Exploring the experiences of loneliness in adults with mental health problems: A participatory qualitative interview study

The Path to Loneliness for Psychiatric Patients: A Qualitative Study of a Journey Marked by Pain, Hopelessness, Prosocial Signaling Deficits, and Coping Strategies That Are Not Effective

Enduring loneliness has serious physical and mental health implications. Patients with mental health problems are at risk of experiencing problems related to loneliness. Therefore, it is important to increase knowledge about how loneliness is experienced and managed in this particular group. The aim of the study was to explore (1) psychiatric patients' experiences of different forms of loneliness, (2) associated problems, including difficulties with prosocial signaling, and (3) strategies used to combat loneliness, to better understand how loneliness affects psychiatric patients and how patients manage their loneliness. A total of 110 psychiatric patients were recruited at eight outpatient clinics in Region Stockholm for a larger study of loneliness. The first fifteen patients who also agreed to participate in the present substudy were invited to meet a trainee psychologist who conducted a semi-structured interview. A reflexive thematic analysis with a codebook approach was used to analyze the transcripts. The described experiences of loneliness were primarily examples of social and emotional loneliness with one prominent theme: "Hopelessly lonely". Associated problems were summarized in two themes: "The inevitable road to loneliness" and "Social signals are confusing and push others away". Regarding patients' strategies for combating loneliness, one theme emerged: "Using strategies that focus on the current moment". The results also included a total of sixteen subthemes. Loneliness was described as something painful that is inevitable and unchangeable, with a self-reinforcing loneliness loop leading to social and emotional loneliness, and as something that is intertwined with mental health problems. These results are in accordance with research. In addition, patients described a variety of prosocial signaling deficits and feelings of being disconnected from others. They also reported using strategies that primarily alleviated their immediate suffering when they were alone, rather than focusing on approaches with long-term effects on reducing loneliness, such as participating in social activities combined with effective social signaling. Future research should investigate whether increased awareness of social signaling, as well as social activities combined with improved prosocial signaling and strengthened self-belief, would constitute effective steps for patients to combat enduring loneliness. It also seems important to help patients reduce hopelessness related to loneliness.

The mental-health patient-activation measure: assessing validity, reliability, and responsiveness in outpatient settings

INTRODUCTION

The patient activation measure-mental health (PAM-MH) scale, adapted from the Patient Activation Measure-13 Items (PAM-13) developed in the United States, was designed to assess patient engagement and activation in mental health care. Despite initial validation of the PAM-MH in its original context, its applicability in other settings and its comparison to the gold standard PAM-13 remain unexplored. Furthermore, research addressing the face and construct validity of the PAM-MH is limited. This multi-phase study evaluated the face validity, construct validity, reliability and responsiveness of the PAM-MH in a Norwegian outpatient setting.

METHODS

A participatory approach was adopted to actively involve user representatives in validating the scale. The validation process consisted of four interconnected studies. In the first sub-study, user representatives were invited to contribute to establish face validity by providing quantitative feedback on the perceived value and burden of completing the PAM-MH. The second sub-study examined the construct validity. It was hypothesised that the PAM-MH measures the construct of patient activation and would therefore correlate with the PAM-13. This hypothesis was tested using Pearson's r in a sample of 55 outpatients. The third sub-study evaluated test-retest reliability (via ICC) and internal consistency (using Cronbach's α), in a sample of 27 outpatients who completed the PAM-MH on two separate occasions. The final sub-study explored the responsiveness of the scale to change, guided by predefined hypotheses, in a sample of 11 outpatients.

RESULTS

Adequate acceptability was established from users' views of the value and burden of the scale (overall mean "value" score was 59.7% and mean "burden" was 39.6%). All hypotheses, established a priori for construct validity, reliability, and responsiveness-to-change, were confirmed.

CONCLUSION

This multi-phase study employed a participatory approach to validate the PAM-MH in a Norwegian outpatient context. Preliminary results demonstrated satisfactory face validity and construct validity, along with good reliability and responsiveness-to-change. The findings suggest that the PAM-MH is both valid and reliable, making it a suitable questionnaire to measure patient activation in a Norwegian outpatient setting.

Conceptualising workplace loneliness: a qualitative investigation with UK workers

PURPOSE

Loneliness has been identified as an important risk factor for mental health problems, and concern about its impact on workers' health and wellbeing has grown in recent years. While a body of workplace loneliness research is emerging, the degree to which existing definitions of the phenomenon reflect workers' experiences has not been investigated. This study aims to develop an evidence-based conceptualisation of workplace loneliness that can inform future research and interventions aiming to improve workers' mental health and wellbeing.

METHODS

Semi-structured interviews exploring experiences of social connection, loneliness and work were conducted with a diverse sample of 31 UK-based workers. The interviews were supplemented with a social mapping task. Interview data were analysed inductively using reflexive thematic analysis. Social maps were analysed using a thematic analysis approach informed by a visual semiology framework.

RESULTS

Three themes were identified, in which loneliness was conceptualised as disconnection from (1) colleagues, (2) one's organisation, and (3) society. Across each theme, disconnection and loneliness were experienced as an unfulfilled desire to feel that one's authentic self was understood, valued or belonged as a result of one's work or occupation.

CONCLUSIONS

Workplace loneliness comprises not only dissatisfaction with interpersonal relationships at work, but also a sense of disconnection from larger social groups and structures, particularly one's employing organisation and society as a whole. Definitions of workplace loneliness that acknowledge the role of the social and organisational context, as well as professional relationships, are needed to better reflect the lived experience of loneliness at work.

The longitudinal association between adverse childhood experiences (ACEs) with transient and chronic loneliness among older adults

OBJECTIVES

Determine whether exposure to adverse childhood experiences (ACEs) confer a greater vulnerability to chronic and/or transient loneliness in older age, and whether specific types of ACEs are more strongly associated with chronic and/or transient loneliness.

METHOD

Participants (N = 1532) were drawn from the English Longitudinal Study of Ageing, a nationally representative sample of UK adults aged 50 years and over. Multinomial logistic regressions adjusted for sociodemographic and health-related covariates were used to determine how ACEs related to chronic and transient loneliness and which subtypes of ACEs (dysfunction, threat, or loss-based) are most associated with chronic and/or transient loneliness.

RESULTS

Experiencing 1 ACE (adjusted odds ratio [AOR] 1.43 [95% confidence interval [CI] 1.01-2.02]) or 2 or more ACEs (AOR 1.63 [95% CI 1.09-2.42]) was associated with a greater likelihood of experiencing chronic loneliness when compared to people who never experienced ACEs. There was no association between number of ACEs with transient loneliness. Dysfunction-based ACEs had a fully adjusted association with chronic loneliness (AOR 1.57 [95% CI 1.12-2.20]) and transient loneliness (AOR 1.58 [95% CI 1.12-2.23]).

CONCLUSION

This research suggests that ACEs are associated with a greater likelihood of experiencing chronic loneliness in older age. More specifically, dysfunction-based ACEs (linked to parental conflict, separation, mental illness, or substance use) were particularly associated with loneliness in older age. These findings suggest that it is important to consider the role of early life adversity when developing interventions to tackle loneliness in older age.

Emerging strategies and clinical recommendations for the management of novel depression subtypes

INTRODUCTION

The phenomenology of depression is characterized by a wide array of emotional, cognitive, and physical symptoms that significantly disrupt an individual's life. Societal changes, driven by technological advancements, economic pressures, environmental concerns including climate change, and shifting cultural norms, have influenced how depression manifests and is understood. These developments have led to the identification of new depression subtypes, highlighting the need for personalized treatment approaches based on individual symptoms and underlying causes.

AREAS COVERED

The authors provide a comprehensive narrative review of the literature on managing novel depression subtypes, focusing on both pharmacological and non-pharmacological treatments. Specifically, scenarios recorded were related to i) depression in adolescents and young adults; ii) depression and social disconnection; iii) depression and alcohol/substance use disorder; iv) depression and gender dysphoria; v) depression, stressful events, and other environmental factors.

EXPERT OPINION

In the novel depression subtypes discussed, individualized treatment approaches tailored to the individual's specific circumstances are necessary. While selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs) remain the cornerstone of treatment for many forms of depression, atypical antidepressants such as trazodone, and emerging therapies like ketamine, neuromodulation techniques, and personalized psychotherapy offer hope for those with complex or treatment-resistant presentations.

Social isolation and poor mental health in young people: testing genetic and environmental influences in a longitudinal cohort study

We assessed genetic and environmental influences on social isolation across childhood and the overlap between social isolation and mental health symptoms including depression symptoms, conduct problems, and psychotic-like experiences from adolescence to young adulthood. Participants included 2,232 children from the Environmental Risk Longitudinal Twin Study. Social isolation was measured at ages 5, 7, 10, 12, and 18. A Cholesky decomposition was specified to estimate the genetic and environmental influences on social isolation across ages 5, 7, 10, and 12. An independent pathway model was used to assess additive genetic (A), shared environmental (C), and non-shared environmental (E) influences on the overlap between social isolation and mental health problems from age 12 to 18. Genetic and non-shared environmental influences accounted for half of the variance in childhood social isolation. Genetic influences contributed to the continuity of social isolation across childhood, while non-shared environmental influences were age-specific. The longitudinal overlap between social isolation and mental health symptoms was largely explained by genetic influences for depression symptoms (r = 0.15-0.24: 82-84% A, 11-12% C, and 5-6% E) and psychotic-like experiences (r = 0.13-0.15: 81-91% A, 0-8% C, and 9-11% E) but not conduct problems (r = 0.13-0.16; 0-42% A, 42-81% C, 16-24% E). Our findings emphasise that rather than a risk factor or an outcome, social isolation is aetiologically intertwined with the experience of poor mental health. An integrative assessment of social isolation could be a helpful indicator of underlying mental health symptoms in young people.

The association between internet-use-disorder symptoms and loneliness: a systematic review and meta-analysis with a categorical approach

Loneliness may lead individuals to spend more time on the internet and increase the likelihood of experiencing internet-use disorders. Similarly, individuals with internet-use disorders may feel lonelier. In the present systematic review and meta-analysis, pre-registered in PROSPERO (CRD42023390483), we quantified associations between internet-use-disorder symptoms (e.g. internet gaming disorder and online gambling disorder) and loneliness. We searched PubMed, Web of Science, and an institutional database aggregator for references that compared degrees of loneliness in groups of individuals with and without symptoms of internet-use disorder. Means and standard deviations of loneliness, or alternatively, odds ratios, were transformed into Cohen's d for statistical pooling through a random-effects model. After screening 2,369 reports, we extracted data from 23 studies. The total number of individuals across the studies was 36,484. Participants were between 13 and 30 years of age (median 20). The pooled difference between those with and without internet-use-disorder symptoms yielded a standardized effect (Cohen's d) of 0.53 (95% CI 0.35-0.7). While heterogeneity was high, there was no indication of publication or small sample biases. Similar effect sizes were found when limiting to specific types of internet-use disorder symptoms. Moreover, meta-regressions did not show an effect of age, sex, or sample size. Individuals with symptoms of internet-use disorders scored 49.35 (43.84-54.85) points on the UCLA-Loneliness scale on average, compared to 43.78 (37.47-50.08) in individuals without symptoms of internet-use disorders (Standardized Mean Difference: 5.18, 95% CI = 2.05-8.34). Individuals with internet-use-disorder symptoms experience greater loneliness. The effect appears moderately sized.

Disruption and Improvisation: Experiences of Loneliness for People With Chronic Illness

Chronic illness can disrupt many aspects of life, including identity, social relationships, and anticipated life trajectories. Despite significant scholarship on chronic illness, we know less about the ways in which chronic illness impacts feelings of loneliness and how people with chronic illness deal with loneliness. Drawing on concepts of biographical disruption and liminality and data from walking and photo-elicitation interviews with 14 people, we aimed to explore how people with chronic illness experience loneliness in their everyday lives. Tracing how past and present illness experiences are implicated in the lived experience of loneliness and the strategies people use to manage loneliness, our findings illustrated that being caught in a liminal state where participants struggled to maintain and adapt to a new normality in life with chronic illness was a central thread woven throughout their experience of loneliness. Although participants drew on their personal agency and adopted strategies to account for, manage, and limit disruptions from chronic illness and loneliness, they found that their strategies were not completely effective or satisfactory. Chronic illness and loneliness continue to be largely considered as an individual's problem, limiting opportunities for people with chronic illness who experience loneliness to seek support and social connection. Our research highlighted that chronic illness and loneliness need to be acknowledged as both a personal and collective problem, with multi-level responses that involve individuals, communities, and society.

The Potential of a Robot Presence in Close Relationship to Influence Human Responses to Experimental Pain

Pain management is a critical challenge in healthcare, often exacerbated by loneliness and emotional distress. This study investigated the potential of a communication robot, Moffuly, to reduce pain perception and influence hormonal responses in a controlled experimental setting. Nineteen healthy participants underwent heat pain stimulation under two conditions: with and without robotic interaction. Pain levels were assessed using the Short-form McGill Pain Questionnaire and the Visual Analogue Scale, while mood and mental states were evaluated through established questionnaires including the Profile of Mood States, Hospital Anxiety and Depression Scale, and Self-Rating Depression Scale. Hormonal changes, including cortisol, growth hormone, oxytocin, estradiol, and dehydroepiandrosterone-sulfate, were measured from blood samples collected at key time points. The results demonstrated significant reductions in subjective pain and improvements in mood following robotic interaction. These effects were accompanied by favorable hormonal changes, including increased oxytocin and decreased cortisol and growth hormone levels. The findings suggest that robotic interaction may serve as an innovative approach to pain management by addressing both physiological and psychological factors. This study highlights the potential of robotics to complement traditional therapies in alleviating pain and enhancing emotional well-being. By mitigating emotional distress and loneliness, robotic interventions may enhance existing pain therapies and offer innovative solutions for resource-limited healthcare systems.

Examining the Dimensionality, Internal Consistency, and Invariance of the Depression, Anxiety, and Stress Scale-21 (DASS-21) Across Age, Race, Ethnicity, and Caretaking Status

This study investigates the performance of the Depression, Anxiety, and Stress Scale-21 (DASS-21) across diverse demographic groups during the COVID-19 pandemic. Utilizing a large, generalizable U.S. sample (N = 676), we applied multiple-group confirmatory factor analysis to examine the scale's internal consistency and measurement invariance in relation to age, race, ethnicity, and caretaking status. Our findings offer mixed evidence on the performance of the original three-factor structure of the DASS-21, which appears to function more consistently across groups defined by caretaking status and ethnicity, but less well across groups defined by age and racial identity. This research contributes substantially to the field by enhancing the understanding of DASS-21's applicability in diverse populations, particularly in the context of a global health crisis. It underscores the need for nuanced interpretation of DASS-21 scores considering significant demographic variability in its interpretation by participant racial identity and age, thereby guiding more accurate mental health assessments and interventions.

The experience of loneliness among people with psychosis: Qualitative meta-synthesis

BACKGROUND

Loneliness can be a significant challenge for people living with psychosis. We currently lack evidence about how to help with this. Understanding the origins, experience, and impact of loneliness in this group is helpful in developing strategies to reduce it. We therefore aimed to conduct a meta-synthesis of the qualitative literature exploring the nature of loneliness, and the factors contributing to the development and maintenance of loneliness, among people living with psychosis.

METHODS

We searched four electronic databases (MEDLINE, Embase, PsycINFO and Web of Science) for studies meeting pre-defined eligibility criteria. We adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines, and appraised the quality of each eligible study using the Critical Appraisal Skills Programme (CASP) checklist. We conducted thematic synthesis to combine the included qualitative findings to generate key overarching themes.

RESULTS

We included 41 articles and our analysis generated six meta-themes: (1) loneliness in the form of disconnection, (2) a rejecting and stigmatising external world, (3) loneliness and acute psychotic episodes and symptoms, (4) thwarted longing for connection, (5) paradoxes of loneliness and psychosis, and (6) well-being embedded in the social world. Our findings suggest a vicious cycle in which loneliness, psychosis and social withdrawal can be mutually reinforcing. Reciprocity of and continuity in relationships were valued by those with psychosis, while self-stigma and experiences of rejection appeared to exacerbate loneliness and impede recovery.

CONCLUSION

Our meta-synthesis offers insights into how people living with psychosis are affected by loneliness. Tailored interventions are needed, which should focus on supporting people in overcoming internal barriers to connection and low self-esteem, challenging stigma and self-stigma, and linking people to social support according to needs and preferences.

Psychedelic group-based integration: ethical assessment and initial recommendations

A number of organizations have developed or are developing psychedelic integration groups, held in person or online. In parallel, there have been calls to make enhanced integration available in the community after clinical trials. Here, we explore a potential reason why individuals may seek out these groups: namely, the feelings of disconnection and loneliness that may arise after the psychedelic experience (noting that there may be other reasons that individuals may seek out these groups). Integration groups can offer significant benefits to participants (e.g. a sense of community, shared coping strategies); however, there may also be a number of associated risks. In this essay, we aim to explore the benefits and risks of integration groups, and offer a preliminary set of guidelines to physicians, researchers and individuals to help assess and evaluate these groups.

Facilitators to alleviate loneliness and social isolation as identified by individuals with spinal cord injuries and disorders: A qualitative study

PURPOSE/OBJECTIVE

Individuals with spinal cord injuries and disorders (SCI/D) are at increased risk for experiencing loneliness and social isolation. The aim is to describe facilitators identified by individuals living with SCI/D to alleviate loneliness and perceived social isolation.

RESEARCH METHOD/DESIGN

Descriptive qualitative design using in-depth interviews with veterans with SCI/D (n = 23). Descriptive statistics was used to calculate demographic and injury characteristics. Audio-recorded and transcribed verbatim transcripts were coded and analyzed using Braun and Clarke's (2006) six thematic analysis phases.

RESULTS

Participants were male (70%), white (78%), and not currently married (35%), with an average age of 66 years (42-88). Participants had paraplegia (61%), with traumatic etiology (65%) and were injured 14 years (1-45) on average. Eight themes were identified by participants living with SCI/D that described facilitators to alleviate loneliness and perceived social isolation. (a) Engage in/pursue interests; (b) Interact with/spend time with others; (c) Embrace acceptance; (d) Take part in reciprocity; (e) Find a purpose/accomplish goals; (f) Get out of residence, get outside; (g) Connect with SCI/D community/SCI/D peers; and (h) Seek help from (mental) healthcare professionals.

CONCLUSIONS/IMPLICATIONS

Individuals with SCI/D identified facilitators to alleviate loneliness that encompasses changes in ways of thinking, actions to expand participation in life, and efforts focused on involving others. Findings can be used to guide healthcare delivery and develop interventions to target feelings of loneliness and social isolation in persons with SCI/D, which may be particularly impactful if they involve reciprocal interactions with peers with SCI/D. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The effect of parental regulatory focus on the loneliness stigma of college children

BACKGROUND

The present study aimed to examine the relationship between regulatory focus and loneliness stigma, as well as the intergenerational transmission of the two. Specifically, the study analyzed the effects of fathers' and mothers' regulatory focus on their own and their spouses' stigma of loneliness. In addition, a mediation model was constructed to explore how parents' regulatory focus influences their children's stigma of loneliness and the potential mediating mechanisms involved.

METHODS

Questionnaires were distributed to 470 college students and their parents, employing the Regulatory Focus Questionnaire (RFQ) and the Stigma of Loneliness Scale (SLS) to collect data.

RESULTS

The analysis of intergenerational transmission effects revealed that parents' regulatory focus and loneliness stigma significantly and positively predicted children's regulatory focus and loneliness stigma, respectively. The Actor-Partner Interdependence Model (APIM) elucidated that both fathers' and mothers' promotion focus exerted significant influence on both actor and partner's loneliness stigma. Furthermore, the mediation model analysis indicated that parents' loneliness stigma, along with children's regulatory focus operate as mediators in the influence of parental regulatory focus on loneliness stigma of their college-aged offspring.

CONCLUSIONS

From a familial context, this study, investigated the association between regulatory focus and loneliness stigma, along with the mediating roles within parent-child groups and couples. The findings enhanced our comprehension of the interrelation between regulatory focus and loneliness stigma, underpinned by empirical evidence.

Associations between constructs related to social relationships and mental health conditions and symptoms: an umbrella review

BACKGROUND

Loneliness and social isolation are increasingly recognised as prevalent among people with mental health problems, and as potential targets for interventions to improve quality of life and outcomes, as well as for preventive strategies. Understanding the relationship between quality and quantity of social relationships and a range of mental health conditions is a helpful step towards development of such interventions.

PURPOSE

Our aim was to give an overview of associations between constructs related to social relationships (including loneliness and social isolation) and diagnosed mental conditions and mental health symptoms, as reported in systematic reviews of observational studies.

METHODS

For this umbrella review (systematic review of systematic reviews) we searched five databases (PsycINFO, MEDLINE, EMBASE, CINAHL, Web of Science) and relevant online resources (PROSPERO, Campbell Collaboration, Joanna Briggs Institute Evidence Synthesis Journal). We included systematic reviews of studies of associations between constructs related to social relationships and mental health diagnoses or psychiatric symptom severity, in clinical or general population samples. We also included reviews of general population studies investigating the relationship between loneliness and risk of onset of mental health problems.

RESULTS

We identified 53 relevant systematic reviews, including them in a narrative synthesis. We found evidence regarding associations between (i) loneliness, social isolation, social support, social network size and composition, and individual-level social capital and (ii) diagnoses of mental health conditions and severity of various mental health symptoms. Depression (including post-natal) and psychosis were most often reported on, with few systematic reviews on eating disorders or post-traumatic stress disorder (PTSD), and only four related to anxiety. Social support was the most commonly included social construct. Our findings were limited by low quality of reviews and their inclusion of mainly cross-sectional evidence.

CONCLUSION

Good quality evidence is needed on a wider range of social constructs, on conditions other than depression, and on longitudinal relationships between social constructs and mental health symptoms and conditions.