psychological distress among recent russian imigrants in the united states

PSYCHOLOGICAL DISTRESS AMONG RECENT RUSSIAN

IMMIGRANTS IN THE UNITED STATES

CHRISTOPHER HOFFMANN, BENTSON H. MCFARLAND, J. DAVID KINZIE,LARISSA BRESLER, DMITRIY RAKHLIN, SOLOMON WOLF & ANNE E. KOVAS

ABSTRACT

Background: The purpose of this study was to examine the psychological statusof Russian immigrants who have recently come to the United States.Aims: The project included creation of a Russian version of the Hopkins Symp-tom Checklist-25 (HSCL-25) in order to identify anxiety and depression inmembers of the Russian-speaking immigrant population.Methods: Translation and adaptation included (a) cross-cultural adaptation;(b) translation; (c) pre-testing; and (d) analysis of validity, reliability and internalconsistency. Seventeen Russian-speaking patients at a Russian psychiatric clinicwere recruited for the study and were compared with a sample of 42 Russian-speaking members of the community.Results: The instrument showed internal consistency when evaluated with coeffi-cient alpha. Clinic patients had significantly higher anxiety and depression symp-tom scores than community subjects. Russian immigrants’ scores on the anxietyand depression scales were less than comparative data for the United States andnotably less than similar measures for Russian immigrants to Israel.Conclusions: Recent Russian immigrants to the United States appear to havelow prevalences of anxiety and depression.

INTRODUCTION

The process of migration and the conditions that immigrants leave behind may predisposethem to mental disorders. Immigrants from the former Soviet Union were among the largestgroups to settle in the United States during the 1990s. Although there has been substantialwork on psychological distress among recent Russian immigrants in Israel (Ponizovsky etal., 1998, 2000; Ritsner et al., 1995, 1996, 2001; Ritsner & Ponizovsky, 1998, 1999) andamong Russian adolescents contemplating emigration to Israel (Mirsky et al., 1992), little isknown about the specific mental health needs of Russian-speaking immigrants to the UnitedStates during the last two decades.

Recent Russian immigrants to the United States differ in several ways from earlier waves ofimmigrants leaving the former Soviet Union. Prior to the 1970s, many immigrants from theformer Soviet Union to the United States – and all immigrants to Israel – were Jewish immi-grants seeking freedom from religious persecution andhuman rights violations (Flaherty et al.,

International Journal of Social Psychiatry. Copyright & 2006 Sage Publications (London, Thousand Oaks and

New Delhi) www.sagepublications.com Vol 52(1): 29–40. DOI: 10.1177/0020764006061252

1986, 1988). In the 1970s, Russian Jewish immigration patterns shifted to favor US immigra-tion, as religious observation declined and immigrants saw greater economic and occupationalopportunities in the United States. Russian emigration declined during the 1980s owing todeteriorating Soviet-American relationships, but resumed following the end of the ColdWar. Since the 1990s, most Russian immigrants to the United States have been Christiansseeking economic and occupational opportunities. Consequently, conclusions about earlierRussian immigrant populations may not pertain to more recent arrivals. Therefore, thisstudy was undertaken to (a) develop a screening instrument for identifying the prevalenceof anxiety and depression among Russian-speaking people in the United States, (b) measuremental disorder among a convenience sample from this population, and (c) compare theresults with analogous data from recent Russian immigrants to Israel.

METHOD

Instrument selection

Early work with Jewish immigrants to Israel from the former Soviet Union used a Russian-language version of the Brief Symptom Inventory (BSI) (Mirsky et al., 1992; Ritsner et al.,1995, 1996). Subsequently, Ritsner and colleagues (1995, 2002) combined portions of theBSI and the Psychiatric Epidemiology Research Interview Demoralization Scale (PERI-D)into the Talbieh Brief Distress Inventory (TBDI), which has been used in several studies ofRussian immigrants to Israel (Ritsner et al., 1995; Ritsner & Ponizovsky, 1998).

However, given the substantial cultural differences among Russian immigrant groups, onecan wonder about the psychometric properties of Israeli instruments when used with newlyarriving Russian immigrants to the United States. Therefore, the present project includeddevelopment of a Russian language instrument designed to measure anxiety and depressionamong recent immigrants to North America. In order to facilitate comparison with otherstudies, the new instrument was based on measures that are similar to those used in Israel(Mirsky et al., 1992; Ritsner et al., 1995, 1996; Ritsner & Ponizovsky, 1998).

The new measure is a translation of the Hopkins Symptom Checklist (HSCL; Parloff et al.,1954), which is a well-known and widely used psychiatric screening instrument. The HSCLinstrument combined a set of symptoms from the Cornell Medical Index and 12 itemsfrom a scale developed by Lorr (1952). The HSCL’s authors have described the historical evo-lution, development, rationale and validation of the original 58-item instrument (Derogatiset al., 1974). The HSCL assesses five underlying symptom dimensions during the precedingweek: somatisation, obsessive-compulsive symptoms, interpersonal sensitivity, anxiety anddepression. In the early 1980s, Rickels and coworkers demonstrated the usefulness of a 25-item version of the HSCL to assess anxiety and depression symptoms in a family practice(Hesbacher et al., 1980) and a family planning service (Winokur et al., 1984). The HSCL-25has 10 items for anxiety symptoms and 15 items for depression symptoms. Like the originalHSCL, the scale for each question includes four categories of response: (‘Not at all’,‘A little’, ‘Quite a bit’ and ‘Extremely’, rated 1 to 4, respectively). Two scores are calculated:the total score is the average of all 25 items, while the depression score is the average of the15 depression items.

30 INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 52(1)

The HSCL-25 has been translated and used widely in Bosnian, Cambodian, Laotian,Senegalese, Sierra Leonean and Vietnamese refugee populations (see, for example, Fox &Tang, 2000; Hollifield et al., 2002; Mollica et al., 1986, 1987, 1999, 2001, Tang & Fox, 2001).A Russian translation of the HSCL-25 has been used in at least one psychiatric study, butresults have appeared only in a Russian language article (Boleloutskii, 1982). Little or nodata on the development and validation of a Russian version of the HSCL are available inthe English language literature.

The adaptation of this instrument for use in another culture and language raises severalquestions. First, are the western diagnostic criteria for psychiatric disorders cross-culturallyapplicable? Second, does a questionnaire developed in one language and translated intoanother remain equivalent? Cross-cultural applicability of a diagnosis does not eliminatethe possibility that symptoms may differ between cultures. Emotional and cognitive variationmay cause varied expressions of the same syndrome. Consequently, the presence of the dis-order may be overlooked in screening because of the use of culturally inappropriate diagnos-tic criteria. A standard set of procedures for cross-cultural adaptation has been proposed byFlaherty et al. (1998) and Guillemin et al. (1993). Their methods cover each step of the devel-opment process: (a) cross-cultural adaptation; (b) translation; (c) pre-testing; and (d) analysisof validity, reliability and internal consistency (Flaherty et al., 1998; Guillemin et al., 1993).Conceptual equivalence can be evaluated by assessing the agreement of the instrument withan independent measurement technique, such as a clinical psychiatric examination. Thismethod for cross-cultural adaptation has been used in Cambodian, Laotian and Vietnamesepopulations (Mollica et al., 1992).

Procedure

To gain an understanding of cultural context, unstructured interviews with Russian-speakingimmigrants were conducted in homes and Russian Pentecostal churches. The interviewsassessed the experience of immigrants in their countries of origin, during emigration, andin the United States. The purpose was to determine the range of traumatic experiences (ifany) that occurred in the country of emigration, the reasons behind these experiences, anddifficulties encountered in adapting to the United States. Home and recreational activitieswere also discussed. In addition, consultations with Russian speakers who work withRussian-speaking immigrants provided cultural context. Survey questions were addedregarding age, gender, level of education, current employment, length of time in theUnited States and religiosity. Two questions were adapted from the Duke Religion Index,a five-item scale designed to capture the major aspects of the importance of religion in an indi-vidual’s life (Koenig et al., 1997). No significant changes were made to the HSCL-25 itself.

Two native Russian speakers independently translated the English version of the instru-ment based on instructions to translate (1) at a sixth-grade reading level and (2) focusingon the intent of questions to identify specific symptoms (rather than the wording of theEnglish-language original). Translators had experience in health care or psychology. Thetwo versions were then reviewed by one of the translators and merged into a single draftthat was assessed for integrity with the targeted mental disorders. An individual uninvolvedin the original translations then back-translated this draft. The draft was further modifiedbased on the back-translation.

HOFFMAN ET AL.: RUSSIAN IMMIGRANTS IN THE US 31

The draft was tested on a convenience sample of 10 educated Russian-speaking adults. Thisprocess revealed numerous confusing and ambiguous questions. The final version (in theAppendix) was created by rewriting and re-testing questions on three Russian-speakingindividuals.

Responses to depression items are summed and divided by the number of answered itemsto generate a depression score ranging from 1 to 4. This process is repeated with anxiety itemsto generate an anxiety score. A score greater than 1.75 on either subscale identifies ‘clinicallysignificant distress’ (Mollica et al., 1986, 1987) and has been used to identify depression andanxiety in multiethnic samples of immigrants (Ekblad & Roth, 1997; Lavik et al., 1996; Siloveet al., 1997). This cut-off also is consistent with community data in US populations (Derogatiset al., 1974; Winokur et al., 1984).

Subjects

All subjects recruited for this study had immigrated to the US between 1998 and 2002. Clinicsubjects were recruited from the Intercultural Psychiatric Program Russian Clinic at OregonHealth & Science University (OHSU). This program is an adult psychiatry clinic with about90 patients. Any client over the age of 18 was a potential subject; they were excluded if theymet one of the following criteria: (a) active psychosis as diagnosed by a psychiatrist, (b) severecognitive impairment, (c) judgement by the patient’s psychiatrist that participation might inany way cause undue anxiety or any other harm, or (d) lack of Russian written literacy.

During regularly scheduled clinic visits, potential subjects were invited to participate andwere informed of the goals of the study, the potential use of the questionnaire, drawbacks toparticipating and remuneration for participating. They were clearly informed that decliningto participate would not affect their care. Potential subjects were also asked to read an infor-mation sheet. Subjects completed questions at the OHSU Psychiatric Clinic and requiredbetween 20 and 30 minutes to complete the instrument – usually following their clinicappointment. Subjects were given $10 in return for their time. Despite encouragement by thepsychiatrist and the psychiatric nurse (both of whom are Russian speakers), many patientsdeclined to participate.

Community subjects were recruited from Russian Oregon Social Services (ROSS), whichprovides social services including community orientation, agency referrals, English classes,domestic violence counseling and citizenship preparation for Russian-speaking immigrants.Inclusion criteria for participation were being over age 18 and either receiving servicesfrom or working at ROSS. All subjects were given $10 for their time.

Data analysis

Data from questionnaires were double entered using EpiInfo 6 (Centers for Disease Controland Prevention). After reviewing original records for inconsistencies between the entries, thedata were transferred to SPSS Version 10 for analysis. The analysis included comparison ofdemographics between clinic and community samples using the Mann-Whitney test. Internalreliability was evaluated using coefficient alpha (Cronbach’s alpha) (Nunnally & Bernstein,1994).

This project was approved by the OregonHealth & Science University Institutional ReviewBoard.


RESULTS

Demographics

Seventeen Russian Clinic patients, less than half of the eligible population, agreed to becomesubjects. A convenience community sample of 42 ROSS clients and staff was obtained. Of thecombined population, 52 subjects answered every question, five subjects (two of whom wereclinic patients) omitted one item, and two subjects (both clinic patients) were unable tocomplete large sections of the questionnaire.

Table 1 describes the community and clinic samples. The two populations differed in ageand employment. Clinic patients were, on average, 12 years older than community subjectsand only one worked outside the home. Medical records showed that psychiatric diagnosesof clinic subjects included 8 (47%) with depression, 5 (29%) with post-traumatic stress dis-order, 3 (18%) with adjustment disorder, 2 (12%) with bipolar disorder, and 1 (6%) withpsychosis. No clinic subject was diagnosed with generalised anxiety disorder. Some subjectshad multiple diagnoses, and medical records were unavailable for one subject.

Reliability

Coefficient alpha (Cronbach’s alpha) was 0.92 for the 10 items on the anxiety scale and 0.94for the 15 items on the depression scale.

Validation

Clinic subjects showed significantly more symptoms of anxiety and depression than commu-nity subjects (see Table 1 and Figure 1). However, the difference in means was not statisticallysignificant (p ¼ 0:145) when subjects with and without the diagnosis of major depression werecompared. No patient was diagnosed with generalised anxiety disorder among the clinicpatients, although the greatest difference in mean scores between community and clinicpatients was on the anxiety scale (see Table 1).

Table 1Community and clinic cohorts

CommunityN ¼ 42

ClinicN ¼ 17

Male gender (%) 13 (31%) 6 (35%)Mean age (SD)a 43.5 (16) 55.9 (16)Age range 18–71 17–759+ years schooling (%) 35 (83) 14 (82)> 2 years in US (%) 32 (76) 15 (88)Employed (%)b 25 (60) 1 (6)Anxiety mean (SD) c 0.55 (0.49) 1.25 (0.63)Depression mean (SD)d 0.59 (0.57) 1.16 (0.56)Anxiety above cut-off (>1.75) e 2% (1 of 42) 24% (4 of 17)Depression above cut-off (>1.75) 2% (1 of 42) 12% (2 of 17)

a p ¼ 0:014 by Student’s t-test; b p ¼ 0:001 by chi-squared test;c p ¼ 0:001 by Mann-Whitney test; d p ¼ 0:002 by Mann-Whitney test;e p ¼ 0:007 by Fisher’s exact test


Prevalences

Table 1 also shows the percentages of each group scoring above cut-off for anxiety anddepression, respectively. As expected, prevalence of anxiety and depression was much greaterin clinic versus community subjects, although only anxiety prevalence was statistically signifi-cantly greater in clinic subjects.

Figure 1. HSCL-25 scales in community and clinic subjects


DISCUSSION

ARussian-language instrument has been prepared that has a high rate of subject completion,good internal consistency, adherence to psychiatric constructs and the ability to discriminatebetween clinic and community samples. The new translation showed encouraging psycho-metric properties in the population of recent Russian immigrants to the United States.Internal consistency is an indicator of how responses to a set of questions correlate witheach other. The minimum alpha coefficient recommended is 0.7 (Nunnally & Bernstein,1994). The depression scale showed an internal consistency of over 0.92. Alpha coefficientfor the anxiety scale was over 0.94. The HSCL-25 also revealed significantly higher anxietyand depression symptom scores among clinic subjects than community subjects. This findingsuggests that the instrument can detect mental disorders.

On the other hand, the number of subjects diagnosed with anxiety and depression was lowand precluded more detailed analysis. Additionally, the significantly higher anxiety scoresamong clinic subjects may be surprising because none was diagnosed with generalised anxiety.One reason is the overlap between anxiety, depression and other mental disorders. Anotherreason is that the diagnostic criteria in the Diagnostic and Statistical Manual, fourth edition(DSM-IV) exclude the diagnosis of generalised anxiety if another psychiatric or somatic diag-nosis can explain the symptoms.

Additionally, the applicability of this instrument may be limited because it was tested on aconvenience sample of the Russian-speaking immigrant population of Portland, Oregon.According to US Census figures, Oregon is the second-largest center of Russian-speakingimmigrant resettlement. Therefore, this sample is believed to be representative of the popula-tion of Russian-speaking immigrants to the US. However, because community subjects wererecruited from a social services agency, Russian-speaking immigrants with more financialstability and social support may not be represented in this sample. Additionally, the majorityof recent Russian-speaking arrivals in Portland are Pentecostal Christians. It is unknown howthis affects the applicability of the instrument to individuals practicing other religions andnon-religious individuals.

Nonetheless, it is informative to compare prevalences from this study with informationfrom the United States and with Russian immigrant data from Israel. Interestingly, asample of US family planning clinic patients who completed the HSCL-25 had higher preva-lence of depression than either Russian immigrant group in this study, much higher prevalenceof anxiety than theRussian community sample, and comparable anxiety prevalence toRussianclinic subjects (Winokur et al., 1984).Moreover, Russian Jewish immigrants to Israel surveyedwith instruments that are similar to the HSCL-25 showed much higher prevalences of anxietyand depression among both community (Ritsner & Ponizovsky, 1998; Ritsner et al., 2001) andmental health clinic samples (Hesbacher et al., 1980) than did corresponding recent Russianimmigrants to the United States.

The pattern of mental disorders affecting recent Russian-speaking immigrants is likely tobe different from that of many immigrant groups coming to the United States (Mollica et al.,1992). Indeed, levels of anxiety and depression found in recent Russian immigrant popula-tions are less than those of patients in other US medical settings and much less than thoseof Russian immigrants in Israel. Moreover, recent Russian immigrants differ markedlyfrom the Jewish immigrants to the United States from the former Soviet Union in the


1970s (Flaherty et al., 1986, 1988). The current waves of Russian-speaking immigrants seemto have notably lower levels of psychiatric disability than these other groups. Based on theseearly results, services for recent Russian-speaking immigrants in the United States might bestfocus on practical issues such as language instruction and employment.

ACKNOWLEDGEMENTS

Supported in part by Providence Portland Medical Center and grant number K02 AA00281from the National Institute on Alcohol Abuse and Alcoholism.

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Christopher Hoffmann, MD, MPH, Resident, Johns Hopkins Hospital, Baltimore, MD 21287, USA.

Bentson H. McFarland, MD, PhD, Professor, Department of Psychiatry, Oregon Health & Science University,Portland, OR 97239, USA.

J. David Kinzie, MD, Professor, Intercultural Psychiatry Program, Oregon Health & Science University, Portland,OR 97239, USA.

Larissa Bresler, MD, Resident, Loyola Urology Department, LUMC, Maywood, IL, USA.

Dmitriy Rakhlin, MN, PMHNP, Nurse Practitioner, Department of Psychiatry, Oregon Health & Science University,Portland, OR 97239, USA.

Solomon Wolf, MD, PhD, Adjunct Assistant Professor, Intercultural Psychiatry Program, Oregon Health & ScienceUniversity, Portland, OR 97239, USA.

Anne E. Kovas, MPH, Research Assistant, Department of Psychiatry, Oregon Health & Science University, Portland,OR 97239, USA.

Address correspondence to Bentson H. McFarland, MD, PhD, Department of Psychiatry CR-139, Oregon Health &Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA.Email: [email protected]


APPENDIX:

Russian Health Survey


psychological distress among recent russian imigrants in the united states

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