Depressive Symptoms and Utilization of Mental Health Services among Older Israelis Across Population Groups

Abstract

This study aimed to assess the prevalence of clinically significant depressive symptoms; utilization of mental health services and associated socioeconomic and clinical factors in three main population groups of older adults in Israel. We used data collected by the Survey on Health, Ageing and Retirement in Europe (SHARE). Our study included data from 3,517 participants (54% female, mean age 64 years), identified as belonging to three population groups living in Israel: Israeli-born and early-immigrant Jews (those born in Israel or immigrated before 1989), Israeli Arabs, and more recent immigrants from the Former Soviet Union (FSU). We applied logistic regression to estimate the association of socioeconomic and clinical characteristics with clinically significant depressive symptoms (4 and more points on the EURO-D scale) and the utilization of mental health services in each population group. The prevalence of clinically significant depressive symptoms was highest amongst FSU immigrants (44%), followed by Israeli Arabs (32%), and the lowest amongst Israeli-born and early-immigrant Jews (30%). Greater levels of self-reported disability and a higher number of chronic diseases were associated with clinically significant depressive symptoms in all three population groups. Utilization of mental health services was the least common in Israeli Arabs (17%) and was related only to physical inactivity, followed by FSU immigrants (36%), where it was associated with female sex, disability, and chronic diseases. Mental health services were utilized the most by Israeli-born and early-immigrant Jews (41%), and was associated with disability, chronic diseases, and working status. Based on these findings, we conclude that taking into account ethnic disparities in the burden of depressive symptoms and the rate of mental health services utilization among older Israelis is essential to tailor better prevention and treatment strategies.

Keywords

depression epidemiology Israel ethnicity mental health utilization

Introduction

Mental health disorders are often under-identified and under-treated among older adults. Contributing factors include limited availability of appropriate services, under-recognition by health care providers and older people themselves, and stigma. Together these lead to a treatment gap, defined as the discrepancy between the prevalence of conditions requiring treatment and the actual utilization of services (Horackova et al., 2019; Kagstrom et al., 2019). Even though depression in older adults has a profound impact on their physical and mental vulnerability and is associated with somatic comorbidities, increased mortality, and a substantial economic burden, the majority of older adults with clinically significant depressive symptoms do not use any mental health services (Pan et al., 2011; Portellano Ortiz et al., 2016).

Like other high-income countries (OECD, 2021), Israel is aging demographically (Dwolatzky et al., 2017). Early studies found that 17% of community-dwelling older adults in Israel had been diagnosed with depression over the preceding year (Biderman et al., 2002). It was estimated that the lifetime prevalence rate of clinical depression in Israel is 10%, with the lifetime risk at age 75 reaching as high as 20% (Levinson et al., 2007). A recent Israeli study among community-dwelling people aged 65 years and older found that about a quarter of them had depressive symptoms (Bentur & Heymann, 2020). The true prevalence of clinically significant depressive symptoms in the community might be even higher (Iancu et al., 2003).

Israeli society is structured along ethnic-religious lines, as well as by place of origin and time since immigration (Shnoor & Cohen, 2021). Examining the older population in Israel, a complex picture emerges. As of 2019, 68.4% of the 65 years and older population in Israel were Israeli-born and early-immigrant Jews, who were born in Israel or immigrated before 1989, 18.2% were Former Soviet Union (FSU) immigrants, who immigrated to Israel from 1989 onward, and 13.4% were Israeli Arabs. Seventy-eight percent of the Jewish population aged 65 years and older were born outside of Israel (Shnoor & Cohen, 2021).

Socio-Cultural Background of the Arab Minority in Israel

The Israeli Arab population, mainly comprised of Palestinians who are citizens of the State of Israel, constitutes around 21% of the Israeli population. Most Israeli Arabs are Muslims (85.5%) with Druze (7.4%) and Christians (6.9%) minorities (Central Bureau of Statistics, 2023). With the establishment of Israel in 1948, some Palestinians living in what became the state of Israel were granted Israeli citizenship. Yet, many identify themselves as ‘sub-citizens’ due to their minority status in a state that defines itself as “ethnically” Jewish, the Israeli-Palestinian conflict, and the cultural differences that shape this population's identity and social dynamics (Mahajne et al., 2022). Socioeconomically, Israeli Arabs face disparities compared to the Jewish population, including lower average income levels, higher rates of unemployment, and limited access to resources and opportunities, such as quality education and healthcare services (Central Bureau of Statistics, 2023). While progress has been made in recent years, there are still many challenges in these areas (Azaiza, 2013; Central Bureau of Statistics, 2023).

Arabs in Israel constitute a community in which many emphasize traditional religious and family values. Their families are, on average, larger compared to the Jewish population, and multigenerational homes are common. However, social change and modern ways of life have brought about significant transformations in the structure of families and communities. These changes impact Israeli Arab culture and communities in various ways, such as in relation to gender roles, family planning, the status and care of older adults, and perceptions of health and wellness (Azaiza, 2013).

Socio-Cultural Background of FSU Immigrants in Israel

Immigrants from the FSU to Israel comprise roughly 10% of the Israeli population (Central Bureau of Statistics, 2023). Immigration from the FSU to Israel occurred in a significant wave, with approximately one million individuals arriving during the 1990s and early 2000s (Remennick, 2007). FSU immigrants to Israel comprise a heterogeneous population. They originated from different republics within the Soviet Union (which subsequently transformed into separate nations) and the length of their time of residency in Israel varies. There is, among them, a spectrum of identifications with and affiliations to Judaism. Some have successfully integrated into mainstream Israeli society and culture, while others have maintained a greater degree of isolation within their communities (Knaifel, 2022; Konstantinov, 2015).

Although they have diverse backgrounds, FSU immigrants in Israel are considered to share certain social characteristics (Knaifel, 2022; Remennick, 2007). They tend to possess a relatively high level of education and professional experience (Central Bureau of Statistics, 2016). Yet their integration into Israeli society has been hampered by challenges such as limited proficiency in Hebrew (especially among middle-aged and older individuals); a struggle to find employment corresponding to their qualifications; and economic hardship (Central Bureau of Statistics, 2016; Konstantinov, 2015). Moreover, the overall health status of these immigrants, particularly among older individuals, is poorer compared to the wider Jewish community (Konstantinov, 2015; Semyonov-Tal & Maskileyson, 2021).

Nonetheless, FSU immigrants, particularly the younger generation, have undergone a continuous process of integration into Israeli society and culture. The majority of these immigrants report a sense of belonging and express their intention to remain in the country (Amit, 2012; Dolberg et al., 2016). Over time, there has been an improvement in the Hebrew language proficiency as well as the employment and professional status of FSU immigrants, with time spent in Israel leading toward a convergence in standard of living with the general Israeli population (Central Bureau of Statistics, 2016; Konstantinov, 2015).

The Present Study

Previous studies suggested a particularly high burden of depression among Israeli Arabs (Abu-Kaf, 2019; Abu-Kaf & Shahar, 2017) and FSU immigrants (Dolberg et al., 2019; Knaifel et al., 2023; Nakash et al., 2020). Being an immigrant has been identified as a significant predictor of developing depressive symptoms (Martinez Tyson et al., 2016), particularly among older adults (Dolberg et al., 2019; Guo & Stensland, 2018; Guo et al., 2019). Unfamiliarity with a place, new social norms and culture, discrimination, and a new language are known stressors related to immigration (Alegría et al., 2017; Cervantes et al., 2019). Moreover, older immigrants are at a double jeopardy for loneliness, and tend to report greater loneliness than native-born persons (Dolberg et al., 2016; Dong et al., 2012; Hurtado-de-Mendoza et al., 2014). Disparities in rates of depressive symptoms between population groups in Israel may be linked to specific cultural, sociodemographic, and lifestyle factors as well as differential access to mental health services, which can contribute to a treatment gap for depression (Abu-Kaf & Shahar, 2017; Schwartz et al., 2019).

Given their diversity, groups of older adults residing in Israel are likely to vary in their population-level treatment gap for depression. One study found that the health status of immigrants in Israel was poorer compared to native-born Israelis, but this disparity could not be fully explained by socioeconomic inequalities in health-related behaviors, suggesting that additional factors, such as cultural norms, acculturation processes, or stress related to minority status, may contribute to the gap (Semyonov-Tal & Maskileyson, 2021). It is plausible that a similar disparity exists for mental health, which may be driven by varying levels of utilization of mental health services.

In the present study, we aimed to determine (1) the prevalence of clinically significant depressive symptoms; (2) the rate of utilization of mental health services, as well as to identify (3) associated socioeconomic and clinical factors amongst Israeli-born and early-immigrant Jews, Israeli Arabs, and FSU immigrants. Better knowledge of the factors that influence the occurrence and treatment of depression in older adults in Israel could offer strategies to approach depression in a way that would benefit each population group.

Methods

Source of Data

We use data from the prospective cohort study Survey on Health, Ageing and Retirement in Europe (SHARE), a pan-European study of health, social network, and economic conditions of community-dwelling individuals, that was previously described in detail (Börsch-Supan et al., 2013). Briefly, individuals eligible for the study were people aged 50 years and older and their spouses. The data were collected via in-person interviews conducted by trained staff using a computer-assisted personal interview (CAPI). SHARE was initiated in 2004, followed by five subsequent waves in approximately two-year intervals, with wave 7 completed in 2017. Israel was a part of SHARE since its beginning, being the first country in the Middle East to initiate a systematic study of its aging population. Israel participated in SHARE in five waves: 1 (2005/2006), 2 (2009/2010), 5 (2013), 6 (2015), and 7 (2017). Of note, waves 1,2,5,6, and 7 of SHARE are referred to as waves 1, 2, 3, 4, and 5 of SHARE-Israel (respectively((Israel Gerontological Data Center, n.d.).

For this study, we followed the group definitions used in SHARE-Israel (Litwin, 2009). Accordingly, three segments of the population were examined: 1) Israeli-born and early-immigrant Jews, defined as born in Israel or who immigrated to before 1989 and were interviewed in Hebrew; 2) Israeli Arabs, who were interviewed in Arabic; and 3) FSU immigrants, who immigrated after 1989 and were interviewed in Russian. Since the SHARE-Israel questionnaire was administered in three different languages, feedback from native speakers and the results of pilot tests were used to reformulate several questions to improve their comparability (Litwin, 2009).

SHARE was approved by the Ethics Committee of the University of Mannheim and the Ethics Council of the Max Plank Society. All participants provided written informed consent. Data were pseudo-anonymized and participants were informed about the storage and use of the data, their right to withdraw consent, and that the data may be reused for future scientific studies within the SHARE project framework (Börsch-Supan et al., 2013).

Depressive Symptoms

All but the last wave of SHARE-Israel used the EURO-D scale (Prince et al., 1999), a tool to measure symptoms of depression in older adults. This scale consists of 12 items: depressed mood, pessimism, wishing for death, guilt, sleep, interest, irritability, appetite, fatigue, concentration, enjoyment, and tearfulness. One point is given for each present symptom, generating a scale ranging from 0 to 12, with higher values indicating the presence of a greater number of depressive symptoms, which is typically interpreted as reflecting more severe depression. In the original validation study, individuals who scored at least four points on the scale were found to be at risk of clinical depression (Prince et al., 1999). Therefore, the cut-off of four points is commonly used to identify clinically significant depressive symptoms. The internal consistency is reported to be moderately high across different cultures, with a Cronbach´s alpha ranging from 0.61 to 0.75 (Guerra et al., 2015). The EURO-D scale and the four-point cut-off have been used in many previous studies (Formanek et al., 2019; Horackova et al., 2019; Kucera et al., 2020).

Two additional subscales (affective suffering and motivation) were suggested by studies literature (Guerra et al., 2015; Maskileyson et al., 2021). Therefore, in descriptive analyses, we also use these to compare the burden of affective suffering (sum of points scored on the items depressive mood, sleep, guilt, irritability, and tearfulness) and the lack of motivation (sum of points scored on the items pessimism, interest, concentration, enjoyment) between the three population groups.

Utilization of Mental Health Services

We defined the utilization of mental health services using four different variables. Participants were asked whether they (1) take drugs for anxiety or depression, (2) have ever been treated for depression by a doctor, (3) have ever been told that they have an affective or emotional disorder, and (4) have ever been admitted to a mental hospital or psychiatric ward. As only the first relates to the present time of the survey, while other variables are defined as “ever”, we opted for the least stringent approach by creating a variable “utilization of mental health services” that applied to participants with current clinically significant depressive symptoms who answered yes to any of the above questions.

Covariates

Potential variables that might be associated with clinically significant depressive symptoms and utilization of mental health services were initially identified based on literature (Formanek et al., 2019; Horackova et al., 2019; Kucera et al., 2020). These included sociodemographic characteristics, socioeconomic position (SEP), family situation, clinical characteristics, and health behavior. Sociodemographic characteristics were age (in years), sex (male vs. female), born in Israel (yes or no), and number of years lived in Israel. Factors related to SEP included education (low vs. middle vs. high), household net worth (standardized difference between household gross financial assets and financial liabilities), current job situation (currently working = employed or self-employed vs. not working = retired, unemployed, permanently sick, homemaker), and type of residence (urban = a big city or suburbs or outskirts of a big city vs. non-urban = a large town, a small town or a rural area or village). Characteristics related to a family situation were a partner in the household (yes vs. no), household size (number of household members), and number of children and grandchildren.

Clinical characteristics were verbal fluency (number of animals named in theanimal fluency test, used as an indicator of cognitive function), the number of limitations in instrumental activities of daily living (IADL), the number of chronic diseases, and maximal grip strength. Data on health behavior included body mass index (BMI), physical inactivity (never engaging in vigorous or moderate physical activity vs. some physical activity), smoking (ever smoked daily vs. never smoked daily), and alcohol use (more than 2 glasses of alcohol almost every day vs. fewer).

Analytical Sample

We restricted the analysis to participants in SHARE aged 50 and older who were assessed for depressive symptoms using the EURO-D scale. After excluding 333 individuals with missing data on depressive symptoms, a further 149 individuals younger than 50 years, and 41 respondents with unknown identity, the final analytical sample consisted of 3,517 participants (54% female, average age 64 years old). To ensure a sample size that would allow for subgroup analyses, for each participant we used data from the first SHARE-Israel wave in which information on depressive symptoms was available, so that each individual contributed data only once. Most of the data used in our study came from the first wave of SHARE-Israel in 2005/2006 (65% of the analytical sample). For 19% of the analytical sample, the data was from the second SHARE-Israel wave in 2009/2010, for 14% from the third SHARE-Israel wave in 2013 (wave 5 of SHARE), and for 2% from the fourth SHARE-Israel wave in 2015 (wave 6 of SHARE), see Table 1 for details. Although SHARE-Israel is a longitudinal survey, in the present analysis each participant contributed data from a single wave only, i.e., each participant's data was used once. Therefore, our design is effectively cross-sectional, pooling participants from different waves.

Table 1.

Information About the Recruitment of Participants in Each Wave.

Wave	New participants	Overall sample size	Included in the analytical sample; n (% of the overall sample)	% of the analytical sample
1 (2005/2006)	2591	2591	2286 (88)	65
2 (2009/2010)	391	2447	668 (27)	19
5 (2013)	500	2599	492 (19)	14
6 (2015)	-	2035	71 (3)	2
Wave-to-wave retention rates by wave number
	Wave 1–2 retention rate (%)	Wave 2–5 retention rate (%)	Wave 5–6 retention rate (%)	Wave 6–7 retention rate (%)
Wave 1	75.6	82.6	74.8	84.5
Wave 2		78.3	86.4	79.9
Wave 5			62.1	75.6
Wave 6				Not available

Sources: Bergmann et al. (2017); Börsch-Supan et al. (2013).

Statistical Analysis

Data is presented as mean ± standard deviation (SD), median and interquartile range (IQR), or frequency (n, %), where appropriate. To compare participants’ characteristics between the three population groups, analysis of variance (ANOVA) was used for continuous normally distributed data, Kruskal-Wallis test for continuous skewed data and, χ² test for categorical variables.

Multivariable analysis was performed in two steps. First, we examined which factors were associated with clinically significant depressive symptoms in each population group. We estimated the odds ratio (OR) with 95% confidence intervals (CI) for this association using the following strategy: After entering all characteristics into the model, we took away each covariate (one by one) that was not statistically significantly associated with depressive symptoms. If McFadden's pseudo-R-squared stayed the same or improved, we omitted this variable from the final model.

Second, we examined which factors were associated with the utilization of mental health services in individuals with clinically significant depressive symptoms in each population group. As the sample size was not large enough to use the modeling strategy applied in the previous step, we first identified variables using logistic regression that are significantly associated with the utilization of mental health services when adjusted for age and sex. We then used these variables in the final multivariable model. For Israeli-born and early-immigrant Jews, these variables were current job situation, number of limitations in IADL, number of chronic diseases, and physical inactivity. For Israeli Arabs, the variables were the number of limitations in IADL, number of chronic diseases, and physical inactivity, and for FSU immigrants the number of limitations in IADL and the number of chronic diseases.

All analyses were conducted using STATA (version 15.1). Collinearity was assessed with variance inflation factor (VIF) in all models and we excluded variables with VIF >5. p < .05 was considered as the threshold for statistical significance.

Results

In our analytical sample of 3,517 individuals, 2,483 (71%) were identified as Israeli-born and early-immigrant Jews, 387 (11%) as Israeli Arabs, and 647 (18%) as FSU immigrants (Table 2). The FSU immigrants had the highest average levels of education, while Israeli Arabs had the lowest (the proportion of individuals with high education was 59% vs. 8%). Israeli-born and early-immigrant Jews had by far the highest average household net worth and proportion of working individuals. The Israeli Arabs had the largest average families and households, while the Israeli-born and early-immigrant Jews had the highest levels of verbal fluency, least functional limitations, and lowest prevalence of obesity and alcohol use.

Table 2.

Characteristics of the Analytical Sample by Population Group.

	Israeli-born and early- immigrant Jews (n = 2483)	Israeli Arabs (n = 387)	FSU immigrants since 1989 (n = 647)	p-value
Clinical characteristics
Depressive symptoms, n (%)	732 (29.5)	124 (32.0)	286 (44.2)	<.001
Affective suffering, median (IQR)	1 (2)	1 (3)	2 (3)	<.001
Lack of motivation, median (IQR)	0 (1)	1 (1)	1 (1)	<.001
Sociodemographic characteristics
Age, mean ± SD	63.5 ± 9.6	62.0 ± 8.3	67.3 ± 10.0	<.001
Female, n (%)	1344 (54.1)	183 (47.3)	376 (58.1)	<.001
Born in Israel, n (%)	1019 (42.5)	360 (97.3)	0 (0)	<.001
Years lived in Israel, median (IQR)	56 (8)	61 (13)	16 (7)	<.001
Socioeconomic position
High education, n (%)	672 (27.1)	32 (8.3)	383 (59.2)	<.001
Highest decile in household net worth, n (%)	330 (13.3)	7 (1.8)	14 (2.2)	<.001
Currently working, n (%)	1132 (45.6)	70 (18.1)	217 (33.5)	<.001
Urban residence, n (%)	1826 (74.9)	79 (20.5)	250 (39.6)	<.001
Family situation
Partner in household, n (%)	1997 (80.4)	365 (94.3)	477 (73.7)	<.001
Household size, median (IQR)	2 (1)	3 (3)	1 (1)	<.001
Three and more children, n (%)	1640 (66.0)	355 (91.7)	73 (11.3)	<.001
Three and more grandchildren, n (%)	1380 (55.6)	292 (75.5)	246 (38.0)	<.001
Clinical characteristics
Verbal fluency, mean ± SD	18.6 ± 7.1	17.0 ± 6.3	15.9 ± 6.3	<.001
Two or more limitation in IADL, n (%)	248 (10.0)	71 (18.3)	142 (21.9)	<.001
Two or more chronic diseases, n (%)	1176 (47.4)	157 (40.6)	431 (66.7)	<.001
Maximal grip strength, mean ± SD	31.4 ± 11.7	32.8 ± 12.6	29.1 ± 11.9	<.001
Health behaviors
Obesity^a, n (%)	448 (18.6)	95 (25.5)	199 (31.1)	<.001
Physical inactivity, n (%)	472 (19.0)	87 (22.5)	100 (15.5)	.016
Smoking, n (%)	1067 (43.0)	98 (25.3)	201 (31.1)	<.001
Alcohol use, n (%)	28 (1.1)	5 (1.3)	24 (3.7)	<.001

body mass index ≥ 30; SD, standard deviation; IQR, interquartile range; IADL, instrumental activities of daily living; FSU, Former Soviet Union.

Clinically Significant Depressive Symptoms and Associated Factors

The prevalence of clinically significant depressive symptoms was 32% in the whole sample and was highest amongst FSU immigrants (44%), followed by Israeli Arabs (32%) and lowest amongst Israeli-born and early-immigrant Jews (30%). The population groups also differed in the subscales of depressive symptoms: Israeli-born and early-immigrant Jews scored the lowest in affective suffering as well as lack of motivation. FSU immigrants had the highest score in affective suffering, while both Israeli Arabs and FSU immigrants had the same score in lack of motivation.

The only variables associated with higher odds of clinically significant depressive symptoms in all three population groups were a higher number of limitations in IADL and of chronic diseases (Table 3). Associations with other characteristics differed between groups. For Israeli-born and early-immigrant Jews, physical inactivity and smoking were related to higher odds of clinically significant depressive symptoms, while older age, being born in Israel, having both middle and high education levels, highest household net worth, and higher maximal grip strength were associated with a lower likelihood of clinically significant depressive symptoms. For Israeli Arabs, having a partner in the household and higher maximal grip strength were related to lower odds of clinically significant depressive symptoms. For FSU immigrants, being female was associated with more than two-fold greater odds of clinically significant depressive symptoms, while high education, urban residence, and greater household size were related to lower odds.

Table 3.

Association of Participantś Characteristics with Depressive Symptoms in Each Group.

	OR (95% CI)
	Israeli-born and early-immigrant Jews	Israeli Arabs	FSU immigrants since 1989
Age	0.97 (0.95; 0.99)*	0.61 (0.35; 1.08)	0.98 (0.95; 1.02)
Female	/	/	2.48 (1.55; 3.96)**
Born in Israel	0.73 (0.54; 0.98)*	0.01 (0.00; 37.11)	/
Years lived in Israel	1.00 (0.99; 1.01)	1.65 (0.94; 2.92)	0.98 (0.94; 1.02)
Education
Low	Reference	Reference	Reference
Middle	0.64 (0.50; 0.82)**	0.72 (0.16; 3.23)	0.79 (0.30; 2.14)
High	0.45 (0.33; 0.62)**	1.15 (0.35; 3.75)	0.35 (0.13; 0.94)*
Trend	<0.001	0.93	<0.001
Highest decile in household net worth	0.65 (0.45; 0.96)*	0.02 (0.00; 143.55)	/
Currently working	0.79 (0.61; 1.02)	/	0.64 (0.36; 1.12)
Urban residence	/	0.40 (0.14; 1.08)	0.54 (0.35; 0.84)*
Partner in household	0.90 (0.67; 1.20)	0.12 (0.02; 0.67)*	1.25 (0.76; 2.04)
Household size	1.10 (1.00; 1.21)	0.96 (0.79; 1.16)	0.80 (0.65; 0.98)*
Children	/	1.13 (0.98; 1.29)	1.25 (0.92; 1.69)
Grandchildren	0.99 (0.97; 1.02)	0.97 (0.90; 1.03)	0.89 (0.78; 1.02)
Verbal fluency	0.99 (0.97; 1.01)	0.96 (0.91; 1.02)	0.98 (0.94; 1.02)
Limitations in IADL	1.46 (1.27; 1.68)**	1.46 (1.03; 2.07)**	1.44 (1.20; 1.73)**
Chronic diseases	1.25 (1.16; 1.35)**	1.90 (1.49; 2.43)**	1.27 (1.13; 1.43)**
Maximal grip strength	0.96 (0.95; 0.97)**	0.96 (0.93; 0.99)*	/
BMI	1.00 (0.98; 1.03)	1.01 (0.94; 1.10)	1.00 (0.96; 1.04)
Physical inactivity	1.39 (1.05; 1.85)*	1.51 (0.69; 3.31)	1.74 (0.91; 3.31)
Smoking	1.45 (1.17; 1.82)*	1.55 (0.67; 3.54)	1.25 (0.78; 1.99)
Alcohol use	1.32 (0.51; 3.40)	4.82 (0.11; 206.88)	/
	AIC: 2161.292 BIC: 2263.402 Pseudo R-Square Cox and Snell: 0.168 Nagelkerke: 0.243 McFadden: 0.157	AIC: 319.685BIC: 392.491Pseudo R-SquareCox and Snell: 0.322Nagelkerke: 0.458McFadden: 0.320	AIC: 650.365BIC: 724.300Pseudo R-SquareCox and Snell: 0.260Nagelkerke: 0.348McFadden: 0.219

OR, odds ratio; CI, confidence interval; IADL, instrumental activities in daily living; FSU, Former Soviet Union; AIC, Akaike Information Criterion; BIC, Bayesian Information Criterion; *p < .05; **p < .001.

Utilization of Mental Health Services and Associated Factors

Of the 1142 participants with clinically significant depressive symptoms in our sample, only 37% reported utilization of mental health services. Therefore, the treatment gap in the whole sample was 63%. This gap was highest among Israeli Arabs (83%), followed by FSU immigrants (64%), and lowest amongst Israeli-born and early-immigrant Jews (59%). In this group, utilization of mental health services was associated with a greater number of limitations in IADL, number of chronic diseases, and currently not working (Table 4). Among Israeli Arabs, the utilization of mental health services was related only to physical inactivity, and among FSU immigrants to female sex, IADL score, and number of chronic diseases.

Table 4.

Association of Participantś Characteristics with Mental Health Service Utilization.

	Israeli-born and early-immigrant Jews	Israeli Arabs	FSU immigrants since 1989
Age	0.99 (0.97; 1.01)	0.99 (0.93; 1.05)	0.98 (0.95; 1.01)
Female	1.22 (0.88; 1.69)	0.69 (0.22; 2.12)	2.05 (1.12; 3.77)*
Currently working	0.55 (0.36; 0.84)*	/	/
Limitations in IADL	1.18 (1.06; 1.32)*	1.28 (0.96; 1.70)	1.32 (1.12; 1.55)*
Chronic diseases	1.14 (1.05; 1.25)*	1.06 (0.79; 1.41)	1.19 (1.04; 1.36)*
Physical inactivity	1.14 (0.79; 1.65)	3.06 (1.00; 9.33)*	/
	AIC: 110.123 BIC: 127.044 Pseudo R-Square Cox and Snell: 0.077 Nagelkerke: 0.104 McFadden: 0.059	AIC: 110.123BIC: 127.044Pseudo R-SquareCox and Snell: 0.112Nagelkerke: 0.187McFadden: 0.130	AIC: 328.356BIC: 346.635Pseudo R-SquareCox and Snell: 0.115Nagelkerke: 0.157McFadden: 0.093

OR, odds ratio; CI, confidence interval; FSU, Former Soviet Union; AIC, Akaike Information Criterion; BIC, Bayesian Information Criterion.

*p < .05.

Discussion

The present study examined the prevalence of clinically significant depressive symptoms, the utilization of mental health services, and associated socioeconomic and clinical factors among older adults in Israel. Our findings indicate notable differences across population groups, emphasizing the importance of considering both ethnic background and immigration history in understanding late-life depression.

Studies indicate a significant burden of clinically significant depressive symptoms among older adults in Israel (Bentur & Heymann, 2020; Nakash et al., 2020). We found a 32% prevalence of clinically significant depressive symptoms in our sample, which is slightly higher than found by a study in Europe, where 29% of Europeans aged 65 and over reached four or more points on the EURO-D scale (Horackova et al., 2019). Like Horackova et al., our results suggest that clinically significant depressive symptoms are mainly associated with functional limitations and comorbidity across population groups. The estimated treatment gap of 63% in our study is higher than the estimated global median treatment gap for affective disorders around the world (50–56%) and the World Health Organization (WHO) regional estimates for Europe (40–45%) (Kohn et al., 2004). However, Horackova et al. (2019) found that as many as 79% of older adults who reached four or more points on the EURO-D scale did not utilize mental health services (Horackova et al., 2019). Taken together, our findings show that the overall treatment gap in the total sample was 63%.

In the total sample, the prevalence of clinically significant depressive symptoms was 32%, with the highest rates among FSU immigrants (44%), followed by Israeli Arabs (32%) and Israeli-born and early-immigrant Jews (30%). Migration takes its toll with personal, cultural, and social losses (Alegría et al., 2017; Cervantes et al., 2019). These potentially traumatic events may be associated with the high prevalence of clinically significant depressive symptoms in this population group. Previous research has shown that language barriers and poor financial state are negative factors affecting older FSU immigrants’ mental health (Dolberg et al., 2019; Remennick, 2007). In this group, the treatment gap reached 64%, indicating that a majority of FSU immigrants with depressive symptoms did not utilize mental health services. The present study suggests that being a female FSU immigrant and having poor health are the factors most strongly associated with clinically significant depressive symptoms. We also found that being female, having a higher burden of chronic diseases, and having greater functional limitations, are associated with mental health service utilization in FSU immigrants. Kagstrom et al. (2019), in their study on mental disorders in the Czech Republic, similarly suggested that men and individuals with less severe or less disabling symptoms were less likely to seek mental health care.

Our findings suggest that high education, urban residence and greater household size are protective factors against developing depressive symptoms. These factors may also contribute to reducing the treatment gap within the FSU immigrant population. Other studies identified additional barriers to mental health service utilization among FSU immigrants, such as language barrier (Davidovitch et al., 2013; Dolberg et al., 2019), availability and accessibility of mental health services in Russian (Knaifel, 2023) and stigma and mistrust in psychiatry (Dolberg et al., 2019; Knaifel et al., 2023). Breaking this vicious cycle of language barriers, limited accessibility of services, and stigma is vital because the undertreatment of mental health issues leads to loneliness, further deepening the social marginalisation of older FSU immigrants (Dolberg et al., 2016).

Overall, the treatment gap in our sample was 63%, with the largest gap observed among Israeli Arabs (83%), followed by FSU immigrants (64%), and Israeli-born and early-immigrant Jews (59%). Among Israeli Arabs, the prevalence of clinically significant depressive symptoms was 32%. In the Israeli Arab group in particular, there remains a considerable disparity between the rate of clinically significant depressive symptoms and the utilization of mental health services. The manifestations of stigma vary significantly across communities (Nakash et al., 2015; Nakash & Levav, 2012). While there has been progress in destigmatizing mental health in recent years, significant challenges persist (Al-Krenawi, 2019; Khatib & Abo-Rass, 2022). The Arab population in Israel has distinctive housing and family patterns. They tend to live in more rural areas, often located in Israel's geographic periphery and distant from major urban centers, with large families (Abu-Kaf, 2019); nearly 92% of our study sample in this group has three or more children. Previous studies suggest that among Israeli Arabs, multigenerational living arrangements and a cultural tendency to rely primarily on close family networks play a key role in limiting the likelihood that individuals will seek help outside the family, which in turn reduces health care referrals and leads to under-utilisation of services (Ayalon et al., 2015; Azaiza, 2013), including specialized medicine (Baron-Epel et al., 2007). Additionally, there is a lack of mental health services that are geographically, linguistically, and culturally accessible to Israeli Arabs (Al-Krenawi, 2019; Khatib & Abo-Rass, 2022).

Our study shows that older Israeli Arabs have the lowest average education levels and have the lowest employment rate and household net worth among all groups. Nevertheless, these factors do not seem to lead to developing depressive symptoms as might be expected. As with FSU immigrants, overall health status is the dominant factor associated with clinically significant depressive symptoms. Furthermore, it is possible that family living arrangements and traditional patterns that still characterize the majority of Arab families in Israel serve as protective factors against symptoms of depression.

Among Israeli-born and early-immigrant Jews, the prevalence of clinically significant depressive symptoms was 30%, the lowest among all groups. The treatment gap was 59%, also the lowest, and close to the global estimate reported by the WHO (56%) (Kohn et al., 2004). Our results point to better socioeconomic conditions as the main reason for this, as evident by an association of greater household net worth and higher education with fewer depressive symptoms. Israeli-born and early-immigrant Jews have higher incomes and are more likely to have supplemental insurance. They are also twice as likely to approach inpatient social workers than FSU immigrants (Auslander et al., 2005). Taken together, these findings indicate that sociodemographic and clinical characteristics contribute differently across population groups, both to the occurrence of clinically significant depressive symptoms and to the utilization of mental health services.

The higher prevalence of depressive symptoms and lower rates of mental health service utilization among FSU immigrants and Israeli Arabs may be attributable to lower mental health literacy (MHL). Immigrants and ethnic minorities often face communication inequalities, characterized by limited access to and understanding of health information (Kontos et al., 2010). MHL serves as a framework to address these barriers and reduce mental health disparities through public education. Improving knowledge about mental health issues can guide help-seeking behavior (Nakash et al., 2020). Recent studies in Israel found that native-born Israeli older adults reported lower emotional distress levels and higher knowledge about accessing mental health information compared to FSU older adult immigrants (Nakash et al., 2020). Acculturation levels, meaning the degree to which individuals adopt the language, norms, and practices of the host society, explained the differences in MHL among FSU immigrants in Israel (Knaifel et al., 2023). For Israeli Arab students, a recent study highlighted the association between sociocultural characteristics – such as strong family-centered values, gender roles, and attitudes toward authority – and MHL, emphasizing the need to enhance MHL and promote positive attitudes toward seeking professional help in this population (Khatib & Abo-Rass, 2022).

This study has several limitations. Some participants did not complete the EURO-D assessment and were therefore excluded from the analysis. This excluded group may include individuals with higher levels of depressive symptoms, potentially leading to underestimation of prevalence. Another limitation concerns the recruitment of participants to SHARE. SHARE was designed to collect data every second year. In Israel, the intervals between data collection waves were longer than in the main SHARE study: The first wave was conducted in 2005–2006, the second in 2009–2010, the third in 2013, and the fourth in 2015. In our study, each individual was included only once (cross-sectional design). Nevertheless, the irregular intervals between waves may have influenced the representativeness of certain subgroups across time.. In addition, the SHARE-Israel survey under-represented FSU immigrants in the first wave, which was corrected it in the second wave. This under-representation may have led to less accurate estimates for FSU immigrants in the first wave, although in our cross-sectional design each participant was included only once, and later waves provided more balanced representation. Finally, the SHARE dataset did not include direct measures of migration-related stress, stigma, cultural norms, or MHL, which we discuss based on previous literature but could not test empirically.

Despite these limitations, our research has major strengths. Using data from SHARE-Israel, a comprehensive population-based study employing random sampling methods, we were able to ensure the generalizability of our findings to the older adult population in Israel. Our results shed light on the distinctive characteristics of older adults with depressive symptoms from different population groups in Israel. Reducing the risk for the development of depressive symptoms in Israel requires a complex approach. Our findings show that while functional limitations and chronic diseases were consistently associated with depressive symptoms across all groups, additional socioeconomic and health-related factors varied between groups. Therefore, we suggest that in future research, both ethnic background and immigration history should be taken into consideration when designing strategies to reduce depressive symptoms and to increase the utilization of mental health services.

Footnotes

Acknowledgments

This paper uses data from SHARE Waves 1, 2, 5 and 6 (DOIs: 10.6103/SHARE.w1.700, 10.6103/SHARE.w2.700, 10.6103/SHARE.w5.700, 10.6103/SHARE.w6.700) (see Börsch-Supan et al., 2013).

ORCID iDs

Hadas Elbaz

Pnina Dolberg

Matěj Kučera

Pavla Brennan Kearns

Ethical Considerations

SHARE has been repeatedly reviewed and approved by the Ethics Committee of the University of Mannheim. Data were pseudo-anonymized and participants were informed about the storage and use of the data and their right to withdraw consent.

Consent to Participate

All participants provided written consent.

Authors’ Contributions

H.E., Y.S., and P.B.K. conceived and planned the study design. P.B.K. developed the analytical strategy, and Y.S., P.B.K. and M.K. performed the calculations. H.E., P.B.K., P.D. and Y.S. wrote the manuscript. P.D. edited and revised the manuscript.

Funding

The SHARE data collection has been primarily funded by the European Commission through FP5 (QLK6-CT-2001-00360), FP6 (SHARE-I3: RII-CT-2006-062193, COMPARE: CIT5-CT-2005-028857, SHARELIFE: CIT4-CT-2006-028812) and FP7 (SHARE-PREP: N°211909, SHARE-LEAP: N°227822, SHARE M4: N°261982). Additional funding from the German Ministry of Education and Research, the Max Planck Society for the Advancement of Science, the U.S. National Institute on Aging (U01_AG09740-13S2, P01_AG005842, P01_AG08291, P30_AG12815, R21_AG025169, Y1-AG-4553-01, IAG_BSR06-11, OGHA_04-064, HHSN271201300071C) and from various national funding sources is gratefully acknowledged (see ). The authors were supported by the grant PRIMUS (247066) conducted at Charles University Prague and by the Ministry of Health of the Czech Republic (grant NU20J-04-00022). All rights reserved.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data from SHARE are available for all researchers free of charge pending registration. See

Code Availability

Upon request from the corresponding author.

Author Biographies

Hadas Elbaz, MD, is a resident psychiatrist in the Department of Psychiatry at Sheba Medical Center, Tel Ha'Shemer, Israel. She is actively engaged in treating severe mental health disorders within secure psychiatric units and providing psychiatric emergency care. Her primary areas of interest encompass neuropsychiatry and psycho-geriatrics, with a particular emphasis on the epidemiology of mental health disorders in the older adult population.

Yuval Saphier, MD, is a resident in internal medicine at Samson Assuta Ashdod Hospital. Specializing in the geriatric field, Dr. Saphier-Avraham has a strong interest in the treatment of skin infections, particularly pressure ulcers, as well as in preventing delirium during hospitalization. As a dedicated researcher, Dr. Saphier-Avraham is committed to improving care and outcomes for older adults.

Pnina Dolberg, PhD is a faculty member in the Department of Social Work at Ruppin Academic Center in Israel. Her research focuses on aging, the formal and informal care of older adults, immigration, and identity, with a particular emphasis on mental health and identity issues related to immigration. Dr. Dolberg's work examines the challenges, risk factors, protective factors, and resilience among immigrant populations in Israel.

Matěj Kučera, MD, is the research and teaching assistant in the Department Epidemiology at the Second Faculty of Medicine, Charles University Prague and National Institute of Mental Health, Czech Republic. His published works focus on public mental health with focus on epidemiology of dementia.

Pavla Brennan Kearns (Pavla Cermakova) is the head of Department of Epidemiology and associate professor at the Second Faculty of Medicine, Charles University Prague, Czech Republic. She has special interest in psychiatric and cognitive epidemiology. Her published work focuses on social inequalities in mental and cognitive disorders and risk and protective factors for the development of cognitive abilities.

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