Loneliness as epidemic

By Wendy S. Salkin

Just a few weeks ago, The New York Times ran an article confirming that, indeed, we are facing an epidemic of loneliness. There is “mounting evidence” that links loneliness to illness, as well as “functional and cognitive decline.” What’s more, loneliness turns out to be a better predictor of early death than obesity.

Neuroscientist John Cacioppo, who has spent much of his career working on loneliness, defines “loneliness” as “perceived social isolation.” Similarly, Masi, et al. (following Russell, et al. 1980) define “loneliness” as “the discrepancy between a person’s desired and actual social relationships.” As Masi, et al., point out, there is a distinction to be made between loneliness, on the one hand, and social isolation, on the other, although the two phenomena may indeed often go together. Whereas social isolation “reflects an objective measure of social interactions and relationships,” loneliness “reflects perceived social isolation or outcast.” Following Peplau & Perlman 1982 and Wheeler, et al. 1983, they go on to point out that “loneliness is more closely associated with the quality than the number of relationships.” (It’s important and timely to note that the 2016 Nobel Laureate in Literature, Bob Dylan, brought out one application of this conceptual distinction in his song, “Marchin’ to the City,” when he sang: “Loneliness got a mind of its own / The more people around the more you feel alone.”)

The health risks posed by loneliness are several and can be severe. Loneliness can contribute to increased risk of coronary heart disease, cardiovascular disease, and stroke. In a 2016 systematic review and meta-analysis in Heart, Valtorta, et al., reported that “poor social relationships were associated with a 29% increase in risk of incident CHD [coronary heart disease] and a 32% increase in risk of stroke.” And in a March 2015 meta-analysis in Perspectives on Psychological Science, Holt-Lunstad, et al., reported that a substantial body of evidence supports the following two claims:

  1. Loneliness puts one at greater risk for premature mortality. In particular, “the increased likelihood of death was 26% for reported loneliness, 29% for social isolation, and 32% for living alone.”
  2. The heightened risk for mortality due to “a lack of social relationships” (whether reported loneliness, social isolation, or living alone) is greater than the risk due to obesity.

And it looks like, at least in some cases, we might have our parents to thank for our loneliness. An article published in Neuropsychopharmacology on September 15 concludes that loneliness is “a modestly heritable trait.”

Although it may be that loneliness poses health risks for all of us, there is a portion of our population that is particularly susceptible to the physical and psychological risks associated with loneliness: older adults.  In May 2015, Drs. Gerst-Emerson and Jayawardhana published an article in the American Journal of Public Health, “Loneliness as a public health issue that disproportionately affects older adults,” in which they reported that “a sizable proportion of those aged 60 years and older in the United States report loneliness.” The results of their study showed that “chronic loneliness contributes to a cycle of illness and health care utilization.” And, while they found that loneliness was linked to increased health care utilization—which we might well have surmised from the results of the aforementioned studies—they posit a further reason why older adults might avail themselves of medical services: “to meet their need for interaction and interpersonal stimulation.” Among the support they offer for this conjecture, the authors point to survey data gathered by the Campaign to End Loneliness: “Three quarters of surveyed family doctors estimated that between 1 and 5 patients a day visited their practice primarily because they were lonely. The campaign estimated that as many as 1 in 10 patients visiting their family doctors in the United Kingdom were there not because of a medical need but because they were lonely.”

What are some strategies that can be pursued and implemented to reduce loneliness, and in so doing hopefully improve patient health? In their July 2016 article in Heart, Holt-Lunstad & Smith propose a number of steps that can and ought to be taken to improve medicine’s responsiveness to the loneliness epidemic at both the clinical and population levels. At the clinical level, they recommend that:

  • Medical training and continuing education for healthcare professionals should include the use of medical case examples and textbooks that integrate discussion of “social factors…to provide realistic patient descriptions with life circumstances relevant to disease development, progression and response to treatment,” as well as explicit instruction concerning how these professionals can make effective referrals to mental health and social support services; and that
  • Patient information at hospitals and clinics “should include assessments of social integration and/or loneliness in electronic medical records” so as to make it easier to identify individuals who are at risk.

At the population level, they recommend that:

  • Major health organizations like the American Heart Association should follow the lead of the WHO in including social connections in lists that identify major risk factors for cardiovascular disease; and that
  • Government and professional health organizations should “establish recommendations for social relationship quantity and quality for the broader population and specific risk groups.”

As the abovementioned New York Times article discusses, there are some resources available to those facing loneliness, at least in the United Kingdom. They cite, in particular, The Silver Line, which describes itself as “the only free confidential helpline providing information, friendship and advice to older people, open 24 hours a day, every day of the year.”(Although it should be noted that the Institute on Aging, a non-profit based in San Francisco, runs The Friendship Line, which provides similar services within the United States.) And Oprah, for her part, brought attention to the health risks associated with loneliness in her Just Say Hello campaign, launched in February 2014.

Given our increased awareness that loneliness can have profound effects on us psychologically and physically (particularly as we age), we are faced with pressing questions concerning what obligations we have to mitigate the effects of loneliness on the health and well-being of others, particularly insofar as social inclusion can mitigate loneliness. Here are just two questions to get us started:

  1. Do we each have some obligation to make it the case that others do not experience loneliness? More specifically:
    1. Insofar as loneliness can be combatted by reducing another’s social isolation, are we duty-bound to ensure that others do not remain socially isolated insofar as it is possible for us to do so (consistent with our other obligations)?
    2. And what is the scope of such a duty, if we have it? Whose social isolation are we responsible to combat—only those we know, only those to whom we are related?[1]
  2. If it is the case that loneliness ought to be treated as a public health issue—and indeed, as an epidemic, as scholars have more recently urged—what role ought our national and state governments play in stemming the tide of this epidemic?

With respect to Question 2, it should be noted that the Administration on Aging (AoA), an agency within HHS, is “designated to carry out the provisions of the Older Americans Act of 1965 (OAA),” which Act (1) “promotes the well-being of older individuals by providing services and programs designed to help them live independently in their homes and communities,” and (2) “empowers the federal government to distribute funds to the states for supportive services for individuals over the age of 60.” So, it may be that it falls to the AoA to determine how best to channel this new research on the serious health effects of loneliness into their strategies for meeting the needs of aging Americans.

In addition to these questions, which I’ll aim to consider in greater detail in coming weeks, I’ll close by noting that despite the recent focus on loneliness as a public health issue that disproportionally affects older persons, we ought also to consider how these findings on the health effects of loneliness can provide support for ongoing efforts to reform and limit the use of solitary confinement in American prisons and immigration detention facilities.

[1] Answering this question will, in part, depend on whether one thinks children have special obligations to parents and other aging relatives and what those obligations turn out to be.

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