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All the lonely people

This is the silent health epidemic of our generation, and I don’t say that lightly.”

Senator Keith Swanick says it is his experience as a GP that has drawn his interest towards the public health challenge posed by loneliness.

A GP in Belmullet in north Mayo and Fianna Fáil Spokesperson on Health and Mental Health, Senator Swanick is also the Chairperson of the Loneliness Taskforce, which recently published a report titled A Connected Island: An Ireland Free from Loneliness. The Taskforce was established by Senator Swanick in collaboration with Mr Seán Moynihan, CEO of the charity group ALONE.

“It [loneliness] is across all demographics. Urban, rural, young and old, rich and poor, and I’ve always felt even in this time of insane online connectivity, it is as prevalent as ever in the younger population, despite this connectivity online,” Senator Swanick tells the Medical Independent (MI).

The report makes a number of specific recommendations, including the provision of annual funding of €3 million towards combating loneliness, the allocation of responsibility to challenging loneliness to a specific Minister, a public campaign, support for organisations that try to alleviate loneliness and specific Irish-based research into the topic.

Senator Swanick has planned a high-level political engagement process for the coming weeks, and the Department of Health has told this newspaper that a “cross-Governmental” response to the report will be needed (see news story, p10).

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CEO of ALONE Mr Sean Moynihan and Senator Keith Swanick

Healthy Ireland

“The fact that loneliness was absent from the Healthy Ireland framework indicates the real lack of awareness around the subject,” says Senator Swanick. “It reinforced to me the necessity to establish the [Loneliness] Taskforce and build awareness around the subject.”

Prof Brian Lawlor, Consultant Psychiatrist at St James’s Hospital, Dublin, is also a member of the Taskforce and he says it is time for loneliness to be viewed from a public health standpoint.

“It’s not a new concept, but loneliness is not part of public health policy anywhere really,” Prof Lawlor tells MI.

“In the UK, they have tried to have the ‘Campaign to End Loneliness’ [but] loneliness is not really part of public health policy anywhere, even though we have known a lot about the impact of loneliness and poor social connection on health.

“Loneliness has the same impact as cigarette smoking, hypertension, obesity — all areas that have a public health policy, but loneliness and social connection doesn’t. And it has much impact both on mental and physical health.

“This is what this Taskforce is about; it is about highlighting it more, making the public aware, not just the general public or healthcare professionals, but also to try to make policy-makers more aware that this is an important area and it should be incorporated into some form of public health policy.

“It wasn’t incorporated into the Healthy Ireland approach, and that perhaps needs to be re-thought,” he adds, echoing Senator Swanick’s concerns.

UK

For his part, Senator Swanick looks to recent progress in the UK, especially a campaign led by the late MP Jo Cox on the issue as an example that gives encouragement to the work that needs to be done here.

“I think the work of Jo Cox and her campaign catalysed a conversation in the UK, I think [British Prime Minister] Theresa May also has to be complimented for appointing Tracy Crouch to the position of Minister for Loneliness,” says Senator Swanick.

“I think after that appointment, the whole conversation has been turbo-charged. People have realised that this is a real issue.”

Senator Swanick says that a copy of the report will be sent out to all GPs in Ireland in the coming weeks and months. So does he see a particularly important role for primary care in facing this challenge?

“I do,” Senator Swanick tells MI. “I’ve been passionate about this topic as a GP long before getting elected to the Seanad.

“I have, over the past number of years, seen many people who are lonely and it may have been misdiagnosed as a mental health issue, as depression.

“So I think it has particular relevance to general practice. General practice is often the first port of call for somebody who might be feeling a little vulnerable or lonely and it might be just a matter of GPs keeping an open mind to the patient sitting in front of them. Could they be lonely, etc?”

Training

Prof Lawlor agrees with this assessment.

“Absolutely, one of the points I really feel strongly about is that there needs to be more educational and training around psychosocial aspects of wellbeing,” he says.

“One of these is loneliness. When I was in medical school, there was no mention of this. It is about trying to understand the contact and supports that an individual has, and also trying to understand what you can recommend or prescribe in terms of contact. They call this ‘social prescribing’ now.

“In my day, in medical school and training, we never dealt with this. So I think the biopsychosocial approach needs to be kind of emphasised, particularly in terms of history-taking [of patients] and talking to families.

“They [doctors] need to ask the question, ‘are you lonely?’ and try to get a sense of who the most important people in their [patients’]  lives are in terms of contact on a daily basis or a weekly basis, and what are their activities like? What connections do they have and do they make? That is most important in the history-taking and understanding the person and the patient. It is also important in terms of prescribing.

“And when I say ‘prescribing’, I don’t mean prescribing medication, but prescribing an intervention. If you don’t ask the questions, if you don’t have a picture, you don’t make a proper assessment or recommendation.”

Senator Swanick agrees that there is a need for more medical training in this area and he welcomed recent comments from RCSI CEO Prof Cathal Kelly at the official launch of the report, who said that the College would look at this issue for undergraduate training.

“But this is not just for GPs,” says Senator Swanick.

“All practice staff, practice nurses and front-of-house people [need to be] trained-up to keep an eye out for vulnerable adults or children.”

Responsibility

The report recommends the “allocation of responsibility to combat loneliness to a specific Minister and Government department”.

Senator Swanick says he thinks this department would most likely be the Department of Health.

“Up to now, this topic has fallen between a few different departments; maybe that is the reason why it has fallen through the cracks. I think [the Department of] Health is where it would be best,” says Senator Swanick. “I think it should be within a portfolio. We need accountability and we don’t have it if we don’t have a specific department in charge of the subject. So I think health is where it should be.”

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The Loneliness Taskforce at the launch of the report

From his perspective working in the area of mental health, Prof Lawlor thinks there is much work that can be done on a policy level.

“There are a number of issues. One is stigma; second is also it [loneliness] falls between two stools. We have had health and social care aspects and also the definition of what is ‘loneliness’ and how do we measure it,” he says.

“Loneliness is different to isolation, so there is an issue around definitional measurement as well. That is where you need a joined-up approach and that is where you need to get into an area like Healthy Ireland.

“But the measurement, the definition and the understanding of it have also kind of hindered development in this area.

“So in terms of definition of, say, smoking — you either smoke or you don’t, or you smoke a certain amount. Also, with obesity we have good measures of weight and so on and so forth. Loneliness is a subjective construct. It is all about [what the patient] reports, or what they say, or how they feel.”

Prof Lawlor says because of these challenges, there is a need for “some more nuanced research…around what actually works in terms of decreasing loneliness, or decreasing the impact on physical and mental health”.

“That is one of the reasons the report calls for more research. If you have more research and evidence, that will help the policy-makers as well.”

Depression

He adds that all this requires greater awareness among doctors and other healthcare workers.

“I am dealing with older people primarily, but I think this is right across the board,” he says. “Unless you ask, you are not going to be told; people do not necessarily volunteer that they are lonely, or are experiencing loneliness.

“So making doctors or [other] healthcare professionals aware… but also in terms of what they can do to help and where they can refer people for advice and support. Now, clearly there is work done by ALONE and others. There are lots of agencies out there that provide support and contact; oftentimes they are dealing with people who are isolated and lonely — that is really important.

“Loneliness is an increasing risk factor for depression. The lonelier you are, the more likely you are to develop depression. If you don’t tackle loneliness when someone is depressed, you may not be able to tackle the depression.”

“So in terms of healthcare workers, it is about increasing knowledge and awareness as part of the training.”

Loneliness can be worse for a person’s health than other well-known risk factors, such as obesity.

The magnitude of health risk associated with social isolation is seen as comparable to that of cigarette smoking.

Evidence highlights that older people experiencing high levels of loneliness are almost twice as likely to die within six years compared to those who are not lonely.

Loneliness increases the risk of death by 26 per cent, lack of social connections increases the risk of death by 29 per cent and living alone increases risk of death by 32 per cent.

Loneliness has been associated with a broad range of adverse psychological conditions, including: Anxiety, depression, substance abuse, social deviance, lower social skills, a more critical view of self, and perfectionism.

Loneliness can increase the risk of heart disease and impede recovery rates from stroke.

A 2010 survey suggested more than a third of American citizens over the age of 45 feel lonely. In 2017, former US Surgeon General Dr Vivek Murthy called loneliness a “growing health epidemic” in a Harvard Business Review essay.

Loneliness has been linked to a wide variety of adverse mental and physical health outcomes, such as depression, nursing home admission and mortality.

Source: A Connected Island: An Ireland Free from Loneliness 

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