MENTAL ILLNESS

Man has been subject to mental illness from the earliest known times. The Bible makes frequent reference   to it among Jews, and describes recognizable types of mental disturbances. The reference in Leviticus 20:27, "A man also or a woman that divineth by a ghost or a familiar spirit…," apparently included the mentally ill and, almost definitely, people subject to hysterical conditions. In Saul's personality, a brooding homicidal paranoia was overlaid by suicidal depression. Some of the prophets seem to have experienced states of ecstasy, and there are indications of neuroses among them. The legal tenets of the Talmud regarding mental illness indicate the existence of conditions ranging from grave types of psychoses to those which develop out of physical states. The writings of the noted Jewish physicians of the medieval period, which were generally based on their practice among Jewish patients, reveal that mental illnesses were frequently encountered. They included melancholia, mania, and other serious psychotic states, states of anxiety, and psychosomatic conditions. The "wonder" cures of the 18th-century folk healers (ba'alei shem) provide evidence of the hysterical nature of the emotional disturbances they treated. In dealing with possession by a dybbuk, which was of the same nature, they were carrying on the practice of the Kabbalists in Safed, in Ereẓ Israel. Toward the end of the 19th century mental disturbances were clearly classified into two major categories. The first is psychosis, where there is profound disturbance of perception (e.g., hallucination), thought (e.g., delusion), and mood (e.g., depression), and accompanying vagaries of behavior, but the patient does not understand that he is disturbed. The second category is neurosis (and deviations of personality), where the disturbance is less profound and the individual retains his perception of reality and knows that he is disturbed, but suffers from worry and guilt, or anxiety, or medically unexplained physical symptoms. Psychotic, neurotic, and "normal" personalities shade imperceptibly into each other and have more in common than appears from these categories. Thus agreement about diagnosis is not constant. Theories of the causes of mental illness fall into three main groups: physical (including genetic); psychological (which has to do with the control of instinct and the personal development of the child within the family); and social (which has to do with the effect of general social influence or stresses and deprivations). Modern theory seeks an explanation for many cases in a varying combination of all three factors. In the study of mental illness, the analysis of large numbers by statistical methods (epidemiology), and comparison between groups, may provide clues to understanding its nature and causation and the mental health situation and needs of a particular group. The most important epidemiological method is the comparison of the incidence (frequency) of new cases. Incidence is measured as a rate: the number of new cases occurring per year in a given number of the population. In this article, incidence and all other rates are noted per 100,000 of the population concerned. A rough but fairly reliable incidence may be determined by calculating the rate of new cases hospitalized per year. More reliable information is obtained by noting all the cases which appear at both mental hospitals and clinics. Prevalence of illness refers to all the cases – old and new – that exist at any given moment, either in an institution or at home. Prevalence is obtained by a total survey of the community. Knowledge about mental illness among Jews at the present time is confined mainly to those in the United States and Israel, since by and large it is only in these countries that specific reference to Jews is made in hospital statistics. In Israel, statistics of mental illness are provided by the Mental Health Services of the Ministry of Health. The statistics available on the rates of mental disturbances among Jews and other significant observations about them through 1970 are presented here under three headings: psychoses; neuroses; and other indicators of mental ill health. -Psychoses DEPRESSION Depression (manic-depressive, affective psychosis – including involutional melancholia in the aging) is a relatively significant mental illness among Jews. The U.S. statistics of the 1920s for manic-depressive and involutional illnesses from hospitals in New York City, Illinois, and Massachusetts, showed Jews to have had slightly lower first-admission rates than non-Jews (including blacks). However, the painstaking work of benjamin malzberg reveals that in 1949–51, Jews in New York State had a notably higher rate of first admission to private and public hospitals than white non-Jews (27 v. 15). These rates are crude, i.e., per 100,000 of the total population of all ages. The crude rate for Jews in Israel in 1958 was about the same (24) as for New York Jews. However, Jews in Israel born in Central and Eastern Europe had in 1958 twice the rates (50, 46) as for New York Jews of the same origin and descent. As usual, the rate is about twice as high in women as in men. On the other hand, in Israel in 1958, Asian-African-born Jews showed only half the rate of European-born Jews and Israel-born Jews even less. The Oriental-born rates were somewhat lower than that for New York Jews and probably only of a slightly higher order than for white non-Jews in New York. Israel-born Jews seem to have had the lowest rates of all these groups, despite the higher proportion among them of those of European rather than Oriental descent. The Israel rates of first admission for psychotic depressive conditions in 1966 seem to bear out all these conclusions and show that (1) European-born Jews in Israel have a notably higher rate (45) than their non-Jewish European counterparts (Sweden: 21); (2) Asian-African-born Jews in Israel have a markedly lower hospital rate (23) than those born in Europe, lower than the known rate for Jews in New York, and resembling that for European non-Jews; (3) Israel-born Jews of both European and Afro-Asian descent show an even lower rate (16) than the Afro-Asian-born and, a fortiori, a lower rate than European-born immigrants. Israel-born Jews have a lower rate than those known for Jews and even non-Jews in New York State. Israel-born Jews in 1966 had a clearly lower crude rate than Swedes (1964) and New Zealanders (1967), the ratio being 6:21:27. The rate for Israel-born over the age of 15   was only 17. The age-specific rate for the population over 15 is a finer measure than the crude rate, since mental illness usually manifests itself after that age. To these conclusions must be added Malzberg's proof of the higher incidence of depressive psychosis in New York State among Jews of European birth and descent than among non-Jews. The hypothetical reasons for the higher incidence of depressive psychoses in Jews of European birth in Israel and those of European birth and descent in the U.S. may well include the family and social tensions accompanying their profound, achievement-oriented ethical system. This has been incorporated in their personality as a sense of individual conscience and responsibility, the control of aggression, and sobriety. This psychosocial system does not allow for easy solutions and the camouflage of problems by the use of alcohol and other reality-denying behaviors. Furthermore, it is known that closed Orthodox societies in the West tend to produce more depression. The very high incidence of depression among European-born Jews in Israel is undoubtedly the result of persecution and concentration-camp experiences, underlain by tendency to depression and exacerbated by migrational upheavals. The hypothesis that there is a hereditary element in the Jewish tendency to depression is probably not tenable in the light of the moderate rate among Asian-African-born Jews. The apparent generational change manifested as a lower incidence of this psychosis in Israel-born Jews also argues against genetic causes. The speculation that the higher incidence is the result of the known readiness of Jews to seek psychiatric help cannot hold much water. The high rates for European-born Jews as compared to Asian-African-born Jews in Israel, where all psychotics have an almost equal chance of hospitalization, rule out that factor. It is certain, therefore, that European Jews have a higher rate of psychotic depression than non-Jews. Research in Israel has proved that Jewish women, like all women, have a depression rate about 100 percent higher than men. In 1966, the rate for Israel-born women (27), because of the particularly low rate for Israel-born men (7), was four times as high as for men. SCHIZOPHRENIA This form of insanity is characterized by profound disturbances such as hallucinations, delusions, and social withdrawal. In this universally found psychosis, the crude rates of first hospitalizations were approximately the same for Israel Jews in 1958 (39) as those given by Malzberg for New York Jews in 1949–51 (36). However, closer examination reveals marked differences in the Israel Jewish population. In 1958, Asian-African-born immigrants of 15-plus showed a considerably higher incidence of first admissions for schizophrenia (57–80) than Central-European-born (44) and East-European-born (34), Israel-born (81) had the highest incidence. Among the Asian-African-born, Yemenite immigrants had the lowest rate and Turkish the highest. The high rate of schizophrenia in the Israel born is difficult to explain and may have something to do with the intergenerational adjustment between them and their foreign-born parents, and with the pressures of mass immigration. However, in 1966 the Israel-born rate in the population over the age of 15, while it had declined, was still the highest (67). In that year the incidence in the Asian-African-born had fallen to 51, indicating that their former high rates were due to transient stresses of immigration and sociocultural change. In 1966 the Asian-African rates were only slightly higher than the European-American, and definitely lower than the Israel-born ones. The total European-American-born crude rate in Israel in 1966 stood at 45, which is about the same as the European-born rate for 1958, but appreciably higher than the earlier-known rate for New York Jews. In every case the schizophrenic rate in Israel Jews still appears to be higher than earlier rates for non-Jews. The general urban crude rate in the U.S. in 1929–31 was 27. In New York in 1949–51 it was 32 for non-Jews. In New Zealand in 1963–67 the general crude rate was 21, while the figures for Jews in Israel in 1958 and 1966 were 39 and 37, and higher if "psychotic episodes" are included. In Israel, among the Asian-African-born the male rate predominates, while among the European-American-born the female rate is in excess of the male. PARANOIA This generally rather firm diagnostic category has often been said to be more common in Jews than in non-Jews. Malzberg's work in New York did not bear this out. However, in Israel in 1958, higher first admission rates were diagnosed among European-born Jews (10) and among the Asian-African-born (8–20). The latter was probably a reaction to migration and change, and not always true paranoia. The Israel-born had the same rate in 1958 as Jews and white non-Jews in New York (0.7). In New Zealand in 1967 the rate was 1.0. More recent information indicates no abatement, but rather an increase, in the rates of paranoia diagnosed and treated among the foreign-born Israelis. It was especially marked in women of European-American origin (21 for the 15-plus age group). It should be noted that among Jews in Israel in 1966 the incidence of all psychoses of a functional, or non-organic nature (schizophrenic, effective, psychotic episode, paranoiac) was approximately the same for the Israel and Asian-African-born (107 and 100 respectively for the 15-plus) and for European-American-born (121). As elsewhere, foreign-born immigrants in Israel in the 15-plus group have higher total rates of first admission to hospital than the native-born, but the differences are not very significant (1966: Israel 188, Asian-Africa 218, European-American 226). Malzberg showed that Jews have about the same total rate of first admissions as white non-Jews. The Israel rate was later discovered to be about 12 per cent higher than both. In the Midtown Manhattan study, Mental Health in the Metropolis (1962), Leo Srole and Thomas Langner found that Jews showed a far higher prevalence of all treated disorders than Protestants and Catholics, but for cases normally treated in hospital approximately the same rate as Protestants and less than Catholics. Jews generally had the lowest rate for serious impairment of mental health. Because Jews were found less frequently in the lower socioeconomic strata, their seriously impaired rates were lower. This leads to the conclusion that the rate of the more severe conditions for which treatment was sought in the U.S. was not greater among Jews than among non-Jews. In Israel, European-American-born Jews had a definitely higher rate for all psychoses (including organic conditions) than Jews of other origins. -Neuroses and Allied Conditions The available hospital statistics in New York City (Bellevue Hospital, 1938. and in New York State (Malzberg's study, 1949–51) indicate a higher rate of neuroses in Jews than in non-Jews. A higher rate of neuroses for Jews was reported among military selectees in Boston in 1941–42. The rate for first admissions to Illinois State mental hospitals, however, was lower for Jews. Leo Srole notes that in the early 1950s the prevalence rate of treated neuroses for Jews was twice that of Catholics and Protestants. In the Manhattan study, Jews also yielded considerably higher patient rates for disorders usually treated in an ambulatory facility. While in the community survey they showed the lowest seriously impaired rate, their mental health was generally not as satisfactory as that of Catholics and Protestants, from which it is to be concluded that neurosis rates in New York are higher among Jews than among non-Jews. In Israel in 1958 Jews had a hospital first admission rate which was definitely higher for neuroses than Jews in New York (1949–51, 21 v. 12). Furthermore, the Asian-African-born had generally twice the rate (15-plus) of the European- and Israel-born. The highest rate (65) was among those born in Iran, who had particular adjustment problems and also showed an apparently greater tendency to paranoid reactions. In 1966 the general Israel rate for neuroses was even higher than in 1958 (30), but the two groups of immigrants had approximately the same rate (±40). This is accounted for by the steep rise in the first admission rate for neurosis among European immigrants and some subsidence in the rate among Oriental immigrants. Concentration-camp survivors, while generally known to have made a good social adjustment in Israel, were in a large proportion of cases deeply affected by the trauma they had suffered. Their emotional reactions often included anxiety, depression, and difficulty in reestablishing relations. Kibbutz-born Israelis appear to have the usual emotional disturbances, and in average proportions. They do not, however, manifest homosexuality or delinquency. For personality (character, behavior disorders), Malzberg's study of hospitalization showed a crude rate slightly less for Jews in New York (1.5) than for white non-Jews. Israel Jews in 1958 showed a very much higher hospital incidence rate. The Asian-African-born in Israel showed remarkably high rates in the population over the age of 15 (36–48), as did the Israel-born (50), when compared to the European-born (15–25). This accords with their rates for schizophrenia, and like these they decreased in 1966 (Asian-African-born 25, Israel-born 23). This indicates that these reactions were the product of immigration and social upset and that they were reduced after social adaptation. In 1958 and 1966 the rates for personality disorders among the European-American-born were the lowest in Israel (9). -Other Indicators of Mental Ill Health ALCOHOLISM Jews are traditionally known for their sobriety. In the 1920s their rate for arrests for drunkenness in Warsaw was 30 v. 1,920 for Christians. In 1925 the rate of admission to public and private mental hospitals in New York City was 0.1 for Jews and 5.9 for non-Jews. A similar picture held in Massachusetts and Illinois State hospitals. In the Boston examination of military selectees, Jews had the lowest incidence of alcoholic psychosis of all ethnic groups. Malzberg found only two cases during a three-year period (1950–52) in Canada, where the Jewish population was 240,000. He also states that he found an intemperate employment of alcohol in 2.2 percent of Jewish first admissions in New York as against 18 percent of non-Jewish first admissions. In the New Haven psychiatric census of 1950, no alcoholic Jews were found among the patients at any treatment site. In a census in Israel in 1964 analyzing cases found in mental hospitals, only 21 (0.3 percent) presented alcoholic problems. In 1966, however, a total of 152 alcoholic cases were admitted to the hospital (2 percent of all cases admitted). This was the total crude rate of 6.6 (for men 12.5), which resembles the earlier rates for non-Jews in the U.S. (urban total rate 7, males 12). However, this rate constituted about one in ten of which only four were Israel-born; 26 were from Europe-America (rate 3. and 44 from Asia-Africa (rate 7). It is evident, therefore that alcoholism in Israel is a problem relating almost entirely to male immigrants, especially those from Asia and Africa. However, social changes in the country and the growing consumption of alcohol may conceivably increase its incidence, in spite of the intense social cohesion in Israel. It is possible that a part of the real incidence of neurosis and depression in many non-Jewish populations is masked by or expressed through alcoholic overindulgence. In Jews it may well be that emotional difficulty is expressed through neurosis and depression rather than through the escape into and physical self-destruction of alcoholism (see drunkenness ). DRUG ADDICTION Drug addiction is relatively speaking not new or uncommon among Jews in Israel. In 1966 and 1967 91 Jews with a primary diagnosis of addiction were admitted to hospital for treatment. Thirty-two of these cases were admitted for the first time (23 males, 9 females). They were composed equally of immigrants from Europe-America and Afro-Asia, with only five or six Israel-born. In 1970 there were probably somewhat more than 400 hard-core addicts in Israel. Drug addiction is known to be associated in the underworld with criminality and with pimping and prostitution, but a few of   the cases were related to medical treatment. The New Haven study of 1950 revealed no drug addicts among Jews. A comparison of half-year figures for 1966 with 1970 shows a rise of first admissions related to drugs (from 20 to 39) with an especial increase of the number of younger Israel-born Jews. In 1970, despite the absence of statistical study, the abuse of drugs was known to have spread to groups of Jewish youth in the U.S. A few who visited Israel after the Six-Day War required treatment. Some of the older immigrants to Israel from North Africa and the Middle East had been in the habit of smoking marijuana, but it became much less evident among them in Israel and was not used by their children except among delinquents and small marginal groups. Following the Six-Day War, with the occupation of the West Bank and the flood of volunteers and students from North America, the use of marijuana increased in marginal groups. The occasional and apparently temporary use of a small amount of marijuana even appeared among groups of pupils at secondary schools. -Suicide emile durkheim demonstrated at the end of the 19th century that Jews had a lower suicide rate than Protestants and Catholics. It was estimated that in 1925 the suicide rate for Jews in New York was ten as compared to a similar general average yearly rate for the period 1950–59 in the U.S., a rate of three in Ireland, and one of 23 in Denmark. In Israel in 1952–58 the general rate was ten (and 15 for the population above 15 years of age in 1949–59). While the suicide rate in Israel represents a mid-point between extremes in other nations, it has special characteristics. The female rate relative to the male rate is unusually high. In European countries males usually have a suicide rate three or four times that of females. In Israel in the years 1949–59, female rates were never less than half that of males and in two of those years equaled that of males. This has been explained as a result of the social equality and shared burdens of the sexes in Israel. A slackening of religious Orthodoxy may be a factor, but high female ratios are not found in other egalitarian societies. It is more probably a result of the high incidence of depression, especially among older Western women in Israel. Since 1949 at least 70 percent of female suicides have occurred in women over the age of 31, which is also the age associated with the onset of depression. The high ratio of suicides in women as compared to men among Jews in Europe can be seen from a report by arthur ruppin in 1940. Of the suicides of Jews in Warsaw between 1927 and 1932, 49.4 percent were women. Ruppin ascribes this to the difficult psychological situation of Jewish girls who, in the secular environment of the Polish capital, had lost touch with their Orthodox parents. Another striking fact is the very low suicide rate in Israel among the Asian-African- and Israel-born. However, attempted suicide is becoming more frequent among young women from Oriental homes in Israel. This is probably related to the psychological conflict described by Ruppin, who ascribes rising rates of suicide among Jews generally to growing secularity. Where Durkheim quotes a rate of 18 for Jews in Prussia in 1890, Ruppin gives a rate of 50 for 1926. Since 1956 the suicide rate in Israel has gradually declined. In 1964 it was 12 for the population above the age of 15, while the rate for the general population was 7.6. This decrease may also be related to the general readaptation which followed the absorption of the mass immigration of the early 1950s. -Criminality and Delinquency While no statistics exist, criminality was known to be rare among Jewish communities in the Diaspora and has generally been so in Ereẓ Israel as well. However, delinquency has been found, especially among the less privileged Oriental, near-slum groups in Israel's cities. Striking evidence of the stress which followed the mass immigration is seen in the high rates of crimes of violence (murder, attempted murder, and manslaughter) and causing death by negligence from 1949 until about 1956–57. The rate for murder dropped from 45 in 1949 to one in 1962. The total rate of these crimes of violence decreased from 20 in 1950 to five in 1960. This again indicates adaptation after the tensions caused by mass immigration (but see below). The percentage of juvenile delinquency rose from 0.7 in 1949 to 1.0 in 1957. The proportion was higher for Oriental groups. In 1957 children of all groups of immigrants constituted 69 percent of the delinquents. Delinquency and criminality are not encountered among kibbutz-born children. The incidence of juvenile delinquency among Oriental groups indicates problems which at times arise out of cultural and social changes in their families. On the other hand, the palpable increase in delinquency among children from a "good" socioeconomic background highlights the difficulties being encountered by some developed city families in the modern, technologically advanced society of Israel. (Louis Miller) -Later Figures At the end of 2002, 5,439 psychiatric patients were occupying hospital beds in Israel and during the year around 58,000 out-patients had been treated in government clinics. Hospitalization resulting from drug and alcohol abuse reached 19,528. In this regard the estimate of 400 addicts in the country in 1970 cited above, reflecting even then the gradual introduction of drugs into the country after the Six-Day War, underscores the extent to which Israel in the early 21st century had evolved a drug and alcohol culture. Hundreds of thousands can be said to be users of illegal drugs of one kind or another. Similarly the sharp rise in criminality and delinquency (see crime ) are further indications of Israel's new realities. -BIBLIOGRAPHY: L. Miller, in: N. Petrilowitsch (ed.), Contributions to Comparative Psychiatry (1967), 96–137; idem, in: A. Jarus et al. (eds.), The Child and the Family in Israel (1970); B. Malzberg, Mental Health of Jews in New York State, 1949–1957 (1963); L. Srole and Th. Langner, in: Mental Health in the Metropolis, 1 (1962), 300–24; M. Mandel, J. Gampel, and L. Miller, Admission to Mental Hospital in Israel – 1966 (1971); L. Eitinger, Concentration Camp Survivors in Norway and Israel (1964). WEBSITE: www.health.gov.il .