Provision of social support and mental health in U.S. military veterans:Results from the National Health and Resilience in Veterans Study

doi:10.21203/rs.3.rs-1374800/v1

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Provision of social support and mental health in U.S. military veterans:Results from the National Health and Resilience in Veterans Study

https://doi.org/10.21203/rs.3.rs-1374800/v1

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While social support has been linked to better health, most research has focused on the receipt of social support. In this study, we evaluated associations between provided support and mental health in a nationally representative cohort of 4,069 US veterans. The majority (60-72%) of veterans reported providing support consistently. Veterans who scored higher on aspects of personality (i.e., agreeableness, conscientiousness, and emotional stability) and received support were more likely to provide support. Further, each standard deviation increase in provided support was independently associated with 15-40% reduced odds of internalizing psychiatric disorders and suicidality, and veterans who scored higher on both provided and received support had 3.5- to 14-fold lower odds of these outcomes relative to those with high received support but low provided support. Results suggest that separate from the receipt of social support, the provision of support may be a potential pathway to mitigate adverse mental health conditions.

“If we focus too much on ourselves, we’ll not be happy, whereas to concern ourselves with the well-being of others is the gateway to great joy.” - Dalai Lama.¹

Since the seminal article by House and colleagues² published more than three decades ago, social support has been thought to improve health and lengthen lives.³ Social support is defined as the perception or experience of being loved and cared for by others.⁴ Previous research identified the impact of lack of social support as a strong risk factor for all-cause mortality rates from various morbidities,^5,6 including cardiovascular disease,⁷ cancer and infectious diseases.⁶ Further, research have shown positive associations between social support and measures of well-being, including cognitive functioning.⁸

In the mental health literature, a recent systematic review of 34 studies found substantial evidence that poorer social support is prospectively linked to worse symptom severity, recovery outcomes and social functioning in individuals with depression.⁹ Further, in studies of older adults with depression, lower subjective social support at baseline predicted poorer recovery one year later (odds ratio [OR]=1.21, 95% confidence interval [CI]=1.09-1.35),¹⁰ as well as longer time to remission (hazard ratio [HR]=0.47, 95% CI=0.31-0.71).¹¹ Although less robust, preliminary evidence suggests that poor social support is associated with negative outcomes, such as greater severity of depressive symptoms and functional impairment, and longer time to recovery in individuals with other mental disorders, such as schizophrenia, bipolar disorder and anxiety disorders.⁹

To date, the majority of research on social support and health outcomes has focused on receipt of social support, and its impact on mental and physical health outcomes.^6,12,13 In contrast, substantially less attention has been given in examining the association between the provision of social support to others and health outcomes. In one of the first studies to examine the relation between received and provided social support and mortality, the association between receiving social support and mortality was found to be moderated by the provision of social support.¹⁴ Specifically, while receiving social support reduced risk of mortality, this effect was nullified after adjusting for provision of social support.¹⁴ More recent work further suggests that provision of social support may also be associated with longevity and positive health outcomes.^13–15 For example, a longitudinal study of 1,492 men and 1,177 women older adults in Taiwan revealed that individuals who provided social support had an 11 percent lower mortality rate (hazard ratio=0.89; 95% confidence interval [CI] 0.83-0.96), even after adjusting for several sociodemographic and health status measures.¹⁶

Extant research on the association between provision of social support and health outcomes is limited in several ways. First, the majority of published studies have focused on the impact of providing social support and physical health outcomes, such as mortality rate. Although some studies have examined the link between provided social support and positive mental health outcomes such as happiness¹⁷ and subjective well-being,¹⁸ no known study has examined the association between provision of social support and adverse mental health outcomes such as major depressive disorder (MDD), posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD) and suicidal ideation (SI). Second, existing studies have not taken into consideration the potential interaction effects between provision of social support and other aspects of support, such as structural support (i.e., number of supportive friends or family members) and received social support (i.e., perceived support from others) in relation to mental health outcomes. Third, previous literature has focused on the general population, and less is known about the association between providing social support and mental health outcomes in higher-risk populations, such as US military veterans. Characterizing the role of provided and other aspects of support in relation to prevalent psychiatric outcomes may help inform targeted clinical and policy interventions to improve mental health outcomes in such populations.

U.S. military veterans are an ideal population in which to examine this topic given national concern about their well-being, ongoing efforts to help veterans with re-integration into civilian life, and the abundance of research on peer support and received social support among veterans, but relative paucity of research on provided support. For instance, we previously found that among veterans returning from deployment to Iraq and Afghanistan, greater perceptions of received social support mediated the relation between PTSD and social functioning.¹⁹

Using data from the National Health and Resilience in Veterans Study (NHRVS), which surveyed a nationally representative sample of more than 4,000 US veterans, we evaluated: 1) the prevalence of different types of provided support; 2) sociodemographic, military, health and psychosocial factors associated with greater provision of social support; and 3) independent and interactive associations between provision of social support and other aspects of support in relation to current internalizing (e.g., PTSD) and externalizing (e.g., alcohol use disorder) mental disorders, as well as suicidality.

2.1 Participants

Data were analyzed from the NHRVS, a nationally representative survey of U.S. military veterans. A total of 4,069 veterans completed a 60-minutes, online survey (median completion date: 11/21/2019). Details of the study, including the recruitment protocol, has been described previously.²⁰ Briefly, the NHRVS sample was drawn from KnowledgePanel®, a survey research panel of more than 50,000 US households maintained by Ipsos, a survey research firm. To ensure generalizability of the results to the US veteran population, poststratification weights were computed based on the demographic distribution of veterans in the Veterans Supplement of the US Census Current Population Survey. The study protocol was approved by the Human Subjects Subcommittee of the VA Connecticut Healthcare System, and all participants provided informed consent.

2.2 Measures

Sociodemographic characteristics. Age, gender (male vs. female), race (White, non-Hispanic vs. other), education (college graduate or higher vs. some college or lower), marital status (married/living with partner vs. unmarried/unpartnered), annual household income ($60,000 or more vs. less than $60,000), employment status (retired vs. working), combat veteran status, military enrollment status (enlisted/commissioned vs. drafted), and years in military service were assessed.

Provision of social support. Level of provided social support was measured using a modified 5-item version of the Medical Outcomes Study Social Support Scale.^21,22 Participants were asked “How often do you provide each of the following kinds of support to others who need it?” on a five-point scale from (1) none of the time to (5) all the time. Examples of items were: “I am someone that others could confide in or talk to about their problems” and “I am someone that others could get together with for relaxation”. Scores range from 5 to 25, with higher scores indicative of greater social support (Cronbach’s α = 0.88).

Receipt of social support. Level of received social support was measured using a 5-item version of the Medical Outcomes Study Social Support Scale.^21,22 Participants were asked “How often each of the following kinds of support are available to you if you need it?” on a five-point scale from (1) none of the time to (5) all the time. Examples of items were: “Someone to confide in or talk about your problems” and “Someone to get together with for relaxation”. Scores range from 5 to 25, with higher scores indicative of greater social support (Cronbach’s α = 0.89).

Positive effect of military on life. Rating on the item: “How has being in the military affected your life? Score range: 1-7 (1=Strong negative effect; 7=Strong positive effect).

Number of medical conditions. Sum of number of medical conditions endorsed in response to question: “Has a doctor or healthcare professional ever told you that you have any of the following medical conditions?” (e.g., arthritis, cancer, diabetes, heart disease, asthma, kidney disease). Range: 0-24 conditions.

Adverse childhood experiences. Score on Adverse Childhood Experiences Questionnaire.²³

Potentially traumatic events. Count of direct/indirect potentially traumatic events on the Life Events Checklist for DSM-5.²⁴

Current psychiatric symptoms MDD symptoms were assessed using the two depressive symptoms of the PHQ-4 (Cronbach’s α = 0.87); a score ≥ 3 was indicative of a positive screen for MDD.²⁵ PTSD symptoms were assessed using the PTSD Checklist for DSM-5 (Cronbach’s α = 0.96); a score ≥ 33 was indicative of a positive screen for PTSD.²⁶ GAD symptoms were assessed using the two generalized anxiety items of the PHQ-4 (Cronbach’s α = 0.86); a score ≥ 3 was indicative of a positive screen for GAD.²⁵

Current AUD/DUD diagnoses. AUD was assessed using the Alcohol Use Disorders Identification Test (AUDIT), a validated measure used to screen for active AUD (Cronbach’s α = 0.85); a score ≥ 8 was indicative of a positive screen for AUD.²⁷ DUD was assessed using the Screen for Drug Use question: “How many days in the past year have you used non-prescription drugs?”; a response of ≥ 7 days on this question is indicative of a positive screen for DUD; if the response to this question is 6 or fewer days, a response of ≥ 2 days to the question “How many days in the past 12 months have you used drugs more than you meant to?” is indicative of a positive screen for DUD.

Suicidal ideation. SI was assessed using two items adapted from the PHQ-9 Item 9,²⁸ which asked participants to report suicidal thoughts during the prior two weeks. A positive screen was indicated by a response of “several days,” “more than half the days,” or “nearly every day” to at least one of the following questions: “How often have you been bothered by thoughts that you might be better off dead?” and “How often have you been bothered by thoughts of hurting yourself in some way?”

Future suicidal intent. Endorsement of “Likely,” “Rather Likely,” or “Very Likely” on question 4 of the Suicide Behaviors Questionnaire-Revised (SBQ-R): “How likely is it that you will attempt suicide someday?”²⁹

Lifetime psychiatric diagnoses. Lifetime diagnoses of MDD, GAD, PTSD, AUD, and/or drug use disorder (DUD) were assessed using the Mini International Neuropsychiatric Interview.³⁰

Personality. The Ten-Item Personality Inventory (TIPI) was used to measure the “Big Five” personality traits of emotional stability (anxious vs. confident and calm), extraversion (outgoing vs. reserved), openness to experience (imaginative and inventive vs. cautious/routine-like), agreeableness (friendly and cooperative vs. detached), and conscientiousness (efficient and organized vs. careless). Respondents rate the ten items on a seven-point Likert scale (1=disagree strongly to 7=agree strongly). Items are paired into five sets of two items. The subscale scores were utilized in the analyses in this study.

Structural social support. Structural social support was assessed with the question: “About how many close friends and relatives do you have – people you feel at ease with and can talk to about what is on your mind?” This was scored as a count, ranging from 0 to 90.

Days visit family/friends per week. Frequency of social engagement was associated using the following questions: “How many days per week do you typically engage in the following activities?” Visiting family; Visiting friends (response options: 0-7).

2.3 Data analysis plan

Data analyses proceeded in five steps. First, descriptive statistics were computed to summarize sample characteristics and prevalence of each aspect of provided support (i.e., None/A Little of the Time; Some of the Time; Most/All of the Time). Second, zero-order correlations were computed between provided support scores, and sociodemographic, military, and health and psychosocial characteristics. Third, a multiple regression analysis was conducted to identify factors that were independently associated with provided support scores; variables that were significantly associated with provided support scores at the p<0.05 level in bivariate analyses were included in this analysis. Fourth, we conducted a series of multivariable binary logistic regression analyses to examine the relation between provided, structural, and received support, and psychiatric and suicidality variables; all possible interaction terms of provided, structural, and received support were including in these models. Fifth, post-hoc analyses were conducted to identify specific aspects of provided support associated with these variables.

The average age of the sample was 62.2 years (standard deviation [SD]=15.7: range 22-99); the majority of whom were male (90.2%) and White, non-Hispanic (78.1%), and 35.0% were combat veterans.

Figure 1 shows the prevalence of different aspects of provided support. The majority of veterans endorsed providing each type of support most or all of the time, the most prevalent of which were providing loving (71.5%) and confiding (70.7%) support, and support for personal problems (64.8%).

Table 1 shows sample characteristics and results of bivariate and multivariable analyses of correlates of provided support. Multivariable analysis revealed that veterans who were married/partnered, perceived a positive effect of the military on their lives, experienced more direct and indirect potentially traumatic events, and who scored higher on measures of the ‘Big 5’ personality indicators, structural support, and received support, and reported greater frequency of visiting family were positively associated with provided support. Male gender and greater number of medical conditions were negatively associated with this measure.

Table 1

Sample characteristics and correlates of provision of social support in U.S. veterans
	Weighted mean (SD) or n (weighted %)	Bivariate correlation	Multivariable analysis (R²=0.48)
		r	β
Sociodemographic characteristics
Age	62.2 (15.7)	0.02	--
Male gender	3,564 (90.2%)	-0.04*	-0.05***
White, non-Hispanic race/ethnicity	3,318 (78.1%)	0.02	--
College graduate or higher education	1,827 (32.7%)	0.06***	-0.01
Married or partnered	2,885 (72.4%)	0.14***	0.03*
Retired	2,225 (44.3%)	-0.01	--
Household income $60K or higher	2,357 (58.5%)	0.14***	0.02
Military characteristics
Enlisted/Commissioned vs. Drafted	3,583 (89.1%)	-0.01	--
Combat veteran	1,353 (35.0%)	0.01	--
10+ years in military	1,476 (36.4%)	0.03	--
Positive effect of military on life	2.0 (1.4)	0.24***	0.08***
Health characteristics
Number of medical conditions	2.9 (2.2)	-0.08***	-0.03**
Adverse childhood experiences	1.5 (2.0)	-0.12***	0.01
Direct PTEs	3.2 (2.5)	0.01	0.05**
Indirect PTEs	5.7 (7.1)	0.04**	0.03**
Lifetime MDD and/or PTSD	833 (22.4%)	-0.16***	0.02
Lifetime AUD and/or DUD	1,673 (42.8%)	-0.08***	0.02
Personality
Extraversion	3.8 (1.5)	0.30***	0.07***
Agreeableness	5.0 (1.2)	0.32***	0.12***
Conscientiousness	5.7 (1.2)	0.36***	0.12***
Emotional stability	5.2 (1.4)	0.36***	0.03*
Openness to experiences	4.8 (1.2)	0.29***	0.10***
Social variables
Structural social support	8.1 (10.9)	0.24***	0.03*
Days visit family per week	1.7 (1.9)	0.15***	0.03*
Days visit friends per week	1.7 (1.6)	0.19***	0.00
Received social support	19.0 (4.3)	0.61***	0.49***
Note. PTEs=potentially traumatic events; MDD=major depressive disorder; PTSD=posttraumatic stress disorder; AUD=alcohol use disorder; DUD=drug use disorder.
Significant association: p<0.05, p<0.01, **p<0.001.

Planned post-hoc analyses of individual aspects of provided support revealed that higher scores on being a confidant to others (odds ratio [OR]=0.79, 95% confidence interval [CI]=0.70-0.89) was associated with lower odds of MDD; being someone others can rely on for relaxing activities with lower odds of GAD (OR=0.84, 95%CI=0.71-0.99); being someone who can help others with daily chores with lower odds of suicidal intent (OR=0.55, 95%CI=0.42-0.73); being someone others can turn to for help with personal problems with lower odds of GAD (OR=0.79, 95%CI=0.67-0.92); and being someone others can love with lower odds of PTSD (OR=0.80, 95%CI=0.69-0.92) and SI (OR=0.82, 95%CI=0.73-0.92).

Table 2 shows results of multivariable analyses of the relation between provided, structural, and received support, and odds of mental health and suicidality variables. Greater provided support was negatively associated with all assessed variables except alcohol use disorder (AUD) and drug use disorder (DUD); structural support with MDD and SI; and received support with all assessed disorders except AUD, DUD, and suicidal intent. Significant interactions of provided and received support were also observed for MDD, GAD, and SI; and of provided and structural support for DUD.

Table 2

Associations between provided, structural, and received social support, and psychiatric variables
	Major Depressive Disorder	Generalized Anxiety Disorder	Posttraumatic Stress Disorder	Suicidal Ideation	Alcohol Use Disorder	Drug Use Disorder	Suicidal Intent
	OR (95%CI)	OR (95%CI)	OR (95%CI)	OR (95%CI)	OR (95%CI)	OR (95%CI)	OR (95%CI)
Provided support	0.78 (0.68-0.89)***	0.68 (0.59-0.78)***	0.85 (0.73-0.99)*	0.85 (0.75-0.97)*	0.89 (0.78-1.00)	1.04 (0.91-1.19)	0.60 (0.45-0.79)***
Structural support	0.50 (0.34-0.74)***	0.99 (0.81-1.21)	0.91 (0.70-1.18)	0.63 (0.48-0.83)**	0.93 (0.80-1.08)	0.90 (0.77-1.06)	0.38 (0.12-1.16)
Received support	0.60 (0.52-0.70)***	0.78 (0.67-0.90)***	0.69 (0.58-0.82)***	0.78 (0.68-0.90)***	0.91 (0.79-1.04)	0.97 (0.85-1.12)	0.96 (0.69-1.34)
Provided support x Received support	0.80 (0.71-0.91)***	0.80 (0.72-0.90)***	NS	0.85 (0.76-0.94)**	NS	NS	NS
Provided support x Structural support	NS	NS	NS	NS	NS	0.67 (0.50-0.90)**	NS
Note. OR=odd ratios; 95%CI=95% confidence interval; NS=not significant.
Odds ratios are adjusted for age, gender, race/ethnicity, education, marital/partnered status, occupational status, income, enlistment status, combat veteran status, years of military service, number of medical conditions, ACEs, direct and indirect trauma exposures, and frequency of social engagement with friends and family. Analyses of suicidal ideation and suicidal intent are additionally adjusted for lifetime major depressive, posttraumatic stress, alcohol and drug use disorder.
Only significant interactions (p<0.05) are shown.

For the interaction of received and provided support in predicting MDD, among veterans who had a 1 SD or greater than the mean score for received support, those who also had a 1 SD greater than the mean score for provided support had a 14-fold lower probability of screening positive for MDD than those who had a 1 SD lower than mean score for provided support (0.9% vs. 13.0%; see Figure 2).

For the interaction of received and provided support in predicting GAD, among veterans who had a 1 SD or greater than the mean score for received support, those who also had a 1 SD greater than the mean score for provided support had a 12-fold lower probability of screening positive for GAD than those who had a 1 SD lower than mean score for provided support (1.4% vs. 17.1%; see Figure 2).

For the interaction of received and provided support in predicting SI, among veterans who had a 1 SD or greater than the mean score for received support, those who also had a 1 SD greater than the mean score for provided support had a 3.5-fold lower probability of screening positive for SI than those who had a 1 SD lower than mean score for provided support (3.8% vs. 13.4%; see Figure 2).

For the interaction of structural and provided support in predicting DUD, among veterans who had a 1 SD or greater than the mean score for structural support, those who also had a 1 SD greater than the mean score for provided support had a nearly 2-fold lower probability of screening positive for DUD than those who had a 1 SD lower than mean score for provided support (8.1% vs. 15.6%).

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.

Conflicts of Interest:

None of the authors have any competing interests.

Funding:

The National Health and Resilience in Veterans Study is supported by the U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder.

Role of the funder/sponsor:

The funding agency had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript, and decision to submit the manuscript for publication.

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No competing interests reported.

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Provision of social support and mental health in U.S. military veterans:Results from the National Health and Resilience in Veterans Study

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1. Introduction

2. Methods And Data Availability

2.1 Participants

2.2 Measures

2.3 Data analysis plan

3. Results

4. Discussion

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