Loneliness

Case scenario

Charlie, a 54-year-old regular patient of your pharmacy, comes in with a prescription for varenicline. He discloses that his smoking has increased significantly since his divorce and that it escalated further during the isolation periods of the COVID-19 pandemic. His other medicines include amlodipine, atorvastatin and fluoxetine. You dispense the varenicline and ask that he join you in the private consulting room to have a chat about his new medicine. 

Introduction

Despite being the most technologically connected society in history, we appear to be the loneliest. Robust scientific evidence has declared loneliness a significant danger to the health of the individual and the public health system.¹

Internationally, countries are recognising its significance. In 2018, London appointed a minister of loneliness and adopted a national loneliness strategy,² and in 2021 Japan also appointed a minister of loneliness.¹ The World Health Organization (WHO) has shared plans for the establishment of a global commission to address loneliness, including the development of a global index on social connection to help measure social connection around the world and allow progress of interventions to be tracked.³ Most recently (May 2023) the US Surgeon General, Dr Vivek Murthy, released an Advisory addressing loneliness and isolation, and laid out a framework for a National Strategy to Advance Social Connection.⁴¹ However,  loneliness has been largely overlooked by the Australian health system.²

Pharmacists are well positioned to recognise and address loneliness. However, pharmacists must be trained in the science of loneliness and understand its far-reaching detrimental impacts on mental and physical health, and on medication adherence. Pharmacists need to be empowered to raise public awareness, screen for loneliness, and be upskilled to deliver evidence-based solutions for loneliness, with most Australians being affected at some point in their lifetime.¹

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What is loneliness? 

Loneliness is a subjective, negative feeling associated with a perceived gap between a person’s current social relationships and their desired social relationships.⁴ This definition was released as a position statement from the Global Initiative on Loneliness and Connection (GILC), which is committed to addressing the pressing global issues of loneliness and social isolation, the aim being to create a standardised, globally accepted definition to enable effective measurement, evaluation and reporting on loneliness, and interventions.⁴ Although loneliness and social isolation are related, they are distinct phenomena. Social isolation refers to objectively having few social relationships, social roles, group memberships and infrequent social interaction.⁴

The distinction between loneliness and social isolation explains why a person can be in a room full of people and feel lonely. Conversely, one can be alone and feel content. Loneliness can be a short-term, transient experience with feelings coming and going, or it may persist in the long term to become a chronic experience.⁵

Prevalence of loneliness

Prior to the Covid-19 pandemic, approximately 25% of Australians aged 12–89 years experienced problematic levels of loneliness, equating to around 5 million Australians.⁶

Survey data collected between March and April 2020 indicated that 54% of Australians reported feeling lonelier since the onset of the COVID-19 pandemic.⁷ It is now estimated that about 36% of the Australian population experiences loneliness.⁸ Contextually, this is significantly greater than the number of people known to have diabetes in Australia (about 5.5%).⁹

Costs of loneliness

Loneliness has significant economic repercussions, costing the Australian economy an estimated $2.7 billion annually, with the average cost approximately $1,565 per person per year.^1,10 These costs include increase healthcare use, sick leave, and the costs resulting from greater incidence of poor health behaviours such as smoking and consumption of excessive alcohol.¹⁰

People aged 15–85 years who report feeling lonely are more likely to visit the doctor than those who do not.¹¹ A recent Irish publication revealed that loneliness was associated with a higher likelihood of availing pharmacy services and requesting medication advice.¹² Given the accessibility of community pharmacists in Australia, it is feasible that an even larger number of people who are lonely visit a community pharmacy more often.

Furthermore, it has been found that lonely older people are ‘60% more likely to use emergency services and twice as likely to be admitted to residential aged care than non-lonely older people’.¹ This increased use of health and aged care services results in greater healthcare costs and impacts the availability and pressure on already stretched resources.

Health impacts of loneliness

People who feel lonely are at a higher risk of potential serious health issues (see Figure 1). There are a range of social behaviours related to loneliness that have further negative implications for health, including chronic disease and death.¹ Loneliness has been associated with a higher incidence of smoking, poor diet, physical inactivity, problem gambling behaviour, sexual risk behaviour and problematic alcohol use.¹

Evidence showing physical and mental health impacts from loneliness include:

• Epidemiological research shows that loneliness is associated with a 26% greater risk of premature mortality.¹³ This is similar to the risk of premature death associated with well-known risk factors such as obesity.⁸
• Lonelier people show poorer cardiovascular health indicators, such as elevated blood pressure and cholesterol, and impaired cardiac function.^14,15
• Loneliness increases the likelihood of cardiovascular disease, with research indicating a 29% increase in the incidence of coronary heart disease and a 32% increase in the risk of stroke in those with poor social relationships.¹⁶
• Research shows that the health effects of loneliness can be likened to smoking 15 cigarettes per day.^17-20
• Loneliness is a risk factor for specific neurological conditions such as dementia and Alzheimer’s disease.²¹
• Suicide Prevention Australia found international evidence that indicates links between loneliness, self-harm and suicide.^22,23 Loneliness is among the most significant risk factors identified by Suicide Prevention Australia’s State of the Nation in Suicide Prevention 2022 report.^8,16,24
• Loneliness predicts future poorer mental health severity and increases the likelihood of experiencing depression by 15.2%.^25,26 However, while loneliness is a risk factor for poor mental health, it is a distinct phenomenon requiring different strategies.
• Loneliness may be one factor that increases the risk of type 2 diabetes.²⁷

Risk factors for loneliness

There is a perception that loneliness is only a concern for the elderly. However, it does not discriminate and can impact all ages, genders and personality types, and can co-exist with any health condition.

Most people will experience loneliness at some point in their lives, but there is a higher proportion of people who experience loneliness in their youth, and then again in older age.²⁸

Research has found certain groups have higher levels of loneliness, including^1,6,29,39:

• People aged 18-25, or those over 56 years of age
• People who live alone 
• People who are unemployed 
• People who are parents of children under the age of 18
• First Nations peoples
• People who identify as LGBTQIA+
• Migrants from non-English speaking countries 
• People from a lower socio-economic status 
• Older adults with hearing loss.

Measuring loneliness

There are various validated screenings tools available, including the UCLA loneliness scale.^5,30 A Guide to Measuring Loneliness for Community Organisations, published by Ending Loneliness Together – a national Australian initiative – uses a modified version of the tool which can be used by pharmacists.³¹ It describes two key methods to measure loneliness: a direct measure (which uses the word ‘lonely’ in the question), and an indirect measure (these do not use the word ‘lonely’ in the questions).

Loneliness: polypharmacy and medication adherence

Researchers analysed data from more than 15,000 adults aged 65 years or older who administered their own medicines and found that loneliness was associated with polypharmacy.³² Lonely older adults also used more opioids and benzodiazepines on a daily basis than their more connected, less lonely counterparts.³² A potential explanation for this is that loneliness may exacerbate a person’s levels of pain or depression, and risk of certain conditions, thereby increasing medication requirements.^32-34

A cross-sectional study, evaluating the relationship between loneliness and medication adherence in patients with diabetes mellitus, found that those who said they had difficulties in medication adherence had on average significantly higher loneliness scores.³⁵

More research is required for full appreciation of these relationships. 

Loneliness interventions by pharmacists

Economic modelling by the National Mental Health Commission showed that for every $1 spent on certain programs addressing loneliness, there was a $2.87 return on investment (ROI) after 5 years.³⁶ Despite this, there is limited evidence to direct health professionals in terms of the best type of interventions to use.

Loneliness is complex and is fraught with stigma and shame, meaning there are countless Australians living with persistent loneliness who do not access help. Loneliness can also be easily overlooked by all health professionals, or is downplayed because of its subjective nature. Additionally, because of the varied risk factors for loneliness, a one-size-fits-all solution will not work.

Pharmacists, as one of the most trusted and frequently accessed health professionals in Australia, have a unique and personal relationship with patients. This social capital is a precious commodity in the rapidly evolving digital healthcare landscape. Patients are engaging far less in face-to-face consultations, resulting in an erosion of the nourishing incidental chit-chats that occur between patients and health professionals. Despite this, the human element and interactions will remain an integral part of pharmacy in the future. Pharmacists often talk to patients about smoking cessation and weight management to reduce their risk of chronic diseases, yet pharmacists rarely talk about social health considerations (e.g. loneliness, despite this being a significant, potentially modifiable risk factor). It is now a professional responsibility to expand health literacy around loneliness and take a leadership position to address it.

Pharmacy Addressing Loneliness and Social-isolation (PALS) is an example of an initiative striving to develop a road map for the pharmacy sector to address loneliness and social isolation. The longer-term goal is for pharmacists to have an in-depth understanding of the health effects associated with loneliness and social isolation, and how to address them, and for this to become an intrinsic part of pharmacy practice across Australia. 

Social prescribing

One intervention, social prescribing, is gaining popularity globally with an opportunity for pharmacy involvement.³⁷ Social prescribing is recognised as ‘a means for trusted individuals in clinical and community settings to identify that a person has non-medical, health- related social needs and to subsequently connect them to non-clinical supports and services within the community by co-producing a social prescription – a non-medical prescription, to improve health and wellbeing and to strengthen community connections’.³⁷

An example of this is encouraging a patient to volunteer, join a local sports club or take a dance class. A pharmacist could create a list of their community’s existing resources and local social activities. This way, pharmacists can ‘prescribe’ local activities to patients promoting connectedness. Pharmacists can also use the Ending Loneliness Directory, which is Australia’s first national online directory to help people experiencing loneliness to find groups, organisations and services providing opportunities for connection.

Other interventions The following are just some of the ways pharmacists can help in this area: 

• Educate patients and carers about the health impacts of loneliness and the importance of social health.
• Check in with at-risk patients regularly and encourage them to seek opportunities for connection (e.g. consider asking about loneliness when delivering medication to at-risk patients).
• Increase community awareness of loneliness with patient education and information leaflets, and support the global consumer campaign Loneliness Awareness Week,38 which aims to reduce the stigma of loneliness.
• Screen for loneliness using validated tools such as the UCLA loneliness scale^5,30,31 (for example during medication reviews).
• Include social health recommendations as part of lifestyle counselling and medication adherence support.
• Where appropriate, recommend FriendLine – a national support line manned by volunteers ‘ready for a cuppa and a conversation’. This service is available 7 days a week for anyone who needs to connect or just wants a chat. All conversations are anonymous.
• Initiate community programs to promote social connectedness (e.g. organise a local community health seminar that will bring people together). 
• Participate in pilot programs, research studies and innovative digital solutions to address loneliness where possible (e.g. recommend evidence-based apps that address loneliness such as Wisdo Health).
• Collaborate with the multidisciplinary team around a patient’s loneliness to provide comprehensive patient care.
• Be empathetic in everyday conversations with patients – even a brief positive interaction can alleviate someone’s loneliness, provided the moment leaves someone feeling seen. 

Knowledge to practice 

Loneliness has been shown to have a significant impact on health outcomes for patients, and with approximately 36% of Australians reporting experiencing loneliness,⁸ this is a common condition that is currently under-addressed.

Pharmacists are well placed to screen for loneliness in their patients. They can educate patients and carers about the health risks associated with loneliness, identify any potential impacts this may be having on medication compliance and health outcomes, and work with the patient and their healthcare team to address these.

Pharmacists can also talk about loneliness more openly to help reduce any stigma, include social health recommendations as part of lifestyle counselling and medication adherence support, and follow up and monitor individuals at risk of loneliness.

Conclusion

Loneliness is complex and is a growing health concern, with potential significant negative health outcomes. Pharmacists should address loneliness to ensure they are applying a personalised and holistic care approach. With the expanded scope of practice for pharmacists in Australia, across different practice locations and critical access points including general practice, community, hospital, aged care and in people’s homes as home medication review pharmacists, there are more opportunities than ever for pharmacists to have an impact on social health.

Key points 

• Loneliness is a subjective, negative feeling resulting from a perceived gap between a person’s current and desired social relationships.
• Loneliness is a growing global challenge with significant health and social impacts.
• Pharmacists are trusted and readily accessible health professionals and should be addressing this risk factor wherever possible to minimise these impacts.
• Social prescribing is one intervention pharmacists can utilise to intervene and address loneliness.

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References

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Our author

Jenny Kirschner (she/her) Bpharm(Hons) is the founder of PALS (Pharmacy Addressing Loneliness and Social-isolation), the first international pharmacy initiative committed to raising awareness and addressing lonelinesss and social isolation to improve the health of patients and society (palsglobalnetwork.com)

Our reviewer

Hana Human (she/her) Bpharm, PGDipClinPharm. MPS (NZ)