A silent and grossly underserved epidemic of loneliness is affecting 60% of all Americans including 75% of young adults and 40% of older adults—influencing and complicating mental health disorders, physical health disorders, adherence to treatment and increasing hospitalizations.
The U.S. Surgeon General, in a recently published and widely discussed “Advisory on our Epidemic of Loneliness and Isolation”, has stated that “we must prioritize building social connection the same way we have prioritized other critical public health issues such as tobacco, obesity, and substance use disorders.”
Numerous experts have called attention to our loneliness epidemic, describing its negative health impact as similar to “smoking 15 cigarettes a day”. It is time for a systematic approach to address the loneliness epidemic that is crippling US healthcare as well as the quality and health of human relationships in America.
A crucial and pressing step toward achieving this goal is universal screening for loneliness.
What is loneliness?
Social isolation is the objective lack of interaction with others (as happens when people live alone). Loneliness is similar but refers to the subjective feeling of being alone or the gap between one’s expectations of the quantity or quality of relationships and what is actually experienced.
In other words, loneliness is a “subjective feeling that the human connections we need in our life exceed the human connections we have." These feelings, as well as comorbid stress, anxiety and depression, have intensified even as the rates of COVID-19 detections have receded.
The “Big Resignation” did not start with COVID-19 and has not slowed down since nor has the adoption of social networks and media that over the past two decades have changed how humans connect and engage with each other.
When the Pew Research Center began tracking social media adoption in 2005, just 5% of American adults used at least one of these platforms. By 2011 that share had risen to half of all Americans, and in 2021 72% of Americans reported using some type of social media. Ad-driven social media sites have made it infinitely easier to create new “human” connections — but research has shown that adults with high social media use seem to feel more socially isolated than their counterparts with lower social media use.
We are all connected it seems—and yet, we are more disconnected than ever.
The documented financial impact of loneliness is disastrous. American Association of Retired Persons estimates that the lack of social contacts among older adults accounts for $6.7 billion in additional Medicare spending annually. The costs to employers have been estimated by the Cigna 2022 Loneliness Index at more than $154 billion annually in stress-related absenteeism alone.
The growing economic burden associated with poorly addressed loneliness is unsustainable. Worse, it is avoidable and worse still—it is likely, if action is not taken, for the loneliness epidemic to spread further. For example, by 2030 the number of older adults on Medicare Advantage—the population AARP has measured to estimate the cost of loneliness—will rise from 30 million today to 43 million.
What can we do? Universal screenings and social health prescriptions
Given the population prevalence of loneliness, we need to screen for it—just as we do for other modifiable risk factors such as tobacco use and elevated blood pressure. We believe all clinicians should screen their patients at least annually about their social health, including loneliness.
Some provider groups are already doing this using evidence-based tools such as the UCLA scale. The Coalition to End Social Isolation and Loneliness, whose members include health insurance leaders, key healthcare providers, among other innovators state the following key policy goal for 2023-2024: “Expand the scope of screenings for health-related social needs or social drivers to include social isolation, loneliness, and social connection.”
Meanwhile, the Centers for Medicare and Medicaid Services already measures loneliness levels annually for millions of Medicare and Medicaid beneficiaries participating in the Accountable Health Communities program, using the question: “How often do you feel lonely or isolated from those around you?” respondents are invited to choose between “Never," “Rarely," “Sometimes," “Often” and “Always."
This and other evidence-based questionnaires for loneliness can be easily incorporated into annual member assessments.
Once we identify a condition like loneliness, then we must act and provide a social health prescription, sometimes called Social Therapeutics, following a “3 As” protocol and cycle, which includes:
- Assess: Let’s measure it. What is the acuity of loneliness and social disconnectedness for a specific member or patient as we screen them to be able to help? This is where questionnaires such as UCLA, Health-Related Quality of Life (aka, HRQOL or Unhealthy Days) and others, if they are asked annually for all patients and quarterly for chronic or seriously ill patients, can become extremely useful.
- Align: Let’s personalize loneliness needs to locally accessible resources. Although more than half of Americans are lonely, every American is lonely in their unique way. What are the specific life experiences or circumstances that are exacerbating a sense of loneliness for members or patients? What resources (aka, loneliness formulary) are available to them if at all, and are they looking for virtual or in-person support? This is where each person should have their own Social Profile with needs and potential resources.
- Act: Let’s prescribe social health. Through shared decision-making with patients and members, providers and other parts of the health system (e.g., payers or health insurance companies, purchasers or employers) should look to prescribe personalized resources along with social connectedness-building actions. In the same way that a prescription for taking a medication or getting a screening test is followed and tracked, we need to make sure “check in” at a later date to see whether those actions were followed through or not, including to what extent and to what effect. Analogous to how we manage and track conditions like hypertension or diabetes, continuous tracking, monitoring, and refining of these recommendations is absolutely crucial.
This is where the Assess-Align-Act cycle can restart as we assure our loneliness epidemic is being continuously measured and addressed.
In the US, we have a $4.3T healthcare budget—yet social health solutions with proven impact like clubhouses, peer support, and community programs still hold bake sales to pay their rent. In tandem with widely administering loneliness assessment, reimbursement of impact-proven solutions must occur.
It is time we address loneliness as an urgent threat to the financial sustainability of US healthcare in the next decade. It’s also time we address Social Health as a vital sign for health with the desired outcome of regular screenings to measure loneliness and social health and actions to prevent and treat the painful impact and rising costs of our loneliness epidemic.
Kyu Rhee is an associate professor at the Johns Hopkins Bloomberg School of Public Health. Tom Insel is the co-founder of Vanna Health. Dan Russell is a professor of human development and family studies at Iowa State University. Dena Bravata is the co-founder of Lyra Health. Boaz Gosc is the CEO of Wisdo Health.