Living alone and depression in Chinese older adults

Transcription

1 Aging & Mental Health, November 2006; 10(6): ORIGINAL ARTICLE Living alone and depression in Chinese older adults K.-L. CHOU 1,A.H.Y.HO 1, & I. CHI 2 1 Sau Po Centre on Aging, The University of Hong Kong, Hong Kong, China and 2 School of Social Work, University of Southern California, USA (Received 10 May 2005; accepted 20 January 2006) Abstract Western literature has repeatedly indicated a strong relationship between living alone and depression among the aged population, however, studies among the Chinese population are scarce. In this paper, we examine whether the association between living alone and depression is independent of health status, social support and financial strain among Chinese older adults, and subsequently assess whether such association persists after adjusting these variables. Cross-sectional data drawn from the Hong Kong Population Census consisting of 2,003 Chinese elderly people aged 60 or over were analyzed. Chi-square tests and logistic regression analyses revealed that living alone results in higher levels of depressive symptoms for older women but not for older men. This relationship remained significant even when socio-demographic variables, health indicators, social support, and financial strains were adjusted; yet, the impact of living alone with depression disappeared when all variables were controlled. In summary, this paper is the first to report that living alone is an independent risk factor contributing to depression among Chinese older women, as well as identifying certain significant factors including social support and health indicators that can affect and explain the link between living alone and depression. Preventive measures and related issues were discussed. Introduction A longer life expectancy has resulted in a rapid increase in the old age population in Hong Kong. In 2001, the number of people aged 65 and above was 739,739 constituting 11.0% of the total population, and it was projected to reach approximately 2.1 million by 2031 to account (24.0% of the total population; Census and Statistics Department, 1997; 2002). Also in 2001, 11.3% of older persons aged 65 and above were identified as living alone. It has been well documented in the USA as well as the UK that the number of elderly living alone had increased substantially in the period between 1971 and 1991 (Glaser, 1997; Kramarow, 1995; Krivo & Mutchler, 1989) due to a number of reasons including the most notable factors of low infertility rate and high divorce rates ( Childless Couples, 1993; Wachter, 1997). Similar trends are expected to be observed in the near future among other highly industrialized, urbanized, and modernized societies like Hong Kong. Specifically, the total fertility rate had declined sharply from 1.93 in 1981 to 0.83 in 1999 (Yip & Lee, 2002; Yip, Lee, Chan, & Au, 2001); while the proportion of persons who were divorced or separated had doubled from 1.4% and 1.1% in 1991 to 3.3% and 2.1% in 2001 for women and men, respectively. This suggests that the percentage of older people living alone will increase considerably (Census and Statistics Department, 2002). Living arrangement affects the amount of social support that elderly people receive from their family members and there is a close linkage between family support and mental health (Blazer, Hughes, & George, 1992; Hays et al., 1998; Krause, 1987; Mitchell, Mathews, & Yesavage, 1993). Older people living alone have more depression (Dean, Kolody, Wood, & Matt, 1992; Chou & Chi, 2000), use mental health services more frequently, and have a higher risk of suicide than their counterparts (Florio et al., 1997; Mindel & Wright, 1982). Correspondence: Dr Kee-Lee Chou, Sau Po Centre on Ageing, The University of Hong Kong, Pokfulam Road, Hong Kong, China. Tel: þ (852) Fax: þ (852) klchou@hku.hk ISSN print/issn online/06/ ß 2006 Taylor & Francis DOI: /

2 584 K.-L. Chou et al. However, a recent study of 90 community dwelling Chinese older adults, found no differences in psychological well-being (CESD-10) between those living with their family and those living alone (Ng, Lee, & Chi, 2004). Given these discrepancies, the first objective of the current study was to examine the relationship between living alone and depression, using a large and representative sample of Chinese older adults. From a cultural perspective, it has been suggested that the relationship between living alone and psychological well-being may be more prevalent in certain ethnic groups especially among the Chinese population (Alexander, Rubinstein, Goodman, & Luborsky, 1992). One reason for such an assertion might be due to the fact that adult children are important sources of financial support to Chinese elderly people. As a matter of fact, slightly more than 60% of older adults major source of income derives from their adult children or children-in-law (Chou, Chi, & Chow, 2004). Moreover, under the umbrella of Chinese traditional values in which the concept of filial piety still dominates the family support system of modern Chinese communities, adult children are and will continue to be the main source of social support to their old aged parents; while support from adult children may even be perceived as more valuable than those from the elders spouses, especially for older women (Chi & Chou, 2001; Chou & Chi, 2003). Furthermore, within the scope of Chinese traditions, older people prefer and are expected to live with their children (Chi, 1998). Not surprisingly then, older adults who lived alone were more likely to report a higher level of depression than the others who did not (Chou & Chi, 2000). Living alone might have a stronger detrimental impact for Chinese elders than their Western counterparts due to the different cultural expectations in respect of the appropriate forms of social integration in later life. The impact of living arrangement on psychological well-being might be different for older women and men. It has been argued that living alone might have a greater negative impact on older men than women because in the case that the elderly person has no son, women prefer to live with their married daughters whereas men prefer to live alone or in an institution (Chi, 1998). On the other hand, it has been found that older men in general have a smaller social network than older women, thus it might be easier for older women than older men to attain social support from those who are not living with them (Chapman, 1989). Moreover, older men tend to be more spouse dependent for emotional intimacy than older women (Kendig, Coles, Pittelkow, & Wilson, 1988; Strain & Chappell, 1982). As a result, it is generally assumed that living alone has more negative consequences for older men but, no study has ever been conducted to test such assumption and to evaluate whether there are in fact gender differences in the effect of living alone on psychological well-being in the aged population (Dean et al., 1992; Glaser, 1997). Moreover, considerable evidence has supported the association between living arrangement and the amount of social support elderly people received. Moreover, there are also data which indicate that living arrangement is associated with financial situation in the elderly (Chou & Chi, 2000; Crimmins & Ingegneri, 1990; Hoyert, 1991; Soldo, Wolf, & Agree, 1990). However, it is important to note that the direction of association is reverse for Hong Kong Chinese elders and elderly in Western countries as Chou and Chi (2000) found that Chinese older adults who were living alone were more likely to be welfare recipients and expressed greater financial strain than those living with family members; conversely, a positive association between higher income and solitary living is consistently found in Western countries and investigators have argued that economic independence enabled older adults to live alone and thus achieving higher levels of privacy and independence (Michael, Fuchs, & Scott, 1980; Mutchler & Burr, 1991). Lastly, some studies have also demonstrated a relationship between living arrangement and health such as: self-rated health status (Chou & Chi, 2000), functional capacity (Angel, Angel, & Himes, 1992; Speare, Avery, & Lawton, 1991), and mortality (Welin et al., 1985; Grundy, 1992) among elderly people. Thus, it is important to understand whether any association between living alone and depression is independent of health status, social support, and financial strain. Based on these prior researches, the second objective of the current study was to assess whether the association between living alone and depression in Hong Kong Chinese older adults would persist after family social support, financial strain, and health indicators have been adjusted for. Method Respondents A sampling frame was randomly drawn by the Census and Statistics Department from the General Household Survey database local census lists (3000 households). Individuals who were aged 60 or above and living in the community were eligible to be interviewed. Of this sampling frame, 2502 elderly aged 60 or above were identified and were eligible to be interviewed. However, some 499 of them either refused to participate or could not be contacted after three attempts. Hence, 2003 elderly respondents were successfully interviewed, yielding an 80.0% response rate from 2502 eligible respondents. The same data set has been used to identify correlates of public health care utilization (Chou & Chi, 2004a),

3 Living alone and depression 585 as well as to assess the association between depression and childlessness, sensory impairment, advanced age as well as diabetes (Chou & Chi, 2004b; 2004c; 2005a; 2005b). A cross-sectional study method was adopted. Structured interviews were conducted with the 2003 respondents in 1996 via a face-to-face format at the respondents household. Ten college students were recruited, trained and closely supervised to conduct the interviews in order to ensure inter-rater reliability. Each interview took about 60 minutes to complete on average. Measures Living arrangement. Respondents were asked whether they were living alone or not. In the current study, 12.5% and 9.7% of male and female respondents, respectively, were living alone. These figures were representative of the Hong Kong general population as they were consistent with those from the population census (n ¼ 2180) conducted by Census and Statistics Department (2002), which found that 10.4% of older adults aged 60 or above (Male ¼ 12.2%; Female ¼ 8.7%) were living alone. Demographic and socio-economic variables. Sociodemographic variables included: age; gender (0 ¼ male, 1 ¼ female); marital status (currently married, single and never married, widowed, divorced or separated); and education (0 ¼ none; 1 ¼ some elementary school; 2 ¼ Elementary graduate or some high school; 3 ¼ high school graduated or above). Health indicators. Self-rated health was assessed by the question How would you rate your health at the present time? which was rated on a five-point scale (1 ¼ excellent, 2 ¼ good, 3 ¼ fair, 4 ¼ poor, 5 ¼ very poor). As the result of this variable was highly skewed to the higher end of the scale, we dichotomized it into a binary variable (0 ¼ excellent to fair; 1 ¼ poor or very poor). Elderly persons functional capability was assessed by basic activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The ADL capacity refers to individuals ability to accomplish six basic activities including feeding, transferring, dressing, bathing, going to toilet, and grooming independently. The IADLs include ability of using the telephone, going out, shopping, cooking, household chore, washing clothes, medication, and financial management. These items were rated on a dichotomous point scale ranging from 0 ¼ independent to 1 ¼ needs help. In both ADL and IADL measures, responses for the items were summed. Family support. Family care was measured in three areas: family instrumental care (four items), family personal care (two items), and family emotional care (three items). Family instrumental care was measured by asking respondents whether their family members had provided them with care in terms of cooking meals, shopping, doing household chore, and escorting. Family care in personal care was assessed by asking respondents whether their family members had provided them with care in terms of bathing and similar personal needs. Family emotional care was obtained by asking respondents whether their family members had provided them with care in terms of giving advice in personal problems, sharing feelings and opinion, and participated in respondents recreational activities. All items had dichotomous responses, and the score for each category of care was the sum of the responses of all relevant items. Financial strain. The measurement of financial strain was based on one item asking subjects whether or not they had sufficient money to pay their daily expenses on a five-point scale (1 ¼ very adequate to 5 ¼ very inadequate). This item was also dichotomized (0 ¼ very adequate to adequate; 1 ¼ inadequate or very inadequate). Depression. The 15-item Geriatric Depression Scale-Short Form (GDS) was used to measure depressive symptoms. Yesavage & Brink (1983) discuss in detail the properties of the scale and its appropriateness for use with communitydwelling adults. The participants were asked about 15 depressive symptoms that they might have experienced in the two weeks preceding the interview. The 15 items were scored on a dichotomous scale from 0 to 1 (0 ¼ no, 1 ¼ yes), and the scale was the unweighted sum of the 15 component items, with a potential range of 0 to 15. The Chinese version of the 15-item GDS had been validated in previous studies (Boey, 2000; Boey & Chiu, 1998; Lee, Chiu, & Kwong, 1994) and the Cronbach s alpha of this Chinese version of total GDS in the present sample was As the GDS scores were highly skewed to the lower end of the scale, a dummy variable, depression, was formed using the cut-off points of 8 (0 ¼ less than 8 of the GDS scores and 1 ¼ 8 or above of the GDS scores). It has been well-documented that the GDS score of 8 is an appropriate cut-off score for screening depressive symptoms among normal elderly people in a Chinese community (Boey, 2000; Boey & Chiu, 1998; Lee et al., 1994). Data analysis Characteristics of respondents by living arrangement are shown in Table I. First, bivariate analyses were performed to assess the differences between the living arrangement and other variables in male and female subjects, separately, by t- or Chi-Square tests wherever appropriate. Secondly, two logistic models

4 586 K.-L. Chou et al. Table I. Characteristics of respondents by living arrangement. Variable Living alone Not living alone Significant Test All subjects (n ¼ 2003) n 181 (9.0%) 1822 (91.0%) Depressed (1/0) 28.7% 19.6% 2 ¼ 8.3** Gender (Female) 50.3% 53.3% 2 ¼ 0.6 NS Age (years) 73.0 (SD ¼ 8.0) 70.4 (SD ¼ 7.0) t ¼ 4.5** Marital status 2 ¼ 258.2** Married 19.9% 70.9% Divorced 8.3% 0.9% Widowed 56.9% 26.1% Never married 14.9% 2.1% Education 2 ¼ 5.7 NS Never 34.8% 33.1% Some elementary 42.0% 39.8% Elementary 12.7% 19.3% High school or above 10.5% 7.8% Self-rated health (poor) 30.4% 23.3% 2 ¼ 4.7* ADL limitation 0.01 (SD ¼ 0.1) 0.07 (SD ¼ 0.5) t ¼ 1.6 NS IADL limitation 0.17 (SD ¼ 0.5) 0.34 (SD ¼ 1.1) t ¼ 2.1* Family instrumental care 0.15 (SD ¼ 0.5) 0.79 (SD ¼ 1.2) t ¼ 7.2** Family personal care 0.01 (SD ¼ 0.1) 0.03 (SD ¼ 0.2) t ¼ 1.7 NS Family emotional care 0.48 (SD ¼ 0.8) 1.21 (SD ¼ 1.1) t ¼ 8.9** Financial strain 32.6% 21.0% 2 ¼ 12.8** *p50.05; **p were used to examine the effect of living alone, age, marital status, and education on depression in older women and men. Moreover, to evaluate whether the impact of living alone on depression disappeared when the other three variables of self-rated health status, functional health, family support and financial strain were controlled, two additional sets of four logistic regression models were performed to depression (for both women and men) in which each of the three variables of family social support, financial strain and health indicators were entered to the original regression models independently; while the last model included all dependent and independent variables. Moderate correlations were observed between independent variables used in the logistic regression models; therefore, tolerance values of independent variables were obtained before performing all four regression models. All tolerance values between predictor variables were found to be at an acceptable level of 0.9 or higher, which were greater than the common cut-off threshold of 0.1 (Hair, Anderson, Tatham, & Black, 1995); as a result, the problem of multi-collinearity was resolved. Results Living alone Table I indicates the effect of living alone on all independent variables and dependent variables used in multi-variant analyses in older persons. Elderly singletons were more likely to report depressive symptoms, be older in age, not currently married, and express financial strain, but less likely to report functional limitation in IADL, receive family support in instrument help, and receive emotional care from the family. Chi-Square tests were performed to determine the association between living alone and depression among older men and older women. Unexpectedly, it was found that living alone was not significantly associated (or only marginally associated) with depression in older men. In other words, older men who were living alone and who were living with others were at the same level of risk for reporting depressive symptoms (25.6% versus 17.9%, 2 ¼ 3.18, p ¼ 0.074). We have investigated this finding further by conducting the remaining bivariate and multivariate analyses for male subjects, the results confirm that no significant association between living arrangement and depression existed for the older men. On the other hand, older women who were living alone were likely to report depressive symptoms than those who were living with others (31.9% versus 21.2%, 2 ¼ 5.48, p50.05). Therefore, details of the remaining bivariate and multivariate analyses were reported for female subjects only. As shown in Table II, older women who were living alone were more likely to be older in age, report poor self-rated health, and be under financial strain, but were less likely to be married or receive instrumental or emotional support from their family. To evaluate whether the impact of living alone on depression for elderly women disappeared when other variables such as gender, marital status, age, education level, self-rated health status, functional health, family support and financial strain were

5 Living alone and depression 587 Table II. Characteristics of respondents by living arrangement in older women. Variable Living alone Not living alone Significant test Female (n ¼ 1,062) n 91 (8.6%) 971 (91.4%) Depressed (1/0) 31.9% 21.2% 2 ¼ 5.5* Age (years) 75.4 (SD ¼ 7.7) 71.0 (SD ¼ 7.2) t ¼ 5.5** Marital status 2 ¼ 96.9** Married 4.4% 54.2% Divorced 4.4% 0.9% Widowed 81.3% 43.0% Never married 9.9% 1.9% Education 2 ¼ 2.8 NS Never 34.8% 33.1% Some elementary 33.3% 33.5% Elementary 5.5% 10.3% High school or above 5.5% 3.8% Self-rated health (poor) 33.0% 27.2% 2 ¼ 1.4 NS ADL limitation 0.02 (SD ¼ 0.1) 0.10 (SD ¼ 0.6) t ¼ 1.2 NS IADL limitation 0.20 (SD ¼ 0.6) 0.42 (SD ¼ 1.3) t ¼ 1.7 NS Family instrumental care 0.22 (SD ¼ 0.7) 0.71 (SD ¼ 1.1) t ¼ 4.0** Family personal care 0.00 (SD ¼ 0.0) 0.04 (SD ¼ 0.3) t ¼ 1.6 NS Family emotional care 0.58 (SD ¼ 0.9) 1.17 (SD ¼ 1.1) t ¼ 5.1** Financial strain 28.6% 18.5% 2 ¼ 5.4* *p50.05; **p Table III. Main effects of living alone on depression: Logistic regression results for older women aged 60 and older. Odds ratio (95% CI) Independent variable Model 1 Model 2 Model 3 Model 4 Model 5 Living alone 1.92* ( ) 1.80* ( ) 1.97* ( ) 1.80* ( ) 1.74 ( ) Age 0.99 ( ) 0.99 ( ) 0.99 ( ) 0.99 ( ) 0.99 ( ) Married (reference) Never married 1.11 ( ) 1.25 ( ) 1.09 ( ) 0.80 ( ) 0.90 ( ) Widowed 0.82 ( ) 0.80 ( ) 0.80 ( ) 0.77 ( ) 0.74 ( ) Divorced 1.49 ( ) 1.48 ( ) 1.54 ( ) 1.24 ( ) 1.23 ( ) Never educated (reference) Some elementary 0.64** ( ) 0.67* ( ) 0.66* ( ) 0.66* ( ) 0.72 ( ) Elementary 0.70 ( ) 0.71 ( ) 0.71 ( ) 0.79 ( ) 0.79 ( ) High school or above 0.27* ( ) 0.29* ( ) 0.28* ( ) 0.27* ( ) 0.33* ( ) Poor self-rated health 4.02** ( ) 3.61** ( ) ADL limitation 0.98 ( ) 0.98 ( ) IADL limitation 0.99 ( ) 1.44 ( ) Family instrumental care 1.13 ( ) 1.09 ( ) Family personal care 0.53 ( ) 0.52 ( ) Family emotional care 0.92 ( ) 0.93 ( ) Financial strain 4.30** ( ) 3.77** ( ) *p50.05; **p50.01; ***p controlled, five logistic regression models were performed to depression. All of the logistic models were found to be significant and the findings are presented in Table III. First, the effect of living alone on depression was statistically significant even when all socio-demographic variables including age, marital status, and education level were controlled for. Second, the association between living alone and depression remained significant even when the socio-demographic and health indicators including self-rated health, ADL and IADL limitation were adjusted. Similarly, living alone was persistently and significantly related to depression even though the socio-demographic variable and three family support variables (instrumental support, personal care, emotional care) and financial strain were adjusted. These findings suggest that the impact of living alone on depression in Chinese older women was quite robust. Lastly, we found that the impact of living alone on depression disappeared when all sociodemographic variables, health indicators, family support variables, and financial strain were all adjusted. However, it was found that education, self-rated health, and financial strain were

6 588 K.-L. Chou et al. significantly related to depression in older women. Specifically, older women with a lower level of education, poorer self-rated health status and a higher level of financial strain, were more likely to be depressed. Discussion A large amount of literature has indicated that social integration is greatly influential to, and may in fact determine, mental health outcomes in later life. Therefore a better understanding of the relationship between one form of social integration, namely living alone, and a specific mental health outcome, namely depression, amongst Chinese elderly is of particular importance considering the high prevalence of both conditions in not only the aged population of Hong Kong (Chou & Chi, 2000; Woo et al., 1994), but also older people from most developed countries. However, studies on this relationship between living alone and depression among the Chinese older adults are scarce (Chou & Chi, 2000). Findings of the current study are interesting because we have identified both similarities and differences between our results and those found in the USA and the local context (Dean et al., 1992; Chou & Chi, 2000; Mui, 1998; Ng et al., 2004; Wilmoth & Chen, 2003). Specifically, the key message derived from this study is that living alone is related to higher levels of depressive symptoms particularly for older women and it is not a more consistent risk factor contributing to depression in Chinese older adults than in older American (Dean et al., 1992; Wilmoth & Chen, 2003). Specifically, the impact of living alone on depression disappeared in Chinese older women after socio-demographic variables, health indicators, social support variables and financial strain were adjusted for. The current study is the first to report that the impact of living alone is only found in older women but not in older men. This result is exactly opposite to what has been found in Western countries (like the USA) where the impact of living alone is greater for older men than for older women (Dean et al., 1992). Furthermore, two previous western studies of elderly women have shown that living alone is not associated with higher levels of depressive symptoms (Holzer, Leaf, & Weissman, 1985; Magaziner, Cadigan, Hebel, & Parry, 1988). One possible explanation for such conflicting results may be due to the fact that some older men who are living alone are unexpectedly married. In the Hong Kong context, it is a rather common practice for older men to marry younger women across the border in Mainland China during their late 40s or 50s as they were unable to find suitable partners locally. Upon marriage, their wives, and possibility children, may remain to reside in China due to immigration restrictions. As a result, elderly men who were living alone in Hong Kong may actually have had wives and children residing in Mainland China and frequent cross-border visits may have taken place. Such remote yet intimate marital ties between Hong Kong older males and their Mainland families may have contributed to our findings in which living alone was not significantly associated with depression in men and 35.6% (n ¼ 32) of those men were married. Another possible explanation may be derived from the traditional values and preferences for Chinese older adults in terms of their living arrangement. With the enduring and dominating concept of filial piety, the Chinese younger generations are expected to provide absolute care to their elderly parents and hence it is still very common to see vast numbers of multi-generational households in contemporary Chinese societies (Lee, 2004). Against such a cultural backdrop, it is customary and preferred for Chinese elders to live with their children rather than to live by themselves. Therefore, Chinese older persons tend to live alone only if they have no other family members or if their family members are not willing to live with them. In the case of the latter, elders may feel a sense of neglect, resentment and insecurity with respect to their family. Moreover, gender divergence of parent-child bonding is still prevalence in traditional Chinese families as older men are much more connected with sons while women are equally attached to their sons and daughters (i.e., Lee, 2004; Logan & Bian, 2003). Therefore, Chinese older men often prefer to live mainly with their sons, and in the case that they did not have sons, they prefer to live alone rather than to live with their married daughters; whereas Chinese older women hold less of such preferences. In other words, older men live alone based on their own choice, while older women do not due to cultural traditions. Consequently, the impact of living alone on depression may be reduced for the older male population. Unfortunately, we did not have data relating to the number of sons and daughters the subjects had. Second, the relation of living alone to depression remained significant in older women even though socio-demographic variables and health indicators, family support, or financial strain were adjusted. However, the impact of living alone on depression disappeared when socio-demographic variables, health indicators, family support and financial strain were controlled for. In other words, it seems that living alone is not an independent risk factor contributing to depression as its effect on depression is mediated through health, social support from family, and financial strain. This is not in line with the findings of a previous study conducted by Dean and his colleagues (Dean et al., 1992) who found that living alone had a statistically reliable effect on depression that was independent of the effects of social support from friends, social interactions with

7 Living alone and depression 589 friends, recent illness events, other negative life events, disability, financial strain and gender. Due to the cross-sectional design nature of the current study, the causal or temporal order of these variables and living alone is not clear. Further longitudinal studies are needed to understand the possible causal and temporal relationship between living alone and financial strain or family social support, in particular, whether financial strain or weakening of family social support are negative consequences of living alone. Lastly, results indicate that self-rated health and financial strain were independent risk factors contributing to depression among older women. In the present study, the elderly people who rated their health status as poor and who expressed financial strain were more likely to report depressive symptoms. These health indicators were found to be a significant correlate of depression in earlier local studies (Woo et al., 1994; Chou & Chi, 2001; Chou & Chi, 2004b). On the other hand, ADL and IADL impairment were not significant correlates when entered in the multivariate logistic regression which might due to the fact that their impact on depression was mediated by self-rated health status. Our findings also reveal that financial strain is positively associated with depression among Hong Kong elderly people. Many older adults in Hong Kong belong to the most impoverished segment of society and financial difficulty is a major source of chronic worry. An increasing amount of research has dealt with modelling the effect of financial strain on depression, identifying sense of control as one factor that may offset the negative psychological consequences of such strain (Chi & Chou, 1999; Chou & Chi, 2001; Krause, 1987). Although the results of our study are conceptually appealing, some caveats should be borne in mind. First, we recognize that this research is based upon cross-sectional data and therefore any conclusion about prediction could only be understood in a statistical and not a causal sense. The preliminary results reported here nevertheless should encourage other investigators to examine how living alone plays a role in the development of depression because its effect is found to be stronger among older women in a Chinese society. Second, the present study did not distinguish between living arrangement due to free choice and childlessness due to situational causes, and quality of relationship between adult children and their elderly parents. Lastly, the present study relied on self-report measures of depression, physical disability and social functioning. However, evidence for the validity of the assessment of depression and physical disability on the basis of self-report has been demonstrated in previous studies (Beekman et al., 1997; Lautenbacher, Spernal, Schreiber, & Krieg, 1999; Myers, Holliday, Harvey, & Hutchinson, 1993; Wells et al., 1989). We have identified that living alone is an independent risk factor contributing to depression in Chinese older women. Unfortunately, this risk factor is not modifiable but it should be used to identify a high-risk group for primary prevention that decreases the occurrence of the depression. On the other hand, we have identified certain significant factors which can affect and explain the link between living alone and depression; especially social support and health indicators, which are changeable attributes and can be adopted for developing prevention strategies for individuals who are living alone. With such, improvement and maintenance of social functioning and IADL functioning must be put into place to reduce the onset of depression for this high-risk group of the aged population. Acknowledgements The authors wish to thank the research assistants for their assistance in the data collection and those who kindly volunteered to participate in the study. Support for this research was provided by the Research Grant Council (HKU 7220/03H). References Alexander, B. B., Rubinstein, R. L., Goodman, M., & Luborsky, M. (1992). A path not taken: A cultural analysis of regrets and childlessness in the lives of older women. Gerontologist, 32, Angel, R. J., Angel, J. L., & Himes, C. L. (1992). Minority group status, health transitions, and community living arrangements among the elderly. Research on Aging, 14, Beekman, A. T., Penninx, B. W., Deeg, D. J., Ormel, J., Braam, A. W., & Van Tilburg, W. (1997). Depression and physical health in later life: Results from the longitudinal aging study Amsterdam (LASA). Journal of Affective Disorder, 46, Blazer, D., Hughes, D. C., & George, L. K. (1992). Age and impaired subjective support: Predictors of depressive symptoms at one-year follow-up. Journal of Nervous and Mental Disease, 180, Boey, K. W. (2000). The use of GDS-15 among the older adults in Beijing. Clinical Gerontologist, 21, Boey, K. W., & Chiu, H. F. K. (1998). Assessing psychological well-being of the old-old: A comparative study of GDS-15 and GHQ-12. Clinical Gerontologist, 19, Census and Statistics Department (1997). Hong Kong Population Projections Hong Kong: Hong Kong Special Administration Region Government Printer. Census and Statistics Department (2002). Hong Kong Population Projections. Hong Kong: Hong Kong Special Administration Region Government Printer. Chapman, N. J. (1989). Gender, marital status, and childlessness of older persons and the availability of informal assistance. In M. D. Petersen & D. L. White (Eds.), Health care of the elderly: An information source book (pp ). Newbury Park, CA: Sage. Childless Couples (1993). American Demography, 15, Chi, I., & Chou, K. L. (2001). Social support and depression among Hong Kong Chinese older adults. International Journal of Aging & Human Development, 52,

8 590 K.-L. Chou et al. Chi, I. (1998). Living arrangement choice of the elderly in Hong Kong. In E. Lo (Ed.), Housing and the elderly in Hong Kong. Hong Kong: University of Hong Kong. Chou, K. L., & Chi, I. (2005a). Correlates of five intellectual abilities in Chinese older adults. Journal of Applied Gerontology, 24, Chou, K. L., & Chi, I. (2005b). Prevalence and correlates of depression in Chinese oldest-old. International Journal of Geriatric Psychiatry, 20, Chou, K. L., & Chi, I. (2004a). Childlessness and psychological well-being in Chinese older adults. International Journal of Geriatric Psychiatry, 19, Chou, K. L., & Chi, I. (2004b). Combined effect of vision and hearing impairment on depression in elderly Chinese. International Journal of Geriatric Psychiatry, 19, Chou, K. L., & Chi, I. (2004c). Factors associated with the use of publicly funded services by Hong Kong Chinese older adults. Social Science & Medicine, 58, Chou, K. L., & Chi, I. (2003). Reciprocal relationship between social support and depressive symptoms among Chinese elderly. Aging & Mental Health, 7, Chou, K. L., & Chi, I. (2001). Stressful events and depressive symptoms among old women and men: A longitudinal study. International Journal of Aging & Human Development, 51, Chou, K. L., & Chi, I. (2000). Comparison between elderly Chinese living alone and those living with others. Journal of Gerontological Social Work, 33, Chou, K. L., Chi, I., & Chow, N. W. S. (2004). Sources of income and depression in Hong Kong elderly Chinese: Mediating effect and moderating effect of social support and financial strain. Aging & Mental Health, 8, Chi, I., & Chou, K. L. (1999). Financial strain and depressive symptoms among Hong Kong Chinese elderly: A longitudinal study. Journal of Gerontological Social Work, 32, Crimmins, E. N., & Ingegneri, D. G. (1990). Interaction and living arrangements of older parents and their children. Research on Aging, 12, Dean, A., Kolody, B., Wood, P., & Matt, G. E. (1992). The influence of living alone on depression in elderly persons. Journal of Aging & Health, 4, Florio, E. R., Hendryxm, M. S., Jensen, J. E., Rockwood, T. H., Raschko, R., & Dyck, D. G. (1997). A comparison of suicidal and non-suicidal elders referred to a community mental health center program. Suicide & Life Threatening Behavior, 27, Glaser, K. (1997). The living arrangements of elderly people. Review on Clinical Gerontology, 7, Grundy, E. (1992). Socio-demographic variations in rates of movement into institutions among elderly people in England and Wales: An analysis of linked census and mortality data Population Studies, 46, Hair, J. F., Anderson, R. E., Tatham, R. L., & Black, W. C. (1995). Multivariate data analysis (4th ed.). New Jersey: Prentice-Hall International. Hays, J. C., Landerman, L. R., George, L. K., Flint, E. P., Koenig, H. G., Land, K. C., et al. (1998). Social correlates of the dimensions of depression in the elderly. Journal of Gerontology: Psychological Science, 53B, P31 P39. Holzer, C. E., Leaf, P. J., & Weissman, M. M. (1985). Living with depression. In M. R. Haug, A. Ford, & M. Sheafor (Eds.), The physical and mental health of aged women (pp ). New York: Springer. Hoyert, D. L. (1991). Financial and household exchanges between generations. Research on Aging, 13, Kendig, H. L., Coles, R., Pittelkow, Y., & Wilson, S. (1988). Confidants and family structure in old age. Journal of Gerontology, 43, S31 S40. Kramarow, E. A. (1995). The elderly who live alone in the United States: Historical perspectives on household change. Demography, 32, Krivo, L. J., & Mutchler, J. E. (1989). Elderly persons living alone: The effect of community context on living arrangements. Journal of Gerontology, 44, S54 S62. Krause, N. (1987). Chronic financial strain, social support, and depressive symptoms among older adults. Psychology & Aging, 2, Lautenbacher, S., Spernal, J., Schreiber, W., & Krieg, J. C. (1999). Relationship between clinical pain complaints and pain sensitivity in patients with depression and panic disorder. Psychosomatic Medicine, 61, Lee, H. C. B., Chiu, H. F. K., & Kwong, P. P. K. (1994). Cross-validation of the Geriatric Depression Scale short form in the Hong Kong elderly. Bulletin of Hong Kong Psychological Society, 32, Lee, W. K. (2004). Living arrangements and informal support for the elderly: Alteration to intergenerational relationships in Hong Kong. Journal of Intergenerational Relationship, 2, Logan, J. R., & Bian, F. (2003). Parents needs, family structure, and regular intergenerational financial exchange in Chinese cities. Sociological Forum, 18, Magaziner, J., Cadigan, D. A., Hebel, J. R., & Parry, R. E. (1988). Health and living arrangements among older women: Does living alone increase the risk of illness? Journal of Gerontology, 43, M127 M133. Michael, R., Fuchs, V., & Scott, S. (1980). Changes in the propensity to live alone. Demography, 19, Mindel, C. H., & Wright Jr, R. (1982). Differential living arrangements among the elderly and their subjective well-being. Activities, Adaptation, & Aging, 2, Mitchell, J., Mathews, H. F., & Yesavage, J. A. (1993). A multidimensional examination of depression among the elderly. Research on Aging, 15, Mui, A. C. (1998). Living alone and depression among older Chinese immigrants. Journal of Gerontological Social Work, 30, Mutchler, J. E., & Burr, J. A. (1991). A Longitudinal analysis of household and non-household living arrangements in later life. Demography, 28, Myers, A. M., Holliday, P. J., Harvey, K. A., & Hutchinson, K. S. (1993). Functional performance measures: Are they superior to self-assessments? Journal of Gerontology, 48, Ng, K. M., Lee, T. M. C., & Chi, I. (2004). Relationship between living arrangements and the psychological well-being of older people in Hong Kong. Australian Journal of Ageing, 23, Soldo, B. J., Wolf, D. A., & Agree, E. M. (1990). Family, households, and care arrangements of frail older women: A structural analysis. Journal of Gerontology, 45, S238 S249. Speare, A., Avery, R., & Lawton, L. (1991). Disability residential mobility and changes in living arrangements. Journal of Gerontology, 46, S133 S142. Strain, L. A., & Chappell, N. L. (1982). Confidants Do they make a difference in quality of life? Research on Aging, 4, Wachter, K. W. (1997). Kinship resources for the elderly. Philosophical Transactions: Biological Science, 352, Welin, L., Svardsudd, K., Ander-Peciva, S., Tibblin, G., Tibblin, B., Larsson, B., & Wilhelmsen, L. (1985). Prospective study of social influences on mortality. Lancet, 453, Wells, K. B., Stewart, A., Hays, R. D., Buram, M. A., Rogers, W., Daniels, M., Berry, S., Greenfield, S., & Ware, J. (1989). The functioning and well-being of depressed patients. Results from the Medical Outcomes Study. Journal of American Medical Association, 262,

9 Living alone and depression 591 Wilmoth, J. M., & Chen, P. C. (2003). Immigrant status, living arrangements, and depressive symptoms among middle-aged and older adults. Journal of Gerontology: Social Sciences, 58B, S305 S313. Woo, J., Ho, S. C., Lau, J., Yuen, Y. K., Chiu, H., Lee, H. C., et al. (1994). The prevalence of depressive symptoms and predisposing factors in an elderly Chinese population. Acta Psychiatric Scand, 89, Yesavage, J. A., & Brink, T. L. (1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, Yip, P. S. F., & Lee, J. (2002). The impact of the changing marital structure on fertility of Hong Kong SAR (Special Administration Region). Social Sciences & Medicine, 55, Yip, P. S. F., Lee, J., Chan, B., & Au, J. (2001). A study of demographic changes under sustained below-replacement fertility in Hong Kong SAR. Social Sciences & Medicine, 53,