|Year : 2021 | Volume
| Issue : 1 | Page : 1-6
Ah, Look at All the Lonely People..... Will Social Psychiatry Please Stand up for Ministering to Loneliness?
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||05-Apr-2021|
|Date of Decision||06-Apr-2021|
|Date of Acceptance||07-Apr-2021|
|Date of Web Publication||29-Apr-2021|
Dr. Debasish Basu
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Basu D. Ah, Look at All the Lonely People..... Will Social Psychiatry Please Stand up for Ministering to Loneliness?. World Soc Psychiatry 2021;3:1-6
Died in the church and was buried along with her name
Wiping the dirt from his hands as he walks from the grave
No one was saved
All the lonely people
Where do they all come from?
All the lonely people
Where do they all belong?
Ah, look at all the lonely people....
Eleanor Rigby (The Beatles, Revolver, 1966)
The United Kingdom appointed its Minister for Loneliness in January 2018. And now, Japan has appointed its Minister for Loneliness in February 2021. These are terms which were unheard of. We have heard of ministries of sports, culture, arts, health, social welfare.… but of loneliness?
So what is loneliness? And why an editorial in the World Social Psychiatry on loneliness?
| What is Loneliness?|| |
Loneliness is most simply defined by the Cambridge Dictionary as “the state of being lonely.” There are more formal definitions, such as “a subjective experience where one perceives a discrepancy between their actual and desired levels of social relationships.” Two related but distinct terms are often used interchangeably: loneliness and social isolation. Both refer to the lack of social connection. However, while social isolation refers to the quantitative, objective, structural aspect of this social disconnection (as often assessed by numerical measures such as marital or living status, social network size and other details, frequency of social contacts, etc.), loneliness represents the “qualitative, subjective, appraisal of perceived lack of intimacy or of adequate social ties.” While generally the two terms are quite closely related (socially isolated persons often feel lonely, and lonely persons are usually socially isolated), there can be socially isolated persons who do not feel lonely and can be in perfect peace with their solitude, while there are many who do feel lonely even while maintaining a quantifiable social network (“alone in the crowd” phenomenon).
It is now known that loneliness is common across the world though reported more from the developed world. It is known that loneliness follows a roughly bimodal age distribution: the first peak is in adolescence and young adulthood, and the second peak in the elderly, though no age is particularly immune.
There is now abundant evidence on the adverse effects of social isolation and loneliness on mortality and both physical (especially cardiovascular disease) and mental (depression, anxiety, suicidality, substance misuse, cognitive decline, and even dementia) morbidities.,,, There is also abundant evidence of social isolation and loneliness being the consequence of physical and mental disorders. Thus, loneliness can both be a cause and a consequence of morbidities – both a predictor and the outcome variable in research terms. This often bidirectional nature of the association between loneliness and morbidities can, understandably, set up formidable vicious cycles.
In view of the above, scientific studies on loneliness have proliferated over the past 2–3 decades, starting from widely isolated publications in the last century. Studies have now shown the enormity of the magnitude of its prevalence in many countries and in various population samples. Loneliness has been termed as an “epidemic,” a “pandemic,” and a “public health issue.” The COVID-19 pandemic has further fuelled awareness and research on the “lockdown loneliness.”
While this is a laudable effort, we need to be conscious of the direction of the wave. The terms epidemic and pandemic are scientifically (not metaphorically) used with reference to a disease. So is the term “public health approach.” But is loneliness a disease? States of loneliness have been associated with neurocircuitry-related, neuroinflammatory, and immune changes, and studies have provided mechanistic hypotheses linking loneliness with physical or mental morbidities and mortality.,, There have been studies on genetics of loneliness, including genome-wide association studies. All these may make the casual reader unsuspectingly drift toward a “biomedical model” of loneliness, and perhaps look for pharmacological drug targets for “treating” the disease of loneliness in future, at the cost of overlooking the essential role of social connection and mental health in understanding, preventing, and mitigating loneliness and its consequences.
This is where social psychiatry needs to stand up.
But before that, a bit of history might help to lay the backdrop.
| A Brief History of Loneliness|| |
According to Merriam–Webster dictionary, the first documented use of the word “lonely” (not loneliness) was in 1598 AD. Some sources attribute the first recorded use of the word “lonely” in William Shakespeare's tragedy Coriolanus. However, according to the British historian Fay Bound Alberti, the word “loneliness,” with its connotation of a painful negative emotionality arising out of the perceived lack of social connectivity, appeared only in the 1800s. Before that, the word was “oneliness,” with the factual denotation of “being alone or without company,” or even a state of peaceful aloneness or solitude, but without the subjective unpleasant painful connotation of the modern use of the word loneliness. Alberti writes with conviction that the word loneliness cropped up around the same era as “individualism” associated with modernization of the western society following the wave of industrialization and its accompanying impact on society, culture, economy, and individuality:
“The contemporary notion of loneliness stems from cultural and economic transformations that have taken place in the modern West. Industrialisation, the growth of the consumer economy, the declining influence of religion and the popularity of evolutionary biology all served to emphasise that the individual was what mattered – not traditional, paternalistic visions of a society in which everyone had a place.”
The first entry of the word loneliness in PubMed dates back to 1890. However, this was a purely spiritual article, under the subject heading “Words of Consolation.” The very next citation, probably for the first time in the medical-psychological context, came a whopping 47 years later, in 1937, with a case series of lonely widows or aging spinsters developing paranoid syndromes. Citations using the word loneliness were extremely sparse throughout the following decades, the numbers reaching double figures only in 1974, and it took this current century to first clock triple-figure citations of loneliness (102 in 2002). Since then, over the last two decades, there has been a sudden and steady spurt in citations, reaching the peak of 1456 citations in 2020, and 584 already in 2021 at the time of this writing (April 5, 2021) [Figure 1]. COVID-19 related articles, not surprisingly, contributed a major share of the citations (347 in 2020 and 249 till date in 2021), but even otherwise, the numbers reflect a burgeoning interest in publications in professional journals with loneliness as an emerging theme.
The very occasional early articles were centered on the themes of psychodynamics, psychology, and case series on various desolate groups including the elderly and mentally ill persons. Perhaps, one of the best and detailed treatises in this era was by the noted psychodynamically oriented psychiatrist Frieda Fromm-Reichmann, titled, simply, “Loneliness.” Published posthumously, this article deals with the severe, “real, psychotogenic loneliness” from several perspectives including those from poets and patients. The closing sentence is quite prophetic: “Thus I suggest that an understanding of loneliness is important for the understanding of mental disorder.”
Articles related to sociology and social sciences started appearing in the 1950s. Probably, the first important publication in a mainstream psychiatric journal – the American Journal of Psychiatry – appeared in 1955. Interestingly, the author, Claude Bowman, was from the Department of Sociology and Anthropology, not Psychiatry or Psychology. He argued that “The problem of loneliness provides an excellent demonstration of the principle that psychiatric phenomena have sociological dimensions.” Bowman laid down four major types of macro-level influences in modern societies (especially the western ones) that create the conditions conducive to loneliness: decline of primary-group contacts (“Primary groups are those face-to-face groups such as the family, playgroup, neighborhood, or village, which provide relationships of intimate fellowship”); increase in formal, impersonal, functionally defined and hierarchically organized relationships as in bureaucratic or corporate setups; horizontal mobility (due to physical movements away from primary groups due to job and other works including rapid travels during globalization); and vertical mobility (rapid movement from one social class to another).
Scientific interest in the study of loneliness was boosted by creation of instruments measuring loneliness in the late 70s and later, though the studies were still a trickle. Pioneering major work came from the Social Neuroscience Lab at the University of Chicago, founded by John Cacioppo, who along with his colleagues worked and published in this area for over three decades till his death in 2018 and advocated loneliness as a public health issue. Their team studied loneliness from an evolutionary and social neuroscience perspective, covering areas widely ranging from sociology, psychology, health outcomes, physiology, genetics, and molecular biology. Essentially and gradually, the currently dominant perspective emerged – one that views loneliness (perceived social isolation) as serving an evolutionary adaptive need for re-establishing social connections for the purpose of safety and stability, but when prolonged or severe can become maladaptive, with myriads of adverse consequences.
| Interventions for Loneliness|| |
Along with these, various interventions have been designed, and a few tested, for mitigating or even preventing loneliness. Ten years ago, an influential meta-analysis identified four main modalities of intervention: (a) improving social skills, (b) enhancing social support, (c) increasing opportunities for social contact, and (d) addressing maladaptive social cognition. Of these, those aimed at improving maladaptive social cognitions were the most evidence based at that time.
The UK Government has recently published an important document named “A connected society: A strategy for tackling loneliness – Laying the foundations for change.” It is a highly commendable document, with a vision, detailed strategies for a multi-level, multi-agency, and multi-pronged approach, and an articulated focus on mental health. Among the many multi-sectoral strategies advocated, one particularly important one is the emphasis on “social prescribing” – community referral to various channels for meeting the social, vocational, emotional, and practical needs by engaging the clients in a variety of activities (usually tailored by link persons to suit the clients' individual preferences and available resources) such as volunteering, arts, gardening, befriending, cookery, and sports, typically in group format.
There are several community-level research projects completed and underway, and several individual-level interventions have been researched, the more recent ones, understandably, focusing on several types of digital interventions.,, A very recently published randomized controlled trial found that even a 10-min telephone call with empathic style made by laypersons with a brief training to clients of the Meals-on-Wheel program in Central Texas, USA, over 4 weeks, reduced loneliness, depression, and anxiety symptoms.
While these are all very optimistic indicators, many questions remain regarding the nature of, and interventions for, loneliness. A selected few are highlighted below in brief.
| Is Loneliness a State or a Trait?|| |
While the intuitively obvious answer is “of course, a state” per the very definition of loneliness, some researchers believe it is also a “personality trait” or even a “biological trait.” While sociologists believe that it is a state experienced by individuals (who may be otherwise healthy) because of social–ecological factors, psychologists see it as a relatively stable personality trait, meaning thereby that (a) loneliness is stable across time in each individual irrespective of fluctuating social conditions and (b) some people will always feel more lonely than others, again irrespective of fluctuating social conditions. Finally, social neuroscientists believe that loneliness is a biological trait (a phenotype), which is partly heritable, has genetic roots, and neurobiological correlates.
| Is Loneliness a Disease, or Perhaps a Disorder?|| |
One corollary of the “loneliness is biological” theme is to conceptualize loneliness as a disease (with defined etiology and pathophysiology), or at least a disorder (the “syndrome” of loneliness, with a course, outcome, and prognosis and perhaps a “treatment”). These trends have become popular with the studies on neurobiological and brain circuitry correlates of acute or perceived social isolation.,, It also is assumed that loneliness is a medical condition just because it is associated with, or can lead to or worsen, other medical conditions. Such medicalization might be beneficial to decrease stigma associated with loneliness and might promote further scientific research as well as potentially draw attention of the funding agencies as a “public health issue,” “behavioral epidemic,” or even “pandemic.”
However, the major risks associated with such medicalization are (a) scientifically misleading notions about the terms such as disease, disorder, epidemic, or pandemic (we need to make a distinction here between the metaphorical or colloquial use of a word or phrase and its scientific or technical use), (b) inaccurate and populist representations in the lay media (such as “genes found as “cause” of loneliness”), (c) the elusive search for pharmacological treatments for loneliness, (d) paradoxical stigma for those suffering from the “disease of loneliness” because they are “diseased,” (e) a tacit de-emphasis on researching and tackling the socio-ecological determinants of loneliness, and (f) discouraging multidisciplinary collaborations, which is vital for studying and remedying a complex concept such as loneliness.
| Is Loneliness a Cause or an Effect of Mental Disorders?|| |
Most likely, both loneliness has been strongly associated with mental health issues and well-being.,,, The direction of the association, however, may be difficult to ascertain because well-conducted longitudinal studies are not easy to come across. A very recent publication on the effect of a baseline measure of loneliness on depressive symptoms on a large elderly UK cohort found that “11%–18% of cases of depression could potentially be prevented if loneliness were eliminated.” Similarly, it is known that loneliness is high in patients with psychotic illnesses, but the association strength is moderate and the causality direction is uncertain. A recent study has given a new twist to the story by finding the substantial genetic overlap between loneliness, severe mental disorders (SMDs), and cardiovascular disease (CVD) risk factors, “suggesting that genetic risk for loneliness may increase the risk of both SMDs and CVD.” Thus, more longitudinal and mechanistic research is warranted in this important area.
| Will Social Psychiatry Stand Up, Please?|| |
This brief and admittedly selective review has traced the roots of loneliness from the industrialization era to our modern times. It has shown that loneliness (defined here as perceived, subjective, unpleasant, and distressing, relatively long-lasting experience of social isolation, as opposed to objective social isolation) is an important construct, which is associated with many adverse outcomes including increased physical–mental morbidity and even mortality and is itself likely to be a product of complex multi-level factors operating at many macro, meso, and micro levels. A biopsychosocial model is the likely best perspective to study, prevent, and intervene with loneliness. The net is cast wide, from large-scale ecological, structural, and social factors to individual, cognitive, and biological factors. Recent articles in influential major medical journals – the Lancet, Lancet Psychiatry, and JAMA Psychiatry, to name a few,, – have emphasized the importance of studying loneliness and provided useful suggestions for multi-level, multi-stakeholder interventions. Some of the hurdles and challenges in conceptualizing and studying loneliness have been highlighted, though certainly there are more.
From all these, the centrality of loneliness as a personal – deeply and essentially personal – experience, must not be forgotten. Nor should it be forgotten that the essence of this personal phenomenon is defined by the concept of social connection or the perceived lack of it. Thus, loneliness as a concept stands at the crossroads between the domains of individuality and social connection and has clear and strong implications for mental health and ill-health in a likely bidirectional relationship [Figure 2]. This, to my mind, is the central argument for social psychiatrists (or mental health professionals with an interest in social psychiatry) to be integrally involved with the conceptualization, assessment, study, intervention, and prevention of loneliness. They should be ministering to loneliness along with the ministers for loneliness.
|Figure 2: Schematic diagram on loneliness, mental health, individual and society. "Macro" level refers to large ecological, historical, secular or such trends as industrialization, urbanization, and globalization. "Meso" level refers to social, familial, other interpersonal and contextual/situational factors. "Micro" level refers to factors within the individual, such as biological (genetic, brain circuitries, neurophysiology) and psychological (personality, cognitive styles especially social cognition).|
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Loneliness needs all – politicians, bureaucracy, social services, mental health services, sports, culture, psychology, sociology, biology.….and social psychiatry – to emphasize and remind us about the inexorable link between the individual mind, the large ecosocial system, and the evolutionarily maintained and psychobiologically mediated need for social connection.
| Epilogue|| |
Since we started from the Beatles, who broke the pop culture stereotype and brought the painfully neglected and stigmatized topic of loneliness in its songs in the mid-60s, perhaps, it would be apt to finish off with another song – written slightly later, by John Lennon, still with The Beatles at that time – one that depicts the sheer desperation, pain, suicidality, and the social–interpersonal context of loneliness.
Black cloud crossed my mind
Blue mist round my soul
Feel so suicidal
Even hate my rock and roll
My mother was of the sky
My father was of the earth
But I am of the universe
And you know what it's worth
The eagle picks my eye
The worm he licks my bone
I feel so suicidal
Just like Dylan's Mr. Jones
I'm lonely, wanna die
Yes, I'm lonely, wanna die.…
Yer Blues (John Lennon, The Beatles “White Album,” 1968)
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[Figure 1], [Figure 2]