1As the end of the 20^th century approaches, the problems related to migration of populations are quite severe. The success of the integration of refugees and immigrants in their new country is generally measured by “objective” parameters, such as: work, living conditions and language acquisition. Good material conditions are of course necessary for a successful integration, but are they sufficient for defining the success of the integration? Another important criterion – to which less attention is generally paid – is certainly psychological adaptation, well being and satisfaction of living in the new country.

2Inherent to the process of immigration are physical, social and cultural changes involving disruption of former social networks, abandonment and relearning of cultural norms. The immigrants must cope with the ensuing complex processes of separation, loss, renunciation, “mourning”, on the one hand, and adaptation and integration in the new country on the other. These processes are undoubtedly potential sources of stress, which may affect the immigrants’ psychological well being (e.g. Flaherty et al., 1986; Mavreas & Bebbington, 1990). There are, however, several studies that contradict these conclusions and show an equal or even lower rate of psychological disorders among immigrants than in the veteran population (Cochrane & Stopes-Roe, 1981, Halldin, 1985).

3In addition to differences between the various migrant populations and their conditions of immigration, an important factor that can explain these discrepancies is the fact that most migratory movements imply some selection, either by the immigrants themselves or by the host society. The selection is sometimes “positive”, when the migrants are more ambitious, adventurous, adaptable or educated, or the host country does not authorize for instance the immigration of the infirm.

4Often, on the contrary, people emigrate following failure in the country of origin and individuals who are more fragile psychologically are more motivated to emigrate (Shuval, 1982).

5Recently, there has been a large wave of migration of Jews from the former Soviet Union to Israel. It has been a mass immigration (about three quarters of a million people), involving whole families rather than isolated individuals (Florsheim, 1991). These two features, and the open-door policy of the State of Israel concerning immigration of Jews, decrease the probability that this immigration has been selective. Furthermore, socio-demographic data tend to confirm this conclusion.

6The relative non-selectivity of this immigration wave gave us an opportunity to examine the question of the relationship between migration and psychological distress. Existing studies published on this subject have typically focused on the first few years post-immigration. Follow-up studies of immigrants beyond the first years deal mainly with the objective aspects of adaptation (work, living conditions, language acquisition, social contacts, etc.). In these studies, a positive correlation has been found between length of time spent in the new country and level of adaptation. Surprisingly, studies relating to the effect of time on psychological distress of immigrants have been scarce and their findings contradictory.

7The present article thus examines the psychological adaptation of those immigrants who came to Israel in 1990 over their five first years in Israel, and the risk factors of prolonged psychological distress.

Level of psychological distress of immigrants from the former Soviet Union during their first year in Israel.

8An initial survey (Zilber & Lerner,1996) concerned immigrants from the former Soviet Union, over 18 years of age, who arrived in Israel between September 1989 and October 1990. A nationwide sample of 600 immigrants was selected: in each of the 40 settlements with the highest concentration of immigrants, a random sample was chosen, proportional to the total number of Soviet immigrants in the settlement. The subjects were interviewed in Russian in their homes during December 1990, i.e. 2-15 months after their immigration.

9The interview dealt with a number of parameters related to life in the USSR, socio-demographic variables, and variables related to life and integration in Israel. Psychological distress was measured by the demoralization scale of the PERI (Psychiatric Epidemiology Research Interview), a 27-item validated scale designed by Dohrenwend et al. (1980) to measure the level of demoralization. Each item is scored on a scale of 0 to 4. The PERI score is the mean of the scores of the various items. A high score indicates high demoralization, i.e. low self-esteem, hopelessness, helplessness, sadness, anxiety, and psychosomatic symptoms. Thus the PERI does not measure psychopathology but rather suffering related to psychological distress. This scale had already been used with various Israeli populations, including Russian immigrants, and its validity and reliability for these populations had been found to be good.

10The mean PERI score in the sample was 1.14 (SD = 0.59), almost identical to what was found in 1985 by Flaherty, Kom & Levav (1988) on a sample of immigrants from the USSR who immigrated to Israel 1-3 years earlier. The score was significantly (P < 0.0001) higher among women (1.28, SD 0.63) than among men (1.00, SD 0.56).

11The level of distress of the immigrant sample was compared to that of the Israeli-born population, using data obtained by Dohrenwend and Levav from a representative nationwide sample of 2,355 Israeli-born Jews, of European origin, aged 24-33, examined in 1983. In our Russian 1990 sample, no difference in demoralization according to age was found, thus enabling comparison of the two samples.

12After controlling for education level, the mean PERI score, i.e. demoralization, was significantly higher in the immigrant sample, both in males (P = 0.001) and in females (P = 10^-6 ). Contrary to what has been suggested (e.g. Beiser, 1990), women did not react more severely than men to the stress of immigration.

13As indicated above, there was no apparent selection in the Soviet Jews who immigrated to Israel. The high educational and professional level of the Jews in the former Soviet Union also characterized those who immigrated to Israel in 1990. Thus, even if Jewish immigration to Israel was to a certain degree selective, this selectivity was certainly not negative and cannot account for the results.

14Immigrants remain at high risk for increased emotional distress even when conditions are relatively favorable, as in the case of the present study, especially when compared to other migratory fluxes in the world. Since late 1989, following Glasnost, Soviet Jews have lived i n a politically and economically unstable situation as well as with an increasing fear of anti-Semitism. The emigrants fled this situation towards what they believed would be better and more secure conditions in Israel. Moreover Jewish immigration to Israel is not merely an uprooting experience but also a replanting of roots in an ancient homeland. In addition, the pluralistic nature of the Israeli society allows the immigrants to become an integral part of it while preserving their previous cultural norms. In Israel, the immigration of Jews from the Diaspora is generally valued and promoted. Finally, Israel has a variety of supportive structures designed to facilitate immigrants’ integration into the society, such as free Hebrew language courses, free retraining courses and direct State financial support. Moreover, an important potential source of stress among the immigrants, separation from family, was relatively uncommon among the Jewish immigrants from the former Soviet Union who, as indicated above, mostly immigrated as family units.

15We have thus shown that in spite of these apparently favorable conditions, the mean level of demoralization of the immigrants, during their first year in Israel, was higher than that of the Israeli-born, confirming the hypothesis of a causal relationship between immigration and increased psychological distress.

Protective and risk factors for psychological distress among the immigrants from the former Soviet Union during their first year in Israel

16As the range of levels of distress is fairly large among the immigrants, we looked for protective and risk factors for psychological distress in their first year in Israel. This was done by examining the correlation between demoralization and two groups of factors: risk factors pre-existing immigration and potential mediating variables (social conditions in the host society). The first group included age at immigration, sex, marital status, number of children, education level, profession, religiosity, place of residence in the former USSR and help-seeking behavior at time of psychological distress in the former USSR. The second group included subjective evaluation of the social support (number of persons to whom the subject says s/he could turn to in order to receive help), present housing conditions, employment, knowledge of Hebrew, etc. These variables of course reflect not only social resources, but also, to a certain degree, personal resources. The analysis was multivariate (analysis of variance), allowing for a study of the relation per se between the dependent variable and each of the independent variables, after controlling for the influence of the other variables.

17For both genders the strongest predictor of distress was lack of social support – the feeling that if help is needed, nobody or practically nobody can help. In this respect, it is interesting to mention that three months after the survey, after the Gulf War, we re-interviewed the same immigrants and found that their distress did not increase and, often, even decreased (Lerner & Zilber, 1996). We associated this rather unexpected result with the feelings of shared fate, belonging, social cohesion and solidarity between all its members, which, from what is known from the previous wars in Israel, characterize the general Israeli population during war time.

18Objective social isolation (living alone) was also found to be a risk factor. In other populations, it has been shown that non-married people are more prone to develop symptoms following stressful life events, because they have less social support (Baton, 1978). We did not find, however, any relationship between marital status and demoralization, probably because, among Russian immigrants, contrary to other Western populations, several generations often live together, for traditional as well as economical reasons.

19A significant association was also found, in both genders, between demoralization and emigration from a region close to Chernobyl (within a radius of 150 km), after controlling for the other variables. Israel is, after the former Soviet Union, the country of residence of the greatest number of potential victims of the Chernobyl accident. Prolonged anxiety about possible serious sequelae of radiation has been described in populations living close to zones contaminated by atomic reactor incidents (e.g. Bromet et al., 1982; Tsvang, 1991). In our study, which was conducted five years after the Chernobyl accident, the same phenomenon persisted although the immigrants had left the contaminated zones.

20Another factor also found to be a risk factor for demoralization after immigration was, especially for men, having been in contact in the former USSR with a health professional for psychological problems. In the Soviet society, it was rare to turn to professional help in case of psychological problems, and men, who were not supposed to express their psychological weakness, certainly turned to this help only for more severe psychopathology than women.

21Finally, emigration from a Central Asian republic was found to be a risk factor, especially for women. These immigrants, coming from traditional societies, needed to become acculturated to social norms of a Western society such as Israel; the cultural gap was bigger for women who, in these societies, are still less in contact with western values than men.

22Lack of acquisition of the host language and unemployment are i n general considered as important risk factors of psychological distress in immigrants. Our study has shown that this is not the case for immigrants from the former Soviet Union during their first year in Israel, probably because of the following specific conditions. During their first year in Israel, all 1990 immigrants received financial aid from the Government and were given six months of intensive daily free Hebrew language courses and free retraining courses. Thus no serious financial problems or problems of loss of prestige related to unemployment were present during the first year. Also, in the Israeli society, which has such a high percentage of new immigrants, speaking and reading newspapers in the mother tongue, and speaking Hebrew with an accent or with mistakes are all quite accepted.

23Having had a manual or technical profession in the former Soviet Union was a protective factor, especially in men. A high level of education is generally considered as a protective factor, mainly because it opens up better employment opportunities (Beiser, 1990). The extremely high percentage of highly qualified immigrants from the former Soviet Union made it problematical for them to find employment in their profession. The threat of loss of social status was of course smaller for immigrants with manual or technical professions. Being religious was also in men a protective factor, as it apparently gives a positive significance to immigration to Israel (Flaherty et al., 1988) and thus mitigates difficulties due to immigration.

24In summary, this study shows that even in relatively favorable conditions, immigration is a risk factor for psychological distress. At least during the first year, the characteristics of the immigrants upon their arrival, rather than factors related to the conditions of absorption or work, modulate the demoralization level. It is possible that the feeling of a lack of social support, which is significantly associated with psychological distress, is itself related in great part to personality traits.

Follow-up study of this population group – how does psychological distress change with time?

25A second study, also on a sample of 1,990 immigrants, was conducted, this time five years after immigration. The aims of the study were:

• To compare parameters of adaptation and level of psychological distress of Soviet immigrants one and five years after their arrival to Israel;

• To identify risk factors for increased psychological distress five years after their arrival in Israel.

26This second study, as the previous one carried out in 1990, concerned all immigrants from the former Soviet Union who arrived in Israel during the year 1990 and were over 18 years of age at their arrival. A sample of 587 immigrants was randomly selected. The research subjects were interviewed in their homes in Russian in 1995. The questionnaire included the following scales and items:

• The PERI Demoralization Scale (cf. above).

• The revised Perceived Social Support Scale (Blumenthal et al., 1987): a 12-item validated scale designed to measure degree of perceived social support.

• The Control Scale, one of the three subscales of the revised Hardiness Scale designed by Kobassa (reviewed by Orr & Westman, 1991): a 17-item scale intended to measure the locus of control, i.e. the degree to which a person believes s/he can influence the course of events within reasonable limits.

• A modified version of the Life Events Scale by Holmes & Rahe (1967).

• A questionnaire relating to socio-demographic data, physical illness, health management, and self-perceived identity of respondents.

27The two samples of immigrants, the 1995 sample, five years after arrival to Israel, and the one in 1990, the year of arrival, were compared on several parameters of adaptation. The percentage of full-time employed immigrants increased from 17 % in 1990 to 70 % in 1995. There was often, however, a downward shift in the professional status (in 41 % of males and 55 % of females). Regarding living conditions, a tremendous increase could be observed in 1995 in the percentage of immigrants who owned their apartment (57 % vs. 2 % in 1990); housing density (number of people per room) significantly decreased (in 29 % of the cases vs. 50 % in 1990, three people or more lived with the subject), and a greater percentage of immigrants intended to remain in their present apartment (61 % vs. 15 % in 1990). Concerning acquisition of the host language, a significant increase was observed in the percent of immigrants having good to fairly good proficiency in speaking Hebrew – 54 % vs. 19 % in 1990.

28These different variables are objective parameters of adaptation. When the interviewees were asked about some subjective aspects of their adaptation, the picture was quite different. In order to assess subjective aspects of social support, the immigrants were asked how many people they felt they could turn to for help if needed. The percentage of immigrants who estimated this number as high did not change significantly after five years (45 % vs. 42 % in 1990). In their first year in Israel, 75 % of Ihe immigrants felt happy with their conditions in the new country (5.7 % very satisfied, 69.7 % satisfied). No increase in these percentages was observed in 1995 (5.3 % very satisfied, 69.5 % satisfied). Notwithstanding the fact that 54 % of the immigrants had, as indicated above, proficiency in speaking Hebrew in 1995, the percentage of those who read a Hebrew newspaper remained as low as in 1990 (20 % vs. 18 % in 1990).

29Since a new sample was interviewed in 1995, all these comparisons were recomputed by a logistic regression after controlling for gender, age at immigration, marital status at immigration, education at immigration and continent of origin. The same results were obtained, except for the variable “reading of Hebrew newspaper”, which became positively associated with the length of time since immigration.

30We also compared the level of psychological distress (PERI score) in the 1995 sample with that found in the 1990 sample during the first year in Israel. This comparison was performed separately for each gender, as the PERI score is known to differ significantly in males and females. The mean PERI score remained unchanged among males and increased significantly among females.

31Since an association, not observed in the 1990 study, was found in the present (1995) study between age and PERI score, with a significantly higher score among older people, it was decided to compare the level of demoralization in 1990 and in 1995 separately for the pension-age group and for the younger one. No significant difference was observed between the mean scores among the group below pension age (65 for men and 60 for women). In the older age group, on the other hand, there was a significant increase in demoralization in 1995, especially among women. The comparisons were recomputed by an analysis of variance, controlling for age at immigration, marital status at immigration, education at immigration and republic of origin. The results remained unchanged in the two age groups. It was also shown that this change in demoralization level could not be attributed to a different age distribution among people at pension age in 1990 and in 1995.

32The absence of a significant difference between the mean PERI score in 1990 and 1995 in the younger age group does not eliminate the possibility that there was a change in the proportion of individuals with a very high demoralization score. The usual cut-off of 1.27 for men and 1.55 for women was chosen, to divide between those with high scores of demoralization and all others. These cut-off points were used by Levav et al (1991) on the basis of previous studies showing that they discriminated between “healthy respondents” and those using mental health services.

33The percentage of immigrants with a PERI score above the cut-off level was compared in 1990 and 1995, separately for women and men. A significant difference was found only in the pension age group and it was more pronounced among women. Thus, among immigrants below pension age, not only did the mean PERI score not change after five years, but also no change was observed in the proportion of high PERI scorers.

34Seventeen immigrants from the 1990 study were randomly chosen and re-interviewed in 1995. Their PERI scores in 1990 and 1995 were compared by a paired t-test; no significant difference was observed.

35In conclusion, this study shows a gap between the changes in the objective and the subjective parameters of adaptation. The changes in the objective integration were quite impressive, thanks to massive support from the government, while the subjective feelings of satisfaction and identification did not change after five years or even worsened among the elderly. As the level of demoralization of first year immigrants was found in 1990 to be higher than that found by others among a nationwide sample of Israeli-born, this indicates that after five years, demoralization still remains higher among immigrants. Time per se, contrary to what has been reported, does not have an attenuating effect on the psychological distress of immigrants for at least the first five years. It is possible that subjective natural feelings of uprooting and estrangement are durably exacerbated among people from the former Soviet Union immigrating to a democratic society, where people must shape their fate alone, rather than depending on omnipotent authorities. The loss of professional status, especially in the older population whose chances of regaining a similar status as in the past are slim, seems to be very painful, all the more as professional life in the Soviet Union was highly valued and was the main source of self-esteem. In any case, routine assessment of the success of immigrants’ absorption should include some measure of their psychological status.

Protective and risk factors for prolonged psychological distress

36If we look at the level of demoralization of the individual immigrants five years after their arrival, a fairly wide range is observed, indicating most probably the effect of protective as well as risk factors on demoralization. We performed a univariate analysis of the association between a long list of independent variables and demoralization.

37The variables most strongly associated with psychological distress (P < 0.001) and explaining the greatest amount of variance of the PERI score (10% or more) were: unemployment or partial work, especially for men; lack of support from friends; health problems; unhappiness with living in Israel; lack of social support; lack of family support; external locus of control (low sense of personal control over what happens in their life); recent negative life events.

38The variables also strongly associated with psychological distress (P < 0.001) but explaining less than 10 % of the variance of the PERI score were: subjective appraisal of insufficiency of income, particularly for men; absence of friends; poor Hebrew skills; self-definition as Soviet rather than Israeli, in women; having sought professional psychological help in the past, in men.

39The variables associated with psychological distress only at the P < 0.05 level and explaining less than 10 % of the variance of the PERI score were: being over pension age (65 for men and 60 for women); total family income lower than the mean Israeli income; for men, renting a private apartment, living in a big city, having less than a third of the family members eligible to work who are actually employed, having lost a close family member in a camp during World War II; for women, being widow, uncertainty as to their future place of residence, reading newspapers in Russian. Religiosity and having come from an Asian republic or from a region close to Chemobyl were no longer associated with demoralization after 5 years in Israel.

40The variables significantly associated with psychological distress were then included into a multivariate analysis, with demoralization as the dependent variable. As gender differentially affected the association between the various independent variables and demoralization, the analyses were performed separately for males and females. The final model was developed in several stages. First, those variables that were considered to be innate or beyond the control of the respondent - age, republic of origin, close family perishing during the Second World War, locus of control and life events - were entered into the model. The variables (age, locus of control and life events) that remained associated with the PERI score when controlling for the other variables were included in the following seven analyses of variance of the PERI score:

• family and social support measures (number of friends, social support scale, family support scale);

• measures related to housing (type of housing, intention to move, size of settlement);

• health status (hospitalization in the last six months, number of visits to a family doctor in the last three months, number of chronic illness, prolonged taking of medication for at least one of these diseases, etc.);

• employment measures (employment of the interviewee, proportion of family members eligible to work who are actually working);

• income factors (total family income as compared to mean Israeli income, subjective evaluation of adequacy of income to meet total family needs);

• acculturation factors (language skills, reading Hebrew newspaper);

• remaining variables (army service, help-seeking behavior in the past and self-defined identity).

41Satisfaction with living in Israel was not included in the model, as this variable was seen to be more of an outcome variable, parallel to that of psychological distress.

42When the significant variables of each analysis were entered together into the model, the following seven variables were found to remain significantly correlated with the PERI score at the P < 0.05 level, in at least one of the genders.

Locus of control

43Locus of control was found to be a very important predictor. The sense of personal control over one's life circumstances attenuates the migrants' natural feelings of being very much dependent on the authorities - which also characterized the Soviet totalitarian culture. Thus, those who succeeded in developing a sense of control over their fate, notwithstanding the cultural background, seem to have some specific personality characteristic that better prepares them to cope with the stress of immigration.

Life events

44The number of negative life events respondents reported experiencing over the past year was positively associated with level of demoralization; the greater the number of negative events, the higher the PERI score. Immigrants are probably more susceptible to recent stressful life events than other populations, due to the enormous changes in their social, vocational and familial life. The measure of life events was included in the study in order to control for its potentially confounding effect on the relationship of other variables with demoralization.

Social support

45Perceived feeling of lack of possible support was significantly associated with higher demoralization. This aspect of social support was defined as the cognitive appraisal of the individual of being reliably connected to others, i.e. the belief that one is cared for.

Health status

46All the measures of health used in the study were strongly associated with demoralization (hospitalization in the last 6 months, visit to the family doctor at least 3 times in the last 3 months, suffering from a chronic disease diagnosed after immigration, etc.). Those respondents who suffered from a number of chronic physical illnesses and who were taking medication for these illnesses were more likely to be demoralized than their healthy counterparts, irrespective of all other factors, including age. Those respondents below pension age who suffered from chronic physical illness were much more likely to be demoralized than their healthy counterparts. This was particularly true for males, among whom none of those in bad health worked full time.

Housing

47Housing arrangement was found to be significantly associated with psychological distress for males. An interaction was found between size of township and type of housing arrangement in the male population group; males living in rental accommodation in a large city were much more likely to be distressed. It should be noted that almost no respondent reported living in government housing in the large cities; most of the available government housing is located in the small townships. In the large cities, given the higher cost of home purchase it is not surprising that most of the immigrants there lived in rental accommodation. For them, the burden of high rental payments and the impermanence of their living situation may lay heavily on the male immigrant's shoulders, contributing to the higher levels of psychological distress found in this sub-population.

Income

48After control of all other factors, income itself was no longer associated with demoralization, contrary to the subjective appreciation of the income. Those respondents who described their total family income as insufficient to meet their needs tended to score above the mean, while those who described it as sufficient tended to score below (P < 0.0005 for male and female respondents).

Identity

49Those respondents who described themselves as Israeli were more likely to score lower on the PERI scale than their “soviet-identifying” counterparts. This was particularly true for women. When entered into the final model, self-description remained significantly associated with demoralization among females only. For males, this association remained in the model only when locus of control was removed from the model. For males, the impact on demoralization of perception of oneself as Israeli seems therefore to depend more on the feeling that they are in control of their destiny than of the degree to which they embrace their new country. This was not found to be true for women.

50Thus the findings regarding risk factors for psychological distress among immigrants are in line with some previously published results. Lack of social networks, such as the situation where elderly single male immigrants live in rental accommodations in large cities, leads to increased psychological distress.

51On the other hand, the results point to the fact that the assets an immigrant brings with him are not less important than the post-migration conditions s/he finds in the new country. Those immigrants having a poor sense of control over their fate are less equipped to cope with the process of immigration, and may need a longer period to adapt psychologically. Moreover, the status of being an immigrant fosters in itself a state of dependency. This suggests that authorities responsible for this field should encourage immigrants to become actively involved in the implementation of absorption programs, and even to participate in larger policy and planning activities which address immigrant problems.

52It would be of interest to follow up this large wave of immigrants, and to examine whether the process of psychological adaptation will lead to a gradual disappearance of the distress associated with the first years of immigration and absorption.

Some results on the psychopathology among these immigrants

54We examined the frequency of psychopathology in a sub-sample of 120 immigrants drawn from the sample used for the study above. They were interviewed in their homes with a structured interview, an abbreviated version of the CIDI (Composite International Diagnostic Interview), the CIDI-S (Kovess et al., 1992, 1993). Prevalence rates were calculated for major depression, dysthymia and anxiety disorder, the most common psychiatric disorders in the general population.

56Another feature is also worth pointing out. Epidemiological studies have demonstrated lower current and lifetime prevalence rates of non-psychotic disorders, mainly those of depression, among people over 65. As indicated above, however, we found that psychological distress was more pronounced among the elderly than among those below the age of 65, five years after their immigration. Psychological distress was assessed in this survey by the PERI-demoralization questionnaire, which is not a clinically diagnostic instrument. We examined whether this relationship between psychological distress and age among immigrants held true for psychiatric diagnoses as well. This was found to be the case, contrary to what exists in other populations. Again, elderly immigrants seem to be a group especially at risk.

Implications of these results for the Israeli health system

57Our study has clearly shown persistent psychological distress among immigrants from the former Soviet Union, with older people being a particularly vulnerable sub-group. Health status appears to be a very strong predictor of psychological distress, even after controlling for other factors such as age and gender. Chronic physical illness is known to be associated with some psychological distress. The lack of immigrant familiarity with the local health system, and with the services they are eligible to receive, may make it difficult for them to get adequate treatment and they may thus suffer even more from their disabilities. In this respect, older people are at a higher risk of psychological distress. We have shown that this risk is increased in particular by the lack of social support, which is characteristic of older people. In addition, whereas grandparents were highly regarded in the USSR, in Israel where there is less interaction between generations, their former central role in the family has weakened, which can lead, for elderly Soviet immigrants, to a significant loss of self-esteem.

58When asked to whom they turned when they felt stressed, emotionally strained or anxious, only 0.7 % of the immigrants answered that they turned to a mental health professional. Although the mentally ill are stigmatized in the Western Society as well, going for mental health treatment to mental health specialists is even more of a stigma among most immigrants from the former Soviet Union. This must be understood in the context of Soviet attitudes towards mental illness: mental patients were viewed as “letting down the image of a happy socialist society”; note as well that psychiatry was politically abused by Soviet psychiatrists.

59This attitude towards psychiatry is probably changing in Israel since, in 1995,19 % of the interviewed immigrants said they might turn to psychological services in the future should the need arise. Nevertheless 63 % said they would turn to primary care physicians should psychological help be needed. Thus, most Soviet immigrants still identity the primary care physicians rather than the mental health professionals as the primary source of mental health assistance, the preferred resource for initial advice and the best source of help.

60The importance of general practitioners regarding mental health care resides in three fundamental roles: to diagnose, refer to specialists and give care. They need to be made aware of our findings, and hence recognize the need to clarify the mental health status of clients having the risk factors described above, in particular as regards the diagnosis and treatment of psychological distress of the elderly infirm. One should determine which kind of intervention program would best meet the needs of this at risk group.

61The following three elements are characteristics of Soviet immigrants:

• A very large proportion of Russian immigrants who came to Israel during the last 9 years are physicians. In addition, many former Russian specialists work in Israel as primary physicians – so that a very large number of Russian physicians work in the primary care services.

• Russian immigrants tend to seek care from Russian doctors.

• It is well known that the rate of detection of mental health problems by primary care physicians is generally low – 10 to 55 % only. It has been shown that the primary medical care practitioner's attitudes towards psychiatry play an important role in the screening of cases: a general practitioner is more likely to identify cases if s/he believes in the psychogenesis of physical disorders, and is not concerned that giving a psychiatric diagnosis or referral to a mental health specialist can have negative consequences for the patient. In this respect, physicians from the former Soviet Union may have particularly low rates of detection.

62Therefore it seems imperative that Russian primary care physicians, who have a common cultural background with their clients, be specifically trained to be sensitive to the psychological aspects of the immigrant population they serve, in order to identify emotional distress at an early phase. They should be a target group for medical education concerning detection and treatment of mental health problems in primary care. As indicated above, immigrants themselves should actively take part in the preparation of such educative programs.