The Impact of Loneliness on Disease Development

In part 2 of this video, Vladimir Maletic, MD, MS, clinical professor of neuropsychiatry and behavioral science, University of South Carolina School of Medicine, Greenville, interviews Bernadette DeMuri-Maletic, MD, medical director of Associated Mental Health Consultants and the TMS center of Wisconsin, Milwaukee, about the impact of loneliness on general health, including disease development such as depression or Alzhiemer, and the brain-body impact of marital connections. The pair recently co-presented a session titled "Love and Loneliness in the Time of COVID-19: Clinical Relevance of Relationships" at Psych Congress 2021 in San Antonio, Texas.

In the previous part 1, Dr Maletic, who is also Psych Congress Network’s attention-deficit/hyperactivity disorder (ADHD) Section Editor, and Dr DeMuri-Maletic, explore the effects of social relationships, including loneliness and isolation, on the brain and the body.

In the upcoming part 3, they discuss the role relationships play in prevention psychiatry and the impact dyadic relationships have on the treatment of major depressive disorder. 

Read the transcript:

Dr Vladimir Maletic:  It appears that disruption of social relationships reverberates as a threat danger signal in the brain and that it causes changes in endocrine regulation, immune regulation, autonomic regulation.

One would suppose that it might have some impact on general health. I know you have recently reviewed the literature on the impact of loneliness on general health. What can you tell us about it?

Dr Bernadette DeMuri-Maletic: Vlad, there certainly is an impact both on physical and mental health. We see it in all areas. We see it in endocrine dysfunction.

Believe it or not, we can see an impact of relationships on things as specific as artery width and artery thickness. For example, in one study, they looked at the quality of dyadic relationships in married couples. They rated their interactions as positive or negative. Then they looked at artery width.

What they found was that those individuals who had negative interactions had thicker artery walls. That's affiliated with risk for stroke. You could draw from that study that perhaps bad marital relationships could put someone at higher risk for stroke. Interestingly, the converse was true.

Vladimir:  That's pretty scary.

Bernadette:  It is scary. The converse was true, if individuals had good relationships, good marital connection, they got along, they had thinner diameters of the carotid artery.

Also, the cardiovascular system is impacted. There was a study that looked at women who had more social support and more social integration, so to speak. They found that those women were at lower risk for cardiovascular disease and for cerebrovascular disease as well.

Vladimir:  One aspect of mental health is a little bit awkward to talk about. We're both psychiatrists. We see patients with a variety of mental health issues but especially mood disorders. Asking about their intimacy is not always easy. Is that an important question? Does the quality of physical relationship have anything to do with mental health outcomes and overall physical health?

Bernadette:  That's a great question. I agree that oftentimes we forget to discuss that. We forget to go deeper into our relationship history to look at people's physical intimacy and their connection in that area.

There was one study that looked at younger women. They were all moms. They were between ages 20 and 50. They corrected for their general health and also for their perceived stress.

They measured their telomere length. They found that women who had more physical intimacy the week before the study had longer telomeres. We know that shortened telomeres are affiliated with oxidative stress, with aging, with general poor health.

You could draw conclusion from that perhaps that physical intimacy can lead to overall better health, longevity, and improved health function. Vlad, to your question, we often forget to ask about physical intimacy in older adults in particular. There's been a strong link with physical intimacy and cognition in the older adult population.

They looked at individuals who were 57 to 83. They gave them questionnaires about their physical contact with their partners. Then they gave them a cognitive assessment, the ACE III. There was a clear correlation with frequency of sexual intimacy and their scores. They had higher scores on their cognitive evaluations suggesting the maintenance of physical relationships later in life.

Vladimir:  That is really interesting. You also quoted a study that looked at the relationship between physical intimacy and the risk for developing Alzheimer's. I'm sorry. It's not physical intimacy if my memory serves me. It is more, did one have a partner in different phases in one's life? Can you remind us what the finding of that study was?

Bernadette:  That was a very interesting study where they looked at partner status at mid‑life and then later in life. They found that individuals who were partnered at mid‑life but lost a partner due to divorce, to break‑up, to death of a partner, those individuals had twice the risk of developing Alzheimer's disease overall.

Individuals who were not partnered, who lived alone both at midlife and later in life, had three times the risk of Alzheimer disease. The most remarkable thing to me in that study was they also factored in for the APOE4 risk gene for Alzheimer's.

Vladimir:  That's apolipoprotein E4, right? It's one of the major risk genes.

Bernadette:  Absolutely.

Vladimir:  What do relationships have to do with genetic risk for Alzheimer?

Bernadette:  This speaks to epigenetics. Those individuals even who had the risk gene, if they were partnered both at mid‑life and later in life, they had a much lower chance of developing Alzheimer's almost to the point where it negated the impact of that risk gene.

It's very interesting epigenetic phenomena that shows us that being partnered can influence our risk for developing Alzheimer's later in life.

Vladimir:  That is amazing. Can you tell us a little bit about health hazards associated with being alone and lonely? Sometimes loneliness is not a choice. What can we do to help these individuals who are lonely? First, what are some of the risks of being lonely? Then, what can be done about it?

Bernadette:  We've seen from multiple studies that we discussed in our talk that loneliness can have an impact on mental health, certainly, individuals, say, for example, health workers in general during the pandemic, they were at higher risk of developing mental health issues, depression and anxiety, if they perceived themselves as experiencing loneliness.

We also saw that loneliness can lead to cognitive dysfunction as we discussed earlier and also has a risk in cardiovascular and cerebrovascular health. The first thing we need to be aware of is, how do we diagnose loneliness? People can be alone and not feel lonely. What kind of interventions can we have to address that?

I've been using the UCLA loneliness screener or questionnaire. That's the screener that's been used in a lot of our studies that we've quoted today. It's a three‑question screener. It's very simple to use. It's downloadable on the Internet. It's free to use and it's quite reliable.

Once we've identified someone with loneliness, then we need to figure out what we can do to address that and how do we treat it?

Vladimir:  There are different levels of loneliness from what I understood from your presentation.

Bernadette:  There are. People can just be at‑risk. Those individuals, we can intervene early and prevent them from having some of the health effects. There are some individuals who are quite isolated, but they're not quite at severe risk.

Then we have the people who are very isolated. Those individuals, we can see oftentimes who have more significant mental health problems who are living alone, who never leave their home. They're at very high risk.

In terms of treatment, we generally talk about things like CBT, looking at individuals who have cognitive distortions about how they interact with others, maybe referring them to a cognitive‑behavioral therapist or doing some cognitive work in our own practices to help them look and change those distorted cognitions can be one treatment for loneliness.

Another treatment for loneliness is simple social skills training. We can do that in terms of our own practice or send them out to an outside therapist. We can look at something called supported socialization where you pair an individual up with someone out in the community and encourage them to do social activities either individually or in larger groups.

Then there are group activities that we can look at. For instance, in individuals who are more severely mentally ill, individuals maybe in community mental health settings, there is the Clubhouse phenomena, the Clubhouse movement. You can go online to Clubhouse International and find a Clubhouse in your area.

These centers have a lot of socialization. They have activities. It's a way for people who have more severe mental illness to get increase in their socialization.

Otherwise, other group activities such as group exercise, group gardening, interest groups, we found that group exercise is beneficial even without the intensity of exercise. Studies that looked at intensity of exercise going down, there was still significant benefit from the group activity.

What I do in my own practice is I often recommend going out for a friend for a walk in the morning or going out with someone, a coworker at work, and making a commitment with someone to do group exercise.

Vladimir:  What are you hearing from your patients? If there is a change in the level of their social interaction, does it have some bearing in how they're doing?

Bernadette:  Yes, I think so. The studies bear that out and anecdotally, I've seen that with my patients. They get double benefit, especially with exercise. In terms of working out with someone, there's more adherence because they have someone else that they have to really be accountable to, and so, it's been quite successful actually.

Vladimir:  Great answer. Thank you.

Vladimir Maletic, MD, MS, is a clinical professor of psychiatry and behavioral science at the University of South Carolina School of Medicine in Greenville, and a consulting associate in the Division of Child and Adolescent Psychiatry, Department of Psychiatry, at Duke University in Durham, North Carolina. Dr Maletic received his medical degree in 1981 and his master’s degree in neurobiology in 1985, both from the University of Belgrade in Yugoslavia. He went on to complete a residency in psychiatry at the Medical College of Wisconsin in Milwaukee, followed by a residency in child and adolescent psychiatry at Duke University.

Bernadette DeMuri-Maletic, MD, received her medical degree from the Medical College of Wisconsin. She completed residencies in both Psychiatry and Neurology at the Medical College of Wisconsin Affiliated Hospitals. Dr DeMuri is the medical director of associated mental health consultants and The TMS center of Wisconsin, both located in Milwaukee. She is an assistant clinical professor at the Medical College of Wisconsin. Dr DeMuri has a special interest in the treatment of mood disorders including treatment-resistant depression.