Loneliness and the onset of new mental health problems in the general population.

PURPOSE: Loneliness is associated with poor health including premature mortality. There are cross-sectional associations with depression, anxiety, psychosis, and other mental health outcomes. However, it is not known whether loneliness is causally linked with the new onset of mental health problems in the general population. Longitudinal studies are key to understanding this relationship. We synthesized evidence from longitudinal studies investigating the relationship between loneliness and new onset of mental health problems, in the general population. METHOD: We systematically searched six electronic databases, unpublished sources, and hand-searched references, up to August 2021. We conducted a meta-analysis of eight independent cohorts and narrative synthesis of the remaining studies. RESULTS: We included 32 studies, of which the majority focused on depression. Our narrative synthesis found most studies show loneliness at baseline which is associated with the subsequent new onset of depression. The few studies on anxiety and self-harm also showed a positive association. Our meta-analysis found a pooled adjusted odds ratio of 2.33 (95% CI 1.62-3.34) for risk of new onset depression in adults who were often lonely compared with people who were not often lonely. This should be interpreted with caution given evidence of heterogeneity. CONCLUSION: Loneliness is a public mental health issue. There is growing evidence it is associated with the onset of depression and other common mental health problems. Future studies should explore its impact across the age range and in more diverse populations, look beyond depression, and explore the mechanisms involved with a view to better informing appropriate interventions.

A Systematic Review of Studies Describing the Effectiveness, Acceptability, and Potential Harms of Place-Based Interventions to Address Loneliness and Mental Health Problems.

Given the links between the built environment and loneliness, there is interest in using place-based approaches (addressing built environment characteristics and related socio-spatial factors) in local communities to tackle loneliness and mental health problems. However, few studies have described the effectiveness, acceptability, or potential harms of such interventions. This review aimed to synthesize the literature describing local community-based interventions that target place-based factors to address loneliness and mental health problems, informing the development of future public health approaches. We searched PsycINFO, Medline, and Embase using a structured search strategy to identify English-language studies evaluating the effectiveness, acceptability, and potential harms of place-based community interventions in addressing loneliness and mental health problems, both in general and clinical populations. Seven studies met the inclusion criteria, classified as evaluating provision of community facilities (such as clubhouses), active engagement in local green spaces, and housing regeneration. None were randomised trials. Quantitative and qualitative findings suggested promising effects and/or acceptability of six interventions, with minimal potential harms. There is a clear need for randomised trials or quasi-experimental studies of place-based interventions to describe their effectiveness in addressing loneliness and mental health problems, as well as complementary qualitative work investigating acceptability. This will inform future policy development.

The association between loneliness and depressive symptoms among adults aged 50 years and older: a 12-year population-based cohort study.

BACKGROUND: Loneliness is experienced by a third of older adults in the UK and is a modifiable potential risk factor for depressive symptoms. It is unclear how the association between loneliness and depressive symptoms persists over time, and whether it is independent of related social constructs and genetic confounders. We aimed to investigate the association between loneliness and depressive symptoms, assessed on multiple occasions during 12 years of follow-up, in a large, nationally representative cohort of adults aged 50 years and older in England. METHODS: We did a longitudinal study using seven waves of data that were collected once every 2 years between 2004 and 2017, from adults aged 50 years and older in the English Longitudinal Study of Ageing (ELSA). The exposure was loneliness at baseline (wave two), measured with the short 1980 revision of the University of California, Los Angeles Loneliness Scale (R-UCLA). The primary outcome was a score indicating severity of depression measured at six subsequent timepoints (waves three to eight), using the eight-item version of the Centre for Epidemiologic Studies Depression Scale (CES-D). Analyses were linear multilevel regressions, before and after adjusting for social isolation, social support, polygenic risk scores, and other sociodemographic and health-related confounders. The secondary outcome was depression diagnosis, measured using a binary version of the CES-D. FINDINGS: 4211 (46%) of 9171 eligible participants had complete data on exposure, outcome, and confounders, and were included in our complete case sample. After all adjustments, a 1-point increase in loneliness score was associated with a 0·16 (95% CI 0·13-0·19) increase in depressive symptom severity score (averaged across all follow-ups). We estimated a population attributable fraction for depression associated with loneliness of 18% (95% CI 12-24) at 1 year of follow-up and 11% (3-19) at the final follow-up (wave eight), suggesting that 11-18% of cases of depression could potentially be prevented if loneliness were eliminated. Associations between loneliness and depressive symptoms remained after 12 years of follow-up, although effect sizes were smaller with longer follow-up. INTERPRETATION: Irrespective of other social experiences, higher loneliness scores at baseline were associated with higher depression symptom severity scores during 12 years of follow-up among adults aged 50 years and older. Interventions that reduce loneliness could prevent or reduce depression in older adults, which presents a growing public health problem worldwide. FUNDING: National Institute on Aging and a consortium of UK Government departments coordinated by the National Institute for Health Research.

Loneliness as a predictor of outcomes in mental disorders among people who have experienced a mental health crisis: a 4-month prospective study.

BACKGROUND: Loneliness has not until recently been a prominent focus in research on outcomes of mental illness. The aim of this study was to determine whether loneliness at baseline predicts poor outcomes at 4-month follow-up for individuals who have experienced mental health crises. The outcomes in this study included overall symptom severity, affective symptoms, self-rated recovery and health-related quality of life. METHODS: Our study reports a secondary analysis of data from a randomised controlled trial. The sample (n = 399) was taken from patients who received treatment from community crisis services. Respondents (n = 310) completed the follow-up measurement 4 months after baseline. Loneliness at baseline was assessed using an eight-item UCLA Loneliness Scale. The four mental health outcomes were measured at both baseline and follow-up. Two scales (or part thereof) assessed objective social isolation and neighbourhood social capital at baseline. Regression analyses were conducted to investigate longitudinal associations between loneliness at baseline and mental health outcomes at follow-up. RESULTS: Loneliness at baseline was associated with all four mental health outcomes at 4-month follow-up, adjusting for psychosocial, socio-demographic and clinical characteristics. A one-point higher loneliness score was associated with 0.74-point (95% CI 0.45, 1.02) and 0.34-point (95% CI 0.21, 0.47) increase in overall symptom severity score and affective symptoms score respectively, and with 1.08-point (95% CI -1.45, - 0.71) and 1.27-point (95% CI -1.79, - 0.75) decrease in self-rated recovery score and health-related quality of life score respectively. Loneliness was a better predictor of clinical outcomes than objective social isolation and social capital, even though the associations with clinical outcomes were reduced and no longer statistically significant following adjustment for their baseline values. A significant association with quality of life persisted after adjustment for its baseline score. CONCLUSIONS: Greater loneliness at baseline predicted poorer health-related quality of life at follow-up. There were cross-sectional associations between loneliness and clinical outcomes, but their longitudinal relationship cannot be confirmed. Further research is needed to clearly establish their underpinning pathways. Reducing loneliness may be a promising target to improve recovery for mental health community crisis service users.

To what extent does severity of loneliness vary among different mental health diagnostic groups: A cross-sectional study.

Loneliness is a common and debilitating problem in individuals with mental health disorders. However, our knowledge on severity of loneliness in different mental health diagnostic groups and factors associated with loneliness is poor, thus limiting the ability to target and improve loneliness interventions. The current study investigated the association between diagnoses and loneliness and explored whether psychological and social factors were related to loneliness. This study employed a cross-sectional design using data from a completed study which developed a measure of social inclusion. It included 192 participants from secondary, specialist mental health services with a primary diagnosis of psychotic disorders (n = 106), common mental disorders (n = 49), or personality disorders (n = 37). The study explored differences in loneliness between these broad diagnostic groups, and the relationship to loneliness of: affective symptoms, social isolation, perceived discrimination, and internalized stigma. The study adhered to the STROBE checklist for observational research. People with common mental disorders (MD = 3.94, CI = 2.15 to 5.72, P < 0.001) and people with personality disorders (MD = 4.96, CI = 2.88 to 7.05, P < 0.001) reported higher levels of loneliness compared to people with psychosis. These differences remained significant after adjustment for all psychological and social variables. Perceived discrimination and internalized stigma were also independently associated with loneliness and substantially contributed to a final explanatory model. The severity of loneliness varies between different mental health diagnostic groups. Both people with common mental disorders and personality disorders reported higher levels of loneliness than people with psychosis. Addressing perceived mental health discrimination and stigma may help to reduce loneliness.

Epidemiology of loneliness in a cohort of UK mental health community crisis service users.

PURPOSE: Loneliness is an important issue for mental health service users. However, it has not been a particularly prominent focus of recent mental health research. This paper aimed to explore the severity of loneliness among people leaving mental health community crisis services, and to identify factors associated with loneliness. METHODS: A total of 399 participants experiencing mental health crises recruited for a research trial from community crisis services were included in this cross-sectional study. They completed the eight-item measure of the University of California at Los Angeles Loneliness Scale and a set of instruments assessing socio-demographic, psychosocial, and psychiatric variables. RESULTS: Severity of loneliness was high among people leaving community crisis services. Longer years since first contact with mental health services (2-10 years, coefficient = 1.83, 95% CI 0.49-3.16; more than 10 years, coefficient = 1.91, 95% CI 0.46-3.36) and more severe affective symptoms (coefficient = 0.32, 95% CI 0.23-0.40) were associated with greater loneliness, whereas bigger social network size (coefficient = - 0.56, 95% CI - 0.76 to - 0.36) and greater social capital (coefficient = - 0.16, 95% CI - 0.31 to - 0.003) were associated with less severe loneliness. CONCLUSIONS: This paper supports a view that people experiencing mental health crises often report relatively severe loneliness, and that loneliness tends to become more severe during the course of illness. A greater awareness of loneliness among mental health professionals may be beneficial. Loneliness is a potential focus of the development of interventions to improve the lives and outcomes of people with significant mental health problems.

The effectiveness of interventions for reducing subjective and objective social isolation among people with mental health problems: a systematic review.

PURPOSE: Subjective and objective social isolation are important factors contributing to both physical and mental health problems, including premature mortality and depression. This systematic review evaluated the current evidence for the effectiveness of interventions to improve subjective and/or objective social isolation for people with mental health problems. Primary outcomes of interest included loneliness, perceived social support, and objective social isolation. METHODS: Three databases were searched for relevant randomised controlled trials (RCTs). Studies were included if they evaluated interventions for people with mental health problems and had objective and/or subjective social isolation (including loneliness) as their primary outcome, or as one of a number of outcomes with none identified as primary. RESULTS: In total, 30 RCTs met the review's inclusion criteria: 15 included subjective social isolation as an outcome and 11 included objective social isolation. The remaining four evaluated both outcomes. There was considerable variability between trials in types of intervention and participants' characteristics. Significant results were reported in a minority of trials, but methodological limitations, such as small sample size, restricted conclusions from many studies. CONCLUSION: The evidence is not yet strong enough to make specific recommendations for practice. Preliminary evidence suggests that promising interventions may include cognitive modification for subjective social isolation, and interventions with mixed strategies and supported socialisation for objective social isolation. We highlight the need for more thorough, theory-driven intervention development and for well-designed and adequately powered RCTs.

Associations between loneliness and perceived social support and outcomes of mental health problems: a systematic review.

BACKGROUND: The adverse effects of loneliness and of poor perceived social support on physical health and mortality are established, but no systematic synthesis is available of their relationship with the outcomes of mental health problems over time. In this systematic review, we aim to examine the evidence on whether loneliness and closely related concepts predict poor outcomes among adults with mental health problems. METHODS: We searched six databases and reference lists for longitudinal quantitative studies that examined the relationship between baseline measures of loneliness and poor perceived social support and outcomes at follow up. Thirty-four eligible papers were retrieved. Due to heterogeneity among included studies in clinical populations, predictor measures and outcomes, a narrative synthesis was conducted. RESULTS: We found substantial evidence from prospective studies that people with depression who perceive their social support as poorer have worse outcomes in terms of symptoms, recovery and social functioning. Loneliness has been investigated much less than perceived social support, but there is some evidence that greater loneliness predicts poorer depression outcome. There is also some preliminary evidence of associations between perceived social support and outcomes in schizophrenia, bipolar disorder and anxiety disorders. CONCLUSIONS: Loneliness and quality of social support in depression are potential targets for development and testing of interventions, while for other conditions further evidence is needed regarding relationships with outcomes.

Social isolation in mental health: a conceptual and methodological review.

PURPOSE: Social isolation and related concepts have been discussed increasingly in the field of mental health. Despite this, there is a lack of conceptual clarity and consistency in the definition and operationalisation of these terms. This review aimed to provide a clear framework for social isolation and related concepts, and to identify well-established measures in the field of mental health for each conceptual domain discussed. METHODS: We used an iterative strategy of expert consultation and literature searching. A multi-disciplinary group of senior academics was consulted both before and after the literature searching to identify relevant terms, conceptual papers, or recommended measures. Our conceptual framework was also validated through expert consultation. We searched the Web of Science database using terms suggested by experts and subsequently identified further relevant studies through review articles and by reading full texts and reference lists of included studies. A narrative synthesis was conducted. RESULTS: We developed a model with five domains incorporating all the concepts relevant to social isolation in regular use in the mental health research literature. These five domains are: social network-quantity; social network-structure; social network-quality; appraisal of relationships-emotional; and appraisal of relationships-resources. We also identified well-developed measures suitable for assessing each of the five conceptual domains or covering multi-domains. CONCLUSIONS: Our review proposes a conceptual model to encompass and differentiate all terms relating to social isolation. Potential uses are in allowing researchers and intervention developers to identify precisely the intended outcomes of interventions, and to choose the most appropriate measures to use in mental health settings.

A life less lonely: the state of the art in interventions to reduce loneliness in people with mental health problems.

PURPOSE: There is growing evidence of significant harmful effects of loneliness. Relatively little work has focused on how best to reduce loneliness in people with mental health problems. We aim to present an overview of the current state of the art in loneliness interventions in people with mental health problems, identify relevant challenges, and highlight priorities for future research and implementation. METHODS: A scoping review of the published and grey literature was conducted, as well as discussions with relevant experts, to propose a broad classification system for types of interventions targeting loneliness. RESULTS: We categorised interventions as 'direct', targeting loneliness and related concepts in social relationships, and 'indirect' broader approaches to well-being that may impact on loneliness. We describe four broad groups of direct interventions: changing cognitions; social skills training and psychoeducation; supported socialisation or having a 'socially-focused supporter'; and 'wider community approaches'. The most promising emerging evidence appears to be in 'changing cognitions', but, as yet, no approaches have a robust evidence base. Challenges include who is best placed to offer the intervention, how to test such complex interventions, and the stigma surrounding loneliness. CONCLUSIONS: Development of clearly defined loneliness interventions, high-quality trials of effectiveness, and identifying which approaches work best for whom is required. Promising future approaches may include wider community initiatives and social prescribing. It is important to place loneliness and social relationships high on the wider public mental health and research agenda.

Gender differences in one-year outcomes of first-presentation psychosis patients in inner-city UK Early Intervention Services.

AIM: Men and women have historically been shown to differ in their presentation and outcome of psychotic disorders and thus are likely to have different treatment needs. It is unclear whether Early Intervention Services (EIS) are able to provide equitable care for both men and women presenting for the first time with psychosis. The main aim of this study was to explore gender differences for first-presentation psychosis patients at the time of their referral to inner-city EIS and their outcomes 1 year later. METHODS: Audit data were utilized from 1098 first-presentation psychosis patients from seven EIS across London, UK, collected via the computerized MiData package. Binary logistic regression was employed to detect potential associations between gender and (i) initial clinical presentation (including duration of untreated psychosis, pathways to care, risk behaviours); and (ii) 1-year clinical and functional outcomes. RESULTS: At entry to EIS, male patients presented with more violent behaviour whereas female patients had more suicide attempts. Following 1 year of EIS care, men still presented as more violent towards others whereas women were more likely to have been admitted to a psychiatric ward. CONCLUSION: Gender differences in clinical outcome, service use and risk behaviours were apparent within the first year of specialist psychosis care. This may be partly due to the different pathways to care taken by men and women and differences in clinical presentation. Greater focus on the specific needs of each gender by EIS in detection and intervention is required to improve equality of outcome.

Predictors of vocational activity over the first year in inner-city early intervention in psychosis services.

AIM: Work and educational activities are an important part of recovery for young people with psychosis, and improving vocational outcomes is a key target for early intervention services (EIS). This study evaluated predictors of vocational activity for first-episode psychosis (FEP) patients during the first year of EIS care. It was hypothesized that longer duration of untreated psychosis (DUP) and minority ethnic status would predict poorer vocational outcomes, whereas a history of good vocational functioning would predict better vocational functioning during follow up. METHODS: FEP patients aged 14-35 years, who presented to seven EIS in London, UK, between 2003 and 2010, were followed for 1 year. Sociodemographic, clinical and vocational information (qualifications obtained and paid employment) were collected using the MiData audit tool at entry to EIS and 1 year later. RESULTS: Approximately one-third of patients (n = 345/1013) were studying or employed at some point during the first year of EIS care. Baseline vocational activity was the strongest predictor of vocational functioning during 1 year of follow up. Moreover, employment prior to entry into EIS strongly predicted change in vocational activity during 1 year of follow up. Individuals with DUP <6 months or of Asian or black African origin were more likely to be studying than their white British counterparts. CONCLUSION: This study confirms that a significant proportion of FEP patients are able to engage in meaningful vocational activities even within the first year of EIS care. However, services need to focus more resources on getting patients with poor educational or employment histories into training programmes to improve their vocational outcomes.

Ethnic variations in compulsory detention and hospital admission for psychosis across four UK Early Intervention Services.

BackgroundSubstantial ethnic variations have been found in incidence, pathways to care and outcomes in psychosis. It is unknown whether these remain as marked in the presence of specialist Early Intervention Services (EIS) for psychosis. We present the first UK study exploring ethnic differences in compulsory detention and hospitalization rates for EIS patients. We investigated whether the excess rates of compulsory admission for people from Black groups have persisted following nationwide introduction of EIS. We also explored variations in compulsory admission for other ethnic groups, and differences by gender and diagnosis.MethodsFour inner-city London EIS teams gathered data from first-presentation psychosis patients between 2004¿2009 using the MiData audit tool. Clinical, sociodemographic and pathways to care data were recorded regarding adult patients from eight different ethnic groups at entry to EIS and one year later.ResultsBlack African EIS service users had odds of being detained and of being hospitalised three times greater than White British patients, even after adjustment for confounders. This was most marked in Black African women (seven to eight times greater odds than White British women). A post-hoc analysis showed that pathways to care and help-seeking behaviour partially explained these differences.ConclusionThese findings suggest EIS input in its current form has little impact on higher admission and detention rates in certain Black and minority groups. There is a need to tackle these differences and engage patients earlier, focusing on the needs of men and women from the most persistently affected groups.

A systematic review of ethnic variations in hospital admission and compulsory detention in first-episode psychosis.

BACKGROUND: Marked ethnic variations in incidence, pathways to care and outcomes have been demonstrated in psychosis. Less research has focused specifically on first-episode psychosis (FEP), particularly adverse contacts such as compulsory detention and hospitalization. This is despite international initiatives to promote equity of care and active early intervention. AIM: Systematically review current evidence for ethnic variations in rates of compulsory admission and hospitalization in FEP. METHODS: Relevant articles published before December 2012 were identified from PubMed, PSYCInfo, and CINAHL together with manual searching of reference lists. Studies providing quantitative data on compulsory detention rates and/or hospitalization, comparing ethnic groups in FEP, were included and quality rated by independent raters. RESULTS: All included studies (n = 7) provided data on compulsory detention while fewer (n = 3) focused on admission rates. Three studies reported increased detention in Black and minority ethnic groups, while one reported more hospitalization in White patients. Only two studies covered early intervention services (EIS). CONCLUSIONS: There is a paucity of high quality, well powered studies addressing this important issue, especially in EIS settings. In order to best inform and evaluate fast-developing services, it will be essential to combine large methodologically robust studies with qualitative analysis of patient, carer, and staff experiences.

Is locating acute wards in the general hospital an essential element in psychiatric reform? The U.K. experience.

Locating psychiatric wards in general hospitals has long been seen in many countries as a key element in the reform of services to promote community integration of the mentally ill. In the U.K., however, this is no longer a policy priority, and the recent trend has been towards small freestanding inpatient units, located either within the communities they serve, or on general hospital sites, but separate from the main building. Whether locating the psychiatric wards in the general hospital is essential to psychiatric reform has been little discussed, and we can find no relevant evidence. Perceived strengths of general hospital psychiatric wards are in normalisation of mental health problems, accessibility to local communities, better availability of physical health care resources, and integration of psychiatry with the rest of the medical profession, which may faclilitate recruitment. However, difficulties seem to have been encountered in establishing well-designed psychiatric wards with access to open space in general hospitals. Also, physical proximity may not be enough to achieve the desired reduction in stigma, and complaints from the general hospital may sometimes result in undue restrictions on psychiatric ward patients. There are strong arguments both for and against locating psychiatric wards in general hospitals: an empirical evidence base would be helpful to inform important decisions about the best setting for wards.