Loneliness in Primary Care Patients: A Prevalence Study

Rebecca A. Mullen, MD, MPH; Sebastian Tong, MD, MPH; Roy T. Sabo, PhD; Winston R. Liaw, MD, MPH; John Marshall; Donald E. Nease Jr, MD; Alex H. Krist, MD, MPH; John J. Frey III, MD

Disclosures

Ann Fam Med. 2019;17(2):108-115. 

In This Article

Discussion

We found that the prevalence of loneliness is 20% in adult English-reading patients participating in routine outpatient primary care, with younger populations carrying a significantly higher burden. In addition to demographic factors such as relationship status and employment status, positive loneliness screens were associated with heath care utilization and poor self-rated health. The relationship with poor health status was significantly maintained even when adjusting for patient characteristics.

Our findings both support and enhance other loneliness research currently in the literature, notably adding the perspective of a broadly representative primary care patient population. In other studies focusing on the general population or subset clinical groups, relationship status,[24] poor subjective health,[25–27] and a variety of health care utilization measures including primary care visits,[28,29] emergency hospitalizations,[30]and emergency department visits in elders[31] have been associated with loneliness. Although few prior studies have shown a higher prevalence of loneliness in rural settings,[26] in our population the prevalence of loneliness did not differ significantly with rurality, suggesting that loneliness is constant among diverse clinical settings. While the prevalence varied between Colorado and Virginia, this is almost certainly explained by the substantially different patient populations included in each state. Importantly, we confirmed that the prevalence of loneliness in those presenting for care is similar to that of the general population.[32,33] In other words, we do not see evidence that lonely individuals isolate themselves from primary care. This indicates that the primary care setting has the potential to identify solutions and implement interventions.

Similar to our study, there have been other reports that illustrate an equal or greater prevalence of loneliness in adolescents.[34,35] The underlying cause for this level of prevalence in adolescents is not well defined, but may be related to significant transitions during this age period including detachment and independence from parents,[1] low self-confidence,[36] and concerns with self-identity and peer status.[37] Generational differences in communication may also play a role in the impact and experience of loneliness. Given the broad age ranges included in this analysis, future studies can assess whether these results can be replicated within more narrow age cohorts among those presenting to primary care practices.

Although the role of screening and integration into routine care remains unclear, there is emerging data that the health care system has a role in helping patients address loneliness. In the clinical setting, interventions have included social support provided by individual or group counseling,[38,39] social recreation interventions offered at mental or clinical health centers,[40] telephone-based social support or social cognitive training delivered by health care providers,[41,42] and even hospital-based social skills training.[43]While many of these interventions are small and not replicated, they have illustrated significant changes in loneliness scores.[44,45] Importantly, patients report the desire to talk to their primary care clinician about loneliness.[46] Therefore, more attention needs to be placed on the role of the physician and the clinical setting in screening for and mitigating loneliness, the methodological rigor of subsequent studies, and the evaluation of the impact on quality of life and health outcomes.

Several limitations to our study need to be acknowledged. First, due to resource constraints our survey was limited to English-reading participants, creating a bias toward including those able to comprehend standardized research instruments and excluding patients with lower socioeconomic status who may be at high risk for loneliness. In fact, based upon prior literature indicating that many immigrant and refugee populations have high loneliness, a more inclusive population may have increased the loneliness prevalence in our study.[47,48] Second, because we did not collect data on nonparticipants, we cannot compare respondents to the general practice population and thus respondents may differ. Additionally, although we surveyed distinct regions, results could differ if this study is repeated in other states or regions. Finally, as this is a cross-sectional study, we cannot establish causation between loneliness and risk factors, nor can we know whether loneliness preceded low self-reported health status and higher health care utilization (or vice versa). Additional research is warranted.

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