8 September 2021

How docs can help lonely patients

Clinical

What can doctors do if they suspect a patient suffers from loneliness?

It’s a risk factor on par with smoking and alcohol consumption for its impact on mortality, and a powerful predictor of using high-risk medications.

But Perth-based clinical research psychologist Professor Johanna Badcock says loneliness can be difficult to spot because, unlike social isolation, it cannot be directly observed.

“Social isolation refers to the objective reduction or lack in number, type or frequency of social connections,” said Professor Badcock, who is vice chair of national charity Ending Loneliness Together. “On the other hand, loneliness is usually described as the unpleasant and sometimes distressing feeling of lacking social connection, along with the desire for more, or more meaningful, social relationships.

“Loneliness is a very subjective state, and we can’t always tell who is lonely simply by looking at what they’re doing. The classic phrase is, ‘you can be on your own and not lonely, or you can be surrounded by friends and still feel lonely’.”

The stereotype of the older patient who lives alone being lonely did not always hold, she added.

“The data definitely shows that there is a big peak of loneliness in younger adults – about 18 to 25 years – and that’s been a bit of a surprise to a lot of people. It’s important that GPs understand that the younger people they see may well be experiencing surprisingly high levels of loneliness.”

Fear that they will be criticised or judged may prevent patients from speaking up, Professor Badcock said.

“You have to be really mindful of how you approach the conversation. The current recommendations are to use indirect assessments and approaches that don’t explicitly use the word loneliness. For example, ‘Do you feel there are people around you who really know you and understand you? Do you feel in tune with the other people around you?’”

Professor Badcock and colleague Professor Michelle Lim recently established the Global Initiative on Loneliness and Connection, to allow national organisations to share skills and information on evidence-based approaches to build social connection.

They have held initial discussions about partnership with the World Health Organisation for their work addressing loneliness.

Professor Badcock said that evaluations of social prescribing models have had mixed results – which doesn’t necessarily mean it doesn’t work, but that the models for implementing it are still evolving.

“Social prescribing typically gets people to join a social group as a means of ending loneliness,” she said. “The risk can sometimes be that the group’s not really a good match for their needs, interests or priorities so it doesn’t work well, they don’t feel connected, and unfortunately it leads to them feeling even more lonely.”

Professor Badcock encouraged GPs to use as much care in identifying the right kind of social prescription as they would when prescribing medication.

“That places GPS in a difficult position – we hope the government will invest a lot more in the social determinants of health so that we can more rapidly produce better evidence about what works for whom, and when.”

GP Dr Caroline Johnson says a patient-centred approach and shared decision-making is key.

“Ask them to describe what their day is like, what things they enjoy. In my experience, the GP’s role is to help the patient explore some solutions and not to be too prescriptive – rather than, ‘you should try X, Y or Z’, say, ‘what have you tried so far?’” says Dr Johnson, who is also an academic in the integrated mental health team at the University of Melbourne.

“It’s classic motivational interviewing: getting the person to talk about how they might solve the problem, empowering them to make choices that are useful.”

But chatting to patients who were well-connected in the community could provide good ideas to pass on when lonely patients needed more information on the options available to them, Dr Johnson said.

“If I have someone who says they go to the local neighbourhood house, I ask what they do, what they like about it, what are the challenges, because that’s knowledge capital that I have for the next person who walks in the door, it’s a recommendation based on someone’s lived experience of accessing it rather than just me taking a stab in the dark.”

Psychologist Professor Alex Haslam, at the University of Queensland, says belonging to social groups seems to be a particularly important part of social prescribing, but when the detail of howto do it is absent, patients struggle.

This ethos underpins the  Groups 4 Health program, a framework that steps patients through the process of identifying, joining, and staying connected with meaningful groups.

“Having functional group memberships is actually critical to equanimity and capacity to function … it doesn’t matter if that’s in the workplace, the community, or the family – if the groups fall apart, the people in them tend to as well,” Professor Haslam said.  

A phase 3 trial – currently available as a preprint – of almost 180 patients showed the program was more effective than CBT at reducing loneliness over 12 months.

“After the program, we saw the benefits sustained in a way that they weren’t with CBT. This makes sense to us, because if you’re building meaningful connections, the likelihood is that you’re going to be able to sustain them and the benefits that go with them in a way that won’t necessarily be true for other kinds of interventions … the sustainability dimension of Groups 4 Health is critical,” he said.

Patients have been referred to take part in the research by GPs in Brisbane, but they hoped to run a community-based phase 4 trial to roll it out at scale, Professor Haslam added. 

Professor Lim, a clinical psychologist and internationally recognised expert in loneliness research, echoed the need for personalisation, noting that a patient’s finances, social environment and mobility issues might make joining a community group inappropriate.

“So, does the patient need to build up their confidence with one-on-one interactions? How do they construct their social environments in a way that they feel like they’re taking a chance to make meaningful connection but are safe enough to interact and not retreat?” she said.

Referral to a psychologist may be needed for patients whose maladaptive thoughts helped sustain loneliness, she added.

“Loneliness might be triggered by social transitions, but then maintained by negative thoughts about relationships and how to manage them, and distrust with people. Working out what’s causing their loneliness will influence where you send them.”

Professor Lim said digital platforms could be used as a transitional tool when social anxiety was a barrier to in-person activities, an area she is researching at Swinburne University.

“Lonely people are much more hypervigilant to social threats and they unconsciously send more negative signals to others even though they want to connect,” Professor Lim said.

“When you’re lonely, you have very high levels of social anxiety. All I’m doing is getting young people to improve their social confidence by learning the skills [online]. It’s not about making more friends, but improving the quality of the relationships they hold, so focussing on improving that relationship with their mum or sister or changing an acquaintance into a friend – it could just be one relationship.”

GPs interested in support or training for their practice should contact Ending Loneliness Together.

Professor Lim, who is the charity’s chair, said it had been invited by the RACGP to propose loneliness for inclusion in the Red Book.

RACGP President Dr Karen Price told TMR:“In the meantime, I urge GPs across the country to have a go at social prescribing and share tips and insights with each other.

“In the years ahead, I believe that if more resourcing and support is provided more patients will have access to this form of non-clinical prescribing. That is why we called for social prescribing to be included in the 10 Year Primary Health Care Plan and that is being considered by government.”