health system to NGOs; public clinics are shutting down, and if the local one can’t give you an appointment, the private sector costs a lot.
To hospitalize or not
Hammer also meets with troubled families directly. Based on the urgency of the situation, he sometimes refers the youth to a hospital emergency room or a safe, secure environment.
“I prefer to avoid the hospital, but what I try to impress upon parents whose child is having suicidal ideations is that their child is in danger. It’s like an open wound. If you don’t stop the bleeding, they will die. If a child uses the vernacular of death, he or she must be taken seriously,” he asserts.
Working with two PhD psychologists and one MA, Hammer helps parents discern between cries for help and concerning but less emergent signals. Gila’s Way has a referral network for medical and psychological resources.Hammer acknowledges that mental illness is a worldwide problem, not just in Israel. “It’s not understood, and there is a lack of appreciation,” he says. “What I don’t see, doesn’t exist. It’s problematic because people deny and don’t want to deal, cope, or recognize because they can’t see it. Also, to deal with a mental illness is procedural and a long arduous process, often a lifetime commitment.” He says he is frequently asked, “Can’t there be an end to this? How long is this going to take?”
According to Hammer, within the Israeli mental health system there is no direct procedure for addressing a young person with suicidal thoughts. “When you take a suicidal patient to the emergency room and try to get him or her admitted for hospital care, often you can’t find a bed,” he says.
“It becomes a money issue. You can wait at least nine months if you try to see a psychiatrist and therapist through the healthcare organizations, and matching the right therapist for the individual can be difficult and costly. Even when a parent is able to access a psychiatrist, just getting immediate follow-up appointments to ensure that the medications are working can take months.”
That is unacceptable, he says, as the medications must be monitored closely, especially when first prescribed. While he makes it very clear that he is not a psychiatrist or mental health professional, Hammer suggests that people explore alternatives to medications, unless absolutely necessary, and he emphasizes the importance of researching and understanding the medications being suggested.
Some psychotropic medications can have “black box warnings” and have been found to sometimes cause suicidal thoughts in youth. The warnings were put on the boxes to increase monitoring of medication. However, recent studies over a period of 14 years found that the warnings against using these medications can actually cause reductions in mental healthcare. After the warnings were issued, instead of increasing monitoring of patients using the medication, there was an abrupt decline in the use of these medications, a decrease in doctor visits, and there were increases in psychotropic drug poisonings, suggesting suicide attempts and suicide deaths among children and young adults.
Which is why most experts agree that while side effects must be monitored, when the right medication is prescribed and taken under supervision, it can help a patient stay balanced and reduces the risk of harmful behavior for years at a time.
Hammer says parents have told him about professionals who refuse giving help to a patient considering suicide. “They don’t want the responsibility of dealing with a child who wants to kill himself,” he recounts.
ELEM’s Avraham explains that as a social worker, she is mandated to not treat youth who threaten suicide but to immediately give them a written referral for their parents to take them to an emergency room and be seen by a psychiatrist. But not all parents listen.
One of the psychiatrists I spoke with says that sometimes hospitalization is not the immediate answer for an at-risk patient. He says that some disorders respond better to forced hospitalization than others. Psychosis, mania, and acutely depressed patients may do better, for instance, than patients with chronic personality disorder.
One psychiatrist confided that when interviewing a new patient’s parents, asking why they were concerned about their child, they answered that their child had threatened to kill himself seven months ago. They took the doctor’s next available appointment – and here they were, seven months later. The psychiatrist noted that in emergencies, when a person threatens to harm himself or others, a hospital may seem like an overwhelming option, yet it might remain the most effective way to ensure timely intervention. Hammer says that it has been proven that 65% of those who attempt suicide once are likely to try again.
Continuity of care is also challenging, says Hammer.
“There are psychiatrists in this country – well-known ones – who drop patients mid-care. Psychiatrists should never drop patients mid-care without passing the torch to someone they trust that can look after them,” he stresses.Gila’s Way educates and informs. It does not provide therapy but helps people access the appropriate mental health professionals and care. In some cases, it helps parents obtain private funding.
Hammer predicts that although at the moment there is no rise in suicides, after the war the situation is likely to get worse before it gets better. “Children evacuated from the North or South are likely to be triggered particularly after they go home. These children were ripped away from their lives, infrastructure – everything has been taken away, and major trauma is likely to trigger and surface after the events we are all experiencing,” he says.
Dr. Gilad Bodenheimer, head of the Mental Health Division at the Health Ministry, says that there is actually a decline in the suicide rate, but he anticipates a postwar surge in suicide. He speculates that while at war, we are united and supporting one another. His concern is that post-trauma, when people get back to a semblance of normal life, there may be a wave. Or not. He points out that with COVID, the anticipated post-COVID reaction never came.
“Israelis have the power to deal with immense pain and trauma and to go back to functioning,” says Bodenheimer. “The resilience of children is especially very impressive.”
WHEN PEOPLE experience suicide in the family, Hammer’s phone begins to ring.
“I’m open. I talk about the issues often seen as taboos. Loss, death, bereavement, suicide – not only am I not afraid to talk about these, but I encourage dialogue regarding them.
“Open dialogue is the essential way to lower rates of suicide,” he explains. “Education is key. The more we learn about it, the better we will address the issues. We need to create a support system. The family needs to feel supported, but so does the community. Unfortunately, we are very good at responding to suicide, but much less effective at preventing it.
“The vast majority of people who die as a result of suicide do not want to die,” explains Hammer. “That is something that people need to know. They send out signals because they want to be helped. And in order to help, we have to be aware of those signals. A suicidal thought at its peak lasts four to five seconds, which means that most times the person experiencing these thoughts can be grounded and brought back to a state of mindfulness with the proper response.”
He says while mental illness can remain prevalent, there should be a preventative mindset when it comes to suicide. The prevention and outreach should come from family, but it can even come from a complete stranger who validates and demonstrates empathy.
He shared with the Karnei Shomron group the definitions and signs of mental illness. People listened attentively.
Serious signs
Not all suicide cases are preventable. One doctor confided, “Some patients suffer, and we can’t alleviate their pain. At some point, they stop believing that we still have tricks up our sleeves for them, and they ask, ‘What right do you have to force me to go on living? I’m suffering, and you’ve been trying to help me – sometimes for years – with no success.’”
Families and friends can do everything right – communicate with their loved one about his or her feelings, leave the door open for conversation – no matter how challenging – and the person can still end his life, leaving family wondering what they missed, and friends berating themselves, even feeling survivor’s guilt.
Hammer and Avraham agree that loneliness is often the main precursor to depressive and suicidal thoughts. Even with consistently caring and attentive family and friends, someone can feel alone and find a moment when no one is there to act.
Signs that someone might be undergoing trauma and may be contemplating ending his or her own life include the following:
- Shifts in behavior. Suddenly stops doing things he/she used to do.
- Talks about feeling hopeless.
- Talks about or makes “plans” for killing oneself.
- Disengages from social peers.
- Avoids things that used to be fun.
- Researches and reads about ways to die (Avraham suggests that all parents monitor the sites their children are visiting on their computer).
- Sudden refusal to go to school.
- Neglect of his/her appearance.
- Anger or sudden mood shifts. Impulsivity.
- Talks about being a burden to others.
- Increased substance abuse (self-medicating behavior).
- Cuts or causes self-harm (which, ironically, is sometimes a means to make the person feel “alive”).
Hammer describes depression as creating a state of dysfunction for the teen within their environment. Even if they want to exert themselves and “get with the program,” normal behavior takes three times the energy, and the simplest things become exertion. Being a parental cheerleader is not the right approach. He advises parents to choose a neutral moment in an environment that doesn’t feel “authoritative” and to use authentic words to reveal their feelings to their child.
“Don’t talk to your child in your kitchen,” he says. “That’s a place where you are the boss.”
Along with helpful lists of where, when, and how to appropriately help, Hammer gives examples of what not to do. He strutted in front of the Karnei Shomron crowd, head buried in his cellphone as he asked his imaginary teen, “So, Lavi, how was your day in school?” Looking up for a moment, he diverted his attention back to his screen, again looking up for just a split-second, asking, “And how did you do on that test?” Without missing a beat, he re-engaged his phone.
“This is how not to talk to your child,” he says.
He says that recently in Tel Aviv, he observed a family sitting in a café. They put their cellphones in a pile in a corner of the table and didn’t even glance at the devices, while engaging one another in spirited conversation. Hammer and his wife went over and complimented the family on their attentiveness to one another during the meal.
Hammer and Avraham advise to not shy away from asking loved ones about suicide. Asking whether they are thinking of killing themselves may seem uncomfortable, but the question must be asked.
“Don’t be afraid of the stigma,” Avraham warns. “Sometimes someone is looking for the opening to talk about their feelings. Don’t worry about copycat behavior in others. Address the subject head-on.”
In his meeting, Hammer also had advice for neighbors of the grieving family. “Do not tell bereaved parents that you understand what they are going through,” he warns, “because (thank God) it is false; you do not and cannot comprehend those feelings.”
He advises the community to let the family know that while they do not understand what they are feeling, they do understand that they are in pain. He says that letting them know that you are there for them is what they need to hear.
Hammer also emphasizes the importance for parents to listen to and trust their instincts, such as when their child is undergoing treatment or therapy. If you “feel” something is just not right, it probably isn’t.
Resources and support
Founded nine years ago to help new immigrant practitioners start their practices, GetHelpIsrael (www.gethelpisrael.com) lists more than 450 clinicians in the mental health field, as well as hospitals. Since the war, it has also been providing free therapy for soldiers. To join the directory, a professional must have at least a master’s degree. The majority are private pay, which fast-tracks the wait time, especially in the case of a psychiatrist, and they speak Hebrew, English, French, or Yiddish. Some of these professionals also have practices affiliated with health funds (kupot holim).
Milam is a counseling center for families of people coping with psychosocial disabilities (milam.org.il) run by Enosh – The Israeli Mental Health Association and funded by the Health Ministry. It provides support and guidance for families in which a member is coping with a mental health crisis. The services are free, with no requirement for the individual to be recognized by the National Insurance Institute or to qualify for governmental rehabilitation services. Milam offers home visits; short-term individual counseling and therapy; support and guidance by a peer supporter; groups for parents, spouses, siblings, and adult children of individuals with mental health challenges; as well as legal counseling, rights advocacy, and workshops, lectures, and study days for families, professionals, and individuals.
Noa Cahana Buskila, director of youth and young adults services at Enosh, says, “When observing adolescents, we cannot ignore that these events intersect with an already complex developmental stage. As a result, if we previously defined ‘youth at risk’ as a distinct group, today all adolescents are at risk. We see adolescents experiencing high levels of distress, manifested in anxiety, depression, and a profound sense of loneliness. The reality is complex, especially against the backdrop of growing demands met with limited resources. Yet, in this situation, we must expand our awareness, understanding that pain is part of resilience and recognizing that adolescents possess inner strengths.”
Milam centers are located in Karmiel, Netanya, Eilat, and Tel Aviv, and there are online articles, lectures, and other resources as well. Extension services are offered in Afula, Kiryat Shmona, Beit She’an, Ariel, Bat Yam, and Hevel Ailot.
Gap year solution
Dr. Sol Adelsky, a Jerusalem and Modi’in board-certified child/adolescent and adult psychiatrist, is licensed to practice in the US and Israel. He made aliyah with his wife and children from Boston upon finishing his training there in 2018. He is a private practitioner who works with English-speaking patients, treating everything from ADHD, anxiety, and depression to OCD and autism.
“Working with gap year students presents many interesting treatment challenges and dilemmas,” he says. “Many significant mental health issues such as depression or bipolar disorder begin to emerge in this age group, while others, such as ADHD, may manifest in new ways. The gap year is usually the first time young adults are living away from home. And they’re not just living away from home – they are in a foreign country, thousands of miles from home, while often immersed in an intense environment that may be religiously, culturally, or otherwise entirely different from what they’re used to. It is often their parents, who are far away and in a different time zone, who are trying to assess the situation from afar and help their kids find help while navigating a different healthcare system.”
Every expert interviewed talked about the importance of a parent advocating for his or her child. Although Israel has a national healthcare system, navigating it can be challenging. As one doctor told me, the system may have flaws, which is all the more reason for the parents’ voices to be heard. When children are in need, the parents have to be their voice and do whatever is necessary to ensure that they receive the care they deserve.
To contact Gila’s Way, refer to www.gilasway.com
Alternative treatments
There are a number of alternative therapies that, used with close professional and parental oversight, are sometimes used to treat mental illnesses. They range from simple omega-3 fish oil supplements to light therapy and psychedelic-assisted treatments, some that are legally approved in Israel, others as yet are not.Essential fatty acids are building blocks of human cells. Located in the cell membrane, they help regulate the transmission of information between cells. Since certain fatty acids cannot be produced by our bodies, some must be taken in by our diet.
People with depression and bipolar disorder appear to have lower levels of a certain type of essential fatty acid – omega-3 fatty acids. There have been some positive results showing decreased symptoms of mania when high-dose supplements of these nutrients are added to a patient’s regular medications.
Herbal preparations such as St. John’s wort, S-adenosyl-methionine (SAM-e), and melatonin can help with mood and sleep cycle regulation. One cautionary note: Just because these products are “herbal” and “natural” doesn’t mean they are unquestionably safe or free of side effects.
Light therapy – Bright lights to reduce symptoms of seasonal depression have sound scientific backing. While not all depression has a seasonal component, light therapy can be helpful. The lights used to provide this treatment are specially designed to expose patients to high-intensity targeted bands of the light spectrum.
Equine therapy, pet therapy, and art and music therapy are popular in Israel and available both privately and if you are willing to wait, through the health funds as well.
Ketamine therapy – KetaMind is a recently opened mental health clinic in Ra’anana specializing in the use of ketamine infusions for psychiatric treatment.
Ketamine is an anesthetic sedative that was approved by the FDA in 1970 and quickly became one of the most widely used anesthetics in the world. It has the ability to anesthetize patients quickly and safely with few side effects. Unlike many other anesthetics, ketamine does not depress patients’ breathing or circulatory systems, and its safety profile is excellent.
In recent years, ketamine has been found to be therapeutic in treating psychiatric illness, most prominently treatment-resistant depression. More than 50 peer-reviewed clinical trials at leading medical institutions and universities have proven the efficacy of ketamine infusion therapy for depression and other mood disorders. There are at least an additional 70 studies about ketamine’s tremendous impact on treating mood disorders underway. Most of these studies have singled out severe, treatment-resistant cases that have not responded to most of the conventional treatment options and still report a success rate of 70% or higher among patients.
The KetaMind clinic specializes in the use of ketamine infusions for psychiatric treatment.
Treatments are administered by Dr. Stuart Seidman, co-founder, a New York-based, Israeli-licensed psychiatrist specializing in psychopharmacology, with extensive experience in using ketamine for psychiatric illness in the US; and Prof. Michael J. Drescher, co-founder, a US- and Israeli-trained emergency physician and, until recently, the head of the Emergency Department at the Rabin Medical Center-Beilinson Campus in Petah Tikva. Drescher has decades of experience in the use of IV ketamine for sedation and for pain.
Other psychedelics being researched and developed for the treatment of mental illnesses, particularly mood disorders, include Psilocybin, a naturally occurring psychedelic compound found in some mushrooms; and MDMA, also known as ecstasy, which is being studied as a possible treatment for PTSD.
The writer is co-author of The Ups & Downs of Raising a Bipolar Child: A Survival Guide for Parents (Simon & Schuster, by Judith Lederman & Candida Fink, MD).