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

  • Jason I. ChenEmail author
  • Elizabeth R. Hooker
  • Meike Niederhausen
  • Heather E. Marsh
  • Somnath Saha
  • Steven K. Dobscha
  • Alan R. Teo
Original Paper



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.


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.


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.


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.


Major depression Suicide Veterans Social support Health services 



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


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.

Supplementary material

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  1. 1.
    Allen J, Balfour R, Bell R, Marmot M (2014) Social determinants of mental health. Int Rev Psychiatry 26(4):392–407CrossRefGoogle Scholar
  2. 2.
    Rosenquist JN, Fowler JH, Christakis NA (2011) Social network determinants of depression. Mol Psychiatry 16(3):273–281. CrossRefPubMedGoogle Scholar
  3. 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 175:53–65CrossRefGoogle Scholar
  4. 4.
    Perlman D, Peplau LA (1982) Theoretical approaches to loneliness. Loneliness: a sourcebook of current theory, research and therapy. Wiley, Hoboken, NJ, pp 123–134Google Scholar
  5. 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):453–463CrossRefGoogle Scholar
  6. 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, USAGoogle Scholar
  7. 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):77–84CrossRefGoogle Scholar
  8. 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):1751–1761CrossRefGoogle Scholar
  9. 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):945–952CrossRefGoogle Scholar
  10. 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):654–662CrossRefGoogle Scholar
  11. 11.
    Demers A (2011) When veterans return: the role of community in reintegration. J Loss Trauma 16(2):160–179CrossRefGoogle Scholar
  12. 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 230:42–49CrossRefGoogle Scholar
  13. 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):2564–2569CrossRefGoogle Scholar
  14. 14.
    Office of Mental Health and Suicide Prevention (2016) Suicide among veterans and other Americans, 2001–2014. US Department of Veterans Affairs, Washington, DCGoogle Scholar
  15. 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. CrossRefPubMedGoogle Scholar
  16. 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):90–97CrossRefGoogle Scholar
  17. 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):95–105CrossRefGoogle Scholar
  18. 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):53–80CrossRefGoogle Scholar
  19. 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):293–301CrossRefGoogle Scholar
  20. 20.
    Burt RS (1984) Network items and the general social survey. Soc Netw 6(4):293–339CrossRefGoogle Scholar
  21. 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):122–129CrossRefGoogle Scholar
  22. 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):337–343CrossRefGoogle Scholar
  23. 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):1208–1217CrossRefGoogle Scholar
  24. 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):281–295CrossRefGoogle Scholar
  25. 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):197–215CrossRefGoogle Scholar
  26. 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):218–223CrossRefGoogle Scholar
  27. 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):1462–1473CrossRefGoogle Scholar
  28. 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):205–215CrossRefGoogle Scholar
  29. 29.
    Cohen S (2004) Social relationships and health. Am Psychol 59(8):676–684CrossRefGoogle Scholar
  30. 30.
    Umberson D, Karas Montez J (2010) Social relationships and health: a flashpoint for health policy. J Health Soc Behav 51(1_suppl):S54–S66CrossRefGoogle Scholar

Copyright information

© This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2019

Authors and Affiliations

  1. 1.Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care SystemU.S. Department of Veterans Affairs (VA)PortlandUSA
  2. 2.Department of PsychiatryOregon Health and Science UniversityPortlandUSA
  3. 3.Oregon Health and Science University-Portland State University School of Public HealthOregon Health and Science UniversityPortlandUSA
  4. 4.Department of MedicineOregon Health and Science UniversityPortlandUSA

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