Depressive Symptoms Among
Community-Dwelling Oldest-Old
Residents in Israel
Paul E. Ruskin, M.D., Zvia Blumstein, M.A.,
Adrian Walter-Ginzburg, Ph.D., Zahava Fuchs, M.A.,
Ayala Lusky, M.Sc., llya Novikov, Ph.D.,
Baruch Madan, M.D.
The authors examined the rate and correlates of depressive symptoms among community-dwelling oldest-old
citizens in Israel with a sample ofabout 1, 200Jewish Israe/is age 75-94. The estimated national rate of depressive symptoms was 43.5%. Significantly higher rates of
depressive symptoms were found in women (52%, vs.
29.5% for men) and those of low .educational level, low
income, andMiddle Eastern orNorth African origin. Having more depressive symptoms was associated with 1) all
measures of impaired health status; 2) the psychosocial
factors of liVing alone or with a nonspouse, haVing no
available caretaker, and social and physical inactivity;
3) the follOWing health behavior and habits: poor sleep,
skipping meals, sexual inactivity, and drinking no alco-

hol; and 4) traumatic life events and immigration after
age 20. The rate ofdepressive symptoms is relatively high
among oldest-old citizens in Israel, possibly because of
the immigrant nature ofthis population. (AmericanJournal of Geriatric Psychiatry 1996; 4:208-217)

N

umerous community-based studies
conducted in the United States l - 14
and other countries 15- 17 indicate that between 5% and 30% of elderly persons
manifest substantial levels of depressive

symptoms. The Epidemiologic Catchment
Area study 18 found that dysthymic disorders were the third-most-common psychiatric illness among elderly women and the
fourth-most-common among elderly

Received May 12, 1995; revised November 25, 1995; accepted December II, 1995. From the Department of
Veterans Affairs Medical Center, Baltimore, MD and the Department of Clinical Epidemiology, Chaim Sheba
Medical Center, Israel. Address correspondence to Dr. Ruskin. VA Medical Center. 10 N. Green St., Baltimore.
MD 21201.

Copyright © 1996 American Association for Geriatric I'sychiatty
208

VOLUME 4 • NUMBER 3 • SUMMER 1996

Ruskin et al.
men. Major depression was the fourthmost-common psychiatric diagnosis
among elderly women in the above study.
Despite the large number of communitybased studies, our knowledge of depressive symptoms in elderly persons is
incomplete in a number of ways. Only a
few studies have been based on a national
random sample; the oldest-old (i.e., those
85 years of age and above) are underrepresented in most studies,6,7 and cross-cultural and ethnic factors other than race are
rarely taken into consideration. 17
The elderly citizens of Israel are
unique in several respects. They are a culturally diverse population, originating
from over 70 countries. They are a highly
traumatized group, having suffered from
numerous wars, immigration, and/or the
Holocaust. On the other hand, Israel has
had a long history ofsubsidized medicine
in which access to at least a minimal level
of health care has been available to virtually everyone. We present the results on
rates and determinants of depressive
symptoms in the oldest-old in Israel based
on data from our national CALAS study
(the Cross Sectional and Longitudinal Aging Study).

METHODS
Israel has a National Population Registry
(NPR) that is updated and corrected on a
routine basis with reported births, deaths,
and immigration. The study sample was
selected by stratifying the portion of the
Jewish population age 75 and over living
in Israel as of January 1, 1989 by age
(75-79, 80-84, 85-90, 90-94), sex, and
place of birth (Israel, Asia-Africa, EuropeAmerica). One hundred subjects were ran..
domly selected from each of the 24
resultant strata. Of these 2,400 potential
interviewees, 1,820 (76.0%) were interviewed; (8.5% refused, and 15.5% could
not be located). Subjects were interviewed between 1989 and 1992 in their

residence (home or institution) by multilingual trained interviewers. When necessary, the interviews were conducted in the
native language of the respondent, occasionally with the help of a translator. In
cases of respondents' death after the sample was drawn or where the respondent
was incapable of replying because ofmental or physical incapacity at the time of the
interview, a knowledgeable individual,
preferably of the same household, was
sought fora proxy interview. The interviews
took an average ofapproximately 2 hours
.to administer and collected extensive information concerning the sociodemographic, physical, health, functioning, life
events (including Holocaust experience),
psychological, mental status, and social
network characteristics of the sample.
The current analysis was based on a
subsample of 1,200 non-proxy interviews
ofelderly citizens living in the communi~
This sample was further reduced to 1,135
because in 65 interviews, a score for depressive symptoms could not be ascertained.
A comparison of the age, sex, and
country of origin distribution of two subsamples, total communi~ and non-proxy
community with complete CES-D scores,
is presented in Table 1. The study sample
(N = 1,135) is significantly younger than
the total community sample, but there is no
evidence that men and women nor the three
ethnic groups are represented in different
proportions between the two samples.

THE AMEIUCAN JOURNAL OF GEIUATRIC PSYCHIATRY

Measurement
A modified version of the Center for
Epidemiological StudieS-Depression
Scale (CBS-D) 19 was used to measure level
ofdepressive symptomatolo~The CES-D
is a 20-item self-report scale that asks respondents to rate the presence of depres..
sive symptoms, such as depressed mood,
poorsleep, poor appetite, feelings oflone..
liness, crying spells, and difficulty concentrating during the past month. Scores
209

Depression in Older Israeli Citizens
TABLE 1.

Percentage distribution of age, gender, and ethnic origin in two subsamplcs of the Cross
Sectional and Longitudinal Aging Study (CALAS)
Total
Community
(II = 1,486)

Age

75-79

80-84

85-89
90-94

Sex

Male
Female
Origin
Israel
Europe/America
Asia/Africa

Non-Proxy
CommunityB
(II = 1,135)

30.4
27.8
24.0
17.8

35.2
28.6
23.1
13.0

55.3
44.7

55.5
44.5

NS

29.5

31.5
31.6
36.9

NS

34.4
36.1

pb

0.03

nWith complete Center for Epidemiologic Studies-Depression (CES-D) scores.
bChi-square test.

range from a low of 0 to a high of60. Studies indicate that the higher the score, the
greater the chance that the subject suffers
from a depressive disorder. The version we
used asked for frequency of each depressive symptom in the past month, instead
of the past week, because it was felt that
symptoms of 1 week's duration were too
transient a phenomenon in people of this
age and that asking about the past month
would provide a more stable measure. The
internal reliability of the CES-D scale as
measured by Cronbach's alpha was 0.88.
Elderly persons who were unable to
provide a response to six or more items
on the CES-D were regarded as unable to
complete the CES..D score. Subjects unable to provide a response to between one
and five ofthe items from the 20..item CESD were assigned their mean item score for
those unanswered items in tabulating a
summary score.
A wide range of predictor variables
were classified into five major groups of
risk factors: 1) demographic; 2) physical
functioning and health status; 3) psychosocial variables; 4) past life events; and
5) lifestyle factors, such as smoking, alco..
hal consumption, and sexual activi~
Several components of health were
used. The number of health conditions
210

the subject ever suffered from was determined from positive responses to a list of
chronic diseases and conditions. The
number of medications was obtained
from a question on current use of medications. Functional ability was measured
by slight modifications of the Katz Activities of Daily Living (ADL) scale,20,21 and
Instrumental Activities of Daily Living
(IADL)22 and physical activity23 24 measures. The ADL items assessed difficulty in
performing seven functions (crossing a
small room, washing, grooming, dressing,
eating, transferring, toUeling). The IADL
assessed difficulty in nine instrumental activities (such as preparing meals, doing
small and large shopping, doing light and
heavy housework, reaching the nearest
bus stop, and using the telephone). The
ability to perform physical tasks was re..
lated to difficulty in performing four sepa..
rate activities: 1) bending, crouching,
stooping, or kneeling; 2) walking 1 kilo..
meter; 3) walking up 10 stairs without
resting; and 4) carrying 5 kilos. 25 Mental
status was measured by a translation ofthe
Katzman et at. 26 mini-mental instrument,
somewhat modified by permitting the Hebrew as well as Gregorian months to be
enumerated backward and changing the
five-item memory recall test to more rec1

VOLUME 4 • NUMBER 3 • SUMMER 1996

Ruskin et al.
ognizably Israeli names and addresses.
Physical activity was defined by number of
times per week the subject performed the
following activities: working outdoors,
walking up to 2 kilometers, and other
sports activities. The number of traumatic
experiences was assessed by asking respondents to list up to three such experiences during their lifetime. Social activity
was defined as a positive answer when
asked if they perform anyone of the following activities: participating in synagogue services, volunteer activities, or
going out often with friends. Availability
of a confidant was defined as having at
least one person to talk to about personal
things and who could be depended on.
Statistical Analysis
A score of 16 was used as the cutoff
for the definition ofdepressive symptoms.
In order to account for the effects of the
stratification design, all calculations were
done by assigning strata weights to the
specific age, sex, and origin of subjects.
Weights were calculated by dividing the
number of people in the population in
each age, sex, and origin cell by the
number of people interviewed in each
cell. Significant differences in rate of depressive symptoms across subcategories
of each predictor variable were tested by
chi-square tests for contingency tables
with the SUDAAN Program 27 for complex
sampling design.
Multiple linear regression analysis for
predicting CES-D score by each of the five
groups ofpredictorvariables separately and
in several combinations ofpredictorgroups
was used to assess the proportion of variance explained by each group (R 2), by use
of the "regress" procedure ofSUDAAN.

RESULTS
The weighted rate of depressive symptoms for non-proxy subjects living in the
THE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY

community was 43.5%. Examining differences in CES-D scores among categories
of the independent variables, we find significantly higher rates ofdepressive symptoms among women (56.2%) than among
men (28.4%; Table 2). The other demographic variables that were significantly related to depressive symptoms include low
educational level, low income, and continent of birth, with the lowest rate found
among elderly subjects born in Israel, and
the highest among those born in Asia or
Mrica. Age and religiosity were not significantly associated with higher levels of
depressive symptoms. The following
measures of impaired health status were
highly related to depressive symptoms: a
greater number ofmedical conditions and
medications, impaired functional status in
ADL, IADL and physical tasks, poor self-assessed health, more frequent doctor visits,
impaired cognitive status, and sleeping
problems (Table 3).
Psychosocial factors related to depressive symptoms included not living with a
spouse, being widowed or divorced, having no available caretaker in time of need,
and social and physical inactivity (Table 4).
Unexpectedly, recent deaths of close
friends or family members were not related to depressive symptoms. Frequent
contact (daily or weekly) with at least one
child and having a confidant were nonsignificantly associated with lower rate of depressive symptoms.
A majority of the subjects immigrated
to Israel from other countries. Those few
who arrived before age 20 had rates of depressive symptoms similar to those born in
Israel, but those who immigrated after age
20 had significantly higher rates of depressive symptoms (fable 5). Holocaust sumvors were not significantly more depressed
than other subjects in the national sample.
Table 6 presents the rates of depressive symptoms by selected health and lifestyle habits. Alcohol consumers (whether
of small or moderate amounts) and those
who are active sexually have significantly
211

Depression in Older Israeli Citizens
TABLE 2.

Percentage of subjects ,vith CES·D score 2: 16 by sociodemograpbic cbaracteristics

N

Total

Age

75-79
80-84
85-89
90-94
Sex
Male
Female
Education. years
0-4

5-8

9-12

13+

Origin

Israel

Europe!
America

AsialMrica
Religious adherence
ncligious
Traditional
Secular
Source of income
Social Security only
Social Security + other income

CES·D ~ 16
in sample

CES·D ~ 16
\veighted

1.135

39.6

43.5

400

35.0

40.0

325
262

41.2

49.1
44.8
43.8

630
50S

29.5
52.1

28.4
56.2

< 0.001

340

52.4
42.4
32.1
21.1

53.6
49.3
37.2
27.5

0.06

26.7

< 0.01

148

288

312

152

41.8

42.7

357
419

28.0
40.8

42.7

359

49.6

49.5

405
419
310

42.2
39.7
35.5

46.7
40.3
44.2

513
588

45.0
35.2

50.9
38.4

< 0.05

Note: CES-D = Center for Epidemiologic Studies-Depression Scale.
aFar differences in weighted percentages.

lower rates of depressive symptoms,
whereas skipping meals was associated
with a higher rate ofdepressive symptoms.
The following R 2 values were ob·
tained when each ofthe five groups ofpre·
dietor variables with age and sex were
regressed separately on CES·D score:
physical and health status, 0.46; social
support, 0.29; demographic variables,
0.15; past life events, 0.18; behavior and
lifestyle, 0.17. The combination of health
status and social support resulted in the
highest R 2 (0.52). When past life events
were added to these two groups, the R2
increased to 0.54. The R 2 using all five
groups of predictor variables simultane·
ously was 0.56.
Twenty-six percent of all the subjects
were taking psychotropic medication
(mainly benzodiazepines) at the time of
the interview, and 3.6% were taking antidepressants. Subjects with a high level of
212

depressive symptoms were significantly
more likely to be taking psychotropic
medication (36.1% vs. 18.3%) as well as
antidepressant medication (5.4 % vs. 2.1 %,
respectively) .

DISCUSSION
Although we found a higher rate ofdepressive symptoms in our study than in other
community studies of elderly sub·
jects, 2,3,5,6,10,11,14 this rate is most likely an
underestimation of the true prevalence
because both proxy subjects and subjects
with missing CES·D scores were significantly older, were in worse health, and
had poorer physical functioning, as com·
pared with the study sample.
This high prevalence of depressive
symptoms raises a methodological ques·
tion as to the psychometric qualities ofthe
VOLUME 4 • NUMBER 3 • SUMMER 1996

Ruskin et al.
TABLE 3.

Selected physical status factors, %

CES·D;:: 16
weigbted

212
343
580

16.5
33.2
51.7

21.0
40.0
51.5

0.02

163
186

25.9
29.5
35.8
45.8
58.8

0.04

259

24.5
28.0
33.7
43.2
56.8

893
240

33.4
62.5

36.0
74.8

< 0.001

429

22.8

35.3
54.5
66.1

28.3
38.0
71.8
74.8

< 0.01

312

12.9
23.7
56.9

15.6
27.9
63.8

< 0.001

33.2
32.7
53.2
56.9

41.9
32.6
53.2
62.8

0.08

3.1
19.2
34.5

13.2
25.7
36.4
69.8

< 0.01

30.4
35.5
49.2
55.6

38.7
34.0

0.06

32.4

37.8

41.8

49.0
54.1

44.1
52.2
54.7

34.7
62.0
54.4

< 0.01

112

30.1
53.2
55.4

415
717

Number of health conditions
0-1
2-3
4-6+
Number of medications
0
1

CES.D;:: 16
in sample

25.1
48.0

30.3
50.5

< 0.01

"

187

2

340

3-4
5+
Number of impaired ADLs
0
lor more
Number of impaired IADLs
0

1-3
4-6

198

165
7-9
Impaired physical ability
0
233
1-2
283
617
3-4
Problems seeing and hearing
Neither
599
Only hearing
196
Only seeing
203
Both
137
Self-assessment of health
64
Excellent
Good
213
Fair
502
Poor
346
Number of doctor visits in past month
None
395
1
335
2-4

313

5+
Hospitalizations in past 5 years
0
1
2

3+

Cognitive status
Not impaired
Slightly impaired
Dementia
Problems sleeping
No
Yes

63
509
383
147
85

684

329

66.2

No/eo' CES-D = Center for Epidemiologic Studies-Depression scale. AnL
IADL Instrumental Activities of Daily Living.
aFor differences in weighted percentages.

=

THE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY

pa

50.1

73.5

= Activities of Daily Living.

213

Depression in Older Israeli Citizens
TABLE 4.

Selected psychosocial factors, %

Living arrangements
With spouse
Alone

With other
(child or other than spouse)
Marital status
Married
Wido\ved
Divorced
Never married
Confidant
Yes
No
Availability of caretaker
For \veeks or days
Emergency only
None
Unknown (Il = 125)

Contact with children
Live with child
Daily
Weekly
Rarely
No children
Social activity
Inactive
Active
Physical activity per \vcck
Never
Rarely
1-2 times
3 or more
Bereavement in past year
No

Yes
Nole:
n For

16
in sample

CES-D ~ 16
weighted

534

29.2
48.3
50.0

30.9
54.0
56.9

0.02

431
170
536
545
37
17

29.7
49.2
43.2
35.3

30.6
54.9
64.4
28.4

0.02

771
332

36.8
44.9

40.8
48.4

809
143
58

33.3
55.2
53.4

37.3
59.9
55.1

192

114

44.8
36.3
36.7
48.3
43.9

45.7
35.1
42.4
50.6
54.0

418
717

51.7
32.5

58.3
35.6

<0.01

470

277
81

58.8
47.6
39.7
21.7

<0.01

304

54.9
39.0
25.9
20.3

734
387

39.8
39.0

44.1
42.7

"

303
425

86

< 0.05

CES-D = Center for Epidemiologic Studies-Depression Scale.
differences in weighted percentages.

Hebrew translation ofthe CES-D. Both the
high inter-item reliability of the scale and
the reaffirmation of the four underlying
constructs of the scale, as originally
proposed by Radloff,19 emphasize the
comparable aspects of the scale to other
populations. Also, the associations of the
CES-D with its determinants were very
similar to those found in studies in other
communities in the United States and
Europe. 3 There are a number of possible
explanations for the higher rate in our
sample. First, the length of time measured
was longer (1 month rather than 1 week).
Second, our population is older than
214

CES-D~

those in most other studies. 2t9 Third,
whereas the rates ofdepressive symptoms
among Israeli-born subjects are comparable to rates found in other studies, 2 the
rates of those who immigrated from other
countries are almost twice as high as
among the Israeli-born. This finding underlines the long-term effect of immigration to a very different cultural setting.
An attempt to relate the supposedly
excessive rate of depressive symptoms to
the Holocaust experience cannot be supported at this point because the Holocaust
survivors did not have a significantly
higher ratc of symptoms. Although other
VOLUME 4 • NUMBER 3 • SUMMER 1996

Ruskin et al.
TABLE

5. Percentage of subjects with CES·D ;:: 16 by selected past life events

Holocaust history
Holocaust survivorsb
Others
Past traumatic experiences
None
1

2-3

Age at arrival in Israel, years
0-19

20-39

40+
Isracl·born

CES·D~ 16

in sample

CES·D ~ 16
weighted

231

47.6
37.6

48.0
40.9

583

32.1
44.8
54.9

46.2
56.5

45
255
468

28.9
39.6
49.6
28.0

25.0
41,4
50.8
26.7

"
902
337
170

357

38.0

0.02

CES·D = Center for Epidemiologic Studies..Deprcssion Scale.
For differences in \veightcd percentages.
b1ncludcs persons who \vcre in concentration camps, ghettos, labor camps, and under Nazi occupation.

Note:
n

TABLE 6.

Percentage of subjects \vidl CES-D ~ 16 by selected lifestyle behaviors

Smoking
Never
Previously
Currently
Skipped meals in past \vcek
No
Yes
Most recent sexual activity
Past 6 mo.
6 mo.-5yr.
Over 5 yr.
Unknown
Current alcohol useb
None or very rarely
Small amount
Modcrate.. to.. large

CES·D ~ 16
in sample

CES-D ~ 16
weighted

346

118

41.9
33.5
44.1

46.3
35.8

1,053
81

37.9
60.5

42.3
66.2

0.07

117
142
548
334

11.1
31.7
44.3
44.6

12.2
36.1
50.8

0.01

820

44.3

49.3
23.2
20.0

0.02

"
671

239

74

26.8

27.0

48.4

Note: CES..D = Center for Epidemiologic Studies-Depression Scale.
a For differences in \vcighted percentages.
b Small amount = several times per month; moderatc..to-Iargc several times per \vcck.

=

community-based studies of Holocaust
survivors have found increased levels of
psychiatric symptomatology,28-31 we
found only a trend toward increased depressive symptoms among Holocaust survivors. It is also possible that cultural
factors playa role in the response to scale
items so that elderlyJewish subjects score
higher in this context. This is in line with
Kennedy et at.'5 finding 2 that Jewish eldTHE AMEIUCAN JOURNAL OF GERIATIUC PSYCHIATRY

erly persons had a much higher rate ofdepressive symptoms (23%) than did Catholics (12%) or Protestants (13%).
Health, functional status, and health
care utilization were highly related to depressive symptoms in our sample and explain 46% of the variance in depressive
symptoms. This finding is consistent with
virtually all studies of depression in elderly subjects. 2,4,6,9 In a longitudinal stud~
215

Depression in Older Israeli Citizens
Kennedy et at 32 found that among elderly
subjects who were not depressed at baseline evaluation, uincreasing disability and
declining health preceded the emergence
of depressive symptoms in many subjects
and accounted for 70% of the variance explained by discriminant analyses."
As expected, subjects who reported
poor sleep or poor appetite had greater
rates of depressive symptoms. However,
these problems could have been a consequence of the depressive symptoms rather
than a cause. There were fewer depressive
symptoms among subjects who smoked
in the past, and those who currently drink
alcohol, although the level of alcohol consumption in this population is very loVl It
is possible that moderate drinking was associated with a more active lifestyle,
whereas being able to stop smoking relates to persons having more control over
their lives.
By use of similar methodology and
predictor variables, Kennedy et al. 2 ob2
tained anR value of0.53, almost identical
to our finding of R 2 = 0.56. As found elsewhere, a model of physiological and psychosocial factors can explain much of the
variance in late-life depressive symptoms
in the Israeli population. This finding, as
well as the high prevalence found in this
stud~ emphasizes the need to be more
aware of the scope of the problem and
look for measures of intervention at the
few points possible, in order to reduce the
level of late-life depressive symptoms.
Psychotropic medication use was
common in this sample, but despite this
high rate of depressive symptoms, antidepressants were rarely used. Given that the
benzodiazepines taken by 36.1 % of the
elderly subjects with CES-D ~ 16 are
known to cause depressive symptoms, it
is possible that in some ofthese depressed
t

subjects the medications were contributing to the depression. On the other hand,
only 5.4% of the subjects with depressive
symptoms were taking antidepressants. It
is possible, therefore, that some ofthe depressed patients were inappropriately
receiving benzodiazepines instead of antidepressants.
The major limitation of the study is
the lack of data on the rate of depression
among those represented by a proxy and
for those who did not complete the CES-D.
Another limitation is the modification of
the CES-D to assess monthly rather than
weekly symptoms. In order to assess the
effect of the instrument modification on
the prevalence of depressive symptoms, a
validation study was conducted byadministering two versions of the scale, asking
for symptoms in the past week and in the
past month to a subsample of subjects in
the study (n = 100). The findings show
that the modification did not increase significantly the prevalence of depression.
Overall, 94% of individuals were classified
the same by both versions (kappa =
0.895; P < 0.01). Considering CES-D
score as a continuous variable, the difference between the CES·D means ofthe two
versions was not significant (by paired ttest). Whether the difference in the prevalence of depressive symptoms between
our sample and other communities reflects true variation in the rate of depressive symptomatology or a potential
cultural difference in the willingness to
endorse CES-D items will be determined
in a future validation study:

This work was supportedinpart bygrants
ROJ A605885·03 and ROI A605885-05

from the National Institute on Aging and
by the Department a/Veterans Affairs.

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