Managing Social Isolation and Loneliness: What Can Medical Professionals Do?
By Ray McBeth, PhD
In the face of an unrelenting pandemic, societies across the world are beginning to grapple with the dramatic effects of two very important, yet often overlooked health conditions: social isolation and loneliness. Though these conditions have been ever-present, they have been significantly exacerbated by the quarantine environment required to manage the spread of the COVID-19 outbreak. As the Substance Abuse and Mental Health Services Administration (SAMHSA) recently stated, the effects of shutdown and social isolation are clear and the negative health effects are potentially long-lasting and of significant consequence. Understanding these conditions and how they contribute to overall health is imperative for both patients and medical providers as we attempt to mitigate the associated risk factors as well as plan interventions that will reduce both the immediate and long term effects of these conditions.
What are Social Isolation and Loneliness?
Social Isolation is defined as: “The objective state of having few social relationships or infrequent social contact with others.” Loneliness, by definition, is “a subjective feeling of being isolated.” While these two definitions seem very similar (and they are), the differences are also very significant.
One such difference is that social isolation is an objective state and, thus, fairly easy to measure, while loneliness is a subjective feeling which is typically measured by individual self-report.
It is also important to note that social isolation and loneliness are not necessarily related. A person might be identified (objectively) as living alone and, therefore, potentially socially isolated. However, despite their objective state, they may feel independent and self-reliant and not feel lonely at all. On the other hand, another person might appear to be surrounded by family and other connections and yet feel (subjectively) lonely due to a variety of personal perspectives on life. Individuals may fit into either of these categories at various times in their lives, or might shift from one to the other due to changing circumstances.
Unfortunately, even though social isolation, loneliness, and related conditions (e.g. social connection, social support) have been recently studied, the studies have used varying definitions of each term, making valid comparisons of the outcomes difficult. In addition, the level of isolation or connection can be measured across a variety of dimensions, including:
Structurally (Existence of various social relationships and roles) - Is the person married? Does the person live alone?
Functionally (Actual or perceived support) - Is the person in frequent contact with his or her family and friends? Do they receive meals-on-wheels?
Qualitatively (The positive and negative aspects of social relationships) - Is the person’s marriage a “happy” one? Do they get along with their siblings?
The results of many of the studies, when compared, are often inconsistent and ambiguous because of the various perspectives used and only bring up more questions. Are married people less lonely? Is it better to simply have a pet? “Well, it depends,” is the only currently available answer, which is precisely why more research using clearer definitions is needed.
Why is Addressing Social Isolation and Loneliness Important?
Social Isolation and Loneliness fall under the category of what are known in the medical field as the social determinants of health (SDOT). This means that they are factors that affect health outcomes, no less so than other more known factors such as food insecurity, housing instability, lack of transportation, interpersonal violence, and a variety of other life conditions. There is also some evidence that there may be a reciprocal relationship between some of the other social determinants and social isolation. For example, a lack of transportation may lead to increased isolation or being isolated may allow for increased interpersonal violence, where it may not otherwise occur.
Social Isolation and Loneliness impact a large percentage of the population. A Kaiser Family Foundation survey found that 22 percent of adults in the United States say they often or always feel lonely, feel that they lack companionship, feel left out, or feel isolated from others. Another study by Cigna found that 46 percent of adults surveyed reported that they sometimes or always felt alone. That study also found that 18-22 year olds were the loneliest age group and that LGBTQ+ individuals, those with lower incomes, those in poor health, and those who were unmarried reported more feelings of loneliness. Feelings of social isolation and loneliness in adolescents is well documented, but it is not limited by age, as even younger children (as young as pre-school and kindergarten) can feel lonely.
The consequences of social isolation and loneliness are significant and certainly not to be underestimated. Social isolation has been associated with a significantly increased risk of premature mortality from all causes. There is some evidence that the magnitude of the effect of social isolation on mortality risk may be comparable to or greater than other well-established risk factors such as smoking, obesity, and physical inactivity. Poor social relationships were also found to be associated with a 29 percent increase in risk of incident coronary heart disease and a 32 percent increase in the risk of stroke.
Social isolation and loneliness are also associated with cognitive decline and dementia as well as depression, anxiety and suicide. Being lonely can also effect other aspects of health; in one study those who identified as lonely were found to be 41% more likely to be affected by chronic diseases, 31% more likely to have high cholesterol levels, 40% more likely to have diabetes, and 94% more likely to report impaired health.
Who is most at risk for becoming Socially Isolated and/or Lonely?
Unfortunately, as the COVID-19 pandemic has so aptly demonstrated, all people are at some level of risk for becoming socially isolated or feeling lonely, but some are at greater risk than others. Any disruptive life event from the personal, such as loss of a job, to the international, such as the pandemic, can increase the chances of social isolation and/or loneliness. Furthermore, disruptive events also need not happen quickly. For example, the effects of aging, a long and ongoing process, can lead to social isolation and often loneliness. The factors affecting risk can be categorized along three dimensions: physical, psychological, and social.
Physical health, or perhaps more accurately the loss of physical health, increases risk. This would include most chronic conditions including heart disease, stroke, and cancer. Unfortunately, the relationship between health and isolation is bi-directional, meaning that each influences the possibility of the other. Functional status (e.g., frailty) is also bi-directionally associated with social isolation and loneliness. Sensory impairment (e.g., loss of vision or hearing) can lead to reduced social participation and social isolation. Some of this may not be inevitable; for example, hearing aids (that work) have been shown to improve social participation and reduce loneliness.
Psychological factors (psychiatric and cognitive) such as depression and anxiety have been shown to increase the risk of loneliness. For example, seniors with depression and/or anxiety report often more loneliness than those without. The impairments associated with dementia can lead to a sense of loneliness. Let us also remember the caregivers of those with physical and/or cognitive impairments who frequently end up isolated from others due to their responsibilities and limited opportunities for involvement in other activities.
Finally, social factors (cultural and environmental) can also play a significant role in creating social isolation and loneliness. Those who have supportive relationships with friends, family, neighbors and caregivers (both paid and unpaid) report less loneliness. Bereavement, which often occurs after the loss of a spouse, child, or even a pet (but can occur after any significant loss) often has loneliness as one of its symptoms. Retirement can lead to isolation and feelings of loneliness. Social environmental status, such as lack of transportation, homelessness and rural vs. urban location can affect social isolation. While there is only limited research on subgroups, it is clear that LGBTQ+ individuals tend to be more isolated and feel lonelier, as do immigrants and others who have language barriers that prevent full participation. Age, gender, race, religion, and many other factors can be used to marginalize, thus leading to isolation and often loneliness.
What does this have to do with health care?
The answer to this question can be best demonstrated through an anecdote shared by a local emergency medical technician (EMT). The EMT tells a story of an older widow who lives alone and has few friends (social factors) with some chronic health conditions, including some heart problems (physical factors) and suffers from some depression and anxiety (psychological factors). One night she experiences some perceived difficulty in breathing (this is pre-COVID) and wonders if it is her heart is acting up.
Because of her anxiety she worries that it might be serious, which only increases her sense of breathlessness. This, of course, increases her anxiety and the cycle continues. She is not sure what to do or who to call since she has few friends or trusted neighbors.
She finally reaches the point where she believes that it is serious and calls 911 who dispatches the EMTs. The EMTs reach her home and are unable to determine what might be happening so they transport her to the Emergency Department (ED), their only choice at the time. The full diagnostic result at the ED is that nothing serious is happening with her heart and she is discharged. A lot of time, money, and energy was expended in the process.
Social isolation and loneliness led to an expensive outcome that may not have been necessary. But what other choices are possible?
What Can Medical Professionals Do?
Social isolation and loneliness, along with all of the other SDOT, have historically not been considered to be under the purview of the health care system. While health care professionals were well aware that hunger, inadequate housing, lack of transportation, and even loneliness affected patient health, they believed that there was little that they, as health care professionals, could do to affect those conditions.
Fortunately, this perspective is changing as medical professionals begin to accept their role as supporters of health and not just providers of health (sick) care. This is not to suggest that the health care system bears full responsibility for solving the problems that lead to poor SDOT, but they certainly have a larger role to play. This is because they are often the first to identify a developing or existing (poor) health condition as the result of social isolation and/or loneliness. As trusted health care professionals, they may also be in a position to recommend interventions that can positively affect the patient’s overall health outcomes.
The first step in this process is for health care professionals to become more educated about the effects of social isolation and loneliness on health, including their impact on mortality and morbidity and on health care system utilization. As value-based payment systems become more prevalent, interventions regarding the SDOT, including social isolation and loneliness, will become more necessary. This is because these types of interventions often affect health outcomes much more than actual clinical interventions. Health Care Professionals at every level, including first responders and community health workers, have a role to play, but they cannot play it unless they know more about both the causes and effects of social isolation and loneliness.
Once these professionals are made aware of the causes and effects of social isolation and loneliness, their magnitude must be measured to see how significant of a threat they impose. Two of the many tools that exist for this are the Berkman–Syme Social Network Index for measuring social isolation and the three-item UCLA Loneliness Scale for measuring loneliness. As with any condition, validated instruments are crucial for ensuring that what is intended to be measured is actually measured.
It is important to remember that social isolation alone is not necessarily of concern. It is when other risk factors are present that it becomes of concern. For example, an isolated person with a heart condition may not be able to receive the treatment s/he needs if no one knows that a heart attack has occurred. Predictive analytics that measure a variety of potential risk factors are also now being used to measure the potential for social isolation to be a cause for concern or loneliness to be occurring. Technology is also being developed to monitor various conditions (e.g., heart irregularities, stroke symptoms, falls) often using wearable devices that are always present.
While there is little in the way of “treatment” for social isolation or loneliness, there are several types of proposed interventions, both direct and indirect. Direct interventions would include reaching out to identified high risk individuals to connect them to services or convening groups of high risk individuals to address their needs. Examples of indirect interventions include, for example:
Prescribing hearing or vision aids, which could lead to the ability to interact more comfortably in social settings thus decreasing isolation
Recommending group exercise, not so much for the benefit of the exercise itself, but for the benefits of interacting with others in a group setting.
Encouraging those with poor oral health, incontinence and other potentially stigmatizing conditions to use the available solutions to increase their comfort level around others.
In virtually all of these interventions, reliance on community and other resources are central for success. Specific interventions relevant to health care include:
Social Prescribing: Social prescribing is not unlike any other referral to a specialist, except that the referral is to a non-medical provider of services. The approach that a clinic or hospital can use could be very informal, such as information posted in the health care facility that the patient can act on (or not). They can also be much more comprehensive, including case management services designed to specifically identify the social determinant(s) of health, including social isolation and loneliness, that are impacting the patient. More comprehensive services also provide specific referral and follow-up to see if services were obtained. In North Carolina a unique public/private partnership has been developed called NCCARE360 to meet this referral need in all 100 counties within the State. Its goal is to not only provide access to comprehensive referral resources for every county, but also to ensure that the “loop is closed” meaning that follow-up occurs to see if services were delivered. While this service is still new, it holds much promise.
Support Groups and Group Membership: While referral to groups like these may be part of social prescribing, they deserve a specific mention. This is because they are typically peer support groups that address the needs of those with a shared condition such as diabetes or those who would benefit from cardiac rehab and including those who are socially isolated or suffering from loneliness. In addition to those referred for a specific condition, there are more generic programs such as “Silver Sneakers” which address overall health through exercise, while also providing the additional benefits of reducing social isolation and feelings of loneliness. Many generic programs, such as those provided by senior centers and churches are not currently available due to the COVID-19 pandemic, thus denying their participants the opportunities for social connectedness that were once more readily available and necessary.
Cognitive Behavioral Therapy (CBT) and Mindfulness: CBT and other forms of individual psychotherapy may also be useful in helping individuals identify and address unproductive thought patterns and other maladaptive behaviors. Mindfulness, wherein an individual focuses on openness, patience, and acceptance, may also be useful for some in reducing feelings of loneliness.
Pharmaceutical Interventions: Therapies directed towards the biological basis of feelings and decisions (often in conjunction with behavioral therapies) may be useful in managing the symptoms that lead to social isolation and loneliness.
Interventions that target SDOH Broadly: Since SDOT are often interconnected, programs of this type, frequently associated with Medicaid, are being developed to address these needs. North Carolina’s Medicaid Transformation initiative (currently on hold until 2021) includes mandatory screening of Medicaid beneficiaries in four areas of SDOH (food, housing, transportation, and interpersonal violence). While social isolation and loneliness are not specified in the required screening, we hope they will also be identified and addressed. Medicaid Transformation is also planned to include a small number of “Healthy Opportunities” pilot projects which would allow Medicaid to pay for interventions in those four areas, with the goal of making those successful types of interventions a permanent part of Medicaid in North Carolina.
Interventions that target Social Isolation and Loneliness in the Healthcare System: There have been a few trial interventions developed mostly by insurance providers in the Medicaid and Medicare markets to address social isolation and loneliness, specifically or in conjunction with other SDOH. Hopefully the success of those programs will lead to wider adoption as a way of reducing health care costs.
Interventions that target Specific Risk Factors: This approach attempts to address the underlying causes of social isolation and loneliness and remediate them. Interventions include programs to enhance cognition, to increase physical mobility, or to address bereavement.
While listed separately, each of these approaches to intervention is likely to occur in conjunction with some of the others. In addition, each can be delivered in an increasing variety of ways.
Methods of Delivering Interventions
Approaches span from the more traditional such as the use of a referral coordinator in a clinic or hospital, or an individual conducting face-to-face therapy to the traditional but innovative, such as, for example, a local community that has established a “Community Paramedic” program that allows EMTs to interact with the patient and determine if an alternative to the ED might be more appropriate (thus avoiding the scenario described earlier).
More technological approaches are also being used. Some of these range from the fairly straight forward, such as the use of video-conferencing for an office visit or therapy session instead of face-to-face, to the more sophisticated, such as the use of the Internet and social media such as Facebook pages for online support groups and groups for those with common interests. Virtual reality is also being used to create alternative environments in which to interact. Finally, social robots and conversational agents, often smart phone-based, can be used to provide interaction and support (Emtiro Health is testing out a partnership with Pyx Health which is smart phone app to support its care management patients).
Ethical Considerations
Interventions, whether traditional or technological, raise important ethical considerations including:
Accessibility – Is the intervention usable by individuals with disabilities?
Privacy and data protection - Is personal information safe and confidential?
Autonomy - Is there independence in decision making?
Informed consent – Do participants have full knowledge of the risks and uses of the data obtained?
Increased isolation - An unintended consequence of especially non-human interventions.
Safety - Is the intervention safe and functional, especially if it is new and relatively untested?
Infantilization – Is the user is treated as an adult?
Unequal access - Does an individual’s location, age, socioeconomic status, disability, or inadequate infrastructure effect their ability to access the intervention?
All of these considerations need to be taken into account as interventions are designed and implemented.
Conclusion
The causes of social isolation and loneliness are many and varied. They range from simple aging through the current pandemic. But they and many other SDOH are affecting an increasing number of individuals throughout society. They directly and indirectly increase health care costs in ways that are unnecessary. They must be addressed if a just, equitable, and cost effective health care system is to be developed and maintained.