Psychiatry Research 268 (2018) 143–151

Contents lists available at ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Loneliness and depression symptoms among the elderly in nursing homes: A T

moderated mediation model of resilience and social support
Xia Zhaoa, Dan Zhanga, Menglian Wua, Yang Yanga, Hui Xiea, Yuqin Lib, Jihui Jiaa,
⁎
Yonggang Sua,c,
a
School of Nursing, Shandong University, Jinan 250012, China
b
School of Philosophy and Social Development, Shandong University, Jinan 250100, China
c
School of Foreign Languages and Literature, Shandong University, Jinan 250012, China

A R T I C LE I N FO A B S T R A C T

Keywords: Loneliness has been identified as a risk factor for depressive symptoms. Resilience and social support have been
Loneliness regarded as underlying protective factors. Little is known about the complex relations among these factors in the
Resilience nursing home elderly. This study aimed to assess the prevalence of depressive symptoms, explore whether re-
Social support silience mediated the association between loneliness and depressive symptoms, and investigate whether social
Depressive symptoms
support moderated the indirect or direct effect of mediation model. A total of 323 nursing home elderly were
Elderly in nursing homes
recruited in Jinan City, China. Loneliness, resilience, social support and depressive symptoms were measured.
Moderated mediation model
Results shown the association between loneliness and depressive symptoms was partially mediated by resilience.
Besides, the indirect effect of the mediation model was moderated by social support. When the level of social
support was higher, the indirect effect of loneliness on depressive symptoms through resilience was weaker. The
incidence of depressive symptoms among the nursing home elderly could not be neglected. The findings suggest
that interventions, such as improving resilience and social support, may help break the link between loneliness
and depressive symptoms among the elderly in nursing homes.

1. Introduction symptoms may experience functional impairments (Mehta et al., 2002)

and increased level of suicide (Wang et al., 2015). It was reported that
Dramatic aging of population, as a result of increased life ex- the depressive risk of the elderly living in nursing homes was 3 to 4
pectancy and reduced mortality (Tarakci et al., 2015), has become a times higher than that of the elderly in the society (Jongenelis et al.,
global phenomenon. In 2000–2025, the speed of population aging, 2004). Besides, depressive symptoms are associated with the in-
which indicates the average annual increase rate of the 60 and over dividual's decline in health and function prior to death, such as cogni-
segment in the total population during a given period, is rapid (2.7%) in tion and physical function (Backman and MacDonald, 2006; Segel-
China, higher than that of the developed countries (average 1.5%) Karpas et al., 2017). The elderly generally view depressive symptoms as
(Mo and Légaré, 2004). It is predicted that the population aging would a normal part of the aging process, rendering it greatly ignored (Segel-
peak in 2050, with the elderly aged 60 and above accounting for 1/4 of Karpas et al., 2017).Therefore, it is important to identify the factors of
the total population (Guo, 2010). Especially, due to the one-child policy depressive symptoms and explore the underlying mechanisms of these
(Lei et al., 2016; Liu, 1997) and the engagement in education and ca- factors on depressive symptoms.
reer for younger couples (Cheng, 2007), average Chinese family has Loneliness has been identified as a noteworthy risk factor for de-
been less efficient in taking care of the increasing number of aging pressive symptoms in both cross-sectional and longitudinal studies
relatives, and an immense elderly population choose to live in nursing (Cacioppo et al., 2010; Wan Mohd Azam et al., 2013). It may appear in
homes (Xiao et al., 2017). Unfortunately, those living in nursing homes all age groups, but it is more typical with the elderly (Aylaz et al.,
suffer from more psychological problems than those at home as a result 2012). Besides, recent research has found that loneliness might be more
of lacking freedom and family support (Karakaya et al., 2009). common among elderly in nursing homes than those living at home
Depressive symptoms are the most frequent psychological problems (Grenade and Boldy, 2008). A meta-analysis revealed that loneliness
in the elderly (Helvik et al., 2016). Older people with depressive was related to inadequate social contact, gender and lower

⁎
Corresponding author at: School of Foreign Languages and Literature, Shandong University, 44 West Wenhua Road, Jinan 250012, Shandong, China.
E-mail address: [email protected] (Y. Su).

https://doi.org/10.1016/j.psychres.2018.07.011
Received 7 January 2018; Received in revised form 3 July 2018; Accepted 6 July 2018
Available online 09 July 2018
0165-1781/ © 2018 Elsevier B.V. All rights reserved.
X. Zhao et al. Psychiatry Research 268 (2018) 143–151

socioeconomic status, and even predicted a series of negative health moderator in the direct and/ or indirect effect (including path a:
outcomes, such as cognitive decline and increased risk of mortality loneliness-resilience and path b: resilience-depressive symptoms) of
(Wilson et al., 2007; Jansson et al., 2017). Residents in nursing homes loneliness on depressive symptoms, respectively.
were also associated with higher degree of loneliness (Pinquart and
Sörensen, 2003). In China, Gan et al. (2015) referred to the impact of 2. Methods
loneliness on depressive symptoms as resultant from the Confucian
influence in Chinese Culture. Empirical findings have provided evi- 2.1. Participants
dence for the positive predictive relationship between loneliness and
depressive symptoms in the elderly (Bodner and Bergman, 2016; Aylaz This cross-sectional survey was performed in Jinan City, Shandong
et al., 2012; Cacioppo et al., 2006). Province, China, from July to October 2017. Based on the level of
Nevertheless, not all lonely individuals report increased depressive economic development, we adopted a stratified cluster sampling from
symptoms (Weeks et al., 1980). Some protective factors may have six administrative districts. Finally, 25 public nursing homes were
worked in helping preventing loneliness from developing into depres- adopted. The elderly, capable of verbal communication, aged 60 and
sion. A series of studies have explored the underlying mechanisms (such over were recruited in the study, and those who were in terminal ill-
as mediators and moderators) between loneliness and depressive ness, severely cognitively impaired (MMSE ≤ 9, Sondell et al., 2018)
symptoms, mainly focusing on adolescence or undergraduate students and in psychotherapy were excluded. A total of 323 elderly nursing
(Swami et al., 2007; Vanhalst et al., 2012), but only few studied the home residents were included, with 9 refusing the investigation and 2
elderly in nursing homes in their researches. failing to complete the interview (effective response rate: 96.7%). Face-
Resilience is considered to be an important protective mechanism to-face interviews were conducted in their own rooms. This study was
for individuals who are faced with adversity (Bonanno, 2004). Based on approved by Shandong University Human Research Protections Pro-
the resilience framework, resilience, as a dynamic course, can play a gram. All participants were given informed consent before completing
mediating role and drive a person to grow in the face of adversity the measures.
(Kumpfer, 1999). A previous study has shown that resilience mediated
the relationship between depressive symptoms and psychological 2.2. Measures
health status among patients with heart failure (Liu et al., 2015). Also,
resilience is proposed as a potential factor to ameliorate negative 2.2.1. Sociodemographic characteristics
emotions and help maintain well-being among older persons Data on age, sex, marital status, education, self-rated financial
(Hardy et al., 2004). Empirical findings have shown that loneliness was status, administrative districts were obtained in the study. Age was
negatively correlated with resilience (Perron et al., 2014), which was divided into: 60–74 years (young-old), 75–89 years (old-old), and ≥90
found to be negatively related to depressive symptoms (Liu et al., years (the oldest-old) (Cherry et al., 2008). Marital status was cate-
2015). Therefore, resilience may mediate the association between gorized as married and unmarried (including single, divorced and wi-
loneliness and depressive symptoms. dowed). Education was classified as primary school or under, middle or
Social support is another focus in the study of protective factors for high school and college or above. Self-rated financial status was divided
depressive symptoms (Stice et al., 2004). Many studies have established into good, fair and poor.
the negative relationship between social support and geriatric depres-
sive symptoms (Lee et al., 2012; Su et al., 2012). Strengthened social 2.2.2. Mini-mental state examination
support could contribute to improving quality of life and decreasing Mini-mental State Examination (MMSE) was used to measure the
depressive symptoms (Unalan et al., 2015). According to the stress- cognitive function of the elderly in nursing homes. The scale includes
buffering model, stress (e.g., the experience of loneliness) interacting 30 items with five aspects, including orientation, registration, attention
with social support could buffer against the negative impact of stress and calculation, recall as well as language and praxis (Folstein et al.,
(e.g., depressive symptoms) (Cohen and Wills, 1985). Most of the el- 1975). Maximum total score was 30, with higher score indicating better
derly in nursing homes have certain degree of functional impairments cognitive function. MMSE ≤ 9 indicated severe cognitively impaired
and suffer from psychological distress (Alpass and Neville, 2003), (Sondell et al., 2018). In the study, the Cronbach’α was 0.904.
which means that inadequate social support will worsen the negative
impact of a stressful environment. A study among childless elderly in 2.2.3. Depressive symptoms
Canada and the U.S. found that social support buffered the negative Depressive symptoms was evaluated by using the 7-item Hospital
impact of individual-level stressors on depression (Wu and Hart, 2002). Depression Scale (HDS), which is one of the dimensions of the Hospital
A prior study has shown that social support moderated the relation Anxiety and Depression Scale and has been verified applicable and
between anxiety and depression (Xu and Wei, 2013). Besides, a specific satisfactorily reliable in nonclinical settings (Crawford et al., 2001;
study has referred to social support for having moderated the associa- Mykletun et al., 2001), including nursing homes (Drageset et al., 2013;
tion of stress and resilience (Wilks and Croom, 2008), and the relation Haugan, 2014). The total score of the scale is 0–21 points, with high
of positive psychological strengths (e.g., resilience) with subjective scores values indicating high levels of depressive symptoms. A cut-off
well-being (Khan and Husain, 2010). However, investigation of social ≥8 predicts a tendency toward depressive symptoms (Li et al., 2012).
support as directly or indirectly buffering the negative impact of lone- In this study, the Cronbach's Alpha was 0.783.
liness on depressive symptoms has been scarcely studied among the
elderly in nursing homes. 2.2.4. Loneliness
Taken together, loneliness, resilience and social support all play Loneliness was assessed by using a Chinese version of the UCLA
important roles in the endorsement of depressive symptoms, but the Loneliness Scale (Russell, 1996). The scale consists of 20 items and
possible influence of these mechanisms on depressive symptoms is not measures the feelings of loneliness, scoring on 4-point Likert scale, from
clear among the elderly in nursing homes. Hence, the present study 0 ("never") to 4 ("often"). The range of scores was 20–80, with higher
aims to assess the prevalence of depressive symptoms, explore whether scores signifying more intense feelings of loneliness. The Cronbach’ α of
resilience mediates the association between loneliness and depressive the scale was 0.932 in the current study.
symptoms, and evaluate a moderated mediation model. In the moder-
ated mediation model, we hypothesized that resilience might work as a 2.2.5. Resilience
mediator between loneliness and depressive symptoms among the Connor-Davidson Resilience Scale-10 item (CD-RISC-10) (Campbell-
nursing home elderly. In addition, social support might play a role as a Sills and Stein, 2007) was applied to measure resilience of the elderly in

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nursing homes. Each item is scored on a 5-point Likert scale (0 = never, score of MMSE was 21.44 (SD = 6.07). After analyzing data, we found
1 = rarely, 2 = sometimes, 3 = usually, 4 = always) and the total sum the prevalence of depressive symptoms among the elderly in nursing
score ranges from 0 to 40, with higher scores reflecting better resi- homes was 26.6% (HDS ≥ 8). By comparison of the means using in-
lience. The CD-RISC-10 showed high internal consistency in this study dependent t-test and ANOVA, the unmarried elderly in nursing homes
(Cronbach's α = 0.947). presented higher depressive symptoms scores (t = −2.201, p = 0.030).

2.2.6. Social support 3.2. Bivariate correlations among all the variables
Social support was measured by the 12-item Multidimensional Scale
of Perceived Social Support (MSPSS) (Zimey et al., 1988), which con- Table 2 provided the means, SD, and correlations among the vari-
tains three subscales indexing perceived support from family, friends ables studied. The results indicated that loneliness was positively re-
and significant others. The item is scored on a 7-point Likert scale (from lated to depressive symptoms (r = 0.458, p < 0.001). Resilience was
1 = strongly disagree to 7 = strongly agree) with total scores of 7–84, positively associated with social support (r = 0.255, p < 0.001), and
and higher scores reflecting higher level of social support. This scale has they were both (resilience: r = −0.531, p < 0.001; social support:
achieved satisfactory validity and reliability (Zhang and r = −0.221, p < 0.001) negatively correlated to depressive symptoms.
Norvilitis, 2002), and the Cronbach's α of the MSPSS was 0.927 in the In addition, loneliness also had a significantly negative relation to re-
present study. silience(r = −0.496, p < 0.001) and social support (r = −0.437,
p < 0.001).
2.3. Statistical analysis
3.3. Mediation analyses
Descriptive analyses, independent t-test and one-way analysis of
variance (ANOVA) were calculated for describing sociodemographic As shown in Table 3, the results of mediation analyses showed that
characteristics and comparing the distribution of depressive symptoms, the total effect (path c) of loneliness on depressive symptoms was sig-
respectively. The correlations of study variables (loneliness, resilience, nificant (B = 0.450, p < 0.001). The significant coefficient of path a
social support and depressive symptoms) were analyzed by Pearson (B = −0.486, p < 0.001) and path b (B = −0.355, p < 0.001) in-
correlation analyses. The mediation and moderated mediation model dicated negative associations of loneliness on resilience, and resilience
were analyzed using the PROCESS macro for SPSS (Hayes, 2013). The on depressive symptoms. Besides, the point estimate of indirect effect
bias-corrected 95% confidence interval (CI) was calculated with 5000 (path a * b ) between loneliness and depressive symptoms through re-
bootstrapping re-samples. Firstly, we tested whether the association silience was 0.172 (SE = 0.034), and the 95% bias-corrected bootstrap
between loneliness and depressive symptoms was mediated by resi- confidence interval was 0.111 to 0.246, which indicated that the in-
lience using Model 4 (see Fig. 1). If the 95% CI of indirect effect (path direct effect of loneliness on depressive symptoms was statistically
a* b) did not contain 0, it indicated that the mediating effect was sig- significant. In addition, the direct effect of loneliness on depressive
nificant. Next, Model 59 was used to examine the moderated mediation symptoms (path c’ = 0.278, p < 0.001) was also significant, indicating
effect, that was, whether social support moderated the direct and in- that resilience partially mediated the relationship between loneliness
direct effects of loneliness on depressive symptoms (see Fig. 2). Like- and depressive symptoms.
wise, if the 95% CI of the interaction did not contain 0, a significant
moderated mediation effect could be established. According to the 3.4. Moderated mediation analyses
Johnson-Neyman technique suggested by Hayes and Rockwood (2017),
the conditional effects and confidence bands were plotted. All statistical Table 4 showed the results of moderated mediation. According to
analyses were conducted using SPSS21.0. Statistical significance was our hypothesis, social support may function as a moderator between
defined as a two-tailed p-value of < 0.05. In addition, all models were loneliness and depressive symptoms either separately, or both in the
controlled for covariates (age, sex, marital status, education, self-rated direct effect (loneliness- depressive symptoms) and indirect effect (path
financial status, administrative districts and MMSE) and the study a: loneliness-resilience and path b: resilience-depressive symptoms).
variables were standardized. However, social support did not play a moderating role in the direct
effect (loneliness- depressive symptoms) of the mediation model
3. Results (loneliness * social support: B = −0.063, 95% CI: −0.165, 0.039). The
results of moderated mediation showed that social support only mod-
3.1. Sociodemographic characteristics and depressive symptoms erated the indirect effect of loneliness on depressive symptoms through
resilience (loneliness-resilience: B = 0.099, 95% CI 0.015, 0.183; resi-
The sociodemographic characteristics and the distribution of de- lience- depressive symptoms: B = 0.112, 95% CI 0.018, 0.206), sig-
pressive symptoms were shown in Table 1. 323 participants in nursing nifying that the indirect effect of resilience on loneliness and depressive
homes had a mean age of 78.62 (SD = 9.25), ranging from 60 to 99 symptoms was moderated by social support among the elderly in nur-
with 205 females (63.5%) and 118 males (36.5%). Most elderly in sing homes. The final moderated mediation model was displayed in
nursing home were unmarried (83.9%), reported primary school edu- Fig. 3.
cation or under (54.5%) and a fair financial status (53.3%). The mean The significant moderated mediation model was further tested by

Fig. 1. Schematic model of resilience as the mediator between loneliness and depressive symptoms (Andrew Hayes's moderation-mediation Model 4).

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X. Zhao et al. Psychiatry Research 268 (2018) 143–151

Fig. 2. Schematic model of social support as a moderator of the mediation model (Andrew Hayes's moderation-mediation Model 59).

Table 1 95% CI: 0.167, 0.350), moderate (B = 0.153, 95% CI: 0.093, 0.231)
Sociodemographic characteristics and the distribution of depressive symptoms and high (B = 0.080, 95% CI: 0.018, 0.171). Then, the Johnson-
(n = 323). Neyman technique indicated that social support, at any value (see
n (%) Depressive symptoms F/t p Fig. 4), could moderate the association between loneliness and resi-
(M ± SD) lience. But Fig. 5 showed that social support could moderate the re-
lationship of resilience on depressive symptoms when the standard
Age (mean 78.62, SD 1.457 0.235
scores of social support were lower than 1.44, in which 95% confidence
9.25 )
60–74 97(30%) 5.83 ± 4.29 internal did not include 0.
75–89 186(57.6%) 5.31 ± 3.81
90–99 40(12.4%) 6.43 ± 4.64
Sex 0.563 0.574 4. Discussion
Female 205(63.5%) 5.43 ± 3.97
Male 118(36.5%) 5.70 ± 4.13 This study investigated the prevalence of depressive symptoms,
Marital status −2.201 0.030
examined the mediating role of resilience between loneliness and de-
Married 52(16.1%) 4.67 ± 3.12
Unmarried 271(83.9%) 5.78 ± 4.21 pression, and explored the relationships among loneliness, resilience,
Education 0.798 0.451 social support and depressive symptoms via a moderated mediation
Primary school or 176(54.5%) 5.86 ± 3.88 model. The findings indicated that loneliness, resilience and social
under
support were all significantly correlated to depressive symptoms, but
Middle or high 118(36.5%) 5.25 ± 4.38
school the effects of these factors were different. Resilience mediated the as-
College or above 29(9%) 5.45 ± 3.92 sociation between loneliness and depressive symptoms. Moreover, the
Self-rated financial 2.626 0.074 indirect effect of the mediation model was moderated by social support
status in that the indirect effect of loneliness on depressive symptoms was the
Good 120(37.2%) 5.09 ± 3.72
lowest in the nursing home elderly with high social support. The results
Fair 172(53.3%) 5.72 ± 3.98
Poor 31(9.5%) 6.90 ± 5.46 also support the important effect of resilience as an internal resource on
Administrative districts 0.866 0.504 the ability of nursing home elderly to overcome the stress of being
1 55 (17.1%) 5.54 ± 4.15 lonely, without developing depressive symptoms.
2 67 (20.7%) 6.01 ± 4.48
In the present study, the prevalence of depressive symptoms among
3 44 (13.6%) 5.47 ± 3.95
4 32 (9.9%) 4.75 ± 4.58
the elderly in nursing homes was 26.6%, lower than that (40%) of the
5 61 (18.9%) 6.21 ± 3.68 elderly residing in nursing homes of the United Kingdom (Ron, 2004)
6 64 (19.8%) 5.14 ± 4.07 and those (30.0–48.0%) in Netherlands (Jongenelis et al., 2004). Recent
studies revealed that the rate for depressive symptoms among the el-
derly in nursing homes was 13–40% in China (Hua et al., 2011; Tao and
Table 2 Ma, 2013; Zheng et al., 2011; Wang et al., 2007), and regional differ-
Bivariate correlation among loneliness, resilience, social support and depressive ences and varied measurements may explain some discrepancy. Our
symptoms (n = 323).
result was higher than that of the nursing home elderly in Singapore
1 2 3 M ± SD (21.1%) (Tiong et al., 2013) and Korea (24%) (Chung, 2008), and lower
than that in Hong Kong (29%) (Chow et al., 2004). However, it was
Loneliness – – – 38.62 ± 10.39
Resilience −0.496⁎⁎⁎ – – 28.35 ± 7.16
higher than the prevalence of depressive symptoms (pooled detection
Social support −0.437⁎⁎⁎ 0.255⁎⁎⁎ – 58.17 ± 15.09 rate of depression was 22.4%) in community-dwelling elderly in a re-
Depressive symptoms 0.458⁎⁎⁎ −0.531⁎⁎⁎ −0.221⁎⁎⁎ 5.60 ± 4.07 cent meta-analysis of China (Nie et al., 2013). Generally speaking, oc-
currence rate of depressive symptoms among the nursing home elderly
⁎⁎⁎
p < 0.001 was higher, and more attention should be paid to this issue.
In the study, the mean score of loneliness was 38.62 ± 10.39,
analyzing the indirect effect of loneliness on depressive symptoms at higher than that in a previous study on loneliness (30.30 ± 8.52)
different levels of social support. As shown in Table 5, social support among community retired elderly in Shenzhen city of China
was divided into low (the mean minus one SD), moderate (the mean) (Huang et al., 2017). Likewise, social support scores (58.17 ± 15.09)
and high (the mean plus one SD). Specifically, Resilience significantly of nursing home elderly were lower than those (65.25 ± 8.92) in
mediated the association between loneliness and depressive symptoms community of Beijing (Zhao et al., 2017). However, the resilience
when social support for the nursing-home elderly was low (B = 0.249, scores (28.35 ± 7.16) among nursing home elderly were a little higher

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Table 3
Mediation analysis (n = 323).
Variable Path c Path c’ and b Path a Path a* b

B SE B SE B SE B SE LLCI ULCI

⁎⁎⁎ ⁎⁎⁎
Loneliness 0.450 0.197 0.278 0.053 – – 0.172 0.034 0.111 0.246
Resilience – – −0.355⁎⁎⁎ 0.054 −0.486⁎⁎⁎ 0.047
R2adj 0.265 0.369 0.320
F 15.528 20.343 18.429

Note: controlling for age, sex, marital status, education, self-rated financial status, administrative districts, MMSE
⁎⁎⁎
p < 0.001

than their counterparts (27.52 ± 7.90) in communities of China The current study found a partially mediating role of resilience
(Li et al., 2017). The reasonable explanation was that the elderly living between loneliness and depressive symptoms, which possibly revealed
in nursing homes was more likely to be faced with various stresses, and the underlying mechanism concerning how loneliness might indirectly
perceived less social support, which caused them to improve the resi- influence depressive symptoms. Also, our finding was in accorded with
lience. the Resilience Framework in which resilience was a dynamic process
Our results revealed a strong positive correlation between loneliness with a mediating role (Kumpfer, 1999). The study by Liu et al. (2015)
and depressive symptoms, which was consistent with previous studies provided support concerning the mediation of resilience in the link
(Cacioppo et al., 2010; Aylaz et al., 2012; Bodner and Bergman, 2016; between loneliness and depression in a more cautious way. Resilience
Wan Mohd Azam et al., 2013). In our study, the elderly in nursing helped them positively cope with and mediate different stressors (e.g.
homes, in a new environment away from their own homes and families, loneliness). In our study, loneliness was reported to be directly asso-
showed decreased social connection and more obvious loneliness, ciated with depressive symptoms; on the other hand, loneliness was
which might contribute to their expression of depressive symptoms. In negatively correlated to resilience which was reversely related to the
addition, resilience and social support were protective factors for de- level of depressive symptoms. Although former research considered
pressive symptoms, respectively as internal and external protective resilience as a stable personality (Luthar and Cicchetti, 2000), a recent
resource. Previous study referred to resilience as a protective factor study regarded it as a dynamic conceptualization which could be
against psychological disorders, with high resilience decreasing the changed and learned throughout one's lifetime (van Kessel, 2013).
level of psychological disorders (Arnetz et al., 2013). Besides, the el- Resilience-enhancing may help decrease the strength between lone-
derly with higher level of social support reported a lower level of de- liness and depressive symptoms. A recent systematic review revealed
pressive symptoms, conforming to the Main Effect Model of social that resilience training programs seem to improve the well-being in
support (Cohen and Wills, 1985). Regardless of the level of stress, social various groups, but the effect was small to moderate (Leppin et al.,
support could promote the psychological health, which was widely 2014), less significant than expected. Hence, further studies are ne-
confirmed in different populations, such as elderly (Lee et al., 2012; Su cessary to deepen our knowledge and explore specifically the effec-
et al., 2012), adults with diabetes (Tovar et al., 2015) and children tiveness of these interventions. For example, cognitive behavioral
(Kwon, 2009). For example, a longitudinal research reported that per- therapy targeting resilience-related concept, such as problem-solving
ceived social support negatively predicted the level of depression over a ability and transforming personal qualities necessary for coping with
six-month period in college students (Ruthig et al., 2009). A previous stress, was found to significantly improve resilience to help individuals
study reported a person's social support decreased over time in late life face depressive symptoms (Songprakun and McCann, 2012).
(Antonucci, 1991). Elderly in nursing homes, due to transfer from their In particular, the moderated mediation analyses demonstrated that
families and old friends to a different environment, commonly received social support moderated the strength of the relationship between
less care than in earlier stages of their life. Thus, they perceived less loneliness and depressive symptoms mediated by resilience. As pre-
social support, likely to increase the risk of depressive symptoms. dicted by Stress-Buffering Model, social support buffered the negative

Table 4
Moderated mediation analysis (n = 323).
Outcome: resilience

Variable B SE t LLCI ULCI

Loneliness −0.461 0.053 −8.691*** −0.565 −0.356

Social support 0.007 0.053 −0.139 −0.111 0.097
Loneliness*Social support 0.099 0.043 2.327* 0.015 0.183

Outcome: depressive symptoms

Variable B SE t LLCI ULCI

Loneliness 0.263 0.056 4.679⁎⁎⁎ 0.152 0.373

Resilience −0.332 0.054 −6.190⁎⁎⁎ −0.438 −0.227
Social support 0.056 0.050 1.114 −0.043 0.155
Resilience*Social support 0.112 0.048 2.355* 0.018 0.206
Loneliness*Social support −0.063 0.052 −1.219 −0.165 0.039

Note: controlling for age, sex, marital status, education, self-rated financial status, administrative districts, MMSE
*p < 0.05
**p < 0.01
***p < 0.001

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Fig. 3. The final moderated mediation model. (* p < 0.05; *** p < 0.001).

Table 5 experience loneliness as a form of psychological stress. Social support

Conditional indirect effects of loneliness on depressive symptoms at values of moderated the indirect link (loneliness-resilience as well as resilience-
social support. depressive symptoms) of loneliness and depressive symptoms, which
B SE LLCI ULCI was a reasonable result in consideration of a stressful environment for
the elderly residents. Besides, the indirect effect was lowest in the group
Low social support 0.249 0.047 0.167 0.350 with high social support, while highest with those in the low social
Moderate social support 0.153 0.035 0.093 0.231
support group. According to the Johnson-Neyman technique, it seems
High social support 0.080 0.039 0.018 0.171
that with increasing social support, the association between loneliness
and resilience got weakened, same as the relation of resilience to de-
influence of stress (e.g. loneliness). As for the elderly in nursing homes, pressive symptoms. However, when social support increased to a cer-
most of them suffered from one stressor or more, such as chronic dis- tain value (the standard score was 1.44) and over, the association be-
ease, disability, declined cognition and/or psychological problems tween resilience and depressive symptoms had no statistical
(Buchanan et al., 2002). Our study focused on the psychology of the significance. Thus, it is vital to take measures to improve social support
elderly in nursing homes and found that they are more likely to to ultimately decrease depressive symptoms among the elderly in

Fig. 4. The conditional effect of loneliness on resilience at the values of social support.

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X. Zhao et al. Psychiatry Research 268 (2018) 143–151

Fig. 5. The conditional effect of resilience on depressive symptoms at the values of social support.

nursing homes. Acknowledgement

Some limitations should be considered in the interpretation of the
results for the current study. First, the study was a cross-sectional We would like to appreciate all the participants who showed great
survey, which could not verify the temporal sequence of the in- patience in answering the questionnaires. Deepest gratitude to the au-
dependent variable, mediator, moderator and dependent variable. As thors for their help and support.
previous findings indicated that loneliness and depressive symptoms
could predict each other reciprocally in a five-wave longitudinal study Disclosure statement
(Vanhalst et al., 2012), we could not rule out the reverse causality that
depressive symptoms may cause a higher degree of loneliness through The authors declare no conflict of interest.
resilience. Therefore, further longitudinal research should be conducted
to validate the findings. Second, this study has adopted self-reported Funding
measurements writing the variables, which can be subjective. There-
fore, there may exist some self-reported bias. Besides, HDS was more This work was supported by Social Science Planning Project of
commonly used as a screening tool for depressive symptoms than a Shandong Province (Grant No. 13CWJJ25) and Reform and Research
diagnostic tool. Third, the sample we adopted was collected only from Program of Cheeloo College of Medicine, Shandong University (Grant
Jinan City in China, which can be geographically limited for a broader No. qlyxjy-201706).
generalization. As a result, a multicenter research is suggested for fur-
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