How many close friends and relatives do you have with whom you feel comfortable and can discuss private matters? How many of them do you see at least once a month? Are you joining a group? These are some of the questions in a survey called the Berkman-Syme Social Network Index, which doctors use to determine if someone is “socially isolated.” People are considered isolated if they have fewer than six confidants, no spouse, and no group affiliations. These circumstances make them less likely to report that they have someone they can count on when they want to talk, offer advice about a problem, or show love and affection.
But you can have many connections, even close ones, and still feel lonely. To assess that subjective state, clinicians can use the UCLA three-item loneliness scale, which asks: How often do you feel like you don’t have company? How often do you feel left out? How often do you feel isolated?
Social isolation and loneliness often go hand in hand. However, researchers have become increasingly aware that you can experience one, but not the other. That means that these conditions can have different causes, different health effects and different possible solutions. In February 2020, a report from the National Academies of Sciences, Engineering and Medicine noted that a third of Americans over 45 feel lonely; a quarter of the over-65s are socially isolated. Each condition increases the risk of premature death from any cause — as much as or more than smoking or lack of exercise — as well as the risk of heart disease and stroke. Social isolation increased the risk of dementia by 50 percent, and loneliness correlated with higher rates of depression, anxiety and suicide. Older adults and people in marginalized groups are at increased risk for both isolation and loneliness.
And that was the situation before the pandemic forced so many people to stay physically distant from others, almost certainly exacerbating both isolation and loneliness in unpredictable ways. “The reality is that we are in a data-free zone to some degree,” Carla Perissinotto, one of the authors of the report and a professor of medicine at the University of California, San Francisco, told the special in June 2020. Senate Aging Committee. “We don’t know how long we have to be lonely or isolated, or how severe this has to be to have lasting negative effects.”
Over a year later, a complicated picture begins to form. In July, researchers at Northeastern University and elsewhere reported the results of an ongoing national survey that began in April 2020. They asked respondents how many people they had in their social circles who they could count on to take care of them if they got sick; to lend them money; to talk to them if they had a problem or felt depressed; or to help them find a job. The number of people reporting having one person or no one in each group tended to be highest last fall, a period when participants also reported a decrease in the amount of time they personally spent with non-household members. Support and closeness to others increased at about the same time between December and April, as vaccines were rolled out and restrictions began to be lifted. But at that point, respondents increasingly began to say that they were again missing all four types of support, although their amount of face-to-face contact continued to grow. Seeing other people again can be “a bit of a reality check,” said Louise Hawkley, principal investigator with NORC at the University of Chicago. You might find that someone you thought could support you, can’t — perhaps because of that person’s own pandemic struggle. Katherine Ognyanova, an associate professor of communications and information at Rutgers University and author of the study, said: “No previous investigation of an event of this magnitude has been done. We’re just learning what happened and how to deal with it.”
Before the pandemic, few studies attempted to assess both social isolation and loneliness in the same group of participants to directly compare their effects. (Researchers also often use conflicting definitions of and metrics to measure concepts like “support,” “isolation,” and “loneliness.”) In 2015, an analysis of existing studies was published in the journal Perspectives on Psychological Science by Julianne Holt-Lunstad, a professor of psychology and neuroscience at Brigham Young University, and her colleagues found that social isolation increased the risk of death by an average of 29 percent; loneliness increased it by 26 percent and living alone by 32 percent. In 2018, a report in the journal Health Psychology saw evidence that social isolation exacerbated the impact of loneliness on mortality and vice versa. Holt-Lunstad says we tend to imagine that being isolated by choice is fine when you’re happy. “But what the evidence suggests is that this may be a wrong assumption,” she adds. “We shouldn’t be so quick to reject isolation alone.”
But exactly how each condition causes its associated health effects is still an open question. Loneliness can increase stress and inflammation, but it can also impair sleep and trigger unhealthy behaviors like drinking and smoking, says Lis Nielsen, director of the behavioral and social research division at the National Institute on Aging. In contrast, isolation can make it more difficult to access medical care or nutritious food or to exercise, which in turn can cause stress. Men are at greater risk of becoming socially isolated, while women are more at risk of being lonely. Being unmarried, widowed or divorced is associated with both; as well as a low income and a lower level of education. A study of incarcerated people published in the journal JAMA Network Open in 2019 noted that the longer someone spends in solitary confinement, the greater the risk of death. (In the past 18 months, many prisons have essentially used solitary confinement to quarantine inmates.) “It’s a form of trauma,” said lead author Lauren Brinkley-Rubinstein, an associate professor of social medicine at the University of North Carolina at Chapel Hill. Afterward, people “can’t just step back into the way things were.”
Figuring out how to reduce the effects of social isolation and loneliness on those most at risk has become of new importance as the number of Covid-19 cases rises again. “We may not be able to do much about isolation if we are forced into more restrictions,” Perissinotto says, “but we may be able to tackle loneliness.” However, existing technology solutions seem to have yielded mixed results. A study of adults aged 55 and older conducted during the pandemic and published this month in the Journal of the American Geriatrics Society by Hawkley and colleagues found higher rates of loneliness, depression and reduction in happiness despite increases in distance contact compared to formerly; Another study with different criteria and published in April in The Journals of Gerontology: Series B found increased physical isolation in adults over 50, stable levels of digital contact, and no increase in loneliness. “It’s complex,” says Holt-Lunstad. “There is some evidence to suggest that technology has helped to maintain social connections, and some evidence to suggest that it has actually increased loneliness.” Indeed, young people, who are often believed to be more digitally savvy than the general population, have reported particularly high levels of loneliness and related conditions such as depression. And surveys often fail to reach very vulnerable groups, including those without internet access and people with dementia.
Because the causes of social isolation and loneliness are so different — from mobility issues that keep someone home-bound to grief over the loss of a spouse — relieving them “requires an individualized approach,” Perissinotto says. There is not one proven intervention; instead, she suggests thinking about what kinds of connections you think you’re missing and looking for ways to forge them. To the extent that the pandemic disrupted our social lives, it has also prepared us to develop new relationships. Being lonely or isolated is now “an experience we all know on some level,” Hawkley says. “I think that will help to do more research and efforts to solve it.”
