The association of widowhood and living alone with depression among older adults in India

The pace of world population aging has been the fastest in recent years. According to Help Age India, the people aged 60 and above are classified as older population in India, whose proportion is projected to rise to 19.5 percent by 2050¹. However, the significance of the rapid increase in life expectancy and its implication is yet to be appreciated as increased life expectancy does not mean the improved quality of life among older adults². Most countries, including developing countries with a constant increase in longevity, pose serious challenges such as increased risks of multi-morbidity, disability, dementia and, weakening their functional capability, and increasing dependence for personal, household, and medical care^3,4.

The average life span in the world is expected to double in the twentieth century⁵. With increased longevity in some countries, the concept of widowhood has broadened due to growing concerns of older adults whose spouse has died, and their likelihood of living alone for a longer period has also increased⁶. Approximately 350 million people are estimated to be widowed in 2020, out of which about 80 percent are females⁷. Some predominant reasons for increased risk for women to outlive men are related to the higher life expectancy of females due to their biological advantages over men. However, the differences in life expectancy between the two sexes are not purely biological and there are intervening social factors such as the age gap in marriage, higher risk-taking behavior, and increased substance use among men⁸.

Widowhood is an irreversible situation⁹. It is a catastrophic event at any stage of life for the surviving partner with serious repercussions on their physical, economic, and emotional well-being, particularly in the first year of the loss or for a longer term in some cases¹⁰. However, the emotional response to the spousal loss is hypothesized to be different depending on various socio-demographic characteristics such as age, gender, widowhood duration, living arrangement, functional ability to perform activities, health status and other factors such as community involvement and economic conditions of the survivor^11–13. Widowhood often places individuals at a greater risk of deteriorating health and depressive symptoms with passing time post spousal loss for both sexes⁷. Across studies, prevalence rates of depressive symptoms are estimated to be high as 15–30 percent within the first year of widowhood¹⁰. However, it remains unclear whether widowhood has more psychological consequences on males or females. Differences between the two sexes in depression due to spousal loss is argued to differ according to gender roles; as compared to men, women are found to invest less in their financial security and more in familial relationships. After the bereavement of the spouse, their only source of income is lost, which increases their economic hardships at older ages leading to an adverse impact on their psychological well-being^7,14,15. Few studies suggest that men and women have similar difficulty adapting to widowhood and reorganizing their lives after the spousal loss⁶. However, the loss of a spouse is not always associated with negative outcomes. For instance, some studies observed improvement of well-being and lower depressive symptoms among older widows after spousal bereavement, due to reorientation of life, and increased time for individual development because of the decreased burden of caregiving¹⁶. Considering the large variation in reaction to spousal loss, this as a generalized hypothesis as an outcome of widowhood is not appropriate. In many countries like India where widows account for a larger proportion of the population, widowhood is considered as the most dreaded phase of life due to strict gender roles, stigma and prevailing traditional customs along with poverty, abuse and lack of social support¹⁷. Widowhood brings serious economic challenges, and studies have found wealth status to be a strong predictor of health outcomes among older adults^17–19. However, it is unclear whether economic status after a spouse's death is a primary cause for the psychological distress among older adults.

Marital status and its link with mental health has been explored previously, concluding that unmarried and widowed individuals show higher rates of loneliness, lower life satisfaction, physical ailments, and higher mortality²⁰. Globally, about 90 million older adults are estimated to live alone, of which roughly about 60 million are females; still, a great majority of older adults have only been in one union and decide not to marry after the spousal bereavement in older age²¹. Troubled mental state during this phase, such as negative emotions and feelings of emptiness, are challenging for many older adults; as a result, they may tend to withdraw and become unresponsive²². However, remarriage in older age is still an exception. Widowed men are observed to remarry at a rate twice as high than female widows²³. Co-residence with family and community involvement is more common for widows^24,25. Previous studies have explicitly discussed depression and other psychological illnesses such as dementia in association with population aging, and a few have also reflected on the role of spousal loss in old age^26,27. The effect of widowhood and co-residence with family together on depression has been observed, but is rather inconclusive; and some studies also suggest that older widowed women who are sick and more depressed might be more likely to co-reside with family²⁸.

In model-2, it was additionally found that older adults who were not working were found to be negatively associated with depression. A lower level of life satisfaction was found to be significantly positively associated with depression [AOR: 2.16, CI 1.93–2.41]. Respondents who reported the life satisfaction as ‘low’ and ‘medium’ were 2.16 [AOR: 2.16, CI 1.93–2.41] times and 1.33 [AOR: 1.33, CI 1.17–1.51] times more likely to have depression in comparison to those who reported their life satisfaction level as ‘high’ respectively. Further, respondents who rated their health as poor were 2.18 times significantly more likely to be depressed than those who reported their health to be good [AOR: 2.18, CI 1.96–2.42]. The likelihood of getting depressed was higher among those who had difficulty with ADL activities than those who did not have any difficulty with ADL activities [AOR: 1.71, CI 1.53–1.91]. Similarly, older adults who had difficulty in IADL 56% significantly more likely to be depressed than older adults who do not have difficulty with IADL activities [AOR: 1.56, CI 1.4–1.74]. Having two and above morbidity conditions had a significant positive association with the prevalence of depression [AOR: 1.53, CI 1.36–1.73]. Older adults from the poorest wealth quintile had lower odds to suffer from depression in reference to older adults from richest wealth quintile [AOR: 0.76; CI 0.65–0.89]. Older adults from OBC had higher odds of suffering from depression in reference to older adults from others category [AOR: 1.19; CI 1.06,1.35]. Older adults from an urban place of residence had higher odds to suffer from depression in reference to older adults from rural counterparts [AOR: 1.24; CI 1.11–1.39].

Several epidemiological studies suggest that the non-co-residential living arrangements of older adults are often associated with the prevalence of depressive symptoms^7,39,40. Supporting this, our study produced similar findings, with 10.3 percent and 13.6 percent of older adults who were widowed and lived alone, respectively (against 7.8 and 8.4 percent of those currently married and co-residing) reporting severe depressive symptoms as measured by the CIDI-SF 10. The current study, using the first large nationally representative survey data of LASI, included a wide range of potential explanatory variables and adds to the few studies that have been conducted in low-income countries. Previous studies in middle- and high-income countries as well as some low-income countries like China have also observed a significant association between marital status, living arrangements and mental health among older adults^41–44.

In our multivariable models, living arrangement and marital status were found to be significantly associated with depressive symptoms. These findings are parallel to studies that identified widowhood and solo living as risk factors to poor mental health among older adults in general^45–48 and those who are oldest-old in particular^48–51. Also, the interactive effect of marital status and living arrangement with depression was concordant with a recent study in Japan that has shown the adverse impact of both widowhood and living alone on depressive symptoms⁵². The possible explanation for the negative effect of widowhood on psychological wellbeing may be the increased stress due to spousal loss that results in reduced emotional support and lack of financial support^53,54. Also, as documented, solo-living older individuals are less likely to have a family or close friends to talk to and are thus more likely to have a strong sense of loneliness resulting in depression^55–57. On the other hand, contrary to other population-based studies^58,59, older age was found to be inversely associated with depression among older adults in the present study. It can be explained in part by older persons’ reduced levels of emotional reactivity by increasing age leading to lesser reporting of symptoms of extreme distress or depression compared to their younger counterparts⁶⁰. However, the increased depression associated with widowhood and solo living in older adults in our study calls for special attention from policy makers since older Indian adults are left with no or minimum social security and support.

Interestingly, the older adults who were currently in a marital union and lived alone in the present study had lower likelihood of late-life depression, as compared to married and co-residing individuals (Fig. 3). This is contrary to multiple studies showing that solo living among older individuals may lead to mental illnesses^22,61. This inconsistent finding could partially be explained by the self-selection for individuals who enjoy living alone. The relatively smaller sample of older people who lived alone in our study could also have resulted in the lower odds of depression in solo living individuals due to power effects. Furthermore, consistent with existing literature, the factors identified with a linkage to the increased rates of depression in later life in this study include sex^40,44, socio-economic resources⁶², and health status^63,64. The results of the study revealed that older females and those who faced poor self-rated health, low ADL and IADL, and a higher number of diseases reported a higher rate of depressive symptoms. Findings are also in line with the evidence suggesting that the cumulative impacts of disadvantages may increase the risk for negative mental health outcomes as people grow older^65,66. Consistent with past studies that have found urban–rural differences in terms of psychological wellbeing and depressive symptoms, the current results show that rural living older adults have an increased risk of depression^67–69. Further, lower social class may contribute to the psychological distress among older adults due to their lack of household economic resources and financial strain⁷⁰, which is supported by current finding of higher prevalence of depression among older adults from OBC category. However, the current study also observed that people from ST are at lower risk of late-life depression in comparison to ‘other’ caste category which includes castes that are considered socioeconomically advantaged. This finding suggests a need for further investigation exploring the variations in mental illnesses among different caste groups in India.

In addition, the significant association of life satisfaction with depression in our study was consistent with previous studies that have shown that older individuals who had greater life dissatisfaction were more likely to suffer from depression and suggested that such a subjective status can be promoted by enhancing their social and economic circumstances^71,72. Nonetheless, the association of higher household economic status with an increased risk of depression among older adults in our study is in variance with the existing literature that shows that economic status is negatively associated with late-life depression^73–75. Further studies are required to better understand the risk of developing depression among higher socio-economic groups.

There are several limitations of the present study to be acknowledged. The major limitation is the cross-sectional design of the study, eliminating the drawing of causal inferences among variables. Indeed, it is important to consider that some individuals may become lonelier because they feel depressed or lack energy. Moreover, the study is limited to older adults who are widowed or currently in a marital union. Thus, the exclusion of those who are never married/ divorced/ separated may affect the findings of the study in terms of the association of marital status with late-life depression. Importantly, in the study sample, only 5.4% of the older adults were found to be living alone. This may have led to underestimation of the association, lack of power or type II error and could also have impacted the current findings. Notwithstanding these limitations, the present study's findings provide empirical support to the body of literature that highlights the vulnerability of widowed older adults living alone.

The findings of the study highlight that being in a marital union and co-residential living arrangements are an essential part of mental well-being in later years of life. The study synthesized its finding with theoretical understandings of vulnerability. As in this study, older widowed women who were exposed to vulnerabilities like lower socioeconomic conditions, poor health status etc. were mainly at a higher risk of depression. Importantly, the information deriving from this study can be used to target outreach programs and service delivery for the older adults who are living alone or widowed and suffering from depression.