How the Loneliness Epidemic Affects Physical and Mental Health

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There are far-reaching consequences of loneliness on physical and mental health, including heart disease, dementia and depression. With half of adults reporting loneliness, psychiatrist Andrew Hunt, MD, shares common causes – from technology to changes in social dynamics – and strategies for improving social connections.

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Macie Jepson
When we first started talking about loneliness as a topic, we thought this has got to be impacting people. I mean, COVID isolated Americans. But it turns out according to a recent advisory from the US Surgeon General, even before the pandemic, about half of US adults reported some level of loneliness. Now maybe you’re thinking just get out there and do something about it. Go hang out with your friends. Go to social events. Get more active. Well, it turns out, and we’ll get into this, it’s really not that easy. The epidemic of loneliness and isolation is now considered a major public health concern.

Pete Kenworthy
And believe it or not, there are physical consequences that result from poor social connection: a 29% increased risk of heart disease, a 32% increased risk of stroke, and a 50% increased risk of developing dementia for older adults. Across all age groups, people are spending less time with others in person than they were 20 years ago. And this is most pronounced in younger people, aged 15 to 24, who had a 70% less social interaction with their friends. 70%. Hi everyone. I’m Pete Kenworthy.

Macie Jepson
And I’m Macie Jepson. And this is The Science of Health. Joining us today is psychiatrist Dr. Andrew Hunt from University Hospitals in Cleveland. Thank you for being with us.

Andrew Hunt, MD
Thank you.

Macie Jepson
We’re going to cover a lot today, but we want to start with understanding the problem. Scientifically speaking, what is loneliness?

Andrew Hunt, MD
So we define loneliness as the subjective sense of distress that occurs when you lack an adequate social connection. So it’s not the same as social isolation, which is just having an inadequate number or inadequate like intensity of interaction. It’s the subjective distress that follows with that. And it’s also different than solitude, which is where you might feel comfortable being alone and feel like that’s okay with you, and it’s part of your balance in the way you feel good.

Macie Jepson
The fact of the matter is people are spending less time with others than they were 20 years ago, though. Why is that?

Andrew Hunt, MD
Well, I think there’s a lot of reasons, and it’s different by age, I would say. So for instance, for children, the question is what are they doing with their time all day? How do they spend it at school? Do they spend it interacting or do they spend it with their face in a phone or tablet? Are they interacting more with computers than with people? With young adults we see the social media as really, really prominent. Computers and internet use increases actually in young adulthood. And then by middle age, we’re sort of worried about social isolation occurring due to social constructs such as your work/life balance, or your experience of parenthood can be isolating sometimes. If you don’t achieve the kind of economic outcomes you’re looking for and there’s instability, that can facilitate a sense of social isolation that goes along with socioeconomic factors. And then for people who are elderly, it’s this idea of maybe you lose your spouse at some point, or maybe your disabilities start to crop up and then you feel like you can’t get out, you can’t be with the people. Maybe you have problems with vision and hearing that make you feel increasingly isolated. And so at each stage, I think we’re looking at different causes, different problems.

Pete Kenworthy
Everything you just talked about, though, I would think existed 20 years ago, and yet the data shows loneliness is more prevalent now. Right? So is there something that has changed in those things that you mentioned or otherwise?

Andrew Hunt, MD
Well, with respect to technology, things have changed dramatically. So for instance, we think that technological interactions have replaced what would’ve been human interactions in many cases. And you’re seeing a decrease in all forms of social connection in terms of number of hours spent doing it. So we used to spend X number of hours talking with people being face-to-face with friends, family, at work, et cetera. Now we do less of that. Also, people’s experience of social isolation definitely has gone up and this has been measured, so people are generally having fewer one-on-one interactions with other humans. There are other factors that are also interesting to look at, such as our political landscape, which is increasingly divided. And so people are experiencing even within their families differences politically that make them interact less easily and less warmly. And we could argue that technology and social media have influenced that trend as well. But I would say at this point in our political history, we’re at a highly polarized political climate, and this has created rifts socially throughout.

Pete Kenworthy
So the surgeon general, Dr. Vivek Murthy, recently wrote in The New York Times that nearly everyone experiences loneliness at some point, but its invisibility is part of what makes it so insidious, the invisibility of it. That’s pretty powerful, right? I mean, he went on to write that there are grave consequences for our mental health, our physical health and collective wellbeing. Before we talk about how to fix it or how to try to fix it, let’s talk about some of those consequences for people who are mired in that isolation or loneliness. The first one I think of is depression.

Andrew Hunt, MD
Sure. So depression and loneliness are highly correlated. In fact, it’s one of the criterias is social withdrawal. That said, we think it’s probably a bi-directional relationship where people who are more depressed feel lonelier, and then people who are lonelier are more likely to be depressed as well. Individuals who have mental health disorders might be more and more likely to experience loneliness and experience the negative health consequences related to that. So say depression causes social withdrawal for you, and you find yourself alone. You might also feel like you’re less likely to reach out for help. You’re less likely to reach out for support. Maybe there’s a feeling of negative self-worth that goes along with depression that influences the way that you interact with people. I think psychologically speaking, the experience of loneliness is fraught with stigma and shame. I shouldn’t feel this way. If everything’s going well for me, why would I feel this way? So that lack of the ability to accept the feeling that goes along with it and the increasing distress associated with that, I think can be a downward spiral that could lead to consequences such as suicidal thoughts, things like that.

Pete Kenworthy
You mentioned the psychological impact, but there’s also biological and behavioral things that are involved as well, right?

Andrew Hunt, MD
Sure. So loneliness specifically has been correlated with biological changes pertaining to what we call the HPA axis or hypothalamic pituitary axis. This is the way that the body and the mind or the brain manage stress. For instance, cortisol is kind of a big name in this. Loneliness increases cortisol, and it also affects the way the body manages inflammation. And thus, we think that that mediates a lot of the biological outcomes related to loneliness.

Macie Jepson
And so that explains why there’s an increased correlation to heart attack and stroke because of these biological changes?

Andrew Hunt, MD
Yeah.

Macie Jepson
Before we continue, Pete, I want to go back to what you said about Dr. Murthy because it’s so disturbing to me when you say the invisibility of it all, because when I hear that, I think of someone who may seem so happy and maybe even outgoing, and then at home, when truth be told, they’re really very lonely. Do you see that a lot?

Andrew Hunt, MD
Sure, yeah. There are lots of people who find they can interact superficially and they do what they’re supposed to do with their role, but inside they are suffering, and they don’t know who they can bring that to. They don’t know how to manage it necessarily. I think that when people experience a sense of shame associated with a negative feeling, it makes them want to hide from it or makes them want to hide it from others. And I think they think that if they bring it out, it’ll bust this bubble that makes them say, well, yeah, I’m making it. I’m doing it. I’m fulfilling all my roles. Everything’s just fine.

Pete Kenworthy
Is there data that shows that loneliness or isolation leads to drug or alcohol abuse? I would think it would.

Andrew Hunt, MD
Sure, yeah. It’s been correlated with both the onset of drug and alcohol use disorders and also the worsening of them, the worsening of the consequences related to them. So I think, again, I think it’s bidirectional. You might find people who feel lonelier are more likely to stumble upon drugs and alcohol as a way of managing strong negative feelings. I think also once people get involved with drugs, the drugs become their best friend. The alcohol becomes like their best friend, and that makes them more isolated from others and leaves them in a downward spiral sometimes.

Macie Jepson
Speaking of best friend or a connection with something, let’s get back to the technology thing. It seems like an easy thing to blame, but people of all ages spend too much time on their phones. I know I do as well. Is that a legitimate source of what we’re talking about here?

Andrew Hunt, MD
So my feeling about technology use in general is that some people use it to the effect of decreasing loneliness probably. So if you really use your social media to connect with friends and to plan outings and then get together with people, and then you succeed in what you’re trying to accomplish with that technology, great. That’s a social glue. But if you find yourself trapped in it and you’re using it constantly instead of interacting with others, instead of furthering your own kind of interests, I think then it becomes something that wastes time at best or at worst may be causing negative effects. So for instance, like some people have bullying experiences online or via social media, and this we think is dramatically impactful in terms of social isolation. A person who gets shamed on the internet, it could be as bad as being shamed in the public square.

Macie Jepson
But Doctor, what about introverts? People who truly enjoy maybe being isolated? Is there a line between isolation and being lonely?

Andrew Hunt, MD
Well, here’s where we get into the idea of solitude, where some people really enjoy their solitude, and that’s great. They might really find that to be a nice time where they can put their thoughts together. They can be creative. They can let themselves relax and recharge, and that’s great. If that’s sort of the balance you’ve struck with the sense of solitude, I wouldn’t call it isolation in that case. Isolation is more of a problematic term. But if you’re spending too much time by yourself, then you can, and you don’t sort of rejuvenate the connections you have, then you can wonder, is that counterproductive? So there are some people probably who spend too much time alone in spite of not feeling a lot of pressure to interact. But those I think are at higher risk for other bad outcomes because maybe they need somebody to just check in on them and make sure that they’re okay. One of the big impacts of living alone, for instance, is that you have nobody to call 911 if you suddenly have an emergency. And so we know that’s part of the risk of mortality increase that goes along with social isolation.

Pete Kenworthy
Let’s talk about some of the good things that come from being more socially connected, because you’ve referenced the value of that. And I’ll pause in between each one to give you time to comment. These are facts from the Surgeon General’s Advisory. Being more socially connected can improve stress responses and minimize the negative health effects of stress.

Andrew Hunt, MD
Sure. Yeah. So this is a kind of well-established phenomenon that we’ve measured stress hormones in response to a sense of social belonging and connectedness. And you see that that correlates biologically speaking. Now, in terms of practicality and behavior, when you have people to help you deal with daily stressors and you sort of share the stress amongst many people, it tends to lighten the burden for all, and you don’t feel like it’s an emergency when things go wrong. You feel like there are resources I can get to and connect to take care of this problem, or it’s going to get taken care of over time by the group, by the whole, as opposed to me just being stuck with it and all the negative consequences related.

Pete Kenworthy
People with strong perceptions of community are more than two and a half times more likely to report good or excellent health than people with low sense of belongingness.

Andrew Hunt, MD
So belongingness is a very interesting topic. It’s been more well studied recently as a potential intervention for depression and other types of mental health disorders. It’s one of the mechanisms of AA. You create the sense of belonging and then people can resist going back to alcohol or drugs. So we think that when you generate social belonging, you induce a lot of positive things in the brain, a lot of positive things in the body, but then you also create these real social connections that help you deal with problems. So, for instance, like in residency training, one of the things we work on is how do we create belonging between our residents/trainees. They’re all coming from different places. They come from different backgrounds. They’re leaving the social structure they came from, and we need to bring them together and build a sense of belonging quickly so that they can deal with all the stress that comes with being a resident and working hard every day.

Pete Kenworthy
The last one here is children and adolescents who enjoy positive relationships with their peers, parents and teachers have improved academic outcomes.

Andrew Hunt, MD
Yeah. So the social experience of school is something that I feel like we are increasingly focusing on. I think that when a child doesn’t perform academically, that can lead to a spiral of sort of disconnections that go on between peers and between parents and between teachers. And so we need to like have the schools able to meet those needs socially. I think that when students can create these connections and can succeed in their social milieu, they tend to have great academic outcomes, generally speaking.

Macie Jepson
But here’s the thing about this issue. It’s a societal one. It’s an epidemic, though, that is extremely individualized. So I’m wondering how we can help. What can we do to help ourselves? What can we do to help our loved ones? And I mean, this is such an issue that we’re talking about it. How can we help our community?

Andrew Hunt, MD
Right. So this is the big question going forward is what changes can we make? In mental healthcare, I help individuals make changes to the way they view themselves and the way that they reach out or don’t reach out for help when they need it. I also work on what are obstacles to sense of self-worth and self-esteem? And what prevents you from being able to connect with the loved ones you have? For people who are socially isolated and truly alone, we have people that reach them and try to interact in a way that shores up that need a bit. But we need more of that, honestly. Like I think our system needs to grow with respect to home care, with respect to social work, with respect to programs that meet people where they are and create connections where they’re more difficult. I think that there’s multiple layers to what needs to happen.

And the Surgeon General’s report is actually a wonderful document that outlines for every stakeholder in the community what you could be doing. So what could you be doing at government? What could you be doing in a workplace? What could you be doing in a healthcare setting? What can individuals and families do? And for each of those, there are lots of things. I think what’s relevant maybe to the listeners might be, what can I do for the people closest to me? And I would say there are clearly, when you think about a relationship, you can ask yourself, well, how frequently am I interacting? Do I reach out often enough? When we reach out, do we talk about real things or do we just kind of like skirt the issue? Can we deepen our interactions and make them more meaningful?

With respect to balancing your life, you can look at work/life balance, and you can make subtle changes to that by reflecting upon that. I think that with children, parents need to develop this relationship where they can interact meaningfully and kind of get a sense of how each other are doing and model that connectiveness. They can also tell children that when you’re on the phone, I don’t feel that connected to you. Can we spend some time with the phones put away? And you can generate family time that excludes obstacles to meaningful interactions.

Macie Jepson
And young adults are really going through a lot.

Andrew Hunt, MD
Yeah. Another thing about young adults, I think young adulthood is a time when you’re losing some of the social structures that are important or had been important such as high school, such as the nuclear family sometimes. And you’re expected to go out and sort of make your way in this new fashion that’s completely something you have not necessarily prepared for. High school is meant to train you to do certain things, but then the ability to go out and like get your first house or find your first long-term partner or succeed in college, succeed in training of some sort, not necessarily a foregone conclusion. Lots of people struggle at different stages of the period after high school, and this leaves them feeling like the strongest period of inadequacy and identity crisis that they may feel in their lifetime. So they were doing fine in high school. Maybe they leave and they go out, they find it’s more difficult than they thought.

They find that the course that they initially were on is not working for them. And so they find themselves stuck, and maybe at that point they’re afraid to go back and start again, or they’re afraid to pick up and change courses. Maybe they’ve invested a large amount of time and money and effort into something, and they’re afraid to sort of say, well, I need to let that go and do something different. At that point is when belonging tends to plunge, loneliness tends to increase, and that’s a time when people are at risk for suicide often. And so in that moment, I would love for people to instead understand that that’s normal for young adulthood, that you’re going to change your mind. You’re going to not do what you expected to do. You’re going to face challenges you didn’t expect to have. You might have the onset of mental illness or the onset of a substance use disorder. This is the most common period when those things occur. And families and young adults do not plan for this, do not expect it to happen, but it’s the point when actually it happens the most frequently.

So at that point, that’s when we need our system to react and try to prevent long-term negative outcomes of mental health, mental disorders. And I think that if we are able to meet the need for young adults with a very robust approach, that that’s a time when we can see long-term outcomes improve for the next generation.

Macie Jepson
At what point does a loved one, and I say this because sometimes you don’t see it in yourself, does a loved one look at someone and say, okay, it’s time to take it to the next level, maybe get some help. And I mean, I’ll ask that about an individual as well. What’s going through their mind that is an indicator that they can’t do this on their own?

Andrew Hunt, MD
So I would say I’m extensively liberal with respect to seeking mental healthcare. I feel that mental health treatment is a gift. We should talk to our doctors about it. If you feel like you’re in distress, there’s nothing that needs to stop you from getting a therapist and having a relationship with somebody you trust. And that could be somebody who you know as a trusted friend. It could be somebody like a religious leader that you reach out to and interact with for support. It could be a counselor or a therapist. I feel that creating those meaningful relationships are invaluable to the development of people at different stages in their lives. I wouldn’t be where I’m at without having had tremendous support and counseling. And I myself sought therapy for myself for 10 years in my process of becoming a psychiatrist. So to me, that was invaluable. And I would not be who I am without that experience. So I think we should have a low threshold for seeking care. We should not wait for it to become a crisis. We shouldn’t wait for it to be the last resort. Why not make it the first resort? You’re feeling bad, you’re feeling distressed. In any way, talk to somebody about it, get an assessment.

Pete Kenworthy
I mean, it really correlates well to if you start not feeling well physically, you call the doctor, right? So if you start not feeling well mentally, call a doctor.

Andrew Hunt, MD
Right. Yeah. And I mean, the majority of people with mental health problems actually find that their primary care doctor is the adequate source of response. So primary care doctors can respond to these things and do.

Macie Jepson
I think it would be an oversight at this point if we didn’t talk about the suicide and crisis hotline, just because people tend to push it back and not take the steps that they need until it’s almost too late. So would you like to remind folks about that?

Andrew Hunt, MD
Sure. So 988 is a new three digit code, kind of like 911. And you can call this and talk to somebody to get support around any kind of a mental health crisis, including suicidality, including other needs for mental health concerns. So it’s kind of a one-stop shop, and it’s replacing all of the numbers that used to exist for every city in the world. You’d have to know what number to call, but 988 is easier to remember and more I think accessible to wherever you are.

Macie Jepson
Wow. I kind of hate to end this conversation on such heavy note with the suicide and crisis hotline, but it really does underscore how serious this issue can be.

Andrew Hunt, MD
I think the fact that we’re paying attention to it now means that it’s risen to the point where everybody’s noticing it. I don’t think anybody would disagree with the need for more attention to this problem. And we can ask lots of questions at every level about what to do next to build a healthy society, to build the outcomes we want to see.

Macie Jepson
Dr. Andrew Hunt from University Hospitals in Cleveland, a psychiatrist there. Thank you so much for joining us today.

Andrew Hunt, MD
Thank you.