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 status of Russian immigrants who have recently come to the United States. Aims: The project included creation of a Russian version of the Hopkins Symptom Checklist-25 (HSCL-25) in order to identify anxiety and depression in members 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 internal consistency. Seventeen Russian-speaking patients at a Russian psychiatric clinic were recruited for the study and were compared with a sample of 42 Russianspeaking members of the community. Results: The instrument showed internal consistency when evaluated with coefcient alpha. Clinic patients had signicantly higher anxiety and depression symptom scores than community subjects. Russian immigrants scores on the anxiety and depression scales were less than comparative data for the United States and notably less than similar measures for Russian immigrants to Israel. Conclusions: Recent Russian immigrants to the United States appear to have low prevalences of anxiety and depression.

INTRODUCTION
The process of migration and the conditions that immigrants leave behind may predispose them to mental disorders. Immigrants from the former Soviet Union were among the largest groups to settle in the United States during the 1990s. Although there has been substantial work on psychological distress among recent Russian immigrants in Israel (Ponizovsky et al., 1998, 2000; Ritsner et al., 1995, 1996, 2001; Ritsner & Ponizovsky, 1998, 1999) and among Russian adolescents contemplating emigration to Israel (Mirsky et al., 1992), little is known about the specic mental health needs of Russian-speaking immigrants to the United States during the last two decades. Recent Russian immigrants to the United States dier in several ways from earlier waves of immigrants leaving the former Soviet Union. Prior to the 1970s, many immigrants from the former Soviet Union to the United States and all immigrants to Israel were Jewish immigrants seeking freedom from religious persecution and human 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): 2940. DOI: 10.1177/0020764006061252

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1986, 1988). In the 1970s, Russian Jewish immigration patterns shifted to favor US immigration, as religious observation declined and immigrants saw greater economic and occupational opportunities in the United States. Russian emigration declined during the 1980s owing to deteriorating Soviet-American relationships, but resumed following the end of the Cold War. Since the 1990s, most Russian immigrants to the United States have been Christians seeking economic and occupational opportunities. Consequently, conclusions about earlier Russian immigrant populations may not pertain to more recent arrivals. Therefore, this study was undertaken to (a) develop a screening instrument for identifying the prevalence of anxiety and depression among Russian-speaking people in the United States, (b) measure mental disorder among a convenience sample from this population, and (c) compare the results 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 Russianlanguage 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 the BSI and the Psychiatric Epidemiology Research Interview Demoralization Scale (PERI-D) into the Talbieh Brief Distress Inventory (TBDI), which has been used in several studies of Russian immigrants to Israel (Ritsner et al., 1995; Ritsner & Ponizovsky, 1998). However, given the substantial cultural dierences among Russian immigrant groups, one can wonder about the psychometric properties of Israeli instruments when used with newly arriving Russian immigrants to the United States. Therefore, the present project included development of a Russian language instrument designed to measure anxiety and depression among recent immigrants to North America. In order to facilitate comparison with other studies, 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; Parlo et al., 1954), which is a well-known and widely used psychiatric screening instrument. The HSCL instrument combined a set of symptoms from the Cornell Medical Index and 12 items from a scale developed by Lorr (1952). The HSCLs authors have described the historical evolution, development, rationale and validation of the original 58-item instrument (Derogatis et al., 1974). The HSCL assesses ve underlying symptom dimensions during the preceding week: somatisation, obsessive-compulsive symptoms, interpersonal sensitivity, anxiety and depression. In the early 1980s, Rickels and coworkers demonstrated the usefulness of a 25item 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-25 has 10 items for anxiety symptoms and 15 items for depression symptoms. Like the original HSCL, 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 the 15 depression items.

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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; Hollield 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, but results have appeared only in a Russian language article (Boleloutskii, 1982). Little or no data on the development and validation of a Russian version of the HSCL are available in the English language literature. The adaptation of this instrument for use in another culture and language raises several questions. First, are the western diagnostic criteria for psychiatric disorders cross-culturally applicable? Second, does a questionnaire developed in one language and translated into another remain equivalent? Cross-cultural applicability of a diagnosis does not eliminate the possibility that symptoms may dier between cultures. Emotional and cognitive variation may cause varied expressions of the same syndrome. Consequently, the presence of the disorder may be overlooked in screening because of the use of culturally inappropriate diagnostic criteria. A standard set of procedures for cross-cultural adaptation has been proposed by Flaherty et al. (1998) and Guillemin et al. (1993). Their methods cover each step of the development process: (a) cross-cultural adaptation; (b) translation; (c) pre-testing; and (d) analysis of 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 with an independent measurement technique, such as a clinical psychiatric examination. This method for cross-cultural adaptation has been used in Cambodian, Laotian and Vietnamese populations (Mollica et al., 1992).

Procedure To gain an understanding of cultural context, unstructured interviews with Russian-speaking immigrants were conducted in homes and Russian Pentecostal churches. The interviews assessed the experience of immigrants in their countries of origin, during emigration, and in the United States. The purpose was to determine the range of traumatic experiences (if any) that occurred in the country of emigration, the reasons behind these experiences, and diculties encountered in adapting to the United States. Home and recreational activities were also discussed. In addition, consultations with Russian speakers who work with Russian-speaking immigrants provided cultural context. Survey questions were added regarding age, gender, level of education, current employment, length of time in the United States and religiosity. Two questions were adapted from the Duke Religion Index, a ve-item scale designed to capture the major aspects of the importance of religion in an individuals life (Koenig et al., 1997). No signicant changes were made to the HSCL-25 itself. Two native Russian speakers independently translated the English version of the instrument based on instructions to translate (1) at a sixth-grade reading level and (2) focusing on the intent of questions to identify specic symptoms (rather than the wording of the English-language original). Translators had experience in health care or psychology. The two versions were then reviewed by one of the translators and merged into a single draft that was assessed for integrity with the targeted mental disorders. An individual uninvolved in the original translations then back-translated this draft. The draft was further modied based on the back-translation.

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The draft was tested on a convenience sample of 10 educated Russian-speaking adults. This process revealed numerous confusing and ambiguous questions. The nal version (in the Appendix) was created by rewriting and re-testing questions on three Russian-speaking individuals. Responses to depression items are summed and divided by the number of answered items to generate a depression score ranging from 1 to 4. This process is repeated with anxiety items to generate an anxiety score. A score greater than 1.75 on either subscale identies clinically signicant distress (Mollica et al., 1986, 1987) and has been used to identify depression and anxiety in multiethnic samples of immigrants (Ekblad & Roth, 1997; Lavik et al., 1996; Silove et al., 1997). This cut-o also is consistent with community data in US populations (Derogatis et al., 1974; Winokur et al., 1984).

Subjects All subjects recruited for this study had immigrated to the US between 1998 and 2002. Clinic subjects were recruited from the Intercultural Psychiatric Program Russian Clinic at Oregon Health & Science University (OHSU). This program is an adult psychiatry clinic with about 90 patients. Any client over the age of 18 was a potential subject; they were excluded if they met one of the following criteria: (a) active psychosis as diagnosed by a psychiatrist, (b) severe cognitive impairment, (c) judgement by the patients psychiatrist that participation might in any 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 and were informed of the goals of the study, the potential use of the questionnaire, drawbacks to participating and remuneration for participating. They were clearly informed that declining to participate would not aect their care. Potential subjects were also asked to read an information sheet. Subjects completed questions at the OHSU Psychiatric Clinic and required between 20 and 30 minutes to complete the instrument usually following their clinic appointment. Subjects were given $10 in return for their time. Despite encouragement by the psychiatrist and the psychiatric nurse (both of whom are Russian speakers), many patients declined to participate. Community subjects were recruited from Russian Oregon Social Services (ROSS), which provides 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 services from 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 Control and Prevention). After reviewing original records for inconsistencies between the entries, the data were transferred to SPSS Version 10 for analysis. The analysis included comparison of demographics between clinic and community samples using the Mann-Whitney test. Internal reliability was evaluated using coecient alpha (Cronbachs alpha) (Nunnally & Bernstein, 1994). This project was approved by the Oregon Health & Science University Institutional Review Board.

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RESULTS Demographics
Seventeen Russian Clinic patients, less than half of the eligible population, agreed to become subjects. A convenience community sample of 42 ROSS clients and sta was obtained. Of the combined population, 52 subjects answered every question, ve subjects (two of whom were clinic patients) omitted one item, and two subjects (both clinic patients) were unable to complete large sections of the questionnaire. Table 1 describes the community and clinic samples. The two populations diered in age and employment. Clinic patients were, on average, 12 years older than community subjects and only one worked outside the home. Medical records showed that psychiatric diagnoses of clinic subjects included 8 (47%) with depression, 5 (29%) with post-traumatic stress disorder, 3 (18%) with adjustment disorder, 2 (12%) with bipolar disorder, and 1 (6%) with psychosis. No clinic subject was diagnosed with generalised anxiety disorder. Some subjects had multiple diagnoses, and medical records were unavailable for one subject.

Reliability Coecient alpha (Cronbachs alpha) was 0.92 for the 10 items on the anxiety scale and 0.94 for the 15 items on the depression scale. Validation Clinic subjects showed signicantly more symptoms of anxiety and depression than community subjects (see Table 1 and Figure 1). However, the dierence in means was not statistically signicant (p 0:145) when subjects with and without the diagnosis of major depression were compared. No patient was diagnosed with generalised anxiety disorder among the clinic patients, although the greatest dierence in mean scores between community and clinic patients was on the anxiety scale (see Table 1).

Table 1 Community and clinic cohorts Community N 42 Male gender (%) Mean age (SD) a Age range 9 + years schooling (%) > 2 years in US (%) Employed (%) b Anxiety mean (SD) c Depression mean (SD) d Anxiety above cut-o (>1.75) e Depression above cut-o (>1.75)
a c

Clinic N 17 6 (35%) 55.9 (16) 1775 14 (82) 15 (88) 1 (6) 1.25 (0.63) 1.16 (0.56) 24% (4 of 17) 12% (2 of 17)

13 (31%) 43.5 (16) 1871 35 (83) 32 (76) 25 (60) 0.55 (0.49) 0.59 (0.57) 2% (1 of 42) 2% (1 of 42)

p 0:014 by Students t-test; b p 0:001 by chi-squared test; p 0:001 by Mann-Whitney test; d p 0:002 by Mann-Whitney test; e p 0:007 by Fishers exact test

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

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

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DISCUSSION
A Russian-language instrument has been prepared that has a high rate of subject completion, good internal consistency, adherence to psychiatric constructs and the ability to discriminate between clinic and community samples. The new translation showed encouraging psychometric 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 with each other. The minimum alpha coecient recommended is 0.7 (Nunnally & Bernstein, 1994). The depression scale showed an internal consistency of over 0.92. Alpha coecient for the anxiety scale was over 0.94. The HSCL-25 also revealed signicantly higher anxiety and depression symptom scores among clinic subjects than community subjects. This nding suggests that the instrument can detect mental disorders. On the other hand, the number of subjects diagnosed with anxiety and depression was low and precluded more detailed analysis. Additionally, the signicantly higher anxiety scores among clinic subjects may be surprising because none was diagnosed with generalised anxiety. One reason is the overlap between anxiety, depression and other mental disorders. Another reason 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 diagnosis can explain the symptoms. Additionally, the applicability of this instrument may be limited because it was tested on a convenience sample of the Russian-speaking immigrant population of Portland, Oregon. According to US Census gures, Oregon is the second-largest center of Russian-speaking immigrant resettlement. Therefore, this sample is believed to be representative of the population of Russian-speaking immigrants to the US. However, because community subjects were recruited from a social services agency, Russian-speaking immigrants with more nancial stability and social support may not be represented in this sample. Additionally, the majority of recent Russian-speaking arrivals in Portland are Pentecostal Christians. It is unknown how this aects the applicability of the instrument to individuals practicing other religions and non-religious individuals. Nonetheless, it is informative to compare prevalences from this study with information from the United States and with Russian immigrant data from Israel. Interestingly, a sample of US family planning clinic patients who completed the HSCL-25 had higher prevalence of depression than either Russian immigrant group in this study, much higher prevalence of anxiety than the Russian community sample, and comparable anxiety prevalence to Russian clinic subjects (Winokur et al., 1984). Moreover, Russian Jewish immigrants to Israel surveyed with instruments that are similar to the HSCL-25 showed much higher prevalences of anxiety and depression among both community (Ritsner & Ponizovsky, 1998; Ritsner et al., 2001) and mental health clinic samples (Hesbacher et al., 1980) than did corresponding recent Russian immigrants to the United States. The pattern of mental disorders aecting recent Russian-speaking immigrants is likely to be dierent 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 populations are less than those of patients in other US medical settings and much less than those of Russian immigrants in Israel. Moreover, recent Russian immigrants dier markedly from the Jewish immigrants to the United States from the former Soviet Union in the

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

ACKNOWLEDGEMENTS
Supported in part by Providence Portland Medical Center and grant number K02 AA00281 from the National Institute on Alcohol Abuse and Alcoholism.

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Christopher Homann, 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 & Science University, 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: mcfarlab@ohsu.edu

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APPENDIX: Russian Health Survey

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