The Role of Marital Satisfaction and Perceived Social Support on Depression of Empty and Full Nest Elderly

ORIGINAL ARTICLE Background: Elderly psychopathology has a special significance that nest status (living with or without offspring) can make it more complicated. This study aimed to assess predictors of depression in the elderly empty and nonempty nest. Methods: This correlational descriptive-casual and effect research was conducted in elderly day care centers, some city locations such as parks and streets, and retirement department of administrations and companies. Participants who answered 7 of 10 questions of Abbreviated Mental Test (AMT) were entered into the research. 274 valid questionnaires were selected from 350 questionnaires distributed between older adults 60 years old and older. The sample was selected by sampling availability but location and population variations were considered. To collect the data we used the Multidimensional Perceived Social Support Scale (12 items, MSPSS), Geriatric Depression Scale (GDS-15), and Index of Marital Satisfaction (IMS). Regression analysis was performed to analyze the data. Results: Depression was negatively correlated with marital satisfaction and all subscales of MSPSS in both groups (empty and nonempty nest). In the empty nest group, the correlation of depression and family (-0.552), significant others (-0.372), and friends (-201) support, and marital satisfaction (0.552) were significant (p < 0.01). In the full nest group, the correlation of depression and family (-0.435), and friends (-0.385) support was significant (p < 0.01). Also correlation of depression and significant others (0.279) support, and marital satisfaction (-0.424) were significant (p < .05). In the empty nest group, marital satisfaction and family support reversely predicted depression. In the full nest group marital satisfaction reversely predicted depression. Conclusion: The findings of this study indicate that considering nest status in elderly depression is important and the type and power of variables in predicting depression in empty and full nest elderly are different. The findings of this study can have significant implications for geriatric health


Introduction
One of the main demographic issues observed in world countries is the issue of an aging population and its leading consequences. Presently, concerning the precipitous current in subfertility in Iran during the past years, it can be predicted that moving towards aging population was accelerating, and the start of the 15th century SH was the beginning of the increasing trend of an aging population in Iran (Mirzaee & Shams, 2007).
In the sensitive period of aging, people are more on the verge of potential threats such as chronic diseases, loneliness, and isolation. In many cases, their individual independence is threatened due to physical and mental disabilities (Shahbazi et al., 2016). Considering the growing increase in the elderly population and the serious risks caused by chronic diseases on their lives and due to the fact that chronic disease can overload the family responsibility of the elderly person and be financially costly, so it is required to conduct studies in order to investigate their physical and mental status and improve the quality of life of this elderly period (Maghsoudi et al., 2016). Meanwhile, depression is among the causes that matter more due to the special conditions of elderly periods.
The factor "age" increases the general risk of depression (Mathiasen & Lavert, 1998). The aging people are susceptible to depression, while the older people are struggling with loneliness, unhealthiness, deprivation (separation), poverty, loss of social status, and changes in family status such as the migration of close people and bereavement (Windmill, 1990), and more complicated they think about death and deny it (Mathiasen & Lavert, 1998), and they are lack of enjoyment of life due to loneliness after their spouse death, consumption of multiple medications, retirement, and fear of death (Jagsan & Doshi, 2013) and empty nest (Liu & Guo, 2007), and empty nest syndrome is the distress feeling of patients due to leaving home by children (Grover & Dang, 2013). Based on the performed surveys, leaving home by children (empty nest) can lead to depression, anxiety, guilt, and stress, the appearance of silent marital conflicts (Grover & Dang, 2013), an opportunity to individuality and increase independence in case of relaxation from parenting role (Harkness, 2008), increase in the feelings of loneliness followed by depression, stress, and anxiety (Liu & Guo, 2007) and etc. For the parents of the present era, the empty nest transition can create more problems than the previous generations who had double communication with large families and communities (Harkness, 2008). Moreover, the social and health issues of older people with empty nest will become a vital issue in the near future (Liu & Guo, 2007).
The other side of the nest status is the full nest. The expression of the revolving door is applicable to the children who have already abandoned their father's home and return to their parents' home after a divorce or financial issues (Harkness, 2008). Here, full nest indicates the life of old parents with their dependent children (Asr-e-Iran, n.d) and can be as a result of not leaving their parental home or returning there due to economic or education issues (Beltrami, 2010). By observing the fact that in Iran the construction of life is in such a way that children usually should live with their parents before they reach legal age and in the case of not achieved independence, the full nest phenomenon can be regarded in some ways. Some factors such as low level of elderly income, young children's expenses, concerns of their children's future careers and marriage, and probable conflicts between parents and adult children, besides the particular issues of elderly time, can exact more psychological burden on the elderly. Marital satisfaction is more critical concerning the restricted social relations in old age. By increasing age, the definition of new intimacy and interdependence will matter, since the reduction of social and physical resources begins continuously while scarcity increases (Perrig-Chiello, 2005) and when the children grow up and their affairs are less related to parents or when they leave their parental home. Loss of roles or reducing them to the parents can able them to be aware of marital conflicts. Some researches declared that marital Rabiee E, et al dissatisfaction could lead to the appearance of depression symptoms (Paul et al., 2006).
Social support can also have a determinant role in the physical and mental health of the individual, as the social relationships of the elderly are discounted due to retirement, illness, and the other factors, as well as the stereotypes of society (such as the inefficiency of the elderly). As mentioned by Vared et al., even conversation on buses can be conductive for the elderly. Membership in friendship groups is also known as one of the activities that signify specifically in this situation. Friendships can eliminate the sense of separation from society in the elderly, and illness and then distance harden the durability of friendships and they profoundly feel the loss of old friends who share common experiences and histories (Shahbazi et al., 2016).
As observed, numerous issues contributed to the depression of the elderly, and naturally, expansive researches were required to identify and survey these issues. Although some researches are carried out on the subject of empty nest and old age, these studies are not adequate in terms of the importance of the subject and the obviousness of the intricacy in the field of empty nest and old age. Furthermore, the full nest is usually not pointed as a problem in the researches, and this is one criterion to measure the problems of people with an empty nest. Also, some contradictory results of researches, and finally a very limited number of this kind of studies in Iran, the explosion of the elderly population in Iran in the near future as well as effects that depression can have on the quality of life of the elderly, will clarify the necessity of study in this area. The main objective of this research was to investigate the role of marital satisfaction and social support in predicting depression in the elderly with an empty and full nest and ultimately suggesting scientific and practical methods appropriate to the elderly characteristics, which can be used for health professionals, psychology and health policymakers.

Methods
This research was descriptive, and correlation and casual-comparative study and its target population were all older people over 60 years conducted in Yazd in the first half of 2017. Based on the particular conditions of the community in this research, sampling was performed using the available sampling method and by referring to the retirement centers, daily care centers for the elderly, workplaces, and parks of Yazd city. The number of 350 questionnaires was answered with the participation of male and female respondents who desired to cooperate, 274 reliable questionnaires were collected among these questionnaires.
To enhance the quality of sampling, the researcher attended the mentioned institutions and parks for 4 months, in the first, middle, and weekend days and at different times in the morning, noon, evening, and night (evening and night did not include the institutions). Inclusion criteria were to be older than 60 years and to answer seven questions correctly from the ten questions of the AMT questionnaire that approved the participants' cognitive health (Forughan et al, 2014). On the other hand, exclusion criteria were unwillingness of participants to continue participating in the research, disability to answer the questions for any reason including fatigue, or lack of propensity for addressing life issues. In data collection step, demographic information questionnaire (age, sex, marital status, residence, number of children, job status, etc), Index of Marital Satisfaction (IMS), Geriatric Depression Scale (GDS), and Multidimensional Scale of Perceived Social Support (MSPSS) were used.
The IMS was a 25-questions tool that was designed by Hudson to measure the extent, intensity, and scope of marital problems. Cronbach's alpha coefficient of IMS was 0.96, which indicated a high internal consistency (Saatchi et al., 2010). In the study conducted by Hoseinian et al., (2007), Cronbach's alpha of this questionnaire was 0/97, and its content validity was investigated and approved. In this paper, two index cutting scores were utilized. One of them was 30±5, which Downloaded from sbrh.ssu.ac.ir at 2:17 IRST on Monday December 14th 2020 [ DOI: 10.18502/sbrh.v4i1.2825 ] its lower scores indicated the lack of clinical problems in the equation, and its higher scores indicated the existence of considerable problems. The other score was 70, which its higher score showed extreme stress and the possibility of marital violence (Saatchi et al., 2010).
GDS-15 was designed to detect depression symptoms in the elderly. This scale was surveyed in the study performed by Malakouti et al. (2006), and its reliability and validity were confirmed. Cronbach's alpha coefficient of this research, which was conducted for standardization of GDS-15, was equal to 0/9, and the reliability of the scale was with the split-half method. Its correlation coefficient was 0/58 by the test-retest method. The validity of this scale was also assessed as optimum. In the present study, Cronbach's alpha coefficient of GDS was calculated to be 0.85. In the 15-questions form of this scale, the volunteer was assumed to give closed-ended (yes) or (no) answers to express their feelings during the past week and the score of each answer was from zero to one and varied in each question.
The MSPSS was a 12-item tool designed by Zimet et al. (1988) to evaluate the perceived social support among the three components of family, friends, and significant others in life. The total alpha coefficient of the test was considered as 0.91, and the alpha coefficient of its subcomponents was to the extent of 0.90 to 0.95 (Hasanzadeh et al., 2014). The rate of Cronbach's alpha coefficients of the total questionnaire and its dimensions were calculated in the present study, and the following results were achieved: the whole questionnaire: 0.877, the family: 0.837, friends: 0.89 and significant others: 0.75. In this test, the scores were as follows: 1 scores for "completely disagree," two scores for "disagree," three scores for "almost disagree," four scores for "no idea," five scores for "almost agree," six scores for "agree" and seven scores for "completely agree." The mean score of the total test was achieved by summing all the phrases divided by its number (12) and the score related to each subscale, the sum of the phrases pertinent to the desired subscale was divided by its number of phrases (4). The high score on this scale represented a high level of perceived social support.
After obtaining the required letters of introduction from Yazd Welfare Organization and referring to the daily centers for the elderly (Bahar, Toranj, Milad, Bagh-e Behesht, Yashaye Sefid, Prochista, Khadijeh Kobra's assistants), retirement centers (education department, electrical department) streets and the parks of Yazd city (Bagh-e Melli, Haftom-e Tir, Ghadir, Azadegan, Azadshahr, Naji), the data were collected through face-to-face interviews and using paper questionnaires.
The ethical considerations observed in this research included: correspondence and obtaining permission from the Welfare Organization and the officials of the daily care centers for the elderly and giving this awareness to the participants, who were likely to leave the interview at any stage of the interview, in case of unwillingness. It is required to note that this research has the ethics identifier of IR.YAZD.REC.1398.015.

Results
Among the 274 participants in the present research, the researcher interviewed with 100 participants in the elderly centers (36.5%), 100 participants in streets and parks (36.5%) and 74 participants (27%) in retirement centers. The minimum age of the sample group was 60 years, and the maximum was 95 years, and the mean age of the participants was 68.77, with a standard deviation of 7.46. The number of participants with an empty nest was 194, and the number of participants with full nest was 80. In the empty nest group, 158 women (81.4%) and 36 men (18.6%) have participated. On the other side, the number of women in the full nest group was 46 (57.5%), and the number of men was 34 (42.5%). Rabiee E, et  Concerning the given data of table1 and out of 274 participants in the sample group, the following results were considered: 112 (40.9%) participants without depression, 101 (36.9%) participants with mild depression, 43 (15.7%) participants with moderate depression and 18 (6.6%) participants with severe depression.
Entry regression analysis method was applied to investigate the prognosis of depression in the elderly in the empty and full nest utilizing the variables of marital satisfaction, family support, friends support, and significant others support.
The significance level of 0.000 in the elderly with an empty nest and the significance level of 0.001 in the elderly with full nest represented that the regression model was significant.
Therefore, the variables of marital satisfaction and family support in the empty nest were entered into the model. Based on R 2 , the entered variables determined 40% of depression changes in the elderly with an empty nest. The beta coefficients in table 4 revealed the degree of the role of each variable.
Since the significance level of the marital satisfaction variable in the full nest was 0.001 and less than an assumed error (0.05) in this research, the marital satisfaction variable in the model was significant, and 28% of the depression changes in elderly with full nest were determined by the marital satisfaction variable.
Following beta coefficients and significance levels, the variables of marital satisfaction and family support were useful in predicting depression in the elderly with the empty nest. They had a direct relation with marital satisfaction and inverse relation with family support. It is worth mentioning that the marital satisfaction variable had a higher score, i.e., weaker satisfaction. Moreover, the marital satisfaction variable was more considerable in predicting depression in the full nest concerning beta coefficients and the significance level.

Discussion
The present study was carried out to investigate the role of marital satisfaction and perceived social support in predicting depression in the elderly with empty and full nests. The results of the data analysis exhibited that the factors predicting depression in the elderly with empty and full nests were somehow different. Indeed. The findings revealed that depression in the elderly with an empty nest was remarkably predictable, with the dimension of family support from the variables of social support and marital satisfaction. In contrast, depression in the elderly with a full nest could be predictable only with the marital satisfaction variable. These findings were in line with some studies conducted by Su et al. (2012) and Liu and Guo (2007) in terms of the role of social support in predicting depression and with other researches such as Wang et al. (2017) in terms of the relationship between marital satisfaction and depression. For example, one study investigated the prevalence and impact of factors affecting depression symptoms in the elderly in the empty nest of China's rural areas. The results indicated that there was a relationship between the depression symptoms and negative coping styles, benefits of support, religious beliefs, marital status, and mental support (Xie et al., 2010). Bakhtiyari et al. (2017) also exhibited a significant negative relationship between perceived social support and depression in the elderly. These results were in line with the results of the present study in terms of the relationship between social support and depression.
An explanation of the role of social support (especially family support), the increasing empirical evidence can be addressed, indicating that emotional and social support of spouse (as part of social support) for all ages, especially the elderly, was a significant variable related to adjustment with growing problems (Xie et al., 2010). But at this time, the scarcities were rising, and the social and physical resources were constantly falling (Perrig-Chiello, 2005). In this regard, the study of MehdiYar et al., (2014), which was conducted to compare parents in terms of empty nest syndrome before and after children leave home, illustrated that the extent of anxiety, depression, and loneliness of parents was Rabiee E, et  On the other hand, perceived support by children was also noticeable as part of family support. Therefore, it was natural that the feeling of support or lack of support from children could affect the mental state of the elderly because children left their father's home (this leaving their home could be itself as a crisis for parents). Such support was able to reduce the sense of isolation and rejection from society in the elderly and give him a sense of worth, particularly when the elderly were not excluded from parental role (Liu & Guo, 2007). But if the elderly did not receive any support from children, some factors such as remembering the past concerning the emotional and supportive investment for children by them could threaten their mental entirety and integrity and direct them towards disappointment, meaninglessness, and depression. On the other side, according to some researchers' idea, creating the sense of loneliness was one of the effects of leaving home by children for the elderly with an empty nest and this feeling was observed as a special risk factor for depression symptoms, and higher levels of loneliness were accompanied with more symptoms of depression (Paul et al., 2006). Hence, the role of family support was completely expected in terms of reducing the depression of the elderly with an empty nest.
Another finding of the present study was the role of marital satisfaction in predicting depression in the elderly in both empty and full nest groups. This finding was consistent with the results of researches that represented marital distress was linked with higher levels of depression (for example, Liu & Chen, 2006;Tower & Krasner, 2006). In the survey carried out by Walker et al. (2013) also indicated that depression symptoms relied on the level of marital satisfaction, and higher depression scores predicted lower marital satisfaction scores. In interpreting of this finding, this matter could be addressed that marital satisfaction generally was a situation in which a couple was like-minded in addition to the feeling of satisfaction to each other about various issues of life, such as spending leisure time, investing, how to continue living, ideas, decision-making for the future and so on (Parcover et al., 2011). Therefore, it was not incomprehensible that high marital satisfaction in old age was remarkably effective in reducing depression in this group by enhancing the quality and common lifestyle of the elderly. In addition to the nature and quality of marital relationships, what was likely to make marital satisfaction important and considerable in this regard were the common benefits of the parents (for example, parenting roles), and somehow they supported each other in maintaining and organizing these common benefits. Besides giving them an identity, these roles would help them not to avoid previous activities completely and to perpetuate their roles. Moreover, tackling the marital conflicts was related to a decrease in the conflict potential and an increase in the pleasure potential from some areas and marital interaction in older couples with more positive emotions and less physiological arousal (Tummala, 2008). Consequently, in the empty nest status, higher marital satisfaction was likely to lead to less depression in older couples utilizing variables such as a healthier lifestyle, happiness, less loneliness, etc., and to moderate the negative side effects of the empty nest. Further researches in this field can facilitate to recognize how marital satisfaction and depression are related to each other.
The findings of the present study presented that among the predictive variables, the only marital satisfaction was able to predict depression in the elderly with a full nest significantly. In elucidating this finding, this issue can be pointed out that the full nest, as a relatively emerging phenomenon in our culture, would create a special psychological state for the elderly couple. The phenomenon of celibacy or divorce of children, at the age when society expects marriage and married life from young people, is one of the reasons for the state of the full nest in old age. In other words, the elderly with full nest and nonconformist with society do not benefit from the family independence of their children. The celibacy state of children or their return to their families after one independent experience can be due to some factors such as unemployment, physical and psychological illnesses, education and economic losses, and the other factors. All of them can be observed as stressful factors for the elderly and are predisposing factors of mental health problems, feelings of inefficiency, lack of control over life events, helplessness, and, consequently, depression. If the role of marital satisfaction means the emotional intimacy of the couple, and especially their concordance in playing a role concerning children, it can be interpreted in this way. Actually, the existence of children (in the situation when they are expected to be independent of the family) maintains and perpetuates the parental role, which again prepares a common goal and encourages parental support and interdependence for this aim. Therefore, higher marital satisfaction can create the greater success of the elderly couple in these common tasks and be effective in preventing depression by reducing failures.

Conclusion
Having supported the research hypotheses, the findings of the present study revealed that depression predictions in the elderly were different concerning their nest status. Regarding the novelty of the research subject, there was an expanded space to discover other cases in this area. Based on the results of this study and considering the type of nest status, obviously, it is required to adopt different strategies in the field of predicting, preventing, and improving the depression of the elderly, which is significantly forceful in physical and mental health.
For the elderly with full nest and concerning the fact that variables of the present study play a relatively slight role in predicting their depression relative to the elderly with an empty nest, more surveys in this field are needed to be conducted. The other variables may be involved in this field, such as the feeling of worry about the future of children. However, decision-making in this regard seeks more researches and discoveries due to the emerging phenomenon of the full nest.
Concerning the infeasibility for preparing a complete list of the elderly by the relevant institutions and lack of comprehensive cooperation of the institutions for providing the list of names of the relevant retirees and using questionnaires with quantitative scores in comparison with qualitative research that can face with more errors, and due to the low tendency of men to participate in the study and the impossibility of interview with the elderly, who were unable to leave home, it is necessary to generalize the results of this research.

Conflicts of Interest
In this study, was not reported any potential conflicts of interest by the authors.