Soc Psychiatry Psychiatr Epidemiol DOI 10.1007/s00127-014-0904-2
ORIGINAL PAPER
Association between living arrangements and depressive symptoms among older women and men in South Korea Dong Hoon Oh • Joon Hyuk Park • Hye Young Lee Shin Ah Kim • Bo Youl Choi • Jung Hyun Nam
•
Received: 11 November 2013 / Accepted: 26 May 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose We investigated the relationship between different types of living arrangements and depressive symptoms among older Korean women and men. Methods Data were obtained from a nationally representative cross-sectional health survey conducted in 2009 in South Korea. A total of 60,305 participants (34,172 women and 26,133 men) aged 60 years and older were included in the analysis. The living arrangements were categorised into six types as follows: (1) living with a spouse only; (2) living with a spouse in an extended family; (3) living with a spouse in a nuclear family; (4) living alone; (5) living without a spouse in an extended family; and (6) living without a spouse in a nuclear family. The Korean version of the Center for Epidemiologic Studies Depression Scale was used as the measurement tool for depressive symptoms. We used multiple regression
analysis to estimate the effects of living arrangement on depressive symptoms. Results A total of 16.8 % of the total study population showed depressive symptoms. Living with a spouse only was the most common type of living arrangement (46.3 %). Women and men living with a spouse only were the least likely to have depressive symptoms. However, living without a spouse in a nuclear family and living alone were most strongly associated with depressive symptoms in women (OR 1.81; 95 % CI 1.64–2.00) and men (OR 2.71; 95 % CI 2.43–3.03), respectively. Conclusions The prevalence of depressive symptoms are associated with the living arrangements of elderly Koreans. There are gender differences in these associations, that may stem from the different demands of social roles and relationships in the family. Keywords Living arrangement Depressive symptoms Old age Gender differences
D. H. Oh J. H. Nam (&) Department of Psychiatry, College of Medicine, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul 133-791, Republic of Korea e-mail: [email protected] D. H. Oh H. Y. Lee S. A. Kim B. Y. Choi J. H. Nam Institute for Health and Society, Hanyang University, Seoul, Republic of Korea e-mail: [email protected] J. H. Park Department of Psychiatry, Jeju National University School of Medicine and Jeju National University Hospital, Jejudo, Republic of Korea H. Y. Lee S. A. Kim B. Y. Choi Department of Preventive Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
Introduction Depression is one of the most common psychiatric disorders among the elderly. It can manifest as major or minor depression and is characterized by a collection of depressive symptoms [1, 2]. Depression in later life is a serious condition that decreases quality of life, not only in terms of psychological health, increased suicide rates and reduced vitality but also in terms of physical health because it can aggravate functional disability and increase mortality [3, 4]. According to the Korea National Statistical Office, the percentage of elderly people in South Korea over the age of 65 reached 7.2 % in 2000 and is expected to exceed 14 %
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Soc Psychiatry Psychiatr Epidemiol Fig. 1 Conceptual framework of the association between the types of living arrangements and depressive symptoms in the elderly
by 2018 and 20.8 % by 2026, making South Korea one of the nations most rapidly transitioning from an aging society to an ultra-aged society [5]. The economic and social burdens of a rapidly growing elderly population are likely to present major public health challenges in Korea. In particular, policy makers have been paying increasing attention to depression in the elderly because of a substantial rise in the suicide rate among elderly Koreans [6]. Depression is an important mental health problem among elderly Koreans. Previous nationwide epidemiologic studies have indicated that approximately 10 % of elderly Koreans have minor or major depression [7], while approximately 15 % of Korean elders have depressive symptoms [8]. The high prevalence of depressive symptoms in the community and their significant association with major depression makes them important from a public mental health perspective [9]. The Korean society has undergone rapid industrialisation, urbanisation and Westernisation in recent decades [7]. In particular, the Confucian tradition of filial piety has weakened over times [8]. Moreover, the traditional extended family is decreasing and living with a spouse only is now the main type of household in which the elderly live in South Korea [9]. This change in the family system may have a major deleterious effect on the physical and mental health of the elderly [10, 11]. Previous studies have indicated that the role of living arrangements in depression among the elderly differs across societies and cultures [14–18]. Nevertheless a commonly held view is that the traditional Korean extended family could prevent depressive symptoms in the elderly by providing economic and emotional support [19].
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A contrasting position is that the stress of living in multigenerational households may lead to depressive symptoms because of conflicts between family members [8], and increasing numbers of elderly people prefer living independently from their adult children [20]. However, there have been few published studies on the relationship between living arrangements and elderly depression in Korea [21]. The aim of this study was to investigate the association between living arrangements and depressive symptoms using a standardised screening tool for depression in the largest number of elderly South Koreans examined to date. We hypothesised that elderly subjects living with their spouse in an extended family would be more protected against depressive symptoms than those living in other types of living arrangements. We also expected that there would be a gender difference in the influence of living arrangements on depressive symptoms. The relationships among the variables of living arrangements, depressive symptoms, health and sociodemographic factors are illustrated in Fig. 1.
Methods Data source This study utilised data from the public use files of the 2009 Community Health Survey (CHS) conducted by the Korean Centers for Disease Control and Prevention (KCDC). No institutional review board approval was required for this study because the data are available for public use and void of identifiers.
Soc Psychiatry Psychiatr Epidemiol
The CHS is an annual nationwide cross-sectional health interview survey conducted since 2008 to estimate the patterns of disease prevalence and morbidity, as well as to understand the personal lifestyle and health behaviour of adults aged 19 years or older. The CHS collects detailed information on demographic and socioeconomic characteristics, health-related problems and past medical histories. The CHS was conducted on an average of 900 subjects selected by a combined use of probability proportional and systematic sampling methods among adults aged 19 years or older living in 253 basic regional self-governing districts. For the sample to be statistically representative of the population, the data collected in the CHS sample were weighted based on the sample design. The CHS was administered face-to-face by trained interviewers. The protocol of the CHS was annually reviewed and approved by the institutional review board of the KCDC. All participants in the CHS signed informed consent forms prior to the interview [22]. Participants
than 1,000,000). The number of chronic diseases was assessed from reports noting diagnosed diseases for each participants from a list of 14 chronic medical diseases. The list contained tuberculosis, hepatitis B, hypertension, angina, myocardial infarction, stroke, cataracts, osteoporosis, arthritis, asthma, allergic rhinitis, atopic dermatitis, diabetes, and dyslipidemia. Types of living arrangement The traditional three-generation family was designated as an extended family. When an elderly subject was living with unmarried children or other relatives, the family was called a nuclear family. Living arrangements were classified into six types based on whether subjects were living with or without a spouse (unmarried, widowed, or divorced), and residing in an extended family system or a nuclear family system, as follows: (1) living with a spouse only; (2) living with a spouse in an extended family; (3) living with a spouse in a nuclear family; (4) living without a spouse in an extended family; (5) living without a spouse in a nuclear family, and (6) living alone.
The 2009 CHS interviewed a total of 230,715 individuals. We included subjects (n = 68,803) who were 60 years and older and were surveyed in the 2009 KCHS. We excluded 811 individuals due to missing information on sociodemographic and medical variables (age, marital status, residence location, generational household composition, household income and educational status and depressive symptoms). In addition, data from 7,687 participants were also excluded due to inconsistencies in the process of assigning types of living arrangements by combining information from five marital status categories (married, divorced, separated, widowed, and never married) and 19 generational household composition types. Finally, the data from 60,305 individuals (34,172 women and 26,133 men) were used in the analysis.
The Korean version of the Center for Epidemiologic Studies-Depression Scale (CES-D) was used for assessment. The CES-D is one of the five most frequently used self-reported measures of depression [23]. It is a 20-item measure consisting of 4 positively worded items and 16 negatively worded items. Positive items are reverse coded so that scores have a potential range from 0 to 60, with higher scores demonstrating more depressive symptoms [24]. The Korean version of the CES-D (CES-D-K) has been previously validated among the Korean population. For estimating the prevalence of depressive symptoms, we used a CES-D score of 16 as the cut-off [25].
Variables
Statistical analyses
Ages were grouped into 60–69, 70–79, and 80 years and over. Educational status was classified as non-educated, elementary school, middle school, high school and college or more. The average monthly household income was classified as follows: one million Korean won (KRW; one thousand won roughly equals one US dollar) or less; 1.01–2 million KRW; 2.01–3 million KRW; 3.01–4 million KRW; and 4.01 million KRW or more. Residence locations were classified into four groups according to the Korean administrative districts based on population size: (1) county (less than 50,000), (2) small city (more than 50,000 but less than 500,000), (3) medium city (more than 500,000 but less than 1,000,000), and (4) metropolitan area (more
All statistical analyses were performed separately for women and men because of known gender differences in depressive disorders [26]. Descriptive statistics were used for socio-demographic characterization and the number of chronic diseases by calculating the proportion of subjects with a given characteristics in each type of living arrangement. Categorical variables were assessed by the Cochran–Mantel–Haenszel test stratified by age group. The variation in the prevalence of depressive symptoms according to living arrangements was analysed with a multivariate logistic regression analysis, adjusting for age and other potential variables, first separately or in sets, and finally for all variables simultaneously. All odds ratios
Rating scale for depressive symptoms
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Soc Psychiatry Psychiatr Epidemiol Table 1 Sociodemographic and clinical characteristics of the study population according to the type of living arrangement Living with a spouse only (n = 27,906)
Living with a spouse in an extended family (n = 1,965)
Living with a spouse in a nuclear family (n = 11,452)
Living with out a spouse in an extended family (n = 3,497)
Living with out a spouse in a nuclear family (n = 3,387)
Living alone (n = 12,098)
n
%
n
%
n
%
n
%
n
%
n
Women
12,384
44.4
923
47.0
5,107
44.6
3,082
88.1
2,893
85.4
9,783
80.9
Men
15,522
55.6
1,042
53.0
6,345
55.4
415
11.9
494
14.6
2,315
19.1
60–69
15,793
56.6
903
46.0
7,629
66.6
885
25.3
1,756
51.9
4,410
36.5
70–79
10,441
37.4
861
43.8
2,671
23.33
1,658
47.4
1,213
35.8
5,598
46.3
1,672
6.0
201
10.2
1,152
10.1
954
27.3
418
12.3
2,090
17.3
College or more
1,658
5.9
82
4.2
865
7.6
55
1.6
107
3.2
287
2.4
High school Middle school
3,960 4,121
14.2 14.8
234 272
11.9 13.8
2,189 1,917
19.1 16.7
162 197
4.6 5.6
274 344
8.1 10.2
738 798
6.1 6.6
10,696
38.3
801
40.8
3,707
32.4
1,119
32.0
1,068
31.5
3,157
26.1
1,234
10.8
830
23.7
116
3.4
47
0.4
% \0.001
Gender
\0.001
Age (years)
C80
\0.001
Education
Elementary school
\0.001
Household income (Korean 10,000 won/month) C401
704
2.5
546
27.8
301–400
412
1.5
311
15.8
970
8.5
571
16.3
118
3.5
37
0.3
201–300
1,840
6.6
494
25.1
2,243
19.6
893
25.5
427
12.6
97
0.8
101–200
5,909
21.2
372
18.9
3,312
28.9
766
21.9
853
25.2
503
4.2
18,357
65.8
139
7.1
3,247
28.4
293
8.4
1,710
50.5
11,124
92.0
684
2.5
103
5.2
446
3.9
144
4.1
163
4.8
290
2.4
15,201
54.5
827
42.1
4,086
35.7
1,197
34.2
1,177
34.8
6,750
55.8
Small city
6,999
25.1
572
29.1
3,002
26.2
1,020
29.2
927
27.4
3,037
25.1
Middle city
1,308
4.7
204
10.4
948
8.3
377
10.8
272
8.0
462
3.8
Metropolitan
4,398
15.8
362
18.4
3,416
29.8
903
25.8
1,011
29.9
1,849
15.3
Number of chronic medical diseases 0 7,464 26.8
465
23.7
3,417
29.8
631
18.0
642
19.0
2,202
18.2
B100 Unknown
\0.001
Residence location County
1*2 3 or more a
P valuea
\0.001
14,811
53.1
1,027
52.3
5,950
52.0
1,803
51.6
1,758
51.9
6,144
50.8
5,631
20.2
473
24.1
2,085
18.2
1,063
30.4
987
29.1
3,752
31.0
P values were calculated by the Cochran–Mantel–Haenszel test stratified by age groups (60–69, 70–79 and C80 years)
(OR) were recorded with the 95 % confidence interval (CI) for each. The data were analysed using SAS 9.2 (SAS Inc., Cary, NC, USA).
Results Sociodemographic and clinical characteristics of the study population The descriptive characteristics of the study population are presented in Table 1. In the study population, the living arrangements were distributed as follows: (1) living with a spouse only, 46.3 %; (2) living with a spouse in an
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extended family, 3.3 %; (3) living with a spouse in a nuclear family, 18.2 %; (4) living without a spouse in an extended family, 6.6 %; (5) living without a spouse in a nuclear family, 5.6 %; and (6) living alone, 20.1 %. The distribution of gender, age, education, household income, residence location and the number of chronic medical diseases differed significantly between the six types of living arrangements (P \ 0.001).The proportion of females reached over 80 % in three types of living arrangements; living without a spouse in an extended family; living without a spouse in a nuclear family; and living alone. Overall, the subjects living with their spouse were younger than those living without a spouse. The proportion of non-educated subjects was the highest in the
23.88, 27.44
27.80, 29.59
594 15.57, 22.49 1,499 Men
9.7
9.19, 10.12
101
9.7
7.90, 11.49
608
9.6
8.86, 10.31
10.64, 17.31
94 14.0 58
19.0
25.7
27.31, 28.91
2,807 25.68, 28.93
28.7
3,401 24.62, 27.58
27.3 17.06, 19.80
16.63, 19.17
790 18.4 568 17.06, 19.17
12.76, 14.01 13.4
18.1 925
1,533 10.86, 13.77
12.96, 17.60 15.3
12.3 242
141 15.29, 16.58
12.05, 12.83
1,973 Women
12.4 3,472 Total
15.9
884 17.9 626
26.1
28.1
95 % CI % n 95 % CI % n % n %
95 % CI
%
95 % CI n n
n
%
95 % CI
95 % CI
Living without a spouse in a nuclear family (n = 3,387) Living without a spouse in an extended family (n = 3,497) Living with a spouse in a nuclear family (n = 11,452) Living with a spouse in an extended family (n = 1,965) Living with a spouse only (n = 27,906)
Table 2 Prevalence rates of depressive symptoms by living arrangement
Living alone (n = 12,098)
Soc Psychiatry Psychiatr Epidemiol
living-alone group (58.8 %) and lowest among those living with a spouse only (26.8 %). Moreover, the overwhelming majority of subjects living alone (91.9 %) had a monthly household income less than 1,000,000 KRW compared with 7.1 % of married couples in the extended family group. Nearly half of the study population (48 %) resided in counties. A total of 29.8 % of those who lived with their spouse in a nuclear family had no chronic medical diseases compared with 18.0 % of the living-alone group. Differences in prevalence of depressive symptoms according to living arrangement The prevalence of depressive symptoms in the total study population was 16.8 % (95 % CI = 16.84–17.14; 21.1 %, 95 % CI = 20.65–21.51 for women; 11.3 %, 95 % CI = 10.92–11.69 for men). As shown in Table 2, depressive symptoms were highest in the 28.1 % of individuals living alone (95 % CI = 27.31–28.91; 28.7 %, 95 % CI = 27.80–29.59 for women; 25.7 %, 95 % CI = 23.88–27.44 for men), and lowest in the 12.3 % of those who lived with a spouse in an extended family (95 % CI = 10.86–13.77; 15.3 %, 95 % CI = 12.96–17.60 for women; 9.7 %, 95 % CI = 7.90–11.49 for men). The association between living arrangements and depressive symptoms Table 3 gives the results of the multivariate logistic regression analysis of the association between living arrangements and depressive symptoms. Adjusting for age only, living with a spouse in an extended family tended to decrease the risk of depressive symptoms. However, this effect did not reach significance for either women (OR 0.91; 95 % CI 0.76–1.10) or men (OR 0.91; 95 % CI 0.74–1.13). Older women who were living alone (OR 1.87; 95 % CI 1.75–2.00) or living without a spouse in a nuclear family (OR 1.86; 95 % CI 1.69–2.05) experienced significantly more depressive symptoms than did older women who were living with their spouse only. Older women living with their spouse in a nuclear family were also disadvantaged on this measure (OR 1.11; 95 % CI 1.02–1.21). Single older men living in a nuclear family and living alone were 2.34 and 3.13 times more likely to suffer from depressive symptoms than those living with a spouse only, respectively. After controlling for age and household income, significantly higher odds of depressive symptoms were associated with any living arrangement compared with those living with a spouse only. In particular, the coefficients for older subjects who were living with their spouse in an extended family rose from 0.91 to 1.42 and 1.59 in women and men, respectively. Adjusting for education,
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residence location and the number of chronic medical diseases had only a modest effect on the association between living arrangements and depressive symptoms. After controlling for all confounding variables, the significant associations between living arrangements and depressive symptoms were slightly reduced in magnitude but remained significant. In both genders, older subjects living with their spouse only were less likely to have depressive symptoms than those living in the five other types of living arrangements (P \ 0.001). The highest odds ratio in women was found for those who lived without a spouse in a nuclear family (OR 1.81; 95 % CI 1.64–2.00). In men, the highest odds ratio was for those living alone (OR 2.71; 95 % CI 2.43–3.03). In both genders, those who were older, had lower incomes, lower education levels, more chronic medical diseases and resided in higher levels of urbanisation had higher frequencies of depressive symptoms than their counterparts in other categories (P \ 0.001).
Discussion In this study, we show that depressive symptoms are significantly related to living arrangements in the older Korean population. Married couples living alone were the most advantaged with respect to depressive symptoms; single women living in nuclear family and single men living alone were the most disadvantaged. Depressive symptoms increased more steeply for men as their type of living arrangement changed than it did for women. These results suggest that the relationships between living arrangements and depressive symptoms in older ages are different for men and women in Korea. Living alone and loneliness are well-established risk factors for depressive symptoms among older adults [16, 27, 28]. The results of previous studies have suggested that the effect of living arrangements on depressive symptoms can be mediated by the level of social support [18, 29]. Living arrangement can be a structural factor of social support [30] and a measure of real-life social bonds [31]. Contradicting our working hypothesis, the present study demonstrated that older men and women living with children and grandchildren (the Korean traditional living arrangement) reported more depressive symptoms than those living with their spouse only. Several factors may contribute to this finding. First, increased respect for privacy and independence due to the Westernisation of lifestyles [32]. There has been a dramatic transition in living arrangements from the extended family system to the nuclear family among elderly Koreans over recent decades. In 1994, more than 50 % of older persons in Korea lived with children. Data from the National Survey of Living
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Profile and Welfare Service Needs of Older Persons in Korea in 2008 and 2011 indicated that living with a spouse only has become the most common living arrangement (48.5 %) for the elderly in Korea [33]. A longitudinal study of three-generation families in the United States, where independence in later life is highly valued, found that the psychological benefits of intergenerational social support are contingent on the vulnerability of the older parent, when expectations for assistance are at their highest [34]. Second, this finding may reflect the fact that multigenerational co-residence is not a normative living arrangement in Korea. The advantages of co-residence enjoyed by some elderly parents in need of support could be offset by the stresses of coresidence for others whose adult children have come back to the parental home following divorce or financial crisis [17]. Korea’s divorce rate nearly quadrupled between 1980 and 2011 (from 0.6 to 2.3) [35]. Additionally, Korea experienced two financial crises in 1997–1998 and in 2008–2009 that caused massive unemployment and slashed wages. As a consequence of the increased rates of divorce and of dual earner couples, parents are increasingly relying on the extended family to care for their children [36]. These extended living arrangements, which developed as a strategy to adapt to social changes, differ from traditional Korean living arrangements based on Confucian filial piety and Patriarchal culture. The present study demonstrates gender differences in the effects of living arrangements on depressive symptoms among elderly Koreans. The association between living alone and depressive symptoms was more pronounced in men (OR 2.71; 95 % CI 2.43–3.03) than in women (OR 1.56; 95 % CI 1.46–1.68) on the basis of each reference condition. These results are in line with previous research that found that living alone is particularly harmful to men, whereas its impact on women is weaker or inconsistent [16, 21, 31]. The differential psychological impact of living arrangements on men and women may be explained from a social role and relationship perspective. In midlife, men are the main beneficiaries of their wives’ household work and child care; they also suffer more distress than women after they lose their spouse, particularly because of the burden of domestic tasks imposed on them and their lack of social networks [21]. Another interesting finding was that single women living in a nuclear family (OR 1.81; 95 % CI 1.64–2.00) appeared more depressive than single women living alone (OR 1.56; 95 % CI 1.46–1.68). This agrees with the result of previous studies showing that single women living with children are disadvantaged with regard to various health outcomes including depressive symptoms [16, 37]. In particular, the subgroup analysis in our study showed that single women who were living with grandchildren (OR 2.07; 95 % CI 1.67–2.56) experienced significantly more
Soc Psychiatry Psychiatr Epidemiol Table 3 Differences in the prevalence of depressive symptoms according to living arrangement in among Korean older women and men, adjusting for age, household income, education, number of Living arrangement
chronic medical diseases and residence location (odds ratios with the 95 % confidence intervals)
Adjusting for Age
Age ? household income
Age ? household income ? education
Age ? household income ? education ? number of chronic medical diseases
All variables
OR
(95 % CI)
OR
(95 % CI)
OR
(95 % CI)
OR
(95 % CI)
OR
(95 % CI)
Living with a spouse only
1
(Referent)
1
(Referent)
1
(Referent)
1
(Referent)
1
(Referent)
Living with a spouse in an extended family
0.91
(0.76, 1.10)
1.42
(1.17, 1.73)
1.33
(1.09, 1.62)
1.29
(1.06, 1.58)
1.27
(1.04, 1.55)
Living with a spouse in a nuclear family
1.11
(1.02, 1.21)
1.42
(1.29, 1.55)
1.39
(1.27, 1.53)
1.44
(1.31, 1.58)
1.37
(1.25, 1.51)
Living without a spouse in an extended family
1.00
(0.90, 1.11)
1.56
(1.38, 1.76)
1.44
(1.27, 1.63)
1.42
(1.25, 1.61)
1.30
(1.15, 1.48)
Living without a spouse in a nuclear family
1.86
(1.69, 2.05)
2.07
(1.88, 2.28)
2.00
(1.82, 2.21)
1.99
(1.80, 2.19)
1.81
(1.64, 2.00)
Living alone
1.87
(1.75, 2.00)
1.69
(1.58, 1.81)
1.64
(1.53, 1.75)
1.61
(1.50, 1.72)
1.56
(1.46, 1.68)
Living with a spouse only
1
(Referent)
1
(Referent)
1
(Referent)
1
(Referent)
1
(Referent)
Living with a spouse in an extended family
0.91
(0.74, 1.13)
1.59
(1.26, 1.99)
1.51
(1.20, 1.90)
1.45
(1.15, 1.83)
1.44
(1.14, 1.82)
Living with a spouse in a nuclear family
1.13
(1.02, 1.25)
1.47
(1.32, 1.63)
1.47
(1.32, 1.63)
1.47
(1.32, 1.63)
1.37
(1.23, 1.53)
Living without a spouse in an extended family
1.17
(0.88, 1.55)
2.09
(1.55, 2.81)
1.92
(1.42, 2.60)
1.90
(1.40, 2.57)
1.80
(1.33, 2.44)
Living without a spouse in a nuclear family Living alone
2.34
(1.85, 2.95)
2.71
(2.14, 3.43)
2.66
(2.10, 3.37)
2.63
(2.07, 3.34)
2.40
(1.89, 3.05)
3.13
(2.81, 3.49)
2.85
(2.56, 3.18)
2.80
(2.51, 3.13)
2.79
(2.50, 3.12)
2.71
(2.43, 3.03)
Women
Men
depressive symptoms than did older women who were living with only their spouse. Previous studies have also shown that traditional gender role beliefs are associated with poorer mental health among women [38]. Older Korean women are burdened with the role of family caregiver for grandchildren or relatives, replacing adult children and their spouse [10]. The burdens of these roles may lead to aggravated depressive symptoms in single older women living in a nuclear family with poor family support. A limitation of our cross-sectional study is that it could not establish a causal relationship between living arrangements and depressive symptoms; in particular the associations observed could have occurred if individuals who were prone to depression were predisposed to particular
living arrangements. Independent living among older Korean adults appears to be conditional on other factors affecting the family, such as the existence of a spouse or the absence of any unmarried child, and by other variables, such as a higher education level, capacity for self-support, and good health [36]. Our finding that the older subjects living alone were mostly women and disadvantaged in terms of education, income, and physical and mental health suggests that living alone may be a forced rather than a chosen situation. In this analysis, we excluded large amounts of data due to inconsistencies in determining the types of living arrangements from information regarding marital status and generational household composition. The inconsistencies between the answers to the two questions may have
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been caused by reluctance on the part of certain participants to disclose private family matters. Finally, due to limited data availability in the 2009 KCHS, we could not assess the influence of other potential confounding factors, such as stressful life events, social support (or networks) and physical disability. In conclusion, depressive symptoms are significantly associated with living arrangements among elderly Korean women and men. Living arrangements can also have gender-specific psycho-social impacts. The present results could be helpful in developing targeted prevention programs to reduce depressive symptoms in the high-risk elderly population groups. In clinical practice, early recognition and intervention for depression among older people may be improved by providing better information on living arrangements.
11.
12.
13.
14.
15.
Acknowledgments The authors appreciate all of the citizens that participated in the 2009 CHS and all members of the 2009 CHS team.
16.
Conflict of interest The authors have no conflicts of interest to report in relation to the research presented in this manuscript.
17.
18.
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ORIGINAL PAPER
Association between living arrangements and depressive symptoms among older women and men in South Korea Dong Hoon Oh • Joon Hyuk Park • Hye Young Lee Shin Ah Kim • Bo Youl Choi • Jung Hyun Nam
•
Received: 11 November 2013 / Accepted: 26 May 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose We investigated the relationship between different types of living arrangements and depressive symptoms among older Korean women and men. Methods Data were obtained from a nationally representative cross-sectional health survey conducted in 2009 in South Korea. A total of 60,305 participants (34,172 women and 26,133 men) aged 60 years and older were included in the analysis. The living arrangements were categorised into six types as follows: (1) living with a spouse only; (2) living with a spouse in an extended family; (3) living with a spouse in a nuclear family; (4) living alone; (5) living without a spouse in an extended family; and (6) living without a spouse in a nuclear family. The Korean version of the Center for Epidemiologic Studies Depression Scale was used as the measurement tool for depressive symptoms. We used multiple regression
analysis to estimate the effects of living arrangement on depressive symptoms. Results A total of 16.8 % of the total study population showed depressive symptoms. Living with a spouse only was the most common type of living arrangement (46.3 %). Women and men living with a spouse only were the least likely to have depressive symptoms. However, living without a spouse in a nuclear family and living alone were most strongly associated with depressive symptoms in women (OR 1.81; 95 % CI 1.64–2.00) and men (OR 2.71; 95 % CI 2.43–3.03), respectively. Conclusions The prevalence of depressive symptoms are associated with the living arrangements of elderly Koreans. There are gender differences in these associations, that may stem from the different demands of social roles and relationships in the family. Keywords Living arrangement Depressive symptoms Old age Gender differences
D. H. Oh J. H. Nam (&) Department of Psychiatry, College of Medicine, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul 133-791, Republic of Korea e-mail: [email protected] D. H. Oh H. Y. Lee S. A. Kim B. Y. Choi J. H. Nam Institute for Health and Society, Hanyang University, Seoul, Republic of Korea e-mail: [email protected] J. H. Park Department of Psychiatry, Jeju National University School of Medicine and Jeju National University Hospital, Jejudo, Republic of Korea H. Y. Lee S. A. Kim B. Y. Choi Department of Preventive Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
Introduction Depression is one of the most common psychiatric disorders among the elderly. It can manifest as major or minor depression and is characterized by a collection of depressive symptoms [1, 2]. Depression in later life is a serious condition that decreases quality of life, not only in terms of psychological health, increased suicide rates and reduced vitality but also in terms of physical health because it can aggravate functional disability and increase mortality [3, 4]. According to the Korea National Statistical Office, the percentage of elderly people in South Korea over the age of 65 reached 7.2 % in 2000 and is expected to exceed 14 %
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Soc Psychiatry Psychiatr Epidemiol Fig. 1 Conceptual framework of the association between the types of living arrangements and depressive symptoms in the elderly
by 2018 and 20.8 % by 2026, making South Korea one of the nations most rapidly transitioning from an aging society to an ultra-aged society [5]. The economic and social burdens of a rapidly growing elderly population are likely to present major public health challenges in Korea. In particular, policy makers have been paying increasing attention to depression in the elderly because of a substantial rise in the suicide rate among elderly Koreans [6]. Depression is an important mental health problem among elderly Koreans. Previous nationwide epidemiologic studies have indicated that approximately 10 % of elderly Koreans have minor or major depression [7], while approximately 15 % of Korean elders have depressive symptoms [8]. The high prevalence of depressive symptoms in the community and their significant association with major depression makes them important from a public mental health perspective [9]. The Korean society has undergone rapid industrialisation, urbanisation and Westernisation in recent decades [7]. In particular, the Confucian tradition of filial piety has weakened over times [8]. Moreover, the traditional extended family is decreasing and living with a spouse only is now the main type of household in which the elderly live in South Korea [9]. This change in the family system may have a major deleterious effect on the physical and mental health of the elderly [10, 11]. Previous studies have indicated that the role of living arrangements in depression among the elderly differs across societies and cultures [14–18]. Nevertheless a commonly held view is that the traditional Korean extended family could prevent depressive symptoms in the elderly by providing economic and emotional support [19].
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A contrasting position is that the stress of living in multigenerational households may lead to depressive symptoms because of conflicts between family members [8], and increasing numbers of elderly people prefer living independently from their adult children [20]. However, there have been few published studies on the relationship between living arrangements and elderly depression in Korea [21]. The aim of this study was to investigate the association between living arrangements and depressive symptoms using a standardised screening tool for depression in the largest number of elderly South Koreans examined to date. We hypothesised that elderly subjects living with their spouse in an extended family would be more protected against depressive symptoms than those living in other types of living arrangements. We also expected that there would be a gender difference in the influence of living arrangements on depressive symptoms. The relationships among the variables of living arrangements, depressive symptoms, health and sociodemographic factors are illustrated in Fig. 1.
Methods Data source This study utilised data from the public use files of the 2009 Community Health Survey (CHS) conducted by the Korean Centers for Disease Control and Prevention (KCDC). No institutional review board approval was required for this study because the data are available for public use and void of identifiers.
Soc Psychiatry Psychiatr Epidemiol
The CHS is an annual nationwide cross-sectional health interview survey conducted since 2008 to estimate the patterns of disease prevalence and morbidity, as well as to understand the personal lifestyle and health behaviour of adults aged 19 years or older. The CHS collects detailed information on demographic and socioeconomic characteristics, health-related problems and past medical histories. The CHS was conducted on an average of 900 subjects selected by a combined use of probability proportional and systematic sampling methods among adults aged 19 years or older living in 253 basic regional self-governing districts. For the sample to be statistically representative of the population, the data collected in the CHS sample were weighted based on the sample design. The CHS was administered face-to-face by trained interviewers. The protocol of the CHS was annually reviewed and approved by the institutional review board of the KCDC. All participants in the CHS signed informed consent forms prior to the interview [22]. Participants
than 1,000,000). The number of chronic diseases was assessed from reports noting diagnosed diseases for each participants from a list of 14 chronic medical diseases. The list contained tuberculosis, hepatitis B, hypertension, angina, myocardial infarction, stroke, cataracts, osteoporosis, arthritis, asthma, allergic rhinitis, atopic dermatitis, diabetes, and dyslipidemia. Types of living arrangement The traditional three-generation family was designated as an extended family. When an elderly subject was living with unmarried children or other relatives, the family was called a nuclear family. Living arrangements were classified into six types based on whether subjects were living with or without a spouse (unmarried, widowed, or divorced), and residing in an extended family system or a nuclear family system, as follows: (1) living with a spouse only; (2) living with a spouse in an extended family; (3) living with a spouse in a nuclear family; (4) living without a spouse in an extended family; (5) living without a spouse in a nuclear family, and (6) living alone.
The 2009 CHS interviewed a total of 230,715 individuals. We included subjects (n = 68,803) who were 60 years and older and were surveyed in the 2009 KCHS. We excluded 811 individuals due to missing information on sociodemographic and medical variables (age, marital status, residence location, generational household composition, household income and educational status and depressive symptoms). In addition, data from 7,687 participants were also excluded due to inconsistencies in the process of assigning types of living arrangements by combining information from five marital status categories (married, divorced, separated, widowed, and never married) and 19 generational household composition types. Finally, the data from 60,305 individuals (34,172 women and 26,133 men) were used in the analysis.
The Korean version of the Center for Epidemiologic Studies-Depression Scale (CES-D) was used for assessment. The CES-D is one of the five most frequently used self-reported measures of depression [23]. It is a 20-item measure consisting of 4 positively worded items and 16 negatively worded items. Positive items are reverse coded so that scores have a potential range from 0 to 60, with higher scores demonstrating more depressive symptoms [24]. The Korean version of the CES-D (CES-D-K) has been previously validated among the Korean population. For estimating the prevalence of depressive symptoms, we used a CES-D score of 16 as the cut-off [25].
Variables
Statistical analyses
Ages were grouped into 60–69, 70–79, and 80 years and over. Educational status was classified as non-educated, elementary school, middle school, high school and college or more. The average monthly household income was classified as follows: one million Korean won (KRW; one thousand won roughly equals one US dollar) or less; 1.01–2 million KRW; 2.01–3 million KRW; 3.01–4 million KRW; and 4.01 million KRW or more. Residence locations were classified into four groups according to the Korean administrative districts based on population size: (1) county (less than 50,000), (2) small city (more than 50,000 but less than 500,000), (3) medium city (more than 500,000 but less than 1,000,000), and (4) metropolitan area (more
All statistical analyses were performed separately for women and men because of known gender differences in depressive disorders [26]. Descriptive statistics were used for socio-demographic characterization and the number of chronic diseases by calculating the proportion of subjects with a given characteristics in each type of living arrangement. Categorical variables were assessed by the Cochran–Mantel–Haenszel test stratified by age group. The variation in the prevalence of depressive symptoms according to living arrangements was analysed with a multivariate logistic regression analysis, adjusting for age and other potential variables, first separately or in sets, and finally for all variables simultaneously. All odds ratios
Rating scale for depressive symptoms
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Soc Psychiatry Psychiatr Epidemiol Table 1 Sociodemographic and clinical characteristics of the study population according to the type of living arrangement Living with a spouse only (n = 27,906)
Living with a spouse in an extended family (n = 1,965)
Living with a spouse in a nuclear family (n = 11,452)
Living with out a spouse in an extended family (n = 3,497)
Living with out a spouse in a nuclear family (n = 3,387)
Living alone (n = 12,098)
n
%
n
%
n
%
n
%
n
%
n
Women
12,384
44.4
923
47.0
5,107
44.6
3,082
88.1
2,893
85.4
9,783
80.9
Men
15,522
55.6
1,042
53.0
6,345
55.4
415
11.9
494
14.6
2,315
19.1
60–69
15,793
56.6
903
46.0
7,629
66.6
885
25.3
1,756
51.9
4,410
36.5
70–79
10,441
37.4
861
43.8
2,671
23.33
1,658
47.4
1,213
35.8
5,598
46.3
1,672
6.0
201
10.2
1,152
10.1
954
27.3
418
12.3
2,090
17.3
College or more
1,658
5.9
82
4.2
865
7.6
55
1.6
107
3.2
287
2.4
High school Middle school
3,960 4,121
14.2 14.8
234 272
11.9 13.8
2,189 1,917
19.1 16.7
162 197
4.6 5.6
274 344
8.1 10.2
738 798
6.1 6.6
10,696
38.3
801
40.8
3,707
32.4
1,119
32.0
1,068
31.5
3,157
26.1
1,234
10.8
830
23.7
116
3.4
47
0.4
% \0.001
Gender
\0.001
Age (years)
C80
\0.001
Education
Elementary school
\0.001
Household income (Korean 10,000 won/month) C401
704
2.5
546
27.8
301–400
412
1.5
311
15.8
970
8.5
571
16.3
118
3.5
37
0.3
201–300
1,840
6.6
494
25.1
2,243
19.6
893
25.5
427
12.6
97
0.8
101–200
5,909
21.2
372
18.9
3,312
28.9
766
21.9
853
25.2
503
4.2
18,357
65.8
139
7.1
3,247
28.4
293
8.4
1,710
50.5
11,124
92.0
684
2.5
103
5.2
446
3.9
144
4.1
163
4.8
290
2.4
15,201
54.5
827
42.1
4,086
35.7
1,197
34.2
1,177
34.8
6,750
55.8
Small city
6,999
25.1
572
29.1
3,002
26.2
1,020
29.2
927
27.4
3,037
25.1
Middle city
1,308
4.7
204
10.4
948
8.3
377
10.8
272
8.0
462
3.8
Metropolitan
4,398
15.8
362
18.4
3,416
29.8
903
25.8
1,011
29.9
1,849
15.3
Number of chronic medical diseases 0 7,464 26.8
465
23.7
3,417
29.8
631
18.0
642
19.0
2,202
18.2
B100 Unknown
\0.001
Residence location County
1*2 3 or more a
P valuea
\0.001
14,811
53.1
1,027
52.3
5,950
52.0
1,803
51.6
1,758
51.9
6,144
50.8
5,631
20.2
473
24.1
2,085
18.2
1,063
30.4
987
29.1
3,752
31.0
P values were calculated by the Cochran–Mantel–Haenszel test stratified by age groups (60–69, 70–79 and C80 years)
(OR) were recorded with the 95 % confidence interval (CI) for each. The data were analysed using SAS 9.2 (SAS Inc., Cary, NC, USA).
Results Sociodemographic and clinical characteristics of the study population The descriptive characteristics of the study population are presented in Table 1. In the study population, the living arrangements were distributed as follows: (1) living with a spouse only, 46.3 %; (2) living with a spouse in an
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extended family, 3.3 %; (3) living with a spouse in a nuclear family, 18.2 %; (4) living without a spouse in an extended family, 6.6 %; (5) living without a spouse in a nuclear family, 5.6 %; and (6) living alone, 20.1 %. The distribution of gender, age, education, household income, residence location and the number of chronic medical diseases differed significantly between the six types of living arrangements (P \ 0.001).The proportion of females reached over 80 % in three types of living arrangements; living without a spouse in an extended family; living without a spouse in a nuclear family; and living alone. Overall, the subjects living with their spouse were younger than those living without a spouse. The proportion of non-educated subjects was the highest in the
23.88, 27.44
27.80, 29.59
594 15.57, 22.49 1,499 Men
9.7
9.19, 10.12
101
9.7
7.90, 11.49
608
9.6
8.86, 10.31
10.64, 17.31
94 14.0 58
19.0
25.7
27.31, 28.91
2,807 25.68, 28.93
28.7
3,401 24.62, 27.58
27.3 17.06, 19.80
16.63, 19.17
790 18.4 568 17.06, 19.17
12.76, 14.01 13.4
18.1 925
1,533 10.86, 13.77
12.96, 17.60 15.3
12.3 242
141 15.29, 16.58
12.05, 12.83
1,973 Women
12.4 3,472 Total
15.9
884 17.9 626
26.1
28.1
95 % CI % n 95 % CI % n % n %
95 % CI
%
95 % CI n n
n
%
95 % CI
95 % CI
Living without a spouse in a nuclear family (n = 3,387) Living without a spouse in an extended family (n = 3,497) Living with a spouse in a nuclear family (n = 11,452) Living with a spouse in an extended family (n = 1,965) Living with a spouse only (n = 27,906)
Table 2 Prevalence rates of depressive symptoms by living arrangement
Living alone (n = 12,098)
Soc Psychiatry Psychiatr Epidemiol
living-alone group (58.8 %) and lowest among those living with a spouse only (26.8 %). Moreover, the overwhelming majority of subjects living alone (91.9 %) had a monthly household income less than 1,000,000 KRW compared with 7.1 % of married couples in the extended family group. Nearly half of the study population (48 %) resided in counties. A total of 29.8 % of those who lived with their spouse in a nuclear family had no chronic medical diseases compared with 18.0 % of the living-alone group. Differences in prevalence of depressive symptoms according to living arrangement The prevalence of depressive symptoms in the total study population was 16.8 % (95 % CI = 16.84–17.14; 21.1 %, 95 % CI = 20.65–21.51 for women; 11.3 %, 95 % CI = 10.92–11.69 for men). As shown in Table 2, depressive symptoms were highest in the 28.1 % of individuals living alone (95 % CI = 27.31–28.91; 28.7 %, 95 % CI = 27.80–29.59 for women; 25.7 %, 95 % CI = 23.88–27.44 for men), and lowest in the 12.3 % of those who lived with a spouse in an extended family (95 % CI = 10.86–13.77; 15.3 %, 95 % CI = 12.96–17.60 for women; 9.7 %, 95 % CI = 7.90–11.49 for men). The association between living arrangements and depressive symptoms Table 3 gives the results of the multivariate logistic regression analysis of the association between living arrangements and depressive symptoms. Adjusting for age only, living with a spouse in an extended family tended to decrease the risk of depressive symptoms. However, this effect did not reach significance for either women (OR 0.91; 95 % CI 0.76–1.10) or men (OR 0.91; 95 % CI 0.74–1.13). Older women who were living alone (OR 1.87; 95 % CI 1.75–2.00) or living without a spouse in a nuclear family (OR 1.86; 95 % CI 1.69–2.05) experienced significantly more depressive symptoms than did older women who were living with their spouse only. Older women living with their spouse in a nuclear family were also disadvantaged on this measure (OR 1.11; 95 % CI 1.02–1.21). Single older men living in a nuclear family and living alone were 2.34 and 3.13 times more likely to suffer from depressive symptoms than those living with a spouse only, respectively. After controlling for age and household income, significantly higher odds of depressive symptoms were associated with any living arrangement compared with those living with a spouse only. In particular, the coefficients for older subjects who were living with their spouse in an extended family rose from 0.91 to 1.42 and 1.59 in women and men, respectively. Adjusting for education,
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Soc Psychiatry Psychiatr Epidemiol
residence location and the number of chronic medical diseases had only a modest effect on the association between living arrangements and depressive symptoms. After controlling for all confounding variables, the significant associations between living arrangements and depressive symptoms were slightly reduced in magnitude but remained significant. In both genders, older subjects living with their spouse only were less likely to have depressive symptoms than those living in the five other types of living arrangements (P \ 0.001). The highest odds ratio in women was found for those who lived without a spouse in a nuclear family (OR 1.81; 95 % CI 1.64–2.00). In men, the highest odds ratio was for those living alone (OR 2.71; 95 % CI 2.43–3.03). In both genders, those who were older, had lower incomes, lower education levels, more chronic medical diseases and resided in higher levels of urbanisation had higher frequencies of depressive symptoms than their counterparts in other categories (P \ 0.001).
Discussion In this study, we show that depressive symptoms are significantly related to living arrangements in the older Korean population. Married couples living alone were the most advantaged with respect to depressive symptoms; single women living in nuclear family and single men living alone were the most disadvantaged. Depressive symptoms increased more steeply for men as their type of living arrangement changed than it did for women. These results suggest that the relationships between living arrangements and depressive symptoms in older ages are different for men and women in Korea. Living alone and loneliness are well-established risk factors for depressive symptoms among older adults [16, 27, 28]. The results of previous studies have suggested that the effect of living arrangements on depressive symptoms can be mediated by the level of social support [18, 29]. Living arrangement can be a structural factor of social support [30] and a measure of real-life social bonds [31]. Contradicting our working hypothesis, the present study demonstrated that older men and women living with children and grandchildren (the Korean traditional living arrangement) reported more depressive symptoms than those living with their spouse only. Several factors may contribute to this finding. First, increased respect for privacy and independence due to the Westernisation of lifestyles [32]. There has been a dramatic transition in living arrangements from the extended family system to the nuclear family among elderly Koreans over recent decades. In 1994, more than 50 % of older persons in Korea lived with children. Data from the National Survey of Living
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Profile and Welfare Service Needs of Older Persons in Korea in 2008 and 2011 indicated that living with a spouse only has become the most common living arrangement (48.5 %) for the elderly in Korea [33]. A longitudinal study of three-generation families in the United States, where independence in later life is highly valued, found that the psychological benefits of intergenerational social support are contingent on the vulnerability of the older parent, when expectations for assistance are at their highest [34]. Second, this finding may reflect the fact that multigenerational co-residence is not a normative living arrangement in Korea. The advantages of co-residence enjoyed by some elderly parents in need of support could be offset by the stresses of coresidence for others whose adult children have come back to the parental home following divorce or financial crisis [17]. Korea’s divorce rate nearly quadrupled between 1980 and 2011 (from 0.6 to 2.3) [35]. Additionally, Korea experienced two financial crises in 1997–1998 and in 2008–2009 that caused massive unemployment and slashed wages. As a consequence of the increased rates of divorce and of dual earner couples, parents are increasingly relying on the extended family to care for their children [36]. These extended living arrangements, which developed as a strategy to adapt to social changes, differ from traditional Korean living arrangements based on Confucian filial piety and Patriarchal culture. The present study demonstrates gender differences in the effects of living arrangements on depressive symptoms among elderly Koreans. The association between living alone and depressive symptoms was more pronounced in men (OR 2.71; 95 % CI 2.43–3.03) than in women (OR 1.56; 95 % CI 1.46–1.68) on the basis of each reference condition. These results are in line with previous research that found that living alone is particularly harmful to men, whereas its impact on women is weaker or inconsistent [16, 21, 31]. The differential psychological impact of living arrangements on men and women may be explained from a social role and relationship perspective. In midlife, men are the main beneficiaries of their wives’ household work and child care; they also suffer more distress than women after they lose their spouse, particularly because of the burden of domestic tasks imposed on them and their lack of social networks [21]. Another interesting finding was that single women living in a nuclear family (OR 1.81; 95 % CI 1.64–2.00) appeared more depressive than single women living alone (OR 1.56; 95 % CI 1.46–1.68). This agrees with the result of previous studies showing that single women living with children are disadvantaged with regard to various health outcomes including depressive symptoms [16, 37]. In particular, the subgroup analysis in our study showed that single women who were living with grandchildren (OR 2.07; 95 % CI 1.67–2.56) experienced significantly more
Soc Psychiatry Psychiatr Epidemiol Table 3 Differences in the prevalence of depressive symptoms according to living arrangement in among Korean older women and men, adjusting for age, household income, education, number of Living arrangement
chronic medical diseases and residence location (odds ratios with the 95 % confidence intervals)
Adjusting for Age
Age ? household income
Age ? household income ? education
Age ? household income ? education ? number of chronic medical diseases
All variables
OR
(95 % CI)
OR
(95 % CI)
OR
(95 % CI)
OR
(95 % CI)
OR
(95 % CI)
Living with a spouse only
1
(Referent)
1
(Referent)
1
(Referent)
1
(Referent)
1
(Referent)
Living with a spouse in an extended family
0.91
(0.76, 1.10)
1.42
(1.17, 1.73)
1.33
(1.09, 1.62)
1.29
(1.06, 1.58)
1.27
(1.04, 1.55)
Living with a spouse in a nuclear family
1.11
(1.02, 1.21)
1.42
(1.29, 1.55)
1.39
(1.27, 1.53)
1.44
(1.31, 1.58)
1.37
(1.25, 1.51)
Living without a spouse in an extended family
1.00
(0.90, 1.11)
1.56
(1.38, 1.76)
1.44
(1.27, 1.63)
1.42
(1.25, 1.61)
1.30
(1.15, 1.48)
Living without a spouse in a nuclear family
1.86
(1.69, 2.05)
2.07
(1.88, 2.28)
2.00
(1.82, 2.21)
1.99
(1.80, 2.19)
1.81
(1.64, 2.00)
Living alone
1.87
(1.75, 2.00)
1.69
(1.58, 1.81)
1.64
(1.53, 1.75)
1.61
(1.50, 1.72)
1.56
(1.46, 1.68)
Living with a spouse only
1
(Referent)
1
(Referent)
1
(Referent)
1
(Referent)
1
(Referent)
Living with a spouse in an extended family
0.91
(0.74, 1.13)
1.59
(1.26, 1.99)
1.51
(1.20, 1.90)
1.45
(1.15, 1.83)
1.44
(1.14, 1.82)
Living with a spouse in a nuclear family
1.13
(1.02, 1.25)
1.47
(1.32, 1.63)
1.47
(1.32, 1.63)
1.47
(1.32, 1.63)
1.37
(1.23, 1.53)
Living without a spouse in an extended family
1.17
(0.88, 1.55)
2.09
(1.55, 2.81)
1.92
(1.42, 2.60)
1.90
(1.40, 2.57)
1.80
(1.33, 2.44)
Living without a spouse in a nuclear family Living alone
2.34
(1.85, 2.95)
2.71
(2.14, 3.43)
2.66
(2.10, 3.37)
2.63
(2.07, 3.34)
2.40
(1.89, 3.05)
3.13
(2.81, 3.49)
2.85
(2.56, 3.18)
2.80
(2.51, 3.13)
2.79
(2.50, 3.12)
2.71
(2.43, 3.03)
Women
Men
depressive symptoms than did older women who were living with only their spouse. Previous studies have also shown that traditional gender role beliefs are associated with poorer mental health among women [38]. Older Korean women are burdened with the role of family caregiver for grandchildren or relatives, replacing adult children and their spouse [10]. The burdens of these roles may lead to aggravated depressive symptoms in single older women living in a nuclear family with poor family support. A limitation of our cross-sectional study is that it could not establish a causal relationship between living arrangements and depressive symptoms; in particular the associations observed could have occurred if individuals who were prone to depression were predisposed to particular
living arrangements. Independent living among older Korean adults appears to be conditional on other factors affecting the family, such as the existence of a spouse or the absence of any unmarried child, and by other variables, such as a higher education level, capacity for self-support, and good health [36]. Our finding that the older subjects living alone were mostly women and disadvantaged in terms of education, income, and physical and mental health suggests that living alone may be a forced rather than a chosen situation. In this analysis, we excluded large amounts of data due to inconsistencies in determining the types of living arrangements from information regarding marital status and generational household composition. The inconsistencies between the answers to the two questions may have
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Soc Psychiatry Psychiatr Epidemiol
been caused by reluctance on the part of certain participants to disclose private family matters. Finally, due to limited data availability in the 2009 KCHS, we could not assess the influence of other potential confounding factors, such as stressful life events, social support (or networks) and physical disability. In conclusion, depressive symptoms are significantly associated with living arrangements among elderly Korean women and men. Living arrangements can also have gender-specific psycho-social impacts. The present results could be helpful in developing targeted prevention programs to reduce depressive symptoms in the high-risk elderly population groups. In clinical practice, early recognition and intervention for depression among older people may be improved by providing better information on living arrangements.
11.
12.
13.
14.
15.
Acknowledgments The authors appreciate all of the citizens that participated in the 2009 CHS and all members of the 2009 CHS team.
16.
Conflict of interest The authors have no conflicts of interest to report in relation to the research presented in this manuscript.
17.
18.
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