Just a castaway an island lost at sea-o
Another lonely day, no one here but me-o
More loneliness than any man could bear
Rescue me before I fall into despair-o
–The Police, from the song Message in a Bottle
“Social relationships, or the relative lack thereof, constitute a major risk factor for health—rivaling the effect of well-established health risk factors such as cigarette smoking, blood pressure, blood lipids, obesity and physical activity”
—House, Landis, & Umberson (Science 1988)
We are entering the holiday season and you know what that means…excessive eating, overspending and loneliness. Not to be the Grinch and all that, but for many people the holidays are more something to fear and less something to welcome. Go ahead, ask whomever you are sitting next to right now if they are more excited about being with their family at the holidays or about getting their arm caught in a slamming elevator door; $5 says they will be all over the elevator option and might even pay extra for that privilege.
It’s a bummer, of course, because these are supposed to be happy times, and it is exactly that “supposed to be” part that gets us. The gap between expectations and reality can be all too stark when one’s circumstances are not as hoped. Every year that doesn’t end with The Rock delivering my holiday gift is one that disappoints. Alas.
But nothing is really worse, in my view, than the amplification that the holidays can have on loneliness. If you are feeling alone and unloved in say, June, December is a nightmare. Everywhere you look its TV families getting along despite their differences, happy couples strolling, cute kids hugging their parents for getting them drones. If you are really alone, the mass media impact is a killer. It is estimated that 25%-45% of adults worldwide feel loneliness some or all of the time and the number hovers around 40% in America, where it is worth noting that 28% of older adults live alone and 43% report feeling lonely on a regular basis. (JAMA).
And if you’re a healthcare person, particularly one whose livelihood depends on getting the cost of healthcare down, these numbers should terrify you. Loneliness is not to be taken lightly. It has been well-documented by numerous scientists (to the extent science is still a good thing) that loneliness is one of the most damaging conditions we can have when it comes to the impact on our health. If, as we all like to spout, 80% of healthcare costs relate to treating people with chronic conditions; and, as we all know, it’s people over age 50, by and large, who have those chronic conditions, then you do the math. How about this for a fact: research shows that loneliness and lacking social connections is as damaging to our health as smoking 15 cigarettes a day (Holt-Lunstad, 2015).
Here’s smorgasbord of other tidbits about the health impact of loneliness that should make you want to join Tinder right this damn minute to avoid being alone (subsequent list exported from Association for Psychological Science, Perspectives on Psychological Science 2015, Vol. 10(2) 238–249):
Loneliness can contribute to a constellation of physical and psychiatric dysfunctions and/or psychosocial risk factors, including:
- depressive symptomatology (J. T. Cacioppo et al., 2010; J. T. Cacioppo et al., 2006; VanderWeele et al., 2011)
- alcoholism (Akerlind & H.rnquist, 1992),
- suicidal thoughts (Rudatsikira, Muula, Siziya, & Twa-Twa, 2007), and
- aggressive behaviors, social anxiety, and impulsivity (e.g., S. Cacioppo, Capitanio, & Cacioppo, 2014; Ernst &Cacioppo, 1999; Kearns, Whitley, Tannahill, & Ellaway, 2014).
In addition, loneliness is a risk factor for:
- cognitive decline and the progression of Alzheimer’s disease (Wilson et al., 2007),
- recurrent stroke (for review see S.Cacioppo, Capitanio, & Cacioppo, 2014),
- obesity (Lauder, Mummery, Jones, & Caperchione, 2006),
- increased vascular resistance ( J. T. Cacioppo, Hawkley, Crawford, et al.,2002),
- elevated blood pressure (J. T. Cacioppo, Hawkley, Crawford, et al., 2002; Hawkley, Masi, Berry, & Cacioppo, 2006),
- increased hypothalamic pituitary adrenocortical activity (Adam, Hawkley, Kudielka, & Cacioppo, 2006; Steptoe, Owen, Kunz-Ebrecht, & Brydon, 2004),
- Decreased sleep salubrity ( J. T. Cacioppo, Hawkley, Berntson, et al.,2002; Pressman et al., 2005),
- diminished immunity (Kiecolt-Glaser, Garner, et al., 1984; Kiecolt-Glaser, Ricker,et al., 1984; Pressman et al., 2005),
- an underexpression of genes bearing anti-inflammatory glucocorticoid response elements and an upregulation of pro-inflammatory gene transcripts (Cole et al., 2007, 2011),
- abnormal ratios of circulating white blood cells (e.g., neutrophils, lymphocytes, and monocytes; Cole, 2008), and; in case that weren’t enough,
- premature mortality (e.g., Holt-Lunstad & Smith, 2015, this issue; Luo, Hawkley, Waite, & Cacioppo, 2012).
And yet, when is the last time a doctor asked you if you were feeling lonely? I’m guessing never or close to never. Loneliness hasn’t been treated as a recognized medical diagnosis, but it should be. If it were, we could “treat” loneliness and thus reduce the incidence and cost of the litany of chronic problems you read above. And the ROI is unbelievably high. The cost of helping a lonely person connect with other humans is negligible vs. the cost of giving them a drug. And a side note to all you health systems and health plans out there: Loneliness has been found have a larger negative impact on satisfaction with physician care and health plans than any common clinical condition (Musich et al, 2015). Hello loneliness, goodbye STAR rating.
Many of us in the healthcare system are finally and fortunately seeing a rising level of awareness of the impact of social determinants on health and healthcare costs. I am delighted to have recently seen companies looking to address issues of housing, nutrition and transportation. These companies come in both non-profit (Health Leads) and for-profit (Circulation) forms and can have a material impact on improving patient experience and health.
But I am especially gratified at a budding trend I am seeing of a few companies specifically forming to address loneliness as a gateway to improved life experience and health, and that is really exciting. If you are an executive at any kind of risk-bearing health enterprise, perk up. This may the most cost-effective set of things you could invest in with nary an expensive drug or device in the mix. Let me lay a few examples on you (note I have no financing interest in any of these):
Agewell Global — There are a zillion companies now in the business of matching caregivers to aging adults. But this one has a unique twist in that it matches healthy seniors with those who need help. In other words, they are using able seniors as visiting caregivers for less able seniors. It’s damn brilliant, as it helps address loneliness for both sides of the equation while helping able seniors learn new skills around how to monitor and engage others in taking care of their chronic conditions, both post-acute and on an ongoing basis. Agewell’s has activated this model so far in South Africa and is bringing it to the United States now. In their South African program, they have already demonstrated a 47% increase in the WHO’s measure of well-being among their patients in one month. They have also demonstrated dramatic reductions in indicators of depression and reduced hospitalizations.
Silvernest – This company is a roommate matching service for baby boomers and those older that that. In other words, it’s a way for older people living alone to find companionship and mutual in-home support. You may say that’s not a healthcare company, but if you have read all the way to here, you know you’re wrong. By giving companionship and shared support, as well as a set of eyes to see when people are suffering or may be in declining health, you have set your population on a road to better outcomes and lower cost.
Silverline –The Silver Line is a confidential, free helpline for older people open 24 hours/day. Seniors call specially trained phone attendants for any reason and can get immediate access to friendship and advice, links to local groups and services. They can also arrange regular friendship calls and letter-writing programs. It is worth noting that Silverline gets 68% of its calls on nights and weekends when loneliness can be particularly acute. In the 2 years they have operated, they have received over 1 million calls and have seen dramatic reductions in physician office visits in the UK that they can directly link to this service. The friendship service appears to be particularly effective, matching people by interest and specifically NOT by medical need. By making this about social isolation and not about care management, the effect has been profound according to those familiar with the company. Charlotte Yeh, Chief Medical Officer of AARP Services, has said that the “non-medicalization” of this service is a critically important component of getting the “cure” for loneliness right. . As she says, “Can we address health by not talking about it? Perhaps so.” While currently operating only in the UK, Silverline, there are efforts underway to try to bring it to the US.
And speaking of the importance of recognizing loneliness and isolation as major social determinants of health. My pal Dr. Jeremy Nobel, Founding CEO at the Foundation for Art and Healing, is spearheading The Creatively Connected Film Festival, which involves a film contest, digital platform, public health outreach, and evening of celebration in New York City on May 11, 2017. The program is centered around the themes and complexities of loneliness and isolation—spotlighting those who have found ways to move forward and applauding the power of creative expression to bring us together authentically and enduringly. The Film Festival (which interestingly has both the CEO of Montefiore Medical Center and the President of Production of Lion’s Gate Motion Pictures involved) is actively seeking submissions. So if you have a way with a video camera (professional or amateur) and an interest in the topic of this blog, have at it. Note they are also looking for event sponsors. All of the info on submitting your film, participating in the program, sponsoring, and attending the fancy event can be found HERE.
Notably, this film festival and set of events is meant to amplify the reach of The Unloneliness Project, an initiative to broaden public awareness of the negative physical and mental health consequences of loneliness associated with a wide range of life conditions and circumstances while also exploring and promoting creative arts based approaches to reduce the burden. Once again, you don’t always need drugs, devices and doctors to improve health. Sometimes you just need friends and beauty. No FDA approval necessary.
And given that this whole post started with me sounding Grinchy, don’t forget that the Grinch himself became healthier and happier when he left Mount Crumpet to join the Who Community. Notably, that prescription was written by a Doctor (Seuss).
Walked out this morning I don’t believe what I saw
A hundred billion bottles washed up on the shore
Seems I’m not alone in being alone
A hundred billion castaways looking for a home
The Police from Message in a Bottle
FYI, some great resources on this topic can be found at:
Mary furlong says
Such an important column.
Lisa Suennen says
Thanks Mary! I so value your knowledge in this area. Lisa
Bruce Fryer says
I’m with to you to get AHRQ to make this a quality measure for CAHPS. Perhaps it could replace pain management (as a bonus that would take a bite of the opiate epidemic fueled by that measure).
Lisa Suennen says
That’s such a good idea.
Thomas Loarie says
“The greatest disease in the West today is not TB or leprosy; it is being unwanted, unloved, and uncared for. We can cure physical diseases with medicine, but the only cure for loneliness, despair, and hopelessness is love. There are many in the world who are dying for a piece of bread but there are many more dying for a little love. The poverty in the West is a different kind of poverty — it is not only a poverty of loneliness but also of spirituality. There’s a hunger for love, as there is a hunger for God.”
― Mother Teresa, A Simple Path: Mother Teresa
Lisa Suennen says
Thank you for this. Lisa
Lisa, this rings so true. It is frankly one of the biggest motivators for my not retiring! I love being in a building with lots of people, activity, noise, ideas and more. I also love feeling productive on a daily basis, and working to share knowledge with younger folks in our start-up incubator. Unfortunately, I don’t play golf, and even if I did, I don’t believe it is a full time activity. I hope to see you at CES!
Lisa Suennen says
Yay! Let’s meet up there. L