Migration of adult children and mental health of older parents ‘left behind’: An integrative review
Migration of adult children and mental health of older parents 'left behind': An integrative review
Deependra Kaji ThapaID 0
Denis VisentinID 0
Rachel Kornhaber 0
Michelle Cleary 0
Takeru Abe, Yokohama City University,
0 School of Health Sciences, College of Health and Medicine, University of Tasmania , Sydney, NSW , Australia
Although a number of studies have examined the effect of the out-migration of children on the mental health of 'left behind' elderly parents, research on the consequences of children's migration on the mental health and well-being of elderly parents left behind is inconclusive and a systematic review is warranted. To identify the association between the left behind or empty nest status and the mental health of older parents, and to identify common risk factors for poor mental health among those left behind.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
Funding: No funding. The first author is receiving Tasmania Graduate Research Scholarship from University of Tasmania, Australia.
Competing interests: The authors have declared that no competing interests exist.
25 articles met the inclusion criteria. The studies identified that left behind older parents had
higher levels of mental health problems compared to non-left behind. Left behind parents
had higher depressive symptoms, higher levels of loneliness, lower life satisfaction, lower
cognitive ability and poorer psychological health. A number of risk factors were identified for
mental health disorders among the left behind parents, which included living arrangements,
gender, education, income, physical health status, physical activity, family and social
support, age, rural residence and frequency of children’s visit.
This review synthesised the various studies related to the mental health of left behind
parents, advancing the theoretical and empirical understanding of the implications of
outmigration of adult children on the psychological health and well-being of older parents. More
responsive preventive measures and effective management approaches are required for
this vulnerable cohort.
Over the past decade, there has been a significant increase in both international and internal
migration rates. There is an increasing trend in the flow of rural surplus labour to big cities
due to an imbalance in economic development between rural and urban areas, exacerbated by
globalization and urbanization. Globally there are an approximately 232 million international
migrants and 740 million internal migrants [
]. Potential migrants are more likely to be male,
young, single and have completed secondary education [
]. The out-migration of young adults
from the household results in children and older family members being ‘left behind’. Studies
concerning the effects of migration on health and well-being often focus on migrants
themselves with the families left behind receiving limited attention [
]. Studies focusing on the left
behind often consider the children [
4, 5, 6
] and spouse [
] of migrants, ignoring the left
behind older family members themselves.
The ‘left behind’ and ‘empty nest’ parents
Left behind parents are those who are living in the originating country or place of residence
with one or more biological or adopted children emigrated. Older adults without living child
(ren) are not considered at risk of being ‘left behind’. When a household consists of only older
adult(s) after children leave the home, it is called the ‘empty nest’ although some studies also
use the term to include childless households. Hence, ‘empty nest older adults’ live alone or
only with a spouse and may experience anxiety, depression, guilt, and loneliness; the so-called
‘empty nest syndrome’ [
While both terms ‘left behind’ and ‘empty nest’ parents portray similar meanings, there are
some important distinctions. Firstly, older adults who do not have a child might not be
considered as ‘left behind’, but may fall into the ‘empty nest’ category if living alone or with a spouse.
Secondly, when one or more children leave the household the parents are ‘left behind’
irrespective of the living arrangement and household structure. However, elders who live alone or with
their spouse only are defined as empty nest elders, while those who live with one or more
children are non-empty nest elders, despite the fact that the parent may have some children who
have migrated. The focus of this paper is on the impact of out-migration of children on the
mental health of the older parents left behind and hence consider studies that use either terms.
Mental health of left behind parents
A number of studies have explored the influence of adult children’s migration on the health of
older parents left behind, with some studies reporting a significant adverse effect on their
mental health. Out-migration of young people has negative consequences for ageing parents, with
loneliness, isolation and loss of basic support [
]. In Mexico, Antman [
] reported that the
migration of adult children was associated with poorer physical and mental health outcomes
2 / 30
for ageing parents. Studies conducted among the older parents in general also show that close
contact and emotional cohesion with children is associated with improved parental mental
health. For instance, Dykstra and de Jong Gierveld [
] found that social and emotional
loneliness among older Dutch women was negatively associated with weekly contact with their
children. Similarly, older European parents who saw or talked to their children more often than
once a week had significantly lower levels of depression [
]. Among the Chinese elderly,
living alone was associated with low subjective well-being and living with immediate family
members improved their general well-being [
]. Internal migration of children in Indonesia
had a negative effect on elderly parents’ daily living, self-rated health and mortality [
In contrast, there are studies reporting better physical and emotional well-being among the
left behind elderly parents. Waite and Hughes [
] found that left behind parents in the USA
enjoyed improved health conditions over parents living with their children. A study in China
] reported non-empty nest elderly utilizing better health care than that of empty nest
elderly. Wenger et al. [
] in their multi-country study showed that elders whose children
were living away had more freedom with more time to make friends, and engage in social
activities. Living alone provides parents with an opportunity for reconnection and reawakened
]. In Moldova , better physical health among the left behind elderly parents
was a consequence of their children’s migration. However, this study and a similar study by
Gibson et al. [
] in Tonga showed no effect of the migration on the mental health of parents.
Among the left behind, a number of risk factors for poorer mental health have been
identified ranging from predisposing inherent factors (such as age, sex, education, existing disease
status, previous mental illness, and place of residence) to a wider community and social factors
such as existing social support, number of social ties, community engagement and
interactions, and access to health services. In general, males, younger parents, living in urban areas,
and better access to medical care are positively associated with improved mental health of
empty nesters. Despite the increased focus of research in this area, the empirical findings are
equivocal. Research on the consequences of children’s migration on the mental health and
well-being of elderly people remains inconclusive and a systematic review is warranted.
Objective of the review
To identify the association between the left behind or empty nest status and the mental health
of elderly parents and to identify the common risk factors for poor mental health among those
Materials and methods
This integrative review considered research relating to the migration of children and the
mental health of the left behind parents. Integrative reviews are an effective method for combining
studies with diverse methodologies and data sources in order to increase understanding of the
topic, subsequently contributing to the evidence-base [
Well-established databases (CINAHL, PsycINFO, PubMed, Scopus and ProQuest) were
searched for research published in English language to identify relevant studies on mental
health status of left behind parents or elderly people. The following search terms were used:
‘left behind’; ‘country staying’; ‘left in hometown’; ‘left in rural areas’; ‘stay at home’; ‘empty
nest’; ‘empty nester’; parents; elderly; aged; adult; aging; ‘mental health’; ‘mental disorders’;
‘psychological well-being’; ‘well-being’; and ‘quality of life’. The search strategy was
supplemented by review of the reference lists of the included research [
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Inclusion and exclusion criteria
Included studies met the following criteria: (a) focused on the relationship between the
migration of the adult child(ren) and the mental health of the elderly parents ( 50 years) left behind
or factors related to the mental health of the left behind parents; and (b) published in English
from January 2000 to September 2017.
Studies were excluded if the focus was on the left behind children, spouse or family members.
In addition, studies related to parents and/or elderly left behind due to the death of a child were
excluded. To account for the cohort effect, studies published before the year 2000 were excluded.
The process of selection included reviewing the titles and abstracts to identify potential
articles and then reading the full text to determine whether articles met the inclusion criteria.
Initial screening was carried out by the first author and then checked independently by all other
authors. The final sample comprised 25 articles from 23 studies that met the inclusion criteria
(see Fig 1).
The first author (DKT) extracted and coded the following information: authors’ names,
publication year, country, design, purpose, sample size, age of participants, mental health related
Fig 1. Study selection process for the review.
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variable(s), data collection tools/scales and data analysis method (Table 1), prevalence and/or
mean scores of the scales in left behind and non-left behind groups (Table 2), and factors
associated with mental health among the left behind group (Table 3). The other authors (DV RK
and MC) verified the extracted data. The variety of tools and instruments used to assess mental
health precluded a quantitative meta-analysis.
The JBI Checklist for Analytical Cross Sectional Studies [
] was adapted to assess quality.
Articles were scored Yes, No, Unclear or Not Applicable (NA) for the following: (1) criteria for
inclusion in the sample clearly defined, (2) study subjects and the setting described in detail,
(3) exposure measured in a valid and reliable way, (4) objective, standard criteria used for
measurement of the condition, (5) confounding factors identified, (6) strategies to deal with
confounding factors stated, (7) outcomes measured in a valid and reliable way, and (8)
appropriate statistical analysis used. (See S1 Table)
Results of the review
Twenty-three studies reported in 25 publications from six different countries were included.
The majority were from China (n = 14). Other countries included Thailand (n = 3), Moldova
and India (n = 2), and Mexico and Ireland (n = 1). Four studies were longitudinal [
26, 30, 35,
] with the remainder cross sectional with the exception of one qualitative study [
The majority of studies (n = 14) used random sampling [
18, 22, 33, 38, 41, 43, 45, 46, 50, 53,
] while five did not provide sampling information [
12, 26, 28, 30, 48
]. One used total
sampling  and another used snowball sampling . The sample size of quantitative
studies ranged from 352 to 28,677, and the qualitative study had 29 participants. The age of subjects
ranged from 50 to 100 plus years.
Nine studies [
26, 33, 38, 41, 45, 48, 55, 58, 60, 62
] reported a response rate above 90% while
18, 30, 46, 53, 59
] had a response rate range of 80–90%. The remaining eight [
12, 22, 28,
43, 49, 50, 56, 57, 64
] did not report the response rate.
Defining ‘left behind’ and ‘empty nest’
Thirteen articles were related to ‘empty nest’ [
18, 26, 33, 38, 43, 45, 46, 50, 55, 57, 58, 60, 62
while the remaining 12 discussed the ‘left behind’ [
12, 22, 28, 30, 35, 41, 48, 49, 53, 56, 59, 64
There was uniformity on the use of the term ‘empty nest’, as elders who living alone, or with a
spouse only, were defined as empty nest and those living with family members were
considered non-empty nest across all studies. The elderly without children were deemed empty nest
if living alone or with a spouse, however one study  excluded elderly who were childless.
For the studies reporting ‘left behind’, the inclusion criteria included elderly parents having
(adult) children and at least one of the children having migrated—excluding those without any
living child. There were some variations in defining the duration of migration. He et al. ,
for example, defined ‘left behind elderly’ as those with adult children having left for more than
6 months while two studies [22, 53] defined migrant children having left home for more than
3 months. Antman [
] and Downer et al. [
] defined parents as left behind if any of their
children were living in the USA. Sekhon and Minhas  considered families which had at
least one member who had permanently emigrated abroad. A follow up study defined left
behind as no children emigrated at baseline but one or more children emigrated at follow up
]. Xie et al.  did not provide clear defining criteria.
5 / 30
Sample and study
809 EN, 60 years
Sixteen studies [
12, 18, 22, 26, 28, 30, 33, 38, 43, 45, 53, 56–60, 62
] had a control group. Two
] separated the left behind group into ‘living alone’ and ‘living with spouse/as
couple’. Abas et al.  compared the mental health status across three groups: ‘all children
migrated’, ‘some children migrated’ and ‘no children migrated’. The remaining seven
41, 46, 48–50, 55, 64
] studied the left behind and did not have a comparison group.
Sixteen studies [
12, 26, 28, 30, 33, 41, 43, 45, 46, 48, 50, 55, 57, 58, 60, 62
] were concerned with
factors affecting the mental health status of the left behind, while the remaining eight only
assessed the relationship between the children’s migration and the mental health status of
Measures of mental health
A range of measures were used to assess mental health status with many using multiple
measures. Depression was assessed in 13 studies [
28, 30, 38, 41, 43, 45, 49, 53, 55, 58–60
] and three
studies assessed loneliness [
30, 45, 62
]. Other measures of mental health included anxiety ,
cognitive function [43, 50], life satisfaction  and social isolation . Some used broader
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LB : 79.6
LB: 69.1 &
1The study reported the scores after logarithmic transformation. We report the raw scores.
–not available/not reported.
measures such as symptoms of poor mental health , self-reported mental health [
psychological well-being , psychological health [
] and measures of mental health
18, 22, 33
Twenty studies used standard instruments for measuring different aspects of mental health.
Depression was measured by the Center for Epidemiologic Studies Depression Scale (CES-D)
10 / 30
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], Geriatric Depression Scale (GDS) [
41, 45, 50, 55, 58, 60, 62
], European Quality of Life-5
Dimensions (EQ-5D) [46, 57] and the European Version of Depression Scale (EURO-D) [53,
59]. Cognitive function of the elderly was assessed using the Mini-Mental State Examination
], Cross-Cultural Cognitive Examination (CCCE) and the Informant
Questionnaire on Cognitive Decline in the Elderly (IQCODE) [
]. Instruments used to measure
mental health included the Mental Health Inventory (MHI) [
], University of California
Los Angeles Loneliness Scale (UCLA-LS) [
30, 45, 60, 62
], Symptom Checklist-90-Revised
], Patient Health Questionnaire-9 scale (PHQ-9) [
], Self-Rating Anxiety
Scale (SAS) , Short Form Health Survey (SF) [
] and the Life Satisfaction Index (LSI)
[60, 62]. Three studies [
38, 45, 48
] used the World Health Organization Quality of Life
Questionnaire abbreviated version (WHO-BREF).
Mental health of the ‘left behind’ parents
Depression. Thirteen studies reported depression among the left behind elderly parents.
All studies used validated scales to measure depression, except Sekhon and Minhas  who
asked ‘Do you feel depressed that your family member has gone abroad and is no longer staying
with you?’ with 98% of participants responding ‘Yes’. Among the studies that used validated
scales, an equal number (n = 4) reported both prevalence and mean scores, prevalence only
and mean scores only. Studies using cut-off scores (n = 8) reported the prevalence of
depression among the left behind elderly ranging from 11.6% to 79.7%. Large variations in the mean
score of depression were observed (Table 2).
Variation in scales resulted in large heterogeneity in depression prevalence as well as mean
scores. Among the seven different scales, the Geriatric Depression Scale-Long Form (GDS-30)
 was the most commonly used. The GDS-30 consists of 30 items with a score ranging from
0 to 30, higher scores represent increased depression. GDS scores of 11 and above suggest
depressive symptoms. The studies using GDS-30 reported the proportion of left behind elderly
having depressive symptoms ranging from 36.9% to 79.7% and mean GDS score from 7.7 and
14.0. Wang et al.  used GDS-Short form  comprising 15 items with a score range from
0 to 15 and reported a mean score of 3.7.
Two studies applied EURO-D, a 12-item depression screening scale with a cut-off of 6 .
Abas et al.  used a cut-off core of 12 and reported a prevalence of 16% among the elderly
with all children migrated. Abas et al.  reported mean scores of 2.9 for the elderly with all
children migrated and 4.0 for some children migrated. Two studies used the Patient Health
Questionnaire (PHQ-9) with 9 items, with a scoring range of 0 to 27 [
]. Zhai et al.  used
a cut-off of 5 and found a depression prevalence of 11.6%. Chang et al. [
] used two different
cut-offs (5 and 10), resulting in the reported prevalence of depression of 26.9% and 8.1% for
elderly living alone and 24.7% and 5.9% for elderly living as couple. A study using the Mental
Health Inventory (MHI-38) [
] reported a mean score of 71.3 [
]. Similarly, a study using
] reported depression among 13.1% of the left behind elderly with a mean
depression score of 1.5 [
Mosca and Barrett [
] used the 20-item Center for Epidemiologic Studies Depression
Scale (CES-D) [
] to measure depressive symptoms in the week prior to the interview. Each
of the 20 items was scored on a four-point scale leading to a total score of 60, with higher
scores indicating higher depressive symptoms, with a mean depression score of 4.7.
Two studies used the EQ-5D scale developed by The EuroQol Group  to measure
health-related quality of life among the empty nest elderly in rural China. Liang and Wu 
reported an anxiety/depression prevalence of 82% using EQ-5D while Sun et al.  reported
the depression prevalence only for sex and age sub groups.
14 / 30
Anxiety. Wang et al.  determined the prevalence of anxiety disorders using the
SelfRating Anxiety Scale (SAS) . The SAS is a 20-item scale with scores ranging from 20 to 80,
with higher scores representing higher anxiety. A cut-off of 50 was used for a SAS standardized
score = 1.5 x SAS sum score. The mean standardized score of 44.5 indicated relatively low
anxiety, while the prevalence of anxiety disorders was 30.1%. The mean SAS standardized scores
were higher in females (46.7) compared to males (42.5); elderly living alone (46.3) compared
to living with spouse (43.9); rural inhabitants (48.9) compared to urban (39.7); and
unmarried/single/divorced or widowed (48.1) compared to married (43.8). In addition, the study also
reported the association of anxiety with education level, occupation and monthly income of
Cognitive impairment. Cognitive function of the left behind elderly was assessed using
the Mini Mental State Examination (MMSE), a 30-item test to assess orientation, attention,
calculation, language, and recall . The MMSE yields a score of 0–30 (cut-off of 24) with
higher scores indicating better functioning. Zhai et al.  found 15.7% of the elderly with
cognitive impairment while Wang et al.  reported a mean MMSE score of 22.1 (SD = 6.8).
The Chinese version of the MMSE [
] with 25 items (score 0 to 25) was used by Gao et al.
] reporting a mean score of 18.9 (SD = 5.5).
Loneliness. Loneliness was assessed using the University of California, Los Angeles
Loneliness Scale (UCLA-LS) [
] which consists of 20 questions, using a four-point scale, with a total
score range of 20 to 80 with higher scores indicating increased loneliness. The mean UCLA-LS
scores reported were 35.7 (SD = 9.9) , 41.5 (SD = 7.0)  and 35.9 (SD = 9.4) [
scores of 20–34, 35–49, 50–64 and 65–80 are considered to be mild, moderate, moderate–
severe, and severe loneliness, respectively [
]. Cheng et al.  reported the prevalence of
mild, moderate, moderate–severe and severe loneliness as 14.4%, 75.8%, 9.9%, and 0%
respectively. Similarly, Liu and Guo [
] found 45.5% experiencing mild loneliness, 43.6% moderate,
and 10.9% moderate–severe loneliness and no severe loneliness. Mosca and Barrett [
included only five items of ULCA-LS and reported a mean score of 1.5 (in a range of 0 to 10).
Other general measures of mental health. The World Health Organization Quality of
Life Questionnaire abbreviated version (WHOQOL-BREF) [
] consists of 26 items
containing two objective items (overall QOL and general health status) and 24 other items divided
into four domains: physiological (seven items), psychological (six items), social relationships
(three items) and environment (eight items). Each item is scored from 1 to 5 and domain
scores range from 4 to 20 points (mean score for all items × 4) with a higher score representing
better quality of life. In this review, only scores for the psychological domain are relevant.
Cheng et al.  report a mean score of 13.5 (SD = 1.9), and Xie et al.  converted the score
into a centesimal grade [(original score– 4) × (100/16)] and reported the mean score of 39.6
(SD = 13.8). The equivalent centesimal score for the Cheng et al.  is 59.1.
Bo¨hme et al. [
] assessed the psychological well-being of elderly parents with at least one
biological child staying abroad for at least three months during the year prior to the survey.
The study used MHI-5, a five question scale based on Mental Health Inventory developed by
Veit and Ware [
] ranging from 5 (very poor) to 30 (very good). The mean score of
psychological well-being reported by Bo¨hme et al. [
] was 18.5.
The 36-Item Short-Form Health Survey (SF-36) [
] was used to assess general health with
Mental Component Summary (MCS) scores ranging from 0 to 100, where higher scores
indicate better mental health. Studies reported mean scores of 69.1 (SD = 18.3) [
] and 68.6
(SD = 17.7) [
] created the ‘Poor Mental Health’ variable, equal to 1 if the respondent
reported feeling depressed, lonely, or sad for the week prior to the survey otherwise 0. The
mean score of ‘Poor Mental Health’ was 0.6 (SD = 0.01) among the left behind parents.
15 / 30
Adhikari et al.  using their own instrument reported 58.9% of the left behind elderly having
symptoms of poor mental health.
Children’s migration status and mental health of left behind parents
Among the studies that compared prevalence or mean scores between the left behind and
non-left behind elderly parents (n = 15), ten reported statistically significant differences while
three were non-significant. Two studies [
] did not provide details on significance. Nine
studies found the mental health status of the left behind elderly to be poorer than that of the
elderly parents living with their children with statistically significant differences in six studies.
More specifically, these studies showed that left behind parents had higher depressive
symptoms [43, 45, 58, 60], higher levels of loneliness [45, 60], lower life satisfaction , lower
cognitive ability  and poorer psychological health [
12, 18, 33, 45, 56, 62
Three studies found statistically significant differences showing better mental health among
the left behind, with one further study showing a non-significant difference. Gao et al. [
reported higher cognitive ability and improved psychological health scores among the left
behind, however confounding by age may account for this result. Decreased prevalence of
depression among the left behind parents was reported [
28, 30, 53
]. Two studies classified left
behind into two groups, among which Chang et al.  found a lower proportion of
depression among the elderly living with a spouse. Similarly, Abas et al.  reported the highest
mean depression scores among the elderly with ‘some children living outside’, followed by ‘no
children living outside’ and ‘all children living outside’ (Table 3). Guo et al. [
] stated that the
mental health status of the left behind parents was better than that of the non-left behind but
reported similar results for both groups.
Sixteen studies analysed the association between the left behind and the mental health of
elderly, of which 12 studies conducted multivariate analysis and the remaining four studies
reported only bivariate association. For multivariate analyses, seven studies [
12, 26, 30, 43, 56,
] showed that parents whose children had migrated were at greater risk of mental health
problems than those with non-migrant children (Table 3). For instance, Gao et al. [
] found a
negative association of empty nest with cognitive ability and psychological health in both
urban and rural elders. Depressive symptoms were found to be higher among the parents of
migrant children [
]. Sun et al.  reported that the risk of anxiety/depression was
higher among the elderly living alone, while the risk was not statistically significant among the
elderly living with spouse. In contrast, Abas et al. , while comparing the depression of
parents without migration of adult children, found that having all or some children migrated
had lower levels of depression. Having all children out-migrated reduced depression compared
to none or some children out-migrated . Three studies [
22, 28, 38
] found no association
between migration of adult children and the mental health of the elderly.
Among the studies reporting a bivariate association, three [
18, 45, 58
] reported higher
prevalence of mental health problems for left behind parents while the remaining study [
showed no significant association.
Factors related to mental health status among the left behind parents
Gender. Eight studies examined the relationship between gender and mental health
among the left behind elderly. Females had poorer mental health than males in five studies [
26, 33, 41, 50
] while Xie et al.  observed women to be at lower risk. Gender differences
were not observed in two studies [45, 46].
Age. Seven studies examined the influence of age on the mental health status of the left
behind elderly and reported varied results. Multiple regression analyses showed cognitive
16 / 30
ability and psychological health were negatively associated with age [
]. In addition, Liu
and Guo  found age was positively related with loneliness in a bivariate analysis. He et al.
 reported the prevalence of depressive symptoms in the 71–80 years age group (45.2%) to
be higher than the 65–70 years (37.4%) and >80 years (6.0%) age groups. Conversely, higher
rates of loneliness  and anxiety/depression  were reported among the younger elders.
No significant change in anxiety with increasing age was reported in a study conducted by
Wang et al. .
Marital status/Type of residence. Marital status using marital status groups including
currently married, never married, divorced, separated and widowed, was a frequently
mentioned factor influencing mental health. Being (currently) married was associated with better
mental health among the left behind elderly [
26, 58, 62
]. Similarly, living with a spouse
decreased the risk of anxiety , depression , loneliness  and psychological ill health
. Two studies [33, 46] found no difference in mental health with respect to marital status.
Education. Seven studies assessed the relationship between education level and mental
health with inconsistent results. Four [
12, 41, 46, 50
] indicated that left behind parents with
higher educational level were less likely to develop mental health problems. Cheng et al. 
reported a lower mean loneliness score among elderly with secondary education. However,
Liu and Guo [
] found a higher level of education had a higher level of loneliness for left
behind with higher levels of education. Guo et al. [
] reported no difference in mental health
symptoms across different education groups.
Economic status. Seven studies addressed the association between economic status
(measured mostly in terms of monthly or yearly income and self-perceived income) and mental
health of the left behind elderly with all observing higher income related with lower levels of
mental health disorders. The results of bivariate analyses showed that elderly in the lower
income groups reported higher scores of anxiety . In addition, low income was associated
with higher levels of loneliness [
], lower life satisfaction , and poorer mental health
]. Similarly, low levels of self-perceived income was identified as a significant
predictor of depression [55, 58]. Furthermore, He et al.  found a lower prevalence of
depression among the elderly who had higher levels of financial support. Two studies used
occupation as an economic indicator. Cheng et al.  reported a higher loneliness mean
score among farmers compared to other occupations; however, the association was not
significant under multiple regression. Similarly, skilled workers had the lowest mean anxiety score
with the highest among farmers .
Place of residence. Three studies assessed the association between place of residence
(urban or rural) and mental health with two reporting improvements for those in urban areas.
Wang et al.  found higher anxiety scores among rural left behind elderly parents, and Su
et al.  reported a lower prevalence of depression in urban residents. However, one study
] showed no significant difference in mental health symptoms by place of residence.
Disease condition. Chronic disease(s) was associated with poor mental health conditions
], depression  and lower levels of life satisfaction . Su et al.  identified physical
illness as a significant risk factor for depression, while Cheng et al.  found no association
between chronic disease and loneliness.
Social support. Four studies measured social support using the Social Support Rate Scale
] comprising three dimensions: objective support, subjective support and support
utilization. Cheng et al.  reported significantly lower social support for left behind parents
and found ‘objective support’ was a strong negative predictor of loneliness. Xie et al. 
found all three dimensions of SSRS were negatively correlated with depression, but in the
multivariate regression, only the dimension of ‘support utilization’ was significant. Social support
was negatively associated with life satisfaction  and positively associated with loneliness
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]. Cheng et al.  also found that the social support from family as measured by Perceived
Social Support from Family Scale (PSS-Fa) [
] and social interaction (as measured by
WHOQOL-BREF) were negatively associated with loneliness.
Other reported factors. Higher levels of exercise and physical activity were found to
improve cognitive function and psychological health [
], and reduce depression [41, 55]
among left behind elderly parents. Increased frequency of the children’s visits was positively
associated with mental health. Left behind parents whose children visited more often had
lower depression  and better psychological health . Xie et al.  identified religious
belief as a risk factor for depression. Better relationships with children was also associated with
higher levels of life satisfaction .
The association between left behind status and mental health
The primary objective of this review was to identify the association between migration of adult
children and the mental health of elderly parents left behind. The study designs were mostly
cross sectional. While this study design limits causal inference, the quality assessment based on
the JBI checklist for cross sectional analytical studies found most to be of high methodological
quality allowing for adequate assessment of associations. The results were relatively consistent,
where being left behind was negatively associated with mental health in 10 of the 16 studies
with only 2 finding a positive association. The qualitative study [
] also found parents with
adult children migrated experienced higher level of loneliness and depression.
Those left behind experienced higher levels of depression, loneliness, cognitive impairment,
anxiety and had lower scores on psychological health compared to older parents with no
migrant children. In a meta-analysis of studies concerning quality of life of the empty nest
elderly by Lv et al. [
] found that mental health among the empty nest elderly was poorer
than non-empty nesters.
In developed countries with higher standards of living and systems for social protection in
older adults, independent living is often preferred [
]. In developing countries without social
security and other welfare supports for older adults, intergenerational extended family is
crucial for elderly health and well-being [
]. In South East Asian cultures, residing with adult
children demonstrates ‘filial piety’ [
]. The majority of studies included in this review
were conducted in countries where filial piety is the major guiding principle and a strong
intergenerational relationship is important. Older adults had emotional ties and high
expectation for their children to provide physical, financial, instrumental and emotional support.
Often when they are older, parents want to live with their children so that they can receive
daily assistance and support. This may contribute to positive mental health and well-being.
Being left behind may make them feel abandoned, and experience emotional ambivalence,
anger and distress . Older parents living with their children are reported to receive better
daily care and support leading to better health [
A number of studies reported positive associations between parent-child co-residence and
the mental health of older parents. Older adults who were left behind by migrant children
were more susceptible to psychological distress such as depression [
coresidence has shown to be protective in many countries in different populations including
], Japan [
], China [
] and Vietnam . In Spain, Zunzunegui et al. [
showed elders living with their children had more instrumental and emotional help and
improved physical and mental health. Left behind adults in Sri Lanka had a higher prevalence
of depression, anxiety and somatoform disorder [
]. Those left behind elderly may also feel a
loss of status and fear for their future [
]. Cheng and Chan [
] demonstrated an association
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between filial behaviour of children and psychological well-being among Chinese older
parents. Living with their son is considered the traditional living arrangement, but those living
with their daughters report better psychological health [
]. Unfortunately, no studies in
our review reported the sex of the migrant children.
A study in India showed that living in multigenerational households had protective benefits
in physical health [
]. Other studies showed older adults with migrant sons were more likely
to report lifestyle-related chronic diseases such as hypertension, diabetes and heart disease [
]. For those left behind, research shows increased time spent on agricultural and domestic
work , especially among older women. Zhou et al. [
] observed lower utilization of
healthcare services among the empty nest elderly. Liu et al. [
] emphasized that despite
having ill health, empty nesters were more likely to report being unable to obtain the health care
needed. Inadequate access to health care is likely to adversely affect mental health, given the
relationship between physical and mental health disorders [
]. However, co-residence is not
always influenced by parents needs. A study in China [
] emphasized parental support
strongly influencing children to live with their parents.
Two of the 16 studies in this review (both from Thailand) [53, 59] showed improved mental
health for those left behind, whilst four reported null findings. Children, who are leaving, are
more likely to feel that their parents have an alternative means of support with most families
having more than one child who can provide emotional, physical and financial support. A
study by Stohr [
] showed that children in Moldova made strategic migration decisions to
ensure some children stayed behind to care for their parents. Other children increase their
contribution to compensate for their migrant siblings [
], and hence the effects of high rates
of out-migration may be mitigated by this support [
Older parents with only some of their children migrated may not experience all the negative
consequences compared to those with all their children migrated. These circumstances allow
financial support from the migrant child and local support from the child(ren) at home which
may have positive outcomes for their mental health and well-being. In addition, technological
developments, especially in communication, have enabled continuous communication
between the left behind parents and migrant children, potentially decreasing the negative
impact of adult child migration [
]. According to White and Edwards  empty nest
status improved marital happiness; termed the ‘post-launch honeymoon’. The departure of the
last child from the household can have a positive impact for parents [
]. The impact of left
behind on the mental health of the elderly also depends on the socio-cultural context of the
families. Mitchell and Lovegreen [
] reported higher levels of empty nest syndrome among
the Indo/East Indian parents compared to British parents. Indian parents found more
difficulties due to their expectations that sons stay with the parents and daughters remain until
marriage. Gao et al. [
] found that that “living resources” and “availability of medical treatment”
have an important mediating role in urban areas while engagement in “social activities”
showed significant mediators among the rural sample.
Risk factors of mental health disorders among the left behind elderly
This review also examined risk factors of mental health disorders among the left behind elderly.
Fourteen factors were identified with different levels of influence, of which nine factors were
associated with mental health disorders across the studies. The risk factors identified among the left
behind elderly in this study are common to the elderly more generally. As there is a higher
prevalence of mental health disorders for this cohort, consideration should be given to those most at risk.
Currently married older people had better mental health consistent with other studies
showing widowhood negatively associated with subjective well-being [
] and mental health
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]. Living with a spouse was beneficial in reducing loneliness [
] and Turner and
Brown  noted co-residence with a spouse to be an important source of social support
decreasing the risk of depression. For Buber and Engelhardt [
] the presence of a spouse or
partner was more important than living with, or having regular contact with, their children.
Pau´l and Ribeiro [
] supported this observation as non-married status and/or widowhood
lacked the support provided by a partner and sharing of intimate feelings that may result in
loneliness. Empty nest couples have to rely on each other with spouses often providing
essential daily care and emotional support [
Females may be at higher risk for mental health disorders consistent with other studies
reporting older women at greater risk of loneliness [
] and depression [
]. Mothers often
have a different bond with their child due to the time and effort they invest in raising their
children. In contrast, males are more often engaged in social activities [
] reducing their
loneliness whereas women whose main role is domestic, may be limited from establishing and
maintaining non-family contacts [
The left behind elderly with lower education may be at greater risk of mental illness. This
review supports the finding that educated empty nesters had greater subjective well-being [
and cognitive function [
]. Lower education is associated with greater risk of depression
], dementia  and loneliness [
]. In general, educated older people are more
likely to access health services [
] and seek new social contacts, thereby improving mental
Higher income was associated with better mental health consistent with research reporting
higher levels of income associated with lower depressive symptoms [
quality of life  and decreased loneliness [
]. Lund et al. [
] reported a strong correlation
between poverty and common mental health disorders. Higher income elderly are more
financially independent and hence can pay expenses, and afford social activities, which may
contribute to improved mental health and well-being [
]. Financial constraints may negatively
affect self-esteem and self-efficacy, reducing social contacts.
Four out of five studies identified physical health as a risk factor for mental health problems
with the other study reporting no association. Huang et al. [
] similarly found that chronic
conditions such as stroke, cardiac/lung disease and loss of hearing/vision were risk factors for
depression among older people. Other evidence [
] shows that chronic disease is
associated with poor psychological health consistent with our review results.
Physical exercise is noted to be beneficial for the elderly, with several studies finding
significant psychological and cognitive benefits from regular physical activity [
systematic review and meta-analysis of randomized control trials showed that exercise was associated
with significantly lower depression in older people [
]. Exercise training was found to
increase fitness, physical function, cognitive function, and positive behaviour in people with
cognitive impairments [
Family and social support is a predictor of better mental health among the left behind
elderly. Studies demonstrate the preventive effect of family and social support on depression
], cognitive impairment [
] and loneliness [
]. Ryan and Willits [
] observed that
the quality of relationships with spouse, children, and other family members was associated
with feelings of well-being, rather than the quantity of relationships with the presence of family
members not necessarily ensuring social support. The absence of positive relations with
children is related to depression [
] as social support provides a buffering role [
support has direct as well as mediating effects among the elderly with mental health status and
personality influencing the availability and perception of social support [
Intergenerational social support networks are important predictors of old-age health and survival in
developing countries [
]. Older adults who participate in socially engaging activities and
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have social support networks are less likely to become cognitively impaired than non-engaged
older adults .
Four out of seven studies identified older age as a predisposing risk factor for mental health
problems. Previous studies have shown that social activities decrease with age, which is a risk
factor for depression [
]. Higher levels of loneliness [
] and depression [
reported with increased age among older adults as they reduced opportunities for social
contact due to physical limitations and loss of close friends and family members [
Three studies compared the mental health of rural and urban elderly left behind with two
finding those living in urban areas at lower risk while the remaining study found no difference.
Rural people often have closer neighbourhood relationships than urban people, which may
help to improve psychological well-being [
]. However, our findings favour urban
inhabitants. This could be due in part to farming being important in the daily life of rural elders, with
the out-migration of adult children directly affecting older parents’ workloads.
Of the 16 studies that examined the associations between migration of adult children and
psychological well-being of the left behind elderly, only four employed longitudinal design.
Three of the four longitudinal studies reported increased risk of psychological ill health among
the parents with migrant children. The cross sectional design of the majority of studies limits
the ability to determine cause and effect relationships  hence the association between the
adult child’s migration and the mental health outcomes of older parents, conceivably due to
reverse causality. The decision to migrate may be influenced by the health status of elderly
parents. Children may be more likely to migrate if the older parents are in good health and
they have strong family and social support networks. Conversely, adult children with elderly
parents with poor health may migrate to pursue higher earnings to help pay for medical
expenses. Migrants and their families may have better education, higher access to
socioeconomic resources or social capital [
], and these characteristics may contribute to better
health outcomes of the elderly parents irrespective of the children’s migration [
The findings of this review have important implications for programs and policies aiming to
promote the mental health of older adults. Targeting social security for the elderly left behind
could enhance the feeling of security and support, thereby improving metal health and
]. Given the higher prevalence of physical illnesses and chronic diseases among the
left behind elderly and its association with mental disorders, it is recommended to consider
this risk group in health service delivery. The health care delivery system in low-income
countries is inadequate to meet the mental health needs of older people [
] resulting in a
range of unmet emotional and physical needs among the older adults left behind.
Programs to extend emotional intimacy between older parents and their migrant children
are required, with intergenerational relationships and translational care particularly important
in reducing risk of mental illnesses among the older adults. Zechner [
] enlisted the three
basic elements of transnational care: distance, resources and circumstances. Attention should
be paid to the social policies involved in care-related activities. Maintaining older parents’
contact with their migrant children, being visited by children more frequently, and engaging older
people in a range of social activities reduces the negative consequences of their children’s
]. Migrant children can provide emotional support or may organize the care
needs of the older parent(s) with someone who lives close by [
]. Certainly, the availability
of social media and communication technologies provides opportunities for more active
communication and interaction within the family irrespective of geographical location.
Consideration should be given to training community health workers and field workers in identifying
21 / 30
older adults who are at risk, connecting to community resources to those who are at risk and
counselling families to better support close family relationships.
Efforts to lower the prevalence of mental health disorders in the left behind elderly should
target those at particular risk. Special attention should be given to the elderly who are
unmarried or widowed, have lower education, poorer socioeconomic background, older, living in
rural areas and with chronic disease.
Finally, physical activity plays an important role to offset the negative influence of an empty
nest on health and well-being. A greater focus on the importance of physical activity levels by
both professionals and volunteers [
] may promote and support physical activities for the
left behind elderly.
Implications for future research
A number of implications for future studies for the mental health of left behind elderly arise from
this review. Family support plays a pivotal role in determining the psychological well-being of the
older parents. While the migration of the younger generation is unavoidable in many societies, its
effect is often to undermine traditional care and support structures for older parents. Hence more
research is required to address care and support needs from friends, neighbours and other
community based organizations. Such studies should also examine the effects of different types of
social support to improve the mental health status among older adults left behind.
The issue of transnational care; care giving across political and geographical spaces, is not
well recognized in gerontology [
137, 140, 141
]. Future studies are required to identify effective
transnational care provision. Well-designed studies are also required to identify additional
factors related to mental health among the left behind elderly, as this review did not identify the
effect of important risk factors such as remittances, frequency and intensity of the
communication between parents and migrant children, purpose of migration, migrant receiving place or
country, physical environment (e.g. housing) in which elderly were residing, religious belief,
functional disability and bereavement or loss of close contacts by the elderly. In particular,
information technology and religious attendance are likely to have a positive effect on mental
health and increased social relationships among the elderly [
]. Future research could also
compare systematic differences in the risk factors of mental health disorders between the left
behind and non-left behind older adults.
Longitudinal studies are required to provide clarity on the direction of causality between
migration of adult children and mental health of elderly parents left behind. Apart from the
longitudinal studies, a matched-control design with parents whose children emigrated with
those with children living nearby would help to distinguish the empty nest component from
the left behind. Qualitative studies are essential to understand diverse and complex
sociocultural contexts. Local surveys and investigations will also inform local service needs.
This review is not without limitations. The definition of ‘left behind elderly’ varied across the
studies and many different definitions of mental health are summarised in this review. Studies
were diverse and often did not report prevalence of any aspects of mental health, nor the
strength of association for each risk factor. The high level of heterogeneity among the studies
Results of the multivariate analyses might be convoluted by adjustments for different
variables in different studies. Likewise, only the main effects of risk factors on mental health
disorders were reviewed and as such, it is not clear whether the concurrent occurrence of multiple
risk factors results in a synergistic increase in the risk.
22 / 30
The studies included in this review did not always measure potential risk factors that could
have affected the mental health of the left behind elderly and often only provided bivariate
analyses, making it difficult to confirm the association between migration of adult children
and the mental health of parents left behind under the influence of potential confounders. In
addition, risk factors for mental health disorders identified in this review are based on studies
reporting risk factors from left behind elderly. Comparison of putative risk factors between left
behind and non-left behind groups would be more informative.
The review did not assess publication bias, with negative or non-significant results being less
likely to be submitted and accepted for publication [
]. Other limitations of this review include
the search was limited to peer-review articles published in English with grey literature excluded.
Many studies employed secondary analyses of large samples, which may have produced
statistically significant results for effect sizes which are small, limiting the clinical significance of the
results. Almost half of the studies included in this review are from China. This may reflect a
general lack of research in other low-income countries, which is unfortunate given the potentially
higher vulnerability of older people being left behind and psychological disorders [
The key finding of this review is that being left behind is negatively associated with the mental
health of older adults. Empty nesters were at higher risk of mental health disorders such as loss
of cognitive function, depression, anxiety and loneliness. Elderly living with their children
may receive better care, economic and emotional supports. The risk factors for mental
disorders include marital status, income, education, physical health status, gender, age, family and
social support, and physical exercise.
This study synthesises the research related to mental health of the left behind elderly
parents, thereby advancing our theoretical and empirical understanding of out-migration of
adult children and its implication on psychological well-being of the parents. Authorities and
organizations working in the field of gerontology should be aware that the left behind elderly
are at increased risk of mental health problems. More responsive preventive measures and
effective management approaches are required for this cohort. More rigorous studies are
required to identify the additional risk factors of mental health problems using clinically
relevant instruments. Additionally, mechanisms of transnational care by the migrant children
should be explored to reduce the psychological cost of the phenomena of being ‘left behind’.
S1 Table. Quality assessment of included studies.
S1 Checklist. PRISMA checklist.
The first author would like to acknowledge the support provided by the University of
Tasmania through the Tasmania Graduate Research Scholarship.
Conceptualization: Deependra Kaji Thapa, Denis Visentin, Rachel Kornhaber, Michelle
23 / 30
Data curation: Deependra Kaji Thapa.
Formal analysis: Deependra Kaji Thapa.
Investigation: Deependra Kaji Thapa, Denis Visentin, Rachel Kornhaber, Michelle Cleary.
Methodology: Deependra Kaji Thapa, Denis Visentin, Rachel Kornhaber, Michelle Cleary.
Supervision: Denis Visentin, Rachel Kornhaber, Michelle Cleary.
Validation: Deependra Kaji Thapa, Denis Visentin, Rachel Kornhaber, Michelle Cleary.
Writing – original draft: Deependra Kaji Thapa.
Writing – review & editing: Deependra Kaji Thapa, Denis Visentin, Rachel Kornhaber,
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