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Assessing risk for depression among immigrants at two-year follow-up
Assessing Risk for Depression Among Immigrants at Two-year Follow-Up Karen J. Aroian and Anne Norris This article reports findings from a longitudinal study of what predicts depression 2 years later in a sample of former Soviet immigrants. Study aims were to: (1) investigate change in depression scores and (2) determine the relative contribution of initial depression scores, select demographic and migration characteristics and common demands of immigration to depression at 2-year follow-up. Data were collected at two time points from 468 former Soviet immigrants who had been in the US 5 years or less at the time of the first data collection appointment. Linear regression was used to predict depression at 2-year follow-up. There was little improvement in depression for the sample as a whole over time. Baseline depression, unemployment, novelty, and not having relatives in the local resettlement area were significant predictors of depression at 2-year follow-up. Initial depression in relatively recent immigrants should be treated aggressively and not assumed to be a transient problem. Immigrants should be assisted to find early employment and overcome novel aspects of their new environment. Immigrants without local families will likely need additional support. Copyright 2002, Elsevier Science (USA). All rights reserved.
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URSES SHOULD routinely assess their immigrant patients for risk of depression because depression is a common response to immigration (Aroian & Norris, 1999; Black, Markides & Miller, 1998; Franks & Faux, 1990; Kim & Rew, 1994; Webster, McDonald, Lewin & Carr, 1995; Williams & Hunt, 1997). When left untreated, depression can develop into a major depressive disorder. Major depressive disorder poses serious economic and emotional consequences for immigrants and their families (Aroian, Spitzer & Bell, 1996; Fox, Cowell & Johnson, 1995). Assessing depression risk in immigrant populations poses at least two major challenges. First, immigrants typically do not complain of feeling depressed. Instead, they usually present with somatic complaints and cultural idioms of distress that are not readily interpretable by health professionals who are unfamiliar with their culture (Angel & Guarnaccia, 1989; Allodi & Rojas, 1985; Kawanishi, 1992; Lin, Carter & Kleinman, 1982). Another assessment challenge involves determining which immigrants are at risk for major depres-
sive disorder. Similar to uncomplicated grief, depression for some immigrants may be a transient, normative response to immigration. Depression of this type may resolve itself over time as immigrants adapt to the immigration experience. On the other hand, immigrants with many adaptive challenges and few resources to cope with immigration demands may develop a major depressive disorder over time. Immigrants from the former Soviet Union are an important population to study. Depression is a common problem for these immigrants and they
From the College of Nursing, Wayne State University, Detroit, MI and the School of Nursing, Boston College, Chestnut Hill, MA. Supported by the National Institutes of Health, National Institute of Nursing Research, grant no. R29 NR0768-01. Address reprint requests to Karen J. Aroian, PhD, RN, CS, FAAN, College of Nursing, Wayne State University, 5557 Cass Ave, Detroit, MI 48202. Copyright 2002, Elsevier Science (USA). All rights reserved. 0883-9417/02/1606-0003$35.00/0
Archives of Psychiatric Nursing, Vol. XVI, No. 6 (December), 2002: pp 245-253
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typically do not seek professional help directly for this problem (Aroian & Norris, 1999; Barankin, Konstantareas & de Bosset, 1989; Factourovich et al., 1996; Flaherty, Kohn, Levav & Birz, 1988; Kohn, Flaherty & Levav, 1989; Lerner & Zilber, 1991; Ritsner et al., 1996). Rather, they usually seek medical treatment for somatic complaints, a practice that is not only costly but also results in misdiagnosis and under treatment of depression (Aroian, Khatutsky, Tran & Balsam, 2001). This article reports findings from a longitudinal study of what predicts depression 2 years later in a sample of fairly recent former Soviet immigrants. Specific research aims were to: (1) investigate change in depression scores and (2) determine the relative contribution of initial depression scores, select demographic and migration characteristics (i.e., gender, marital status, employment, education, age at immigration, and local family), and common demands of immigration (i.e., loss, novelty, occupation, language, discrimination, and not feeling at home) to depression at 2-year follow-up. The goal was to facilitate clinical assessment by identifying objective indicators of risk for depression in former Soviet immigrants. A strength of the study was the use of a longitudinal design with a sample of individuals at various time points in their relatively recent immigration experience. LITERATURE REVIEW
Two decades of research with varied immigrant groups have yielded fairly consistent findings about the personal and situational variables associated with immigrants’ depression. Specifically, lack of local family, female gender, not being married, unemployment, premigration loss, novelty, language difficulties, occupational change, discrimination, and not feeling at home have been associated with depression in Asian, Southeast Asian, Middle Eastern, Latin American, Eastern European, and Southern European immigrants (Aroian & Norris, 2000; Aroian, Norris, Patsdaughter & Tran, 1998; Berry, Kim, Minde & Mok, 1987; Flaherty et al., 1988; Frye & D’Avanzo, 1994; Furnham & Sheikh, 1993; Hattar-Pollara & Meleis, 1995; Kim & Rew, 1994; Lipson, 1992; Lipson & Miller, 1994; Moghaddam, Ditto & Taylor, 1990, 1990; Moon & Pearl, 1991; Thompson, 1991; Vega, Kolody & Valle, 1987; Westermeyer, Vang & Neider, 1983). Longitudinal studies have found that some of these variables, such as lack of local family, also
predict future distress (Beiser, 1988; Noh & Avison, 1996). Other variables, such as premigration loss, lose their significance over time (Westermeyer & Uecker, 1997). Initial or early depression is another strong predictor of future depression (Beiser, 1988; Noh & Avison, 1996; Westermeyer & Uecker, 1997). There is much less consensus on the course of immigrants’ depression. Two alternative truisms are commonly cited on this topic. One frequent statement, usually generalized from a single but exemplary longitudinal study by Beiser (1988), is that emotional distress is highest during initial resettlement (particularly the first few to 18 months). Another position, usually credited to observations made of immigrant families by Sluzki (1986), maintains that early resettlement (i.e., the first 6 months) is marked by a “honeymoon” period of euphoria, followed by distress that persists for a number of years. Neither of these two positions is consistently supported by research and, in some cases, research findings portray a more complex or contingent course. Although a number of studies have documented higher rates of distress among recent rather than longstanding immigrants (Beiser, 1988; Black et al., 1998; Cwikel, Abdelgani, Goldsmity, Quastel & Yevelson, 1997; Kim & Rew, 1994; Moon & Pearl, 1991; Pernice & Brook, 1996; Vega et al., 1987), a number of other studies have found that years since arrival is unrelated to distress (Hauff & Vaglum, 1995; Lipson, 1992; Locke, Southwick, McClosky & FernandezEsquer, 1996; Moghaddim et al., 1990; Pernice, Trlin, Henderson & North, 2000; Webster, McDonald, Lewin & Carr, 1995). In a comparative study of Russian and Ethiopian immigrants, years since arrival was associated with decreased depression in Ethiopian immigrants but the time factor was not significant for Russian immigrants (Ponizovsky et al., 1998). In two studies, number of years was unexpectedly associated with increased depression (Chung & Kagawa-Singer, 1993; Franks & Faux, 1990). One of these two studies, however, only noted this association for early but not longstanding (5 or more years in resettlement) immigrants (Chung & KagawaSinger, 1993). Yet another study documented a two-phase temporal pattern where depression increased for the first 27 months, declined for the next 54 months, and then began to elevate again (Ritsner & Ponizovsky, 1999).
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Part of the difficulty with disentangling these conflicting or, at best, overlapping conclusions is attributable to methodological problems. More than half of the studies mentioned above used cross sectional data from study participants who were in the resettlement country for varying lengths of time to study the effects of time on psychological status. See Bernstein and Shuval (1998), Beiser (1988), Cwikel et al. (1997), Flaskerud and Uman (1996), Hauff and Vaglum (1995), Ritsner and Ponizovsky (1999) for exception. Cross sectional approaches potentially confound time with cohort differences among various immigrant waves or immigrant groups. Also, there is a growing belief that the typical trajectory for depression among immigrants is group specific and depends on the nature of their pre- and postmigration stressors (Chung & Kagawa-Singer, 1993). Thus, a current recommendation is to use longitudinal designs to study immigrant groups in context to understand how their unique circumstances and characteristics influence their risk (Franks & Faux, 1990; Hauff & Vaglum, 1995). METHODS
Sample Study participants were part of a larger study of stress and adaptation among community dwelling former Soviet immigrants in the Boston area of the US (n⫽1,647). Participants were recruited through written advertisement in ethnic newspapers and verbal advertisement by the data collection team. Twelve people who were also former Soviet immigrants comprised the data collection team. The data collection team was representative of the local former Soviet immigrant population so that their recruitment efforts would not bias the sample toward particular demographic characteristics. Specifically, the data collectors were of both genders, of various age groups, from representative republics of origin in the former Soviet Union, and had been in the US for varying lengths of time. Study participants from the larger study were eligible for the second or longitudinal phase of the study if they were in the US 5 years or less during the initial data collection (n⫽1,350). Change of address cards were mailed every 6 months after the first data collection appointment to maintain contact with these people. Over the course of 2 years, 833 of the 1,350 study participants (61.7%) either
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moved without providing a forwarding address or were no longer eligible for study participation because of moving out of the Boston area. Only 9.5% or 49 of the remaining 517 study participants who could be located and maintained eligibility declined to participate in the second phase of data collection. Thus, 468 study participants provided data 2 years later for the second phase of the study. Analyses are reported here for the 454 study participants who had no missing data for the variables of interest. These longitudinal study participants did not differ significantly from those who participated only in the first phase of the study in terms of gender, education, marital status, presence of relatives in the local area, or depression (p ⱖ .17). They did differ slightly in employment, time in the US, and age at immigration: Longitudinal study participants were more likely to be unemployed (75.2% vs 62.5%; Chi-Square⫽21.92, df⫽1, p ⬍ .001), had lived in the US a shorter time (the Mean for the longitudinal study participants was 1.73 years, SD⫽1.26 as compared to the Mean for first phase only study participants only of 2.13 years, SD⫽1.72; t⫽4.854, df⫽1216.35, p ⬍ .001), and were older when they immigrated to the US (the mean for longitudinal study participants was 47.97 years, SD⫽16.39, as compared with the mean for first phase only study participants of 43.28 years, SD⫽16.91, t⫽-4.78, df⫽1346, p ⬍ .001). The mean age of the longitudinal sample at the time of the first data collection appointment was 49.59 (SD⫽16.45). The mean number of years in the US at the first data collection was 1.73 (SD⫽1.26). The majority of study participants were refugees (94.4%), had a minimum of a college degree (71%), and identified their ethnicity as Jewish (80.5%). The second largest ethnic group was Armenian (10.5%), followed by Russian (6.4%). Republic of origin from the former Soviet Union was as follows: 45.8% from Russia, 27.4% from the Ukraine, 13.5% from Azerbaijan, and 13.3% from “other republics.” These study participant characteristics reflect the local population of former Soviets (refugees and immigrants in Massachusetts, 1997) and, to some extent, the national population of former Soviets (Basok & Brym, 1991; US Immigration and Naturalization Service, 2000). For instance, most former Soviet immigrants in the US have refugee status based on ethnic and minority persecution in the former Soviet Union and Soviet
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Jews are the largest ethnic minority (Basok & Brym, 1991). On the other hand, the educational status of former Soviets who reside in Boston is, on the average, slightly higher than the educational status of former Soviet immigrants who reside elsewhere in the US (Simon, 1985). Only 25% of the study participants were employed, which is most likely an indication of their limited time in the US. By the second data collection appointment 2 years later, 45.2 % were employed. INSTRUMENTS AND PROCEDURE
During the first as well as the second data collection appointment, study participants provided consent and completed Russian language versions of a demographic questionnaire, the Demands of Immigration Scale (DI) (Aroian, Norris, Tran & Schappler-Morris, 1998), and the Depression Scale of the Symptom Checklist 90-R (SCL-90-R; Derogatis, 1992). Russian-speaking research assistants collected these data in person in the study participants’ homes. A $10.00 gratuity was given at the conclusion of each data collection appointment. Russian language forms of the data collection materials were developed through translation and back translation (Werner & Campbell, 1970). More in depth description of the translation procedure is provided in Aroian and Norris (1999). The demographic questionnaire elicits information about city of origin, length of time in the US, immigration status, age, gender, marital status, educational level, language of preference, occupation pre- and postmigration, and employment status. At its second administration 2 years later, items about city of origin, age, premigration employment, and gender were omitted. The DI Scale is a 23-item, standardized, paper and pencil measure with six subscales, including loss, not feeling at home, novelty, occupational adjustment, language accommodation, and discrimination. The Loss Subscale elicits information about longing and unresolved attachment to people, places, and things in the homeland. The Not Feeling at Home Subscale asks about feeling like a stranger or a foreigner who is not part of one’s surroundings or included in the social structure. The Novelty Subscale asks about newness, unfamiliarity, or information deficits related to living in the new country. The Occupational Adjustment Subscale taps difficulty finding acceptable work,
status demotion, and lack of opportunities for professional advancement. The Language Accommodation Subscale pertains to the immigrant’s subjective perception of having a less than adequate command of the host language, including extent of vocabulary, comprehension of local dialect, and ability to be understood given the strength of one’s accent. Finally, the Discrimination Subscale includes items about active or subtle discrimination, such as the notion that immigrants do not belong in the US or deserve the same rights as the native born. Respondents rate the extent to which they have been distressed by each of the stated demands as it applies to their recent (within the last 3 months) personal experiences as immigrants. Items are rated along a six-point scale ranging from not at all (1) to very much (6) distressed. Content for the DI Scale was derived from three separate studies with Polish (N⫽25), Irish (N⫽25), and Russian (N⫽42) immigrants (Aroian, 1988; Aroian, 1990; Aroian, 1993a; Aroian, 1993b). The DI Scale was evaluated in a fourth study with a validation sample of 857 Russian immigrants who had resided in the US from a few months to 20 years (Aroian et al., 1998). Confirmatory factor analysis supported the proposed sixfactor model (The standardized factor loadings for the items ranged from .67 to .88). The DI subscales were internally consistent (range of alpha⫽.82 to .88) and had good test-retest reliability over a 3 week time interval (r⫽.82 to .87). The SCL-90-R is a multidimensional, self-administered questionnaire of psychological distress that asks respondents to rate each item along a 5-point scale of distress from not at all (0) to extremely (4) distressed. The 13-item Depression Scale of the SCL-90-R reflects a broad range of manifestations of clinical depression, including dysphoric mood and affect, lack of motivation and energy, feelings of hopelessness, and other cognitive and somatic correlates of depression. Cronbach’s alpha for the Russian language version of the Depression Scale was .91. Test-retest reliability over a one-week interval was .85 (Aroian & Norris, 1999). DATA ANALYSIS
A three-step hierarchical linear regression was used to address the second aim after checking that the proposed independent variables were signifi-
ASSESSING DEPRESSION RISK
cantly correlated with the dependent variable, depression, 2 years later. First, gender (male⫽1, female⫽0), baseline employment status (employed full- or part-time⫽1, not working⫽0), baseline education status (college graduate⫽1, not a college graduate⫽0), and baseline depression scores were entered to control for the effects of these demographic variables and pre-existing depression. Second, age at immigration and all DI subscale scores except Occupation were entered. The Occupation subscale was not included because 12.3% of the sample did not complete this scale and the missing Occupation subscale data were systematic: 91.2% of those who failed to complete this scale were retired. Finally, baseline marital status (married⫽1, not married⫽0) and having relatives in the area (yes⫽1, no⫽0) were entered to determine whether the effects of social support as captured by these two variables mediated the effects of age at immigration or the demands of immigration on depression. FINDINGS
Table 1 displays the means and frequencies for the continuous and categorical variables planned to be included in the hierarchical linear regression analysis. Note that depression scores on the SCL-90 2 years later were not significantly lower than at baseline (paired t⫽1.05, df⫽467, p⫽.29), indicating little improvement in depression for the sample as a whole over time. Neither marital status (r⫽-.06) nor education (r⫽.07) were significantly correlated with depression at 2 years (p ⬎ .05). Consequently both variables were dropped from the hierarchical linear regression analysis. Table 2 contains the correlations among the independent variables that were retained in the regression analysis. Correlations with the dependent variable are included in the first column of the table. As expected, depression scores at baseline and 2 years later were highly correlated (r⫽.48). The other independent variables had small to moderate size correlations with the dependent variable, ranging from r⫽-.12 for gender to r⫽.23 for the Novelty DI subscore. Results for the three-step, hierarchical regression are shown in Table 3. Despite the fairly high intercorrelation between the two depression scores, collinearity diagnostics indicated that there were no problems with multicollinearity.
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Table 1. Frequencies and Mean Scores for Variables in Proposed Regression Analysis Demographics
Gender (n⫽468) Male Female Employment (n⫽463) Unemployed, looking Unemployed, not looking Retired Employed part-time Employed full-time Education (n⫽467) Incomplete high school High school graduate Incomplete college College degree Graduate course work Depression score at baseline (n⫽468) Depression score 2 years later (n⫽468) Age at immigration (n⫽468) Scores on DI subscales: Home (n⫽467) Language (n⫽464) Loss (n⫽467) Novelty (n⫽467) Occupation (n⫽411) Discrimination (n⫽464) Marital Status (n⫽467) Single Married Divorced Legally separated Geographically separated Widowed Relatives in local area (n⫽465)
Percentage/M (SD)
43% 57% 33% 8% 34% 11% 14% 3% 19% 9% 65% 6% .91 (SD⫽.76) .87 (SD⫽.77) 48 yrs (SD⫽16.4) 3.09 (SD⫽1.41) 4.20 (SD⫽1.47) 3.91 (SD⫽1.33) 3.64 (SD⫽1.37) 4.00 (SD⫽1.51) 2.60 (SD⫽1.26) 10% 73% 7% 0% 2% 8% 82%
Abbreviations: M, mean; SD, standard deviation.
As expected, the depression score at baseline was a significant predictor of depression 2 years later in the first step of the regression and remained so throughout the analysis (p ⱕ .001). A similar pattern was observed for employment status (p ⬍ .05). However, gender was not a significant predictor (Beta⫽-.04, p⫽.35). Together these three variables explained 26% of the variance (F(3, 450)⫽51.39, p ⱕ .001). Adding age when immigrated and the DI subscale scores in step two of the regression explained an additional 2% of the variance, but this increment was not significant (F(7, 397)⫽1.51, p⫽.17). Only the Novelty DI subscale score (Beta⫽.12) was significant in this step of the regression (p ⬍ .05). Adding the measure of social support, having relatives in the area, in step three of the regression
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Table 2. Correlations Among Variables in the Regression Analysis (nⴝ454).
Depression 2 years later (D2) Depression at baseline (D1) Gender (G) Employment (E) Age at immigration (A) DI subscales: Home (DI-H) Language (DI-La) Loss (DI-Lo) Novelty (DI-N) Discrimination (DI-D) Relatives in local area (R)
D2
D1
G
E
1.00 .48* ⫺.12* ⫺.19* .14*
⫺.17* ⫺.09‡ .03
.03 .05
⫺.40*
.19* .17* .14* .24* .17* ⫺.16*
.41* .22* .29* .27* .29* ⫺.13*
⫺.11† ⫺.02 ⫺.20* ⫺.15* ⫺.05 .01
⫺.04 ⫺.20* ⫺.14* ⫺.22* ⫺.05 .05
A
DI-H
DI-La
⫺.01 .27* .07 .09‡ .02 .08*
.34* .56* .49* .45* ⫺.01
.34* .53* .42* .06
*p ⱕ .005 †p ⱕ .01 ‡p ⬍ .05
explained an additional 1% of the variance, which was again significant (F(1, 443)⫽6.36, p ⬍ .005). However, there was no evidence that this measure acted as a mediator in the analysis. None of the coefficients for the variables entered on the previous steps of the regression were reduced substantively in size with the addition of this variable. Having relatives in the area did have the pre-
dicted negative effect on depression 2 years later (Beta⫽-.10, p ⬍ .05). Additional regressions were performed using depression scores 2 years after baseline and only the significant predictor variables identified in the previous regression analysis. In the first analysis, employment, novelty, and relatives in the local area were entered first. Together these variables
Table 3. Results of Hierarchical Linear Regression Step
Variables in Analysis
B
SE
Beta
t
p
1
(Constant) Depression at baseline Gender Employment (Constant) Depression at baseline Gender Employment Age at immigration Home Language Subordination Novelty Loss (Constant) Depression at baseline Gender Employment Age at immigration Home Language Subordination Novelty Loss Relatives in local area
.537 .465 ⫺6.001E-02 ⫺.269 .281 .461 ⫺6.549E-02 ⫺.186 3.691E-03 ⫺1.814E-02 ⫺5.959E-03 1.524E-02 6.664E-02 ⫺3.481E-02 .420 .443 ⫺6.904E-02 ⫺.171 4.188E-03 ⫺1.677E-02 ⫺1.695E-03 1.960E-02 6.357E-02 ⫺3.464E-02 ⫺.209
.064 .042 .065 .073 .167 .046 .066 .082 .002 .031 .028 .030 .031 .030 .175 .046 .065 .081 .002 .031 .028 .030 .031 .030 .083
— .460 ⫺.038 ⫺.150 — .456 ⫺.042 ⫺.104 .078 ⫺.033 ⫺.011 .025 .116 ⫺.059 — .439 ⫺.044 ⫺.096 .088 ⫺.030 ⫺.033 .032 .111 ⫺.059 ⫺.104
8.409 11.102 ⫺.929 ⫺3.682 1.683 10.027 ⫺.994 ⫺2.283 1.697 ⫺.579 ⫺.214 .511 2.134 ⫺1.147 2.399 9.594 ⫺1.054 ⫺2.109 1.928 ⫺.538 ⫺.061 .660 2.046 ⫺1.149 ⫺2.522
.000 .000 .353 .000 .093 .000 .321 .023 .090 .563 .831 .610 .033 .252 .017 .000 .292 .036 .054 .591 .951 .510 .041 .251 .012
2
3
ASSESSING DEPRESSION RISK
explained 10% of the variance (F (3, 455)⫽16.69, p ⱕ .001). When the baseline depression score was entered on the second step, it explained an additional 17% of the variance (F (1, 454)⫽107.51, p ⱕ .001). In the second analysis, the steps were reversed so that the baseline depression score was entered first. In this analysis, depression at baseline explained 23% of the variance (F (1, 457)⫽139.65, p ⱕ .001), and employment, novelty, and relatives in the area explained an additional 4% of the variance (F (3, 454)⫽7.81, p ⱕ .001). This suggests that about 6% of the variance that could be explained by Employment, Novelty, and Relatives in the Area could also be explained by the baseline depression score. DISCUSSION
Baseline depression, unemployment, novelty, and not having relatives in the local resettlement area were significant predictors of depression at 2-year follow-up, accounting for 27% of the variance. Depression at baseline was the strongest predictor of depression at 2-year follow-up. Nonetheless, employment status, novelty, and local relatives provided additional explanatory power. This study also found that there was little improvement in depression for the sample as a whole over time. Our findings are consistent with other research findings that identified initial psychological status and lack of local family (Beiser, 1988; Noh & Avison, 1996) as risk factors for longstanding distress as well as the insignificance of time for immigrants’ depression (Hauff & Vaglum, 1995; Lipson, 1992; Locke, Southwick, McClosky & Fernandez-Esquer, 1996; Moghaddim, Ditto & Taylor, 1990; Pernice, Trlin, Henderson & North, 2000; Webster, McDonald, Lewin & Carr, 1995). The insignificance of age, immigration demands other than novelty (i.e., loss, language, discrimination, and not feeling at home), marital status, and education in our study, however, are not consistent with the literature. One likely explanation is that some of these insignificant variables were highly correlated with variables that were significant in our study. For example, age at immigration was highly correlated with employment status. Similarly, loss, language, discrimination, and not feeling at home were highly correlated with novelty. The insignificance of education and marital status may be because these variables did not vary much in our sample. Like the local and to a great extent,
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the national and international former Soviet immigrant population (Basok & Roberts, 1991), the former Soviet immigrants in our study were mostly married and college educated. Another possible explanation for the insignificance of marital status is that this variable did not capture quality of the relationship, which has been previously discussed as strained among former Soviet immigrants (Aroian, Spitzer & Bell, 1996). The insignificance of gender for depression at 2-year follow-up, however, bears special mention. Numerous studies have documented higher rates of distress in immigrant women (see Aroian [2001] for an extensive review on this topic). Perhaps the insignificance of gender in our study is because gender inequity in education, work status, and language skills is less among women from the former Soviet Union than it is for many other groups of immigrant women (Remennick & OttensteinEisen, 1998). In any event, the insignificance of gender for depression at 2-year follow-up is at least in part because gender had a weak relationship with depression at follow-up that did not remain significant once baseline depression scores was accounted for. Findings from this study may be limited to immigrants who change their residence less often. Although the level of depression among people who could not be located to continue in the study was similar to people who participated in phase two, participants in phase two did differ in some respects: They were on average about 4 years older when they came to the US, had lived in the US on average for 5 fewer months, and were less likely to be employed. Perhaps these participants could be located for phase two because they lacked the resources to be mobile. This would be consistent with their greater likelihood of being unemployed. Despite this potential limitation, findings from our study suggest that health professionals who have contact with immigrants from the former Soviet Union need to anticipate possible depression at least through the first 5 to 7 years of resettlement. Current depression as well as early employment status, novelty, and family availability are important areas to assess. Findings from our study also suggest areas for prevention and early intervention. Initial depression in immigrants should be aggressively treated and not assumed to be a transient or situational problem that will resolve with time. Immigrants
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should also be assisted to find early employment and overcome novel aspects of their new environment. Immigrants without local families will likely need additional support. Future research with this immigrant group is needed to determine the full course of their depression. Extending the period of longitudinal study past 2 years and including more longstanding immigrants (immigrants who are in the resettlement country longer than 5 years) would allow investigating whether depression might abate with the passage of more time. This research would lay the groundwork for clinical trials to determine the efficacy of hastening the typical course of former Soviet immigrants’ depression. REFERENCES Allodi, F., & Rojas, A. (1985). The health and adaptation of victims of political violence in Latin America. Proceedings of Psychiatry, the State of the Art, 7th World Congress of Psychiatry, Austria, 1983. New York: Plenum Press. Angel, R., & Guarnaccia, P.J. (1989). Mind, body, and culture: Somatization among Hispanics. Social Science Medicine, 28(12), 1229-1238. Aroian, K.J. (2001). Immigrant women’s health. In N. Woods and D. Taylor (Volume Eds.), & J. Fitpatrick (Series Ed.) Annual Review of Nursing Research, 19. New York: Springer Publishing. Aroian, K.J. (1988). From leaving Poland to feeling at home: Psychological adaptation to migration and resettlement. Unpublished doctoral dissertation, University of Washington, Seattle, WA. Aroian, K.J. (1990). A model of psychological adaptation to immigration and resettlement. Nursing Research, 39, 5-10. Aroian K.J. (1993a). Mental health risks and problems encountered by illegal immigrants. Issues in Mental Health Nursing, 14, 379-97. Aroian K.J. (1993b). Extension and refinement of a model of psychological adaptation to migration and resettlement. Paper presented at the Sigma Theta Tau International Research Congress, Madrid, Spain. Aroian, K.J., Khatutsky, G., Tran, T.V., & Balsam, A.L. (2001). Health and social service utilization among elderly immigrants from the former Soviet Union. Journal of Nursing Scholarship, 33(3). Aroian, K.J., & Norris, A.E. (2000). Resilience, stress, and depression among Russian immigrants. Western Journal of Nursing, 21(1), 52-65. Aroian, K.J., & Norris, A.E. (1999). Somatization and depression among former Soviet immigrants. Journal of Cultural Diversity, 6(3), 93-101. Aroian, K.J., Norris, A.E., Patsdaughter, C.A., & Tran, T.V. (1998). Predicting psychological distress among former Soviet immigrants. International Journal of Social Psychiatry, 44(4), 284-94.
Aroian, K.J., Norris, A.E., Tran, T.V., & Schappler-Morris, N. (1998). Development and psychometric evaluation of the demands of immigration scale. Journal of Nursing Measurement, 6(2), 175-94. Aroian, K.J., Spitzer, A., & Bell, M. (1996). Family support and conflict among former Soviet immigrants. Western Journal of Nursing Research, 18(6), 655-74. Barankin, T., Konstantareas, M.M., & Bosset, F. (1989). Adaptation of recent Soviet Jewish immigrants and their children to Toronto, Canada. Canadian Journal of Psychiatry, 34, 512-8. Basok, T., & Brym, R.J. (1991). Introduction. In T. Basok and R. J. Brym (Eds.) Soviet-Jewish emigration and resettlement in the 1990s: An overview, pp. xi-xxii. Toronto: York Lanes Press, Inc. Beiser, M. (1988).Influences of time, ethnicity, and attachment on depression in Southeast Asian refugees. American Journal Psychiatry, 145(1), 46-51. Bernstein, J.H., Shuval, J.T. (1998). The occupational integration of former Soviet physicians in Israel. Social Science Medicine, 47(6), 809-19. Berry, J.W., Kim, U., Minde, T., & Mok, D. (1987). Comparative studies of acculturative stress. International Migration Review, 21, 490-511. Black, S.A., Markides, K.S., & Miller, T.Q. (1998). Correlates of depressive symptomatology among older community-dwelling Mexican Americans: The Hispanic EPESE. Journal of Gerontology: Social Sciences, 53B(4), S198208. Chung, R.C., & Kagawa-Singer, M. (1993). Predictors of psychological distress among southeast Asian refugees. Social Science Medicine, 36(5), 631-9. Cwikel, J., Abdelgani, A., Goldsmith, J.R., Quastel, M., & Yevelson, I.I. (1997). 2-year follow-up stress-related disorders among immigrants to Israel from the Chernobyl area. Environmental Health Perspespectives, 105(Suppl. 6), 1545-50. Derogatis, L.R. (1992). SCL-90-R. Administration, scoring, and procedures manual - II. (2nd ed.). Maryland: Leonard R. Derogatis, Ph.D. Factourovich, A., Ritsner, M., Maoz, B., Levin, K., Mirsky, J., Ginath, Y., Segal, A., & Bar Nata, E. (1996). Psychological adjustment among Soviet immigrant physicians: Distress and self-assessments of its sources. Israeli Journal of Psychiatry and Related Sciences, 33(1), 32-9. Flaherty, J.A., Kohn, R., Levav, I., & Birz, S. (1998). Demoralization in Soviet-Jewish immigrants to the United States and Israel. Comprehensive Psychiatry, 29(6), 588-97. Flaskerud, J.H., & Uman, G. (1996). Acculturation and its effects on self-esteem among immigrant Latina women. Behavioral Medicine, 22, 123-33. Fox, P.G., Cowell, J.M., Johnson, M.M. (1995). Effects of family disruption on Southeast Asian refugee women. International Nursing Review, 42(1), 27-30. Franks, F., & Faux, S.A. (1990). Depression, stress, mastery, and social resources in four ethnocultural women’s groups. Research in Nursing and Health, 13, 283-92. Frye, B.A., & D’Avanzo, C.D. (1994). Cultural themes in family stress and violence among Cambodian refugee
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women in the inner city. Advances in Nursing Science, 16, 64-77. Furnham, A., & Sheikh, S. (1993). Gender, generational and social support correlates of mental health in Asian immigrants. The International Journal of Social Psychiatry, 39(1), 22-33. Hattar-Pollara, M., & Meleis, A.I. (1995). The stress of immigration and the daily lived experiences of Jordanian immigrant women in the United States. Western Journal of Nursing Research, 17, 521-39. Hauff, E., & Vaglum, P. (1995). Organised violence and the stress of exile. British Journal of Psychiatry, 166, 360-7. Kawanishi, Y. (1992). Somatization of Asians: An artifact of western medicalization? Transcultural Psychiatric Research Review, 29, 536. Kim, S., & Rew, L. (1994). Ethnic identity, role integration, quality of life, and depression in Korean-American Women. Archives of Psychiatric Nursing, 8(6), 348-56. Kohn, R., Flaherty, J. A., & Levav, I. (1989). Somatic symptoms among older Soviet immigrants: An exploratory study. The International Journal of Social Psychiatry, 35(4), 350-60. Lerner, Y., & Zilber, N. (1991). Psychological distress and help seeking behavior among Soviet immigrants. Paper presented at the National Conference on Soviet Refugee Health and Mental Health, Chicago, IL. Lin, E. HB., Carter, W.B., & Kleinman, A.M. (1985). An exploration of somatization among Asian refugees and immigrants in primary care. American Journal of Public Health, 75(9), 1080-1084. Lipson, J.G. (1992). The health and adjustment of Iranian immigrants. Western Journal of Nursing Research, 14(1), 10-29. Lipson, J.G., & Miller, S. (1994). Changing roles of Afghan refugee women in the United States. Health Care for Women International, 15(3), 171-80. Locke, C.J., Southwick, K., McCloskey, L.A., & FernandezEsquer, M.E. (1996). The psychological and medical sequelae of war in Central American refugee mothers and children. Archives Pediatric Adolescent Medicine, 150, 822-8. Moghaddam, F., Ditto, B., & Taylor, D.M. (1990). Attitudes and attributions related to psychological symptomatology in Indian immigrant women. Journal of CrossCultural Psychology, 21(3), 335-50. Moon, J.H., & Pearl, J.H. (1991). Alienation of elderly Korean American immigrants as related to place of residence, gender, age, years of education, time in the U.S., living with or without children, and living with or without a spouse. International Journal of Aging and Human Development, 32(2), 115-24. Noh, S., & Avison, W.R. (1996). Asian immigrants and the stress process: A study of Koreans in Canada. Journal of Health and Social Behavior, 37, 192-206. Office of Refugees and Immigrants (1997). An overview of selected communities. Boston, MA: Massachusetts Department of Public Health. Pernice, R., & Brook, J. (1996). The mental health pattern of migrants: Is there a euphoric period followed by a
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mental health crisis? International Journal of Social Psychiatry, 42(1), 18-27. Pernice, R., Trlin, A., Henderson, A., & North, N. (2000). Employment and mental health of three groups of immigrants to New Zealand. Employment and Mental Health of Immigrants, 29(1), 24-9. Ponizovsky, A., Ginath, Y., Durst, B., Wondimeneh, S., Safro, S., Minuchin-Itzigson, S., & Ritsner, M. (1998). Psychological distress among Ethiopian and Russian Jewish immigrants to Israel: A cross-cultural study. International Journal of Social Psychiatry, 44(1), 35-45. Remennick, L., I., & Ottenstein-Eisen, N. (1998). Reaction of new Soviet immigrants to primary health care services in Israel. International Journal of Health Services, 28(3), 555-74. Ritsner, M., & Ponizovsky, A. (1999). Psychological distress through immigration: The two-phase temporal pattern? International Journal of Social Psychiatry, 45(2), 12539. Simon, R.J. (1985). New lives: The adjustment of Soviet Jewish immigrants in the United States and Israel. Lexington, Massachusetts: Lexington Books. Sluzki, C.E. (1986). Migration and family conflict. In R.H. Moos (Ed.) Coping with Life Crises. 277-88. New York: Plenum. Thompson, J.L. (1991). Exploring gender and culture with Khmer refugee women: Reflections on participatory feminist research. Advanced Nursing Science, 13, 30-48. Aspen Publishers. U.S. Department of Justice Immigration and Naturalization Service. (2000). 1998 statistical yearbook of the immigration and naturalization service. Washington, DC: U. S. Department of Justice Immigration and Naturalization Service. Vega, W.A., Kolody, B., & Valle, J.R. (1987). Migration and mental health: An empirical test of depression risk factors among immigrant Mexican women. International Migration Review, 11(3), 512-29. Webster, R.A., McDonald, R., Lewin, T., & Carr, V.J. (1995). Effects of a natural disaster on immigrants and host populations. The Journal of Nervous and Mental Disease, 183(6), 390-7. Werner, O., & Campbell, D.T. (1970). Translating, working through interpreters, and the problem of decentering. In R. Naroll & R. Chen (Eds.) A handbook of method in cultural anthropology, 398-420. New York: Columbia University Press. Westermeyer, J., & Uecker, J. (1997). Predictors of hostility in a group of relocated refugees. Cultural Diversity and Mental Health, 3(1), 53-60. Westermeyer, J., Vang, T.F., Neider, J. (1983). Migration and mental health among Hmong refugees. The Journal of Nervous and Mental Disease, 171(2), 92-6. Williams, R., & Hunt, K. (1997). Psychological distress among British South Asians: The contribution of stressful situations and subcultural differences in the West of Scotland Twenty-07 Study. Psychological Medicine, 27, 1173-81.
N
URSES SHOULD routinely assess their immigrant patients for risk of depression because depression is a common response to immigration (Aroian & Norris, 1999; Black, Markides & Miller, 1998; Franks & Faux, 1990; Kim & Rew, 1994; Webster, McDonald, Lewin & Carr, 1995; Williams & Hunt, 1997). When left untreated, depression can develop into a major depressive disorder. Major depressive disorder poses serious economic and emotional consequences for immigrants and their families (Aroian, Spitzer & Bell, 1996; Fox, Cowell & Johnson, 1995). Assessing depression risk in immigrant populations poses at least two major challenges. First, immigrants typically do not complain of feeling depressed. Instead, they usually present with somatic complaints and cultural idioms of distress that are not readily interpretable by health professionals who are unfamiliar with their culture (Angel & Guarnaccia, 1989; Allodi & Rojas, 1985; Kawanishi, 1992; Lin, Carter & Kleinman, 1982). Another assessment challenge involves determining which immigrants are at risk for major depres-
sive disorder. Similar to uncomplicated grief, depression for some immigrants may be a transient, normative response to immigration. Depression of this type may resolve itself over time as immigrants adapt to the immigration experience. On the other hand, immigrants with many adaptive challenges and few resources to cope with immigration demands may develop a major depressive disorder over time. Immigrants from the former Soviet Union are an important population to study. Depression is a common problem for these immigrants and they
From the College of Nursing, Wayne State University, Detroit, MI and the School of Nursing, Boston College, Chestnut Hill, MA. Supported by the National Institutes of Health, National Institute of Nursing Research, grant no. R29 NR0768-01. Address reprint requests to Karen J. Aroian, PhD, RN, CS, FAAN, College of Nursing, Wayne State University, 5557 Cass Ave, Detroit, MI 48202. Copyright 2002, Elsevier Science (USA). All rights reserved. 0883-9417/02/1606-0003$35.00/0
Archives of Psychiatric Nursing, Vol. XVI, No. 6 (December), 2002: pp 245-253
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typically do not seek professional help directly for this problem (Aroian & Norris, 1999; Barankin, Konstantareas & de Bosset, 1989; Factourovich et al., 1996; Flaherty, Kohn, Levav & Birz, 1988; Kohn, Flaherty & Levav, 1989; Lerner & Zilber, 1991; Ritsner et al., 1996). Rather, they usually seek medical treatment for somatic complaints, a practice that is not only costly but also results in misdiagnosis and under treatment of depression (Aroian, Khatutsky, Tran & Balsam, 2001). This article reports findings from a longitudinal study of what predicts depression 2 years later in a sample of fairly recent former Soviet immigrants. Specific research aims were to: (1) investigate change in depression scores and (2) determine the relative contribution of initial depression scores, select demographic and migration characteristics (i.e., gender, marital status, employment, education, age at immigration, and local family), and common demands of immigration (i.e., loss, novelty, occupation, language, discrimination, and not feeling at home) to depression at 2-year follow-up. The goal was to facilitate clinical assessment by identifying objective indicators of risk for depression in former Soviet immigrants. A strength of the study was the use of a longitudinal design with a sample of individuals at various time points in their relatively recent immigration experience. LITERATURE REVIEW
Two decades of research with varied immigrant groups have yielded fairly consistent findings about the personal and situational variables associated with immigrants’ depression. Specifically, lack of local family, female gender, not being married, unemployment, premigration loss, novelty, language difficulties, occupational change, discrimination, and not feeling at home have been associated with depression in Asian, Southeast Asian, Middle Eastern, Latin American, Eastern European, and Southern European immigrants (Aroian & Norris, 2000; Aroian, Norris, Patsdaughter & Tran, 1998; Berry, Kim, Minde & Mok, 1987; Flaherty et al., 1988; Frye & D’Avanzo, 1994; Furnham & Sheikh, 1993; Hattar-Pollara & Meleis, 1995; Kim & Rew, 1994; Lipson, 1992; Lipson & Miller, 1994; Moghaddam, Ditto & Taylor, 1990, 1990; Moon & Pearl, 1991; Thompson, 1991; Vega, Kolody & Valle, 1987; Westermeyer, Vang & Neider, 1983). Longitudinal studies have found that some of these variables, such as lack of local family, also
predict future distress (Beiser, 1988; Noh & Avison, 1996). Other variables, such as premigration loss, lose their significance over time (Westermeyer & Uecker, 1997). Initial or early depression is another strong predictor of future depression (Beiser, 1988; Noh & Avison, 1996; Westermeyer & Uecker, 1997). There is much less consensus on the course of immigrants’ depression. Two alternative truisms are commonly cited on this topic. One frequent statement, usually generalized from a single but exemplary longitudinal study by Beiser (1988), is that emotional distress is highest during initial resettlement (particularly the first few to 18 months). Another position, usually credited to observations made of immigrant families by Sluzki (1986), maintains that early resettlement (i.e., the first 6 months) is marked by a “honeymoon” period of euphoria, followed by distress that persists for a number of years. Neither of these two positions is consistently supported by research and, in some cases, research findings portray a more complex or contingent course. Although a number of studies have documented higher rates of distress among recent rather than longstanding immigrants (Beiser, 1988; Black et al., 1998; Cwikel, Abdelgani, Goldsmity, Quastel & Yevelson, 1997; Kim & Rew, 1994; Moon & Pearl, 1991; Pernice & Brook, 1996; Vega et al., 1987), a number of other studies have found that years since arrival is unrelated to distress (Hauff & Vaglum, 1995; Lipson, 1992; Locke, Southwick, McClosky & FernandezEsquer, 1996; Moghaddim et al., 1990; Pernice, Trlin, Henderson & North, 2000; Webster, McDonald, Lewin & Carr, 1995). In a comparative study of Russian and Ethiopian immigrants, years since arrival was associated with decreased depression in Ethiopian immigrants but the time factor was not significant for Russian immigrants (Ponizovsky et al., 1998). In two studies, number of years was unexpectedly associated with increased depression (Chung & Kagawa-Singer, 1993; Franks & Faux, 1990). One of these two studies, however, only noted this association for early but not longstanding (5 or more years in resettlement) immigrants (Chung & KagawaSinger, 1993). Yet another study documented a two-phase temporal pattern where depression increased for the first 27 months, declined for the next 54 months, and then began to elevate again (Ritsner & Ponizovsky, 1999).
ASSESSING DEPRESSION RISK
Part of the difficulty with disentangling these conflicting or, at best, overlapping conclusions is attributable to methodological problems. More than half of the studies mentioned above used cross sectional data from study participants who were in the resettlement country for varying lengths of time to study the effects of time on psychological status. See Bernstein and Shuval (1998), Beiser (1988), Cwikel et al. (1997), Flaskerud and Uman (1996), Hauff and Vaglum (1995), Ritsner and Ponizovsky (1999) for exception. Cross sectional approaches potentially confound time with cohort differences among various immigrant waves or immigrant groups. Also, there is a growing belief that the typical trajectory for depression among immigrants is group specific and depends on the nature of their pre- and postmigration stressors (Chung & Kagawa-Singer, 1993). Thus, a current recommendation is to use longitudinal designs to study immigrant groups in context to understand how their unique circumstances and characteristics influence their risk (Franks & Faux, 1990; Hauff & Vaglum, 1995). METHODS
Sample Study participants were part of a larger study of stress and adaptation among community dwelling former Soviet immigrants in the Boston area of the US (n⫽1,647). Participants were recruited through written advertisement in ethnic newspapers and verbal advertisement by the data collection team. Twelve people who were also former Soviet immigrants comprised the data collection team. The data collection team was representative of the local former Soviet immigrant population so that their recruitment efforts would not bias the sample toward particular demographic characteristics. Specifically, the data collectors were of both genders, of various age groups, from representative republics of origin in the former Soviet Union, and had been in the US for varying lengths of time. Study participants from the larger study were eligible for the second or longitudinal phase of the study if they were in the US 5 years or less during the initial data collection (n⫽1,350). Change of address cards were mailed every 6 months after the first data collection appointment to maintain contact with these people. Over the course of 2 years, 833 of the 1,350 study participants (61.7%) either
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moved without providing a forwarding address or were no longer eligible for study participation because of moving out of the Boston area. Only 9.5% or 49 of the remaining 517 study participants who could be located and maintained eligibility declined to participate in the second phase of data collection. Thus, 468 study participants provided data 2 years later for the second phase of the study. Analyses are reported here for the 454 study participants who had no missing data for the variables of interest. These longitudinal study participants did not differ significantly from those who participated only in the first phase of the study in terms of gender, education, marital status, presence of relatives in the local area, or depression (p ⱖ .17). They did differ slightly in employment, time in the US, and age at immigration: Longitudinal study participants were more likely to be unemployed (75.2% vs 62.5%; Chi-Square⫽21.92, df⫽1, p ⬍ .001), had lived in the US a shorter time (the Mean for the longitudinal study participants was 1.73 years, SD⫽1.26 as compared to the Mean for first phase only study participants only of 2.13 years, SD⫽1.72; t⫽4.854, df⫽1216.35, p ⬍ .001), and were older when they immigrated to the US (the mean for longitudinal study participants was 47.97 years, SD⫽16.39, as compared with the mean for first phase only study participants of 43.28 years, SD⫽16.91, t⫽-4.78, df⫽1346, p ⬍ .001). The mean age of the longitudinal sample at the time of the first data collection appointment was 49.59 (SD⫽16.45). The mean number of years in the US at the first data collection was 1.73 (SD⫽1.26). The majority of study participants were refugees (94.4%), had a minimum of a college degree (71%), and identified their ethnicity as Jewish (80.5%). The second largest ethnic group was Armenian (10.5%), followed by Russian (6.4%). Republic of origin from the former Soviet Union was as follows: 45.8% from Russia, 27.4% from the Ukraine, 13.5% from Azerbaijan, and 13.3% from “other republics.” These study participant characteristics reflect the local population of former Soviets (refugees and immigrants in Massachusetts, 1997) and, to some extent, the national population of former Soviets (Basok & Brym, 1991; US Immigration and Naturalization Service, 2000). For instance, most former Soviet immigrants in the US have refugee status based on ethnic and minority persecution in the former Soviet Union and Soviet
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Jews are the largest ethnic minority (Basok & Brym, 1991). On the other hand, the educational status of former Soviets who reside in Boston is, on the average, slightly higher than the educational status of former Soviet immigrants who reside elsewhere in the US (Simon, 1985). Only 25% of the study participants were employed, which is most likely an indication of their limited time in the US. By the second data collection appointment 2 years later, 45.2 % were employed. INSTRUMENTS AND PROCEDURE
During the first as well as the second data collection appointment, study participants provided consent and completed Russian language versions of a demographic questionnaire, the Demands of Immigration Scale (DI) (Aroian, Norris, Tran & Schappler-Morris, 1998), and the Depression Scale of the Symptom Checklist 90-R (SCL-90-R; Derogatis, 1992). Russian-speaking research assistants collected these data in person in the study participants’ homes. A $10.00 gratuity was given at the conclusion of each data collection appointment. Russian language forms of the data collection materials were developed through translation and back translation (Werner & Campbell, 1970). More in depth description of the translation procedure is provided in Aroian and Norris (1999). The demographic questionnaire elicits information about city of origin, length of time in the US, immigration status, age, gender, marital status, educational level, language of preference, occupation pre- and postmigration, and employment status. At its second administration 2 years later, items about city of origin, age, premigration employment, and gender were omitted. The DI Scale is a 23-item, standardized, paper and pencil measure with six subscales, including loss, not feeling at home, novelty, occupational adjustment, language accommodation, and discrimination. The Loss Subscale elicits information about longing and unresolved attachment to people, places, and things in the homeland. The Not Feeling at Home Subscale asks about feeling like a stranger or a foreigner who is not part of one’s surroundings or included in the social structure. The Novelty Subscale asks about newness, unfamiliarity, or information deficits related to living in the new country. The Occupational Adjustment Subscale taps difficulty finding acceptable work,
status demotion, and lack of opportunities for professional advancement. The Language Accommodation Subscale pertains to the immigrant’s subjective perception of having a less than adequate command of the host language, including extent of vocabulary, comprehension of local dialect, and ability to be understood given the strength of one’s accent. Finally, the Discrimination Subscale includes items about active or subtle discrimination, such as the notion that immigrants do not belong in the US or deserve the same rights as the native born. Respondents rate the extent to which they have been distressed by each of the stated demands as it applies to their recent (within the last 3 months) personal experiences as immigrants. Items are rated along a six-point scale ranging from not at all (1) to very much (6) distressed. Content for the DI Scale was derived from three separate studies with Polish (N⫽25), Irish (N⫽25), and Russian (N⫽42) immigrants (Aroian, 1988; Aroian, 1990; Aroian, 1993a; Aroian, 1993b). The DI Scale was evaluated in a fourth study with a validation sample of 857 Russian immigrants who had resided in the US from a few months to 20 years (Aroian et al., 1998). Confirmatory factor analysis supported the proposed sixfactor model (The standardized factor loadings for the items ranged from .67 to .88). The DI subscales were internally consistent (range of alpha⫽.82 to .88) and had good test-retest reliability over a 3 week time interval (r⫽.82 to .87). The SCL-90-R is a multidimensional, self-administered questionnaire of psychological distress that asks respondents to rate each item along a 5-point scale of distress from not at all (0) to extremely (4) distressed. The 13-item Depression Scale of the SCL-90-R reflects a broad range of manifestations of clinical depression, including dysphoric mood and affect, lack of motivation and energy, feelings of hopelessness, and other cognitive and somatic correlates of depression. Cronbach’s alpha for the Russian language version of the Depression Scale was .91. Test-retest reliability over a one-week interval was .85 (Aroian & Norris, 1999). DATA ANALYSIS
A three-step hierarchical linear regression was used to address the second aim after checking that the proposed independent variables were signifi-
ASSESSING DEPRESSION RISK
cantly correlated with the dependent variable, depression, 2 years later. First, gender (male⫽1, female⫽0), baseline employment status (employed full- or part-time⫽1, not working⫽0), baseline education status (college graduate⫽1, not a college graduate⫽0), and baseline depression scores were entered to control for the effects of these demographic variables and pre-existing depression. Second, age at immigration and all DI subscale scores except Occupation were entered. The Occupation subscale was not included because 12.3% of the sample did not complete this scale and the missing Occupation subscale data were systematic: 91.2% of those who failed to complete this scale were retired. Finally, baseline marital status (married⫽1, not married⫽0) and having relatives in the area (yes⫽1, no⫽0) were entered to determine whether the effects of social support as captured by these two variables mediated the effects of age at immigration or the demands of immigration on depression. FINDINGS
Table 1 displays the means and frequencies for the continuous and categorical variables planned to be included in the hierarchical linear regression analysis. Note that depression scores on the SCL-90 2 years later were not significantly lower than at baseline (paired t⫽1.05, df⫽467, p⫽.29), indicating little improvement in depression for the sample as a whole over time. Neither marital status (r⫽-.06) nor education (r⫽.07) were significantly correlated with depression at 2 years (p ⬎ .05). Consequently both variables were dropped from the hierarchical linear regression analysis. Table 2 contains the correlations among the independent variables that were retained in the regression analysis. Correlations with the dependent variable are included in the first column of the table. As expected, depression scores at baseline and 2 years later were highly correlated (r⫽.48). The other independent variables had small to moderate size correlations with the dependent variable, ranging from r⫽-.12 for gender to r⫽.23 for the Novelty DI subscore. Results for the three-step, hierarchical regression are shown in Table 3. Despite the fairly high intercorrelation between the two depression scores, collinearity diagnostics indicated that there were no problems with multicollinearity.
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Table 1. Frequencies and Mean Scores for Variables in Proposed Regression Analysis Demographics
Gender (n⫽468) Male Female Employment (n⫽463) Unemployed, looking Unemployed, not looking Retired Employed part-time Employed full-time Education (n⫽467) Incomplete high school High school graduate Incomplete college College degree Graduate course work Depression score at baseline (n⫽468) Depression score 2 years later (n⫽468) Age at immigration (n⫽468) Scores on DI subscales: Home (n⫽467) Language (n⫽464) Loss (n⫽467) Novelty (n⫽467) Occupation (n⫽411) Discrimination (n⫽464) Marital Status (n⫽467) Single Married Divorced Legally separated Geographically separated Widowed Relatives in local area (n⫽465)
Percentage/M (SD)
43% 57% 33% 8% 34% 11% 14% 3% 19% 9% 65% 6% .91 (SD⫽.76) .87 (SD⫽.77) 48 yrs (SD⫽16.4) 3.09 (SD⫽1.41) 4.20 (SD⫽1.47) 3.91 (SD⫽1.33) 3.64 (SD⫽1.37) 4.00 (SD⫽1.51) 2.60 (SD⫽1.26) 10% 73% 7% 0% 2% 8% 82%
Abbreviations: M, mean; SD, standard deviation.
As expected, the depression score at baseline was a significant predictor of depression 2 years later in the first step of the regression and remained so throughout the analysis (p ⱕ .001). A similar pattern was observed for employment status (p ⬍ .05). However, gender was not a significant predictor (Beta⫽-.04, p⫽.35). Together these three variables explained 26% of the variance (F(3, 450)⫽51.39, p ⱕ .001). Adding age when immigrated and the DI subscale scores in step two of the regression explained an additional 2% of the variance, but this increment was not significant (F(7, 397)⫽1.51, p⫽.17). Only the Novelty DI subscale score (Beta⫽.12) was significant in this step of the regression (p ⬍ .05). Adding the measure of social support, having relatives in the area, in step three of the regression
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Table 2. Correlations Among Variables in the Regression Analysis (nⴝ454).
Depression 2 years later (D2) Depression at baseline (D1) Gender (G) Employment (E) Age at immigration (A) DI subscales: Home (DI-H) Language (DI-La) Loss (DI-Lo) Novelty (DI-N) Discrimination (DI-D) Relatives in local area (R)
D2
D1
G
E
1.00 .48* ⫺.12* ⫺.19* .14*
⫺.17* ⫺.09‡ .03
.03 .05
⫺.40*
.19* .17* .14* .24* .17* ⫺.16*
.41* .22* .29* .27* .29* ⫺.13*
⫺.11† ⫺.02 ⫺.20* ⫺.15* ⫺.05 .01
⫺.04 ⫺.20* ⫺.14* ⫺.22* ⫺.05 .05
A
DI-H
DI-La
⫺.01 .27* .07 .09‡ .02 .08*
.34* .56* .49* .45* ⫺.01
.34* .53* .42* .06
*p ⱕ .005 †p ⱕ .01 ‡p ⬍ .05
explained an additional 1% of the variance, which was again significant (F(1, 443)⫽6.36, p ⬍ .005). However, there was no evidence that this measure acted as a mediator in the analysis. None of the coefficients for the variables entered on the previous steps of the regression were reduced substantively in size with the addition of this variable. Having relatives in the area did have the pre-
dicted negative effect on depression 2 years later (Beta⫽-.10, p ⬍ .05). Additional regressions were performed using depression scores 2 years after baseline and only the significant predictor variables identified in the previous regression analysis. In the first analysis, employment, novelty, and relatives in the local area were entered first. Together these variables
Table 3. Results of Hierarchical Linear Regression Step
Variables in Analysis
B
SE
Beta
t
p
1
(Constant) Depression at baseline Gender Employment (Constant) Depression at baseline Gender Employment Age at immigration Home Language Subordination Novelty Loss (Constant) Depression at baseline Gender Employment Age at immigration Home Language Subordination Novelty Loss Relatives in local area
.537 .465 ⫺6.001E-02 ⫺.269 .281 .461 ⫺6.549E-02 ⫺.186 3.691E-03 ⫺1.814E-02 ⫺5.959E-03 1.524E-02 6.664E-02 ⫺3.481E-02 .420 .443 ⫺6.904E-02 ⫺.171 4.188E-03 ⫺1.677E-02 ⫺1.695E-03 1.960E-02 6.357E-02 ⫺3.464E-02 ⫺.209
.064 .042 .065 .073 .167 .046 .066 .082 .002 .031 .028 .030 .031 .030 .175 .046 .065 .081 .002 .031 .028 .030 .031 .030 .083
— .460 ⫺.038 ⫺.150 — .456 ⫺.042 ⫺.104 .078 ⫺.033 ⫺.011 .025 .116 ⫺.059 — .439 ⫺.044 ⫺.096 .088 ⫺.030 ⫺.033 .032 .111 ⫺.059 ⫺.104
8.409 11.102 ⫺.929 ⫺3.682 1.683 10.027 ⫺.994 ⫺2.283 1.697 ⫺.579 ⫺.214 .511 2.134 ⫺1.147 2.399 9.594 ⫺1.054 ⫺2.109 1.928 ⫺.538 ⫺.061 .660 2.046 ⫺1.149 ⫺2.522
.000 .000 .353 .000 .093 .000 .321 .023 .090 .563 .831 .610 .033 .252 .017 .000 .292 .036 .054 .591 .951 .510 .041 .251 .012
2
3
ASSESSING DEPRESSION RISK
explained 10% of the variance (F (3, 455)⫽16.69, p ⱕ .001). When the baseline depression score was entered on the second step, it explained an additional 17% of the variance (F (1, 454)⫽107.51, p ⱕ .001). In the second analysis, the steps were reversed so that the baseline depression score was entered first. In this analysis, depression at baseline explained 23% of the variance (F (1, 457)⫽139.65, p ⱕ .001), and employment, novelty, and relatives in the area explained an additional 4% of the variance (F (3, 454)⫽7.81, p ⱕ .001). This suggests that about 6% of the variance that could be explained by Employment, Novelty, and Relatives in the Area could also be explained by the baseline depression score. DISCUSSION
Baseline depression, unemployment, novelty, and not having relatives in the local resettlement area were significant predictors of depression at 2-year follow-up, accounting for 27% of the variance. Depression at baseline was the strongest predictor of depression at 2-year follow-up. Nonetheless, employment status, novelty, and local relatives provided additional explanatory power. This study also found that there was little improvement in depression for the sample as a whole over time. Our findings are consistent with other research findings that identified initial psychological status and lack of local family (Beiser, 1988; Noh & Avison, 1996) as risk factors for longstanding distress as well as the insignificance of time for immigrants’ depression (Hauff & Vaglum, 1995; Lipson, 1992; Locke, Southwick, McClosky & Fernandez-Esquer, 1996; Moghaddim, Ditto & Taylor, 1990; Pernice, Trlin, Henderson & North, 2000; Webster, McDonald, Lewin & Carr, 1995). The insignificance of age, immigration demands other than novelty (i.e., loss, language, discrimination, and not feeling at home), marital status, and education in our study, however, are not consistent with the literature. One likely explanation is that some of these insignificant variables were highly correlated with variables that were significant in our study. For example, age at immigration was highly correlated with employment status. Similarly, loss, language, discrimination, and not feeling at home were highly correlated with novelty. The insignificance of education and marital status may be because these variables did not vary much in our sample. Like the local and to a great extent,
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the national and international former Soviet immigrant population (Basok & Roberts, 1991), the former Soviet immigrants in our study were mostly married and college educated. Another possible explanation for the insignificance of marital status is that this variable did not capture quality of the relationship, which has been previously discussed as strained among former Soviet immigrants (Aroian, Spitzer & Bell, 1996). The insignificance of gender for depression at 2-year follow-up, however, bears special mention. Numerous studies have documented higher rates of distress in immigrant women (see Aroian [2001] for an extensive review on this topic). Perhaps the insignificance of gender in our study is because gender inequity in education, work status, and language skills is less among women from the former Soviet Union than it is for many other groups of immigrant women (Remennick & OttensteinEisen, 1998). In any event, the insignificance of gender for depression at 2-year follow-up is at least in part because gender had a weak relationship with depression at follow-up that did not remain significant once baseline depression scores was accounted for. Findings from this study may be limited to immigrants who change their residence less often. Although the level of depression among people who could not be located to continue in the study was similar to people who participated in phase two, participants in phase two did differ in some respects: They were on average about 4 years older when they came to the US, had lived in the US on average for 5 fewer months, and were less likely to be employed. Perhaps these participants could be located for phase two because they lacked the resources to be mobile. This would be consistent with their greater likelihood of being unemployed. Despite this potential limitation, findings from our study suggest that health professionals who have contact with immigrants from the former Soviet Union need to anticipate possible depression at least through the first 5 to 7 years of resettlement. Current depression as well as early employment status, novelty, and family availability are important areas to assess. Findings from our study also suggest areas for prevention and early intervention. Initial depression in immigrants should be aggressively treated and not assumed to be a transient or situational problem that will resolve with time. Immigrants
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