Tackling Loneliness: Have individuals with mental health problems fallen through the cracks?

Individuals with mental health problems are at a higher risk of loneliness compared to the general population. You may be wondering, why is this the case?

By Mariam Adeniji, Featured Writer.

What is Loneliness?

Loneliness can be defined as a subjective negative feeling about the perceived disparity between a person’s desired level of significant social relationships and the actual level and quality of these relationships (Mann et al., 2017). Loneliness can be felt by all, however when it becomes persistent this can have harmful effects on our physical and mental health. These include symptoms of depression, cognitive decline, and increased mortality rate (Pimlott, 2018).

Evidence suggests that the prevalence of loneliness worldwide ranges from 6-76%; with the UK reporting a prevalence of 14% (Pimlott, 2018; Groarke et al., 2020). Rates of loneliness are now estimated to have increased to 27% due to lockdown measures imposed during the COVID-19 pandemic in the UK (Groarke et al., 2020). Due to these high rates and its negative effects, loneliness is a significant public health issue.

Loneliness and Mental Health

Individuals with mental health problems are at a higher risk of loneliness compared to the general population. You may be wondering, why is this the case?

Society can hold certain negative stigmatising views about individuals experiencing mental health problems. An example of this is ‘people with mental illnesses are dangerous’ (Corrigan, 2004). This can cause an individual experiencing a mental health problem to internalise this view which can cause them to isolate themselves or have difficulty building relationships with others. This individual can then begin to feel lonely, further damaging their mental health as loneliness is associated with depression and anxiety (Mushtaq, Shoib, Shah, & Mushtaq, 2014). This leads to a vicious cycle:

The individual’s mental health makes them feel lonely and feeling lonely further damages their mental health (Mind, 2019).

Therefore, stigma can act as a precipitating factor that triggers loneliness and a perpetuating factor that sustains the feeling of loneliness in these individuals. Thus, it is important to identify evidence-based interventions that tackle loneliness in this vulnerable group.

Evidence-based interventions to reduce loneliness in individuals with mental health problems.

A meta-analysis identified four strategies that are applied to loneliness interventions (Masi, Chen, Hawkley, & Cacioppo, 2011, Cacioppo et al., 2015):

1.    Improving social skills e.g., listening skills, verbal and nonverbal communication skills

2.    Enhancing existing social support e.g., befriending and mentoring programs

3.    Increasing opportunities for new social contact e.g., social gatherings

4.    Addressing maladaptive social cognitions e.g., cognitive behavioural therapy

However, evidence has largely focused on reducing loneliness in older adults within the general population (Bessaha et al., 2020). This poses the question: can these four strategies identified by Masi and colleagues (2011) be used to reduce loneliness in individuals with mental health problems?

Interventions focused on enhancing social skills were found to be effective for individuals with serious mental illnesses such as psychosis (Bessaha et al., 2020; Mann et al., 2017). However, it seems that this specific intervention strategy measures social competence and social functioning rather than loneliness. Therefore, this strategy may increase an individual’s social network, however it may not directly tackle the subjective negative feelings associated with loneliness (Cacioppo et al., 2014).

There are inconsistencies within the literature regarding interventions focused on addressing maladaptive cognitions. Several studies have found that these interventions are effective in reducing loneliness in individuals with mental health problems, however some have not (Masi et al., 2011; Mann et al., 2017). This is due to such interventions being in their early stages, making it difficult to establish effectiveness (Mann et al., 2017). Equally, studies evaluating this intervention largely consisted of individuals with depression. CBT has strong evidence in reducing depressive symptoms (Hofmann et al., 2012). Considering that depression and loneliness are positively correlated due to having similar symptoms i.e., persistent sadness, this can confound findings (Mustaq et al., 2014). Therefore, further research evaluating this specific intervention is required.

Group-based programs which increase opportunities for new social contact have been found to be effective particularly for serious mental illnesses such as psychosis (Bessaha et al., 2020). However, peer support programs that aim to enhance social support were found to be effective for individuals with depression and anxiety (Pfeiffer et al., 2011). This suggests that individuals with different mental health conditions may benefit from different loneliness interventions.

Studies have also identified a practical method in which services can support those who are at risk of loneliness. This is called Social Prescribing (SP). This enables individuals to be linked with support within the community e.g., peer support, exercise groups and befriending services (Bickerdike et al., 2016). Though it is not yet evidence-based, Hassan et al. (2020) found that SP focused on recovery, wellbeing and peer support decreases the burden of mental illness and loneliness.

It can be concluded from these studies that there is mixed evidence concerning loneliness interventions for people with mental health problems. Therefore, further research is needed to identify how these interventions can be implemented in this population group and how the type of mental health condition can impact the effectiveness of this intervention.

Equally, it is important that researchers and practitioners consider the additional barriers individuals with mental health problems face when accessing treatment compared to the general population, specifically stigma (Knaak, Mantler, & Szeto, 2017). As a result, stigma should be addressed both in preventing loneliness in this vulnerable group and as a psychoeducation component in interventions.

References

Bessaha, M.L., Sabbath, E.L., Morris, Z., Malik, S., Scheinfeld, L., & Saragossi, J. (2019). A Systematic Review of Loneliness Interventions Among Non-elderly Adults. Clinical Social Work Journal, 48, 110-125. doi: https://doi.org/10.1007/s10615-019-00724-0.

Bickerdike, L., Booth, A., Wilson, P.M., Farley, K., & Wright, K. (2016). Social prescribing: less rhetoric and more reality. A systematic review of the evidence. BMJ Open, 7 (4), e013384. doi: 10.1136/bmjopen-2016-013384.

Cacioppo, S., Capitanio, J.P., & Cacioppo, J.T. (2014). Toward a neurology of loneliness. Psychological Bulletin, 140 (6), 1464-1504. doi: 10.1037/a0037618.

Cacioppo, S., Grippo, A.J., London, S., Goossens, L., & Cacioppo, J.T. (2015). Loneliness: Clinical Import and Interventions. Perspectives on Psychological Science, 10 (2), 238-249. doi: 10.1177/1745691615570616.

Corrigan, P. (2004). How Stigma Interferes With Mental Health Care. American Psychologist, 59 (7), 614-625. doi: 10.1037/0003-066X.59.7.614.

Groarke, J.M., Berry, E., Graham-Wisener, L., McKenna-Plumley, P.E., McGlinchey, E., Armour, C. (2020). Loneliness in the UK during the COVID-19 pandemic: Cross-sectional results from the COVID-19 Psychological Wellbeing Study. PLoS One, 15 (9), e0239698. https://doi.org/10.1371/journal.pone.0239698

Hassan, S.M., Giebel, C., Morasae, E.K., Rotheram, C., Mathieson, V., Ward, D., Reynolds, V., Price, A., Bristow, K., & Kullu, C. (2020). Social prescribing for people with mental health needs living in disadvantaged communities: the Life Rooms model. BMC Health Services Research, 20 (19). doi: https://doi.org/10.1186/s12913-019-4882-7.

Hofmann, S.G., Asnaani, A., Vonk, I.J.J., Sawyer, A.T., & Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive Therapy and Research, 36 (5), 427-440. doi: 10.1007/s10608-012-9476-1.

Knaak, S., Mantler, E., & Szeto, A. (2017). Mental illness-related stigma in healthcare. Health Management Forum, 30 (2), 111-116. doi: 10.1177/0840470416679413.

Mann, F., Bone, J.K., Lloyd-Evans, B., Frerichs, J., Pinfold, V., Ma, R., Wang, J., & Johnson, S. (2017). A life less lonely: the state of the art in interventions to reduce loneliness in people with mental health problems. Social Psychiatry and Psychiatric Epidemiology, 52 (6), 627-638. doi: 10.1007/s00127-017-1392-y.

Masi, C.M., Chen, H-Y., Hawkley, L.C., & Cacioppo, J.T. (2011). A Meta-Analysis of Interventions to Reduce Loneliness. Personality and Social Psychology Review, 15 (3), 219-266. doi: 10.1177/1088868310377394.

Mind (2019). Loneliness. Retrieved from https://www.mind.org.uk/information-support/tips-for-everyday-living/loneliness/about-loneliness/

Mushtaq, R., Shoib, S., Shah, T., & Mustaq, S. (2014). Relationship between loneliness, psychiatric disorders and physical health? A review on the psychological aspects of loneliness. Journal of clinical and diagnostic research, 8 (9), WE01-WE04. doi: 10.7860/JCDR/2014/10077.4828.

Pfeiffer, P.N., Heisler, M., Piette, J.D., Rogers, M.A.M., & Valenstein, M. (2011). Efficacy of peer support interventions for depression: a meta-analysis. General Hospital Psychiatry, 33 (1), 29-36. doi:10.1016/j.genhosppsych.2010.10.002

Pimlott, N. (2018). The ministry of loneliness. Canadian Family Physician, 64 (3), 166.