The effect of widowhood on depression of caregivers

Large number of studies have demonstrated that widowhood increased depression of older adults [10‐14]. In China, it found that scores on the geriatric depression scale (GDS) were higher in the widowhood group, and the detection rate of depression in the widowed group was 29.8%, about 2.2 times higher than that in the elderly with spouse [15]. Widowhood significantly increased depression of older adults [11]. By using the PSM-DID method, it further found that widowhood significantly increased depression among the elderly who were females, lived in rural areas, and with low education attainment [16]. Sun and Zhang et al. found that lower mental health scores for widowed older adults than those with a spouse by using subjective well-being as a proxy for mental health [17]. In conclusion, widowhood, as a common event in later life, leads to a high risk of depression, poor physical health and high risk of death [18].

Economic status and social network were possible channels in the association between widowhood and caregivers’ depression. Loss of social support, and poor economic resources after widowhood had a negative effect on physical and mental health in later life [7, 9, 16]. It has been found that both individual and family social capital after widowhood were lower than those with a spouse, and the mental health became better when increasing social capital [19]. There is a correlation between personal social capital and loneliness among widowed elderly, and the rural widowed elderly had higher loneliness than urban because of lower social capital [20]. At the same time, higher pension benefits could weaken the adverse effects of widowhood [21]. In addition, some studies found that family networks mediated the relationship between widowhood and depression from the perspective of family network and social network, while social networks masked the relationship [11]. And the mental health could be improved by more daughters and neighborhood’s interactions, and frequent relative interactions [17].

Similarly, caregiving also increased depression of caregivers [2, 22, 23]. Providing in-home care for the disabled increased the center for epidemiological studies depression scale (CES-D) scores by 10% [2], and the probability of depression among rural caregivers was 49.4%, which was higher than the 41.7% in urban areas [24]. There was a poorer mental health for those who provided caregiving compared to those who did not [25]. Several studies focusing on older caregivers have found that older caregivers are more depressed than the older adults without caregiving [26], which was associated with changes in social relationships in response to role transitions [27].

Stress process model explained why providing caregiving impaired caregivers’ health [2, 22, 25, 28]. Family caregiving was persistent, uncontrollable, unpredictable, and created physical and psychological stress [29]. It found that participating in basic pension insurance reduced caregivers’ CES-D scores, and pension insurance smoothed out the negative effects of caregiving on mental health [2]. And further studies showed that providing support to caregivers, living with children, participating in social activities and personal economic resources weakened the negative effect of caregiving [25]. Additionally, social support and self-efficacy significantly reduced depression of caregivers [30]. Based on above studies, in Chinese context, caregivers’ depression may be relieved after widowhood due to the disappearance of caregiving burden, but the depression may also be exacerbated by the disappearance of marital resources. Therefore, dose widowhood reduce the burden of caregivers or increase the depression of caregivers? The channel was shown in Fig. 1. The association is few explored in China and needs to be supported by further empirical evidence.

Four hundred sixty-six caregivers who have experienced widowhood from China Health and Retirement Longitudinal Study (CHARLS) in 2018 cross-sectional data were selected for this study, which was a large micro-survey data of people aged 45 and above hosted by Peking University in China. The reason why we selected 2018 cross-sectional data was representative and timeliness, which was a nationwide survey and latest available data. 466 caregivers were identified by following steps: CHARLS team randomly selected a family member aged over 45 years from each household as the main interviewee. So, first, 2015 CHARLS data was used to identify households with one disabled person who received spouse care. Second, the data was matched with 2018 CHARLS data. Thirdly, we identified whether the disabled person died in the matched data, indicating whether the caregiver suffered from widowhood. Finally, 466 caregivers were retained after excluding outliers and missing values.

The CHARLS was approved by the Ethics Committee of Peking University Health Science Center. Written informed consent was obtained from each participant.

83.3% of the individuals were not widowed and 16.7% were widowed. Firstly, in terms of CES-D scores, the mean scores of the widowed group were higher than that non-widowed group. Secondly, compared to the non-widowed group, the widowed group was older, female, and had lower level of education. There were almost no differences between the widowed and non-widowed groups in terms of living area, number of chronic diseases, region and ethnic group, and a high proportion of rural households, northern and Han ethnic group, and about 2 or 3 chronic disease co-morbidities. The mean of personal assets was lower for the widowed group than for the non-widowed group, and the probability of living with children and participating in social activities were higher than for the non-widowed group.

Comparing the depression scores of caregivers in 2015 and 2018, it was clear that there were more high depression scores in 2018 than in 2015 from the Figs. 2 and 3.

Table 2 showed the effect of widowhood on depression of caregivers in model 1 and 2. It found that the CES-D scores of caregivers increased significantly after widowhood, which was consistent with existing research. For example, some studies found that the negative effect of widowhood on the mental health of caregivers did exist after excluding differences in the sample [8].

In addition, control variables were associated with depression. Compared to the males, female caregivers had a higher CES-D scores after widowhood, which was consistent with the existing research findings [16, 25]. Caregivers in the south were more likely to be depressed after widowhood. Higher education attainment was beneficial to decrease the CES-D scores among older adults, which was consistent with the existing research finding [11]. More chronic diseases also were associated with higher CES-D scores, which was consistent with existing studies [36].

The effect of widowhood on depression of caregivers might be influenced by individual characteristics and social and economic factors, thus showing differences among different subgroup. Age was selected for heterogeneity analysis due to different physical depreciation and opportunity cost of time for caregivers in different age group. First, China’s Law on the Protection of the Rights and Interests of the Elderly stipulates that the starting age standard for the elderly is 60 years old, and the elderly are usually regarded as a group with higher depreciation and lower health levels, with greater physical depletion caused by providing care. Second, the legal retirement age for male workers in China is 60 years old, and the legal retirement age for female workers is before 60 years old. The difference between retirement and employment is reflected in the lower economic income level and lower opportunity cost of time. There was a question that whether men or women suffered more from depression after becoming widowed, and other studies have shown no gender differences in the mental health consequences of widowhood [5, 6].

The gender was selected for heterogeneity analysis due to the different family roles in gender in China, such as earning money for men and family care for women. The living area was also selected for heterogeneity analysis because the long-term urban–rural structure in China leads to large differences in the economic development, medical services, and social support, which has a different effect on mental health due to different stress exposure environment. And education attainment was associated with economic status, which played an important role in mental health. So, the education was selected also. Table 5 showed that compared to the non-widowed group, widowhood significantly increased depression among the female, the middle-aged adults, rural, and higher-level education groups. From models 3 to 4, the CES-D scores of the middle-aged adults increased significantly after widowhood. The CES-D scores of women were higher than men in models 5 ~ 6 after widowhood. The results from models 7 ~ 8 and model 9 ~ 10 suggested that the CES-D scores among the rural and the higher education level group were higher than those living in urban or with low education level.

The channels between widowhood and depression were explored through personal assets, living with children, and social activities. Table 6 showed that widowhood decreased caregivers’ personal assets, and widowhood reduced the economic resources available of individuals. However, widowhood increased the probability of living with children and the probability of participating in social activities.

Widowhood significantly increased the depression of caregivers based on the above estimation. Widowhood might lead to lower economic income from marital resource theory. The survivor pension system was implemented in developed countries to buffer negative effect of the late-life widowhood, while China did not has the system. Widowhood led to poverty of older adults [21], and income could be considered as a resource advantage, which had a significant positive effect on the mental health of older adults [37]. Second, widowhood leads to a stress exposure environment and a high incidence of social isolation from the stress process theory. Social isolation was manifested by narrowing social networks and increased loneliness [38], social networks, including family and friend networks, became smaller after widowhood [11, 39].

There were significant group differences of caregivers. Women were more likely to be depressed after widowhood because of the different psychological health status of different genders. Some studies have shown that the incidence of depression in older women in China is higher than in men, with women having a higher propensity to depression [15]. Women suffered more economic loss after widowhood based on marital resources theory [40]. The rural group was more likely to be depressed after widowhood, which was supported by existing studies. Some studies have shown that the mental health of older people in urban areas in China was usually better than that of older people in rural areas [41]. Community environment influenced the individual stress, and the difference of living in urban and rural community environments directly or indirectly affected the psychological health of older adults based on stress process theory. In China, social support, such as social security, health care, and mental recreation for older adults, was relatively weak in most rural areas [42]. The higher education level group was more likely to be depressed after widowhood, which might be explained by the fact that the relationship between education level and depression was not linear, showing a “U” shape distribution [43]. The group with higher education level had higher depression scores before widowhood, which may be explained by the more emotional needs of higher-education group.

Widowhood has a negative effect on family economic resources. In Chinese older adults, their income in later life was mainly from medical insurance² and pension.³If widowhood happened, family economic resources decreased and the total income from pension decreased. Living with children not only alleviated the financial stress but also compensated for the lack of spiritual companionship, which had a positive effect on older adults’ health [44]. Additionally, the behavior of participating in social activities increased after widowhood. Shrinking family networks and the absence of spiritual companionship caused by widowhood could be made up with participating in social activities.