How many close friends and relatives do you have with whom you feel at ease and can discuss private matters? How many of them do you see at least once a month? Do you participate in any groups? These are among the questions on a survey called the Berkman-Syme Social Network Index, which physicians use to determine whether someone is “socially isolated.” People are considered isolated if they have fewer than six confidants, no spouse and no group affiliations. Those conditions make them less likely to report that they have someone they can count on to listen if they need to talk, give advice about a problem or show them love and affection.
But you can have plenty of connections, even close connections, and still feel lonely. To assess that subjective state, clinicians may use the three-item U.C.L.A. Loneliness Scale, which asks: How often do you feel you lack companionship? How often do you feel left out? How often do you feel isolated?
Social isolation and loneliness tend to go together. Researchers have become increasingly aware, though, that you can experience one but not the other. That means these states of being may have different causes, different impacts on health and different potential solutions. In February 2020, a report from the National Academies of Sciences, Engineering and Medicine noted that a third of Americans over 45 feel lonely; a quarter of those over 65 are socially isolated. Each condition increases a person’s risk of premature death from any cause — as much as or more than smoking or a lack of physical activity do — as well as the risk of heart disease and stroke. Social isolation increased the risk of dementia 50 percent, and loneliness correlated with higher rates of depression, anxiety and suicide. Older adults, along with people in marginalized groups, are at heightened risk of both isolation and loneliness.
And that was the situation before the pandemic forced so many people to remain physically distant from others, which almost certainly exacerbated both isolation and loneliness in unpredictable ways. “The reality is that to some extent we are in a data-free zone,” Carla Perissinotto, one of the report’s authors and a professor of medicine at the University of California, San Francisco, told the Senate Special Committee on Aging in June 2020. “We do not know how long we have to be lonely or isolated, or how severe this must be for us to have lasting negative consequences.”
More than a year later, a complicated picture has begun to emerge. In July, researchers at Northeastern University and elsewhere reported the results of an ongoing national survey that started in April 2020. They asked respondents how many people they had in their social circle whom they could depend on to care for them if they fell ill; to lend them money; to talk to them if they had a problem or felt depressed; or to help them find a job. The number of people who reported having one person or no one in each group tended to be highest last fall, a period when participants also reported decreases in the amount of time spent with nonhousehold members in person. Support and proximity with others increased roughly in tandem between December and April, as vaccines were rolled out and restrictions began to be lifted. But at that point, respondents increasingly began to say that they again lacked all four kinds of support, even though their amount of in-person contact continued to grow. Seeing other people again can be “a bit of a reality check,” says Louise Hawkley, a principal research scientist at NORC at the University of Chicago. You might discover that someone you thought could support you can’t — perhaps because of that person’s own pandemic struggles. Katherine Ognyanova, an associate professor of communication and information at Rutgers University and an author of the study, says: “There isn’t research on an event of that magnitude before. We’re just learning about what happened and how to deal with it.”
Before the pandemic, few studies tried to assess both social isolation and loneliness in the same group of participants to directly compare their effects. (Researchers also often use conflicting definitions of, and metrics to measure, concepts like “support,” “isolation” and “loneliness.”) In 2015, an analysis of existing studies published in the journal Perspectives on Psychological Science by Julianne Holt-Lunstad, a professor of psychology and neuroscience at Brigham Young University, and her colleagues found that social isolation increased the risk of mortality by 29 percent on average; loneliness increased it by 26 percent and living alone by 32 percent. In 2018, a report in the journal Health Psychology saw evidence that social isolation exacerbated the impact of loneliness on mortality and vice versa. Holt-Lunstad says we tend to imagine that being isolated by choice is fine if you’re happy. “But what the evidence suggests is that might be a faulty assumption,” she adds. “We shouldn’t be so quick to dismiss isolation alone.”
Yet how exactly each condition causes its associated health effects is still an open question. Loneliness could increase stress and inflammation, but it can also impair sleep and drive unhealthful behaviors like drinking and smoking, says Lis Nielsen, director of the division of behavioral and social research at the National Institute on Aging. Isolation, on the other hand, might make it harder to access medical care or nutritious foods or to exercise, which could in turn create stress. Men tend to have a greater risk of being socially isolated, whereas women have more risk of being lonely. Being unmarried, widowed or divorced are associated with both; so are having a low income and less education. A study of incarcerated people published in the journal JAMA Network Open in 2019 noted that the longer someone spends in solitary confinement, the greater their mortality risk. (Over the past 18 months, many prisons have essentially used solitary confinement as a means of quarantining inmates.) “It’s a form of trauma,” says the lead author Lauren Brinkley-Rubinstein, an associate professor of social medicine at the University of North Carolina at Chapel Hill. Afterward, people “can’t just step back into the way things were.”
Figuring out how to mitigate the effects of social isolation and loneliness on those most at risk has taken on new importance as cases of Covid-19 surge again. “We may not be able to do much about the isolation piece if we are forced into more restriction,” Perissinotto says, “but we may be able to target loneliness.” Existing technological solutions, though, appear to have had mixed results. A survey of adults 55 and older conducted during the pandemic and published this month by the Journal of the American Geriatrics Society by Hawkley and colleagues found higher rates of loneliness, depression and reductions in happiness despite increases in remote contact compared with before; another survey using different criteria and published in April in The Journals of Gerontology: Series B found increased physical isolation among adults over 50, stable levels of digital contact and no increase in loneliness. “It’s complex,” Holt-Lunstad says. “There’s some evidence to suggest that technology helped preserve social connections, and some evidence to suggest that it actually increased loneliness.” Indeed, young people, often assumed to be more digitally savvy than the general population, have reported particularly high rates of loneliness as well as related conditions like depression. And surveys often fail to reach highly vulnerable groups, including those without internet access and people living with dementia.
Because the causes of social isolation and loneliness vary so much — from mobility problems that keep someone housebound to grief over the loss of a spouse — alleviating them demands “an individualized approach,” Perissinotto says. There is no single proven intervention; instead, she suggests thinking about what kinds of connections you feel are missing and looking for ways to forge them. To the extent that the pandemic disrupted our social lives, it has also primed us to develop new relationships. Being lonely or isolated is now “an experience that all of us are all familiar with on some level,” Hawkley says. “I think that will help drive more research and attempts to resolve it.”