Social Connectedness and Overall Health Among Individuals with Serious Mental Illness: A Serial Multiple Mediation Analysis of Psychological Distress and Functioning

Background/Purpose: Individuals with serious mental illness (SMI; e.g., schizophrenia, bipolar disorder, major depression) have higher mortality rates and a life expectancy that is approximately 25 years less than that of the general population. Contributing factors include inadequate access to preventive health care and high incidence of cardiometabolic disorders, typically exacerbated by sedentary lifestyles, poor nutrition, and side effects of psychotropic medications. Integrated primary and behavioral health care (PBHC) programs address excess mortality of persons with SMI and comorbid medical disorders using an interdisciplinary collaborative approach. Conceptually rooted in the social determinants of health (SDoH) model, the current study examined the mediating roles of psychological distress and daily functioning in the relationship between social connectedness and overall health among persons with SMI receiving integrated PBHC services. The study tested how social connectedness, a critical SDoH construct, directly and indirectly increases or decreases overall health through psychological distress and functioning:

[H₁]Social connectedness is directly and indirectly associated with overall health through psychological distress.

[H₂]Social connectedness is directly and indirectly associated with overall health through functioning.

[H₃]Both psychological distress and functioning mediate the relationship between social connectedness and overall health (Serial Multiple Mediation Model).

Method: The current cross-sectional, descriptive study used a sample composed of adults with SMI (N=423) receiving integrated PBHC services in a public mental health agency. The independent variable was social connectedness(Perception of Social Connectedness Scale; 4 items; α=.79). The dependent variable in the mediation models was overall health(1 item). The mediators were psychological distress(K6 scale; 6 items; α=.87) and functioning(Modified Perception of Functioning Subscale; 8 items; α=.75). The control variables were age, gender, race, and living arrangement. PROCESS Macro Version 4.2 was used with a bootstrapping approach to test the three hypothesized mediation models.

Results: In the first mediation model, the direct effect of social connectedness on overall health was significant(B=04, p<.05), and the indirect effect of social connectedness on overall health through the mediation of psychological distress was significant (B=.03, bootstrapped 95% CI[.02, .04]). Similarly, in the second mediation model, the indirect effect of social connectedness on overall health through the mediation of daily functioning was significant (B=.05, bootstrapped 95% CI[.03, .07]); however, the direct effect was not. In the Serial Multiple Mediation Model, psychological distress and functioning significantly mediated the relationship between social connectedness and overall health (B=.02, bootstrapped 95% CI[.01, .03]). Social connectedness was associated with decreased psychological distress and increased daily functioning, which led to increased overall health.

Conclusions/Implications: Results of the Serial Multiple Mediation Model underscore the importance of including social connectedness, a key determinant of health for persons with SMI, along with strategies to simultaneously reduce distress and promote functioning when seeking to improve their overall health. Interventions should specifically aim to expand social networks and increase social connectedness by encouraging peer and other support, as well as mitigate symptoms of psychological distress. Further, interventions for improving health among persons with SMI should seek to enhance their day-to-day functioning using concrete strategies such as person-centered care management