Talk to the Veterans Crisis Line now
U.S. flag
An official website of the United States government

VA Health Systems Research

Go to the VA ORD website
Go to the QUERI website

CDA 14-428 – HSR Study

CDA 14-428
Optimizing Veterans' Social Relationships to Enhance Depression Care
Alan R. Teo, MD MS
VA Portland Health Care System, Portland, OR
Portland, OR
Funding Period: July 2015 - June 2020
People with robust social relationships have better health outcomes, and close relationships may be especially important in mental health care. Among those with depression, having close relationships and involving them in their treatment is associated with lower rates of depression, reduced suicide risk, higher rates of treatment initiation and adherence, better self-management skills, and higher satisfaction with care. Though many close relationships appear willing to participate in patients' care, in clinical practice, they are often not formally engaged in Veterans' depression care.

Several gaps related to involving those relationships in depression care exist. Though other chronic conditions and psychiatric disorders have been examined, strikingly little research has addressed the involvement of close relations in depression care. Specific mechanisms and processes by which involving close relations may improve depression outcomes have not been elucidated. Measures are lacking to identify whether close relation involvement is supportive and treatment-promoting. Integrating involvement of close relations into primary care-based mental health treatment is poorly understood.

Thus, the overarching objective of this proposed CDA is inform development of an intervention for primary care patients with major depression that harnesses the positive influences of close relationships in Veterans' depression care. My central hypothesis is that systematically identifying and actively engaging Veterans' close relations will improve depression-related health behaviors, attitudes, and clinical outcomes.

To inform and guide development of health services interventions that identify, engage, and harness the influences of Veterans' close relationships into their depression care in order to improve treatment response and reduce suicide behavior risk.

We will address the following aims:
Aim 1: Determine which features of VA patients' close relationships are associated with depression-related behaviors and outcomes.
Aim 2: Assess perceptions of key stakeholders in Veterans' depression treatment in primary care, including Veterans, their close relations, and clinicians involved in primary care-mental health integration.
Aim 3: Develop and test a pilot intervention that promotes effective engagement of close relations in the care of VA primary care patients with major depressive disorder.

We will conduct a prospective cohort study of 304 primary care patients with depression to identify to what extent social processes close support, social support, interpersonal conflict, social norms, and loneliness) are associated with depression severity, suicidal ideation, medication adherence, patient activation, and general help-seeking (Aim 1). Results from Aim 1 will highlight which specific aspects of Veterans' close relationships will be the focus of a pilot intervention.

We will conduct 30 interviews with a subset of the enrolled cohort. We will also conduct focus group with individuals whom patients identify as close supports in their social networks as well as conduct focus groups with VA clinicians (Aim 2). Results from Aim 2 will provide a nuanced description of how close relations perceive Veterans' depression, existing ways that close relations are involved in Veterans' depression care, and preferences, barriers, and facilitators to engagement of close relations in Veterans' depression care.

Results from Aims 1 and 2 will support preparation of an IIR proposal for a larger study to determine the extent to which social processes predict development of incident major depressive disorder and suicide behaviors in Veterans. The expected outcome of this project will be preliminary data to guide development of a proposal for a larger randomized controlled trail of an intervention designed to be implemented in VA primary care settings.

Not yet available.

Major depression is a top health services priority because of its high prevalence, large impact on quality of life, and association with suicide. Suicide prevention is the top clinical priority for VHA. The anticipated impacts of this project also include enhancing our understanding of involvement of Veterans' loved ones in care, another area of importance within VHA.

For the published manuscript, "No Show Rates Higher When Phone Appointment Reminders are Not Directly Delivered," we found that appointment attendance rates among VA patients with major depression are considerably lower when phone appointment reminders result in no answer or leaving a message/voicemail. This finding has implications for VA quality improvement efforts to reduce no-shows, improve mental health access, and enhance system-level suicide prevention strategies. Our results suggest a target group of patients who could benefit from additional or alternative mental health care appointment reminder strategies.

From the published manuscript, "Help-Seeking on Facebook Versus More Traditional Sources of Help: Cross-Sectional Survey of Military Veterans," we found that Facebook users were very unlikely to turn to Facebook as a venue for support when experiencing either emotional problems or suicidal thoughts. Compared to help-seeking intentions for Facebook, help-seeking intentions for formal (e.g., psychologists), informal (e.g. friends), or phone help lines sources of support were significantly higher. The impact of this study is that more traditional sources of support appear to be the most viable venues for help-seeking in this population.

Another impact specific to our research findings, from the published manuscript, "Loneliness is Closely Associated with Depression Outcomes and Suicidal Ideation Among Military Veterans in Primary Care," suggests that interventions to increase social connectedness for depression care should target loneliness. In addition, our findings suggest a link between social norms and help-seeking intentions. Thus, there may be value in large-scale promotion of positive social norms campaigns or social norms marketing in order to target depression and suicide prevention.

My research exploring the potential for social media platforms such as Facebook as a tool for Veteran suicide prevention has implications for several stakeholders. For example, our results suggest that Veterans who do not use VHA services may be effectively reached through social media. Furthermore, our results showed high rates of active suicidal ideation (>20%) among Iraq and Afghanistan-era Veterans who use Facebook and participated in our study. We also found evidence that Facebook ads may be tailored to better reach Veterans at-risk for suicide.

External Links for this Project

NIH Reporter

Grant Number: IK2HX001789-01

Dimensions for VA

Dimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects.

Learn more about Dimensions for VA.

VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address.
    Search Dimensions for this project


Journal Articles

  1. Kato TA, Kanba S, Teo AR. A 39-Year-Old "Adultolescent": Understanding Social Withdrawal in Japan. The American journal of psychiatry. 2016 Feb 1; 173(2):112-4. [view]
  2. Teo AR, Andrea SB, Sakakibara R, Motohara S, Matthieu MM, Fetters MD. Brief gatekeeper training for suicide prevention in an ethnic minority population: a controlled intervention. BMC psychiatry. 2016 Jul 7; 16(1):211. [view]
  3. Kato TA, Teo AR, Tateno M, Watabe M, Kubo H, Kanba S. Can Pokémon GO rescue shut-ins (hikikomori) from their isolated world? Psychiatry and clinical neurosciences. 2017 Jan 1; 71(1):75-76. [view]
  4. Sullivan DR, Teo AR. Depression Screening and Treatment: A Missed Opportunity in Lung Cancer Care. Federal practitioner : for the health care professionals of the VA, DoD, and PHS. 2017 Aug 1; 34(suppl5):S24-S27. [view]
  5. Teo AR, Choi H, Andrea SB, Valenstein M, Newsom JT, Dobscha SK, Zivin K. Does Mode of Contact with Different Types of Social Relationships Predict Depression in Older Adults? Evidence from a Nationally Representative Survey. Journal of the American Geriatrics Society. 2015 Oct 1; 63(10):2014-22. [view]
  6. Chen JI, Mastarone GL, Ambrosino SA, Anzalone N, Carlson KF, Dobscha SK, Teo AR. Evaluation of the Safety and Design of Community Internet Resources for Veteran Suicide Prevention. Crisis. 2019 Sep 1; 40(5):347-354. [view]
  7. Denneson LM, Cromer RD, Jacobson LE, Teo AR, Dobscha SK. Female Veterans Who Died by Suicide: Qualitative Analysis of Medical Records. Military Behavioral Health. 2016 Feb 17; 4(3):276-284. [view]
  8. Teo AR, Chan BK, Saha S, Nicolaidis C. Frequency of social contact in-person vs. on Facebook: An examination of associations with psychiatric symptoms in military veterans. Journal of affective disorders. 2019 Jan 15; 243:375-380. [view]
  9. Nagata T, Suzuki F, Teo AR. Generalized social anxiety disorder: A still-neglected anxiety disorder 3 decades since Liebowitz's review. Psychiatry and clinical neurosciences. 2015 Dec 1; 69(12):724-40. [view]
  10. Liu LL, Li TM, Teo AR, Kato TA, Wong PW. Harnessing Social Media to Explore Youth Social Withdrawal in Three Major Cities in China: Cross-Sectional Web Survey. JMIR mental health. 2018 May 10; 5(2):e34. [view]
  11. Teo AR, Marsh HE, Liebow SBL, Chen JI, Forsberg CW, Nicolaidis C, Saha S, Dobscha SK. Help-Seeking on Facebook Versus More Traditional Sources of Help: Cross-Sectional Survey of Military Veterans. Journal of medical Internet research. 2018 Feb 26; 20(2):e62. [view]
  12. Tateno M, Teo AR, Shirasaka T, Tayama M, Watabe M, Kato TA. Internet addiction and self-evaluated attention-deficit hyperactivity disorder traits among Japanese college students. Psychiatry and clinical neurosciences. 2016 Dec 1; 70(12):567-572. [view]
  13. Teo AR, Marsh HE, Forsberg CW, Nicolaidis C, Chen JI, Newsom J, Saha S, Dobscha SK. Loneliness is closely associated with depression outcomes and suicidal ideation among military veterans in primary care. Journal of affective disorders. 2018 Apr 1; 230:42-49. [view]
  14. Denneson LM, Teo AR, Ganzini L, Helmer DA, Bair MJ, Dobscha SK. Military Veterans' Experiences with Suicidal Ideation: Implications for Intervention and Prevention. Suicide & Life-Threatening Behavior. 2015 Aug 1; 45(4):399-414. [view]
  15. Kato TA, Hashimoto R, Hayakawa K, Kubo H, Watabe M, Teo AR, Kanba S. Multidimensional anatomy of 'modern type depression' in Japan: A proposal for a different diagnostic approach to depression beyond the DSM-5. Psychiatry and clinical neurosciences. 2016 Jan 1; 70(1):7-23. [view]
  16. Tateno M, Skokauskas N, Kato TA, Teo AR, Guerrero APS. New game software (Pokémon Go) may help youth with severe social withdrawal, hikikomori. Psychiatry Research. 2016 Dec 30; 246:848-849. [view]
  17. Teo AR, Forsberg CW, Marsh HE, Saha S, Dobscha SK. No-Show Rates When Phone Appointment Reminders Are Not Directly Delivered. Psychiatric services (Washington, D.C.). 2017 Nov 1; 68(11):1098-1100. [view]
  18. Teo AR, Liebow SB, Chan B, Dobscha SK, Graham AL. Reaching Those At Risk for Psychiatric Disorders and Suicidal Ideation: Facebook Advertisements to Recruit Military Veterans. JMIR mental health. 2018 Jul 5; 5(3):e10078. [view]
  19. Teo AR, Strange W, Bui R, Dobscha SK, Ono SS. Responses to Concerning Posts on Social Media and Their Implications for Suicide Prevention Training for Military Veterans: Qualitative Study. Journal of medical Internet research. 2020 Oct 30; 22(10):e22076. [view]
  20. Tateno M, Kim DJ, Teo AR, Skokauskas N, Guerrero APS, Kato TA. Smartphone Addiction in Japanese College Students: Usefulness of the Japanese Version of the Smartphone Addiction Scale as a Screening Tool for a New Form of Internet Addiction. Psychiatry investigation. 2019 Feb 21; 16(2):115-120. [view]
  21. Chen JI, Hooker ER, Niederhausen M, E Marsh H, Saha S, Dobscha SK, Teo AR. Social connectedness, depression symptoms, and health service utilization: a longitudinal study of Veterans Health Administration patients. Social psychiatry and psychiatric epidemiology. 2020 May 1; 55(5):589-597. [view]
  22. Kaveladze B, Diamond Altman A, Niederhausen M, Loftis JM, Teo AR. Social relationship quality, depression and inflammation: A cross-cultural longitudinal study in the United States and Tokyo, Japan. The International Journal of Social Psychiatry. 2022 Mar 1; 68(2):253-263. [view]
  23. Andrea SB, Siegel SA, Teo AR. Social Support and Health Service Use in Depressed Adults: Findings From the National Health and Nutrition Examination Survey. General hospital psychiatry. 2016 Mar 1; 39:73-9. [view]
  24. Nelson HD, Denneson LM, Low AR, Bauer BW, O'Neil M, Kansagara D, Teo AR. Suicide Risk Assessment and Prevention: A Systematic Review Focusing on Veterans. Psychiatric services (Washington, D.C.). 2017 Oct 1; 68(10):1003-1015. [view]
  25. Teo AR, Marsh HE, Ono SS, Nicolaidis C, Saha S, Dobscha SK. The Importance of "Being There": a Qualitative Study of What Veterans with Depression Want in Social Support. Journal of general internal medicine. 2020 Jul 1; 35(7):1954-1962. [view]
  26. Franz D, Marsh HE, Chen JI, Teo AR. Using Facebook for Qualitative Research: A Brief Primer. Journal of medical Internet research. 2019 Aug 13; 21(8):e13544. [view]
  27. Teo AR, Markwardt S, Hinton L. Using Skype to Beat the Blues: Longitudinal Data from a National Representative Sample. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry. 2019 Mar 1; 27(3):254-262. [view]
Journal Other

  1. Teo AR, Stufflebam K, Saha S, Fetters MD, Tateno M, Kanba S, Kato TA. Psychopathology associated with social withdrawal: Idiopathic and comorbid presentations. [Letter to the Editor]. Psychiatry Research. 2015 Jul 30; 228(1):182-3. [view]
Online News Media Articles

  1. Teo AR. New OHSU/VA study finds people very unlikely to reach out for emotional help on Facebook. OHSU Brain Institute [Internet]. 2018 Feb 26. Available from: [view]
  2. Kaveladze B, Teo AR. New study explores how social relationships protect against the harmful effects of stress. The OHSU Brain Institute: On the Brain Blog [Internet]. 2021 Jan 26. Available from: [view]
  3. Teo AR, Call A. New Study Reveals Patients with Depression Value Friends and Family Who Can "Be There" for Them. OHSU Brain Institute On the Brain [Internet]. 2020 Apr 3:(Blog). Available from: [view]

  1. Nelson HD, Denneson LM, Low A, Bauer BW, O ME, Kansagara D, Teo AR. ESP Report: Systematic Review of Suicide Prevention in Veterans. Washington, DC: Department of Veterans Affairs; 2015 Nov 1. 145 p. Report No.: VA ESP Project #05-225. [view]
  2. Nelson HD, Denneson LM, Low AR, Bauer BW, O'Neil ME, Kansagara D, Teo AR. Systematic Review of Suicide Risk Assessment and Prevention. Health Service Research and Development; 2017 Jun 15. [view]
Center Products

  1. Characterizing OEF/OIF Veterans Use of Facebook for Social Support. Portland, OR: CIVIC; 2015 Aug 7. [view]
  2. Teo AR. Getting the Recognition We Deserve: Working with Public Relations. Portland, OR: CIVIC; 2016 Jul 15. [view]
  3. Teo AR. IIR grant proposal: Reducing No-shows through a Behavioral Economics-Informed Intervention. Portland, OR: CIVIC; 2016 Aug 5. [view]
  4. Teo AR. Ten Mistakes You've Probably Made Writing Survey Questions (and how to fix them). Portland, OR: CIVIC; 2016 Jan 22. [view]
VA Cyberseminars

  1. Teo AR, Denneson LM. Suicide Risk Assessment and Prevention: A Systematic Review Focusing on Veterans. Veterans Health Administration Northwest Mental Illness Research Education and Clinical Center (MIRECC) Webinar [Cyberseminar]. Veterans Health Administration Northwest Mental Illness Research Education and Clinical Center (MIRECC). 2016 Jun 1. [view]
  2. Denneson LM, Gleason T, Teo AR. Systematic Review of Suicide Prevention in Veterans. Spotlight on Evidence-based Synthesis Program [Cyberseminar]. US Department of Veterans Affairs, HSR&D. 2016 Jun 9. [view]
Conference Presentations

  1. Teo AR, Andrea S, Sakakibara R, Motohara S, Matthieu M, Fetters M. Brief Gatekeeper Training for Suicide Prevention in an Ethic Minority Population: A Controlled Intervention. Paper presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2016 Apr 1; Washington, DC. [view]
  2. Teo AR, Choi H, Andrea SB, Valenstein M, Newsom JT, Dobscha SK, Zivin K. Does Mode of Contact with Different Types of Social Relationships Predict Depression in Older Adults? Evidence from a Nationally Representative Survey. Paper presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2015 Apr 25; San Antonio, TX. [view]
  3. Teo AR. International research on social withdrawal. Paper presented at: European Congress of Psychiatry; 2016 Mar 15; Madrid, Spain. [view]
  4. Siegel S, Andrea S, Teo AR. Social Support and Health Service Use in Depressed Adults: Findings from the National Health and Nutrition Examination Survey. Paper presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2016 Mar 31; Washington, DC. [view]
  5. Teo AR, Kato TA, Lu F. Social Withdrawal in Modern Society: An Emerging Cultural Concept of Distress in East Asia. Paper presented at: American Psychiatric Association Annual Meeting; 2016 May 17; Atlanta, GA. [view]
  6. Teo AR. Suicide Risk Assessment and Prevention Interventions in Military Veterans. Paper presented at: European Congress of Psychiatry; 2016 Mar 13; Madrid, Spain. [view]

DRA: Mental, Cognitive and Behavioral Disorders
DRE: Technology Development and Assessment
Keywords: Social Support
MeSH Terms: none

Questions about the HSR website? Email the Web Team

Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.