Relationship Instability and Depression among Women at Midlife: A Longitudinal Analysis

doi:10.21203/rs.3.rs-5374110/v1

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Relationship Instability and Depression among Women at Midlife: A Longitudinal Analysis

https://doi.org/10.21203/rs.3.rs-5374110/v1

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This study explores the relationship between family complexity and major depressive symptoms among middle-aged women, using data from the National Longitudinal Survey of Youth 1979 (NLSY79). By analyzing relationship trajectories, transitions, and statuses, this research uncovers how various relational dynamics influence mental health outcomes. Findings reveal that stable marital relationships are associated with lower depression rates, while individuals with multiple relationship transitions or complex trajectories experience higher odds of major depressive symptoms. These results underscore the importance of relational history in diagnosing and treating depression among women, advocating for the incorporation of relational context into mental health assessments. The study’s implications suggest that addressing relational instability in therapeutic interventions can significantly improve mental health outcomes for women in midlife.

Sociology

relationship transitions

marital status

depression

midlife women

mental health assessment

Depression stands as one of the most prevalent mental health disorders in the United States, affecting over 21 million adults aged 18 and older in 2021 alone (National Institutes of Mental Health [NIMH], 2021). This disorder presents differently across genders, with women reporting nearly double the incidence compared to men (NIMH, 2021), and a higher propensity to seek treatment, especially as they age (NIMH, 2016b). Yet, historical clinical research has often neglected the female perspective, leaving a gap in effective mental health interventions for women (National Institutes of Health [NIH], 2001; Bentley, 2005).

It is imperative to address these disparities, particularly considering that women place significant emphasis on relational contexts for their growth and development (Hurst, Leberman, & Edwards, 2017). Women’s relational distress, frequently associated with transitions such as the end of a marriage or cohabitation (Sassler & Lichter, 2020), is a common precipitant of seeking mental health services (Federal Partners Committee on Women and Trauma, 2013). Therefore, a nuanced understanding of relational dynamics is essential for effective diagnosis and treatment. There is an emerging body of research that does explore this nuance. For example, recent research has examined relationship confidence, defined as the belief that both partners possess the skills to manage conflict and sustain their partnership (Johnson et al., 2020). In their study of unmarried young adults, the authors find relationship confidence was generally stable but exhibited notable gender differences. Women began with higher confidence, which declined over time, while men’s confidence increased. Factors such as longer partnerships, cohabitation, and lower avoidant attachment were linked to greater confidence in their study, especially among those who married during the study.

Similarly, Bae and Kogan (2020) explored how adverse life contexts shape African American men’s romantic relationship trajectories. Their study identified three distinct trajectories—Normative, Uncertain, and Conflictual—with early adversity, socioeconomic instability, and community disadvantage significantly contributing to Uncertain and Conflictual patterns. Taken together, this underscores the nuance and complexity of relational dynamics and their implications for mother’s mental well-being, but additional work is needed to disentangle the link between relationship histories and well-being.

Current documentation tools such as genograms, timelines, and ecomaps, while providing detailed relational histories (Marquis & Holden, 2008), suffer from a lack of standardization, rendering cross-patient comparison difficult (Nakash et al., 2008). To this end, our paper proposes the development of standardized relational instability survey items to supplement traditional intake methods, thereby offering a more objective and comparable means of assessing relational factors.

By integrating these refined tools into initial assessments, practitioners can more accurately identify risks for depression based on relational history, contributing to more effective case conceptualization and treatment planning (Meyer & Melchert, 2011). This approach also responds to the critique of previous practices being marriage-centric, heteronormative, and inadvertently condescending towards women, by promoting inclusivity and appreciating the diversity of human relationships (Federal Partners Committee on Women and Trauma, 2013).

To this end, the central objective of our study was to identify the most effective family complexity measures for predicting depression among middle-aged women, enhancing diagnostic assessments for practitioners. Our work is groundbreaking in its integration of academic and professional expertise to propel strength-based, empirically-supported practices. We leverage the National Longitudinal Survey of Youth 1979 for its longitudinal data on women's family experiences from adolescence to midlife, informing the development of our family instability measures. By reducing bias by controlling for covariates altering key family practices, we thoroughly test the efficacy of each measure in understanding midlife depression.

The study was executed in five methodical steps. Initially, we analyzed 24 waves of the NSLY79 to craft three innovative measures of family change, benchmarking them against existing scholarly metrics. We then scrutinized the relationship between these family instability measures and major depression, using NLSY sampling weights to ensure accuracy reflective of complex sample designs. This helped us confirm the consistency of our measures with previous findings. In our third step, we considered a breadth of contextual factors potentially impacting the health-instability nexus, informed by practitioner input and literature suggesting that family diversity encompasses both structure and socioeconomic stratification, including race, education, and poverty. Additionally, recognizing the impact of parental depression on children, we factored in childbearing.

We generate four hypotheses. First, people in formal, stable relationships (e.g., marriage) are hypothesized to have lower odds of experiencing major depressive symptoms compared to single individuals. Within relationship types, the least complex relationships (fewest transitions such as separation or divorce) are associated with the lowest odds of depression. Second, histories create a continuum of depressive symptomology risk, with stably married individuals at one end (lowest risk) and those with multiple divorces at the other (highest risk). Within this continuum, currently partnered individuals (married, remarried, cohabiting) have lower odds of major depressive symptoms than single individuals (always single, single post-cohabitation, widowed, separated, divorced). Additional divorces increase the odds of major depressive symptoms, indicating a correlation between relationship transitions and depressive symptomology. Third, there is a direct correlation between the number of relationship transitions a woman has experienced and the likelihood of experiencing major depressive symptoms. The more transitions, such as separations or divorces, the higher the odds of depressive symptoms. The final hypothesis integrates previous theories, proposing that the odds of depressive symptoms are distributed across three hierarchical groupings: (a) partnered vs. single, with partnered individuals having lower odds, (b) within each group, most-formal/least-complex relationships are associated with the lowest odds, and (c) within each relationship type, a higher number of transitions correlates with higher odds of depressive symptoms.

Women’s Mental Health in Midlife

Midlife often brings health declines, occupational stagnation, and stress, which can heighten mortality awareness and regret over unachieved goals, potentially exacerbating existing mental health issues (Sievert et al., 2018). Additionally, the caregiver responsibilities assumed by individuals at this life stage can lead to significant family and generational stress when compounded by mental health crises (Guzzob& Hayford, 2020; Infurna et al., 2020).

Middle-aged women are particularly susceptible to depression, with rates nearly double those of men (NIMH, 2021), influenced by societal norms and an accumulation of stressors such as poverty and caregiving demands (Kessler et al., 1993; Afifi, 2007; Cawthorne, 2008).

Family Change and Instability

American family structures have evolved, with middle-aged women now more likely to navigate complex relationship trajectories than previous generations (Smock & Schwartz, 2020). Women's greater likelihood to initiate divorce and the associated mental health impacts call for a deeper understanding of how family dynamics influence depression (Raley & Sweeney, 2020).

Research measures family instability through current relationship status, cumulative transitions, and relationship trajectories. Each metric contributes differently to our understanding of women's depression in midlife, informed by foundational theories such as the Life Course Perspective, Pearlin’s Stress Process Model, and Family System’s Boundary Ambiguity Theory (Elder, 1985; Pearlin & Johnson, 1977; Pearlin et al., 1981; Boss & Greenberg, 1984).

These theories suggest that relationships significantly influence mental health through mechanisms like role strain and boundary ambiguity, which may intensify with transitions such as divorce and remarriage (Brown & Manning, 2009; Carroll et al., 2007; Pasley, 1987).

Relationship Status and Instability

A woman's current relationship status, from single to married, impacts her mental health, with formal relationships potentially offering stability and informal or complex relationships possibly increasing stress and depression risk (Brown, Manning, & Wu, 2022; Raley & Sweeney, 2020). The end of relationships, whether through divorce, widowhood, or separation, also correlates with mental health declines, though these effects can vary over time and by individual circumstances (Raley & Sweeney, 2020).

Cumulative Transitions and Relationship Sequences

Beyond current status, the number and sequence of relationship transitions across a woman's life play a role in mental health outcomes. Cumulative transitions often indicate increased mental health risks (Umberson & Thomeer, 2020), supported by research on the stress and confusion arising from complex family dynamics (Meadows, McLanahan, & Brooks-Gunn, 2008; Wu & Hart, 2002; Amato, 2010).

The National Longitudinal Survey of Youth 1979 is a nationally representative sample of American civilian and military youth aged 14 to 21 years old in 1978, including 6,283 female respondents who were first interviewed in 1979 and have been re-interviewed at least biennially through 2014. Because of the staggered measurement of depression, which was assessed in the first survey after a woman turned 40 years old, we pooled the data and anchored responses based on age rather than survey year to assess our outcome and key midlife covariates. As might be expected for a survey spanning over 30 years, the sample suffered from attrition, and about one-third of the original respondents either dropped out of the survey altogether or did not complete enough survey waves to reliably assess relationship histories (dropping 2,132 women). A further six percent of cases were omitted due to missing the key dependent or independent variables (dropping 390 women). The final analytic sample for this project includes 3,761 women who responded to the 40-year-old health module on depression and provided relevant relationship history and sociodemographic information. Given that selection bias may lead to inaccurate inferences about social process when sample attrition is not independent of the key outcome (Winship & Mare, 1992) we analyzed whether early life characteristics predicted whether a woman would remain in the study, and further, whether the probability of being included was associated with our key predictor of depression. Consistent with the work of Quesnel-Valee & Taylor (2012) on this sample, we found that even though attrition was not random, it does not introduce significant bias in mental health outcomes at age 40, including depression.

Suspected Major Depression. The Center for Epidemiologic Studies-Depression scale (CES-D) was originally published by Radloff (1977) and is one of the five most frequently used measures for depression (Wood, Taylor & Joseph, 2010). The measure has been shown to have high reliability for measuring depressive symptoms, high internal consistency, as well as high construct validity (Radloff, 1977). The CES-D used for this project is a self-report, 7-item summed scale that ranges from 0–21 based on respondents’ rating of depressive symptoms over the past week, such as feeling hopeless, poor appetite or crying spells. Response options range from 0 “Rarely or None of the Time” to 3 “Most or Almost All the Time” for each item. Levine’s (2013) analysis of the seven-item scale finds it has acceptable psychometric properties and is appropriate for use in screening for suspected major depressive disorders in US community samples. The assessment of suspected major depression (1 = yes, 0 = no) reflects a score of 8 or higher on the summed scale, and indicates a woman may meet the requirement for major depressive episode, or at minimum is experiencing subthreshold depressive symptoms (Levine, 2013). We chose to focus on the clinical cutoff rather than the overall scale because major depression is more likely to negatively affect functioning, lasts longer, and reoccurs more often than subclinical depression (American Psychiatric Association, 2013). The distinction between major depression, as characterized by prolonged and severe impairment, and clinical depression, which requires formal diagnosis by a clinician, was considered in our analysis to inform potential clinical interpretations.

Family Change and Instability. Our key independent variables focus on women’s relationship experiences from adolescence to adulthood. To accurately measure relationship structure, instability, and sequences, each woman’s relationship history was coded using the NLSY79 Fertility and Relationship File and the Household Roster for each of the 24 waves of data collection following established protocal (Dorius, 2010). Each year of survey completion, participants responded with information on relationship structure (married, divorced, cohabited, widowed), up to three changes in relationship status since the previous survey (move out, divorce, move in, marriage), as well as the beginning and termination of each relationship (coded in months). This information was used to create three of the most common approaches to assessing relationship experiences in the larger demographic family literature.

Relationship structure was centered on women’s current relationship experiences at age 40 and reflects contemporary scholarship distinguishing between direct marriages and marriages proceeded by cohabitation, relationship churning, and variations in singlehood. Our construct includes both partnered relationships (such as married directly, married but cohabited first, marital reunification following a separation, and cohabiting) as well as a variety of singlehood categories, including separated from marriage, divorced, widowed, single due to a cohabitation ending, and continuously single (never married or cohabiting).

Relationship instability consists of the sum of relationship transitions women experience from adolescence through middle age, and range from zero (always single) to seven or more. In the case of a woman who cohabited before marriage (+ 1), married (+ 1), and then divorced (+ 1), the cumulative assessment would equal three.

Relationship sequences comprise the type of transitions experienced over time, such as the movement from marriage to divorce to remarriage (coded as married, divorced once). These sequences distinguish between one’s current relationship (married, cohabiting, or single) and prior relationships (e.g., the number of times one has been divorced, and whether someone has been previously widowed). To create this measure, every woman’s unique relationship trajectory was identified and coded, producing over 530 distinct patterns. These pathways were then consolidated to 17 detailed relationship histories, replicating the pioneering work on marital biographies by Wilmoth and Koso (2002) with HRS data. Due to analytic sample size requirements, the patterns were further refined to the 12 most common sequences in the NLSY data, including: continuously married (reference), remarried following one divorce, remarried following two divorces, remarried following three or more divorces, continuously cohabiting, cohabiting following one divorce, cohabiting following two or more divorces, married or cohabiting following widowhood, continuously single, single following one divorce, single following two or more divorces, and single following the death of a partner.

Covariates. Covariates from early adulthood reflect our theoretical orientation and help tap into the notion that having a positive affect may help people to effectively cope with stressful environments throughout life, including relationship disruptions. Therefore, we assess personal traits related to positivity such as self-esteem, delinquency, and self-mastery (see Bickehaupt, 2017 for a review). The summed 10-item Rosenberg Self Esteem Scale was administered in the 1980 interviews, and is designed to assess the degree of strong disapproval (1) to strong approval (4) adolescents and adults feel towards themselves by responding to question prompts such as: I am a person of worth, I have a number of good qualities, I take a positive attitude towards myself, and I am satisfied with myself (Rosenberg, 1965). The scale has a possible range of 10 to 40 and is positively oriented (negatively worded prompts are reverse coded), with higher scores designating higher self-esteem. The scale is widely used and has high internally consistency across datasets, with a reliability coefficient of .83 for NLSY79 women. The Pearlin Self-Mastery scale (Pearlin et al., 1981) was administered in 1992 and assesses whether respondents strongly disagree (1) to strongly agree (4) that they are in control of forces that significantly impact their lives, with seven items such as “There is no way I can solve some of the problems I have”, “Sometimes I feel that I am being pushed around in life”, and “I have little control over the things that happen to me”. The summed scale has a possible range of 7 to 28 and is positively oriented such that higher scores reflect a sense of greater mastery over one’s environment. The reliability coefficient for the 7 items is .78 for women in the NLSY sample. Delinquency was assessed in 1980 and is comprised of 17-items designed to discriminate between highly delinquent youth from occasional participants, including experience with vandalism, fighting, shoplifting, assault, drug use, drug sales, car theft, and gambling, et cetera (ranging from 0 ‘none’ to 6 ‘more than 50 times’. The 17-items were summed together and have a possible range of 0 to 102, and an alpha reliability of .74 for the women’s sample.

Covariates from the time of the 40-year-old survey include items associated with family diversity (Demo, Allen, & Fine, 2000) and previously described as covarying with mental health, such as race and ethnicity (included as a set of three indicators, including: non-Hispanic White [reference], African American, and Hispanic), the percentage of years the women have reported living in poverty from the 1979 survey through age 40 (ranges from 0 to 100%), education in years (ranges from 0 to 20 years), a count of the total number of biological children the woman has conceived by age 40 (ranges from 0 to 11), and overall physical health (ranges from 11 to 67). Physical health was measured with the SF-12 Physical Health Component Score created by NLSY according to unpublished and copyrighted criteria from John E. Ware and Medical Outcomes Trust (see www.sf36.com for more details). The measure draws from six sources of information, including a general assessment of health, whether health limits typical activities, whether there have been problems with daily activities during the last month, and how much pain interfered with normal work over the last month. The scale is designed to measure physical health in large community samples irrespective of one’s usage of formal health services. It is normed to a score of 50 and standard deviation of 10, and is relatively straightforward to interpret: scores that are higher than 50 reflect better than average health while scores under 50 reflect poorer than average health.

Sample Characteristics at Midlife

Beginning with Table 1, the study's findings indicate variability in the prevalence of major depression among different racial groups. African American respondents showed the highest prevalence at 20.2%, followed by Hispanic respondents at 17.9%. White, Non-Hispanic respondents reported a lower prevalence of major depression at 14.5%. Education level appeared to inversely correlate with major depression. Respondents with less than a high school education had the highest prevalence of major depression at 27.6%. Those who completed high school reported a prevalence of 19.4%, which decreased further to 13.3% among those with some college education. Respondents with college degrees or more exhibited the lowest prevalence at 9.0%. The number of children did not show a strong correlation with major depression. Respondents with zero children had a prevalence of 15.9%, one child at 16.4%, two children at 14.9%, and those with three or more children at 15.4%.

Percent time spent in poverty was associated with major depression. Respondents who spent 0% of their adult life in poverty had a low prevalence of major depression at 10.1%. This increased to 11.3% among those who spent 1 to 9% of their adult life in poverty, jumped to 19.5% for 10 to 29%, and was highest at 30.1% for those spending 30 to 100% of their adult life in poverty. Physical health, as measured by the SF-12, showed a clear association with major depression. Respondents with a physical health score of 49 or less had a prevalence of 32.0%, which decreased to 11.9% for scores between 50 to 54 and further to 10.2% for scores of 55 and higher.

Self-esteem levels, assessed by the Rosenberg scale, were inversely related to major depression. A higher prevalence of 23.2% was noted among those scoring 19 or less, which decreased to 14.0% for scores of 20 to 24, and to 11.0% for scores of 25 and higher. The level of self-reported delinquency was also examined. Respondents with no delinquent acts had a prevalence of major depression of 13.2%. This prevalence was slightly higher among those with 1 to 2 delinquent acts at 15.2%, remained similar for 3 to 6 acts at 15.0%, and increased for those with 7 or more acts to 18.5%. Self-mastery, according to the Pearlin scale, showed a negative correlation with major depression. Respondents with a score of 20 or less had a prevalence of major depression at 23.8%, which decreased to 14.3% for those scoring between 21 to 23, and was lowest at 9.2% for scores of 24 and higher.

In summary, lower levels of education, poorer physical health, lower self-esteem, lower self-mastery, and higher economic hardship were associated with higher rates of major depression among the study's respondents.

Relationship Experiences at Midlife

Relationship Status and Major Depression

Examining Table 2, the data revealed variations in the percentages of major depression across different relationship statuses. Married individuals who did not cohabit before marriage exhibited the lowest prevalence of major depression (9.6%), whereas those currently cohabiting showed the highest prevalence (30.1%). Individuals who had separated from marriage or ended a cohabitation had notably higher percentages of major depression (24.9% and 27.6%, respectively) compared to those who were widowed (16.2%). Notably, individuals who experienced 'churning' in their relationships (Married, reunited) reported a major depression percentage of 23.9%.

Cumulative Transitions

Respondents reported an average of 2.6 cumulative relationship transitions (SD = 2.0). Those with no transitions had a major depression percentage of 21.1%, while those with one transition had a significantly lower percentage of 8.8%. As the number of transitions increased to two or three, the percentage of major depression also increased slightly to 15.2% and 13.2%, respectively. Notably, respondents who experienced six or more transitions reported the highest percentages of major depression (30.5% for six transitions and 31.9% for seven or more transitions).

Relationship Trajectories

Continuous marriage was associated with the lowest percentage of major depression (8.7%). In contrast, individuals with more complex relationship trajectories, such as cohabiting continuously or having multiple divorces (cohabiting, divorced twice+), reported the highest percentages of major depression (28.9% and 34.9%, respectively). Respondents who remained single or experienced widowhood had major depression percentages ranging from 15.9–20.8%.

In summary, the findings suggest that individuals in stable marital relationships have the lowest rates of major depression, while those in non-marital cohabitation or with multiple relationship transitions have higher rates. This pattern indicates a potential association between relationship stability and mental health outcomes.

Women's Relationship Experiences and Suspected Major Depression

Table 3 presents findings from logistic regression analyses that explored the odds of suspected major depression across different relationship statuses, cumulative transitions, and relationship trajectories. Two models were used: a reduced model and a full model, with odds ratios (OR) adjusted for various covariates.

Current Relationship Status

In the reduced model, compared to those who were married directly (reference group), all other categories of relationship status had higher odds of suspected major depression. Notably, those who were cohabiting had over three times the odds (OR = 3.16, p < .001), and the odds remained significantly higher in the full model (OR = 2.15, p < .001). Individuals who ended a cohabitation had the highest odds of suspected major depression in the reduced model (OR = 3.23, p < .001), with a decrease in the full model (OR = 1.82, p < .001). The full model showed a decrease in the odds ratios across all categories, suggesting the influence of other covariates accounted for in the full model.

Cumulative Transitions

For each additional transition experienced, there was an 18% increase in the odds of suspected major depression in the reduced model (OR = 1.18, p < .001), which slightly decreased to a 12% increase in the full model (OR = 1.12, p < .001).

Relationship Trajectories

Compared to individuals who were married continuously (reference group), those with more complex marital histories showed increased odds of suspected major depression. In particular, those who were cohabiting after being divorced twice or more had the highest odds in both the reduced (OR = 3.92, p < .001) and full models (OR = 2.55, p < .01). The full model generally showed a decrease in the odds ratios, indicating that other factors partially explain the association between relationship trajectories and suspected major depression.

The Pseudo R-squared values indicate that the full model explained a larger portion of the variance (13.8% for relationship trajectories) compared to the reduced model (3.4% for relationship trajectories), suggesting that the additional variables included in the full model contribute significantly to the explanation of suspected major depression.

These results demonstrate that relationship status, transitions, and trajectories are significant predictors of suspected major depression, with the full model revealing a nuanced understanding when accounting for additional covariates.

Women's Suspected Major Depression by Relationship Experience

Figure 1 represents the analysis of the correlation between current relationship status and cumulative transitions and the odds of suspected major depression, with reference categories being 'Married Directly' and 'One Transition', respectively.

Current Relationship Status

The top left panel of the figure indicates significant variations in the odds of suspected major depression among different relationship statuses compared to the reference group of individuals who were married directly. Those who were cohabiting had the highest odds ratio (OR = 81.4), followed by individuals who were separated (OR = 95.8), and those who had reunited with a partner (MarReunite) (OR = 69). Married individuals who cohabited first (MarCoh) and singles who were widowed (SingWid) had lower but still elevated odds (OR = 98.9 and 44.2, respectively). The lowest odds were observed among continuously single individuals (SingCont) and singles who were separated from a cohabiting relationship (SingCoh) (OR = 4.3 and 18.5, respectively).

Cumulative Transitions

When examining the impact of cumulative transitions on suspected major depression, in the top right panel of the figure, it was observed that individuals with no transitions (0 trans) had substantially lower odds (OR = 36.2) compared to the reference group of one transition. As the number of transitions increased, so did the odds of suspected major depression, with the highest odds observed in individuals with seven or more transitions (OR = 134.2). A notable increase in odds was also observed in those with six transitions (OR = 101.3), five transitions (OR = 57.3), and four transitions (OR = 41.3).

In summary, the results suggest that there is a significant association between relationship status and cumulative life transitions with the likelihood of experiencing suspected major depression. The data points to higher odds with increasing numbers of transitions and among those not in a directly married relationship status.

Relationship Trajectories

Turning to the bottom left panel of the figure, the data indicates that individuals who have remarried after three or more divorces (Rem-div3+) have the highest odds ratio (OR = 174.6) for suspected major depression when compared to the reference group. This is substantially higher than for any other category, suggesting a strong association between multiple marital disruptions and the likelihood of major depression.

Individuals who have been continuously single (Sing-cont) or who have remarried after one divorce (Rem-div1) also show increased odds ratios for suspected major depression (OR = 82.3 and OR = 85.2, respectively), significantly above the reference group's odds.

Those who have remarried following two divorces (Rem-div2) have a moderately elevated odds ratio (OR = 66.6), while individuals who have been widowed (Part-wid) have the lowest odds ratio (OR = 15.9) compared to the continuously married.

Cohabitants with one prior divorce (Coh-div1) and singles with one prior divorce (Sing-div1) exhibit intermediate odds ratios (OR = 43.4 and OR = 24.6, respectively), indicating an increased risk compared to the reference but lower than those with more complex histories.

A notably high odds ratio is observed for individuals who are cohabiting after having been divorced twice or more (Coh-div2+), with an OR of 156.9, pointing to a significant correlation with suspected major depression.

In summary, these results suggest that individuals with more complex relationship trajectories, particularly involving multiple divorces, are at a higher risk for suspected major depression. Continuously single individuals and those with one or more divorces also show elevated odds, but to a lesser extent than those with more disrupted relationship histories. Individuals who have been widowed or have fewer marital transitions have comparatively lower odds ratios, indicating that the stability and continuity in relationships may be protective against major depression.

In striving to enhance mental healthcare for women, particularly during midlife—a period characterized by significant relational transitions—it is essential to adopt empirically validated, strength-based approaches (Infurna, Gerstorf, & Lachman, 2020). By integrating relationship-centric questions into the standard intake assessment protocol, clinicians can identify key relational factors that contribute to mental health outcomes (Umberson & Thomeer, 2020). This initiative is grounded in the recognition of women's relational competencies as vital resources for both diagnosis and treatment (Brown, Manning, & Wu, 2022). Through this practice, we aim to deepen our theoretical understanding of the connections between family changes and mental health, thus equipping practitioners with a robust framework for diagnosing depression in women at midlife. The necessity for evidence-based intake assessments is underscored by the lack of standardized measures that account for the complexity of women's relational histories (Smock & Schwartz, 2020).

Our research advocates for the development of an intake protocol that integrates these histories, thereby facilitating a more comprehensive and nuanced approach to mental health care. The multifactorial nature of major depression in women at midlife is evident when considering the intersection of socioeconomic, health, and relational variables (Infurna et al., 2020). The study's findings reveal significant variability in depression prevalence across racial and educational lines, with African American individuals and those with lower educational attainment experiencing higher rates of depression. Economic hardship is similarly linked to increased depression rates, with a clear gradient of risk associated with more time spent in poverty.

Physical health, self-esteem, and self-mastery also emerged as important correlates, each inversely related to depression. Specifically, poorer physical health and lower levels of self-esteem and self-mastery are associated with higher depression rates, highlighting the importance of considering both psychological and physical well-being in understanding mental health (Infurna et al., 2020). Furthermore, the study's exploration into midlife relational experiences underscores the profound impact of relationship status and transitions on depression (Brown et al., 2022). Stable marital relationships are associated with the lowest depression rates, while non-marital cohabitation, especially when following multiple divorces, presents the highest risk. The number of relationship transitions experienced correlates with increased depression, pointing to the potential mental health benefits of relationship stability and continuity (Smock & Schwartz, 2020).

The data presents a complex picture where various facets of life—socioeconomic status, education, racial background, health, self-perception, and relationship history—intertwine to influence the risk of major depression. This underscores the necessity for a holistic approach in both research and clinical practice, where the nuances of women's lives are considered in their mental health assessment and treatment planning (Umberson & Thomeer, 2020). It also suggests that interventions to improve mental health outcomes in women at midlife may benefit from focusing on enhancing self-esteem and self-mastery, providing support for those with complex relationship histories, and addressing socioeconomic disparities (Sassler & Lichter, 2020).

Limitations

The current study's findings are constrained by several methodological limitations that warrant careful consideration. The use of the CES-D scale for assessing depressive symptomatology, while widely accepted, introduces certain constraints, particularly in its temporal scope which may not capture the fluctuating nature of depressive symptoms over time. This limitation points to the need for future research to employ longitudinal designs that can monitor changes in symptomatology and provide a more dynamic understanding of depression.

Additionally, the study's focus excludes non-residential romantic relationships, which could be significant in understanding the full spectrum of relational influences on depressive symptoms. The evolving nature of relationships in contemporary society, with an increase in long-term, non-cohabiting partnerships, calls for these relationships to be included in future investigations to obtain a more comprehensive picture.

Another major concern is the age of the data. Changes in societal norms, economic conditions, and healthcare access over time mean that the study's results may not fully represent the current state of mental health and its associations with relational contexts. This temporal gap suggests a pressing need for updated research that reflects the current socio-cultural climate.

Attrition is also a critical factor to consider. Participants drop-out over the course of the study may lead to a survivorship bias, where those who remain may not be fully representative of the original or general population, potentially skewing the results and their applicability.

The study also relies heavily on self-reported data, which can introduce various biases such as recall bias, where participants may not accurately remember past events or feelings, and social desirability bias, where participants may report what they think is expected rather than their true experiences. Moreover, self-reporting measures can sometimes fail to distinguish between clinical depression and transient feelings of sadness that do not meet the clinical threshold.

Future studies should aim to mitigate these limitations by using a mix of quantitative and qualitative data, incorporating clinical diagnoses, and considering the diversity of modern relationships. Additionally, they should account for the potential attrition impact and strive for up-to-date data collection to ensure the relevance and accuracy of their findings in today's context.

Implications for Researchers and Clinicians

Limitations notwithstanding, this paper highlights the importance of the integration of relationship history into the assessment and treatment of women seeking mental health services in midlife. For researchers, this underscores the need to design studies that can parse the nuanced effects of relationship patterns on mental health. Longitudinal research, in particular, could provide insights into how relationship trajectories influence the onset and course of depression over time.

For clinicians, a comprehensive understanding of a patient's relationship history offers a valuable context for treatment. It is recommended that mental health professionals adopt a holistic approach that considers these histories in the development of treatment plans. By doing so, they not only address the immediate symptoms but also empower their patients to make life choices that positively impact their mental health.

This dual focus can refine theoretical models of family dynamics and mental health and enhance clinical practice. In practical terms, this could mean incorporating targeted psychoeducation, therapy that addresses relationship issues, and possibly involving partners in treatment when appropriate. The ultimate goal is to develop a methodology that is both theoretically sound and pragmatically effective in managing depression among women at midlife, thereby improving both patient outcomes and the quality of care.

The study’s results allow us to draw several important conclusions about the relationship experiences of women at midlife and their association with major depression. First, it is evident that stability in marital relationships serves as a protective factor against depression. Specifically, those who enter marriage without prior cohabitation show the lowest prevalence of major depression, pointing to the possible benefits of stability and commitment in a relationship. Second, the number of relationship transitions an individual experiences plays a significant role in mental health, with an increased number of transitions being associated with higher rates of major depression. This suggests that the psychological impacts of relationship changes are substantial and that individuals facing multiple transitions may require additional support.

Furthermore, the data reveals that complex relationship trajectories, such as continuous cohabitation or multiple divorces, are linked to higher rates of suspected major depression, indicating that non-traditional or unstable relationship paths may pose risks to mental health. Finally, these findings have direct implications for clinical practice. Clinicians must take into account the full scope of a woman's relationship history when assessing and planning treatment for depression. This includes recognizing the need for relationship counseling and support as part of a comprehensive approach to treatment, especially for those with a history of relationship instability or numerous transitions. These insights are crucial for refining therapeutic strategies aimed at addressing the unique challenges faced by women at midlife.

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Table 1

Description of Sample Characteristics and Depression at Midlife. N = 3,761.
		Range		Freq.^a	Mean(SD) or Percent ^b	% Major Depression^b
All Respondents		-		3,761	100.0%	15.52%
Race		-		-	-	-
African American		0–1		1,145	14.9	20.2
Hispanic		0–1		700	6.2	17.9
White, Non-Hispanic		0–1		1,916	79.0	14.5
Education in Years		0–20		3,761	13.6 (2.4)	-
Less than high school		0–1		347	6.7	27.6
High school		0–1		1,535	40.1	19.4
Some college		0–1		1,030	25.9	13.3
College or more		0–1		849	27.3	9.0
Number of Children	0–11		3,761		1.9 (1.3)	-
0 Children	0–1		594		17.3	15.9
1 Child	0–1		613		16.5	16.4
2 Children	0–1		1,287		36.3	14.9
3 + Children	0–1		1,241		29.9	15.4
Percent Time in Poverty	0-100		3,761		14.5(21.8)	-
0% of adult life	0–1		1,096		38.2	10.1
1 to 9% of adult life	0–1		861		26.0	11.3
10 to 29% of adult life	0–1		786		19.0	19.5
30 to 100% of adult life	0–1		1,018		16.8	30.1
Physical Health, SF-12	11–67		3,761		51.9 (8.5)	-
49 or less	0–1		901		22.4	32.0
50 to 54	0–1		1,115		26.7	11.9
55 and higher	0–1		1,745		50.9	10.2
Self Esteem, Rosenberg	7–30		3,761		22.3 (4.1)	-
19 or less	0–1		1,095		26.9	23.2
20 to 24	0–1		1,559		41.2	14.0
25 and higher	0–1		1,107		31.8	11.0
Delinquency	0–57		3,761		5.0 (6.5)	-
Zero	0–1		1,139		30.1	13.2
1 to 2	0–1		732		17.5	15.2
3 to 6	0–1		899		23.5	15.0
7 or more	0–1		991		28.9	18.5
Self Mastery, Pearlin	7–28		3,761		22.3 (4.1)	-
20 or less	0–1		1,201		30.0	23.8
21 to 23	0–1		1,402		38.0	14.3
24 and higher	0–1		1,140		32.1	9.2

Notes: ^a Unweighted ^b Weighted by NLSY 1979 Sampling Weight

Table 2

Description of Relationship Experiences and Depression at Midlife. N = 3,761.
		Range	Freq.^a	Mean(SD) or Percent ^b	% Major Depression^b
	All Respondents	-	3,761	100.0%	15.5%
Panel 1:	Current Relationship Status	1–9	-	-	-
	Married directly	0–1	1,173	35.7	9.6
	Married, cohabited first	0–1	850	25.5	11.6
	Married, reunited (churn)	0–1	53	1.0	23.9
	Cohabiting	0–1	214	5.4	30.1
	Separated from marriage	0–1	189	4.0	24.9
	Divorced	0–1	535	12.9	20.1
	Widowed	0–1	80	1.8	16.2
	Cohabitation end	0–1	373	8.0	27.6
	Continuously single	0–1	294	5.6	21.1
Panel 2:	Cumulative Transitions	0–7	3,761	2.6 (2.0)	-
	0 Transitions	0–1	294	5.6	21.1
	1 Transition	0–1	1,247	38.1	8.8
	2 Transitions	0–1	542	11.6	15.2
	3 Transitions	0–1	651	18.8	13.2
	4 Transitions	0–1	343	7.7	24.9
	5 Transitions	0–1	249	6.7	17.8
	6 Transitions	0–1	175	4.2	30.5
	7 + Transitions	0–1	260	7.3	31.9
Panel 3:	Relationship Trajectories	1–12	-	-	-
	Married continuously	0–1	1,374	36.5	8.7
	Remarried, divorced once	0–1	526	14.0	13.1
	Remarried, divorced twice	0–1	102	2.7	17.2
	Remarried, divorced three+	0–1	29	0.8	18.9
	Cohabiting continuously	0–1	59	1.6	28.9
	Cohabiting, divorced once	0–1	112	3.0	29.4
	Cohabiting, divorced twice+	0–1	46	1.2	34.9
	Partnered, widowed	0–1	46	1.2	18.0
	Single continuously	0–1	465	12.4	20.8
	Single, divorced once	0–1	631	16.8	21.6
	Single, divorced twice+	0–1	281	7.5	27.7
	Single, widowed	0–1	90	2.4	15.9

Notes: ^a Unweighted ^b Weighted by NLSY 1979 Sampling Weight

Table 3

Logistic Regression Models of Women’s Relationship Experiences on Suspected Major Depression. Odds Ratios Reported, Standard Errors in Parentheses. N = 3,761.
		Suspected Major Depression
		Reduced Model		Full Model
		OR	(SE)	OR	(SE)
Panel 1:	Current Relationship Status
	Married directly	(ref)		(ref)
	Married, cohabited first	1.27	(0.18) ⁺	1.05	(0.16)
	Married, reunited (churn)	2.83	(0.94) ^**	1.87	(0.67) ⁺
	Cohabiting	3.16	(0.57)^***	2.15	(0.43)^***
	Separated from marriage	3.04	(0.58) ^***	1.60	(0.34) ^*
	Divorced	2.33	(0.33) ^***	1.96	(0.30) ^***
	Widowed	2.17	(0.64) ^**	1.19	(0.38)
	Cohabitation end	3.23	(0.49) ^***	1.82	(0.32) ^***
	Continuously single	2.47	(0.42) ^***	1.44	(0.29) ⁺
	Intercept	0.12	(.01)^***	.13	(0.02)^***
	Pseudo R²	.033		.135
Panel 2:	Cumulative Transitions
	Total number transitions	1.18	(0.02)^***	1.12	(0.03) ^***
	Intercept	.13	(0.01)^***	.12	(0.01)^***
	Pseudo R²	.017		.132
Panel 3:	Relationship Trajectories
	Married continuously	(ref)		(ref)
	Remarried, divorced once	1.35	(0.21) ⁺	1.16	(0.19)
	Remarried, divorced twice	2.32	(0.61) ^**	1.83	(0.51) ^*
	Remarried, divorced three+	2.34	(1.09) ⁺	1.17	(0.59)
	Cohabiting continuously	2.79	(0.89) ^**	1.67	(0.58)
	Cohabiting, divorced once	3.58	(0.82) ^***	2.75	(0.67) ^***
	Cohabiting, divorced twice+	3.92	(1.30) ^***	2.55	(0.92) ^**
	Partnered (R or C), widowed	1.61	(0.68)	1.20	(0.54)
	Single continuously	2.61	(0.37) ^***	1.43	(0.24) ^*
	Single, divorced once	2.60	(0.34) ^***	1.82	(0.26) ^***
	Single, divorced twice+	3.38	(0.54) ^***	2.42	(0.42) ^***
	Single, widowed		(0.62) ^**	1.25	(0.37)
	Intercept	.11	(0.01)^***	.12	(0.01)^***
	Pseudo R²	.034		.138

Notes: Full model covariates: race/ethnicity, education at age 40, number of children at age 40, percent of life in poverty, physical health at age 40, self-esteem and delinquency in 1980, and self-mastery in 1992.

The authors declare no competing interests.

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Relationship Instability and Depression among Women at Midlife: A Longitudinal Analysis

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Abstract

Figures

Introduction

Women’s Mental Health in Midlife

Family Change and Instability

Relationship Status and Instability

Cumulative Transitions and Relationship Sequences

Methods

Results

Sample Characteristics at Midlife

Relationship Experiences at Midlife

Relationship Status and Major Depression

Cumulative Transitions

Relationship Trajectories

Women's Relationship Experiences and Suspected Major Depression

Current Relationship Status

Cumulative Transitions

Relationship Trajectories

Women's Suspected Major Depression by Relationship Experience

Current Relationship Status

Cumulative Transitions

Relationship Trajectories

Discussion

Limitations

Implications for Researchers and Clinicians

Conclusions

References

Tables

Additional Declarations

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