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Psychosomatics 40:117-125, April 1999
© 1999 The Academy of Psychosomatic Medine

Depression and Demoralization Among Russian-Jewish Immigrants in Primary Care

Zinoviy Gutkovich, M.D., Richard N. Rosenthal, M.D., Igor Galynker, M.D., Ph.D., Christopher Muran, Ph.D., Sarai Batchelder, Ph.D., and Elena Itskhoki, M.D.

Received December 17, 1997; revised July 19, 1998; accepted July 30, 1998. From the Departments of Psychiatry and Medicine, Beth Israel Medical Center, New York. Dr. Gutkovich is currently at Schneider Children's Hospital, Long Island Jewish Medical Center, Division of Child and Adolescent Psychiatry, New York. Address correspondence and reprint requests to Dr. Gutkovich, Schneider Children's Hospital, Long Island Jewish Medical Center, Division of Child and Adolescent Psychiatry, 269–01-76th Ave., New Hyde Park, NY 11040; e-mail: ZGUTKOV{at}aol.com


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The purpose of this study was to examine the levels and nature of psychological distress and depression among Russian-Jewish émigrés in primary care. Fifty-seven consecutive patients at the primary care clinic were assessed with the Hamilton Depression Scale (Ham-D). The subjects completed self-rating scales, including the Beck Depression Inventory (BDI), Life Orientation Test, Beck Hopelessness Scale, Attributional Style Questionnaire, and Snaith-Hamilton Pleasure Scale. Data on demographics and physical complaints were collected and analyzed. Of the patients studied, 82.5% experienced psychological distress (BDI >=10), and 43.9% had clinically significant depressive symptoms (Ham-D >=17). BDI and Ham-D scores were significantly correlated with the number of psychosomatic complaints, hopelessness, lack of optimism, anhedonia, and dysfunctional attributional style. The distressed, but not depressed, patients had preservation of hedonic capacity. The authors found a high rate of depression based upon Ham-D scores among the Russian-Jewish émigrés in primary care. The authors suggest that this high rate is attributable to a culturally specific tendency to express distress in somatic terms. The nature of distress was phenomenologically similar to demoralization.

Key Words: Depression • Jews • Russia • Immigration • Primary Care • Depression

  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
It is recognized that psychological distress, depression, and psychosomatic illness are elevated in immigrant populations.1–3 The current wave of Russian-Jewish immigration to the United States consists of about a quarter of a million people4 and has been described as a group that has significant difficulties in their cultural adjustment5–10 and a large proportion of older immigrants.11 These difficulties may be caused by the dramatic differences in values between an authority-oriented Soviet society and an autonomy-oriented American society.6,7 Another factor may be differences in family structure, with patriarchal, mutually dependent extended families in the former Soviet Union10,12 vs. more independent family relationships in the United States, differences that are further exaggerated because of the quicker integration of adult children into the American society.10 Still other causes include lack of intrinsic motivation ("immigration for the sake of the children"),10,13 loss of the professional status very highly valued by Russian Jews,6,12 identity conflict (being unable to see themselves either as Russians or as Jewish-Americans),6,7,9 and relatively low social support.9

Several studies have reported elevated distress in Russian-Jewish immigrants to the United States within the community. Increased levels of demoralization, as measured by the Psychiatric Epidemiology Research Interview and Demoralization Scale (PERI-D), were reported among Russian-Jewish immigrants to the United States, compared with a general American population8 and compared with Russian-Jewish immigrants to Israel.9 Increased levels of depression and somatization, as measured by the Symptom Checklist-90, were reported among these émigrés.14

Epidemiological studies15–20 have documented high prevalence rates of depression in different primary care populations, which vary from 12.2% to 25% when assessed by self-rated scales.21 In studies that used structured psychiatric interviews, the prevalence rates of depression were considerably lower, but still elevated, compared with community samples: 5.8% vs. 9.7%.22,23 In spite of high prevalence rates, patients with depression often go undiagnosed or are misdiagnosed.21 The evidence suggests a multifactorial etiology of this problem: while in some cases depression and medical disorders occur concomitantly, many patients with depression selectively focus on the somatic components of their depressive syndrome and minimize or even deny affective and cognitive components.24,25

The tendency to express psychological distress in somatic terms is typical, especially for patients coming from a non-Western cultural background26–28 and, in particular, for Russian-Jewish immigrants.5,7,14 Goldstein states that Russian-Jewish immigrants deny existence of psychological problems instead of blaming external factors or converting psychological problems into psychosomatic symptoms.7 More physical complaints of a psychosomatic nature were found among Russian-Jewish immigrants, compared with the American population, with heart disease, hypertension, and gastrointestinal complaints being the most frequent problems. (Williams A, Rose Medical Center-Family Practice Center, University of Colorado, Denver, 1980, unpublished). Forty-nine percent of elderly Russian-Jewish immigrants viewed their health as below average, compared with only 9% in a sample of Americans. (Jewish Family and Children's Service of Colorado: Elderly Immigrant Project. Denver, Colorado, 1982, unpublished). These émigrés overuse the primary care system.5,14 Explanations that have been proposed for this overutilization5,14 are a culturally specific tendency to express psychological distress through somatic complaints and historically predetermined negative attitudes toward mental health services.7 Generally, the tendency to somatize has also been shown to correlate with a high degree of neuroticism,29 and Russian Jews have been described as high in measures of neurotic conflict.7 It is reasonable to hypothesize that the rates of depression among Russian-Jewish émigrés seen in the primary care setting are especially high given the relatively high rates of distress among Russian-Jewish émigrés within the community, a tendency to express that distress through somatic symptoms, culturally specific negative attitudes toward mental health systems and, perhaps, a high degree of neuroticism. Determining whether this is a high-risk group can be practically important, because screening for depression by using self-rated depression scales, while not practical for all medical outpatients, has been shown to be useful for selected high-risk groups.30

The problem of demoralization and its relationship to psychopathology is of theoretical and practical importance. Although this term is widely used in the literature and authors agree that demoralization is a problem in its own right,31,32 there is no uniform definition of this concept. It is usually viewed31 as "nonspecific" distress,33 a self-perceived incapacity to deal effectively with a specific stressful situation,34 or a combination of both distress and subjective incompetence.31 In our view, this last definition is the most meaningful. The concept of demoralization has been noted to be reminiscent of Seligman's concept of learned helplessness,35 a position noted to render one more vulnerable to depression.36 Subjective incompetence corresponds to learned helplessness and to related concepts that originate from the learned helplessness model: external locus of control33 or dysfunctional attributional style.37 An external locus of control (the belief to which one feels factors that determine the course of one's life are outside of one's direct control) was shown to have a significant effect on the demoralization score, as measured by the PERI-D, among Russian-Jewish émigrés to Israel.9 Preserved hedonic capacity is another very important characteristic of demoralization. As Klein and colleagues pointed out,34 demoralized patients often refuse to admit any form of enjoyment in response to direct inquiry but can experience pleasure passively when they are not called on to initiate or pursue pleasurable activities. There is a notion in the literature that core symptoms of depression in nonpsychiatric patients (i.e., those seen in nonpsychiatric setting) are phenomenologically similar to demoralization and that demoralization appears to be one of the most common reasons that people seek nonpsychiatric treatment.31 Luborsky and Auerbach showed, for example, that complaints of migraine headache and stomach pain often occur in the context of hopelessness and helplessness.38 A better understanding of the relationship among psychological distress, depression, and demoralization is of practical importance because specific psychotherapeutic and psychosocial interventions aimed to relieve demoralization, for example, a reformulation of an individual's assumptions to resolve subjective incompetence,31 may be useful in treatment of depressive syndrome in demoralized patients.

To our knowledge, there are no published studies of depression and demoralization among Russian-Jewish immigrants in a primary care setting, and no studies of depression among these émigrés that used more reliable clinician-rated scales. Also, prior studies on demoralization among Russian-Jewish émigrés8,9 used scales such as the PERI-D that measures nonspecific psychological distress33 and did not address other important aspects of demoralization described earlier.

The objectives of our study, conducted in 1997, were to investigate in a sample of Russian-Jewish immigrants followed in a primary care setting 1) the levels of clinically significant depressive symptoms by using the physician-rated Hamilton Depression Scale (Ham-D);39 2) the levels of psychological distress and different aspects of demoralization, such as hopelessness, lack of optimism, subjective incompetence, and hedonic capacity, by using self-rated scales; and 3) the relationship among psychological distress, depression, and different aspects of demoralization. We also collected and analyzed the data on presenting medical problems and sociodemographic characteristics of the subjects. We hypothesized that 1) there would be a significant correlation between depressive symptomatology and demoralization; 2) there would be a clinically relevant proportion of patients who are demoralized but not clinically depressed; and 3) the demoralized patients who are depressed will have additional vulnerabilities, such as older age, being single, or having poor English-language skills.


  METHODS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Sample
Over 1 month, all Russian-Jewish patients (N=153) who were either scheduled for a visit to a bilingual primary care physician (E.I.) or walk-ins were evaluated for study participation. To minimize the influence of factors other than immigration, we excluded patients age >=65 (n=50), with known history of mental illness before immigration (n=5), and with terminal medical illness (n=1). Patients with dementia (n=2) and first-visit patients (due to lack of history) (n=12) were also excluded. No patients demonstrated a history of drug or alcohol abuse, which was another exclusion criterion. Of the remaining 83 patients, 68 were asked to participate, and 15 did not show up for their visit. To maximize the compliance rate, the patient was asked to complete self-rated scales and questionnaires and be interviewed by a rater (Z.G.) who administered the Ham-D at the primary care setting at the time of patient visit. The rater was blind to the self-report responses at the time of testing. Nine patients refused to participate, and two patients failed to complete the questionnaires. Fifty-seven subjects completed the questionnaires, had an interview with the rater, and were included in our analysis. All subjects signed informed consent.

Data on age; gender; marital status; educational level, place of origin in the former Union of Soviet Socialist Republics; time of residency in the United States; employment status before immigration; level of English language proficiency on a 5-point scale after entry into the United States; attitude toward mental health services (neutral, negative, or strongly negative); and main physical complaints were collected by questionnaire. Physical complaints listed in the questionnaire included high blood pressure, headaches, gastrointestinal discomfort or pain, chest discomfort or pain, back pain, and arthralgia, which are reported to be the most typical psychosomatic problems.40,41 The primary care physician provided data on each subject's medical diagnosis, main problems, diagnosis of depression, and current psychiatric treatment.

Instruments
For the assessment of depressive symptomatology, we used a 25-item version of the original Ham-D39 with the structured interview guide42 to obtain more objective results. In cases in which it was difficult to separate medical and psychiatric causes of vegetative symptoms of depression (e.g., low energy, decrease in libido,etc.), we rated the reported symptom, unless it clearly was attributable to a medical problem, which is similar to an "inclusive approach" and which has been shown to be a reliable strategy for diagnosing major depression in patients with physical illness.43 We selected a cutoff score of 17 or above as indicative of a clinically significant depressive disorder. This number is close to the anchor point of 16 on the 21-item Ham-D suggested by Bech et al.,44 and corresponds to the range of 17 to 20 used in other studies as indicative of major depressive disorder.45–49

We used the Beck Depression Inventory (BDI)50 to assess the level of subjective psychological distress. The choice of this instrument was based on its proven efficacy in the studies of depression in primary care.15,51 A conventional cutoff score of 10 or above51 was used as indicative of distress. Four measures were used to assess different aspects of demoralization: the Life Orientation Test (LOT),52 the Beck Hopelessness Scale (BHS),53 the Snaith-Hamilton Pleasure Scale (SHAPS),54 and the Attributional Style Questionnaire (ASQ).37 The LOT measures dispositional optimism, defined in terms of generalized expectancies.52 The BHS measures a person's hopelessness, defined in terms of a system of negative expectancies concerning the individual's self and future.53 The SHAPS is a scale estimating the degree to which a person is able to experience pleasure.54 We chose the ASQ as a measure of subjective incompetence. The ASQ is designed to measure three dimensions of attributional style: 1) internal vs. external, 2) stable vs. unstable, and 3) global vs. specific. These attributional style dimensions are assessed for negative and positive events separately, resulting in 6 subscales (i.e., Negative Internal [NI], Negative Stable [NS], Negative Global [NG], Positive Internal [PI], Positive Stable [PS], and Positive Global [PG]). Composite attributional style scores can be calculated based on all of the items for negative events ("composite negative") and all of the items for positive events ("composite positive").37 Attributing uncontrollable negative events to internal, stable, and global factors and, to a lesser degree, the opposite style for attributing positive events is associated with helplessness.37

All instruments were translated twice: into Russian and then back into English by another translator who was blind to the original. All distortions that appeared on back translation were corrected. The SHAPS was especially designed by authors to ensure cross-cultural validity;54 the BHS,55 Ham-D,55–57 and BDI55,58 have been used before in other languages, including Russian for the Ham-D57 and BDI.58

Data Analysis
Pearson correlations were computed between the scores on the Ham-D and self-rated scales, as well as the number of psychosomatic complaints and sociodemographic variables. In addition, we divided all subjects into three groups: "depressed" with Ham-D scores >=17 and BDI >=10, "in distress/not depressed" or "demoralized" with BDI >=10 and Ham-D <17, and "normal" with BDI <10 and Ham-D <17. Means ± standard deviations were computed for variables within the groups, and differences between the groups were analyzed by a one-way analysis of variance (ANOVA). We also compared the scores of the "normal" group on the demoralization scales with the norms for the general American population. The depressed subjects were subdivided into three groups: those not receiving psychiatric treatment, those in treatment with a psychiatrist, and those taking psychotropic medications prescribed by their primary care physician. Differences among these groups were then analyzed by ANOVA. We used a significance criterion P<0.05 for the planned comparisons. Bonferroni correction was applied for the exploratory statistical tests.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
The sociodemographic profile of the sample is presented in Table 1. As can be seen, the older émigrés and former professionals with the university degrees were overrepresented in the sample. Most of them had been in the United States less than 6 years, and almost all were unemployed. Eighty-two percent of the patients in the sample (47/57) experienced psychological distress, as defined by a BDI score >=10. Twenty-five of these 47 patients (53.2% or 43.9% of the total sample) were also clinically depressed, as defined by Ham-D score >=17. Nine subjects (15.8%) had a BDI score <10 and a Ham-D score <17. One subject had a BDI score of 8 but a Ham-D score of 17. This subject was not included in the analyses, as he did not fit inclusion criteria for any of the defined groups. There was a high degree association between Ham-D and BDI scores: r=0.7931; P<0.001. Data on the relationships among the BDI, Ham-D, the four demoralization scales, and the number of psychosomatic complaints are presented in the Table 2. The BDI positively correlated with the hopelessness scale (r=0.6770, P<0.001); the SHAPS (r=0.6004, P<0.001); the composite negative subscale of the ASQ (r=0.2810, P=0.034); and the stability of attributions for negative events (r=0.2652, P=0.046) and negatively correlated with the LOT (r=-0.5795, P<0.001).


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TABLE 1. Sample characteristics




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TABLE 2. Correlation coefficients between scores on the scales



Similar relationships were found for Ham-D scores and scores on the other scales. There was a significant positive relationship between depression and the hopelessness scale (r=0.6630, P<0.001); the SHAPS (r=0.5774, P<0.001); the composite negative subscale of the ASQ (r=0.3045, P=0.021), and internality of attributions for negative events (r=0.2934, P=0.027) and a negative relationship with the LOT (r=-0.5297, P<0.001).

There was a significant correlation between scores on BDI and Ham-D and number of psychosomatic complaints reported by the patient (r=0.3900, P=0.003 for BDI; r=0.4101, P=0.002 for Ham-D scores).

In addition, several exploratory analyses were performed to examine the relationship between composite attributional style and other aspects of demoralization (Bonferroni correction applied; correlations with a P-value 0.05/4=0.0125 or less are considered significant associations.) There was a significant positive relationship between the composite negative subscale of the ASQ and the hopelessness scale (r=0.4632, P<0.001) and a significant negative relationship between the composite negative subscale of the ASQ and the LOT (r=-0.4744, P<0.001). A significant relationship was found between the composite positive subscale of the ASQ and the LOT (r=0.3317, P=0.012).

Group Comparison
A one-way ANOVA was performed to determine the differences among the depressed, demoralized, and normal groups on the dependent variables. Data on comparison of the three groups as well as norms for the American population are presented in Table 3.


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TABLE 3. Group comparison



Scores on all the scales in the normal group were consistent with the norms for the American population.

Significant differences among the three groups were found on the BHS (F=27.11, df=2,53, P<0.0001), with the depressed group (mean [M]=15.92) scoring significantly higher than the demoralized group (M=10.41) and the demoralized group scoring significantly higher than the normal group (M=4.56).

There were significant differences on the LOT (F=8.67, df=2,53, P=0.0006), with the depressed group (M=12.80) and the demoralized group (M=15.95) scoring significantly lower than the normal group (M=21.89).

Significant differences were found on the SHAPS (F=12.63, df=2,53, P<0.0001), with the depressed group (M=4.52) scoring significantly higher (i.e., being more anhedonic) than both the demoralized group (M=2.00) and the normal group (M=0.11).

There were no significant differences among the groups on sociodemographic variables.

Among the 25 patients who had clinically significant depressive symptoms, 22 patients (88%) were identified as depressed by their internist.

Among those patients who were clinically depressed, 15 (60%) were in treatment with psychiatrist, 3 (12%) were taking psychotropic medications prescribed by their primary care physician, and 7 (28%) did not receive any psychiatric treatment.

The patients who received psychiatric treatment (with either a psychiatrist or a primary care physician) had significantly higher Ham-D scores (F=4.99, df=2,53, P=0.016) than those who did not. Otherwise, there were no significant differences between these groups on BHS, SHAPS, LOT, ASQ, and BDI scores and sociodemographic variables.


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
As was expected, there was a very high percentage of the patients with clinically significant depressive symptoms. Eighty-two percent of the patients in the sample (47/57) experienced psychological distress, as defined by a BDI score >=10. Twenty-five of these 47 patients (53.2% or 43.9% of the total sample) were also clinically depressed, as defined by Ham-D score >=17. This figure is clearly higher than the epidemiological data reported for primary care settings in the United States: 12.2% vs. 25% when assessed by self-rated scales21 and 5.8% vs. 9.7% in the studies that used structured interviews.22,23 There may be several explanations for these findings. First, patients may express their depression through somatic complaints24,25 or the threshold for somatic discomfort is decreased by depression,21 either of which results in an accumulation of such patients in the primary care setting. This suggestion is supported by the significant relationship in our sample between both BDI and Ham-D scores and the number of psychosomatic complaints. Second, depressed patients may not go to a psychiatrist because of culturally based negative attitudes toward mental health services7 but may turn to their family or doctor for social support.5 In our sample, five subjects (8.8%) expressed negative attitudes toward mental health services, and three subjects (5.3%) did not respond to this question. Ten of the 25 depressed patients (40%) were not in treatment with a psychiatrist; this number includes 7 patients who were identified as depressed by their internist. This finding provides some support for the second explanation. We believe that an interplay of the aforementioned factors contributes to such a high proportion of Russian-Jewish immigrants who have nonspecific psychological distress and depression in a primary care setting.

The high agreement between the BDI and Ham-D scores suggests that the BDI can be useful as a screening instrument in this population. In our sample, the recognition of depression by the primary care physician was unusually high (88%) and is probably attributable to her ability to speak Russian. Despite this, 12% of the cases were missed. This number might have been much higher if the patients were seen by a nonbilingual physician. In this case, the Russian version of the BDI can be especially useful.

The fact that scores on BHS, LOT, ASQ, and SHAPS for the normal group were consistent with the norms for the American population supports the cultural validity of the scales. Psychological distress and depression in our sample correlated positively with hopelessness and negatively with optimism. Although no significant differences among the depressed, demoralized, and normal groups were found in their attributional style, there was a significant correlation between both BDI and Ham-D scores and dysfunctional attributional style for negative events. The concept of dysfunctional attributional style originates from the learned helplessness model and holds that attributing uncontrollable negative events to internal, stable, and global factors and, to a lesser degree, the opposite style for attributing positive events is associated with helplessness and depression.37 Helplessness or subjective incompetence is considered to be the critical feature of the demoralized state.31 Interestingly, the subjects who had subclinical depressive symptoms and experienced psychological distress had preserved hedonic capacity, another feature of demoralization. These data support our hypothesis that psychological distress in this population is phenomenologically similar to demoralization. There was a large proportion of the patients (38.6% of the total sample) who were demoralized but not clinically depressed, which confirms our second hypothesis. About half (53.2%) of the patients who were demoralized were also depressed, which is very similar to the ratio between demoralization and depression for the American population described by Link and Dohrenwend.32 Possibly, the state of demoralization in itself is a risk factor for the development of the major depressive disorder.

The relationship between attributional style for negative events and both hopelessness and optimism appeared to be stronger than the relationship between attributional style for bad events and depression. Also, a significant relationship emerged for attributional style for positive events and optimism that did not appear for BDI and Ham–D scores. This finding is consistent with the findings of Keller and Haase59 that hopelessness is a direct result of dysfunctional attitudes, with little unique contribution from depression. One may speculate that while dysfunctional attributional style correlates highly with hopelessness and lack of optimism, some other factors modulate the development of subjective distress and depressive symptoms.

The patients who were receiving psychiatric treatment did not differ significantly in their scores on demoralization scales from the patients who were not in treatment. Although we did not address specifically modalities of treatment, it is realistic to expect that these patients received medications for symptom relief but not specific psychotherapeutic or psychosocial interventions aimed at relieving their sense of subjective incompetence. Taking this into account, the fact that these subgroups did not differ in their demoralization scores provides further support for the hypothesis that psychological distress in this population is phenomenologically similar to demoralization. Demoralization may be a syndrome independent from other mood disorders that potentially increases the risk for major depressive disorder but has its own symptom construct and treatment strategies. There is no literature on the specific pharmacological treatment of demoralization in immigrants or any other group. Possibly, specific forms of help similar to the Psychological Support Project for Russian-Jewish immigrants in Israel58 or L'Chaim, the Russian Adult Day Program in San Francisco,5 can be useful.

Unexpectedly, our third hypothesis was not confirmed. We did not observe any relationship between level of distress and depression and sociodemographic variables. This finding is inconsistent with other studies that report higher levels of distress among older Russian-Jewish immigrants and women8,9 and divorced or widowed individuals9 and a decline in demoralization after the fourth year since immigration.8 If such a relationship exists—but we could not see it in our sample—it could be attributable to the relatively small sample size and lack of variability in the aforementioned parameters or attributable to the nature of the sample: most patients were Medicaid recipients, and 54 of 57 were unemployed. This means that for one reason or another, they were not protected against vulnerability by their younger age, family support, better English skills, or longer stay in the United States.

There are several study limitations. The rate of clinically significant depression assessed by using the Ham-D in our study was 43.9%, which is much higher than prior epidemiological data: 5.8% vs. 9.7%22,23 for primary care settings in the United States. This comparison is limited because the aforementioned studies used structured, as opposed to semistructured, instruments such as Ham-D. It is likely, however, that this major discrepancy reflects true differences. This likelihood is further supported by the fact that the level of self-reported psychological distress in our study was 82.0%, which is much higher than epidemiological data of 12.2% to 25%21 from the studies that used similar self-reported scales. Our data were collected in a single primary care clinic. Further research is needed to determine if these results could be generalized to Russian-Jewish immigrants in other primary care settings. Another study limitation is a possible overlap between concepts of demoralization and minor depression. Our subjects who were in significant distress but not clinically depressed could have met criteria for minor depression. We defined them as demoralized because of their preserved hedonic capacity. More research is needed to establish if lesser severity of depressive symptoms is uniformly associated with preserved hedonic capacity.

We could not address the issue of a causal relationship between attributional style and distress or depressive symptoms. It is unclear whether dysfunctional attitudes make people more vulnerable to depression or depression affects attributional style or both. Some prospective studies60 suggest a causal relationship between dysfunctional attributions and depression. The main limitation in this study lies in the nature of our sample. Although we excluded patients with terminal illness, serious medical problems in some patients may confound the relationship among immigration, psychological distress, and psychosomatic problems. Almost all patients were unemployed, which is a separate factor of social vulnerability, although likely to be related to unsuccessful acculturation. The percentage of unemployed patients in this sample is slightly higher than it is in the overall caseload, since according to the primary care physician (EI), the patients who do not show up for their visit (15 patients in the study) tend to be younger, healthier, and employed. An unemployment rate of 77% among older Soviet Jewish immigrants (mean age: 61.5 years) was reported by Kohn et al. in a community-drawn sample.14 Although it is likely that a high unemployment rate is typical for Russian-Jewish immigrants seen in primary care setting, it is impossible to know with certainty without further research.

We suggest that a high proportion of Russian-Jewish immigrants seen in primary care are in need of psychiatric help, which many do not receive. The high rate of distress and depression in this population is attributable to a culturally specific tendency to express distress in somatic terms. The nature of distress in this population is phenomenologically similar to the syndrome of demoralization, which has characteristics that differentiate it from depression. The BDI can be a useful screening tool for detecting cases of psychological distress and depression in this high-risk group. Patients may benefit from psychotherapeutic and psychosocial interventions aimed at relieving their demoralization, in addition to psychopharmacological treatments for diagnosable mood disorders.


  ACKNOWLEDGMENTS

 
The authors thank Dr. Arkadiy Chernyak, Dr. Anna Filova, and Dr. Irina Surbnshanyan for their help with translation of the scales and Lyudmila Chernyakova for her assistance with subject enrollment.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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