Wednesday, May 30, 2018

Loneliness and Health

It's easy to make jokes about the British "Minister of Loneliness," as Steven Colbert did when Theresa May announced creation of the new position this winter. But for several decades we've known that loneliness isn't a joke - it's a significant risk factor for poor health and premature death.

Here's how Vivek Murthy, the former Surgeon General, explains the health impact of loneliness:

...Over thousands of years, the value of social connection has become baked into our nervous system such that the absence of such a protective force creates a stress state in the body. Loneliness causes stress, and long-term or chronic stress leads to more frequent elevations of a key stress hormone, cortisol. It is also linked to higher levels of inflammation in the body. This in turn damages blood vessels and other tissues, increasing the risk of heart disease, diabetes, joint disease, depression, obesity, and premature death.

Understanding the toxicity of loneliness has implications for public policy and health care practice. The UK ministry exemplifies a public policy action. But my interest for this post is health care.

Physicians are overburdened with requirements, but asking about our patients' social connectedness is central to understanding them. Loneliness is often the result of illness. People who are ill may withdraw from the social world, and sometimes others may withdraw from them. And loneliness can cause vulnerability to illness and diminish the resilience we need to recover.

In my psychiatric practice I sometimes took out my prescription pad and wrote instructions like "talk with a friend at least once every day" to dramatize my belief that in many circumstances, persons could be more effective than pills. And I kept a file with resources patients mentioned: AA and NA groups, Alliance for the Mentally Ill support programs, and more. Over time this helped me suggest venues that aligned with my patients' temperaments for those who might benefit from the right kind of peer support.

When I was asked to start an HMO outpatient program for patients with chronic mental illness I surveyed the literature for guidance. While the term "loneliness" wasn't used, the most promising models were group-based programs with an informal, friendly and welcoming atmosphere. For several years I had the privilege of being the psychiatrist who met with the group. Patients could come as often or as rarely as they wished. When a patient had a question about medication of some other aspect of treatment, I could usually direct the question to another patient with first hand experience of the treatment in question. Patients often became friends.

The widening recognition of loneliness as a toxic state and meaningful social connection as a health promoting factor is a positive step for health care. But, unfortunately, valuable insights can be drowned in bureaucratic regulations. Reducing inquiry about loneliness to a required checklist of questions risks coming across to patients as sterile and perfunctory, and to physicians as one more requirement in the ever-lengthening list of externally driven expectations.

But when interest in the social texture of our patients' lives is part of the clinician and patient coming to know each other as human beings and collaborating in service of health, both parties will gain.