Results of this nationally representative study revealed that the majority of the US veteran population (60-72%) reported frequent engagement in providing various kinds of social support to others. Personality factors, notably agreeableness, conscientiousness and openness to experiences, as well as greater received social support were strongly associated with frequency of provided support. Provision of social support was independently associated with internalizing mental disorders (i.e.., MDD, GAD, PTSD), as well as SI and future suicidal intent, with each standard deviation increase in provided support associated with a 15-40% reduced odds of these outcomes. Further, significant interaction effects were observed between provided and received support, with veterans who reported high received and provided support having 3.5- to 14-fold reduced probability of screening positive for MDD, GAD, and SI relative to veterans who reported high received social support but low provision of social support.
The high prevalence of provided social support among veterans is noteworthy and encouraging. While veterans are often identified as a high-risk population for adverse mental health outcomes, accumulating evidence has demonstrated that military experience may also be linked to increased resilience and post-traumatic growth.31–33 For example, a study of 1,287 male veterans aged between 44 to 91 years (40% combat veterans) found that perceiving benefit from stressful military experiences mitigated the negative consequences of combat exposure.33 In the present study, positive perceptions of military experience were independently linked to higher scores on a measure of provided support. This finding extends prior work from our group showing that positive perceptions of military service are linked to reduced likelihood of mental disorders and suicidal thinking in veterans.34 One interpretation of this finding is that veterans who perceived greater benefits from their military experience, which include factors such as cooperation and teamwork, dependability, and lifelong friendships,33 may be less likely to develop mental health problems, which may in turn increase their engagement in altruistic behaviors. Alternatively, positive perceptions of military service may lead to greater engagement in altruistic behaviors, which may in turn mitigate risk for mental health problems. Further, while there is a large literature on prosocial behavior and altruism, which represent broad constructs, this study focused specifically on the provision and receipt of social support. Additional research is needed to determine whether the findings are specific to social support or prosocial behaviors more broadly,35 as well as to disentangle longitudinal associations among these variables.
The positive association between the Big-Five personality factors, particularly agreeableness, conscientiousness and emotional stability, and provision of social support accords with extant literature. Previous studies have similarly identified associations between personality factors such as extraversion and agreeableness and received social support, as well as provided support.36–38 One plausible explanation to these findings is that those who scored highly on both received and provided support are highly socially connected, and thus this association is bidirectional and mutually sustained. Personality factors and received support may also interact. For example, a previous longitudinal study of patients with chronic kidney disease found that greater receipt of social support among individuals with greater agreeableness was associated with a decrease in depressive symptoms, whereas support had little effect on depression change for individuals who scored lower in agreeableness.39 Collectively, these findings underscore the importance of trait personality characteristics as potential drivers of the provision of support, as well as moderators of the protective effects of received social support.
To our knowledge, this study is the first to observe robust independent associations between provision of social support and various adverse mental health outcomes. Further, the findings of significant interactions between provided and received social support in relation to certain adverse mental health outcomes highlight the importance of considering the multi-faceted nature of social connectedness when examining associations with mental health outcomes. Our results revealed substantially reduced probabilities of MDD, GAD, and SI for veterans who reported both greater provided and received support relative to greater received support alone. Several neurobiological mechanisms may underlie these associations. For example, subcortical neural regions critical in parental care, such as greater activity in the ventral striatum and septal area,40 and reduced amygdala activity41 have been linked to greater provision of support behaviors. The reinforcing-related neural mechanisms in the ventral striatum and septal area related to providing support have also been proposed to promote emotional and social well-being.13 Conversely, greater amygdala activity to acute stressors has previously been linked to greater elevation in blood pressure42 and proinflammatory cytokines.43 Taken together, these findings implicate fear and reward processing as possible neural mechanisms that mediate the relation between provision of social support and reduced stress and risk for adverse mental health outcomes.
Results of this study have several clinical implications. In the United Kingdom, there have been recent increasing efforts to promote social prescribing as a means of helping improve both mental and physical health of patients who present to their primary care physicians.44 In the US, the VA offers a tele-support program called Compassionate Contact Corps to veterans who are socially isolated to talk regularly with trained volunteers via phone or video calls.45 In addition, previous research has demonstrated that peer-outreach interventions may help improve depressive symptoms, as well as loneliness.46,47 Volunteerism, which encourages physical activity, social connection, and meaningful purpose, has also been linked to improved mental well-being, social capital, and personal empowerment.48,49 Results of our study suggest that interventions and social prescriptions to promote the ‘provision of support to others’ may be another avenue to potentially mitigate risk for adverse mental health outcomes in veterans. For example, clinicians and researchers may manualize a training to provide social support to others and train individuals who have psychiatric disorders or are at high risk of adverse mental health conditions. Alternatively, clinicians could assign tasks to provide social support via clinical interventions that are designed to promote certain behaviors, such as behavioral activation.50,51 However, given the cross-sectional nature of the study, it is also possible that veterans with MDD, GAD, and SI reported substantially lower provided support. Longitudinal studies are needed to disentangle the temporal/causal nature of these associations, and consider the role of provided support, as well as other aspects of social support (e.g., structural, received support) in relation to mental health outcomes. Given that individuals may have different “profiles” of social connectedness (e.g., high received support, low provided support), it is also be helpful to evaluate personalized approaches to assessing, monitoring, and bolstering domains of social connectedness.
This study has three notable limitations. First, while nationally representative, the sample consisted primarily of older, male, and White, non-Hispanic veterans. Thus, it is unclear whether the results of the study may generalize to more diverse samples of veterans or non-veteran population. Second, as noted above, cross-sectional design does not make it possible to ascertain temporal/causal associations between provision of social support, other aspects of social support (e.g., structural support, received support) and adverse mental health outcomes. Third, screening instruments were utilized to assess mental disorders. Further research utilizing structured clinical interviews is needed to replicate the results reported herein.
Notwithstanding these limitations, results of this study provide the first-known population-based data on the prevalence and correlates of providing social support in US military veterans. They suggest that the majority of veterans frequently engage in some form of providing support, and that greater engagement in such activities is linked to a significant reduction in the odds of internalizing psychopathology, as well as suicidality. Additional research is needed to replicate and extend these results in a prospective cohort, and in more diverse veteran and non-veteran populations; elucidate the mechanism of interaction between provided, received, and other aspects of social support, and their independent and interactive effects on adverse mental health outcomes; and evaluate the efficacy of interventions designed to bolster engagement in provision of social support to others in mitigating risk for adverse mental health outcomes in veterans and other at-risk populations.
Authors Contribution Statement: Peter J. Na assisted with the study conceptualization and study design, and wrote the main manuscript. Jack Tsai and Steven M. Southwick collaborated in the writing and editing of the manuscript. Robert H. Pietrzak designed the study, analyzed the data, and collaborated in the writing and editing of the manuscript.