By JOSHUA SEIDMAN
In 2023, U.S. Surgeon General Vivek Murthy boldly declared that our country has a “loneliness epidemic.” In the Surgeon General’s public health advisory, “Our Epidemic of Loneliness and Isolation,” he draws on decades of empirical evidence demonstrating the tremendous toll that loneliness has on people’s quality of life, and how it also increases the risk of premature death by 26%.
The question is: What can be done to tackle this intractable public health crisis? Perhaps even more pointedly, what is anybody actually doing that successfully reduces loneliness?
Steps Required to Reduce Loneliness
The first thing we have to do, as the Surgeon General said in his report, is “consistently and regularly track social connection using validated metrics.” Without ongoing measurement, we can’t even assess the problem, understand whether it’s getting better or worse, and know what interventions might be helping.
Furthermore, we need to tie those measurements to some sort of payment model. In order to focus providers and other stakeholders on the importance of loneliness, we need to hold them accountable for outcomes. Since we know that loneliness dramatically impacts both the quality and length of people’s lives, we should raise it as a priority for providers by tying some portion of their payment to their success in reducing loneliness.
We need to orient the health care system toward addressing factors that substantially affect the health of the population. Since the powers that be in the health care world accept smoking cessation as a valid performance measure, then it absolutely makes sense for payers and purchasers to hold providers accountable for addressing loneliness, a condition that the Surgeon General’s research equates to smoking 15 cigarettes per day.
Case Study of Success in Tackling Loneliness
Just as with any other proposed performance measure used to hold providers accountable, it’s fair to demand evidence that providers can actually influence outcomes for their patients. New research from Fountain House does just that —making clear that, with the right interventions, it is absolutely possible to measure and dramatically reduce loneliness in a way that meaningfully improves lives.
Fountain House pioneered the clubhouse model, a psychosocial rehabilitation model that supports people with serious mental illness (SMI). By addressing social drivers of health, we not only facilitate recovery, but we also reduce Medicaid costs by 21% relative to a comparable high-risk SMI population. An economic model we built also found that clubhouses reduce overall costs to society by more than $11,000 per person annually (when factoring in costs for mental and physical health, disability, criminal justice, and productivity/lost wages).
More to the point here, our population (and people with SMI generally) faces tremendous economic and social isolation and therefore are 2 to 3 times more likely than the general population to be lonely. Furthermore, research demonstrates that loneliness can be more intractable in the SMI population and failure to address it compromises their recovery and raises risk for an array of acute health events.
Fountain House didn’t stumble into measuring loneliness. A few years ago, Fountain House staff and members discussed what performance measures mattered most to them, which led to the identification of 3 patient-reported outcome measures (PROMs) that we began collecting on a longitudinal basis (in addition to loneliness, we also track quality of life and thriving).
For the first time, we now have pre-post data, and we can see the dramatic effects of our community on our members (the term used to describe the people with SMI who voluntarily join clubhouses, operate day-to-day functions of the clubhouse, and co-create programming). For people who identified as lonely when they joined Fountain House, 58% experienced reduced loneliness at follow-up (typically 12 to 18 months after becoming members), a majority of whom had scores decline so much that they became “non-lonely” according to the UCLA 3-Item Loneliness Scale.
Measuring Loneliness with the UCLA Scale
The UCLA Loneliness Scale consists of three simple questions:
How often do you feel you lack companionship?
How often do you feel left out?
How often do you feel isolated from others?
For each question, respondents select one of three possible answers:
hardly ever (1 points)
some of the time (2 points)
often (3 points)
The scale assigns a score to each response as noted above, yielding a total score that ranges from 3 to 9. 6 or over is defined as “lonely”
Implications for Policy and Practice
Feasibility. Part of the beauty of this robust, validated instrument is its brevity (3 straightforward survey questions), which facilitates great feasibility. If a community-based organization like Fountain House can institute a process for collecting, tracking, and improving on this metric, it is clearly an endeavor that other providers can handle.
Quality Improvement. In addition to understanding what’s going on with our population, we also are beginning to use the loneliness results to inform our operations and programming. Since members have told us how important it is and we know how much it affects their overall health, we have begun to look at correlations between loneliness and specific interventions and supports we provide to drive resource prioritization to better serve Fountain House members.
Accountability. Under New York City’s new contract with clubhouses through the city, we will be required to report 3 PROMs, including this loneliness instrument. Initially, clubhouses will simply be required to report results on it, and we anticipate that—as experience is gained with baseline data—that all clubhouses will be held accountable for their performance on this measure.
The Center for Medicare & Medicaid Innovation has recently announced details of their Innovation in Behavioral Health (IBH) model to test out a value-based payment approach to supporting people with moderate to severe mental illness. They announced plans to use PROMs as part of the IBH model’s performance assessment, and we recommend that the loneliness measure be incorporated into that demonstration’s accountability framework given its feasibility and impact on population health.
Conclusion
The epidemic of loneliness assumed greater prominence during the pandemic and only exacerbated the profound and varied detrimental health effects that have plagued society for decades. We can’t solve this epidemic overnight or with a single intervention, and we had better attack it forcefully as a population health crisis so we can help the tens of millions of Americans who suffer from the mental and physical health complications of this condition. We know how to measure loneliness, and we have evidence regarding ways to reduce it. Now we need to make these changes for the sake of public health.
Joshua Seidman, PhD, is Chief Research and Knowledge Officer for Fountain House, a national mental health nonprofit working for and alongside people with serious mental illness to support their recovery.
