Marital stress may be associated with worse patient‐reported outcomes after acute myocardial infarction

About 46% of American adults are divorced, widowed or have never been married, according to the U.S. Census Bureau, and the proportion of never-marrieds has been rising steadily in modern times.

A casual glance at health research about the benefits of being wed, though, can read like a lecture from overeager mom in an old TV sitcom. "Why don't you get married already?" the data seems to ask.

But despite abundant research linking marriage and good health, the situation is actually nuanced, said Amy Canevello, a professor in the department of psychological science at the University of North Carolina at Charlotte.

"It's complicated," she said. "It's not just that relationships are good for health. It's that good relationships are good for health. Bad relationships—not so much."

Dr. Arshed A. Quyyumi, director of the Emory Clinical Cardiovascular Research Institute in Atlanta, has studied links between marriage and heart health. The connection can be complex, he said, but it's also clear.

He was senior author on a review, published in Trends in Cardiovascular Medicine in 2020, that said studies have found that people who are not married have an increased rate of bad heart-related events when compared to their married counterparts.

Some studies, the review said, suggest that men may benefit more from marriage than women do.

Quyyumi also was senior author on a study published in the Journal of the American Heart Association in 2017 that found, in comparison with married people, unmarried people had 45% higher rates of death from cardiovascular causes and a 52% higher risk of dying from a heart attack. Rates were similar whether the unmarried person was widowed, divorced/separated or had never married.

But although the mortality data is clear, Quyyumi said the lack of a wedding ring does not spell doom for all the single people.

"I don't think it's a 'Without this, you're dead' kind of thing," he said. Rather, it's more likely that marriage plays a positive role in many areas.

A caring spouse might help you make sure you get regular medical checkups and stay on medication, he said. Or with combined incomes, you might be able to afford a healthier neighborhood and better health insurance.

Some studies also have found that marriage might be more of a mixed bag for health. People who have never been married are less likely to smoke or regularly use alcohol, for example.

Long-term data on marriage has limits. The 2020 analysis notes that younger, never-married people have more behavioral risk factors than older never-marrieds, "which may suggest that only the healthier persons in the never-married groups live to be included in the studies." And results among never-married, divorced and widowed people can vary.

Also, studying the health benefits of marriage is not the same thing as studying health in single people, Quyyumi said.

And given that marriage was traditionally available only to heterosexual couples, long-term studies don't capture newer definitions of marriage. A 2018 analysis by the National Bureau of Economic Research did find that legal marriage boosted the access to health insurance and access to care for married gay men.

But Quyyumi and Canevello agree: In discussions about health and relationships, quality matters. "Being in a bad relationship is not good for people," Canevello said.

Relationship quality is not often captured in health studies. In a fresh example of one that did capture such data, a study published in the Journal of the American Heart Association in August found that stress in a marital relationship hurt the ability of younger people to recover from a heart attack.

Loneliness and isolation, however, are well-established as serious health risks, Canevello said.

"We know that people who are in happy, well-functioning relationships tend to just be more healthy overall," she said, "because we know that such relationships can decrease our stress, which has all kinds of physical implications."

But, she said, "you can be in an unhappy marriage and be miserable, or you could be single and be totally fine and not feel lonely."

People assume that married people would be less lonely than unmarried people, but Canevello noted the research of social scientist Bella DePaulo, who has challenged the way researchers have compared married and unmarried people.

"Her work suggests that actually, single people are not terribly lonely," Canevello said. "They can be, but they don't have to be."

And the benefits of a healthy social network aren't confined to people we're married to, she said.

"Having connections with other people doesn't have to be in a romantic context," Canevello said. Some experts, she said, have suggested that in recent times, "we've probably put a ton of pressure on our romantic partners." Forty or 50 years ago, a romantic partner was not also expected to be the lone best friend and source of social support. "People had bowling groups," craft groups and book clubs. "And those groups all fulfilled these other needs that weren't then put on the partner."

Canevello's own work emphasizes how people can build connections by being supportive to all kinds of people. "It's about mutual concern, and caring," she said.

It would be hard to argue against the data on the benefits of marriage, she said. "I just think we assume that your marriage is the only way you can get those things, and it's just not."

Quyyumi agreed that the power of connectedness is not limited to marriage.

"It's not like we should just rush out and start dating and getting married," he said. Social support could come from a sibling or a group of co-workers. Someone with a life full of such relationships, he said, "is probably OK being single."

People who want to be at their healthiest also can focus on traditional heart-health lifestyle factors related to diet and exercise, he said.

Canevello suggested that when it comes to health, it doesn't come down to, "do you have the marriage license?" The key questions, she said, are "do you have people in your life who care about you? And do you have people in your life that you care about?"