In this study we examined the relationship between marital separation and contact with PHC services for mental health problems using high quality panel data. Compared with the men and women who remain married, those who eventually separated were significantly more likely to have a MH-consultation both several years prior to separation and several years after separation. In the year of separation, one in four men and more than one in three women contacted PHC services for mental health problems. Although the odds of a MH-consultation decreased substantially following the years of marital separation, it remained at a higher level than before the separation. This is in line with studies that have examined symptoms of mental health problems [4,5,6, 10], quality of life [6, 8] and the use of psychotropics [16].
As did Buffel et al. [15], we found a positive relationship between marital separation and MH-consultation rates for both men and women. This indicates that both men and women are negatively affected by marital separation. However, the strength of this relationship may differ. To test this, we performed an interaction analysis (results not shown). The results did not provide support for an interaction effect.
This study also shed some light on the mechanisms in play. We found support for both social selection and a causal relationship between marital separation and MH-consultations. Evidence suggesting that men and women who eventually separate are more likely to be in contact with PHC services for mental health problems than the continued married, up to 7 years prior to the separation, adds support to the selection explanation. The strong increase in MH-consultations in the two-year period leading up to marital separation suggests that marital discord and conflicts in these last years prior to separation increase the risk of mental health problems. After taking time invariant characteristics into account, we still found that marital separation was associated with a strong increase in MH-consultations and that although this contact decreased with time after separation, it remained at a higher level than prior to separation. This suggests that marital separation may cause transient mental health problems, and that for some people these problems persist.
The results from our study indicate that marital separation is a distressing event that leaves a potentially long-lasting imprint on the mental health of men and women. However, this group is also more prone to experience mental health problems several years prior to separating. Prevention and adequate treatment of mental health problems among adults in general may in turn potentially prevent marital separation. In order to alleviate and prevent the mental health problems accompanying marital separation, more knowledge into factors causing and maintaining such problems is required.
Future research should look more closely into the nature of the mental health problems that separated present to their GPs. It would also be important to gain more knowledge about the treatment offered by GPs. Increased knowledge regarding the extent to which those separated are offered any form of psychological therapy in the PHC services, psychotropics, referral to specialist healthcare services, or utilisation of sick leave is warranted. Finally, it is important to address how changes in life circumstances in association with marital separation (e.g. reduced household income, custody arrangements, moving) may impact the mental health of those experiencing marital dissolution.
Strengths and limitations
To our knowledge, this is the first study to address contact with PHC services for mental health problems in relation to marital separation utilizing a prospective design, high-quality panel data with a large sample size, and a long observation period with annual updates. Previous studies have been based on cross-sectional data, which is unsuited for examining the mechanisms at play in martial dissolution.
The outcome, a consultation with the PHC services for mental health problems, was collected from a high-quality and reliable administrative register, reflecting reimbursement to GPs for consultation expenses not covered by patients’ fee-for-service. In addition to complete data, the utilization of this kind of data eliminates possible problems related to risk of self-report bias and sample attrition, as may be the case with longitudinal survey data. Other studies addressing PHC service use in relation to marital separation have been based on self-reported measures of health care use, and may as such be vulnerable to both recollection bias and sample attrition.
The main limitation of this study is that we were not able to include separation among cohabitants. In Norway and the other Nordic countries, cohabitation is considered largely indistinguishable from marriage [23, 24]. Cohabitation is the preferred first union among young adults, with more than half of all first-born children being born to cohabiting parents. In the Nordic countries in general, cohabitation enjoys wide social acceptance. On the other hand, cohabiting unions are less stable than marriage and cohabitation typically also involve more short-lived unions [25]. Hence, it is difficult to generalize our findings to separation in cohabiting unions. However, in marriage-like cohabiting unions, that is long-lived cohabiting unions and those involving children, one may find similar MH-consultation patterns in relation to separation as reported in our study. Another group not included in our study are same-sex unions. In Norway, there are about 300 same-sex marriages annually [26].
A study from 2014 found a higher divorce rate among same-sex couples than opposite-sex couples, but little is so far known about the relationship between marital separation and mental health problems in same-sex couples. Finally, we have not accounted for re-partnering among those who separated. This may have contributed to an underestimation of the more long-term effects of marital separation.
