More Americans are living alone, but the COVID-19 pandemic has quickly elevated loneliness as a universal experience in the U.S. And while research has shown loneliness can have profound long-term health effects—including dementia, cardiovascular disease and premature death—often it’s thought of as a social issue, not a medical one, and its diagnosis is obstructed by stigma and shame.

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During a recent “Ethics Talk” videocast from the AMA Journal of Ethics® (@JournalofEthics), Carla Perissinotto, MD, MHS, a geriatrician, palliative care specialist and associate professor of medicine at the University of California, San Francisco, talked about why loneliness needs to be included in the national dialogue about health and health care, as well as how to identify it in a patient’s social history.


A longstanding and growing problem

In the 50 years from 1969 to 2019, the share of U.S. households of just one person grew from less than 17% to more than 28%, according to the National Academy of Sciences. Some 35 million Americans now live alone.

Of course, some people living alone do so by choice and are quite happy, Dr. Perissinotto noted. But many have been forced into social isolation, with serious effects on their health.

“There's often a misconception that, by being alone, you are automatically lonely and that is absolutely not the case,” she said. “One way to think about it is—being alone—is it a choice and something you desire, or is it something that you're forced into and that is causing distress?”

Still, medicine has had a hard time understanding how to conceptualize social determinants of health and the magnitude of how they affect health, and, “in many ways, loneliness and isolation actually fit into this framework of a social determinant,” Dr. Perissinotto said.

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Compare with depression

One of the things keeping physicians from tackling loneliness with patients is that research on the topic often shows up in social sciences literature but not medical literature, Dr. Perissinotto said.

“I would compare this … to what we saw decades ago when we first started asking about depression,” she said. “And though there's still some stigma around mental health—depression being part of mental health—there’s improvement, because there's been a more open dialogue around ... this is a significant thing that affects us and affects our health.’”

Give patients a chance to talk

One of the tools already available to physicians to introduce discussion of loneliness with patients is the three-item loneliness questionnaire.

“What's nice about it is that it’s quick,” she noted. “It’s three questions, it’s validated, it's been used in different languages. And it's pretty reasonable to be able to implement that into routine care."

Ways to meet the moment

What’s distressing to geriatricians about the response to the COVID-19 pandemic from an ethics perspective, Dr. Perissinotto said, is that rules and recommendations often have been placed on older adults and other vulnerable people before anyone has asked what they want for themselves.

This is common practice in institutional settings, she said, “but it may even be family members deciding for their parents: ‘We’re not going to see you because we don't want you to get sick.’”

Surrogates should instead ask what the person’s preferences are and whether they feel they can manage the associated risks.

"Because some older adults may actually say, ‘You know what? I would prefer to see you for a small amount of time, because of my quality of life, rather than not see you for months. And how can we do that safely?’” she added.

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Listen and claim CME credit

This episode of “Ethics Talk” is CME activity designated for 0.5 AMA PRA Category 1 Credit™. Check out previous episodes of the “Ethics Talk” podcast or subscribe to the series in iTunes or other services.

The AMA and the Centers for Disease Control and Prevention are closely monitoring the COVID-19 pandemic. Learn more at the AMA COVID-19 resource center. Also check out pandemic resources available from the AMA Code of Medical Ethics, JAMA Network™ and AMA Journal of Ethics, and consult the AMA’s physician guide to COVID-19.

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