Living alone and antidepressant medication use: a prospective study in a working-age population

The proportion of one-person households has doubled during the past three decades, with every third person in the U.S. and the U.K. living alone [1, 2]. It has been estimated that by 2020, nearly 40% of all households will have only one inhabitant [3]. At the same time, there has been a dramatic increase in the consumption of antidepressant medications [4, 5]. The potentially catastrophic consequences of single living were evident during the 1995 heat wave in Chicago, when most of the deaths occurred among elderly people living alone [6]. However, the long-term consequences of single living are poorly understood, because never before in history has there been such a great proportion of people living alone.

Living alone has been associated with psychological disadvantages and an increased risk of mental health problems, higher rates of consumption of psychotropic drugs [7–12], and a higher risk of suicide [13] compared to living with other persons in the same household. A prospective study demonstrated that household structure, that is, the social composition of people who reside in the same household, was a more important determinant of well-being than marital status in middle-aged people [14]. However, most studies in this field of research have been cross-sectional and have concentrated on selected populations such as elderly people living alone [15, 16] or single parents [17]. Little is known about the mental health outcomes associated with single living in economically active people who represent the majority of the working-age population [13, 18].

Several possible reasons may explain why people living alone suffer from poorer mental health, and why people living with others generally have better mental health. Living with other persons may offer emotional support, feelings of social integration, as well as tangible factors that protect against mental health problems [16, 19, 20]. Living alone, in turn, may be associated with psychosocial deficits such as feelings of isolation [13, 19–22] and a lack of social integration and trust, which, in turn, are risk factors for mental health [23–25]. Single people may also face distress due to socioeconomic disadvantages, such as financial difficulties, and they may be prone to adverse health behaviors [19, 21, 22, 26]. In working-age people, single living may be associated with poorer well-being in working life which, in turn, is known to be a predictor of mental health problems [24, 27]. We are aware of no previous study that has examined aspects of working life as potential contributors to the association between living arrangements and mental health outcomes.

In the present study, we used antidepressant medication as a proxy measure for the most common mental disorders [28], as antidepressants are indicated for both depression and anxiety-related conditions. Our aim was two-fold: to examine 1) whether living alone was associated with antidepressant use during a 7-year period, and 2) the extent to which psychosocial, socioeconomic, and behavioral factors explained any observed association between living alone and the use of antidepressant medication. This study was based on data from Finnish working-age (30 to 65 years) men and women who formed a representative sample of the Finnish working population.

Sociodemographic factors attenuated these associations by 18%, 21%, and 20%. As shown in Table 3 the ORs adjusted for sociodemographic factors were 1.48 (CI = 1.04-2.09) for baseline antidepressant use, 1.64 (CI = 1.32-2.05) for 7-year use, and 1.57 (CI = 1.21-2.05) for incident antidepressant use. Psychosocial factors attenuated the associations by 30%, 12%, and 6%, with the adjusted ORs being 1.43 (CI = 1.03-1.99) for baseline use, 1.71 (CI = 1.38-2.11) for 7-year use, and 1.67 (CI = 1.29-2.16) for incident antidepressant use. Finally, health behaviors had only a marginal effect on the associations between living arrangements and antidepressant use, with adjusted ORs of 1.58 (CI = 1.25-2.21), 1.74 (CI = 1.41-2.14), and 1.64 (CI = 1.26-2.12), corresponding to a contribution of 5% to 9% owing mainly to heavy alcohol use.

Finally, we conducted a sensitivity analysis to examine whether the associations were dependent of the length of the follow-up period. We repeated the analysis of living arrangements and antidepressant use for a 2-year instead of a 7-year follow-up period. The association was directionally similar but slightly weaker than in the main analysis (Additional file 2: Annex Table 2). The contributing factors were similar in magnitude to those in the main analysis, with sociodemographic factors having the greatest contribution and health behaviors the lowest contribution to the greater antidepressant use of participants living alone.

This study suggested that living alone is associated with the prospective use of antidepressant medication in a nationally representative Finnish working-age sample. Those who lived alone had an 80% higher risk of initiating antidepressant use during the 7-year follow-up compared with participants who did not live alone. Socioeconomic adversity explained part of this relationship, especially in women. Psychosocial factors, including a lack of social support, were important explanatory factors in men. Health behaviors had only a marginal contribution to the association between living alone and antidepressant use among men and women, with the exception of heavy alcohol use in men. This is in agreement with a previous register-based study showing a strong link between living alone and alcohol-related mortality [36]. All the factors included in this study explained 46% of the associations, thus leaving the majority of the association between living alone and antidepressant use unexplained.

Our findings are in line with previous reports suggesting that single people suffer from ill health due to material and socioeconomic disadvantages [19, 21]. In our study, urban living, poor housing conditions, and rental living contributed to the association between living alone and antidepressant use. Their effect was more pronounced in women than men. A systematic review demonstrated that the very same environmental factors - housing quality, housing tenure, and urban living - had the strongest mental health effects [37]. The direction of causality in our study may go either way: poor living conditions may cause depression, but they may also be a consequence of earlier mental health problems.

A lack of social support, a poor job climate, and a hostile personality were among the psychosocial factors that were associated with living alone and antidepressant use. A lack of supportive social contacts at work and in private life explained part of the association between living alone and antidepressant use in men. Previously, social problems at work and in private life have been associated with antidepressant consumption [24, 27]. The concept of "social capital" may offer a theoretical framework for interpreting these findings. Living alone may be associated with less social capital [13, 19–22], which, in turn, is a risk for mental health [23–25]. As hostility is a rather enduring personality characteristic associated with irritability, lack of trust, and negative social interactions [38], reverse causation may also play a role. Hostile personalities may be more likely to end up being without a partner due to unwillingness or a lack of skills to form warm and close social relations.

Our data were limited firstly due to the systematic drop-out, causing healthier and economically better-off individuals to be slightly over-represented. This may have restricted the variance in both the predictor variable (living arrangement) and in the outcome variable (antidepressant use), thus underestimating their effects. Second, we were unable to examine whether changes in living arrangements had an effect on antidepressant use. As we had no data on living status on follow-up, some misclassification was possible due to changes in living status after baseline, that is, someone who was originally living alone may have been co-habiting at the time of purchase of antidepressants. Although the main findings were replicated in sensitivity analyses over a shorter time-span, when a change in living status was less likely, this question remains to be examined in further studies. Moreover, we had no data on antidepressant use before the baseline measurement, and thus were unable to examine reverse causation, that is, whether people with prior depression are likely to drift into living alone. Although we showed that living arrangements were associated with starting to use antidepressants (incident use), inferences on whether living alone causes mental health problems are not possible based on this observational data set. Third, different reasons for living alone may be differently related to mental health, but we were unable to compare individuals who unwillingly lived alone with those living alone through choice. Neither were we able to measure the effect of different household compositions on mental health, such as the presence of children, a spouse, or elderly relatives. A large prospective study has shown that under certain circumstances, living with other people may be more stressful than living alone [14]. Future studies should examine the possible benefits of living alone, and the advantages and disadvantages of having other persons with different statuses in the household.

Furthermore, antidepressant use as the outcome variable may reflect help-seeking behavior or differences in access to health care. People using antidepressants have depression that has been diagnosed by a health care professional, and people with undiagnosed depression were not therefore identified. Moreover, people typically seek help if the disease is severe enough to cause functional disability [39], suggesting that participants with mild depressive symptoms may have been undetected. This may have resulted in underestimation of the number of depressed people and underestimation of the effects. Finally, some antidepressants, particularly tricyclic medication, are commonly used for non-psychiatric indications such as pain or sleeping problems [12, 40]. However, it is unlikely that the indication of antidepressant use varies according to living arrangements [12].

The strengths of this study were that common rater variance was excluded because the sources of information on the outcome (national register-based data) and contributing factors (self-reported data) were independent of each other. Because all purchases of antidepressants are recorded in the national registers in Finland, we were able to track 100% of participants who had purchased antidepressant medication at least once during the study years (excluding medications used during hospitalization). We included a rather extensive set of well-established risk factors for mental health problems. To our knowledge, this is the first study to examine both private life and work life factors as contributors to the association between living arrangements and mental health outcomes within the same sample.

This study focused on a working-age population and its antidepressant use over almost a decade. Persons living alone faced several types of psychosocial and material disadvantage. We found evidence to suggest that the explanatory factors may be gender specific, with a lack of social support playing a greater role in men and socioeconomic disadvantages in women. These finding suggest that improving the quality of social relations and material circumstances should be important targets in mental health promotion. Further research is needed, as over half of the association between living alone and antidepressant use remained unexplained by the variables included in this study. Further insights may arise, for example, from assessments that cover social capital (that is, feelings of alienation and a lack of trust in society), critical life events and their accumulation over time, and childhood circumstances giving rise to psychological vulnerabilities in adulthood.