A cross-sectional study of the relationship between daily social contact features and the prevalence of common mental disorders in Taiwan, 2000–2015

Abstract

The aim of this study was to examine the influence of daily contact features on the prevalence of common mental disorders (CMDs) in Taiwan from 2000 to 2015. Data from the Taiwan Social Change Survey for 2000, 2005, 2010, and 2015 were used to examine the relationship between the number and level of familiarity with daily social contacts with the probable CMDs (determined by score of ≥ 3 on a 12-item Chinese Health Questionnaire). Descriptive statistics and multivariable logistic regression analyses were used to assess the association. Among the 7,841 respondents, the prevalence of probable CMDs increased from 18.28% in 2000 to 21.29% in 2015. Multivariable analysis showed that respondents with more daily social contacts were less likely to have probable CMDs in the four observed years adjusting for sociodemographic characteristics and physical health limitations on daily activities in the past two weeks. A negative relationship between probable CMDs and level of familiarity with daily contacts was found in 2000 (OR = 0.67, 95% CI-0.48–0.94) and 2005 (OR = 0.70, 95% CI-0.53–0.93). Findings from our study suggest the development of culturally tailored programs/interventions through features of daily social contacts may reduce the prevalence of CMDs in Taiwan.

Introduction

Mental health is one of rising global health concerns [1]. Particularly, mental and substance use disorders are rampant worldwide [2] and are the leading cause of years lived with disability (YLDs) [3]. Common mental disorders (CMDs) represent a broad diagnostic definition for depressive and anxiety disorders [4] and are distinct from the feelings of sadness, stress, or fear that most people occasionally experience [5]. Both depressive and anxiety disorders have a higher prevalence than other mental and substance use disorders [2], accounting for the majority of YLDs [3] as well as disability-adjusted life years (DALYs) [2]. A nationwide cross-sectional study in Taiwan showed that the prevalence of CMDs doubled between 1990 and 2010 [4]. The prevalence of treated depressive disorders increased from 1.61% in 2007 to 1.92% in 2016 according to data from Taiwan’s National Health Insurance Research Database (NHIRD) [6].

Mental health outcomes are influenced by socio-ecological factors encompassing individual, familial, and community environments, as well as broader societal structures, cultures, and beliefs across one’s lifespan [4, 7–10], which has been linked to social interaction. Social interaction (sometime used interchangeably with daily social contacts) is defined as interpersonal contact with others on the daily bases regardless of whether individuals know those people and which pathway they used [11]. Evidence has shown that daily social contact positively influences psychological well-being and mental health [12–17]. Daily social contacts may influence mental health by providing social support [12, 13, 15], improving access to material resources [18], and moderating the adverse effects of stressful life events [12, 19–22]. By interacting with other people, individuals can exchange useful information and receive material resources and emotional support, which could improve their mental health [23, 24]. In addition to general mental health, evidence has also shown the association between social interaction and depressive symptoms. A lack of social interaction has been linked to an increased risk of depression [15, 25], especially among older adults [26]. Therefore, such evidence highlights the potential influence of daily social contacts on overall mental health.

Although daily social contact is known to be related to mental health, most studies have been limited by a single point in time, small sample sizes, specific populations, a single social contact feature, and/or Western countries [27–29]. None of these particularly focus on CMDs in Taiwan. Only one study investigating the prevalence of CMDs over a 20-year period in Taiwan but without considering the influence of various daily social contacts [4]. Because daily social contacts differ from culture to culture [30, 31], the study examining how various daily social contacts (e.g., frequency or level of familiarity) impact CMDs among Taiwanese is needed. Various daily social contact features are crucial for developing an individual’s social network and represent a pivotal aspect of social action, as it contributes to the formation of network resources and social capital [32, 33]. Therefore, findings from our study may have potential for informing the development of culturally tailored interventions aimed at reducing the prevalence of CMDs through their daily social contact features. To address the gap, this study expands the research scope by examining the relationship between differential features of daily social contacts, including the number of daily contacts and levels of familiarity, and CMDs using a representative sample of Taiwan across a 15-years study period.

Materials and methods

Data, design, and participants

This is a secondary data analysis of the Taiwan Social Change Survey (TSCS), which was conducted by the Institute of Sociology, Academia Sinica and sponsored by the Ministry of Science and Technology, Republic of China. The TSCS is a long-term and nationally representative cross-sectional survey in Taiwan with access to social issues related to family, culture, religion, politics, social networks, and social class cyclically. The detailed methodology of the TSCS has been described elsewhere [4, 34–37]. In brief, this survey used a stratified multi-stage probability proportional to size (PPS) method to select Taiwanese citizens older than 18 years to participate in the survey. All townships and cities in Taiwan were divided into distinct clusters according to their geographic location, demographic structure, and economic situation. The sampling design involved random selection from the following three stages: 1) townships and districts, 2) lis (one of the administrative regions in Taiwan), and 3) individuals based on their respective proportional sizes. The survey is conducted by interviewers chosen by the Center for Survey Research (CSR) at Academia Sinica. These interviewers undergo training in questionnaire instructions, workflow, interviewing skills, and precautions by TSCS and CSR teams. The face-to-face data collection using a structured questionnaire was implemented by those trained interviewers at each participant’s residence address, and oral consent to participate was provided before the interviews by all participants. Ethics approval was obtained from the Institutional Review Board (IRB) of Academia Sinica.

TSCS data from the years 2000, 2005, 2010, and 2015 were used in this research and the data were accessed on October 1^st, 2020. Data extracted for this study were publicly available and de-identified. Ethics standards for this research was approved by the Central Regional Research Ethics Committee, China Medical University, Taichung, Taiwan (CMUH REC No. CRREC-109-051). There were 1,895 respondents in 2000; 2,146 in 2005; 1,895 in 2010; and 2,034 in 2015. Out of these, 129 respondents were excluded because of missing information on age, mental health, and features of daily contacts. Ultimately, 7,841 respondents (98% of the original responses) were included in this study.

Measures

The study outcome was common mental disorders (CMDs) measured using the 12-item Chinese Health Questionnaire (CHQ-12). The CHQ-12 is a self-reported survey included in the TSCS to evaluate respondents’ mental health every five years since 1990 and is one of the most popular and widely used screening instruments for identification and measurement of CMDs [34, 36, 38–40] (Cheng & Williams, 1986; Cheng, 1988; Cheng et al., 1990; Liu et al., 2002; Wang et al., 2004). This questionnaire not only cover direct mental health expression but also two novel aspects relevant to Chinese cultural characteristics, conveyed by somatization (the physical manifestation of psychological concerns) and family relationships. First, Cheng (1985) developed the Chinese Health Questionnaire (CHQ) by incorporating 30 items directly retrieved and translated from the General Health Questionnaire [41]. Additional 30 specifically created items aimed to be pertinent to the manifestation of CMDs in Chinese populations due to language and culture differences. Further, Cheng and Williams (1986) performed the discriminant function analysis on the CHQ to derive the CHQ-12. Scores of 0 or 1 were assigned to responses for each item in the CHQ-12, resulting in a total score ranging from 0 (better) to 12 (worse) [4, 41]. Therefore, we used the definition of total CHQ-12 scores of 3 or more as being likely to have CMDs (termed probable CMDs) and less than 3 as being unlikely to have CMDs [4, 42], which had been validated by previous research. By using this cut-off point, the sensitivity and specificity of the CHQ-12 were 87% and 77% among general medical settings in Taiwan [39] and 75% and 71% among Chinese population in Brazil [40]. In this study, the range of Cronbach’s alpha were between 0.73 and 0.79 from 2000–2015 TSCS data.

Daily contact features were our main exposures, including the number of daily contacts and level of familiarity with their daily contacts. They usually come from a direct question utilized in various large-scale social surveys that serve as a proxy measure of the size of an individual’s personal network [11]. Thus, we used a single-item survey question to measure the number of daily contacts: "How many people do you have contact with in a typical day, including all those who you say hello, chat, talk or discuss matters with, whether you do it face-to-face, by telephone, by mail or on the internet and whether you personally know the person or not?” There were six response options for the question on the number of daily contacts, including 0–4 people, 5–9 people, 10–19 people, 20–49 people, 50–99 people, and ≥ 100 people. Further, we converted each response to a single score from 1 (0–4 people) to 6 (100 or more people). Finally, the level of familiarity was evaluated by using a TSCS question, which is “How many of these people do you know?”. The responses of “almost all” and “most” were defined as a high level of familiarity and the rest responses were defined as low familiarity.

Covariates of interest were selected based on the association with probable CMDs used in previous studies [4, 43]. For sociodemographic characteristics, we included gender (male or female), age (less than 34 years, 35–49, 50–64 or 65 years or older), marital status (single, married, divorced/separated or widowed), religion (no or yes), education (elementary school or below, middle school, high school, college, university, or graduate school), employment status (employed, unemployed, retired, housewife/husband or student) and family income (score range, 1–22). Physical health limitations on daily activities were assessed using a single question, “Have you experienced any physical discomfort or injury in the past two weeks that has affected your daily activities, such as studying, working, or housekeeping?” Four response options were used, which are ranging from “no impact” to “high impact”.

Statistical analysis

Descriptive statistics were performed to characterize probable CMDs, number of daily contacts, level of familiarity with daily contacts, sociodemographic characteristics, and physical health problems that limited daily activities during 2000–2015. Cross-tabulation of probable CMD status was also conducted to describe the differences in these characteristics by four observed data years. Chi-square tests for categorical variables and independent t-tests for continuous variables were used to examine the relationship between number of daily contacts and familiarity levels with probable CMDs. Multivariable logistic regression analyses were applied to assess the association between number of daily contacts and familiarity levels with probable CMDs, adjusted for sociodemographic characteristics and physical health limitations on daily activities in the past two weeks. The relationship between the number of daily contacts and probable CMD status modified by the level of familiarity with daily contacts was also examined in each data year. Such modification enables the explanation on whether the association between the number of daily contact and common mental disorders would vary by the level of familiarity with daily social contacts. All multivariable results were reported as odds ratios (ORs), 95% confidence intervals (CIs), and p-values. Data analyses were conducted using STATA Version 16 (Stata Corporation LLC, College Station, TX, USA). All p-values were based on two-sided probability tests. The level of statistical significance was set at 0.05.

Results

Participant characteristics

The distribution of features of daily contacts, sociodemographic characteristics, and physical health problems that limit daily activities are presented in Table 1. Of the eligible 7,841 respondents, 18.3%, 25.5%, 23.8%, and 21.3% reported having probable CMDs in 2000, 2005, 2010, and 2015, respectively. In 2010 and 2015, the average number of daily contacts was higher than that in 2000 and 2005. The results showed a significant increase from 2005 to 2010 (p-value <0.001); however, a reduction in the number of daily contacts was observed between 2010 and 2015 (p-value > 0.05). Regarding the level of familiarity with daily contacts, most respondents reported having a high level of familiarity during 2000–2015. A reduction was found from 79.8% in 2005 to 73.1% in 2010 (p-value < 0.001), and a slight increase was observed in 2015 (76.5%) (2010 vs. 2015; p-value = 0.01) among those with a high level of familiarity with daily contacts. Regarding sociodemographic characteristics, most respondents were male and aged 49 years or lower between 2000–2015. The majority of participants were married, religious, had high school education, were employed, and had no impact of physical health limitations on daily activities (Table 1).

[Figure omitted. See PDF.]

Table 2 shows the differences between probable CMDs and features of daily contacts. Respondents with probable CMDs had significantly fewer daily contacts between 2000 and 2015 (p-value = 0.02 in 2000, p-value <0.001 in 2005, p-value = 0.002 in 2010, and p-value <0.001 in 2015). In 2000–2010, most participants with probable CMDs reported having a low level of familiarity with daily contacts; however, a reduction was observed from 25.2% in 2010 to 20.7% in 2015, although there were no significant differences. Moreover, the majority of participants were female, younger (aged ≤ 49 years), divorced or separated, unemployed, and had an impact of physical health limitations on daily activities among respondents with probable CMDs during 2000–2015.

[Figure omitted. See PDF.]

Association between daily social contacts and prevalence of CMDs

We used multivariable logistic regression to examine the association between probable CMDs and the number of daily contacts and the level of familiarity with daily contacts, adjusted for sociodemographic characteristics and physician health problems (Table 3). Results showed that respondents with more daily contacts as being less likely to have probable CMDs in 2000 (OR = 0.89, p-value = 0.04), 2005 (OR = 0.88, p-value = 0.009), 2010 (OR = 0.88, p-value = 0.02), and 2015(OR = 0.85, p-value = 0.01). However, a significant relationship between probable CMDs and the level of familiarity with daily contacts was only found in 2000 (OR = 0.67, p-value = 0.02) and 2005 (OR = 0.70, p-value = 0.02). Participants with a high level of familiarity with daily contact had lower odds of probable CMDs (Table 3).

[Figure omitted. See PDF.]

In addition, our findings showed that females had greater probability of developing CMDs in 2000 (OR = 1.52, p-value = 0.02), 2005 (OR = 1.3, p-value = 0.02), and 2010 (OR = 1.72, p-value = 0.02) compared with males. Age and physical health problems imposing limitations on daily activities in the past two weeks were also associated with probable CMD status. Adults aged ≥ 65 years were less likely to have probable CMDs than younger respondents(OR = 0.39, p-value = 0.001 in 2005; OR = 0.44, p-value = 0.01 in 2010; OR = 0.45, p-value = 0.02 in 2015).Those with any impact of physical health limitation on daily activities had greater odds of having probable CMDs during 2000–2015, particularly those who reported a high impact on daily activities due to physical health problems (OR = 12.91, p-value <0.001 in 2000; OR = 10.25, p-value <0.001 in 2005; OR = 11.66, p-value <0.001 in 2010; OR = 5.08, p-value <0.001 in 2015) (Table 3).

Finally, we examined the relationship between the number of daily contacts and probable CMDs by the level of familiarity with daily contacts (Table 4). Among those with high level of familiarity with daily contacts, participants with a greater number of daily contacts had lower odds of having probable CMDs in 2010 (OR = 0.88, p-value = 0.05) and 2015 (OR = 0.78, p-value <0.001). Among respondents with low levels of familiarity with daily contacts, 2000 and 2005 data indicated that those with a greater number of daily contacts were less likely to have probable CMDs, despite the lack of statistical significance in 2000 (OR = 0.08, p-value = 0.06 in 2000; OR = 0.07, p-value = 0.003 in 2005).

[Figure omitted. See PDF.]

Discussion

Four times cross-sectional surveys demonstrated significant differences in the prevalence of probable CMDs among a nationally representative sample of Taiwanese adults. We found that an increase in the prevalence of probable CMDs was observed from 2000 to 2010, and a slight reduction was observed in 2015, which is consistent with a previous study [4]. Evidence has shown that an increase in suicide rates had been reported since 1994, but also that a reduction has been observed since 2006 [44]. This change in suicide rates in Taiwan may explain a slight reduction in prevalence rates of probable CMDs from 25.5% in 2005 to 21.3% in 2015 in our study. A possible reason may be because suicide prevention strategies advanced by establishment of efficient networks nationwide capable of delivering related care services in Taiwan [45]. Moreover, our study found that the number of daily contacts increased from 2000 to 2015; meanwhile, the high level of familiarity with daily contacts decreased from 2000 to 2010 with a slight increase observed in 2015. This shift in level of familiarity with daily contacts may be due to the high accessibility of the Internet, expansion of social networks, and replacement of the time spent in face-to-face interactions, particularly with close friends and family [29].

In our multivariable regression analysis, we found that respondents with a higher number of daily contacts or a higher level of familiarity with daily contacts were less likely to have probable CMDs. This finding is consistent with previous studies that reported fewer daily contacts associated with loneliness and depression [23, 24, 46, 47]. Individuals who have more social support and high-quality existing relationships may have better mental health [27, 48]. A greater number of daily contacts not only provide emotional support but also provide psychological comfort when needed; consequently, it enhances overall mental well-being [12, 19–22].

We also observed that the association between the number of daily contacts and probable CMDs varied across years according to various levels of familiarity with daily contacts. People with a high level of familiarity with daily contacts and a higher number of daily contacts were less likely to have probable CMDs in 2010 and 2015. In contrast, the influence of the number of daily contacts on probable CMDs among people with low levels of familiarity with daily contacts was found in 2000 and 2005. Possible explanation may be due to the rapid development of Internet technologies. People not only meet in person but also expand their social contact features by using online platforms. This is particularly true because Internet use has significantly increased since 2006 among individuals aged 12 years or older [49]. The increase in social media use, including texting, direct messaging, and video calls with close friends and family, was also observed in Taiwan [49, 50]. This is in line with our finding on having a high level of familiarity with daily social contacts was associated with lower likelihood of prevalence of CMDs in 2010 and 2015. Having a higher level of familiarity with their contacts may play a more significant role on improving mental health despite having greater number of daily social contacts [51]. Although online interpersonal interaction can overcome the limitations of time and location and make it possible to connect with a larger number of contacts, people could be more heterogeneous within those networks, resulting in low familiarity with their contacts [52, 53] which would relate to the high risk of depression [54]. However, we were unable to further evaluate the relationship of heterogeneous network and low familiarity because TSCS survey did not collect the information on heterogeneous network. Further research examining this relationship may also be helpful.

Despite not being the main study objective, our study found an increasing prevalence of probable CMDs among women. The rise in female suicide rates in Taiwan in 2000 and 2015 due to work-life balance could partially explain our finding [55]. Further, we also observed that physical limitations were associated with greater prevalence of probable CMDs. For example, chronic illnesses such as cancer, heart disease, or diabetes were associated with the risk of depression [56]; ultimately, the physical limitations of daily activities may contribute to the likelihood of probable CMDs. Finally, another important insight from our finding is that older individuals were less likely to have probable CMDs, particularly those aged 65 years or older. The dissimilar results with prior studies may be that most older individuals were retired with less stress from work or financial needs compared to younger individuals [57, 58].

Although the association between daily social interaction and mental health has been established [27–29], research particularly evaluating the influence of various daily social contact features on CMDs in Taiwan is limited. To our best knowledge, this is the first study to examine the association between the specific features of daily contacts (e.g., number of daily contacts and level of familiarity) and the prevalence of probable CMDs. Therefore, findings from our study may inform culturally tailored interventions aimed at reducing the prevalence of CMDs through individual’s daily social contact features for Taiwanese. Integrated interventions involving their social network may also be helpful. For example, use of a socio-ecological model to addresses/integrate the cumulative and intersectional experience may have potential for reducing the likelihood of probable CMDs [4, 7–10]. Finally, the association between social interaction and loneliness has been established, meanwhile during the COVID-19 pandemic, loneliness has been found as a strong predictor of mental illness [59–61]. Further research evaluating the changes of daily social contact features on mental health that are possibly linked to the pandemic is also needed.

Despite its strengths, this study has a few limitations that should be noted. First, the research design was cross-sectional, and the temporal relationship between the prevalence of probable CMDs and daily contact features cannot be established. Second, our study only considered the number of daily contacts and level of familiarity with daily contacts, without taking into account how other aspects of social interaction with daily contacts, such as frequency of contact and social settings (such as location) affects the prevalence of probable CMDs. Third, the definition of probable CMDs was only dependent on the self-reported CHQ-12 survey, which may lead to potential interpretation bias compared to clinical diagnosis. Further, as with any self-reported survey research, study participants may have given socially acceptable responses instead of answering with genuine and accurate facts. Recall bias may also have affected the accuracy of responses. Therefore, it is possible that the influence of daily contact features on probable CMDs may be overestimated or underestimated in this study. Finally, our study only included data from 2000 to 2015, which may limit ability to generalize results to the most current timeframe. Future research including more data year with a longitudinal cohort design may further elucidate the impact of various daily social contact features on the prevalence of CMDs.

Conclusions

Overall, the prevalence of probable CMDs has increased from 2000 to 2015 in Taiwan. Individuals with more daily contacts and/or a higher level of familiarity with daily contacts were strongly associated with decreased probable CMDs. Variations in daily contact features across different periods may highlight different influences on mental health. Because of the increase in mental illnesses on psychological wellbeing, more studies are needed to further elucidate various daily contacts features in mental health. Future research with a longitudinal study design may also benefit the development of mental health promotion/intervention.

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Citation: Tsai M-H, Wu Y-H, Lai S-J, Yang Y-C (2024) A cross-sectional study of the relationship between daily social contact features and the prevalence of common mental disorders in Taiwan, 2000–2015. PLoS ONE 19(10): e0312154. https://doi.org/10.1371/journal.pone.0312154

About the Authors:

Meng-Han Tsai

Roles: Conceptualization, Writing – original draft, Writing – review & editing

Affiliations: Georgia Prevention Institute, Augusta University, Augusta, GA, United States of America, Cancer Prevention, Control, & Population Health Program, Georgia Cancer Center, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, United States of America

ORICD: https://orcid.org/0000-0001-6511-156X

Yun-Hsuan Wu

Roles: Conceptualization, Formal analysis, Funding acquisition, Methodology, Supervision, Validation, Writing – review & editing

E-mail: [email protected], [email protected]

Affiliation: Department of Public Health, China Medical University, Taichung, Taiwan

ORICD: https://orcid.org/0000-0002-8279-9201

Sih-Jie Lai

Roles: Formal analysis

Affiliation: School of Chinese Medicine & Graduate Institute of Chinese Medicine, China Medical University, Taichung, Taiwan

Yun-Chieh Yang

Roles: Formal analysis, Visualization

Affiliation: Department of Public Health, China Medical University, Taichung, Taiwan

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