On May 1st, 2023, the Surgeon General of the Untied States released a public health advisory with a surprising title: “Our Epidemic of Loneliness and Isolation: The U.S. Surgeon General’s Advisory on the Healing Effects of Social Connection and Community.”
As a nation, we’ve experienced two major public health emergencies in recent years. The first, the opioid overdose/drug overdose epidemic, has claimed over a million lives since it began in the late 1990s. It’s ongoing as we speak. The second, the COVID-19 pandemic, also claimed over a million lives, but that happened over a much shorter period of time. Both were and are devastating, and we’re still experiencing the fallout from each one.
This public health crisis – as the title of the advisory indicates – is different. The crisis is not caused by a pathogen or by substance use. It’s something that can occur inside of each of us on an individual and personal level, but nevertheless impacts each and every one of us, as a collective whole.
Dr. Vivek H. Murthy, U.S. Surgeon General, summarizes the impact of loneliness in the introduction to the new advisory:
“Loneliness is far more than just a bad feeling—it harms both individual and societal health. It is associated with a greater risk of cardiovascular disease, dementia, stroke, depression, anxiety, and premature death. The mortality impact of being socially disconnected is similar to that caused by smoking up to 15 cigarettes a day, and even greater than that associated with obesity and physical inactivity. And the harmful consequences of a society that lacks social connection can be felt in our schools, workplaces, and civic organizations, where performance, productivity, and engagement are diminished.”
Before we dive into the details on this advisory and its contents, we should define what, exactly, a Surgeon General’s Advisory is.
What is a Surgeon General’s Advisory?
Here’s how the Department of Health and Human Services define an SGA:
“A Surgeon General’s Advisory is a public statement that calls the American people’s attention to an urgent public health issue and provides recommendations for how it should be addressed. Advisories are reserved for significant public health challenges that require the nation’s immediate awareness and action.”
That’s clear, and needs no further explanation.
Next – so we’re all on the same page – let’s define exactly what we mean when we say the words loneliness and isolation in this context.
What Are Loneliness and Isolation?
Social isolation and loneliness are related, but they are not the same.
Social isolation is defined by:
- Few social relationships
- Small number of/no social roles
- Few memberships in groups
- Low level of social interaction
Studies show social isolation increases risk of premature death by 29%.
Loneliness is defined as a subjective internal state, characterized by:
- A disconnection between social/emotional needs and social/emotional experiences
- A sense of emptiness
- Feelings of isolation, while wanting to feel connected
- Feeling unwanted, while wanting to feel wanted
Studies show loneliness increases risk of premature death by 26%.
That information is straightforward: social isolation and loneliness are easy to understand because most of us experience both, to some degree, at some point in our lives. What many people may not understand is the information in italics: isolation and loneliness are associated with premature mortality.
For the record, premature mortality is a fancy way of saying early death.
Thankfully, the Surgeon General identifies an antidote to social isolation and loneliness: social connection.
What is Social Connection?
Social connection includes all the ways in which an individual interacts with others. That means their relationships, their social roles, their family life, their work life, and the incidental interactions they have throughout each day.
Social connection is more than the number of friendships or social interactions a person has. relationships they have. Experts on social interaction identify the various ways we can interact, and the various ways these interactions may increase or decrease our sense of connection. The ways we connect or disconnect from others are associated with the three vital components of social connection: structure, function, and quality.
The Three Core Components of Social Connection
- The number, variety, and frequency of our relationships and interactions with others. Structure is determined by:
- Number of family members
- Number of friends
- Relationship status
- How much we can rely on others for:
- Social and emotional support
- Mentorship and advice
- Crisis/emergency support
- Whether our relationships and interactions with other with others help or harm us. This includes:
- Level of satisfaction in relationships
- Level of stress or strain in relationships
- Quality of participation in social activities
Those are the primary components of healthy social connection. That information leads to a basic question.
Are People in the U.S. Connected, or Not?
Research into social connection in the general population of the U.S. indicates that overall, our social networks are gradually shrinking alongside the average amount of time we spend each week and month engaging in in-person social interactions.
Data collected between in a long-range study from 2003-2023 shows that over the past two decades, the average time we spend alone increased:
- 2003: 4 hours and 45 minutes per day, 142 and a half hours (5.9 days) per month
- 2019: 5 hours and 10 minutes per day, 154 and half hours (6.4 days) per month)
- 2020: 5 hours and 33 minutes per day, 166 and a half hours (6.9 days) per month
In other words:
The average person in the U.S. spends 24 more hours per month alone in 2020 than they did in 2023. That’s an entire day.
The study also shows participation in specific types of relationships has declined.
Time engaged with friends socially in-person:
- 2003: 1 hour per day, 30 hours (1.25 days) per month
- 2020: 20-minutes per day, 10 hours (0.4 days) per month
In other words:
The average person in the U.S. spends 20 fewer hours per month with friends in 2020 than they did in 2023.
This decline is particularly evident among younger people.
Social time spent in-person with friends, people 15-24.
- 2003: 2 hours 30 minutes per day
- 2020: 40 minutes per day
In other words:
The average teen/young adult in the U.S. spends 55 fewer hours per month with friends in 2020 than they did in 2003 – that’s a reduction of almost 70 percent.
We’ll summarize this data now, with additional information. Between 2003 and 2023:
- Social isolation increased by 24 hours per month
- Household social/family engagement decreased by 5 hours per month
- Companionship decreased by 14 hours per month
- Social time with friends decreased by 20 hours per month
- Non-household social/family engagement decreased by 6.5 hours per month
- General social time with others decreased by 10 hours per month
The loneliness epidemic is also reflected in a decline in close friendships.
Consider these statistics:
- 90% of people who say they do not feel alone or isolated have at least three close friends
- In 2021, 49% of people in the U.S. say they have fewer than three close friends
- In 1990, 27% of people in the U.S. said they had fewer than three close friends
- During the COVID-19 pandemic, one study reported the size of an average individual’s social network decreased by 16% (June 2019-June 2020)
We can stop here with the data, because the evidence is clear and unmistakable. Across the board, people in the U.S. are less connected to one another, socially, than they were 20 years ago. That means that on average, an individual has a higher chance of feeling lonely and isolated. That begs an important question:
What are the consequences of loneliness and isolation?
We’ll discuss those now.
The Impact of Loneliness and Isolation on Health and Wellbeing
We may be reluctant to admit the extent to which our personal experience of loneliness and isolation impacts our physical health and wellbeing, but that’s a reluctance we need to leave in the past. Scientific evidence demonstrate the connection, and there’s no longer any doubt: a lack of real social connection can have serious negative consequences.
“Over four decades of research has produced robust evidence that lacking social connection— and in particular, scoring high on measures of social isolation—is associated with a significantly increased risk for early death from all causes.”
-2020 Consensus Study Report, National Academies of Sciences Engineering and Medicine
Another recent report shows that lack of social connection associated with:
- A 32% increased likelihood of stroke
- A 29% increased risk of heart disease
That’s not all. Lack of social connection increases risk of premature mortality more than:
- Smoking 15 cigarettes a day
- Drinking 6 alcoholic beverages a day
- A sedentary lifestyle
- Air pollution
Those are the big-picture, top-line statistics on the impact of loneliness and isolation on health. Let’s drill down on this data and look at the impact of loneliness and isolation on specific diseases and conditions.
Compared to people who report low levels of loneliness, people who report high levels of loneliness have:
- 68% increased risk of hospitalization
- 57% increased risk of ER visits
- 16% increased risk of outpatient visits
- People with high levels of social support have a 36% decreased risk of hypertension, compared to people with low levels of social support
- Presence of feelings of social isolation increase risk of hypertension more than a diagnosis of diabetes
Compared to those without a large social support network, people with diabetes with a large social support network show:
- Higher adherence to medication plan
- Higher levels of physical activity
- Healthier diet
- Higher levels of self-care
- Higher adherence to glucose monitoring
This data is counter intuitive. Less contact with people should decrease the risk of contracting an infectious disease. Right? Not according to the following data:
- After exposure to the common cold virus:
- People with 4-6 social roles – e.g. spouse, friend, parent, coworker, member of a social/activity group – had a 400% decreased risk of developing illness
- People with 1-3 social roles had a corresponding increase in risk of developing illness
- Experts theorize a high level of social connection is associated with improved/increased/more robust immune response
People who report high levels of loneliness and isolation show:
- 50% increased risk of developing dementia
- 20% faster rate of cognitive decline in old age
People who report high levels of social support and connection show:
- Lower risk of dementia
- Higher levels of cognitive function
Those are the physical and cognitive consequences of loneliness and isolation, as supported by peer-reviewed journal studies. To read the original studies, please follow the links in the Surgeon General’s report, which we link to above.
Now let’s look at the impact of this epidemic on mental health.
The Impact of Loneliness and Isolation on Mental Health and Wellbeing
The facts and figures we shared in the previous section may be surprising, since loneliness is a psychological state associated with isolation, and the significant impact of both loneliness and isolation on our physical health is not something many of us understand. Nevertheless, the data above indicate loneliness and isolation have a measurable negative impact on physical health, which includes cognitive function.
Now we’ll look at the effect of loneliness and isolation on an area most of us expect them to have an impact: mental health.
Depression and Anxiety
Withdrawal from friends and family, resulting in self-isolation, is a symptom of both depression and anxiety. However, isolation and loneliness, both akin to social withdrawal, are also predictors that indicate increased risk of depression and anxiety.
- Adults who report feeling lonely often have double the chance of developing depression than adults who report rarely feeling lonely
- In older adults:
- Isolation and loneliness increase rates of anxiety
- Isolation and loneliness increase rates of depression
- In adolescents and children:
- Isolation and loneliness increase risk of developing anxiety
- Isolation and loneliness increase risk of developing depression
- Elevated risk persists for up to 9 years
- In adolescents and children, having a close friend or confidant is associated with reduced risk of developing depression
Suicide and Self-Harm
We’ll open this section with something everyone should understand:
“Social isolation is arguably the strongest and most reliable predictor of suicidal ideation, attempts, and lethal suicidal behavior among samples varying in age, nationality, and clinical severity.”
-2010 Study, “The Interpersonal Theory of Suicide”
In a long-range study of over half a million middle aged adults, data showed:
- Men who lived alone had double the chance of dying by suicide, compared to men who did not live alone
- Women who lived alone had higher odds of engaging in self-harming behavior than women who did not live alone
- In inpatient medical facilities, loneliness, isolation, and low social support were associated with suicidal ideation among cancer patients, nursing home residents, and adolescents.
In a meta-analysis on self-harm that reviewed data from 60,000 adults, patients identified loneliness as a primary motivator for engaging in self-harming behavior.
How We Can Address the Epidemic of Loneliness and Isolation
The information above tells us that loneliness and isolation are more than what tough love advocates used to call personal problems. They’re real. They contribute to an overall degradation of happiness, wellbeing, and health. They impact individuals, families, and communities. They’re associated with increased rates of mental health disorders, and a driving factor in the phenomenon of self-medication with alcohol and drugs, which can lead to alcohol/substance use disorder.
In other words, the Surgeon General is right: isolation and loneliness are a threat to the public health and need our immediate attention and action.
Thankfully, there are steps we can take to decrease loneliness and isolation and increase our sense of social connection. We list the three core components of social connection above: structure, function, and quality. The Surgeon General’s report outlines a six-point national strategy to increase social connection in the general population. The report calls these points pillars. Here’s an overview of this new national strategy.
Six Pillars to Advance Social Connection
Pillar 1: Strengthen Social Infrastructure in Communities
We need to:
- Design communities – on an environmental/physical level – to promote social activity, inclusion, and connection
- Create and scale-up connection programs in communities
- Allocate funds to local programs and institutions that increase social connection
Pillar 2: Enact Pro-Connection Policies
We need to:
- Increase connection and communication between public sector policymakers and constituents
- Create policies that mitigate the harm caused by lack of or poor social connection
- Increase and improve connection between leadership at every level of government, from the local to the federal
Pillar 3: Mobilize the Health Sector
We need to:
- Train providers to recognize loneliness and isolation
- Train providers to support people who feel lonely and isolated
- Identify and help people who are lonely and isolated
- Expand public health programs to meet the needs implied by the previous there bullet points
Pillar 4: Reform Digital Environments
We need to:
- Require tech companies to share data on the impact of their technology on the health, safety, and wellbeing of the general public
- Create and enforce digital safety standards, especially for children and adolescents
- Recognize that the responsible use of digital technology can promote social connection, and leverage its positive potential to decrease loneliness and isolation in the general public
Pillar 5: Deepen Our Knowledge
We need to:
- Create a national research plan to enhance our understanding of the impact of loneliness and isolation on health and wellbeing
- Increase funding for research into loneliness and isolation
- Raise awareness among the general public about the negative consequences of loneliness and isolation
Pillar 6: Cultivate a Culture of Connection
We need to:
- Reiterate the importance of core values:
- Community service
- Encourage leaders to model those core values
- Model those core values in our families and communities
- Initiate and engage in conversations about the importance of social connection in schools, at work, and in our communities
Those pillars, and the goals described therein, don’t need a great deal of explanation. At the local level, they’re simple: cultivate kindness, respect, and connection between ourselves and our neighbors. At the national level, they’re more complex, but the wide-ranging strategy we outline above is a good start. If our politicians get on board and commit fully to allocating resources to mitigating the harm caused the the epidemic of loneliness and isolation, we can change every “We need to” in the list above to a more proactive “We can.”
Or, even better: “We will.” That’s the attitude we plan to adopt in response to this report.
At Pinnacle Treatment Centers, we guarantee we will work to improve the quantity and quality of social connectedness for our patients, our staff, our families, and our communities.