By Jeremy Nobel, MD, MPH as published in in the blog for:
With more than 6 million diagnosed cases and nearly 200,000 deaths in the United States, the novel coronavirus is our nation’s most pressing public health crisis. And further, physical distancing measures have resulted in significant loneliness and social isolation—a parallel epidemic on the rise even before the COVID-19 pandemic. Nearly 50% of Americans report struggling with loneliness since the initial COVID surge in the US—and this loneliness can have devastating impacts on mental and physical health.
With its causal factors on the rise, the increasing numbers of people who feel lonely are also less likely to be motivated to adhere to COVID-19 public health measures, like wearing a mask and physical distancing, thereby increasing the risk for viral transmission. As a result, loneliness has turned even more deadly, and an urgent response is required. Primary care is uniquely positioned to be a leader in this response.
Primary care providers are integral to the American medical system and have long been the frontline for acute and chronic illness management, offering diagnosis, treatment, follow-up, and prevention. According to Dr. Russell Phillips, Director of the Harvard Medical School Center for Primary Care, and Dr. Andrew Ellner, Founding Co-Director of the Harvard Center for Primary Care:
Geographic areas with a higher concentration of primary care providers demonstrate better health outcomes, better healthcare quality, lower total medical expenditures, and more equitable health outcomes.
Primary care is fundamental to achieving lifetime health goals for individuals and communities, particularly when defining health as not merely the absence of disease or infirmity but achievement of complete physical, mental, and social well-being. And to achieve social well-being, there is perhaps no bigger challenge to overcome than loneliness and social isolation—especially now, in the midst of the COVID-19 pandemic.
What is loneliness?
What IS loneliness, and how does it relate to social isolation? Social isolation can be objectively measured and is defined by absence of social contact. It’s experienced by many, often by those in rural settings or living alone in urban ones and with limited interactions with others.
Loneliness, on the other hand, is purely subjective. It is the self-perceived gap between the social connections one wants to have and what one is actually experiencing. Social isolation can be linked to loneliness, but one can also be “lonely in a crowd.” Loneliness is an emotional burden felt especially keenly by certain groups, including many older adults, caregivers, certain veterans, those marginalized because of gender, race, disability or immigration status, those dealing with adverse childhood events and other traumas, and those living with chronic illness.
Why should we care about loneliness? Loneliness has long been recognized as a risk factor for mental illness, including depression, addiction, and suicidality. In many cases, loneliness may initially arise or increase in intensity from a mental health disorder, driving a pernicious cycle of increasing illness severity.
And further, loneliness has significant implications for physical health. Recent research shows that loneliness can increase mortality risk by as much as 30%—on par with smoking 15 cigarettes per day. Loneliness has also been linked to cardiovascular disease, gastrointestinal illness, musculoskeletal disorders, and dementia. While the mechanisms by which loneliness causes physical disease are unclear, the increased morbidity and mortality risk is likely linked to evidence that loneliness is pro-inflammatory and immune suppressive.
Why has loneliness been so hard to get our arms around? Stigma and silence play key roles, making it hard to track and quantify. And personal inadequacy often accompanies loneliness… many perceive loneliness as their own fault, attributable to falling short in some way, to not being worthy of friendship, attention, or authentic connection to others. Essentially, it’s something to be ashamed of. As a result, many don’t talk about their loneliness or even allow themselves to self-identify as lonely, no matter how great their distress.
But now, things may be different. Amidst the COVID pandemic, the loneliness that so many of us are experiencing directly stems from the common enemy of a potentially deadly virus. When we’re lonely as the result of a pandemic, there is nothing to feel ashamed about. In fact, we’re united in our struggle. This shared bond is a powerful invitation to talk about loneliness, engage together in physically distanced social activities to achieve some shared connection, and ultimately, enhance our social health.
The role of primary care in addressing loneliness
With the increased visibility that now surrounds loneliness, there exists an opportunity to explore new ways to identify and respond to patients’ loneliness, partnering with them to address their social well-being.
And this is where primary care can play such a timely role. We could approach loneliness the way we approach depression in primary care, with a screening tool (Patient Health Questionnaire or PHQ-9) that has become routine. Similarly, we could screen patients with a short set of questions for loneliness, then confirm loneliness with a longer screening survey or open conversation, or both. Fortunately, a fully vetted three-question screening questionnaire already exists—the UCLA Loneliness Scale.
When loneliness is confirmed, primary care providers can direct patients towards effective resources to assist them. This approach is already used extensively in the United Kingdom and referred to as “social prescribing.” A primary care team member evaluates the patient’s social circumstances, then recommends a range of activities to increase social connectedness. Activities include group programs around special interests like nature walks, crafts, creative arts, sports, volunteering in programs that serve the community (e.g. school tutoring), workshops to develop interpersonal skills, or simply opportunities to talk regularly with others. While many of these programs are already available through community centers, libraries, and faith-based organizations, patients are more likely to engage in social programs when recommended by their primary care team.
Is addressing loneliness something that primary care can take on? Already stretched thin and with high levels of burnout, primary care teams may not be equipped to do more unless payment models are adjusted to reflect the value that addressing loneliness creates. If research can demonstrate those socially connected and less lonely patients are indeed healthier—including fewer and less severe illness episodes, fewer ED visits, and fewer and shorter hospitalizations—then the money saved can be reinvested in programs and personnel. But theory alone won’t change payment models. Rigorous outcome studies are required to drive innovation, scaling, and sustainability of loneliness remediation activities.
So, back to COVID-19 as a driver for addressing loneliness. The pandemic has shone a bright light on the US healthcare system, illuminating the need for meaningful change. Because of the virus and its forced isolation, there is both an urgency and window of opportunity to design, evaluate, and optimize programs that deliver enhanced social cohesion and connectedness. Addressing loneliness within primary care fulfills our obligation to promote the achievement of health in its fullest human dimension and to make a measurable and sustained difference in the lives of our patients. How can we not give it our best shot?
Acknowledgments: The author thanks Frank Spiro (from the Foundation for Art & Healing’s UnLonely Project) for his contributions to this blog post. This post is also available on the Center for Primary Care, Harvard Medical School website.
Jeremy Nobel, MD, MPH, is a primary care physician and public health practitioner whose work focuses on exploring and promoting innovative ways to improve health and well-being for individuals and communities. He holds faculty positions at the Harvard Medical School Center for Primary Care and Harvard T.H. Chan School of Public Health. He also directs The UnLonely Project, an initiative of the Foundation for Art & Healing, a 501c3 non-profit founded in 2004.