Risk Factors for Depression in Empty Nesters: A Cross-Sectional Study in a Coastal City of Zhejiang Province and China

The aging population phenomenon is a major social problem around the globe in the 21st century. At present, most people can expect to live to 60 or older as the youth mortality rate is greatly reduced and life expectancy continues to grow [1]. Combined with the decline in the fertility rate, the increase in life expectancy is leading to a rapid aging of the world’s population [1]. In China, as of the end of 2018, the number of people aged 60 or older was close to 250 million, accounting for 17.9% of the total population [2]. In 2015, the “Family Development Report of China (2015)” issued by the National Health and Family Planning Commission showed that empty nesters accounted for half of all elderly people. It is estimated that the proportion of empty-nest families will account for 90% of elderly families in 2030, when the elderly families in China will be empty-nested across the board [3,4].

On a global scale, the burden of depression continues to increase [5]. Depression is a common mental disorder, and approximately 300 million people of all ages suffer from it worldwide. Depression is the leading cause of disability in the world and it is a major factor contributing to the global burden of disease [6]. Depression can lead to suicide in the worst cases [7]. Depression is expected to be the main cause of disease burden in 2030 [4]. The elderly are more susceptible to depression than other populations, especially empty nesters [8]. In China, the prevalence of depression in the elderly is worrying. In 2012, the results of an investigation using the Geriatric Mental State examination among 4265 community elderly people conducted in four provinces in China showed that the detection rate of depression symptoms in empty nesters was 8.18%, which was higher than the 6.31% for non-empty nesters [9]. Empty nesters are more likely to develop depression than average elderly people [10]. The depression problem of empty nesters has become a major social problem related to the health status of China’s aging population [4].

Empty nesters are susceptible to different adverse conditions and they are confronted with age-related problems, such as chronic diseases [5,11,12,13,14] and irreversible reductions in cognitive function [15]. In addition, more and more studies have shown that social support [16], behaviors and lifestyles [17,18], self-care ability [19,20], negative life experiences [14,18,21,22], obesity [23], etc., are the main risk factors for depression in empty nesters. Some studies have also shown that gender, age, occupation, education level, marital status, etc. affect the occurrence of depression [7,24,25,26,27,28,29]. Therefore, this study aimed to assess the prevalence and distribution of depression in empty nesters in a coastal city of China through cross-sectional questionnaires and physical examinations, and to explore the risk factors associated with depression in empty nesters in order to provide an effective theoretical basis for resolving the problem.

A total of 813 people (326 males and 487 females) were enrolled in the study. The GDS was used to evaluate the depressive symptoms of empty nesters. The estimated prevalence of depressive symptoms in empty nesters was 46.5% (95% CI: 8.6–54.6%). The prevalence of depressive symptoms in different populations is shown in Table 1. The prevalence of depressive symptoms in men was lower than the prevalence of depressive symptoms in women, and the weighted prevalence rates were 41.2% (95% CI: 33.0–49.9%) and 50.0% (95% CI: 41.8–58.2%), respectively. The weighted prevalence of depressive symptoms in overweight/obese participants was 55.8% (95% CI: 46.1–59.9%), which was higher than weighted prevalence of depressive symptoms in participants with lean/normal weight. The weighted prevalence of depressive symptoms in participants engaged in housework was 56.8% (95% CI: 45.6–67.2%), which was significantly higher than individuals with cultivation or other occupations. The weighted prevalence of depressive symptoms among religious believers (49.7%, 95% CI: 40.9–58.5%) was significantly higher than weighted prevalence of depressive symptoms among non-religious believers (29.0%, 95% CI: 17.3–44.4%). The prevalence of depression in participants with chronic diseases, such as dyslipidemia (62.0%, 95% CI: 50.2–72.5%), chronic respiratory diseases (54.1%, 95% CI: 50.3–57.8%), and cancer (84.5%, 95% CI: 55.0–96.1%), was high. Smokers (39.4%, 95% CI: 27.0–53.2%) and drinkers (33.5%, 95% CI: 21.7–47.9%) showed a lower prevalence of depressive symptoms than non-smokers/drinkers or participants who had quit smoking/drinking. In terms of negative life experiences, individuals who had experienced the death of a loved one (73.7%, 95% CI: 60.4–83.8%), financial losses (80.0%, 95% CI: 53.5–93.3%), and sad experiences (72.9%, 95% CI: 55.9–85.1%) demonstrated a high prevalence of depressive symptoms.

The results of the multivariate weighted logistic regression analysis of depressive symptoms (Table 2) showed that being overweight/obese could increase the risk of depressive symptoms (adjusted OR = 1.64, 95% CI: 1.04–2.56) compared to people with a normal BMI. Compared to participants with cultivation, individuals engaged in housework demonstrated a higher risk of depressive symptoms (adjusted OR = 2.48, 95% CI: 1.86–3.31). Religious people showed a higher risk of depressive symptoms than individuals without religious beliefs (adjusted OR = 2.24, 95% CI: 1.19–4.20). At the same time, chronic diseases, such as cancer (adjusted OR = 5.19, 95% CI: 1.14–23.56) and chronic pain (adjusted OR = 1.60, 95% CI: 1.18–2.17), could significantly increase the risk of depressive symptoms. Compared to non-smokers, quitters were prone to depressive symptoms (adjusted OR = 3.08, 95% CI: 1.89–5.02); drinking appeared to produce a certain protective effect against depressive symptoms (adjusted OR = 0.60, 95% CI: 0.37–0.99). Negative life experiences, such as the death of a loved one (adjusted OR = 2.26, 95% CI: 1.75–2.91) and financial losses (adjusted OR = 5.30, 95% CI: 2.99–9.39), could significantly increase the risk of depressive symptoms in empty nesters. In addition, the incapability of providing self-care (adjusted OR = 1.53, 95% CI: 1.10–2.13) also increased the risk of depressive symptoms in empty nesters.

This study showed that the prevalence of depressive symptoms in empty nesters reached 47%, which was significantly higher than the rate of 23.6% seen in the general elderly population. This finding was consistent with the findings of other studies [10,11,25], which may be due to the fact that, compared to non-empty nesters, empty nesters report lower incomes, a higher prevalence of chronic diseases, and no intimate siblings, friends, or even neighbors, which may increase their susceptibility to discomfort and anxiety and a higher risk of depression.

This study showed that the occurrence of depression in empty nesters was related to chronic conditions, such as being overweight/obese, religious beliefs, cancer, and chronic pain, as well as practices such as smoking and drinking. Being overweight/obese is a common problem among the elderly in China. In 2012, the rate of overweight residents aged 60 or older in China was 31.9% and the obesity rate was 11.6%, which were 7.6% and 2.7% higher than in 2002, respectively [31]. Being overweight/obese is a risk factor for many chronic diseases, which, to some extent, increases the psychological burden of the elderly. Chronic diseases damage the health of empty nesters and they also reduce their quality of life [32]. Empty nesters are likely to complain about emptiness and helplessness in life and feel that they lack friends and, therefore, are likely to be depressed [33,34]. Because of the poor prognosis and high mortality rate of many cancers, people generally have negative thoughts toward cancer. Therefore, after the diagnosis of cancer, the elderly, including empty nesters, are prone to anxiety and depression [19]. A strong association was found between cancer and the risk of depressive symptoms. Similarly, chronic pain is a long-term affliction in the elderly that negatively impacts their normal life, sleep, rest, and even psychology, making them prone to depressive symptoms [23,35]. Seemingly, empty nesters with religious beliefs are at a high risk of developing depressive symptoms, which may be related to the search for mental support by empty nesters after the occurrence of diseases or negative life experiences. In other words, many empty nesters develop religious beliefs after experiencing depressive symptoms or corresponding risk factors [36,37]. Smoking and drinking can relieve the psychological stress and anxiety of the elderly to a certain extent. On the other hand, however, smoking cessation may cause certain depressive symptoms in the elderly [38,39], and this may be due to the fact that, for some elderly, smoking was one of their pleasures that has now been taken away from them.

This study showed that the negative life experiences of losing loved ones and financial losses are risk factors for depression in empty nesters. These experiences often negatively impact the mental state of the elderly, making them prone to anger, loneliness, sadness, etc. Moreover, empty nesters cannot share their negative life events with other individuals due to the lack of an effective social support system, and negative coping strategies are often used, which can easily lead to symptoms of depression [1,40]. Chan et al. [41] found that negative life events, as stressors, were positively correlated with depression and they were potential risk factors for depression in the elderly. One study [42] showed that the number of negative life events was directly proportional to the risk of developing senile depression, and the number of negative events had an additive effect on senile depression. Therefore, negative life events, such as the death of a loved one and financial losses (e.g., due to natural disasters such as earthquakes), are likely to induce depressive symptoms in empty nesters [43,44].

High economic levels tend to lead to better health conditions and high life satisfaction [45,46]. A study on health and life satisfaction among the elderly showed that their perceptions of life satisfaction varied according to their health status [47], while life satisfaction was negatively correlated with depression [48]. Economic hardship may limit the ability of empty nesters to live independently and meet their social needs or desires [49]. Studies have shown that, compared with non-empty nesters, the income of empty nesters is lower, which may prevent them from interacting with friends or family in life or work, limiting their opportunities to increase their satisfaction with these aspects, increasing the incidence of depression [45].

The incapability of providing self-care is a risk factor for depression in elderly people. Self-care ability is the basis for the elderly to maintain social activities. Elderly people with impaired self-care ability will reduce their activities due to the weakening of the body, leading to a decline in physical flexibility and social adaptability. Consequently, elderly people will experience declines in their confidence to care for themselves, leading to fear and depression [50]. Self-care ability is closely related to the occurrence of depression [51]. The risk of depression in empty nesters with impaired self-care ability is significantly higher than the risk of depression in elderly people with normal self-care ability, which may be due to impaired self-care ability and leaves empty nesters dependent on their family and society. If these individuals are not properly cared for, they will experience negative emotions, such as helplessness or worthlessness, leading to depressive symptoms [52]. Therefore, improving the self-care ability of empty nesters is of great significance to the prevention and treatment of depression in this population.

This study investigated the prevalence of depressive symptoms and the corresponding risk factors in empty nesters and provided primary evidence for exploring the health problems of this population and proposing interventions. The main limitation of this study is that it was a cross-sectional investigation, which cannot determine the chronological order of factors and depressive symptoms necessary to determine causality. Through the study, it was found that the prevalence of depression in empty nesters was high and its occurrence was related to many factors. Being overweight/obese, cancer, chronic pain, smoking cessation, the death of a loved one, financial losses, and the incapability of providing self-care are risk factors for depression in empty nesters. We suggested that comprehensive measures should be taken to enhance health interventions for empty nesters, which include encouraging proper diets and physical activity to help them lose weight, delivering psychological counseling for negative life experiences, and teaching correct methods of smoking cessation. Further in-depth research on the major health issues of empty nesters is also suggested [42,53], such as lower limb atherosclerosis disease (LEAD), which is associated with increased risk of incident heart failure and may cause subsequent heart failure [54].

The authors would like to acknowledge Danjiang Sun at the Taizhou Tumor Hospital for his time and support for this research. Further, we would like to thank all participants and investigators at Wenling Center for Disease Control and Prevention.

Methodology, Y.Y. and W.F.; validation, Y.Y., G.D., and W.F.; investigation, L.W., Y.J., J.L., and W.F.; resources, W.F.; formal analysis, Y.Z., T.Z., and F.H.; writing—original draft preparation, Y.Y.; writing—review and editing, Y.Y. and W.F. and all the other authors; funding acquisition, W.F.

This research was funded by Wenling Center for Disease Control and Prevention, grant number 2016C311144.

The authors declare no conflict of interest.