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Loneliness—The Missing Element in the Social Determinants of Health

When thinking about the Social Determinants of Health, one would assume Loneliness should be front and center. Yet, the Social Determinants of Health do not specifically mention loneliness. In the following article we will define what loneliness is, the risks associated with loneliness, major causes, and how to combat loneliness for yourself or your patients.

What is Loneliness?

Emily Dickinson called loneliness “the horror not to be surveyed,” If anyone knew about loneliness, it would be Emily Dickinson.

Robin Williams once said: “I used to think the worst thing in life was to end up all alone. It’s not. The worst thing in life is to end up with people who make you feel all alone.”

These two quotes provide insights into loneliness and how the lonely perceive it.  Loneliness corresponds to a discrepancy between an individual’s preferred and actual social relations. This discrepancy leads to the negative experience of feeling alone and/or the distress and unease of feeling socially isolated even when among family or friends. This definition underscores the fact that feeling alone or lonely does not necessarily mean being alone, nor does being alone necessarily mean feeling lonely. 

Social isolation denotes few social connections or interactions, whereas loneliness involves the subjective perception of isolation – the discrepancy between one’s desired and actual level of social connection. Our social relationships are widely considered crucial to emotional wellbeing; however, the possibility that social connection may be a biological need, vital to physical wellbeing and even survival, is commonly unrecognized.

Loneliness is different from being alone. Being alone refers to the objective state of social isolation when people have no or only a limited number of contacts with others. In contrast, loneliness is defined as “perceived social isolation,” emphasizing its subjectivity.  At least a third of people studied before COVID 19 expressed feelings associated with loneliness. That number has risen to almost 40% as a result of COVID 19.

The Risks Associated with Loneliness

Loneliness can contribute to a constellation of physical and psychiatric dysfunctions and or psychosocial risk factors, including depression, alcoholism, suicidal thoughts, aggressive behaviors, social anxiety, and impulsivity. In addition, loneliness is a risk factor for cognitive decline and the progression of Alzheimer’s Disease, recurrent stroke, obesity, increased vascular resistance, elevated blood pressure, abnormal ratios of circulating white blood cells, smoking, physical inactivity, high blood pressure

While each example is an endpoint in itself, researchers have identified each as a pathway to mortality risk. Thus, we also have substantial evidence supporting psychological, behavioral, and biological pathways by which social connections influence risk for premature mortality. 

While many U.S. health organizations have been slow to recognize this, the World Health Organization (n.d.) explicitly recognizes the importance of social connections. Indeed, many nations around the world now suggest we are facing a loneliness epidemic. The challenge we face now is what we can do to respond. Sustained efforts, attention, and resources are needed to address loneliness and its associated risks adequately.

Is Loneliness the Cause or Byproduct?

There is now strong evidence relating more significant depressive symptoms to increased progression from normal cognition to mild cognitive impairment and from mild cognitive impairment to dementia. Many researchers suggest that loneliness and low-grade and more severe depression may have similar effects on the brain. Loneliness was linked to worsening cognitive function over a 12-year period, whereas initially, poor cognitive function did not increase loneliness.

When looking at the relationship between loneliness and social isolation, researchers find there is no significant correlation.  One may exist without the other.  However, loneliness is both a risk factor and a consequence of depression. We can also conclude that loneliness may be the byproduct of many of the health risks described above. The risk is in ignoring loneliness and only treating the underlying health risk.

What Can We Do

We know that the experience of loneliness is a growing public health concern that is largely ignored, despite the broad-reaching detrimental impacts on mental and physical health. But even before COVID-19, we were slow to address the need of the lonely. There were some programs designed to address loneliness. 

In Great Britain, the Commission on loneliness created ‘The Campaign to End Loneliness’, which took a more grassroots advocacy approach. They built up a network of more than 2,500 organizations and people in the U.K. who campaign to policymakers and commissioners. They actively spread awareness on social media, facilitate shared learning among the network members, and partner with academics and specialists to make research actionable.

They established the great get-together where neighborhoods invited one and all to share lunch, company, and social interaction; over 10,000 people joined the event.

In another program, the ‘Great Wirral Door Knock’ was a local push to identify the ‘hidden lonely’ within a metropolitan area, which used loneliness’ heat maps’ to identify communities most in need of support. 

In the United States, a few programs include “Just Say Hello,” created by Oprah Winfrey, Sanjay Gupta, and Gayle King and supported by Skype, the AARP Foundation Initiative on Social Isolation, and the Do-It Campaign to end isolation. 

These campaigns created before COVID 19 were essential to raise awareness about and reduce the stigma surrounding loneliness, but these represent only a first step. Effective treatments are also needed.

Since COVID-19, many communities have started programs that reach out to the lonely and the socially isolated; towns, college campuses, and regional areas have all started these types of programs.  In addition, “The UnLonely Project” through the Foundation for the Art & Healing has resources and tools to engage in creative activities and enable social connections. Researchers at the University of Massachusetts published It’s the Little Things: A Community Resource for Strengthening Social Connections.” These and other projects are attempting to connect lonely and socially isolated people with others in their community.

Social media is also available to make connections. While it may allow for connection, it also can make users feel less connected, not enough likes or friends.  There is no one answer to the conundrum of social media during the pandemic, and it is both a means to connect and maybe a means to a greater sense of social isolation and loneliness.

Last Thoughts

We can screen for loneliness; the UCLA loneliness scale is only three questions.  The DeJong  Gierveld Loneliness Scale is only six questions. The time to screen and calculate is minimal; the value of the information is without question. To make these simple questions a part of Social Determinant of Health assessments would bring loneliness to the front in understanding how critical factors impact health.  Finally, maybe we could all just knock on a door and say hi, understanding the quality of that simple interaction.

 

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