Do you feel like someone has your back? And think about how this may change the way we navigate the world, or manage daily life stressors? Whether one feels supported or meaningfully connected is important. Traditionally, we focus on measuring objective indicators, e.g., the number of friends you have, or the number of people you live with. However, research has shown that this may not necessarily influence the way people feel, that is objective indicators are not always predictive of subjective indicators. Hence, subjective indicators such as perceived social support and loneliness defined as subjective feelings of social isolation (Peplau et al, 1982) should be included in scientific research.
One example is that people with psychosis, one of the most vulnerable and marginalised groups in our community may report receiving instrumental support (e.g., financial assistance: Windell et al, 2013), but 80% of 1,825 people surveyed in Australia continue to report loneliness as a problem (Stain et al, 2012). Additionally, almost half (49.1%) wanted more friends. However, I would argue that having more friends may not be as beneficial unless these friendships are meaningful and supportive. Together with my colleagues, I found that relationship satisfaction and the reciprocity of relationships (i.e., supports where the individual both receive social support but also gave social support) was crucial in moderating delusional distress levels in individuals with psychosis (Lim et al, 2014).
Wang and her colleagues understood the importance of subjective indicators and wrote a comprehensive systematic review of how subjective indicators can influence outcomes in people with mental health. First, existing studies that measured loneliness, subjective social constructs (e.g., perceived social support, presence of confiding relationships) was the main focus. Wang et al. were specifically interested in whether these subjective indicators may predict poorer outcomes for adults with mental health disorders. Outcomes were defined as either relapse, functional outcome measurements (e.g., recovery, quality of life, disability), symptom severity, and global outcomes.
The authors conducted a systematic search using search terms to capture relevant papers. Papers were deemed eligible based on several inclusion criterion; these related to the types of study, participants, exposure variables and outcomes. The search was undertaken using six electronic databases and search terms related to loneliness, social support, mental disorders and outcomes (e.g. quality of life, social functioning).
At the end of their search, a narrative synthesis was conducted and a total of 34 quantitative papers were identified as eligible. Samples most frequently included people with depression, followed by bipolar disorder, anxiety disorders, and then schizophrenia or schizoaffective disorders. The number of studies extracted hold similar prevalence rates of these clinical mental disorders in our population (Andrews et al, 2001; Slade et al, 2009).
People with depression who perceive themselves to have poor social support, often do worse across different areas (from their ability to recover, functioning socially and have more symptoms). Although loneliness was not central to the results, there is evidence to indicate that those with depression report poorer outcomes if they report lower perceived social support.
- Wang and her colleagues found the strongest evidence points to the crucial relationship between depression and perceived social support.
- A similar relationship also seems to exist between poorer perceived support and poor outcomes for those with bipolar and anxiety disorders.
- Compared with the construct of perceived social support, loneliness was not central to the results but there is some evidence to say that feeling lonely may also predict poorer outcomes for those with depression.
- I highly recommend that more research is done in measuring loneliness severity and how it impacts on poorer outcomes in people diagnosed with mental health disorders.
Strengths and limitations
The attempt to measure these constructs across different mental health disorders was a formidable task. The authors registered their systematic review on the PROSPERO database, which is becoming good practice in recent years. The authors reported a clear systematic format in conducting their study. Furthermore, they used a standard form for the mixed methods appraisal tool. However, I wondered if there were crucial papers that were missed because online delivery of social therapies (including clinician support and peer support) for individuals with psychosis is fairly well-known (Alvarez-Jimenez M. et al., 2013) but the search terms did not capture these studies.
One result that stood out clearly was the lack of studies focusing on loneliness that were identified by their review. This is similar to what I found in the treatment of loneliness in people with psychosis (Lim et al, 2018). Given the extensive introduction in their review about loneliness and the title of the study, I had incorrectly assumed that loneliness was the main focus on the studies they extracted. The authors were only able to identify two studies that directly measured loneliness (as opposed to perceived social support). But their ability to identify more studies makes sense given that loneliness has not been traditionally seen as an important subjective indicator. Hence, there is a lack of rigorous research studies with a focus of loneliness so far.
I wondered if including the two studies on loneliness made the interpretation of the overall results more difficult to conclude in this systematic review. The authors correctly noted that while loneliness and perceived social support were both subjective constructs, it does not mean they are indeed equivalent. Unpublished results of the studies I have conducted using UCLA-Loneliness Scale and the Multidimensional Scale of Perceived Support have indicated that one does not predict the other over time and they are only moderately correlated (rs range from .50 to .60).
Implications for practice
Clinicians should consider addressing how people perceive their social support during treatment. This is important because those who feel less supported or lonely are more likely to have poorer outcomes and slower recovery. Feeling connected with others and feeling supported is likely to improve the person’s wellbeing and mental health symptom severity.
Loneliness is on the agenda particularly in the UK, where it is being recognised as a public health priority. We need clinicians and first responders to assess and find effective solutions for those who report loneliness. My previous research has shown that in the general population, loneliness is an antecedent to more problematic mental health symptoms such as depression, paranoia, and social anxiety (Lim MH et al, 2016). Hence targeting loneliness within individual treatments, community solutions or public campaigns may prevent the onset of more problematic mental health symptoms.
Conflicts of interest
Dr. Michelle Lim does not have any existing collaborations with the authors of this review, but has presented at a conference symposium with Dr Farhana Mann in the past, and will be appearing with Prof Sonia Johnson and Dr Farhana Mann at the Loneliness Mental Health Question Time in London on 3rd Dec 2018.
Wang J, Mann F, Lloyd-Evans B, Ma R, Johnson S. (2018) Associations between loneliness and perceived social support and outcomes of mental health problems: a systematic review (PDF). BMC Psychiatry, 18(1), 156. https://doi.org/10.1186/s12888-018-1736-5
Alvarez-JimenezM, Bendall S, Lederman R. et al (2013) On the HORYZON: Moderated online social therapy for long-term recovery in first episode psychosis (PDF). Schizophrenia Research, 143(1), 143-149. https://doi.org/10.1016/j.schres.2012.10.009
Andrews G, Henderson S, & Hall W (2001) Prevalence, comorbidity, disability and service utilisation: overview of the Australian National Mental Health Survey (PDF). The British Journal of Psychiatry, 178(2), 145-153. https://doi.org/10.1192/bjp.178.2.145
Lim MH, Gleeson JF, Jackson HJ. et al (2014) Social relationships and quality of life moderate distress associated with delusional ideation (PDF). Social psychiatry and psychiatric epidemiology, 49(1), 97-107. https://doi.org/10.1007/s00127-013-0738-3
Lim MH, Gleeson JF, Alvarez-Jimenez M. et al (2018) Loneliness in psychosis: a systematic review (PDF). Social psychiatry and psychiatric epidemiology, 1-18. https://doi.org/10.1007/s00127-018-1482-5
Lim MH, Rodebaugh TL, Zyphur MJ. et al (2016) Loneliness Over Time: The Crucial Role of Social Anxiety (PDF). Journal of Abnormal Psychology. https://doi.org/10.1037/abn0000162
Peplau L, & Perlman D (1982) Perspectives on loneliness. In L. Peplau & D. Perlman (Eds.), Loneliness: A Sourcebook of Current Theory, Research and Therapy. (pp. 1-20). New York: John Wiley and Sons.
Slade T, Johnston A, Oakley Browne MA. et al (2009) 2007 National Survey of Mental Health and Wellbeing: methods and key findings (PDF). Australian and New Zealand Journal of Psychiatry, 43(7), 594-605. https://doi.org/10.1080/00048670902970882.
Stain HJ, Galletly CA, Clark S. et al (2012) Understanding the social costs of psychosis: The experience of adults affected by psychosis identified within the second Australian national survey of psychosis (PDF). Australian and New Zealand Journal of Psychiatry, 46(9), 879-889. https://doi.org/10.1177/0004867412449060
Windell D, & Norman RM. (2013) A qualitative analysis of influences on recovery following a first episode of psychosis (PDF). International Journal of Social Psychiatry, 59(5), 493-500. https://doi.org/10.1177/0020764012443751
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[…] on mental health outcomes is eloquently discussed in Michelle Lim’s recent Mental Elf blog (Do you have my back? Perceived social support, loneliness, and its impact on mental health outcomes). Interventions to address loneliness among people with mental health problems remain in their […]