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Loneliness and depression among rural empty-nest elderly adults in Liuyang, China: a cross-sectional study

Objective To compare loneliness, depressive symptoms and major depressive episodes between empty-nest and not-empty-nest older adults in rural areas of Liuyang city, Hunan, China. Methods A cross-sectional multi-stage random cluster survey was conducted from November 2011 to April 2012 in Liuyang, China. A total of 839 rural older residents aged 60 or above completed the survey (response rate 97.6%). In line with the definition of empty nest, 25 participants who had no children were excluded from the study, while the remaining 814 elderly adults with at least one child were included for analysis. Loneliness and depressive symptoms in rural elderly parents were assessed using the short-form UCLA Loneliness Scale (ULS-6) and the Geriatric Depression Scale (GDS). Major depressive episodes were diagnosed using the Structured Clinical Interview for DSM-IV (SCID-I). Results Significant differences were found between empty-nest and not-empty-nest older adults regarding loneliness (16.19±3.90 vs. 12.87±3.02, Cohen’s d=0.97), depressive symptoms (8.50±6.26 vs. 6.92±5.19, Cohen’s d=0.28) and the prevalence of major depressive episodes (10.1% vs. 4.6%) (all p<0.05). After controlling for demographic characteristics and physical disease, the differences in loneliness, depressive symptoms and major depressive episodes remained significant. Path analysis showed that loneliness mediated the relationship between empty-nest syndrome and depressive symptoms and major depressive episodes. Conclusion Loneliness and depression are more severe among empty-nest than not-empty-nest rural elderly adults. Loneliness was a mediating variable between empty-nest syndrome and depression.

the rapid increase in the size of the older adult population, and known associations between living alone, loneliness, depression, and suicide risk. The authors report finding an association between empty nester status and loneliness, but no association with the other mental health outcomes. The paper is interesting to read but has limitations both in its conceptualization and in specifics of the methods and rendering of the findings that reduce its value.
I have two conceptual concerns. The first relates to the construct of the "empty nest". As defined here, it includes both older adults who are not living with their children (but could be living with other family members) and those who had no children (and also may or may not be living alone). In the West the term "empty nest" ordinarily refers only to parents whose children have left home. Those who never had children would not be subject to the feelings of grief and despair to which the "empty nest syndrome" typically refers. So the use of the term here does not translate well to a US audience, and actually may explain the lack of observed associations with depression and SI. It would be of greater clinical and policy importance perhaps, therefore, to limit the "empty nest" group to those who did have children, but the children had moved away (ie, include those who never had children in the non-empty nest group; although this may result in greater sample size problems.) Similarly, it seems off the mark to call "empty nest" a residential status or living situation, since it does not communicate anything about whether the person is living alone or with others. So that core construct is a bit blurry.
The second concern is relatedthat there is no definition of "loneliness" given and a lack of clarity about why the construct is significant. Loneliness is ordinarily defined in the research literature as perceived social isolation, a painful state in which one"s psychological need for social connectedness is unmet. But how do the authors see it being related to depression and SI? It would be interesting if the authors more fully developed the hypothesized associations between the empty nest, loneliness, and the other dependent variables.
Also, loneliness has significant impacts on other health outcomes besides depression and suicide risk, such as diabetes, heart disease, all cause mortality, dementia and more. Because the association between empty nest and loneliness was significant, the implications for this finding for other health outcomes not tested here warrants discussion, even though the findings regarding the mental health outcomes were negative.
Other more specific and minor concerns include these: Introduction: The order in which the argument is laid out is hard to follow. Eg, the concept and epidemiological correlates of empty nest are introduced in the first paragraph, but it is not defined until the third paragraph; and the conceptual model (or relationships between the variables) is unclear.
Methods: The high response rate is a strength, as is the sampling strategy. Also, it is good to see that the study attempted to control data quality including by test-retest reliability exercises. It would be helpful to know the results of that testing.
How did the interviewers manage the situations in which there were two or more older adults living in one home who met criteria for inclusion?
Discussion: Do the authors have an idea why the prevalence of the empty nest status appears to have been so much lower (<8%) than the figures cited in the introduction?
The difference between groups on the ULS-8 is statistically significant, but is it clinically significant?
The language used to describe the findings goes a bit far sometimes. Eg, the first sentence of the discussion suggests a causal relationship when no such conclusion can be drawn from a cross sectional study. Also the concluding statement of that first paragraph (that "loneliness is a serious mental health issue of empty-nest elderly") is not justified by the findings.

Reviewer: 1
Reviewer Name: Tonelle Handley Institution and Country: University of Newcastle, Australia 1) How were the original two townships selected? It is not specified whether this initial selection was random or not.
The two townships were randomly selected. We have included this point in the revised manuscript.
2) Why was the Patient edition of the SCID used? The patient edition is designed for psychiatric patients, whereas the non-patient edition is recommended for community surveys and other studies in which the subjects are not identified as psychiatric patients.
In this study, we only used the MAJOR DEPRESSION EPISODE part of the MOOD DISORDERS section in SCID. They are the same in the SCID-P and SCID-NP. We have revised it to avoid confusion.
3) Despite previous research finding that depressive symptoms were higher in empty nest adults, the current study found no differences between empty nest and non-empty nest adults for depressive symptoms, depression or suicidal ideation. There is some discussion around potential explanations for this, however an exploration of the methodological differences between this study and previous research would also be beneficial.
We have revised our analyses and discussion as described above.
4) The main variables of interest in this study are loneliness, depressive symptoms, depression and suicidal ideation. Yet each of these variables are explored in isolation. It would be interesting to explore the relationships between these variables, including any possible interaction effects, as it is likely that these factors are related and may interact in their relationship with the outcome.
We have revised our analyses and discussion as described above. The interaction among the outcomes was analyzed using path analysis.

Reviewer: 2
Reviewer Name: Yeates Conwell Institution and Country: University of Rochester Medical Center, USA Competing Interests: None declared This is an interesting manuscript has as its objective to explore the relationships among older adult Chinese between not living with one"s children or not having children (termed "empty nesters") on one hand and loneliness and a series of mental health outcomes (depressive symptoms, major depressive episode, and suicidal ideation) on the other. This is an important issue because of the pronounced changes in demographic shifts over recent years in China (including changes in family structure and internal migration), the rapid increase in the size of the older adult population, and known associations between living alone, loneliness, depression, and suicide risk. The authors report finding an association between empty nester status and loneliness, but no association with the other mental health outcomes. The paper is interesting to read but has limitations both in its conceptualization and in specifics of the methods and rendering of the findings that reduce its value. I have two conceptual concerns. The first relates to the construct of the "empty nest". As defined here, it includes both older adults who are not living with their children (but could be living with other family members) and those who had no children (and also may or may not be living alone). In the West the term "empty nest" ordinarily refers only to parents whose children have left home. Those who never had children would not be subject to the feelings of grief and despair to which the "empty nest syndrome" typically refers. So the use of the term here does not translate well to a US audience, and actually may explain the lack of observed associations with depression and SI. It would be of greater clinical and policy importance perhaps, therefore, to limit the "empty nest" group to those who did have children, but the children had moved away (ie, include those who never had children in the nonempty nest group; although this may result in greater sample size problems.) Similarly, it seems off the mark to call "empty nest" a residential status or living situation, since it does not communicate anything about whether the person is living alone or with others. So that core construct is a bit blurry.
The second concern is related -that there is no definition of "loneliness" given and a lack of clarity about why the construct is significant. Loneliness is ordinarily defined in the research literature as perceived social isolation, a painful state in which one"s psychological need for social connectedness is unmet. But how do the authors see it being related to depression and SI? It would be interesting if the authors more fully developed the hypothesized associations between the empty nest, loneliness, and the other dependent variables.
We have revised the definition of empty-nest and added the definition of loneliness in the revised MS.
Also, loneliness has significant impacts on other health outcomes besides depression and suicide risk, such as diabetes, heart disease, all cause mortality, dementia and more. Because the association between empty nest and loneliness was significant, the implications for this finding for other health outcomes not tested here warrants discussion, even though the findings regarding the mental health outcomes were negative.
We have added this point in the discussion.
Other more specific and minor concerns include these: Introduction: The order in which the argument is laid out is hard to follow. Eg, the concept and epidemiological correlates of empty nest are introduced in the first paragraph, but it is not defined until the third paragraph; and the conceptual model (or relationships between the variables) is unclear.
We have re-written the introduction part.
Methods: The high response rate is a strength, as is the sampling strategy. Also, it is good to see that the study attempted to control data quality including by test-retest reliability exercises. It would be helpful to know the results of that testing.
We have reported the test-retest reliability in the revised manuscript.
How did the interviewers manage the situations in which there were two or more older adults living in one home who met criteria for inclusion?
In this situation, we interview them both.
Discussion: Do the authors have an idea why the prevalence of the empty nest status appears to have been so much lower (<8%) than the figures cited in the introduction?
After revising the operational definition of empty-nest, the prevalence was 41.2%.
The difference between groups on the ULS-8 is statistically significant, but is it clinically significant?
We have added Cohen D to describe the clinical significance of loneliness and depressive symptoms.
The language used to describe the findings goes a bit far sometimes. Eg, the first sentence of the discussion suggests a causal relationship when no such conclusion can be drawn from a cross sectional study. Also the concluding statement of that first paragraph (that "loneliness is a serious mental health issue of empty-nest elderly") is not justified by the findings.
We have re-written the discussion based on this comment and tried to avoid over-statement when interpreting our results.

REVIEWER
Tonelle Handley University of Newcastle, Australia REVIEW RETURNED 16-Feb-2017

GENERAL COMMENTS
Thank you for responding to the concerns raised in my previous review. I have no further comments.

Yeates Conwell
University of Rochester Medical Center USA REVIEW RETURNED

22-Feb-2017
GENERAL COMMENTS This is a revised and resubmitted paper the major change in which is redefinition of the "empty nest" sample. Revised analyses yield more interesting and positive findings of differences between empty nesters and non-empty nest older adults in depressive symptoms and major depressive episode diagnoses, and indicate through path analyses that loneliness mediates the relationship. As before, the paper is interesting and important by virtue of its focus on rural older adults given their rapid growth as a segment of the population and the importance of internal migration in China that results in so many children moving out of their home villages to the city leaving empty nest elders behind. This is a complex and dynamic situation of course. For example, elders whose children are healthy enough to take higher paying jobs in cities may indirectly benefit in ways that offset the psychological challenges of the empty next. The study begins to get at some of these questions. Others, it could expand on further. Abstract 1. The paper has become an examination of older adults in rural China with children, given the exclusion of childless elders from the sample. The abstract should introduce this notion as an objective of the study and note in the methods section that the sample is limited to those with children. The abstract should also introduce the notion of the empty nest in its opening sections. Introduction 1. The paper would be made stronger by some brief reference in the introduction to studies addressing the psychological impact of children leaving the parents" home (ie, the empty nest). Depression and loneliness are consequences examined here, but as background, understanding the psychological dynamics of why loneliness and depression might result would be useful to help establish the developmental context for the study. 2. A clear definition of the term "empty nest" as it is used here, and how it differs from other studies referenced, should be provided. 3. The construct of suicidal ideation as a correlate of empty nest status is introduced only in the last paragraph of the introduction without any justification for why it might be pertinent to examine. Maybe it is obvious, but some justification for inclusion of suicidal ideation as an outcome variable in the introduction is warranted. Alternatively, it could be deleted from the analysis. 4. Similarly, some justification for why you pose the hypothesis that loneliness mediates the relationship between empty nest status and depression should be included. This could be done by simply referencing the work of Hawkley and Cacioppo (eg, Annals of Behavioral Medicine, 40 (2), 218-227). Methods 1. It would be help with conciseness and clarity to provide a clear definition of the comparison group as well as the empty nest sample early in the methods section. 2. It is a minor point, but it may also be useful to describe that living with others besides ones children, cognitive impairment, or duration of separation from ones children were not exclusion criteria.
3. Please provide a little more information about how the dichotomous variable for physical disease was derived from the interview question: "participants were asked to report their physical diseases". 4. As I understand it from your previous response, it is possible that both parents would be included from a given household. If so, this should be acknowledged, and some description given of how many instances there were in each group. I defer to a statistician on whether this design feature requires use of "nested" analyses. Discussion 1. The discussion is well done. I particularly appreciate the inclusion of implications of the findings for preventive interventions to decrease depression and loneliness in empty nest elders. 2. It is reasonable to list as a limitation of the study that its findings are not necessarily applicable to urban elders. However, I see it as a real strength of the paper that its focus is specifically and solely on rural elders for reasons noted abovethat they are a large segment of the population and growing rapidly, and that internal migration in China is chiefly a phenomenon of rural to urban moves. It may be worth underscoring the importance of this specific focus somewhat more in the discussion. 3. In the second paragraph of the discussion you make the statement that, "our results indicate that adult children and spouses are important resources of social support for rural elderly". Why mention spouses here? I don"t see how these results yield that conclusion. 4. You also might consider adding a brief bit to the discussion on limitations/future directions regarding the need to examine other factors that may moderate the relationships observed here. These might include the quality of the parent-child relationship, the nature of their ongoing contacts following separation, and other potentially moderating factors related to social supports that do remain available to the older person after the children have departed (eg, other family and friends and sources of "social capital").
Overall the paper is much improved. Thank you for the contribution to our understanding of family factors in late life depression.

Tingting Zhan
Thomas Jefferson University, USA REVIEW RETURNED 01-May-2017 Introduction 1. The paper would be made stronger by some brief reference in the introduction to studies addressing the psychological impact of children leaving the parents" home (ie, the empty nest). Depression and loneliness are consequences examined here, but as background, understanding the psychological dynamics of why loneliness and depression might result would be useful to help establish the developmental context for the study.
We have cited a reference about the social and psychological effects of the emigration of adult children on non-immigrant Indian patents (paragraph 1, last sentence). This may help understanding the importance of loneliness and depression.
2. A clear definition of the term "empty nest" as it is used here, and how it differs from other studies referenced, should be provided.
We have introduced our definition of "empty-nest" in the introduction section (paragraph 3, last sentence).
3. The construct of suicidal ideation as a correlate of empty nest status is introduced only in the last paragraph of the introduction without any justification for why it might be pertinent to examine. Maybe it is obvious, but some justification for inclusion of suicidal ideation as an outcome variable in the introduction is warranted. Alternatively, it could be deleted from the analysis.
Yes, we agree with the reviewer. We have deleted the analysis on suicidal ideation for it is probably an indicator of life distress, and is only remotely related to suicide behavior.
4. Similarly, some justification for why you pose the hypothesis that loneliness mediates the relationship between empty nest status and depression should be included. This could be done by simply referencing the work of Hawkley and Cacioppo (eg, Annals of Behavioral Medicine, 40 (2), 218-227).
We have added this point in our hypothesis.
Methods 1. It would be help with conciseness and clarity to provide a clear definition of the comparison group as well as the empty nest sample early in the methods section.
We have clearly described the two groups in page 6, last line.
2. It is a minor point, but it may also be useful to describe that living with others besides ones children, cognitive impairment, or duration of separation from ones children were not exclusion criteria.
We have added this point in the method section, page 6, line 7.
3. Please provide a little more information about how the dichotomous variable for physical disease was derived from the interview question: "participants were asked to report their physical diseases".
We have added some description in this section.
4. As I understand it from your previous response, it is possible that both parents would be included from a given household. If so, this should be acknowledged, and some description given of how many instances there were in each group. I defer to a statistician on whether this design feature requires use of "nested" analyses.
Among the 814 participants, 436 were couples (218 couples). We have added this point in the results section, Discussion 1. The discussion is well done. I particularly appreciate the inclusion of implications of the findings for preventive interventions to decrease depression and loneliness in empty nest elders. 2. It is reasonable to list as a limitation of the study that its findings are not necessarily applicable to urban elders. However, I see it as a real strength of the paper that its focus is specifically and solely on rural elders for reasons noted abovethat they are a large segment of the population and growing rapidly, and that internal migration in China is chiefly a phenomenon of rural to urban moves. It may be worth underscoring the importance of this specific focus somewhat more in the discussion.
We have added one sentence in the beginning of the last paragraph, trying to say a bit more on this point.
3. In the second paragraph of the discussion you make the statement that, "our results indicate that adult children and spouses are important resources of social support for rural elderly". Why mention spouses here? I don"t see how these results yield that conclusion.
We found that unstable marital status is also a risk factor of loneliness among rural elderly. We think that spouses, as well as adult children, are important resources of social support for rural elderly.
5. You also might consider adding a brief bit to the discussion on limitations/future directions regarding the need to examine other factors that may moderate the relationships observed here. These might include the quality of the parent-child relationship, the nature of their ongoing contacts following separation, and other potentially moderating factors related to social supports that do remain available to the older person after the children have departed (eg, other family and friends and sources of "social capital").
We have added this point in the limitation section, last paragraph.
Overall the paper is much improved. Thank you for the contribution to our understanding of family factors in late life depression.

GENERAL COMMENTS
Thank you for carefully considering my concerns.