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Social support mediates social frailty with anxiety and depression

BMC Pulmonary Medicine volume 24, Article number: 390 (2024) Cite this article

Abstract

Background

Anxiety and depression are prevalent comorbidities in patients with chronic obstructive pulmonary disease (COPD). However, existing research has yielded conflicting findings regarding the effects of social frailty on anxiety and depression. The primary aim of this study is to validate the relationship between social frailty and social support with anxiety and depression in patients with acute exacerbations of COPD (AECOPD) and to investigate whether social support could explain the variations in prior study outcomes for patients with AECOPD.

Methods

Of the 315 patients hospitalized with AECOPD at the respiratory intensive care unit of a large tertiary care institution in Sichuan Province of China, between August 2022 and June 2023 who were surveyed, 306 were included in the analysis after excluding missing data. We conducted a logistic regression analysis to examine the associations of social frailty and social support with anxiety and depression and performed mediation analyses to examine whether social support mediates the relationship of social frailty with anxiety and depression.

Results

The logistic regression analysis revealed that social frailty did not associate anxiety or depression in patients with AECOPD. The mediation analysis supported this idea and indicated that while social frailty does not directly influence anxiety or depression, it can through social support.

Conclusions

The findings suggest that while social frailty may not directly impact anxiety or depression in patients with AECOPD, social support plays a crucial mediating role. Enhancing social support can indirectly alleviate anxiety and depression among these patients. Enhancing social support networks should thus be prioritized by healthcare providers and family members to improve mental health outcomes in this patient population.

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Background

Anxiety and depression are common comorbidities in patients with chronic obstructive pulmonary disease (COPD) [1] and may co-occur together [2]. These comorbidities can reduce patients’ adherence to treatment, extend the length of hospitalization [3, 4], and elevate the risk of acute exacerbations (AECOPD) [5, 6]. Several factors, including age, the severity of COPD [7], sex [8], economic status [9], exercise [10], modified Medical Research Council (mMRC) dyspnea scores [11], and COPD Assessment Test (CAT) score [12], have been shown to influence anxiety and depression in patients with COPD.

Beyond these individual factors, social frailty and social support have gained attention for their significant impact on health outcomes. Social frailty refers to the lack of social relationships and the inability to actively participate in society. Previous studies have indicated that social frailty is associated with anxiety [13] and depression [14]. Mediation analysis has suggested that social frailty may affect anxiety both indirectly and directly [15]. However, the relationship between social frailty and psychological distress (anxiety and depression) remains inconclusive [16]. Some studies have not found a significant direct association between social frailty and depression [15], while others have reported only indirect effects between frailty and anxiety [17]. Consequently, the relationship between social frailty and anxiety or depression remains controversial and poorly evidenced. Additionally, the prevalence of anxiety and depression may be higher in patients with AECOPD, and there is a lack of relevant research in these populations.

Social support, defined as the extent of support people receive from their surroundings, is distinct from social frailty in that it involves active, two-way interactions with society [18]. The absence of social support can lead to depression [19,20,21]. Previous studies have proposed a mediation model, where frailty affects social isolation—which in turn affects health outcomes [22]—and have indicated that social support mediates the relationship between social frailty and depression [23]. However, the role of social support in the relationship of social frailty with anxiety and depression in patients with AECOPD remains unclear.

Therefore, this study aimed to explore two research questions: (1) Are social frailty and social support associated with anxiety and depression among patients hospitalized for AECOPD in the respiratory intensive care unit of a hospital in Sichuan Province, China? (2) Does social support mediate the association between social frailty and anxiety and depression in patients with AECOPD?

Methods

Study design and participants

This cross-sectional study utilized data from patients hospitalized with AECOPD at the respiratory intensive care unit of a large tertiary care institution in Sichuan Province, between August 2022 and June 2023. A total of 315 patients who were previously diagnosed with COPD according to the GOLD guidelines [24], were diagnosed with AECOPD by a specialist respiratory team on admission, hospitalized in a ward for more than 24 h, not diagnosed with pulmonary fibrosis, not diagnosed heart failure class III or higher according to New York Heart Association, and were able to complete the survey questions were initially included. After applying a listwise deletion strategy to handle missing data, 306 patients were ultimately included in the analysis. Missing data were identified in variables including residence (1 patient), smoking status (1 patient), sleep quality (3 patients), anxiety (2 patients), mMRC score (1 patient), and Charlson Comorbidity Index (CCI; 1 patient).

Measures

Social Frailty

Social frailty was assessed using the HALFT scale [14], comprising five items: the inability to help others, limited social participation, loneliness, financial difficulties, and not having anyone to talk to. Specifically, patients were considered to have an inability to help others if they answered “No” to the question, “Have you been able to help others in the last 12 months?” They were considered to have limited social participation if they answered “No” to the question, “Have you engaged in any social or leisure activities in the past 12 months?” Loneliness was indicated if they answered “Yes” to the question, “Did you feel lonely in the last week?” They were considered to have financial difficulties if they answered “No” to the question, “Has your income been sufficient (more than 1000 CNY/month) to live on in the last 12 months?” Finally, they were considered to not have anyone to talk to if they answered “No” to the question, “Do you have someone you can talk to every day?” Each of these criteria, if met, was scored as 1 point, and 0 points otherwise. The HALFT scale scores range from 0 to 5 points, with 0 points indicating no social frailty, 1–2 points indicating pre-social frailty, and 3–5 points indicating social frailty.

Anxiety and depression

The Hospital Anxiety and Depression Scale (HADS) [25] is a 14-item scale, with 7 items each assessing anxiety (HADS-A) and depression (HADS-D).

The HADS-A comprises the following items: (1) I feel tense or wound up; (2) I get a sort of frightened feeling as if something awful is about to happen; (3) Worrying thoughts go through my mind; (4) I can sit at ease and feel relaxed; (5) I get a sort of frightened feeling like butterflies in the stomach; (6) I feel restless as I have to be on the move; and (7) I get sudden feelings of panic.

The HADS-D comprises the following items: (1) I still enjoy the things I used to enjoy; (2) I can laugh and see the funny side of things; (3) I feel cheerful; (4) I feel as if I am slowed down; (5) I have lost interest in my appearance; (6) I look forward with enjoyment to things; and (7) I can enjoy a good book or radio or TV program.

Each item is rated on a 4-point scale, with scores 3 and 0 representing the most negative response and 0 representing the most positive response. The HADS-A and HADS-D scores range from 0 to 21, with scores greater than 7 considered indicative of anxiety and depression.

Social support

The Multidimensional Scale of Perceived Social Support (MSPSS) [26] was used to assess the level of social support of patients. It consists of 12 items as follows: (1) There is a special person who is around when I am in need; (2) There is a special person with whom I can share joys and sorrows; (3) My family really tries to help me; (4) I get the emotional help and support I need from my family; (5) I have a special person who is a real source of comfort to me; (6) My friends really try to help me; (7) I can count on my friends when things go wrong; (8) I can talk about my problems with my family; (9) I have friends with whom I can share my joys and sorrows; (10) There is a special person in my life who cares about my feelings; (11) My family is willing to help me make decisions; (12) I can talk about my problems with my friends.

Each item is rated on a 7-point scale, ranging from 1 (“very strongly disagree”) to 7 (“very strongly agree”). The maximum possible score is 84 points, with higher scores indicating higher levels of social support.

Covariables

The following covariables were considered in the study: age, sex, body mass index, education level, marital status, living status, residence, smoking status, alcohol consumption, exercise frequency, sleep quality, self-rated health (SRH), activities of daily living (ADL), course of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage, CAT score, mMRC dyspnea scores, and CCI.

All covariables were assessed using self-reported questionnaires. Exercise frequency was categorized as sedentary (no exercise), regular exercise (more than 3 times a week), and moderate activity (other frequencies). Sleep quality was evaluated using the Pittsburgh Sleep Quality Index [27]. The total score ranged from 0 to 21, with higher scores indicating poorer sleep quality (0–5: very good; 6–10: good; 11–15: normal; 16–21: poor). Participants’ SRH was assessed on a 5-point scale (very good, good, normal, relatively poor, poor). ADL was measured using the Barthel Index [28], ranging from 0 to 100, with higher scores indicating greater independence. The severity of COPD was classified according to GOLD guidelines [29] and categorized into grades I–IV based on increasing severity. The scores on the 8-item CAT [30] ranged from 0 to 40, categorizing impacts as mild (0–10), moderate (11–20), severe (21–30), and very severe (31–40). Dyspnea severity was assessed using the mMRC Dyspnea Scale [31], categorizing patients from grade 0 to IV with increasing severity. CCI [32] scores were calculated based on 19 diseases of varying severity levels, with higher scores indicating more severe comorbidities.

Statistical analysis

First, sociodemographic characteristics were detailed, and the significance of each independent variable and covariable with anxiety and depression was assessed using the chi-square and Mann–Whitney U tests. Second, logistic regression was employed to examine the relationships between social frailty and social support with anxiety and depression, respectively. Spearman correlation analysis was conducted to explore the intercorrelations among anxiety, depression, social frailty, and social support. Finally, a mediation model was applied to investigate the mediating role of social support in the associations of social frailty with anxiety and depression. All analyses were performed using IBM SPSS version 29.0.1.0, with a significance level (α) set at 0.05.

Results

Table 1 presents the demographic characteristics of the 306 patients with AECOPD. Of these, the majority were men (73.9%), graduated from primary school (69.3%), were married (87.3%), were living with others (89.9%), were ex-smokers (63.7%), did not drink daily (98.4%), engaged in exercises (59.8%), did not have anxiety (85.9%), did not have depression (86.3%), and had pre-social frailty (70.6%).

Table 1 Demographic characteristics (N = 306)
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Table 2 presents the significance of the demographic characteristics with respect to anxiety and depression. Exercise, sleep quality, SRH, GOLD stage, CAT, mMRC, social support, and social frailty were significant for both anxiety and depression groups.

Table 2 Comparison of demographic characteristics between anxiety and depression groups (N = 306)
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Table 3 presents the results of logistic regression models examining the associations between significant demographic characteristics, anxiety, and depression. The models were adjusted for variables found to be significant in the chi-square and Mann–Whitney U tests, including exercise, sleep quality, SRH, GOLD stage, CAT, and mMRC score, and we also adjusted them for age and sex. The logistic regression analysis revealed that social support showed significant associations with anxiety and depression in both unadjusted and adjusted models. However, neither pre-social frailty nor social frailty demonstrated significant associations with anxiety or depression when compared to patients without social frailty in adjusted models.

Table 3 Logistic regression analysis of associations of social frailty and social support with anxiety and depression (N = 306)
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Table 4 presents the correlations among social frailty, social support, anxiety, and depression. Statistical analysis indicated significant correlations between social frailty and social support, social frailty and anxiety, social support and anxiety, social frailty and depression, and social support and depression.

Table 4 Bivariate correlations among social frailty, social support, anxiety, and depression (N = 306)
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Figures 1 and 2; Table 5 present the results of the mediation analysis examining the relationship of social frailty with anxiety and depression, with social support as a mediator. The analysis demonstrated that although social frailty did not directly affect anxiety or depression, it exerted an indirect effect on both through social support.

Fig. 1
figure 1

Mediation model illustrating the relationship between social frailty and anxiety, with social support as the mediator. *P < 0.05, ** P < 0.01

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Fig. 2
figure 2

Mediation model depicting the relationship between social frailty and depression, with social support as the mediator. *P < 0.05, ** P < 0.01

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Table 5 Mediation analysis of social frailty, anxiety, and depression with social support as the mediator (N = 306)
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Table 6 shows the indirect conditional effects of social frailty on anxiety and depression. The results demonstrated significant conditional indirect effects of social frailty on both anxiety and depression.

Table 6 Conditional indirect effect of social frailty on anxiety and depression (N = 306)
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Discussion

Whether social frailty affects anxiety and depression directly or indirectly remains controversial, and limited research has focused on patients with AECOPD. Our results suggest that social support, but not social frailty, is associated with anxiety and depression in this patient population. The mediation analysis revealed that social frailty only indirectly affects anxiety and depression through social support.

In contrast to previous studies [13, 14], our unadjusted logistic regression model revealed a higher likelihood of anxiety or depression among patients with social frailty. However, this association was not significant in the adjusted model. This discrepancy may arise from variations in measures of social frailty, anxiety, and depression, as well as differences in target populations. Additionally, differences in participant characteristics and prevalence of anxiety or depression across studies may contribute to varying conclusions. These findings suggest that the impact of social frailty on anxiety and depression may differ between populations.

The mediation model supports our logistic regression findings, indicating no direct effect of social frailty on anxiety or depression. This contradicts some studies that found a direct effect on anxiety [15] but aligns with those reporting no direct effect on depression [15, 16]. Our bivariate correlation analysis showed significant negative correlations in the indirect pathways (social frailty to social support and social support to anxiety and depression) and significant positive correlations in the direct pathways (social frailty to anxiety and depression). These negative indirect correlations likely attenuated the direct effects of social frailty on anxiety and depression. Consequently, owing to these mediating factors, no significant direct associations were found between social frailty and anxiety or depression.

Furthermore, our findings are consistent with previous studies [17, 23] that suggest that social frailty may indirectly affect anxiety and depression through social support. This implies that social frailty reduces support from one’s surroundings, leading to anxiety and depression. Potential mechanisms may also be related to reduced cortisol sensitivity to stress [33, 34]. In addition, a previous study noted that stigma in patients with chronic respiratory diseases tends to reduce active seeking of support [35], resulting in more severe inflammation and further leading to psychological disorders [33, 36, 37]. Therefore, robust social support may mitigate the direct effect of social frailty on anxiety and depression in patients with COPD.

In conclusion, our findings suggest that in patients with AECOPD, social frailty does not directly affect anxiety and depression, but rather influences these outcomes indirectly through social support. These findings highlight the importance of bolstering social support systems to alleviate anxiety and depression in this population.

The current study is not without its limitations. First, its cross-sectional design precludes establishing causal relationships between social frailty, social support, anxiety, and depression and may overlook reverse causality in the mediation models. Second, some characteristics such as age, sex, education level, marital status, living status, anxiety, depression, and social frailty were skewed, potentially leading to biased results. Specifically, there was a low prevalence of anxiety (14.1%) and depression (13.7%) in our sample, which may explain the absence of an observable relationship of social frailty with anxiety or depression. Third, the limited sample size may have resulted in a smaller number of patients with anxiety or depression, potentially biasing the results. Future research should employ a longitudinal design with larger sample sizes and use repeated-measures data (e.g., cross-lagged panel models) to explore causal relationships between social frailty, social support, anxiety, and depression. This approach could provide deeper insights into the dynamics over time and inform the development of targeted interventions aimed at mitigating psychological distress in patients with AECOPD.

Conclusions

Social frailty does not directly affect anxiety or depression but can indirectly influence them through social support in patients with AECOPD. Anxiety and depression are common comorbidities in patients with COPD and are influenced by multiple factors. Although social frailty has no direct effect, social support can indirectly alleviate the burden on patients with AECOPD by helping them meet their social needs and promoting social participation. Regarding implications for clinical practice, we recommend that healthcare providers integrate assessments and interventions for social support into routine clinical care. This approach can help address the mental health needs of these patients, leading to improved overall well-being and quality of life.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

ADL:

Activities of daily living

AECOPD:

Acute exacerbations of chronic obstructive pulmonary disease

BMI:

Body mass index

CAT:

COPD Assessment Test

CCI:

Charlson Comorbidity Index

COPD:

Chronic obstructive pulmonary disease

GOLD:

Global Initiative for Chronic Obstructive Lung Disease

mMRC:

Modified Medical Research Council

SRH:

Self-rated health

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Acknowledgements

We would like to thank all the study participants.

Funding

This work was supported by JST, the establishment of university fellowships for the creation of science technology innovation (Grant Number JPMJFS2106), the Funds for Cooperation Project of Nanchong City and North Sichuan Medical College, Grant No. 22SXQT0189, and the Nanchong Federation of Social Science Associations, Grant No. NC22B032; and a grant from the China Scholarship Council, Grant No. 202208510018.

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Author notes

  1. Yang Liu, Mengjiao Yang and Yangyang Zhao contributed equally to this work.

Authors and Affiliations

  1. Graduate School of Comprehensive Human Science, University of Tsukuba, Tsukuba, Japan

    Yang Liu & Mengjiao Yang

  2. Department of Cardiovascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong City, 637000, Sichuan Province, China

    Mengjiao Yang & Yali Wang

  3. Department of Blood Transfusion, Affiliated Hospital of North Sichuan Medical College, Nanchong City, 637000, Sichuan Province, China

    Yangyang Zhao

  4. Department of Respiratory and Critical Care Medicine, Affiliated Hospital of North Sichuan Medical College, Nanchong City, 637000, Sichuan Province, China

    Ziwei Wang

  5. Department of Nursing, Affiliated Hospital of North Sichuan Medical College, Nanchong City, 637000, Sichuan Province, China

    Jie He

  6. Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, 3058577, Ibaraki, Japan

    Tokie Anme

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Contributions

LY and YMJ conceptualized the study. WZW, ZYY, and JH curated the data. LY, YMJ, and ZYY contributed to the methodology and drafted the original manuscript. All authors, including WZW, ZYY, JH, LY, and YMJ, participated in reviewing and editing the manuscript. WYL and TA supervised the study. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Tokie Anme.

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Ethics approval and consent to participate

This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and approved by the Medical Ethics Committee of the Affiliated Hospital of North Sichuan Medical College (Approval no. 2022ER444-1 and 2023ER324-1) and the Institutional Review Board of the University of Tsukuba (approval no. 1841-1). Informed consent was obtained from all participants for their participation in the study, and well as for publication of information.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Liu, Y., Yang, M., Zhao, Y. et al. Social support mediates social frailty with anxiety and depression. BMC Pulm Med 24, 390 (2024). https://doi.org/10.1186/s12890-024-03202-7

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Keywords

BMC Pulmonary Medicine

ISSN: 1471-2466

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