Between modern and traditional values: Informal mental health help-seeking attitudes according to Israeli Arab women, primary care patients and their providers

Determinants of intentions to seek formal mental health help among Palestinian adolescents in Israel

BACKGROUND

Mental health challenges are widespread among adolescents undergoing significant physical, emotional, social, and academic changes. However, rates of formal help-seeking remain low, particularly among those from ethnic minorities.

AIMS

This study investigated the determinants of intentions to seek formal mental health help among Palestinian adolescents in Israel, focusing on mental health literacy (MHL) and trust in formal sources of information.

METHODS

A total of 178 adolescents (Mage = 16.24 ± 1.24 years, 61.8% female) completed measures assessing intention for formal help-seeking, psychological distress, MHL, trust in formal sources of information, sociodemographic, and clinical characteristics.

RESULTS

Findings revealed low levels of intention to seek formal help and psychological distress, alongside average or above-average levels on all MHL dimensions and trust in formal sources for information. Our analysis identified socioeconomic status (β = .17, p < .05), psychological distress (β = .18, p < .05), trust in formal sources of information (β = .28, p < .001), and two MHL dimensions: knowledge of where to seek information (β = .25, p < .01) and attitudes that promote recognition or appropriate help-seeking behavior (β = .16, p < .05) - as the main determinants of intention for formal help-seeking.

CONCLUSIONS

This study underscores the critical role of trust in formal sources of information and MHL in seeking formal help among adolescents from ethnic minorities. Interventions aiming to improve access to mental health-related information, address and enhance attitudes, and foster trust in formal professionals and institutions may contribute to an increased tendency for formal mental health help-seeking among this population and others.

Mental illness and help-seeking behaviours among Middle Eastern cultures: A systematic review and meta-synthesis of qualitative data

BACKGROUND

Western literature has long explored help-seeking behaviours related to mental health issues. However, this has been relatively neglected in the Middle East despite an increase in mental health needs in the region. The purpose of this review was to conduct a systematic review and qualitative meta-synthesis exploring help-seeking behaviours related to mental health issues in the Middle East.

METHODS

We conducted a systematic review and meta-synthesis to gain a comprehensive overview of what is known about mental health and help-seeking behaviours in the Middle East from published qualitative research in the Middle Eastern region. A search of electronic databases (MEDLINE, Embase, CINAHL, PsycINFO and QScience) was carried out from inception to July 2022. The quality of the included studies was assessed using the Critical Appraisal Skills Programme tool, and the review protocol was pre-registered with PROSPERO (Ref: CRD42022311494).

RESULTS

We identified 16 qualitative studies exploring mental health-seeking behaviours in Middle East countries. Facilitators and barriers to help-seeking were captured under six overarching themes. Across all studies, we identified negative attitudes towards seeking help for mental health issues, economic and structural barriers to accessing mental healthcare, and misconceptions surrounding religious beliefs, all of which had a critical role in impacting decisions to seek mental healthcare services. Many sought help from alternative sources, such as traditional healers or family members before consulting a healthcare professional. The role of the family and cultural norms was also identified as key contributors to people's help-seeking behaviours.

CONCLUSIONS

This meta-synthesis indicates the existence of many challenges surrounding mental health-seeking in the Middle East, including public and internalizing stigmas. This suggests an urgent need for an increase in psychoeducation and mental health awareness in the region.

Ethnic identity and barriers for using mental health services among Arab-Bedouin women coping with emotional distresses

The study aimed to explore barriers to mental health service attainment among Bedouin women living in different residential environments in southern Israel. We hypothesized that emotional distress and the utilization of mental health services would be influenced by the living environment and ethnic identity factors. The sample included 376 Arab-Bedouin women, 126 Arab-Bedouin women from the recognized and unrecognized villages, and 250 Arab-Bedouin women from the central localities. Quantitative methods were used, including emotional distress (GHQ12), ethnic identity scale (EIS), mental health literacy (MHLS), and barriers to mental health services attainment (BACE). Results indicated that participants from the central localities demonstrated a greater inclination to seek and utilize mental health services. Furthermore, higher rates of affirmation of ethnic identity were also found to be a predictive factor for the willingness to attain mental health services. These findings further support the role of residential environment and ethnic identity in shaping mental health service utilization patterns. Current research explored barriers to mental health services seek and attainment for Arab-Bedouin women in different residential environments in southern Israel. Ethnic identity factors and barriers such as stigma and access to resources predicted the tendency to seek help. Findings emphasize the need to address barriers to seeking help and the role of ethnic identity in mental health service attainment for Arab-Bedouin women.

Understanding experiences of mental health help-seeking in Arab populations around the world: a systematic review and narrative synthesis

BACKGROUND

Racial and ethnic disparities in mental health service utilisation and access is well established. Mental illness is common among Arab populations globally, but most individuals display negative attitudes towards mental health and do not seek professional help. The aim of this systematic review was to determine 1) help-seeking behaviours 2) help-seeking attitudes and 3) help-seeking barriers and facilitators, related to mental health services among Arab adults.

METHOD

A pre-defined search strategy and eligibility criteria allowed for database searching using terms related to: mental health, Arabs, help-seeking, as well as experiences and behaviours. Seventy-four articles were included and analysed through narrative synthesis. Results were reported using the PRISMA guidelines. The review protocol was registered prospectively on PROSPERO (CRD42022319889).

RESULTS

Arabs across the world have negative attitudes towards formal help-seeking and are reluctant to seek help, despite the presence of psychological distress. There is little information on factors that influence help-seeking behaviours and rates of service use. Preference for informal help sources such as family and friends were expressed and considered more acceptable. Low mental health literacy, stigma, gender, age, education, religion, acculturation, and immigrant status were the most common factors influencing help-seeking attitudes. Barriers to help-seeking included stigma, privacy and confidentiality, trust, mental health literacy, language, logistics, and culture related barriers. Increasing societal and family awareness, external support and encouragement, shared culture between the client and therapist, quality of doctor patient relationship, and feelings of connectedness with the host country among refugees were mentioned facilitators. Mixed findings for the role of religion, and family and community, in relation to facilitating or hindering help-seeking were reported.

CONCLUSIONS

There is an increased likelihood and preference to seek informal sources of psychological support among Arabs. Contextual and cultural factors impeding help-seeking for Arabs are common across the world. Future research should address actual utilisation rates of services to better understand factors that influence help-seeking behaviours and facilitators to help-seeking. Increasing mental health literacy and developing anti stigma campaigns is necessary. Developing culturally informed interventions should inform future efforts to promote help-seeking among this population.

A qualitative study of a mental health awareness intervention for Jordanian and resettled Syrian refugees in host communities

BACKGROUND

Mental health disorders significantly contribute to the global burden of disease, however, prevention and treatment programs are often inaccessible in low- and middle-income countries.

AIMS

The goal of this qualitative evaluation was to examine participants experiences of the healthy community clinic (HCC-MH), an integrated mental health awareness intervention delivered in primary care clinics to Jordanians and resettled Syrians in a border community in Jordan.

METHODS

Four focus group discussions (FGDs) with Jordanians and Syrians (N = 21) who participated in the HCC-MH were conducted. FGDs examined knowledge, acceptability, and applicability of the intervention. Open coding and the constant comparison method were used to identify themes that emerged from the FGDs.

RESULTS

Six central themes emerged from the data including : (1) awareness; (2) behavior changes; (3) reduction in stigma; (4) connecting physical and mental health; (5) relationships; and (6) coping. Notably, female participants stated participation in the intervention fostered awareness of their own emotional needs, which led to positive lifestyle and behavior changes. Participants also described how the information provided in the intervention normalized emotional distress and aided understanding of the interconnection between physical and mental health. The amplification of healthy coping strategies to reduce stress and distress was also a prominent theme.

CONCLUSIONS

Findings are discussed within the cultural and contextual setting of the study, and implications for mental health awareness interventions in complex settings are provided.

Palestinian Muslim College Students' Attitudes to Mental Health Treatment: A Comparative Study

This study examined the association between the degree of religiosity, combined with cultural beliefs, social stigmas, and attitudes towards mental-health treatment in two groups, who, despite having similar cultural and religious affiliation, have experienced different socio-political contexts: Palestinian Muslim college students living in the Occupied Palestinian Territory (OPT) and Israel. The study was guided by Tanhan and Young's (2021) conceptual framework. Methods: A snowball recruitment strategy was applied, using a cross-sectional survey. A total sample size was 214 students, 105 from the OPT and 109 from Israel. Results indicate that students from the OPT (n = 105) did not differ from those living in Israel (n = 109) on religiosity using the Islamic Belief scale, or Attitudes Towards Mental Health treatment (F(1, 189) = 1.07, p = 0.30). However, students from the OPT had higher confidence in mental-health professionals (M = 15.33) than their counterparts (M = 14.59), and women had higher confidence (M = 16.03) than men (M = 13.90). The reliance on traditions for Muslim students over Western mental-health approaches is a critical factor in predicting the attitudes towards students' mental problems and their chosen treatment. Sociopolitical context played a significant role in shaping attitudes toward mental-health providers.

Barriers to Mental Health Service Use among Palestinian-Arab Women in Israel: Psychological Distress as Moderator

BACKGROUND

Many studies indicate that ethnic minority women, including women from the disadvantaged Palestinian-Arab minority in Israel, experience higher rates of psychological distress but are less likely to use mental health services. This study examined psychological distress and its role as a moderator in the relationship between mental health service use and stigma-related, attitudinal, and instrumental barriers.

METHOD

Cross-sectional study of 146 Palestinian-Arab women who completed measures of psychological distress, mental health service use, the Barriers to Care Evaluation scale, and sociodemographic characteristics.

RESULTS

Participants who did not utilize mental health services reported higher levels of all barrier types compared to participants who reported previous use, but lower levels of psychological distress. Psychological distress was a significant moderator only in the relationship between attitudinal barriers and mental health service use.

CONCLUSIONS

This study highlights the role of psychological distress in the relationship between barriers to and utilization of mental health services, helping professionals and policymakers increase mental health service use among Palestinian-Arab women in Israel and other vulnerable women elsewhere.

Ageism from a cross-cultural perspective: results from a national survey of Israelis over the age of 50

OBJECTIVES

We examined differences across three groups in Israel to test the double jeopardy versus the intersection escape hypotheses-which evaluate whether being older and belonging to an underrepresented group serves as a double burden, exposing older minorities to higher levels of perceived ageism or on the contrary, older age serves as a protective factor, especially for underrepresented groups.

DESIGN

A cross-sectional, nationally representative sample, consisting of three groups: Veteran Israelis, Israeli Arabs and immigrants from the Former Soviet Union. The latter two groups represent underrepresented (minority) populations in Israel.

SETTING

Community-dwelling Israelis over the age of 50.

PARTICIPANTS

The sample was composed of 1570 participants.

MEASUREMENT

To examine the double jeopardy versus the intersectional escape hypothesis, self-perceptions of aging (SPA) and perceived age-based discrimination in the healthcare system were examined as outcome variables.

RESULTS

Among Israeli Arabs, being older was related to better SPA, whereas among the immigrants being older was related to worse SPA. As immigrants became older, they were more likely to report ageist experiences. Israeli Arabs reported higher levels of ageist experiences, regardless of their age.

CONCLUSIONS

The findings point to certain groups that require education about ageism and the aging processes and might require further protection from the experiences of ageism. The findings also point to the relevance of different theoretical paradigms that advocate for the consideration of culture and group membership in the understanding of the experiences of ageism.

The mediating effect of social support and coping strategies on the relation between family stigma and caregiver burden among Israeli Arab family caregivers of people with Alzheimer's disease (AD)

OBJECTIVES

Many studies have attempted to identify the factors that are associated with caregiver burden among family caregivers of people with Alzheimer's disease (AD), because of its plethora of negative consequences. One unique factor that has been investigated recently is family stigma. However, the path leading from family stigma to caregiver burden has not been thoroughly studied. Hence, this study had two main objectives. The first was to examine whether family stigma was a predictor of caregiver burden among Israeli Arab family caregivers of a person with AD. The second was to examine the interplay of family stigma and caregiver burden with coping strategies and social support.

METHODS

Structured face-to-face interviews were conducted with 175 Israeli Arab family caregivers (adult children and spouses) of elderly people with AD (87.4% female; 71.4% adult children; mean age = 54.28).

RESULTS

Overall, the participants reported moderate levels of caregiver burden and family stigma. Additionally, as expected, family stigma made a unique - although modest - contribution to the explanation of caregiver burden. Whereas neither problem-focused coping nor emotion-focused coping played a significant role in mediating the relation between family stigma and caregiving burden, social support did mediate the relation between these variables.

CONCLUSIONS

Our findings reveal how social support is important as a specific way to reduce the impact of family stigma on caregiver burden.

Exploring the Motivations for Completing Advance Care Directives: A Qualitative Study of Majority/Minority Israeli People Without Dementia

Background

Completing advance directives has been declared an essential instrument for preserving and respecting the autonomy and preferences for end-of-life care of people living with dementia. However, research deciphering the reasoning behind the decision to complete or not advance directives in the case of dementia remains limited, especially among people pertaining to different majority/minority groups.

Objectives

To explore the motivations of people without dementia in Israel to complete or not to complete advance directives and to compare these motivations among the majority veteran Jewish group, the minority Jewish Former Soviet Union immigrant group, and the minority Arab group.

Methods

This qualitative study used purposive sampling and focus groups with discussions elicited by a vignette. A total of 42 Israeli people without dementia participated in 6 focus groups: two with veteran Jews (n = 14), two with Jewish immigrants from the Former Soviet Union (n = 14), and two with Arabs (n = 14). The analysis followed recommended steps for thematic content analysis.

Results

Four overarching themes were identified: (1) the meaning of dementia-related advance directives, (2) motivations for willingness to complete advance directives, (3) motivations for not being willing to complete advance directives, and (4) ethical dilemmas. Some of the themes were common to all groups, while others were informed by the groups' unique characteristics. Participants displayed a lack of knowledge and misunderstanding about advance directives, and central concepts such as autonomy and competence. Furthermore, stigmatic images of dementia and of the person with the diagnosis were associated to participants' motivations to complete advance directives.

Conclusions

There is need to expand comparative research among culturally and socially similar and dissimilar groups within a country as well as between countries in order to better guide public health efforts to increase the rates of advance directives completion. Special attention should be paid to decreasing stigmatic beliefs and understanding unique cultural values and motivations.

Examining the mediating effect of psychosocial resources on the relationship between ambivalent feelings and depression among Israeli Arab family caregivers of people with dementia

Objectives

Providing care for family members of individuals with dementia can be accompanied by a myriad of emotions, usually involving negative as well as positive feelings, or “ambivalent feelings.” Recent studies conducted among family caregivers of people with dementia have shown ambivalent feelings to be associated with serious psychological consequences, such as increased depression. However, little is known about the path leading from ambivalent feelings to depression. Thus, the aim of this study was to examine the interplay of ambivalent feelings and depression with family caregivers’ psychosocial resources—that is, their coping strategies and social support.

Methods

A cross-sectional study using face-to-face interviews (via structured questionnaire) was conducted with 175 Israeli Arab family caregivers (adult children and spouses) of elderly people with Alzheimer’s disease (87.4% female; 72% adult children; mean age = 54.28).

Results

Overall, the participants reported a mild level of depression (mean = 7.93; SD = 4.30; range 0–15) and a moderate level of ambivalent feelings (mean = 1.63; SD = 1.04; range 0–3). Additionally, as expected, ambivalent feelings made a unique—although modest—contribution, adding an additional 6% ( p < 0.001) to the explanation of depression ( R2 = 0.56, p<0.001). Whereas, neither problem-focused coping nor emotion-focused coping played a significant role in mediating the relationship between ambivalent feelings and depression, social support did mediate the relationship between these variables.

Conclusions

Our findings show that strengthening and expanding social networks among Israeli caregivers of people with Alzheimer’s disease can minimize the impact of experiences of emotional feelings on depression.

Public image of the profession is associated with the choice of nursing career among Arab high school students: A cross-sectional study

AIMS

The aim of this study is to examine (a) public image of nursing and the intention to choose nursing as a future career and (b) the relationship between the public image, gender roles and the choice of the nursing career among Arab high school students.

BACKGROUND

School graduates from the Arab sector represent an important social group with the potential to provide quality candidates for the nursing profession in Israel.

METHODS

In this cross-sectional study, 138 high school students from two Arab schools in Israel completed a structured questionnaire.

RESULTS

One third of the sample intended to choose nursing as a future career. Students from families with a higher level of paternal education and those exposed to the work of nurses perceived nursing as more positive. The profession's public image contributed to the explanation of 21% of the variance of the intention to choose a nursing career.

CONCLUSION

A positive public image of nursing contributes to decisions about choosing a nursing career in the future among Arab high school students.

IMPLICATIONS FOR NURSING MANAGEMENT

School graduates may be influenced by providing information and presenting the role of a nurse as significant, as well as by emphasizing the positive image of nursing to parents and influential people in the Arab community.

The Arabic and Hebrew versions of the caregiving ambivalence scale (CAS): examining its reliability, validity, and correlates among Israeli caregivers of individuals with Alzheimer's disease

Objectives: Providing care for family members with Alzheimer's disease (AD) might awaken ambivalent feelings in caregivers. This topic, however, has received little research attention. Having reliable and valid scales is a first step in expanding our knowledge in this area, particularly among different cultural groups, as ambivalent emotions have been found to be dependent on culture. Thus, the aims of this study were (1) to test the reliability and validity of the Caregiving Ambivalence Scale (CAS) among Israeli Jewish and Arab caregivers of individuals with AD and (2) to examine the contribution of caregivers' ethnocultural affiliation (Jewish/Arab) to the experience of ambivalent feelings.Methods: Structured face-to-face interviews were conducted with 370 family caregivers (adult children and spouses) of elderly people with AD. Approximately half of the participants (55.3%) were Israeli Jews (79.5% female; 61.3% adult children; mean age = 65.52), and the rest (44.7%) were Israeli Arabs (87.4% female; 72% adult children; mean age = 54.28).Results: Our findings indicated that the CAS has good-to-excellent internal reliability and validity both in Hebrew and Arabic. Additionally, as expected, ethnocultural affiliation (Jewish/Arab) made a unique - although modest - contribution to the explanation of ambivalence as reflected in the CAS score, with Arab caregivers reporting significantly higher levels of ambivalent feelings than did Jewish caregivers.Conclusions: The CAS is a reliable and valid structured measure to assess ambivalent feelings among Arab and Jewish caregivers of individuals with AD in Israel. Cultural context is a unique factor in understanding their mixed emotions.

Service use and perceptions of service effectiveness by parents of individuals with intellectual disabilities: comparing Jewish and Arab Israeli parental caregivers

BACKGROUND

The relationship between ethnicity, service use and perceptions of service effectiveness is inconclusive. This study examined differences in service use and perceptions of service effectiveness between Israeli Jewish (Jewish) and Israeli Arab (Arab) parental caregivers of individuals with intellectual disabilities and dual diagnosis of psychopathology.

METHODS

Parental caregivers (n = 186) of individuals with intellectual disabilities or dual diagnosis, aged 10 to 30 years, completed a self-report questionnaire.

RESULTS

Arab parental caregivers perceived health services to be more accessible than did Jewish caregivers, but there was no difference between the two groups in the use of the services. Overall, greater enabling factors and accessibility were associated with higher use of education and social services. No differences were found between the groups in their perceptions of service effectiveness.

CONCLUSION

Arab family caregivers use education and social services less than do their Jewish peers, possibly because they have fewer enabling resources. The finding that both groups reported similar use of health services may be explained by a shared perception that informal help may not be suitable for dealing with situations of psychopathology. The similar perceptions of service effectiveness may be explained by extensive services available in Israel, to the satisfaction of both groups, or by the fact that participants perceived these services as their only alternative, and therefore fear losing them.

Knowledge and attitudes about mental health among older immigrants from the former Soviet Union to Israel and their primary care physicians

Previous studies have documented a high prevalence of psychological distress and mental illness among older immigrants from the former Soviet Union (FSU) in Israel. Yet, this population rarely seeks help from mental health providers. The present study aimed to identify beliefs and attitudes about depression and anxiety among older immigrants from the FSU treated in primary care, and among their primary care physicians, who were also FSU immigrants. The study used focus group (FG) interviews with primary care patients (n = 12) and physicians (n = 23). The interviews were transcribed and analyzed using open thematic coding. Three main themes were identified: a) avoidance of discussion of mental health and stigma regarding mental illness; b) expectations to control one's mental state; and c) limited opportunities to acquire knowledge about Western mental health. Primary care physicians recognized the barriers facing their older immigrant patients concerning mental health diagnosis and treatment. Yet, due to work overload, their ability to assist older immigrants was limited. The findings suggest that older immigrants from the FSU might benefit from mental health information and exchange of ideas about Western mental health.

Searching the Internet for psychiatric disorders among Arab and Jewish Israelis: insights from a comprehensive infodemiological survey

Israel represents a complex and pluralistic society comprising two major ethno-national groups, Israeli Jews and Israeli Arabs, which differ in terms of religious and cultural values as well as social constructs. According to the so-called “diversification hypothesis”, within the framework of e-health and in the era of new information and communication technologies, seeking online health information could be a channel to increase health literacy, especially among disadvantaged groups. However, little is known concerning digital seeking behavior and, in particular, digital mental health literacy. This study was conducted in order to fill in this gap. Concerning raw figures, unadjusted for confounding variables (time, population size, Internet penetration index, disease rate), “depression” searched in Hebrew was characterized by 1.5 times higher search volumes, slightly declining throughout time, whereas relative search volumes (RSVs) related to “depression” searched in Arabic tended to increase over the years. Similar patterns could be detected for “phobia” (in Hebrew 1.4-fold higher than in Arabic) and for “anxiety” (with the searches performed in Hebrew 2.3 times higher than in Arabic). “Suicide” in Hebrew was searched 2.0-fold more than in Arabic (interestingly for both languages search volumes exhibited seasonal cyclic patterns). Eating disorders were searched more in Hebrew: 8.0-times more for “bulimia”, whilst “anorexia” was searched in Hebrew only. When adjusting for confounding variables, association between digital seeking behavior and ethnicity remained statistically significant (p-value < 0.0001) for all psychiatric disorders considered in the current investigation, except for “bulimia” (p = 0.989). More in details, Israeli Arabs searched for mental health disorders less than Jews, apart from “depression”. Arab and Jewish Israelis, besides differing in terms of language, religion, social and cultural values, have different patterns of usage of healthcare services and provisions, as well as e-healthcare services concerning mental health. Policy- and decision-makers should be aware of this and make their best efforts to promote digital health literacy among the Arab population in Israel.

Family Relations and Elder Care Among Arabs in the North of Israel

The study examined family relations and elder care, in light of the modernization processes that are taking place in the Arab sector. Interviews with 25 older adults, 27 family members, and 5 paid home care workers of an Arab origin were conducted. Qualitative analysis consisted of constant comparisons and contrasts of relevant themes. Most Arabs reported that intergenerational solidarity is very strong in the Arab sector. Whereas many older adults and a few of their family members tended to favor paid care, the majority of Arab family members and fewer older adults stated that family care is preferred. Finally, a third theme outlined the desired properties of care, which consists of a true mix between formal and informal care. The study points to two sources of tension between (a) older adults and their family members and (b) perspectives on care held by the National Insurance Institute and the Arab sector.

Epidemic Use of Benzodiazepines among Older Adults in Israel: Epidemiology and Leverage Points for Improvement

BACKGROUND

Benzodiazepines and benzodiazepine-receptor agonists (BDZRAs, often known as "Z-drugs") are commonly used in older adults despite well-documented harms.

OBJECTIVE

To evaluate patterns of benzodiazepine and BDZRA use in Israel, focusing on potential leverage points where quality improvement initiatives might effectively curtail new use or the transition from intermittent to chronic use.

DESIGN AND PARTICIPANTS

We used national electronic medical data to assess a 10% random sample of adults receiving care in Clalit Health Services, which serves half of Israel's population. The sample included 267,221 adults, of whom 56,808 (21%) were age 65 and older.

MAIN MEASURES

Medication use from 2013 to 2015 was ascertained using pharmacy dispensing data.

RESULTS

In 2014, 7% of adults age 21-64 and 32% of adults age 65 and older received at least one benzodiazepine/BDZRA, including 49% of adults age 85 and older (P < 0.001). The majority of older users (59%) were long-term users of the drugs, and 21% of older adults who were short-term users in 2014 transitioned to medium- or long-term use in 2015. Older Arab Israelis were much less likely to receive benzodiazepine/BDZRAs than older Jewish Israelis (adjusted OR 0.28, 95% 0.25-0.31), but within each community there was no major variation in prescribing rates across clinics. Depression diagnosis was associated with particularly high rates of benzodiazepine/BDZRA use: 17% of older adults with depression received a benzodiazepine/BDZRA but no antidepressant, and 42% received both. Recent hospitalization increased the risk of new benzodiazepine/BDZRA use (adjusted OR 1.41, 95% CI 1.01-1.96), but the absolute risk increase was only 3%.

CONCLUSIONS

Benzodiazepines/BDZRAs are used at exceptionally high rates by older Israeli adults, especially the oldest old. Important leverage points for quality improvement efforts include curtailing the transition from short-term to long-term use, reducing use in older adults with depression, and identifying reasons that explain large differences in benzodiazepine/BDZRA prescribing between different ethnic groups.

Barriers to the Treatment of Mental Illness in Primary Care Clinics in Israel

The present study examined physicians' perceived barriers to the management of mental illness in primary care settings in Israel. Seven focus groups that included a total of 52 primary care Israeli physicians were conducted. Open coding analysis was employed, consisting of constant comparisons within and across interviews. Three major themes emerged: (a) barriers to the management of mental illness at the individual-level, (b) barriers to the management of mental illness at the system-level, and (c) the emotional ramifications that these barriers have on physicians. The findings highlight the parallelism between the experiences of primary care physicians and their patients. The findings also stress the need to attend to physicians' emotional reactions when working with patients who suffer from mental illness and to better structure mental health treatment in primary care.