Association between social capital and depression among critically ill patients: evidence from a cross-sectional study in rural Shandong, China

Critical illnesses, such as cancer, refractory diseases, etc., usually refers to diseases that are typically costly, long-lasting, difficult to cure, and significantly affect the productivity and quality of life of patients and their families [1]. To prevent families of critically ill patients from falling into catastrophic health expenditure (CHE) [2], the Chinese government introduced the Critical Illness Insurance in 2012 and defined critical illnesses as one in which annual out-of-pocket medical expense exceeds a certain threshold, which is usually set with reference to local disposable income [3]. Critical illnesses are growing increasingly common globally, for example, cancer rates have increased, with new cases of cancer ranged from 14.9 million to 18.1 million, and their associated death toll ranging from 8.2 to 9.6 million between 2013 and 2018 [4, 5].

There has been increasing recognition that social capital has a positive effect on health outcomes, not only physical health, but also mental health [6, 7]. For instance, Coll-Planas found that social capital had a protective influence on health, furthermore, interventions based on the social capital had achieved wonderful results on the health of the elderly [8]. Ehsan hold the view that individual cognitive social capital is negatively associated with common mental disorders [9]. In Bassett’s study, neighborhood social capital reduced the likelihood of depressive symptoms among urban-dwelling adults [10]. Moreover, previous researchers concluded that social networks, and social participations promoted health and decreased depression [11, 12].

Social capital’s demonstrable effect on people’s mental health has been well documented in previous studies [9, 13]. However, there is also a group of people whose psychological problems and reduced social capital as a result of critical illness deserve our attention. For one thing, patients with critical illnesses suffered from long-term diminished quality of life [14], daily functioning and long periods of stay at home or in hospital [15], which resulted in having narrow social networks cycle and social participation [16]. For the other thing, depression is usually a co-morbidity for critical illnesses, as the pain, disappointment and helplessness caused by cancer may result in low psychological resilience or psychological impairment [17‐19]. Nevertheless, both the government and society typically focus more on the economic burden and physical health of critically ill patients, and less to their declining mental health and social capital.

Previous studies have shown that, cancer patients who have good interpersonal relationships with others, were less depressed than that with poor relationships, which were linked to low-level social support [20, 21]. As an extended concept of social determinants of mental illness [9], social capital measures the quality and quantity of social relationships [22], will provide us with better evidence on how to promote mental health at the societal level. For patients with critical illnesses whose social capital is lower than that of the general population, there are few theoretical and empirical studies on whether social capital is still a protective factor of mental health. Our study attempts to partially fill this gap.

In addition, this study pays special attention to rural patients in China. Compared with urban areas, rural China has scarce medical human and material resources which increased the prevalence of critical illnesses in part to the unavailability of timely treatment, low utilizations of medical services [23], and imperfect community characteristics [24], although it also boasts closer relationships between relatives and neighbors [25]. However, with the process of urbanization, the phenomenon of hollowing out has become increasingly serious in rural regions [26], and the originally close interpersonal relationships has been gradually destroyed. According to the data from National Bureau of Statistics, unbelievably, the urban population of the total population has ranged from 18% in 1978 to 61% in 2019 [27]. Most young people choose to live or work in cities, the remaining older, large “empty-nesters” population, are more vulnerable to both critical illnesses and depression due to age, loneliness and their relatively lower family support [28, 29]. Data from China’s 12th Five-Year Plan for the Development of Aging illustrated that, the empty-nest rate of the elderly in rural China was 38.3%. The proportion of empty-nest elderly households is expected to reach 90% by 2030 [30]. As the population shrinks and ages rapidly, rural interpersonal relationships based on geographical location and blood has been hit hard [31]. Family size shrinking, interpersonal networks decreasing, family pension weakening made the elderly remained in rural areas lonely and depressed [29].

Accordingly, our study investigated the relationship between both structural and cognitive social capital and depression among patients with critical illnesses and explored ways in which they might improve their mental health and quality of life.

Many studies have explored the mental health of the elderly or mental illness unilaterally, but few concentrated on the impact of social capital on mental health among critically ill patients. Our study found that 68.5% of patients with critical illnesses were depressed, a population higher than that of the general population [47, 48]. Our sample was somewhat unusual (patients with critical illnesses) and depression understandably has greater incidence in patients who experience long-term physical impairments and a reduced quality of life [12, 33, 49]. Along similar lines, one earlier study suggested that patients with critical illnesses are prone to heart failure due to decreased body function and greater vulnerability to underlying diseases [50], a finding that may be extrapolated to patients’ mental health.

Here, we consider the relationship between social capital and depression for patients who suffering from critical illnesses. For one thing, about structural social capital, frequent contacts within social networks were negatively correlated with depression. This implied that frequent contacts interacted with patients and provided them with both material and emotional support. In our study, 76.0% patients who lived alone and 92.1% patients who had no frequent contacts were depressed, confirming previous findings that loneliness, social isolation and living alone are all risk factors for depression and a leading cause of mortality [51]. For another, the reasons why social participation was not significantly associated with depression may be there are few opportunities for critically ill patients to participate in formal or informal social activities (such as mahjong, chess, cards, or community sports participation) due to physical impairments [52]. In our sample study, the social participation rate was only 16.0%. Previous findings demonstrated that 14 countries have carried out social participation intervention activities to improve the mental health of critically ill patients, such as social skills training and supported community engagement, even offering patients economic incentives for participation [53].

From the perspective of social support, patients whose homes were far from the nearest medical institutions were more vulnerable to depression because they could not have timely treatment for their illnesses, lowering their recovery rate. We found that by reducing depression among critically ill patients, social capital also lowered medical support requirements. Although great progress has been made in access to health services in rural areas since China’s new medical reforms and its promotion of the ‘15 minutes medical circle’ construction initiative, a gap remained between the capacities of medical services in urban and rural areas [54]. Additionally, psychological interventions are difficult to implement, because there were rarely skilled psychological and guidance counselors in township health centers and village clinics with high medical demands [55], or more generally in communities with high patient density [56]. Besides, China clinical psychology has yet to catch on within primary medical institutions or indeed the rural residents themselves [55]. As things stand, insufficient attention is paid to patients’ mental health. But for many patients, there are more practical issues with care availability. Indeed, our research suggests that only 24.9% patients enjoyed high levels of medical convenience and that 35.9% received daily life-care support from spouses. One reason why spouses supplied medical convenience to critically ill patients was a risk factor is that spouses not only must take care of patients and their parents, but also assume the financial burdens and reduce social activities, which lead to depression and anxiety that can negatively influence critically ill patients [57]. Paradoxically, the support provided by the spouse is the most effective among close relationships at lowering stress in Kang and Han’s study [58]. Medical support, critical illness insurance and measures such as China’s New Cooperative Medical System (NCMS) can relieve the anxiety and depression among patients. Patients with critical illness insurance and NCMS attach more importance to health risk factors and choose healthy lifestyles [59].

When it comes to cognitive social capital, the effect of mental help, as well as financial aid, proved to be statistically non-significant, which was unexpected. With respect to our findings, 80.9% of patients with economic difficulties were depressed. Except for individual cognitive social capital, neighborhood social capital may influence collective mental health, and a deficit of such social capital may have an impact on self-rated health and psychological distress [60]. In contrast to the above, spiritual comfort enhances individual well-being, which, in turn, may reduce the risk of unhealthy behaviors [61]. Finally, interpersonal trust, or individual trust in relatives and friends, reduces social complexity and helps to build strong and sincere social networks [62]. 76.1% of our study’s critically ill patients who had low levels of trust in others generally, and 75.4% of patients who had low trust in doctors were depressed that was inconsistent with other researchers’ findings [16], which may link to the poor capacities of village doctors. Though Chinese medical competences have improved nationally, rural China lags behind. Indeed, only 15% of doctors in township health centers and 2.3% of doctors in village clinics had a bachelor degree or above [63].

Differentiated with previous findings in the general population [64], gender was not a risk factor for depression in our findings. Moreover, 65.6% of patients were aged 60 and over in our study, and the prevalence of critical illnesses among the elderly is continuously increasing owing to population aging which calls for more insight into the factors that contribute to their mental health [65]. China will have a significant elderly population by 2022, and this population will grow at rates exceeding those of Sweden or France [66]. Accordingly, attention must be paid to the mental health of the elderly, especially for those suffering from critical illnesses. Our research also showed that, contrary to traditional thinking [67, 68], education, living status, number of diseases have nothing to do with the patients’ depression. Self-rated health status is a subjective indicator, and often used to describe patients’ health status, which is similar to the CESD scale.

Our research has some limitations. First, our survey is cross-sectional, which precludes us from identifying causal relationships between depression and social capital. Second, there is no specific scale or theoretical framework for social capital, in which biases measurement. Third, our research objects were critically ill patients, so we cannot know whether the social capital of patients with critical illnesses is different from that of the general population.

Encouragingly, social capital including occupations of frequent contacts in social networks, social trust in relatives and friends, distance to the nearest medical institution, and spouse-provided medical conveniences in social support play a positive role in depression. Due to functional disabilities and relatively low social capital, patients with critical illnesses are more likely to have depression than others.

Looking to the future, effective measures should be taken to improve the quality of life and mental health among critically ill patients. Patients can be encouraged to be optimistic about all aspects of their lives via frequent communication. Family members should call more, go home more often, and supply both necessary financial support and spiritual comfort for patients. Alternatively, it is essential to strengthen mental health services and set up specific personnel such as rural doctors or psychologists to provide health education and psychological counseling to patients. Social participation interventions, like social skills training and supported community engagement [53] should be implemented. Additionally, we propose that governments increase funding for rural medical resources to reduce urban-rural disparities and health inequity, strengthen training of grassroots medical staffs, and make primary care medical insurance more accessible. Otherwise, group-based education and social support programs aiming to prevent social isolation by improving community knowledge and networks are meaningful, such as focus-group discussions or city tours [69]. In summary, our communities, families, and individuals each need to provide a greater degree of both medical support and spiritual comfort to critically ill patients.