Understanding loneliness and its relationship with mental health issues
Intended for healthcare professionals
Evidence and practice    

Understanding loneliness and its relationship with mental health issues

Bronwen Williams Mental health nurse and educator, Bronwen Williams Development Training & Consultancy, Worcestershire, England

Why you should read this article:
  • To enhance your understanding of the causes and effects of loneliness

  • To recognise the link between loneliness and mental health issues

  • To identify different ways to support people who are experiencing loneliness and social isolation

The coronavirus disease 2019 (COVID-19) pandemic has brought loneliness and related issues to the forefront of public awareness. Most people will have experienced some form of social isolation or loneliness during the repeated lockdowns and shielding requirements that were introduced to reduce the spread of infection. Mental health issues can also lead to loneliness and social isolation, while loneliness can produce similar signs and symptoms to mental health issues or exacerbate such issues. This article explores the concept of loneliness and its effects and describes how, in its most severe form, it can result in significant mental and physical harm. The article also considers what mental health practitioners, including nurses, can do to support people at risk of or experiencing loneliness.

Mental Health Practice. doi: 10.7748/mhp.2022.e1601

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@stray_hamster

Correspondence

bronwen.williams@yahoo.com

Conflict of interest

None declared

Williams B (2022) Understanding loneliness and its relationship with mental health issues. Mental Health Practice. doi: 10.7748/mhp.2022.e1601

Acknowledgements

This article was written following the author’s involvement with the Better Together Project, funded by The Health Foundation and supported by Public Health Wales. The author would like to acknowledge this project and its contributors

Published online: 11 January 2022

Most people experience social isolation and loneliness at some point in their lives (Mind 2019, Shovestul et al 2020) and these experiences can occur across all social groups and in all age ranges (British Red Cross and Co-op 2016). Loneliness is linked with suboptimal health outcomes, is a greater risk factor for mortality than obesity and has been recognised as a public health concern (Holt-Lunstad et al 2015). The issue was highlighted by the work of MP Jo Cox, who set up a cross-party loneliness commission before her death in 2016, which published a report entitled Combating Loneliness One Conversation at a Time (Jo Cox Commission on Loneliness 2017). In 2018 the UK Government published its strategy for addressing the issue (Department for Digital, Culture, Media and Sport (DDCMS) 2018), while in Wales loneliness has been identified as the seventh highest public health issue contributing to suboptimal health and well-being (Public Health Wales NHS Trust 2018).

The coronavirus disease (COVID-19) pandemic has affected everyone’s social relationships and may have prompted people to consider their importance, bringing loneliness and related issues to the forefront of public awareness. It also may have provided an opportunity for mental health practitioners to reflect on their own experiences of enforced social isolation and to use these to be increasingly alert to how reduced or no social contact might affect those with mental health issues.

This article explores the concept of loneliness and its effects, dispels some common myths and discusses what mental health practitioners, including nurses, can do to support people at risk of or experiencing loneliness.

Social isolation and loneliness

The terms social isolation and loneliness are often used interchangeably but although they are related they are different entities (Holt-Lunstad et al 2015). Social isolation is objective and describes a situation in which reduced or no meaningful contact with others can be observed and measured, while loneliness is a subjective condition in which there is a difference between the quality and/or number of relationships that people experience and what they would like to experience (Holt-Lunstad et al 2015). The two concepts are complex; for example, some people may prefer to have little contact with others but do not feel lonely or isolated, while for others simply increasing social contact might not reduce their loneliness (Holt-Lunstad et al 2015).

Many people will have experienced feeling alone, isolated or lonely while being with others, and living alone or being alone in other ways does not necessarily cause loneliness (Evans et al 2019). Globally, over the past 50 years the way people live has changed, with increasing numbers aspiring and choosing to live alone (Klinenburg 2014), sometimes driven by a desire to be independent and autonomous (Gawande 2014). According to Klinenburg (2014), who has written extensively on the subject, even older people often choose to live alone and in Europe around one in three of them are doing so.

The causes of loneliness are complex and multifaceted. Common triggers are life events that reduce or remove connections with others, such as a loss of important relationships, significant health issues or retirement (British Red Cross and Co-op 2016). Other life events include becoming a parent, moving to a different area or accommodation, change in employment, becoming a carer, experiencing bullying or leaving care (DDCMS 2018). For some people loneliness may be a consequence of mental health issues but for others it can lead to mental health issues (Mind 2019).

Transient and chronic loneliness

A British Red Cross and Co-op (2016) investigation of loneliness in the UK identified two types: transient and chronic. Transient loneliness is regarded as a ‘normal’ experience that everyone encounters at some point in their life (Mind 2019) and is an important internal mechanism, like hunger, that alerts people to something that requires attention (Cacioppo et al 2014). Therefore, transient loneliness highlights the need for a person to address the deficit in the quantity and/or quality of their social contacts and prompts them to seek connections with others. While uncomfortable, it is short-lived if new connections are sought and made (Cacioppo et al 2014). However, if loneliness becomes ingrained it can stop people from connecting with others (British Red Cross and Co-op 2016), potentially leading to chronic loneliness (Holt-Lunstad et al 2015).

Chronic loneliness can have significant negative effects on people’s physical and mental health. For example, it can increase the risk of coronary heart disease by 29% and of stroke by 32% (Valtorta et al 2016) and increases the risk of premature mortality (Holt-Lunstad et al 2015). The effects of chronic loneliness on people’s mental health and well-being can include feeling unsafe and hypervigilant to social threats, which can result in low expectations or suspicion regarding social interactions (Hawkley and Cacioppo 2010).

It has been suggested that a third type of loneliness, known as ‘lockdown loneliness’, has emerged from the COVID-19 pandemic and the requirements to socially distance, work from home, self-isolate or shield for extended periods (Office for National Statistics (ONS) 2020). It is likely that, for most people, lockdown loneliness will be transient and remedied as social contact increases, but for others it could lead to chronic loneliness.

Key points

  • Mental health practitioners need to be aware of social isolation and loneliness, particularly chronic loneliness, and the different ways in which this can affect people

  • Loneliness can induce thoughts, emotions and behaviours that can be misinterpreted as signs and symptoms of mental health issues such as anxiety, depression, psychosis or dementia

  • Conversely, mental health issues can cause loneliness, which can subsequently increase the risk of self-harm or suicide

  • A combination of three models of support has been recommended to address loneliness, depending on an individual’s circumstances: preventative, responsive and restorative support

People most affected by loneliness

Certain age groups are more at risk of loneliness than others. Although older people are most likely to be considered at risk of loneliness, this is not the case. Evidence suggests that people in the 16-24 years age group are most likely to experience loneliness (ONS 2020, Shovestul et al 2020), followed by those in their fifties (Holt-Lunstad et al 2015, Campaign to End Loneliness 2020). This may be because younger people often measure social interactions and connections in terms of quantity, while people in their fifties tend to view relationships in terms of quality (Shovestul et al 2020). Thus, older people may focus on having fewer but more valuable relationships (Gawande 2014).

As well as being more discerning about where they invest their social energy, older people appear to have a ‘sense of coherence’, the psychological resources people develop to cope with stressors, and it appears that life experiences give older people greater resilience when experiencing challenges (Di´az-Castillo and Razo-Gonza´lez 2018). Another factor for older people, and for individuals with health conditions, is that they often have appointments around which they have to base their daily lives, which can leave less time and energy for social contacts (British Red Cross and Co-op 2016). This reduction in the time available for social interaction, careful investment of energy and sense of coherence might explain why older people do not report loneliness as much as might be expected. This does not appear to have changed during the COVID-19 pandemic, despite the need for this group to socially distance and shield. For example, McQuaid et al (2021) conducted an online survey in Canada (n=661) to examine the negative health effects of the pandemic on potentially at-risk groups and found that the younger age groups continued to be the loneliest.

The UK government’s Wellbeing and Loneliness - Community Life Survey 2020/21 (DDCMS 2021) identified that women are more likely to report loneliness than men. However, men can have difficulty making more than superficial connections with other men (British Red Cross and Co-op 2016) and can find it challenging to seek assistance and support (Public Health England 2019). This is recognised by initiatives such as Men’s Sheds, a global movement that provides community spaces for men to connect, with the aim of reducing loneliness and isolation.

Assessing loneliness

Various standards for measuring loneliness are used in research, and it can be beneficial for mental health practitioners, including nurses, to use some of these in their practice. For example, the ONS (2018) suggested using four simple questions to identify different aspects of loneliness (Table 1). The first three of these questions are from the University of California, Los Angeles (UCLA) three-item loneliness scale (Hughes et al 2004) and the last question asks directly how often a person feels lonely, which is used in the Community Life Survey (DDCMS 2021). The lowest possible combined score on the UCLA scale is 3, indicating less frequent loneliness, and the highest is 9, indicating more frequent loneliness. There is no standard accepted score for which a person would definitely be considered lonely (ONS 2018), but these questions can instigate conversations about isolation and loneliness and give an indication of a person’s situations and experiences.

Table 1.

Questions to identify different aspects of loneliness

SourceQuestionsResponse options
University of California, Los Angeles (UCLA) three-item loneliness scale (Hughes et al 2004)How often do you feel that you lack companionship?
  • Hardly ever or never (score 1)

  • Some of the time (score 2)

  • Often (score 3)

How often do you feel left out?
  • Hardly ever or never (score 1)

  • Some of the time (score 2)

  • Often (score 3)

How often do you feel isolated from others?
  • Hardly ever or never (score 1)

  • Some of the time (score 2)

  • Often (score 3)

Loneliness question from the Community Life Survey (Department for Digital, Culture, Media and Sport 2021)How often do you feel lonely?
  • Often or always

  • Some of the time

  • Occasionally

  • Hardly ever

  • Never

The fourth question can be asked after the first three or, if there are time pressures for the assessor, it can be used on its own. However, this question may result in under-reporting due to the potential shame or stigma associated with feeling lonely (ONS 2018). The first three questions are useful because they relate to different aspects of loneliness and people might respond more accurately.

Effects of loneliness on mental and physical health

Chronic loneliness can affect people’s self-worth significantly and can be challenging for them to admit to because of the stigma and sense of shame associated with being lonely (British Red Cross and Co-op 2016). People might feel they have nothing of value to contribute, which can result in their perception that they do not deserve support and should not burden others. Consequently, people who are lonely are less likely to consult a GP or other potential sources of support (British Red Cross and Co-op 2016).

Research by the British Red Cross and Co-op (2016) identified that those who were lonely often said they looked and acted differently and did not ‘feel like themselves’. They also often avoided others, spoke less, had altered sleep and eating patterns and took less care of their appearance and personal hygiene. Furthermore, the effect of loneliness on people’s self-confidence and purpose in life can include thoughts of self-harm and suicide (British Red Cross and Co-op 2016). These signs and symptoms could be regarded and assessed as those associated with mental health issues, such as depression, psychosis or the onset of dementia, rather than chronic loneliness.

It is not only those who experience loneliness who can behave differently – the people around them and their communities can avoid or shun them and move them to the edges of social groups. This issue was recognised by participants in the British Red Cross and Co-op (2016) investigation, who said they felt unwelcome in their own communities. These experiences can reduce the likelihood of people accessing the social contacts and situations that could assist them with chronic loneliness. This ‘loneliness loop’ (Hawkley and Cacioppo 2010) can become a spiral of negative thoughts, emotions and behaviours that leads to suspicion and avoidance of others, making finding and accepting psychological support and other interventions highly challenging.

Chronic loneliness can increase anxiety, anger and depression, consequently reducing people’s ability to experience pleasure from available social contacts (British Red Cross and Co-op 2016). People who are lonely experience more depressive signs and symptoms than those who are not, while depression and loneliness have so many similar signs, symptoms and experiences that it can be challenging to distinguish between them (Mushtaq et al 2014). Loneliness is also linked to personality disorders, particularly borderline personality disorder (Mushtaq et al 2014).

Mushtaq et al’s (2014) review of the psychological aspects of loneliness recognised that it can affect cognition and increase the risk of developing dementia significantly, although it is not clear whether this is due to the effects of loneliness on cognition or because the process of dementia leads to loneliness. Fox et al (2021) conducted a longitudinal study of post-traumatic stress disorder (PTSD) and loneliness in older people (n=1,276) in the Netherlands, finding that these conditions had many similar features, such as feeling alienated, sleep issues, negative thinking patterns and social withdrawal. The authors also found that treatment for PTSD in those with the two conditions was less effective because the loneliness maintained the signs and symptoms of PTSD (Fox et al 2021).

Shovestul et al (2020) undertook a US study involving 4,885 people aged 10 years to 97 years, which used the three-item UCLA loneliness scale to examine risk factors. They identified that loneliness peaks at the age of 19 years, slowly reduces then starts to increase again in later years. The authors drew attention to the fact that this peak is similar to the age at which the incidence of psychotic disorders peaks, which is 20 years, and noted that loneliness is often accompanied by social withdrawal, social exclusion and social isolation, recognised predictors of the onset of psychotic disorders (Shovestul et al 2020). Therefore, early intervention services should observe and/or assess for loneliness in clients referred for support.

Loneliness can lead to or exacerbate alcohol misuse and sleep issues, which increase the risk of developing or exacerbating mental health issues. A UK study by Wang et al (2020) explored whether loneliness at baseline in people who had experienced mental health crises (n=310) and been treated by community crisis teams predicts suboptimal outcomes at follow up. It found that loneliness indicated poorer recovery and quality of life.

Mental health practitioners should consider how people’s experience of loneliness, particularly chronic loneliness, can mimic the signs and symptoms of mental health issues and, conversely, how mental health issues can lead to chronic loneliness. For example, the negative signs and symptoms of psychosis – such as a lack of interest in other people, avoiding social contact and low motivation (National Institute for Health and Care Excellence (NICE) 2014) – may cause or exacerbate loneliness. People with bipolar disorder may be particularly prone to loneliness due to the social consequences of manic episodes and depression (NICE 2021). For individuals with anxiety, avoiding social contact may lead to loneliness, which could initially be transient but become chronic if support and/or treatment are not sought or offered. Misuse of substances such as drugs or alcohol is another potential cause of isolation and loneliness due to the issues often experienced by people with these difficulties, such as loss of work, friendships, family or accommodation, or being shunned by society.

People with severe mental illness have shortened life expectancies and are at increased risk of physical co-morbidities (World Health Organization 2015) and this can be exacerbated by the physical and psychological effects of chronic loneliness. Informal carers of people with mental or physical health issues can also become isolated and experience loneliness, and are at a higher risk of experiencing depression and developing dementia compared with the general population (British Red Cross and Co-op 2016).

The National Confidential Inquiry into Suicide and Safety in Mental Health (University of Manchester 2021) linked loneliness to suicide, while McClelland et al’s (2020) systematic review and meta-analysis found that loneliness was a predictor of suicidal ideation and behaviour in the medium and long-term (five years and over), rather than in the short-term. This finding has implications for mental health assessments, since it suggests that loneliness can affect people and their suicide risk for a longer period than might be initially considered. Therefore, mental health practitioners need to consider people’s experiences of loneliness over a long period when assessing risk of suicide.

Finally, the pandemic has raised awareness of the importance of having an effective immune response and the risks of contracting infection due to suboptimal immunity. This is relevant because people who experience high levels of social isolation and loneliness have suboptimal immune responses (Cacioppo et al 2014), therefore addressing social isolation and loneliness is important as part of maintaining people’s overall health.

Interventions and implications for practice

Wang et al (2020) acknowledged there is no clear evidence-based guidance for clinicians on how to support people with mental health issues who are experiencing loneliness but emphasised that interventions should be personalised and reviewed regularly, particularly since the experience of loneliness is guided by how an individual perceives their relationships with others. Therefore, it is essential that mental health practitioners understand the terms social isolation and loneliness, including the difference between transient and chronic loneliness.

Interventions should be delivered over different lengths of time depending on the type of loneliness an individual is experiencing. For example, those at risk of or experiencing transient loneliness may require short-term interventions, while longer-term involvement may be required for those with chronic loneliness. The British Red Cross and Co-op (2016) recommended a combination of three models of support to address loneliness, depending on an individual’s circumstances: preventative, responsive and restorative support (Box 1).

Box 1.

Models of support to address loneliness

Preventative support

  • Providing support to anticipate potential risk points for loneliness

  • Developing strategies to mitigate loneliness

  • Ensuring that there is support available during challenging situations

Responsive support

  • Providing support at crucial moments of transition, particularly if these are potentially traumatic events such as the death of a loved one or a divorce

  • Offering support during these crucial moments could assist people to cope better in general and address the loneliness that they may begin to experience during these challenging situations

Restorative support

  • Offering services and support that assist people to overcome an established habit of disconnection

  • Some people may require confidence building, particularly if they are experiencing low self-worth

  • Other people may simply want encouragement, something to do and support to maintain positive social connections

(Adapted from British Red Cross and Co-op 2016)

Preventative support

Barber (2018) emphasised that all mental health practitioners, including those who work in general acute hospitals, mental health wards and community mental health teams, should identify people who are lonely. Therefore, asking about loneliness should be part of all assessments and the questions in Table 1 can be used for this. Initial and ongoing mental health reviews and assessments should consider the long-term effect of loneliness on suicide risk.

Preventative interventions require mental health practitioners to be aware that people may be at increased risk of loneliness due to life changes, for example divorce, bereavement, moving area or accommodation, redundancy, retirement or physical or mental health issues, including those already known to mental health services and/or part of current caseloads. Mental health practitioners should work collaboratively with clients to support them to reconnect with others socially to achieve the quality and quantity of contact they would like. This can be short-term work and may include social prescribing, which is a means of referring people to various community-based activities to improve their health and well-being. Mental health practitioners should also support clients to create crisis and contingency plans for situations that could cause or increase loneliness.

As part of preventative support, it is important to be aware of how different age groups experience loneliness and to understand that age can affect people’s social expectations, since younger people may desire numerous social relationships, while older people may be more selective about the relationships they engage in. An awareness of what might support people to develop resilience or a sense of coherence can be useful to focus on and include in care plans as these factors can reduce the risk and effects of loneliness.

Responsive support

Mental health practitioners should consider how to support people experiencing loneliness to improve the situation. They should undertake detailed assessments or reassessments of an individual’s experiences and mental health issues, and ascertain if there is a ‘loneliness loop’ (Hawkley and Cacioppo 2010) by observing for thoughts or behaviours that might be fuelling social withdrawal. Mental health practitioners also need to recognise that signs and symptoms of loneliness are similar to those of certain mental health issues and how loneliness can cause or exacerbate such issues. An awareness and thorough assessment of suicide risk remains important in responsive support.

Restorative support

People with chronic loneliness may be less visible to health and social care services and they can find it challenging to engage in interventions so may require different or longer-term solutions, for example through assertive outreach. Mental health practitioners should consider how chronic loneliness affects social interaction and engagement with others. They also need to be aware of the risk of misinterpreting the effects of loneliness as psychosis or other mental health issues and recognise when negative signs and symptoms of these conditions are causing loneliness and social isolation.

A person’s lack of engagement in and difficulties maintaining treatment should not be regarded as making an ‘unwise decision’ or a ‘lifestyle choice’, because doing so simplifies a complex situation and infers a possible lack of understanding of the issues causing or maintaining their difficulties. Such issues must be understood by all healthcare practitioners working in services that provide support and care for people experiencing chronic loneliness. Adult safeguarding may be required in some instances due to the physical health risks associated with chronic loneliness, for example if someone appears to be neglecting themselves, not accepting support services or not seeking or engaging with medical treatment. Appropriate physical health assessments and care for those experiencing chronic loneliness are essential to maintaining their health.

Training for healthcare practitioners, including in clinical risk assessment and management and adult safeguarding, should incorporate the effects of chronic loneliness. Practitioners should also be encouraged to listen to clients’ experiences, with the aim of identifying loneliness and attempting to reduce the associated perceived stigma or shame.

Conclusion

It is essential that mental health practitioners, including nurses, are aware of the causes and effects of social isolation and loneliness, particularly chronic loneliness. Loneliness can induce thoughts, emotions and behaviours that can be misinterpreted as signs and symptoms of mental health issues such as anxiety, depression, psychosis or dementia. Conversely, mental health issues can cause loneliness which can lead to thoughts about self-harm or suicide. Therefore, mental health practitioners must ensure clients with chronic loneliness are not overlooked and support them to access appropriate services.

Further resources

Men’s Sheds

menssheds.org.uk

References

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