Effects of individual differences, society, and culture on youth-rated problems and strengths in 38 societies.

BACKGROUND: Clinicians increasingly serve youths from societal/cultural backgrounds different from their own. This raises questions about how to interpret what such youths report. Rescorla et al. (2019, European Child & Adolescent Psychiatry, 28, 1107) found that much more variance in 72,493 parents' ratings of their offspring's mental health problems was accounted for by individual differences than by societal or cultural differences. Although parents' reports are essential for clinical assessment of their offspring, they reflect parents' perceptions of the offspring. Consequently, clinical assessment also requires self-reports from the offspring themselves. To test effects of individual differences, society, and culture on youths' self-ratings of their problems and strengths, we analyzed Youth Self-Report (YSR) scores for 39,849 11-17 year olds in 38 societies. METHODS: Indigenous researchers obtained YSR self-ratings from population samples of youths in 38 societies representing 10 culture cluster identified in the Global Leadership and Organizational Behavioral Effectiveness study. Hierarchical linear modeling of scores on 17 problem scales and one strengths scale estimated the percent of variance accounted for by individual differences (including measurement error), society, and culture cluster. ANOVAs tested age and gender effects. RESULTS: Averaged across the 17 problem scales, individual differences accounted for 92.5% of variance, societal differences 6.0%, and cultural differences 1.5%. For strengths, individual differences accounted for 83.4% of variance, societal differences 10.1%, and cultural differences 6.5%. Age and gender had very small effects. CONCLUSIONS: Like parents' ratings, youths' self-ratings of problems were affected much more by individual differences than societal/cultural differences. Most variance in self-rated strengths also reflected individual differences, but societal/cultural effects were larger than for problems, suggesting greater influence of social desirability. The clinical significance of individual differences in youths' self-reports should thus not be minimized by societal/cultural differences, which-while important-can be taken into account with appropriate norms, as can gender and age differences.

Testing Syndromes of Psychopathology in Parent and Youth Ratings Across Societies.

As societies become increasingly diverse, mental health professionals need instruments for assessing emotional, behavioral, and social problems in terms of constructs that are supported within and across societies. Building on decades of research findings, multisample alignment confirmatory factor analyses tested an empirically based 8-syndrome model on parent ratings across 30 societies and youth self-ratings across 19 societies. The Child Behavior Checklist for Ages 6-18 and Youth Self-Report for Ages 11-18 were used to measure syndromes descriptively designated as Anxious/Depressed, Withdrawn/Depressed, Somatic Complaints, Social Problems, Thought Problems, Attention Problems, Rule-Breaking Behavior, and Aggressive Behavior. For both parent ratings (N = 61,703) and self-ratings (N = 29,486), results supported aggregation of problem items into 8 first-order syndromes for all societies (configural invariance), plus the invariance of item loadings (metric invariance) across the majority of societies. Supported across many societies in both parent and self-ratings, the 8 syndromes offer a parsimonious phenotypic taxonomy with clearly operationalized assessment criteria. Mental health professionals in many societies can use the 8 syndromes to assess children and youths for clinical, training, and scientific purposes.

Mental disorders in primary care in Israel: prevalence and risk factors.

OBJECTIVE: Psychiatric morbidity is common among patients in primary care services and leads to disability and increased use of medical services. Comparison of primary care and community prevalence data is of interest in relation to the health services planning for mental disorders. The aim of the present study was to measure prevalence of mental disorders in six primary care clinics in Israel and to assess risk factors for these disorders. METHOD: Prevalence of mental disorders was measured in a sample of 2,948 primary care consecutive attendees, using two-stage stratified sampling with the General Health Questionnaire 12 (GHQ-12) and the Composite International Diagnostic Interview (CIDI). RESULTS: A high rate (46.3%) of current mental disorders was found, with rates of current depressive episode, generalized anxiety disorder, somatization disorder, and neurasthenia being relatively high in comparison with rates in other countries. Low education was a risk factor for all categories of disorders, unemployment a risk factor for depressive disorders, and parenthood was protective for most categories of disorders. CONCLUSIONS: High rates of mental disorders were found in this Israeli primary care sample as compared to other countries, while in the community the rates were midrange as compared to other countries, pointing to a relatively higher use of primary care services by patients with mental disorders in Israel than in other countries.

Effect of implementation of mental health services within primary care on GP detection and treatment of mental disorders in Israel.

BACKGROUND: Psychiatric morbidity is frequent in primary care, but a substantial proportion of these psychiatric problems appear to be neither recognized nor adequately treated by GPs. There exists a number of models of introduction of mental health services (MHS) into primary care, but little data are available on their effect on GPs' detection or management of mental disorders. The study aimed to measure the effect of referring patients to a psychiatrist within primary care (Shifted OutPatient model-SOP) or consultation of psychiatrists by the GPs (Psychiatric Community Consultation Liaison-PCCL) on the detection and treatment of mental disorders by GPs. METHODS: In six primary care clinics in Israel (three "SOP clinics" and three "PCCL clinics"), GP detection of mental disorders and treatment of GP-detected cases were evaluated before and after provision of 1-year MHS, according to GP questionnaires on a sample of primary care consecutive attenders whose psychological distress was determined according to the GHQ12 and psychiatric disorders according to the Composite International Diagnostic Interview. RESULTS: After model implementation, a significant reduction in detection of mental disorders was found in SOP clinics, while no significant change was found in PCCL clinics. No significant change in detection of distress was found in any clinic. An increase in referrals to MHS for GP-diagnosed depression and anxiety cases, a reduction in GP counselling for GP-detected cases and those with diagnosed anxiety, an increased prescription of antidepressants and a reduced prescription of antipsychotics were found in SOP clinics. In PCCL clinics, no significant changes in GP management were observed except an increase in referral of GP-diagnosed depression cases to MHS. CONCLUSIONS: MHS models did not improve GP detection of mental disorders or distress, but possibly improved referral case mix. The SOP model might have a deskilling influence on GPs, resulting from less involvement in treatment, with decrease of detection and counselling. This should be taken into consideration when planning to increase referrals to a psychiatrist within primary care settings. Lack of positive effect of the PCCL model might be overcome by more intensive programs incorporating educational components.

[Impairment status and related predictors for adults hospitalized as children in a psychiatric ward in Israel].

BACKGROUND: The few studies that exist on long term outcome of psychiatric hospitalization of children show poor prognosis. OBJECTIVES: To study the level of functioning of adults who were hospitalized as children in a psychiatric ward in Israel and to identify prognosis predictors. METHODS: The study population consisted of all 1654 people who had been hospitalized in a psychiatric hospital in Israel and whose age at the time of the study was 21 years and above. For each subject, demographic and clinical data were extracted from a national case registry and data on disability benefits were retrieved from another file in the Ministry of Health. RESULTS: Only 8% of the study subjects were married, 8.3% died (3.5 times more in men compared to the general population), and 21% received disability benefits. More than half of the people who were hospitalized as children were rehospitalized during the follow-up (43% as adults). Younger age at first hospitalization was associated with a longer cumulative duration of hospitalization, while an older age was associated with a greater number of hospitalizations and a higher rate of eligibility for disability benefits. Diagnosis at first hospitalization was associated with all measures of functioning in adulthood. Diagnosis of an "organic" or severe psychiatric disorder was associated with poor prognosis. Longer duration of first hospitalization was associated with a higher rate of death and eligibility for disability benefits. CONCLUSIONS: This study shows poor prognosis for adults who were hospitalized in child psychiatry wards and calls for long-term prospective and controlled studies.

Suicide rates and risk factors for suicide among Israeli immigrants from Ethiopia (1985-2017).

BACKGROUND: Suicide rates among Ethiopian immigrants to Israel (EI) are relatively high. This study sought to identify suicide-risk factors in this population in order to suggest some potentially preventive measures to mental health policymakers who are struggling to prevent suicide among EI. METHOD: Nationwide age-adjusted suicide rates were calculated for EI, Former Soviet Union immigrants (FSUI) and Israeli-born (IB) Jews by age, gender, and year of death and, for EI, by marital status and immigration period in the years 1985-2017 (1990-2017 for FSUI). RESULTS: Age-adjusted suicide rates for the period 1990-2017 confirmed the significantly higher rate among EI--3.1 times higher than for FSUI and 4.1 times higher than for IB. Similar rates were obtained for both genders, within each age group, and in all study years. Comparable male/female rate ratios were found among EI and IB (3.3, 3.6, respectively). Over the years of the study, only among the Ethiopian immigrants were there large fluctuations in suicide rates: a decrease (1992-2001), followed by an increase (2001-2006), and then a progressive decrease (from 2006). The secular changes differed greatly according to age. Among females, these fluctuations were smaller, the decrease began earlier and was greater, and the subsequent increase was much smaller. Marriage was found to be less protective for Ethiopian immigrants than for the other surveyed populations. CONCLUSIONS: The considerable gap between the EI's and FSUI's suicide rates highlights the critical role of immigrants' integration difficulties. These difficulties among EI lead to ongoing conflict within the family, which may explain why marriage is less protective for EI. Nevertheless, progressive integration is occurring as indicated by the decline in suicide rates since 2006. The fluctuations in EI suicide rates over time seem to be associated with modifications in social welfare allowances, which are crucial for EI of low socioeconomic status. Groups at risk, particularly EI men facing socioeconomic challenges and EI with considerable family conflict, typically identified by HMOs and welfare services, should be screened for suicide risk, and those identified as at risk referred to tailored workshops sensitive to Ethiopian culture.

Estimating the changes in demand for public mental health services following changes in eligibility: analysis of national survey data.

BACKGROUND: Numerous national surveys have shown that the rate of use of mental health services in a population lags behind the prevalence rate of psychiatric disorder. The preparations to provide universal coverage in Israel require estimates of the utilization levels likely to be reached once mental health care becomes a legal right of each resident. AIMS: This paper aims to provide an estimate of the size of the population which not only will be eligible for specialty mental health care, but which will also demand ambulatory mental health specialty care from public providers METHODS: Data for this study were extracted from a national survey conducted during 2003-2004 in Israel as part of the WMH2000 initiative. Use and perceived need to use services among eligible respondents was used to estimate likely levels of demand. RESULTS: The estimates for future demands on public mental health clinics ranged between 1.2%--the size of the population that is eligible by law and is currently using public mental health services to 5.5%--the size of the eligible population that is currently using some type of service or perceives the need for care in mental health. DISCUSSION: The estimate of the expected use falls in the range of other universal access systems. CONCLUSIONS AND IMPLICATIONS FOR POLICY: The present study provides estimates that are much higher than the estimated size of the population currently using public mental health services, yet the upper limit of the range of estimates is close to those on which the new legislation is based.

Adapting the SRQ for Ethiopian populations: a culturally-sensitive psychiatric screening instrument.

The objective of the study was to develop a culturally sensitive psychiatric screening instrument valid for Ethiopians in Ethiopia and Israel. The study sample was composed of 356 Amharic-speaking Ethiopians from Ethiopia and Israel, aged 18-55, divided into three groups: i) general population; ii) people in non-psychiatric treatment; iii) people in psychiatric treatment. They were interviewed with the Self-Reporting Questionnaire (SRQ), modified to include 10 culturally specific items, and the Brief Psychiatric Research Scale (BPRS) as a criterion of psychopathology. Physicians also completed an encounter form about the presence of mental health symptoms in participants. To make the questions more culturespecific, the translation of 12 items on the SRQ was changed. The content, construct, and criterion validity of each question were also examined, leading to the deletion of five items. The validity of the revised instrument (SRQ-F) was superior to that of the original instrument (SRQ). This study demonstrates the need for psychiatric screening instruments to be adapted to different cultures by incorporating meaningful translations and adding culturally specific items.

Epidemiological comparisons of problems and positive qualities reported by adolescents in 24 countries.

In this study, the authors compared ratings of behavioral and emotional problems and positive qualities on the Youth Self-Report (T. M. Achenbach & L. A. Rescorla, 2001) by adolescents in general population samples from 24 countries (N = 27,206). For problem scales, country effect sizes (ESs) ranged from 3% to 9%, whereas those for gender and age ranged from less than 1% to 2%. Scores were significantly higher for girls than for boys on Internalizing Problems and significantly higher for boys than for girls on Externalizing Problems. Bicountry correlations for mean problem item scores averaged .69. For Total Problems, 17 of 24 countries scored within one standard deviation of the overall mean of 35.3. In the 19 countries for which parent ratings were also available, the mean of 20.5 for parent ratings was far lower than the self-report mean of 34.0 in the same 19 countries (d = 2.5). Results indicate considerable consistency across 24 countries in adolescents' self-reported problems but less consistency for positive qualities.

The generalizability of the Youth Self-Report syndrome structure in 23 societies.

As a basis for theories of psychopathology, clinical psychology and related disciplines need sound taxonomies that are generalizable across diverse populations. To test the generalizability of a statistically derived 8-syndrome taxonomic model for youth psychopathology, confirmatory factor analyses (CFAs) were performed on the Youth Self-Report (T. M. Achenbach & L. A. Rescorla, 2001) completed by 30,243 youths 11-18 years old from 23 societies. The 8-syndrome taxonomic model met criteria for good fit to the data from each society. This was consistent with findings for the parent-completed Child Behavior Checklist (Achenbach & Rescorla, 2001) and the teacher-completed Teacher's Report Form (Achenbach & Rescorla, 2001) from many societies. Separate CFAs by gender and age group supported the 8-syndrome model for boys and girls and for younger and older youths within individual societies. The findings provide initial support for the taxonomic generalizability of the 8-syndrome model across very diverse societies, both genders, and 2 age groups.

Prevalence of mood and anxiety disorders in the community: results from the Israel National Health Survey.

OBJECTIVE: To estimate the 12-month and lifetime prevalence rates of mood and anxiety disorders in Israel and their socio-demographic correlates. METHOD: A representative sample of respondents extracted from the National Population Register of non-institutionalized residents, aged 21 or older, were interviewed at home between May, 2003, and April, 2004. DSM-IV disorders were assessed using a revised version of the Composite International Diagnostic Interview. RESULTS: Seventeen percent of the sampled adult population reported a lifetime occurrence of a mood or anxiety disorder, while nearly one in 10 (9.7%) reported a mood or anxiety disorder occurring during the previous 12 months. Mood disorders were twice as common as anxiety disorders. CONCLUSION: Contrary to expectations born out of Israel's unique life circumstances, the prevalence of mood or anxiety disorders fall within the range of other western countries. However, given the current age structure and the age of onset of these disorders, their total burden in the near future is likely to increase.

Twelve-month service utilization rates for mental health reasons: data from the Israel National Health Survey.

OBJECTIVE: To measure the 12-month utilization rates for mental health reasons in all types of services. METHOD: A representative sample extracted from the National Population Register of non-institutionalized residents aged 21 or older were interviewed at their homes between May 2003 and April 2004. DSM-IV disorders were assessed using a revised version of the Composite International Diagnostic Interview (WMH-CIDI). RESULTS: About 10% of the adult population receives some type of treatment for emotional or mental health problems within a single year. More than half of service consumers were not classified as suffering from mood or anxiety disorders. Of those diagnosed with mood or anxiety disorders in the past 12 months only about 50% used any type of service for mental health problems. CONCLUSION: There is only a partial overlap between those who utilize the services and those who meet the criteria for a clinical diagnosis of mental disorder.

Does Specializing in Family Medicine Improve the Detection and Diagnosis of Mental Health Problems?

BACKGROUND: Approximately half the patients seeking mental health (MH) treatment consult primary care practitioners (PCPs). Previous research indicates that patients often do not receive correct MH diagnoses or appropriate treatment from PCPs. The present study examines whether a specialization in family medicine compared to other or no PCP residency programs enhances physicians' ability to detect, diagnose and treat MH problems. METHODS: Face-to-face interviews with 49 physicans in eight clinics in Israel. Two case vignettes and questionnaires assess MH awareness and factors influencing treatment. RESULTS: Significantly more family practitioners (FPs) compared to others correctly diagnosed depression and anxiety vignettes were aware of patients' MH problems and prescribed psychotropic drugs. LIMITATIONS: Small sample size, indirect examination of PCPs' skills using vignettes and the absence of psychotherapy options. CONCLUSIONS: FPs are more likely than other PCPs to detect, diagnose and treat MH problems. To improve MH detection among a broad range of PCPs, an expanded MH curriculum should be encouraged. Additional MH training should be available for all PCPs.

Comparisons of problems reported by youths from seven countries.

OBJECTIVE: This study compared ratings for self-reported behavioral and emotional problems in adolescents from seven countries. METHOD: Youth Self-Report scores were analyzed for 7,137 adolescents ages 11-18 years from general population samples from Australia, China, Israel, Jamaica, the Netherlands, Turkey, and the United States. RESULTS: Comparisons of problems scores yielded small to medium effect sizes for cross-cultural variations. Youths from China and Jamaica had the highest and youths from Israel and Turkey had the lowest mean total problems scores. With cross-cultural consistency, girls scored higher for internalizing and lower for externalizing than boys. Cross-cultural correlations were high among the mean item scores. CONCLUSIONS: Empirically based assessment provided a robust method for assessing and comparing adolescents' self-reported problems. Self-reports thus supplemented empirically based assessments of parent-reported problems and offered a cost-effective way of identifying problems for which adolescents from diverse cultural backgrounds may need help.

Epidemiology of dementia in Ashkelon: the influence of education.

A population study aimed at evaluating the influence of education on the prevalence of dementia was carried out in Ashkelon, a rural city in Israel. The whole population aged over 75 years was screened, with a very low refusal rate. Altogether, 1501 people were examined, using DSM III-R criteria for dementia. The prevalence of dementia increased with age and was higher among females and immigrants to Israel from Africa and Asia. The most significant correlation was with a low level of education, which completely explained the ethnic differences and partially the female predominance in the frequency of dementia. Our study confirms that schooling appears to be an important protective factor against the development of dementia.

Effect of transfer of long-stay psychiatric inpatients from hospital to hospital.

BACKGROUND: Chronic psychiatric patients hospitalized in institutions about to be closed are not always fit to be transferred to community-based facilities. The purpose of our study was to investigate how the mental health of a group of such patients was affected by their being transferred to another hospital. METHODS: 202 patients were evaluated prior to transfer and six months after the transfer, by means of the Clinical Global Impression (CGI), the World Health Organization (WHO) Disability Scale and the Nurses' Observation Scale for Inpatient Evaluation (NOSIE). RESULTS: On the CGI, half the patients showed evidence of improvement while only 4% seemed to deteriorate. For the NOSIE and WHO Disability Scale, improvement of scores was similarly more common than deterioration. Factors that correlated with improvement included male sex, younger age, and a shorter hospital stay. LIMITATIONS: This is a naturalistic study of the effects of transfer which does not include a control group. CONCLUSION: Institutional transfer of psychiatric patients can be carried out without harm to the patient's welfare, and may even be beneficial.

[Development of a culturally sensitive psychiatric screening instrument for detecting emotional problems among Ethiopian immigrants in Israel].

BACKGROUND: Studies have demonstrated that a large percentage of patients in primary care clinics suffer from emotional problems. Many of the patients who suffer from these problems are not diagnosed properly, and do not receive appropriate treatment by the medical staff. The problem is especially severe for patients who immigrated to Israel from Ethiopia. This is mainly due to the difference between the medical belief system familiar to the Ethiopian immigrants and that of the non-Ethiopian doctors. It is also the result of the use of culturally typical idioms of distress by the Ethiopians that are not clearly understood by the doctors. The WHO developed the SRQ--Self-Reporting Questionnaire, a psychiatric screening instrument to assess populations in developing countries. Although this instrument has been widely used both in developing and developed countries, it has been found to be problematic in certain cultures. The difficulties stem partly from differences between the spontaneous idioms of distress used by the interviewees, for example the Ethiopians, and the idioms of distress that appear in the SRQ. OBJECTIVE: The goal of this research was to develop a psychiatric screening instrument, based on the SRQ, which would be valid and culturally sensitive to Ethiopian immigrants in Israel. METHODS: The sample included 161 immigrants from Ethiopia, aged 18-55 years, who were born in the Gondar region. The interviewees were divided into three groups according to their "level of treatment": healthy individuals from the general population, who were sampled, mainly using the "quota sampling" method, in those cities where a high percentage of Ethiopian immigrants reside; consecutive patients in primary care clinics and in specialist clinics in the same cities; and consecutive patients in care in psychiatric clinics throughout the country. The research instruments included an expanded version of the SRQ (the SRQ-E) and the expanded version of the BPRS--Brief Psychiatric Rating Scale. The validity of each question of the SRQ-E was examined in order to create a new psychiatric screening questionnaire that is both valid and parsimonious. The internal consistency and the construct and criterion validity of this new screening questionnaire were then examined. The sensitivity and specificity of the instrument for detecting psychopathology were assessed. RESULTS: The new screening instrument was determined to be valid: a score of 7 distinguishes between those with and without psychopathology, with a sensitivity and a specificity of 87%.

Physicians' influence on primary care patients' reluctance to use mental health treatment.

OBJECTIVES: The study examined attitudes of primary care patients toward mental health treatment and whether ambivalent or negative attitudes change after patients receive recommendations from their primary care physicians to seek treatment from a mental health professional. METHODS: Data were collected in face-to-face interviews with 902 Jewish patients aged 25-75 in eight primary care clinics in Israel. Measures included validated mental health instruments and a vignette eliciting patients' readiness to consider treatment and potential influence of a physician's recommendation. RESULTS: Initially, almost half of patients were reluctant to consider specialized mental health treatment. The probability of having a more positive attitude after the physician's recommendation was significantly higher among patients with more severe clinical diagnoses. CONCLUSIONS: A major finding was the positive impact of primary care physicians' recommendations on reluctant patients. Encouraging physicians to discuss mental health issues would likely promote more positive attitudes and increase patients' willingness to access treatment.

Use of unconventional therapies by primary care patients--religious resources vs. complementary or alternative medicine services.

OBJECTIVES: The study examines the difference in characteristics between primary care patients who turn to "religious resources for medical purposes" (RRMP) and those who turn to "complementary or alternative medicine" (CAM) services to cope with a physical or mental health problem. DESIGN AND SETTING: Data were collected from eight primary care clinics in Israel and included 905 Jewish patients aged 25-75. MAIN OUTCOME MEASURE: A self-report questionnaire with a battery of validated mental health assessment instruments and two questionnaires regarding use of unconventional therapies (RRMP and CAM services) were administered to the participants. The association of various variables with type of 'service use' was examined through logistic regression analysis. RESULTS: Primary care patients suffering from emotional problems have a propensity to utilize unconventional therapies in addition to conventional medical treatment. However, differences exist between patients who turn to RRMP and to CAM. The risk factors for turning to RRMP are North African, Middle Eastern or Israeli origin, low SES, religious observance, and high use of primary care clinics. For using CAM services the risk factor is high SES. CONCLUSIONS: In the present study, a quarter of primary care patients also use additional resources for their medical problems. While all segments of the population use unconventional resources, our study reveals that two types of unconventional therapies - RRMP and CAM - tend to be used by two different population sectors. It is noteworthy that those suffering from mental health problems are more likely to utilize unconventional resources.

Utilization patterns of ambulatory psychiatric services by Ethiopian immigrants in Israel.

BACKGROUND: Ethiopian immigrants in Israel (EI) have limited familiarity with western psychiatric care and, reciprocally, their culture is hardly known by mental health professionals. OBJECTIVE: to compare utilization patterns of ambulatory psychiatric services in Israel by EI and other population groups. METHODS: EI, former Soviet Union immigrants and Israel-born users of the 64 psychiatric governmental clinics and of the nationwide psychiatric rehabilitation services were compared on demographic and clinical data. Data were obtained from the Ministry of Health for the years 1997-2003. RESULTS: Among the EI cared in psychiatric clinics, there was a greater proportion of users with psychotic disorders; a lesser proportion was referred by self, family or friends; a greater proportion was prescribed psychotropic medications; and a lesser proportion received individual psychotherapy. EI used more protected housing facilities and less social and leisure services. DISCUSSION: Patterns of utilization of both types of services were found to be different among EI, suggesting a need to develop culturally-sensitive programs for both the Ethiopian immigrants and the mental health professionals.