Loneliness is associated with higher health risks than obesity and physical inactivity.
Loneliness has been described as a global health problem, with a negative health status and a lifetime prevalence of 20–30 per cent (Kung et al 2021).
It is associated with adverse physical and mental health outcomes and premature mortality (Vancampfort et al 2019) and creates substantial costs for government and healthcare systems (Kung et al 2021).
In recognition of the costs and health impacts, the UK government recently set up a ‘Ministry of Loneliness’ to address the psychological and health needs of lonely people (Lee et al 2019).
The current global COVID-19 pandemic with consequent social distancing, isolation and lockdowns has triggered even further increases in loneliness (Australian Bureau of Statistics 2020).
Contemporary physiotherapy practice reflects an ongoing paradigm shift from a biomedical to a biopsychosocial care model.
This paradigm shift, which acknowledges how biological, psychological, behavioural, environmental and social aspects interact with each other, has been described as ‘essential’ for multifactorial approaches to clinical care and complex conditions (Sondena et al 2020).
The Physiotherapy Pain Network within World Physiotherapy lists as one of its aims ‘to promote the biopsychosocial model of people-centred care’ and the International Organization of Physical Therapy in Mental Health describes ‘applying a model including biological and psycho-social aspects’.
A recent study of ‘older men living alone’ and ‘how they could be helped’ concluded it was important that healthcare and rehabilitation staff work from a biopsychosocial perspective (Wagert et al 2020).
Understanding loneliness within this holistic framework and how it presents in people’s lives can be beneficial for therapeutic outcomes.
As Vancampfort et al (2019) state, ‘Exploring variables associated with loneliness is important for the development of targeted interventions’ (p 149).
What is loneliness and who experiences it?
While various definitions of loneliness exist, the majority agree that it is distress resulting from a discrepancy between the frequency and quality of actual and desired social relationships.
Loneliness is not the same as living alone, solitude and social isolation, although these factors are interrelated, with social isolation having the greatest influence.
Loneliness may be transient, characterised by short and infrequent bouts, or chronic, persisting most days for longer than two years.
Prior to COVID-19, one in four Australians reported feeling lonely (Australian Psychological Society 2020).
In evolutionary theory, transient loneliness is explained as a biological driver, a motivating force which promotes behaviours of reconnection and increases our chances of survival.
When we socially (and amicably) connect, there is an increased chance of transmission of genes and sharing of resources and we are better able to protect ourselves.
This concept of transient loneliness is reflected in the life stage figures that show peaks of loneliness in young people (15–24 years), middle-aged people (in their 50s) and older people (80-plus years) (Kung et al 2021), with each life stage group telling a different story.
What are the impacts of loneliness and how are they mediated?
A meta-analytic review (Holt-Lunstad et al 2010) concluded that the risk of premature mortality associated with loneliness was higher than the risk for obesity and physical inactivity and equal to that of smoking 15 cigarettes per day.
Ellen Lake reflects on the health risks of loneliness as part of National Mental Health Month.
Other studies link loneliness with malnutrition, worse motor function or mobility, hypertension, disrupted sleep, frailty, fatigue, somatic symptoms (especially pain and headache), cardiovascular disease and cognitive decline (Vancampfort et al 2019, Lee et al 2019).
In one study, reduced grip strength, slower walking speed and impaired cognitive tasks were positively associated with loneliness (Martin-Maria et al 2020).
In another, adolescents engaging in leisure time sedentary behaviour for greater than three hours per day (outside of school and homework) were more likely to feel lonely, with evidence of dose dependency; that is, 8.9 per cent reporting feeling lonely with less than one hour leisure time sedentary behaviour per day and 17.5 per cent reporting feeling lonely at eight hours leisure time sedentary behaviour per day (Vancampfort et al 2019).
Mental health impacts have also been reported, with social isolation and loneliness associated with depression, anxiety, self-harm, suicidality and PTSD-like symptoms (Bird et al 2021).
Both are considered risk factors for schizophrenia (Fiorollo & Gorwodd 2020).
The Productivity Commission’s inquiry into mental health in Australia (Productivity Commission 2020) described reciprocal relationships, whereby loneliness was associated with increased mental illness and those with mental illness tending to report feeling more lonely.
In addition, loneliness has an economic impact, with increased absenteeism, absence due to sickness, reduced productivity and increased healthcare costs (Kung et al 2021).
Data from the Household, Income and Labour Dynamics in Australia Survey (HILDA v19, 2001–19) show a clear relationship, with an increased number of doctor visits and hospital admissions in all age groups in the ‘lonely’ category compared to the ‘non-lonely’.
Several mediating pathways between loneliness and health impacts are identified, with dominance given to the role of enhanced chronic inflammation through a heightened response to stress, poor physiological repair and immune function and pathways of lifestyle factors, worse health behaviours and less optimal use of healthcare (Kung et al 2021).
Who is at risk?
As noted above, mental illness is a risk factor for loneliness and vice versa.
Other risk factors include having fewer relationships, being single, living alone, physical health issues and disability, lower physical activity, increased sedentary behaviour and lower socioeconomic status (Martin-Maria et al 2020).
Higher educational level and income are generally protective against loneliness and yet it is noted that social and economic studies on the ‘inequalities’ of loneliness are not common (Kung et al 2021).
Risk factors for the differing life stage groups are not all the same, an important consideration when applying interventions.
Lower educational levels are associated with increased loneliness in younger age groups, but not in older age groups.
Higher incomes and full-time employment correlate greatest with reduced loneliness in the mid-50-year age group; however, full-time employment in young people correlates with increased loneliness.
Mental health and loneliness have a stronger association in younger age groups, while chronic physical ill health, disability and loss of relationships are factors in older age groups (HILDA v19, 2001–19).
What can we do?
Physiotherapy targets for loneliness include functional outcomes, physical health needs, levels of physical activity and sedentary behaviour and somatic symptoms.
Health promotion, emotional wellbeing programs, animal-assisted therapy and social prescribing to community activities such as gardening groups can be effective (Martin-Maria et al 2020).
Asking ‘Do you ever feel lonely?’ when taking a social history may be a way of opening a conversation and checking in.
Prefacing the question with commentary about these times of social isolation and links with physical inactivity and increased ‘sitting’, for the purposes of physiotherapy education and reducing stigma, may be helpful.
One interesting study highlights the links between emotional regulation, self-reflection and prosocial behaviours such as empathy and compassion, decisiveness, social advising and tolerance of divergent values and spirituality—qualities collectively called ‘wisdom’ (Lee et al 2019).
Cultivating wisdom through practices such as mindfulness strengthens connections between the prefrontal cortex and the anterior cingulate cortex and limbic system, and is associated with decreased loneliness and an increased sense of overall wellbeing.
Another recent study looked at links between negative solitude and physical activity in old age, finding that participants in solitude reported more obstacles to physical activity, which included reduced awareness of one’s own strengths and ability to problem-solve (Mielcarske et al 2019).
Cultivating self-acceptance (the realistic awareness of one’s own strengths, limitations and general worth) was useful and linked to behaviour change.
As physiotherapists, we are encouraged to work within the biopsychosocial model and consider all factors influencing the health status of those we therapeutically care for.
Being there for our clients, listening compassionately, providing symptom relief and activity guidance, and supporting wellbeing and social connection can contribute to reducing loneliness.
October is all about mental health: it’s National Mental Health Month, Mental Health Week is recognised around Australia with each state and territory adopting its own theme and holding its own events, and 10 October is World Mental Health Day.
>> Ellen Lake, APAM, works in inpatient care with Active Rehabilitation Physiotherapy and in clinical and gym-based care with people with chronic conditions and comorbidity. Ellen is the national chair of the APA Mental Health group and is currently completing a Master of Cognitive Behaviour Therapy.
1. Kung, C.S., Kunz, J.S. & Shields, M.A. (2021). Economic Aspects of Loneliness in Australia, The Australian Economic Review, 54,1, 147-163.
2. Vancampfort,D., Ashdown-Franks, G., Smith, L., Firth, J., van Damme, T., Christiaansen, L., Stubbs, B. & Koyanagi, A. (2019). Leisure-time sedentary behavior and loneliness among 148,045 adolescents aged 12-15 yrs from 52 low- and middle-income countries, Journal of Affective Disorders, 251, 149-155.
3. Lee ,E., Depp, C., Palmer, B., Glorioso, D., Daly, R., Liu, J., Tu, X., Kim, H., Tarr, P., Yamoda., Y. & Jeste, D. (2019), High prevalence and adverse health affects of loneliness in community-dwelling adults across the lifespan: role of wisdom as a protective factor, International Psychogeriatrics, 31,10,1447-1462.
4. Australian Bureau of Statistics (2020), ‘Household impacts of COVID-19 survey’, https://www.abs.gov.au/statistics/people/people-and-communities/househol...
5. Sondena,P., Dalusio-King, G. & Hebron, C.(2020). Conceptualisation of the therapeutic alliance in physiotherapy: is it adequate?, Musculskeletal Science and Practice, 46, 102131.
6. Wagert,P., Nygard,S. & Cederbon, S. (2020). Everyday life in older men living alone – a complex view needing biopsychosocial perspective, Disability and Rehabilitation, 42, 1, 44-52.
7. Loneliness/APS- Australian Psychological Society (2020), http://www.psychology.org.au/for-the-public/Psychology-topics/Loneliness
8. Holt-Lunstad, J., Smith, T.B. & Layton, J.B. (2010), Social relationships and mortality risk: A meta-analytic review, PLoS Medicine, 7, e1000316.
9. Martin-Maria,N., Caballero, F., Miret, M., Tyrovolas, S., Haro, J., Ayuso-Mateos, J. & Chatterji, S. (2020). Differential impact of transient and chronic loneliness on health status. A longitudinal study, Psychology and Health, 35, 2, 177-195.
10. Household, Income and Labour Dynamics in Australia (HILDA), v19, 2001-19.
11. Bird, J., Karageorghis, C. & Hamer, M. (2021). Relationships among behavioural regulations, physical activity and mental health pre-and during COBID-19 UK lockdown, Psychology of Sport and Exercise, 55, http://doi.org/10.1016/j.psychsport.2021.101945
12. Fiorollo, A. & Gorwodd, P. (2020). The consequences of the COVID-19 pandemic on mental health and implications for clinical practice, European Psychiatry Journal.
13. Productivity Commission (2020), Mental Health, Report no. 95, Productivuty Commission, Canberra, Australia.
14. Mielcarske, J., Graf, P., Ashe, M, & Hoppmann, C. (2019), S3lf-Acceptance Buffers Negative Solitude – Physical Activity Links in Old Age, Innovation in Aging, 3, 1, S939-S940.
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