Mental health and loneliness are connected: most of us understand that. The recent pandemic increased feelings of loneliness among many people in the U.S., and had a measurable impact on general health and wellbeing nationwide.
Mental Health, Loneliness, and the New Normal
Over the past three years, we’ve experienced a once-in-century public health crisis we all know as the COVID-19 pandemic. Spring of 2020 was stressful. The pandemic arrived, and we all watched as one by one, cities, states, and then most of the nation enacted shelter-in-place orders, social distancing requirements, mask mandates, and rules about which business could stay open – essential businesses – and which should stay closed – the non-essential businesses.
To say it was stressful is an understatement. Stress was literally off the charts. People lost jobs, lost income, long-standing business closed, kids stayed home from school, parents had to figure out how to work from home and manage their now at-home kids, other parents in essential jobs had to figure out how to manage their kids back at home doing virtual school – yes, it was stressful.
That public health crisis arrived at a moment when we were almost two decades into another public health crisis: the opioid overdose crisis, which has claimed over a million lives since 1999. We’ve enacted national strategies to address this crisis, in the same way we enacted national strategies to address the COVID-19 pandemic.
Now, in 2023 – as we’ve finally reached a new normal with regards to COVID-19 and our efforts to address the opioid crisis are beginning to have an effect – we have a new public health crisis that demands our immediate attention.
It didn’t happen overnight, and it didn’t come from nowhere, but now that it’s here, it’s time for us, as a nation, to join together and act.
We say that because, unlike these other crises, one way out of this crisis is to simply talk to one another more.
Really.
When we explain this current crisis, you’ll understand what we mean.
A Surgeon General’s Advisory on Isolation and Loneliness
First of all, let’s define what we mean by Surgeon General’s Advisory, or SGA. According to the Surgeon General’s Office, an SGA is defined as:
“A public statement that calls the American people’s attention to an urgent public health issue and provides recommendations for how it should be addressed. Advisories are reserved for significant public health challenges that require the nation’s immediate awareness and action.”
For example, recent SGAs include:
Protecting Youth Mental Health (2021)
Confronting Health Misinformation (2021)
The content of those advisories are explained by their titles. One addresses the crisis of increasing rates of mental health disorders and suicidality among youth and adolescents. The other addresses the problem of incorrect and/or misleading information about important public health topics that spreads via social media, person-to-person, or through television news and opinion programming. Both issues threaten the health and wellbeing of the general public, which is why the Surgeon General informs us of what’s going on, why it matters, and what we can do to help remedy the situation.
The latest SGA, published on May 1st, 2023, is called “Our Epidemic of Loneliness and Isolation: The U.S. Surgeon General’s Advisory on the Healing Effects of Social Connection and Community.” Here’s an excerpt from the introduction that outlines both the content and the reason for the advisory:
“Loneliness is far more than just a bad feeling—it harms both individual and societal health. It is associated with a greater risk of cardiovascular disease, dementia, stroke, depression, anxiety, and premature death. The harmful consequences of a society that lacks social connection can be felt in our schools, workplaces, and civic organizations, where performance, productivity, and engagement are diminished.”
To put it simply, the Surgeon General is the top doctor in the country. Right now, what he’s telling us is that loneliness and social isolation have a greater impact on our overall health and wellbeing than most of us realize – that’s why we need to be advised about it. As he indicates, loneliness and isolation are more than small personal problems we have to handle on our own, in silence. They impact our physical health, our psychological health, and our mental/emotional health.
In this article, we’ll focus on the impact of loneliness and isolation on mental health. First, though, we’ll define what the Surgeon General means when he says the following three things:
- Loneliness
- Social isolation
- Social connection
We’ll start with loneliness, then move on to social isolation, then discuss what the Surgeon General indicates can cure loneliness and isolation: social connection.
Social Isolation and Loneliness: Similar, But Not Identical
Most of us understand how isolation and loneliness resemble on another, but are not exactly the same thing. Think about it this way: if you’ve ever been in a room full of people but felt lonely, then you understand. You weren’t socially isolated, but nevertheless, you felt lonely. On the other hand, there may have been times when you were isolated – living alone, traveling alone, or simply spending time alone – but because of letters, the phone, the internet, or your memories, you didn’t feel lonely. You were isolated, but loneliness was not an issue.
Let’s look at how the SGA defines loneliness.
Loneliness is an internal state that’s subjective by nature. Characteristics of loneliness include:
- A sense of emptiness
- Feelings of separation, while needing to feel connection
- Feelings of not being needed or wanted, while needing and wanting to be needed and wanted
- A dissonance between emotional needs and lived emotional experiences
That’s what loneliness is: internal feelings of separation in the presence of a need for connection. Now let’s look at how the SGA defines social isolation.
Social isolation means having:
- Infrequent/low number of social interactions per day/per week
- Small number of defined social roles, such as parent, sibling, coworker, friend
- Little experience with groups/no direct membership in social groups, such as activity groups, sports clubs, trivia teams, or similar social milieus
- Few social relationships
Data from the SGA show that people who report high levels of loneliness have a 26 percent increased risk of premature mortality, while people who report high levels of social isolation have a 29 percent increased risk of premature mortality. Note: premature mortality means early death.
Now let’s look at what can counteract loneliness, isolation, and the associated negative consequences: social connection.
The Core Elements of Social Connection
When we say social connection, most of understand it refers to the various ways we, as individuals, connect with other individuals in contexts and situations that are not work, home, or school – although those relationships are part of our social networks, of course. The strength of our social connections have a direct impact on our sense of loneliness, and therefore, our mental health.
The concept of social connection is defined by more than the number of friends we have and how often we meet them for dinner or coffee. Social connection has three core elements:
- Structure. This refers to our relationships and interactions. The structure of our social connectedness is shaped by:
- How many family members we have and interact with
- How many friends we have and interact with
- Our personal relationship status
- Function. This refers to the role our social connections play in our lives. The function of our social connections is shaped by:
- The degree of social/emotional support they provide
- The quality and amount of advice and mentorship they provide
- Whether they can help us in times of crisis or emergency
- Quality. This refers to the impact of these relationships on our wellbeing: do they help us or harm us? The quality of our social connections is shaped by:
- Our satisfaction with them
- The amount of stress they cause or relieve
- How much we enjoy/derive pleasure from/feel fulfilled by them
This brings us to the core issues at the heart of the advisory: what has happened to our social connections? What caused our Surgeon General to use an alarming phrase like “an epidemic of loneliness and isolation” in a public announcement?
2003-2020: A Nationwide Decline in Social Connectedness
The SGA draws on data from a long range study called “US Trends in Social Isolation, Social Engagement, and Companionship ⎯ Nationally And By Age, Sex, Race/Ethnicity, Family Income, and Work Hours, 2003-2020” to support its primary assertion that loneliness and isolation in the U.S. has reached problematic levels and can be called a true epidemic with a negative impact on our collective mental health.
We’ll offer the top-line results from this study now.
Social Connectedness in the United States: 2003-2020
- Overall levels of social isolation – as defined above – rose by an average of 24 hours per month per person
- The amount of household social/family engagement – meaning time spent socially at home with the family – dropped by an average of 5 hours per month per person
- Average time spent in social companionship dropped by 14 hours per month per person
- Average social time spent with non-family friends/peers dropped by 20 hours per month per person
- The amount non-household social/family engagement – social time spent with family outside the home – dropped by 6.5 hours per month per person
- The amount social time we spend with others, in general, dropped by 10 hours per month per person
In addition, on average, we have fewer close friends than we did around 30 years ago.
Data shows the following:
- In 2021: Almost half the people in the U.S. said they had less than three close friends
- In 1990: About a quarter of the people in the U.S. said they had less than three close friends
The case the SGA makes is compelling: the evidence shows we’re more isolated and less connected than ever before. While the rest of this article will discuss the connection between loneliness and mental health, it’s important to understand that evidence shows social isolation and loneliness have a significant impact on physical health, as well. Loneliness and isolation increase risk of:
- Heart disease
- Hypertension
- Diabetes
- Infectious disease
- Cognitive decline
In addition, evidence from the study “Advancing Social Connection as a Public Health Priority in the United States” shows that social isolation and loneliness increase risk of premature mortality – i.e., early death – more than:
- A sedentary lifestyle
- Obesity
- Air pollution
The same study indicates social isolation and loneliness increase risk of premature mortality more than smoking 15 cigarettes a day and drinking 6 alcohol beverages a day.
Those facts are eye-opening – and everyone should know them.
Now let’s look at the impact of social isolation and loneliness on mental health.
Social Isolation, Loneliness, and Mental Health
In treatment for mental health disorders, we know that withdrawing from friends and family, ceasing participation in favorite activities, and an overall decline in social engagement in general are simultaneously symptoms and consequences of clinical mental health disorders. They also indicate increased risk of the development of the two most common mental health disorders worldwide: anxiety and depression.
With regards to anxiety and depression, data from the SGA show:
- High levels of loneliness double the chance of developing clinical depression
- Loneliness increases rates of anxiety in older adults
- Isolation increases rates of depression in older adults
- Loneliness increases risk of anxiety in children and teens
- Isolation increases risk of anxiety in children and teens
- The presence of at least one close friend or confidant reduces risk of developing depression for children and teens
That evidence is clear. Isolation and loneliness are primary contributors to the increasing rates of anxiety and depression in the U.S., and are also likely contributors to the increasing rates of anxiety and depression worldwide.
Next, we’ll look at the impact of isolation and loneliness on rates of suicidality and self-harming behavior, called non-suicidal self-injury (NSSI). A study published in 2010 called “The Interpersonal Theory of Suicide” establishes a direct connection between isolation and suicide:
“Social isolation is arguably the strongest and most reliable predictor of suicidal ideation, attempts, and lethal suicidal behavior.”
Data from a meta-analysis on the health records of over 500,000 adults shows the following:
- Compared to men who live with family, friends, or others, men who live alone have double the risk of dying by suicide
- Women who live with family, friends, or others have significantly reduced likelihood of engaging in NSSI, compared to women who live alone
- Loneliness, isolation, and low levels of social support among people in long-term medical were associated with increases in suicidal ideation. Researchers observed increased suicidality as a result of loneliness/isolation in:
- Cancer patients
- Residents of nursing homes
- Adolescents in long-term care facilities
- A study on self-harm that analyzed data from over 60,000 older adult patients showed loneliness was a primary reason for engaging in NSSI
Again, we see the evidence that caused the Surgeon General to label social isolation and loneliness as an epidemic. They’re directly associated with a host of physical, psychological, and emotional problems that impact not only the individuals who experience them, but also the families and communities they live in. In other words, when one person is isolated and lonely, they’re not the only one who experiences negative consequences: the cumulative effects of loneliness and isolation impact us all.
How Healthcare Providers Can Work to Reduce Isolation and Loneliness
The Surgeon General’s report goes beyond describing the problem: it also outlines actions steps we can take at the individual, community, public, and professional levels to increase the quantity and quality of social connectedness in our society as a whole.
Since we’re mental health treatment providers, we’ll summarize the eight-steps the Surgeon General advises in the section of the advisory titled “What Health Workers, Health Care Systems, and Insurers Can Do.”
What Providers and Clinicians Can Do: Eight Action Steps
- Recognize the fact that social connection is a critical component of overall health and wellbeing.
- Train clinicians and staff about the role of social connectedness in the healing process.
- Train clinicians and staff on the health risks of isolation and loneliness.
- Include assessment of isolation and loneliness in official medical records.
- Educate patients about the risks of insufficient social connectedness. Specific focus should be paid to people the following populations:
- Patients with chronic physical or mental conditions
- People experiencing financial insability
- Patients who live alone
- Single patients, i.e., unmarried or unpartnered
- Youth and adolescent
- Seniors age 65+
- Incorporate social connection into care across all settings, including primary- and secondary- care facilities and milieu:
- Assess social connectedness/isolation to identify at-risk patients
- Educate patients about the importance of social connectedness
- Educate patients about the dangers of social disconnection
- Provide psychosocial support to patients as needed
- Partner with community advocates to support people who are currently lonely, isolated, and have low levels of social support or lack supportive, healthy relationships.
- Evaluate assessment tools and interventions in clinical settings to improve support for specific populations at risk of experiencing the negative consequences of isolation or loneliness.
Those eight action steps are within our reach as professional clinicians working in mental health treatment: we can and will evaluate ourselves to ensure we understand how we can apply this knowledge in supporting our patients.
How Individuals Can Help Reduce Isolation and Loneliness
The list in the previous section outlines what we can do as professionals to address the loneliness epidemic.
On an individual and personal level, the action steps we can take are simple – and we’ve now come full circle. At the beginning of this article, we hinted that one way out of the crisis of loneliness is to talk to one another more. What we really mean is this: to address this epidemic, we need to look for ways to truly connect with one another. If a friend, loved one, or peer looks isolated and lonely, you can help.
How?
Go ask them how they’re doing.
That’s it.
Lead with a question and strike up a conversation: you may be surprised how much good that one simple question can do.
Gianna Melendez
Jodie Dahl, CpHT