depression among women in midlife

Menopause: The Journal of The North American Menopause SocietyVol. 19, No. 12, pp. 000/000DOI: 10.1097/gme.0b013e318258b1dd* 2012 by The North American Menopause Society

Cultural/ethnic differences in the prevalence of depressivesymptoms among middle-aged women in Israel: the WomensHealth at Midlife Study

Tzvia Blumstein, MA,1 Yael Benyamini, PhD,2 Ariel Hourvitz, MD,3,4 Valentina Boyko, MSc,1

and Liat Lerner-Geva, MD, PhD1,4

AbstractObjective: The aim of this study was to assess the prevalence and correlates of depressive symptoms among

Israeli midlife women from different cultural origins and to identify sociodemographic, lifestyle, psychosocial,health, and menopause status characteristics that could explain cultural differences in depressive symptoms.

Methods: Data were collected for the Womens Health in Midlife National Study in Israel, in which women aged45 to 64 years were randomly selected according to age and ethnic/origin group strata: long-term Jewish residents(n = 540), immigrants from the former Soviet Union (n = 151), and Arab women (n = 123). The survey instru-ment included a short form of the Center for Epidemiological StudiesYDepression Scale dichotomized accordingto a G10/Q10 cutpoint.

Results: The crude prevalence of depressive symptoms was 17%, 39%, and 46% for long-term residents,immigrants, and Arabs, respectively. Among women aged 45 to 54 years, 46% were postmenopausal. After ad-justment for sociodemographics, health and menopause status, and lifestyle and psychosocial characteristics, im-migrants and Arab women were at a significantly higher risk of depressive symptoms as compared with native-born/long-term Jewish residents (odds ratio, 2.97 and 2.79, respectively). Perimenopause status, numbers of medicalsymptoms, being unmarried, and negative attitude to aging were positively associated with depressive symptoms,whereas social support and perceived control were associated with lower odds of depressive symptoms. Theseassociations differed across cultural groups when analysis was stratified by study group.

Conclusions: Our findings demonstrate that the high level of depressive symptoms among Israeli women isrelated to cultural/minority status. The high risk for depressive symptoms in these minority groups calls for inter-vention policy to improve their mental health.

Key Words: Depressive symptoms Y Menopause Y Ethnicity Y Women at midlife.

Depressive symptoms are a significant problem formiddle-aged women. Both physiological and psy-chosocial changes occurring during the menopausal

transition may play a role in womens emotional health andgeneral quality of life. The extensive epidemiological litera-ture devoted to the determinants of depressive symptomsamong women at midlife emphasized that stressful life cir-cumstances contribute more to depressive symptoms than do

physiological changes due to the menopausal transition.1

covariates, racial/ethnic differences in depressive symptomswere no longer significant between white and minority women(African/American, Hispanic, Chinese, Japanese) aged 42 to52 years.8 Similar results were shown in a study on majordepression among preretirement adults.9 On the other hand,differences between Hispanic and non-Hispanic rural olderwomen (aged Q60 y) showed a significant 2-fold risk for highdepressive symptoms after adjustment for multiple sociode-mographic and health risk factors among Hispanic rural womencompared with non-Hispanic women and a 2.5-fold risk amongthe low acculturation stratum of Hispanic women.10

Another type of minority group consists of recent immi-grants from the former Soviet Union, who also form a highlyvulnerable group in terms of their emotional state, accordingto several US studies.11,12 Higher levels of depressive symp-toms have been found for midlife and older immigrant womenthan for those in the general population.12,13

The current study focuses on the prevalence and correlatesof depressive symptoms among Israeli women in midlife andaims to assess the role of ethnicity and immigrant status on theemotional health of women. The main objectives were (1) toestimate the prevalence of depressive symptoms in three majorpopulation groups of women at midlife: native-born/long-termresident (LTR) Jewish women, Jewish women who immigratedfrom the former Soviet Union after 1989, and Arab Israeliwomen; (2) to investigate the relationship of sociodemo-graphic characteristics, health status, menopause status, andlifestyle and psychosocial factors to depressive symptoms andidentify to what extent these characteristics could account forthe differences in depressive symptoms between the culturalgroups; and (3) to explore differences in the role of the corre-lates of depressive symptoms among each study group.

The LTR group includes women from either Western orMid-Eastern descent who have lived in Israel from an earlyage (ie, since birth, childhood, or early adulthood). This groupis heterogeneous in terms of educational attainment and ethnicorigin but shares lifelong exposure to Israeli life circumstancesand norms of expression of mental and emotional difficulties.The two minority groups are unique and represent sociallydifferent groups in terms of educational background, socio-economic status, and lifestyle factors.14 These groups alsodiffer in the extent and nature of acculturation into the major-ity Jewish group. Arab Israeli women, mostly Muslim, wereborn in Israel and have lived there for their entire lives yet liveboth geographically and socially secluded in Arab localities orneighborhoods without much social mixing with the major-ity group. The immigrant group has undergone a major lifechange, and at the time of our study, women of this age groupwere somewhat integrated into the Jewish Israeli society yetstill far from being fully acculturated into the Israeli society.15

Previous studies on mental health disparities between theminority groups and the majority Jewish LTRs in Israel haveshown that the immigrants from the former Soviet Unionreported poorer health compared with the LTRs16 partly be-cause of the stress of immigration.17 Women immigrants wereexposed to higher stress because many of them were single

providers of care for both older parents and children.18

Participants were randomly selected in each of the 12 age andgroup strata with the aim of reaching 600 LTRs, 200 immi-grants, and 200 Arab women. The sampled women received apreliminary formal letter from the principal investigator stat-ing the aims and importance of the research. Later, they werecontacted by telephone to set up a face-to-face interview attheir home. To arrive at a maximal number of interviewees,replacement of those who refused or were not located wasallowed. Response rate was calculated based on 1,494 womenapproached in the original sample: 814 were interviewed(54.5%), 389 refused (26.0%), 256 were not located (17.1%),and 35 were not interviewed because of health or languagebarriers (2.3%). Response rate was highest among Arab women(79%, with 7.1% refusals and 27.6% not located), followedby LTRs (53.5%, with 26.0% refusals and 14.7% not located),and lowest among immigrants (45.5%, with 36.6% refusalsand 17.9% not located). No difference was observed in theresponse rate by age category across each ethnic group. Thefinal study sample included 540 LTRs, 151 immigrants, and123 Arab women. The immigrants had been living in Israel for11.7 years, on average (mean age upon arrival, 45 y), comparedwith 44.3 years among LTRs not born in Israel (mean age uponarrival, 13 y). All Arab participants were born in Israel and havelived there for their entire lives. Additional information aboutsample recruitment can be found elsewhere.14,27

ProcedureData collection, using a structured questionnaire, took place

from June 2004 to March 2006 and was conducted at theparticipants homes by trained interviewers from the sameethnic groups as the participants. The questionnaire was pro-fessionally translated to Russian and Arabic with backwardtranslation to Hebrew.

MeasuresAn extensive structured questionnaire was composed to col-

lect information on womens physical and mental health at ages45 to 64 years in Israel and to examine a wide range of healthbehaviors, health beliefs, and attitudes to preventive behavior.

The outcome variable Bdepressive symptoms[ was mea-sured using a short form of the Center for EpidemiologicalStudiesYDepression Scale (CES-D).28 The index includes 11of the 20 original items, each referring to feelings reportedin the past week, rated on a scale of 0 (no), 1 (one to two timesa week), 2 (three to four times a week), and 3 (five to seventimes a week). For the current analysis, to ensure comparabil-ity to international studies, we adopted the CES-D-10 version(excluding item 1, BI had no appetite[), which was validatedfor the cutpoint of 10 or greater in several midlife and elderlysurveys.29Y31 Cronbach > coefficients were 0.87 and 0.86 inthe respective 11- and 10-item scales. Factor analysis of theseitems yielded four factors consistent with the factor structureof the full 20-item CES-D.

Independent variables (measures from several domains)Sociodemographic characteristics included age (continuous),

years of education (0-8, 9-12, and Q13 y), household monthly

income (Q12,000, 6000-12,000, and G6,000 Israeli Shekels),work status (currently employed, housewife/unemployed,retired), marital status (married/other), and study group (LTRs,immigrants, Arab Israelis).

Measures of menopause status and lifestyle behaviorMenopause status was based on menstrual characteris-

tics and was defined as the following categories: postmeno-pausal, indicating menses had stopped for at least 12 months;perimenopausal, indicating menses had occurred in the last12 months but with irregularities; and premenopausal, indicat-ing menses had occurred in the past month, with no changesin expected cycle during the past year.32 Women aged 45 to54 years who reported that their menses had stopped after agynecological surgical operation were included in the studyas a separate category (12.7%).

The symptoms questionnaire related to the occurrenceof the following 16 medical symptoms in the past 6 months:back or neck pains, headaches, stomach aches, dizziness,chronic tiredness, sleeping problems, urinary problems, dryskin, heartburn, weight loss/gain, dry eyes, hot flashes, short-ness of breath, irritability, chest pressure, and memory loss.Each positive response was followed by a question with re-gard to how bothersome the symptom was, rated on a scalefrom 1 (not bothersome), 2 (a little bothersome), 3 (bother-some), to 4 (extremely bothersome). Number of symptoms wasdefined as a count of the bothersome occurrence (more than) of15 symptoms excluding hot flashes. Report of hot flashes wasincluded separately to represent a vasomotor symptom widelyaccepted across cultural groups as a distinct factor associatedwith menopause.

Lifestyle and health behavior measures included (1) smok-ing status, defined as currently not smoking versus never/pastsmoking; (2) engaging in any physical activity in the pastyear; and (3) adhering to at least three healthy dietary habitsfrom a checklist of five items (including low percentage of fatin cheese, low frequency of eating fried food, low frequencyof eating red meat, low frequency of eating fast-food, and highfrequency of consuming whole wheat bread).

Body mass index (BMI) was included as a three-point cat-egorical variable defined as follows: normal, BMI less than25.0 kg/m2; overweight, BMI between 25.0 and 29.9 kg/m2;and obese, BMI of 30.0 kg/m2 or greater.

Health measuresSelf-rated health was assessed with the question BWould

you say your health now is excellent (1), good (2), fair (3), notso good (4), or poor (5)?[ The scale was recoded to threecategories: excellent/good (1), fair/not so good (2), and poor(3). Physical limitation was assessed with the question BDoyou have any type of physical limitation?[ with a follow-upitem on the type of limitation for those who responded pos-itively. Number of prescribed medications was defined asa count of all medications reported by the respondent as cur-rently taken and purchased with a physicians prescription.Ever diagnosed chronic conditions were measured by a pos-itive response (yes or suspected) to a direct question and/or a

Menopause, Vol. 19, No. 12, 2012 3

DEPRESSIVE SYMPTOMS AMONG MIDLIFE WOMEN

Copyright 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.

report of currently taking medication for at least one of thefollowing five conditions: hypertension, diabetes, heart dis-ease, stroke, and cancer (as part of a checklist of diseases andmedical conditions).

Measures for psychosocial functioningSocial support was assessed with a seven-item scale evalu-

ating the perceived availability of emotional and instrumentalsocial support from people in ones social network. The sevenitems were part of a scale developed by Vinokur and Vinokur-Kaplan,33 translated to Hebrew and adapted by Benyaminiand Lomranz34 in an Israeli study. The Cronbach > coefficientfor the seven-item scale was 0.89.

Perceived control was measured using a modified instru-ment, a seven-item scale each rated ranging from 1 (low per-ceived control) to 7 (highest perceived control), adapted fromPearlin et al.35 The scale was translated and used in the Israelipopulation by Hobfoll and Walfisch.36 The Cronbach > co-efficient for the scale in the current study was 0.70.

Caregiving load was assessed with a four-item scale con-sisting of the following statements: (1) I go to sleep exhaustedat night; (2) I have more things to do than I can handle; (3)I have no time for myself; and (4) I work hard in taking careof others and feel that it is endless.35 Responses were pro-vided on a 4-point Likert scale from 1 (not at all), 2 (sometime),3 (most of the time), to 4 (always). Cronbach > coefficientwas 0.74.

Attitudes toward menopause and aging items were adaptedfrom the SWAN.37 These items were drawn from existing in-struments and modified to provide a balance of negative andpositive wording. The participants were asked whether they(1) agreed, (2) felt neutral, or (3) disagreed with each of sevenstatements concerning menopause and aging (eg, BWomen whono longer have menstrual periods feel free and independent[and BA woman is less attractive after menopause[). Scoringwas recoded to provide a consistent direction (3 = negativeattitude; 1 = positive attitude). The Cronbach > of the sevenitems (> = 0.53) increased to 0.59 when the item BThe older awoman is, the more valued she is[ was deleted. The finalscore for each respondent was calculated as the mean of sixitems.

Data analysisTo account for the effects of the stratification design, all

analyses were performed by assigning strata weights to thespecific age group and population subgroup of participants.Weights were calculated by dividing the number of women inthe population in each strata cell by the number of womeninterviewed in each such cell. Statistical analyses were per-formed using SAS 9.1 statistical software (SAS Institute Inc,Cary, NC) with the relevant procedures for taking into accountthe sampling design and sampling weights.

The outcome variable CES-D-10 was dichotomized accord-ing to the G10/Q10 cutpoint validated in several studies.28,30

The univariate associations of categorical variables to de-pressive symptoms were tested by the Wald W2 test. For con-tinuous variables (eg, age and number of medical symptoms),

associations were tested as the mean difference between womenwith high depressive symptoms (CES-D Q10) and those withlow or no depressive symptoms in each indicator of interest.

Logistic regression models were fitted to assess the con-tribution of each covariate to the risk of high depressive symp-toms (CES-D Q10) using SAS procedure SURVEYLOGISTIC.ORs and 95% CIs were calculated. The final model includedthe variables that were significantly or borderline significantly(P G 0.10) related to high depressive symptoms in the uni-variate analysis in the total sample. Because of the smallersample size of the minority groups as compared with LTRs,associations with borderline significance (P G 0.10) in thestratified multivariate analyses by cultural groups were con-sidered as trends. Age was included in all models irrespectiveof its association to the outcome variable, whereas monthlyincome and work status were not entered into the final modelsbecause they were strongly correlated with education (schoolyears). For example, 88% of women with low education (0-8 y)were not working, and 95% of them had low income. Numberof children and hormone therapy (HT) use were also not in-cluded in the final models because number of children washighly correlated with the study groups (Table 1) and the var-iable Bever use of HT[ could not be related to depressivesymptoms because of the unknown time frame.

RESULTS

Differences in sociodemographic characteristics and health,lifestyle, and psychosocial indicators among the three studygroups are described in Table 1. Arab women were in thelowest brackets of the sociodemographic characteristics: loweducation, low income, high rate of unemployment, and largefamilies (three or more children). Immigrants from the formerSoviet Union reported higher education than did both LTRsand Arab Israelis but lower income than LTRs and more un-married women than the other two groups. The comparison oflifestyle characteristics showed that LTRs reported a higherfrequency of HT use and performing physical activity than didimmigrants and Arab women, and their dietary habits werebetter than those of Arab women (but not better than thoseof immigrants), which is also expressed in their lower rates ofobesity. On the other hand, LTRs exhibited a higher rate ofcurrent smokers (23%) than did immigrants (14%) and Arabwomen (11%). The differences in health measures among thegroups were partly consistent with the socioeconomic differ-ences noted above. LTRs reported better self-rated healthand lower medication use but higher rates of physical limi-tations and hot flashes. Psychosocial indicators also showedtrends in favor of the LTR group, with greater social supportand sense of control, lower caregiving load, and less nega-tive attitude toward aging. Interestingly, the mean scale forattitude toward menopause and aging ranged between 1.75and 1.94 on a scale of 1 to 3, suggesting that most women inall three groups were ambivalent (not strongly negative norpositive), yet all means were on the positive side of the atti-tude toward menopause and aging. Arab women, who had thelargest families, reported the lowest level of social support, the

4 Menopause, Vol. 19, No. 12, 2012 * 2012 The North American Menopause Society

BLUMSTEIN ET AL


highest levels of caregiving overload, and the most negativeattitude to aging.

Prevalence and correlates of depressive symptomsOverall, 23.5% of the study population had a CES-D score

of 10 or higher. The prevalence of high depressive symptomswas 17%, 39%, and 46% for LTRs, immigrants, and Arab

women respectively (Table 2). Univariate results for the fullsample showed that except for age and smoking status, allvariables of interest were significantly related to depressivesymptoms, with one borderline significance for menopausestatus (P = 0.08).

The multivariate logistic regression for the total sample(Table 3) showed that after taking into account the differences

TABLE 1. Descriptive characteristics of the population by three cultural groups

Characteristics

Total (N = 811)

Long-termresidents(n = 539)

Russianimmigrants(n = 151)

Arab Israelis(n = 121)

n %b n %b n %b n %b Pa

SociodemographicsAge, mean, y 54.9 54.6 56.1 55.0 G0.001Family status G0.001Married 599 76.0 419 78.6 92 61.6 88 78.3

Education, y G0.0010-8 184 19.0 85 14.3 0 Y 99 78.49-12 258 34.2 208 39.1 36 24.7 14 13.6Q13 368 46.8 245 46.6 115 75.3 8 8.0

Household monthly income, ILS G0.001912,000 94 14.8 90 19.3 4 3.4 0 Y6,000-12,000 236 35.1 198 41.4 33 25.8 5 4.9G6,000 412 50.1 204 39.3 99 70.8 109 95.1

Work status G0.001Employed currently 416 58.1 331 66.1 79 55.9 6 5.6

Number of children G0.001None 41 4.9 28 5.2 4 2.7 9 6.21 84 9.4 28 5.2 51 33.5 5 3.82 201 25.3 131 24.6 69 45.9 1 0.9Q3 485 60.4 352 65.0 27 17.9 106 89.1

Health and menopause statusMenopause status 0.38Premenopausal 83 12.7 52 12.2 16 12.3 15 16.5Perimenopausal 128 20.0 90 21.0 21 15.8 17 19.2Postmenopausal 492 54.6 317 53.3 98 61.5 77 54.2Surgical menopause 108 12.7 80 13.5 16 10.4 12 10.1

Hot flashes 262 34.7 195 37.6 31 21.6 36 32.6 G0.001Ever use of HT 199 24.6 173 29.6 19 13.0 7 5.7 G0.001Chronic morbidityc 417 47.2 260 44.6 95 60.1 62 47.0 0.002Number of medicalsymptoms, mean

4.0 4.0 4.3 3.9 0.34

Physical limitation 166 20.8 134 23.6 26 17.8 6 5.5 G0.001Self-rated health G0.0001Good/excellent 395 53.3 332 63.8 25 17.0 38 32.9Fair 359 41.1 180 32.0 117 77.0 62 52.8Poor 55 5.6 25 4.2 9 6.0 21 14.3

Lifestyle characteristicsPhysical activity in the past year 412 54.1 347 64.1 40 25.9 25 25.3 G0.001Current smoking 150 20.1 118 22.6 20 14.2 12 11.1 0.002Healthy dietary habits 496 61.6 348 64.0 108 70.7 40 31.7 G0.001BMI G0.001Normal, G25 kg/m2 290 39.5 241 46.6 31 21.2 18 15.7Overweight, 25-G30 kg/m2 276 34.1 170 31.9 65 44.4 41 35.0Obese, Q30 kg/m2 227 26.4 117 21.5 53 34.4 57 49.3

Psychosocial characteristicsSocial support, mean(range, 1 = low to 5 = high)

4.1 4.2 3.9 3.7 G0.001

Perceived control, mean(range, 1 = low to 5 = high)

3.2 3.3 2.9 3.0 G0.001

Caregiving overload, mean(range, 1 = low to 4 = high)

2.1 2.0 2.2 2.7 G0.001

Attitude toward aging, mean(range, 1-3 [negative])

1.8 1.8 1.8 1.9 G0.001

ILS, Israeli Shekels; HT, hormone therapy; BMI, body mass index.aWald W2 tests were used for comparison of categorical variables, taking into account the survey design.bPercentages are population estimates projected from sample data.cHypertension, diabetes, heart disease, stroke, cancer.




in sociodemographic, health, and lifestyle characteristics, bothimmigrants and Arab women were at a significantly higher riskof high depressive symptoms (almost threefold) as comparedwith LTRs. Comparing the adjusted ORs for immigrants andArab women (2.97 and 2.79, respectively) with the respective

TABLE 3. Multivariable logistic regression analysis of depressivesymptoms for the total sample (N = 811)

Characteristics OR 95% CI Overall Pa

SociodemographicsCultural group 0.002Russian immigrants vslong-term residents

2.97 1.45-6.07

Arab Israelis vs long-termresidents

2.79 1.17-6.62

Age (per 1 y increase) 1.04 0.98-1.10 0.17Family statusNot married vs married 2.86 1.71-4.78 G0.0001

Education 0.540-8 y vs Q13 y 1.62 0.69-3.779-12 y vs Q13 y 1.16 0.65-2.06

Health and menopause statusMenopause status (referencecategory: postmenopause)

0.0004

Premenopause 4.00 1.72-9.31Perimenopause 4.72 2.20-10.1Surgical menopause 1.35 0.67-2.70

Hot flashes 1.13 0.97-1.33 0.12Chronic morbidityb 0.76 0.45-1.26 0.28Number of medical symptoms(per one symptom increase)

1.33 1.21-1.47 G0.0001

Physical limitation 1.46 0.82-2.59 0.20Self-rated health 0.89Fair vs good/excellent 1.08 0.59-1.97Poor vs good/excellent 1.35 0.40-4.53

Lifestyle characteristicsNo physical activity in thepast year

1.43 0.85-2.40 0.18

Current smoking 1.48 0.81-2.70 0.20Poor dietary habits 1.38 0.85-2.25 0.19BMI 0.73Overweight (25-G30 kg/m2)vs normal (G25 kg/m2)

0.88 0.49-1.60

Obese (Q30 kg/m2) vs normal(G25 kg/m2)

1.12 0.61-2.04

Psychosocial characteristics(per one unit increase)Increasing social support 0.54 0.41-0.72 G0.0001Increasing perceived control 0.25 0.16-0.39 G0.0001Increasing caregiving overload 1.16 0.84-1.62 0.36Negative attitude toward aging 2.78 1.69-4.59 G0.0001

OR, odds ratio; BMI, body mass index.aWald W2 tests were used for comparison of categorical variables, taking intoaccount the survey design.bHypertension, diabetes, heart disease, stroke, cancer.

TABLE 2. Associations of sociodemographic, health-related,lifestyle, and psychosocial characteristics to depressive symptoms

(CES-D Q 10) for the total sample (N = 811)

Characteristics Total sample %a Pb

SociodemographicsCultural group G0.0001Long-term residents 539 17.0Russian immigrants 151 39.4Arab Israelis 121 46.1

Age, mean, y 0.90CES-D G10 604 54.9CES-D Q10 207 54.9

Family status G0.001Married 599 18.9Not married 211 38.4

Education, y G0.0010-8 184 47.69-12 258 21.6Q13 368 15.2

Health and menopause statusMenopause status 0.08Premenopausal 83 25.5Perimenopausal 128 31.3Postmenopausal 492 20.2Surgical menopause 108 23.6

Hot flashes 0.003No 541 19.9Yes 262 30.0

Ever use of HT G0.0001No 610 26.9Yes 199 12.9

Chronic morbidityc 0.07No 394 21.0Yes 417 26.4

Number of medical symptoms, mean G0.001CES-D G10 604 3.4CES-D Q10 207 6.2

Physical limitation G0.001No 639 19.5Yes 166 39.0

Self-rated health G0.0001Good/excellent 395 10.3Fair 359 35.1Poor 55 63.1

Lifestyle characteristicsPhysical activity in the past year G0.001No 399 36.6Yes 412 12.5

Current smoking 0.19No 661 22.4Yes 150 27.8

Healthy dietary habits 0.0004No 315 30.6Yes 496 19.1

BMI G0.001Normal, G25 kg/m2 290 17.3Overweight, 25-G30 kg/m2 276 22.1Obese, Q30 kg/m2 227 34.6

Psychosocial characteristicsSocial support, mean G0.001CES-D G10 604 4.24CES-D Q10 207 3.52

Perceived control, mean G0.001CES-D G10 604 3.38CES-D Q10 207 2.75

Caregiving overload, mean G0.001CES-D G10 604 1.97CES-D Q10 207 2.44

TABLE 2. (Continued)

Characteristics Total sample %a Pb

Attitude toward aging, mean G0.001CES-D G10 604 1.69CES-D Q10 207 2.08

CES-D, Center for Epidemiological StudiesYDepression Scale; HT, hormonetherapy; BMI, body mass index.aPercentages are population estimates projected from sample data.bWald W2 tests were used for comparison of categorical variables, taking intoaccount the survey design.cHypertension, diabetes, heart disease, stroke, cancer.


BLUMSTEIN ET AL


crude ORs, 3.16 (95% CI, 2.1-4.75) and 4.16 (95% CI, 2.65-6.5; data not shown), respectively, indicates that only for Arabwomen, part of the gap in depressive symptoms was explainedby the model correlates.

As expected, being unmarried remained a significant riskfactor for depressive symptoms, and both premenopausal andperimenopausal women were at a significantly higher risk forhigh depressive symptoms as compared with postmenopausalwomen. Among the health and lifestyle characteristics, onlythe number of reported medical symptoms in the past 6 monthswas significantly related to depressive symptoms. Hot flashes,although significant at the univariate analysis in the full sam-ple and among LTRs, were not significantly related to depres-sive symptoms in the adjusted model. Among the psychosocialcharacteristics, greater social support and sense of control overones life remained significant correlates of lower depressivesymptoms, and negative attitudes toward aging were associatedwith an almost threefold risk of a high level of depressivesymptoms.

Differences in the correlates of depressive symptomsacross cultural groups

In the first stage of the stratified analysis, all interactions ofindependent variables with study group (LTRs, immigrants,and Arabs) were evaluated. Three interactions were signifi-cant: years of education (P = 0.02), physical limitation (P G0.0001), and perceived control (P = 0.03). To study furtherthe differences in the associations of all correlates to depres-sive symptoms within each cultural group, the set of univar-iate and multivariate analyses was performed within eachcultural group.

The stratified univariate analyses by the three culturalgroups (Table 4) showed that being married was associatedwith lower depressive symptoms among LTRs and immigrants,whereas higher education was significantly related to lowerdepressive symptoms among LTRs and Arab women but notamong immigrants (possibly because there was little variabil-ity in their level of education). Menopause status was related todepressive symptoms, with borderline significance only amongArab women. Poorer self-rated health, more medical symptomsin the past 6 months, and physical limitation were associatedwith high depressive symptoms in the three study groups,whereas reporting chronic conditions was significantly associ-ated with depressive symptoms only among Arab women.Consistent trends of lower depressive symptoms among thosephysically active were observed across the three groups (non-significant among Arab women). Lifestyle indicators such assmoking, unhealthy dietary habits, and obesity were associatedwith higher levels of depressive symptoms only among LTRs.Women with high depressive symptoms reported a signifi-cantly lower sense of control and increased negative attitudestoward menopause and aging in each of the cultural groups.

Separate multivariate models for the cultural groups(Table 5) revealed differences in the patterns of associationsbetween sociodemographic indicators and depressive symp-toms across the study groups. Among immigrants and the LTR

group, but not among Arab women, unmarried status remaineda significant risk actor for depressive symptoms. It is interest-ing to note that although lower education (G13 school years)was associated with more depressive symptoms among theLTRs and the Arab women (although nonsignificantly), it wassignificantly associated with less depressive symptoms amongthe immigrants. Across the three study groups, perimenopausalwomen were at a significantly higher risk for depressive symp-toms as compared with postmenopausal women, whereas amongimmigrants, the premenopausal group showed a significantlyhigher risk with depressive symptoms as well. Hot flasheswere related to high depressive symptoms, with borderline sig-nificance only among Arab women. Among the health andlifestyle characteristics, number of medical symptoms showeda similar pattern of associations, so that it was related to higherdepressive symptoms among LTRs and immigrants. The patternof associations of marital status, number of medical symptoms,and hot flashes to depressive symptoms differed for Arabwomen as compared with the other two groups.

In the final model, among the psychosocial characteris-tics, the protective effect of social support for LTRs and Arabwomen was not observed among immigrants, whereas greatersense of control was unrelated to lower level of depressivesymptoms among Arab women. Negative attitude toward agingwas strongly related to high depressive symptoms (more thanfourfold) among LTRs and immigrants, with a weaker non-significant association among Arab women. It seems that onlysocial support remained a protective factor to emotional healthamong Arab women.

In addition, the multivariate model for immigrants wasperformed including length of time since arrival in Israel (range,2-16 y; mean, 1.6 y). The results showed a significantlyreduced OR for depressive symptoms (OR, 0.73; 95% CI, 0.62-0.85) with each additional year since arrival to the country.

DISCUSSION

The current study contributes to the understanding of animportant issue in the mental health of ethnic and immigrantminority women. Both immigrants to Israel and Israeli Arabwomen were at a significantly higher risk of depressive symp-toms as compared with native-born/long-term Jewish residents.In fact, the crude threefold odds for high depressive symptomsamong immigrants remained at the same level in the fully ad-justed model, whereas for Arab women, the fourfold crude riskwas reduced to a little less than threefold after adjustment.Thus, adjusting for a large number of sociodemographic, health,and psychosocial measures could not explain differences indepressive symptoms levels between immigrants and LTRsand explained only part of the gap between Arab women andLTRs. Because the two minority groups are of different cul-tural backgrounds, the potential reasons for their emotionalstatus probably differ as well.

The case of immigrant womenAs reported earlier, a previous study of the subjective well-

being of immigrants 50 years or older in Israel showed that the




TABLE 4. Associations of sociodemographics, health-related, lifestyle, and psychosocial characteristics to depressive symptoms(CES-D Q 10) in each cultural group

Characteristics

Long-term residents (n = 539) Russian immigrants (n = 151) Arab Israelis (n = 121)

n %a Pb n %a Pb n %a Pb

SociodemographicsAge, mean, y 0.84 0.21 0.95CES-D G10 446 54.6 92 56.6 66 55.0CES-D Q10 93 54.7 59 55.4 55 54.9

Family status 0.001 0.001 0.12Married 419 13.9 92 29.1 88 42.4Not married 119 28.9 59 56.0 33 59.2

Education, y G0.001 0.67 0.020-8 85 43.3 0 Y 99 53.09-12 208 19.4 36 36.4 14 26.3Q13 245 7.0 115 40.4 8 11.7

Health and menopause statusMenopause status 0.17 0.56 0.07Premenopausal 52 15.3 16 56.3 15 45.3Perimenopausal 90 25.6 21 38.6 17 66.1Postmenopausal 317 14.2 98 36.2 77 35.8Surgical menopause 80 16.6 16 39.6 12 64.4

Hot flashes 0.001 0.33 0.08No 343 12.5 116 37.1 82 40.3Yes 195 24.6 31 46.7 36 59.2

Ever use of HT 0.01 0.30 0.52No 366 19.6 131 41.3 113 46.1Yes 173 10.9 19 29.0 7 33.3

Chronic morbidityc 0.82 0.66 0.01No 279 16.7 50 37.2 59 34.5Yes 260 17.5 95 40.8 62 59.1

Number of medical symptoms, mean G0.001 G0.001 0.007CES-D G10 446 3.40 92 3.45 66 3.20CES-D Q10 93 6.99 59 5.67 55 4.61

Physical limitation G0.001 G0.001 0.01No 404 12.5 120 32.8 115 42.9Yes 134 31.8 26 73.4 6 100.0

Self-rated health G0.001 G0.001 0.006Good/excellent 332 9.1 25 11.4 38 24.9Fair 180 26.6 117 42.6 62 55.0Poor 25 59.9 9 76.7 21 61.5

Lifestyle characteristicsPhysical activity in the past year G0.001 0.02 0.11No 192 28.9 111 44.9 96 50.7Yes 347 10.4 40 23.7 25 32.5

Current smoking 0.02 0.50 0.34No 421 14.7 131 38.2 109 47.6Yes 118 25.0 20 46.4 12 33.8

Healthy dietary habits 0.63No 191 24.3 43 45.9 81 44.5Yes 348 13.0 0.002 108 36.7 0.31 40 49.5

BMI 0.06 0.20 0.53Normal, G25 kg/m2 241 13.5 31 44.9 18 42.6Overweight, 25-G30 kg/m2 170 16.5 65 31.8 41 40.3Obese, Q30 kg/m2 117 24.8 53 47.0 57 51.9

Psychosocial characteristicsSocial support, mean G0.001 0.27 G0.001CES-D G10 446 4.29 92 4.00 66 4.08CES-D Q10 93 3.45 59 3.84 55 3.30

Perceived control, mean G0.001 G0.001 0.01CES-D G10 446 3.46 92 3.07 66 3.11CES-D Q10 93 2.78 59 2.62 55 2.85

Caregiving overload, mean G0.001 0.09 0.15CES-D G10 446 1.89 92 2.08 66 2.64CES-D Q10 93 2.36 59 2.30 55 2.82

Attitude toward aging, mean G0.001 G0.001 0.05CES-D G10 446 1.67 92 1.68 66 1.86CES-D Q10 93 2.15 59 1.97 55 2.04

CES-D, Center for Epidemiological StudiesYDepression Scale; HT, hormone therapy; BMI, body mass index.aPercentages are population estimates projected from sample data.bWald W2 tests were used for comparison of categorical variables, taking into account the survey design.cHypertension, diabetes, heart disease, stroke, cancer.


BLUMSTEIN ET AL


group of recent arrivals from the former Soviet Union reportedlower quality of life and higher depression levels than didother ethnic immigrant groups. These findings remained evenafter controlling for background variables, including yearssince immigration and language.15 The findings from the samestudy with regard to depression also showed that women hadsignificantly higher levels of depression than men did, whichemphasizes that this group of women, recent immigrants fromthe former Soviet Union, forms a particularly vulnerable group.

Results from studies on former Soviet Union immigrantsin the United States also show that they report psychologicaldistress and adjustment difficulties,11 particularly among mid-life women.12,38,39 Several explanations were proposed forthese findings in Israel and the United States. First, a decreasein occupational roles and prestige compared with the occupa-tions held in their country of birth21,39 may have had a strongimpact on their self-esteem and satisfaction with life and, con-sequently, on their psychological status. This speculation wasstrengthened in our study by the finding of an inverse asso-ciation between education and depressive symptoms in immi-grants in comparison with LTRs and Arab women. Among

immigrants, higher educational level was associated with moredepressive symptoms, which may suggest a high frustrationlevel among those with high skills when confronted with occu-pational downgrading. Other explanations include immigration-related losses of former family roles and social support as wellas caring for older parents in a foreign land, often in crowdedthree-generation homes.18Y20,39 In this context, it is interestingto note that in the current study, immigrants caregiving over-load was significantly higher than LTRs, although this mea-sure was not significantly related to depressive symptoms in themultivariate models in any of the study groups. An additionalsource of stress among immigrants could be related to past lifeevents and the perception of leaving home for a new countryas a traumatic event. Indeed, according to our data, 81% ofthe immigrants reported past traumatic events as compared with63% of the LTRs and 54% of the Arab women.

Recent studies on the well-being of immigrants include in-dicators of the level of acculturation into the host society,40

such as language skills and length of time since immigration.In the current study, immigrants were interviewed in theirnative language, but the results for length of residence in Israel

TABLE 5. Multivariable logistic regression analysis of depressive symptoms by each cultural group

Characteristics

Long-term residents (n = 539) Russian immigrants (n = 151) Arab Israelis (n = 121)

OR 95% CI Overall P OR 95% CI Overall P OR 95% CI Overall P

SociodemographicsAge (per 1-y increase) 1.04 0.96-1.13 0.39 1.07 0.95-1.21 0.24 0.99 0.88-1.10 0.83Family statusNot married vs married 3.90 1.77-8.62 0.0008 3.78 1.20-11.8 0.02 1.86 0.40-8.61 0.43

Education 0.30 0.140-8 y vs Q13 y 1.71 0.47-6.26 Y 6.41 0.56-73.89-12 y vs Q13 y 1.96 0.84-4.58 0.28 0.08-0.96 0.04 1.42 0.07-28.5

Health and menopause statusMenopause status(reference category: postmenopause)

0.006 0.07 0.31

Premenopause 1.96 0.45-7.96 10.90 1.60-74.6 4.97 0.68-36.3Perimenopause 5.76 2.06-16.1 5.20 1.13-23.9 5.56 0.68-45.5Surgical menopause 1.15 0.43-3.05 2.04 0.39-10.7 3.36 0.29-39.3

Hot flashes 1.06 0.85-1.32 0.64 1.19 0.76-1.85 0.45 1.47 0.94-2.30 0.09Chronic morbiditya 0.51 0.23-1.13 0.10 0.83 0.22-3.04 0.78 2.25 0.55-9.24 0.26Number of medical symptoms(per one symptom increase)

1.39 1.20-1.62 G0.0001 1.23 0.98-1.53 0.07 1.14 0.90-1.45 0.27

Physical limitation 1.11 0.47-2.61 0.82 3.06 0.62-15.12 0.17 Y Y b

Self-rated health 0.55 0.62 0.94Fair vs good/excellent 0.97 0.40-2.38 2.83 0.35-23.14 1.32 0.29-6.05Poor vs good/excellent 2.48 0.38-16.11 1.55 0.06-43.51 1.32 0.14-12.24

Lifestyle characteristicsNo physical activity in thepast year

1.45 0.67-3.13 0.34 2.98 0.88-10.04 0.08 1.33 0.34-5.24 0.68

Current smoking 1.71 0.76-3.88 0.20 0.71 0.21-2.39 0.59 0.68 0.12-3.84 0.67Poor dietary habits 1.72 0.81-3.67 0.16 2.81 0.99-8.01 0.06 0.70 0.18-2.67 0.60BMI 0.84 0.22Overweight (25-G30 kg/m2) vs normal(G25 kg/m2)

1.28 0.54-3.04 0.39 0.10-1.44 0.69 0.10-4.62 0.64

Obese (Q30 kg/m2) vs normal (G25 kg/m2) 1.19 0.47-3.01 0.95 0.25-3.54 1.27 0.22-7.33Psychosocial characteristics(per one unit increase)Increasing social support 0.50 0.33-0.76 0.001 0.88 0.49-1.60 0.68 0.34 0.16-0.72 0.005Increasing perceived control 0.15 0.08-0.30 G0.0001 0.17 0.06-0.45 0.0004 0.97 0.29-3.27 0.96Higher caregiving load 1.31 0.79-2.17 0.30 1.02 0.48-2.17 0.96 0.82 0.32-2.10 0.68Negative attitude toward aging 3.67 1.72-7.83 0.001 3.70 1.28-10.68 0.02 1.77 0.56-5.56 0.33

OR, odds ratio; BMI, body mass index.aHypertension, diabetes, heart disease, stroke, cancer.bPhysical limitation was not included in the model for Arab women because of the very low prevalence of this condition.




show a significantly reduced level of depression with increas-ing time interval since arrival to the country. Similar findingswere shown in the US study of women 40 to 70 years old whoemigrated from the former Soviet Union less than 8 years beforeenrollment12 and among older community-dwelling MexicanAmericans.40 On the other hand, several studies of former SovietUnion immigrants (including men and women) in the UnitedStates and Israel did not show this association after adjustmentfor additional risk factors.11,15 These findings point to a pos-itive acculturation process with time among this group ofwomen. This speculation is reinforced by the findings that formost of the correlates considered in this study, the patterns ofassociations among the immigrants were similar to the patternsobserved for the LTRs.

The case of Arab Israeli womenThe higher prevalence of depressive symptoms among Arab

Israeli women is partly in line with several Israeli studies.22,23,41

In one of these studies, based on a sample of Israeli adultsaged 25 to 67 years in one urban district in Israel, the cruderate of depression was 2.5 times higher among Arabs, but nosignificant association remained between ethnicity (Arabs vsJews) and depression after adjustment for educational leveland health status.23 In the current study, only part of the crudegap between Arab women and LTRs was reduced after ad-justment for their lower educational level and lower socialsupport as compared with LTRs, but the adjustment did notexplain the entire gap between Arab and LTR Israeli women.It seems that Arab women at midlife are a risk group fordepressive symptoms, as was shown also in studies amongMuslim Arabs in other countries, such as the United ArabEmirates,42,43 and in the aforementioned Israeli study withregard to a subgroup of women 56 years or older within thestudy sample.23 A higher vulnerability to depressive symp-toms among women of minority ethnic groups was observedin a study of Hispanic and white rural older adults as well.10 Astudy of anxiety and depression levels (using the full CES-D)of adult Arab Americans showed significantly higher levelsamong these individuals as compared with rates of normativecommunity samples and other minority groups.44 Other studieson the role of the acculturative stress and immigration stressorsamong Arab Americans suggested that Arab Americans may beat risk for mental health problems45 and depression,46 partic-ularly among Arab immigrant women exposed to premigrationtrauma.47 However, these findings cannot be directly comparedwith the Israeli Arab minority group because their greater vul-nerability to anxiety and depressive symptoms may be partlyrelated to the Palestinian-Israeli political conflicts.36,48

Another possible explanation for this high vulnerability todepressive symptoms among Arab midlife women is the lowerstatus of women in the family within the traditional and reli-gious society to which they belong. This notion was expressedby Daradkeh et al,42 who found that the sex ratio for depres-sion in the Arab culture is the highest reported and is higher infamilies with four or more children. In the current study, 83%of the Arab women had four or more children, as compared

with 30% of LTRs and only 6% of the immigrants. The mul-tivariate model performed separately for Arab women showedthat increasing social support was the only significant factorassociated with reduced odds for high depressive symptoms.However, as shown before, large families and other measuresof the structure of the social network are not necessarilyrelated to their supportiveness.49,50

Another explanation is the potential influence of perceiveddiscrimination by the Arab minority in Israel. Social stressors,such as those invoked by prejudice and discrimination, weresuggested in the literature as factors contributing to disparitiesin mental and physical health outcomes.51 Individuals whobelong to a group with disadvantaged social status are exposedto more stressful conditions and fewer resources to deal withthese conditions than are those of higher social standing.52

Thus, Arab women may be in double jeopardy, experiencinglower status in the Israeli society and within their culture.Additional speculation can be attributed to both environmen-tal and familial changes for Arab Israeli women. They aremembers of a cultural minority in transition from agrarianculture to more Western societal norms, where younger womenacquire higher education and have more opportunities to ful-fill career ambitions, while they, as middle-aged women, aremostly uneducated homemakers, slowly losing their primaryrole in the family as their children leave home.

Other correlates of depressive symptoms at midlifeThe current findings with regard to menopause status showed

that both premenopausal and perimenopausal women were at asignificantly high risk of depressive symptoms as compared withpostmenopausal women (OR, 4.00 and 4.7, respectively). Tocompare our findings with those of other cited studies, theanalysis was performed again using the premenopause group asa comparison group (data not shown). A borderline trend forincreased depressive symptoms among the perimenopause groupas compared with the premenopause group was observed mainlyamong the LTR group (OR, 3.0; 95% CI, 0.8-11.0), whereasfor the immigrant group, the odds for perimenopause (as com-pared with premenopause) were lower but not significant (OR,0.48; 95% CI, 0.1-2.9). The findings with regard to LTRs arepartly in line with cross-sectional results from the multieth-nic SWAN, in which women at early perimenopause had higherdistress levels as compared with those at premenopause.53 Ourfindings are also partly in line with longitudinal studies usingthe CES-D as an outcome measure demonstrating an increasedlikelihood of depressive symptoms during transition to meno-pause and a decreased likelihood after menopause.6,50 Onthe other hand, in another longitudinal study, higher CES-Dscores among early perimenopausal, late perimenopausal, andpostmenopausal women compared with premenopausal womenwere reported.4 These results differ in comparison with thecurrent results, where postmenopausal women showed thelowest level of depressive symptoms. These differences maystem from the different age groups studied (45-64 y in thecurrent study and much younger age groups in the cited lon-gitudinal studies). It should be noted that the current findings


BLUMSTEIN ET AL


are adjusted among other confounders to the effect of bothsomatic and mental symptoms included within the list ofmedical symptoms. The current results point especially to thereduction in depressive symptoms among women during thepostmenopausal stage in life perhaps because of lower stressrelated to life demands at the age of 55 years or older.

In the current study, none of the lifestyle indicators suchas physical activity, smoking, and dietary habits were relatedto depressive symptoms in the adjusted models (except for aborderline significant higher risk of depressive symptoms amongimmigrants with poor dietary habits). The trend of higher de-pressive symptoms among women with no physical activitywas significant at the univariate level (among LTRs and im-migrants) and for current smokers and women with poor diet-ary habits among LTRs only. In several studies, health behaviorindicators such as smoking and no/little physical activity werefound to be risk factors for depression among midlife women,5,54

although the findings from a Japanese longitudinal study showedthat the benefit of physical activity for reduced depressivesymptoms was not confirmed for middle-aged adults (40-64 yold).53 Although we did not find evidence for a direct significantassociation once health and other covariates were accountedfor, we can assume that women benefited indirectly from phys-ical activity through its association with physical health.

Marriage was protective against high depressive symptomsin the full model and in the separate models for LTRs and im-migrants but not among Arab women. This is in line with find-ings among Arab and Jewish Israelis22 and for participants fromspecific ethnic groups (Chinese and Japanese) in the SWANbut not for white, African American, or Hispanic women.8

There seem to be cultural differences in the status of unmar-ried women that may be reflected in its link to emotional sta-tus. Among Arab Israelis in the current study, 70% of thoseunmarried were widows, whereas among immigrants and LTRs,the rates were 36% and 29%, respectively, with more than50% divorcees among these two groups. In addition, the geo-graphical proximity of widows in the Arab localities to theirchildren and extended family may be related to reduced traumaas a result of spousal death. Thus, we can speculate that beingwidowed in the Arab society is more respected and associatedwith the support of the extended family. Alternatively, beingmarried may not be protective in a society in which womenexperience lower status, most marriages are arranged, and di-vorce is not considered a legitimate option.

The number of medical symptoms that are bothersome toeveryday life was strongly related to depressive symptoms inthe full and stratified multivariate models, whereas self-ratedhealth, which was significant in the univariate analysis, wasno longer significant in the multivariate models. Our findingsare not in line with other studies, in which both self-rated healthand number of menopausal symptoms remained significantcorrelates of depression in the multivariate model54 and longi-tudinally in middle-aged Australian women.55 However, thecurrent list of symptoms (n = 15) was more comprehensive thanin the above-mentioned studies and was moderately (or highly)associated with self-rated health (r = 0.49, P G 0.0001).

Personal resilience, as expressed by increasing locus of con-trol and more positive attitude toward menopause and aging,was an important contributor to the level of depressive symp-toms. Personality domains such as higher perceived controlover life events may be related to better coping with stress,leading to depressive symptoms.56 A number of studies havedemonstrated that anxiety and depression levels are higher inindividuals with low levels of perceived control among pa-tients57 and healthy individuals58 and depression is higher withmore negative attitudes toward aging.55 Similarly, perceivedsocial support is an additional personal resource that was re-lated with decreased depressive symptoms in the current studyas well as in other studies,59 including longitudinal follow-ups.4 This is to be expected in light of the extensive evidenceof the benefits of the perceived support of social relationshipson mental health among older adults.60

fully taken into account in this study. As discussed above,these circumstances differ across the two minority groups:for immigrants, loss of social and occupational status after theimmigration to Israel, and for Arab women, changes in thetraditional female role in the family, lower status in society aswomen, and perceived discrimination from the majority groupmay be responsible for the high depressive symptoms. Forimmigrants, emotional state is likely to improve with time andthe acculturation process. It is important to increase familyphysicians awareness of the issue of high depressive symp-toms among midlife women and their ability to identify it,especially among minority women, and to encourage womento seek appropriate health and social services. In addition,promoting positive attitudes to aging and menopause could beused as part of the family physicians care with middle-agedwomen. Further studies should evaluate the effect of possibleintervention strategies in these high-risk groups.

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depression among women in midlife

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