Editorial: Treatment Gap in Mental Health Care
Abramowitz, M. Z., Greenberg, D., Levav, I., The Israel Journal of Psychiatry and Related Sciences
In Israel, as in other parts of the world (1), not every person in need of mental health care receives it (2). Although not all individuals with a diagnosable disorder require care (3), many do and yet remain untreated. The obstacles to care reside in a triad of factors: attitudes of the potential user, family and community; availability, accessibility and cultural adequacy of the services; and openness to psychiatry and belief system of the enveloping culture (1, 3). Recognition of this treatment gap by all stakeholders is an essential first step to diminish the burden of disease of the mental disorders (4).
How large is the treatment gap in Israel? The Israel National Health Survey (INHS) showed a considerable treatment gap in the care of common psychiatric disorders among adults (2). Among the findings: there was a 9.7% one-year prevalence rate of combined anxiety and mood disorders among Israeli residents aged 21 and over, of whom 64% were untreated. Projected, this would result in approximately 281,000 individuals untreated nationwide.
The treatment gap is even wider in selected population groups, such as residents of what is commonly referred to as the "periphery" (northern and southern Israel, in contrast to the cities of the central region) where mental health services are less available. Levinson reported that while 6.0% and 6.6% of the population in Jerusalem and Tel Aviv, respectively, consulted services for a mental health problem during a 12-month period, the corresponding figures in the northern and southern districts were 3.9% and 4.1%, respectively (5). With regard to the young, "39.1% of mothers whose child had any mental disorder consulted a professional source in the preceding year concerning the emotional or behavioral problems of their child, while only one-third of their children who had any mental disorder consulted someone in school in the past year" (6). In the ArabIsraeli minority, the treatment gap with regard to anxiety and depressive disorders is twice as high as in the Jewish-Israeli population (7). This may result from a combination of the three sets of potential obstacles to care referred to earlier. Members of other minority groups (i.e., ultra-Orthodox Jews) may be under-users of services even when available, perhaps because of the limited fit between the respective "assumptive worlds" (8) of users and providers as discussed by Rosen et al. in a study of ultra-Orthodox referrals to a North Jerusalem community mental health center (9).
As a consequence of the treatment gap, many people may remain without proper care, facing continued suffering and disability. Often, the impact of the psychiatric disorder extends to family members and caregivers (1). Additionally, the instrumental burden is considerable, measured in terms of the direct costs (for example, needless laboratory tests in the primary care context when the psychiatric disorder is not recognized) and of indirect costs (e.g., days lost from work). The INHS found that the treatment gap was narrower when the disorder had the highest level of severity (2). This burden is compounded further by the higher prevalence rates of the common mental disorders of mild and moderate severity, since they are characterized by a relatively higher treatment gap than the prior group. These findings are not confined to Israel. Other countries that carried out similar surveys under the coordination of Harvard University and the World Health Organization have reported similar findings (2).
The stigma attached to mental disorders and psychiatric services has been recognized as one of the factors present in the individual, family and community that prevent or delay mental health consultations. This issue of the Israel Journal of Psychiatry reports the results of a study on the attitudes of the Israeli public towards psychiatric disorders and the preferred site for mental health care (10).
The combined findings of two recent community-based studies, the INHS, that explored the gap between people with diagnosable disorders and those actually treated (2), and the paper by Struch et al. …