SAN FRANCISCO — Living in densely populated urban areas isn't protective against severe loneliness in middle-aged women, new research suggests.
Results from a small study of urban-dwelling women between the ages of 35 and 60 years showed that caregiver responsibilities, past trauma, and social isolation, as well as having strained family and romantic relationships, are all contributors to feelings of significant loneliness. In addition, 42% of the respondents said they had "no one to turn to."
However, having supportive relationships appeared to be a protective factor against loneliness.
Further research is now needed, "including further analysis of the individual interviews for common themes and trends that will inform mental health programming, such as support groups or group therapy," lead author Jennifer Trinh, MD, department of psychiatry, Temple University Hospital, Philadelphia, Pennsylvania, told Medscape Medical News.
She presented the results at a press briefing here at the American Psychiatric Association (APA) 2019 Annual Meeting.
Ranna Parekh, MD, moderator at the briefing and deputy medical director for the APA, told Medscape Medical News that although the study was small, the findings highlight a continually growing public health concern.
"We really wanted to spotlight this topic. At the APA, if people aren't already noticing certain areas that are emerging, we want to make sure it's on their radar," said Parekh, who is also director of the APA's Division of Diversity and Health Equity.
If an individual is socially isolated, there are risks for loneliness, she added. "But in an urban area, where there are people all around, you can still be at risk for loneliness?" she asked. It would be interesting to now examine these issues in other populations, such as rural women, kids, rural vs urban men, and between different age groups, she said.
"I'd say there's more to come" in terms of research and possible interventions, Parekh added. "We wanted people to start thinking about the hot topics in psychiatry, and we're hearing more and more about loneliness."
Perceived Lack of Contact
Trinh noted that social isolation is defined as an "actual lack of contact," whereas loneliness is a perceived lack of meaningful contact, as well as a sense of disconnectedness and of not belonging.
"Loneliness has long been linked with detrimental health effects in different populations [and] social isolation has been associated with functional decline and increased mortality in the elderly," the investigators write.
Previous research showed an association between loneliness in midlife and coronary artery disease in women. Loneliness has also been linked to long-term anxiety and depression in residents of low-income areas.
The Temple University Hospital 2016 community health needs assessment identified loneliness as a mental health priority in North Philadelphia. In the assessment, 7% of older adults reported talking to family or friends, on average, less than once a week.
A mental health study, entitled "Exploring Mental Health Concerns and Solutions: Women From Philadelphia Speak," was co-sponsored by the Temple Health: Block-by-Block initiative and the Temple University Department of Psychiatry in order to identify mental health concerns and barriers to treatment for women.
The researchers enrolled 50 women aged 35 to 60 years (mean age, 50.3 years; 76% black, 20% Hispanic, 4% white) from 11 zip codes in North Philadelphia. While 88% of the women completed high school, only 6% completed college. In addition, 50% reported being single, 20% said they were married, 18% had a partner, 8% were divorced or separated, and 2% said they were widowed.
A total of 70% of the participants said they struggled with mental health issues.
Home-based, semistructured, one-on-one interviews were conducted by two female members of the research staff. Eight items from the UCLA Loneliness Scale-Revised (UCLA LS-R) were included in the interviews. A subgroup of 21 study participants also attended a post-interview focus group event.
The current analysis focused on the loneliness findings.
Relationship Quality, Not Quantity, Important
Asked "How often do you feel that there is no one you can turn to?" 22% of the participants selected "always" and another 20% selected "sometimes." In answer to how often they felt close to other people, 14% said "rarely" and 10% said "never."
In the focus groups, four distinct themes emerged, including loneliness due to one of the following:
Burden of responsibility
Trauma and loss
"Mentally I grew up alone, even though I was in a house [with] a family and people around me," one study participant noted. "Mentally, I was broken. It's a sadness and the darkness that I've experienced as a child never allowed me mentally to have a life."
On the other hand, having supportive relationships was found to be preventive against loneliness — and was the fourth theme from the focus groups.
"Kids keep me sane, I love the children," another participant said. "I have three grandchildren so they lift my day a lot."
Another woman credited a group of friends who supported her after her mother's death, even though she thought that wasn't what she wanted. "They came and bombarded my house. They helped me clean. They helped me write the cards," she said.
Trinh noted that although most of the participants reported mild-to-moderate symptom scores on the UCLA LS-R, 10% reported severe levels of loneliness.
"Urban minority midlife women face unique life challenges. Though they may be involved in interpersonal relationships, the poor quality of these relationships leads to subjective feelings of loneliness and isolation," the investigators write.
"By identifying and characterizing these nuances, targeted interventions and community initiatives can be devised and implemented for improved engagement in mental health treatment," they write, but note that further research is needed.
During the post-presentation question-and-answer session, Trinh noted that although she couldn't yet suggest any specific interventions for combatting loneliness, the women reported befit from the focus groups themselves.
"They liked coming together and speaking about each other's issues. So, a support group in the community is something we'll be looking into," she said. Interpersonal therapy, couples counseling if there are relationship issues, or additional community-based interventions are also possibilities, she added.
In answer to why the investigators focused on urban women, Trinh said it was because "these women were in our backyard at Temple University. They are like the backbone of families for the patients that we treat, and we noticed that there are less women who seek treatment. So this was a way to better understand what's preventing them from coming in and what they're dealing with day-to-day."
She added that she would expect some differences with rural women and would like to see research done looking at that particular population.
After the presentation, Trinh told Medscape Medical News that, although this was a small study, the findings are such that she recommends that clinicians ask about loneliness.
"Especially in the psychiatric outpatient setting, but also in primary care settings and even in pediatric settings where we see moms and grandmas who bring in kids, checking in with caregivers instead of just focusing on the patient can help," she said.
"Loneliness is so prevalent and it's something we don't really talk about because it can bring a lot of shame. It's like, 'I'm lonely but I'm in a busy household with all these responsibilities.' It's hard to admit or talk about feeling lonely," Trinh said.
She noted that if a new case of depression "pops up," yet a patient has a lot of people around them, a clinician might not think to ask about loneliness. "You'd think, 'Oh, you must have a lot of support.' It can be hard for a person to say, 'I don't have anyone to really talk to. I don't have anyone to rely on,' " she said.
Instead of asking if a patient or caregiver is lonely, Trinh suggested asking whether the individual is feeling overwhelmed or needs a break, whether they have someone they can turn to, and what a normal day is like for them. "It's a more subtle, nuanced thing that is important to talk about," she said.
Parekh told Medscape Medical News that as a clinician, "I'd say that research's biggest objective is to inform us practitioners."
"As we start to hear more about [loneliness], I wouldn't be surprised if people aren't asking folks about this topic. 'You've told me about your social networks and now the question is: Do you subjectively feel lonely?' " she noted.
Also asked to comment on the topic, Lloyd Sederer, MD, adjunct professor at Columbia University Mailman School of Public Health and director of the Columbia Psychiatry Media Center, New York City, told Medscape Medical News that loneliness is a "widespread" public health issue.
"Psychiatrists are among the doctors and others who are recognizing this problem," said Sederer, who was not involved with the research.
He also cited a quote by Douglas Nemecek, MD, chief medical officer for behavioral health at Cigna, about a recent survey conducted by the health insurer that loneliness has a health risk equivalent to smoking 15 cigarettes a day.
"When we feel all alone, whatever our troubles are, they are so much more magnified because we feel like we are the only one or there's no one to reach out or understand. That just mobilizes the body's stress response all the more," Sederer said.
He also echoed the importance of distinguishing between loneliness and social isolation.
"We could be in a room full of people and still feel isolated. It's the experience of not being part of a community, even though you may be surrounded by other people. It's not a matter of the density of the population, it's the density of the connection that people have in their lives," he said.
Asking about loneliness "should be a routine part of the inquiry in a clinical encounter. And it's not a hard thing to ask about," said Sederer. "Just ask, 'Who do you have in your life? Who do you spend time with? Who do you care about and who cares about you?' It's opening a door to the concerns that a person has."
The study was funded by the Commonwealth of Pennsylvania. The study authors, Parekh, and Sederer have disclosed no relevant financial relationships.
American Psychiatric Association (APA) 2019 Annual Meeting: Poster abstract P1-158. Presented May 18, 2019.
Follow Deborah Brauser on Twitter: @MedscapeDeb
Medscape Medical News © 2019
Cite this: Deborah Brauser. Loneliness Common in Urban-Dwelling, Mid-Aged Women - Medscape - May 23, 2019.