Loneliness is closely associated with depression outcomes and suicidal ideation among military veterans in primary care

Variables Associated With Moderate to High Loneliness Among Individuals Living With Spinal Cord Injuries and Disorders

OBJECTIVE

To identify variables independently associated with moderate to high loneliness in individuals living with Spinal Cord Injuries or Disorders (SCI/D).

DESIGN

A cross-sectional, national survey of a random sample of community-dwelling Veterans with SCI/D in the United States. Survey methodology was used to collect data on demographic and injury characteristics, general health, chronic and SCI-secondary conditions, and loneliness.

SETTING

The VHA SCI/D System of Care including 25 regional SCI/D Centers (or Hubs).

PARTICIPANTS

Among 2466 Veterans with SCI/D, 592 completed surveys (24%). Most participants were men (91%), white (81%), not currently married (42%), had tetraplegia (33%), and on average injured for 18 years at the time of data collection (N=562).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The dependent variable, loneliness, was collected using the UCLA-3 instrument. Loneliness was dichotomized into never/low loneliness and moderate/high loneliness (UCLA score ≥ 4).

RESULTS

Bivariate analyses assessed unadjusted associations in demographics, injury characteristics, chronic disease, and SCI-secondary conditions. Multivariable logistic regression was used to identify factors independently associated with moderate/high loneliness. Participants had a mean loneliness score of 5.04, SD=1.99. The point prevalence of moderate to high loneliness was 66%. Lower duration of injury, paraplegia, being unmarried, being in fair/poor general health, having dysfunctional sleep, and having a diagnosis of bowel dysfunction were each independently associated with greater odds of moderate/high loneliness.

CONCLUSIONS

Findings suggest that interventions to reduce/manage loneliness in the Veteran SCI/D population should focus on those who are more newly injured, have paraplegia, currently unmarried, have bowel problems, and experience dysfunctional sleep.

Do measures of social support and social distress share general factors associated with suicidal ideation and attempts?

INTRODUCTION

Aspects of social relationships have variably been associated with suicidal ideation (SI) and suicide attempts (SAs). This study assessed whether social support and social distress measures have general factors versus measure-specific factors that are associated with suicide risk.

METHODS

Adults (N = 455, 60.0% female), admitted to psychiatric inpatient units following a recent suicide attempt or active SI, completed assessments of social support (emotional support, instrumental support, friendship, perceived support from significant others, friends, family) and social distress (loneliness, perceived rejection, perceived burdensomeness, thwarted belongingness). Bifactor modeling examined general and specific factors of social support and distress in relation to SI (week prior to hospitalization, via the Beck Scale for SI) and SAs (past 30 days, via the Columbia Suicide Severity Rating Scale).

RESULTS

SI was significantly associated with the general social support (B = -1.51), the general social distress (B = 1.67), and the specific perceived burdensomeness (B = 1.57) factors. SAs were significantly associated with the specific Perceived Rejection (OR = 1.05) and Thwarted Belongingness (OR = 0.91) factors.

CONCLUSION

General social support and social distress were associated with SI but not recent SAs. Specific social distress factors were also related to SI and SAs controlling for general social distress, suggesting areas for future interventions.

Master resilience trainer course quality improvement evaluation

The Master Resilience Training (MRT) course is the U.S. Army's resilience program of record to develop soldiers as resilience trainers within their home units. The Walter Reed Army Institute of Research (WRAIR) recently conducted an MRT Quality Improvement Evaluation (QIE) to understand perceptions of the MRT course, determine the effectiveness of the course, and provide revision recommendations for the next iteration of the course. Soldiers who were completing the MRT course were invited to take surveys and participate in interviews. Results from quantitative and qualitative data suggest that most participants felt satisfied with the training and that it was relevant for soldiers. Most participants also agreed that the training would help them become better soldiers and leaders. Along with positive feedback about the course, participants also identified areas that could be improved. Soldier feedback along with program evaluators' observation informed recommendations for improving the overall MRT course and its implementation. Program evaluators recommend MRT participants learn fewer and less complex skills, focus on coach education throughout the course, and highlight leader development by promoting motivation and enhancing effective communication. Program evaluators recommendations for ways to improve buy-in from leaders and graduated MRTs are also discussed.

Loneliness partially mediates the relation between substance use and suicidality in Veterans

America has experienced a rapid increase in loneliness, substance use, and suicidality. This increase is particularly deleterious for Veterans, who, as compared to nonmilitary-connected civilians, experience elevated rates of loneliness, substance use, and suicidality. In this project we investigated the link between loneliness, substance use, and suicidality, paying particular attention to the mediational role of loneliness between substance use and suicidality. 1,469 Veterans (male, n = 1004, 67.2%; female, n = 457, 32.3%; transgender/non-binary/prefer not to say, n = 8, 0.5%) answered online surveys in the Mental Health and Well-Being Project. Items assessed participants on psychosocial antecedents of health and wellness. Pearson correlations and mediational models were used to determine if loneliness, substance use, and suicidality were related and if loneliness mediated the link between substance use and suicidality. Results indicated that loneliness, substance use, and suicidality were significantly and positively related (rs = .33-.42, ps < .01). Additionally, loneliness partially mediated the link between substance use and suicidality (β = .08 [.06-.10]), suggesting that, within the context of substance use in Veterans, loneliness may account for significant variance in suicidality. Together findings suggest the Veterans Health Administration should support, fund, and study community engagement activities that could reduce the development or intensity of substance use, loneliness, and suicidality in Veterans.

Findings from a Peer-Facilitated, Social Isolation Intervention in the Veterans Health Administration Healthcare System: A Mixed-Methods, Pilot Feasibility Study

BACKGROUND

Social isolation is a global public health threat. Veterans are particularly at risk for social isolation due to high rates of comorbid physical and mental health problems. Yet, effective interventions are limited.

OBJECTIVES

Our primary objective was to assess the feasibility and acceptability of CONNECTED, a novel, transdiagnostic intervention to reduce social isolation that includes individual and group components and is delivered by peers via telehealth. Secondary objectives were to identify appropriate outcome measures and explore preliminary intervention effects.

METHODS

This was a two-phase study. In Phase 1, to evaluate study feasibility, we surveyed 200 veterans to assess prevalence of social isolation and their interest in social connectedness interventions. In Phase 2, we employed a mixed-methods, pre-post study design in which we piloted CONNECTED with 19 veterans through 2 successive cohorts to further assess feasibility, to evaluate acceptability, and to explore preliminary effectiveness. Quantitative analyses involved descriptive and bivariate analyses as well as multivariate modeling. Qualitative interviews were analyzed using thematic analysis.

RESULTS

For Phase 1, 39% of veterans surveyed were socially isolated. Participants who were ≤ 55 years old, caregivers, and those who experienced unmet social needs were more likely to report social isolation. Over 61% expressed interest in VA programs to reduce social isolation. For Phase 2, the pilot intervention, recruitment rate was 88% and the enrollment rate was 86%. Retention rates for the two cohorts were 80% and 50%, respectively, and satisfaction rates among intervention completers were 100%. Results also showed statistically significant improvements in social isolation (+ 5.91, SD = 4.99; p = .0028), social support (+ 0.74, SD = 1.09; p = .03), anxiety (-3.92, SD = 3.73; p = .003), and depression (-3.83, SD = 3.13; p = .001). Results for the other measures were not statistically significant.

CONCLUSION

CONNECTED is a feasible and acceptable intervention and is likely to be an effective tool to intervene on social isolation among veterans.

Characteristics Associated With Loneliness and Coping Skills Utilization During the COVID-19 Pandemic

Although stay-at-home orders and physical distancing measures are vital to managing the COVID-19 outbreak, there is concern these limitations on in-person contact may increase feelings of loneliness. The present study examined loneliness in relation to living situation, psychiatric symptoms, and coping skills utilization during the COVID-19 pandemic. The aim was to identify demographic and psychological factors that may contribute to greater feelings of loneliness. A sample of 125 adults (18 years and older) completed measures on loneliness, psychiatric symptoms, and coping skills in September 2020. Multiple regression analysis indicated living situation moderates the relationship between hours spent having remote conversations and loneliness. Remote conversation hours were associated with decreased loneliness in those living alone but was not associated with loneliness in those living with others. Multivariate regression analysis indicated that substance use and self-blame were associated with increased loneliness whereas the use of emotional support to cope with pandemic-related stress was associated with decreased loneliness. The current study highlights the importance of finding alternative ways to remain socially connected, particularly for those living alone. Increasing access to videoconferencing technology and promoting help-seeking behaviors may be a promising approach to manage loneliness during times of increased social isolation.

The Association Between Loneliness and Maladaptive Moods and Beliefs: A Pilot Study in U.S. Veterans

INTRODUCTION

Loneliness is a powerful predictor of several medical and psychiatric conditions that are highly prevalent in Veterans, including depression and PTSD. Despite this, few studies have examined loneliness in Veterans or how best to intervene upon Veteran loneliness. Additional empirical research is needed in these areas in order to define clear intervention targets and improve Veteran care.

MATERIALS AND METHODS

In this pilot study, we used 62 Veterans' self-reported loneliness and symptoms of post-traumatic stress to examine whether specific symptom clusters of post-traumatic stress were associated with greater loneliness. Post-traumatic stress was measured using the PTSD Checklist for DSM-5, and responses were further parsed into four symptom clusters: intrusions, avoidance, negative alterations in mood and cognition (excluding the social withdrawal item), and alterations in arousal and reactivity.

RESULTS

Results revealed that only the negative alterations in mood and cognition symptom cluster was associated with increased Veteran loneliness, even after adjusting for sociodemographic factors, social isolation, and symptoms of depression. These analyses were also repeated using a subset of our sample (n = 29) who completed repeated measures of the PTSD Checklist. Results again revealed that the same symptom cluster predicted Veteran loneliness over 1 year later.

CONCLUSIONS

This pilot study demonstrates the value of a publicly available PTSD measure for identifying lonely Veterans and highlights how reducing negative alterations in mood and cognition may serve as a potentially critical target for future Veteran loneliness interventions.

Translating Discovery Science. Fostering relationships: Service provider perspectives on community building among veteran families

Objective

We sought to identify the social process through which communal support can be established among veteran couples and families.

Background

On the basis of the social organization theory of action and change, a sense of community is crucial for military veterans' well-being and may serve as a resource for intervention.

Method

We interviewed service providers (n = 8) and corroborated their perspectives by triangulating evaluations from veteran family participants (n = 143). Data were analyzed using grounded theory techniques.

Results

Providers suggested promoting a sense of community in prevention and intervention programming by (a) establishing a safe and empowering space, (b) bridging existing gaps within family and community systems, and (c) encouraging interpersonal healing by promoting connection and facilitating the sharing of common experiences. Providers also described challenges to facilitating the program, including logistics, time, and funding constraints.

Conclusion

According to our results, fostering community among veterans and their family members may be achieved by applying an integrative approach that goes beyond siloed individual, couple, and group therapy orchestrated by practitioners.

Implications

We recommend multicomponent interventions that create synergy between different levels and forms of social support. Providers recommended being intentional about the program structure to focus on community strengths and shared connection.

Exploring the trajectory and correlates of social isolation for veterans across a 6-month period during COVID-19

Social isolation is a relevant problem for veterans who are at risk for disengaging from others as a function of transition stress from military life to civilian life, and given high rates of exposure to trauma and psychological distress. Few researchers have examined social isolation in veterans over time, particularly during COVID-19 that led to significant barriers and restrictions on social interactions. The purpose of this longitudinal study was to assess veterans' experience of social isolation and its mental health and social functioning correlates during a 6-month period of the COVID-19 pandemic. Participants were 188 United States veterans of the Iraq and Afghanistan wars. A total of four assessments were administered: one every two months for a total duration of six months. The average number of completed assessments across all participants was 3.70 (SD = 0.75) with 159 participants (84.13%) completing all four timepoints. Surveys included measures of global mental health and social functioning as indicated by perceived emotional support, quality of marriage, and couple satisfaction. Multilevel modeling was used to assess 1) growth models to determine whether social isolation changed over time and the trajectory of that change (i.e., linear or quadratic); and 2) whether social isolation was related to both concurrent and prospective indicators of mental health and social functioning. All analyses included person mean centered and grand mean centered isolation to assess for within-and between-person effects. Veterans reported a quadratic trajectory in social isolation that decreased slightly and stabilized over time. Findings indicate that higher social isolation, at both the within- and between-person level, was negatively associated with concurrent emotional support, mental health, quality of marriage, and couple satisfaction. However, all prospective effects were nonsignificant at the within-person level. Results suggest although isolation may decrease over time, veterans report worse mental health and social functioning during times when they report higher levels of social isolation compared to themselves and others. Future work is needed to determine if interventions can be applied during those times to prevent or target those negative associations.

Veterans Crisis Line Call Outcomes: Treatment Contact and Utilization

INTRODUCTION

Crisis lines are a central component of suicide prevention strategies in the U.S. and for the Department of Veterans Affairs. The purpose of this study is to evaluate the impact of calling the Veterans Crisis Line on treatment contact and utilization.

METHODS

Call records from 599 veterans who called in 2019 were linked with medical records and analyzed in 2020. Multilevel generalized linear modeling examined pre-post changes in treatment contact (yes/no) and utilization (number of days of care).

RESULTS

In the month after the call, 85% of callers made contact with health care, and 79% made contact with behavioral health care. Callers were more likely to make contact with health care in the month after the call than in the preceding month (AOR=6.27, 95% CI=4.22, 9.32) and more likely to make contact with behavioral health care (AOR=10.21, 95% CI=6.66, 15.67). Days of health care nearly doubled to 4.82, and days of behavioral health care more than doubled to 3.52.

CONCLUSIONS

Among veteran callers who are linked to medical records, calling the Veterans Crisis Line may increase contact and utilization of health care and behavioral health care. These findings support crisis lines that are linked with healthcare systems in public health strategies for suicide prevention.

Suicidal ideation among men during COVID-19: Examining the roles of loneliness, thwarted belongingness, and personality impairment

Suicidal ideation (SI) is a known precursor to suicide among men. While loneliness and thwarted belongingness (TB) have been identified as key factors influencing SI, no study has reported on all three constructs to investigate whether loneliness is associated with SI by way of TB. Furthermore, it is not clear whether personality impairment has a moderating role on this process. The present study examined the impact of loneliness on SI among men and whether TB mediated this relationship. Additionally, the study investigated whether personality impairment (i.e., self-functioning, interpersonal functioning) moderated the relationship between loneliness and TB. Canadian men (N = 434) completed an online survey that included self-report assessments of the study constructs. Conditional process modeling was used to test the indirect effect of loneliness on SI via the mediating effect of TB. Findings indicated a significant association between loneliness and SI that was mediated by TB. Further, impairment in self-functioning moderated the relationship between loneliness and TB, indicating that the relationship was stronger among men with greater difficulties in self-functioning. The findings are important to consider within the COVID-19 context, as they point to the need to reduce the detrimental impacts of loneliness, thereby potentially mitigating male SI.

Prevalence of loneliness and its correlates among patients with schizophrenia

BACKGROUND

There are limited data on loneliness and its correlates in patients with schizophrenia.

OBJECTIVE

To evaluate prevalence and correlates of loneliness in patients with schizophrenia, currently in clinical remission.

METHODOLOGY

A total of 160 patients of schizophrenia in clinical remission were assessed on UCLA Loneliness Scale, Positive and Negative syndrome scale, Calgary Depression Scale for Schizophrenia (CDSS), Internalized Stigma of Mental Illness Scale, Rosenberg Self-esteem Scale, Brief COPE, Beck's Hopelessness Scale, Brief Dyadic Scale of Expressed Emotions, and Self-report Quality of Life Measure.

RESULTS

The mean age of the study sample was 34.99 (SD = 9.13) years. The prevalence of loneliness in the study sample was 80%, with mean total UCLA-loneliness scale score of 30.04 (16.9).Compared to participants without loneliness, those with loneliness had had higher CDSS score, had poor quality of life, lower self-esteem, experienced higher level of stigma, more often used maladaptive coping strategies such as self-blaming and reported a higher level of hopelessness. In the correlation analysis, higher level of loneliness was associated higher severity of depression, higher level of stigma (except for stigma resistance) and discrimination, poorer quality of life, lower self-esteem, perception of a higher level of expressed emotions, higher use of maladaptive coping in the domains of behavioral disengagement, and self-blaming, and a higher level of hopelessness. In regression analysis, the maximum variance of loneliness was explained by quality of life score (29%), followed by hopelessness score (8.8%) and discrimination score (2%).

CONCLUSION

There is a high prevalence of loneliness in patients with schizophrenia, and there is a need to routinely evaluate the patients of schizophrenia for loneliness and address the same.

Using Veterans Socials to Build a Community: Feasibility of the VOICES Intervention

Increasing social connection and access to care has been found to decrease the rate of suicide in U.S. veterans. The Veteran Outreach Into the Community to Expand Social Support (VOICES) is an intervention developed by Department Veteran Affairs (VA) staff to improve social connection and provide information about services by implementing community-based Veterans Socials. Seventy veterans at eight locations completed an anonymous cross-sectional survey. This evaluation examined three domains, acceptability (i.e., perceived value), demand (i.e., estimated or actual use), and expansion (i.e., sustainability and increase of Veterans Socials across time and locations). Findings indicated considerable levels of acceptability, demand for, and expansion of this intervention. Additionally, data suggested this intervention may increase social connection and utilization of VA services among attendees.

Feasibility of Patient Reported Outcome Measures in Psychosocial Palliative Care: Observational Cohort Study of Hospice Day Care and Social Support Groups

Palliative care patients can be at risk of social isolation or loneliness. Interventions that can provide effective social support, and particularly emotional support, could facilitate healthy coping that bolsters quality of life and reduces depression in palliative care patients. This is an observational cohort study which recruited thirty patients (n = 30) from the day services of four independent hospices in England. Participants completed patient reported outcome measures in perceived social support, loneliness, and depression, at up to three time points. Age range was 56-91 years, males and females were equally represented, and the sample was 93% white British. In participants that provided two or more timepoints, perceived social support increased, and loneliness and depression decreased. Largest changes with the least variation between participants was in emotional support (p = 0.165) and loneliness (p = 0.104). These results suggest that the psychosocial patient reported outcome measures used (MOS-SS, UCLA, BEDS) could be sensitive to change aligned with the goals of this intervention in palliative care. Participants in this study were observed to derive psychosocial benefit from attending the hospice day service.

A survey of hospice day services in the United Kingdom & Republic of Ireland : how did hospices offer social support to palliative care patients, pre-pandemic?

INTRODUCTION

Social support is described by patients and other stakeholders to be a valuable component of palliative day care. Less is known about the range of hospice services that have been used in practice that facilitate social support. An online survey aimed to gain an overview of all hospice day services that facilitated social support for adults outside of their own homes.

METHODS

An online survey was distributed via email to people involved in managing hospice day services. Questions were asked on hospice characteristics, including staff and volunteer roles. Respondents were asked to identify services they felt offered social support to patients. Data collection took place between August 2017 and May 2018.

RESULTS

Responses were received from 103 hospices in the UK and ROI (response rate 49.5%). Results provide an overview of hospice day and outpatient services that offer social support to patients. These are: multi-component interventions, activity groups, formal support groups, befriending, and informal social activities. Multi-component interventions, such as palliative day care, were the most commonly reported. Their stated aims tend to focus on clinical aspects, but many survey respondents considered these multicomponent interventions to be the 'most social' service at their hospice. The survey also identified a huge variety of activity groups, as well as formal therapeutic support groups. Informal 'social-only' activities were present, but less common. Over a third of all the services were described as 'drop in'. Most responding hospices did not routinely use patient reported outcome measures in their 'most social' services.

CONCLUSIONS

The survey documents hospice activity in facilitating social support to be diverse and evolving. At the time of data collection, many hospices offered multiple different services by which a patient might obtain social support outside of their own home and in the presence of other patients.

A peer approach to suicide prevention and recovery: Study protocol for a feasibility and acceptability trial of Caring Cards for veterans

Introduction

There is a need to develop, evaluate, and implement interventions that reduce Veteran suicide. Caring Cards (CC) is a novel intervention that integrates aspects of caring contacts and peers (i.e., persons with lived mental health experience). In CC, Veterans meet in a weekly group to create hope-filled cards that are sent to Veterans with mental health concerns. This study will examine feasibility and acceptability of CC with Veterans with a history of and current elevated suicide risk via in-person and virtual modalities and preliminarily evaluate pre/post changes on suicide-specific outcomes.

Methods

This 2-year open-trial study will employ a pre/post research design. Recruited Veterans with a history of suicide risk (n = 30) will make up CC groups (card makers) and Veterans currently at high-risk for suicide (n = 50) will be card recipients. Feasibility and acceptability (recruitment, retention, attendance, card receipt rates, and satisfaction questionnaire responses) and pre/post changes on suicide-specific outcomes (i.e., thwarted belonginess, perceived burdensomeness, social connectedness, suicidal ideation, and behavior) will be evaluated. Groups will meet weekly for 90–120 min for three to six months; card recipients will receive one card per month for six months.

Discussion

This study builds on preliminary data which indicate Veterans are interested in and find participating in CC highly meaningful. This study is innovative as it will target two new Veteran populations and use both in-person and virtual modalities. If feasible and acceptable, a large-scale efficacy trial will be conducted to further examine CC as a suicide prevention intervention for Veterans.

Loneliness, internalizing symptoms, and inflammatory markers in adolescent COVID-19 survivors

BACKGROUND

Concerns about the psychiatric sequelae after COVID-19 infection have increased as the pandemic spreads worldwide. The increase in self-isolation during this pandemic period has also revealed the importance of feelings of loneliness. This study aimed to examine the relationship between baseline inflammation levels, internalizing symptoms, and feelings of loneliness in adolescent COVID-19 survivors in the long term.

METHODS

A total of 74 adolescents (41 girls, 55.4%, mean age 14.88) and their parents were included in the study. This cross-sectional study assessed internalizing symptoms via Revised Children's Anxiety and Depression Scale (RCADS) and feelings of loneliness using the UCLA-loneliness scale. Baseline inflammatory markers at COVID-19 diagnosis were collected. Logistic regression analysis was used to determine predictors for depression in adolescents.

RESULTS

The most common disorder was Major Depressive Disorder (MDD) (25.7%), and 33.8% of the adolescents were in the clinical range in at least one internalizing domain. Baseline C-Reactive Protein (CRP) levels correlated weakly with MDD scores. Loneliness scores correlated with all internalizing symptoms, strong association with MDD scores. Loneliness, anxiety, and parental anxiety were associated with an increased likelihood of MDD. Baseline CRP positivity did not predict MDD in adolescent COVID-19 survivors.

CONCLUSIONS

This study indicates that anxiety, loneliness, and parental anxiety play an important role in adolescents' experience of depressive symptoms after COVID-19 infection. Thus, screening parental psychopathology and loneliness in COVID-19 survivors seems to be preventive for adolescent mental health problems.

Patient activation for self‐management among adult patients with multimorbidity in primary healthcare settings

Background and Aims

Methods

Results

Conclusion

Reculturation: A new perspective on military-civilian transition stress

Various forms of assistance are offered to help US Veterans achieve success in their post-military lives in recognition of their service. Despite the many successes, a significant number of Veterans continue to remain at risk for negative mental health outcomes, including suicidality and low levels of life satisfaction. These findings may be due to challenges arising from cultural identity dissonance. Problematic strategies used by Veterans to reduce this dissonance can result in a lack of belongingness, a key component in Joiner's Interpersonal Theory of Suicide. The authors suggest that research on the immigrant experience of acculturation may provide a new perspective to better understand issues of identity and sense of belonging in Veterans. Given that most Veterans return to the culture in which they grew up, the authors offer the term "reculturation." The authors propose clinical psychology focus on exploring the reculturation process of Veterans to support program engagement and suicide prevention.

Ex-military personnel's experiences of loneliness and social isolation from discharge, through transition, to the present day

OBJECTIVES

This study aimed to examine the unique factors of loneliness and social isolation within the ex-military population from discharge, through transition, to the present day.

DESIGN

A qualitative, Phenomenological approach was adopted.

METHODS

In-depth semi-structured interviews were carried out with 11 participants who had all served in the British Armed Forces and represented all three military services (Royal Navy; Army; Royal Air Force). Reflexive Thematic Analysis was used to analyse the data.

RESULTS

Three themes were generated-a sense of loss; difficulty in connecting in civilian life; and seeking out familiarity. The findings of this study were examined through the lenses of the Social Needs Approach and the Cognitive Discrepancy Model.

CONCLUSIONS

Individuals developed close bonds in the military through meaningful and prolonged contact, reducing feelings of loneliness and social isolation during their time in service. The sense of belonging was key to social connection, but transition out of the military severed existing relationships, and a lack of belonging hindered the development of relationships within the civilian community. This study has implications for service provision relating to ex-military personnel and future service leavers.

Home Health Aides' Increased Role in Supporting Older Veterans and Primary Healthcare Teams During COVID-19: a Qualitative Analysis

BACKGROUND

Home health aides are important but often overlooked members of care teams, providing functional and emotional support to patients. These services became increasingly important during the COVID-19 pandemic as older adults faced disruptions in in-person medical services and family caregiving. Understanding how aides supported healthcare teams is important for informing emergency planning and better integrating home health services with primary care.

OBJECTIVE

To describe aides' roles in supporting veterans and working with primary care teams during COVID-19 and identify COVID-related changes in tasks.

DESIGN

Semi-structured interviews.

PARTICIPANTS

Eight home health aides, 6 home health agency administrators, and 9 primary care team members (3 RNs, 3 social workers, 3 MDs) serving veterans at a large, urban, Veterans Affairs medical center.

APPROACH

Combined deductive and inductive analysis to identify a priori concepts (aide roles; changes in tasks and new tasks during COVID-19) and emergent ideas. Aide, administrator, and provider interviews were analyzed separately and compared and contrasted to highlight emergent themes and divergent perspectives.

KEY RESULTS

Participants reported an increase in the volume and intensity of tasks that aides performed during the pandemic, as well as the shifting of some tasks from the medical care team and family caregivers to the aide. Four main themes emerged around aides' roles in the care team during COVID-19: (1) aides as physically present "boots on the ground" during medical and caregiving disruptions, (2) aides as care coordination support, (3) aides as mental health support, and (4) intensification of aides' work.

CONCLUSIONS

Home health aides played a central role in coordinating care during the COVID-19 pandemic, providing hands-on functional, medical, and emotional support. Integrating aides more formally into healthcare teams and expanding their scope of practice in times of crisis and beyond may improve care coordination for older veterans.

Behavioral Epidemic of Loneliness in Older U.S. Military Veterans: Results From the 2019-2020 National Health and Resilience in Veterans Study

OBJECTIVE

This study aimed to characterize the current prevalence of loneliness, and the relation between loneliness severity and mental and physical health conditions, suicidality, and functional measures in a predominantly older sample of U.S. military veterans.

METHODS

This cross-sectional study used data from the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of U.S. veterans (N = 4,069; mean age = 62) from November 2019 through March 2020. Veterans were classified into one of 3 groups based on their current level of loneliness (hardly ever, sometimes, often) on an adapted version of the Revised UCLA Loneliness Scale. A comprehensive range of mental and physical health, and functioning variables were assessed using valid and reliable self-report assessments.

RESULTS

A total of 56.9% of veterans endorsed feeling lonely sometimes (37.2%) or often (19.7%). Loneliness severity was independently associated with a range of mental health (odds ratios [ORs] = 1.21-33.30), physical health (ORs = 1.21-6.80), and functional difficulties (d's = 0.09-0.59). Relative to hardly ever feeling lonely, feeling lonely often or sometimes was associated with a more than 12- and three-fold greater likelihood of current suicidal ideation (29.0% versus 7.3% versus 1.5%), even after adjustment for sociodemographic, military, and psychiatric risk factors.

CONCLUSIONS

Loneliness is highly prevalent in U.S. military veterans, with more than half endorsing feeling lonely sometimes or often, and 1-of-5 reporting feeling lonely often. Loneliness severity was independently associated with a broad range of mental and physical health and functional measures, ias well as suicidal ideation. Results underscore the importance of loneliness as a transdiagnostic prevention and intervention target in the U.S. veteran population.

Loneliness, coping, suicidal thoughts and self-harm during the COVID-19 pandemic: a repeat cross-sectional UK population survey

Objectives

There has been speculation on the impact of the COVID-19 pandemic and the associated lockdown on suicidal thoughts and self-harm and the factors associated with any change. We aimed to assess the effects and change in effects of risk factors including loneliness and coping, as well as pre-existing mental health conditions on suicidal thoughts and self-harm during the COVID-19 pandemic.

Design

This study was a repeated cross-sectional online population-based survey.

Participants and measures

Non-probability quota sampling was adopted on the UK adult population and four waves of data were analysed during the pandemic (17 March 2020 to 29 May 2020). Outcomes were suicidal thoughts and self-harm associated with the pandemic while loneliness, coping, pre-existing mental health conditions, employment status and demographics were covariates. We ran binomial regressions to evaluate the adjusted risks of the studied covariates as well as the changes in effects over time.

Results

The proportion of individuals who felt lonely increased sharply from 9.8% to 23.9% after the UK lockdown began. Young people (aged 18–24 years), females, students, those who were unemployed and individuals with pre-existing mental health conditions were more likely to report feeling lonely and not coping well. 7.7%–10.0% and 1.9%–2.2% of respondents reported having suicidal thoughts and self-harm associated with the pandemic respectively throughout the period studied. Results from cross-tabulation and adjusted regression analyses showed young adults, coping poorly and with pre-existing mental health conditions were significantly associated with suicidal thoughts and self-harm. Loneliness was significantly associated with suicidal thoughts but not self-harm.

Conclusions

The association between suicidality, loneliness and coping was evident in young people during the early stages of the pandemic. Developing effective interventions designed and coproduced to address loneliness and promote coping strategies during prolonged social isolation may promote mental health and help mitigate suicidal thoughts and self-harm associated with the pandemic.

Associations of Embeddedness and Posttraumatic Stress Disorder among 9/11 Survivors

Following exposures to traumatic events on 9/11, survivors have reported heightened levels of posttraumatic stress disorder (PTSD). Multiple factors contribute to both the exacerbation and amelioration of PTSD symptoms, including social integration and support. This cross-sectional study aimed to understand and identify associations of embeddedness and psychosocial risk factors by PTSD status for survivors and first responders of 9/11. Results indicate that those with chronic PTSD had the lowest prevalence of both social and emotional embeddedness and many who reported no PTSD symptoms following 9/11 reported moderate levels of social and emotional embeddedness. Overall, our findings suggest those individuals who reported little to no PTSD also reported the most social/emotional embeddedness; whereas those individuals who report greater or chronic PTSD report the least social/emotional embeddedness. As such, it may be beneficial for clinicians across multiple care disciplines and contexts to consider and address the social lives and needs of those individuals experiencing symptoms of PTSD to ensure their emotional and physical needs are truly being met.

Addressing Depression Symptoms among University Students under COVID-19 Restrictions-The Mediating Role of Stress and the Moderating Role of Resilience

Background: The COVID-19 pandemic has contributed to a decline in mental health globally. Compared to the general population, university students have been identified as a group vulnerable to developing depression symptoms during the pandemic. Social isolation, a signature mental health consequence under physical-distancing regulations, is a known predictor of depression symptoms during the pandemic. Yet, more research is required to understand the mechanism that underpins the isolation–depression association and identify psychological factors that may attenuate the association. The current study aimed to understand the role of stress and resilience in the isolation–depression association among university students. Methods: Data were collected from 1718 university students between 28 and 31 May 2020. Partial least squares structural equation modelling (PLS-SEM) was used to examine the mediating role of perceived stress and the moderating role of resilience in the isolation–depression association. Results: We found that perceived stress partially mediated the association between social isolation and depression symptoms. Both the direct and indirect effects were moderated by participants’ resilience levels. Conclusions: Social isolation during the pandemic may contribute to depression symptoms both directly and through elevated stress levels. As an internal strength, resilience may buffer the adverse effects of isolation and stress on depression symptoms. Targeted interventions including mindfulness and physical exercise training may provide promising results in reducing depression symptoms among university students and should be considered by university administrators particularly during times of imposed physical-distancing measures.

Feasibility, Acceptance, and Initial Evaluation of a Telephone-Based Program Designed to Increase Socialization in Older Veterans

Loneliness is a public health issue, particularly for older Veterans. To increase older Veterans' access for socialization opportunities, a community-based telephone-delivered activity program was developed, in which Veterans can call in and engage in social activities through telephone. This paper illustrates the feasibility, acceptance, and preliminary outcomes of this program using a mixed-methods design. Thirty-two Veterans enrolled in the program, with 14 attendees who called in to the program at least once. Attendees were more likely to be depressed than those who did not call in at baseline. Program was acceptable with high client satisfaction. Perceived benefits included a structured program with interesting topics to spend time on and the opportunity to socialize, exchange ideas, and connect with other Veterans. Individual challenges (e.g., hearing difficulty) and program-level challenges (e.g., complicated procedures) were reported during qualitative interviews. Among attendees, a significant decrease in loneliness from baseline to 3-months was found but should be interpreted with caution based on the small sample size. While positive findings emerged regarding feasibility, acceptance, preliminary benefits of this program, further refinement is needed to improve future program implementation.

Substance use, depression, and loneliness among American veterans during the COVID-19 pandemic

BACKGROUND AND OBJECTIVES

Behavioral health issues, such as substance use, depression, and social isolation, are of grave concern during COVID-19, especially for vulnerable populations. One such population is US veterans, who have high rates of pre-existing behavioral health conditions and may thus be at-risk for poorer outcomes. The current study aimed to investigate substance use among US veterans during COVID-19 as a function of pre-existing depression, loneliness, and social support.

METHODS

We investigated the relationship between pre-pandemic depression and substance use during COVID-19 using linear (alcohol) and logistic (cannabis) regression among a large sample of US veterans (N = 1230). We then tested if loneliness and social support moderated these effects.

RESULTS

Though there was a decrease in alcohol and cannabis use among the overall sample, veterans who screened for depression prior to the pandemic exhibited higher levels of substance use after the pandemic's onset. Loneliness compounded the effects of depression on rates of alcohol use. Social support was not protective for the effects of depression on either alcohol or cannabis use.

DISCUSSION AND CONCLUSIONS

Veterans with pre-existing depression may be in need of attention for substance use behaviors. Interventions aimed at alleviating loneliness among veterans may be useful in mitigating alcohol use, but not cannabis use, amid COVID-19.

SCIENTIFIC SIGNIFICANCE

Our findings are among the first to report tangible behavioral health outcomes experienced by US veterans as a result of COVID-19. Results can help inform treatment efforts for veterans who are struggling with substance use during and post-pandemic.

Loneliness and Current Environmental Context Are Associated With False Perceptions Regarding Social Relations

ABSTRACT

The consequences of loneliness include anxiety, depression, and chronic illnesses, but little is known about its association with cognitive distortions. Three experiments investigated the effect of loneliness, and current context, on the content of false perceptions. A total of 446 participants completed psychometric tests (University of California, Los Angeles Loneliness Scale, Hospital Anxiety and Depression Scale, and a Schizotypy Scale) and a word detection task. The word detection task explored the effects of "lonely" and "neutral" contexts (experiments 1 and 2), as well as "positive social" contexts (experiment 3), on false perceptions. In all experiments, participants reporting higher loneliness reported more false perceptions with a lonely content, but only when in a context reflecting a lonely theme. The results show current environmental context and individuals' psychological state combine to affect false perception content. That such findings are found with loneliness, when controlling for depression, anxiety, and schizotypy, show the degree to which this state can distort cognition and perception.

Role of resilience and social support in the relationship between loneliness and suicidal ideation among Chinese nursing home residents

OBJECTIVES

Loneliness is a risk factor of suicidal ideation, while resilience and social support are protective factors; however, the complex mechanisms behind these factors have not been examined among nursing home residents. This study evaluated the mediating effect of resilience on the association between loneliness and suicidal ideation and whether this mediating effect was moderated by social support.

METHODS

Residents (N = 538; Aged ≥60years; 321 female, 217 male) from 37 nursing homes in China completed this cross-sectional study. Their loneliness, resilience, social support, and suicidal ideation were measured. Regression analyses using bootstrapping methods were conducted to explore the mediating and moderating effects.

RESULTS

Some residents (14.9%, 80/538) reported current suicidal ideation. The correlation between loneliness and suicidal ideation was partially mediated by resilience (indirect effect = 0.067, 95% CI = 0.011-0.122). Overall social support moderated the resilience on suicidal ideation, indirectly impacting loneliness on suicidal ideation (moderating effect = 0.086 [95% CI = 0.005-0.167]). Support from family and nursing home staff moderated the direct (path c') and indirect path (path b) of the mediation model, respectively.

CONCLUSIONS

Our findings underscore the vital role of resilience and social support to buffer against suicidal ideation, which is common among nursing home residents in China.HighlightsWe evaluated suicidal ideation in mainland Chinese nursing home residentsLoneliness and suicidal ideation were partially mediated by resilienceSocial support moderated the effect of loneliness and resilience on suicidal ideationThe results were self-reported and are not generalizable to all of ChinaResilience and social support can buffer against suicidal ideation among residents.

The protective effect of self-esteem on suicidal ideation among nursing home residents with limited social support in China: A cross-sectional study

Aim

This cross‐sectional study aimed to assess the impact of limited social support and loneliness on suicidal ideation, under the influence of self‐esteem, an important inner resource for quality living.

Design

An observational cross‐sectional study conducted from September 2018–April 2019.

Methods

The participants comprised 538 nursing home residents selected by a stratified sampling method from all seven administrative districts in a capital city of eastern China. All the participants completed the survey that constituted the measurement of suicidal ideation, self‐esteem, social support and loneliness. Path analysis was performed using the structural equation modelling method.

Results

A moderating effect, with satisfactory model fit indices and significant path coefficients, was detected between self‐esteem and suicidal ideation through limited social support and loneliness, revealing the multiple protective mechanisms of this psychological characteristic on the change of suicidal ideation.

The Differential Effects of Social Media on Depressive Symptoms and Suicidal Ideation Among the Younger and Older Adult Population in Hong Kong During the COVID-19 Pandemic: Population-Based Cross-sectional Survey Study

BACKGROUND

Social media has become a ubiquitous part of daily life during the COVID-19 pandemic isolation. However, the role of social media use in depression and suicidal ideation of the general public remains unclear. Related empirical studies were limited and reported inconsistent findings. Little is known about the potential underlying mechanisms that may illustrate the relationship between social media use and depression and suicidal ideation during the COVID-19 pandemic.

OBJECTIVE

This study tested the mediation effects of social loneliness and posttraumatic stress disorder (PTSD) symptoms on the relationship between social media use and depressive symptoms and suicidal ideation, as well as the moderation effect of age on the mediation models.

METHODS

We administered a population-based random telephone survey in May and June 2020, when infection control measures were being vigorously implemented in Hong Kong. A total of 1070 adults (658 social media users and 412 nonusers) completed the survey. Structural equation modeling (SEM) and multigroup SEM were conducted to test the mediation and moderation effects.

RESULTS

The weighted prevalence of probable depression was 11.6%; 1.6% had suicidal ideation in the past 2 weeks. Both moderated mediation models of depressive symptoms (χ²₆₂=335.3; P<.05; comparative fit index [CFI]=0.94; nonnormed fit index [NNFI]=0.92; root mean square error of approximation [RMSEA]=0.06) and suicidal ideation (χ²₃₄=50.8; P<.05; CFI=0.99; NNFI=0.99; RMSEA=0.02) showed acceptable model fit. There was a significantly negative direct effect of social media use on depressive symptoms among older people (β=-.07; P=.04) but not among younger people (β=.04; P=.55). The indirect effect via PTSD symptoms was significantly positive among both younger people (β=.09; P=.02) and older people (β=.10; P=.01). The indirect effect via social loneliness was significant among older people (β=-.01; P=.04) but not among younger people (β=.01; P=.31). The direct effect of social media use on suicidal ideation was not statistically significant in either age group (P>.05). The indirect effects via PTSD symptoms were statistically significant among younger people (β=.02; P=.04) and older people (β=.03; P=.01). Social loneliness was not a significant mediator between social media use and suicidal ideation among either age group (P>.05).

CONCLUSIONS

Social media may be a "double-edged sword" for psychosocial well-being during the COVID-19 pandemic, and its roles vary across age groups. The mediators identified in this study can be addressed by psychological interventions to prevent severe mental health problems during and after the COVID-19 pandemic.

Temporal variation in suicide in peri-urban Pretoria

Background

Suicide is a public health problem, and the third major cause of death in Indian, black and mixed race groups. In whites suicide is the second cause of death. The patterns of suicide vary by time of day, day of the week, month of the year and seasons. As a result of limited and inaccurate data, these variations have not been fully examined in the developing world. This study investigated the diurnality and seasonality of suicide in peri-urban Pretoria, as opposed to studies conducted previously in the country’s metropolitan.

Methods

A retrospective analysis of suicides recorded between 2007 and 2019 was undertaken. Data were extracted from the forensic pathology department’s database (university mortuary).

Results

Of the 1515 cases of suicides examined, majority were black Africans (95.9%), male (83.9%), aged 21–40 years (50.5%). Hanging was the most common method of suicide irrespective of demographics (72.8%). Diurnal suicide variations were distinct for men and women, occurring at (16:00–20:00) and (08:00–12:00), respectively. Suicide peaked on days preceding and after the weekend (Mondays and Fridays) and in warmer seasons (summer and spring)

Conclusion

The overall patterns of suicide in peri-urban Pretoria, mimic local and global trends with regard to methods, demographics and temporal characteristics. The underlying mechanism for these trends is unclear requiring in-depth investigation in order to develop appropriate interventions.

A room with a green view: the importance of nearby nature for mental health during the COVID-19 pandemic

The COVID-19 pandemic and its global response have resulted in unprecedented and rapid changes to most people's day-to-day lives. To slow the spread of the virus, governments have implemented the practice of physical distancing ("social distancing"), which includes isolation within the home with limited time spent outdoors. During this extraordinary time, nature around the home may play a key role in mitigating against adverse mental health outcomes due to the pandemic and the measures taken to address it. To assess whether this is the case, we conducted an online questionnaire survey (n = 3,000) in Tokyo, Japan, to quantify the association between five mental health outcomes (depression, life satisfaction, subjective happiness, self-esteem, and loneliness) and two measures of nature experiences (frequency of greenspace use and green view through windows from home). Accounting for sociodemographic and lifestyle variables, we found that the frequency of greenspace use and the existence of green window views from within the home was associated with increased levels of self-esteem, life satisfaction, and subjective happiness and decreased levels of depression, anxiety, and loneliness. Our findings suggest that a regular dose of nature can contribute to the improvement of a wide range of mental health outcomes. With the recent escalation in the prevalence of mental health disorders, and the possible negative impacts of the COVID-19 pandemic on public mental health, our findings have major implications for policy, suggesting that urban nature has great potential to be used as a "nature-based solution" for improved public health.

Longitudinal courses of suicidal ideation in U.S. military veterans: a 7-year population-based, prospective cohort study

BACKGROUND

Varied longitudinal courses of suicidal ideation (SI) may be linked to unique sets of risk and protective factors.

METHOD

A national probability sample of 2291 U.S. veterans was followed over four assessments spanning 7 years to examine how a broad range of baseline risk and protective factors predict varying courses of SI.

RESULTS

Most veterans (82.6%) denied SI at baseline and all follow-ups, while 8.7% had new onset SI, 5.4% chronic SI, and 3.3% remitted SI. Compared to the no-SI group, chronic SI was associated with childhood trauma, baseline major depressive and/or posttraumatic stress disorder (MDD/PTSD), physical health difficulties, and recent traumatic stressors. Remitted veterans had the highest risk of a prior suicide attempt (SA) compared to no-SI [relative risk ratio (RRR) = 3.31] and chronic SI groups (RRR = 4.65); and high rates of MDD/PTSD (RRR = 7.62). New onset SI was associated with recent stressors and physical health difficulties. All symptomatic SI groups reported decrements in protective factors, specifically, social connectedness, trait curiosity/exploration, and purpose in life.

CONCLUSION

Nearly one-in-five veterans reported SI over a 7-year period, most of whom evidenced new onset or remitted SI courses. Chronic and remitted SI may represent particularly high-risk SI courses; the former was associated with higher rates of prospective SA, and psychiatric and physical distress, and the latter with increased likelihood of prior SA, and isolation from social and mental health supports. Physical disability, MDD/PTSD, and recent stressors may be important precipitating or maintaining factors of SI, while social connectedness may be a key target for suicide prevention efforts.

Evolution and Emerging Trends in Depression Research From 2004 to 2019: A Literature Visualization Analysis

Depression has become a major threat to human health, and researchers around the world are actively engaged in research on depression. In order to promote closer research, the study of the global depression knowledge map is significant. This study aims to map the knowledge map of depression research and show the current research distribution, hotspots, frontiers, and trends in the field of depression research, providing researchers with worthwhile information and ideas. Based on the Web of Science core collection of depression research from 2004 to 2019, this study systematically analyzed the country, journal, category, author, institution, cited article, and keyword aspects using bibliometric and data visualization methods. A relationship network of depression research was established, highlighting the highly influential countries, journals, categories, authors, institutions, cited articles, and keywords in this research field. The study identifies great research potential in the field of depression, provides scientific guidance for researchers to find potential collaborations through collaboration networks and coexistence networks, and systematically and accurately presents the hotspots, frontiers, and shortcomings of depression research through the knowledge map of global research on depression with the help of information analysis and fusion methods, which provides valuable information for researchers and institutions to determine meaningful research directions.

[Medical applications of social networks. Specific aspects of the COVID-19 pandemic]

For years, social networks have been incorporated into the day-to-day of the majority of the population. In this context, a new area of knowledge in medicine has been developed: infodemiology. It is defined as the evaluation, with the objective of improving public health, of health-related information that users upload to the network. In addition, social networks offer many possibilities for conducting public health campaigns, accessing patients, or carrying out treatment interventions.

The Impact of Coping Strategies and Perceived Family Support on Depressive and Anxious Symptomatology During the Coronavirus Pandemic (COVID-19) Lockdown

The coronavirus pandemic represents a severe global crisis, affecting physical, and psychological health. Lockdown rules imposed to counteract the rapid growth of COVID-19, mainly social restrictions, have represented a risk factor for developing depressive and anxious symptoms. The research aims are to explore the effect of coping strategies and perceived social support on depressive and anxious symptomatology during the COVID-19 pandemic. Ninety-six healthy people (46 males, mean age = 39.3; SD = 16.6) completed through on-line platform: Socio-demographic questionnaire, Coping Inventory for Stressful Situations (CISS), Multidimensional Scale of Perceived Social Support (MSPSS) and Symptom Checklist-90-Revised (SCL-90-R), 3 weeks after the imposition of lockdown restrictions. SCL-90-R Depression scores showed significant positive correlation with CISS Emotion (r = 0.85; p = 0.001) and Avoidant (r = 0.34; p = 0.018), a significant negative correlation with MSPSS Family support (r = -0.43; p = 0.003). SCL-90-R Anxiety scores showed a significant positive correlation with CISS Emotion (r = 0.72; p = 0.001) and Avoidant (r = 0.35; p = 0.016). No significant correlations between both CISS Emotion and Avoidant scales with social support emerged. Two Multiple Linear Regression analysis were performed using, respectively, SCL-90-R Depression and Anxiety scores as dependent variables, and the CISS and MSPSS scales, age, and gender as predictors. The first regression model (R 2 = 0.78; adjusted R 2 = 0.75) revealed CISS Emotion (β = 0.83; p = 0.001) and MSPSS Family support (β = -0.24; p = 0.004) had a predictive effect on SCL-90-R Depression scores. The second regression model (R 2 = 0.52; adjusted R 2 = 0.472) revealed that only CISS Emotion (β = 0.71; p = 0.001) predicted the SCL-90-R Anxiety scores. In conclusion, during the COVID-19 pandemic lockdowns, coping focus on emotions seemed to increase anxious and depressive symptoms, probably due to the uncontrollable nature of the stressful event and the high emotional response. Family support which reduces the sense of loneliness had an exclusive role in mitigating depressive symptoms. These results highlight the importance of promoting psychological strategies to improve emotional regulation skills, reducing isolation from family, to prevent mood symptomatology in healthy citizens during large-scale health crises.

Soldiering on only goes so far: How a qualitative study on Veteran loneliness in New Zealand influenced that support during COVID-19 lockdown

Introduction: On April 25, 2020, Veterans’ Affairs in New Zealand (NZ) contacted approximately 3,000 of 8,000 known military Veterans by phone during the SARS-CoV-2 pandemic to ensure they were safe during the government-imposed lockdown. The impetus to this initiative were the findings of a cross-sectional quantitative survey of NZ Veterans, followed by the qualitative survey reported here, both carried out in 2019. The former report found 33% of 89 respondents were lonely and reported barriers to seeking support, and over half of Veterans felt uncomfortable accessing it. Methods: To understand the factors underlying loneliness, a qualitative survey was developed based on the barriers previously identified and a literature review. A purposeful sample based on gender, age, and ethnicity identified 20 respondents from the initial survey: 10 lonely and 10 non-lonely. Interviews were followed by an inductive thematic analysis, and themes and sub-themes were developed. Results: Ten of the 20 potential participants responded: 6 lonely and 4 non-lonely. Social and geographic isolation, problems with re-integration into the civilian community, and health problems were found to contribute to Veteran loneliness. Social connectedness, particularly to service peers, was the primary mitigating factor. Barriers included stoicism and perceptions of ineffective and inaccessible services. Inequity in the Veteran support system also emerged as a barrier for Veterans who had not deployed on operational missions. Discussion: During the pandemic, social connectedness will have decreased, and loneliness increased. Designing interventions with these factors in mind, and ensuring equity of access to support, should help combat Veteran loneliness.

Direct and Indirect Associations Between Loneliness and Thoughts of Self-Harm Among a Clinical Sample of Older Adults With Serious Mental Illness

This cross-sectional study examines the relationships of loneliness and depressive symptoms to thoughts of self-harm among a clinical sample (n = 150) of older adults (M = 58.42 years, SD = 5.86 years; male, 55.3%; African American, 61.3%) with serious mental illness (SMI) receiving publicly funded, community-based psychiatric rehabilitation services. Participants completed the De Jong Gierveld Loneliness Scale, Multidimensional Scale of Perceived Social Support, Patient Health Questionnaire 9, and Geriatric Depression Scale-Short Form. Mediation analyses tested the association of loneliness with thoughts of self-harm through depressive symptoms and were adjusted for social support and demographic variables. The direct association of loneliness with thoughts of self-harm was mediated by depressive symptoms; indirect associations of overall and emotional loneliness to thoughts of self-harm were significant. Findings suggest the need for clinicians to reduce feelings of loneliness among older adults with SMI as a means of partially ameliorating depressive symptoms and thoughts of self-harm.

To what extent does severity of loneliness vary among different mental health diagnostic groups: A cross-sectional study

Loneliness is a common and debilitating problem in individuals with mental health disorders. However, our knowledge on severity of loneliness in different mental health diagnostic groups and factors associated with loneliness is poor, thus limiting the ability to target and improve loneliness interventions. The current study investigated the association between diagnoses and loneliness and explored whether psychological and social factors were related to loneliness. This study employed a cross-sectional design using data from a completed study which developed a measure of social inclusion. It included 192 participants from secondary, specialist mental health services with a primary diagnosis of psychotic disorders (n = 106), common mental disorders (n = 49), or personality disorders (n = 37). The study explored differences in loneliness between these broad diagnostic groups, and the relationship to loneliness of: affective symptoms, social isolation, perceived discrimination, and internalized stigma. The study adhered to the STROBE checklist for observational research. People with common mental disorders (MD = 3.94, CI = 2.15 to 5.72, P < 0.001) and people with personality disorders (MD = 4.96, CI = 2.88 to 7.05, P < 0.001) reported higher levels of loneliness compared to people with psychosis. These differences remained significant after adjustment for all psychological and social variables. Perceived discrimination and internalized stigma were also independently associated with loneliness and substantially contributed to a final explanatory model. The severity of loneliness varies between different mental health diagnostic groups. Both people with common mental disorders and personality disorders reported higher levels of loneliness than people with psychosis. Addressing perceived mental health discrimination and stigma may help to reduce loneliness.

Occupational Therapy in the Promotion of Health and Well-Being

A balanced pattern of occupations enhances the health and fulfills the needs of individuals, families, communities, and populations (American Occupational Therapy Association [AOTA], 2014b; Hocking, 2019; Meyer, 1922). Occupations are personalized "everyday activities that people do as individuals, in families, and with communities to occupy time and bring meaning and purpose to life" (World Federation of Occupational Therapists, 2012, para. 2). The purpose of this statement is to describe occupational therapy's role and contribution in the areas of health promotion and prevention for internal and external audiences. AOTA supports and promotes the involvement of occupational therapy practitioners¹ in the development and delivery of programs and services that promote health, well-being, and social participation of all people.

Loneliness as a predictor of suicidal ideation and behaviour: a systematic review and meta-analysis of prospective studies

BACKGROUND

Suicide and suicidal behaviour are global health concerns with complex aetiologies. Given the recent research and policy focus on loneliness, this systematic review aimed to determine the extent to which loneliness predicts suicidal ideation and/or behaviour (SIB) over time.

METHODS

A keyword search of five major databases (CINHAL, Medline, PsychArticles, PsychInfo and Web of Knowledge) was conducted. Papers for inclusion were limited to those using a prospective longitudinal design, written in English and which measured loneliness at baseline and SIB at a later time-point.

RESULTS

After duplicates were removed, 947 original potential papers were identified, with 22 studies meeting the review criteria. Meta-analysis revealed loneliness was a significant predictor of both suicidal ideation and behaviour and there was evidence that depression acted as a mediator. Furthermore, studies which consisted of predominantly female participants were more likely to report a significant relationship, as were studies where participants were aged 16-20 or >55 years at baseline.

LIMITATIONS

There was considerable variability in measures, samples and methodologies used across the studies. Middle-aged adults were under-represented, as were individuals from minority ethnic backgrounds. All studies were conducted in countries where self-reliance and independence (i.e. individualism) are the cultural norm.

CONCLUSIONS

Loneliness predicts later SIB in select populations. However, due to the heterogeneity of the studies further research is needed to draw more robust conclusions. Suicide death also needs to be included as an outcome measure. A focus on more collectivist countries is also required.

Psychosocial Syndemic of suicidal ideation: a cross-sectional study among sexually transmitted infection patients in Shanghai, China

BACKGROUND

Patients with sexually transmitted infections (STIs) experience difficulties with stability and trust in long-term relationships and have poor mental health, factors that may lead to suicidal ideation. We sought to verify whether psychosocial health problems among patients with STIs were associated with these patients' suicidal ideation and to examine the syndemic effect of multiple psychosocial problems on suicidal ideation.

METHODS

This was a cross-sectional study of 519 STI patients at the Shanghai Skin Disease Hospital. Demographic, psychosocial, and suicidal ideation information about the participants was collected by questionnaire. Logistic regressions were performed to detect the association between demographic variables and suicidal ideation, as well as each individual psychosocial variable and suicidal ideation, and to verify the syndemic effect of psychosocial factors.

RESULTS

Of the participants, 25.0% (130/519) reported having suicidal ideation. In univariable analysis, low self-esteem, loneliness, depression, entrapment, defeat, and unsatisfied interpersonal needs were associated with suicidal ideation. Multivariable analysis found depression (odds ratio [OR]: 4.1; 95% confidence interval [CI]: 2.3-7.2) and entrapment (OR: 2.1; 95%CI: 1.1-4.1) each had a more significant relation with suicidal ideation than the other psychosocial problems examined. STI patients who experienced two or more psychosocial health problems had approximately fourfold odds of suicide ideation (adjusted OR [AOR]: 4.2; 95%CI: 2.6-6.8) compared with those in the non-syndemic group, especially in the high-level (five or more psychosocial problems) group (AOR: 7.0; 95%CI: 3.9-12.5).

CONCLUSIONS

The study found the participants had a high rate of suicidal ideation and suffered from severe psychosocial problems. These results show a syndemic effect of psychosocial problems on increasing the odds of suicidal ideation. Our findings suggest an urgent need for efforts to prevent suicidal ideation among STI patients toward improving the social and health conditions of this population.

Problems with Social Acceptance and Social Victimization Predict Substance Use among US Reserve/Guard Soldiers

The effects of negative social interactions/experiences on substance use have largely been studied in civilian populations, but less is known about United States Army Reserve/National Guard (USAR/NG) soldiers-a high-risk group. We examined the associations between problems with social acceptance, social victimization, and substance use among USAR/NG soldiers, and examined potential differences by deployment history. The sample consisted of soldiers who completed baseline and 1-year follow-up assessments (N = 445) of Operation: SAFETY, an ongoing study of USAR/NG soldiers. We examined the effects of baseline problems with social acceptance/social victimization on nonmedical use of prescription drugs (NMUPD), illicit drug use, frequent heavy drinking (FHD), and alcohol problems at follow-up. Significant effects were small in magnitude but consistent in direction. Greater problems with social acceptance were associated with higher odds of NMUPD and illicit drug use. Greater social victimization was associated with higher odds of NMUPD and illicit drug use. There were no differences by deployment history. Problems with social acceptance/social victimization were not associated with FHD or alcohol problems. Problems with social acceptance/social victimization may contribute to drug use among USAR/NG soldiers. Intervention programs should address social issues, regardless of deployment history.

Patient-reported outcomes in major depressive disorder with suicidal ideation: a real-world data analysis using PatientsLikeMe platform

BACKGROUND

The current analysis utilized data collected via an online patient community platform, PatientsLikeMe (PLM) to compare patient-reported experiences in patients with major depressive disorder (MDD) with suicidal ideation (MDSI) to those with MDD but without suicidal ideation.

METHODS

PLM members who joined PLM between May-2007 and February-2018 and reported a diagnosis of MDD were included. The MDSI cohort included patients with MDD who reported at least one suicide-related symptom at a severity greater than "none". Demographics, comorbidities, symptoms, and side-effects were compared between MDSI and MDD cohorts. Factors correlated with suicidal ideation (SI) were determined by a random forest procedure.

RESULTS

Patients in the MDSI cohort (n = 266) were younger (median age, 36 vs 44 years) with an earlier disease onset (before 30 years, 83% vs 71%), and a longer diagnosis latency (median, 4 vs 2 years) vs patients in the MDD cohort (n = 11,963). Majority of patients were women in both cohorts (73% vs 83%). Median number of psychiatric comorbidities was higher in the MDSI cohort (4 vs 3). Unprompted symptoms (e.g., loneliness, feeling of hopelessness, social anxiety, impulsivity, and self-hating thoughts) were more frequent in the MDSI cohort. Hopelessness, loneliness, anhedonia, social anxiety, and younger age were highly correlated with suicidal ideation.

CONCLUSIONS

This analysis utilized patient-reported data to better understand symptoms, experiences, and characteristics of patients with MDSI compared to patients with MDD. The results identified various risk factors correlated with suicidal ideation that may help guide clinical judgement for patients with MDD who may not voluntarily report suicidal ideation.

The Importance of "Being There": a Qualitative Study of What Veterans with Depression Want in Social Support

BACKGROUND

Social connectedness exerts strong influences on health, including major depression and suicide. A major component of social connectedness is having individual relationships with close supports, romantic partners, and other trusted members of one's social network.

OBJECTIVE

The objective of this study was to understand how individuals' relationships with close supports might be leveraged to improve outcomes for primary care patients with depression and at risk for suicide.

DESIGN

In this qualitative study, we used a semi-structured interview guide to probe patient experiences, views, and preferences related to social support.

PARTICIPANTS

We conducted interviews with 30 primary care patients at a Veterans Health Administration (VA) medical center who had symptoms of major depression and a close support.

APPROACH

Thematic analysis of qualitative interview data examined close supports' impact on patients. We iteratively developed a codebook, used output from codes to sort data into themes, and selected quotations that exemplified themes for inclusion in this manuscript.

KEY RESULTS

"Being there" as an important quality of close supports emerged as a key concept. "Being there" was defined in three ways: physical proximity, frequent or responsive contact, or perceived availability. Close supports who were effective at "being there" possessed skills in intuitively sensing the patient's emotional state and communicating indirectly about depression. Three major barriers to involving close supports in depression care were concerns of overburdening the close support, a perception that awareness of the patient's depression would make the close support unnecessarily worried, and a desire and preference among patients to handle depression on their own.

CONCLUSIONS

"Being there" represents a novel, patient-generated way to conceptualize and talk about social support. Suicide prevention initiatives such as population-level communication campaigns might be improved by incorporating language used by patients and addressing attitudinal barriers to allowing help and involvement of close supports.