It’s Rosh Hashanah Eve, seven in the morning. The streets of Tel Aviv are empty. A 38-year-old woman enters the on-duty pharmacy and asks for a pill to ease what she says is a feeling of pressure – maybe an anxiety attack. The pharmacist suggests an over-the-counter medication based on the plant valerian but advises: It won’t really help – go to a doctor and get a prescription. It’s nothing to be ashamed of. There’s been a big increase in the number of people using it recently.
Neither the Health Ministry nor the health maintenance organizations are willing to confirm that there has been a recent spike in the use of prescription drugs to ease anxiety, tension or depression. But the Tel Aviv pharmacist can attest that it’s for real and so can many doctors.
There are many signs that Israel’s second lockdown has brought an increase in the number of people reporting anxiety, both new cases and cases of people who suffered it in the past and experienced a new bout due to the stress of pandemic and lockdown.
“I can say unequivocally that today there’s an outbreak,” says Dr. Yarden Levinsky, a psychiatrist and consultant for the community division of Clalit Health Services. “Family doctors have detected an increase in emotional distress, report an increase in the symptoms of anxiety and depression, tell of patients who come with complaints that are not specific to a single problem that can be diagnosed.
“Many complain of stomach aches, headaches and fatigue, as well as symptoms specific to anxiety, such as heart palpitations and a feeling that everything is closing in on you. For most people it takes time to say, ‘Okay, I’m having a crisis and something is happening to me,’” he says.
In August, the Health Ministry told the coronavirus cabinet that the HMOs had seen a “significant increase in visits to the clinics due to emotional distress, mainly cases of anxiety and depression.” But it wasn’t able to give a precise number of such people or even an estimate.
Despite the increase in the numbers of people seeking help, no additional care is being offered, the ministry said. A survey conducted last July found that the waiting time for an initial diagnosis was usually about six weeks – sometimes more – and that the wait for an appointment for individual psychiatric care is about six months on average. The ministry said it was examining expanding the system to shorten waiting times.
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In addition, since July it has offered support services over the phone – up to three sessions with a mental health therapist within three days of a request. However, the service hasn’t been widely publicized and as of the end of September, only about 1,800 people had used it.
Before the onset of the coronavirus, Dr. Aviv Segev, head of the Psychiatric Emergency Department at the Clalit HMO’s Shalvata Mental Health Center, had never encountered anyone who had retired and wanted to commit suicide. Since March, however, he has dealt with two such cases.
Segev describes one of them as an ordinary 60-year-old man who worked for years in the services industry and had taken early retirement in February.
“Everyone told him ‘Enjoy life,’ but suddenly there’s no life to enjoy,” Segev recounts. “Suddenly he comes to us after an attempted suicide. We treat him, he leaves and promises that he’ll go to a fitness room and a swimming pool, but three months later he’s back again after another attempted suicide. This a man who never in his life used mental health services. We have no drugs to give him, people’s social needs are not solved by drugs, so that those whose social reserves – whether financial or emotional – have run out, begin to break.”
Segev says that after a significant rise in cases in July and August, the situation stabilized towards September. Starting about three weeks ago, he saw a sharp increase in requests, which he attributed to the High Holy Days, a difficult time for many.
“But there’s no question that fear of the lockdown intensified the feelings. According to many therapists there’s a sense of fatigue among the public – people are exhausted by the uncertainty, by the change from having a framework to not having one, that they’re going, or not going, to work. There’s something terrible about this pandemic, in which the entire routine changes,” he explains.
These days many of those coming to Levinsky’s clinic haven’t lost a job or experienced other upheavals but still feel something is wrong.
One of his patients was D., a 34-year-old married man with two children, who works in high-tech. Since the onset of the coronavirus he has been working from home and everything seemed fine. Yet slowly but surely, he began to feel it was harder to concentrate, that he was checking news websites all the time and burrowing through the social media searching for information about COVID-19. That caused him to lose sleep.
He felt that his mood was deteriorating and that he was incapable of working. “D. is a good example of the fact that the crisis is beginning to take its toll,” says Levinsky. “He calls it an attention deficit, but he came with anxiety.”
Facing up to the problem
Levinsky says the “new victims of anxiety” can be divided into two groups. In the first group are those who started to suffer at the start of the crisis, and very soon requested therapy or consulted the family doctor. The second group is comprised of people like D. “They’re part of a larger group of people suffering from anxiety, who simply don’t define what they’re feeling as anxiety, but as a bad feeling, restlessness or insomnia,” he explains.
“These aren’t people who suddenly have an anxiety attack, rather people who come to the family doctor with less blatant and more common symptoms: They don’t fall asleep at night, the quality of their sleep suffers, they wake up early and thoughts race through their heads.
“These are not specific symptoms that we identify with an anxiety attack – the kind with a beginning and an end – these are thoughts that are in their head all day long: What if we don’t manage, what if something happens to our children, our parents or our neighbors. Their heads rattle, and then they can’t concentrate. When you can’t concentrate, you feel unsuccessful. People are busy ‘managing,’ they’re trying to survive and tell themselves that it’s all right that they don’t sleep, can’t concentrate or read the news obsessively, because in this case it’s normal – but the truth is that it isn’t.”
What about transparent anxiety?
“Absolutely. Everyone is in distress. A large percentage of people experience these things without naming them, and keep on going. But these psychological symptoms disrupt their lives – which means that it’s an anxiety disorder.”
Why are the symptoms appearing now?
“One of our ways of dealing with such situations is to say that it will pass very soon. But if you survived for half a year and now they tell you, ‘Sir, the pandemic isn’t over and there’s another lockdown,’ then people begin to recognize that they have a problem that they can’t deal with – and then they ask for help. But that’s the final stage, because before those people turn to a professional, they’ll express their difficulty on Facebook or talk to friends. Only when they lose hope will they take care of themselves. It’s common behavior among people who don’t want to recognize the fact that they’re undergoing a crisis.”
What Levinsky calls “transparent anxiety sufferers,” A. of Tel Aviv calls mental overload, which she has felt since the outbreak of the coronavirus. She describes it as “a desire to keep everything strong and stable in an impossible situation.”
Before the first lockdown, A., a mother of two, was self-employed, with a big project that was interrupted by the virus. “Within a few days I turned into an impatient person, into a mother who mainly waves away her bored children, or in her free time crawls on the floor with wet wipes to clean up after them.
A. got tired of the uncertainty of being self-employed and at the end of the first lockdown returned to her old job. She was forced to compromise on her salary and title, and today she feels like someone “who is once again trying to climb my way up, just like a decade ago. Only this time it’s with two young children and without an economic safety net.”
Prof. Golan Shahar, director of clinical studies and the Strength, Self and Health Lab of Ben-Gurion University’s psychology department, heads a team that in the first days of the virus constructed an anxiety index. It showed that women were having it worse than men.
“There’s a simple explanation for that. Who suffers the most? Stays at home more with the children and takes care of them? … Many women find themselves at home, taking care of the children, supervising them during online lessons – and also trying to work.”
With the advent of the second lockdown, there’s been a moderate but unequivocal increase in the anxiety level due to the virus’ persistence and to economic anxiety. Despite the increase, the numbers don’t indicate panic.
“The second wave and lockdown are arousing more tension than the first because it’s a second blow,” explains Shahar. “Israelis are a people who know how to cope. With the outbreak of the pandemic we saw everyone buckling down. There was hope, there was success, they flattened the curve, people carried on.
“But then they discovered that the reopening of the economy wasn’t managed well and that there isn’t really anyone overseeing the situation. That’s harmful. The public’s trust in the leadership is weakening, and is undergoing a psychological process like that of a child who no longer believes in his parents.”
He defines the anxiety as a result of the coronavirus, rather than as a side effect. “Just like a ripple of waves, when one wave moves a second wave. Every feeling of stress intensifies the incidence of psychological symptoms of anxiety and depression. Therefore, it’s not surprising that people are only now beginning to develop psychological symptoms from the coronavirus.”
Although the pandemic is about health, one can see in Shahar’s study that economic worries are equally paramount. “Although the illness is hitting harder than what they thought at first, lots of people got through it with relative ease. In the end, the chances of incurring economic damage is greater than the chances of incurring health-related damage – unless you are in the at-risk population.”
A study of economic anxiety Shahar conducted with Dr. Liad Bareket-Bojmel of the Peres Academic Center, found that in Israel, Great Britain and the United States, the level of economic anxiety was equal to the anxiety regarding health. This is particularly prevalent among younger people.
“Older people nearing retirement age already have the means to support themselves. The pandemic harms mainly people who are now at a stage of life where their obligations are at a peak, like mortgages. Young people are the population at risk at present, even though this is a population at a highly productive stage of life in terms of participation in the economy – people who have young children, and consume and keep the economy moving. People who are the future of society, they of all people face the greatest danger. That shouldn’t be taken lightly.”
In answer to the question about what employers can do, Bareket-Bojmel offers studies showing that a “perception of support” is an important factor in terms of people’s resilience. “People who feel that someone supports them and is there for them definitely function better,” she says. “On the psychological level they have hope, satisfaction with life and an ability to function.”
An informal check of Israeli companies revealed a large disparity in the emotional support offered to workers. In high-tech and banking, which usually place an emphasis on human resources, they invest more.
Bank Leumi, for example, has a dedicated hotline offering psychological assistance for employees. For the 5,000 employees of Dan Hotels, of whom about 2,600 were sent on unpaid leave, the company set up a loan fund. Other companies outsource psychological consulting services.
“There’s a difference between actual support and a perception of support,” adds Bareket-Bojmel. “The question is whether employees perceive the organization’s support as effective. The CEO of Mobileye, for example, declared that he was not going to lay off workers – and that’s the kind of declaration that enhances the perspective of support.”