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Depression Trajectories in Relatively Recent Immigrants

Karen J. Aroian and Anne E. Norris


This longitudinal study of 253 ever-depressed former
Soviet immigrants (1) examined the life circumstances, demographic characteristics, and immigration demands of individuals whose depression lifted,
or who remained or became depressed over a 2-year
period; and (2) investigated whether immigration demands, local relatives, age at immigration, gender,
education, employment, and marital status differed
among the three groups. Depression was determined
based on depression scores at baseline and at 2-year
follow-up. Forty-three percent of the sample remained depressed, 26% became depressed, and 30%
had their depression lift over the course of 2 years.
The three groups did not differ with regard to demographic characteristics or loss of employment or a
negative change in marital status over the 2-year
study period. They did differ with respect to the pres-

ence of local family and immigration demands (P <


.05). Those who remained depressed were less likely
to have family in the area and had the highest immigration demand score at both time points. However,
the effect for presence of local family was not significant when immigration demands were included in
the analysis (P .32). Analysis of variance (ANOVA)
for repeated measures revealed that the group whose
depression lifted experienced the greatest change in
immigration demand scores over the 2-year study
period. Our findings argue that clinicians should not
expect immigrants depression to always decrease
over time and should assess depression by asking
about immigration demands, even if depression was
not present during an earlier clinical encounter.
2003 Elsevier Inc. All rights reserved.

by focusing on depression in the sample as a


whole. Improvement in depression could have
been present but obscured by the existence of sample subgroups that each had different patterns of
depression trajectories. Specific aims of the reanalysis were to: (1) describe the life circumstances,
demographic characteristics, and immigration demands of individuals with different depression trajectories, and (2) investigate whether individuals
with different depression trajectories also experience different changes in the demands of immigration over time. Identifying different depression trajectories and the characteristics associated with
various depression trajectories is of clinical relevance because this information alerts clinicians to
possible changes in emotional status and describes
how these changes may be related to changing life
circumstances and immigration demands in their
immigrant patients.
Findings about the course of immigrants depression are mixed. A number of studies report higher
rates of distress among recent rather than longstanding immigrants.13-18 A number of other studies report that years since arrival is unrelated to
distress.19-24 In two studies, number of years since
arrival was unexpectedly associated with increased
depression.25,26
Nonetheless, there is a general expectation that
immigrants emotional status will improve over
time as they adapt to and overcome immigration
demands like language, novelty, and finding suitable work. When there is empirical evidence to the

EPRESSION AMONG IMMIGRANTS from


the former Soviet Union (FSU) is an important topic of inquiry. There are more than 1 million
immigrants from the FSU throughout the world1
and depression is common in this group.2-7 In one
study of relatively recent former Soviet immigrants
(mean 3.73 years in Israel, SD 1.21), 55% of
the sample was depressed.8 In another study of
more longstanding former Soviet immigrants
(mean 3.80 years in the United States, SD
4.44), 36% of the sample was depressed.9 Depression significantly impairs immigrants ability to
adapt to the new country and has serious emotional
and economic consequences for immigrants and
their families.10,11
In an earlier report, we described findings from
a longitudinal study of depression 2 years later in a
sample of relatively recent, FSU immigrants.12
Surprisingly, there was little improvement in depression for the sample over time. Thus, we decided to reanalyze the data to determine if we
missed improved depression in some individuals
From the Wayne State University College of Nursing and
Department of Anthropology, Detroit, MI; and the Boston College School of Nursing, Boston, MA.
This work was conducted through Boston College and was
funded by the National Institutes of Health R29 NR 02866.
Address reprint requests to Karen Aroian, Ph.D., Wayne State
University, Cohn Building, 5557 Cass Ave, Detroit, MI 48202.
2003 Elsevier Inc. All rights reserved.
0010-440X/03/4405-0002$30.00/0
doi:10.1016/S0010-440X(03)00103-2
420

Comprehensive Psychiatry, Vol. 44, No. 5 (September/October), 2003: pp 420-427

DEPRESSION TRAJECTORIES IN IMMIGRANTS

contrary, a common post hoc explanation for unchanged or worsening depression is that depression
trajectories are group-specific and contingent upon
the nature of the groups stressors.19,25,26 For example, immigrants from countries that are war torn
or had repressive political regimes (e.g., Cambodia
or El Salvador) typically suffer extensive family
loss or personal violence like torture. These extreme premigration conditions are associated with
long-lasting emotional consequences that are initially masked by a brief period of post-traumatic
numbness or relief over surviving horrific
events.11,19,21,27 Group explanations, however, are
not always applicable. For example, most FSU
immigrants are refugees based on their ethnic minority status as Jews, Armenians, or Pentecostals.
These minority groups may have encountered discrimination in their daily life, such as decreased
access to career choices, or some pressure and
intimidation when trying to obtain exist visas to
immigrate to the United States. However, very few,
if any former Soviet immigrants suffered the horrific experiences that were common experiences in
groups with documented delayed or long-lasting
consequences.11,19,21,27 Yet, former Soviet immigrants appear to have sustained, unchanging depression.12
Individual differences in depression trajectories
within a single population of immigrants are seldom considered. Mixed findings regarding both the
course of depression in immigrants and its predictors could easily result when data are analyzed for
a sample as a whole and not according to individual differences in depression trajectories or demands of immigration.
We could locate only one study that looked for
patterns of increasing and decreasing emotional
distress in a single group of immigrants and for
factors, such as immigration demands, that might
be related to these patterns. Ritsner et al.28 found
different individual patterns of distress at 1-year
follow-up in a sample of relatively recent immigrants from the FSU. They assigned individuals to
one of three groups based on their pattern of distress: (1) stable low distress, (2) moderate or decreasing distress, and (3) high or increasing distress. The three groups differed in type and amount
of social support and number of immigration-related stressors. Lack of family support and ongoing
immigration-related stressors were associated with

421

high or increasing distress. However, the authors


considered a limited set of immigration demands,
specifically language and perceived discrimination.
Here, we consider a more complete set of immigration demands, one that includes novelty, occupation, loss, and not feeling at home in addition to
language and perceived discrimination.
Although biological factors also affect depression, we expect that immigration demands, specifically the changes experienced in these demands
during the resettlement period, play a key role in
the resolution, development, or even maintenance
of depression. This expectation is based on the
causal relationship between life stress and depression that has been documented in general populations.29-31 Like the causal relationship between generic stressors and depression, immigrants may
move into or out of depression as a function of the
changing demands they experience in their new
resettlement country or their ability to respond to
these demands. Conversely, one could expect that a
decrease in these demands would lead to an improvement in depressive symptoms.
Immigration demands are the most relevant set of
stressors to consider with respect to depression in immigrant populations. First, loss, not feeling at home,
novelty, occupation, language, and discrimination have
been identified as demanding aspects of the immigration experience for immigrants from the Middle East,
Asia, Latin America, and Southern and Eastern Europe.32-40 These stressors have been correlated with
distress in immigrants.15,18,22,41 Second, immigration
demands are a stronger predictor of distress in immigrants than are normative stressors.42-44 Finally, immigration demands have greater predictive value than
demographic variables. For example, age, gender, marital status, employment, and education have been associated with depression in immigrants.15,27,45-48 However, these demographic variables lose significance
once the demands of immigration are taken into account.15,18,22,43,49
In addition to the demands of immigration, we
also expect that family support may play a role in
the resolution or development of depression during
the resettlement period. For example, family support has been documented to buffer or prevent
immigration difficulties in Southeast Asian and
Mexican immigrants.18,19,50 Also, as noted earlier,
Ritsner et al.28 found that a lack of family support
was associated with a high or increasing pattern of

422

AROIN AND NORRIS

distress in their sample of immigrants from the


FSU.
METHOD

Sample
The data presented here are from 253 FSU immigrants to the
Boston area of the United States who were depressed at some
point during their early resettlement. These ever-depressed
participants were part of a larger longitudinal study of former
Soviet immigrants. In the larger study, 468 FSU immigrants
were interviewed twice, initially if they had been in the United
States 5 years or less, and again 2 years later. Participants were
considered ever-depressed if at least one of their Symptom
Checklist 90-R (SCL-90-R) depression scores (baseline, 2 years
later) met Derogatiss51 gender-specific criteria for caseness in a
community sample. Using these criteria, 253 (56.1%) of the
participants from the longitudinal study were categorized as
ever-depressed. Of these 253 ever-depressed participants, 109
participants were depressed at both time points or remained
depressed (RD); 77 participants were depressed at baseline
only, or, alternatively stated, their depression lifted (DL); and
77 participants were not depressed at baseline but became
depressed (BD) 2 years later.
As a group, ever-depressed participants were older at immigration (mean 49.76, SD 15.14) than the never-depressed
participants (mean 45.87, SD 17.55; t 2.539, df
425.73, P .01). Ever-depressed participants were also less
likely to be employed (36.8% v 53.8%, 2 13.38, df 1, P
.001). However, the two groups did not differ in terms of current
gender, marital status, ethnicity, education, years living in the
United States, or presence of relatives in Boston (P .08).
Also, like the never-depressed participants, the majority of the
ever-depressed participants were refugees (94.4%), had a minimum of a college degree (67.2%), and identified their ethnicity
as Jewish (79.1%). The second largest ethnic group was Armenian (11.5%), followed by Russian (6.3%). Their republics of
origin were as follows: 46.6% from Russia, 24.5% from the
Ukraine, 14.6% from Azerbaijan, and 14.3% from other republics. Almost all of the study participants were from urban
areas in these republics.
These demographic characteristics are similar to the local
Boston population of former Soviets52 and, to some extent, the
national US population of former Soviets.1,53 The educational
status of former Soviets who reside in Boston is, on average,
slightly higher than the educational status of former Soviet
immigrants who reside elsewhere in the United States.54 However, most FSU immigrants in the United States are from Russia
or the Ukraine and, as previously stated, have refugee status
based on ethnic minority status in the FSU. Soviet Jews are the
largest ethnic minority.1 Additional demographic characteristics
of the ever-depressed sample, including breakdown by depression trajectory group, are discussed later.
Participants were originally recruited through written advertisement in ethnic newspapers and verbal advertisement by a
data collection team of 12 people who were also FSU immigrants. The data collection team was representative of the local
former Soviet immigrant population so that their recruitment
efforts would not bias the sample toward particular demographic characteristics. Specifically, the data collectors were of
both genders, of various age groups, from representative repub-

lics of origin in the FSU, and had been in the United States for
varying lengths of time.
Change-of-address cards were mailed every 6 months after
the first data collection to maintain contact with the initial study
participants. Over the course of 2 years, 61.7% of the baseline
participants either were no longer eligible because of moving
out of the Boston area or moved without providing a forwarding
address. Of the remaining participants who were eligible and
could be located, only 9.5% declined to participate in the
second phase of data collection. More in-depth description of
the baseline-only sample is available elsewhere.12 Of note,
however, is that the longitudinal sample (i.e., the combined
ever- and never-depressed groups) did not differ significantly
from the baseline only sample in gender, education, marital
status, presence of relatives in Boston, or depression scores
(P .17).

Instruments and Procedure


During the first and the second data collection appointments,
study participants provided consent and completed Russian
language versions of a demographic questionnaire, the Demands of Immigration Scale (DI),52 and the Depression Scale of
the SCL-90-R.51 Russian-speaking research assistants collected
these data in person in the study participants homes. Russian
language forms of the data collection materials were developed
through translation and back translation.56 More in-depth description of the translation procedure is provided elsewhere.9
The demographic questionnaire elicits information about city
of origin, length of time in the United States, immigration
status, age, gender, marital status, educational level, language of
preference, occupation pre- and postmigration, employment
status, and availability of local relatives. At its second administration 2 years later, items about city of origin, age, premigration employment, and gender were omitted.
The DI Scale is a 23-item, standardized, paper-and-pencil
measure that contains items about loss, not feeling at home,
novelty, occupational adjustment, language accommodation,
and discrimination. Loss items elicit information about longing
and unresolved attachment to people, places, and things in the
homeland. Not feeling at home items ask about feeling like a
stranger or a foreigner who is not part of ones surroundings or
included in the social structure. Novelty items ask about newness, unfamiliarity, or information deficits related to living in
the new country. Occupational adjustment items tap difficulty
finding acceptable work, status demotion, and lack of opportunities for professional advancement. Language accommodation
items pertain to the immigrants subjective perception of having
a less than adequate command of the host language, including
extent of vocabulary, comprehension of local dialect, and ability
to be understood given the strength of ones accent. Discrimination items ask about active or subtle discrimination, such as
the notion that immigrants do not belong in the United States or
deserve the same rights as the native born. Respondents rate the
extent to which they have been distressed by each of the stated
demands as it applies to their recent (within the last 3 months)
personal experience as immigrants. Items are rated along a
six-point scale ranging from not at all (0) to very much (5)
distressed. The grand total indicates the magnitude of immigrant demands.
Content for the DI Scale was derived from three separate
studies with Polish (N 25), Irish (N 25), and Russian (N

DEPRESSION TRAJECTORIES IN IMMIGRANTS

42) immigrants.33,34,57 The DI Scale was evaluated in a fourth


study with a validation sample of 857 Russian immigrants who
had resided in the United States from a few months to 20
years.55 Confirmatory factor analysis supported the proposed
six-factor model (the standardized factor loadings for the items
ranged from .67 to .88). The DI was internally consistent
(alpha .94) and had good test-retest reliability over a 3-week
interval (r .92).
The SCL-90-R is a multidimensional, self-administered
questionnaire of psychological distress that asks respondents to
rate each item along a five-point scale of distress from not at
all (0) to extremely (4) distressed. The 13-item Depression
Scale of the SCL-90-R reflects a broad range of manifestations
of clinical depression, including dysphoric mood and affect,
lack of motivation and energy, feelings of hopelessness, and
other cognitive and somatic correlates of depression. Cronbachs alpha for the Russian language version of the Depression
Scale was .91. Test-retest reliability over a 1-week interval was
.85.9

Data Analysis
A series of analyses were used to investigate differences in
demographic characteristics, life circumstances, and demands
of immigration for three depression trajectory groups (BD, RD,
and DL). First, chi-square analyses and analysis of variance
(ANOVA) were used to determine if these three groups differed
on any demographic variables. Next ANOVA for repeated measures was used to study changes in the demands of immigration
experienced by these three groups over time. Scores on the DI
at baseline and 2 years later served as the dependent variable.
Independent variables included: time (baseline, two years later)
and depression group (BD, RD, DI). Finally, the ANOVA was
repeated with any demographic variables that the three groups
differed on significantly treated as additional independent variables in the analysis.

RESULTS

Demographic Characteristics
With the exception of having a relative in Boston, the three depression trajectory groups did not
differ in their demographic characteristics. A
greater proportion of those whose depression lifted
(87%) had at least one relative in Boston as compared to those who became depressed (82%) or
remained depressed (73%; 2 3.96, df 1, P
.05). However, the three groups did not differ in
their age at immigration (P .59) and there was
no association with age group, gender, education,
or employment (P .34). In addition, neither
becoming unemployed, nor divorced, separated, or
widowed was associated with becoming depressed,
remaining depressed, or having ones depression
lift (P .40). The proportion of those who had
become unemployed (3% to 5%) or experienced a
negative change in their marital status (2% to 4%)

423

was small and fairly consistent across all three


groups (Table 1).
Demands of Immigration
As expected, the three groups did differ in their
scores on the DI Scale. Main effects for depression
group [F(2,250) 20.59] and time [F(1,250)
37.83] were both significant (P .001). As predicted, there was a significant depression group by
time interaction [F(2,250) 18.12, P .001). An
inspection of the means indicated that it was the
group whose depression lifted who had the greatest
change in their demands of immigration (Table 2).
Post hoc comparisons, using the Scheffe test, confirmed that it was only the group whose depression
lifted that had significantly different DI scores at
the two time points (P .001).
The significant differences in DI scores over
time for the depression groups remained after including having a relative in Boston in the repeatedmeasures analysis (P .001). Both the main effect
for depression group and time, as well as the interaction between these two variables, was significant (P .001). However, the main effect for
relatives in Boston was not significant (P .32),
and there were no significant interactions involving
this term (P .29).
DISCUSSION

This study confirmed that there are different


depression trajectories over a 2-year period in a
single group of relatively recent immigrants from
the FSU. Although analysis of individual differences revealed that the greatest number of people
(43%) remained depressed, a sizeable number either became depressed (26%) or had their depression lift (30%).
By disaggregating our data, we uncovered a
distribution that led to the misleading conclusion
from an earlier group analysis that depression remains unchanged in former Soviet immigrants.
This distribution was an almost equal number of
people with opposing depression scores, that is,
26% got worse and 30% got better at 2-year follow-up. Combined, this proportion of opposing
individual scores (56%) was close to the number of
individuals whose depression did not change
(46%). Thus, opposing directions of change in a
sizable number of individuals canceled out real
changes and affected the mean depression change
score. Reanalyses of group data from other studies

424

AROIN AND NORRIS

Table 1. Demographics for Sample


Became Depressed
(n 67)

Remained Depressed
(n 109)

Depression Lifted
(n 77)

Total
(N 253)

11.9%
44.8%
43.3%
49.20
(SD 16.49)
3.59
(SD .28)

7.3%
48.3%
44.0%
50.86
(SD 12.97)
3.47
(SD .06)

14.3%
41.6%
44.2%
48.68
(SD 16.80)
3.80
(SD 1.11)

10.7%
45.5%
43.9%
49.76
(SD 15.15)
3.60
(SD 1.14)

56.7%
43.3%

53.2%
46.8%

58.4%
41.6%

55.7%
44.3%

82.1%
0.0%
14.9%
0.0%
3.0%

76.1%
6.4%
1.9%
3.7%
1.8%

80.5%
11.7%
7.8%
0.0%
0.0%

79.1%
6.3%
11.5%
1.6%
1.6%

4.5%
23.9%
7.5%
61.2%
3.0%
34.3%
65.7%
81.8%

1.8%
15.6%
8.3%
66.1%
8.3%
33.3%
71.6%
72.5%

1.3%
6.5%
11.7%
74.0%
6.5%
42.9%
74.0%
87.0%

2.4%
15.0%
9.1%
67.2%
6.3%
36.5%
70.8%
79.4%

Current age group (yr)


20-32 y
33-57 y
58 y
Age at immigration
Years in the United States
Gender
Female
Male
Ethnicity
Jewish
Russian
Armenian
Ukranian
Other
Education
Some high school
High school grad
Some college
College grad
Grad degree
Currently employed
Currently married
Relative in Boston*
*P .05.

on this topic may also reveal that certain individual


patterns are distorting mean scores and contributing to misleading impressions about group-specific
depression trajectories. There may be a predominant course of depression for particular immigrant
groups. However, individual differences should be
explored before embracing this conclusion.
The three depression groups in this study did not
differ with regard to the demographic variables or,
in the final analysis, the presence of local family.
The only significant difference among the three
groups was change in their demands of immigration over a 2-year period: the groups whose depression worsened or remained the same had rela-

tively little change from baseline in their


immigration demands, whereas the group whose
depression lifted had significantly lower immigration demand scores at the 2-year follow-up than
they had at baseline. FSU immigrants become depressed if immigration demands do not lesson over
a 2-year time period. Conversely, overcoming or at
least lessening the demands of immigration over
the course of 2 years decreases depression in this
sample of relatively recent former Soviet immigrants. These findings are also consistent with findings from another study with former Soviet immigrants where ongoing immigrant demands were
associated with sustained or ongoing distress.28

Table 2. Depression Group Means on Demands of Immigration Scale at Times One and Two
Demands of Immigration
Depression Group

Time 1

Time 2

Results of Scheffe Test


Within-Group Comparison

Became depressed (n 67)


Remained depressed (n 109)
Depression lifted* (n 77)

3.47 (.98)
4.05 (.92)
3.70 (.87)

3.42 (1.09)
3.85 (1.01)
2.67 (1.09)

P .05
P .05
P .001

NOTE. Standard deviations are reported in parentheses. Significant between-group comparisons at time one were: BD v RD; RD
v BD, DL (P .05). Significant between-group comparisons at time two were: BD v RD, DL; RD v BD, DL (P .05).

DEPRESSION TRAJECTORIES IN IMMIGRANTS

425

The lack of significance of demographic variables in this study was somewhat anticipated. Even
though the literature suggests that demographic
variables make some contribution, we expected
immigration demands to provide more information. Gender, on the other hand, may be insignificant because we used gender-specific norms for
interpreting depression scores. An unexpected
finding was that the three depression groups did
not differ with regard to the availability of local
family. This finding is contradictory to findings
from studies that document the importance of family for buffering or preventing immigrants depression.18,19,50 On the other hand, family presence
may not have been a good indicator of family
support. In one study of former Soviet immigrants,
families were only supportive if family members
were not preoccupied or overwhelmed with their
own immigration difficulties.10
This study contributed to understanding the
range of individual differences in depression trajectories in relatively recent FSU immigrants.
More importantly, it identified the life circumstances associated with clinically relevant distinctions, specifically improved, worsening, or unchanging depression. Study findings suggest that
clinicians should not expect immigrants depression to always decrease over time. Individual assessments should include directly inquiring about
the signs and symptoms of depression, even if
depression was not present during an earlier clinical encounter. Key questions about the presence
and magnitude of immigration demands over time
should also be included. Interventions should be
geared toward alleviating immigration demands.
Specifically, clinicians should intervene by addressing practical issues, such as learning English
and obtaining meaningful employment, as well as

emotional issues, such as grieving and overcoming


losses and not feeling at home in the new country.
Directions for further research are to investigate
whether variation in depression trajectories also
exists in other immigrant groups. Research of this
nature is preliminary to comparative studies that
focus on group differences in depression trajectories. Also of interest is the mechanisms underlying
these group differences. For example, do the individuals expectations, and their perceptions of
whether or not their expectations are being met,
play a role? Some individuals could be optimistic
upon arrival and expect immigration demands like
language difficulties, joblessness, and the like to be
temporary and easily resolvable. These immigrants
could conceivably become depressed later if their
expectations are not met. Similarly, early depression over immigration demands could dissipate or
become long lasting depending on how initial expectations differ from the actual course of resettlement. Alternatively, it may be the social milieu in
which the immigrant finds his or herself that is
most critical. Hence, at a minimum, it would be
helpful to use more direct measures of family support to determine the role family members play in
immigrants emotional status over time. Lastly, a
limitation of this research is that we did not obtain
data on medical or psychiatric treatment for depression or prior personal or family history of
depression. Possibly, some immigrants may have
became depressed or had their depression lift over
the course of the 2-year study period because of
biological factors that were unrelated to their life
circumstances. Future studies should include these
variables as they also likely play a key role in the
development and maintenance of depression over
time.

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