have to write bibliography Write an Outline for your paper. From the articles you’ve looked at, what are some ideas/arguments you can make about the topic? What about a main thesis? Introduction — es

Regression analysis was applied to examine the associations between food security status, social support, and mental health. Results: Food insecurity and social support are both correlated with psychiatric symptom severity. Speci fically, support from family members has the largest protective role against food insecurity. Conclusions and Implications for Practice: This study found food insecurity is likely a critical issue to address whenever it is present in adults with severe mental illness (SMI) and type 2 diabetes. The presence offamily support mitigates the need for addressing food insecurity. Practices and policies aimed at both addressing health inequities such as food insecurity and strengthening family support among people living with SMI and comorbid medical conditions are important adjuncts to self-management interventions.

Impact and Implications Medical care for diabetes for people who have SMI must address the impact of social determinants of health, including food insecurity and social support. For adults with SMI and type 2 diabetes, family support may have important effects on the link between food insecurity and adverse mental health outcomes.

Keywords: food insecurity, social support, psychotic disorders, psychiatric rehabilitation Background Severe mental illnesses (SMI), such as schizophrenia and bipolar disorder, are associated with substantial premature cardiovascular mortality ( Olfson et al., 2015 ). Schizophrenia is the third most disabling health condition worldwide and has an annual economic burden of $300 billion in the U.S., due in large part to high rates of disability ( Wander, 2020 ). People living with severe mental ill- nesses are twice as likely to develop type 2 diabetes compared with the general population ( Stubbs et al., 2015 ). There are complex interrelated factors that increase risk for diabetes in people with psychosis. First, antipsychotic medications can increase the risk of diabetes through causing weight gain or increasing insulin resistance ( Gucciardi et al., 2019 ;Vancampfort et al., 2016 ). Second, people with SMI are disproportionally impacted by poverty and food insecurity ( Coleman-Jensen, 2010 ). Food insecurity is de fined as the disruption of food intake or eating patterns because of lack of money and other resources ( Koh et al., 2014 ). Food insecurity is correlated with poorer mental health, poorer physical health, multiple chronic conditions including diabetes, and heightened nutritional vulnerability ( Elgar et al., 2021 ;Seligman et al., 2012 ;Tarasuk et al., 2013 ). For instance, people with food insecurity are more likely to develop mental disorders ( Fang et al., 2021 ). Approximately 71% of adults with severe mental illness e xperience food insecurity ( Mangurian et al., 2013 ). This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. This article was published Online First May 5, 2022.

Cameron Michels https://orcid.org/0000-0001-7877-4370 Kevin A. Hallgren https://orcid.org/0000-0001-8386-3984 Allison Cole https://orcid.org/0000-0003-4393-464X Lydia Chwastiak https://orcid.org/0000-0003-4159-7934 Sunny Chieh Cheng https://orcid.org/0000-0001-8073-5733 We thank the participants of this study. The study was approved by the University of Washington research ethics committees. Informed consent was obtained from participants and con fidentiality was maintained. All authors have nothing to disclose.Correspondence concerning this article should be addressed to Sunny Chieh Cheng, School of Nursing and Healthcare Leadership, University of Wahington Tacoma, 1900 Commerce Street, Box 358421, Tacoma, WA 98402, United S tates. Email: [email protected] Psychiatric Rehabilitation Journal © 2022 American Psychological Association 2022, Vol. 45, No. 3, 212 –218 ISSN: 1095-158X https://doi.org/10.1037/prj0000525 212 Improving household food security status has the potential to reduce the impact of mental disorders. Limited access to adequate nutrition and high-quality diet is especially problematic to diabetes management efforts ( Krishnan et al., 2010 ) as food-insecurity is associated with poorer glycemic control. Therefore, several diabetes self-management interventions emphasize the importance of dietary interventions —such as strategies for purchasing healthy food on a budget —to mitigate the impact of poverty and social disadvantages on mental health symptoms among people with severe mental illnesses ( Druss et al., 2010 ). Low social support from natural supporters (e.g., family, schoolmates, coworkers, and community) is also strongly associated with poor mental health and food security ( Hammami et al., 2020 ; Russell & Fish, 2016 ;Stowkowy et al., 2012 ). A meta-analysis of 64 studies af firmed the association between social support and better mental health functioning ( Harandi et al., 2017 ). Substantial research and theoretical models indicate that family support plays an especially important role in self-management of severe mental illness ( Frongillo et al., 2017 ). The Family and Self-management framework by Gray et al. (2015) linked self-management of chronic conditions with family-level risk and protective factors as self-management occur in the context of family management over the lifecycle. Chronic disease management practices need to be incorporated into daily family routines in order to ensure the best possible outcomes. An Institute of Medicine (IOM) and National Research Council report ( 2011 ) also indicated that family-level involvement is an essential component of managing chronic conditions, which can impact the health and well-being of the entire family. However, research to date has been inconsistent about the nature of social support ’s moderating effect in the relationship between food security status and mental well-being among people with SMI and comorbid diabetes ( Na et al., 2019 ). This study aimed to test whether perceived social support is a moderating factor in the relationship between food insecurity and mental illness self-management among adults with SMI and comor- bid diabetes. The primary aim of the study was to characterize the association of food security, social support, and psychiatric symp- toms among adults with SMI and comorbid diabetes who receive primary care services through a large academically af filiated health- care system in Western Washington State. Speci fically, we hypoth- esized that food insecurity would be associated with more frequent psychiatric symptoms and lower social support, as shown in previous studies. Further, we hypothesized that the association between food insecurity and psychiatric symptoms would be stronger among individuals with lower social support from family members. Method Participants and Data Collection The study involved a cross-sectional survey of adults who had diagnoses of both type 2 diabetes and a severe mental illness (described below). Surveys were administered online or by tele- phone. Potential participants were identi fied through administrative data from a large academically af filiated health-care system in Western Washington State. Adults over 21 years old who received primary care services at one of twelve primary care clinics in the healthcare system between 2017 and 2020 were included in the sample if they 1) had at least one inpatient or two outpatient diagnoses of type 2 diabetes (ICD-10 codes E08-E13.9) and at least one inpatient or two outpatient diagnoses of a severe mental illness, which included schizophrenia or schizoaffective disorder (F20-F29), bipolar disorder (F31), or major depressive disorder with psychotic symp- toms (F32.3; F33.3). Those with a diagnosis of dementia were excluded, as were individuals who could not speak or read English.

Figure 1 outlines the flow of participant recruitment. Potential participants were initially introduced to the study by a mailed letter, which explained the purpose of the study and invited them to either complete the survey, learn more about the study, or decline future contact from study staff. Two weeks after the letter was mailed, an email was sent to those who had email addresses listed in the administrative data. Two email reminders were automatically sent one and 2 weeks after the email introduction to those who had neither completed the survey nor declined further contact. Indi- viduals who did not respond also received a phone call and were offered the opportunity to complete the survey over the phone. All questionnaires were administered using research electronic data capture (REDCap), a secure web-based tracking and online data acquisition system ( Harris et al., 2009 ). Participants received a $30 gift card for completing the survey. The study was approved by the University of Washington Inst itutional Review Board (IRB). Measures Demographic and Clinical Variables The survey included questions related to participants ’age, gen- der, race, ethnicity, marital status, highest level of education, and type of insurance. The survey also included questions characterizing This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Figure 1 Recruitment Flowchart * 14 potential participants ’caregivers or family members declined on their behalf when contacted by phone. ** One potential participant was deemed cognitively impaired and two potential participants had a language barrier and could not complete the survey over the phone with the research coordinator. IMPACT OF SOCIAL SUPPORT AND FOOD INSECURITY 213 participant ’s diabetes and primary psychiatric diagnosis, including duration of illnesses.

Food Insecurity Food insecurity was measured by participant self-report using the U.S. Department of Agriculture ’s Food Security Survey Module. The six items in this module address inadequate food in the household, reduced or skipped meals, or hunger because of inability to afford food. Five of the items have response options of yes or no; one item includes response options of almost every month, some months, but not every month, or only 1 or 2 months. By established convention, participants were food-insecure if two or more items were answered af firmatively ( Bickel et al., 2000 ). This survey has been widely used in community surveys and has shown associations with reduced dietary variety, increased consumption of calorically dense foods, and reduced intake of fruits and vegetables ( Hanson & Connor, 2014 ). Cronbach ’sαcoef ficient in this sample was 0.68. Multidimensional Scale of Perceived Social Support The multidimensional scale of perceived social support (MSPSS) is a brief 12-item self-reported measurement tool that measures perceived adequacy of social support from three domains: family, friends, and signi ficant others ( Wilcox, 2010 ). Participants are asked to indicate their agreement with items on a 7-point Likert scale, ranging from 1 =very strongly disagree to 7 =very strongly agree , yielding a total score between 12 and 84. Scores of 12 –48 indicate low social support, scores of 49 –68 indicate moderate social sup- port, and scores of 69 –84 indicate high social support. Several studies have demonstrated its robust psychometric properties in adults with schizophrenia ( Rabinovitch et al., 2013 ;Teh et al., 2019 ). Cronbach ’sαcoef ficient in this sample was 0.93. Mental Health (Modi fied Colorado Symptom Index) The modi fied Colorado Symptom Index (CSI) is a 14-item self- reported measurement tool that assesses frequency of mental illness symptoms ( Conrad et al., 2001 ). Survey respondents are asked to indicate how often in the last 30 days they have experienced a range of mental illness symptoms on a 0 –4 scale where 0 =not at all and 4 =at least every day . The scale includes symptoms of depression, mania, and psychosis. As this was a cross-sectional survey that could be completed online and had no clinical follow-up, the final two items that relate to suicidal and homicidal ideation were removed from this measure and the range of possible scores for this modi fied scale was 0 –48, with higher scores indicating more frequent psychiatric symptoms. The CSI has been shown to have excellent internal consistency (.92) and test-retest reliability (.71); research suggests that 30 is an appropriate “clinical ”cutoff score, that is, discriminates individuals with psychiatric disabilities ( Boothroyd & Chen, 2008 ). Cronbach ’sαcoef ficient in this sample was 0.90.

Data Analysis Data were reviewed for completeness, potential errors, and consistency issues. Variable distributions were examined to identify potential outliers and the appropriateness of outcome distributions for analysis. Descriptive analyses were performed to identify the percentage of participants reporting food insecurity and to charac- terize the mean ( SD ) responses to the measures of social support and psychiatric symptoms. Differences in mean levels of social support (full scale and family, friends, and signi ficant other subscales) and psychiatric symptoms were compared between food secure and food insecure participants using independent sample ttests. Effect sizes and 95% CI ’s of these differences were estimated using the Cohen ’s d statistics, which re flects the difference in subgroup means in pooled standard deviation units.

Linear regression analysis was used to test the hypothesis that social support would moderate the association between food inse- curity and psychiatric symptoms. Psychiatric symptoms were entered as the dependent variable, and independent variables included mean-centered MSPSS scores (main effect of social sup- port), a dummy-coded food insecurity variable (main effect of food insecurity; 0 =food secure, 1 =food insecure), and the interaction of these two measures (moderation effect). All analyses were con- ducted using SPSS statistical software ( IBM Corp, 2020 ). Results Hospital administrative data identi fied ( n=624) individuals with severe mental illness (SMI) and type 2 diabetes who received primary care between 2017 and 2020 in one of the health-care system ’s primary care clinics. Six individuals had mailing addresses that were out of state and were presumed to no longer be receiving primary care in the system. Twenty of these individuals had no valid mailing addresses, phone numbers, nor email addresses in the administrative data and could not be contacted. Of the 598 individuals who we attempted to reach by letter, email, or phone, 156 completed the survey for a response rate of 26%. Three individuals were ineligible (two did not speak or read English and one could not demonstrate capacity to consent to the study) and 146 (22%) were reached out to but declined to participate. Fifty-eight percent of respondents filled out the survey online and 42% completed the survey over the phone with the study coordinator. Of the 156 respondents ( Table 1 ), majority were White ( N=107; 69%), male ( N=73; 46.8%); reported income below the federal poverty line ( N=67; 44%) and had a primary psychiatric diagnosis of bipolar disorder ( N = 93; 59.6%). Most participants were Medicaid/Medicare bene ficiaries while 24.6% of the patricians were privately insured. The average age was 51.89 years old ( SD =12.59) and duration of diabetes ranged from 0 to 41 years ( M=12.8, SD =9.3). The study results are representative of the population of adults with diagnosis and diabetes because the sex and ethnicity distributions of the (57% White, 56% male) in this partici- pated health-care system in Western Washington State are aligned with the demographics distributions in our study.

Thirty-nine participants (25% of the sample) met the criteria for food insecurity (i.e., af firmative response to ≥2 of the 6 questions on the Food Security Survey Module). These respondents cut the size of their meals or skipped meals because there was not enough money for food. Of people who skipped meals in the past year, 50% did so almost every month. Twenty-three participants (16% of the sample) reported having low social support, 61 (43% of sample) reported moderate social support, and 58 (41% of sample) reported high social support. The mean score on the CSI was 19.36 ( SD =12.00), suggesting that participants, on average, experienced psychiatric symptoms like racing thoughts and paranoia several times per month This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 214 MICHELS, HALLGREN, COLE, CHWASTIAK, AND CHENG (not daily or weekly). Table 2 presents the differences between food- insecure and food-secure individuals on social support and psychi- atric symptom severity. Compared with participants with food security, those with food insecurity had signi ficantly lower social support ( Mdifference =0.69, d=0.47, p=.008), with a signi ficant difference between food insecure and food secure patients being present for the subscale re flecting social support from family ( Mdifference = 1.17, d= 0.26, p< .001), but not the subscale re flecting social support from friends ( Mdifference = 0.54, d= 0.29, p= .061) or signi ficant others ( Mdifference = 0.30, d= − 0.20, p = .19). People with food insecurity also had greater psychiatric symptom severity than people with food security ( Mdifference =6.57, d=−0.95, p<.001). Table 3 presents results from the regression model testing for the potential moderating effect of social support on the association between food insecurity and psychiatric symptom severity. The results indicate that both food security and perception of social support were independently and additively associated with fre- quency of mental health symptoms ( p< .01), such that food insecurity and/or lower perception of social support were each associated with more frequent psychiatric symptoms. However, social support did not signi ficantly moderate the relationship between food security and frequency of psychiatric symptoms, as indicated by a nonsigni ficant food insecurity ×Perception of social support interaction (see Table 3 ). Discussion This study fills an important knowledge gap related to the relationships among food security, social support, and psychiatry symptoms ( Gray et al., 2020 ) for individuals with severe mental illness (SMI) and type 2 diabetes. Our study found that food insecurity is signi ficantly associated with both perceived low sup- port from family and elevated severity of psychiatric symptoms. In this sample of adults with SMI and type 2 diabetes receiving primary care through a large academically af filiated health-care organization, 25% were living with food insecurity. Forty-four percent of parti- cipants reported annual household income less than $15,000, which could be a main source of food insecurity ( Sareen et al., 2011 ). 59.6% of our sample reported that they or someone else in their household was receiving some form of food assistance like food stamps. This could contribute to the lower rate of food insecurity when compared with the rate of individuals reporting income levels below the federal poverty line. As suggested by both the evidence from this and previous studies ( Silverman et al., 2015 ), future research should explore the feasibility and ef ficacy of screening low-income individuals with both SMI and diabetes for food insecurity in both mental health and primary care settings.

Our study reaf firms the signi ficant association between food insecurity and elevated severity of psychiatric symptoms suggested by previous research ( Martin et al., 2016 ). In one study for example, two-third of the people with food insecurity had a bipolar diagnosis and 39% had a major depression diagnosis. The impact of the mood episodes of bipolar disorder on diabetes may be quite different than the impact of schizophrenia symptoms and functional impairment on diabetes. Because previous studies have revealed that, among people with diabetes, food insecurity is signi ficantly associated with depressive symptoms, experts have recommended addressing eco- nomic issues in conjunction with addressing psychosocial issues for comprehensive diabetes care ( Silverman et al., 2015 ). Given this, physicians should connect adults who experience food insecurity in food assistance programs ( Patil et al., 2018 ;Sareen et al., 2011 ) such as Supplemental Nutrition Assistance Program, Meals on Wheels and local food pantries ( Holben & Myles, 2004 ). Strategies to strengthen the accessibility and reach of nutritional assistance This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Table 1 Characteristics of Survey Respondents (N =156) Characteristics N % Age (years) 21 –35 18 11.5 36 –44 29 18.6 45 –59 62 39.7 60 –74 42 26.9 75 + 5 3.2 GenderMale 73 47.0 Female 81 52.0 Nonbinary 2 1.0Race a White 107 68.6 Black 32 20.5 Asian 9 5.8Native American/Native Alaskan 11 7.1 Native Hawaiian or Paci fic Islander 2 1.3 Other 11 7.1 Latinx (any race) 7 4.5Marital statusSingle 62 39.7 Divorced/widowed 45 28.9 Married/living with partner 49 31.4Education levelBelow high school 13 8.3 High school or equivalent 79 50.6 2-year or 4-year degree 53 33.9Higher than 4-year degree 11 7.2 Household income (in USD) b Below $15,000 67 44.1 $15,000 –$24,999 19 12.5 $25,000 –$49,000 25 16.4 $50,000 –$74,999 12 7.9 $75,000 –$99,999 10 6.6 $100,000 and above 19 12.5Health insurance a Medicaid 78 50.0 Medicare 96 61.5 Private insurance 38 24.4VA or military 4 2.6 None 2 1.3 Primary psychiatric diagnosis c Schizophrenia 28 17.9 Schizoaffective disorder 15 9.6 Bipolar disorder 93 59.6 Major depressive disorder 11 7.1 Other psychotic disorder 6 3.8Duration of diabetes (years since diagnosis)0 –1 years 22 14.1 2 –5 years 24 15.4 6 –10 years 33 21.2 11 –15 years 28 17.9 16 –20 years 20 12.8 More than 20 years 29 18.6 Note . VA = Veterans Affairs. aParticipants were allowed to select more than one response. bFour participants did not disclose income. cThree participants did not disclose primary psychiatric diagnosis IMPACT OF SOCIAL SUPPORT AND FOOD INSECURITY 215 programs ( Melchior et al., 2009 ) are worthy public policy goals to ensure that resources are prioritized for this vulnerable population with mental health conditions.

We additionally con firmed the association between food insecurity and lower social support. Our study further examined the roles of social support and found support from families was signi ficantly associated with food security status. This finding is consistent with a recent study ( Mokari-Yamchi et al., 2020 ) that among support from family, friends, and signi ficant others as measured by the MSPSS, family support has the largest protective role against food insecurity.

This result provides a better understanding of the relationship between food insecurity status and perceived support from families and may identify new intervention targets for individuals with SMI and diabetes.

In our study, food insecurity is signi ficantly higher among individuals reporting elevated psychiatric symptom severity and lower perceived social support, but the moderating effect of social support on the relationship between food insecurity and psychiatry symptoms, was not statistically signi ficant. This finding is consistent with a prior study ( Martin et al., 2016 ). There are two potential explanations for this lack of moderating effect. First, previous research suggests that there is a gender difference in self-reported level of food insecurity. Men tend to underreport food insecurity ( Carter et al., 2011 ) while women have a higher probability of being food insecure relative to men ( Broussard, 2019 ). Inconsistent with previous findings, there was no signi ficant difference between the food security status of men and that of other genders in this sample.

Second, both social support levels and the food security status were self-reported, and there is a risk of self-report bias. The finding that the presence of social support did not mitigate the need for addressing food insecurity suggests a critical need for government and community-based programs who care for people with SMI and comorbid diabetes to speci fically address food insecurity and additional social and contextual factors ( Muldoon et al., 2013 ). The findings from this study should be interpreted in light of several limitations. First, causality cannot be determined from this cross-sectional study. This is especially important as the frequency of mental illness symptoms only represent respondent ’s experiences in the most recent month. Second, self-reported data may result in recall bias. Third, only 26% of the 614 people identi fied by hospital administrative data completed the survey. The sample restriction limits the generalizability of our findings to the U.S. adults with severe mental illness and diabetes but provides important new information about the population generally at risk for food insecurity.

In particular, it is possible that those whom we were unable to reach or who did not complete the survey were more likely to be experiencing food insecurity, which would result in our findings under-estimating the true prevalence of food insecurity in this population. The individuals who completed this survey were man- aging their mental illnesses effectively as they were only experienc- ing symptoms several times a month as opposed to daily or weekly.

A sample with more frequent psychiatric symptoms might have a higher prevalence of food insecurity. It is important to note that 26% is a high response rate for mail surveys, and the only individuals we can be certain that we reached are those who either completed the survey, agreed to complete the survey but were ineligible, or who actively declined. Finally, our study did not explore how speci fic mechanisms of social support might impact psychiatric symptom frequency or food insecurity, but we did investigate which speci fic group of natural supports (family, friends, and signi ficant others) might have the greatest effect. Our finding that support from family may have the greatest impact on food insecurity is consistent with previous studies which have shown that strengthening supports from family may alleviate mental distress ( Cheng et al., 2014 ). In conclusion, food insecurity is a critical issue to address whenever it is present and may have particularly signi ficant clinical implications for people with mental health conditions who also manage chronic conditions such as diabetes. References Bickel, G., Nord, M., Price, C., Hamilton, W., & Cook, J. (2000). Measuring food security in the United States: Guide to measuring household food security . US department of agriculture. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Table 2 Differences Between Food-Insecure and Food-Secure Individuals on Social Support and Psychiatric Symptoms Measure Food insecure ( n=39) Food secure ( n=117) Cohen ’sd p M(SD) M(SD) Estimate [95% CI] Social support (full scale) 3.97 (1.28) 4.66 (1.54) 0.47 [0.09, 0.85] .008 Family subscale 3.54 (1.69) 4.71 (1.87) 0.26 [0.26, 1.02] <.001 Friend subscale 3.85 (1.98) 4.38 (1.76) 0.29 [ −0.08, 0.66] .061 Signi ficant other subscale 4.62 (1.89) 4.92 (1.83) −0.20 [ −0.20, −0.53] .192 Psychiatric symptoms mean 27.34 (11.91) 16.77 (10.89) −0.95 [ −1.34, −0.55] < .001 Note . The social support full scale and the family, friends, and signi ficant other subscales have a possible range of 1 –5, with higher scores re flecting greater perceived social support. The measure for psychiatric symptoms has a possible range of 0 –48, with higher scores re flecting more frequent and severe mental illness symptoms.

Table 3 Linear Regression Model Predicting Frequency and Severity of Mental Illness Symptoms by Food Insecurity and Perceived Social Support Effect Unstandardized coefficients Standardized coefficients p B (SE) β (Intercept) 16.84 (1.07) <.001 Food insecurity 10.37 (2.35) 0.37 <.001 Perceived social support − 1.90 (0.70) −0.24 .008 Food insecurity ×Perceived social support 1.274 (1.61) 0.07 .430 216 MICHELS, HALLGREN, COLE, CHWASTIAK, AND CHENG Boothroyd, R. A., & Chen, H. J. (2008). The psychometric properties of the Colorado Symptom Index. Administration and Policy in Mental Health , 35 (5), 370 –378. https://doi.org/10.1007/s10488-008-0179-6 Broussard, N. H. (2019). What explains gender differences in food insecurity?

Food Policy ,83,180 –194. https://doi.org/10.1016/j.foodpol.2019.01.003 Carter, K. N., Kruse, K., Blakely, T., & Collings, S. (2011). The association of food security with psychological distress in New Zealand and any gender differences. Social Science & Medicine ,72(9), 1463 –1471. https:// doi.org/10.1016/j.socscimed.2011.03.009 Cheng, Y., Li, X., Lou, C., Sonenstein, F. L., Kalamar, A., Jejeebhoy, S., Delany-Moretlwe, S., Brahmbhatt, H., Olumide, A. O., & Ojengbede, O.

(2014). The association between social support and mental health among vulnerable adolescents in five cities: Findings from the study of the well-being of adolescents in vulnerable environments. The Journal of Adolescent Health ,55(Suppl. 6), S31 –S38. https://doi.org/10.1016/j. jadohealth.2014.08.020 Coleman-Jensen, A. J. (2010). U.S. food insecurity status: Toward a re fined de finition. Social Indicators Research ,95(2), 215 –230. https://doi.org/10 .1007/s11205-009-9455-4 Conrad, K. J., Yagelka, J. R., Matters, M. D., Rich, A. R., Williams, V., & Buchanan, M. (2001). Reliability and validity of a modi fied Colorado Symptom Index in a national homeless sample. Mental Health Services Research ,3(3), 141 –153. https://doi.org/10.1023/A:1011571531303 Druss, B. G., Zhao, L., von Esenwein, S. A., Bona, J. R., Fricks, L., Jenkins- Tucker, S., Sterling, E., & Lorig, K. (2010). The Health and Recovery Peer (HARP) program: A peer-led intervention to improve medical self- management for persons with serious mental illness. Schizophrenia Research , 118 (1–3), 264 –270. https://doi.org/10.1016/j.schres.2010.01.026 Elgar, F. J., Pickett, W., Pförtner, T. K., Gariépy, G., Gordon, D., Georgiades, K., Davison, C., Hammami, N., MacNe il, A. H., Azevedo Da Silva, M., & Melgar-Qui ˜nonez, H. R. (2021). Relative food insecurity, mental health and wellbeing in 160 countries. Social Science & Medicine ,268 ,Article 113556. https://doi.org/10.1016/j.socscimed.2020.113556 Fang, D., Thomsen, M. R., & Nayga, R. M. (2021). The association between food insecurity and mental health during the COVID-19 pandemic. BMC Public Health ,21(1), Article 607. https://doi.org/10.1186/s12889-021- 10631-0 Frongillo, E. A., Nguyen, H. T., Smith, M. D., & Coleman-Jensen, A. (2017).

Food insecurity is associated with subjective well-being among individuals from 138 countries in the 2014 Gallup World Poll. The Journal of Nutrition , 147 (4), 680 –687. https://doi.org/10.3945/jn.116.243642 Grey, I., Arora, T., Thomas, J., Saneh, A., Tohme, P., & Abi-Habib, R. (2020).

The role of perceived social support on depression and sleep during the COVID-19 pandemic. Psychiatry Research ,293 , Article 113452. https:// doi.org/10.1016/j.psychres.2020.113452 Grey, M., Schulman-Green, D., Kna fl, K., & Reynolds, N. R. (2015). A revised Self- and family management framework. Nursing Outlook ,63(2), 162 –170. https://doi.org/10.1016/j.outlook.2014.10.003 Gucciardi, E., Yang, A., Cohen-Olivenstein, K., Parmentier, B., Wegener, J., & Pais, V. (2019). Emerging practices supporting diabetes self-management among food insecure adults and families: A scoping review. PLOS ONE , 14 (11), Article e0223998. https://doi.org/10.1371/journal.pone.0223998 Hammami, N., Leatherdale, S. T., & Elgar, F. J. (2020). Does social support moderate the association between hunger and mental health in youth? A gender-speci fic investigation from the Canadian Health Behaviour in School-aged Children study. Nutrition Journal ,19(1), Article 134. https:// doi.org/10.1186/s12937-020-00648-3 Hanson, K. L., & Connor, L. M. (2014). Food insecurity and dietary quality in US adults and children: A systematic review. The American Journal of Clinical Nutrition ,100 (2), 684 –692. https://doi.org/10.3945/ajcn.114 .084525 Harandi, T. F., Taghinasab, M. M., & Nayeri, T. D. (2017). The correlation of social support with mental health: A meta-analysis. Electronic Physician , 9 (9), 5212 –5222. https://doi.org/10.19082/5212 Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G.

(2009). Research electronic data capture (REDCap) —A metadata-driven methodology and work flow process for providing translational research informatics support. Journal of Biomedical Informatics ,42(2), 377 –381. https://doi.org/10.1016/j.jbi.2008.08.010 Holben, D. H., & Myles, W. (2004). Food insecurity in the United States: Its effect on our patients. American Family Physician ,69(5), 1058 –1063. https://www.aafp.org/afp/2004/0301/p1058.html IBM Corp. (2020). IBM SPSS statistics for windows (Version 27.0). Koh, H. K., Blakey, C. R., & Roper, A. Y. (2014). Healthy People 2020: A report card on the health of the nation. JAMA ,311 (24), 2475 –2476. https:// doi.org/10.1001/jama.2014.6446 Krishnan, S., Cozier, Y. C., Rosenberg, L., & Palmer, J. R. (2010).

Socioeconomic status and incidence of type 2 diabetes: Results from the Black Women ’s Health Study. American Journal of Epidemiology , 171 (5), 564 –570. https://doi.org/10.1093/aje/kwp443 Mangurian, C., Sreshta, N., & Seligman, H. (2013). Food insecurity among adults with severe mental illness. Psychiatric Services ,64(9), 931 –932. https://doi.org/10.1176/appi.ps.201300022 Martin, M. S., Maddocks, E., Chen, Y., Gilman, S. E., & Colman, I. (2016).

Food insecurity and mental illness: Disproportionate impacts in the context of perceived stress and social isolation. Public Health ,132 ,86 –91. https:// doi.org/10.1016/j.puhe.2015.11.014 Melchior, M., Caspi, A., Howard, L. M., Ambler, A. P., Bolton, H., Mountain, N., & Mof fitt, T. E. (2009). Mental health context of food insecurity: A representative cohort of families with young children. Pediatrics ,124 (4), e564 –e572. https://doi.org/10.1542/peds.2009-0583 Mokari-Yamchi, A., Faramarzi, A., Salehi-Sahlabadi, A., Barati, M., Ghodsi, D., Jabbari, M., & Hekmatdoost, A. (2020). Food security and its association with social support in the rural households: A cross-sectional study. Preventive Nutrition and Food Science ,25(2), 146 –152. https:// doi.org/10.3746/pnf.2020.25.2.146 Muldoon, K. A., Duff, P. K., Fielden, S., & Anema, A. (2013). Food insuf ficiency is associated with psychiatric morbidity in a nationally representative study of mental illness among food insecure Canadians.

Social Psychiatry and Psychiatric Epidemiology ,48(5), 795 –803. https://doi.org/10.1007/s00127-012-0597-3 Na, M., Miller, M., Ballard, T., Mitchell, D. C., Hung, Y. W., & Melgar- Qui ˜nonez, H. (2019). Does social support modify the relationship between food insecurity and poor mental health? Evidence from thirty-nine sub-Saharan African countries. Public Health Nutrition ,22(5), 874 –881. https://doi.org/10.1017/S136898001800277X National Research Council. (2011). Toward an integrated science of research on families: Workshop report . Olfson, M., Gerhard, T., Huang, C., Crystal, S., & Stroup, T. S. (2015).

Premature mortality among adults with schizophrenia in the United States.

JAMA Psychiatry ,72(12), 1172 –1181. https://doi.org/10.1001/jamapsychia try.2015.1737 Patil, S. P., Craven, K., & Kolasa, K. (2018). Food insecurity: How you can help your patients. American Family Physician ,98(3), 143 –145. Rabinovitch, M., Cassidy, C., Schmitz, N., Joober, R., & Malla, A. (2013).

The in fluence of perceived social support on medication adherence in fi rst-episode psychosis. Canadian Journal of Psychiatry ,58(1), 59 –65. https://doi.org/10.1177/070674371305800111 Russell, S. T., & Fish, J. N. (2016). Mental health in lesbian, gay, bisexual, and transgender (LGBT) youth. Annual Review of Clinical Psychology , 12 , 465 –487. https://doi.org/10.1146/annurev-clinpsy-021815-093153 Sareen, J., A fifi, T. O., McMillan, K. A., & Asmundson, G. J. G. (2011). Relationship between household income and mental disorders: Findings from a population-based longitudinal study. Archives of General Psychiatry , 68 (4), 419 –427. https://doi.org/10.1001/archgenpsychiatry.2011.15 Seligman,H.K.,Jacobs,E.A.,Lo ´pez, A., Tschann, J., & Fernandez, A. (2012). Food insecurity and glycemic control among low-income patients with type 2 diabetes. Diabetes Care ,35(2), 233 –238. https://doi.org/10.2337/dc11-1627 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. IMPACT OF SOCIAL SUPPORT AND FOOD INSECURITY 217 Silverman, J., Krieger, J., Kiefer, M., Hebert, P., Robinson, J., & Nelson, K. (2015). The relationship between food insecurity and depression, diabetes distress and medication adherence among low-income patients with poorly-controlled diabetes. Journal of General Internal Medicine ,30(10), 1476 –1480. https://doi.org/10.1007/s11606-015-3351-1 Stowkowy, J., Addington, D., Liu, L., Hollowell, B., & Addington, J. (2012). Predictors of disengagement from treatment in an early psychosis program.

Schizophrenia Research ,136 (1–3), 7 –12. https://doi.org/10.1016/j.schres .2012.01.027 Stubbs, B., Vancampfort, D., De Hert, M., & Mitchell, A. J. (2015). The prevalence and predictors of type two diabetes mellitus in people withschizophrenia: A systematic review and comparative meta-analysis. Acta Psychiatrica Scandinavica ,132 (2), 144 –157. https://doi.org/10.1111/ acps.12439Tarasuk, V., Mitchell, A., McLaren, L., & McIntyre, L. (2013). Chronic physical and mental health conditions among adults may increase vulner- ability to household food insecurity. The Journal of Nutrition ,143 (11), 1785 –1793. https://doi.org/10.3945/jn.113.178483 Teh, W. L., Shahwan, S., Abdin, E., Zhang, Y., Sambasivam, R., Devi, F.,Verma, S., Chong, A. S., & Subramaniam, M. (2019). Con firmatory factor analysis and measurement invariance of the multidimensional scale of perceived social support in young psychiatric and Non-Psychiatric Asians.

Annals of the Academy of Medicine, Singapore ,48, 314 –320. Vancampfort, D., Correll, C. U., Galling, B., Probst, M., De Hert, M., Ward, P. B., Rosenbaum, S., Gaughran, F., Lally, J., & Stubbs, B.

(2016). Diabetes mellitus in people with schizophrenia, bipolar disorder and major depressive disorder: A systematic review and large scale meta- analysis. World Psychiatry ,15(2), 166 –174. https://doi.org/10.1002/ wps.20309 Wander, C. (2020). Schizophrenia: Opportunities to improve outcomes and reduce economic burden through managed care. The American Journal of Managed Care ,26(Suppl. 3), S62 –S68. https://doi.org/10.37765/ajmc .2020.43013 Wilcox, S. (2010). Multidimensional scale of perceived social support.

Psychological Trauma: Theory, Research, Practice, and Policy ,2(3), 175 –182. https://doi.org/10.1037/a0019062 Received August 31, 2021 Revision received December 17, 2021 Accepted March 10, 2022 ▪ This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 218 MICHELS, HALLGREN, COLE, CHWASTIAK, AND CHENG