The Journal of International Medical Research
2011; 39: 1142 – 1154
Marital Status and Risk for Late Life
Depression: a Meta-analysis of the
Published Literature
X-Y YAN1, S-M HUANG1, C-Q HUANG2, W-H WU1
1
Department of Nephrology, The West China Hospital of Sichuan University, Chengdu,
China; 2Department of Geriatrics, The Third Hospital of Mianyang, Mianyang, China;
3
Department of Cardiology, The Third Military Medical University, Chongqing, China
This study assessed the relationship
between marital status and the risk for
depression in people ≥ 55 years old. Using
the Medline™, EMBASE™ and Cochrane
Library databases, clinical studies that
published data on the association between
marital status and risk of depression
among individuals aged ≥ 55 years were
identified. A quantitative meta-analysis of
24 cross-sectional and eight longitudinal
studies was performed. Compared with
married elderly people, unmarried elderly
KEY WORDS: DEPRESSION; RISK; MARITAL
Introduction
Depression is a major contributor to the
healthcare costs associated with elderly
populations, and is projected to be the
leading cause of disease burden in such
populations by 2020.1,2 The prevalence of
depression in subjects aged ≥ 65 years may
be as high as 40% in hospitalized and
nursing-home settings, and 30% in
community settings.3 The prognosis of these
depressive states is poor. For example, a
meta-analysis of outcomes at 24 months
estimated that only 33% of subjects were
well: 33% remained depressed and 21% had
died.4 Moreover, studies of depressed adults
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AND Y QIN3
people had a higher risk for depression
(odds ratio [OR], 1.55; relative risk [RR],
1.36). Compared with married elderly
people, the widowed elderly people (OR
1.49; RR 1.71), divorced people (RR 2.14)
and never-married people (OR 1.32) had a
higher risk for depression. Among elderly
unmarried people, widowed people had a
higher risk for depression than those who
never married (OR 1.51). In conclusion,
being unmarried was an important risk
factor for depression in elderly people.
STATUS; OLD AGE; META-ANALYSIS
indicated that those with depressive
symptoms, with or without depressive
disorder, had poorer functioning,
comparable with (or worse than) those in
people with chronic medical conditions such
as heart and lung disease, arthritis,
hypertension and diabetes.5 – 7 In addition to
poor functioning, depression increased the
perception of poor health, the utilization of
medical services, and healthcare costs.7 – 9
Marital status is commonly viewed as a
risk factor for depression in the elderly, as
shown by longitudinal and cross-sectional
studies.10 – 12 In contrast, some studies have
reached the opposite conclusion.13,14
 X-Y Yan, S-M Huang, C-Q Huang et al.
Marital status and risk for depression: a meta-analysis
Moreover, a previous systematic review and
meta-analysis showed that the odds ratio
(OR) of unmarried status as a function of
increased depression was not significant (OR
1.0, 95% confidence intervals [95% CI] 0.8,
1.3).15 Thus, it remains unclear whether
marital status is a risk factor for depression
in the elderly.
Depression is a critically important issue
for elderly people and those working with
them. As the elderly population increases,
the number of depressive individuals is
expected to rise.16,17 Thus, it is important to
investigate the risk for depression in these
people. Although being unmarried is
generally viewed as a risk for depression in
the elderly, this has not been confirmed.
Moreover, the relationship between marital
status (including married, widowed, never-
married and divorced) and risk for
depression in elderly people remains unclear.
Thus, the present meta-analysis was
conducted in order to measure the
magnitude and shape of the association
between marital status and depression in
people aged ≥ 55 years.
Patients and methods
SEARCH METHOD
This study was part of a best-evidence
research project on depression in the elderly.
Relevant literature was identified through
searching Medline™ (from the beginning of
1966), EMBASE™ (from the beginning of
1980) and the Cochrane Library (from
January 1990 to August 2007). The search
terms (provided by the Cochrane Centre,
Oxford, UK) included ‘depression’, ‘older’
and ‘clinical trials’. Literature selection was
based on studies that involved clinical trials,
depression (diagnostic criteria using formal
depression scales) and elderly subjects (≥ 55
years). Studies that were not clinical trials,
were unrelated to depression, or did not
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include elderly people were rejected. The
literature search included three stages: (i) an
initial review of article titles to identify those
that might be included; (ii) a review of titles
and abstracts of those articles identified in
the first stage, with papers failing to meet the
inclusion criteria being rejected; and (iii) a
reading of the full text of the articles that
survived the second stage. Articles that
remained at the third stage were classified
into four subgroups according to the
objective of the research programme: (i)
aetiology-related studies (the study of the
causes or origin of disease and the factors
that produce or predispose toward a certain
disease or disorder) or epidemiological
studies (the study of the causes, distribution,
and control of disease in populations); (ii)
diagnostic studies (the study of the science
and practice of the diagnosis of disease in
populations); (iii) therapeutic studies (the
study of the treatment and cure of diseases in
populations); and (iv) prognostic studies (the
study of the prediction of the course or
outcome of a disease in populations). The
search terms, search results and classification
of the literature have been reported
previously.18 Selection and classification of
the literature were performed by four
researchers (X.-Y.Y, C.-Q.H, W.-H.W, Y.Q.),
and each article was selected and classified
by two researchers (X.-Y.Y, C.-Q.H),
independently, with any discrepancies being
addressed through discussion. In this meta-
analysis, the magnitude and shape of the
association between marital status and
depression in old age was measured, so that
only aetiology-related or epidemiological
studies might be included.
INCLUSION CRITERIA
Studies were included in the present meta-
analysis if they met the following inclusion
criteria: (i) a cross-sectional or longitudinal
 X-Y Yan, S-M Huang, C-Q Huang et al.
Marital status and risk for depression: a meta-analysis
study where all participants were ≥ 55 years
(the age at the end of the follow-up for
longitudinal studies); (ii) original research
reported in English; (iii) included complete
information on the prevalence or incidence
of depression in the different marital status
groups; and (iv) used an acceptable
definition of depression. The diagnostic
category of depression, as applied by the
authors of each study, was accepted and
included the following: (i) the presence of
depressive disorder, depressive symptoms, or
psychological distress, as defined by scores
above a cut point for an abnormality on a
standard mood scale; (ii) severity of
depressive disorder, depressive symptoms, or
psychological distress, as defined by scores
on a standard mood scale; and (iii) the
presence of major depression or minor
depression (or dysthymia) according to the
Diagnostic and Statistical Manual of Mental
Disorders (DSM)-IIIR, DSM-IV, or other
standard psychiatric diagnostic criteria.19
EXCLUSION CRITERIA
Studies were excluded if they had any of the
following: limited to specific subject
characteristics (such as convenience
sampling); retrospective recruitment; or if
there was only an unstructured assessment
of mood.
DATA EXTRACTION AND CHECKING
For longitudinal studies, information about
the country of study, group size at baseline
and follow-up, age, proportion of men,
depression criteria, exclusion criteria at
baseline, length of follow-up, and number of
incident cases of depression in each group
was extracted from each report. For cross-
sectional studies, information about the
country of study, group size, age, proportion
of men, depression criteria, exclusion criteria
and the number of cases of depression in
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each marital status group was extracted
from each report. Every paper included in
the meta-analysis was read in full and the
data were extracted and cross-checked
independently by two authors (X-Y.Y., C-Q.H.);
discrepancies were resolved by discussion.
STATISTICAL ANALYSES
Data were entered into the RevMan 4.2
meta-analysis program (Cochrane
Collaboration, Oxford, UK; http://www.cc-
ims.net/RevMan/current.htm). The meta-
analysis of the cross-sectional studies had the
advantage of huge sample sizes and so could
readily show any association between
marital status group and prevalence of
depression, while the meta-analysis of
longitudinal studies had the advantage of
readily obtaining a causality conclusion. In
the meta-analysis of cross-sectional studies
for the prevalence rates of depression, ORs
and 95% CIs were calculated. Results were
summarized using conventional forest plots
and ORs, stratified by features of the studies
included. In the meta-analysis of
longitudinal studies for incidence rates of
depression, relative risk (RR) and 95% CIs
were calculated. Results were summarized
using conventional forest plots and RRs,
stratified by features of the studies included.
Summary ORs and RRs were estimated using
a random-effects model. A P-value of < 0.05
was considered to be statistically significant
Results
The literature search identified 6420 articles
by the third stage of the search process and
these were classified into the four subgroups
according to the objective of the research
programme. Of these, 1027 studies were
potentially aetiology or epidemiology
related. Abstracts from all 1027 papers were
reviewed and 899 were rejected as obviously
unsuitable: e.g. unrelated to marital studies.
 X-Y Yan, S-M Huang, C-Q Huang et al.
Marital status and risk for depression: a meta-analysis
The remaining 128 papers were read in full
and 96 were rejected for reasons including no
usable data or no recognized instrument
used for the diagnosis of depression. The
remaining 32 studies were included in the
meta-analysis, including eight longitu-
dinal20 – 27 and 24 cross-sectional13,28 – 50
studies, the characteristics of which are
summarized in Tables 1 and 2, respectively.
Publication bias was assessed using
funnel plots (Fig. 1). The funnel plot of the
ORs (under a fixed-effects model) was
constructed from the 32 studies in Tables 1
and 2. In the absence of publication bias, the
points should be symmetrical about the
vertical line at the pooled ORs. The
reasonably symmetrical shape suggested the
absence of publication bias.
A forest plot of the ORs from the 24 cross-
sectional studies is shown in Fig. 2,13,20 – 50
ordered by the marital status groups. In the
24 cross-sectional studies, there were 28 759
married and 24 044 unmarried subjects, and
4065 and 4885 cases of depression in the
married and unmarried subjects,
respectively. After pooling these 24 studies,
unmarried subjects had a higher prevalence
of depression than married subjects (OR
1.55, 95% CI 1.37, 1.74; P < 0.00001).
Of the 24 cross-sectional studies, 12, six
and two studies compared the risk for
depression in old married people versus
those who were widowed,31,33,34,36,39 – 43,46 – 48
never-married,29,31,41,43,46,48 or divorced,31,41
respectively. After pooling these studies,
widowed and never-married subjects were at
a significantly higher risk for depression
than married subjects (OR 1.49, 95% CI 1.19,
1.87, P = 0.0006; OR 1.32, 95% CI 1.12, 1.55,
P = 0.0007 respectively), and subjects who
were divorced had a non-significantly higher
risk for depression than those who were
married (OR 1.23, 95% CI 0.57, 2.65).
Of the 24 cross-sectional studies, two, five
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and two studies compared the risk for
depression between widowed and divorced
subjects,31,41 between widowed and never-
married subjects,31,41,43,46,48 and between
divorced and never-married subjects.31,41
Pooling these studies, widowed subjects had
a higher risk for depression than those who
had never married (OR 1.51, 95% CI 1.14,
1.98, P = 0.004). There were non-significant
differences in the risk for depression between
widowed and divorced subjects and between
divorced and never-married subjects (OR
1.42, 95% CI 0.57, 3.55; OR 1.02, 95% CI
0.44, 2.34 respectively).
A forest plot of RR from the eight
prospective longitudinal studies is shown in
Fig. 3.20 – 27 After pooling these studies,
unmarried subjects had a higher risk for
depression than those who were married (RR
1.36, 95% CI 1.01, 1.84, P = 0.04). Of these
eight longitudinal studies, four, three and
two studies compared the risk for depression
in married people with those
widowed,20,21,23,27 never-married21,23,27 and
divorced,21,27 respectively. After pooling these
studies, compared with married subjects,
those widowed and divorced had higher risks
for depression (RR 1.71, 95% CI 1.09, 2.68,
P = 0.02; RR 2.14, 95% CI 1.45, 3.16, P =
0.0001; respectively), and there was no
significant difference in the risk for
depression between never-married and
married subjects (RR 0.96, 95% CI 0.30,
3.08). Three studies compared the risk for
depression among never-married, widowed,
and divorced people, and there were no
significant differences among these three
groups.21,23,27
Discussion
This meta-analysis of 24 cross-sectional and
eight prospective longitudinal studies
demonstrated that unmarried status was a
risk factor for depression in elderly people,
 TABLE 1:
Characteristics of the eight longitudinal studies included in the current meta-analysis of marital status and risk of depression20 – 27
Cases of
Exclusion incident
Baseline Age, Criteria for criteria at Follow-up, depression
Study n follow-up years Male,% depression baseline months n (%) Country
Mendes de Leon et al. 1046 731 ≥ 65 65 CES-D ≥ 20 – 36 77 (10.1) USA
199420
Forsell 200021 1777 903 ≥ 75 23 DSM-IV Depression, 36 29 (3.2) Sweden
criteria anxiety,
psychosis
Geerlings et al. 200222 325 234 55 – 85 48 CES-D > 16 Depression 36 40 (14.1) The
plus 5 points Netherlands

1146
above 5
Kennedy et al. 199023 1243 1243 ≥ 65 46 CES-D > 16 CES-D > 16 24 163 (13.1) USA
plus 5 points
above baseline
Meller et al. 199724 358 263 ≥ 85 GMS-AGECAT – 12 – Germany
Schoevers et al. 200025 3747 1940 65 – 84 38 GMS-AGECAT Depression 36 309 (14.1) The
criteria (level 3.5) Netherlands
X-Y Yan, S-M Huang, C-Q Huang et al.

Stek et al. 200626 334 141 ≥ 85 37 GDS-15 > 4 Cognitive 46 56 (39.7) The

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impairment Netherlands
Turvey et al. 199927 – 5449 70 – 103 38 Modified CES-D ≥ 6 – 24 327 (6) USA
CES-D, Center for Epidemiologic Studies-Depression Scale; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders-IV; GMS-AGECAT, Geriatric
Marital status and risk for depression: a meta-analysis

Mental State Schedule Automated Geriatric Examination for Computer Assisted Taxonomy; GDS-15: Geriatric Depression Scale.
 TABLE 2:
Characteristics of the 24 cross-sectional studies included in the current meta-analysis of marital status and risk of depression13,28 – 50
Age Criteria for Exclusion Cases of
Study Country n Population (years) Male (%) depression criteria depression
Al-Shammari and Saudi Arabia 7970 Community > 60 62 GDS-30 ≥ 20 – 670
Al-Subaie 199928
Blay et al. 200729 Brazil 6961 Community > 60 34 Short Psychiatric – 2722
Evaluation Schedule
(six-item version) ≥ 20
Bergdahl et al. 200530 Sweden 242 Community ≥ 85 25 DSM-IV – 65
Blazer and Williams 198031 USA 997 Community ≥ 65 37.4 DSM-III-DIS-R – 147
Brody et al. 200132 USA 151 Community ≥ 60 32.4 SCID-IV – 49
Carnethon et al. 200733 USA 4681 Community ≥ 65 40.8 CES-D-10 ≥ 8 Diabetes –
Carpiniello et al. 198934 Italy 317 Community ≥ 65 38.7 BDI ≥ 10 – 31
Cassidy et al. 200435 Australia 278 Community ≥ 65 0 BDI ≥ 10 – 85
Chen et al. 200536 China 1600 Community ≥ 60 47.1 GMS-AGECAT – 95

1147
Chi et al. 200537 China 917 Community ≥ 60 47.5 GDS-15 ≥ 8 Cognitive
impairment 113
Chong et al. 200138 China 1500 Community ≥ 65 53.4 GMS-AGECAT – 287
Friedman et al. 200739 USA 926 Primary care ≥ 65 25.7 Mini International Cognitive 119
Neuropsychiatric impairment
Interview, major
depressive
Heok et al. 199640 China 1062 Community ≥ 65 43 GMS-AGECAT – 55
X-Y Yan, S-M Huang, C-Q Huang et al.

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Kivela et al. 198841 Finland 1235 Community ≥ 65 40.9 DSM-III – 330
McDougall et al. 200742 UK 2640 Institutional and ≥ 65 35.6 GMS-AGECAT – 346
non-institutional
Marital status and risk for depression: a meta-analysis

settings
O’Hara et al. 198543 USA 3159 Non-institutionalized 65 – 105 37.1 CES-D ≥ 16 – 285
older adults
Sewitch et al. 200413 Canada 193 Emergency ≥ 65 43 GDS-15 > 5 – 76
department
 TABLE 2 (continued):
Characteristics of the 24 cross-sectional studies included in the current meta-analysis of marital status and risk of depression13,28 – 50
Age Criteria for Exclusion Cases of
Study Country n Population (years) Male (%) depression criteria depression
Sonnenberg et al. The 3056 Community 55 – 85 48.4 CES-D ≥ 16 – 455
200044 Netherlands
Steffens et al. 199945 USA 3660 Community ≥ 65 44.2 CES-D scores, – 880
quartiles for
comparisons. The
highest versus
the others
Tsai et al. 200546 China 1200 Nursing homes ≥ 65 55.8 GDS-15 > 5 Cognitive 330
(Taiwan) impairment

1148
Tsai et al. 200547 China 364 Nursing homes ≥ 65 – GDS-15 > 8 Cognitive 98
(Taiwan and impairment
Hong Kong)
Tsai 200748 China 200 Care homes ≥ 65 65.5 GDS-15 > 8 Cognitive
(Taiwan) impairment
Walters et al. 200449 UK 13349 Community 75 – 102 38.7 GDS-15 > 6 – 1065
Wang et al. 199950 China 1421 Community ≥ 65 44.2 GDS-S score ≥ 8 Dementia, 191
chronic
X-Y Yan, S-M Huang, C-Q Huang et al.

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psychosis
GDS, Geriatric Depression Scale; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders-IV; DSM-III-DIS-R, Diagnostic and Statistical Manual of
Mental Disorders-III-Distributed Input System Replacement; SCID-IV, Structured Clinical Interview for DSM-IV; CES-D, Center for Epidemiologic Studies-
Marital status and risk for depression: a meta-analysis

Depression Scale; BDI, Beck Depression Inventory; GMS-AGECAT, Geriatric Mental State Schedule Automated Geriatric Examination for Computer Assisted
Taxonomy; SCL-90-R, the Symptom Checklist-90-R.
 X-Y Yan, S-M Huang, C-Q Huang et al.
Marital status and risk for depression: a meta-analysis

0.0

0.2

0.4
SE (log OR)

0.6

0.8

0.1 0.2 0.5 1.0 2.0 5.0 10.0

OR (fixed)

FIGURE 1: Funnel plot undertaken to assess publication bias in the 32 studies included in
the current meta-analysis of marital status and risk of depression (OR, odds ratio)13,20 – 50

and that the risk for depression among
elderly people who had never married was
significantly higher than that for elderly
married people, but was significantly lower
than that for elderly widowed people. This
was a robust finding about the relationship
between marital status and the risk for
depression among elderly people.
In the 24 cross-sectional studies, it was
unclear whether the subjects included were
all having their first depressive episode after
the age of 55 years, or whether they had
experienced depression previously at a
younger age. In contrast, in the eight
longitudinal studies, the subjects included
were all having their first depressive episode
after the age of 55 years. In the meta-
analysis of the cross-sectional studies,
unmarried subjects had a higher prevalence
of depression than married subjects. It has
been reported that depression doubles the
proportion of transitions from common-law
or married to separated or divorced status.51
Thus, it is reasonable to assume that
depression might negatively influence
marital status, and that being depressed
might also reduce the chances of marrying a
suitable partner. In contrast, marital status
can also have an effect on depression as
shown by the present study. Based on the
meta-analysis of the longitudinal studies, we
conclude that, in elderly people, unmarried
subjects had a higher incidence of depression
than married subjects.
The observation that being unmarried was
a risk factor for late depression might be
explained by the fact that, compared with
married people, unmarried elderly people
might experience more loneliness, poorer
social support, lower self-confidence and are
more likely to be living alone, all of which are
commonly viewed as risk factors for depression
in the elderly population.51 Compared with
widowed elderly people, however, those who
had never married had a lower risk for
depression. Being widowed is a negative life

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 X-Y Yan, S-M Huang, C-Q Huang et al.
Marital status and risk for depression: a meta-analysis

Study OR (random) Weight OR (random)

or sub-category 95% CI % 95% CI
Others vs married
Al-Shammari and Al-Subaie 199928 3.75 1.59 (1.35, 1.87)
Bergdahl et al. 200530 0.63 1.80 (0.65, 4.93)
Blay et al. 200729 4.10 1.40 (1.27, 1.55)
Blazer and Williams 198031 2.44 1.59 (1.10, 2.29)
Brody et al. 200132 1.13 1.02 (0.51, 2.05)
Carnethon et al. 200733 3.84 1.63 (1.41, 1.89)
Carpiniello et al. 198934 1.10 2.71 (1.33, 5.54)
Cassidy et al. 200435 1.61 1.67 (0.97, 2.87)
Chen et al. 200536 2.14 1.73 (1.14, 2.63)
Chi et al. 200537 2.28 1.48 (1.00, 2.20)
Chong et al. 200138 3.01 1.79 (1.36, 2.36)
Friedman et al. 200739 2.28 1.00 (0.67, 1.48)
Heok et al. 199640 1.58 0.68 (0.39, 1.18)
Kivela et al. 198841 3.15 1.63 (1.27, 2.10)
McDougall et al. 200742 0.98 0.47 (0.22, 1.01)
O’Hara et al. 198543 3.17 2.28 (1.78, 2.94)
Sewitch et al. 200413 1.48 1.46 (0.82, 2.60)
Sonnenberg et al. 200044 3.51 2.80 (2.29, 3.42)
Steunenberg et al. 200612 2.93 2.34 (1.75, 3.12)
Tsai et al. 200546 3.05 1.47 (1.12, 1.92)
Tsai 200748 0.73 0.61 (0.24, 1.54)
Walters et al. 200449 3.92 1.57 (1.38, 1.80)
Wang et al. 199950 3.41 1.29 (1.04, 1.59)
Tsai et al. 200547 1.61 1.11 (0.65, 1.91)
Subtotal (95% CI) 57.83 1.55 (1.37, 1.74)
Total events: 4885 (other), 4065 (married)
Test for heterogeneity: χ2 = 90.91, d.f. = 23 (P < 0.00001), I 2 = 74.7%
Test for overall effect: Z = 7.28 (P < 0.00001)

Widowed vs married
Blazer and Williams 198031 2.38 1.65 (1.13, 2.40)
Carnethon et al. 200733 3.76 1.71 (1.45, 2.01)
Carpiniello et al. 198934 0.97 3.03 (1.40, 6.60)
Chen et al. 200536 2.05 1.97 (1.27, 3.05)
Friedman et al. 200739 2.13 0.84 (0.55, 1.29)
Heok et al. 199640 1.52 0.77 (0.44, 1.35)
Kivela et al. 198841 3.03 1.91 (1.45, 2.50)
McDougall et al. 200742 0.92 0.49 (0.22, 1.09)
O’Hara et al. 198543 3.10 2.25 (1.73, 2.92)
Tsai et al. 200546 0.90 2.00 (0.88, 4.51)
Tsai 200748 0.64 1.87 (0.69, 5.07)
Tsai et al. 200547 1.50 0.99 (0.56, 1.75)
Subtotal (95% CI) 22.89 1.49 (1.19, 1.87)
Total events: 931 (other), 1270 (married)
Test for heterogeneity: χ2 = 38.51, d.f. = 11 (P < 0.00001), I 2 = 71.4%
Test for overall effect: Z = 3.45 (P = 0.0006)

Never vs married
Blay et al. 200729 3.53 1.33 (1.09, 1.62)
Blazer and Williams 198031 0.83 1.30 (0.55, 3.06)
Kivela et al. 198841 2.04 1.07 (0.69, 1.66)
O’Hara et al. 198543 1.58 1.47 (0.85, 2.55)
Tsai et al. 200546 1.00 1.73 (0.81, 3.70)
Tsai 200748 0.67 1.46 (0.55, 3.85)
Subtotal (95% CI) 9.66 1.32 (1.12, 1.55)
Total events: 303 (other), 1618 (married)
Test for heterogeneity: χ2 = 1.57, d.f. = 5 (P = 0.91), I 2 = 0%
Test for overall effect: Z = 3.37 (P = 0.0007)

Divorced vs married
Blazer and Williams 198031 0.51 1.91 (0.61, 5.93)
Kivela et al. 198841 0.64 0.87 (0.32, 2.36)
Subtotal (95% CI) 1.16 1.23 (0.57, 2.65)
Total events: 9 (other), 200 (married)
Test for heterogeneity: χ2 = 1.05, d.f. = 1 (P = 0.31), I 2 = 4.6%
Test for overall effect: Z = 0.53 (P = 0.60)

0.1 0.2 0.5 1.0 2.0 5.0 10.0

Favours treatment Favours control

FIGURE 2: Forest plot of the odds ratio (OR) for depression from the 24 cross-sectional
studies that compared the risk for depression between married and unmarried people
≥ 55 years of age13,28 – 50

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 X-Y Yan, S-M Huang, C-Q Huang et al.
Marital status and risk for depression: a meta-analysis

Study OR (random) Weight OR (random)

or sub-category 95% CI % 95% CI
Widowed vs divorced
Blazer and Williams 198031 0.52 0.86 (0.28, 2.65)
Kivela et al. 198841 0.64 2.19 (0.80, 5.95)
Subtotal (95% CI) 1.16 1.42 (0.57, 3.55)
Total events: 227 (other), 9 (married)
Test for heterogeneity: χ2 = 1.49, d.f. = 1 (P = 0.22), I 2 = 32.7%
Test for overall effect: Z = 0.76 (P = 0.45)

Divorced vs never
Blazer and Williams 198031 0.37 1.46 (0.38, 5.69)
Kivela et al. 198841 0.58 0.81 (0.28, 2.35)
Subtotal (95% CI) 0.95 1.02 (0.44, 2.34)
Total events: 9 (other), 38 (married)
Test for heterogeneity: χ2 = 0.45, d.f. = 1 (P = 0.50), I 2 = 0%
Test for overall effect: Z = 0.04 (P = 0.97)

Widowed vs never
Blazer and Williams 198031 0.86 1.26 (0.55, 2.92)
Kivela et al. 198841 1.99 1.78 (1.14, 2.80)
O’Hara et al. 198543 1.61 1.53 (0.89, 2.62)
Tsai et al. 200546 0.55 1.15 (0.39, 3.43)
Tsai 200748 1.34 1.29 (0.69, 2.39)
Subtotal (95% CI) 6.35 1.51 (1.14, 1.98)
Total events: 419 (other), 108 (married)
Test for heterogeneity: χ2 = 1.19, d.f. = 4 (P = 0.88), I 2 = 0%
Test for overall effect: Z = 2.91 (P = 0.004)

Total (95% CI) 100.0 1.51 (1.38, 1.64)

Total events: 6783 (other), 7308 (married)
Test for heterogeneity: χ2 = 142.32, d.f. = 52 (P < 0.00001), I 2 = 63.5%
Test for overall effect: Z = 9.26 (P < 0.00001)
0.1 0.2 0.5 1.0 2.0 5.0 10.0
Favours treatment Favours control

FIGURE 2 (continued): Forest plot of the odds ratio (OR) for depression from the 24
cross-sectional studies that compared the risk for depression between married and
unmarried people ≥ 55 years of age13,28 – 50

event and elderly people experience a huge Cumulative Index to Nursing and Allied
change in their lifestyle following widowhood. Health Literature (CINAHL®) and PsycINFO®
This might be one of the reasons for the higher were not included. The literature was
risk for depression in elderly widowed people screened by reading the abstracts rather
compared with those who remain married or than the full text, which was also a
have never married. limitation. Additionally, the search was
Publication bias was assessed in this limited to articles published in English.
meta-analysis and the results suggest it was Finally, there was heterogeneity among the
absent. Although the present study included studies, which was perhaps related
attempted to adhere to the guidelines for to the different definitions of depression in
reporting meta-analyses of observational different studies, and the small study groups
studies, there were several limitations to the in some studies. Thus, the random-effects
review. First, journals were not hand- model, which has less precision than the
searched and no attempt was made to fixed-effects model, was used in this meta-
identify unpublished studies, raising the analysis and the results must therefore be
possibility that some studies have been interpreted with caution.
missed. Secondly, despite the extensive
literature search, only Medline™, EMBASE™ Conflicts of interest
and The Cochrane Library were included in The authors had no conflicts of interest to
the search; and other databases such as the declare in relation to this article.

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 X-Y Yan, S-M Huang, C-Q Huang et al.
Marital status and risk for depression: a meta-analysis

Study RR (random) Weight RR (random)

or sub-category 95% CI % 95% CI
Others vs married
Mendes de Leon et al. 199420 5.14 2.75 (1.77, 4.27)
Forsell 200021 2.59 1.85 (0.71, 4.79)
Geerlings et al. 200222 4.31 2.10 (1.18, 3.74)
Kennedy et al. 199023 6.05 0.85 (0.63, 1.13)
Meller et al. 199724 5.25 1.29 (0.85, 1.97)
Schoevers et al. 200025 6.50 1.02 (0.83, 1.25)
Stek et al. 200626 4.90 0.79 (0.49, 1.28)
Turvey et al. 199927 6.38 1.71 (1.36, 2.15)
Subtotal (95% CI) 41.14 1.36 (1.01, 1.84)
Total events: 539 (unmarried), 515 (married)
Test for heterogeneity: χ2 = 37.71, d.f. = 7 (P < 0.00001), I 2 = 81.4%
Test for overall effect: Z = 2.03 (P = 0.04)

Widowed vs married
Mendes de Leon et al. 199420 5.14 2.75 (1.77, 4.27)
Forsell 200021 2.48 1.96 (0.73, 5.24)
Kennedy et al. 199023 6.00 1.01 (0.75, 1.36)
Turvey et al. 199927 6.37 1.79 (1.43, 2.26)
Subtotal (95% CI) 20.01 1.71 (1.09, 2.68)
Total events: 288 (unmarried), 248 (married)
Test for heterogeneity: χ2 = 16.16, d.f. = 3 (P = 0.001), I 2 = 81.4%
Test for overall effect: Z = 2.33 (P = 0.02)

Never vs married
Forsell 200021 1.84 1.53 (0.45, 5.20)
Kennedy et al. 199023 3.62 0.36 (0.18, 0.72)
Turvey et al. 199927 4.33 1.73 (0.98, 3.08)
Subtotal (95% CI) 9.79 0.96 (0.30, 3.08)
Total events: 25 (unmarried), 194 (married)
Test for heterogeneity: χ2 = 13.15, d.f. = 2 (P = 0.001), I 2 = 84.8%
Test for overall effect: Z = 0.07 (P = 0.94)

Divorced vs married
Forsell 200021 1.19 1.93 (0.39, 9.68)
Turvey et al. 199927 5.37 2.15 (1.44, 3.22)
Subtotal (95% CI) 6.56 2.14 (1.45, 3.16)
Total events: 29 (unmarried), 117 (married)
Test for heterogeneity: χ2 = 0.02, d.f. = 1 (P = 0.90), I 2 = 0%
Test for overall effect: Z = 3.81 (P = 0.0001)

Widowed vs divorced
Forsell 200021 1.44 1.01 (0.24, 4.26)
Turvey et al. 199927 5.47 0.83 (0.57, 1.23)
Subtotal (95% CI) 6.91 0.84 (0.58, 1.23)
Total events: 194 (unmarried), 29 (married)
Test for heterogeneity: χ2 = 0.07, d.f. = 1 (P = 0.80), I 2 = 0%
Test for overall effect: Z = 0.89 (P = 0.38)

Divorced vs never
Forsell 200021 1.20 1.26 (0.25, 6.31)
Turvey et al. 199927 3.89 1.24 (0.65, 2.39)
Subtotal (95% CI) 5.09 1.25 (0.68, 2.28)
Total events: 29 (unmarried), 17 (married)
Test for heterogeneity: χ2 = 0.00, d.f. = 1 (P = 0.99), I 2 = 0%
Test for overall effect: Z = 0.71 (P = 0.48)

Widowed vs never
Forsell 200021 2.50 1.28 (0.48, 3.41)
Kennedy et al. 199023 3.61 2.83 (1.39, 5.75)
Turvey et al. 199927 4.39 1.04 (0.59, 1.82)
Subtotal (95% CI) 10.50 1.54 (0.79, 3.01)
Total events: 265 (unmarried), 25 (married)
Test for heterogeneity: χ2 = 4.98, d.f. = 2 (P = 0.08), I 2 = 59.9%
Test for overall effect: Z = 1.28 (P = 0.20)

Total (95% CI) 100.0 1.38 (1.14, 1.68)

Total events: 1369 (unmarried), 1145 (married)
Test for heterogeneity: χ2 = 90.23, d.f. = 23 (P < 0.00001), I 2 = 74.5%
Test for overall effect: Z = 3.29 (P = 0.001)
0.1 0.2 0.5 1.0 2.0 5.0 10.0
Favours treatment Favours control

FIGURE 3: Forest plot of the relative risk (RR) for depression from the eight
prospective longitudinal studies that compared the risk for depression between
married and unmarried people ≥ 55 years of age20 – 27

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 X-Y Yan, S-M Huang, C-Q Huang et al.
Marital status and risk for depression: a meta-analysis
• Received for publication 3 February 2011 • Accepted subject to revision 18 February 2011
• Revised accepted 16 June 2011
Copyright © 2011 Field House Publishing LLP
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Author’s address for correspondence
Professor Song-Min Huang
Department of Nephrology, The West China Hospital of Sichuan University, Guoxuexiang 37,
Chengdu, Sichuan 610041, China.
E-mail: hsongm@medmail.com.cn
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