How Do We Address the Epidemic of Loneliness and Isolation?

In May 2023, US Surgeon General Vivek Murthy, MD, raised the alarm about the public health crisis of loneliness, isolation, and lack of connection. "Our epidemic of loneliness and isolation has been an underappreciated public health crisis that has harmed individual and societal health," he explained. Loneliness is an increasingly common issue that contributes to cardiovascular and cerebrovascular diseases, dementia, and depression. It can even result in premature death. The biological and behavioral mechanisms potentially involved in this association have been debated, but there still are no definitive answers. Let's look at some possible strategies for combating this epidemic.

Common Assessment Instruments

Social connection encompasses indices of social isolation and loneliness. The two values are closely related but distinct measurements.

Social isolation is an objective measurement that describes the absence of contact with others and social relations. It is measured by the quantity of social interactions. This index is assessed using three questions:

"Including you, how many people live in your house? Include those who usually live there." Patients who live alone score 1 point.
"How often do you visit friends or family or host them at your house?" Patients who visit friends or family less than once per month score 1 point.
"Which of the following [leisure or social activities] do you take part in at least once per week? You can select more than one [activity]." Patients who do not participate in leisure or social activities at least once per week score 1 point.

The results are calculated on a 3-point scale:

≥ 2 points = person is socially isolated
0 or 1 point = person is not socially isolated

Loneliness, on the other hand, is the subjective feeling of being alone and occurs as a discrepancy between an individual's desired and perceived levels in interpersonal relationships. It is more associated with the quality of relationships. The assessment of this index includes two questions:

"Do you often feel lonely?" (No: 0 points; Yes: 1 point)
"How often do you trust a person close to you?" (From "almost daily" to "once every few months": 0 points; from "once every few months" to "never or almost never": 1 point)

The results are calculated on a 2-point scale:

1 or 2 points: person suffers from loneliness
0 points: person does not suffer from loneliness

Health Policies

The Surgeon General's Advisory lays out a framework for the United States to establish a National Strategy to Advance Social Connection, based on six foundational pillars:

Strengthen social infrastructure: Connections are influenced not just by individual interactions but also by a community's physical elements (eg, parks, libraries, playgrounds) and programs and policies. To strengthen social infrastructure, communities must design environments that promote connection, establish and scale community connection programs, and invest in institutions that bring people together.
Enact pro-connection public policies: National, state, local, and tribal governments play a role in establishing policies like accessible public transportation or paid family leave that can support and enable more connection within a community or a family.
Mobilize the health sector: Because loneliness and isolation are risk factors for several major health conditions (including heart disease, dementia, and depression), as well as for premature death, healthcare providers are well positioned to assess patients for risk of loneliness and intervene.
Reform digital environments: We must critically evaluate our relationship with technology and ensure that how we interact digitally does not detract from meaningful and healing connection with others.
Deepen our knowledge: A more robust research agenda, beyond the evidence outlined in the advisory, must be established to further our understanding of the causes and consequences of social disconnection, populations at risk, and the effectiveness of efforts to boost connection.
Cultivate a culture of connection: The informal practices of everyday life (the norms and culture of how we engage one another) significantly influence the relationships we have in our lives. We cannot be successful in the other pillars without a culture of connection.

In Our Offices

There is no medication to treat social isolation and loneliness. So, what should we clinicians do? These steps are a starting point:

Recognize the severity of the problem.
Put the assessment instruments of these indicators into practice.
Prescribe socialization, which currently means referring patients in need of social support to community connection programs. But there are still some things missing, including a consensus on the definition of social prescribing, robust and large-scale methodologic studies on its clinical efficacy and cost-benefit profile, and actions for fighting loneliness systemically.

Implications

An editorial recently published in the European Heart Journal highlights the need to implement a biopsychosocial cardiovascular disease model. The authors argue, "The human species is inherently social. Humans not only require the presence of others, but also rely on meaningful social relationships to develop into healthy adulthood. As individuals, we strive to belong to a family, a peer group, a community. These social interactions with family, friends, neighbors, or colleagues are paramount for our physical and mental well-being."

It is important to note that in the longest scientific study on happiness, the happiest participants had two major factors in common throughout 85 years of follow-up: they took care of their health and built strong ties with other people.

As a result, there is an increasing awareness of the importance of valuing social relationships and the impact that they have on health. But there is still more to be done. This incentive is part of caring for the general population, our patients, and our own happiness.

This article was translated from the Medscape Portuguese edition.

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