Evaluation of Anxiety and Depression Among Female Spouses of Iranian Male Drug Dependents

AUTHORS

Roya Noori 1 , Firoozeh Jafari 1 , * , Babak Moazen 2 , Hamid Reza Khoddami Vishteh 1 , Ali Farhoudian 1 , Hooman Narenjiha 1 , Hassan Rafiey 1

1 Substance Abuse and Dependence Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, IR Iran

2 Non Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, IR Iran

How to Cite: Noori R, Jafari F, Moazen B, Khoddami Vishteh H R, Farhoudian A, et al. Evaluation of Anxiety and Depression Among Female Spouses of Iranian Male Drug Dependents, Int J High Risk Behav Addict. 2015 ; 4(1):e21624. doi: 10.5812/ijhrba.21624.

ARTICLE INFORMATION

International Journal of High Risk Behaviors and Addiction: 4 (1); e21624
Published Online: March 20, 2015
Article Type: Research Article
Received: June 30, 2014
Revised: August 24, 2014
Accepted: October 1, 2014
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Abstract

Background: Existing evidences suggest the more vulnerability of spouses of drug dependents, in exposure to mental disorders.

Objectives: This study aimed to evaluate the associated parameters of anxiety and depression among female spouses of male drug dependents.

Patients and Methods: With a cross-sectional design in 2010, a total of 237 Iranian women were selected and divided into three groups: 1. non-drug-dependent wives who had non-drug-dependent husbands (Group I), 2. non-drug-dependent wives who had drug-dependent husbands (Group II), and 3. drug-dependent wives who had drug-dependent husbands (Group III). Socio-demographic characteristics were collected by a checklist, and the levels of anxiety and depression were measured through the Hospital Anxiety and Depression Scale (HADS). Linear regression was applied for determination of anxiety and depression predictors.

Results: Mean age of the participants was about 35 years, and mean duration of marriage was 14 years. Drug dependence of the husband (P = 0.010) and lower monthly income of the family (P = 0.007) predicted the higher level of anxiety among the participants, while older age (P = 0.031), shorter marital duration (P = 0.016), and lower educational level (P = 0.045) in addition to spousal drug dependence (P = 0.023), and lower family income (P = 0.014) were significantly associated with higher levels of depression.

Conclusions: Findings of the present study demonstrate that spousal drug dependence and lower monthly income were common predictors of anxiety and depression among spouses of drug dependents in Iran, while older age, shorter marital duration and lower educational level were predictors of depression. However, more research is needed to find casual relationships between spousal drug dependence and mental health in Iran.

Keywords

Mental Health Anxiety Depression Spouses Drug Users

Copyright © 2015, Zahedan University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

Although positive impact of marriage on better health and decreased risk taking (such as substance use) among couples has frequently been suggested in the literature, possibly due to the involved socio-cultural norms (1, 2), some existing theories have also pointed to its likely negative effects. In this regard, Stein et al. suggested that if one side of the couples has a health behavior problem, it is possible that the other side has the same problem as well (3). In line with this suggestion, Siegel et al. suggested that having a spouse with more depressive symptoms is significantly associated with higher follow-up depressive symptoms among couples (4). Homish et al. also believed that addition of a new adult role (such as spouse, parent, or etc.) might lead to more stress, and consequently substance use among couples (5). Therefore, it seems that the positive and negative impact of marriage on mental, physical, and behavioral health outcomes of individuals is still a subject of debate. The possible relationship between drug dependence and psychological well-being seems to be clear. Firstly, numerous clinical and biological studies have suggested a higher prevalence of mental disorders among substance dependents (6-8). For instance, “higher risk of delayed diagnosis, more severe psychopathological symptoms, less compliance with treatment, poorer effects of treatment, more impairment of social functioning, increased admissions to emergency departments, higher prevalence of physical comorbidity, and suicidal ideation” as well as unemployment, homelessness, and involvement in violent or criminal behavior are among parameters which have been suggested to justify the higher frequency of comorbid mental disorders among narcotic substance abusers (9). Secondly, higher rates of substance abuse have been suggested among people with serious mental disorders (10, 11). Although anecdotal circumstances demonstrate the possible association between drug use and mental disorders, it should be considered that mental problems are not restricted to drug users, and might also influence their family members as well (12-14). The existing socio-cultural situation has made drug dependence a highly stigmatized activity in Iran (15-17), and consequently has totally restricted access to drug users in this country, and has also made their family members a hidden population. In 2010, Jamilian et al. conducted a controlled study to evaluate mental status of mothers and wives of Iranian male drug users (14). Despite the local setting, and different samples and measures from our study, they found significantly higher hypochondriasis, psychopath deviation, paranoia, psych asthenia, schizoid, and F scales amongst spouses of drug dependents, compared with the control group. However, to the best of our knowledge this is the only study evaluating mental health status of females with drug dependent husbands in Iran. Overall, more vulnerability, lack of available data and inevitable maternal role in the society has persuaded us to design and conduct the present study to evaluate anxiety and depression among women with drug dependent husbands in Iran.

2. Objectives

This study aimed to evaluate the associated parameters of anxiety and depression among female spouses of male drug dependents.

3. Patients and Methods

3.1. Design and Setting

During the year 2010, this cross-sectional study was designed and conducted to evaluate the associated parameters of anxiety and depression among three groups of Iranian women including: 1) non-drug-dependent wives who had non-drug-dependent husbands, 2) non-drug-dependent wives who had drug-dependent husbands, and 3) drug-dependent wives who had drug-dependent husbands, in Tehran, Iran.

3.2. Participants and Sampling

One hundred and four non-drug dependent women who had non-drug dependent husbands were sampled from blood donor centers of Tehran, through the random sampling method (Group I). The included women had been married for at least two years, while those with shorter marital duration, serious chronic conditions or mental health problems before marriage, and/or a history of drug dependence were excluded from the study. Participants of the other groups included 121 non-drug dependent women who had drug dependent husbands (Group II), and 12 drug dependent women who had drug dependent husbands (Group III), who were also selected from addiction treatment centers through the random sampling method (RSM).

3.3. Ethical Procedure

An informed consent was obtained from all participants, after they were verbally assured about the confidentiality of their information. All the utilized checklists and questionnaires were anonymous. The ethical committee of the University of Social Welfare and Rehabilitation Science, Tehran, Iran approved the present study.

3.4. Research Instruments

In this study a checklist was used to measure socio-demographic characteristics of the participants including: age, marital duration, educational level, occupation, monthly family income, and having children. The Hospital Anxiety and Depression Scale (HADS) is a standard questionnaire with 14 questions, which was used to measure the level of anxiety and depression among the participants of this study. Higher scores demonstrated higher levels of anxiety and depression among the participants (18). The validity and reliability of the questionnaire were also checked by other researchers from Iran (19, 20).

3.5. Statistical Analyses

The obtained data were processed using the Statistical Package for Social Sciences (SPSS Inc, Chicago, IL, USA) version 13 for Windows. The chi-square test was used to compare the qualitative variables. Furthermore, analysis of variance (ANOVA), analysis of covariance (ANCOVA) and linear regression model were applied as the statistical models. The scores of anxiety or depression were considered as dependent variables, and age, marital duration, having children, education level, family income, physical abuse, self-drug use and spouse drug use were entered in to the analysis with the enter method. P values less than 0.05 was considered significant.

4. Results

The mean age of the participants was 35 ± 9 years, and mean duration of marriage was 14 ± 10 years. From all 237 women, 186 (79%) had at least one child, 62 (26%) had attained higher than diploma education, 68 (28.7%) were employed, 150 (63%) were housewives, 122 (52%) had 400 USD monthly family income or less, and 69 (29%) reported a history of physical abuse by their husbands. Mean scores of anxiety and depression among the participants were 10 ± 4.2 and 6.3 ± 3.9, respectively. In terms of comparison based on qualitative variables, educational level (P = 0.005), monthly income (P < 0.001) and history of physical abuse (P < 0.001) were significantly different between the groups (Table 1).

Table 1. Comparison of Groups in Terms of Qualitative Variables a,b
Group I (n = 104)Group II (n = 121)Group III (n = 12)P Value c
Having child77 (74)99 (82)10 (83)0.336
Educational level, diploma or higher38 (37)21 (17)3 (25)0.005
Job, housekeeper60 (58)83 (69)7 (58)0.224
Family income, ≤ 400 USD33 (32)81 (67)8 (67)< 0.001
Physical abuse9 (9)51 (42)9 (75)< 0.001

a Data are presented as No. (%).

b Group I: non-drug dependent women with non-drug dependent husbands, Group II: non-drug dependent women with drug dependent husbands, Group III: drug dependent women with drug dependent husbands.

c Chi-square test.

After comparing the quantitative variables, it was found that duration of marriage (P = 0.018), mean scores of anxiety (P < 0.001) and depression (P < 0.001) were significantly different between the groups. Bonferroni Post hoc test showed that duration of marriage for Group I was significantly lower than Group II, while no significant difference was seen between Groups I and III, and Groups II and III. Anxiety and depression scores were significantly lower in Group I than the other groups, while no significance difference was seen between the second and third group (Table 2). In addition, two separate ANCOVA analyses for anxiety and depression scores, in order to moderate the confounding effects of age and marital duration, confirmed these results.

Table 2. Comparison of Groups in Terms of Quantitative Variables a,b
Group I (n = 104)Group II (n = 121)Group III (n = 12)P Value c
Age, y34 ± 936 ±835 ± 90.121
Marital duration, y12.0 ± 9.615.6 ± 9.712.7 ± 8.00.018 d
Anxiety score8.5 ± 3.411.1 ± 4.412.0 ± 4.2< 0.001 e
Depression score5.1 ± 3.47.1 ± 3.79.4 ± 5.4< 0.001 e

a Data are presented as mean ± SD.

b Group I: non-drug dependent women with non-drug dependent husbands, Group II: non-drug dependent women with drug dependent husbands, Group III: drug dependent women with drug dependent husbands.

c ANOVA test.

d Group I was significantly lower than the group II (Bonferroni Post hoc test).

e Group I was significantly lower than the groups II and III (Bonferroni Post hoc test).

From all variables only drug dependence of the husband (Beta = 0.185, P = 0.010), and lower monthly income of the family (Beta = - 0.186, P = 0.007) predicted a higher level of anxiety among the participants (Table 3).

Table 3. Predictors of Hospital Anxiety and Depression Scale Scores (Linear Regression) a
Unstandardized CoefficientsStandardized Coefficients, BetatSig95% Confidence Interval for B
BStandard ErrorLower BoundUpper Bound
Age0.0590.0730.1220.8190.414- 0.0840.203
Marriage duration- 0.0660.068- 0.153- 0.9650.336- 0.1990.068
Having children- 0.2360.749- 0.023- 0.3160.753- 1.7111.239
Educational level- 1.0920.677- 0.116- 1.6130.108- 2.4250.242
Family income- 1.5390.561- 0.186- 2.7420.007- 2.645-0.433
Physical abuse1.0360.6150.1141.6860.093- 0.1752.247
Self-drug use0.5321.2010.0280.4430.658- 1.8342.899
Spouse drug use1.5460.5970.1852.590.010.372.722

a Dependent variable: HADS anxiety score.

In terms of higher level of depression, the following variables were the predictors; drug dependence of the husband (Beta = 0.163, P = 0.023), older age (Beta = 0.321, P = 0.031), shorter marital duration (Beta = - 0.382, P = 0.016), lower educational level (Beta = -0.144, P = 0.045), and less monthly income of the family (Beta = - 0.166, P = 0.014) (Table 4).

Table 4. Predictors of Depression Score (Linear Regression) a
Unstandardized CoefficientsStandardized Coefficients, BetatSig95% Confidence Interval For B
BStandard ErrorLower BoundUpper Bound
Age0.1450.0670.3212.1660.0310.0130.277
Marriage duration- 0.1520.063- 0.382- 2.4270.016- 0.276- 0.029
Having children0.9960.6910.1061.4410.151- 0.3662.359
Educational level- 1.2590.625- 0.144-2.0140.045- 2.490- 0.027
Family income- 1.2820.518- 0.166-2.4740.014- 2.303- 0.261
Physical abuse0.7720.5680.0911.3610.175- 0.3461.891
Self-drug use1.7381.1090.0991.5670.119- 0.4483.923
Spouse drug use1.2620.5510.1632.2890.0230.1762.349

aDependent Variable: HADS Depression Score.

5. Discussion

In this study drug dependence of the husband and lower monthly income of the family predicted a higher level of anxiety among the participants, while older age, shorter marital duration, and lower educational level in addition to the predictors of anxiety (spouse drug dependence and lower monthly income) were significantly associated with higher levels of depression among the participants. As mentioned previously, spousal drug dependence was found to be significantly associated with higher levels of anxiety and depression among women. Several studies have pointed to the higher levels of mental disorders among the spouses of drug dependents (21-23). Less optimism, a negative attitude towards life, and less social support are among factors, which have been suggested to justify frequent mental disorders among substance dependents (24). However, accepting drug dependence as a type of chronic condition, and considering the following claim: “reported new or increased symptoms among the spouse during the illness of the partner might be interpreted as a reflection of the psychophysiological impact of the partner’s illness” (25), might partly justify our findings. Moreover, prevalence of violence among substance dependents (26, 27) might also lead to higher symptoms of mental disorders among their intimate partners such as spouses (28). Lower monthly income of the family was the other variable, which showed a significant association with higher depressive and anxious symptoms among Iranian women. Several studies have found a close relationship between economic problems and poor mental wellbeing (29-31), although a few others found no or weak association (32). In this regard Pearlin (33) suggested that increased risk of adverse mental health outcomes might occur due to stress exposure (whether caused by discrete life events, or enduring life stressors such as financial problems). Considering the fact that more than one fourth of the participants reported being employed, effort-reward imbalance (34) is the other parameter, which might be associated with the higher prevalence of anxiety and depression among these subjects. Older age showed a significant association with higher levels of depression among the participants. Erikson is one of the most famous theorists, whose identity theory suggests an association between the role of nature and identity development during the eight stages of human life including: infancy, early childhood, childhood, puberty, adolescence, early adulthood, middle adulthood, and late adulthood (35). Drawing on this theory, during the middle adulthood stage (aged between 35 and 55 years), family relations play the most important role in people’s mental health, along with their career and job. Considering the mean age of the participants (35 ± 9 years), an abnormal relationship with their husband, due to his addiction might be associated with their higher prevalence of depressive symptoms. Lower education level also showed a significant association with higher depressive symptoms among the participants. Several previous studies have found lower education level as a risk factor for mental health problems (36-38). Lorant et al. have pointed to poorer coping styles, ongoing life events, exposure to express and weaker social support as possible risk factors for greater prevalence of psychiatric disorders among people with lower socio-economic status (SES) (39). In this regard they also suggested a more controversial association between depression and SES, compared to other psychiatric disorders. Considering the mentioned justifications, our findings seem not to be surprising. Based on the results of this study, shorter marital duration was found to be significantly associated with higher level of depression among the participants. Proulx et al. introduced the length of marriage as a possible moderator of the association between marital quality and personal wellbeing (e.g. mental health) (40). They suggested that quality of marriage declines during the first few years of couple’s marriage, especially after the honeymoon. Amato et al. also reported that half of divorces occur during the first seven years of marriage (41). This hypothesis might justify higher depressive symptoms among Iranian women. This possible health impact of marriage has been explained by two related and complementary theories; the "selection theory" suggests that healthier people are more likely to get married, and the "protection theory" talks about providing a shield against health risk behaviors among couples (42). Although we have not assessed health behavior among the participants of this study, the results of this study highlight the need for greater attention towards the negative aspects of marriage, especially while one side or both sides are facing a health problem such as substance dependence. The present study had a number of limitations. Because of its cross-sectional design causative relations were not conclusive in this study. Moreover, since data have been obtained based on the self-report method, over report and/or under report might have taken place by the participants. The existing sociocultural situation in Iran and extreme addiction stigma in this country strengthens this hypothesis. Since female drug users and those with drug dependent husbands were sampled only from drug treatment centers, a selection bias might have occurred. However, the existing difficulties to reach these two vulnerable (and mostly hidden) groups might justify our sampling strategy. Despite the mentioned limitations it should be considered that the present study is one of the first studies, which has been conducted to evaluate the predictors of mental health among spouses of drug dependents in Iran. In conclusion, in this study “spousal drug dependence”, and “lower family income” were found as the predictors of anxiety, while “older age”, “shorter marital duration”, and “lower education level” as well as “spousal drug dependence” and “lower family income” predicted higher symptoms of depression among women with drug dependent husbands in Iran. These findings highlight the importance of financial problems and spousal drug dependents as shared predictors of anxiety and depression among Iranian women. More research is needed for multi-dimensional evaluation of mental health among family members of drug dependents in Iran, preferably to find the casual associations.

Acknowledgements

Footnotes

References

  • 1.

    Duncan GJ, Wilkerson B, England P. Cleaning up their act: the effects of marriage and cohabitation on licit and illicit drug use. Demography. 2006; 43(4) : 691 -710 [PubMed]

  • 2.

    Osler M, McGue M, Lund R, Christensen K. Marital status and twins' health and behavior: an analysis of middle-aged Danish twins. Psychosom Med. 2008; 70(4) : 482 -7 [DOI][PubMed]

  • 3.

    Stein JA, Nyamathi A, Ullman JB, Bentler PM. Impact of marriage on HIV/AIDS risk behaviors among impoverished, at-risk couples: a multilevel latent variable approach. AIDS Behav. 2007; 11(1) : 87 -98 [DOI][PubMed]

  • 4.

    Siegel MJ, Bradley EH, Gallo WT, Kasl SV. The effect of spousal mental and physical health on husbands' and wives' depressive symptoms, among older adults: longitudinal evidence from the Health and Retirement Survey. J Aging Health. 2004; 16(3) : 398 -425 [DOI][PubMed]

  • 5.

    Homish GG, Leonard KE, Cornelius JR. Predictors of marijuana use among married couples: the influence of one's spouse. Drug Alcohol Depend. 2007; 91(2-3) : 121 -8 [DOI][PubMed]

  • 6.

    Hoxmark E, Benum V, Friborg O, Wynn R. Reduction in mental distress among substance users receiving inpatient treatment. Int J Ment Health Syst. 2010; 4 : 30 [DOI][PubMed]

  • 7.

    Hoxmark E, Nivison M, Wynn R. Predictors of mental distress among substance abusers receiving inpatient treatment. Subst Abuse Treat Prev Policy. 2010; 5 : 15 [PubMed]

  • 8.

    Wyman KM, Chamberlain JA, Castle DJ. Anxiety, psychosis and substance use: prevalence, correlates and recognition in an outpatient mental health setting. Afr J Psychiatry (Johannesbg). 2011; 14(3) : 218 -24 [PubMed]

  • 9.

    Langas AM, Malt UF, Opjordsmoen S. Comorbid mental disorders in substance users from a single catchment area--a clinical study. BMC Psychiatry. 2011; 11 : 25 [PubMed]

  • 10.

    Brown CH, Bennett ME, Li L, Bellack AS. Predictors of initiation and engagement in substance abuse treatment among individuals with co-occurring serious mental illness and substance use disorders. Addict Behav. 2011; 36(5) : 439 -47 [PubMed]

  • 11.

    Winokur G, Turvey C, Akiskal H, Coryell W, Solomon D, Leon A, et al. Alcoholism and drug abuse in three groups — bipolar I, unipolars and their acquaintances. J Affect Disord. 1998; 50(2) : 81 -9

  • 12.

    Duran B, Oetzel J, Parker T, Malcoe LH, Lucero J, Jiang Y. Intimate partner violence and alcohol, drug, and mental disorders among American Indian women in primary care. Am Indian Alsk Native Ment Health Res. 2009; 16(2) : 11 -27 [PubMed]

  • 13.

    Finzi-Dottan R, Cohen O, Iwaniec D, Sapir Y, Weizman A. The drug-user husband and his wife: attachment styles, family cohesion, and adaptability. Subst Use Misuse. 2003; 38(2) : 271 -92 [PubMed]

  • 14.

    Jamilian H, Khansari M. P03-495 - Comparison of mental status in mothers and wives of addicted men, with mothers and wives of non-addicted men. Eur Psychiatry. 2011; 26 : 1665

  • 15.

    Ahmadi K, Rezazade M, Nafarie M, Moazen B, Yarmohmmadi-Vasel M, Assari S. Unprotected sex with injecting drug users among Iranian female sex workers: unhide HIV risk study. AIDS Res Treat. 2012; 2012

  • 16.

    Mirabi P, Yarmohmmadi-Vasel M, Moazen B, Sehat M, Rezazadeh M, Ahmadi K. Unprotected anal intercourse among Iranian intra-venous drug users. Front Public Health. 2013; 1

  • 17.

    Jafari F, Noori R, Moazen B, Khoddami-Vishteh HR, Narenjiha H, Mirabi P. Perceived sexual satisfaction among women with drug-dependent husbands in Iran. J Subst Use. 2014; 19(6) : 1 -5

  • 18.

    Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983; 67(6) : 361 -70 [PubMed]

  • 19.

    Bayat N, Alishiri GH, Salimzadeh A, Izadi M, Saleh DK, Lankarani MM, et al. Symptoms of anxiety and depression: A comparison among patients with different chronic conditions. J Res Med Sci. 2011; 16(11) : 1441 -7 [PubMed]

  • 20.

    Saleh DK, Nouhi S, Zandi H, Lankarani MM, Assari S, Pishgou B. The quality of sleep in coronary artery disease patients with and without anxiety and depressive symptoms. Indian Heart J. 2008; 60(4) : 309 -12 [PubMed]

  • 21.

    Corrigan PW, Watson AC, Miller FE. Blame, shame, and contamination: the impact of mental illness and drug dependence stigma on family members. J Fam Psychol. 2006; 20(2) : 239 -46 [DOI][PubMed]

  • 22.

    Peters EN, Khondkaryan E, Sullivan TP. Associations between expectancies of alcohol and drug use, severity of partner violence, and posttraumatic stress among women. J Interpers Violence. 2012; 27(11) : 2108 -27 [DOI][PubMed]

  • 23.

    Ponnudurai R, Uma TS, Rajarathinam S, Krishnan VS. Determinants of suicidal attempts of wives of substance abusers. Indian J Psychiatry. 2001; 43(3) : 230 -4 [PubMed]

  • 24.

    Alterman AI, Cacciola JS, Dugosh KL, Ivey MA, Coviello DM. Measurement of mental health in substance use disorder outpatients. J Subst Abuse Treat. 2010; 39(4) : 408 -14 [DOI][PubMed]

  • 25.

    Klein RF, Dean A, Bogdonoff MD. The impact of illness upon the spouse. J Chronic Dis. 1967; 20(4) : 241 -8

  • 26.

    Hines DA, Douglas EM. Alcohol and drug abuse in men who sustain intimate partner violence. Aggress Behav. 2012; 38(1) : 31 -46 [DOI]

  • 27.

    Moore BC, Easton CJ, McMahon TJ. Drug abuse and intimate partner violence: a comparative study of opioid-dependent fathers. Am J Orthopsychiatry. 2011; 81(2) : 218 -27 [PubMed]

  • 28.

    Golding JM. Intimate Partner Violence as a Risk Factor for Mental Disorders: A Meta-Analysis. J Fam Violence. 1999; 14(2) : 99 -132 [DOI]

  • 29.

    Diaz RM, Ayala G, Bein E, Henne J, Marin BV. The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: findings from 3 US cities. Am J Public Health. 2001; 91(6) : 927 -32 [PubMed]

  • 30.

    Dooley D, Catalano R. Money and mental disorder: toward behavioral cost accounting for primary prevention. Am J Community Psychol. 1977; 5(2) : 217 -27 [PubMed]

  • 31.

    Gardner J, Oswald AJ. Money and mental wellbeing: a longitudinal study of medium-sized lottery wins. J Health Econ. 2007; 26(1) : 49 -60 [PubMed]

  • 32.

    Diener E, Suh EM, Lucas RE, Smith HL. Subjective well-being: Three decades of progress. Psychol Bull. 1999; 125(2) : 276

  • 33.

    Pearlin LI. The sociological study of stress. J Health Soc Behav. 1989; 30(3) : 241 -56 [PubMed]

  • 34.

    Kudielka BM, Hanebuth D, von Kanel R, Gander ML, Grande G, Fischer JE. Health-related quality of life measured by the SF12 in working populations: associations with psychosocial work characteristics. J Occup Health Psychol. 2005; 10(4) : 429 -40 [DOI][PubMed]

  • 35.

    Tsang SK, Hui EK, Law BC. Positive identity as a positive youth development construct: a conceptual review. ScientificWorldJournal. 2012; 2012 : 529691 [DOI][PubMed]

  • 36.

    Bjelland I, Krokstad S, Mykletun A, Dahl AA, Tell GS, Tambs K. Does a higher educational level protect against anxiety and depression? The HUNT study. Soc Sci Med. 2008; 66(6) : 1334 -45 [DOI][PubMed]

  • 37.

    Blazer DG, Kessler RC, McGonagle KA, Swartz MS. The prevalence and distribution of major depression in a national community sample: the National Comorbidity Survey. Am J Psychiatry. 1994; 151(7) : 979 -86 [PubMed]

  • 38.

    Gavin AR, Simon GE, Ludman EJ. The association between obesity, depression, and educational attainment in women: the mediating role of body image dissatisfaction. J Psychosom Res. 2010; 69(6) : 573 -81 [DOI][PubMed]

  • 39.

    Lorant V, Deliege D, Eaton W, Robert A, Philippot P, Ansseau M. Socioeconomic inequalities in depression: a meta-analysis. Am J Epidemiol. 2003; 157(2) : 98 -112 [PubMed]

  • 40.

    Proulx CM, Helms HM, Buehler C. Marital Quality and Personal Well-Being: A Meta-Analysis. J Marriage Fam. 2007; 69(3) : 576 -93

  • 41.

    Amato PR, Cheadle J. The long reach of divorce: Divorce and child well-being across three generations. J Marriage Fam. 2005; 67(1) : 191 -206

  • 42.

    Prior PM, Hayes BC. Marital status and bed occupancy in health and social care facilities in the United Kingdom. Public Health. 2001; 115(6) : 401 -6 [DOI][PubMed]

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