Soc Psychiatry Psychiatr Epidemiol (2008) 43:79–86
DOI 10.1007/s00127-007-0270-4
ORIGINAL PAPER
Yuan-Pang Wang Æ Luciana Pajecki Lederman Æ Laura Helena Andrade Æ Clarice Gorenstein
Symptomatic expression of depression among Jewish adolescents: effects of gender and age
Accepted: 25 September 2007 / Published online: 24 October 2007
j Abstract Background Depression symptomatology was assessed with the Beck Depression Inventory (BDI) in a sample of Jewish adolescents, in order to compare the frequency and severity of depression with non-Jewish adolescents as well as examine gender difference of the expression of depressive symptomatology. Method Subjects comprised 475 students from Jewish private schools, aged 13–17 years, who were compared with an age-matched non-Jewish sample (n = 899). Kendall’s definition was adopted to classify these adolescents according to level of depressive symptoms. The frequency of depression was calculated for ethnicity, gender and age strata. Discriminant analysis and principal component analysis were performed to assess the importance of depression-specific and non-specific items, along with the factor structure of the BDI, respectively. Results The overall mean score on the BDI in the Jewish and the non-Jewish sample was 9.0 (SD = 6.4) and 8.6 (SD = 7.2), respectively. Jewish girls and boys had Y.-P. Wang, MD, PhD Æ L.H. Andrade, MD, PhD C. Gorenstein, PhD (&) Institute of Psychiatry (LIM-23) Medical School, University of Sa˜o Paulo Rua Dr. Ovı´dio Pires de Campos, 785, te´rreo CEP 05403-010 Sa˜o Paulo (SP), Brazil E-Mail:
[email protected]
comparable mean BDI scores, contrasting with nonJewish sample, where girls complained more of depressive symptoms than boys (p < 0.001). The frequency of depression, adopting a BDI cutoff of 20, was 5.1% for the Jewish sample and 6.3% for the nonJewish sample. The frequency of depression for Jewish girls and boys was 5.5% (SE = 1.4) and 4.6% (SE = 1.5), respectively. On the other hand, the frequency of depression for non-Jewish girls and boys was 8.4% (SE = 1.2) and 4.0% (SE = 1.0), respectively. The female/male ratio of frequency of BDI-depression was 1.2 in the Jewish sample, but non-Jewish girls were twice (2.1) as likely to report depression as boys. Discriminant analysis showed that the BDI highly discriminates depressive symptomatology among Jewish adolescents, and measured specific aspects of depression. Factor analysis revealed two meaningful factors for the total sample and each gender (cognitive-affective dimension and somatic dimension), evidencing a difference between Jewish boys and Jewish girls in the symptomatic expression of depression akin to non-Jewish counterparts. Conclusions Ethnic-cultural factor might play a role in the frequency, severity and symptomatic expression of depressive symptoms in Jewish adolescents. The lack of gender effect on depression, which might persist from adolescence to adulthood among Jewish people, should be investigated in prospective studies. j Key words depression – Beck Depression Inventory – adolescents – Jews – Brazil
L.P. Lederman Institute of Psychology Sa˜o Paulo University Sa˜o Paulo, Brazil
Mental health in Jewish people
C. Gorenstein, PhD Dept. of Pharmacology Institute of Biomedical Sciences; LIM-23, Laboratory of Psychopharmacology Institute of Psychiatry, HCFMUSP University of Sa˜o Paulo Sa˜o Paulo, Brazil
Previous reviews on the mental health of Jews have reported an increased vulnerability to affective disorders in this ethnic group [27, 28, 32]. Over the past decade, two analyses of North-American Epidemiological Catchment Area Study (ECA) [29, 49] con-
SPPE 270
Y.-P. Wang, MD, PhD Dept. of Psychiatry Medical School of Santo Amaro, UNISA Sa˜o Paulo, Brazil
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firmed a partially higher prevalence of depression among Jewish adults. In fact, while the overall lifetime rate of psychiatric disorders among Jews did not differ from the rate among non-Jews [49], there was a significant difference between Jewish and non-Jewish adult samples when comparing the distribution of specific psychiatric disorders. Compared with Catholics and Protestants, Jews had significantly higher rates of major depression and dysthymia, but lower rates of alcohol abuse. Jews were more likely than Catholics or Protestants to seek treatment with mental health specialists and general practitioners [34]. These differences remained statistically significant after adjusting for sex, age, and socioeconomic status. Some key results have indicated that the rate of depression in male Jews accounted for the view of higher prevalence among Jewish people. While female Jews displayed rates of depression comparable to their non-Jewish counterparts, male Jews reported more depression than non-Jewish males [29]. Another important finding constitutes the absence of gender difference for depression among Jewish people [29, 32]. Several hypotheses have been raised to explain Jewish intraethnic vulnerability to affective disorders when compared with other communities, based on observational studies of low incidence of alcoholism among Jews men [35]. Further evidence on the hypothesis regarding the relation between the alcohol abuse/dependence and depression in population groups [15, 24, 28] highlight the fact that males at risk for major depression are also at risk for developing alcoholism and may not depend on biological factors alone. Possibly, societal norms and cultural rules, e.g. drinking prohibition, may determine which disorder will prevail. As an ethnic group, there are many heterogeneous Jewish communities around the world, whose similarity, among other factors, can be explained by their biological ancestry and religious attachment. For example, Ashkenazi and Sephardic Jewish [1, 22] display different drinking patterns, dietary habits, acculturation levels, and religious practices. Biologically, they may differ greatly as is the case for European, Ethiopian, and Yemeni Jews [2]. The development of young Jews within their specific cultural environment is unclear [28]. As the second and third post-war generations grow up worldwide, the focus has turned to intergenerational traumatic aftereffects of the Nazi Holocaust on the Jewish population [23, 30], and the cultural identity of modern Jewish people as a group [42, 44].
essentially the same across an individual’s life span, occasionally there is a symptomatic constellation that does not fulfil diagnostic criteria for major depression in adolescents [17]. For instance, in contrast to adults and the elderly, the developmental stage of adolescents appears to influence the expression of certain mood symptoms, such as through displaying irritability, sadness, self-esteem, and negative attributions, with greater frequency over others within the framework of depressive disorders [17]. Consequently, depression in puberty is under-detected and under treated [5, 25]. Moreover, epidemiological studies have indicated that the development of depressive disorders in adulthood can be anticipated by the presence of depressive symptoms in adolescence [16, 40], as the impact on social functioning, academic underachievement, higher alcohol and drug consumption, cigarette smoking, and the risk of recurrence, co-morbidity, and suicide [17, 38]. The Beck Depression Inventory (BDI) is considered useful in measuring and predicting subsequent depression in samples of adolescents [7, 11]. The scale is written in a clear format, is straightforward to administer, and can be easily understood by this population [47]. The psychometric properties and construct validity of the Portuguese version of the BDI have been studied in Brazilian patient samples, college students, and adolescent populations [18–20]. Jewish adolescents who attend Jewish schools in the city of Sa˜o Paulo offered an opportunity to investigate the psychological adjustment of this group.
Depression in adolescents
The subjects were drawn from non-Orthodox Jewish schools located in the city of Sa˜o Paulo. These institutions consisted of three private schools attended by adolescents from middle and uppermiddle socioeconomic classes. The classrooms were randomly chosen for application of the questionnaire. The final sample comprised 475 adolescent students (258 girls, 217 boys), aged 13– 17 years (mean 14.5, SD = 1.2), all of whom were single and where only 5.3% (n = 25) had a regular job after school. These adoles-
Mood disorders in adolescents and their treatment have been the subject of increasing attention and clinical investigation over recent decades. Although the core features of mood disorders are seen as
Aims of the study In order to investigate the hypothesis that there is an increased vulnerability to affective disorders among Jewish adolescents, as previously suggested in Jewish adult samples, we first compared the frequency and severity of depression in a Jewish adolescent school sample with their non-Jewish counterparts. The second aim was to test the hypothesis of lack of gender difference for mood disorders as has also been reported in Jewish adults by international studies. We also assessed the differential expression of depressive symptomatology between genders.
Methods j Subjects
81 Table 1 BDI mean scores and standard deviation, according to age, gender and severity level for Jewish sample (n = 475) and non-Jewish sample (n = 899) Category
Jewish sample
Non-Jewish sample
n (%)
Mean (SD)
n (%)
8.3 9.4 8.5 9.3 10.3
201 196 268 194 40
Age 13 years 119 14 years 151 15 years 81 16 years 106 17 years 18 Gender Female 257 Male 218 BDI Cutoffs BDI £ 15 408 16 £ BDI £ 20 43 BDI > 20 24 BDI total 475
(25.1) (31.8) (17.1) (22.3) (3.8) (54.1) (45.9)
(6.7) (6.6) (6.2) (6.1) (6.0)
(22.4) (21.8) (29.8) (21.6) (4.4)
8.9 (6.1) 475 (52.8) 9.1 (6.8)** 424 (47.2)
(85.9) 7.0 (4.2) (9.1) 17.8 (1.3) (5.1) 25.9 (5.4) (100.0) 9.0 (6.4)
776 69 57 899
Mean (SD) 8.0 9.0 8.0 9.4 9.6
(7.5) (7.0) (6.7) (7.3) (8.7)
9.4 (7.6)* 7.6 (6.6)
(86.0) 6.4 (4.3) (7.7) 17.6 (1.5) (6.3) 27.3 (7.3) (100.0) 8.6 (7.2)
SD, standard deviation *ANOVA F = 13.956, df = 1, p < 0.0001: non-Jewish girls > non-Jewish boys **ANOVA F = 6.848, df = 1, p = 0.009: Jewish boys > non-Jewish boys cents were from second or third generations Brazilians and all descended from Jewish families. Jewish affiliation was also selfreported by the adolescent participants. A comparison group comprised of an age-matched non-Jewish sample of 899 adolescents (475 girls, 424 boys), aged 13–17 years (mean 14.6, SD = 1.2), was recruited from non-Jewish private schools attending daytime classes. Age and gender characteristics for both groups are shown in Table 1. For the sake of convenience, the group of Brazilian Jewish adolescents will be henceforth referred to as the Jewish sample, and the comparative group of Brazilian non-Jewish adolescents as the non-Jewish sample. j Instrument BDI—the Portuguese version of the 21-item revised Beck Depression Inventory [8]—was used. The scale consists of items including depressive symptoms and attitudes in past weeks, whose intensity ranges from neutral to maximum level of severity, rated from 0 to 3. We adopted Kendall’s et al. [26] recommendations for non-clinical populations, namely scores between 16 and 20 detected dysphoria, while scores over 20 were indicative of depression. These cutoff scores have been adopted in previous studies of a similar nature [37]. The scale calibration of the Portuguese version of the BDI has been demonstrated in an associated paper on Brazilian adolescents [20]. Subjects were asked to fill out the questionnaire voluntarily and anonymously in their classrooms prior to their regular classes. The self-report questionnaire was handed out at the beginning of their class and there were no refusals. This study was approved by the Brazilian ethics committee of the University and was in accordance with the Helsinki Declaration of 1975. j Data analysis The comparison by sociodemographic characteristics was performed through one-way ANOVA followed by the post hoc Tukey’s t-test, whilst Levene’s test was used to check for homogeneity of variance assumption. Multiple comparisons were performed to test the effect of age on the BDI score. Psychometric properties of the BDI were compared by gender and level of depressive symptomatology according to Kendall’s cutoffs for non-clinical populations. Individual item means were compared through independent-sample t-tests with Bonferroni adjustments of p = 0.05 for the 21 comparisons, in order to protect
against family-wise error rates (individual significant values, p < 0.002). The frequency of depression was calculated for Jewish and non-Jewish samples, by age stratum and gender. Factor analysis and discriminant analysis were performed for both the Jewish and non-Jewish sample. The main results for nonJewish adolescents have been detailed in a previous paper [20]. Internal consistency of the BDI was calculated by Cronbach’s alpha coefficient. Item-total correlation was evaluated in order to identify which items were more closely associated with the BDI total score. Principal components analysis (PCA) was performed to assess the factor structure of the scale across the total sample and by gender after checking for sample factorability. Factor retention criteria were based on Cattell’s scree test, where the initial solution was subjected to varimax rotation for better interpretation. Items with loading higher than 0.40 were considered significant for the factor. Two discriminant analysis models were performed to explore the predictive ability of the set of BDI items on depression in Jewish and non-Jewish adolescents. In the first model we tested if the ‘‘depressed’’ and ‘‘non-depressed’’ subgroups could be predicted according to all individual items, whereas the second model estimated if those subgroups could be discriminated according to depression-specific and non-specific items defined as follows [43]: specific items—sadness, pessimism, sense of failure, guilty feelings, self-dislike, suicidal wishes, and weight loss; non-specific items—work inhibition, sleep disturbance, fatigability, and loss of libido. The entire analysis was performed with SPSS software.
Results For the Jewish sample, psychometric consistency analysis of the item scale was carried out for the BDI raw scale by correlating item scores with the total scale score (data not shown). Correlation coefficients between each item score and total BDI score ranged from 0.06 to 0.52. Items 1, 3, 4, 7, 9, 10, and 17, sadness, failure, lack of satisfaction, self-dislike, suicidal wishes, crying, and fatigability, respectively, correlated highly with the total scale (p < 0.05). In contrast, items 11, 19, and 21, irritability, weight loss, and loss of libido, respectively, correlated poorly with the total scale (p > 0.05). Additionally, the inter-item consistency value (Cronbach’s alpha) of 0.78, 0.76, and 0.79 was obtained for the total sample, and girl and boy sub-groups, respectively. Overall mean BDI scores and standard deviations (SD) of the total sample and according to age strata, gender, and BDI cutoffs for the Jewish and non-Jewish samples can be found in Table 1. The overall mean score on the BDI in the Jewish and the non-Jewish sample was 9.0 (SD = 6.4) and 8.6 (SD = 7.2), respectively. For the Jewish sample there was no significant difference in total score for girls (mean = 8.9, SD = 6.1) or boys (mean = 9.1, SD = 6.8, p = 0.61). However, non-Jewish girls presented a significantly higher BDI mean score (mean = 9.4, SD = 7.6) than boys (mean = 7.6, SD = 6.6, p < 0.001). The mean BDI score of Jewish boys was significantly higher than non-Jewish peers (9.1 vs. 7.6, p = 0.009). Dysphoria (BDI between 16 and 20) was observed in 9.1% (n = 43) and 7.7% (n = 69) of the subjects, respectively, for the Jewish and non-Jewish total samples. The threshold level of possible depression (BDI > 20) was reached by 5.1% (n = 24) of the Jewish sample,
82 Table 2 Frequency of depression level (BDI > 20) among Jewish and nonJewish adolescents, by age strata and gender Variable
Age 13 years 14 years 15 years 16 years 17 years Total sample Gender Female Male Female/Male ratio
Jewish adolescents (n = 24)
Non-Jewish adolescents (n = 57)
n
Frequency (SE)
n
Frequency (SE)
6 7 4 6 1 24
5.0% 4.6% 4.9% 5.7% 5.6% 5.1%
(2.0) (2.2) (2.4) (2.3) (5.6) (1.0)
11 13 17 14 2 57
5.5% 6.6% 6.3% 7.2% 5.0% 6.3%
14 10
5.5% (1.4) 4.6% (1.5) 1.2
40 17
8.4% (1.2) 4.0% (1.0) 2.1
(1.6) (1.8) (1.5) (1.8) (3.4) (0.8)
SE, standard error
and 6.3% (n = 57) for the non-Jewish counterparts. Summarizing, a comparable proportion of Jewish (14.2%) and non-Jewish (14.0%) adolescents has presented some degree of depressive symptomatology, or BDI scores higher than 15. Table 2 displays the frequency and standard error (SE) of depression, according to a criterion of BDI higher than 20, among Jewish and non-Jewish subjects by age stratum and gender. The frequency of depression was 5.1% (SE = 1.0) for the Jewish sample and 6.3% (SE = 0.8) for the non-Jewish sample. Although the proportion of depressed adolescents by age strata was similar or different without reaching significance, data inspection showed a trend toward higher rates for the 13–16-year-stratum in the nonJewish sample, yet a similar trend was not observed in Jewish adolescents. Considering the Jewish sample by gender, 5.5% of girls (SE = 1.4, n = 14), in contrast to 4.6% of boys (SE = 1.5, n = 10), had scores compatible with depression. On the other hand, the frequency of depression for non-Jewish girls and boys was 8.4% (SE = 1.2, n = 40) and 4.0% (SE = 1.0, n = 17), respectively. The female/male gender ratio for depression was 1.2 (5.5 vs. 4.6%) in the Jewish sample, contrasting with the non-Jewish ratio of 2.1 (8.4 vs. 4.0%). Interestingly, the main difference was between Jewish vs. non-Jewish girls (5.5 vs. 8.4%, p < 0.05) and not between boys (4.6 vs. 4.0%, NS). The discriminant analysis of the Jewish sample (data not shown), considering all BDI items, showed a 96.5% correct classification for non-depressed subjects, 100% for depressed subjects, and 96.7% for the total sample. The most powerful discriminating items in descending order were (please refer to Table 3 for item identification): 3, 4, 7, 9, 1, 16, 2, 6, 17, 10, and 5. The discriminant analysis considering depressionspecific items showed a 94.8% correct classification for non-depressed subjects, 75% for depressed subjects, and 93.9% for the total sample. The most powerful discriminating items in descending order were 3, 9, 7, 1, 2, and 5, while the least important was
Table 3 Rotated component matrix after varimax rotation, total Jewish sample and by gender BDI item
1. Sadness 2. Pessimism 3. Sense of failure 4. Lack of satisfaction 5. Guilty feelings 6. Sense of punishment 7. Self-dislike 8. Self-accusations 9. Suicidal wishes 10. Crying spells 11. Irritability 12. Social withdrawal 13. Indecisiveness 14. Distortion of body image 15. Work inhibition 16. Sleep disturbance 17. Fatigability 18. Loss of appetite 19. Weight loss 20. Somatic preoccupation 21. Loss of Libido % explained variancea Cronbach’s alpha
Total Jewish (n = 475)
Jewish girls (n = 257)
Jewish boys (n = 218)
1
1
1
2
2
2
0.66 0.07 0.62 0.05 0.66 0.13 0.38 0.08 0.28 0.17 0.51 )0.04 0.74 )0.01 0.68 )0.02 0.78 )0.03 0.59 0.20 0.63 0.10 0.53 0.30 0.23 0.44 0.23 0.32 0.25 0.51 0.48 0.20 0.55 0.02 0.42 0.31 0.67 0.16 0.67 0.09 0.66 0.23 0.29 0.37 0.35 0.30 0.20 0.45 0.62 0.15 0.53 0.12 0.68 0.21 0.28 0.37 0.40 0.36 0.21 0.33 )0.01 0.27 0.03 0.30 )0.02 0.27 0.35 0.24 0.30 0.36 0.42 0.14 0.22 0.46 0.30 0.41 0.20 0.50 0.54 0.02 0.50 0.05 0.53 0.06 0.23 0.48 0.41 0.30 0.05 0.61 0.22 0.45 0.22 0.53 0.22 0.45 0.30 0.56 0.41 0.45 0.15 0.70 0.03 0.55 0.04 0.55 0.05 0.54 )0.013 0.26 )0.21 0.36 0.01 0.11 )0.01 0.57 )0.02 0.65 0.07 0.44 0.21 0.28 0.30 0.27 0.20 0.17 16.4 11.9 17.3 10.8 16.3 13.3 0.73 0.67 0.75 0.53 0.75 0.68
Boldface: factor loading higher than 0.40 a Rotated solution
item 19. Discriminant analysis considering depression non-specific items showed a 91.8% correct classification for non-depressed subjects, 69.2% for depressed subjects, and 90.7% for the total sample. The most powerful discriminating items in descending order were 17, 16, 21, and 15. The strongest predictive items for depressed Jewish adolescents were similar for girls and boys, and included sense of failure (3), lack of satisfaction (4), self-dislike (7), and suicidal wishes (9). For the non-Jewish sample, discriminant analysis showed that the BDI also performed well for detecting depressive symptomatology in adolescent students and also measures specific aspects of depression, displaying an overall diagnostic value of 95% [20]. The initial PCA solution revealed the presence of six components with eigenvalue exceeding 1.0, but Cattell’s scree plot recommended extracting only two components. For the total sample, the two-factor solution accounted for a total of 28.3% of the variance, with the first factor accounting for 16.4% and the second for an additional 11.9% of the data variability (rotated solution). Factor loadings greater than 0.40 were retained in a factor. The rotated component matrix after varimax rotation (Table 3) revealed the presence of a simple structure, with both components showing a number of salient loadings, and variables loaded substantially on one of the components. On factor 1, the following items presented high loadings: 1, 3, 4, 6, 7, 9, and 14; and on factor 2, items 5, 10, 13, 15, 16, 17, 18, and 20. Cronbach’s alpha coefficients for
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the sub-scales based on the items related to factors 1 and 2 were 0.73 and 0.67, respectively. Factor 1 represented the cognitive-affective dimension, while factor 2 represented items more related to a somaticnonspecific dimension (Table 3). Items 11, 19, and 21, irritability, weight loss, and loss of libido, respectively, did not load significantly for the extracted factors. For the girl sub-group, two components were extracted from the PCA. Unrotated factors accounted for 17.3 and 10.8% of the variance, respectively. The rotated solution showed that the following items are related to factor 1: items 1, 3, 4, 6, 7, 9, 10, 14, 15; and factor 2: items 13, 16, 17, 18 and 20. Cronbach’s alpha coefficients for the sub-scales were 0.75 and 0.53, respectively. The symptom ‘‘crying spells’’ (item 10) stands out among Jewish girls, given that it presents no factorial loading among boys. For the male sub-group, two factors were also extracted, accounting for 16.3% and 13.3% of the variance, respectively. The PCA solution suggested that the following items were related to factor 1: items 1, 2, 3, 4, 6, 7, 9, 12, 14, and 15; and factor 2: items 5, 8, 13, 15, 16, 17, 18, and 20. Cronbach’s alpha coefficients for the sub-scales were 0.75 and 0.68, respectively. In contrast to girls, ‘‘pessimism’’ (item 2) and ‘‘social withdrawal’’ (item 12) are prominent items on factor 1, while ‘‘guilty feelings’’ (item 5) and ‘‘selfaccusation’’ (item 8) were loaded higher on factor 2 for Jewish boys. For the non-Jewish adolescents, PCA also showed two common factors for the total sample and for each gender: the cognitive-affective dimension and the somatic-nonspecific dimension. In those adolescents showing clinical depression, items related to selfdepreciation, sense of failure, guilty feelings, selfdislike, suicidal wishes, and distortion of body image were common components of BDI factors [20].
Discussion j Frequency of depression among Brazilian Jewish adolescents In the present study, the frequency of depressive symptoms in Jewish adolescents was similar to that found in the local non-Jewish sample for the same age group. Although there were no differences in the frequency of depression by gender, a difference in the expression of depressive symptomatology was seen between Jewish girls and boys. These findings have suggested that the clinical features of major depressive disorders among children and adolescents would manifest as a syndrome with the same core features in adulthood [39], and depressive symptoms may be present from childhood and adolescence [48]. The overall rate of major depressive disorders in adolescents is estimated to lie between 15 and 20% for lifetime prevalence, and to be between 1.6 and 8.9%
for the current point estimate, similar to that of adult populations [17]. In our study using the mean score technique, if we consider the cutoff point to detect the group of dysphoric and depressive adolescents as a BDI > 15, the point-prevalence for possible depression (mild to moderate level) stands at 14.2 and 14.0% for the Jewish and non-Jewish samples, respectively. For depression level, or BDI > 20, we found 5.1% (SE = 1.0) and 6.3% (SE = 0.8) of depressed adolescents in Jewish and non-Jewish samples, respectively. Our current estimates corroborate the prevalence rate found in similar studies on BDIdepression in school-age adolescents [37]. One exception is the study by Teri [47], which reported a higher estimate of 32% for the adolescent sample. Studies on ethnicity and depression in minority adolescents are scarce in the literature [9]. Therefore, the ethnicity component in the aetiology of adolescence depression remains poorly understood, as differences exist between some but not all ethnic groups. For instance, Hispanic-American adolescents display higher rates of depression than non-Hispanics [9, 41], while no differences between African-American and Caucasian youths have been found [17]. Asian adolescents may report more somatic symptoms than North-American counterparts [12, 46]. The major point in evaluating depression in Jewish adolescents should address the issue of whether depression in this ethnic sample is different from other groups, in nature, frequency, severity, age distribution, and gender ratio.
j Age of depression A number of factors were found to be associated with depressive disorders among youths, including age. The reported incidence of mood disorders among youths over past decades has consistently increased, whereas the age of onset has decreased [13]. This phenomenon has been explained as a ‘‘cohort effect,’’ which is most evident in studies of mild-to-moderate depression [4]. In studies comparing early and late adolescents, older groups reported higher rates of depressive disorders [13]. However, mean score according to age in Table 1 shows no such trend for either Jewish or non-Jewish samples. Table 2, on the other hand, shows an apparent lower proportion of depressed non-Jewish adolescents at around 13 years of age, followed by an increasing proportion in late adolescence up to 16 years of age (Table 2). Yet, this same trend was not observed in the Jewish sample, suggesting that different mechanisms might influence the onset of depression in the two groups.
j Gender difference Results regarding gender and depression among adolescents have been inconsistent [6, 21]. While in
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children depressive disorders were either equal in prepubertal girls and boys or higher in boys; among adolescents, they were either equal or higher in girls [37]. Indeed, several child and adolescent studies using diagnostic interviews have generally suggested that rates of depression rise with age in adolescent girls [14, 21, 31, 36]. Population-based studies examining the effects of age on depression all agreed that adolescence is associated with an increasing prevalence of depression in girls, and this change only becomes apparent at or after the age of 13 years [4, 14, 21, 36]. These findings suggest that an interaction effect between age and gender may be involved. For our gender-balanced sample of Jewish and non-Jewish adolescents, there was no gender difference in the mean BDI score for the Jewish group, but non-Jewish girls scored significantly higher than boys. The overall mean BDI scores of Jewish boys are significantly higher than their non-Jewish counterparts (9.1 vs. 7.6, p = 0.009). While there is no gender difference in the depression level of Jewish adolescents aged 13–17, non-Jewish girls showed twice as much depression as boys. Most studies reviewed reported substantial difference between boys and girls [37], except the present Jewish sample. Our results support the finding of Levav et al. [29] for Jewish adults, indicating that this lack of gender difference would possibly persist from adolescence until adulthood among Jewish people. Recently, an alcohol-depression hypothesis attempted to explain the vulnerability to depression among Jewish men: they may be relatively more likely to become depressed under stressful conditions, and less likely to misuse and abuse alcohol [35]. Culturally determined negative beliefs about alcohol use seem to be involved. Compared to Protestants, alcohol-related behaviors were described by Jewish men as threatening to self-control, in as much as loss of inhibition was viewed as unenjoyable and dangerous, and therefore drinking behaviors were viewed as inappropriate for Jews [35]. Perhaps the drinking patterns among Jewish adolescents in Sa˜o Paulo are similar to the patterns among their non-Jewish peers. Since the pattern of alcohol consumption was not documented among our Jewish participants, we could not go further this explanation in the present study. Although Jewish girls and boys exhibited a similar frequency of depression, they express their depressive symptomatology in different ways. The factor analysis of this Jewish sample was able to confirm the bidimensional structure of the BDI as being similar to that found for non-Jewish college and adolescent samples [19, 20]. A cognitive-affective and somatic-non-specific factor was extracted. Investigation of the factor loading for Jewish girls and boys revealed that some differential item loadings account for their symptomatic expression of depression. Both boys and girls agreed on reporting more negative feelings such as sense of failure, sadness, self-dislike, and suicidal
wishes. Negative cognition such as pessimism, guilty feelings, self-accusation, and social withdrawal were typically observed for boys. Crying spells are common symptoms in girls, and work inhibition loaded higher in the first factor for girls, whereas for boys it was higher in the second factor. These items provided some evidence that Jewish girls and boys tend to express their subjective experience of depression in a diverse manner, while the BDI’s factorial cross-cultural invariance between Jewish and non-Jewish samples needs further assessment [10]. Taking the Jewish group as a whole, symptoms such as irritability, weight loss, and loss of libido did not contribute significantly to either cognitive or somatic factors of depression, where their factor loadings were all below 0.40 (Table 3). An interesting finding was that the two DSM-IV symptoms [3] that were modified for diagnosis of major depression in youth—(1) irritable mood, and (2) failure of weight gain replacing the weight loss and/or disturbance of appetite—were not found to be important in the factor structure obtained in the Jewish sample of our study. Analysis of item-total correlation indicated that these three items were poorly correlated with the whole construct evaluated by BDI, therefore, displaying a lower ability to detect the construct underlying the BDI scale in this cultural sample. Irritability and weight loss are common features of depression observed among non-Jewish adolescents [20], but were not present in our Jewish sample. The lack of irritability seems to represent a unique feature in this Jewish sample, while suppression of anger indicates the mediation of a coping mechanism in psychological adjustment for Jewish adolescents from non-Orthodox schools. Although these adolescents came from private schools, these institutions were not overly rigid or religious. Indeed, the importance of irritability was observed among nonJewish teenagers. On the other hand, traditional Jewish beliefs of non-violence and gentleness among men might prevent their loss of self-control and inhibition. Therefore, irritability would be viewed as dangerous and threatening feeling by Jewish people [35, 42, 44]. A more passive, than active, attitude may represent strategies to deal with adverse life events in Jewish adolescents, who internalise negative feelings into depression and anxiety symptoms [33, 45]. More importantly, perhaps the ‘‘suppression of anger,’’ or the lack of irritability (item #11) as self-reported in the BDI by Jewish adolescents, might be causing them to mask their symptoms when answering the questionnaire, downward biasing the prevalence rate of depressive symptoms. Some potential bias of this study should be highlighted. Although this is a non-clinical sample, subjects were not selected with a stratified sampling technique for a community or school cluster. This is a convenient sample of students from a Jewish background, attending daytime classes. As they studied in
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private schools such students came from wealthier families, thus we selected adolescents from a higher socioeconomic status. Since subjects in Jewish and non-Jewish samples have been recruited from private schools, comparable academic demands are unlikely to have biased the results of the present study. Moreover, we have demonstrated previously [20] that some sociodemographic characteristics may increase the score of the BDI or the level of depression in student samples (e.g., attending evening classes, working in a part-time job etc.). Since the Jewish sample comprised daytime class students and only 5.3% of them worked after school, their overall mean BDI score may possibly be lower than that of the general population.
Conclusions Puberty is a complex developmental process where timing, along with endocrine and morphological changes, participate in this whole process. Although the occurrence of depression in adolescents is as frequent as in the adult population, many questions go unanswered. Cross-cultural studies of puberty and depression in minority adolescents may contribute information to this field. Even though our study is not strictly a prevalence study of depression in Jewish adolescents, the estimate of depression by the BDI mean score was comparable with an age-matched non-Jewish adolescent group as well as other international adolescent studies. The present paper found comparable frequency and severity of depression between Jewish and nonJewish Brazilian adolescents. This study also confirmed some evidence gathered from adult Jewish samples on the absence of gender difference for depression. The generalised assumption of gender difference in adolescence, that girls have higher depression rates, had proved false in this Jewish sample. Future studies should focus on a random sampling strategy to select Jewish adolescents in the community, devoting particular attention to the age of onset of psychiatric morbidity. Given culture is a dynamic process, the comparison of an Israeli Jewish sample with another immigrant Jewish sample would be of great interest, as our Jewish adolescents may have been influenced by beliefs and habits of Brazilian society, e.g., alcohol-related behavior. Inter-country comparison of various Jewish adolescent samples may demonstrate the invariance of some cultural features found in the present study that are characteristic of Jewish people as a whole.
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