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The value of maintaining social connections for mental health in older people

DOI:10.1016/S2468-2667(19)30253-1
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Michelle Gayle Newman at Pennsylvania State University
Michelle Gayle Newman
Nur Hani Zainal at Harvard Medical School
Nur Hani Zainal
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www.thelancet.com/public-health Vol 5 January 2020
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.
... Innovative measures to curb the impact of social distancing on older people and increase connectivity are more imperative now. Scholars have argued that the use of digital technology can assist to bridge communication gaps during the COVID-19 pandemic and provide social support network to older people (Hamilton et al., 2020;Newman & Zainal, 2020;Vogels, 2020). However, older people remain a demographic population with very low internet use when compared to younger people (Anderson et al., 2019;Ekoh et al., 2021c;Hunsaker & Hargittai, 2018;Yang et al., 2020) and this is worse for older rural dwellers with lower education and limited income (Henning-Smith, 2020). ...
... This might become a public health challenge if the right interventions are not provided immediately, as studies have shown that social isolation and loneliness put older people at heightened risk of depression and anxiety (Armitage & Nellums, 2020;Ekoh, 2021;Santini et al., 2020), cardiovascular and neuro-cognitive problems (Holt-Lunstad et al., 2015), premature mortality (Holt-Lunstad et al., 2015;Plagg et al., 2020), and accelerated disease progression in existing conditions (Friedler et al., 2015). Hamilton et al. (2020), Newman and Zainal (2020), and Vogels (2020) have recommended the use of digital technology to bridge the communication gap created by the pandemic as well as facilitate online services and contents such as health information, digital events, online shopping, and healthcare delivery. However, participants of this study are among those who are digitally disenfranchised as they lack access to digital technology (Ekoh et al., 2021c;Henning-Smith, 2020) given that they are old, have low educational level and live in rural setting (Anderson et al., 2019;Yang et al., 2020). ...
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... However, with older people utilising these technologies at disproportionately lower rates than the general population prior to the pandemic (Cosco et al., 2021), barriers to uptake have presented a huge challenge for many. Almost overnight, older individuals have faced the reality that these digital platforms are now more critical than ever, in particular for maintaining meaningful connections which may help to counter the rising tide of depression or anxiety due to increased social isolation (Newman & Zainal, 2020). ...
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Background: Traditional metrics for population health ageing tend not to differentiate between extending life expectancy and adding healthy years. A population ageing metric that reflects both longevity and health status, incorporates a comprehensive range of diseases, and allows for comparisons across countries and time is required to understand the progression of ageing and to inform policies. Methods: Using the Global Burden of Diseases, Injuries, and Risk Factors Study 2017, we developed a metric that reflects age-related morbidity and mortality at the population level. First, we identified a set of age-related diseases, defined as diseases with incidence rates among the adult population increasing quadratically with age, and measured their age-related burden, defined as the sum of disability-adjusted life-years (DALYs) of these diseases among adults. Second, we estimated age-standardised age-related health burden across 195 countries between 1990 and 2017. Using global average 65-year-olds as the reference population, we calculated the equivalent age in terms of age-related disease burden for all countries. Third, we analysed how the changes in age-related burden during the study period relate to different factors with a decomposition analysis. Finally, we describe how countries with similar levels of overall age-related burden experience different onsets of ageing. We represent the uncertainty of our estimates by calculating uncertainty intervals (UI) from 1000 draw-level estimates for each disease, country, year, and age. Findings: 92 diseases were identified as age related, accounting for 51·3% (95% UI 48·5-53·9) of all global burden among adults in 2017. Across the Socio-demographic Index (SDI), the rate of age-related burden ranged from 137·8 DALYs (128·9-148·3) per 1000 adults in high SDI countries to 265·9 DALYs (251·0-280·1) in low SDI countries. The equivalent age to average 65-year-olds globally spanned from 76·1 years (75·6-76·7) in Japan to 45·6 years (42·6-48·2) in Papua New Guinea. Age-standardised age-related disease rates have decreased over time across all SDI levels and regions between 1990 and 2017, mainly due to decreases in age-related case fatality and disease severity. Even among countries with similar age-standardised death rates, large differences in the onset and patterns of accumulating age-related burden exist. Interpretation: The new metric facilitates the shift from thinking not just about chronological age but the health status and disease severity of ageing populations. Our findings could provide inputs into policymaking by identifying key drivers of variation in the ageing burden and resources required for addressing the burden. Funding: National Institute on Aging of the National Institutes of Health.
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The cross-lagged panel model (CLPM) is believed by many to overcome the problems associated with the use of cross-lagged correlations as a way to study causal influences in longitudinal panel data. The current article, however, shows that if stability of constructs is to some extent of a trait-like, time-invariant nature, the autoregressive relationships of the CLPM fail to adequately account for this. As a result, the lagged parameters that are obtained with the CLPM do not represent the actual within-person relationships over time, and this may lead to erroneous conclusions regarding the presence, predominance, and sign of causal influences. In this article we present an alternative model that separates the within-person process from stable between-person differences through the inclusion of random intercepts, and we discuss how this model is related to existing structural equation models that include cross-lagged relationships. We derive the analytical relationship between the cross-lagged parameters from the CLPM and the alternative model, and use simulations to demonstrate the spurious results that may arise when using the CLPM to analyze data that include stable, trait-like individual differences. We also present a modeling strategy to avoid this pitfall and illustrate this using an empirical data set. The implications for both existing and future cross-lagged panel research are discussed. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
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Full-text available
  • May 2002
Two studies using cross-sectional designs explored four possible mechanisms by which loneliness may have deleterious effects on health: health behaviors, cardiovascular activation, cortisol levels, and sleep. In Study 1, we assessed autonomic activity, salivary cortisol levels, sleep quality, and health behaviors in 89 undergraduate students selected based on pretests to be among the top or bottom quintile in feelings of loneliness. In Study 2, we assessed blood pressure, heart rate, salivary cortisol levels, sleep quality, and health behaviors in 25 older adults whose loneliness was assessed at the time of testing at their residence. Total peripheral resistance was higher in lonely than nonlonely participants, whereas cardiac contractility, heart rate, and cardiac output were higher in nonlonely than lonely participants. Lonely individuals also reported poorer sleep than nonlonely individuals. Study 2 indicated greater age-related increases in blood pressure and poorer sleep quality in lonely than nonlonely older adults. Mean salivary cortisol levels and health behaviors did not differ between groups in either study. Results point to two potentially orthogonal predisease mechanisms that warrant special attention: cardiovascular activation and sleep dysfunction. Health behavior and cortisol regulation, however, may require more sensitive measures and large sample sizes to discern their roles in loneliness and health.
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Article
Loneliness has been described as a common source of discomfort based on a subjective discrepancy between the actual and desired social situation. For some people this feeling may become a sustained state that is associated with a wide range of psychiatric and psychosocial problems. While there are few existing treatment protocols, interventions based on Cognitive Behavioral Therapy (CBT) have shown positive effects. The current study investigated the efficacy of an eight-week internet-based treatment containing CBT components aimed at reducing feelings of loneliness. Seventy-three participants were recruited from the general public and randomly allocated to treatment or a wait-list control condition. Participants were assessed with standardized self-report measures of loneliness, depression, social anxiety, worry, and quality of life at pre-treatment and post-treatment. Robust linear regression analysis of all randomized participants showed significant treatment effects on the primary outcome measure of loneliness (between group Cohen’s d = 0.77), and on secondary outcomes measuring quality of life and social anxiety relative to control at post-assessment. The results suggest the potential utility of internet-based CBT in alleviating loneliness but more research on the long-term effects and the mechanisms underlying the effects is needed.
Harnessing Peer Support in an Online Intervention for Older Adults with Depression
Article
  • May 2017
Objective: This pilot study evaluated the feasibility and efficacy of two methods of delivering a cognitive behaviorally informed Internet intervention for depression for adults 65 years and older. Methods: Forty-seven participants were enrolled and assigned to receive one of two versions of the Internet intervention, either delivered individually (III) or with peer support (II+PS), or to a wait list control group (WLC). Primary outcomes included change in depressive symptoms from baseline to post-intervention (week 8), site use, self-reported usability, and coach time. Secondary outcomes included measures of social support and isolation and anxiety. Results: Follow-up data were provided by 85.1% (40 of 47) of enrolled participants. There were significant differences in depression change across groups (F(2,37) = 3.81, p = 0.03). Greater reductions in depressive symptoms were found for the III (p = 0.02) and II+PS (p = 0.03) compared with WLC, and significantly less coach time was required in the II+PS (p = 0.003). Conclusions: These results highlight the potential of cognitive-behaviorally informed Internet interventions for older adults with depression, and indicate that peer-supported programs are both acceptable and equivalent to individually delivered Internet interventions. Including peer support may be a viable and potentially more cost-effective option for disseminating online treatments for depression for older adults.
Social Isolation, Loneliness, and Living Alone: Identifying the Risks for Public Health
Article
  • May 2016
Aging in place: From theory to practice
Article
  • Jan 2014
The rapid aging of many Western societies has compelled policymakers and professionals to develop concepts, programs, and services to meet the complex and diverse needs of their elderly populations, in particular the segment of older persons who are frail, chronically ill, and functionally disabled. Aging-in-place has become a key and guiding strategy in addressing and meeting the needs of older people. This paper discusses the multifaceted aspects of aging-in-place and presents an ecological approach to understanding the interaction between the individual and her or his environment and its impact on agingin- place. Community care and its components are discussed, examples of programs that reflect aging-in-place and community care are presented, and problems of fragmentation between services are highlighted. The paper concludes with challenges that societies have to confront in order to enable their aging populations to age-in-place.
Loneliness as a Public Health Issue: The Impact of Loneliness on Health Care Utilization Among Older Adults
Article
We aimed to determine whether loneliness is associated with higher health care utilization among older adults in the United States. We used panel data from the Health and Retirement Study (2008 and 2012) to examine the long-term impact of loneliness on health care use. The sample was limited to community-dwelling persons in the United States aged 60 years and older. We used negative binomial regression models to determine the impact of loneliness on physician visits and hospitalizations. Under 2 definitions of loneliness, we found that a sizable proportion of those aged 60 years and older in the United States reported loneliness. Regression results showed that chronic loneliness (those lonely both in 2008 and 4 years later) was significantly and positively associated with physician visits (β = 0.075, SE = 0.034). Loneliness was not significantly associated with hospitalizations. Loneliness is a significant public health concern among elders. In addition to easing a potential source of suffering, the identification and targeting of interventions for lonely elders may significantly decrease physician visits and health care costs. (Am J Public Health. Published online ahead of print March 19, 2015: e1-e7. doi:10.2105/AJPH.2014.302427).