A Prescription for Loneliness: Mitigating Social Isolation and Loneliness in Older Adults

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Social isolation, the objective lack of social contact with others, and loneliness, the subjective perception of missing social contacts or a desired companion, are significant public health concerns, particularly among older adults.¹ In the United States, approximately 33% of adults aged 45 and older report feelings of loneliness, and nearly 25% of those aged 65 and older are considered socially isolated.¹ Societal changes such as increased life expectancy, smaller family sizes, and geographic dispersion of families contribute to this growing issue.¹ Older adults are especially vulnerable due to factors such as retirement, loss of loved ones, declining physical health, and decreased mobility.^2-4

For practicing psychiatrists, it is crucial to recognize the profound impact of social isolation and loneliness on mental health. Both have been associated with elevated levels of depressive symptoms, anxiety, poor cognitive function, suicidality, poorer health behaviors, and worse physical health.^1,3,5,6 Some data suggest that 11% to 18% of cases of depression are attributable to loneliness.⁶ Moreover, loneliness has been linked to a 50% increase in dementia risk, a 57% increased risk for suicidal ideations, and 12 times the odds of having anxiety.^1,7 Additionally, 80% of individuals with psychosis report loneliness as a significant challenge.⁷ Social isolation and loneliness have also been associated with an increased risk of tobacco, alcohol, and substance abuse.¹ These data mean that psychiatrists should be screening for social isolation and loneliness among patients with mental illness, as these factors may contribute to and exacerbate clinical presentations, reduce treatment adherence, and increase health care utilization.^1,7

Given that individuals aged 50 and older frequently interact with the health care system, providers and systems have a significant opportunity to play a pivotal role in preventing and mitigating the adverse effects of social isolation and loneliness.¹ By prescribing social interventions, health care professionals can address these issues directly, improving individual well-being and reducing the burden on health care systems.⁸

Interventions

Videoconferencing

A promising intervention is the use of videoconferencing to connect older adults with others. In a year-long quasi-experimental study of 102 nursing home residents with mild to moderate depressive symptoms, participants were enrolled in a videoconference program that facilitated weekly face-to-face social interactions via tablets.⁹ Over 6 months, participants reported a 25% reduction in loneliness scores and a 30% decrease in depressive symptom severity. These effects persisted at the 1-year follow-up. These programs offer social support and a sense of community by facilitating face-to-face interaction through digital means, even when proximity is impossible.

To scale these interventions, partnerships can be formed with community centers, local libraries, senior centers, and health care facilities to supply the necessary technology, alongside training sessions to enhance digital literacy. Ensuring a reliable internet connection and ongoing technical support is essential, as confusion or frustration with devices can deter older adults from sustaining engagement.

Daily Conference Lines

Another innovative approach is the establishment of a daily conference line where older adults can call in to engage in noncrisis conversations on varied topics, excluding sexually explicit or violent content. While crisis lines exist for mental health emergencies, extending this service to those who are not in acute crisis but at risk of loneliness could serve as a preventive intervention. These platforms would provide a space for social interaction and shared experiences. Existing models, such as senior chat lines or friendship lines, can offer insights. Examples include the Institute of Aging’s Friendship Line, Covia’s Well Connected and Social Call, and in the UK, Silver Line.^10-12 A qualitative study of 40 older adults participating in a telephone befriending service revealed themes of an improved sense of belonging, decreased loneliness, and an overall feeling of enhanced well-being.¹³

Implementing such a program requires careful consideration. The effectiveness of these lines depends on the training of call center responders, who must be adept at navigating sensitive topics and distinguishing benign expressions of emotional or sexual desire from inappropriate solicitation. Clear policies regarding boundaries, particularly around transference and countertransference, are imperative to ensure professional relationships. Other factors to consider include pairing participants (e.g., male-to-male interactions) and protocols for when romantic feelings develop between callers and responders. Engaging community mental health professionals to supervise call center staff can help ensure quality and safety for all participants.

Peer Support via Digital Platforms

Peer support interventions have shown efficacy in reducing social isolation and loneliness. In Zimbabwe, WhatsApp was utilized to create moderated support groups offering daily discussions on health and well-being.¹⁴ Participants, primarily adolescent mothers, engaged with peers on shared experiences and challenges. Moderators ensured a safe, supportive environment, intervening when necessary to defuse conflicts or misinformation. Quantitative data from participant self-reports (n=104) indicated lower depressive symptoms, improved perceived social support, improved parenting and communication strategies, and decreased stigma over 6 months. The study demonstrated the utility of WhatsApp as a medium to deliver interventions to improve social support. Given the ubiquity of WhatsApp and other social media platforms, innovative programs can leverage these digital platforms to create social environments that foster peer connections.

Applying this model to older adults requires addressing potential barriers such as digital literacy through workshops on smartphone basics. Key considerations include determining operational hours, deciding between open or closed group formats, and establishing rules about members forming friendships outside the group. The demographic composition of the group (e.g., male only or mixed sex participants) can influence dynamics and effectiveness.

Face-to-Face Peer Pairing

Face-to-face peer pairing matches individuals experiencing social isolation and loneliness with peers who share similar life experiences or backgrounds. In a mixed-methods study of low income older adults (n=74) with a median age of 70, participants were paired with peers based on demographics and social interests, with the number of meetings dependent on participants’ interest, perceived loneliness, and social isolation.¹⁵ The study found a significant decrease in loneliness and social isolation scores, a decrease in the proportion of those who reported depressive symptoms from 38% to 18%, and a 50% decrease in barriers to socializing over a 24-month period. Qualitative interviews revealed tangible benefits such as connections to health and social services and accompaniment on errands.

A major limitation of the study was selection bias, with participants more inclined toward social connection being more likely to engage. Additionally, potential barriers to this form of intervention include trust issues among individuals with histories of trauma, posttraumatic stress disorder, or mental illness, who may be less likely to trust others. Strategies to overcome these challenges include involving mental health professionals in the pairing process, providing trauma-informed training for peers, and facilitating initial meetings in safe, supervised environments. When this intervention was conducted over the phone or digitally due to COVID-19 restrictions, its effectiveness declined because of higher loss to follow up.¹⁵ While in person interactions can foster deeper bonds, relationships formed via phone or video may require more time but could still offer sustained connections over time. Psychiatrists and other clinicians may recommend such programs in tandem with structured therapy, ensuring that individuals have both professional guidance and peer-based support in their community.

Role of Health Care Providers

Health care providers—especially mental health professionals—are well-positioned to detect and respond to social isolation and loneliness among older adults. Incorporating standardized instruments like the UCLA Loneliness Scale or the Lubben Social Network Scale into routine psychiatric and primary care visits can help identify at-risk individuals early.^16,17 Moreover, health care systems can integrate these findings into personalized care plans, prescribing social interventions alongside medication management and psychotherapy. This social prescribing model, which helps patients access nonclinical sources of support often available in the community, is integral to patient-centered care and can help foster collaboration between health care and social systems.⁸

The most effective approach is to integrate social prescriptions into electronic health records (EHR) to streamline the process and facilitate follow up. Health care systems can develop a system-wide strategy to identify and address social isolation and loneliness. An example is Boston Medical Center’s THRIVE, an EHR-based social determinants of health screening and referral model.¹⁸ THRIVE uses a universal social determinants of health screener embedded in the EHR, capturing information in several domains, including education, employment, food insecurity, housing, transportation, problems affording medications, and problems paying utilities. If a patient screens positive, the EHR automatically generates an order set to print out relevant resource referral guides. Upon review, the clinician can also refer the patient to a care coordinator for additional support.¹⁸ The community resources were developed in partnership with a community organization that maintains a comprehensive database and uses quality rankings to generate the most effective community resources.¹⁸ In the first 6 months of implementation, 70% of new patients attending the general internal medicine clinic were screened, with 31% screening positive for 1 or more social needs, and 86% of those who screened positive receiving referrals to community resources.¹⁸

This model can be applied to prescribing for social isolation and loneliness. Health care systems can implement a universal EHR-based screening process and a robust referral network to mitigate social isolation and loneliness. Psychiatrists within the system can track these referrals, collaborating with social workers to ensure follow up and continuity of care.

Policy Implications

Policymakers play a crucial role in supporting these interventions. Funding allocations for social programs targeting loneliness and social isolation can enhance the scalability and sustainability of these initiatives. Policies encouraging the integration of social health into routine assessments and care plans can institutionalize this approach. Additionally, investing in infrastructure to improve digital access for older adults, especially in underserved communities, can broaden the reach of digital interventions.

Diversity, Equity, and Inclusion

Social isolation and loneliness affect individuals across all demographic groups, but minority groups, LGBTQ+ older adults, and those residing in rural or socioeconomically disadvantaged areas have a higher risk of experiencing these conditions.^19,20 Racial and sexual minority groups often face discrimination, victimization, and lack of family acceptance, leading to social disconnection, interruptions in health care access, and increases in mental health symptoms—especially depression, anxiety, and suicidality.²¹ Disparities also exist in interventions designed to address social isolation and loneliness among racial and sexual minorities, as well as between rural and urban areas.²² In a systematic review of digital interventions, none reported on interventions among LGBTQ+ populations, no studies reported on affordability or the digital divide, and the majority were conducted in urban, high-income areas.²²

It is imperative that interventions for social isolation and loneliness strive for equity. Given the increasing diversity in the population, clinicians need to tailor interventions to patients’ cultures and identities. Understanding patients’ cultural contexts can provide insights into their conceptualization of social isolation and loneliness. Additionally, screening tools should be inclusive and culturally acceptable. When prescribing interventions, clinicians should work collaboratively with patients, adopt a trauma-informed approach for those from marginalized populations, and remain flexible in accommodating individual preferences. It is also important to consider the intersectionality of social determinants of health; screening for these should be part of routine practice. Partnering with community organizations that understand the unique needs of marginalized communities can help build trust, reduce barriers to care, and ultimately enhance the effectiveness of these interventions.

Concluding Thoughts

Social isolation and loneliness among older adults are pressing issues that require comprehensive interventions. By prescribing social connections through videoconferencing, moderated online groups, and peer support programs, health care providers can play a pivotal role in mitigating these conditions. Addressing ethical considerations, embracing diversity, and advocating for supportive policies will further enhance the effectiveness of these interventions. As the population ages, it is imperative to recognize loneliness as a critical determinant of health and to act decisively to foster connections that improve the well-being of older adults.

Dr Ogundare is a psychiatry resident and schizophrenia fellow at Boston Medical Center.

References

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