Posted on Monday July 9 2018 by RIG Healthcare
By Baguiasri Mandane
Loneliness can often be described as an emotional perception of lack or loss of companionship associated with social isolation.1 But its interpretation is subjective, individuals can also feel lonely regardless of the breadth of their social networks.1-2 This particular topic has caught significant attention not only from the UK Prime Minister but also Public Health England directors, specialists from the World Health Organization and various researchers across the world.2-7
The Impact of Loneliness
Statistics from the Age UK review “Loneliness in Later Life” state that over 1 million older people say they always or often feel lonely, and nearly half say that television or pets are their main form of companionship.8 But how significant is this? How can we understand this subject better? In terms of threat, loneliness can be just as harmful as smoking 15 cigarettes a day.8 Research has also shown that individuals with a high degree of loneliness are twice as likely to develop Alzheimer’s disease.8 This subject does not only affect older people, but also the younger individuals. Up to 85% of young disabled adults (age: 18-34 years) also feel lonely.3 Loneliness has been shown to increase the likelihood of mortality by 26%.4 So is loneliness really the new reality of modern life?
Physiological and Psychological Changes
Loneliness and social isolation negatively impact on both physical and mental health, increasing the risk of morbidity and mortality.2, 4, 9 The scientific mechanisms underpinning this changes are wide-raging. Hawkley and colleagues highlighted that chronic social isolation, rejection and/or feelings of loneliness in early childhood, adolescence and young adulthood, exhibit a dose-response relationship with cardiovascular health risk, including increased systolic blood pressure.9 Scientific evidence has also shown loneliness to be associated with higher concentrations of adrenaline in overnight urine samples in middle-aged and older adult samples.9 At higher concentrations, adrenaline binds to α-1 receptors on vascular smooth muscle cells, in turn causing vasoconstriction and thereby potentially contributing to the increase in systolic blood pressure.9
The link between loneliness and mental health conditions, ranges from personality disorders, depression, addiction and psychoses to suicide and impaired cognitive performance and cognitive decline over time.9 The impact of loneliness extends to heightened feelings of vulnerability and unconscious vigilance for social threat, implicit cognitions adversely impacting relaxation and sound sleep.9 Research conducted by Kiecolt-Glaser and colleagues has demonstrated loneliness to be associated with significantly higher concentrations of cortisol in urine samples.9-10 Additionally, other studies show a similar pattern in saliva samples and plasma cortisol levels.9, 11-12 But what does this really mean? The relevance of this association between loneliness and hypothalamo-pituitary-adrenocortical regulation, can impact changes occurring at gene level.9 Cortisol activates the glucocorticoid receptor at molecular level, exerting anti-inflammatory effects by inhibiting pro-inflammatory signalling pathways. This conflicts, with the research findings which suggest loneliness to be associated with increased risk of inflammatory diseases. Various studies have found evidence around glucocorticoid insensitivity at gene expression level in chronically lonely individuals versus socially connected older adults.9-13 Furthermore, the impact of the markers of immune activation and inflammation being over-expressed in genes of the lonely group, have implications thus favouring increased cell cycling and inflammation in the lonely group.9 Translating this to clinical context, chronic exposure to high levels of glucocorticoids (e.g. cortisol) have been shown to have neurotoxic effects on the brain.13
Lastly, there is an element of “emotional pain” and personal experiences which science often struggles to measure objectively.14 In 2016, Veerocchio and colleagues conducted a systematic review around “mental pain” and suicide.14 Their findings highlighted that whilst mental pain shows to be a predictor of suicidal behaviour, loneliness and other interpersonal difficulties show to be predictors of the seriousness and lethality of suicidal behaviour.14 The point is that “mental pain” is a critical factor in understanding various consequences (e.g. suicide) in the context of both mood disorders and independently from depression.14 This interrelates to clinical practice in that healthcare professionals suspecting loneliness, should be aware of the higher suicidal risk in patients reporting mental pain and signpost or refer these patients to the appropriate services at the earliest possible opportunity.
Thinking about Solutions
First and foremost, it is important to recognise that social isolation and loneliness are two different things and although they can be interlinked, they require different interventions.2
There are currently various cross-organisational approaches aiming to tackle this issue. From evidence reviews of “what works” for using a community assets-based approach aimed at reducing social isolation to various other projects, such as the pilot with the Fire and Rescue services aiming to identify lonely older adults and signpost to relevant services.2 Additionally, work is also being done alongside the Alzheimer’s Society to promote Dementia Friendly Communities to address loneliness in people living with dementia. A number of evidence based resources have also been created for Professionals: Mental Health Employer Toolkit and Wellbeing in Mental health, in addition to the Suicide Prevention Toolkit.2
How can you help as a Healthcare Professional in the fight against loneliness?
As a pharmacist you might see patients suffering from loneliness, but this might not always become apparent unless conversation strikes. It is important to start these conversations with patients and if there is any suspicion of loneliness, below are some details for signposting services:
1) Age UK: https://www.ageuk.org.uk/information-advice/health-wellbeing/loneliness/; You can help patients to sign up for a free weekly friendship call or sign up for a "befriender service" where volunteers can visit the person’s home or call to offer regular conversation while building lasting companionships.
2) Royal Voluntary Service: Good Neighbour Community Volunteer Scheme: https://www.royalvoluntaryservice.org.uk/get-help/support-at-home/good-neighbours
3) Become a Campaign Support: End Loneliness Campaign – https://www.campaigntoendloneliness.org/about-the-campaign/
4) The Silver Line: “The Silver Line operates the only confidential, free helpline for older people across the UK that’s open 24 hours a day, seven days a week.” Link: https://www.thesilverline.org.uk/what-we-do/
5) Independent Age: help people sign up for receiving regular phone calls or visits. Link: https://www.independentage.org/get-support
Future Research Directions
It appears to be that there are a lot of “reactive” measures and campaigns out there to address loneliness. Going forward more needs to be done to ensure “proactive” measures are taken to address this potential dangerous epidemic. Future directions should aim to prevent this from arising in the first place. Possible solutions could include investing more in local services. For example, better transportation services, more local community services both for the young and senior citizens, better strategies to address those at risk, and possibly introducing awareness of these concepts earlier on not just in schools but also in workplaces. If you want to help make a difference but do not know where to start, why not become a "Campaign to End Loneliness" supporter? Link: https://www.campaigntoendloneliness.org/support-us/
(1) Jo Cox Commission. (2018) Jo Cox Commission on Loneliness: Combatting loneliness one conversation at a time – a call to action. Available from: https://www.jocoxloneliness.org/pdf/a_call_to_action.pdf [Date accessed: 30/03/2018]
(2) Ali, N. (2017) Public Health England: Recognising the Impact of Loneliness: a Public Health Issue. Available from: http://www.insidegovernment.co.uk/uploads/2017/05/nuzhatali.pdf [Date accessed: 30/03/2018]
(3) Gov.uk (2018) PM commits to government-wide drive to tackle loneliness. Available from: https://www.gov.uk/government/news/pm-commits-to-government-wide-drive-to-tackle-loneliness [Date accessed: 30/03/2018]
(4) Henderson, G. (2013) Public Health Approaches to Social Isolation and Loneliness: A Health and Wellbeing Directorate Seminar. Available from: https://www.campaigntoendloneliness.org/wp-content/uploads/downloads/2013/07/Public-Health-Approaches-to-Social-Isolation-and-Loneliness-Part-1.pdf [Date accessed: 30/03/2018]
(5) Yasamy, M.T. Dua, M. Harper, S.S. (2013) Mental Health of Older Adults, Addressing a Growing Concern. Available from: http://www.who.int/mental_health/world-mental-health-day/WHO_paper_wmhd_2013.pdf [Date accessed: 30/03/2018]
(6) Freyer, F. (2018) ‘Loneliness kills’: Former surgeon general sounds alarm on emotional well-being. The Boston Globe. Available from: https://www.bostonglobe.com/metro/2018/01/16/former-surgeon-general-sounds-alarm-hidden-toll-loneliness/GweBtw1woQyll1Tl8CYpVL/story.html [Date accessed: 30/03/2018]
(7) Baker, B. (2017) The biggest threat facing middle-age men isn’t smoking or obesity. It’s loneliness. The Boston Globe. Available from: https://www.bostonglobe.com/magazine/2017/03/09/the-biggest-threat-facing-middle-age-men-isn-smoking-obesity-loneliness/k6saC9FnnHQCUbf5mJ8okL/story.html?p1=Article_Related_Box_Article [Date accessed: 30/03/2018]
(8) Age UK. (2015) Evidence Review: Loneliness in Later Life. Available from: https://www.ageuk.org.uk/globalassets/age-uk/documents/reports-and-publications/reports-and-briefings/health--wellbeing/rb_june15_lonelines_in_later_life_evidence_review.pdf [Date accessed: 30/03/2018]
(9) Hawkley, L. Cacioppo, J. (2013) Loneliness Matters: A Theoretical and Empirical Review of Consequences and Mechanisms. Annals of Behavioral Medicine. Volume 40 (2). DOI: 10.1007/s12160-010-9210-8.
(10) Kiecolt-Glaser, J.K. Ricker, D. George, J. et al. (1984) Urinary cortisol levels, cellular immunocompetency, and loneliness in psychiatric inpatients. Psychosomatic Medicine. Volume: 46 (1), 15-23. PMID: 6701251.
(11) Steptoe, A. Owen, N. Kunz-Ebrecht, S.R. et al. (2004) Loneliness and neuroendocrine, cardiovascular, and inflammatory stress responses in middle-aged men and women. Psychoneuroendocrinology. Volume: 29 (5), 593–611. DOI: 10.1016/S0306-4530(03)00086-6.
(12) Pressman, S.D. Cohen, S. Miller, G.E. et al. (2005) Loneliness, social network size, and immune response to influenza vaccination in college freshmen. Health Psychology. Volume: 24 (4), 297–306. DOI: 10.1037/0278-622.214.171.1247.
(13) Lupien, S.J. Juster, R. Raymond, C. et al. (2018) The effects of chronic stress on the human brain: From neurotoxicity, to vulnerability, to opportunity. Frontiers in Neuroendocrinology. Available from: https://doi.org/10.1016/j.yfrne.2018.02.001 [Date accessed: 30/03/2018]
(14) Verrocchio, M. Carrozzino, D. Marchetti, D. et al. (2016) Mental Pain and Suicide: A Systematic Review of the Literature. Frontiers in Psychiatry. Available from: https://doi.org/10.3389/fpsyt.2016.00108 [Date accessed: 30/03/2018]
Author details and bio:
Baguiasri Mandane, graduated with a 1st class honours degree (MPharm) from De Montfort University in 2014. She then completed her pre-registration and succeeding junior residency training at the University Hospitals of Leicester NHS Trust. Mandane now works as a Specialist Pharmacist – Clinical Oncology and Haematology at the Trust.
Mandane is also an Ambassador for the Pharmacist Support Charity, member of the Royal Pharmaceutical Society’s Leicestershire, Northamptonshire and Rutland Steering group, Hospital Employee PDA Representative for the West and Wales Region, Clinical Tutor for the PreRegRoom and Visiting Lecturer at the Leicester School of Pharmacy, De Montfort University.
RIG Healthcare are proud to support Mental Health research. Daniel Conway-Smith, our Specialist Doctors recruiter, is taking part in the Prudential Ride London 100 mile cycle ride on Sunday 29th July 2018 in aid of MIND, The Mental Health Charity fits perfectly with this blog to help make people aware of mental health illnesses. Dan has set himself a target to raise £500 for MIND which is very close to his heart, if you would like to you can donate here.