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Journal of Epidemiology logoLink to Journal of Epidemiology
. 2018 Jul 5;28(7):315–322. doi: 10.2188/jea.JE20170065

Living Alone or With Others and Depressive Symptoms, and Effect Modification by Residential Social Cohesion Among Older Adults in Japan: The JAGES Longitudinal Study

Kaori Honjo 1,2, Yukako Tani 3,4, Masashige Saito 5, Yuri Sasaki 6, Katsunori Kondo 6,7, Ichiro Kawachi 8, Naoki Kondo 9
PMCID: PMC6004365  PMID: 29398683

Abstract

Background

There is little longitudinal evidence on the impact of specific living arrangements (ie, who individuals live with) on mental health among older adults, and no studies have examined the modifying effect of residential social cohesion level on this association. We aimed to examine the association between living arrangements and depressive symptoms and whether this association varies with residential neighborhood social cohesion level among 19,656 men and 22,513 women aged 65 years and older in Japan.

Methods

We analyzed the association between baseline living arrangements in 2010 and depressive symptoms in 2013. We calculated gender-specific odds ratios (ORs) of living arrangements for depressive symptoms using a logistic regression and conducted subgroup analyses by neighborhood social cohesion level.

Results

Among men (but not women), living alone (OR 1.43; 95% confidence intervals [CI], 1.18–1.73) and living with spouse and parent (OR 1.47, 95% CI, 1.09–1.98) were associated with increased odds of depressive symptoms compared with living with a spouse only. Living with spouse and child was a risk for men in the young age group but a protective factor for women. We also identified that the negative impact of living arrangements on depressive symptoms was attenuated in neighborhoods with higher levels of social cohesion.

Conclusions

Living arrangements are associated with risk of depressive symptoms among men and women; these associations differ by gender and neighborhood social cohesion level. Our results suggest the need to pay more attention to whether individuals live alone, as well as who individuals live with, to prevent depressive symptoms among older adults.

Key words: living arrangement, depressive symptoms, Japan, aged, social cohesion

INTRODUCTION

Major depressive disorder is a primary cause of disability, as measured by years lived with disabilities.1 Depression in later life decreases individuals’ quality of life in terms of both psychological and physical health2 and increases the risk of premature death.3 In Japan, the number of older people with mood disorder and depression has substantially increased in recent years.4 Moreover, the population is rapidly aging, and it has been predicted that one in three Japanese people will be aged ≥65 years by 2030.5 Therefore, there needs to be a greater focus on mental health among older adults to reduce the individual and social burden of these diseases.

Previous studies have reported an association between living arrangement and mental health6–12 and agree that older adults living alone are at higher risk of experiencing deteriorations in mental health. Most studies conducted in Western countries on living arrangements among older adults have focused on whether individuals live alone or not. Studies in Asian countries (including Japan) have also examined detailed living arrangement (ie, who individuals live with) and depressive symptoms.6,8 However, to the best of our knowledge, there are few longitudinal studies on the association between variation in living arrangements and risk of developing depressive symptoms among older adults, and no such studies in Asia.

Living with someone has both advantages and disadvantages. Receiving various types of social support through cohabitants may positively impact their mental health,6,13 while relational conflicts and extra duties and responsibilities for cohabitants may negatively affect their mental health.14 In addition, impact of living arrangements could differ by gender, particularly in societies characterized by strong gender role norms (ie, the male bread-winner model).15 In such societies, women are generally more likely to adopt the role of providing a various types of social support for family members at home compared to men.16 Thus, we hypothesized that types of living arrangement affect people’s mental health differently, and the impact could differ by gender.

Social capital, defined as the resources that individuals access through their social networks, has been identified as a crucial social determinant of health.17 These social resources comprise trust between people in a network, the exchange of information, instrumental support, emotional support, and social reinforcement. Several studies have examined the effect of social capital on mental health among older adults,14,18–20 but few have investigated the interactive effect of social capital and other social factors. One study examined the interactive effect of marital status on the association between neighborhood disorder and depression among older adults and demonstrated that social relationships with marital partners buffer the association between social disorder and depression.18 In other words, residential social characteristics may affect the association between individual living conditions and mental health. Thus, we hypothesized that one aspect of social capital, social cohesion, could affect the association between living arrangements and depressive symptoms. For example, a high level of community social cohesion may mitigate loneliness, increase social support, or reduce the likelihood of social exclusion among individuals living alone or living without a spouse, which in turn may reduce the negative impact of living arrangements on mental health.

The objectives of this study were to investigate the associations of living arrangements (living alone; with spouse only; with spouse and parent(s); with spouse and child; with spouse, parent(s), and child; with parent(s) and/or child without spouse; or other arrangements) with depressive symptoms over a 3-year follow-up period among older Japanese adults. We aimed to answer the following specific research questions:

  • 1)

    Does the risk of developing depressive symptoms differ according to living arrangements among Japanese men and women aged 65 years and older?

  • 2)

    Is the association between depressive symptoms and living arrangements modified by gender?

  • 3)

    Is the association between depressive symptoms and living arrangements modified by the level of neighborhood social cohesion?

MATERIALS AND METHODS

Study population

This study used longitudinal data from the Japan Gerontological Evaluation Study (JAGES) conducted in 2010 and 2013. Details of the study procedure have been described elsewhere.22 Briefly, the baseline sample in 2010 comprised 92,272 participants (response rate: 65%). Among them, 77,714 participants were targeted in the follow-up survey after the exclusion of participants who had died, received benefits from public long-term care insurance, or moved to another municipality during the follow-up period. Approximately 80% of the participants (n = 62,438) completed the follow-up self-report questionnaire in 2013.

Of these 62,438 men and women, we excluded the following: those who reported limitations in activities of daily living (defined as inability to walk, bathe, or use the toilet without assistance in 2010 or missing information on activities of daily living; n = 2,007), those with depressive symptoms (defined as a score of ≥5 on the Geriatric Depression Scale [GDS] at baseline; n = 15,125), those with missing information about depressed mood in 2010 and/or 2013 (n = 1,871), and those with missing information about living arrangements in 2010 (n = 1,149). We included the remaining 19,656 men and 22,513 women as our final study population.

The JAGES protocol was approved by the Ethics Committee on Research of Human Subjects at Nihon Fukushi University (No. 10-05). Use of the data for this study was approved by the Ethics Committee of the University of Tokyo, Faculty of Medicine (No. 10555).

Primary predictor: living arrangements

Living arrangements were assessed using a self-reported baseline questionnaire. Participants responded to the question “Who do you live with” by choosing all the applicable options from the following: (a) living alone, (b) spouse, (c) child, (d) child-in-law, (e) grandchild, (f) parent(s), (g) parent(s)-in-law, (h) siblings, and (i) others. Based on the responses, we created seven types of living arrangement: (1) living with spouse only; (2) living alone; (3) living with spouse and parent(s); (4) living with spouse and child; (5) living with spouse, child, and parent(s); (6) living with parent(s) and/or child but not spouse; and (7) other living arrangements.

Outcome: depressive symptoms

Participants were followed up to 2013. The endpoint of this study was depressive symptoms assessed with the Japanese short version of the GDS (the GDS-15)23 using a simple yes/no format suitable for self-administration.21 The GDS is a well-known instrument to measure depression among older adults and has been extensively validated and used for healthy older adults in community setting; the GDS score was found to have a sensitivity 88–92% and specificity of 62–81% compared with a structured clinical interview for depression.23 Following previous research,22–25 those with a score of ≥5 on the GDS in 2013 were considered to have newly developed depressive symptoms during the follow-up period.

Modifying factor: neighborhood social cohesion level

For the subgroup analysis, we created a neighborhood social cohesion variable using a validated neighborhood social cohesion scale derived from Saito et al.26 Briefly, school district was defined as level of neighborhood and a measure of neighborhood social capital was generated by using factor analysis. The analysis produced three social capital components, one of which was social cohesion. Social cohesion was measured by summing up the scores on three questions about community trust, reciprocity, and community attachment for each school district, following our previous studies.26 The total number of school districts was 525 in this study. For the subgroup analysis, we created two social cohesion groups using the median: high and low. We did not calculate a social cohesion score for school districts with a small number of households (less than 25; n = 368) but treated these as missing data for this variable.

Covariates

Age (years), GDS score at baseline, age group (60–74 years, 75 years and older), years of educational attainment (9 years or less, 10–12 years, 13 years or more), equivalent household income groups (0–1.99 million yen, 2–3.99 million yen, and 4 million yen and more per year), employment status (working, retired, or never worked), receiving treatment for any disease (yes/no), poor self-rated health (yes/no), time spent walking per day, and residential area (municipality; n = 24) at baseline were treated as confounding factors.

Social support exchange was hypothesized to be a mediating factor. Social support was assessed using the following questions: “Is there someone who listens to your concerns and complaints?” (Emotional support receipt), “Is there someone whose concerns and complaints you listen to?” (Emotional support provision), “Is there someone who helps and takes care of you when you are sick in bed?” (Instrumental support receipt), and “Is there someone who you help and take care of when s/he is sick in bed?” (Instrumental support provision). Responses to each question were classified as “Yes” or “No.”

Statistical analysis

Proportions and mean values of GDS score, age, sociodemographic factors, and other covariates were calculated by gender as well as by living arrangements. We estimated gender-specific multivariable odds ratios (ORs) and 95% confidence intervals (CIs) for depressive symptoms according to living arrangements using men and women who lived with a spouse only as the reference group. We tested statistical interaction using cross-product terms for living arrangement and gender. Subgroup analysis by age (60–74 years group or 75 years and older group) was also performed. To examine if the identified associations were modified by the level of neighborhood social cohesion, we conducted subgroup analysis by neighborhood social cohesion level among those aged 65–74 years. We further included social support variables in the model in order to examine if social support could explain the impact of neighborhood social cohesion on the associations. Analyses were performed using SAS, version 9.4 (SAS Institute, Inc., Cary, NC, USA).

RESULTS

During the mean follow-up period of 2.6 years, 2,577 men (13.0%) and 2,897 women (12.5%) developed depressive symptoms (Table 1). The proportions of women living alone and living with child and/or parent without spouse were higher than those of men. The proportion of men living with spouse and child was higher than that of women. The distributions of depressive symptoms differed by living arrangements. Moreover, the distribution of educational attainment level, household equivalent income level, working status, receiving treatment for any disease, poor self-rated health, time spent walking per day, social support exchange, mean age, and mean GDS score at baseline differed according to living arrangements among both men and women.

Table 1. Characteristics of subjects in the longitudinal samples of older Japanese men (n = 19,656) and women (n = 22,513) according to living arrangement.

  MEN
(n = 19,656)		 Living arrangement P-value for difference
of living arrangement
With spouse only
(n = 9,468, 48%)		 Living alone
(n = 983, 5%)		 With spouse and parent(s)
(n = 447, 2%)		 With spouse
and child
(n = 6383, 32%)		 With spouse, child and parent(s)
(n = 403, 2%)		 Child only, parent(s) only,
or child and parent(s) only
(n = 1,736, 9%)		 Others
(n = 218, 1%)
n % n % n % n % n % n % n % n %
MEN                                  
Depressive symptoms (GDS score ≥5) (2013)                                 <.0001
Yes 2,490 13 1,144 12 174 18 60 13 797 12 31 8 253 15 31 14  
Younger age group                                 <.0001
65–74 years old 13,090 67 6,341 67 566 58 412 92 4,330 68 373 93 933 54 135 62  
Years of education attainment                                 <.0001
13 years and more 5,121 26 2,764 29 250 25 165 37 1,507 24 121 30 284 16 30 14  
10–12 years 6,849 35 3,469 37 310 32 168 38 2,220 35 147 36 480 28 55 25  
9 years and less 7,447 38 3,140 33 402 41 109 24 2,597 35 129 32 945 54 125 57  
missing 239 1 113 1 21 2 5 1 59 1 6 2 27 2 8 4  
Household equivalent income                                 <.0001
4 million yen and higher 2,510 13 866 9 101 10 56 13 1,155 18 84 21 233 13 15 7  
2–3.99 million yen 8,303 42 4,004 42 414 42 235 53 2,847 45 169 42 577 33 57 26  
1.99 million yen and lower 7,221 37 4,099 43 302 31 136 30 1,795 28 124 31 658 38 107 49  
missing 1,622 8 517 6 166 17 20 4 586 9 26 6 268 15 39 18  
Working status                                 <.0001
Working 6,070 31 2,738 29 238 24 178 40 2,172 34 186 46 504 29 54 25  
Retired 11,872 60 6,016 63 599 61 246 55 3,694 58 195 48 982 57 138 63  
Never work 592 3 283 3 58 6 6 1 152 2 5 1 79 5 9 4  
missing 1,122 6 449 5 88 6 17 4 365 6 17 4 169 9 17 8  
Disease treatment           9                     <.0001
No 5,301 27 2,452 26 284 29 157 35 11,756 28 121 30 467 27 64 29  
Yes 13,050 66 6,389 67 615 63 273 61 4,236 66 265 66 1,140 66 132 61  
Missing 1,305 7 645 7 84 9 17 4 391 6 17 4 129 7 22 10  
Poor self-rated health                                 0.05
No 17,535 89 8,442 89 890 90 420 94 5,689 89 362 90 1,536 88 196 90  
Yes 1,992 10 990 10 87 9 27 6 642 10 38 9 186 11 22 10  
Missing 129 1 54 1 6 1 0 0 52 1 3 1 14 1 0 0  
Walking time period per day                                 <.0001
29 min and less 4,642 24 2,195 23 251 26 85 19 1,473 23 96 24 471 27 71 33  
30–59 min 6,806 35 3,469 37 328 33 152 34 2,119 33 113 28 550 32 75 34  
60–89 min 3,597 18 1,747 18 189 19 87 19 1,174 18 84 21 286 17 30 14  
90 min and more 3,790 19 1,670 18 167 17 107 24 1,383 22 92 23 335 19 36 17  
missing 821 4 405 4 48 5 16 4 234 4 18 4 94 5 6 3  
Emotional social support receipt                                 <.0001
No 1,045 5 410 4 183 19 13 3 255 4 9 2 145 8 30 14  
Yes 17,645 90 8,627 91 727 74 417 93 5,852 92 377 94 1,466 85 179 82  
Missing 966 5 449 5 73 7 17 4 276 4 17 4 125 7 9 4  
Emotional social support provision                                 <.0001
No 975 5 359 4 171 17 13 3 242 4 11 3 150 9 29 13  
Yes 17,735 90 8,686 92 748 76 417 93 5,873 92 376 93 1,461 84 174 80  
Missing 946 5 441 5 64 7 17 4 268 4 16 4 125 7 15 7  
Instrumental social support receipt                                 <.0001
No 488 2 85 1 280 28 2 1 39 1 2 1 65 4 15 7  
Yes 18,379 94 9,045 95 643 65 430 96 6,115 96 386 96 1,568 90 192 88  
Missing 789 4 356 4 60 7 15 3 229 4 15 4 103 6 11 5  
Instrumental social support provision                                 <.0001
No 1,372 7 346 4 422 43 15 3 272 4 7 2 264 15 46 21  
Yes 17,271 88 8,710 92 482 49 412 92 5,811 91 378 94 1,319 76 159 73  
Missing 1,013 5 430 5 79 8 20 5 300 5 18 5 153 9 13 6  
  Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD  
Age 72.6 5.5 72.6 5.2 73.8 6.1 69.0 3.6 72.4 5.5 68.7 3.6 74.5 6.3 73.6 5.8 <.0001
GDS score in 2010 1.6 1.3 1.6 1.3 1.8 1.4 1.5 1.3 1.6 1.3 1.5 1.3 1.7 1.3 1.9 1.4 0.0002
 
  WOMEN
(n = 22,513)		 Living arrangement P-value for
difference
of living
arrangement
With spouse only
(n = 7,805, 35%)		 Living alone
(n = 3,355, 15%)		 With spouse
and parent(s)
(n = 227, 1%)		 With spouse
and child
(n = 5232, 23%)		 With spouse,
child and
parent(s)
(n = 177, 1%)		 Child only,
parent(s) only,
or child and
parent(s) only
(n = 5294, 24%)		 Others
(n = 423, 2%)
n % n % n % n % n % n % n % n %
WOMEN                                  
Depressive symptoms (GDS score ≥5) (2013)                                 <.0001
Yes 2,767 12 915 12 471 14 21 9 548 11 19 11 726 14 67 16  
Younger age group                                 <.0001
65–74 years old 14,833 66 5,963 77 1,788 53 216 95 3,915 75 163 92 2,544 48 224 53  
Years of education attainment                                 <.0001
13 years and more 3,236 14 1,346 17 556 17 51 23 661 13 27 15 521 10 74 17  
10–12 years 8,505 38 3,289 42 1,288 38 111 49 1,934 37 75 42 1,652 31 156 37  
9 years and less 10,340 46 3,060 39 1,418 42 61 27 2,566 49 75 42 2,983 57 177 42  
missing 432 2 110 1 93 3 4 2 71 1 0 0 138 3 16 4  
Household equivalent income                                 <.0001
4 million yen and higher 2,366 11 582 8 146 4 21 9 852 16 31 18 716 14 18 4  
2–3.99 million yen 7,607 34 3,046 39 869 26 124 55 1,935 37 61 34 1,480 28 92 22  
1.99 million yen and lower 8,475 38 3,451 44 1,515 45 64 28 1,442 28 56 32 1,735 33 212 50  
missing 4,065 18 726 9 825 25 18 8 1,003 19 29 16 1,363 26 101 24  
Working status                                 <.0001
Working 3,888 17 1,286 16 558 17 54 24 1,057 20 56 32 816 15 61 14  
Retired 11,550 51 4,307 55 1,753 52 120 53 2,633 50 76 43 2,420 46 241 57  
Never work 3,735 17 1,287 16 525 16 34 15 855 16 24 14 964 18 46 11  
missing 3,340 15 925 12 519 15 19 8 687 13 21 12 1,094 21 75 18  
Disease treatment                                 <.0001
No 5,533 25 2,147 28 755 23 63 28 1,372 26 49 28 1,034 20 113 27  
Yes 15,168 67 5,076 65 2,278 68 153 67 3,515 67 120 68 3,772 71 257 61  
Missing 1,812 8 582 7 322 10 11 5 348 7 8 5 488 9 53 13  
Poor self-rated health                                 0.27
No 20,259 90 7,014 90 3,065 91 203 89 4,716 90 159 90 1,726 89 376 89  
Yes 1,997 9 706 9 251 8 22 10 461 9 16 9 502 10 39 9  
Missing 257 1 85 1 39 1 2 1 55 1 2 1 66 1 8 2  
Walking time period per day                                 <.0001
29 min and less 6,027 27 1,921 25 917 27 47 21 1,350 26 44 25 1,630 31 118 28  
30–59 min 7,886 35 2,894 37 1,255 37 87 38 1,724 33 46 26 1,750 33 130 31  
60–89 min 3,534 16 1,287 16 535 16 33 15 801 15 27 15 788 15 63 15  
90 min and more 3,754 17 1,285 16 454 13 46 20 1,055 20 53 30 786 15 75 18  
missing 1,312 6 418 5 194 6 14 6 302 6 7 4 340 6 37 9  
Emotional social support receipt                                 <.0001
No 429 2 96 1 148 4 1 1 48 1 0 0 120 2 16 4  
Yes 21,061 94 7,400 95 3,038 91 213 94 4,987 95 173 98 4,882 92 368 87  
Missing 1,023 5 309 4 169 5 13 6 197 4 4 2 292 6 39 9  
Emotional social support provision                                 <.0001
No 692 3 165 2 157 5 2 1 81 2 2 1 264 5 21 5  
Yes 20,619 92 7,281 93 3,023 90 211 93 4,906 94 171 97 4,669 88 358 85  
Missing 1,202 5 359 5 175 5 14 6 245 5 4 2 361 7 44 10  
Instrumental social support receipt                                 <.0001
No 658 3 112 1 400 12 1 1 39 1 1 1 80 2 25 6  
Yes 20,866 93 7,401 95 2,762 82 213 94 4,981 95 172 97 4,982 94 355 84  
Missing 989 4 292 4 193 6 13 6 212 4 4 2 232 4 43 10  
Instrumental social support provision                                 <.0001
No 1,828 8 177 2 762 23 0 0 120 2 2 1 721 14 46 11  
Yes 19,135 85 7,285 93 2,267 68 214 94 4,857 93 168 95 4,024 76 320 76  
Missing 1,550 7 343 4 326 10 13 6 255 5 7 4 549 10 57 13  
  Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD  
Age 72.7 5.5 71.3 4.5 74.4 5.6 68.5 3.0 71.5 4.8 68.6 3.5 75.3 6.2 74.4 5.9 <.0001
GDS score in 2010 1.7 1.3 1.7 1.3 1.8 1.3 1.7 1.3 1.7 1.3 1.6 1.4 1.8 1.3 1.9 1.3 <.0001
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Table 2 shows the gender-specific multivariable ORs of depressive symptoms according to living arrangements with living with spouse only as a reference. Among men, living alone (OR 1.43; 95% CI, 1.18–1.73) and living with spouse and parent(s) (OR 1.47; 95% CI, 1.09–1.98) were associated with increased odds of developing depressive symptoms; however, no such associations were identified among women (the P-values for the gender interaction were 0.07 and 0.09, respectively). Living with spouse and child had a protective effect for women (OR 0.84; 95% CI, 0.74–0.95) but not for men (OR 1.08; 95% CI, 0.97–1.20) (the P-value for the gender interaction was 0.18). Compared with women living with spouse and child, women living alone showed increased odds of having depressive symptoms (OR 1.19; 95% CI, 1.06–1.35; not shown in the table).

Table 2. Gender-specific adjusted odds ratios of living arrangement for depressive symptoms.

  ALL n = 42,169 P-value for interaction
of gender
Men (n = 19,656) Women (n = 22,513)
n n of case ORa 95% CI n n of case ORa 95% CI
Living arrangement                  
With spouse only 9,468 1,144 1.00   7,805 915 1.00    
Living alone 983 174 1.43 (1.18, 1.73) 3,355 471 1.04 (0.91, 1.18) 0.07
With spouse and parent(s) 447 60 1.47 (1.09, 1.98) 227 21 0.82 (0.51, 1.32) 0.09
With spouse and child 6,383 797 1.08 (0.97, 1.20) 5,232 548 0.84 (0.74, 0.95) 0.18
With spouse, child and parent(s) 403 31 0.72 (0.49, 1.06) 177 19 0.95 (0.57, 1.58) 0.12
Child only, parent(s) only, or child and parent(s) only 1,736 253 1.12 (0.96, 1.32) 5,294 726 0.95 (0.84, 1.07) 0.62
Others 218 31 0.97 (0.65, 1.46) 423 67 1.11 (0.83, 1.48) 0.27
                 
GDS score in 2010 19,656 2,490 1.84 (1.78, 1.91) 22,513 2,767 1.91 (1.85, 1.98)  
Age 19,656 2,490 1.02 (1.00, 1.03) 22,513 2,767 1.02 (1.01, 1.04)  
Age group                  
65–74 years old 13,090 1,475 1.00   14,833 1,675 1.00    
75 years and older 6,566 1,015 1.04 (0.88, 1.23) 7,680 1,092 0.90 (0.77, 1.06)  
Years of education attainment                  
13 years and more 5,121 458 1.00   3,236 320 1.00    
10–12 years 6,849 851 1.30 (1.14, 1.47) 8,505 903 0.99 (0.86, 1.14)  
9 years and less 7,447 1,140 1.37 (1.20, 1.56) 10,340 1,469 1.19 (1.03, 1.36)  
missing 239 41 1.62 (1.11, 2.36) 432 75 1.34 (0.99, 1.81)  
Household equivalent income                  
4 million yen and higher 2,510 194 1.00   2,366 195 1.00    
2–3.99 million yen 8,303 881 1.17 (0.98, 1.39) 7,607 767 1.14 (0.96, 1.35)  
1.99 million yen and lower 7,221 1,154 1.54 (1.29, 1.83) 8,475 1,194 1.37 (1.15, 1.62)  
missing 1,622 261 1.43 (1.16, 1.77) 4,065 611 1.39 (1.16, 1.67)  
Working status                  
Working 6,070 655 1.00   3,888 441 1.00    
Retired 11,872 1,562 0.99 (0.89, 1.10) 11,550 1,358 0.86 (0.76, 0.97)  
Never work 592 116 1.21 (0.95, 1.53) 3,735 485 0.89 (0.76, 1.03)  
missing 1,122 157 0.85 (0.69, 1.04) 3,340 483 0.91 (0.78, 1.06)  
Disease treatment                  
No 5,301 526 1.00   5,533 525 1.00    
Yes 13,050 1,800 1.20 (1.07, 1.34) 15,168 1,994 1.12 (1.01, 1.25)  
Missing 1,305 164 1.04 (0.86, 1.28) 1,812 248 1.10 (0.92, 1.31)  
Poor self-rated health                  
No 17,535 1,963 1.00   20,259 2,266 1.00    
Yes 1,992 501 1.70 (1.51, 1.93) 1,997 466 1.57 (1.39, 1.78)  
Missing 129 26 1.46 (0.92, 2.32) 257 35 0.97 (0.66, 1.42)  
Walking time period per day                  
29 min and less 4,642 732 1.00   6,027 915 1.00    
30–59 min 6,806 822 0.93 (0.83, 1.04) 7,886 947 0.93 (0.83, 1.03)  
60–89 min 3,597 414 0.96 (0.84, 1.10) 3,534 375 0.86 (0.75, 0.98)  
90 min and more 3,790 406 0.94 (0.82, 1.08) 3,754 370 0.85 (0.74, 0.98)  
missing 821 116 1.05 (0.83, 1.31) 1,312 160 0.79 (0.65, 0.96)  
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CI, confidence interval; GDS, Geriatric Depression Scale; OR, odds ratio.

aAdjusted by all variables in the table. Residential area was also adjusted using a fixed model (ie, using 23 dummy variables).

We identified associations between living arrangements and depressive symptoms among both men and women in the younger age group, but found no statistically significant associations in the older age group (Table 3). In particular, men living with spouse and child was a significant risk of depressive symptoms for men aged 65–74 years. Thus, we decided to use only the younger age group (65–74 years old) for further subgroup analysis.

Table 3. Gender-specific adjusted odds ratios of living arrangement for depressive symptoms.

  ALL n = 42,169
Men (n = 19,656) P-value for interaction of age group Women (n = 22,513) P-value for interaction of age group
n n of case ORa 95% CI n n of case ORa 95% CI
Living arrangement                    
Age 65–74 years                    
With spouse only 6,341 663 1.00     5,983 663 1.00    
Living alone 566 107 1.79 (1.40, 2.29) 0.03 1,788 253 1.16 (0.98, 1.37) 0.95
With spouse and parent(s) 412 56 1.68 (1.23, 2.30) 0.23 216 20 0.86 (0.53, 1.41) 0.96
With spouse and child 4,330 496 1.19 (1.04, 1.36) 0.53 3,915 375 0.81 (0.71, 0.94) 0.93
With spouse, child and parent(s) 373 25 0.68 (0.44, 1.05) 0.03 163 19 1.08 (0.64, 1.80) 0.95
Child only, parent(s) only, or child and parent(s) only 933 110 1.08 (0.86, 1.35) 0.38 2,544 304 0.96 (0.82, 1.13) 0.94
Others 135 18 1.05 (0.62, 1.79) 0.71 224 41 1.48 (1.02, 2.16) 0.96
Age ≥75 years                    
With spouse only 3,145 481 1.00     1,822 252 1.00    
Living alone 417 67 1.03 (0.76, 1.40)   1,567 218 0.88 (0.71, 1.09)  
With spouse and parent(s) 35 4 0.82 (0.27, 2.49)   11 1 0.43 (0.05, 3.73)  
With spouse and child 2,053 301 0.91 (0.77, 1.09)   1,317 173 0.88 (0.70, 1.10)  
With spouse, child and parent(s) 30 6 1.62 (0.62, 4.26)   14 0 NA    
Child only, parent(s) only, or child and parent(s) only 83 143 1.14 (0.91, 1.44)   2,750 422 0.87 (0.72, 1.06)  
Others 88 13 0.88 (0.46, 1.66)   199 26 0.74 (0.46, 1.17)  
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CI, confidence interval; OR, odds ratio.

aAdjusted by GDS score in 2010, age, age group, years of education attainment, household income, working status, disease treatment, poor self-rated health, and walking time period per day. Residential area was also adjusted using a fixed model (ie, using 23 dummy variables).

Table 4 shows the gender-specific ORs for depressive symptoms according to living arrangements by neighborhood social cohesion level in men and women in the younger age group (65–74 years old). The negative impact of living arrangements on depressive symptoms was attenuated in neighborhoods with higher levels of social cohesion among men and women aged 65–74 years, although the multiplicative interaction was not significant (P-value for the interaction of social cohesion level = 0.66). The ORs of living alone for men were 2.01 (95% CI, 1.44–2.82) in the less socially cohesive neighborhood group and 1.46 (95% CI, 0.98–2.18) in the more socially cohesive neighborhood group. In addition, the OR of living alone for men in the less socially cohesive neighborhood group was significantly reduced by adjusting for social support variables (OR 1.54; 95% CI, 1.04–2.30).

Table 4. Gender-specific adjusted odds ratios of living arrangement for depressive symptoms by social cohesion level among men and women aged 65–74 years.

Living arrangement n n of case Model 1 Model 2 P-value for interaction
of social cohesion level
OR 95% CI OR 95% CI
Men (n = 12,572)              
Social cohesion level              
LOW              
With spouse only 3,330 334 1.00   1.00    
Living alone 289 60 2.01 (1.44, 2.82) 1.54 (1.04, 2.30) 0.66
With spouse and parent(s) 162 21 1.80 (1.09, 2.97) 1.82 (1.10, 3.00) 0.57
With spouse and child 1,979 238 1.29 (1.07, 1.56) 1.29 (1.07, 1.57) 0.52
With spouse, child and parent(s) 135 11 0.80 (0.41, 1.55) 0.81 (0.42, 1.57) 0.83
Child only, parent(s) only, or child and parent(s) only 410 51 1.11 (0.80, 1.56) 1.05 (0.75, 1.48) 0.33
Others 77 13 1.54 (0.81, 2.93) 1.39 (0.72, 2.67) 0.28
HIGH              
With spouse only 2,769 300 1.00   1.00    
Living alone 235 36 1.46 (0.98, 2.18) 1.27 (0.81, 2.01)  
With spouse and parent(s) 236 32 1.54 (1.01, 2.34) 1.54 (1.01, 2.36)  
With spouse and child 2,192 242 1.10 (0.91, 1.34) 1.10 (0.90, 1.34)  
With spouse, child and parent(s) 227 13 0.56 (0.31, 1.01) 0.55 (0.30, 1.00)  
Child only, parent(s) only, or child and parent(s) only 481 57 1.08 (0.78, 1.49) 1.05 (0.76, 1.45)  
Others 50 5 0.70 (0.26, 1.88) 0.62 (0.23, 1.68)  
 
Women (n = 14,266)              
Social cohesion level              
LOW              
With spouse only 3,078 356 1.00   1.00    
Living alone 955 140 1.19 (0.95, 1.50) 1.08 (0.85, 1.38) 0.62
With spouse and parent(s) 90 9 0.81 (0.39, 1.68) 0.81 (0.39,1.68) 0.82
With spouse and child 1,712 163 0.77 (0.62, 0.95) 0.77 (0.62, 0.95) 0.87
With spouse, child and parent(s) 64 10 1.45 (0.70, 2.98) 1.43 (0.69, 2.96) 0.23
Child only, parent(s) only, or child and parent(s) only 1,183 128 0.80 (0.64, 1.01) 0.78 (0.62, 0.99) 0.13
Others 126 20 1.19 (0.71, 2.01) 1.11 (0.65, 1.89) 0.31
HIGH              
With spouse only 2,656 287 1.00   1.00    
Living alone 737 101 1.11 (0.85, 1.45) 1.02 (0.78, 1.35)  
With spouse and parent(s) 117 11 0.91 (0.47, 1.79) 0.91 (0.46, 1.78)  
With spouse and child 2,075 188 0.80 (0.64, 0.98) 0.80 (0.64, 0.98)  
With spouse, child and parent(s) 95 9 0.84 (0.40, 1.77) 0.86 (0.41, 1.81)  
Child only, parent(s) only, or child and parent(s) only 1,290 163 1.07 (0.86, 1.35) 1.07 (0.85, 1.34)  
Others 88 18 1.70 (0.95, 3.02) 1.60 (0.90, 2.86)  
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CI, confidence interval; GDS, Geriatric Depression Scale; OR, odds ratio.

Model 1: adjusted by GDS score in 2010, age, years of education attainment, household income, working status, disease treatment, poor self-rated health, and walking time period per day. Residential area was also adjusted using a fixed model (ie, using 23 dummy variables).

Model 2: Model 1+ emotional support receipt, emotional support provision, instrumental support receipt, and instrumental support provision.

DISCUSSION

In this study of Japanese older adults, living arrangements were significantly associated with risk of depressive symptoms. Our results indicated that the association between living arrangements and depressive symptoms differs by gender. We found that men living alone and living with a spouse and parent(s) had higher odds of developing depressive symptoms than those living with their spouse only; however, no such association was identified among women. In contrast, women living with a spouse and child had lowered odds of developing depressive symptoms compared with those living with a spouse only, whereas increased odds were identified among men in the younger age group. Moreover, our results suggest that neighborhood social cohesion level may affect the associations between living arrangements and depressive symptoms. The increased odds of depressive symptoms for those living alone were slightly attenuated in those living in neighborhoods with greater social cohesion.

There is good evidence that living alone is a risk factor for depressive symptoms among older adults.7,27 However, to the best of our knowledge, there are few longitudinal studies on specific living arrangements and depressive symptoms among older adults. A cross-sectional study in South Korea reported that older men and women living with spouse only were the least likely to have depressive symptoms; however, living with other family members in addition to a spouse, as well as living alone, were associated with higher odds of depressive symptoms among men and women.8 Another cross-sectional study in Japan also indicated that living with family members other than a spouse was associated with increased odds of psychological distress among men and women aged 65–74 years.6

Our results are partly consistent with these previous results; living alone was significant risk of developing depressive symptoms. However, while previous studies showed no gender differences in the association between living arrangement and depressive symptoms, we identified clear gender difference in the effect of living with spouse and living with child/parent. Living with a spouse only was beneficial for mental health among men, but it was not necessarily true for women. For women, living with a spouse and child was most beneficial factor, but it seemed to be a risk for men at least in the younger age group. In addition, living with a spouse and parent(s) was risk for depressive symptoms for men but not for women. Our results suggested that who an individual lives with, not just whether they live with someone, is important for mental health among older adults, and suggested significant gender differences in the association between living arrangements and depressive symptoms among older Japanese adults.

The gender differences identified may be a result of differences in the expected social roles of men and women in Japanese society, which is characterized by strong gender role norms.15 Under such gendered norms, men may feel role conflicts when they cannot fulfill their role responsibility, such as provision of financial support for family members, when they retire. In contrast, because women are expected to take care of their family members, this may shape their identity within the family; living with their child/parent(s) may enhance women’s roles.16 Moreover, women are generally more likely to adopt the role of providing a range of social support to their spouse under such social norms. Therefore, for men, living with a spouse may mean that they have someone to take care of them; for women, living with a spouse may mean that they have someone who needs their care. These different roles may be the basis of the identified gender differences in the associations between living arrangements and depressive symptoms.

Another explanation for these findings may be differences in how men and women construct and maintain social networks. Older adults are likely to be vulnerable to social isolation because they are more likely to lose their social ties.28 However, women living alone are not necessarily socially isolated and often show better psychological health compared with those living with a spouse.29 Constructing social relationships is beneficial for mental health among older adults.30 Women are likely to maintain their active social networks with their friends, immediate family, and other relatives and experience more social support regardless of their marital status,30 whereas older men tend to mainly have relationships with their spouses.28

We found that living in socially cohesive neighborhoods may prevent the occurrence of depressive symptoms among people living alone. One possible explanation for this is that cohesive communities may provide more social support for residents,17 which may reduce the likelihood of social isolation and social exclusion among community members. As social isolation and social exclusion are risks for depressive symptoms,31 community cohesiveness may reduce the risk of depressive symptoms among people living alone. Indeed, the results of our mediating analysis indicated that the increased odds of depressive symptoms in individuals living alone in less socially cohesive neighborhoods could be explained by less social support exchange among people in those areas. Our results indicate that interventions to improve aspects of social cohesion may help to prevent depressive symptoms among older individuals.

This is one of the few longitudinal investigations to examine the association between living arrangements and risk of depressive symptoms. However, several limitations should be mentioned. First, we did not account for changes in our primary predictor or in other variables during the follow-up period. Second, this was an observational study and selection bias could not be ruled out. Unfortunately, we have no demographic information on those who did not participate in this cohort study, so no information on the direction of this selection bias was available. Third, residual confounding could have occurred from unmeasured confounding variables, such as family history of mental health. Fourth, measurement errors could also occur. Measurement error of our outcome was assumed to be non-differential and might have reduced the reliability of our result. Fifth, although it was a strength of our study design to have data on depressive symptoms at baseline and follow-up, our study population was limited to those who responded to both questionnaires, which may introduce some selection bias. Those who did not response to the following survey was likely to be older, have lower socioeconomic conditions, and poorer self-rated health, and to live with parent(s) and/or child but not spouse, compared to our study population, which did not indicate clear direction of this bias.

Although these cautions are necessary to interpret, our results suggest that public health practitioners and policy makers should pay more attention to whether individuals live alone, as well as who individuals live with. It also support that interventions to strengthen community social cohesion may be effective to prevent depressive symptoms of older community residents, regardless of their living arrangements. Given the increasing diversity in family conception, it is unrealistic to promote specific cohabitation statuses among older adults. Alternatively, community interventions to strengthen social cohesion may work; for example, by creating more opportunities of social informal gathering, such as “community salons”.32

ACKNOWLEDGEMENTS

We are particularly grateful to the staff members in each study area and in the central office for conducting the survey. We would like to thank everyone who participated in the surveys.

Funding: This study used data from JAGES (the Japan Gerontological Evaluation Study), which was supported by MEXT (Ministry of Education, Culture, Sports, Science and Technology-Japan)-Supported Program for the Strategic Research Foundation at Private Universities (2009–2013), JSPS (Japan Society for the Promotion of Science) KAKENHI Grant Numbers (22330172, 22390400, 23243070, 23590786, 23790710, 24390469, 24530698, 24683018, 25253052, 25870573, 25870881, 26285138, 26882010, 15H01972), Health Labour Sciences Research Grants (H22-Choju-Shitei-008, H24-Junkanki [Seishu]-Ippan-007, H24-Chikyukibo-Ippan-009, H24-Choju-Wakate-009, H25-Kenki-Wakate-015, H25-Choju-Ippan-003, H26-Irryo-Shitei-003 [Fukkou], H26-Choju-Ippan-006, H27-Ninchisyou-Ippan-001), the Research and Development Grants for Longevity Science from AMED (Japan Agency for Medical Research and development), the Research Funding for Longevity Sciences from National Center for Geriatrics and Gerontology (24-17, 24-23), and Japan Foundation For Aging And Health (J09KF00804).

Conflicts of interest: None declared.

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