What doctors wish patients knew about social isolation

In an increasingly connected world, a paradoxical crisis is silently gripping communities: social isolation. And it is casting a long shadow over public health, from older adults grappling with seclusion to the unexpected repercussions for younger generations. 

AMA policy adopted last year identifies loneliness as a public health issue that affects people of all ages. The policy also supports evidence-based efforts to combat loneliness. This year, the AMA adopted policy further addressing the growing public health problem of loneliness and isolation.

Understanding that lack of social connection has profound effects on mental and physical health, U.S. Surgeon General Vivek H. Murthy, MD, released an advisory on the epidemic of loneliness and isolation. About half of U.S. adults experience loneliness, which presents a major public health threat that is akin to smoking and obesity. 

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines. In this installment, four physicians took time to discuss what patients need to know about social isolation as a public health issue. These AMA members are:

• Tiffani Bell Washington, MD, MPH, an outpatient general, child and adolescent psychiatrist working with Centurion and also in private practice in North Carolina. She is an American Psychiatric Association delegate to the AMA Young Physicians Section, alternate delegate to the Section Council on Psychiatry and a member of the AMA Ambassador Program.
• Frank Clark, MD, an adult outpatient psychiatrist at Prisma Health in Greer, South Carolina, and associate clinical professor at the University of South Carolina School of Medicine-Greenville. He is also an American Psychiatric Association delegate to the AMA Section Council on Psychiatry.
• Douglas DeLong, MD, an internal medicine physician in Cooperstown, New York, and alternate delegate for the AMA Senior Physicians Section.
• Peter Hollmann, MD, a geriatrician and chief medical officer for Brown Medicine. He is also a delegate for the Rhode Island Medical Society. 

Social isolation is “a lack of engagement with others, having very few social contacts or people you would call, text or visit,” Dr. Bell Washington said, adding that social isolation is also “not having a fulfilling quality relationship. You may have people you talk to at work, but you still can be socially isolated if that doesn’t equate to you being able to really consider them a friend or someone you depend on.”

“We all need our time away for rejuvenation and reflection,” Dr. Clark said. “But social isolation is a form of solitude that is unhealthy and can occur due to multitude of reasons.”

“It absolutely impacts all ages across the spectrum, but there are definitely at-risk groups,” Dr. DeLong said. “In terms of social isolation, that tends to be more of a u-shaped issue, particularly the seniors—older than 65—and the younger individuals—adolescents and young adults.”

For example, “the younger people may have some social isolation due to social media use, depending on how superficial those relationships are,” Dr. Bell Washington said. “They may be called friends, but they’re not really friends. So, when it comes down to it, they’re home feeling lonely while being socially isolated.”

“Then in older adults, they may have health issues that are causing them to be socially isolated. For example, maybe they used to go to the gym … and now they can’t do that anymore because they’re sick or a family member is sick,” she said. 

“And then of course, there are other people where it gets intermingled with all the other social drivers of health,” Dr. DeLong said. “So, if you're of a marginalized community, you're at increased risk. If you have chronic medical conditions, you're at increased risk. If you're in a low socioeconomic status, you're at increased risk. Immigrants are at increased risk. LGBTQ+ individuals are at increased risk.”

Social connection is as important to long-term survival as food and water, according to the surgeon general’s advisory. Yet loneliness is more widespread than other major health issues. This epidemic of loneliness and isolation is a major public health concern. 

To that end, “loneliness is the subjective sensation of recognizing that there’s a disconnect between your social connectiveness and what you really need,” said Dr. DeLong. 

“It is the perception of being socially isolated, but people may not be isolated and feel lonely or they may be isolated but not feel lonely,” Dr. Hollmann said. “In fact, while isolation increases with older age, younger aged individuals are the most lonely.”  

“Social isolation can contribute to loneliness, but not everybody who experiences loneliness is socially isolated,” Dr. Clark said. For example, “a person at a family gathering can be surrounded by relatives that care about them but still experience the subjective distress of feeling alone despite being socially connected.” 

“Many things can contribute to social isolation: loss of friends due to death, a new illness making social connections difficult to maintain, a caregiver responsibility, a traumatic event or just life change can all be causes,” Dr. Hollmann said. “Think of your own connections—what if you moved or changed jobs or lost your job or retired? 

“Many people both anticipate the risks and plan prevention and that is likely why we see older people experiencing more isolation yet relatively less loneliness,” he added. For example, “people may expect social losses and lower expectations or increase contact by taking part in activities that involve others, especially of different age groups.”

“Some individuals may experience social isolation in the context of assimilation to a new culture. We see that especially in immigrant populations,” Dr. Clark said. “Additionally, social isolation can be experienced by persons who have been discriminated against due to their race, ethnicity, gender identity or sexual orientation.” 

Social withdrawal may also be a trauma response “and this is why supporting people after trauma is so important. Isolation will only compound the effects of the trauma itself,” Dr. Hollmann echoed.

“Sometimes the bully excludes the person, but oftentimes they just make it so that the person will take themselves out of that social environment for their own safety or because they’ve become depressed or humiliated,” Dr. Bell Washington said. “Oftentimes the bullying will make it so that they don’t actually attend school like they used to or maybe they’re cheerleading, and they don’t want to go to practice because they’re being bullied there. 

“So, that certainly could lead to a worsening social isolation for that child, which usually does lead to loneliness,” she added, noting “it will have the impact of not having proper support in someone to lean on.”

“It is important to recognize that social isolation does impact physical and mental health,” Dr. Hollmann said. “In the surgeon general’s report on the epidemic of loneliness and isolation brought home the point that the adverse effects of isolation are greater than those of smoking up to 15 cigarettes a day.’

“Social isolation and loneliness each independently have more than a 25% increased risk for significant health issues and not just mental health issues like anxiety, depression or suicidal ideation, but other diseases, particularly heart disease, stroke, diabetes and dementia,” Dr. DeLong said. “It’s a major public health issue that’s been very much underappreciated.”

In fact, “studies have shown that social isolation was associated with about a 50% increased risk of developing dementia,” Dr. Clark said. “Furthermore, having poor social relationships was associated with a 29% increased risk of heart disease and a 32% risk of stroke.”

“We know that it can also affect a person’s immune system resulting in an increased susceptibility to various infections,” he said. “Additionally, social isolation is associated with an increased risk of developing obesity, high blood pressure and premature death.”

“We need a combination of social fitness, physical fitness and creative fitness in order thrive in society,” Dr. Clark said.

“Unfortunately, warning signs of social isolation may not be obvious, and the help is more than the type that many medical practices can readily provide,” Dr. Hollmann said. But “it makes sense to just ask patients about loneliness and to be aware of their social support network, especially for those at high risk.” 

That’s because “medicine can improve health and function, even for those who have chronic illnesses,” he said. In fact, “something as basic as a hearing aid or mobility aid can dramatically reduce social isolation.”

“People might feel guilty about experiencing social isolation. Sometimes it may be uncomfortable for them to talk with their doctors because they may feel like they are the only ones who are experiencing this,” Dr. Clark said. 

“We know that there are plenty of people in our society who are experiencing social isolation,” he said. “The COVID pandemic is a sobering example that illustrates the impact that social isolation can have on a person’s well-being."

Additionally, “the numbers are staggering, actually. Something like 60% of people don’t feel like they have adequate social connections,” Dr. DeLong said. 

“The way a lot of parents remember their own childhood may be skewed a bit, but they may say kids don’t have a reason to be sad,” Dr. Bell Washington said. “Or the child will become irritable instead of visibly sad or depressed. So, they think their child is acting out when really it could be depression or any other mental health problems.”

“A lot of times, when parents are dealing with their own struggles of being an adult, it’s hard to empathize with their child having sadness or some difficulty and they kind of just minimize it,” she said. “It’s not with the intention to be cruel or misunderstanding, they are just in their own worlds and don’t hear the child saying they are depressed.” 

“We cannot decide if someone is lonely or socially isolated, unless we ask them,” Dr. Hollmann said. “We also cannot assist them without asking what they think the solution may be. And certainly, everyone needs time to themselves.”

“There are periods during the week where that can be extremely taxing … and we need a weekend to not do anything—no social commitments,” Dr. Clark said. “I may write poetry or watch a sporting event on TV. But I’m not going to commit to any type of social engagement.” 

“Self-care is vital for our health. The time we take to replenish our energy is beneficial for us and for the people we interact with in various settings,” he said. 

One way to overcome social isolation is to “think about why you are isolated. Can the cause be changed—mobility, transportation, hearing?” Dr. Hollmann said. “Is it a self-imposed phenomenon because you may feel differently about yourself than you did at another time?

“Maybe making new connects was always difficult, but you can push yourself a little,” he added. “It may be that professional assistance is needed with depression, anxiety or physical illness. It may be that as a caregiver, you need to get help on how to use community supports and make time for yourself.”

When it comes to combating social isolation, “that’s going to be different for everyone,” Dr. Clark said. But one “thing I would recommend is finding a new hobby. That goes back to creative fitness—finding something that brings you joy that would foster meaningful connections and social engagement.”

“Join a book club or take a painting class,” he said. “If you enjoy exercise, join a gym or the YMCA. All of these activities can help cultivate meaningful relationships.” 

Additionally, “particularly for adults, we know that volunteering seems to be a very effective way at increasing social connectivity,” Dr. DeLong said. “I would certainly be encouraging my older patients as much as possible to be doing things like that.”

“To overcome social isolation, people should be intentional about how they would like their life to look. But it’s different for every person,” Dr. Bell Washington said. “If you’re someone who wants to be really social and you want to go out once a week, then you would need to design this life that could support that. 

“So, maybe for that person they would find a community center that they could go to for classes and meet people in these classes or doing things they already enjoy and meeting people that way,” she added.  “If you want to feel more connected, you need to start out with that intention and go to community groups.”

“Then as much as you can, if you’re going to do social media, make sure there’s some substance behind it and try not to have superficial relationships. Try to go deeper when you can and when it’s appropriate,” Dr. Bell Washington said.

“If you’re feeling socially isolated, don’t hesitate to reach out to a family member or friend to talk about how you have been feeling,” Dr. Clark said. “If you feel like you can’t talk about it with a family member or a close friend, reach out to your physician or someone you trust, because there are interventions that can help.”