Aging & Mental Health

ISSN: 1360-7863 (Print) 1364-6915 (Online) Journal homepage: https://www.tandfonline.com/loi/camh20

Widowhood and depression: a longitudinal study

of older persons in rural China

Jie Xu, Zheng Wu, Christoph M. Schimmele & Shuzhuo Li

To cite this article: Jie Xu, Zheng Wu, Christoph M. Schimmele & Shuzhuo Li (2019): Widowhood
and depression: a longitudinal study of older persons in rural China, Aging & Mental Health, DOI:
10.1080/13607863.2019.1571016

To link to this article: https://doi.org/10.1080/13607863.2019.1571016

Published online: 10 Feb 2019.

Submit your article to this journal

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=camh20
AGING & MENTAL HEALTH
https://doi.org/10.1080/13607863.2019.1571016

Widowhood and depression: a longitudinal study of older persons in

rural China
Jie Xua, Zheng Wub , Christoph M. Schimmelec and Shuzhuo Lid
a
Institute for Population and Development Studies, School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an, Shaanxi
Province, P. R. China; bDepartment of Gerontology, Simon Fraser University, Vancouver, BC, Canada; cStatistics Canada, Ottawa, ON,
Canada; dInstitute for Population and Development Studies, School of Public Policy and Administration, Xi’an Jiaotong University, Xi’an,
Shaanxi Province, P. R. China

ABSTRACT ARTICLE HISTORY

Using six waves of longitudinal data (2001–2015) collected in Anhui, China (N ¼ 2,131) and general- Received 3 August 2018
ized estimating equations (GEE) models, this study fulfilled several objectives. First, the study com- Accepted 2 January 2019
pared the widowed to the married to examine if the transition to and duration of widowhood
KEYWORDS
contributes to changes in depression. Second, the study examined if the bereavement-depression
Widowhood effect;
relationship is a process that precedes widowhood or is an abrupt change following the death of bereavement; depression
a spouse. Third, the study examined if social resources influence the bereavement-depression rela-
tionship. The study found that there is pre-widowhood effect on depression and that the widow-
hood event also contributes to increases in depression. Levels of post-widowhood depressive
symptoms peak during the first six months bereavement and taper off within 25 months.
Controlling for social support, contact with children, and living arrangements does not change the
bereavement-depression relationship. The findings support Attachment Theory, which suggests
that the loss of a spouse leads to emotional isolation that cannot be overcome with kin-based
social support and social integration.

Widowhood is a stressful life transition and associates with
a wide range of negative mental health outcomes (Stroebe,
Schut, & Stroebe, 2007). These outcomes include mood dis-
orders such as depression and anxiety as well as cognitive
(e.g. lower self-esteem) and behavioral (e.g. social with-
drawal) reactions that increase the risk of mood disorders
or intensify their consequences. These negative outcomes
(termed the widowhood effect) are a short-lived experience
for the majority of widowed persons, but 10–20% experi-
ence clinical or major depression and 25–45% experience
subclinical depression (Mendes de Leon, Kasl, & Jacobs,
1994; Stroebe et al., 2007). The widowhood effect has been
observed across many countries (Boyle, Feng, and Raab,
2011), but our knowledge is still based largely on studies
from Western countries and mostly White study samples.
There is a limited amount of evidence that suggests that
widowhood is a threat to the mental well-being of Chinese
persons (Guo, Chi, & Silverstein, 2015; Li et al., 2005).
To our knowledge, only two longitudinal studies have
considered the widowhood effect on depression in the
Chinese context. Li et al. (2005) examined this effect on
CES-D (Center for Epidemiologic Studies Depression Scale)
outcomes for respondents aged 60 and older from Wuhan,
China. The authors observed a pre- and post-widowhood
effect. Individuals widowed between the baseline (1991)
and follow-up (1994) interviews had higher CES-D scores
than the continuously married at the baseline interview
and also at the follow-up interview, controlling for baseline
depression and other factors. Using four waves of longitu-
dinal data (2001–2009), Guo, Chi, and Silverstein (2015)
found that widowhood contributes to increases in depres-
sive symptomatology for men, but not women. The key
limitation of both studies is that their measurement of
recent widowhood combined respondents widowed for
between 0 and 36 months, which obscures the shorter-
term effects of widowhood. According to longitudinal stud-
ies from other countries, post-widowhood levels of depres-
sive symptoms reach a pinnacle in the first 6 months of
bereavement, flatten out after 12 months, and return to
pre-widowhood levels after about 24 months (Carnelley,
Wortman, & Kessler, 1999; Mendes de Leon et al., 1994;
Sasson & Umberson, 2014; Vable et al., 2015).
This study aims to document similarities between the
widowhood effect in the Chinese context and what has
been observed in Western countries. Cross-cultural similar-
ities would support the notion that the widowhood effect is
a ubiquitous phenomenon rather than a subjective experi-
ence that is rooted in cultural factors. However, research
from the United States offers compelling evidence for cul-
tural heterogeneity. This research suggests that some non-
White cultural groups are able to avoid the widowhood
effect (on mortality) because their sources of social support
and integration are comparatively less marriage-centric
(Elwert & Christakis, 2006). Since social ties and resources
are central to this explanation, the processes that contribute
to post-widowhood differences in mortality are presumably
relevant to depression, given that social support is well-
known to influence the outcomes of stressful life events
(Pearlin et al., 1981). Hence, this study considers whether
Chinese cultural practices (e.g. filial piety) influence the con-
sequences of widowhood for depression.

CONTACT Zheng Wu z_wu@sfu.ca

ß 2019 Informa UK Limited, trading as Taylor & Francis Group
2 J. XU ET AL.
Conceptual background
The Deficit Model of Partner Loss applies stress theory to
bereavement outcomes and focuses on the indirect conse-
quences of bereavement (Stroebe, Stroebe, Abakoumkin, &
Schut, 1996). When a spouse dies, widows often face finan-
cial strain and widowers face the loss of an emotional con-
fidant and instrumental support (Li et al., 2005). According
to the Deficit Model, these secondary stressors are a major
reason for post-widowhood increases in depression
(Stroebe et al., 1996). Evidence from China is consistent
with this position, showing that greater dependency on a
spouse for social support increases vulnerability to depres-
sion in widowhood (Li et al., 2005). The Deficit Model pos-
its that social support from network members can mitigate
(though not eliminate) these secondary stressors to the
extent that network members replace the social support
that the deceased spouse provided (Stroebe et al., 1996).
The need for social support is expected to peak during the
first 12 months of bereavement, which is the period of
greatest role change and emotional need (Stroebe, 1994).
Since previous Chinese studies do not adequately account
for recency of widowhood, their findings on whether social
support mitigates the bereavement-depression relationship
are inconclusive.
In China, the extended family is the primary source of
social support for older people, especially in rural areas (Li
et al., 2005). Chinese culture emphasizes filial piety and
adult children are expected to provide for their aging
parents. Under China’s Marriage Law of 1980, older parents
who cannot care for themselves have the right to financial
and instrumental support from their adult children (Krause
& Liang, 1993). Because of the absence of adequate public
welfare, adult children are the primary sources of support
for rural elders (Silverstein, Cong, & Li, 2006). Co-residence
with adult children is a common living arrangement for
older Chinese parents, and it represents the strictest fulfill-
ment of filial piety. Insufficient social support from children
can increase vulnerability to depression through unmet
instrumental and financial needs, poor intergenerational
relations, and feelings of helplessness (Cong & Silverstein,
2008). In the context of filial piety, kin-based social support
has value besides its functional elements. Support from
children and grandchildren can also be conceptualized as a
cultural good because it represents a sign of respect that
associates with the self-esteem of older persons.
The comparatively high prevalence of co-residence in
China represents a cultural resource that could reduce the
impact of widowhood on depression. The psychological
benefits of co-residence are irreducible to access to social
support, and this points attention to the structural aspects
of social relationships. Silverstein et al. (2006) found that
older Chinese adults living in stem families (i.e., with adult
Table 1. Theoretical models and associated hypotheses.
Model
Pre-widowhood depression The near widowed will have elevated depressive symptoms at baseline, controlling for the provision of
anticipatory grief social support
Caregiver burden The near widowed will have elevated depressive symptoms at baseline, but the provision of social support will
explain this outcome
Duration effect The widowhood effect will be strongest during the first six months of bereavement and attentuate over time
Stress process theory deficit model The widowhood effect will represent a loss of social support
Social isolation The widowhood effect will represent a loss of social integration
Attachment theory The widowhood effect will represent a loss of an attachment figure
children and grandchildren) have lower depressive symp-
toms than those living alone, controlling for social support
and other risk factors. The negative effect of living alone is
no different for respondents whose children live inside or
outside the village, which points to the intrinsic benefits of
co-residence rather than geographic proximity. Stem fami-
lies appear to be a structural arrangement that integrates
older people into their social network through conferring
on them a “culturally sanctioned role” and sense of pur-
pose. In contrast, living with adult children only has a non-
significant effect on depression, according to Silverstein
et al. (2006). Whether living in a stem family (versus other
living arrangements) influences the impact of widowhood
is unknown.
In the literature on attachment theory, there is a distinc-
tion between the social and emotional isolation that associ-
ates with widowhood. Social loneliness is a condition that
a social network can mitigate through providing compan-
ionship and a sense of belonging (Weiss, 1975). In contrast,
emotional loneliness refers to the absence of an attach-
ment figure and represents a “sense of utter aloneness”
that occurs even if companionship and social support are
available from relatives and friends (Stroebe et al., 1996).
Hence, attachment theory rejects the notion that network-
based support can compensate for the loss of a spouse
(Stroebe et al., 1996). This theory posits that the widow-
hood effect is not simply an outcome of unmet needs or
the stress of role change. In this perspective, the spouse is
an attachment figure who provides feelings of security and
emotional sustenance that are difficult to replace. This the-
ory has considerable face-value. In previous studies, the
widowhood effect remains after controlling for social sup-
port, which tends to have a weak or non-significant influ-
ence on levels of depression among the widowed (
Dimond, Lund, & Caserta, 1987; Li et al., 2005).
Hypotheses
Table 1 summarizes our hypotheses. Our first hypothesis is
that the widowhood effect on depression is a process that
precedes the widowhood event. This pre-widowhood effect
could represent anticipatory grief, caregiver burden, or a
combination of these factors (Lee & DeMaris, 2007; Vable
et al., 2015). Our analysis controls for the pre-widowhood
provision of instrumental support, which helps disentangle
the effect of anticipatory grief from the effect of caregiver
burden. If caregiver burden is a major reason for the pre-
widowhood effect, we would expect to observe a post-
widowhood decrease in depressive symptomology, since
the stress associated with caregiving would abate after the
spouse dies. Our second hypotheses posits that the widow-
hood effect involves an abrupt increase in depressive
symptoms upon the death of a spouse. The increase in
Hypothesis

Figure 1. Sample Selection and Attrition in the Longitudinal Study of Older
People in Anhui, China: 2001–2015.
post-widowhood depression will be strongest in the first
six months of bereavement and taper off overtime.
Following stress process theory, we propose that depres-
sive symptoms will increase because of losses of social sup-
port (the Deficit Model) and/or because of social isolation.
After controlling for social support and aspects of social
integration (e.g. co-residence, network size, frequency of
contact with children), our default hypothesis is that the
widowhood effect will represent the direct effect of grief
associated with the loss of an attachment figure.
Data and methods
Sample
The empirical analysis used six waves of primary data from
the Longitudinal Study of Older People in Anhui Province.
The survey was conducted in Chaohu, a primarily agricul-
tural region in the central part of Anhui Province with a
population of 4.5 million people. This region was selected
as the study site because of its high-level of out-migration
of working-age adults to urban areas, which has limited
the amount of social support available for older adults. The
baseline survey was conducted in April 2001 and five fol-
low-up surveys were conducted in November 2003,
December 2006, June 2009, September 2012, and
September 2015. Using a stratified multistage sampling
method, respondents were selected from 72 randomly
selected villages within 6 randomly selected rural
AGING & MENTAL HEALTH 3
townships. Using administrative records, residents aged 60
and older were identified and randomly selected from
household rosters, with an oversampling of individuals
aged 75 and older. The surveys were conducted in the
respondents’ homes and included questions on family rela-
tions, intergenerational transfers, and sociodemographic
characteristics as well as assessments of physical and men-
tal health. The original questionnaire was written in English
and we used a standard back-translation method to ensure
the accuracy of the Mandarin-translated questionnaire.
Of the 1,800 respondents in the baseline sample, 1,715
completed the survey, yielding a response rate of 95.3%.
The 2009 (wave 4) survey recruited 416 new participants
aged 60-67 randomly selected from the same villages. The
original and replenished samples were followed up in 2012
and 2015. The sample sizes for the follow-up surveys are
1391, 1067, 808, 979, and 764, respectively. The response
rates for each follow-up survey ranged between 75.7% and
81.1%. The rates of sample attrition due to death were
14.0%, 17.0%, 16.2%, 14.5%, and 15.7%, respectively, leav-
ing a small amount of attrition due to out-migration or
refusal to participate in the follow-ups. Only one person
per household was included in the survey. The final study
sample includes 2,131 respondents and 7,129 (person-year)
observations. At baseline, 1,162 were married, 762 were
widowed, and 207 were in other marital statuses. A flow
chart showing sample selection and attrition is presented
in Figure 1.
Measures
We used a short form of the Center for Epidemiological
Studies Depression Scale (CES-D) to measure depressive
symptomatology in older adults (Radloff, 1977). We
adapted a subset of the CES-D scale that was developed
and tested for Chinese older adults in the Study of Health
and Living Status of the Elderly in Taiwan (Hermalin, 2002).
The 9-item scale includes three questions on positive affect
(feeling happy, enjoying life, feeling pleasure), two ques-
tions on negative affect (feeling lonely, feeling upset), two
questions on marginalization (feeling useless, having noth-
ing to do), and two questions on somatic symptoms (hav-
ing poor appetite, having trouble sleeping). Respondents
were asked how often they experienced each of the symp-
toms in the past week with three response options: (a)
rarely or none of the time (0), (b) some of the time (1), or
(c) most of the time (2). The positive items were reverse
coded and all items were summed, resulting in a continu-
ous variable ranging from 0 to 18, with a higher score indi-
cating higher depressive symptomatology. The reliability
coefficient (Cronbach’s alpha) for the scale based on the
baseline data is 0.78. Table 2 presents the descriptive statis-
tics for average CES-D scores at baseline and all other
selected variables.
The principal independent variable in our analysis is
marital status. For the purpose of our study, in the multi-
variate regressions, marital status was measured with four
categories: (a) respondents who were married at baseline
and remained married throughout the observation period
(the continuously married); (b) respondents who became
widowed between follow-up waves (transition to widow-
hood); (c) respondents who were widowed at baseline and
remained widowed throughout the observation period (the
4 J. XU ET AL.

Table 2. Descriptive statistics for variables used in the analysis: Rural Chinese Elders Aged 60þ, 2001, 2009.
Women Men
Mean or % S.D. Mean or % S.D. p-valuea
CES-D score (range: 0–18) 6.44 4.08 5.62 4.02 0.000
Marital status
Married 46.4% 63.4% 0.000
Widowed 48.3% 22.1% 0.000
Divorced/never married 5.3% 14.5% 0.000
Demographics
Age (range: 60–89) 72.07 7.82 69.71 6.80 0.000
Number of children alive (range: 0–10) 3.85 1.58 3.62 1.78 0.001
Socioeconomic status
Formal education (1 ¼ yes) 9.3% 43.7% 0.000
Logged household income in yuan (range: 0–10) 3.27 3.69 5.05 3.46 0.000
Health status
ADLs (range: 0–30) 6.8 7.6 3.2 6.0 0.000
Self-reported health (1 ¼ excellent/good) 23.2% 32.2% 0.000
Chronic illness (1 ¼ yes) 89.0% 81.4% 0.000
Living arrangement
With children and grandchildren 21.9% 19.6% 0.198
With children only 11.0% 7.5% 0.005
With grandchildren only 18.8% 18.9% 0.949
Closest child lives in village 33.4% 29.4% 0.048
All children live beyond village 14.9% 24.6% 0.000
Contact with children (range: 0–42) 11.08 6.83 10.06 6.90 0.001
Kin support
Logged financial support received (range: 0–11) 6.28 1.79 5.94 2.39 0.000
Logged financial support provided (range: 0–10) 1.25 2.26 1.72 2.58 0.000
Instrumental support received (range: 0–52) 4.57 6.66 2.95 6.02 0.000
Instrumental support provided (range: 0–56) 3.98 5.69 3.08 5.06 0.000
Emotional support from children (range: 0–6) 4.48 1.41 4.47 1.31 0.860
N 1,111 1,020
a
Significance test of the gender difference on a t-test.
Source: The Longitudinal Study of Older People in Anhui Province.

continuously widowed); and (d) others. The last category
includes: (a) respondents who were never married or
divorced at baseline (n ¼ 48) and remained single or
divorced (none married/remarried during the study period)
and (b) respondents who made other union transitions (i.e.,
from widowhood or divorce to remarriage; n ¼ 17). We
combined these respondents into one group because of
the small counts in these categories and because divorce
and remarriage were rare events. Between waves, 216
respondents experienced a transition to widowhood. For
these respondents, time since widowhood was measured
in months.
Our analysis also considered whether living arrange-
ments and kin support (instrumental, financial, and emo-
tional) influences the relationship between widowhood and
depression. Following Silverstein, Cong, and Li’s (2006) typ-
ology, five different living arrangements were compared:
(a) with adult children and grandchildren (stem families),
(b) with adult children only (truncated stem families), (c)
with grandchildren only (skipped-generation families), (d)
closest child lives in the village (network families), and (e)
all children live beyond the village (isolated families). We
used dummy variables to measure these different family
types, with stem families coded as the reference group. We
selected stem families as the reference group because
these living arrangements represent the strictest fulfillment
of filial piety and offer the ideal environment for the social
integration of older adults (Chen & Silverstein, 2000). In
addition, contact with children is measured as the
frequency of contact with children in the past 12
months, ranging from seldom (1) to everyday or almost
every day (6). Contact with children is a summed score of
the frequency of contact with all children.
We considered measures of exchanges of social support
between older adults and their family members in three
domains: financial assistance, instrumental support, and
emotional support. The measure of emotional support was
restricted to exchanges between respondents and their
adult children, but the measures of financial and instru-
mental support included exchanges between respondents
and all family members, such as children, grandchildren,
and son- or daughter-in-laws. We measured financial
exchanges based on the total amount exchanged in the
past 12 months. We used two continuous variables to
measure financial transfers: one for receiving and one for
providing financial support. The total amount was meas-
ured in Chinese currency, Yuan or Renminbi. We used the
log of total financial support because the distribution of
this variable was skewed (Guo, Chi, & Silverstein, 2015).
Female respondents received an average of 1678 Yuan
(SD ¼ 3393) in the past 12 months and provided 162 Yuan
(SD ¼ 837) on average. Male respondents received an aver-
age of 1537 Yuan (SD ¼ 2853) and provided 242 Yuan
(SD ¼ 1084) on average.
We measured instrumental support based on the total
amount of support that the respondent had received from
all family members in the past 12 months. We considered
whether respondents received instrumental support
because of health-related needs, such as a functional limi-
tation. Instrumental support was measured on two task
domains: Household tasks (e.g. cooking, cleaning, and laun-
dry) and personal care tasks (e.g. bathing and dressing).
The response categories for each task are: none (0), seldom
(1), several times a month (2), at least once a week (3), and
every day (4). For the receipt of social support, the scale
reflects the sum of the responses on both tasks from all
family members. For example, a respondent who received
support at least once a week from two family members on
both task domains would have a total score of 12 on the
instrumental support scale. Using a similar scale, the
 AGING & MENTAL HEALTH 5

Table 3. Mean CES-D score by year of interview: Rural Chinese elders Aged 60þ, 2001–2015.
Marital status
Continuously married Continuously widowed Transition to widowhood N p-valuea
Women
Year of interview
2001 6.175 7.084 – 859 0.002
2003 5.895 7.532 7.588 698 0.000
2006 6.933 8.059 7.317 530 0.007
2009 6.373 7.631 7.203 398 0.018
2012 6.263 7.352 7.206 295 0.123
2015 6.242 6.974 7.154 204 0.405
Men
Year of interview
2001 5.397 6.095 – 702 0.033
2003 5.016 5.986 6.579 548 0.018
2006 5.652 6.306 7.967 418 0.007
2009 5.465 6.562 6.710 321 0.032
2012 5.227 7.309 6.306 241 0.002
2015 5.763 5.455 5.472 183 0.873
The analysis used 6-wave longitudinal data from the original panel (excluding data from the replenished sample).
a
Significance test of the difference in depression measure on a F-test.
Source: The Longitudinal Study of Older People in Anhui Province.

provision of instrumental social support was measured as
how often the respondent provided support to all family
members in the past 12 months. The measures of instru-
mental and financial support are standard measures of the
provision of need-based support. They have high face val-
idity and have been widely used in the literature (e.g. Cong
& Silverstein, 2008; Guo, Chi, & Silverstein, 2015; Silverstein,
Cong, & Li, 2006; Silverstein et al., 2013).
Emotional support was based on a three-item scale that
measures the quality of parent-child relationships. The scale
was adapted from the Affectual Solidarity Scale (Mangen,
Bengtson, & Landry, 1988), and constructed using the fol-
lowing questions: (a) “Taking everything into consideration,
how close do you feel to (this child)?”, (b) “How much do
you feel that (this child) would be willing to listen when
you need to talk about your worries and problems?” and c)
“Overall, how well do you and (this child) get along togeth-
er?” The response categories were: not at all close/not at
all/not at all well (0), somewhat close/somewhat/somewhat
well (1), and very close/very much/very well (2). The scale
was based on the sum of the three items, ranging from
0–6, for each child. To address the issue of multiple chil-
dren a respondent might have, the scale was constructed
using the highest score across all children. The reliability
coefficient (Cronbach’s alpha) for the items based on the
Wave 1 data was 0.82.
Our regression analysis included a number of control
variables. We considered three demographic variables: gen-
der, age, and number of living children. Gender was a
dummy variable and age was measured in years. Number
of living children was a continuous variable, ranging from
0 to 10 (mean ¼ 4.74 and SD ¼ 1.68). Less than 4% of the
respondents did not have any surviving children at the
baseline of the survey. Education was measured as a
dummy variable indicating whether the respondent
received any formal education. Education was originally
measured as a 4-level categorical variable: no education/
illiterate, some primary school, some middle school, and
some high school or higher. We combined the last three
categories into one group because of the small counts in
these categories (less than 25% of the respondents have
any formal education). Household income (from all sources)
was measured in Yuan or Renminbi. We considered three
health measures. Limitations in activities of daily living
(ADLs) were coded as a continuous variable based on the
sum of 15 questions on the level of difficulty in performing
personal activities (e.g. dressing, walking, getting out of
bed), instrumental activities (e.g. preparing meals, shop-
ping), and activities requiring physical strength, mobility,
and flexibility (e.g. lifting a 10-kg bag of rice, climbing one
flight of stairs). There were three response options for each
question: (a) no difficulty (0), (b) some difficulty (1), and (c)
cannot do it without help (2). Self-reported health was
coded as a dummy variable indicating whether the
respondent assessed their own health to be good/excellent
or lower. Chronic illness was measured as a dichotomous
variable indicating the presence of any chronic illnesses
(e.g. arthritis, cardiovascular diseases, cancers, diabetes mel-
litus). Except for gender and education, all variables in the
analysis are time-variant.
Statistical methods
We used conventional regression techniques to examine
the widowhood effect on depressive symptomology in
rural Chinese older adults. Specifically, we estimated a ser-
ies of ordinary least squares (OLS) models to examine pre-
widowhood depression and a series of generalized estimat-
ing equations (GEE) models (also known as marginal mod-
els) to examine post-widowhood depression, taking into
account repeated observations of older adults (Diggle
et al., 2002). We examined various OLS model assumptions
and found no notable violation of the main assumptions
(e.g. multicollinearity). The GEE method is an extension of
generalized linear models (GLMs) by incorporating random
effects, arising from the dependence of the data, and by
drawing inference from changes within individuals over
time and differences between individuals. We chose the
GEE method for two reasons. First, GEE models focus on
inferences about the average effects between subpopula-
tions, not on predicting responses for any given individual.
The objective of our study is to compare widowed persons
with persons in other marital statuses, which makes the
GEE method an appropriate analytical model for our data.
Second, although modeling the effects of covariates
requires specifying a model for within-subject associations,
the GEE method yields consistent estimates of regression
6 J. XU ET AL.

coefficients even if the model for correlated data is mis- Table 4. Mean CES-D Score at baseline and follow-up: Rural Chinese Elders
specified. To assess the sensitivity of our regression esti- Aged 60þ, 2001–2015.
mates, we experimented with fitting two other popular Depression scale
models for longitudinal data, namely fixed-effects and ran- Baseline Follow-up N p-valuea
dom-effects models (Fitzmaurice, Laird, & Ware, 2004). We Women
found no substantive differences in regression estimates Continuously married 5.707 5.695 311 0.961
Continuously widowed 6.836 7.419 420 0.018
between these models, suggesting that our estimates are Transition to widowhood 6.609 7.790 138 0.003
quite robust across the model assumptions underlying Widowed for 6 months 7.464 8.536 28 0.243
these different statistical methods for panel data. Widowed for 7–12 months 7.176 7.735 34 0.470
Widowed for 13–24 months 5.932 7.576 59 0.014
Widowed for 25 or more months 6.412 7.412 17 0.239
Men
Results Continuously married 4.974 5.056 468 0.690
Continuously widowed 6.026 6.013 156 0.976
Our empirical analysis examined the relationship between Transition to widowhood 5.692 7.244 78 0.006
widowhood and depressive symptomatology among the Widowed for 6 months 4.636 6.182 11 0.391
elderly in rural China. The descriptive statistics for mean Widowed for 7–12 months 6.500 7.143 14 0.616
Widowed for 13–24 months 5.810 7.452 42 0.035
CES-D scores for the baseline and follow-up interviews Widowed for 25 or more months 5.273 7.636 11 0.089
(excluding the replenished sample) are presented in Table a
Significance test of the difference in depression measure on a t-test.
3. We provided separate statistics for women and men Source: The Longitudinal Study of Older People in Anhui Province.
because gender may influence the effect of widowhood on
depression and exchanges of social support (Guo, Chi, & the follow-up survey, depressive symptomatology did not
Silverstein, 2015). Since our focus is on the widowhood change much between the baseline interview (the time at
effect, the bivariate/regression estimates for the divorced/ which their spouses were still alive) and follow-up. This
never married are not presented in the tables. The esti- finding is consistent with our expectation that widowhood
mates for those already widowed at the beginning of the would have a long-term negative effect, but the effect
survey and who remained widowed are shown to provide would taper off after about two years. What is unexpected
a basic comparison between this group and those for is the absence of an increase in depressive symptomatol-
whom the transition to widowhood is observed in the ogy for respondents widowed for 0–6 months and 7–12
empirical analysis. months before the follow-up interview. Our suspicion is
For women, respondents who were married at the begin- that a pre-widowhood effect on depressive symptomatol-
ning of the observation period (2001) and remained married ogy at baseline could account for this lack of change. This
throughout the observation period (the continuously mar- research question is taken up in the following table.
ried) had significantly lower rates of depressive symptom- The OLS models in Table 5 focused on pre-widowhood
atology than both widowed groups. At the baseline CES-D scores in order to examine the role of anticipatory
interview in 2001, the average CES-D score was 6.17 for con- grief and caregiver strain in the widowhood effect. Our
tinuously married women and 7.08 for the continuously wid- focus here was to compare respondents about to become
owed. The average CES-D score was 7.59 for those who widowed (using the interview immediately before widow-
became widowed between 2001 and 2003. Although men hood occurs) to the married on depressive symptomatol-
had somewhat lower CES-D scores than women, the differ- ogy. According to the findings in this table, anticipatory
ences in CES-D scores between marital status groups for grief contributes to the widowhood effect. Respondents
men are similar as those observed for women. who experienced widowhood between waves had higher
The bivariate results for changes in CES-D scores between levels of depressive symptomatology than the married
waves are presented in Table 4, which offers an initial test before the widowhood event actually occurred. This finding
of how the transition to widowhood and duration of widow- is robust across all model specifications. The magnitude of
hood influences vulnerability to depression. For the continu- the widowhood effect was stronger for those about to lose
ously married and continuously widowed, the baseline a spouse than those already widowed (see Model 5, the
survey is 2001 and the follow-up survey is 2003, but for full model), after controlling for factors such as demograph-
respondents who experienced widowhood between waves ics, socioeconomic status (SES), and health status. Model 5
the “baseline” and “follow-up” represent, respectively, the in Table 5 controlled for the provision of instrumental sup-
waves immediately before and after the widowhood event port to a spouse, and eliminated caregiver strain as the
occurred. Among women and men, depressive symptom- most likely candidate for this pre-widowhood effect.
atology did not change much between the baseline and fol- The GEE models in Table 6 compared the widowed and
low-up waves for the continuously married and the the married on CES-D scores, using data from all waves of
continuously widowed (men only). In contrast, women and observation. All covariates in the models are time-variant,
men who became widowed between waves experienced except for gender and education. The focus of this table
significant increases in their depressive symptomatology. was the effect of the transition to widowhood on depres-
The results for duration of widowhood are inconclusive sive symptomatology and whether social resources mitigate
in this analysis, but are consistent for women and men. this effect. According to Model 1, respondents who transi-
These results represent within-person changes in depres- tioned to widowhood experienced significantly higher lev-
sive symptomatology among those widowed for 0–6, 7–12, els of depressive symptomatology than the continuously
13–24, and 25þ months before the follow-up survey. Only married. Comparing Model 1 to Model 2, this difference
respondents widowed for 13–24 months experienced a sig- between the (recently) widowed and the married is par-
nificant increase (p < 0.05) in depressive symptomatology tially attributable to group level differences in demographic
between waves. For those widowed for 25þ months before characteristics, SES, and health status. This difference
 AGING & MENTAL HEALTH 7

Table 5. Ordinary least squares models of baseline CES-D score on marital status and support resources: Rural Chinese Elders
Aged 60þ, 2001–2015.
Model 1 Model 2 Model 3 Model 4 Model 5
Marital status
Transition to widowhood 1.011 0.925 0.874 0.839 0.847
Continuously widowed 1.349 0.584 0.678 0.666 0.520
Other marital statuses 1.570 1.255 1.228 1.224 0.908
Continuously married (ref.)
Demographics
Age 0.017 0.026 0.021 0.036
Female (1 ¼ yes) 0.150 0.171 0.155 0.027
Number of children alive 0.240 0.230 0.053 0.135
Socioeconomic status
Formal education (1 ¼ yes) 0.314 0.320 0.313 0.208
Logged income 0.015 0.023 0.027 0.032
Health status
ADLs 0.179 0.184 0.181 0.170
Self-reported health (1 ¼ excellent/good) 1.602 1.630 1.632 1.450
Chronic illness (1 ¼ yes) 1.058 0.957 0.961 1.026
Living arrangement
With children only 1.319 1.255 1.088
With grandchildren only 0.605 0.639 0.637
Closest child lives in village 1.349 1.674 1.341
All children live beyond village 1.300 1.324 0.978
With children and grandchildren (ref.)
Contact with children 0.065 0.064
Social support
Logged financial support received 0.294
Logged financial support provided 0.094
Instrumental support received 0.014
Instrumental support provided 0.007
Emotional support from children 0.320
Intercept 5.267 6.710 6.432 6.049 9.939
R2 0.028 0.201 0.218 0.222 0.261
N 1,761 1,761 1,761 1,761 1,761
p < 0.001.
p < 0.01.
p < 0.05 (two-tailed test).
Source: The Longitudinal Study of Older People in Anhui Province.

appears to primarily reflect a health disadvantage among
the widowed. The magnitude of the increase in depressive
symptomatology among the widowed attenuated (but
remained significant) after these factors were controlled.
Similar changes in the regression estimates are also
observed among respondents in other marital groups.
In Table 6, Models 3–5 examined whether social resour-
ces influence the relationship between widowhood and
depressive symptomatology. Model 3 focused on living
arrangements. As expected, living with children and grand-
children (stem families) is the optimal living arrangement for
the psychological well-being of Chinese elders. All other liv-
ing arrangements (except living with grandchildren only –
skipped-generation families) associate with comparatively
higher increases in depressive symptomatology. Despite the
general importance of living arrangements for psychological
well-being, the introduction of this variable into the model
did not change the relationship between widowhood and
depression. Model 4 added contact with children. Contact
with children is an important salutogenic resource, with
higher frequency of contact decreasing the level of depres-
sive symptomatology, but this factor did not change the
relationship between widowhood and depressive symptom-
atology. Model 5 added controls for social support. Social
support has protective effects, but again these are insuffi-
cient to reduce the negative effect of widowhood.
Table 7 compared the widowed to the married, focusing
on duration of widowhood. The models had the same
specifications as those shown in Table 6. To conserve
space, the regression estimates for the control variables are
not shown in the table. Respondents widowed for 6 or
fewer months experienced the highest level of depressive
symptomatology. This finding holds across all model speci-
fications. At both 7–12 and 13–24 months, the widowed
continued to experience higher levels of depressive symp-
tomatology than the married, which further illustrates the
long-term negative effect of bereavement. Among those
widowed for 25þ months, the difference between the wid-
owed and the married was non-significant when demo-
graphics, SES, and health status were controlled.
Discussion and conclusion
This study demonstrated that the transition to widowhood
contributes to an increase in depressive symptoms among
older Chinese people. This widowhood effect is strongest
during the first six months of bereavement, but individuals
widowed for 7–12 and 13–24 months also experience
higher levels of depressive symptoms compared to the
continuously married. Since our longitudinal data analysis
(GEE) models allowed us to incorporate both within-person
changes and between-person differences in estimating
the effect of a time-varying covariate (marital status), this is
direct evidence that individuals who transitioned to widow-
hood experienced a higher increase in CES-D scores
between waves compared to the continuously married.
Most individuals recovered from the widowhood effect.
After 25þ months of bereavement, there is a non-signifi-
cant difference between the widowed and the married in
depressive symptoms. This confirms our hypothesis that
the bereavement-depression relationship is dependent on
the duration of widowhood.
8 J. XU ET AL.

Table 6. Generalized estimating equations of CES-D score on marital status and support resources: Rural Chinese Elders
Aged 60þ, 2001–2015.
Model 1 Model 2 Model 3 Model 4 Model 5
Marital status
Transition to widowhood 1.330 0.793 0.731 0.716 0.792
Continuously widowed 1.480 0.410 0.490 0.484 0.502
Other marital statuses 0.901 0.611 0.571 0.563 0.370
Continuously married (ref.)
Demographics
Age 0.008 0.003 0.002 0.002
Female (1 ¼ yes) 0.213 0.200 0.208 0.293
Number of children alive 0.215 0.204 0.100 0.004
Socioeconomic status
Formal education (1 ¼ yes) 0.226 0.257 0.243 0.153
Logged Income 0.050 0.074 0.079 0.070
Health status
ADLs 0.132 0.136 0.135 0.141
Self-reported health (1 ¼ excellent/good) 1.457 1.442 1.441 1.402
Chronic illness (1 ¼ yes) 0.823 0.780 0.779 0.834
Living arrangement
With children only 0.614 0.592 0.580
With grandchildren only 0.321 0.379 0.342
Closest child lives in village 0.912 1.087 0.973
All children live beyond village 0.974 0.978 0.857
With children and grandchildren (ref.)
Contact with children 0.041 0.037
Social support
Logged financial support received 0.166
Logged financial support provided 0.078
Instrumental support received 0.036
Instrumental support provided 0.004
Emotional support from children 0.065
Intercept 5.638 5.359 5.586 5.531 6.573
Wald Chi square 145.4 1430.5 1522.5 1540.2 1724.1
d.f. 3 11 15 16 21
Number of observations 7,129 7,129 7,129 7,129 7,129
N 2,131 2,131 2,131 2,131 2,131
p < 0.001.
p < 0.01.
p < 0.05 (two-tailed test).
Source: The Longitudinal Study of Older People in Anhui Province.

Table 7. Generalized estimating equations of CES-D score on time since widowhood and selected control
variables: Rural Chinese Elders Aged 60þ, 2001–2015.
Model 1 Model 2 Model 3 Model 4 Model 5
Marital status
Transition to widowhood
6 months or less 2.229 1.821 1.784 1.780 1.816
7–12 months 1.613 1.284 1.251 1.273 1.394
13–24 months 1.927 1.352 1.329 1.329 1.353
25 or more months 0.867 0.293 0.207 0.176 0.279
Continuously widowed 1.479 0.404 0.485 0.479 0.498
Other marital statuses 0.900 0.608 0.567 0.559 0.369
Continuously married (ref.)
Intercept 5.639 5.194 5.411 5.349 6.399
Wald Chi square 155.5 1444.7 1538.0 1556.6 1739.0
d.f. 6 14 18 19 24
Number of observations 7,129 7,129 7,129 7,129 7,129
N 2,131 2,131 2,131 2,131 2,131
All models include the control variables and have the same model specifications as those shown in Table 6.
p < 0.001.
p < 0.01.
 p < 0.05 (two-tailed test).
Source: The Longitudinal Study of Older People in Anhui Province.

Our rationale for comparing the widowed to the mar-
ried on depression is based on evidence from Western
studies that conclude that pre-widowhood depression
accounts for a portion of the widowhood effect. Hence,
we conceptualized the widowhood effect as a process
that begins well before the widowhood event occurs. Our
findings confirmed the hypothesis that the near widowed
have higher levels of depressive symptoms than people
who remained married between waves. This pre-widow-
hood effect is present for as long as 36 months before
widowhood occurs, and we found that the combined pre-
and post-widowhood effect on depression lasts longer
than three years.
We hypothesized that the widowhood effect could be
spurious, reflecting caregiver strain rather than the hardship
of losing one’s spouse. We can reasonably rule out this
hypothesis, since controlling for the provision of social sup-
port (i.e., providing instrumental support to someone with
health needs) did not change the difference in depressive
symptoms between the near widowed and the married.
Thus our findings provide stronger evidence for anticipatory
grief than caregiver strain. Anticipatory grief refers to

changes in depressive symptoms that occur prior to an
impending loss (Holley & Mast, 2009). This involves a grief
reaction to future emotional loss and role change.
Unfortunately, a limitation of this study is that our data-
set lacked a measure of the health status of spouses prior
to their death, which influences pre- and post-widowhood
vulnerability to depression (Carnelley, Wortman, & Kessler,
1999). Certainly, caregiving can contribute to depression
since it tunes caregivers into the likelihood of their
impending loss. While we can conclude that the provision
of instrumental support is not responsible for the differ-
ence in depressive symptoms between the near widowed
and the married, it is possible that the emotional work of
caring for an ailing spouse is at least partly responsible for
this difference (see Holley & Mast, 2009). That said, this
possibility better fits our hypothesis on anticipatory grief
than on caregiver strain.
We also hypothesized that social support and integration
could reduce the health-damaging effects of widowhood.
However, our results failed to support this hypothesis as the
provision of social support to the widowed (even during the
early months of bereavement, when the need for support
would presumably be greatest) did not change the bereave-
ment-depression relationship. Controlling for social support
did not influence the difference between the widowed and
the married on either pre-widowhood levels of depressive
symptoms or post-widowhood changes in depressive symp-
toms. Controlling for living arrangements and frequency of
contact with children – two key measures of social integra-
tion – produced similar null results. In other words, the
widowhood effect on depression in the Chinese context is
not attributable to post-widowhood deficits of social support
or social isolation.
Clearly, widowhood is a loss event that is irreducible to
losses of social support and corresponding role strain. Even
in a cultural setting that provides rich sources of support
and integration outside marriage, widowhood causes an
increase in depressive symptoms that social relationships
with kin members cannot reduce let alone prevent. Our
results suggest that the loss of a spouse – a key attachment
figure – leaves an emotional void that significant others can-
not fill in the short term. The positive message is that this
emotional void is not long-term and appears to disappear
over time. Whether Chinese widow(er)s are overcoming this
emotional void through forming new emotional attachments
or other coping mechanisms is a topic for future study.
Acknowledgments
The authors gratefully acknowledge support from the Social Sciences
and Humanities Research Council of Canada and National Natural
Science Foundation of China (No. 71573207).
ORCID
Zheng Wu http://orcid.org/0000-0002-8525-6966
References
Boyle, P. J., Feng, Z., & Raab, G. M. (2011). Does widowhood increase
mortality risk?: Testing for selection effects by comparing causes of
spousal death? Epidemiology (Cambridge, MA), 22(1),1–5.
AGING & MENTAL HEALTH 9
Carnelley, K. B., Wortman, C. B., & Kessler, R. C. (1999). The impact of
widowhood on depression: Findings from a prospective survey.
Psychological Medicine, 29(5),1111–1123.
Chen, X., & Silverstein, M. (2000). Intergenerational social support and
the psychological well-being of older parents in China. Research on
Aging, 22(1),43–65.
Cong, Z., & Silverstein, M. (2008). Intergenerational support and
depression among elders in rural China: Do daughters-in-law mat-
ter?. Journal of Marriage and Family, 70(3),599–612.
Diggle, P. J., Heagerty, P., Liang, K.-Y., & Scott, L. Z. (2002). Analysis of
longitudinal data. (2nd ed.). Oxford: Oxford University Press.
Dimond, M., Lund, D. A., & Caserta, M. S. (1987). The role of social sup-
port in the first two years of bereavement in an elderly sample. The
Gerontologist, 27(5),599–604.
Elwert, F., & Christakis, N. A. (2006). Widowhood and race. American
Sociological Review, 71(1),16–41.
Fitzmaurice, G. M., Laird, N. M., & Ware, J. (2004). Applied longitudinal
analysis. (2nd ed.). New York: Wiley.
Guo, M., Chi, I., & Silverstein, M. (2015). Intergenerational support and
depression among older Chinese adults: Do gender and widow-
hood make a difference? Ageing & Society, 37(4),695–724.
Hermalin, A. I. (Ed.). (2002). The well-being of the elderly in Asia. Ann
Arbor: University of Michigan Press.
Holley, C. K., & Mast, B. T. (2009). The impact of anticipatory grief on
caregiver burden in dementia caregivers. The Gerontologist,
49(3),388–396.
Krause, N., & Liang, J. (1993). Stress, social support, and psychological
distress among the Chinese elderly. Journal of Gerontology:
Psychological Sciences, 48(6),P282–P291.
Lee, G. R., & DeMaris, A. (2007). Widowhood, gender, and depression.
Research on Aging, 29(1),56–72.
Li, L., Liang, J., Toler, A., & Gu, S. (2005). Widowhood and depressive
symptoms among older Chinese: Do gender and source of social
support make a difference? Social Science & Medicine, 60(3),637–647.
Mangen, D. J., Bengtson, V. L., and Landry, P. H., (Eds.). (1988).
Measurement of intergenerational relations. Thousand Oaks: Sage.
Mendes de Leon, C. F., Kasl, S. V., & Jacobs, S. (1994). A prospective study
of widowhood and changes in symptoms of depression in a commu-
nity sample of the elderly. Psychological Medicine, 24(03),613–624.
Pearlin, L. I., Menaghan, E. G., Lieberman, M. A., & Mullan, J. T. (1981).
The stress process. Journal of Health and Social Behavior,
22(4),337–356.
Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for
research in the general population. Applied Psychological
Measurement, 1(3),385–401.
Sasson, I., & Umberson, D. J. (2014). Widowhood and depression: New
light on gender differences, selection, and psychological adjust-
ment. The Journals of Gerontology. Series B, Psychological Sciences
and Social Sciences, 69(1),135–145.
Silverstein, M., Lowenstein, A., Katz, R., Gans, D., Fan, Y.-K., & Oyama, P.
(2013). Intergenerational support and the emotional well-being of
older Jews and Arabs in Israel. Journal of Marriage and the Family,
75(4),950–963.
Silverstein, M., Cong, Z., & Li, S. (2006). Intergenerational transfers and
living arrangements of older people in rural China: Consequences
for psychological well-being. Journal of Gerontology: Social Sciences
B, 61(5),S256–S266.
Stroebe, M. (1994). The broken heart phenomenon: An examination of
the mortality of bereavement. Journal of Community & Applied
Psychology, 4(1), 47–61.
Stroebe, M., Schut, H., & Stroebe, W. (2007). Health outcomes of
bereavement. Lancet (London, England), 370(9603),1960–1973.
Stroebe, W., Stroebe, M., Abakoumkin, G., & Schut, H. (1996). The role
of loneliness and social support in adjustment to loss: A test of
attachment versus stress theory. Journal of Personality and Social
Psychology 20, 70(6),1241–1249.
Vable, A. M., Subramanian, S. V., Rist, P. M., & Glymour, M. M. (2015).
Does the ‘Widowhood Effect’ precede spousal bereavement?
Results from a nationally representative sample of older adults.
American Journal of Geriatric Psychiatry, 23(3),283–292.
Weiss, R. (1975). Loneliness: The experience of emotional and social isola-
tion. Cambridge: MIT Press.