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e12
The value of maintaining social connections for mental
health in older people
By 2050, it is estimated that about a fifth of the general
population will be aged 65 years and older.1 Social
isolation and loneliness among young (18–40 years),
middle-aged (41–64), and older adults (65 years and
older) is thus a serious public health concern of our time
because of its strong connection with cardiovascular,
autoimmune, neurocognitive, and mental health
prob lems.2 The scientific literature has documented
the bidirectional and complex relationship between
psychological issues and social disconnectedness in
the past 40 years.3 Despite extensive work done to
date on this topic, previous research has had several
shortcomings. Limitations include preponderance of
cross-sectional data that precludes causal inferences,
use of single measure or single-item assessments of
loneliness, absence of testing bidirectionality, and small
sample sizes.
In The Lancet Public Health, Ziggi Ivan Santini and
colleagues4 build on previous work by examining the
bidirectional relations between depression or anxiety
severity and social disconnectedness between 2005
and 2016, and the degree to which perceived isolation
mediated those relationships. The authors tested these
hypotheses in a large sample of 3005 community-
dwelling adults aged 57 to 85 years in the National Social
Life, Health, and Aging Project using random-intercept
cross-lagged panel modelling.5 The analyses showed
that social disconnectedness independently predicted
depression and anxiety symptom severity (and vice versa).
Additionally, self-perceived social isolation was found to
mediate the link between social disconnectedness and
depression and anxiety in both directions. For example,
social disconnectedness predicted higher subsequent
perceived isolation, which in turn predicted higher
depression symptoms and anxiety symptoms (all
p<0·0001). The random-intercept cross-lagged panel
modelling approach, which adjusts for previous outcomes
and between-person variation, permits the inference that
these observed relations unfold within (as opposed to
between) people, thus bringing us closer toward causal
models. Moreover, the authors exemplified the best
practices of longitudinal structural equation modelling
by testing for measurement equivalence to verify that the
latent constructs were assessed along the same scale at
various timepoints (an often-neglected step).
These findings can potentially inform public health
and social policies. Brief evidence-based preventive
interventions could plausibly be developed for older
adults and implemented within multiple health-
care venues, religious or cultural organisations, and
community centres. Such skills could help older adults
form meaningful connections with others. Cognitive
skills could help them to critically evaluate the degree to
which their social support network fulfills their need for
friendships and a sense of belonging. Relatedly, action-
based strategies, such as establishing more frequent
social contact with significant others or repairing
strained relationships, might be important to deliver
the best quality care. Randomised controlled trials
examining the effects of cognitive behavioural based
therapies, delivered online or in-person, have been
shown to alleviate depression and anxiety symptoms
while simultaneously decreasing loneliness.7,8 For
instance, internet-delivered cognitive behaviourial
therapy has been shown to enhance both the general
impression and tangible indicators of social affiliation
and support compared with waitlist controls.7,9 Similarly,
establishing community volunteer outreach could also
help in this regard, particularly for adults who are less
mobile or more secluded.
These approaches can be implemented in geriatric and
other clinical contexts, as well as welfare organisations
that provide a range of meaningful and health-
promoting social activities to older adults. Second,
health-care providers can benefit from being mindful of
the potentially scarring effects of untreated depressive
and anxiety disorders in middle and late adulthood.
Late-life affective disorders can trigger vicious cycles of
social withdrawal, unhelpful self-referential thought
patterns, and worsened psychiatric symptoms in the
long term. Collectively, findings suggest that access to
ageing or retirement communities that provide a sense
of belonging and security is imperative for delivering
high standards of mental health care to older adults.6
However, some study limitations deserve mention.
It remains unclear if the results would be replicated if
See Articles page e62
Comment
e13
www.thelancet.com/public-health Vol 5 January 2020
diagnostic or clinician rated measures (as opposed to
self-report) were used; future replication efforts could
thus administer multimodal diagnostic psychiatric
instruments. In addition, although the prospective,
observational design approximates causality by estab-
lishing temporal precedence and co-variation, no strong
causal conclusions can be drawn because of the absence
of experimental manipulation required for internal
validity.
Finally, it is important to keep in mind that most
psychological treatments targeting loneliness and
related constructs to date were limited by small sample
size, non-randomised controlled designs (eg, pre-
post effectiveness trials), absence of multiple-domain
assessments of social disconnectedness, and use of an
inactive no-treatment or waitlist comparison group.
Accordingly, public health can benefit from future
studies using a randomised controlled trial design
with a bigger sample size, alongside a multiple-group
factorial design to tease apart the treatments’ causal
mechanisms. Further, an active control comparison
group should be used to rule out regression to the
mean, expectancy effects, and other confounders, to
analyse factors that contribute to treatment effects
on change in outcomes. For example, it might be
worth examining if the remedying effect of cognitive
behavioural treatments on social disconnectedness
might be mediated or moderated by changes in
allostatic load, immune functioning, lifestyle, or
other putative variables.10 Nonetheless, the study by
Santini and colleagues is an important first step toward
understanding the importance of social support for
older adults in helping to prevent depression or anxiety.
*Michelle G Newman, Nur Hani Zainal
Department of Psychology, The Pennsylvania State University,
University Park, PA 16802-3103, USA
mgn1@psu.edu
We declare no competing interests.
Copyright © 2020The Author(s). Published by Elsevier Ltd. This is an Open
Access article under the CC BY NC ND 4.0 license.
1 Chang AY, Skirbekk VF, Tyrovolas S, Kassebaum NJ, Dieleman JL. Measuring
population ageing: an analysis of the Global Burden of Disease Study 2017.
Lancet Public Health 2019; 4: e159–67.
2 Gerst-Emerson K, Jayawardhana J. Loneliness as a public health issue:
the impact of loneliness on health care utilization among older adults.
Am J Public Health 2015; 105: 1013–19.
3 Klinenberg E. Social isolation, loneliness, and living alone: identifying the
risks for public health. Am J Public Health 2016; 106: 786–87.
4 Santini ZI, Jose PE, York Cornwell E, et al. Social disconnectedness,
perceived isolation, and symptoms of depression and anxiety among older
Americans (NSHAP): a longitudinal mediation analysis. Lancet Public Health
2020; 5: e62–70.
5 Hamaker EL, Kuiper RM, Grasman RP. A critique of the cross-lagged panel
model. Psychol Methods 2015; 20: 102–16.
6 Iecovich E. Aging in place: From theory to practice. Anthropol Noteb 2014;
20: 21–32.
7 Käll A, Jägholm S, Hesser H, et al. Internet-based cognitive behavior therapy
for loneliness: a pilot randomized controlled trial. Behav Ther 2019;
published online May 11. DOI:10.1016/j.beth.2019.05.001.
8 Bessaha ML, Sabbath EL, Morris Z, Malik S, Scheinfeld L, Saragossi J.
A systematic review of loneliness interventions among non-elderly
adults. Clin Soc Work J 2019; published online Oct 16.
DOI:10.1007/s10615-019-00724-0.
9 Tomasino KN, Lattie EG, Ho J, Palac HL, Kaiser SM, Mohr DC. Harnessing
peer support in an online intervention for older adults with depression.
Am J Geriatr Psychiatry 2017; 25: 1109–19.
10 Cacioppo JT, Hawkley LC, Crawford LE, et al. Loneliness and health:
potential mechanisms. Psychosom Med 2002; 64: 407–17.
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