Loneliness Is A Dangerous, Complex, and Misunderstood Mental Health Epidemic

Navigating loneliness in a coronavirus world

A pervading sense of social isolation and loneliness has echoed throughout the world as we shut ourselves off from loved ones and our communities, all to tackle one major universal task: stop the spread of COVID-19 and keep our communities safe. Borders shut down, businesses closed their doors and the world stopped to hold its collective breath.

With little time to prepare for this social isolation and shutdown, governments and communities worked hard to prepare for the socioeconomic and health impacts of the COVID-19 (SARS-CoV-2) coronavirus pandemic.

We spent hours glued to television screens and clicking refresh buttons on news updates, living out our worst imaginings as family members were ripped from our arms. We suffered on the other side of the glass where we couldn’t hold their hands, where we couldn’t kiss them goodbye. Sequestered behind our closed doors and cut off from our families and our social and community networks, we were left completely alone.

That vice around our throats, the deep pain in our chests, the disconnect from every person we knew and loved. It left us completely alone. How do you grieve when you cannot say goodbye together?

The hollow ache of nothingness grew and we dismissed it. Surely everyone is feeling this way. The global response: “You aren’t alone in being alone.”

Another silent, still deadly, epidemic had begun. Increased reports of loneliness, anxiety and depression began to emerge. An already well-established epidemic was starting to strengthen its momentum. In the US reports of anxiety and depression with 41.1% of adults reporting symptoms of anxiety or depressive disorder. In Australia, the ABS reported that “loneliness was most widely reported personal cause of stress due to COVID-19.”

We dismissed it as individuals. As a society, we disregarded it as an emotion that would ebb with our grief, decided that it would pass the way of the pandemic. After all, we weren’t alone in being lonely. We needed to stay safe. We needed to protect each other. An emotion we could handle. Social isolation we could manage. We sought distractions. Online entertainment subscription sales rocketed. Online networking platforms had never had more use. We still struggled to connect. We still struggled in feeling alone.

In the midst of a global pandemic, the immediate dangers of a deadly novel virus are understandably being prioritised. However, social isolation and loneliness can result in both short- and long-term health effects that cannot be ignored.

— Julianne Holt-Lunstad, a Professor of Psychology and Neuroscience and Director of the Social Connections and Health Research Laboratory at Brigham Young University

A definition of loneliness

There is a real danger of individuals dismissing their own mental health and feelings because there is a resounding expectation in society that we will all experience loneliness. That it cannot be avoided and that it is normal and natural. Cacioppo, Grippo and Cacioppo, a renowned and respected research team in the study of loneliness, strongly argue this point. The experts all agree this idea has cemented a dangerous cultural precedent that leaves individuals powerless to overwhelming, self-deafening thoughts that prevent them from seeking diagnosis and treatment.

In a Health Policy Brief, Julianne Holt-Lunstad, a Professor of Psychology and Neuroscience at Brigham Young University writes that loneliness is “the subjective and distressing feeling of social isolation, often defined as the discrepancy between actual and desired level of social connection.” The subjectivity of feeling is a defining difference between social isolation and loneliness.

Researchers have found that some social groups are considered to be more vulnerable to this social isolation including older people who live alone, psychiatric patients, long-term patients with limited mobility, stigmatized groups, and adolescents and young adults.

Cacioppo et al. in their study of the evolutionary theory defined loneliness as “perceived isolation”. A response to our biologically inherent instincts to survive. We, as evolved human beings, instinctively recognize the high risks associated with social isolation. In another article, Cacioppo et al. explained that this perceived isolation was the difference between an individual’s preferred and actual human connection. This addresses why people may not objectively be experiencing social isolation but subjectively lonely.

Someone once said:

“I used to think the worst thing in life was to end up all alone. It’s not. The worst thing in life is ending up with people who make you feel all alone.”

A definition of social isolation

No one could possibly argue 2020 wasn’t a year of isolation. As the pandemic continues and vaccinations roll out we are still frightened to cross that invisible 1.5-meter social distancing abyss. We carefully consider every movement, eyes scanning ahead through the crowds, avoiding anyone that clears their throat. It doesn’t matter anymore that we aren’t locked behind closed doors. We cannot risk touch. We cannot risk connecting.

Holt-Lunstad defines social isolation as “an objective state marked by few or infrequent social contacts”. She adds that social isolation provides a major risk factor for loneliness, depression, and anxiety.

Is Loneliness a Symptom of Depression?

Cacioppo, Grippo and Cacioppo in their clinical research and study found that depression and loneliness share similar characteristics. Because of the similarity, loneliness was once and is still frequently incorrectly considered to be simply a symptom of depression.

Dr Seepersad, in his article on loneliness and depression, explains there is a prevailing assumption among health care professionals that loneliness is a form of depression. Seepersad quotes Cacioppo and Patrick defining the difference between loneliness and depression:

“Loneliness reflects how you feel about your relationships. Depression reflects how you feel, period.”

He then goes on to conclude, given this information, for patients, loneliness and depression can exist together, separately or not at all.

Cacioppo, Grippo and Cacioppo describe the psychiatric and physical consequences and symptoms of loneliness.

Psychiatric symptoms include depressive symptoms, alcoholism, suicidal thoughts, aggression, social anxiety, impulsivity, and cognitive decline.

Physical symptoms and risks include elevated blood pressure, slow adrenal response, decreased sleep and insomnia, a change in eating patterns often leading to obesity, decreased immunity, increased risk of recurrent stroke and vascular resistance, and premature mortality.

We can easily see the mirror of the risks between loneliness and depression. The physical and emotional symptoms can mask one another.

The NIMH defines depression as a clinical mood disorder with severe symptoms that affect an individual's emotional well-being, cognitive and physical abilities and describe the psychiatric and physical symptoms of depression.

Psychiatric symptoms include feelings of disconnect, anxiety, hopelessness, or guilt, irritability, loss of interest or enjoyment in activities, suicidal thoughts, decreased concentration, problem-solving, and decision making.

Physical symptoms include fatigue, restlessness, insomnia, or hypersomnia, persistent aches, pains, or digestive difficulties without clear medical reasons, dramatic appetite changes and weight changes.

Cacioppo, Grippo and Cacioppo explain the danger of the misunderstood nature of loneliness and its diagnosis and treatment. Treating loneliness as merely a symptom of depression does not allow for effective treatment. Effective interventions for the condition of loneliness are founded in social opportunities for social connection and therapies that foster belonging and address negative thought patterns that facilitate isolation. Pharmaceutical interventions that can manage depressive symptoms will fail to manage the symptoms of loneliness as they cannot effectively foster connection. There is still currently no proven pharmaceutical intervention available to effectively manage loneliness.

Understanding Loneliness

In becoming socially isolated during the coronavirus pandemic we no longer had a physical connection to our larger social circles. Under the most severe lock-down restrictions the majority of individuals were left with limited contact with anyone except the people who lived within their home in an intimate environment. This social isolation therefore particularly limited social and public interaction.

Cacioppo, Grippo and Cacioppo explain that following the three main spaces where people form relationships there are three dimensions for loneliness.

1. Intimate loneliness is a result of perceived absence or disconnect from someone who offers key emotional support, assistance, and affirmation. ie. romantic partners and confidantes.
2. Relational loneliness is a result of perceived absence of relationships in the social space. ie. quality friendships or family relationships.
3. Collective loneliness is a result of perceived absence or disconnect to our public space. ie. wider community groups or teams.

They note that anyone can experience loneliness because loneliness is subjective. It is based on perceptions. An individual can also experience loneliness in one or all of the categories and be suffering considerably from symptoms of loneliness. It becomes a challenge in diagnosis and treatment because the perception of the individual is paramount. Their perception of their need for intervention and treatment can also be dissuaded and discounted through an objective self-assessment of their social circumstances.

There can be a way to identify a risk factor for loneliness. Some social groups do present as more vulnerable with a higher risk of loneliness including older people who live alone, psychiatric patients or those experiencing preexisting mental health conditions, those with limited mobility, including long-term health patients and, stigmatized groups.

Loneliness during the pandemic

Holt-Lunstad found that several surveys suggested a 20–30% increase in feelings of loneliness during the pandemic period. In her most recent brief published January of this year, she urged governments to acknowledge the severity of this hidden epidemic and lists the devastating and lethal reality of the cultural and social ignorance of loneliness.

The lethal effects of social isolation and loneliness may be more immediate, in the case of suicide or domestic violence, or more long‐term, in the case of disease‐related deaths. International data from over 3.4 million people demonstrate the association of social isolation and loneliness with a significantly increased risk of death from all causes (4). Conversely, being socially connected is protective and increases odds of survival by 50% (5).

The coronavirus pandemic put pressure and limitations on all relationships. We were all cut off from the social and public space by proximity and thrust into a crisis.

There was an increased pressure on intimate or our immediate relationships to provide that emotional support. Social media presented many pictures of the benefits of togetherness during this time. This proximity too, however, saw a rapid global increase in incidents of domestic violence. The UN categorized it as a ‘shadow pandemic’ reporting on the increased violence specifically against women. In New South Wales, Australia front-line workers reported a 40% increase in pleas for help. In the US, some regions reported almost a 50% decrease in calls for assistance, not because violence had decreased, because access to assistance was severely limited.

Individuals who are isolated living alone, cut off from their social and public space, present another urgent risk factor for loneliness. A study published halfway through 2020 found that every social group at risk for loneliness was identical with the addition of the student category who were cut off from their immediate routine and social schedule.

A Preexisting Epidemic

The loneliness epidemic was already on the rise across the world prior to the pandemic. A US national survey, released in 2018, examining the prevalence of loneliness as an epidemic found that 47% of participants reported feelings of loneliness. A second national survey, released in 2020, found that this number had risen to 61% of participants reporting feelings of loneliness.

In a snapshot of ‘Social Isolation and Loneliness’ released in September 2019, just months before the pandemic, the Australian Institute of Health and Welfare found that 1 in 3 Australians were reporting feelings of loneliness in surveys conducted. Their paper highlighted the complexity and subjectivity of the loneliness phenomenon:

Some definitions include loneliness as a form of social isolation (Hawthorne 2006) while others state that loneliness is an emotional reaction to social isolation (Heinrich & Gullone 2006). The two concepts do not necessarily co-exist — a person may be socially isolated but not lonely, or socially connected but feel lonely (Australian Psychological Society 2018; Relationships Australia 2018).

Dr Michelle H. Lim, Scientific Chair of Ending Loneliness Together and Senior Lecturer Swinburne University of Technology, applauds the advancement of digital access to counseling services but expresses continuing concern. Research proves that digital connections do not necessarily decrease feelings of loneliness. This is because they may not facilitate meaningful connections. She also states that it is likely that people experiencing loneliness are more inclined to avoid or shy away from establishing or re-establishing social connections.

A study published in 2020 by Tejada, Dunbar and Montero explored the relationship between physical touch, relationship, and an individual’s feelings of loneliness. They built upon established theories that touch, the emotional aspect of relationships, and feelings of loneliness and isolation are interlinked. Their study supported the theory that touch and physical contact is important for an individual's psychological well-being.

Feelings of loneliness and social isolation presents significant short and long-term mental and physical health concerns. Lim highlights an immediate concern is that poses a real threat to an individual's mental health status, especially for those with existing mental health concerns. The evidence suggests a higher likelihood of anxiety, depression, and suicide. Extended feelings of loneliness can have long-term and short-term negative impacts on our physical health. A widespread study published in 2018 established that loneliness and social isolation is a risk factor for heart disease and stroke.

What this means for 2021

Wang, Xu and Volkow released their findings at the end of 2020 drawing an alarming parallel showcasing persons with a preexisting mental health disorder presenting with a significantly increased risk of COVID-19 infection and higher mortality rates.

Sheldon Cohen, a Professor of Psychology at Dietrich College of Humanities and Social Sciences published his own findings in July 2020 valuable insight into these concerning rates. The result is a 35-year research effort in “identifying psycho-social factors that predict who becomes ill when they are exposed to a virus affecting the upper respiratory tract.”

Factors we found to be associated with greater risk of respiratory illnesses after virus exposure included smoking, ingesting an inadequate level of vitamin C, and chronic psychological stress. Those associated with decreased risk included social integration, social support, physical activity, adequate and efficient sleep, and moderate alcohol intake. We cautiously suggest that our findings could have implications for identifying who becomes ill when exposed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for coronavirus disease 2019 (COVID-19).

Julianne Holt-Lunstad, in her new paper published in the February issue of World Psychiatry journal, urged governments, individuals, and community groups to take an interdependent approach to address the problem. To address issues of relational and collective loneliness she urged governments to reconsider policies limiting social contact in response to the loneliness epidemic.

Instead “foster norms of support, inclusion, and trust” to promote social and public inclusion and security before we create permanence in the “new normal”. For individuals and family groups, to address issues of intimate and relative loneliness, Holt-Lunstad encourages individuals to focus on quality interactions with immediate family members, friends, and neighbors. She also urges awareness.

“Right now, the world you are inheriting is locked in a struggle between love and fear. Fear manifests as anger, insecurity, and loneliness. Fear eats away at our society, leaving all of us less whole, so we teach you that every healthy relationship inspires love, not fear. Love shows up as kindness, generosity, and compassion. It is healing. It makes us more whole. The greatest gift to ever receive will come through these relationships.

― Vivek H. Murthy, Together: Why Social Connection Holds the Key to Better Health, Higher Performance, and Greater Happiness

It is unclear now just what the future will be. One thing is certain, however, as the World Health Organization acknowledged, not a single individual or community has been left unaffected. We have evolved into a global community and relied and depended on one another for trade, commerce, and even survival. Inherently in it all however there is a rising trend of loneliness, not talked about, shrouded in stigma and lack of information.

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Holt-Lunstad, 2020. Health Policy Brief: Social Isolation and Health. Health Affairs, Maryland.

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