Background
The influence of social relations on mental health has attracted increased interest in recent years [
1,
2], as studies have reported an elevated risk of poor mental health among individuals with limited social relations [
3,
4]. WHO defines mental health as a state of
“well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.” [
5]. The World Health Organization (WHO) has underlined the need for preventing poor mental health because it is estimated to be one of the major global burdens of disease [
6,
7]. Social relations include both structural (e.g., social networks and social integration) and functional aspects (e.g., social support), which influence mental health through different pathways [
1,
8,
9]. As the definitions of social relations and methods of measuring relations vary greatly [
10], it is difficult to draw firm conclusions about social relations, their effects on mental health, and their universality [
10‐
12]. Berkman et al. considered the impact of social relations on health as a
cascading causal process. The social context affects the network structures (i.e. network size, range, density, reachability), which influence mental health through different psychosocial mechanisms (i.e. social support, social influence, social engagement). Thus, social support is only one of multiple pathways by which the social networks influence mental health. Social support is divided into subtypes that can include emotional and instrumental support. Emotional support refers to the love and caring provided by significant others, while instrumental support relates to help with practical problems. These psychosocial mechanisms, by which social networks may operate, affect other downstream pathways including health behavioural, psychological and physiological pathways. These three paths, most proximate to the health outcome, may as well be involved simultaneously [
1]. This implies that the mental health of individuals depends on how often the individual are in contact with family and friends and the accessibility of social relations, which affects the emotional and instrumental support. This can be understood as a cascade of processes by which social relations influence mental health [
9].
The influence of social relations differs by gender [
2,
10,
13]. Men and women have different needs for emotional and instrumental support [
14]; social support was more beneficial to women than men [
14]. A recent systematic review indicated that sources of relations varied over a lifetime and that different age groups had different social relation needs in terms of how much support the individuals needed and from whom the support should be provided [
15]. Those with a low socioeconomic position were at a higher risk of poor mental health [
16,
17]. The effects on mental health depend on the type of network, such as if the support was provided by family or friends, who can be both a source of support and strain [
4,
13].
Prior studies have primarily focused on the influence of either structural or functional aspects of social relations on mental health [
9,
11]. Including both structural and functional aspects in studies showed that diverse, quality networks were related to better mental health and may help to protect against poor mental health [
4,
8,
10]. The effects on mental health were further related to the type of network; for example, spouses and children had a greater influence on mental health than relatives and friends [
8,
10]
. These findings indicated that both aspects of social relations influenced mental health. As also seen in other studies, the results were limited by small subgroups, such as older adults, decreasing their generalizability [
4,
8,
11‐
14,
17‐
20].
From a broader population perspective, there is a need to further investigate the association between social relations and poor mental health with consideration for how age, sex and socioeconomic status influence the association between social relations and poor mental health. There seems to be a lack of knowledge of the complexity of social relations and the impact on the individual’s health. To improve understanding of the complexity of social relations and the association between social relations and poor mental health, we examined the association between both structural and functional aspects of social relations and poor mental health.
Discussion
Overall, low levels of social relations were associated with poor mental health in our study. Our findings suggested that the frequency of contact with friends and the reachability of network had a significant influence on poor mental health. Likewise, all functional aspects of social relations, such as emotional and instrumental support, significantly influenced poor mental health.
Interpretation
Our findings indicated that the odds for poor mental health increased as the individual’s frequency of contact with family, friends, colleagues and neighbours decreased. This corresponds with previous studies that found that mental health was influenced by the frequency of contact with different kinds of networks [
8,
38]. Those with self-reported good mental health had more frequent contact than those with poor mental health. Based on our results, poor mental health may depend more on the frequency of contact with friends than with family. This can be a consequence of different networks providing different types of support. Furthermore, friendship is often characterized by interchangeability, where friends, who can contribute to strains, can be excluded from the individuals’ network [
10]. The findings in this study indicated that those who were not in contact with their family, friends and acquaintances as often as they liked had twice the risk of poor mental health compared to those who were in contact as often as they liked. Therefore, it is possible that the association between low levels of contact and mental health depend on whether the frequency of contact corresponds to the individual’s need for contact.
In agreement with other studies, the present study found a higher prevalence of women with self-reported poor mental health than men [
17], but our findings did not support the influence of gender. A possible explanation is that while social relations are essential for both genders, different aspects of social relations can have different meanings across genders, which was also found by Almquist et al. and Fiori et al. [
13,
14]. One fourth of participants with poor mental health in our study lacked emotional support. In particular, young individuals had a higher risk for poor mental health if they did not receive emotional support. From a life course perspective, it has been suggested that the individual is more dependent on social relations in some stages of life than in others [
2,
9]. We did not find interactions between age and other measures for social relations, which suggest that, regardless of age, social relations have a significant influence on poor mental health.
A lack of instrumental and emotional support resulted in an approximately threefold increased risk of poor mental health. This finding of a strong association between instrumental and emotional support and poor mental health is consistent with other studies [
4,
9,
10,
39,
40]. This may be because the support enables the individual to overcome challenges and instrumental and emotional support strengthens coping strategies [
9]. These findings underline the need for a reachable social network where individuals have the opportunity for contact others as often as they need. Furthermore, the relations should provide both instrumental and emotional support. The findings underline the importance of both structural and functional aspects of social relations on mental health, as emphasized by Berkman et al. [
9].
Individuals with poor mental health have an increased risk for mental disorders, such as depression [
5,
41]. Therefore, there is a close relation between poor mental health and depression [
42]. We had a low tolerance for classifying individuals as depressed, and while depression is the major reason for using antidepressant these drugs are also used for anxiety. Consequently, 10% of the study population was classified as depressed, while the prevalence in Europe was 6,9% [
43] and it was 4,1% in the Danish population [
44]. Therefore, the estimates for poor mental health where adjusted for depression to ensure that estimates correspond to poor mental health, although adjustment may have caused an underestimation of the association between social relations and poor mental health.
Limitations and strengths
A strength of this study was the large sample size and the use of nationwide registers, providing high quality data and reliable information on a wide range of covariates, which enabled reliable, comprehensive confounder adjustment [
45]. In addition, we could use self-reported data on social relations and mental health. The individual’s perceptions of social relations and mental health are essential to understanding the association because both aspects are characterized by the individual’s experience. This is underlined by the WHO definition of mental health as
“a state of well-being in which every individual realize his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” [
5].
The cross-sectional design of the study excluded conclusions about causality, i.e. poor mental health causing less contact with family, friends and acquaintances. The use of the survey logistic regression reduced potential selection bias from unequal selection in each municipality [
46‐
48]. Non-response can contribute to the risk of selection bias, where people with poor mental health are assumed to participate less in a survey, which can cause an underestimation of the association [
17]. Respondents were more likely women, middle-aged, native, and married and they had a higher education and good mental health [
21,
49‐
51].
We were inspired by Berkman et al.’s conceptual model that incorporates both structural and functional aspects of social relations. Our use of a narrow selection of measures for social relations may be a limitation because the use of a few measures is less likely to capture the full complexity of an individual’s social relations. The specific social relations-related questions asked in the health study have been used for several years in major Danish health surveys [
21,
52] and to answer similar questions in international studies [
10]. However, there is a need for further development and validation of a scale to measure structural and functional aspects of social relations.
The SF-12 is a reliable, validated measurement based on the SF-36 Health Survey [
30,
33]. Other studies have validated the SF-12 in both general and specific populations. In a Danish setting, the SF-12 was validated in 2012, and it was documented as a reliable, valid instrument for measuring health-related quality of life [
30]. The dichotomization of mental health followed the recommendations from the SF 12 user’s manual, which strengthened the generalizability of our results. The sensitivity analysis based on the US standard cut-off (40.0) did not alter the results; therefore, it is likely that our results can be compared and interpreted across populations [
34]. However, the dichotomization of the mental health score reduced the statistical power [
53] and the nuances of mental health.
Implications for research and practise
This study adds to the existing knowledge about the association between social relations and mental health. Mental health depends on the frequency and type of interactions with others and to what degree a person’s network of friends and family is reachable; a lack of all aspects of social relations is a risk factor for poor mental health. In the prevention of poor mental health, it is important to consider a broader perspective on social relations to capture their complexity. There is a need for further research on how both aspects can be included in interventions that target mental health.
Conclusion
The present study demonstrated that both structural and functional aspects of social relations were associated with poor mental health among citizens in Northern Jutland, Denmark. Poor mental health was more prevalent among the young and adults. Our study indicated that the odds for poor mental health increased as the individual’s frequency of contact with family, friends, colleagues and neighbours diminished. The young individuals who lacked emotional support were at the highest risk for poor mental health. The study contributes to the understanding of the complexity of social relations and their effect on the mental health of individuals and claim attention to avoiding simplifying the mechanisms behind social relations. It underlines the importance of an understanding of the complexity of social relations and the need for interventions aimed at preventing poor mental health as well as further research to consider both structural and functional aspects of social relations.
Acknowledgements
The authors would like to thank the Public Health and Epidemiology Group at the Department of Health Science and Technology, Aalborg University, Aalborg, Denmark and the Department of Clinical Epidemiology, Aalborg University Hospital for their help and support. The North Denmark Region Health Survey 2013 was founded by The North Denmark Region.