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Social connectedness, depression symptoms, and health service utilization: a longitudinal study of Veterans Health Administration patients

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Social Psychiatry and Psychiatric Epidemiology Aims and scope Submit manuscript

Abstract

Purpose

Our study explored whether aspects of veterans’ social connectedness (social support, interpersonal conflict, loneliness, social norms, number of confidants) are associated with change in their depression symptoms and health services utilization over 1 year.

Methods

We conducted a prospective, longitudinal study of 262 military veterans who obtained primary care and other services at a Veterans Health Administration (VHA) facility and screened positive for depression. Participants completed surveys at baseline and 12-month follow-up. We measured social connectedness variables using the NIH Toolbox Adult Social Relationship Scales. We used the Patient Health Questionnaire to assess depression symptoms and suicidal ideation and administrative medical record data for health services utilization. We calculated change scores to model outcomes over time using multivariable regressions.

Results

We found that higher levels of baseline loneliness were associated with decreased depression severity over 1 year (B = − 1.55, 95% CI [− 2.53, − .56], p < .01). We found a similar association for suicidal ideation. In contrast, higher baseline number of confidants was associated with increased depression (B = .55, 95% CI [.18, .92], p < .01). Higher levels of emotional support were associated with decreased mental health visits (B = − 3.88, 95% CI [− 6.80, − .96], p < .01). No significant associations were found between social connectedness variables and primary care visits.

Conclusions

Emotional support may play an important role in reducing mental health treatment utilization among VHA-using veterans. Additional investigation as to how and why loneliness and number of confidants might be paradoxically associated with depression symptoms remains necessary.

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References

  1. Allen J, Balfour R, Bell R, Marmot M (2014) Social determinants of mental health. Int Rev Psychiatry 26(4):392–407

    Article  PubMed  Google Scholar 

  2. Rosenquist JN, Fowler JH, Christakis NA (2011) Social network determinants of depression. Mol Psychiatry 16(3):273–281. https://doi.org/10.1038/mp.2010.13

    Article  PubMed  CAS  Google Scholar 

  3. Santini ZI, Koyanagi A, Tyrovolas S, Mason C, Haro JM (2015) The association between social relationships and depression: a systematic review. J Affect Disord 175:53–65

    Article  PubMed  Google Scholar 

  4. Perlman D, Peplau LA (1982) Theoretical approaches to loneliness. Loneliness: a sourcebook of current theory, research and therapy. Wiley, Hoboken, NJ, pp 123–134

    Google Scholar 

  5. Cacioppo JT, Hawkley LC, Thisted RA (2010) Perceived social isolation makes me sad: five year cross-lagged analyses of loneliness and depressive symptomatology in the Chicago health, aging, and social relations study. Psychol Aging 25(2):453–463

    Article  PubMed  PubMed Central  Google Scholar 

  6. American Psychological Association (2010) Perceived social isolation makes me sad: 5-year cross-lagged analyses of loneliness and depressive symptomatology in the Chicago Health, Aging, and Social Relations Study [press release]. American Psychological Association, USA

    Google Scholar 

  7. Mojtabai R, Olfson M, Mechanic D (2002) Perceived need and help-seeking in adults with mood, anxiety, or substance use disorders. Arch Gen Psychiatry 59(1):77–84

    Article  PubMed  Google Scholar 

  8. Mojtabai R, Olfson M, Sampson NA et al (2011) Barriers to mental health treatment: results from the National Comorbidity Survey Replication (NCS-R). Psychol Med 41(8):1751–1761

    Article  PubMed  CAS  Google Scholar 

  9. Fröjd S, Marttunen M, Pelkonen M, von der Pahlen B, Kaltiala-Heino R (2007) Adult and peer involvement in help-seeking for depression in adolescent population. Soc Psychiatry Psychiatr Epidemiol 42(12):945–952

    Article  PubMed  Google Scholar 

  10. Spoont Michele R, Nelson David B, Murdoch Maureen et al (2014) Impact of treatment beliefs and social network encouragement on initiation of care by va service users with PTSD. Psychiatr Serv 65(5):654–662

    Article  PubMed  Google Scholar 

  11. Demers A (2011) When veterans return: the role of community in reintegration. J Loss Trauma 16(2):160–179

    Article  Google Scholar 

  12. Teo AR, Marsh HE, Forsberg CW et al (2018) Loneliness is closely associated with depression outcomes and suicidal ideation among military veterans in primary care. J Affect Disord 230:42–49

    Article  PubMed  Google Scholar 

  13. Trivedi RB, Post EP, Sun H et al (2015) Prevalence, comorbidity, and prognosis of mental health among US veterans. Am J Public Health 105(12):2564–2569

    Article  PubMed  PubMed Central  Google Scholar 

  14. Office of Mental Health and Suicide Prevention (2016) Suicide among veterans and other Americans, 2001–2014. US Department of Veterans Affairs, Washington, DC

    Google Scholar 

  15. Goetter EM, Bui E, Weiner TP, Lakin L, Furlong T, Simon NM (2017) Pilot data of a brief veteran peer intervention and its relationship to mental health treatment engagement. Psychol Serv 15(4):453–456. https://doi.org/10.1037/ser0000151

    Article  PubMed  Google Scholar 

  16. Greden JF, Valenstein M, Spinner J et al (2010) Buddy-to-Buddy, a citizen soldier peer support program to counteract stigma, PTSD, depression, and suicide. Ann N Y Acad Sci 1208(1):90–97

    Article  PubMed  Google Scholar 

  17. Carmichael CL, Reis HT, Duberstein PR (2015) In your 20s it’s quantity, in your 30s it’s quality: the prognostic value of social activity across 30 years of adulthood. Psychol Aging 30(1):95–105

    Article  PubMed  PubMed Central  Google Scholar 

  18. Wrzus C, Hänel M, Wagner J, Neyer FJ (2013) Social network changes and life events across the life span: a meta-analysis. Psychol Bull 139(1):53–80

    Article  PubMed  Google Scholar 

  19. Cyranowski JM, Zill N, Bode R et al (2013) Assessing social support, companionship, and distress: NIH toolbox adult social relationship scales. Health Psychol 32(3):293–301

    Article  PubMed  PubMed Central  Google Scholar 

  20. Burt RS (1984) Network items and the general social survey. Soc Netw 6(4):293–339

    Article  Google Scholar 

  21. McMillan D, Gilbody S, Richards D (2010) Defining successful treatment outcome in depression using the PHQ-9: a comparison of methods. J Affect Disord 127(1):122–129

    Article  PubMed  Google Scholar 

  22. Ouimette P, Wade M, Prins A, Schohn M (2008) Identifying PTSD in primary care: comparison of the primary care-PTSD screen (PC-PTSD) and the general health questionnaire-12 (GHQ). J Anxiety Disord 22(2):337–343

    Article  PubMed  Google Scholar 

  23. Bradley KA, DeBenedetti AF, Volk RJ, Williams EC, Frank D, Kivlahan DR (2007) AUDIT-C as a brief screen for alcohol misuse in primary care. Alcoholism 31(7):1208–1217

    Article  PubMed  Google Scholar 

  24. Selim AJ, Fincke BG, Ren XS et al (2004) Comorbidity assessments based on patient report: results from the veterans health study. J Ambul Care Manag 27(3):281–295

    Article  Google Scholar 

  25. Van Orden KA, Cukrowicz KC, Witte TK, Joiner TE Jr (2012) Thwarted belongingness and perceived burdensomeness: construct validity and psychometric properties of the interpersonal needs questionnaire. Psychol Assess 24(1):197–215

    Article  PubMed  Google Scholar 

  26. Possemato K, Wade M, Andersen J, Ouimette P (2010) The impact of PTSD, depression, and substance use disorders on disease burden and health care utilization among OEF/OIF veterans. Psychol Trauma 2(3):218–223

    Article  Google Scholar 

  27. Markovic A, Bowker JC (2017) Friends also matter: examining friendship adjustment indices as moderators of anxious-withdrawal and trajectories of change in psychological maladjustment. Dev Psychol 53(8):1462–1473

    Article  PubMed  PubMed Central  Google Scholar 

  28. Zlotnick C, Kohn R, Keitner G, Della Grotta SA (2000) The relationship between quality of interpersonal relationships and major depressive disorder: findings from the national comorbidity survey. J Affect Disord 59(3):205–215

    Article  PubMed  CAS  Google Scholar 

  29. Cohen S (2004) Social relationships and health. Am Psychol 59(8):676–684

    Article  PubMed  Google Scholar 

  30. Umberson D, Karas Montez J (2010) Social relationships and health: a flashpoint for health policy. J Health Soc Behav 51(1_suppl):S54–S66

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We would like to acknowledge Jason T. Newsom, Ph.D., who provided feedback on the ideas within this manuscript.

Funding

This project was funded by a VA Health Services Research and Development Career Development Award (Teo; CDA 14-428). Dr. Chen completed this work under the auspices of a Trans-NIH-funded K12 award in Emergency Care Research (5K12HL133115). This material is the result of work supported with resources and the use of facilities at the VA Portland Health Care System, Portland, OR. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, the National Institutes of Health, or the United States government. On behalf of all authors, the corresponding author states that there are no conflicts of interest.

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Authors and Affiliations

  1. Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, U.S. Department of Veterans Affairs (VA), 3710 SW U.S. Veterans Hospital Road, R&D 66, Portland, OR, 97239, USA

    Jason I. Chen, Elizabeth R. Hooker, Meike Niederhausen, Heather E. Marsh, Somnath Saha, Steven K. Dobscha & Alan R. Teo

  2. Department of Psychiatry, Oregon Health and Science University, Portland, OR, USA

    Jason I. Chen, Steven K. Dobscha & Alan R. Teo

  3. Oregon Health and Science University-Portland State University School of Public Health, Oregon Health and Science University, Portland, OR, USA

    Meike Niederhausen

  4. Department of Medicine, Oregon Health and Science University, Portland, OR, USA

    Somnath Saha

Authors
  1. Jason I. Chen
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  2. Elizabeth R. Hooker
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  3. Meike Niederhausen
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  4. Heather E. Marsh
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  5. Somnath Saha
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  6. Steven K. Dobscha
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  7. Alan R. Teo
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Corresponding author

Correspondence to Jason I. Chen.

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Appendix: Sensitivity analyses for regression models evaluating change in depression

Appendix: Sensitivity analyses for regression models evaluating change in depression

To explore potential statistical confounds that led to unexpected results, we explored in detail the unexpected relationship between loneliness and depression change in various ways. Boxplots showed that participants whose depression score decreased had on average higher loneliness scores than participants whose depression stayed the same or increased, but the differences between the groups were not significant. Scatter plots and Pearson correlations showed a strong positive correlation between loneliness at baseline and depression score at baseline (r = .57; p < .01) and a weaker positive correlation between loneliness at baseline and depression score at follow-up (r = .29; p < .01). All collinearity diagnostics and test assumptions were within normal limits. The magnitude and significance of the association remained the same, despite the following variations to the model: (1) additional adjustment for all social process variables, (2) altering the outcome to PHQ-8 score change rather than PHQ-9 score change, (3) removing potential outliers with high leverage (n = 4), (4) additional adjustment for self-reported antipsychotic or antidepressant medication use, (5) additional adjustment for number of confidants at baseline or number of confidants change between baseline and follow-up, and (6) testing for interaction between loneliness and number of confidants at baseline.

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Chen, J.I., Hooker, E.R., Niederhausen, M. et al. Social connectedness, depression symptoms, and health service utilization: a longitudinal study of Veterans Health Administration patients. Soc Psychiatry Psychiatr Epidemiol 55, 589–597 (2020). https://doi.org/10.1007/s00127-019-01785-9

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  • DOI: https://doi.org/10.1007/s00127-019-01785-9

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