research essays on loneliness

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• Published: 06 December 2020

Experiences of loneliness: a study protocol for a systematic review and thematic synthesis of qualitative literature

• Phoebe E. McKenna-Plumley   ORCID: orcid.org/0000-0001-5627-5730 1 ,
• Jenny M. Groarke 1 ,
• Rhiannon N. Turner 1 &
• Keming Yang 2  

Systematic Reviews volume  9 , Article number:  284 ( 2020 ) Cite this article

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Loneliness is a highly prevalent, harmful, and aversive experience which is fundamentally subjective: social isolation alone cannot account for loneliness, and people can experience loneliness even with ample social connections. A number of studies have qualitatively explored experiences of loneliness; however, the research lacks a comprehensive overview of these experiences. We present a protocol for a study that will, for the first time, systematically review and synthesise the qualitative literature on experiences of loneliness in people of all ages from the general, non-clinical population. The aim is to offer a fine-grained look at experiences of loneliness across the lifespan.

We will search multiple electronic databases from their inception onwards: PsycINFO, MEDLINE, Scopus, Child Development & Adolescent Studies, Sociological Abstracts, International Bibliography of the Social Sciences, CINAHL, and the Education Resource Information Center. Sources of grey literature will also be searched. We will include empirical studies published in English including any qualitative study design (e.g. interview, focus group). Studies should focus on individuals from non-clinical populations of any age who describe experiences of loneliness. All citations, abstracts, and full-text articles will be screened by one author with a second author ensuring consistency regarding inclusion. Potential conflicts will be resolved through discussion. Thematic synthesis will be used to synthesise this literature, and study quality will be assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. The planned review will be reported according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement.

The growing body of research on loneliness predictors, outcomes, and interventions must be grounded in an understanding of the lived experience of loneliness. This systematic review and thematic synthesis will clarify how loneliness is subjectively experienced across the lifespan in the general population. This will allow for a more holistic understanding of the lived experience of loneliness which can inform clinicians, researchers, and policymakers working in this important area.

Systematic review registration

PROSPERO CRD42020178105 .

Peer Review reports

Loneliness has become the focus of a wealth of research in recent years. This attention is well placed given that loneliness has been designated as a significant public health issue in the UK [ 1 ] and is associated with poor physical and mental health outcomes [ 2 , 3 , 4 , 5 ] and an increase in risk of death similar to that of smoking [ 6 ]. In light of this, it is concerning that recent research has found that loneliness is highly prevalent across age groups, with young people (under 25 years) and older adults (over 65 years) indicating the highest levels [ 7 , 8 ].

Whilst an ever-increasing body of research is situating loneliness at its centre, there is relatively little work which focuses on the lived experience of loneliness: how loneliness feels and what makes up experiences of loneliness. Phenomena that might appear to describe loneliness, such as social isolation, are distinct from the actual experience of it. Whilst loneliness is generally characterised as the distress one experiences when they perceive their social connections to be lacking in number or quality, social isolation is the objective limitation or absence of connections [ 9 ]. Social isolation does not necessarily beget loneliness, and indeed, Hawkley and Cacioppo [ 3 ] remark on how humans can perceive meaningful social relationships where none objectifiably exist, such as with God, or where reciprocity is not possible, such as with fictional characters. Whilst associations between aloneness and loneliness have been richly demonstrated [ 10 , 11 ], other research has found moderate and low correlations between social isolation and loneliness [ 12 , 13 ]. These findings underline the need to better understand what makes up the subjective experience of loneliness, given that it is clearly not sufficiently captured by the objective experience of being alone. Given the subjective nature of the phenomenon, qualitative methods are particularly suited to research into experiences of loneliness, as they can aim to capture the idiosyncrasies of these experiences.

A number of qualitative studies of loneliness experiences have been carried out. In perhaps the largest study of its type, Rokach [ 14 ] analysed written accounts of 526 adults’ loneliest experience, specifically asking about their thoughts, feelings, and coping strategies. This generated a model with four major elements (self-alienation, interpersonal isolation, distressed reactions, and agony) and twenty-three components such as emptiness, numbness, and missing a specific person or relationship. Although this study offered impressive scale, the vast majority of participants were between 19 and 45 years old, and as a result, the model may underestimate factors experienced across the lifespan. The findings might be usefully integrated with more recent research which qualitatively explores loneliness in other age groups (e.g. [ 15 ]). Harmonising this research by looking closely at how people describe their experiences of loneliness and working from the bottom-up to create a fine-grained view of what makes up these experiences will provide a more holistic understanding of loneliness and how it might best be defined and ameliorated.

There are a number of available definitions of loneliness offered by researchers. The widely accepted description from Perlman and Peplau [ 16 ], for example, states that loneliness is an unpleasant and distressing subjective phenomenon arising when one’s desired level of social relations differs from their actual level. However, research lacks an overarching subjective perspective, by which we mean a description of loneliness which is grounded in accounts of people’s lived experiences. This is a significant gap in the field given that loneliness is, by its nature, a subjective experience. Unlike objective phenomena like blood pressure or age, loneliness can only be definitively measured by asking a person whether they feel lonely. Weiss [ 17 ] argued that whilst available definitions of loneliness may be helpful, they do not sufficiently reflect the real phenomenon of loneliness because they define it in terms of its potential causes rather than the actual experience of being lonely. As such, studies which begin from definitions of loneliness like these may obscure the ways in which it is actually experienced and fail to capture the components and idiosyncrasies of these experiences.

A recent systematic review report [ 18 ] has explored the conceptualisations of loneliness employed in qualitative research, finding that loneliness tended to be defined as social, emotional, or existential types. However, the review covered only studies of adults (16 years and up), including heterogenous clinical populations (e.g. people receiving cancer treatment, people living with specific mental health conditions, and people on long-term sick leave), and placed central importance on the concepts, models, theories, and frameworks of loneliness utilised in research. Studies which did not employ an identified concept, model, framework, or theory of loneliness were excluded. Moreover, rather than synthesising how people describe their loneliness, the authors aimed to assess how research conceptualises loneliness across the adult life course. This leaves a gap with respect to how research participants specifically describe their lived experiences of loneliness, rather than how researchers might conceptualise it. Achterberg and colleagues [ 19 ] recently conducted a meta-synthesis of qualitative studies on experiences of loneliness in young people with depression. As the findings are specific to experiences in this population, they may not reflect those of wider age groups or individuals who do not have depression. Kitzmüller and colleagues [ 20 ] used meta-ethnography to synthesise studies regarding experiences and ways of dealing with loneliness in older adults (60 years and older). However, they synthesised only articles from health care disciplines published in scientific journals from 2001 to 2016 and included studies on clinical populations, such as older women with multiple chronic conditions. Moreover, there has been an increase in research output regarding loneliness in recent years, and relevant studies may have been published since this review was conducted (e.g. [ 15 ]). To the authors’ knowledge, the systematic review report on conceptual frameworks used in loneliness research [ 18 ], the meta-synthesis of loneliness in young people with depression [ 19 ], and the meta-ethnography of older adults’ loneliness [ 20 ] are the only such systematic reviews of qualitative literature regarding experiences of loneliness to date. The current systematic review will instead take a bottom-up approach which focuses on non-clinical populations of all ages to synthesise findings on participants’ experiences of loneliness, rather than the conceptualisations that might be imposed by study authors. This will fill a gap in the literature by synthesising the qualitative evidence focusing on experiences of loneliness across the lifespan. This inductive synthesis of the available subjective descriptions of loneliness will offer a nuanced view of loneliness experiences. It is imperative for research and practice that we deepen the current understanding of these experiences to inform how we approach describing, researching, and attempting to ameliorate loneliness.

The proposed research aims to offer a holistic view of the experience of loneliness across the lifespan through a systematic review and thematic synthesis of the qualitative literature focusing on these experiences. To address this aim, there is one central research question: How do people describe their experiences of loneliness?

This research question concerns aspects of loneliness which participants discuss when describing their lived experiences. Whilst we expect that this would concern emotional, social, and cognitive components of the experience, we understand that these findings may also come to reflect perceived causes or effects of loneliness.

This review will also consider the age groups that have been studied and how experiences of loneliness might vary across the different age groups examined in this literature. Loneliness research is often weighted towards investigations of older adults, despite the fact that the prevalence of loneliness is high across the lifespan; recent UK research found a prevalence of 40% in 16- to 24-year-olds and 27% in people over 75 [ 7 ]. This review will also shed light on the age groups that have been included in qualitative research on loneliness experiences. In doing so, this research may identify age groups which have been understudied and may be underrepresented in this field of research, potentially pointing to life stages where experiences of loneliness might be usefully explored in more detail in the future.

Furthermore, given the relatively small number of qualitative studies into the experience of loneliness compared with quantitative research in this area, this review will also consider the reasons that study authors may offer for the relative shortage of qualitative work. This is an important point given that the review will inherently be constrained by the number of studies that exist and the focus that has primarily been given to quantitative loneliness research thus far.

Protocol registration and reporting

The review protocol has been registered within the International Prospective Register of Systematic Reviews (PROSPERO) database from the University of York (registration number: CRD42020178105). This review protocol is being reported in accordance with the reporting guidance provided in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement [ 21 ] (see checklist in Additional file 1 ). The proposed systematic review will be reported in accordance with the reporting guidance provided in the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement [ 22 ]. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [ 23 ] will inform the process of completing and reporting this planned review.

Eligibility criteria

Due to its suitability for qualitative evidence synthesis, the SPIDER tool [ 24 ] was used to assist in defining the research question and eligibility criteria in line with the following criteria: Sample, Phenomenon of Interest, Design, Evaluation, Research type (see Table 1 for details of these criteria). The exclusion criteria are as follows:

Studies not meeting the inclusion criteria described in Table 1

Studies not published in English

Studies with no qualitative component

Studies of clinical populations

Studies which report solely on objective phenomena such as social isolation rather than the subjectively perceived experience of loneliness

Studies in which the primary focus or one of the primary focuses is not experiences of loneliness

Papers will be deemed to focus sufficiently on experiences of loneliness if studying these experiences is a key aspect of the work rather than simply a part of the output. Accordingly, studies will only be included if authors state a relevant aim, objective, or research question related to investigating experiences of loneliness (i.e. to study experiences of loneliness) or if loneliness experiences are clearly explored and described (e.g. relevant questions are present in an appended interview guide). At the title and abstract screening stage, at least one relevant sentence or information that indicates likely relevance must be present for inclusion. The decision to exclude articles which do not primarily or equally focus on these experiences was made in order to gather meaningful data about loneliness experiences specifically and to capture experiences identified as loneliness by participants as much as possible, rather than related phenomena which may be grouped and labelled retrospectively as loneliness by researchers.

Information sources and search strategy

The primary source of literature will be a structured search of multiple electronic databases (from inception onwards): PsycINFO, MEDLINE, Scopus, Child Development & Adolescent Studies, Sociological Abstracts, International Bibliography of the Social Sciences (IBSS), CINAHL, and the Education Resource Information Center (ERIC). The secondary source of potentially relevant material will be a search of the grey or difficult-to-locate literature using Google Scholar. In line with the guidance from Haddaway and colleagues [ 25 ] on using Google Scholar for systematic review, a title-only search using the same search terms will be conducted and the first 1000 results will be screened for eligibility. These searches will be supplemented with hand-searching in reference lists, such that the titles of all articles cited within eligible studies will be checked. When eligibility is unclear from the title, abstracts and full-texts will be checked until eligibility or ineligibility can be ascertained. This process will be repeated with any articles that are found to be eligible at this stage until no new eligible articles are found. Systematic reviews on similar topics will also be searched for potentially eligible studies. Grey literature will be located through searches of Google Scholar, opengrey.eu, ProQuest Dissertations and Theses, and websites of specific loneliness organisations such as the Campaign to End Loneliness, managed in collaboration with an information specialist. Efforts will be made to contact authors of completed, ongoing, and in-press studies for information regarding additional studies or relevant material.

The search strategy for our primary database (MEDLINE) was developed in collaboration with an information specialist. In collaboration with a specialist, the strategy will be translated for all of the databases. The search strategy has been peer reviewed using the Peer Review of Electronic Search Strategies (PRESS) checklist [ 26 ]. Strategies will utilise keywords for loneliness and qualitative studies. A draft search strategy for MEDLINE is provided in Additional file 2 . Qualitative search terms were supplemented with relevant and useful subject headings and free-text terms from the Pearl Harvesting Search Framework synonym ring for qualitative research [ 27 ]. The inclusion of search terms related to social isolation specifically and related terms (e.g. “social engagement”) was considered and tested extensively through scoping searches and discussion with an information specialist. Adding these terms (and others such as “Patient Isolation” and “Quarantine”) did not appear to add unique papers that would be included above and beyond subject heading and free-text searching for “Loneliness”. Given the aim to include studies focused on experiences of loneliness specifically, this search strategy was deemed most appropriate. A similar strategy has been employed in other recent systematic review work focusing on loneliness (e.g. [ 28 , 29 ]). Moreover, test searches employing the search strategy retrieved all of seven informally identified likely eligible articles indexed in Scopus, indicating good sensitivity of the strategy. A free-text search to capture “perceived social isolation” was included as this specific term is used by some authors as a direct synonym for loneliness. The completed PRESS checklist is provided in Additional file 3 .

Data collection and analysis

Study selection.

Firstly, the main review author (PMP) will perform the database search and hand-searching and will screen all titles to remove studies which are clearly not relevant. PMP will also undertake abstract screening to exclude any which are found to be irrelevant or inapplicable to the inclusion criteria. A second author (JG) will independently screen 50% of the titles and abstracts. Finally, full-text versions of the remaining articles will be read by PMP to assess whether they are suitable for inclusion in the final review. JG will independently review 50% of these full texts. In cases of disagreement, the two reviewers will discuss the study to reach a decision about inclusion or exclusion. In case agreement cannot be reached after discussion between the two reviewers, a third reviewer will be invited to reconcile their disagreement and make a final decision. The reason for the exclusion at the full-text stage will be recorded. After this screening process, the remaining articles will be included in the review following data extraction, quality appraisal, and analysis. The PRISMA statement will be followed to create a flowchart of the number of studies included and excluded at each stage of this process.

Data management

The articles to be screened will be managed in EndNoteX9, with subsequent EndNote databases used to manage each stage of the screening process.

Data extraction

Data will be extracted from the studies by PMP using a purpose-designed and piloted Microsoft Excel form. Information on author, publication year, geographic location of study, methodological approach, method, population, participant demographics, and main findings will be extracted to understand the basis of each study. JG will check this extracted data for accuracy.

For the thematic synthesis, in line with Thomas and Harden [ 30 ], all text labelled as “results” or “findings” will be extracted and entered into the NVivo software for analysis. This will be done because many factors, including varied reporting styles and misrepresentation of data as findings, can make it difficult to identify the findings in qualitative research [ 31 ]; accordingly, a wide-ranging approach will be used to capture as much relevant data as possible from each included article. The aim is to extract all data in which experiences of loneliness are described.

Quality appraisal

Quality of the included articles will be assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research [ 32 ]. This quality will be considered during the development of the data synthesis. Different authors hold different viewpoints about inclusion versus exclusion of low-quality studies. However, given that they may still add important, authentic accounts of phenomena that have simply been reported inadequately [ 33 ], it is common to include lower-quality studies and consider quality during the synthesis process rather than excluding on the basis of it. Accordingly, this approach will be used in the present research.

Data synthesis

There are various accepted approaches to reviewing and synthesising qualitative research, including meta-ethnography [ 34 ], meta-synthesis [ 35 ], and narrative synthesis [ 36 ]. The current systematic review will utilise thematic synthesis as a methodology to create an overarching understanding of the experiences of loneliness described across studies. In thematic synthesis, descriptive themes which remain close to the primary studies are developed. Next, a new stage of analytical theme development is undertaken wherein the reviewer “goes beyond” the interpretations of the primary studies and develops higher-order constructs or explanations based on these descriptive themes [ 30 ]. The process of thematic synthesis for reviewing is similar to that of grounded theory for primary data, in that a translation and interpretative account of the phenomena of interest is produced. Thematic synthesis has been used to synthesise research on the experience of fatigue in neurological patients with multiple sclerosis [ 37 ], children’s experiences of living with juvenile idiopathic arthritis [ 38 ], and parents’ experiences of parenting a child with chronic illness [ 39 ]. This use of thematic synthesis to consider subjective experiences (rather than, for example, attitudes or motivations) melds well with the present research, which also sets its focus on a subjective experience.

As well as its successful application in similar systematic reviews, thematic synthesis was selected based on its appropriateness to the research question, time frame, resources, expertise, purpose, and potential type of data in line with the RETREAT framework for selecting an approach to qualitative evidence synthesis [ 40 ]. The RETREAT framework considers thematic synthesis to be appropriate for relatively rapid approaches which can be sustained by researchers with primary qualitative experience, unlike approaches such as meta-ethnography in which a researcher with specific familiarity with the method is needed. This is appropriate to the project time frame and background of this research team. The Joanna Briggs Institute Reviewer’s Manual [ 41 ] also notes that thematic synthesis is useful when considering shared elements across studies which are otherwise heterogenous, which is likely to be the case in this review given that the common factor (experiences of loneliness) may be present across studies with otherwise diverse populations and methodologies.

Guidance from Thomas and Harden [ 30 ] will be followed to synthesise the data. Firstly, the extracted text will be inductively coded line-by-line according to content and meaning. This inductive creation of codes should allow the content and meaning of each sentence to be captured. Multiple codes may be applied to the same sentence, and codes may be “free” or structured in a tree formation at this stage. Before moving forward, all text referred to by each code will be rechecked to ensure consistency in what is considered a single code or whether more levels of coding are required.

After this stage, similarities and differences between the codes will be examined, and they will begin to be organised into a hierarchy of groups of codes. New codes will be applied to these groups to describe their overall meaning. This will create a tree structure of descriptive themes which should not deviate largely from the original study findings; rather, findings will have been integrated into an organised whole. At this stage, the synthesis should remain close to the findings of the included studies.

At the final stage of analysis, higher-order analytical themes may be inferred from the descriptive themes which will offer a theoretical structure for experiences of loneliness. This inferential process will be carried out through collaboration between the research team (primarily PMP and JG).

Sensitivity analysis

After the synthesis is complete, a sensitivity analysis will be undertaken in which any low-quality studies (as identified through the JBI checklist) are excluded from the analysis to assess whether the synthesis is altered when these studies are removed, in terms of any themes being lost entirely or becoming less rich or thick [ 42 ]. Sensitivity analysis will also be used to assess whether any age group is entirely responsible for a given theme. In this way, the robustness of the synthesis can be appraised and the individual findings can remain grounded in their context whilst also extending into a broader understanding of the experiences of loneliness.

Risk of bias in individual studies

Risk of bias in individual studies will be taken into account through utilisation of the JBI checklist, which includes ten questions to assess whether a study is adequately conceptualised and reported [ 32 ]. PMP will use the checklist to assess the quality of each study. Whilst all eligible studies will be included in the synthesis (as described in the “Quality appraisal” section), any lower-quality studies will be excluded during post-synthesis sensitivity analysis in order to assess whether their inclusion has affected the synthesis in any way as suggested by Carroll and Booth [ 43 ].

Confidence in cumulative evidence

The Grading of Recommendations, Assessment, Development and Evaluation – Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) approach [ 44 , 45 ] will be used to assess how much confidence can be placed in the findings of this qualitative evidence synthesis. This will allow a transparent, systematic appraisal of confidence in the findings for researchers, clinicians, and other decision-makers who may utilise the evidence from the planned systematic review. GRADE-CERQual involves assessment in four domains: (1) methodological limitations, (2) coherence, (3) adequacy of data, and (4) relevance. There is also an overall rating of confidence: high, moderate, low, or very low. These findings will be displayed in a Summary of Qualitative Findings table including a summary of each finding, confidence in that finding, and an explanation for the rating. Assessments for each finding will be made through discussion between PMP and JG.

The proposed systematic review will contribute to our knowledge of loneliness by clarifying how it is subjectively experienced across the lifespan. Synthesising the qualitative literature focusing on experiences of loneliness in the general population will offer a fine-grained, subjectively derived understanding of the components of this phenomenon which closely reflects the original descriptions provided by those who have experienced it. By including non-clinical populations of all ages, this research will provide an essential view of loneliness experiences across different life stages. This can be used to inform future research into correlates, consequences, and interventions for loneliness. The use of thematic synthesis will enable us to remain close to the data, offering an account which might also be useful for policy and practice in this area.

There are a number of limitations to the planned research. Primarily, this review will be unable to capture aspects of loneliness experiences which have not been described in the qualitative literature, for example, due to the sensitivity of the topic, given that loneliness can be stigmatising, or aspects that are specific to a given unstudied population. Moreover, by focusing on lifespan non-clinical research, we aim to offer a general synthesis which can in future be informed by insights from clinical groups, rather than subsuming and potentially obscuring the aspects of loneliness which might be unique to them. Whilst primary empirical studies are not themselves extensive sources, with books in particular often offering rich descriptions of loneliness (see, e.g. [ 11 , 46 ]), this research will focus on primary empirical studies of subjective descriptions to offer a manageable level of scope and rigour. As with any systematic review, some studies may also be missing information which would inform the synthesis. Quality appraisal and sensitivity analysis will aim to capture and potentially control for this issue, but it will ultimately be difficult to ascertain how missing information might affect the synthesis.

By providing a thorough overview of how loneliness is experienced, we expect that the findings from the planned review will be informative and useful for researchers, policymakers, and clinicians who work with and for people experiencing loneliness, as well as for these individuals themselves, to better understand this important, prevalent, and often misunderstood phenomenon. Mansfield et al. [ 18 ] have offered an illuminating systematic review covering the conceptual frameworks and models of loneliness included in the existing evidence base (i.e. social, emotional, and existential loneliness). This review will build upon this work by including research with children and adolescents and taking a bottom-up approach similar to grounded theory where the synthesis will remain close to the participants’ subjective descriptions of loneliness experiences within the included studies, rather than reflecting pre-existing themes in the evidence base. As such, this systematic review will offer specific insights into lifespan experiences of loneliness. This synthesis of lived experiences will shed light on the nuances of loneliness which existing definitions and typologies might overlook. It will offer an experience-focused overview of loneliness for people studying and developing measures of this phenomenon. In focusing on qualitative work, the planned review may also identify processes relevant to loneliness which are not expressed by statistical models. In this way, it may also provide a starting point for more nuanced qualitative work with specific populations and circumstances to ascertain components which may be characteristic of certain experiences.

Availability of data and materials

Not applicable.

Abbreviations

Enhancing Transparency in Reporting the Synthesis of Qualitative Research

Education Resource Information Center

Grading of Recommendations, Assessment, Development and Evaluation – Confidence in the Evidence from Reviews of Qualitative Research

International Bibliography of the Social Sciences

Joanna Briggs Institute

Jenny Groarke

Keming Yang

Phoebe McKenna-Plumley

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Preferred Reporting Items for Systematic Reviews and Meta-Analyses – Protocol

International Prospective Register of Systematic Reviews

Review question – Epistemology – Time/Timescale – Resources – Expertise – Audience and purpose – Type of data

Rhiannon Turner

Sample, Phenomenon of Interest, Design, Evaluation, Research type

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Acknowledgements

The authors would like to acknowledge and thank Ms. Norma Menabney and Ms. Carol Dunlop, subject librarians at the McClay Library, Queen’s University Belfast, for their advice and assistance with designing a search strategy for this review. The authors would also like to acknowledge and thank Dr. Ciara Keenan, a research fellow at Queen’s University Belfast and associate director of Cochrane Ireland, for her completion of the PRESS checklist and guidance regarding the search strategy and systematic review methodology.

PMP wishes to acknowledge the funding received from the Northern Ireland and North East Doctoral Training Partnership, funded by the Economic and Social Research Council with support from the Department for the Economy Northern Ireland. The funder did not play a role in the development of this protocol.

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McKenna-Plumley, P.E., Groarke, J.M., Turner, R.N. et al. Experiences of loneliness: a study protocol for a systematic review and thematic synthesis of qualitative literature. Syst Rev 9 , 284 (2020). https://doi.org/10.1186/s13643-020-01544-x

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Loneliness is not a new phenomenon but in recent years, there has been a growing interest in understanding how feelings of ‘perceived social isolation’ can influence our health and wellbeing. Objective indicators of social isolation—such as living alone and number of social connections—have well-demonstrated links with poorer health outcomes [ 1 ]. However, the latest evidence indicates that feeling lonely is also associated with a multitude of poorer health outcomes, ranging from an increased risk of depression and dementia [ 2 ], increased risk of heart disease and stroke [ 3 ] and higher levels of inflammatory responses [ 4 ] to name a few. Indeed, those who are socially isolated (odds ratio = 1.29; 95% CI 1.06, 1.56), living alone (odds ratio = 1.32; 95% CI 1.14, 1.53), or those who are lonely (odds ratio = 1.26, 95% CI 1.04, 1.53) are at increased risk of earlier mortality [ 5 ].

Current “hotspots” in loneliness research include studies examining how perceived social isolation influences mental health symptoms [ 6 ] and disorders [ 7 , 8 , 9 ], older [ 10 ] and younger adults [ 11 ], workplace productivity [ 12 , 13 ], and social media use [ 14 ]. The contributions to this special issue illustrate some of the progress, possibilities, and problems in contemporary research on loneliness, including two systematic reviews [ 15 , 16 ], one conceptual review [ 17 ], two pilot studies evaluating a novel approach to reduce loneliness in young people with psychosis [ 18 , 19 ], and two studies exploring personalized approaches to reduce loneliness [ 20 , 21 ].

First, Ma et al. (2019) provide a review of the effectiveness of interventions targeting subjective and objective social isolation in people with different mental health problems [ 15 ]. The authors examined: (1) interventions that alter maladaptive cognitions about others (e.g., cognitive-behavioural therapy); (2) social skills training and psychoeducation programmes (e.g., family psychoeducation therapy); (3) supported socialisation (e.g., peer support groups); and (4) community approaches (e.g., social prescribing). When considering only those studies specifically targeting interventions for loneliness, Ma et al. [ 15 ] found that the most promising results emerged for cognition modification interventions.

The study by Mihalopoulos et al. [ 16 ] highlights the importance of understanding the economic burden of loneliness and/or social isolation and is one of the first to evaluate the cost-effectiveness of interventions targeting loneliness and/or social isolation. The authors reported that all but one of the published cost-of-illness studies indicated greater healthcare costs for individuals experiencing loneliness and/or social isolation. However, Mihalopoulos et al. [ 16 ] noted that these costs “are likely to be underestimated” due to the limited evidence available, particularly for younger populations. Of the interventions included in this systematic review, the authors highlight “promising” cost-effective interventions that involved increasing social and peer-contact.

In the conceptual review by Lim, Eres, and Vasan [ 17 ], the authors outline emerging and established correlates and risk factors associated with loneliness. Importantly, the review identified two newer variables of interest in loneliness research, namely workplaces and the use of digital communication. Lim and colleagues also highlight the complexity of loneliness and introduce a new conceptual model that describes how multiple risk factors/correlates can affect loneliness severity. The authors stress that there is no ‘one-size-fits-all’ solution for loneliness; rather, how loneliness is resolved is dependent on an individual’s circumstances and available resources.

The next two studies illustrate how a theory-driven approach (i.e., strengths-based positive psychology) was used to develop an intervention targeting loneliness. In a brief report, Lim et al. [ 18 ] evaluate the feasibility and acceptability of a positive psychology intervention group program called Positive Connect for young people experiencing psychosis. This 6-week positive psychology group intervention was designed to help young people identify their strengths and practice interpersonal skills that could be used to build close relationships with others. Preliminary evidence presented suggests that the program is both feasible and acceptable for this patient population. Encouragingly, exploratory analyses also indicate a positive benefit for reducing loneliness over time.

In the second related study, the authors describe the development of the same positive psychology program being translated and delivered via a digital smartphone app called + Connect [ 19 ]. The authors used focus groups to steer the design, functionality, and language of the 6-week program, to facilitate consumer engagement. Using an innovative blend of content, concepts were conveyed via text and videos (featuring young people with lived experience, academics, and actors). The feasibility, acceptability, and usability of + Connect is reported for a pilot sample ( N  = 12) of young people with psychosis, along with tentative evidence of a benefit in reducing loneliness.

The next study by Tymoszuk et al. [ 20 ] looked at the impact of arts engagement on loneliness, specifically, whether the frequency of receptive arts engagement was associated with lower odds of loneliness in older adults. The authors used existing data drawn from the English Longitudinal Study of Ageing (ELSA), analyzing participants (over 50 years old) with complete data on engagement with arts, covariate variables, and loneliness from the second wave ( n  = 6222) for cross-sectional analyses, and loneliness data from the seventh wave ( n  = 3127) for longitudinal analyses. In cross-sectional findings, frequent engagement with arts activities was associated with lowers odds of loneliness. However, longitudinal findings were less supportive, including no evidence that cinema engagement reduced loneliness.

Finally, consistent with the need to develop individualized solutions, Wang et al. [ 21 ] examined variables associated with loneliness for individuals (18–75 years old) leaving a Crisis Resolution Team (CRT). A total of 399 participants, with most reporting depression/anxiety disorders (35.0%), followed by schizophrenia/psychosis (27.0%), bipolar affective/manic (16.3%), and other disorders (8.4%) were included in the analyses. Results showed that loneliness was more severe for individuals who have more mental health contact over the years (2–10 years), compared to those who have less than 3 months, and those who have less than 1 year of mental health service contact. Higher loneliness was also associated with more severe affective, positive or negative symptoms. Those who had depression, anxiety, personality disorders or other disorders compared with those who had psychotic disorders were also lonelier. In those with a mental disorder, lower loneliness was also associated with greater social network size and increased neighbourhood social capital [ 21 ].

Many of the studies in this special issue, draw attention to the importance of the need for rigorous loneliness research so that we can extend our knowledge on how loneliness impacts on health. Accordingly, it is crucial that we measure loneliness as a key variable of interest alongside specific health-related outcomes in future research. In doing so, we are also more likely to measure loneliness in a comprehensive way using psychometrically validated assessment tools, avoiding dichotomous measurement of loneliness to draw accurate comparisons across different samples. Given the significant public health implications, the current studies also call attention to the need for a routine and consistent approach to assessing and documenting loneliness as psychosocial “vital signs” of care [ 7 ].

Many of the reviewed studies also highlight the need to conduct longitudinal research to clarify the relationships between loneliness and poorer health outcomes. Pertinent questions such as ‘are people with pre-existing health problems more predisposed to feeling lonely’, or ‘are people who are lonely more predisposed to developing problematic health conditions?’ have significant, real-world implications for the development of effective treatments.

In addition, it is also clear that greater attention is needed in the development and evaluation of solutions/interventions for loneliness. Designing consumer relevant programs can improve uptake and adherence to programs and Lim et al.’s study shows an example of how consumers are increasingly engaged within research to help tailor evidence-based material to be more engaging to relevant groups [ 19 ]. However, there is currently mixed evidence of what is helpful and unhelpful for loneliness in terms of solutions. Hence, solely relying on consumers’ ideas concerning what they can do to address their own loneliness may be helpful for engagement but may not be necessarily effective. What is more crucial is the rigorous evaluation of theory-driven evidence-based interventions that are intended to reduce loneliness, and researchers need to move swiftly from pilot evaluations to high quality, adequately powered randomised controlled trials (RCTs). Furthermore, economic evaluations of interventions should be more frequently included in RCTs, to further augment the evidence-base. This involves including both resource use, cost and utility information, and ensuring that the economic evaluation examines both the costs and benefits in healthcare.

Clearly, there are many unanswered questions. For example, if loneliness is a common experience, when does loneliness make a significant negative impact on health outcomes? When does loneliness as a transient experience become a chronic issue? Much work is required to understand the negative impact of loneliness on ourselves, our community and the society we live in and we look forward to learning more about loneliness within a dynamic social world.

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

Roles Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Division of Psychiatry, University College London, London, United Kingdom

Roles Formal analysis, Investigation, Writing – original draft, Writing – review & editing

Affiliation The Loneliness and Social Isolation in Mental Health Research Network Co-Production Group, Division of Psychiatry, University College London, London, United Kingdom

Roles Formal analysis, Methodology, Writing – original draft, Writing – review & editing

Affiliation NIHR Mental Health Policy Research Unit COVID-19 Co-Production Group, Division of Psychiatry, University College London, London, United Kingdom

Roles Formal analysis, Investigation, Writing – review & editing

Roles Formal analysis, Writing – original draft

Roles Conceptualization, Investigation, Methodology, Writing – review & editing

Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Supervision, Writing – review & editing

Roles Conceptualization, Formal analysis, Funding acquisition, Writing – review & editing

Affiliations Centre for Performance Science, Royal College of Music, London, United Kingdom, Faculty of Medicine, Imperial College London, London, United Kingdom

Roles Formal analysis, Funding acquisition, Writing – review & editing

Affiliation Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, London, United Kingdom

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Supervision, Writing – review & editing

Affiliation Great Ormond Street Institute of Child Health, University College London, London, United Kingdom

Roles Conceptualization, Formal analysis, Funding acquisition, Methodology, Supervision, Writing – review & editing

•  [ ... ],

Roles Conceptualization, Formal analysis, Funding acquisition, Methodology, Writing – original draft, Writing – review & editing

Affiliations Division of Psychiatry, University College London, London, United Kingdom, Camden and Islington NHS Foundation Trust, London, United Kingdom

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• Mary Birken, 
• Beverley Chipp, 
• Prisha Shah, 
• Rachel Rowan Olive, 
• Patrick Nyikavaranda, 
• Jackie Hardy, 
• Anjie Chhapia, 
• Nick Barber, 
• Stephen Lee, 

• Published: March 7, 2023
• https://doi.org/10.1371/journal.pone.0280946
• Reader Comments

Loneliness is associated with many mental health conditions, as both a potential causal and an exacerbating factor. Richer evidence about how people with mental health problems experience loneliness, and about what makes it more or less severe, is needed to underpin research on strategies to help address loneliness.

Our aim was to explore experiences of loneliness, as well as what helps address it, among a diverse sample of adults living with mental health problems in the UK. We recruited purposively via online networks and community organisations, with most interviews conducted during the COVID-19 pandemic. Qualitative semi-structured interviews were conducted with 59 consenting participants face-to-face, by video call or telephone. Researchers with relevant lived experience were involved at all stages, including design, data collection, analysis and writing up of results.

Analysis led to identification of four overarching themes: 1. What the word “lonely” meant to participants, 2. Connections between loneliness and mental health, 3. Contributory factors to continuing loneliness, 4. Ways of reducing loneliness. Central aspects of loneliness were lack of meaningful connections with others and lack of a sense of belonging to valued groups and communities. Some drivers of loneliness, such as losses and transitions, were universal, but specific links were also made between living with mental health problems and being lonely. These included direct effects of mental health symptoms, the need to withdraw to cope with mental health problems, and impacts of stigma and poverty.

Conclusions

The multiplicity of contributors to loneliness that we identified, and of potential strategies for reducing it, suggest that a variety of approaches are relevant to reducing loneliness among people with mental health problems, including peer support and supported self-help, psychological and social interventions, and strategies to facilitate change at community and societal levels. The views and experiences of adults living with mental health problems are a rich source for understanding why loneliness is frequent in this context and what may address it. Co-produced approaches to developing and testing approaches to loneliness interventions can draw on this experiential knowledge.

Citation: Birken M, Chipp B, Shah P, Olive RR, Nyikavaranda P, Hardy J, et al. (2023) Exploring the experiences of loneliness in adults with mental health problems: A participatory qualitative interview study. PLoS ONE 18(3): e0280946. https://doi.org/10.1371/journal.pone.0280946

Editor: Giuseppe Carrà, Universita degli Studi di Milano-Bicocca, ITALY

Received: March 8, 2022; Accepted: January 11, 2023; Published: March 7, 2023

Copyright: © 2023 Birken et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Full transcriptions of the interviews analysed in this study cannot be shared publicly to protect the privacy and anonymity of participants. If you wish to obtain access to this data, please contact the UCL ethics committee on [email protected] and/or the corresponding author.

Funding: This paper presents independent research funded by the UK Research and Innovation, through the Loneliness and Social Isolation in Mental Health Research Network (grant no. ES/S004440/1, co-authors MB, BC, PS, JH, AC, NB, SL, EP, BLE, RP, DM, RS, AP, SJ). The study was further supported through funding from the National Institute for Health Research (NIHR) Policy Research Programme, conducted by the NIHR Policy Research Unit (PRU) (grant no. PR-PRU-0916-22003, co-authors RRO, PN, BLE, SJ) in Mental Health. The views expressed are those of the authors and not necessarily those of the UKRI or NIHR, the Department of Health and Social Care or its arm’s length bodies, or other government departments. Neither the funding bodies nor the sponsors played any role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Inter-relationships between loneliness and mental health problems are the focus of a growing body of literature [ 1 ]. Loneliness is defined as a subjective experience where individuals feel there is a discrepancy between social relationships that they desire to have and those they actually have [ 2 ]. Loneliness is more prevalent among people with mental health problems than the general population [ 1 , 3 , 4 ].

Important associations are found between loneliness and a range of health indicators. It is a risk factor for multiple poor physical health outcomes, including early mortality, impaired cognition, hypertension, stroke, and cardiovascular disease [ 5 – 8 ]. Health service use is greater among lonely people, especially older people [ 9 , 10 ]. Regarding mental health, loneliness appears to put people at risk of onset of depression [ 11 , 12 ], whilst loneliness (and a closely related construct, lack of subjective social support) is associated longitudinally with recovering less well from mental health problems [ 13 , 14 ].

Whilst the evidence linking loneliness to mental ill health, as well as its inherently distressing nature, make loneliness a potentially promising focus for developing strategies to improve quality of life and outcomes among people living with mental health problems [ 15 ], few evidence-based and implementation-ready interventions are available [ 16 ]. Strategies to reduce loneliness are more likely to be successful if rooted in an understanding of what people with mental health problems mean when they say they are lonely, how this relates to experiences of mental distress, and what they find improves or exacerbates loneliness. Much of the empirical research on loneliness and mental health has deployed measures that treat loneliness as a straightforward uni-dimensional phenomenon. This is despite philosophical, historical and experiential writing suggesting that the term captures a complex cluster of emotions and experiences [ 17 , 18 ]. Currently used measures are also not tailored to investigating loneliness in the context of mental ill-health, nor have they been developed in collaboration with people with relevant lived experience.

Qualitative research on lived experiences of loneliness among people with mental health problems has important potential to yield a deeper account of the nature of such experiences and what improves or exacerbates loneliness. Such an understanding should underpin further research, including development of interventions, measures and hypotheses for quantitative investigations. The few published investigations are small-scale, and suggest a complex, intertwined relationship. A phenomenological study of people diagnosed with “borderline personality disorder” [ 19 ] found that participants perceived loneliness as rooted in traumatic early experiences and strongly associated with negative feelings about self and others. Participants also described feeling disconnected from those around them and on the outside of social activities at which they were present. Lindgren and colleagues [ 20 ] interviewed five individuals with mental health problems, who described multifaceted and shifting experiences of loneliness that varied with life situation but were also persistent. A meta-synthesis of studies on the experience of loneliness among young people with depression identified a range of factors, including depressive symptoms, non-disclosure of depression, and fear of stigma, which perpetuated cycles of loneliness and depression [ 21 ]. However, the qualitative literature on loneliness experiences among people living with mental health problems overall remains very limited in scope and size.

Our aim in the current study is therefore to develop an understanding of the lived experiences of loneliness among a broad range of people living with mental health problems. This was identified as a high priority evidence gap by the UKRI (United Kingdom Research and Innovation) Loneliness and Social Isolation in Mental Health Research Network, a cross-disciplinary research network established to advance research on the relationship between loneliness and mental health [ 22 ].

We present data from a qualitative interview study [ 23 ] which employed a co-production approach [ 24 ], involving collaboration between people with relevant lived experience, clinicians and university-employed researchers (some of the team had multiple relevant perspectives). Semi-structured individual interviews were used to explore the experiences of loneliness in adults with mental health problems.

Ethical approval was obtained from the University College London Research Ethics Committee on 19/12/2019 (Ref: 15249/001), with a subsequent amendment approved to extend the study to include experience of the COVID-19 pandemic among people with mental health problems, meeting a pressing need for this. In this paper we report only on findings relevant to the original question regarding experiences of loneliness and their relationship with mental health. Findings relevant to the pandemic are reported in three other papers [ 23 , 25 , 26 ].

Research team

A team of Lived Experience Researchers, (LERs), drawing on their own experiential knowledge about living with mental health problems, and other researchers from the UKRI Loneliness and Social Isolation and Mental Health network and the National Institute for Health and Care Research Mental Health Policy Research Unit (MHPRU) planned and conducted the study. The team included clinical academics and non-clinical researchers from a range of backgrounds (including qualitative and mixed methods research, health policy, health economics, and the arts). The research team met weekly by Zoom video call [ 27 ] to plan the study and discuss progress. Most interviews were conducted by thirteen LERs involved in the study, except for eight telephone interviews conducted by MB, an experienced qualitative researcher and occupational therapist. Three LERs were employed in university research roles; others had honorary research contracts with University College London. Eleven of the LER interviewers were female and five were from minority ethnic backgrounds. The LERs received training on conducting face-to-face and online interviews and obtaining written and verbal informed consent. A weekly lived experience reflective space provided LERs with emotional support and space to discuss the research process and emotional impact, peer-facilitated by four experienced LERs.

Sampling and recruitment

Purposive sampling was used to ensure diversity regarding participants’ diagnoses, use of mental health services, and demographic characteristics, including age, gender, ethnicity, and sexuality, and whether they lived in rural or urban areas. We reviewed our sample during recruitment and implemented targeted strategies to ensure diversity. These included approaching community organisations working with Black and Minority Ethnic communities and using targeted recruitment materials.

Participants were eligible to take part if they were aged 18 years or over, had a self-reported mental health problem and lived in the UK. We recruited through three London-based community organisations (a mental health charity, a homeless charity and a community arts organisation), as well as through social media, especially Twitter, supported by the Mental Elf. Several charities and community organisations supporting people with mental health problems also agreed to disseminate an invitation to participate to their networks. Potential participants contacted the research team by email. Researchers then checked eligibility, provided a participant information sheet, answered questions about the study, and booked interviews.

Data collection

The topic guide (see S1 Appendix ) was developed collaboratively by members of the Loneliness Network’s Co-Production Group to explore the nature of loneliness experiences, their relationship to mental health, and alleviating and exacerbating factors. Prompts were included for questions asked to ensure topics were fully explored. Following the onset of the COVID-19 pandemic, further questions were added regarding experiences of living with mental health problems during the pandemic (see S2 Appendix for revised topic guide). Semi-structured interviews took place between March and July 2020. Ten participants were interviewed before the introduction of COVID-19 infection control measures, (two face-to-face with LERs and 8 by phone with MB and 49 participated in online interviews with LERs following the pandemic’s onset. Informed consent (verbal or written) was obtained prior to all interviews. All interviews were audio-recorded, with verbatim transcripts produced by an external transcription company. All transcripts were then checked by the researchers and any identifying information was anonymised.

We took a participatory approach to the analysis as a large team of researchers from varying backgrounds. We used Template Analysis [ 28 ], a form of thematic analysis [ 29 ] involving a codebook approach. Analysis involved defining and organising themes using a coding template, which was developed and refined during data analysis through an iterative approach. All interview transcripts were analysed by four Lived Experience Researchers (RRO, BC, PS and PN) and a network researcher (MB) facilitated by NVivo 11 software [ 30 ]. MB undertook a preliminary analysis of three transcripts, reading and re-reading to identify initial themes. Three LERs independently analysed one each of those transcripts and discussed points of divergence. Differences were compared with MBs initial themes identified to highlight areas requiring closer examination and to ensure the coding captured complex and nuanced data relevant to the research topic. The aim was to capture richer data, to guide further coding, and not to seek a consensus on meaning, in keeping with the approach of reflexive thematic analysis [ 29 ]. All themes formed an initial coding template. A further set of five transcripts were then analysed individually and the further initial themes were then discussed between the researchers conducting the analysis. This group reflected on the themes together to ensure important ideas in the transcript had not been overlooked, and to refine the initial coding template.

The analysis followed an iterative process where the core coding team met fortnightly with the wider research team to discuss and refine the developing list of themes in the coding template, obtaining further perspectives on the analysis. All transcripts were then coded following the final template.

Fifty-nine participants were recruited. The majority were female (n = 41, 69%), aged between 25–54, and living in a city (n = 43, 73%). The main ethnic groups reported were White British (n = 32, 54.2%), White Other (n = 8, 13.5%) and Black/Black British (n = 7, 11.9%). Table 1 outlines the demographics of all 59 participants. Our analysis identified four over-arching themes.

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https://doi.org/10.1371/journal.pone.0280946.t001

Theme one: What the word “lonely” meant to participants

Loneliness was described in a variety of ways, including as an emotional or physical state, or through accounts of lack of connection, feeling of belonging, or love and support. A unifying element was that it was not just an unwanted lack of contact with people but had important psychological elements.

1.1 How loneliness feels emotionally.

Participants often used words synonymous with low mood to describe emotional aspects of loneliness, including “ sad ”, “ depressing ”, “ miserable ”, “ despondent ” and “ tearful ”, and generally conveyed that loneliness was a painful state negatively impacting mental health.

1.2 Not feeling connected.

Being alone featured in definitions, but the experience of not feeling connected to others was more prominent:

“ The last 35 years has been lonely … I mean I’ve got a husband , I’ve got four kids and everything else , but it doesn’t stop you from feeling lonely .” [P47, female, White British, 46–55, urban]

People spoke about emotional, psychological and spiritual disconnection and “ not sharing energy ”. They often described being in the company of others, yet feeling unable to connect with them emotionally. This was a chronic state for some, or coincided with periods of mental unwellness for others:

"Remember becoming very depressed and … with a group of friends doing things I used to enjoy and literally not feel any connection with the people around me , especially if I was having a lot of intrusive thoughts … " [P44, female, White British, 36–45, urban]

Most interviews occurred under COVID lockdown when many social and mental health communications were digital. Physical presence clearly mattered to many people. One participant described loneliness as:

“ Less connection to people and specifically decreasing face-to-face contact .” [P28, female, White British, 56–65, urban]

Loneliness was sometimes conceptualised as a feeling of disconnection going beyond relationships merely with people:

“ Disconnect from the world , both the physical and the spiritual world as well .” [P37, female, Black, 26–35, urban]

Pets were mentioned as valued companions by several interviewees. Connections with them sometimes appeared on a par with humans, and their constancy was an asset that could be either cherished or missed.

“ Not having contact with other people or animals ” [P49, male, British Asian, 46–55, urban]

1.3 Lack of a sense of belonging

Some people described loneliness as related to objective isolation:

“ Some people … they have no choice … they don’t have the care and support from family and friends .” [P38, male, Black, 46–55, urban]

For others, loneliness involved not feeling they belonged in a social environment or community:

“ No , I don’t feel part of this community , not at all … I feel lonely where I live , yes .” [P51, female, White other, 46–55, urban] “ Sometimes the feelings of , well I do belong to that community but do I really ? Am I a bona fide member of it ? Feel like I am a hanger-on in the community .” [P11, male, White British, 66–75, urban]

Some described a sense of thwarted belongingness, being ‘ on the outside looking in’ or ‘ missing someone or something , but not always knowing what . ’

Not being able to find others who shared values and interests was part of the sense of not belonging:

“ I feel like I struggle with my identity sometimes , like who am I and stuff like that . Yeah , I’m always like , trying to find like , my tribe , and like-minded people and stuff like that .” [P29, female, Black, 26–35, urban]

For one participant this feeling of being ‘other’ and not belonging followed relocation from a large city to a more rural area with a different recreational culture:

“ It’s not actually the act of being alone , it’s … not having [the right] people to do things with or to share things with .” [P2, female, 36–45, White British, urban]

Social class played a role in some people’s lack of a sense of belonging:

“ I’m from a working-class background , I’m very around middle-class professionals at work -who speak very differently to me . …I have to constantly think about how I’m coming across , how I’m speaking… makes me feel a bit disconnected…I rarely join them for lunch and things … I find it a bit like I’m an outsider .” [P37, female, Black African, 26–35, urban]

1.4 Not feeling loved, supported or understood.

Not feeling loved or supported underpinned many of the narratives, sometimes resulting in a deep sense of emotional pain. This applied whether participants were objectively isolated or not:

“ Don’t have anyone to speak to or anyone to support you … don’t have anyone to turn to .” [P34, female, Asian, 18–25, urban]

Lack of help and support in dealing with mental health problems was one source of such loneliness:

“ No one helps , no one cares .” [P4, female, White British, 26–35, urban]

Several participants recounted interpersonal rejections that had triggered self-doubts, and these ruminations undermined their mental wellbeing:

“ You think … this person is not interested in me . Then you start to … make some negative judgements about yourself .” [P10, male, Black British, 56–65, urban]

Not feeling understood was also described as increasing feelings of loneliness:

“ When I’m not feeling understood … it feels like I’m on my own little planet .” [P9, female, White other, 36–45, urban]

1.5 Physical sensations of loneliness.

A few participants described loneliness in terms of physical sensations, such as “ tightness or stabbing in the heart ”, and “ a body ache ”, but with most sensations relating to the digestive system, such as “ physically feel nauseous ”, “ hunger ”, “ craving ” or “ a blow in the guts ”.

Theme two: Connections between loneliness and mental health

Participants described close connections between mental health and feelings of loneliness. These included loneliness leading to deterioration in mental health, and feeling lonely because of impacts of mental health problems.

2.1 Loneliness causing or worsening mental health problems.

Social isolation and loneliness may lead to negative thoughts, low mood and deteriorating mental health, and may prevent people accessing support from others that might help them stay well:

“ I think the sense of loneliness would have preceded the mental health problem , because then … if I had the social interaction then I suspect I would have probably managed to find some way to sort it out .” [P49, male, British Asian, 46–55, urban] “ Loneliness can trigger depression in me , it can take me to a dark place .” [P59, male, White British, 46–55, urban] “ The negative thoughts and the looping thoughts get much worse if I’m lonely . So … because seeing people helps interrupt them , without that , the anxious thoughts can get a bit out of control ” [P15, demographic information not available]

2.2 Impact of having long term mental ill-health on loneliness.

Conversely, participants described how having an ongoing mental health problem contributed to erosion of social contacts and to loneliness:

“ My depression involved me sitting in the dark at night with the lights off … I used to be popular . People stopped coming to see me because I’d changed . Yeah , so I became lonely then in the end .” [P10, male, Black British, 56–65, urban]

Ultimately this participant felt there was no choice but to be on their own and anxiety reduced their ability to reach out to people.

Some participants found managing day-to-day life tasks, such as handling household chores, in addition to coping with their mental health problems challenging, resulting in less time available to address their loneliness:

“ Always playing catch up to get everything sorted in my life … I have to find more ways to either quickly execute the things that need to be done to run a life and a flat or be very strict about just cutting things that don’t seem to matter so much and so concentrate more on … finding ways to sort of overcome loneliness .” [P28, female, White British, 56–65, urban]

2.3 Cyclical relationship.

Participants described a cyclical relationship between feeling lonely and changes in their mental health:

“ It’s a bit of a vicious cycle because I think feeling lonely…will make it worse , you need to be able to talk to people … So , it’s a bit of a cycle … your mental health means you can’t connect to people , then not being able to connect makes your mental health worse and then you’re just cycling around .” [P46, female, white British, undisclosed, urban]

2.4 Relationships between loneliness and specific mental health conditions and symptoms.

Some participants identified links between particular mental health difficulties and loneliness, although many themes were found to be cross-cutting rather than condition-specific. Depressive symptoms and loneliness were often described by participants as reinforcing each other, as also described in some of the quotes above:

“ I’ve learnt from the depressive part of my disorder , that when I’m depressed I haven’t got the energy , and it’s … like you inhabit a different space to the one you normally do . It’s kind of like you’re (behind) a glass wall and you’re not able to connect (emotionally) with the person who’s on the other side of the glass , even if you wanted .” [P55, female, White British, 46–55, rural]

Impacts from anxiety, especially social anxiety, were also described, leading to difficulty in social situations and resulting loneliness:

“ So anxiety can make me feel … lonely even if I’m in a party . I can be in a party with all my friends , all just want me to be happy and free and relaxed and dance , enjoy the music . But I can’t come out of my shell . I’m constantly preoccupied with my anxiety and this sense of…not enjoying myself . …Then I do kind of feel very lonely .” [P8, male, White British, 36–45, urban] “ If I’ve got nobody there who can sort of help fight against the social anxiety… the fear of the people around me combined with struggling to start up conversations means I feel very lonely .” [P27, female, White British, 25–34, urban]

Participants also described loneliness resulting from or being reinforced by symptoms of psychosis:

“ When I first developed schizophrenia I felt very , very lonely … I didn’t know , … none of my friends has schizophrenia . I had constant voices giving me orders so ‘you’re not worthy sleeping’ or ‘you’re not worthy’ of sitting down . I’d just stand there in a room .” [P8, male, White British, 36–45, urban] “ Getting out the flat is hard because of mental health and then having conversations with friends , like the voices would tell me stuff like ‘they hate you’ ‘don’t talk to them’ so that side . And then sort of like lacking motivation sometimes to sort of hold conversation .” [P20, female, White British, 26–35, urban]

Others described loneliness as resulting from difficulties in forming relationships that they saw as part of their mental health condition: a participant who reported having a diagnosis of “borderline personality disorder” said:

“ Because of my condition , I worry about having relationships with people and that keeps me isolated and keeps me lonely .” [P1, female, White British, 36–45, urban].

2.5 Stigma and social exclusion.

A key factor reported by multiple participants was the negative impact of stigma related to mental health problems on relationships:

“ People walk away . You mention the word hospital , people walk . You mention the word psychiatry and people walk away .” [P50, male, White British, 56–65, urban] “ I think because of what I have , and the stigma associated with personality disorders … in the press ,… some of the family members , some work colleagues , I think if I’m feeling lonely then that sort … of stigma , I think it just all compounds more ” [P30, female, White British, 36–45, urban]

Cultural taboos related to mental health were reported by some participants as having resulted not only in loneliness but in being ostracised:

“ People within my culture … my family don’t understand and friends from my culture don’t get it so I feel more isolated . I’m losing friends because of this .” [P34, female, Asian, 18–25, urban]

2.6 Choice and control—Social withdrawal and masking as a coping mechanism.

Some participants recognised an element of choice in not communicating with others or living in self-imposed isolation:

“ I could pick up the phone and ring someone anytime any day and I don’t…so that is sort of self-imposed isolation .” [P11, male, White British, 66–75, urban]

One participant, who had experienced childhood trauma said they avoided authentic connections, and always ‘ wore a mask ’ when relating to others because that kept them safe:

“ There’s certain parts of you , you just don’t let people in . And that can be lonely .” [P47, female, White British, 46–55, urban]

Choice and control, however, were complex, and beneath the conscious decisions there could be unconscious barriers or mental health factors:

“ It could be something which is self-inflicted for example , when I was depressed I felt lonely but some of it was that I felt comforted by being left alone and yet I also felt really anxious about being alone as well .” [P49, male, British Asian, 46–55, urban]

Theme three: Factors contributing to ongoing loneliness

As well as impacts of mental health problems, participants identified contributing factors to loneliness that included both historic root causes and current triggers, which were internal and external in nature.

3.1 Root causes of loneliness.

Perceived internal root causes of loneliness included being an introvert, or having low self-esteem and self-confidence, and therefore spending less time around people:

“ Because I have issues of self-esteem and all that kind of thing … For example , I don’t go to birthdays and that kind of thing . Which causes me to feel lonely .” [P41, female, Black British, 26–35, urban]

Participants also identified earlier traumatic events such as bereavement, domestic violence and experiences of being bullied that negatively affected how they viewed other people and their social interactions. Thus, earlier external events such as trauma shaped ways of thinking and choices, resulting in current psychological underpinnings of loneliness:

“ Sometimes I feel comfortable to just go up to them [at work function] and interrupt and join in the conversation but other times I feel like ‘oh they haven’t included me therefore they don’t want me there’ … and I think that has probably stemmed from you know being bullied at school . … . and then feeling like I’m being left out deliberately because that’s how the bullying worked at the time .” [P21, female, White other, 36–45, urban]

Experiences such as bereavement or domestic violence were seen as relevant because they resulted in great deficits in emotional needs being met and then subsequent difficulties in forming warm and trusting relationships, both leading to loneliness.

3.2 Current factors that maintain loneliness.

Current factors influencing loneliness included separation and loss, difficulties in relationships, and physical barriers.

3 . 2 . 1 Loss and separation . Forms of loss that resulted in loneliness included romantic, platonic, physical and emotional loss, encapsulated in accounts of loss of friendships and of love, and loss through bereavement. One participant felt that their independence and well-being, especially their mental health, required them to stay physically away from family and friends, but that this nonetheless resulted in a sense of loneliness:

“ The one thing that I need for my sanity is my own space … although it’s better for me to live here [in own home far from family and long-term friends] because I have that , I do feel lonely .” [P2, female, 36–45, White British, urban]

For some, grief was a factor in feelings of loneliness and in being unable to engage in activities that might reduce these:

“ I have faced grieving for someone that died close to me . I despaired and just be at home alone and just not able to function… ” [P48, female, 46–55, White other, urban].

3 . 2 . 2 Compounding intersectional factors and external barriers . For some participants a physical or age-related disability, was associated with barriers to using transport and getting involved in activities and this contributed to current feelings of loneliness, especially to the lack of a sense of belonging described under Theme 1.

“ I don’t think I have ever felt like not lonely . I think like disability , age , everything else creeps up on to make everything feel a hundred times worse . Loneliness to me is a disability .” [P52, female, 45–54, White Other, urban] “ When I developed a physical disability , I found there was very little in my community as a person in my thirties that I was eligible to do .” [P44, female, White British, 36–45, urban]

Even within groups where they felt they belonged, people could experience inhibiting differences in attitudes, interests, speech style, access or social norms.

Other compounding intersectional factors cited by participants included sexuality, discrimination, race relations and the complexities of age differences in interactions with others.

3 . 2 . 3 Time alone–impacts of solitude . Some participants described negative effects of spending time physically alone, including for some a loss of skills needed to interact with others.

“ It will affect my mood , it will make me feel low . It will affect my loneliness greatly if there are several days I have not been out somewhere or seen someone or had face-to-face time with people …” [P23, male, Asian British, 36–45, urban] “ You forget how to socialise . You become kind of quite selfish , actually , you don’t think about other people’s feelings .” [P42, female, Asian, 36–45, urban]

However, some people described a need to withdraw and ensure periods of solitude, even if this might exacerbate loneliness:

“ I need time on my own to recover and relax and rejuvenate but I don’t think it’s good to be on my own for long periods of time .” [P8, male, White British, 36–45, urban]

Theme four: Ways of reducing loneliness

Two broad sub-themes emerged: external and internal approaches to reducing loneliness. These were categorised based on participants’ emphasis and experiences, but were often intertwined rather than being two clearly distinct categories. Strategies and ideas classed as “external ways to reduce loneliness” are those where participants emphasised how their experience depended on specific needs being met by people or environments external to themselves; those classed as “internal ways to reduce loneliness” highlight internal changes in thought patterns or other psychological shifts in participants’ ways of being and relating to the world around them.

Overall, different forms of social contact were seen as important for many participants in reducing loneliness, with quality of relationships and a sense of “belonging” being attributes of social contact that were particularly pertinent. Mental health challenges could act as a barrier to improving social contact and so addressing this was also seen as a key step for some participants. A booklet [ 31 ] ( http://tiny.cc/Lonely ) drafted by members of the research team summarises suggestions from study participants on coping with loneliness.

4.1 External ways to reduce loneliness.

Many participants described social contact as key to feeling less lonely. Some people had a preference for specific types of contact, whereas for others, any contact with people was important. Participants also described how volunteering gave them a sense of purpose and connection.

For some, just being able to get out, locally or in nature, was enough to lessen feelings of loneliness. Sometimes getting out resulted in unplanned encounters with people, as was the development of hobbies that could be enjoyed alone.

“ Try and communicate with people . Even if it’s going to [botanic] gardens by yourself , you’re going to meet people when you sit down at the café and they’re going to say to you “ isn’t the weather lovely ?” [P38, male, Black, 46–55, urban]

The quality of connection, and being able to talk about how you were feeling was essential for many:

“ My advice would be to talk to … someone that you trust … if you say it out loud … it does lift your feelings a bit because you’ve connected with someone , you’ve shared , you’ve … offloaded to them .” [P32, female, Asian, 26–35, urban]

Accessing mental health support was cited by some as a key first stage in decreasing loneliness by helping to improve mood and anxiety, and being able to reflect on oneself and develop better coping skills:

“ Before I … started medical treatment for my depression and anxiety I felt that being off feeling . Even if I was around people , I felt separated , that there was a kind of barrier that was stopping me from being able to communicate .” [P33, female, white British, 26–35, urban]

Taking part in activities and shared interests was mentioned by many participants, with “ structured socialisation ” being a route into developing new friendships or sense of belonging to a group, and technology being an enabler for some. Often, the shared interests gave purpose and fostered connection.

“ Structured socialisation , it provides that structure and … gives you a purpose so that you feel compelled to keep going and make friends and stuff and be sociable with other people .” [P5, female, White British, 26–35, rural] “ The gym was really great , it was quite near me you know , and I’d never been to the gym before but I really got into that , and I was just getting to know people .” [P6, female, White other, 66–75, urban] ‘‘I managed to find the live role-playing community … I have organised events to help kind of increase the hobby outreach and activities within the hobby .” [P19, female, White British, 36–45, urban]

For this participant, finding her kind of people online led to her then taking the initiative and organising her own online events and thus wrapping this community around her. Naturally occurring proximity, as well as freely chosen activities, could foster important connections: one participant found that living in a multiple occupancy house helped build friendships that increased their sense of belonging despite mental health struggles:

“ I had people that were close… in proximity quite a lot , and we got to become really good friends , and I felt safe in that … friendship and then was able to open up , even when I wasn’t feeling great ” [P5, female, White British, 26–35, rural]

Thus finding a greater sense of belonging in a group or community could help people feel less lonely. Positive neighbourly encounters and informal interactions within a local community lessened feelings of loneliness for some. Others felt less lonely when connected to communities with whom they had something in common, such as people of the same ethnicity:

“ The ones that make me feel less lonely , …for a long time now , are my black friends . I feel more connected… I can express myself more freely without having to talk about certain things … so ethnicity is … playing a massive role in terms of feelings of loneliness .” [P37, female, 26–35, Black African, urban]

Religious worship, volunteering and acquiring a pet were among the other ways of connecting with others and becoming part of a valued group that were discussed:

“ Get a dog , if it’s possible because , you know , it’s much easier to interact with people in that case .” [P44, female, White British, 36–45, urban] “ The [volunteer job] has been life changing … For me that connection … And people listening , realising that they are connecting … I feel like I’m doing something good .” [P9, female, White Other, 36–45, urban]

Some participants reflected that finding new activities and purpose required them to make a concerted effort:

“ I just have this thing that , when you walk around a town … there’s always posters and notices up of things happening… , even in your local [supermarket]… you’ll have what’s happening in your local community … libraries have loads of things happening now .” [P2, female, White British, 45–56, urban] “ When I was [living] alone in a flat … I was much more lonely because I wasn’t tagged into those things which helped me to be less lonely … But we have to find these things and , if they make sense , they give us community .” [P13, male, White British, 66–75, urban]

4.2 Internal ways to reduce loneliness.

Internal strategies leading to better self-awareness, sometimes followed by taking steps to reducing anxiety and improving mood, were mentioned by many participants:

“ I’m more recognising it now in the last few years … what loneliness looks and feels like and therefore , because you can recognise it , you suddenly think oh I haven’t seen anybody for a while , I need to … make more of an effort now .” [P14, female, white British, 46–55, rural]

Participants reflected on relationships and learning to recognise what worked well for them and what made loneliness worse, thus improving the quality and connection in relationships:

“ With loneliness , what I can control is … who I’m around and who I feel most comfortable with , so maybe not hanging on to these friendships that make me feel even more lonely , even more isolated .” [P37, female, black, 26–35, urban]

Some people reported that acceptance of having time by yourself, being connected with yourself and your wishes and desires, was important. Carrying out activities like writing in a journal or art was helpful. For some, internal reflections and time alone led to better quality relationships and a reduction in loneliness.

“ To not beat yourself up , it’s not because there’s anything wrong with you , and that spending time on your own can be good ‘cause you can do things that you can then share with people .” [P2, female, White British, 45–56, urban]

Participants’ thoughts and feelings about isolation could also change because of psychological therapies, potentially resulting in taking steps to increase connection with others:

“ Through therapy and facing what I’ve been doing … in terms of anxiety or depression , I understand that … being sociable , going out and meeting people is healthy , and the longer I stay isolated… the harder it gets ” [P26, male, White British, 36–45, urban]

Main findings

Our findings conveyed how differently loneliness is experienced by different people, as expressed in terms of emotions, or even physical sensations. Loneliness appeared to comprise psychological elements, related to people’s thoughts and feelings about themselves in relation to other people and wider groups and communities, and social elements, related to the impacts of everyday interactions and contacts. Participants described a range of contributing factors to the origins of their loneliness, and the ways that their loneliness was maintained. They also perceived clear links between their loneliness and their mental health, and vice versa, and sometimes a feedback loop between the two.

Our participants’ accounts, as encapsulated in Theme 1, confirm that feelings of loneliness do not simply relate to dissatisfaction with the amount of time spent with others, but, perhaps more centrally, to not feeling connected to them in meaningful ways, and to not experiencing a sense of belonging. Loneliness has long been characterised as a physically and psychologically harmful manifestation of fundamental needs for social connection not being met [ 32 ]. Our findings regarding the importance of sense of belonging can be connected to investigations of loneliness from a social identity perspective, which supports that having multiple valued group memberships is associated with less loneliness and greater well-being [ 33 ]. The ways in which participants described both the nature of their loneliness and its origins were diverse, congruent with quantitative findings that suggest a complex causal web underlying loneliness [ 1 ]. Contributing factors identified included external factors such as losses and transitions or excessive time alone, but also aspects of personality such as introversion or lack of self-confidence, as well as the long-range impacts of trauma and adverse early experiences on the ability to form relationships (Theme 3).

Some of the themes illuminate aspects of loneliness relevant across populations, but a central aim of our work was to better understand loneliness among people living with mental health conditions. We found that loneliness and mental health appear intertwined in several ways (Themes 2). Participants described how feelings of not being connected to others could arise directly from a range of mental health conditions by pathways including feeling negative about self and others; withdrawing when depressed; and feeling unable to connect with others even when in company because of preoccupying social anxiety and hearing inner voices with negative content impeding trust and ability to socialise. This is in keeping with findings of greater loneliness associated with a range of mental health conditions [ 13 , 34 – 36 ]. Some participants also described how their loneliness could lead directly to onset or exacerbation of the mental health conditions they were experiencing including depression, which is congruent with longitudinal studies establishing loneliness as an independent risk factor for depression [ 11 , 12 ], and with findings of a bidirectional relationship between loneliness and depression [ 37 ].

Going beyond direct links from mental health symptoms to loneliness, the actions people took to cope with their mental health problems sometimes also placed them at greater risk of loneliness, such as when they withdrew from the stresses of social contacts and activities in order to recover and to ensure they had time and energy to cope with pressing practical needs. The circular relationship between loneliness and mental ill health identified in Theme 3 evoked the paradox identified by Achterbergh et al. [ 21 ] in their meta-synthesis of qualitative studies on loneliness and depression among young people: social withdrawal to cope with mental ill health can result in loneliness that further exacerbates mental health problems.

Significant contributors to loneliness among people with mental health problems in our sample were stigma and self-stigma associated with mental health problems, especially as impediments to having a sense of belonging. This is in keeping with previous findings of an association between self-stigma and social withdrawal among people with severe mental health problems [ 38 ], and of high levels of persisting mental health stigma despite a longstanding UK public anti-stigma campaign, focused primarily on common mental health problems [ 39 ].

Experiences of stigma and social exclusion related to mental health intersected for many participants with social exclusion associated with being part of other disadvantaged or marginalised groups at increased risk of mental health problems, including racial and sexual minorities and people with disabilities, and with impacts of social deprivation. As Lever-Taylor et al. [ 40 ] argue in their qualitative study of perinatal women, an intersectional focus is helpful in understanding social drivers of loneliness. Participants’ accounts of the many impediments to a sense of belonging, including stigma, reinforce a need to take a societal and community as well as individual approach to understanding loneliness. Thus, loneliness appears to result not only from individuals’ inability to connect, but also from failures of communities to welcome and integrate people living with mental health problems, and from practical barriers to connecting with others that result from poverty [ 41 ].

Many of the themes and sub-themes so far discussed cohere with previous literature, for example illuminating potential mechanisms underpinning epidemiological findings. To our knowledge, our exploration of the strategies and types of help people employ to combat loneliness is novel (Theme 4). We found that many participants were aware of their loneliness and its impacts, and of a variety of strategies that could help: we reflect further on implications for interventions below.

Strengths and limitations

Our study represents a substantial contribution to the limited qualitative literature on loneliness among people with mental health problems. We recruited a diverse sample, encompassing a range of backgrounds, types of mental health problem, service use histories and locations. Although using a digital platform for most interviews will have excluded a substantial section of the population using mental health services, we did conduct some interviews by telephone and face-to-face to accommodate the digitally excluded. Lived experience was embedded in the study at each stage, with people with relevant personal experiences designing interview guides, conducting interviews, analysing data and writing up findings.

Limitations include that we conducted a broad-brush analysis of a large sample of interviews, and searched for commonalities across a group that was very diverse in characteristics and experiences rather than focusing in more depth on more defined groups. Some people discussed links between specific mental health conditions and onset or exacerbation of loneliness, but our sample was very varied and diagnosis was based on self-report, so we cannot discuss links between particular symptoms and conditions and loneliness in depth; a potential direction for future work. We did not measure severity of mental health difficulties, and note that while a majority had used specialist mental health services (inpatient or community teams), thirteen participants reported not having used services for mental health.

The majority of interviews were conducted during the COVID-19 pandemic, and we have reported baseline [ 23 ] and follow-up [ 26 ] findings elsewhere, but the pandemic context may have influenced accounts of loneliness, even though participants were encouraged to talk about experiences of loneliness in general rather than specifically in a pandemic context, and appeared for the most part to be doing so.

Research and clinical implications

The rich and complex accounts given by participants of the nature of their experiences of loneliness, and the great variety of pathways into and out of it, indicate considerable further scope for research to understand associations between loneliness and mental health. In qualitative research, many of our themes warrant more in-depth exploration, including focusing on particular groups at high risk of loneliness, or who are currently lonely. In quantitative research, it would be valuable to investigate further the longitudinal relationships between loneliness and mental health problems, and the extent to which contributory factors identified in our study are also reflected in epidemiological analyses. Much research on loneliness has employed single-item or brief measures not tailored to people with mental health conditions: we reflect that such measures are unlikely to capture the diversity of experiences of loneliness and links to mental health.

As yet there are very few clearly evidence-based strategies for helping with loneliness among people living with mental health problems [ 16 ]. Our findings show people with mental health problems recognising and taking steps to address their loneliness. This supports the greater deployment of co-production approaches, incorporating the forms of help that people with relevant personal experience see as potentially effective. With few exceptions [ 42 ], interventions tested thus far have tended not to be co-produced. The diversity of pathways into and out of loneliness that people described, and of suggested strategies, indicate that a variety of approaches are potentially helpful depending on the nature and context of loneliness, delivered singly or in combination. These would include self-help and psychoeducation about day-to-day strategies that people have found helpful, psychological interventions focused on thoughts and feelings about others, and social approaches to help people develop meaningful connections and a sense of belonging [ 15 , 43 ].

The range of mental health-related factors triggering and perpetuating loneliness suggest benefits to developing or adapting specific strategies for this population rather than deploying strategies developed for the general population. Approaches to loneliness in a mental health context based on peer support seem rarely to have been reported, but have clear potential benefits such as in overcoming obstacles due to stigma and self-stigma, fostering a sense of belonging and supporting people with self-help strategies to reduce loneliness. Finally, our perspective in this study was on improving the support offered in mental healthcare settings, but our findings illustrated the community-level, intersectional and socio-economic drivers of loneliness in multiple ways. We suggest that addressing such drivers will have a central influence on whether levels of loneliness can be reduced among people living with mental health problems.

Lived experience commentary written by Beverley Chipp

This paper must be understood in the context of the COVID-19 lockdown occurring when we had only conducted a few interviews. All participants had already felt lonely as this was our inclusion criteria, but limitations upon movement and social contact imposed by government, and, significantly, the cessation of many support services will have influenced subsequent interviewees’ responses. For some these changes made things worse and for others life became easier. The shifts triggered significant reflections on life and participants’ relationships, and perhaps provided richer data than would have been collected in normal times.

Access to mental health support has been increasingly difficult over the last decade but the suspension of face to face services, or for some, services altogether, exacerbated loneliness leaving many feeling brushed aside.

We learned that loneliness and social isolation were distinct entities and experienced in multiple and diverse ways. The causes and perpetuating factors were more complex than we had imagined, even though we identified with some of the narratives.

Solutions need to take a psychologically informed, holistic approach rooted in community and co-production. Without addressing stigma and other barriers within society–prejudice and discrimination, hostility against those that don’t ‘fit’–people’s sense of belonging will be hindered, and loneliness increased. Where loneliness has childhood origins it may be more difficult to unpick. Simply engineering people to be with other people is too simple a solution for most individuals also living with mental health conditions.

Commonality between lived experience researchers and participants fostered greater trust in interviews and thus sharing of deeper insights. We felt that research often stays within a ‘research bubble’, not reaching the people it directly affects. Recognising the wealth garnered from asking participants ‘what helped?’ and their willingness to offer suggestions, we co-produced a self-help booklet ( http://tiny.cc/Lonely ) which acknowledges their resourcefulness.

Supporting information

S1 appendix. interview topic guide..

https://doi.org/10.1371/journal.pone.0280946.s001

S2 Appendix. Revised interview topic guide.

https://doi.org/10.1371/journal.pone.0280946.s002

Acknowledgments

The Loneliness and Social Isolation in Mental Health Research Network Co-Production Group and The NIHR Mental Health Policy Research Unit Covid coproduction research group contributed to the development of the study design, conduct of interviews and recruitment to the study.

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• Published: 10 December 2021

Loneliness as an active ingredient in preventing or alleviating youth anxiety and depression: a critical interpretative synthesis incorporating principles from rapid realist reviews

• Eiluned Pearce   ORCID: orcid.org/0000-0002-4347-317X 1 ,
• Pamela Myles-Hooton 2 ,
• Sonia Johnson   ORCID: orcid.org/0000-0002-2219-1384 1 , 3 ,
• Emily Hards   ORCID: orcid.org/0000-0001-9274-4995 4 ,
• Samantha Olsen   ORCID: orcid.org/0000-0001-7879-7345 2 ,
• Denisa Clisu 5 ,
• Sarah M. A. Pais 1 ,
• Heather A. Chesters 2 ,
• Shyamal Shah 1 ,
• Georgia Jerwood 1 ,
• Marina Politis   ORCID: orcid.org/0000-0003-1406-5967 1 ,
• Joshua Melwani 1 ,
• Gerhard Andersson   ORCID: orcid.org/0000-0003-4753-6745 6 &
• Roz Shafran   ORCID: orcid.org/0000-0003-2729-4961 2  

Translational Psychiatry volume  11 , Article number:  628 ( 2021 ) Cite this article

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Loneliness is a relatively common problem in young people (14–24 years) and predicts the onset of depression and anxiety. Interventions to reduce loneliness thus have significant potential as active ingredients in strategies to prevent or alleviate anxiety and depression among young people. Previous reviews have focused on quantitative evidence and have not examined potential mechanisms that could be targets for intervention strategies. To build on this work, in this review we aimed to combine qualitative and quantitative evidence with stakeholder views to identify interventions that appear worth testing for their potential effectiveness in reducing loneliness, anxiety and depression in young people aged 14–24 years, and provide insights into the potential mechanisms of action. We conducted a Critical Interpretative Synthesis, a systematic review method that iteratively synthesises qualitative and quantitative evidence and is explicitly focused on building theory through a critical approach to the evidence that questions underlying assumptions. Literature searches were performed using nine databases, and eight additional databases were searched for theses and grey literature. Charity and policy websites were searched for content relevant to interventions for youth loneliness. We incorporated elements of Rapid Realistic Review approaches by consulting with young people and academic experts to feed into search strategies and the resulting conceptual framework, in which we aimed to set out which interventions appear potentially promising in terms of theoretical and empirical underpinnings and which fit with stakeholder views. We reviewed effectiveness data and quality ratings for the included randomised controlled trials only. Through synthesising 27 studies (total participants n  = 105,649; range 1–102,072 in different studies) and grey literature, and iteratively consulting with stakeholders, a conceptual framework was developed. A range of ‘Intrapersonal’ (e.g. therapy that changes thinking and behaviour), ‘Interpersonal’ (e.g. improving social skills), and ‘Social’ Strategies (e.g. enhancing social support, and providing opportunities for social contact) seem worth testing further for their potential to help young people address loneliness, thereby preventing or alleviating depression and/or anxiety. Such strategies should be co-designed with young people and personalised to fit individual needs. Plausible mechanisms of action are facilitating sustained social support, providing opportunities for young people to socialise with peers who share similar experiences, and changing thinking and behaviour, for instance through building positive attitudes to themselves and others. The most convincing evidence of effectiveness was found in support of Intrapersonal Strategies: two randomised controlled studies quality-rated as ‘good’ found decreases in loneliness associated with different forms of therapy (Cognitive Behavioural Therapy or peer network counselling), although power calculations were not reported, and effect sizes were small or missing. Strategies to address loneliness and prevent or alleviate anxiety and depression need to be co-designed and personalised. Promising elements to incorporate into these strategies are social support, including from peers with similar experiences, and psychological therapy.

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Introduction.

Loneliness can be defined as a perceived mismatch between actual and desired quantity or quality of relationships, arising through the interplay of predisposing (individual, situational and cultural) and precipitating factors (e.g. life transitions such as bereavement or moving to university) [ 1 ]. If the situation remains unchanged, chronic loneliness may develop: an intrinsically aversive and stable state associated with the inability to develop satisfying social relationships over a sustained period, linked with physical and psychiatric consequences [ 2 ]. Given that many intervention studies to date do not distinguish between transitory and chronic loneliness, we explore loneliness in general here.

Loneliness is relatively prevalent amongst 16–25-year olds [ 3 ], and longitudinal studies demonstrate that loneliness during childhood increases risk of depression and emotional symptoms up to 24 years later [ 4 , 5 ]. A meta-analysis demonstrated a negative feedback loop between adolescent social anxiety and loneliness over time [ 6 : across studies r  = 0.1–0.3]. In a clinical sample of adolescents, loneliness measured at 9 months post-baseline was found to mediate an indirect relationship between baseline social anxiety and suicidal ideation measured at 18 months post-baseline [ 7 ]. Moreover, loneliness was found to be a significant mediator in the relationship between anxiety and depression in both a school-based sample and youth receiving residential treatment [ 8 ]. Despite loneliness, social anxiety and depressive symptoms being interrelated, they are statistically and experientially distinguishable [ 9 , 10 ].

Three recent systematic reviews of quantitative studies have included in their scope investigation of loneliness interventions in the context of mental health and/or young people. First, Ma et al. [ 11 ] examined randomised controlled trial (RCT) interventions for reducing loneliness in individuals of all ages experiencing mental ill-health, and found one intervention for female undergraduates with depression [ 12 ] and one for high school students with social anxiety [ 13 ]. Second, Loades et al. [ 14 ] reviewed two RCTs of (i) a mentorship programme for 12–15-year olds experiencing victimisation [ 15 ], and (ii) a school-based intervention for 15–19-year olds involving either a one-tier intervention comprising class activities and student mentors, or a two-tier programme that additionally involved a staff mental health support team [ 16 ]. Third, a meta-analysis found that a range of interventions reduced loneliness in youth aged 25 years or younger across diverse samples including those with anxiety or depression [ 17 ].

However, these recent reviews only include quantitative evidence and do not focus on anxiety and depression despite the clear links between these internalising problems and loneliness. Moreover, these previous reviews do not include investigations of potential mechanisms of action. Thus, while interventions to reduce loneliness have potential as active ingredients in strategies to reduce depression and anxiety among young people, currently we do not have robust evidence as to which strategies have potential to be effective and in which contexts, and why. Loneliness interventions in the area of mental health is an emerging field, and insufficient numbers of adequately powered and appropriately designed studies means the quantitative evidence is limited. Consequently, identifying promising approaches also requires qualitative evidence to provide a more nuanced and experiential perspective to complement the quantitative work [ 10 ]. Additionally, third sector organisations are active in addressing loneliness, and new insights can be gained from incorporating their practical service-led perspectives. Synthesis of quantitative, qualitative and grey literature evidence, together with consideration of mechanisms and pathways underpinning potential interventions, and stakeholder views regarding intervention acceptability and potential usefulness, is needed to provide convergent support for which strategies are worth testing for their potential to reduce loneliness in young people, and therefore prevent or alleviate anxiety and depression.

To fill this gap, we conducted a Critical Interpretive Synthesis (CIS) [ 18 , 19 ], in order to iteratively critique and integrate multidisciplinary and multi-method evidence, generate overarching conceptual constructs and form a new, critically-informed theoretical framework. CIS is a robust method that draws on both systematic review and qualitative methods to identify links between constructs already reported in the literature, and higher-level overarching ‘synthetic’ constructs that draw together different sources of evidence. The aim is to generate theory with strong explanatory power [ 18 ]: that is, which makes clear and testable predictions based on observations rather than assumptions, including about causal mechanisms. For instance, in this review we aimed to generate a theoretically driven framework that allows hypotheses to be proposed about what interventions to reduce loneliness might work for whom, and why. The overarching synthetic constructs in CIS are generated through critically exploring how the authors of included quantitative and qualitative studies have conceptualised and constructed the phenomenon under consideration, and questioning the assumptions made in different empirical and theoretical approaches. This review method is particularly useful in optimising the usefulness of the limited data available in separate research fields, by meaningfully integrating cross-disciplinary, cross-method and cross-sector evidence to yield new holistic insights. This approach takes an iterative but systematic approach to question formulation, searches and selection of evidence, with the latter being based on relevance to the research question rather than quality. There is an active questioning of underlying assumptions in the literature and a conceptual framework is developed through a dialectic process between the evidence and theory. To complement the CIS approach, we also incorporated principles from Rapid Realist Review (RRR) [ 20 ] by engaging stakeholders with academic and/or lived experience expertise, ensuring relevance to policy and practice.

A number of different classifications of loneliness interventions have been proposed previously. For instance, in a meta-analytic review of 50 studies that together spanned all age groups, Masi et al. [ 21 ] adopted a classification comprising four primary intervention strategies, which they identified from previous qualitative reviews: (i) improving social skills, (ii) enhancing social support, (iii) increasing opportunities for social contact, and (iv) addressing maladaptive social cognition. More recently, Mann et al.’s [ 22 ] scoping review focused on individuals with mental health problems, and categorised ‘direct’ interventions that targeted loneliness and concepts related to social relationships (as opposed to broader wellbeing interventions, which might also impact on loneliness ‘indirectly’) into four broad groups: (i) changing cognitions (e.g. cognitive behavioural therapy or reframing), (ii) social skills training and psychoeducation (e.g. family psychoeducation therapy), (iii) supported socialisation or having a ‘socially-focused supporter’ (e.g. peer support groups, social recreation groups), and (iv) wider community approaches (e.g. social prescribing and asset-based community development approaches) [ 11 , 22 ]. Mann et al. classified specific interventions based on the main approach used, but point out that these categories are not mutually exclusive. This latter typology was adopted by Ma et al. [ 11 ] in their review of RCTs described above. Eccles and Qualter [ 17 ] divided interventions for individuals under 25 years into (i) social skills, (ii) social interaction, (iii) social and emotional skills, (iv) enhanced social support, (v) psychological intervention, (vi) learning new skills, (vii) other, as well as noting whether delivery was individual or group, and using technology or not.

In our conceptual framework we aimed to provide insights into promising approaches that should be targeted for further development and testing by answering the research questions: (i) in which ways and in which contexts does addressing loneliness appear to have potential to prevent and/or improve anxiety and depression in young people and why, and, (ii) in which ways and which contexts and for whom, does addressing loneliness appear not to work, and why? Consequently, in contrast to the previous classifications of loneliness interventions described above, we not only aimed to provide a typology of interventions, but also a conceptual model that additionally incorporates a classification of context (who the intervention works or does not work for) and mechanism (why the intervention works or does not work). As is inherent in the CIS approach, we aimed to question the relevance of previous typologies of loneliness interventions to this particular age group and from the perspective of preventing and alleviating anxiety and depression. We focus on the 14–24 age group in line with the Wellcome Trust’s mental health programme strategy [ 23 ], since half of all lifetime cases of mental health problems start by age 14 and 75% by age 24 years, meaning that this is a critical period for potential intervention [ 24 ].

Search strategy

The aim of the searches was to identify interventions to address loneliness in 14–24-year olds that also related to anxiety or depression: for example because the intervention targeted participants already experiencing depressive symptoms or diagnosed with depression, or because the measured outcomes included anxiety or depression as well as loneliness. We began with an ‘a priori’ search strategy focusing on interventions to address loneliness in young people that either also measured anxiety and/or depression (to identify prevention strategies and their mechanisms) or for which the sample comprised young people experiencing anxiety and/or depression (to identify treatment strategies and their mechanisms) [ 25 ]. Studies conducted outside of the UK were included as long as they were reported in English.

The initial searches were followed by further iterations of targeted searches [ 18 ] for terms raised by the Lived Experience Advisory Group (LEAG) and academic experts, such as ‘stigma’. Initial searches used modified search terms from [ 14 ] to update quantitative literature published subsequently to [ 14 ], and to search for qualitative studies (see Supplementary Materials for details of searches, including for grey literature; search terms are given in Supplementary Table S1 ). We chose to update the search for quantitative papers rather than conducting searches for all published studies from all dates because the previous review had been published within 6 months of our searches, and related specifically to loneliness and mental health in young people. Moreover, unlike in ‘standard’ systematic reviews, the aim of the CIS approach is not to identify and include all relevant literature but to reach ‘theoretical saturation’, that is, to include enough literature from a range of sources (including from prior reviews) to ensure that all key themes and concepts are covered [ 18 ]. The searches for published qualitative and grey literature were novel searches that included all dates and were not updates of previous reviews.

Due to the small number of studies found in test searches, we widened the search and inclusion criteria to incorporate ‘mental health’ (including wellbeing) more generally. For inclusion, quantitative and qualitative studies required: loneliness as a primary or secondary outcome in the context of anxiety, depression, or ‘mental health’ (broadly defined to include wellbeing), publication in English in a peer-reviewed journal, a mean sample age within the 14–24 years range, and that the study included an intervention or coping strategy addressing loneliness. Grey literature was included along similar lines, without the publication criterion. Articles were excluded that did not: investigate loneliness, depression, anxiety, mental health or wellbeing, fit the age range, or include an intervention or strategy addressing loneliness. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement [ 26 ] was followed (Fig. 1 ) and the review protocol was registered on the PROSPERO database [CRD42020197953].

The number ( n ) of records identified, screened by (i) title and abstract and (ii) full text, excluded (with reasons for exclusion) and included in the synthesis from different sources are provided.

Integrating the views of experts

A LEAG of 18–24-year olds with lived personal experience of loneliness and mental ill-health (in the recruitment material mental ill-health was described as anxiety, depressive symptoms, mental distress, low mood, or excessive worry) ( n  = 18) were recruited by circulating an advert through the UKRI Loneliness & Social Isolation, Emerging Minds and SMaRteN mental health research networks ( http://mentalhealthresearchmatters.org.uk/networks/ ), the McPin Foundation (a mental health research charity) and the Birmingham University Institute of Mental Health Youth Advisory Group. These networks and organisations facilitate patient and public involvement in research and young people were invited to be stakeholder consultants in this research project; the young people involved were not research participants. Individuals interested in being involved were asked to complete an online expression of interest form. All young people who expressed an interested in being involved were invited to join the group: 19 young people expressed an interest but one dropped out before the first meeting for personal reasons. Due to time constraints, we did not recruit through non-UK networks, but three LEAG members were international students studying in the UK. We did not collect standard demographic information from LEAG members as they were providing consultation and were not research participants, but the expressions of interest form invited applicants to provide any information they thought would be relevant given our aim to recruit a diverse group. The information volunteered indicated that several members identified with a non-binary gender, and a range of sexual orientations and ethnic groups were represented. Several members identified as having Autism Spectrum Disorder (ASD) and several were care leavers. The majority were students or recent graduates from UK universities. At the same time as expressing an interest in joining the LEAG, individuals could also volunteer to become ‘Lived Experience Leads’, who would take a more active role in creating the dissemination outputs required by our funder. About half of the group expressed an interest in the ‘Lead’ role and we chose four individuals who would provide a variety of perspectives given their demographic characteristics and backgrounds, and who had experience relevant to research, and creating videos, infographics and lay summaries. All LEAG members were invited to attend three online meetings (2 h each) across the 4 months of the project. In preparation for the second and third meetings they were asked to review, respectively, (i) the initial conceptual framework and (ii) the dissemination materials including drafts of the lived experience commentary included in this paper, and to provide feedback during the meetings, which were facilitated by the four Leads. The Leads provided additional comments on the search protocol, the developing conceptual framework and this research paper outside of the meetings, as well as creating the lived experience commentary on this paper, a lay summary, an infographic for policy makers and a short video aimed at 14-year olds explaining the research findings. All LEAG members received Patient and Public Involvement payments of £20 per hour, reflecting standard UK rates at the time.

Written and verbal feedback was sought on the search protocol from interdisciplinary experts (co-investigators of the Loneliness and Social Isolation in Mental Health Research Network: see Acknowledgments for the diverse disciplines represented) and four Lived Experience Leads selected from the LEAG. Three further academic experts were consulted for additional published or unpublished work. The authors of this paper include clinicians (clinical psychology and psychiatry) who also conduct academic research, an evolutionary anthropologist, and people with lived experience of mental ill-health and/or loneliness. This paper reflects a process of discussion between these diverse perspectives that was ongoing throughout the research project.

Study selection

New searches.

Twenty-two potential studies were found and four were excluded (see Supplementary Materials for screening details), leaving 18 (Fig. 1 and Table 1 ; ref. [ 27 ] is a Ph.D. thesis). Thirty-three papers related to built environment interventions for youth mental health provided by an expert did not meet inclusion criteria: these papers were a subset from a wider systematic review search looking at built environment interventions for improving mental and physical health in children and young people. Although six of these papers included concepts related to loneliness (1 paper related to ‘community belonging’, 1 to ‘sense of community’, and 4 to ‘social cohesion’), none of the papers related to loneliness per se and were therefore excluded.

Two unpublished M.Sc. dissertations that had been supervised by one of the authors (SJ) were included: these reported qualitative interviews with the staff of youth charities about their strategies for addressing loneliness in young people [ 28 , 29 ].

Studies selected from previous review

Eight studies from [ 17 ] and one from [ 11 ] that met our age criterion and included mental health-related outcomes were included (Table 2 ).

Grey literature

Twenty-five sources from UK-based third sector organisations or public bodies related to addressing youth loneliness and mental health were included (Table 3 ). Although some sources included younger age groups, only information relating to 14–24-year olds was used in developing the framework.

Quality assessment

Although the CIS approach traditionally does not include quality assessment but instead focuses on the relevance of studies in order to build a conceptual map of the topic in question [ 18 ], we provide quality ratings of all the included studies in Supplementary Table S2 , as this may be helpful in considering possible further research and clinical potential of the approaches discussed. Consistent with [ 14 ], a shortened quality assessment using criteria adapted from the National Institutes for Health (NIH) was used to assess the quality of included quantitative studies and final rating are given as ‘poor’, ‘fair’ and ‘good’. The Consolidated Criteria for Reporting Qualitative Research [COREQ: 30 ] rating scale was used to assess the quality of included qualitative studies, and for these raw scores are given as a proportion of the number of relevant rating items, as the COREQ does not provide guidance on how to convert raw scores to a categorical rating of quality. In the main text we discuss the quality ratings for the included studies only in relation to those that used randomised controlled methods: we discuss study quality in relation to RCTs in order to provide context on how confident we can likely be about the outcome findings for these studies, and we focus on RCTs because it is only this study design that can provide meaningful information on effectiveness.

Where interventions related to more than one type of strategy (e.g. intrapersonal therapy and peer support), these were coded within the relevant category for the dominant approach. For example, the online Entourage platform delivers evidence-based therapeutic content to address social anxiety, and is coded and discussed as an individual-level therapeutic intervention, even though it also included a peer support element. However, interventions that used multiple approaches are referenced in all relevant categories in Fig. 2 .

Synthetic constructs are given in bold and are structured under the overarching themes of Context (who an intervention might work for), Content (what the intervention involves), Mechanisms (how and why an intervention might work) and Barriers (why an intervention might not work). Sub-constructs are bullet-pointed and given in bold, and their attributes are also provided. References: anew search of academic evidence, b papers from [ 17 ] or [ 11 ], c MSc, d Third sector/policy, e LEAG; reference numbers match the main text, f reviewed in [ 37 ].

Through CIS, the underlying data are transformed into ‘synthetic constructs’: higher-order theoretical concepts that capture diverse evidence [ 18 , 25 , 31 ]. These concepts summarise the key overarching themes in a diverse body of evidence, which may not be found in the literature being synthesised itself. Identifying these constructs requires questioning underlying assumptions in the literature, and thus offering a critical interpretation of the evidence. In the CIS approach, each ‘synthetic construct’ has ‘attributes’, which are the characteristics that define it and can be thought of in a similar way to subthemes in qualitative analysis.

To build a coherent framework, we drew on elements of a conceptual model developed through CIS [ 31 ], pertaining to ‘Context’ (population characteristics and setting), ‘Content’ (what the key elements of strategies are, where ‘strategy’ encompasses both formal interventions and broader coping strategies), and the proposed ‘Mechanisms of Action’ that mediate effectiveness based on individual context (Fig. 2 ). In addition, we synthesised the construct ‘Barriers’. To incorporate stakeholder input following RRR principles, we extracted themes from notes taken during initial discussions with the LEAG and these were used in coding the academic and grey literature, with additional themes being added as necessary. Using the themes raised during consultation with the LEAG allowed us to bring a critical perspective to the academic literature to identify key gaps in existing strategies (e.g. addressing family relationships and stigma) and to understanding possible mechanisms of action as well as potential barriers, which were not always clear in the intervention studies. Critically comparing the academic literature with grey literature from the third sector also highlighted gaps in the evidence base (e.g. place-based approaches). By drawing together stakeholder input (an innovation to the CIS method based on RRR), quantitative and qualitative academic literature and evidence from third sector and policy grey literature, we iteratively synthesised cross-cutting ‘Intrapersonal’, ‘Interpersonal’, and ‘Social’ constructs, in addition to nested sub-constructs (Fig. 2 ). These constructs identified the key elements of different types of strategies to address loneliness and their potential mechanisms of action.

Twenty-seven studies (total participants n  = 105,649; range 1–102,072) were included (Fig. 1 ): 18 from the new searches (Table 1 ), eight from [ 17 ] and one from [ 11 ] (Table 2 ). Twenty-five third sector sources (Table 3 ) and two M.Sc. dissertations [ 28 , 29 ] were also included. Please see Supplementary Materials for discussions of the loneliness (Supplementary Tables 3−5 ), and anxiety and depression measures used in the included studies.

We first outline a conceptual framework of potentially promising approaches for different needs, and the possible mechanisms by which these might work. Iterative development of the framework involved discussions of the review results with academic and lived experience experts and yielded a visual summary of interventions for potential future development and testing, and their content, mechanisms and potential applications (Fig. 2 ). Within this framework, we then discuss outcomes and study quality for the randomised controlled studies only, as other study designs do not meaningfully pertain to assessing effectiveness. Outcomes for all studies (including effect sizes where available) are summarised in Tables 1 and 2 .

We started by categorising the Content as ‘Intrapersonal’, ‘Interpersonal’ and ‘Social’ and then identified the contextual factors that might lend themselves to that particular strategy, and the mechanisms by which the strategy might work, to create three ‘pathways’. ‘Intrapersonal’ level constructs are taken to be those that relate to psychological characteristics and mechanisms and the strategies that specifically target these internal characteristics and mechanisms, including steps that an individual has taken themselves to manage their internal psychological states, such as journaling or exercising to moderate their mood. We use ‘Interpersonal’ to refer to individual-level factors, strategies and mechanisms that require interaction with others: the behavioural manifestations of ‘Intrapersonal’ psychological factors. Although Interpersonal factors are also inherently social, in this framework we use ‘Social’ to refer to strategies that target social interaction per se rather than the underlying psychological (e.g. trust) and behavioural (e.g. social skills) elements involved in a social interaction. ‘Social’ factors and mechanisms of action are taken to be those that relate to the presence or absence of satisfying intimate and community relationships. We acknowledge that there is overlap between these categories: for example, self-confidence and social skills are individual-level variables but we have focused on their behavioural manifestations and therefore describe these as interpersonal-level characteristics. Similarly, although having ASD is an intrapersonal characteristic, the social difficulties that people with ASD encounter are often to a considerable degree the result of negative societal attitudes and expectations that they will impersonate ‘neurotypical’ behaviour. We therefore categorise the communication challenges and difficulties with ‘neurotypical’ social skills encountered by people with ASD as key contextual factors with regard to loneliness, listing them as ‘Interpersonal’ factors, rather than Intrapersonal ones. Moreover, ‘recognising the shared understanding of peers’ is a psychological change in thinking but has been listed under'Social’ mechanisms because it appears to be a key mechanism of change for ‘Social’ strategies that enhance social support or increase opportunities for social contact, and has thus been included in the ‘Social’ pathway. ‘Sense of belonging’ could similarly be listed as an Intrapersonal factor, but has been listed under ‘Social’ because it is the key contextual factor for strategies that increase opportunities for social contact.

‘Context’ captures variation in possible factors underlying an individual’s loneliness. Consequently, ‘Context’ affects which strategy might be feasible, acceptable and effective for particular individuals. Rather than focusing on specific demographic groups, the synthetic constructs within ‘Context’ represent key causes of loneliness that could result from different combinations of predisposing, precipitating and maintaining factors (Fig. 2 ). For example, a young person may be hospitalised, a refugee, or have recently started university, but all of these experiences could lead to ‘Social Factors: Lack of Close Relationships’. These constructs were drawn out of consultation with the LEAG about possible underlying causes of youth loneliness and formulated with reference to the included published and grey evidence, as well as conceptualisations of loneliness from the broader literature (e.g. the distinction between emotional and social loneliness [ 32 ]). A combination of these factors might precipitate or maintain an individual’s loneliness.

‘Intrapersonal Factors’ include whether anxiety and depression are already present, and psychological barriers associated with loneliness, such as cognitive biases [ 33 ], low interpersonal trust [ 34 ], and low self-esteem [ 35 ]. ‘Interpersonal Factors’ primarily relate to specific groups facing challenges with communication skills, such as those with ASD, or who lack social confidence, such as those with social anxiety, but might be more broadly applicable (e.g. [ 36 ] found that lonely university students reported they felt they lacked social skills). ‘Social Factors’ relate both to lacking or unsatisfactory close emotional relationships with family and friends (‘emotional’ loneliness) and lacking a wider sense of community belonging (‘social’ loneliness), since loneliness can be experienced in relation to one or both of these [ 32 ].

These proximate individual-level factors are seen against the backdrop of wider ‘Socio-economic Factors’. For instance, although Lim et al.’s [ 37 ] recent review and proposed model of loneliness across the life-course reported limited evidence for the impact of socioeconomic status, greater loneliness was found to be associated with lower income, lower educational attainment, having more economic problems, living in poor neighbourhoods and being a migrant. Such factors can create both loneliness and barriers to addressing loneliness (see ‘Barriers’). These Socioeconomic Factors may lead to loneliness via Intrapersonal, Interpersonal and Social Factors and we focus on these potentially mediating factors in this review, due to the need to develop individual-level clinical and social intervention strategies. It is beyond the scope of this current review to address potential socio-political strategies to address socioeconomic inequalities and thus loneliness, but such strategies are likely to play a major role in reducing loneliness and preventing and alleviating anxiety and depression in this age group (and beyond), and research in this area is much needed.

The ‘Content’ (sub)constructs outline six key active ingredients of strategies to reduce loneliness in young people (Fig. 2 ).

Content: co-designed and personalised

The ‘Co-designed and Personalised’ construct highlights both that young people need to be integrally involved in the development and testing of intervention strategies, and that different strategies may work for different individuals, and for the same individual at different times. Co-designed and personalised interventions may be individual or collective, and the key element is that strategies suit each individual and their needs, for example, through a flexible modular approach that might combine individual, dyadic and collective elements. The LEAG highlighted the importance of engaging young people in developing strategies to reduce loneliness and the need to address individual needs and interests. The ability to modify intervention delivery may be a key component of success. For instance, the online platform Entourage uses a participant’s unique strengths profile to personalise therapeutic suggestions for social anxiety, and piloting suggests it has potential for reducing loneliness [ 38 , 39 ]. Different strategies may be needed for different individuals, and over time for the same individual. For example, the LEAG suggested that therapeutic input to manage psychological barriers may subsequently allow better engagement with community-based social opportunities later on. Equally, enhancing meaningful social support may facilitate effective therapeutic processes [ 40 ]. Consequently, effective interventions may require multiple elements, depending on individual ‘Context’.

Content: intrapersonal strategies

In contrast to previous loneliness intervention taxonomies, we do not use the terms ‘changing cognitions’ [ 22 ] or ‘addressing maladaptive social cognition’ [ 21 ] for psychological interventions, in order to encompass a broader range of Intrapersonal Strategies that also included psychoeducation and mood regulation. Eight quantitative studies used some form of ‘Therapy’ (Tables 1 and 2 ). Two interventions for social anxiety involved online or smartphone platforms using positive psychology content designed to improve relationship quality and facilitate social goals [ 39 , 41 ]. Another study looked at cognitive behavioural therapy (CBT) for high school students reporting depressive symptoms and the mediating effect of loneliness [ 42 ], and one looked at the effect of reframing in female college students experiencing loneliness and depression [ 12 ]. Studies looking at young people not explicitly experiencing mental ill-health used in-person interventions and focused on groups potentially at risk of loneliness, such as gay and bisexual [ 43 ] or incarcerated [ 44 ] young men, adolescents at risk of substance abuse presenting at primary care clinics [ 45 ], or ‘runaway’ adolescent girls [ 46 ].

‘Self-help or Personal Strategies’ could include both direct forms, such as therapeutic apps [ 41 ] or self-reflection [ 47 ], and indirect forms, such as exercise or listening to music [ 48 , 49 ]. However, the Co-op Foundation [ 50 ] reported a mis-match between the self-help approaches most widely tried by young people, and subjective reports of what helps. For example, ‘waiting for the feeling to pass’ was not always helpful, and ‘trying to make new friends’ seemed a less reliable way of addressing loneliness than turning to existing friends and family. Young people reported that social media can exacerbate loneliness, for example because a contact failed to respond or connections felt inauthentic [ 51 ]. One intervention involved quitting social media [ 52 ].

Content: interpersonal strategies

Following Masi et al.’s [ 21 ] taxonomy of loneliness interventions, the key Interpersonal Strategy is ‘Improving social skills’. Two interventions for using this approach were delivered to people with ASD [ 53 , 54 ]; in one of these, social skills training was part of an intervention specifically for university students [ 54 ]. It is worth noting that interventions aimed at improving social skills for individuals with ASD have been criticised for promoting ‘neurotypical’ social skills, and that LEAG members identifying as having ASD preferred the term ‘communication challenges’ and emphasised that people with ASD may have different ways of interacting that are not necessarily problematic. The LEAG suggested that social spaces that allowed individuals with ASD to engage socially without having to ‘camouflage’ by adopting ‘neurotypical’ social skills would be highly beneficial. A third, school-based, social skills training intervention was designed to help adolescents with social anxiety [ 13 ].

Content: social strategies

Following Masi et al.’s [ 21 ] taxonomy of loneliness interventions, the key Social Strategies are labelled ‘Enhanced Social Support’ and ‘Increasing Opportunities for Social Contact’. Interventions that ‘Enhanced Social Support’ appeared feasible and acceptable. Approaches included an online peer support forum for university students [ 36 ], a Moderated Anonymous Online Group (MAOG) for young adults not in employment or education [ 55 ], an in-person school-based intervention comparing peer mentorship versus both peer mentors and a staff mental health support team [ 16 ], and in-person peer support groups for homeless youth [ 56 ]. A one-to-one peer support intervention for refugee adolescents involved both in-person and online communication [ 57 ]. In terms of strategies for helping those already experiencing mental ill-health, a case study reported that meaningful close relationships allowed a young woman to engage more fully with therapy for post-traumatic stress disorder [ 40 ].

Meaningful shared activities provided ‘Increasing Opportunities for Social Contact’, as illustrated by the impact of music therapy on hospitalised young people:

“…I don’t feel lonely anymore cause I’m surrounded by people who are all talking or sharing one common thought like what beat are we doing or what is going to come next….” ([ 27 ]: page 59)

Music therapy not only brought participants together, but also created a new activity to share with family [ 27 ]. Equally, engaging with physical education classes and active leisure time was found to be linked with lower perceived social isolation [ 58 ], and part of this benefit may come through engagement with others.

Third sector staff and the LEAG emphasised the importance of creating a variety of accessible ‘safe spaces’ meeting different needs and preferences, including the non-neurotypical social and communication preferences of people with ASD [ 28 , 59 , 60 , 61 ]. Online spaces such as Facebook were not always considered ‘safe’ by young people [ 51 ], and more moderated and specific online spaces may be required (e.g. [ 55 ]). Third sector sources also advocated addressing bullying to reduce youth loneliness [ 62 , 63 , 64 ].

Mechanisms of action: intrapersonal

‘Changing thinking patterns and behaviour’, for example in relation to negative self-perceptions and withdrawal, may be a key mechanism in addressing chronic loneliness. A group intervention for high-schoolers with depression included a focus on replacing negative cognitions with positive ones, as well as on increasing participant involvement in pleasant activities [ 42 ]. Furthermore, the quantitative association found between loneliness and negative attitudes towards aloneness [ 52 ] suggests that reframing such thinking might be a potential intervention target. We did not find interventions focusing on changing social cognitions, such as interpreting ambiguous social stimuli as threatening, despite theoretical grounds for expecting such interventions to be promising [ 33 ].

Another potential psychological mechanism was ‘Building a positive attitude to oneself’, which was given preliminary support as a plausible mechanism by the qualitative literature and was emphasised by the LEAG. Associated qualitative themes included greater self-awareness [ 47 ], self-reliance [ 48 ], self-confidence [ 49 ], and self-efficacy [ 56 ].

Creating a sense of ‘purpose, ownership and control’ might counteract feelings of helplessness about chronic loneliness (LEAG). For example, the CBT-based online Entourage platform uses bespoke therapy comics to help users with social anxiety work towards their goals (e.g. attending a party) using a strength-based approach, alongside support from e-mentors (trained clinicians and peer mentors) who provide opportunities for social connectedness [ 38 , 39 ].

Mechanisms of action: interpersonal

‘Building social skills’ and ‘building social confidence’ are plausible interpersonal mechanisms for reducing loneliness. For instance, participants in an intervention for ASD university students reported:

“Well I figured out…how to change my social skills and little bits and pieces that I didn’t know were actually very negative.” ([ 54 ]: page 25)

“For the first time in my life, my friends from group and I went to [coffee shop]…I’ve had good opportunities from this group to practice good social skills and how to apply them elsewhere.” ([ 54 ]: page 25)

A similar increase in social confidence was echoed for an intervention for homeless youth:

“I’m a bit more outgoing and, like, I’ll go do more things now. I’m not so shy. I used to be really shy. (19-year-old)” ([ 56 ]: page 70)

Mechanisms of action: social

Having meaningful companionship seems to be a key way to alleviate loneliness [ 48 , 51 , 56 , 65 ]. For instance, although social media can be seen as a useful way to maintain contact with family and friends,

[the] sense of connectedness to the world through Facebook dissipates if people cannot establish meaningful communication, beyond greetings. ([ 51 ]: page 11)

The importance of ‘consistent social support’ from a relatable adult to build trust was highlighted by third sector staff [ 28 ] and in the published literature ([ 49 ]: page 182):

“… it was incredibly nice to have an adult I could call when I wanted…”

The Social Mechanisms construct ‘Recognising the shared understanding of peers’ was strongly supported for in-person and online group activities, and relevant to medical students [ 47 ], hospitalised youth [ 27 ], young people with a parent suffering mental ill-health [ 49 ], youth not in education or employment [ 55 ], and university students with depression [ 36 ] or ASD [ 54 ].

“I think it just makes me feel better, just knowing there’s people out there just like me [with ASD]…I know I have people to talk to and people that I can ask for support”. ([ 54 ]: page 25)

In evaluating their intervention, [ 55 ] noted that their Moderated Anonymous Online Groups (MAOGs) should be specific to both location and the young people’s situation, for example having shared experiences of being bullied. Communicating about shared experiences might overcome the barrier of ‘not talking about loneliness’ identified by third sector staff [ 28 , 29 ] and reported for homeless youth [ 65 ] and students [ 48 ]. Finding commonality and belonging with others is likely to help ‘create meaningful relationships’ and ‘build a sense of community’, as well as potentially addressing psychological barriers such as mistrust.

Activities that ‘build social identity’, such as music therapy ([ 27 ]: page 94) or activities that facilitate shared family identity [ 66 ], could plausibly reduce loneliness through increasing feelings of belonging. For instance, a peer-support group for ASD university students facilitated identity-building:

“Trying to find who I am. Trying to figure out my identity. Even with the ASD, the spectrum disorder, knowing that I can pretty much do anything that anyone else can. I just have a back-up system [the support group].” ([ 54 ]: page 25)

A number of third sector and policy sources advocated training of parents, educators, service providers and community members to improve understanding of loneliness and specific needs, for example associated with disability, mental ill-health or particular social and communication needs, as well as anti-bullying campaigns [ 62 – 64 , 67 – 70 ]. The LEAG proposed addressing familial, community and societal stigma related to loneliness and mental ill-health as an important backdrop to individual-level strategies.

Individual hurdles probably mediate whether the strategies outlined above are effective. For example, a mentoring scheme would be inappropriate for someone who is housebound with severe anxiety or depression, but might suit someone with milder symptoms. Individual hurdles to addressing chronic loneliness may include psychological barriers such as not wanting to be a burden and feeling that others do not share the same experiences [ 48 , 49 ], as well as situational factors such as caring responsibilities or work patterns (LEAG). The LEAG also raised being a refugee as being both a risk factor for loneliness (as also reported by [ 37 ]) and a potential barrier to addressing loneliness: for instance, due to language barriers creating challenges to accessing information and engaging with available support and activities, as well as a potential lack of access to employment and the social networks that work can provide, or the financial resources to engage with community activities that provide opportunities for social interaction. Qualitative data suggested that receiving professional therapy might help overcome the barrier of not wanting to be a burden:

“Having somebody external that didn’t know me personally so that I didn’t feel guilty about telling them about what was going on would have really helped me to be able to talk about what I was feeling…” ([ 48 ]: page 24)

Broader practical hurdles include the inaccessibility of services and community assets related to transport, finances, disability, neurodiversity, waiting times, and the digital divide, as well as whether an individual’s interests are catered for locally [ 59 , 60 , 61 , 62 , 68 ]. It is likely that digital exclusion has presented a substantial barrier during the current COVID-19 pandemic. Social hurdles include stigma of both loneliness and mental ill-health, which relates to the tendency to not discuss loneliness [ 28 , 65 ], lack of understanding from service providers [ 59 , 60 , 61 ], and unsupportive home environments (LEAG, [ 29 ]).

Which aspects of interventions may be most effective, and in which combinations?

Through a CIS approach incorporating RRR principles we developed a conceptual framework that can be used to generate testable hypotheses about which strategy(s) might work best for whom and why. The conceptual framework proposes possible pathways through which particular “Context” factors might influence which “Content” is most effective for which group of young people under which circumstances. For instance, it is plausible that if loneliness primarily arises from psychological barriers including anxiety or depression, then therapy may be most effective in reducing loneliness, acting through intrapersonal mechanisms such as changing thinking and behaviour that help build more positive attitudes to self and others and which feed back into reduced anxiety and depression (the ‘Intrapersonal’ pathway). In contrast, if an individual would like support building communication skills or confidence, for example due to ASD, interventions focusing on these needs may be more effective (‘Interpersonal’ pathway). Lacking close relationships might be best addressed through enhancing social support via peer mentors or support groups, whereas a lack of belonging might be alleviated through shared activities such as music-making or sports, all of which can help individuals recognise commonality and build connections with others (‘Social’ pathway).

To complement the CIS-derived framework, in this section we outline the current state of the evidence for the effectiveness of interventions in these ‘Intrapersonal’, ‘Interpersonal’ and ‘Social’ pathways. Convincing assessment of the effectiveness requires fully-powered RCTs. Only nine of the 27 included studies (33%) were randomised controlled trials [ 12 , 13 , 16 , 42 , 44 , 45 , 52 , 53 , 55 ]. Of these, only two report power calculations [ 16 , 44 ]. First, Rohde et al. ([ 44 ]: n  = 109] report an effect size calculation, with this pilot study being powered to detect medium to large effect sizes. However, no significant difference between the CBT Coping Course treatment and control groups of incarcerated young men was found for loneliness, and the significantly greater improvements in externalising scores, self-esteem and reduced suicide-proneness in the treatment group compared to controls showed only small effects sizes (Table 2 ). Second, Larsen et al. [ 16 ] indicate in their study protocol [ 71 ] that a sample of 975 students and 49 classes was needed to detect a small effect size of 0.25. The retained sample size of 1937 high school students in their study suggests that this trial is potentially adequately powered, but they do not report how many classes participated and in their discussion of study limitations the authors report lack of statistical power due to the low number of participating schools ( n  = 17 schools), since the analyses were adjusted for the clustered structure of the data. This study found no effect of the school-based intervention on students’ mental health problems or loneliness, and severity actually increased in all conditions [ 16 ] (Table 2 ). However, girls in the multi-tier group, who received professional support with mental health in addition to having peer mentors and class-based activities that aimed to enhance the psychosocial environment of the school, had a significantly smaller increase in mental health problems compared to girls in the control group [ 16 ]. Both these studies were quality rated as ‘fair’. In summary, the two RCTs that appear to have been sufficiently powered found no significant effect of either intervention on loneliness, thus yielding no evidence for the effectiveness of ‘Intrapersonal’ (CBT Coping Training) or ‘Social’ (improved social support in schools) strategies.

Of the RCTs that did not explicitly report sufficient power, four primarily involved Intrapersonal Strategies (Tables 1 and 2 ). First, undergraduate psychology students with moderate depression receiving a “reframing” intervention were found to experience greater reductions in depressive symptoms than those in “self-control” intervention or control conditions, but loneliness was found to decrease over time irrespective of condition [ 12 ]. The sample size for this study was n  = 57 and it was quality rated as ‘fair’; no effect sizes were reported. Second, it was found that quitting social media sites did not change social or emotional loneliness compared to controls continuing use as usual [ 52 ]. However, this study was quality rated as ‘poor’ ( n  = 77). Moreover, this finding contrasts with an earlier RCT [ 72 ], which found that in a sample of undergraduates ( n  = 143) reduced use, rather than complete cessation, of Facebook, Instagram and Snapchat led to a greater reduction in loneliness and depression than in a ‘behaviour as normal’ control group (please note that this paper was not included in our initial analysis because our quantitative searches aimed to update Loades et al. [ 14 ] and did not include papers before 2020—we thank an anonymous reviewer for bringing this paper to our attention). Third, loneliness significantly decreased in adolescents at risk of alcohol and marijuana use presenting at primary care clinics receiving peer network counselling compared to active controls in a study quality rated as ‘good’ and with a sample size over 100 ( n  = 117), albeit with a minimal effect size [ 45 ]. Fourth, CBT yielded greater reductions in loneliness and depressive symptoms in a group of at-risk adolescents with elevated depression symptoms compared to controls with no effect size reported and a small effect size, respectively, in a ‘good’ quality study with a relatively large sample size ( n  = 341) [ 42 ]. While the findings were mixed regarding Intrapersonal Strategies, it is worth noting that both studies with sample sizes over 100, which were both quality rated as ‘good’, found significant decreases in loneliness after peer network counselling or CBT compared to controls, although effect sizes were small or not reported [ 42 , 45 ].

Two further RCTs examined ‘social skills’ training interventions (Table 2 ). The first was quality rated as ‘fair’ but the authors explicitly identified lack of statistical power as a limitation of their study, and present their findings as preliminary findings from a pilot study: in a group of adolescents with ASD, they found large effect sizes for reductions in loneliness and improvements in ‘social skills’ after social skills training with or without peer supporters compared to waiting list controls ([ 53 ]: n  = 34]. In the second study, which was quality rated as ‘good’, a similar sample size was used ( n  = 35), suggesting that this can also be considered a pilot study: moderate to strong effect sizes were found for greater reductions in social anxiety in participants receiving social skills training compared to waitlist controls, but no difference in loneliness was found between conditions over time [ 13 ]. Pilot findings are therefore mixed regarding Interpersonal Strategies, with some suggestion that ‘social skills’ training maybe particularly useful for young people with ASD in addressing their loneliness.

Regarding Social Strategies, in a quasi-experimental study in which young adults not in employment or education were randomly allocated to either join a moderated anonymous online group or not, no significant changes in quality of life or loneliness were detected ([ 55 ]: n  = 147; quality rated as “fair”) (Table 1 ). Alongside the apparently well-powered school-based RCT described above [ 16 ] (Table 2 ), which did not find any effect on loneliness or mental health of class-based activities, peer mentors or a professional mental health support team, this yields no evidence so far of the effectiveness of Social Strategies for addressing loneliness in young people.

Based on current evidence, the new framework provides exploratory insights into what might help address loneliness in particular contexts and why. The framework should be seen as a provisional library of potential strategies that researchers, in collaboration with young people, clinicians and policy-makers, can use to co-design, develop and test effective strategies for addressing loneliness as an active ingredient in preventing and alleviating anxiety and depression in young people. Interventions that flexibly combine Intrapersonal, Interpersonal and Social approaches may be particularly effective: for example, Entourage combines an individualised online therapeutic platform with e-mentor support [ 38 , 39 ]. Further development and evaluation of approaches that provide both social support and psychological therapy (e.g. [ 39 , 40 ]) is needed, as Intrapersonal and Social strategies may reinforce one another [ 40 ]. Discussion with the LEAG indicated that a certain level of psychological health and confidence was required before engagement with social opportunities became viable, suggesting that Intrapersonal strategies may be a key gateway into other approaches.

The framework builds on previous taxonomies of interventions for loneliness [ 21 , 22 ], which only incorporate a classification of the ‘Content’ of strategies to address loneliness. The purpose of this current review was to also conceptualise both the contextual factors that may determine what individual-level strategies might work for whom, and the potential mechanisms of action that might explain why particular strategies work. Future work should seek to incorporate socio-political-level strategies as well, but this was beyond the scope of this current review. Our new conceptualisation of the Content of strategies to address loneliness maps straightforwardly on to Mann et al’s [ 22 ] categorisation of loneliness interventions for people with mental ill-health, indicating that this typology remains relevant in this specific age group of 14–24-year olds. In the new framework ‘Intrapersonal Strategies’ includes Mann et al.’s ‘changing cognitions’ but also includes psychoeducation, which Mann et al categorise along with ‘social skills training’. The broader label of ‘Intrapersonal Strategies’ used here also incorporates informal self-help strategies. ‘Interpersonal Strategies’ is used to describe Mann et al.’s ‘social skills training’ category. Mann et al. distinguish between ‘supported socialisation or having a socially-focused supporter’ and ‘wider community approaches’, which we have combined into ‘Social Strategies’. However, within our framework we continue to acknowledge this distinction through two sub-constructs that draw on Masi et al.’s classification [ 21 ]: strategies that ‘Enhance social support’ (e.g. involving peers, family, or relatable adults) may best serve deficits in close relationships, whereas ‘Increasing opportunities for social contact’ may best answer a ‘Sense of difference’ or lack of connection to the wider community. However, we combined these two approaches because we hypothesis that they likely act through common ‘Social Mechanisms’. These potential mechanisms can themselves be targeted in future intervention development.

We reviewed outcome findings for RCTs in order to assess effectiveness of these different types of strategies. The lack of reported power calculations for most studies limits the strength of the conclusions that can be drawn. Although findings were mixed, the most convincing evidence was found in support of Intrapersonal Strategies: two studies with sample sizes over 100, which were both quality rated as ‘good’ but did not report power calculations, found significant decreases in loneliness after peer network counselling (for adolescents at risk of alcohol and marijuana use presenting at primary care clinics) or CBT (in adolescents with elevated depression symptoms) compared to controls, although effect sizes were small or not reported [ 42 , 45 ]; CBT was also found to decrease depressive symptoms [ 42 ]. However, a third RCT that seemed to be fully powered failed to find an effect of CBT Coping Training on loneliness in a sample of incarcerated young men despite finding improvements in externalising scores, suicide-proneness and self-esteem [ 44 ]. Pilot findings were also mixed regarding Interpersonal Strategies, with some suggestion that training on developing social skills maybe useful for young people with ASD in addressing their loneliness [ 53 ], but perhaps not those with social anxiety [ 13 ]. However, there was some concern in the LEAG that such interventions for ASD may promote only ‘neurotypical’ social skills and that societal attitudes and expectations also need to be addressed to help reduce loneliness in individuals with ASD. No evidence was found in support of the effectiveness of Social Strategies for addressing loneliness in young people [ 16 , 55 ].

An important finding from this review is that creating opportunities for young people to engage with others with similar experiences is a key Social Mechanism for addressing loneliness, perhaps alongside more targeted social skills training (e.g. [ 54 ]: for university students with ASD, likely involving Interpersonal Mechanisms) or therapy to overcome psychological barriers such as self-stigma (e.g. [ 43 ]: for gay and bisexual young men, which may be transferable to other demographics, and likely involves Intrapersonal Mechanisms). Social skills and confidence may also develop inadvertently in group-based interventions, and social confidence may come not only from greater assurance in the individual’s own ability to socialise, but also in greater trust that others will respond positively. The most prominent social hurdle raised by the LEAG was stigma attached to both loneliness and mental ill-health (as well as stigma related to other experiences, such as having ASD or low socioeconomic status), which may hint at why ‘Recognising the shared understanding of peers’ seemed so powerful as a potential mechanism of action.

Despite the evidence for associations between loneliness and youth anxiety and depression [ 14 ], few studies directly tested whether reductions in loneliness also reduced anxiety or depression, or the mechanisms by which this might occur. Given the clear role of identity and sharing experiences in reducing loneliness, interventions such as Groups4Health [ 73 , 74 ], which aim to build stronger social identities, might be particularly promising. No interventions for loneliness were found addressing societal stigma or incorporating the built environment, and these were flagged as important areas to address (LEAG, expert panel, [ 64 , 67 , 68 , 69 , 70 ]). Given the importance of familial social support for adolescents [ 75 ], interventions to improve such relationships might also be helpful. Equally, cognitive biases such as hypersensitivity to social threat are known to be associated with loneliness [ 33 ], yet no psychological interventions were found addressing these specifically in relation to loneliness (i.e. with loneliness as a measured outcome) for this age group. There are likely to be a number of promising interventions that were not included in this review because they did not aim to target loneliness specifically but could nonetheless yield reductions in loneliness for young people, for instance through targeting a related social construct. One such promising intervention [ 76 ] aimed to modify social appraisals by targeting university students’ sense of belonging (a concept related to loneliness and part of the ‘Social’ pathways in the conceptual framework presented here). This study found that African American university students who were randomly assigned to an intervention in which they reframed feelings of not belonging as shared and transitory, being a natural part of starting at college rather than due to their minority status, were found to have improved health and wellbeing compared to controls [ 76 ]. Such findings suggest that changing social cognitions in this age group may also help in reducing at least social loneliness, which is linked to not feeling part of a wider community. Only one of the included studies specifically targeted young people who were lonely [ 48 ], whereas others recruited those who might be at risk of loneliness, and none of the studies distinguished chronic from transitory loneliness so our framework pertains to loneliness in general [ 17 ]. Broader community-level or societal approaches that aim to improve education attainment, raise household income and build neighbourhood assets may also have downstream effects on reducing loneliness and improving mental health, since these socioeconomic factors are associated with increased loneliness [ 37 ]. Future work could expand the conceptual framework presented here to incorporate such approaches, which were outside of the current remit, which was to identify potential approaches to incorporate in clinical and social interventions at the individual level.

A strength of this review was the novel methodology: we critically synthesised diverse strands of evidence collated through a robust and iterative search and extraction strategy involving independent raters, and incorporated rapid realist review principles to ensure policy and practice relevance. We included coping strategies as well as formal interventions to gain a wider perspective on what might help young people overcome loneliness. Another distinctive strength is that we not only consulted with young people with relevant lived experience but also a cross-disciplinary panel of academic experts that included perspectives from neuroscience, the built environment, arts and health, social work and digital technology, and which complements the strong clinical psychology and psychiatry expertise in our author team. However, some disciplines pertinent to loneliness in young people were not represented, such as sociology, social psychology and experts on complex interventions, which may have limited the scope of the evidence and biased the framework to some extent.

A limitation was that despite the iterative nature of our search strategy and consultation of experts from diverse disciplines, we may have missed relevant studies. In particular, we relied on three recent reviews [ 11 , 14 , 17 ], two of which were both published within 6 months of our searches [ 14 , 17 ], to provide quantitative studies, which we supplemented with updated searches based on the protocol of the most recent review, which specifically looked at loneliness and mental health in young people [ 14 ]. A downside of this is that any quantitative papers that were missed in these previous reviews will also be missing from this one. Nonetheless, we employed consultation with academic experts to try to minimise the likelihood of missing key papers. We did not rely on previous reviews for published qualitative studies or grey literature. We also focused specifically on interventions to reduce loneliness, and therefore do not include interventions targeting related social constructions, which may also yield reduced loneliness. Broadening the proposed framework to include related social constructs, such as belonging, is an area for future research. We consulted 18–24-year olds and although LEAG members drew on their adolescent experiences, young adults may not be aware of current barriers and opportunities facing younger age groups in a rapidly changing social environment. CIS includes studies on the basis of relevance rather than quality, meaning the synthesised evidence was limited by study quality (Supplementary Table S2 ), particularly since we included grey literature evidence that was not peer-reviewed. However, constructs supported by academic studies were associated with at least one study rated as ‘fair’ or ‘good’ or with COREQ scores over 70% (Fig. 2 ). Furthermore, we focused our discussion of outcomes on RCTs as only this study design can contribute meaningfully to understanding the effectiveness of interventions. The limited number of good quality RCTs indicate that more fully-powered RCTs are required in relation to all the constructs. Nonetheless, by triangulating diverse academic evidence and a wealth of lived and professional experience, we developed a single coherent framework in order to facilitate researchers, practitioners and policy-makers in thinking about what might help or not help young people to address loneliness in different contexts, as an active ingredient in preventing or alleviating anxiety and depression.

Commentary written by young people with lived experience

The LEAG agreed that improving loneliness can be an active ingredient in preventing and reducing youth depression and anxiety. Despite individual differences between whether loneliness or mental ill-health arose first, there was general agreement that loneliness and depression/anxiety are interlinked and can feed into each other.

The developed framework aligns with the experiences of the group and the co-designed, individualised construct in particular resonated with members, who emphasised the importance of personalised strategies. The LEAG highlighted that individuals should have more agency when engaging in mental health interventions, have their voices heard and challenge ideas provided from the services. The LEAG also expressed frustrations surrounding a lack of communication between services, highlighting the importance of transitions and treating the individual rather than a set of symptoms.

The group agreed that activities which build self-esteem, social skills and confidence are essential in reducing loneliness, but felt that practical and social barriers affect this: for example, lack of socioeconomic accessibility and stigma. The group identified these barriers as often occurring together, creating further obstacles in alleviating their loneliness. For those with chronic loneliness or depression, the experience may become the individual’s identity. As a result, treatments focusing on developing an alternative identity may be a promising avenue for reducing chronic loneliness.

Along with those presented in the study, having a meaningful job was added as providing purpose, helping reduce loneliness and improving mental health. Denial about illness and a lack of mental health interventions were also suggested as further intrapersonal barriers.

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Acknowledgements

The following academic experts, all co-investigators of the Loneliness and Social Isolation in Mental Health Research Network, provided feedback on the search protocol based on their diverse fields of expertise: Essi Viding (cognitive neuroscience), Rosie Perkins (arts and health), Bryn Lloyd-Evans (social work), Laura Vaughan (built environment), James Kirkbride (epidemiology, focusing on social determinants of mental health), Alexandra Pitman (epidemiology, focusing on suicide), John Vines (digital technology), Sarah Carr (policy), David McDaid (health economics), and Evangelia Chrysikou (built environment). Prisha Shah, a member of the Network lived experience Co-Production Group, also provided feedback on the protocol. Alice Eccles and Tim Matthews, experts in youth loneliness, were consulted about further (un)published studies to complement our searches, and Adriana Ortegon kindly provided a subset of potentially relevant academic papers from a systematic search on built environment interventions for youth mental and physical health. We would also like to thank Olga Perski, who gave advice on conducting a Critical Interpretive Synthesis review. We would like to thank non-author members of the Lived Experience Advisory Group (LEAG) for their invaluable input into this project: Alex Adams, Heather Campbell, Alyssa Eden, Abi Haynes, Anna Mason, Lucas Melvin, Lizzie Mitchell, Emily Muir, Bushra Nawaz, Lucy Power, Keerthi Ramesh, Shreena Shah, Kris Taneva, and one member who wished to remain anonymous.

This work was commissioned by The Wellcome Trust as part of their Active Ingredients mental health programme ( https://wellcome.ac.uk/what-we-do/our-work/mental-health-transforming-research-and-treatments/strategy ). The authors are members of the UKRI-funded Loneliness and Social Isolation in Mental Health Research Network (grant number ES/S004440/1), which is led by SJ, coordinated by EP, and of which RS is a co-investigator.

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EP, RS, GA and SJ conceived the research. PM-H, EH, SO, and DC undertook searches, screening, data extraction and quality assessment for the academic literature, and SMAP conducted searches and extracted data for the third sector website searches. HAC provided technical support for the searches. EP led on framework development with input from the other authors. SS, MP, GJ, and JM wrote the lived experience commentary. All authors contributed to the manuscript.

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Pearce, E., Myles-Hooton, P., Johnson, S. et al. Loneliness as an active ingredient in preventing or alleviating youth anxiety and depression: a critical interpretative synthesis incorporating principles from rapid realist reviews. Transl Psychiatry 11 , 628 (2021). https://doi.org/10.1038/s41398-021-01740-w

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The prevalence of loneliness across 113 countries: systematic review and meta-analysis

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We need a public health approach to loneliness

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• Peer review
• Daniel L Surkalim , doctoral student 1 2 ,
• Mengyun Luo , doctoral student 1 2 ,
• Robert Eres , postdoctoral research fellow 3 4 ,
• Klaus Gebel , senior lecturer 5 ,
• Joseph van Buskirk , research fellow 1 ,
• Adrian Bauman , emeritus professor 1 2 ,
• Ding Ding , associate professor 1 2
• 1 Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
• 2 Charles Perkins Centre (D17), The University of Sydney, Camperdown, NSW, 2006, Australia
• 3 Neurodisability and Rehabilitation, Murdoch Children’s Research Institute, Royal Children’s Hospital, Parkville, VIC, Australia
• 4 Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia
• 5 Australian Centre for Public and Population Health Research, School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
• Correspondence to: D Ding melody.ding{at}sydney.edu.au
• Accepted 15 December 2021

Objectives To identify data availability, gaps, and patterns for population level prevalence of loneliness globally, to summarise prevalence estimates within World Health Organization regions when feasible through meta-analysis, and to examine temporal trends of loneliness in countries where data exist.

Design Systematic review and meta-analysis.

Data sources Embase, Medline, PsycINFO, and Scopus for peer reviewed literature, and Google Scholar and Open Grey for grey literature, supplemented by backward reference searching (to 1 September 2021)

Eligibility criteria for selecting studies Observational studies based on nationally representative samples (n≥292), validated instruments, and prevalence data for 2000-19. Two researchers independently extracted data and assessed the risk of bias using the Joanna Briggs Institute checklist. Random effects meta-analysis was conducted in the subset of studies with relatively homogeneous research methods by measurement instrument, age group, and WHO region.

Results Prevalence data were available for 113 countries or territories, according to official WHO nomenclature for regions, from 57 studies. Data were available for adolescents (12-17 years) in 77 countries or territories, young adults (18-29 years) in 30 countries, middle aged adults (30-59 years) in 32 countries, and older adults (≥60 years) in 40 countries. Data for all age groups except adolescents were lacking outside of Europe. Overall, 212 estimates for 106 countries from 24 studies were included in meta-analyses. The pooled prevalence of loneliness for adolescents ranged from 9.2% (95% confidence interval 6.8% to 12.4%) in South-East Asia to 14.4% (12.2% to 17.1%) in the Eastern Mediterranean region. For adults, meta-analysis was conducted for the European region only, and a consistent geographical pattern was shown for all adult age groups. The lowest prevalence of loneliness was consistently observed in northern European countries (2.9%, 1.8% to 4.5% for young adults; 2.7%, 2.4% to 3.0% for middle aged adults; and 5.2%, 4.2% to 6.5% for older adults) and the highest in eastern European countries (7.5%, 5.9% to 9.4% for young adults; 9.6%, 7.7% to 12.0% for middle aged adults; and 21.3%, 18.7% to 24.2% for older adults).

Conclusion Problematic levels of loneliness are experienced by a substantial proportion of the population in many countries. The substantial difference in data coverage between high income countries (particularly Europe) and low and middle income countries raised an important equity issue. Evidence on the temporal trends of loneliness is insufficient. The findings of this meta-analysis are limited by data scarcity and methodological heterogeneity. Loneliness should be incorporated into general health surveillance with broader geographical and age coverage, using standardised and validated measurement tools.

Systematic review registration PROSPERO CRD42019131448.

Introduction

Humans thrive on meaningful social connections. Feelings of loneliness set in when a discrepancy exists between one’s desired and one’s actual level of social relationships. 1 Loneliness is a negative, subjective experience 2 closely linked to the quality of social connections. 3 Loneliness is similar to, but distinct from, social isolation, which is defined as a lack of social contacts, and being alone, characterised as being physically removed from social connections. 4 Transient loneliness is a common experience, 5 but chronic or severe loneliness pose threats to health and wellbeing.

Growing evidence has linked loneliness to various adverse health outcomes. Loneliness is associated with unfavourable cardiovascular health indicators, such as increased activation of the hypothalamic-pituitary-adrenal axis, 6 high blood pressure, increased cholesterol levels, 2 7 and coronary heart disease. 8 Loneliness is associated with sleep disturbance 9 and increased risk of mild cognitive impairment and dementia. 10 Loneliness may also be detrimental to behavioural, mental, and social health throughout the lifespan, 2 influencing outcomes such as substance misuse, suicidal ideation, 11 anxiety, depression, 12 and poor subjective wellbeing. 7 According to a 2015 meta-analysis, people with chronic loneliness had a 26% increased risk of mortality. 13 This increased risk is comparable to established risk factors such as physical inactivity 14 and grade 1 obesity. 15

Culture affects levels of loneliness. 16 Individualism-collectivism has been long considered an important cultural determinant of loneliness. 17 A recent conceptual model 2 postulated that risk factors, such as age, interact with triggering events, such as retirement, resulting in feelings of loneliness. Considering that some well established risk factors of loneliness, such as depression 18 and chronic disease, 19 are increasing, and that triggering events are part of life (eg, the covid-19 pandemic), it is likely that these risk factors would impact the prevalence of loneliness. Accordingly, loneliness is increasingly recognised as an important health and social issue, with some health professionals, including former US surgeon general Vivek Murthy, labelling it as an epidemic. 20 In 2018, the United Kingdom appointed the world’s first minister for loneliness. Worldwide, initiatives have been launched to address “the epidemic of loneliness.” 21 22 23

With loneliness now defined as a public health problem, 24 25 tackling it requires public health approaches, which begin with defining the magnitude and distribution of the problem through surveillance. 26 A recent estimate suggests that one third of the population in industrialised countries experience loneliness, and one in 12 people experiences loneliness at a problematic level 25 ; however, the basis of this estimate is unclear. Understanding the prevalence of loneliness globally can help decision makers gauge the scope and severity of the problem. In light of the covid-19 pandemic, summarising the global prevalence of loneliness before the pandemic would help to identify a prepandemic baseline for subsequent monitoring. Identifying data gaps would also help to inform research endeavours and public health surveillance. In our systematic review and meta-analysis we identified data availability, gaps, and patterns for population level prevalence of loneliness among different age groups globally. We summarised and compared available prevalence estimates within World Health Organization regions when feasible through meta-analysis, and examined temporal trends of loneliness in countries with data.

Protocol and data sources

Our reporting conforms to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. 27 The reporting of meta-analysis conforms to the meta-analyses of observational studies in epidemiology (MOOSE) checklist. 28

We searched for scientific literature published in any language using Embase, Medline, PsycINFO, and Scopus, supplemented by searching the grey literature using Google Scholar and Open Grey up to 1 September 2021. Search terms included “loneliness”, “social isolation”, and “prevalence”, as well as other medical subject headings, truncations, and adjacent operators (supplementary table S1). After duplicates had been removed, additional literature was identified through backwards reference searching.

Eligibility criteria

Studies were included if they were observational, reported prevalence of loneliness, included data from January 2000 to December 2019 (pre-covid-19 pandemic), and had nationally representative study samples. To ensure population representativeness and comparability across estimates, we excluded studies if the sampling frame or process was inappropriate for assessing the general population 29 (eg, university students), the sample size was smaller than 292 (calculated using the formula by Naing et al, 30 with an expected prevalence of 5%), the measurement instrument was not validated, and the prevalence of chronic or severe loneliness could not be obtained (eg, studies asked about transient loneliness, which is a common experience and not at a problematic level).

Study selection and data extraction

References were imported into Endnote (Philadelphia, version X8.2) and duplicates removed. Two reviewers (DS, ML) independently screened articles by title and abstract followed by full text and independently extracted study characteristics, including author, population, country, study design, sample size, measurement instrument of loneliness (type, time frame, and operational definition or cut-off points), prevalence estimate, funding role, and conflicts of interest. Disagreements were discussed with a third reviewer (DD) until consensus was reached. Inter-rater agreement was high (94% for study selection and 93% for data extraction). When information was missing or ambiguous, we searched for related publications or emailed the authors. When estimates were non-comparable between studies, such as different definitions of loneliness (eg, feeling lonely “often” or “very often”), we tried to harmonise measures by manually recalculating prevalence based on available information or asking the authors to recalculate the prevalence. Risk of bias was assessed based on the Joanna Briggs Institute critical appraisal checklist for prevalence studies, 31 which is recommended by the Systematic Review Methodology Group for critical appraisal of studies reporting prevalence data. 32 Two authors (DS and DD) independently assessed risk of bias, with 91% inter-rater agreement. Differences were resolved by discussion.

Measures of loneliness

Scale and single item instruments were used to measure loneliness. Because estimates based on the two types of measures were not directly comparable, we summarised prevalence separately. Loneliness is a common experience, thus we excluded transient experiences of loneliness 5 and focused on problematic loneliness, defined by severity (eg, moderate to severe) or chronicity (eg, feeling lonely all the time, usually, or often).

Scale measures

All selected studies with a scale measure used either the University of California Los Angeles (UCLA) Loneliness Scale 33 or the de Jong Gierveld Loneliness Scale 34 ; both have shown good internal consistency, test-retest reliability, and convergent and discriminant validity. 35 The de Jong Gierveld scale measures both emotional and social loneliness but can also be used as a unidimensional construct. 34 Abbreviated versions have been validated for both scales and correlate strongly with their respective original versions. 34 36 Although certain cut-off points are more commonly used than others, such as ≥6 for the three item UCLA Loneliness Scale, different cut-off points have been selected by authors based on various rationales. We have summarised the cut-off points, documented the differences, and extracted prevalence estimates based on the original cut-off points.

Single item direct measures

Single item direct measures are the most commonly used assessment tools of loneliness. 37 Questions were usually worded as “How often do you feel lonely?,” with non-substantial variations across studies. Different single item instruments have specified different recall periods, such as in the past week or year, although some did not specify a recall period and asked about general experience. Previous studies found that single item direct measures of loneliness had a moderate correlation with the UCLA Loneliness Scale 38 and the de Jong Gierveld Loneliness Scale. 39

Data synthesis

Narrative review.

For all studies we summarised study characteristics, including country, study name, sample size, response rate, sample characteristics (age and sex), and conflict of interest. To demonstrate data availability and gaps, we used MapChart.net to map the availability of classification of country level prevalence of loneliness separately for four age groups (adolescents (12-17 years), young adults (18-29 years), middle aged adults (30-59 years), and older adults (≥60 years); fig 1 ). For studies that applied a scale measure, we tabulated the measurement instrument of loneliness (eg, 20 item UCLA Loneliness Scale, six item de Jong Gierveld Loneliness Scale), country level prevalence of loneliness, and the cut-off points for loneliness at a problematic level. For studies that applied a single item direct measure of loneliness, we summarised the time scale such as past week or year, and the operational definition of loneliness, such as feeling lonely “all the time” or “most of the time.”

International estimates for prevalence of loneliness by age groups

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We summarised data separately for adolescents (12-17 years), young adults (18-29 years), middle aged adults (30-59 years), and older adults (≥60 years). These age categories reflected the sample characteristics of most studies, although the specific age range could differ. When age categorisations were different from our defined categories, we recalculated age specific prevalence to best match our overall categories. For example, if a study reported the prevalence of loneliness for those aged 60-79 and ≥80 years separately, we recalculated the prevalence for all adults aged ≥60 years based on information presented in the study or obtained through contacting the authors. Similarly, if a study reported loneliness prevalence by sex only, we recalculated prevalence for males and females combined using available or additionally obtained information. Because most studies only reported point estimates for prevalence of loneliness nationally, we used a logit transformation 40 to obtain pooled variance estimates to calculate 95% confidence intervals. Finally, we narratively summarised studies that reported multiple measures of loneliness using identical sampling frames, procedures, and instruments over time.

Meta-analysis

Meta-analysis was conducted for relatively similar studies whenever feasible. We pooled prevalence estimates from studies that applied the same or comparable measures, followed similar study protocols (eg, Global School-Based Student Health Survey), and included similar samples (eg, adolescent school students). In cases when multiple studies reported estimates of loneliness prevalence using identical samples, measures, and surveys, we only included the estimate with the largest analytical sample in the meta-analysis, to avoid double counting. Whenever possible we pooled estimates within WHO regions (Africa, the Americas, Eastern Mediterranean, Europe, South-East Asia, Western Pacific) and conducted subgroup analysis based on the World Bank classification of country income group (low, lower middle, upper middle, and high income countries). For Europe, considering the smaller variability in country income level and the established evidence on geographical difference, particularly the divide between east and west, 41 42 we conducted subgroup analysis based on modified geographical region classification by the United Nations standard country or area codes for statistical use (M49; https://unstats.un.org/unsd/methodology/m49/ ), which classified the WHO European region further into northern, southern, eastern, and western Europe, and central and western Asia. For pooled estimates of prevalence and variance, both overall and in subgroups, we used generalised linear mixed effects models with random intercepts by subgroup. 40 This approach has been used in about 94% of recent meta-analyses of prevalence estimates. 43 Binomial-normal models were specified to allow for the calculation of pooled proportion estimates. We conducted additional sensitivity analyses using a double arcsine transformation 44 to pool prevalence estimates, and reported both τ 2 and I 2 statistics to describe heterogeneity. 45 The τ 2 estimates between study variability, whereas I 2 refers to the proportion of the total variance between studies as a result of “true” variance between populations. 46 47 Meta-analysis was performed in R (version 4.0.3).

Patient and public involvement

Patients and members of the public were not involved in the design and execution of the study. However, we plan to engage the public in the dissemination of our findings, including media coverage, social media engagement, newsletters, and public talks and presentations.

The initial database search yielded 7290 records. After the removal of duplicates, the title and abstract of 2853 were screened, resulting in 194 articles for full text screening. Supplementary figure S1 lists the reasons for exclusion, and supplementary table S2 provides further explanations. Two additional articles were identified through reference searching and three through searches of grey literature. Data on prevalence were extracted from 57 studies for 113 countries or territories.

Data availability

Eleven studies (nine using the UCLA Loneliness Scale, two using the de Jong Gierveld Loneliness Scale) provided 30 scale based prevalence estimates for 16 countries, and 46 studies provided 295 estimates for prevalence of loneliness measured by single item instruments for 110 countries or territories (supplementary table S3). Across measures, the prevalence of loneliness was identified for adolescents in 77 countries or territories, young adults (18-29 years) in 30 countries, middle aged adults (30-59 years) in 32 countries, and older adults (≥60 years) in 40 countries (supplementary table S4). Of those, 212 estimates for 106 countries from 24 studies were included in meta-analyses (supplementary table S5). Supplementary tables S6 and S7 summarise the characteristics of each study. Overall, data showed disparities in loneliness research and surveillance across regions ( fig 1 ) and age groups; while data on adolescents were available across all WHO regions—primarily through the Global School-Based Student Health Survey, data on adults, particularly younger and middle aged adults, were mainly concentrated in Europe.

Risk of bias assessment

All included studies scored 5-9 out of 9 based on the Joanna Briggs Institute checklist (supplementary table S8). Although all studies met criteria 1 (sampling frame), 3 (sample size), 6 (valid measures), and 7 (standardised measures) as part of this review’s inclusion criteria, only eight studies (14%) met criterion 8 (appropriate statistical analysis), mainly because of missing confidence intervals. Around half of the studies (49%) reported using random probabilistic sampling (criterion 2), whereas the rest did not provide sufficient information on participant recruitment procedures.

Except for one Australian study 48 and two American studies, 49 50 all studies using scale based measures focused on older adults (supplementary table S9). In the meta-analysis of estimates for older adults in 12 countries based on the six item de Jong Gierveld Loneliness Scale, 42 51 prevalence of loneliness showed a clear geographical pattern ( fig 2 ), with much lower estimates in western European countries (pooled estimate 11.1%, 95% confidence interval 9.3% to 13.2%) than eastern European countries (27.7%, 21.2% to 35.3%). Subgroup effect was statistically significant (P<0.01); however, variance between studies was high in western and eastern European countries (τ 2 =0.047 and 0.224, respectively, P<0.01), with this variance mostly related to true differences between populations (I 2 =94% and 99%, respectively). In the meta-analysis of 13 estimates derived from the three item UCLA Loneliness Scale for older adults (including subgroup analysis based on different cut-off points), 52 53 54 55 56 four countries (England, Poland, Spain, and US) had estimates ranging from 9% to 19%. A fifth country, Finland, had a reported prevalence of 5.9% (95% confidence interval 4.7% to 7.2%). No subgroup effect by cut-off point was significant (P=0.91). Variance between studies was high overall and in subgroups with the same cut-off points.

Meta-analysis of loneliness prevalence using scale based measures (de Jong Gierveld Loneliness Scale, six item version, and University of California Los Angeles (UCLA) Loneliness Scale, three item version) in older adults (≥60 years). *Thresholds of five or six were applied. Generalised linear mixed effects models with binomial-normal distribution were used. Norway is included as part of western Europe owing to the lack of data from other northern European countries

Single item measures

Adolescents —Twenty eight studies reported 132 prevalence estimates of loneliness for adolescents in 76 countries (supplementary table S10). Of these, 76 estimates for 68 countries across 17 studies were included in meta-analysis ( fig 3 , fig 4 , fig 5 , fig 6 ), nearly all from the Global School-Based Student Health Survey. Five meta-analyses were conducted, one for each of the following WHO regions: Africa (five studies, 57 58 59 60 61 11 countries), the Americas (five studies, 62 63 64 65 66 26 countries), Eastern Mediterranean (two studies, 58 67 10 countries), South-East Asia (five studies, 58 68 69 70 71 nine countries), and Western Pacific (four studies, 58 71 72 73 12 countries). A meta-analysis was not performed for Europe owing to fewer comparable measures across a small number of countries with prevalence data for this age group. Pooled prevalence estimates ranged from 9.2% (95% confidence interval 6.8% to 12.4%) in South-East Asia to 14.4% (12.2% to 17.1%) in the Eastern Mediterranean. High heterogeneity was observed in all regions, indicated by high τ 2 and I 2 . Subgroup analysis showed no clear patterns by country income level, although a significant subgroup effect by country income group was detected in Africa and the Americas (P<0.05).

Meta-analysis of loneliness prevalence based on single item measures in adolescents (12-17 years) by World Health Organization Africa region. Generalised linear mixed effects models with binomial-normal distribution were used

Meta-analysis of loneliness prevalence based on single item measures in adolescents (12-17 years) by World Health Organization The Americas region. Generalised linear mixed effects models with binomial-normal distribution were used

Meta-analysis of loneliness prevalence based on single item measures in adolescents (12-17 years) by World Health Organization Eastern Mediterrean and South-East Asia regions. Generalised linear mixed effects models with binomial-normal distribution were used

Meta-analysis of loneliness prevalence based on single item measures in adolescents (12-17 years) by World Health Organization Western Pacific region. Generalised linear mixed effects models with binomial-normal distribution were used

Young adults —Five studies reported 34 prevalence estimates for young adults (18-29 years) in 30 countries ( fig 7 ). After removing one duplicate (same estimate reported by two studies 74 75 ), 33 estimates were meta-analysed. All but two estimates 39 76 came from two multicountry studies: the Europe and Health in Times of Transition study 77 and the European Social Survey. 74 The overall pooled prevalence estimate was 5.3% (4.4% to 6.4%), although dispersion was high (τ 2 =0.280, P<0.01). When stratification was by the United Nations regional classification, dispersion reduced, although a large proportion remained owing to true variance between populations (I 2 range 44-85%). A statistically significant subgroup difference was detected (P<0.01), with pooled prevalence being the highest in eastern Europe (7.5%, 5.9% to 9.4%) and the lowest in northern Europe (2.9%, 1.8% to 4.5%).

Meta-analysis of loneliness prevalence based on single item measures in young adults (18-29 years) in Europe. Generalised linear mixed effects models with binomial-normal distribution were used. *Unspecified recall period; past week otherwise. †Includes Israel. ‡Includes Georgia

Middle aged adults —Four studies reported 36 prevalence estimates for middle aged adults (30-59 years) in 32 countries ( fig 8 ). Similar to studies for young adults, all estimates came from European countries, and all but one 39 came from the Europe and Health in Times of Transition study 77 (nine countries) and the European Social Survey 74 (additional 23 countries). After excluding one duplicate estimate, 75 35 estimates for 32 countries were meta-analysed. 39 74 77 The pooled prevalence estimate was 6.9% (5.6% to 8.6%), with high dispersion (τ 2 =0.483, P<0.001). Subgroup difference was significant (P<0.01), where the pooled prevalence was the lowest in northern Europe (2.7%, 2.4% to 3.0%) and highest in eastern Europe (9.6%, 7.7% to 12.0%) and central and western Asia (9.8%, 5.1% to 18.0%).

Meta-analysis of loneliness prevalence based on single item measures in middle aged adults (30-59 years) in Europe. Generalised linear mixed effects models with binomial-normal distribution were used. *Unspecified recall period; past week otherwise

Older adults —Seventeen studies reported 93 prevalence estimates for 38 countries, including 30 European countries and eight non-European countries ( fig 9 ). A total of 43 estimates from 30 European countries were included in meta-analysis. All but two estimates 39 78 came from large multicountry studies: the Europe and Health in Times of Transition study, 77 the European Social Survey, 74 and the Survey of Health, Ageing, and Retirement in Europe. 79 Overall dispersion was high (τ 2 =0.461, P<0.01). Although less variability was shown within geographical subgroup, the proportion of observed variance due to true differences between populations remained high (I 2 range 78-89%). Subgroup difference was significant (P<0.01), where northern European countries had the lowest pooled prevalence (5.2%, 4.2% to 6.5%), followed by western Europe (8.7%, 7.3% to 10.5%), southern Europe (15.7%, 13.2% to 18.7%), and eastern European countries had the highest prevalence of loneliness (21.3%, 18.7% to 24.2%).

Meta-analysis of loneliness prevalence based on single item measures in older adults (≥60 years) in Europe. Generalised linear mixed effects models with binomial-normal distribution were used. *Includes Israel. †Includes Georgia. ‡Unspecified recall period; past week otherwise

Sensitivity analysis

For meta-analysis of loneliness prevalence in younger, middle aged, and older adults in Europe, additional analysis was conducted using the World Bank country income group for subgroups. For young adults, no evidence was found for statistically significant subgroup differences (P=0.35) (supplementary figure S3). For middle aged and older adults (both using the de Jong Gierveld Loneliness Scale and single item measures), high income European countries had a lower pooled prevalence than middle income European countries, and the subgroup difference was statistically significant (supplementary figures S2, S4, S5). Additional sensitivity analysis using the Freeman-Tukey double arcsine transformation approach to meta-analyses resulted in nearly identical findings 80 (supplementary figures S6-10).

Temporal trends in loneliness

Four studies reported multiple comparable prevalence estimates of loneliness based on repeated cross sectional surveys. One study in Danish school children (11-15 years old) found that the prevalence of loneliness increased from 4.4% (95% confidence interval 3.4% to 5.4%) in 1991 to 7.2% (6.4% to 8.0%) in 2014 (P<0.001 for trend). 81 Similarly a significant and steady increase in loneliness was found in Norwegian secondary school children, from 9.0% (95% confidence interval 8.5% to 9.5%) in 2014 to 12.1% (11.7% to 12.5%) in 2018 (P<0.001). 82 Additionally, a study found no change in loneliness prevalence among adolescent school students between 2005 and 2016 in the United Arab Emirates (P>0.05). 67 Finally, a study in adults aged 77 years or older in Sweden found no significant trend in prevalence of loneliness from 1992 to 2014 (P=0.71). 83

Based on data from 113 countries or territories during 2000-19, we found that loneliness at a problematic level is a common experience worldwide. We further identified important data gaps and substantial geographical variation in loneliness. Considering the physical, mental, and social health consequences of loneliness, our study findings reinforce the urgency of approaching loneliness as an important public health issue. 24 25

Although 113 countries or territories reported some data on loneliness prevalence, globally there is still a dearth of data across broader geographical areas. International surveillance systems, such as the Global School-Based Student Health Survey, are important for priority setting, benchmarking progress, and cross country comparisons. The Global School-Based Student Health Survey has provided valuable data for loneliness in children and adolescents in 67 countries or territories, most of which are low and middle income countries. Disparities still exist in data availability across WHO regions and country income levels. While Europe is leading in loneliness research and surveillance with a wealth of data sources, such as the Survey of Health, Ageing, and Retirement in Europe, the European Social Survey, and the Europe and Health in Times of Transition study, other regions and most low and middle income countries have much less data coverage. Importantly, no low income countries and only five of all 47 lower middle income countries have reported any nationally representative data on loneliness in adults. Such data gaps might be a result of limited resources and competing priorities from issues deemed more urgent, such as food security, housing, and basic provision of medical services. 84

Data on loneliness prevalence is also lacking for young and middle aged adults, compared with adolescents and older adults. Such data gaps could be driven by the widely held belief that middle aged adults are the least susceptible to loneliness, and that young and old people are particularly vulnerable because of the changes experienced during these life stages. 85 Although our meta-analysis based on European data suggests that young and middle aged adults have a lower prevalence of loneliness compared with their older adult counterparts, findings from the AARP national loneliness survey 49 and the 2020 Cigna Report 50 from the US suggested otherwise. According to the Australian Loneliness Report, adults aged between 36 and 65 years reported consistently higher loneliness scores than those aged between 26 and 35 years, and those aged 65 and older. 86 Such findings suggest that the age pattern of loneliness might be context specific, although more data are needed among the general adult population to fully understand the susceptibility to loneliness throughout the lifespan. 87

Based on our meta-analysis, the prevalence of loneliness is highly heterogenous across countries, even within the same region. While insufficient data prevented us from identifying geographical patterns of loneliness outside of Europe, within Europe the pattern is clear and consistent. Across different adult age groups, northern European countries consistently reported the lowest prevalence of loneliness, whereas eastern European countries reported the highest. One study attributed country level differences to demographic characteristics, health status, social participation, and social support. 41 Others have cited welfare systems and social security schemes as contributing factors, 42 as welfare generosity has been positively linked to social participation and inversely associated with social exclusion. 88 A previous meta-analysis found an inverse association between socioeconomic status and loneliness. 89 A combination of high socioeconomic status, overall health, welfare generosity, and high social participation could explain the low levels of loneliness in northern European countries. In contrast, eastern European countries tend to have poorer health outcomes, healthcare services, and state welfare. 41 Other demographic characteristics, such as large gaps in life expectancy between men and women (hence a high proportion of widows) and increasing emigration among young people, might have contributed. 42 Changes associated with transition from socialism, such as reductions in pensions paired with rising living expenses, change in care arrangements, and reduced social trust are also potential explanations for high levels of loneliness in eastern Europe. 41 90

Despite media and public dialogue describing loneliness as a worsening social problem, 91 92 we found insufficient evidence to support this claim. We only identified four studies that repeatedly examined loneliness using comparable measures over time, and the findings from these studies were mixed. Even if the problem of loneliness had not worsened during our search period (2000-19), covid-19 might have had a profound impact on loneliness. 93 94 In this context, our review provides an important prepandemic baseline for future surveillence.

Strengths and limitations of this study

To maximise the validity of our findings, we limited our study selection to those based on nationally representative samples, sufficient sample sizes, and validated instruments. We maximised comparability across studies by harmonising results when feasible and summarising findings according to measurement instrument and age groups. However, our findings should be interpreted in light of weaknesses. Comprehensive global comparison and quantitative synthesis is limited by heterogeneity in study design, sampling procedures, and measurement instruments. Despite our attempts to improve comparability through harmonisation and stratification, we still found considerable evidence of heterogeneity, even within smaller subgroups of regions. Such heterogeneity is common in meta-analyses of prevalence, 43 and the pooled estimates should be interpreted as indicative only.

Understanding loneliness as a global health issue requires data from most countries—however, data are lacking for most regions outside of Europe. Meanwhile, the lack of repeated measurements limited our conclusions about temporal trends. Additionally, no studies explicitly reported elements of “co-design” with the intended communities. This might be the case particularly for translated instruments. Even though the instruments reviewed in our study have been translated, validated, and widely used in many countries, cross cultural adaptations of these questions could have limitations. 95 What loneliness means in one cultural and linguistic context might not be the same in another.

Differences in age groups and survey time also introduced additional complications. Although we limited study selection to those with data from 2000 to 2019, estimates in some countries could be more than 10 years older than those from other countries. Despite our attempts to provide prevalence estimates for different age groups, specific age categories differed by study, further limiting comparability across studies. Finally, different interpretation and operationalisation of loneliness (eg, cut-off points, recall time frame) across countries may lead to differential reporting biases. Because no single definition of problematic loneliness exists, what was labelled as “problematic” varied (eg, severity versus chronicity). This poses further challenges in interpreting prevalence across countries.

Strengths and limitations in relation to other studies

Another systematic review on the prevalence of loneliness has been peformed. 96 This review, however, was of a narrower scope than ours, as it only synthesised studies among older adults in high income countries published between 2008 and 2020. This review was subject to methodological limitations, such as not considering population representativeness and not accounting for different measurement instruments or operational definitions of loneliness across studies.

In early 2021, researchers reported the prevalence of loneliness for adults in 237 countries and territories based on the BBC loneliness experiment dataset. 97 As a primary study (in contrast with our systematic review and meta-analysis), it benefited from being able to apply the same measurement instrument to all participants and directly model predictors of loneliness, such as age, sex, and individualism, of the country of residence. Participants were, however, recruited as a convenience sample through BBC programmes (presumably in English only) and thus were not representative of populations—32% of the participants were men and 74% were UK residents. Therefore, prevalence estimates derived from this study are unlikely to be representative of the countries and territories.

Meaning of the study

We advocate among health professionals, decision makers, and the general public for better awareness of widespread loneliness. The data gaps in low and middle income countries raised an important issue of equity. Public health efforts to prevent and reduce loneliness require well coordinated ongoing surveillance across different lifes stages and broad geographical areas. High quality data based on validated and comparable instruments are urgently needed to tackle loneliness. Sizeable differences in prevalence of loneliness across countries and regions call for in-depth investigation to unpack the drivers of loneliness at systemic levels and to develop interventions to deal with them.

Recommendations for future research

Measurement is an ongoing challenge in loneliness research and surveillance. Researchers have previously documented the difficulty in comparing estimates of loneliness prevalence across studies and advocated for maximising comparability across survey instruments. 39 Conflicting evidence resulting from different definitions and measurements of loneliness has been identified as a major challenge. 84 One fundamental difference between measures is that single item questions directly asked about “loneliness,” but scales exclude direct reference to loneliness. Therefore, single item estimates might consistently misclassify loneliness. The UK Office for National Statistics recommends using both direct and indirect scale measures of loneliness when possible, and using direct single item questions when constrained by space. 37 Future studies could benefit from probabilistic sampling, repeated measures, and sufficient reporting of prevalence (eg, including uncertainty in addition to point estimates). Finally, considering the potential impact of covid-19 on social health worldwide, we encourage more studies to track long term trends of loneliness across the lifespan using the estimates we summarised as a prepandemic baseline for comparison.

What is already known on this topic

Increasing evidence suggests that loneliness at a problematic level has serious health consequences

As loneliness is increasingly recognised as an important health and social problem, governments worldwide should aim to tackle this issue through policies and initiatives

It is still unclear how widespread loneliness is on a global scale

What this study adds

Loneliness at a problematic level is prevalent in many countries, and important data gaps exist, particularly in low and middle income countries

A geographical pattern for loneliness prevalence was found, with northern European countries consistently showing low levels

Data are insufficient to make conclusions about temporal trends of loneliness on a global scale

Ethics statements

Ethical approval.

Not required.

Data availability statement

No additional data available.

Contributors: DS, KG, and DD conceived the study. DS, AB, and DD developed the review protocol. DS and DD conducted the literature search. DS and ML independently screened the studies, extracted data, and discussed results with DD. DS, RE, and DD conducted the literature search. JvB conducted the meta-analysis. DS and DD drafted the manuscript. All authors provided critical input during the writing and revision of the paper. DD supervised the study. DS, ML, and DD are the guarantors. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

Funding: None received.

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

The lead author (DS) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Dissemination to participants and related patient and public communities: The authors plan to disseminate the findings of this research to the public communities through media outlets, social media engagement, talks, and presentations.

Publisher’s note: Published maps are provided without any warranty of any kind, either express or implied. BMJ remains neutral with regard to jurisdictional claims in published maps.

Provenance and peer review: Not commissioned; externally peer reviewed.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

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• Open access
• Published: 21 November 2023

“It’s a feeling of complete disconnection”: experiences of existential loneliness from youth to older adulthood

• Phoebe E. McKenna-Plumley 1 , 2 ,
• Rhiannon N. Turner 2 ,
• Keming Yang 3 &
• Jenny M. Groarke 1 , 4  

BMC Psychology volume  11 , Article number:  408 ( 2023 ) Cite this article

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Existential loneliness is a feeling which stems from a sense of fundamental separation from others and the world. Although commonly mentioned in the loneliness literature, there is relatively little empirical work on this construct, and existing work tends to focus on older and seriously ill individuals. The present study aimed to understand how people experience existential loneliness without specific constraints on precipitating factors like illness or age.

A qualitative online survey collected data from 225 adults aged 16 to 72 years old. Participants were asked to write about their experiences of existential loneliness and how these experiences compared to non-existential loneliness. Data were analysed using reflexive thematic analysis.

Of 225 participants, 51% knew the meaning of “existential loneliness” upon accessing the survey and in total, 83% had experienced existential loneliness. 93% of these participants had also experienced loneliness that was not existential in nature. 175 participants provided qualitative data regarding their experiences of existential loneliness, from which four themes were identified: Existential loneliness is (1) A deeper form of loneliness, and (2) A feeling of deep disconnection, in which (3) Cognitive evaluations and negative emotions are central elements, and (4) Stress and mental health issues are perceived as relevant factors.

Conclusions

Existential loneliness is a deeply rooted and impactful form of loneliness which involves feelings of profound separateness. This aspect of loneliness is deserving of further attention. Future research directions are suggested.

Peer Review reports

Loneliness is a distressing and painful experience which negatively impacts physical health, mental health, and wellbeing [ 1 , 2 , 3 ]. Although loneliness can occur when a person is socially isolated, it is a subjective feeling that one’s connections are lacking in some way which is separable from objective isolation [ 4 ]. Previous research indicates that loneliness may be more appropriately conceptualised as multidimensional, despite the dominance of a unidimensional approach in the loneliness literature [ 5 , 6 ]. For example, a recent systematic review of qualitative studies on loneliness found that loneliness can be felt in a pervasive sense, but can also relate to deficiencies in specific relationships or relationship types [ 7 ]. This aligns with Weiss’s [ 8 ] social needs theory which proposes two dimensions of loneliness related to specific relational deficits: (i) social loneliness, which arises when one feels that they lack a sufficient social network, and (ii) emotional loneliness, which results from the lack of satisfying intimate relationships. Another dimension is existential loneliness, which describes a deeply rooted form of loneliness stemming from a sense of fundamental separation from others and the world [ 9 ]. A wealth of literature describes loneliness as including social, emotional, and existential types [ 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 ] and two studies of older adults provide empirical support for this three-dimensional model [ 6 , 18 ], but the existential dimension has been relatively neglected in loneliness research. Existential loneliness may represent the pervasive type of loneliness evidenced by recent qualitative evidence synthesis [ 7 ]. It has been noted that efforts to address loneliness need to move beyond a ‘one-size-fits-all’ approach [ 19 ] and it is likely that different dimensions require different approaches – for example, increasing general social contact may not be effective for someone who is emotionally lonely and lacks a close, intimate connection. Given the adverse effects of loneliness on health and wellbeing, as well as substantial public health and policy interest in alleviating this issue, a comprehensive understanding of specific dimensions like existential loneliness is vital to improve efforts to address loneliness.

Existential loneliness has been the focus of writing by scholars and practitioners from existential [ 20 ], humanistic [ 21 ], and theological traditions [ 22 ], but it has been relatively overlooked in empirical work. This may be partly due to the challenges of operationalising the construct. Existential loneliness has been defined variably in the literature. Examples presented in Table  1 demonstrate the diffuse aspects of these definitions, although each definition describes a sense of fundamental separation. The lack of conceptual clarity has been noted in systematic and scoping reviews of the construct [ 13 , 23 ]. In addition to challenges defining the construct, different approaches to labelling it may explain the relative dearth of empirical work on existential loneliness. While existential loneliness is discussed across the health psychology, nursing, and gerontology literature and by humanistic and existential writers such as Clark Moustakas and Irvin D. Yalom, the term existential isolation is also used by writers such as Yalom and in a growing area of existential psychological literature. Existential isolation research defines the construct as “feeling as though one differs, either chronically or acutely, with respect to one’s subjective experience” [ 24 , p. 56]. This quantitative research has found associations with being a man [ 25 ], having a minority identity [ 26 ], insecure attachment [ 27 ], and negative outcomes including depression and suicide ideation [ 28 ]. This work focuses on the degree of shared perspective a person experiences, which may not exhaustively account for feelings of existential loneliness, and does not explicitly tap into the negatively valent aspects of loneliness indicated by scholarly writing in existential, humanistic, and theological traditions [ 20 , 21 , 22 ] and the existing qualitative literature [ 29 , 30 , 31 , 32 ]. A conceptualisation of existential isolation as an objective state and existential loneliness as a subjective feeling has also been employed [ 13 , 33 ]. Research conceptualising existential loneliness as a felt experience of loneliness that impacts interpersonal relationships may complement this literature.

Qualitative research on existential loneliness to date has typically focused on older [ 15 , 32 , 36 , 37 , 38 , 39 ] and chronically or seriously ill [ 33 , 40 ] populations, although one recent study includes adolescents [ 41 ]. Research with these groups depicts existential loneliness as involving feelings of not belonging [ 15 , 32 , 36 , 37 , 38 , 39 , 41 ], feeling distant from meaningful relationships [ 15 , 32 , 36 , 37 , 38 , 39 , 41 ], lacking meaning in life [ 15 , 37 , 39 ], and having concerns about frailty, death, and the future [ 36 , 37 , 41 ]. A systematic review of the literature suggests that existential loneliness can be characterised as a condition (people are fundamentally separate), an experience (of a specific component of loneliness involving a total lack of relatedness), and a process (wherein the negative experience is transformed into a positive one) [ 13 ]. Additionally, a more recent review suggests that existential loneliness involves two characteristics: the perception of oneself as inherently separate, and the emotional aspects that come alongside that perception [ 9 ]. While cross-cultural research is lacking, one study expresses consistency in descriptions across Chinese and Swedish older adults [ 37 ]. This research underlines the importance of considering existential loneliness within the larger loneliness and social wellbeing literature, given that it is a distressing experience of interpersonal separation which may have negative consequences for wellbeing and health. This is particularly important given that existential loneliness has been described as a universal experience [ 42 , 43 ] which is at least somewhat culturally invariant [ 37 ] and may emerge in adolescence due to increased awareness of oneself as a separate being [ 44 ]. Indeed, recent research indicates the presence of low levels of existential loneliness, which were associated with feelings of general isolation, in young adults in Greece [ 45 ]. However, existing research on existential loneliness is limited by the focus on a specific life period and circumstances. A thorough conceptualisation of existential loneliness requires consideration of the lived experiences of a range of people, given that loneliness is a personal and subjective experience. Given the need to move beyond generic loneliness interventions [ 46 ], this knowledge may facilitate the development of more effective strategies to address specific aspects of loneliness.

A comprehensive understanding of how existential loneliness is experienced across the lifespan is lacking due to the relative dearth of literature on this construct and the focus on older and seriously ill individuals in the studies which have been carried out. Various definitions of existential loneliness exist (see Table  1 ), but there is a lack of knowledge regarding how individuals define their own experiences. Given that loneliness is a subjective experience, it is important that we ground our understanding of existential loneliness in first-hand experiences. This study aimed to address these aspects of the literature by gathering information regarding experiences of existential loneliness in individuals at various stages of the lifespan without specific constraints on contextual factors like illness or age. Additionally, this study aimed to explore perceived similarities and differences between experiences of existential loneliness and loneliness that is not existential in nature. Two research questions were investigated:

How do people describe their experiences of existential loneliness?

How do experiences of existential loneliness differ from experiences of loneliness that is not specifically existential in nature?

A qualitative online survey was used to collect data. While face-to-face interviews and focus groups have traditionally been used for qualitative data collection, technological advances afford the opportunity for innovative methods such as online qualitative surveys. Methodologists have argued that qualitative survey data are unique from interview data; they are usually very focused and dense with information, so smaller volumes can contain larger amounts of data [ 47 , 48 ]. Moreover, this method can facilitate disclosure and reduce the social desirability that may be inherent in face-to-face collection methods [ 47 ]. Online surveys can engender an enhanced sense of anonymity which is welcomed by participants [ 49 ], particularly for a sensitive and stigmatised topic such as loneliness, and provide opportunities to participate for those who might not engage in face-to-face data collection methods [ 50 ]. Moreover, they can generate openness regarding study design, allowing participants to comment on the appropriateness of the questions or wording [ 47 ]. With the aim to recruit widely to understand experiences of a sensitive and personal topic, an online qualitative survey method was therefore chosen for the present study.

Ethical approval was granted by the Research Ethics Committee in the Faculty of Engineering and Physical Sciences at Queen’s University Belfast.

Ontological and epistemological approach

Critical realism underpins the present study. This approach asserts that the context of the social world filters what we can learn about a potential reality. It is believed that participants’ descriptions of their experiences of existential loneliness are grounded in an experiential reality – they are accurate – but they are not independent from their context [ 51 ].

In terms of epistemology, the research is contextualist. This basis assumes that context is part of knowledge generation, such that all activity is situated within a sociocultural network of meanings [ 52 ]. Reality is an active, dynamic event rather than a single truth [ 53 ]. Knowledge is always incomplete but still grants us insight into the world.

Recruitment

Participants were recruited via advertisements on social media (Twitter, Reddit), John Krantz’s ‘Psychological Research on the Net’ web portal, researchers’ networks, posters, and emails to relevant groups (e.g. university philosophy societies). These posts briefly explained the study and provided a link to the online survey. Participants had to be over the age of 16; they did not need to be aware of the meaning of the term “existential loneliness” at the outset of the study.

Decisions regarding sample size were guided by Braun and Clarke’s [ 54 , p. 211] guidance that, having estimated an anticipated sample size range, “researchers should then make an in-situ decision about the final sample size, shaped by the adequacy (richness, complexity) of the data for addressing the research question”. We anticipated that up to 100 participants may be appropriate, but this was exceeded due to high interest from participants. PMP regularly checked the survey responses to assess whether a sufficiently rich and complex body of data had been collected; the survey was closed when the data appeared sufficiently rich and nuanced.

The online qualitative survey was piloted with three potential participants (1 woman, 2 men, aged 26–33 years old) and edited in line with their feedback on comprehensibility and comprehensiveness. The final survey questions are provided in Fig.  1 .

Questions presented to participants in the online survey

Upon accessing the online survey, participants were presented with an information sheet, consent form, and six-digit code which could be used to later remove their response if they wished to withdraw. No participants requested to withdraw. Participants were then asked if they had experienced existential loneliness. If they stated yes, they were asked to provide their definition of existential loneliness. If they stated no, they were taken to the end of the survey. If they stated “I don’t know what existential loneliness is”, they were taken to a page which provided three definitions of existential loneliness from existing research [ 9 , 13 , 34 ; see Fig.  1 ]. They were then asked again if they had experienced this feeling, at which point they were taken to the end of the survey if they stated “no”. Participants who had stated yes originally were presented with these definitions after providing their own definition so that all participants had the same information. Following this, demographic questions were presented and then participants were asked to think carefully about a time they had felt existentially lonely and give open-ended responses to questions about this experience.

Participants were then asked if they had ever experienced loneliness that was not existential in nature, with an example provided of the distress one feels when they feel like their social life or relationships are lacking (see Fig.  1 ). If they stated yes, they were asked to think carefully about this experience and answer open-ended questions about the experience and how it compared to experiences of existential loneliness. Finally, all participants were asked to add anything relevant or significant about their experience of existential loneliness and thanked for participating. A list of resources for support organisations (e.g. the Samaritans) was provided.

The qualitative data analysis utilised reflexive thematic analysis, which is a flexible analytic approach in which themes are generated through iterative and reflexive engagement with the data [ 55 ]. This method was chosen as it allows the identification of overarching patterns in data regarding experiences [ 56 ] which is the aim of this study.

The analysis process followed guidance from Braun and Clarke [ 55 , 57 ]. This involved repeated close reading of the data to become familiar with key points. Points of interest and early ideas were noted. The data were then thoroughly coded by PMP, a PhD candidate with advanced qualitative training and experience, with points which could be relevant for the research questions assigned one or multiple codes. Data were coded from the first participant onward and then a second time working backwards from the midpoint of the dataset to check, add to, and refine codes. Codes were checked to ensure their coherence, appropriate labelling, and thorough representation of the data without undue influence from the researcher’s preconceptions, for example that existential loneliness may stem from ideas about fundamental separation. Following this, the codes were organised into themes which explained important patterns in the data relevant to the research questions. Some themes also included subthemes, representing distinct but related aspects of the larger theme. Themes and subthemes were reviewed by PMP and JG to ensure their coherence, distinctiveness from other themes, and representation of the dataset. Finally, the full dataset was read again to check that the themes represented the data well.

Participants

Data were collected from 225 participants. Of these, 186 stated that they had experienced existential loneliness and were therefore invited to complete the qualitative survey. Of these, ten participants answered none of the open-ended qualitative questions and one reported in the qualitative questions that they had never experienced existential loneliness, so these eleven participants were excluded from qualitative analysis. Therefore, 175 participants were included in the qualitative analysis. The qualitative responses ranged from 5 to 2,036 words total ( Mdn  = 142.5).

These 175 participants’ ages ranged from 16 to 72 years ( M  = 26.38, SD  = 11.77); 129 were younger adults (16–29 years old), 40 were middle-aged adults (30–59 years old), and 6 were older adults (60 + years old). The majority identified as female (69.14%, N  = 121), 44 (25.14%) identified as male, 10 (5.71%) identified another gender identity (including non-binary, genderfluid, and agender), and one preferred not to say. Most participants were located in the United States of America ( N =  109, 62.29%), Northern Ireland ( N =  20, 11.43%), England ( N =  10, 5.71%), Canada ( N =  10, 5.71%), and the Republic of Ireland ( N =  7, 4%), while a smaller number were located in Germany, Australia, Wales, France, Guatemala, Israel, the Netherlands, Panama, the Philippines, and other parts of the United Kingdom. The majority ( N  = 108, 61.71%) identified themselves as White, while 19 (10.86%) identified themselves as Latino/Hispanic, 12 (6.86%) as Black, 11 (6.29%) as East Asian, and a smaller proportion as a mixed ethnicity, South Asian, Middle Eastern, another ethnicity, or preferred not to say. Most ( N  = 162, 92.57%) had completed secondary school or a higher level of education. The majority were employed ( N  = 103, 58.86%) and/or studying ( N  = 112, 64%), while 6 (3.43%) were retired and 6 (3.43%) were not employed or studying.

Knowledge & prevalence of existential loneliness in the sample

Approximately half of the individuals who accessed the survey knew the meaning of the term “existential loneliness” ( N  = 115, 51.11%). Of those, 86.96% ( N  = 100) had experienced the feeling. 78% ( N  = 86) of those who did not initially know the meaning of the term “existential loneliness” also identified as having experienced it after being presented with definitions of the construct. In total, the majority of participants ( N  = 186, 82.67%) had experienced existential loneliness. Almost all individuals who had experienced existential loneliness had also experienced loneliness that was not existential in nature, but 13 (6.99%) had not.

Definitions of existential loneliness

Definitions of existential loneliness were sought to check that the term “existential loneliness” was conceptualised in a congruent manner by participants and the research team. Ninety-three participants included in the qualitative analysis gave a definition. These were coded inductively to create a summary of major elements. Participants’ definitions described existential loneliness as a type of loneliness that revolved around feeling alone, disconnected and separate from the world and everyone around you, that was not related to isolation, was deeper and cosmic in scale, included a sense that one could not be understood by or fully share their experiences and thoughts with others, and involved a lack of meaning in life and disconnection from greater purpose. Some definitions indicated that existential isolation (our fundamental aloneness in the universe) was a fact or a thought, but existential loneliness was generally defined as a feeling. These definitions generally aligned closely with the definitions which are available in existing literature, although a lack of purpose was more prominently mentioned by participants in the current study. This indicates that lay conceptualisations of existential loneliness are similar to those used in the academic literature and that participants were writing about experiences of the same phenomenon that we aimed to explore. A comparison of major elements of existential loneliness related in definitions given in this study and in the extant literature is given in Table  2 .

Qualitative analysis

In the process of characterising existential loneliness, it is relevant to note that some participants described it as difficult to define and mentioned that it could overlap with loneliness that was not existential in nature ( “In ways there are similarties [sp] as […] with both I feel a sense of isolation but also that sense of wanting to feel wanted and needed.” – P55, 17-year-old, female), although most participants distinguished between forms of loneliness ( “For me, existential lonelieness [sp] is a far different can of worms compared to general loneliness.” – P106, 17-year-old, male) and provided rich descriptions of their experiences.

The process of reflexive thematic analysis ultimately produced four themes. Some include subthemes (indicated by subordinate numbering in Fig. 2 , e.g. 1.1., 2.1., 2.2.), which express distinct but cohesive parts of the theme. These themes are described below and visualised in Fig.  2 .

Visual representation of themes and subthemes

A feeling of complete disconnection

In the participants’ accounts, experiences of existential loneliness involved feelings of complete disconnection.

“[I]t’s a feeling of complete disconnection. I don’t know how to resolve it.” (P46, 36-year-old, female).

This was described as feeling alone in the world, feeling an essential separation from other people, and in some cases as feeling disconnected from the world and from oneself. Existential loneliness appeared to constitute a feeling of essential aloneness and separation.

“It made me feel separated entirely from society and other people. It was upsetting to realise that other people would not be able to relate to, or understand, my experiences and perceptions.” (P70, 18-year-old, nonbinary).

Others described this more simply as feeling separated from the people around them. People experiencing existential loneliness often felt that others did not care about them, that they were alienated from other people, and that they did not belong.

“I felt completely alone like there was no one there that would ever love me or care about me.” (P155, 20-year-old, female).

These experiences were often linked to being different from other people and feeling that one was not understood by others. This could be due to specific aspects of identity, to certain experiences, or to personality factors. In a broader sense, people touched on the inability to fully know or be fully known by another person, and the impossibility of being fully understood.

“I felt like no one else had lived my life, so no one else could relate to the experiences I had.” (P63, 25-year-old, female).

For some people, feelings of disconnection were so intense that they provoked derealisation.

“Felt like I was sort of outside of my body/the situation” (P61, 30-year-old, female).

Several participants also noted a longing for a deeper relationship with another person.

“[I]ts mostly a deeper longing for true soul connection that I experience, which I would equate more to existential loneliness.” (P87, 37-year-old, female).

One subtheme was developed in connection with this theme:

Perceptions and experiences of interpersonal disconnection

In describing experiences of existential loneliness, participants often described negative interpersonal experiences or perceptions. People described feeling inadequate or wrong.

“All of this combined caused me to think why can I not be normal. I felt as though everyone was on some new kind of programming and I hadn’t received the update.” (P74, 21-year-old, female).

There were also descriptions of being left out, not fitting in, and having no one to speak to. Participants described feeling invisible and unwanted, which may represent causes or symptoms of their feelings of disconnection.

“I felt invisible and alone” (P166, 60-year-old, female).

A deeper form of loneliness

Existential loneliness was depicted by participants as a form of loneliness which was more pervasive, deeply rooted, and impactful. This also involved descriptions of existential loneliness as a deeply bad experience which was “debilitating” (P3, 48-year-old, female), “far worse” (P31, 17-year-old, male), and “like a punch in the gut” (P72, 18-year-old, male).

“Existential loneliness feels like I’m alone in a void that only I can see and feel and it doesn’t exist or matter to others, however non-existential loneliness just makes me feel sad.” (P151, 18-year-old, genderfluid).

This was described in terms of feelings and, for some, a statement of fundamental separation as a fact. Some participants characterised existential loneliness as universal or inevitable.

“I think it was so overwhelming because it’s less a temporary state of being and more like an inherent part of human life. I think life is a distraction from the fact that we are all alone fundamentally (regardless of how depressing that sounds!).” (P8, 24-year-old, female).

This deeper aspect of existential loneliness was also represented through descriptions of it as longer-lasting or in some cases permanent. Existential loneliness would persist, lasting days, weeks, or longer, as opposed to other forms of loneliness which were depicted as more fleeting. Indeed, some reported existential loneliness as a constant. Accordingly, experiences of existential loneliness often involved a sense of hopelessness or endlessness.

“I felt completely lost and overwhelmed, like there was no light at the end of tunnel.” (P53, 29-year-old, female).

Relatedly, participants described existential loneliness as difficult or impossible to resolve. It was harder to deal with than non-existential forms of loneliness, which could be eased through social connection. However, a small number of participants reported ways of managing existential loneliness through religion, positive thinking, gratitude, and shared experiences with others. When this was possible, positive outcomes such as acceptance and a better understanding of oneself were described by some participants.

“Looking For ANYTHING to be thankful for even it were as simple as air to breath [sp] or the ability to blink, see and hear…… That is how I escaped being in that position.” (P93, 53-year-old, female).

Additionally, some participants indicated that existential loneliness coincided with experiences of loneliness that was not existential and suggested that other forms of loneliness may lead to existential loneliness when they become chronic, further indicating the characterisation of existential loneliness as a deeper form of loneliness.

“I think it would be easy for non-existential loneliness to culminate over a long time into existential, which has happened to me before.” (P116, 21-year-old, female).

Two subthemes were developed as part of this theme:

Less context-bound

Alongside descriptions of existential loneliness as longer-lasting was the experience of existential loneliness as less context dependent than other forms of loneliness. “The existential loneliness I feel seems to always be inside me, but it can come to the surface when I go too long to try to remedy it. Non-existential loneliness is situational and usually tied to a certain date or event.” (P42, 32-year-old, female).

Existential loneliness was often depicted as lacking a clear cause – it was internal or constant, rather than arising due to a specific situation.

“It happens randomly. I will be happy one moment and then lonely the next.” (P85, 16-year-old, female).

However, while participants described existential loneliness as less context-bound, several interpersonal contextual elements did seem to drive experiences of existential loneliness: experiencing objective isolation, lacking social support, and periods of aloneness and, conversely, periods of socialising. Nonetheless, participants stressed that existential loneliness could arise despite strong social connections.

“Existential loneliness is like sitting in your room with a phone full of messages and phone calls from loved ones still feeling like you are completely alone in the world” (P159, 21-year-old, female).

Events which precipitated mental distress were also mentioned as relevant contextual factors for existential loneliness; see theme 4 for a full discussion.

Wider concerns about meaning and purpose

Existential loneliness was described as an experience in which many people reflected on meaning and purpose in life, particularly concerns about lacking meaning or purpose. This differed from other forms of loneliness, which were generally described more straightforwardly with respect to social and interpersonal relationships.

“Existential loneliness stems from me feeling like I’m going through the motions of life like a robot and my life is meaningless without connection to ground me” (P171, 29-year-old, male).

In this respect, existential loneliness appeared to involve or emerge in light of wider existential concerns about one’s place and purpose in the world. Indeed, some participants remarked that finding or reaffirming their purpose in life eased feelings of existential loneliness.

“Finding religion, love (romantically and socially), and an overall sense of purpose are essential for decreasing the power and frequency that existential loneliness can have on someone.” (P158, 22-year-old, male).

Cognitive evaluations and negative emotions are central elements

As described by the participants, existential loneliness appeared to involve cognitive and emotional facets: it was commonly linked to thinking or reflecting and was regularly described as involving sadness and other negative emotions. The experience was often described in times of thought or reflection. Several participants also described existential loneliness in respect to “overthinking”.

“I[t] typically comes about when I’m having a bad day or when I just start thinking a bit too much about life.” (P106, 17-year-old, male).

In some cases, these thoughts lingered on purpose in life, death, and the inevitability of being alone in the end. People often described feelings of insignificance alongside existential loneliness. Social comparison was another cognitive evaluation that was linked to existential loneliness, with descriptions of thoughts about being less connected or socially active than others.

“I imagined every room having people my age enjoying warmth and company. I could see myself finally arriving at my hall and knowing no one from the foyer to my room.” (P47, 72-year-old, male).

Negative emotions also featured in descriptions of existential loneliness. Existential loneliness was described as involving sadness and in some cases fear, dread, anger, and frustration.

“It was just sadness and frustration feeling alone, in a crowd of people.” (P85, 16-year-old, female).

Emptiness also characterised experiences of existential loneliness.

“I just remember the fear of wondering will I always feel this empty inside and if one would be there for me or with me.” (P99, 19-year-old, female).

Stress and mental health issues are perceived as relevant factors

Mental health issues, stress, and trauma appeared to be relevant to the experience of existential loneliness for participants. Participants regularly described feeling existentially lonely during times of mental ill health and mentioned mental health issues in discussing their experiences.

“I thought it was something more specifically triggered by my anxiety or depression.” (P131, 38-year-old, female).

Stress was also described as a driver of existential loneliness. Participants felt existentially lonely in times of stress, after difficult days or life periods, and following life transitions which may constitute stressful events.

“I have noticed it occurs when I go through some sort of prolonged stress in my life.” (P53, 29-year-old, female).

Additionally, traumatic life events and experiences of abuse were described as pertinent to existential loneliness. These included abusive relationships, assault, childhood neglect and maltreatment, and unspecified traumatic experiences.

“They can be triggered by periods of my life when I’m struggling with trauma of past experiences” (P60, 19-year-old, male).

In some cases, periods of generally strong emotion were described as precipitating existential loneliness. This may be linked to descriptions by a small number of participants that existential loneliness was a feeling that was specific to their adolescence or early adulthood.

“Now I look back on my young self and feel sad for her, but would like to tell her that it will be all right!” (P165, 64-year-old, female).

This is the first research, to our knowledge, which specifically explores lived experiences of existential loneliness without constraints on sample characteristics like age group or health. Experiences of existential loneliness in people from 16 to 72 years old were investigated via an online qualitative survey. Additionally, this research sheds light on knowledge, prevalence, and definitions of existential loneliness using data from 225 adults. While these individuals were recruited to a study on existential loneliness and may therefore have a higher likelihood of knowing the term, just over half (51%) initially knew what existential loneliness was and 83% of all participants had experienced the feeling. The majority of these individuals had also experienced other forms of loneliness but 7% had experienced only existential loneliness. Data from 175 individuals with lived experiences of existential loneliness characterised it as (1) a deeper form of loneliness, and (2) a feeling of deep disconnection, in which (3) cognitive evaluations and negative emotions are central elements, and (4) stress and mental health issues are perceived as relevant factors.

Defining the experience of existential loneliness

This study aimed to ascertain how people describe their experiences of existential loneliness and found that it was described as a deeper feeling of loneliness involving a sense of profound disconnection from other people, as well as in some cases from the world and from oneself. This study strengthens the conceptualisation of existential loneliness by adding empirical evidence of how individuals define and describe the construct. This is important given the lack of conceptual clarity regarding existential loneliness [ 13 ] and the relatively small amount of research on this dimension compared to social and emotional loneliness. It appeared that the central feature of existential loneliness experiences was a sense of profound disconnection from others; this is echoed in existing literature which characterises existential loneliness as “a total lack of relatedness” [ 13 , p. 157] and “a feeling of fundamental separateness from others and the wider world” [ 14 , p. 36]. While existing literature is inconsistent with regard to the definition and boundaries of this construct, through the present research, we suggest a core definition of existential loneliness as a negatively valent feeling of profound aloneness and separation from other people . Attempts to encapsulate the meaning of a construct may inevitably objectify and simplify it [ 58 ], but we suggest that this bottom-up conceptualisation, which centres lived experiences identified as existential loneliness, may be useful for research and practice. The present findings underline the complex, multidimensional nature of loneliness and indicate that attempts to manage loneliness will benefit from addressing feelings of deeper disconnection rather than solely providing opportunities for social interaction.

Existential loneliness was described as worse or more debilitating than other loneliness experiences, indicating the importance of considering this subgroup of experiences and their potential impact on wellbeing. Indeed, these experiences were described as involving negative emotional and cognitive characteristics such as sadness, dread, emptiness, and overthinking. This expands on previous research with older adults which indicates feelings of fear, guilt, and questioning life choices [ 36 , 38 , 39 ]. This research also noted a lack of purpose, which may link to behavioural outcomes if lacking purpose leads to a lack of motivation or action to pursue goals, interests, or responsibilities. Cognitive appraisals of social relationships are also a key facet of loneliness theory [ 59 ] and maladaptive social cognitive processes such as social hypervigilance appear to arise in response to loneliness [ 60 ], but this study suggests that reflecting or overthinking are also perceived as relevant for existential loneliness. The centrality of reflection and overthinking also indicates a potential role of rumination, which involves prolonged repetitive negative thinking and is associated with hopelessness, depression, and suicidality [ 61 ]. Existential loneliness may be related to a person’s awareness or belief in their fundamental separation from others, which may account for the heavier weighting of thought processes as a precipitating factor and the perception of it as a deeper experience.

This depth was also related to the perception of existential loneliness as longer-lasting, harder to resolve, and in some cases constant. This is concerning given that longer-lasting or recurring experiences of loneliness are associated with poorer health and mortality outcomes [ 62 , 63 ]. While some have suggested that existential loneliness is irresolvable [ 33 ], a portion of participants described ways to resolve the experience through positive thinking and shared experiences. In these cases, positive outcomes such as acceptance and self-knowledge were possible for some individuals, and these aligned with those suggested by existing literature and research with older adults [ 13 , 21 , 32 ]. However, this research indicated that existential loneliness was generally characterised by negative emotions. Consequently, it may be useful for research and interventions focusing on alleviating loneliness to consider existential loneliness as well as more socially driven dimensions.

An existential dimension of the loneliness experience

This research provides support for a multidimensional conceptualisation of loneliness with existential loneliness as one dimension or type. While various research conceptualises loneliness as including social, emotional, and existential dimensions [ 10 , 11 , 13 , 14 , 17 ], this conceptualisation has received relatively little empirical attention and existential loneliness has been particularly neglected in loneliness research. This study suggests that loneliness dimensions are subjectively separable. Descriptions of existential loneliness deviated from conceptualisations of social and emotional loneliness as described by Weiss [ 8 ] and from some aspects of loneliness experiences described in qualitative synthesis [ 7 ]. Namely, existential loneliness was deeper, less context-bound, and involved concerns about meaning and purpose, as opposed to relating more specifically to deficiencies in intimate relationships (emotional loneliness) or the larger social network (social loneliness).

Participants described existential loneliness as deeper, longer-lasting, harder to resolve, and less context-bound than other loneliness experiences. However, it did appear that existential loneliness is a recognisable dimension of loneliness, including key aspects of loneliness that have been outlined previously: it is generally aversive, labelled as loneliness by individuals experiencing it, can be impacted by social relationships, is associated with poor mental health, and is one of multiple forms of loneliness [ 64 ]. Moreover, whilst the majority of individuals who reported existential loneliness had also experienced another form of loneliness, 7% of participants reported that they had only experienced existential loneliness, indicating that dimensions of loneliness are subjectively separable for individuals experiencing them. These findings provide empirical support for a multidimensional conceptualisation of loneliness including existential loneliness. They also indicate that this dimension of loneliness is more persistent, suggesting that interventions and policy aimed at loneliness may benefit from targeting existential loneliness specifically.

The relevance of social relationships to existential loneliness

Relatedly, while definitions stressed that existential loneliness could occur despite the presence of others, it was clear that social relationships played an important role. Existential loneliness was described as less context-bound, persisting or arising without an obvious cause. However, in describing their experiences, participants often described times of objective isolation and aloneness. These elements indicate that existential loneliness is perceived as less tied to objective social network characteristics but is nonetheless impacted by social activity. However, it is not inherently linked to social isolation, as participants also described existential loneliness after periods of socialising. This was perhaps linked to the sense that others could not understand them and that they were separate despite the presence of objective social contact. Quantitative research suggests that having a smaller social network and not living with a partner each predict existential loneliness, although it reports inconsistent findings around having daily contact with one’s social network [ 6 , 18 ]. Similarly, existential loneliness has been described as more internal, rather than specifically related to relationship quality [ 65 ]. While the subjective experience of loneliness is separable from the objective circumstance of social isolation, they are associated [ 4 ]. Existential loneliness may represent a form of loneliness which is less directly tied to objective characteristics of the network and impacted more by internal cognitive processes, given that it relates to other people and the world generally, as opposed to deficits in specific relationships. Indeed, existing research indicates that experiences of loneliness differ in the degree to which they are related to specific social relationships versus being a generalised experience [ 7 , 8 , 66 ]. Future research should assess the degree to which existential loneliness is impacted by objective network characteristics, relative to other forms of loneliness.

Precipitating factors and duration of existential loneliness

Existential loneliness was experienced as constant by some participants, but many described it as a regularly occurring experience, highlighting its transience for some individuals. Existing loneliness research emphasises the role of prolonged loneliness on outcomes like mortality and mental health [ 62 , 63 ]. For some people, it appears that existential loneliness may function as a trait or mood which is relatively consistent, whereas for others it may be more of a state or emotion experience which is precipitated by certain events. Indeed, it has been suggested that a trait disposition towards existential isolation may occur if existential isolation states occur often or cannot be relieved [ 67 ]. In the current study, existential loneliness was depicted as less context-bound, with a lack of a clear cause in many situations, but various precipitating factors were mentioned. Being isolated or alone, socialising, periods of stress, and poor mental health were identified as particularly relevant. Existential loneliness has been identified as relevant for individuals with mental ill health [ 68 ] and this research indicates that it could be precipitated by anxiety, depression, trauma, and periods of stress; further exploring how existential loneliness might act a cause, consequence, or factor in experiences of poor mental health may help to delineate the relationship between these constructs. Boundary situations, in which people experience urgent and significant life-changing events such as serious illness, suffering, and death, are theorised to bring about existential loneliness [ 33 , 69 ] and this research suggests that challenging events, whether internal or external, may be particularly relevant for this dimension of loneliness.

Additionally, in a sample which included individuals from 16 to 72 years old, experiences of existential loneliness were described by a small proportion of individuals as occurring particularly during adolescence and young adulthood. Indeed, existential loneliness has been suggested to emerge in adolescence [ 44 ] and has been evidenced in adolescents and young adults [ 41 , 45 ]. This may be related to the finding that existential loneliness could occur following strong emotions, given that adolescence is a period of increased emotional intensity and older adults are more proficient at emotion regulation [ 70 , 71 ]. While there is little research focusing on existential loneliness in younger adults, this may be a pertinent developmental stage for these experiences which is deserving of further attention. As existential loneliness was described as long-lasting and potentially permanent in the current study, easing the experience in younger people may be particularly helpful to avoid ongoing distress and mitigate the personal and public health impact of loneliness.

Limitations and future directions

Although the findings of this research extend our understanding of the lived experience of existential loneliness across the lifespan, there are a number of limitations. While the use of online methods represents a novel and effective way to collect qualitative data, it excludes individuals without internet access or proficiency, who tend to comprise groups impacted by other sources of social inequality [ 72 ] and may obscure some aspects of in-person data collection such as tone of voice. This may also have contributed to the smaller proportion of older adults in this sample, although this group are strongly represented in other research on existential loneliness [ 15 , 32 , 34 , 36 , 37 , 39 ]. Future qualitative work might usefully focus on how mental health and trauma are involved in experiences of existential loneliness, while quantitative research is needed to clarify how well this conceptualisation of existential loneliness fits within a wider multidimensional model of loneliness and with dimensions such as social and emotional loneliness.

In summary, our results suggest that existential loneliness is a deep and pervasive form of loneliness involving feelings of deep disconnection. Reflection, overthinking, and negative emotions appear to play a role in these experiences, as do periods of stress, trauma, and poor mental health. A portion of individuals who had experienced existential loneliness had never experienced a non-existential form of loneliness, indicating that this represents a subjectively separable loneliness experience. This aspect of loneliness is deserving of further attention, which was specifically indicated by comments from several participants. Future research, policy, and practice around loneliness should take into account this deeply impactful but often overlooked dimension to improve our understanding of loneliness and inform supports for people experiencing loneliness.

Data availability

The datasets generated and/or analysed during the current study are not publicly available as research participants did not consent to raw data transcripts being made available and the content may compromise participant confidentiality. Reasonable requests may be addressed to the corresponding author.

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Acknowledgements

The authors would like to acknowledge and thank the participants who contributed their time and experience to this research.

This work was supported by PMP’s doctoral funding from the Northern Ireland and North East Doctoral Training Partnership, funded by the Economic and Social Research Council with support from the Department for the Economy Northern Ireland [Grant number ES/P000762/1]. The funder did not play a role in the development of this study.

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McKenna-Plumley, P.E., Turner, R.N., Yang, K. et al. “It’s a feeling of complete disconnection”: experiences of existential loneliness from youth to older adulthood. BMC Psychol 11 , 408 (2023). https://doi.org/10.1186/s40359-023-01452-4

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Addressing loneliness and social isolation in 52 countries: a scoping review of National policies

• Nina Goldman   ORCID: orcid.org/0000-0002-3058-1251 1 , 2   na1 ,
• Devi Khanna   ORCID: orcid.org/0000-0002-9254-0869 1   na1 ,
• Marie Line El Asmar   ORCID: orcid.org/0000-0002-0733-3911 3 ,
• Pamela Qualter   ORCID: orcid.org/0000-0001-6114-3820 1 &
• Austen El-Osta   ORCID: orcid.org/0000-0002-8772-4938 2  

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Even prior to the advent of the COVID-19 pandemic, there was ample evidence that loneliness and social isolation negatively impacted physical and mental health, employability, and are a financial burden on the state. In response, there has been significant policy-level attention on tackling loneliness. The objective of this scoping review was to conduct a loneliness policy landscape analysis across 52 countries of the UN European country groups. Our policy analysis sought to highlight commonalities and differences between the different national approaches to manage loneliness, with the goal to provide actionable recommendations for the consideration of policymakers wishing to develop, expand or review existing loneliness policies.

We searched governmental websites using the Google search engine for publicly available documents related to loneliness and social isolation. Seventy-eight documents were identified in total, from which 23 documents were retained. Exclusion of documents was based on predetermined criteria. A structured content analysis approach was used to capture key information from the policy documents. Contextual data were captured in a configuration matrix to highlight common and unique themes.

We could show that most policies describe loneliness as a phenomenon that was addressed to varying degrees in different domains such as social, health, geographical, economic and political. Limited evidence was found regarding funding for suggested interventions. We synthesised actionable recommendations for the consideration of policy makers focusing on the use of language, prioritisation of interventions, revisiting previous campaigns, sharing best practice across borders, setting out a vision, evaluating interventions, and the need for the rapid and sustainable scalability of interventions.

Conclusions

Our study provides the first overview of the national loneliness policy landscape, highlighting the increasing prioritisation of loneliness and social isolation as a major public health and societal issue. Our findings suggest that policymakers can sustain this momentum and strengthen their strategies by incorporating rigorous, evidence-based intervention evaluations and fostering international collaborations for knowledge sharing. We believe that policymakers can more effectively address loneliness by directing funds to develop and implement interventions that impact the individual, the community and society.

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Introduction

The significant increase in research on loneliness and social isolation over the last decade, and especially following the advent of the COVID-19 pandemic [ 1 , 2 , 3 ] highlighted the detrimental consequences of loneliness to individuals, society and governments worldwide. For older adults, the pandemic led to feelings of loneliness due to a lack of companionship and connections, which can negatively impact cognition, and mental health [ 4 ]. The paradox of social distancing, intended to protect older adults, further isolated them and exacerbated the negative effects of loneliness [ 5 ]. A longitudinal study on adolescents showed that they also experienced social isolation from peers, and that resulted in increases of loneliness due to COVID-related school closures [ 6 ]. Evidence shows that a lack of social connection impacts physical and mental health [ 7 ], employability opportunities [ 8 ], and how it is related to social disparities [ 1 , 9 ]. In response, there has been significant policy-level attention on loneliness, with, for example, the United Kingdom of Great Britain and Northern Ireland (GB) [ 10 ] and Japan [ 11 ] both appointing a Minister for Loneliness in 2018 (GB) and 2021 (Japan) respectively. In a joint press statement, both an EU Commissioner and the Japanese Loneliness Minister agreed that “loneliness and social isolation pose crucial challenges to the cohesion, economy and mental and physical health in 21st century societies across the world” [ 12 ]. In November 2023, the World Health Organization highlighted the importance of social connection, recognising the significant and often underestimated impact of loneliness and isolation on our health and well-being. This recognition led to the launch of its Commission on Social Connection (2024–2026), which aims to address this issue as a public health concern [ 13 ]. However, little is known about the extent that loneliness is currently included in national strategies and policies across the world.

Loneliness is often defined in psychological terms as an unpleasant feeling that people experience when they perceive their social relationships to be qualitatively or quantitatively inadequate [ 14 ]. The quality, rather than the quantity, of social relationships plays a greater role in loneliness [ 15 ]. While temporary loneliness is a natural human experience, chronic loneliness has serious negative consequences for health and life expectancy. There are three main types of loneliness: intimate (also known as emotional) loneliness, relational (also known as social) loneliness and collective loneliness, first identified by McWhirter (1990) [ 16 ], and empirically validated by Hawkley et al. (2005) [ 17 ] and Panayiotou et al. (2023) [ 18 ]. Loneliness is distinct from social isolation, which Nicholson Jr. (2009) [ 19 ] defines as “a state in which the individual lacks a sense of belonging socially, lacks engagement with others, has a minimal number of social contacts, and they are deficient in fulfilling and quality relationships” (p. 1346). This does not mean that socially isolated individuals necessarily feel lonely and vice versa.

There are different scales to measure loneliness and social isolation. The most commonly used instruments for measuring loneliness are the indirect measures from De Jong Gierveld Loneliness Scale [ 20 ] and the full UCLA Loneliness Scale [ 21 ], as well as the direct measure from the UK Office for National Statistics [ 22 ]. However, what these definitions fail to measure is the “intensity, frequency and duration of loneliness. Loneliness can be acute (i.e., transient) or chronic (i.e., enduring), and it can be mild to severe in its intensity” [ 23 , p.2]. There are also a variety of scales to measure social isolation, but there is no consensus on which should be used [ 24 ]. Some common scales include the Lubben Social Network Scale [ 25 ], the Cudjoe social isolation typology [ 26 ] or a social isolation index used by Shankar et al. [ 27 ].

Our study contributes to existing literature by presenting an overview of current governmental documents that address loneliness and social isolation. Our intention is that the scoping review would be used by federal agencies or local communities who want to develop their own strategies to address loneliness and social isolation, or by researchers to gain an overview of the policy landscape.

The aim of this study was to characterise the policy landscape relevant to tackling loneliness and social isolation across the UN European country groups to identify commonalities and differences between national approaches to loneliness. A secondary aim was to provide actionable recommendations including their implications based on the scoping review for the consideration of policy makers to help promote the rapid and widescale adoption and diffusion of sustainable, scalable and evidence-based interventions to manage loneliness.

We conducted a scoping review based on Mak and Thomas’ recommendations (2022) [ 28 ] to identify (i) how loneliness and social isolation are defined, (ii) the common characteristics between loneliness policies across countries, (iii) which population groups were targeted, and (iv) whether there was an identifiable commitment to action and funding. We contextualised findings using five domains (geographic, social, health, economic, political) that all affect or are affected by experiences of loneliness and social isolation. We have taken every step to make the scoping review as clear and reproducible as possible, following the PRISMA-ScR guidelines [ 29 ] [see file: Supplementary Material _PRISMA-ScR-Checklist].

Eligibility criteria

A multi-method review approach inspired by Schnable et al. (2021) [ 30 ], including a qualitative policy analysis, was used to identify and describe the characteristics of a collection of national-level government documents with reference to loneliness and social isolation. As national policy documents and commissioned governmental strategies and action plans are not available on a central database, a systematic review was not feasible.

We retrieved and reviewed policy documents that address loneliness or social isolation from a total of 52 countries from the UN European Country Groups: Albania (AL), Andorra (AD), Armenia (AM), Australia (AU), Austria (AT), Azerbaijan (AZ), Belarus (BY), Belgium (BE), Bosnia and Herzegovina (BA), Bulgaria (BG), Canada (CA), Croatia (HR), Czechia (CZ), Denmark (DK), Estonia (EE), Finland (FI), France (FR), Georgia (GE), Germany (DE), Greece (GR), Hungary (HU), Iceland (IS), Ireland (IE), Israel (IL), Italy (IT), Latvia (LV), Liechtenstein (LI), Lithuania (LT), Luxembourg (LU), Malta (MT), Monaco (MC), Montenegro (ME), Netherlands (NL), New Zealand (NZ), North Macedonia (MK), Norway (NO), Poland (PL), Portugal (PT), Republic of Moldova (MD), Romania (RO), Russian Federation (RU), San Marino (SM), Serbia (RS), Slovakia (SK), Slovenia (SI), Spain (ES), Sweden (SE), Switzerland (CH), Türkiye (TR), Ukraine (UA), United Kingdom of Great Britain and Northern Ireland (GB), and United States of America (US). We chose this geographic focus of Europe because the European Union was the first supranational union of states to put loneliness on its agenda with a policy brief published in 2018 [ 31 ]. To ensure comprehensive coverage of European nations, we chose the UN European country groups, recognising that they include some members beyond the continent’s geographical borders.

Articles including policies, reports, strategies and policy briefs were included in the analysis if they were (i) from the two UN country groups under study, (ii) officially published or commissioned by a national government, (iii) publicly available, (iv) published between 1 January 2003 and 1 July 2023, (v) related directly to loneliness and social isolation or indirectly by using other language such as social connection, (vi) published in any language.

Information sources

The main information sources were governmental websites of relevant ministries and departments of the 52 selected countries. Additionally, we used the Google search engine for all publicly available national policies related to loneliness and social isolation.

We conducted desktop research using the key terms “loneliness” and “social isolation” for all publicly available national policies, including a review of government websites to generate an asset map of key policy documents and white papers from each country. Online searches were conducted between 1st February 2023 and 1st July 2023.

Internet searches, using the Google search engine, included the following keywords: [(“loneliness” OR “social isolation” OR “social connection”)] and [(“policy” OR “strategy” OR “actions” OR “reports”) and “Country”]. If this did not yield any results for a specific country, we searched for the government website of that country using primary (loneliness and social isolation) and secondary (strategy/policy) terms to determine if governments published documents on loneliness and social isolation. The Google website translator was used to navigate non-English governmental websites.

Selection of sources of evidence

The documents were not limited to policies, but also included national strategies, technical reports, brochures and webpages published by government agencies, studies commissioned by a government agency, governmental press releases, and parliamentary enquiries from politicians to federal ministers or councillor regarding data on loneliness in their respective countries. If multiple strategies/policies from the same government were found, the most recently published one was included. We focused on national level documents only (excluding any regional strategies).

Where documents retrieved were not in English, they were translated into English using a paid (subscription) version of DeepL Pro, a powerful and sophisticated online translator. For reasons of pragmatism, no attempt was made to quality assure the translation with native speakers.

We excluded 40 documents after a first round of reviews where there was no disagreement between the researchers. For 20 documents there was no consensus, so a third researcher reviewed the documents. After reviewing each document, consensus was reached to exclude 16 of the 20 documents. Documents were excluded for the following reasons: (i) loneliness and social isolation were only mentioned in passing and did not elaborated on the issue of loneliness, or loneliness was not part of a proposed intervention, (ii) highlighted or acknowledged loneliness as a problem but we could not identify any detail or strategies or commitments on how to address it, (iii) short news piece or press releases that did not specifically touch on loneliness or social isolation, (iv) documented queries raised by political representatives addressed to parliament, (v) research articles not commissioned by the government, (vi) local focus, not national, (vii) NGO reports not commissioned by a government and (viii) older versions of included documents.

Data charting process

The principal investigator (NG) developed a coding matrix using Excel based on the study objectives and considerations from Braun and Clarke (2006) [ 32 ]. This matrix was first tested on the British documents (NG, DK, MLEA), as we knew these to be extensively detailed. In an iterative process this matrix was reviewed and adapted after testing it on a random selection of five sources of evidence (NG, DK, MLEA, PQ). After a final round of reviewing and adapting, all authors agreed by consensus that they have captured all desired variables needed to address the study objectives. Each policy document was coded independently by at least two investigators (NG, DK, MLEA) to minimise human error in information extraction.

The configuration matrix was completed for all sources of evidence containing information on: (i) document overview (title, publisher, year of publication, original language of publication), (ii) recommended measurement tool for loneliness, (iii) definitions for loneliness, social isolation and other language around social connection, (iv) target group of policy, (v) proposed or suggested actions by government (raising awareness, funding pledge, call for a development of a loneliness measure, proposed interventions or actions, type of evidence cited, commitment to work with specific charities), and (vi) five key domains (geographic, social, health, economic, political) that affect or are affected by experiences of loneliness and social isolation. We also coded whether the documents referred to five domains (geographic, social, health, economic, political) that have been shown to affect or are affected by experiences of loneliness and social isolation.

Synthesis of results

The data of the configuration matrix were consolidated and are presented as Table  1 , Supplementary Table A [see file: Supplementary Material_Table   A ], and within the text where a presentation in table format was not deemed useful (for data items 3–5 as detailed above). We used the document analysis as proposed by [ 33 ] to analyse all the included documents. This approach is based on an iterative processes of qualitative content analysis [ 34 ], with a specific thematic analysis [ 32 ]. The configuration matrix captured all extracted data from which the authors (NG, DK, MLEA) could identify emerging sub-themes within these broad pre-defined domains of loneliness (geographic, social, health, economic and political domain) using thematic analysis [ 32 ]. To create recommendations, two authors (NG, PQ) reviewed the extracted data, with the team revisiting the sources of evidence where needed.

Our scoping review identified 79 sources of evidence that discussed loneliness and social isolation from across 32 countries in both UN European country groups. We excluded a total of 56 documents after two review rounds for reasons shown in the PRISMA flowchart Fig.  1 . This yielded a subset of 23 documents that were included in our final analysis.

PRISMA flow chart based on [ 24 ]

Wider awareness of loneliness and social isolation in our study area

Here, we delve into the sources of evidence that were excluded from our study, but which are nonetheless noteworthy because they illustrate the momentum of the international conversations around loneliness. In some countries (AT, CH), we found parliamentary enquiries asking about data on loneliness in their respective countries, and whether there were any strategies in place to alleviate loneliness. DE does not have a loneliness strategy, but the governmental Committee for Family Affairs, Senior Citizens, Women and Youth has partially funded the organisation (the Competence Network on Loneliness (KNE)) which looks at the causes and consequences of loneliness and promotes the development and exchange of possible prevention and intervention measures in DE. NZ is a good example where there was no specific policy, despite there being great public awareness. They have an established nationwide trust called “Loneliness New Zealand Charitable Trust”. While some countries had excellent resources targeted at policy makers (e.g. CA), they have not yet been translated into a nationwide policy to address loneliness and social isolation. In countries where there was no national strategy, some cities have designed their own regional strategies or organisations, e.g. Barcelona [ 57 ], Helsinki [ 58 ], or Vancouver [ 59 ]. A map highlighting the loneliness policy development landscape across 52 countries of the UN European Country Groups is shown in Fig.  2 .

Current state of the loneliness policy landscape across the study area. Map created with [ 28 ]

It is important to note that for many countries in the study area we could not identify any resources that met the inclusion criteria. It is difficult to assess why loneliness and social isolation are not on the policy agenda of more national governments. Connel and t’ Hart [ 60 ] have developed a typology of policy inaction. Three of the five types may apply to our context: Type I: Calculated inaction. Governments may make a strategic decision not to act, or not to act now, because they believe that the costs of action outweigh the perceived benefits, or because they want to see a stronger evidence base on an issue. Type II: Ideological inaction. Government inaction as a product of ideology, where governments rely on non-governmental and not-for-profit organisations to address the issue of loneliness. The strong third or social-economy sector in the European Union [ 61 ], which includes more volunteers than paid employees, could give the impression that loneliness and social isolation can be managed without government policies. Type IV: Reluctant inaction. Governments do not act because they perceive an absolute or relative lack of resources to fund loneliness and social isolation policies. This may be the case for the less economically strong countries in our study area that do not have policies in place.

Characteristics of sources of evidence

Table  1 gives an overview of the 23 documents that we included in our analysis. Half the documents were published after 2020. Seven documents had to be translated into English. Certain countries released documents in conjunction with one another. For instance, Denmark published a National Strategy and an Action Plan simultaneously in 2023 that were complementary. Similarly, GB’s 2021 Action Plan builds on the GB Loneliness Strategy published in 2018.

Results of individual sources of evidence

For each of the included sources of evidence, we extracted information with our configuration matrix presented in the section Data items . We believe that presenting the results this way will better suit our study objectives, i.e., to highlight common and unique themes.

Target group of policies

Eight documents (from AL, CA, IT, MT, US) were targeted specifically at the older adult population, often classified as age 65 + years. Definitions, causes and proposed interventions for loneliness and social isolation in those documents were contextualised within the framework of old age. The other documents addressed the general population, often highlighting that there are specific groups that are more vulnerable to becoming lonely or socially isolated. Five of the documents identified target groups at increased risk of loneliness (AU, IE, CH, GB, DK). For instance, children (IE), young adults ages 18–25 years (AU, DK, IE, GB), older adults ages 65 + years (AU, CH, IE, GB), people with disabilities & special needs (AU, DK), people suffering from mental illness (CH), those with long-term illness (GB), migrants and refugees (AU, CH, GB), lower income households (AU), and people living alone (AU, CH), people with lower levels of schooling (CH), single parents (CH), young single men (CH), care leaver (GB), victims of domestic violence (US), LGBTQ + individuals (US) and minorities (DK, US).

Defining loneliness and social isolation

Of the 23 documents included in the review, 11 documents from seven countries (AU, AT, CA, DE, NL, GB, US) provided specific definitions of loneliness and social isolation. Those definitions were based on academic sources, explicitly referenced and cited, except for AT which based their definition on general “experts” rather than a specific source. Peplau and Perlman (1982)’s widely used framework is drawn upon in multiple documents, and some countries (AU, DE, NL, GB) go further in their definitions to distinguish between different types of loneliness, (e.g., social, emotional, and existential loneliness in the NL document).

The 11 documents that used a specific definition of loneliness used the Peplau and Perlman (1982) definition that highlights differences between loneliness and social isolation. Documents noted social isolation as an objective lack of social relationships, while loneliness is considered to be the subjective feelings as a result of that social isolation.

Across all the documents included in our review, both with and without specific definitions of loneliness, other language used around social connection can be classified as follows:

Inclusion in wider society, which includes the terms social inclusion (CZ, DK, IE, MT), social integration (CA) and social participation (DE, NL, CH).

Connecting with others, which includes the terms social networks (CA, DK, DE), social support (CH, US), social connection (AU, US), and social contacts (AT, DE, NL, GB).

Existing resources, which includes the terms social resources (CH), social capital (CH, CA), and social skills (CA, NL).

Covering a deficit, which includes the terms social exclusion (AL, CZ, CA), social vulnerability (IT, CA) and social recovery (AU).

Relationship between loneliness and mental health, which includes the term social wellbeing (GB), and discussions of social prescribing (GB) and the contribution of loneliness to poor mental health (IE).

Mental health, which includes the term social wellbeing (GB), and discussions of social prescribing (GB) and the contribution of loneliness to poor mental health (IE).

Funding pledges

Despite the governmental strategies and action plans to reduce loneliness and social isolation, we found little evidence of a commitment to funding. We identified concrete funding pledges or already provided funding for AL (0.75 m USD for 5 years), DK (145 m USD for 2014–2025), GB (24.8 m USD in 2018; 44.5 m USD in 2020), and NL (10.7 m USD per year for 2022–2025; 5.5 m USD 2018–2022) governments. DK provided a detailed overview of initiatives that can be achieved within the already approved budget, initiatives that could be delivered within existing financial frameworks and over 80 initiatives that should be advanced but required additional funding. The Australian government has not yet made a funding pledge but has received a specific budget and initiative proposal for funding from an alliance of three different national organisations. Other government strategies either stated that different ministries are to ensure the necessary financial and human resources for initiatives that fall under their respective jurisdiction (MT) or did not specify funding pledges, merely stating that adequate funding needs to be identified (IT). We identified that some governments (DE, SE) are (partially) funding research on loneliness to gather scientific evidence to help them build their own policy.

Interventions and partnerships

Strategies, policies and action plans proposed a variety of interventions, while technical reports focused on reviewing existing evidence. We have provided many intervention examples across various domains in the policy landscape analysis section below. Of those countries and documents included in our analysis, only AU and GB have committed to work with specific charities, organisations or initiatives to address loneliness and social isolation. Other governments (CA, IE, IT, MT) stated their intention to work with NGOs and local services, but did not mention any specific organisations.

Development of a loneliness and social isolation measure

None of the documents called for the development of new tools to measure loneliness or social isolation. US, DK and GB reviewed existing measures of loneliness for use in possible interventions and strategies. Notably, GB described its own use of a consistent and direct measure of loneliness, developed by the Office of National Statistics (ONS) in 2018. The Direct Measure of Loneliness is a single item measure developed by the ONS that should be used in conjunction with three questions from the University of California Los Angeles (UCLA) Loneliness Scale. A US documents considered multiple ways in which loneliness and social isolation should be measured in research and recommended the appropriate choice of measures in targeted interventions and in major health strategies. The US did not call for the creation of a new measure, but rather recommended the use of existing validated tools tailored to the purpose of proposed interventions. DK’s national strategy considered the applicability of adult measures to adolescents and children.

Policy landscape analysis

This section highlights the wider policy context of the loneliness debate. All 14 countries that have published documents on loneliness are aware that loneliness touches many different dimensions (geographical, health, social, economic, and political; see Table  2 for a brief overview). In 91% ( n  = 21) of the analysed documents, the social and health dimension was most prominent, highlighting the impact of loneliness on various aspects of people’s lives and across age groups, as well as the health implications. However, not all dimensions were addressed with the same level of detail. An extensive overview of the different dimensions touched upon in every document can be found in the Supplementary Table A . For each of the five dimensions, we have identified themes that recur across the documents. We have also added some intervention examples to show how loneliness could be addressed in this dimension from a policy perspective.

Geographic dimension

Most documents (74%, n  = 17) touched on various geographic dimensions that influence or are influenced by loneliness. Four governments observed geographical variation in loneliness prevalence within their country (AU, CA, DE, GB). Only one document suggested reforming the digital environment (US). Within the geographic dimension the following themes were most often mentioned as being influential regarding loneliness and social isolation in the context of geography: (i) place or residence and housing, (ii) public transport, (iii) community services, and (iv) urban planning.

Place of residence and housing

Four governments (AU, CA, DE, GB) reported that the place of residence (urban or rural) significantly influences loneliness. Loneliness levels were also considered to vary due to population changes (AT, DE) but acknowledged that regional distribution was complex and cannot be solely attributed to urban-rural differences. Relocating to a new place was also reported to lead to feelings of being disconnected from familiar social networks and support systems. Additionally, insufficient affordable and suitable housing contributed to social isolation. Living conditions were mostly mentioned in connection with older adults where the effect of the type of housing was mentioned to affect social interactions and feelings of loneliness (CA, DK). Intervention examples to manage loneliness as a result of a change in residence, or loss of housing include working within local municipal authorities’ strategies on housing policies and reform plans (IT, DK, NL), creating models of apartments that foster community life (AL, DK), creating flexible housing solutions to support life transitions, e.g. homes that can be adjusted in size or adapted to changing needs (DK).

Public transport

The impact of public transport, especially access and affordability, was mentioned as a key issue for social integration, especially for older people (AL, CA). The place of residence (especially if rural) was recognised as a barrier to public transport use. Intervention examples that were put in place to address this issue include an increase of public transport access for the poorer older adults by subsidising the costs locally (AL, DK), and further strengthening accessible transport for communities in residential areas specifically (DK, GB).

Community services

Limited awareness of or access to community services contributed to loneliness. Financial support and grants for rural projects are needed to promote social inclusion. GB, DK and NL documents highlight the importance of the central government working together with local authorities, as the latter play a key role in actively supporting local transport, voluntary groups and initiatives that promote social cohesion and reduce isolation. Intervention examples included subsidies for community work to promote social inclusion specifically in rural areas (CZ), expanding the services in and of community centres (AL), and promoting the use of tailored community-based services (US).

Urban planning

There was general awareness that the physical environment can pose challenges to social participation, especially for the more vulnerable groups, e.g. older adults (CA), in terms of access to public toilets or walkability. Intervention examples included cultivating a sense of belonging that should be considered by urban planners (CA, IT), ensuring proximity to public services (IT), access to public toilets (CA), establishment of healthy and active movement paths (IT) aimed at encouraging walking groups (IT, CH), maximising the use of underutilised community spaces (GB), and use of participatory design in the development of child-friendly neighbourhoods in local environments (CH).

Social dimension

Most documents (90.9%, n  = 20) highlighted a range of interrelated social factors associated with loneliness; the social determinants covered various aspects of people’s lives that shape experiences of loneliness across age groups. Throughout these documents were notes on groups more vulnerable to loneliness as well as everyday life transitions and triggers. Some risk factors for loneliness such as lacking contact with family and friends, the negative impact of unemployment, and inadequate income support were also prominently highlighted.

Groups vulnerable to loneliness

Many governments identified groups more vulnerable to loneliness and social isolation, in line with research findings (AL, CA, IT, MT, NL, CH, GB, US). The following groups were identified as more vulnerable to becoming lonely or socially isolated: single parents, widows, newly retirees, single households, those living in changing family structures, immigrants with language barriers or low socioeconomic status, individuals dealing with addiction, those from the LGBTIQ + community, young adults (around 18 to 29), older adults (above 80), individuals that experience bullying or harassment, and individuals with criminal records. The importance of cultivating inclusive communities and establishing safe spaces for individuals, particularly for groups like migrants, single parents, and older adults was emphasized. Interventions were often tailored to specific groups. For example, community-led interventions targeted older adults who were homebound or in residential long-term care (MT). Others strengthened the resources of older people caring for relatives (CH), invested in a Carers Action Plan (GB), levelled up the volunteering infrastructure through collaboration of the voluntary sector and the government especially for those out-of-work (GB), developed social prescribing pilots and peer support groups (GB, US), facilitated befriending and socializing (AU), and linked vulnerable groups of people in the form of self-help and enabled them to help each other (CH). Here are some examples of targeted interventions for specific groups:

Women: language classes for women who do not speak the local language with crèche facilities alongside the classes (GB), Mitigate the risks of lifelong gender inequalities that result in female old-age poverty and gender pension gaps by ensuring adequate levels of income security for older women (MT).

Men: increase offers for older (single) men such as Men’s Meeting Places or Men’s Communities (DK), active aging centres to mitigate against the tendency of older men to experience difficulties in seeking help and talking about loneliness (MT).

Young people: Strengthen detection of loneliness in day care, primary schools and educational institutions (DK), provide education courses as a source of mitigating loneliness among children (DK), create more binding communities for young people without education and jobs (DK).

Older adults and low-income households: offer free local cultural and leisure activities (CH), increase public transport access (AL), guaranteeing the living minimum and gradual improvement of lowest pensions (AL), activation of computer literacy paths (IT).

Everyday life

The impact of events like the pandemic on individuals and communities was noted, with reference to mental well-being and social interactions, including potential changes in post-pandemic work patterns that might limit personal engagement. The absence of support or opportunities within society, communities, and workplaces is discussed as hindering social integration and fosters loneliness. The role of technology and social media as both a potential mitigating and exacerbating factor was recognized. Intervention examples include enhancement of popular traditions by developing new forms of technologically-oriented interactions, while still including cultural heritage (IT), expansion of existing community interventions (MT) including specific funding allocated to national, local, and community levels (AU), development of national and community awareness or anti-stigma campaigns (AU, CA, DK, DE, IE, NL, GB, US), and awareness spreading specifically towards politicians, administrations, managers, health care providers and others who work on loneliness (DK, US).

Health dimension

The health dimension of loneliness was very prominent in most documents (91%, n  = 21), often noting that socially isolated individuals faced an increased risk of engaging in negative health behaviours. The evidence of interconnection between chronic illnesses, mental health and social isolation was also highlighted. Overlapping with recommendations identified in the social domain, the need for policy development to prioritize social function among older individuals, aiming to enhance their overall health and well-being, was mentioned by (AT, DE, IE).

Institutional intervention examples included the development of an integrated health and social system on a community basis (AL, DK), national training for health practitioners and community care services to systematically identify, monitor and direct people experiencing loneliness (AU, DK, MT, US), linking healthcare practitioners with researchers to further evaluate and use loneliness assessment tools in clinal settings (US), and the inclusion of loneliness and social isolation in electronic health records (AU, US).

Physical health

Documents noted the evidence that individuals with higher levels of chronic diseases, geriatric syndromes, reduced mobility, chronic pain, frailty, hearing and sight impairment, urinary incontinence, or other health issues necessitating long-term care were more susceptible to loneliness. Governments acknowledged these links, often targeting interventions to support disabled people. Intervention examples included the provision of sensory impairment guides for those whose social lives are impacted by a change in their senses due to accidents or disabilities (GB), strengthening bridge-building for civil society and other actors was recommended in the context of in-system transitions and among high-risk groups (DK), the establishment of mobility centres to help people stay mobile or provide information on alternative modes of transport (GB), increased focus on digital inclusion of older and disabled to reduce loneliness as they face reduced mobility (GB), and the advancement of physical activity interventions, especially promising for improving the health outcomes of older adults (US).

Mental health

The policy documents showed empirical evidence that individuals experiencing depression, mental health problems and addiction were at risk of social exclusion. Depression and anxiety are specifically mentioned as significant factors in the context of loneliness; the consequences of loneliness are also discussed, with reference to the increased risk of depression, suicide, anxiety disorders, dementia, and reduced cognitive abilities. Intervention examples included the introduction of community care for people with mental health problems (CZ), while others focused attention on cognitive behavioural therapy, interpersonal psychotherapy and mindfulness (US). The reduction of addictive substances in populations at risk of social exclusion was targeted (CZ); mental health literacy programs were also discussed (DE, IE), specifically in reference to school education initiatives such as social emotional learning programs for use in preschool, school, and youth settings (IE); mental health literacy campaigns were also highlighted (DE, IE).

Economic dimension

Economic factors relating to loneliness were also addressed most documents (74%, n  = 17). In line with research evidence, documents noted that unemployment, receiving income support, and dissatisfaction with financial situation contribute to loneliness. The need for allocating more resources to combat poverty and address the loneliness experienced by older individuals was emphasised, with reference to the fact that it plays a crucial role in enhancing their overall well-being and quality of life. The following themes were prominent within this dimension.

Economic poverty stemming from insufficient income was identified as a key concern for the older adult population. Notably, social exclusion and family poverty were found to be directly linked, posing a risk to children as well. One document (AU) noted that men ages 25–44 years with high incomes and women of all ages with low incomes have been to be more susceptible to loneliness, revealing a discrepancy based on gender. The economic burden of loneliness extended to health service utilization costs, especially for mental health services. Intervention examples included allocating more resources to combat poverty and address the loneliness of older people specifically (IT), guaranteeing dignified living conditions through the adoption of the minimum pension and the gradual improvement of the lowest pensions by offering sustainable support for the poorer elderly was also suggested within the economic domain (AL), early support interventions for children from disadvantaged families, including support for their parents (CH), and more widely to reduce risk of social exclusion due to over-indebtedness (CZ).

Unemployment

Lack of affordable and suitable housing and care options was noted as being linked to social isolation. Loneliness and lack of social support could lead to reduced community participation, hindering employment prospects and workplace progress. This can result in reduced productivity, lower job satisfaction, increased absenteeism, and longer recovery times due to stress and health issues, which in turn negatively affects the economy. Intervention examples included facilitation of the integration of vulnerable individuals into the workforce (CZ, DK), prevention of loneliness among the unemployed through volunteerism and community initiatives (GB, DK), focus on ensuring a smooth transition from work to retirement (DK), working in collaboration with job centres (GB), and creating a cultural shift in work environments for employees at risk of social exclusion (CZ).

Political dimension

Political factors pertaining to loneliness and social isolation were only identified in few documents (30%, n  = 7), indicating less governmental awareness of the political implications of loneliness. Instances of elderly individuals being denied many rights were observed to be associated with loneliness (AL). Additionally, the effects of COVID-19 lockdown policies were connected to the loneliness because of social isolation. DE mentioned the political relevance of loneliness as it correlates with decreased political engagement of individuals. Thus, it was stated that implementing political measures at the federal level is imperative to effectively foster a more socially connected society (DE). One of the documents mentioned the need for the government to establish a comprehensive national strategy targeting loneliness, accompanied by the allocation of sufficient funding, with active engagement from regions and municipalities, especially when it comes to implementation (DK). Furthermore, the same document underscored the contribution of various other key stakeholders, including research institutions, foundations, employers, and civil society, in combating loneliness (DK). Multiple countries acknowledged the relevance of working across government bodies and levels in combatting loneliness (AU, DE, NL, GB). One document highlighted the need for a “connection-in-all-Policies” [ 62 , p.49] approach as social connection, an antidote to loneliness and social isolation, is relevant in all sectors (US).

To our knowledge, this is the first study to characterise the loneliness policy landscape across the UN European country groups (52 countries). The scoping review provided comprehensive coverage of how countries address loneliness and social isolation on a national level, allowing for a much clearer understanding of the diversity in country-level strategies and better coordination across countries in tackling loneliness. This is particularly important because loneliness and social isolation have been increasingly identified as a public health concern [ 63 , 64 ]. The findings of this review can be used by a wide range of stakeholders including federal agencies and local community groups who want to develop their own strategies to address loneliness and social isolation, or by researchers to gain an overview of the policy landscape.

Summary of principal findings

While not all governments (14 of 52 countries; 27%) had official documents that addressed loneliness, the vast number of documents we identified (79 documents) highlight the growing momentum in the loneliness discourse in the study area. The inclusion of research findings in the vision and strategy documents from different nations suggests widespread evidence-to-policy across the world and calls for a cross-disciplinary approach to addressing loneliness, including efforts to leverage asset-based community development and place-based approaches to tackling loneliness [ 65 ].

All 14 countries that published documents on loneliness demonstrated an awareness that loneliness impacted various dimensions including geography (through place of residence and housing, public transport, community services, urban planning), social (some groups are more vulnerable to loneliness than others, social support, technology), health (physical and mental), economics (income, unemployment) or politics (effects of COVID policies, political engagement, working across sectors to address loneliness). Notably, none of the documents reviewed acknowledged that (i) most research on physical health and loneliness is cross-sectional, where the researcher measures both the outcome and the exposures of the study participants at the same time, and thus, the findings of these studies cannot be used to make causal inferences, and (ii) such work does not control for other predictors of health, including, for example, socioeconomic status and actual health conditions. These are important considerations because (a) we cannot be certain that healthy individuals are more likely to get sick if they experience loneliness compared to other healthy individuals who do not experience loneliness, and (b) whether the link between loneliness and health is actually driven by structural inequalities that determine our physical and social environments. We have also found that the documents rarely mention the transient nature of loneliness and the discourse often seems to frame loneliness like an illness that can be treated. The documents also did not address the cultural context (i.e. beliefs, values, religion) that can shape expectations of relationships and the welfare regime.

Policy targets proposed in the documents

Most countries in our sample showed some attempt at raising public awareness about loneliness (AL, AU, CA, DK, DE, IE, IT, MT, NL, CH, UK, US). Such policies are often informative, but there appeared to be a lack of deadlines and appropriate funding. That means the strategy cannot be evaluated. Another point of concern is the perception that loneliness is something that only affects older adults. Some documents lacked information about how to address loneliness, probably because here is limited evidence of what works and for whom. Also absent was a commitment to evaluation of interventions, which is crucial to verify the effects of any intervention and any risks related to action.

Recommendations for policy makers

Despite the adoption of an evidence-to-policy approach to loneliness, given the issues noted above, we encourage policymakers to be cautious in making claims in relation to loneliness, and to ensure that part of their strategy includes the funding of research that fill the gaps in knowledge. Policymakers should also ensure that the work they quote includes study populations that are well-represented in all relevant demographics and that the research is able to make causal claims about how loneliness impacts health. The World Health Organisation (WHO) and the European Union have identified the limits of their own knowledge and skills in this field, commissioning experts to write evidence gap reports [ 66 , 67 ] or GB and DK for example have had loneliness researchers help write their vision and strategy.

Policymakers should also adopt a similar approach in relation to interventions that address loneliness. A recent meta-analytic review [ 68 ] suggested that in order for interventions designed to reduce loneliness to be effective, matching the intervention to the loneliness type is essential, whereas a one size fits all will not be effective. For example, social support interventions and social and emotional skills training are all promising interventions for reducing loneliness, albeit they are usually only appropriate for loneliness that is linked to the perceived absence of a close friend or partner and perceived lack social encounters and acquaintances respectively. Such an understanding of the nuances surrounding loneliness interventions is absent from the documents we evaluated, and policymakers will want to fill that gap in their knowledge so that appropriate decisions about intervention work, and suitable funding, can be provided. The effects of current interventions have been shown to be only moderate, highlighting the need for funding for rigorous and systematically developed interventions that are also appropriately evaluated.

Based on our scoping review and underlying evidence we propose a list of actionable recommendations for national and regional governments wishing to establish or incorporate loneliness into their policy documents (Table  3 ). In sum, we believe that revisiting previous national and local campaigns to identify connection points for loneliness interventions is an effective way to include loneliness into the policy agenda. For example, a walkability campaign that focuses on making cities more pedestrian friendly will benefit individuals in terms of physical health and mental health but it also increases the likelihood of social encounters when walkability is higher [ 69 ]. We also believe that sharing best-practice approaches internationally and accessible to everyone ensures the development of a strong knowledge base. The EU has taken the lead as the first supranational union to address loneliness amongst its member states by recently organizing various roundtables and conferences around loneliness [ 70 ]. Globally, WHO has recently published an evidence gap report on in-person interventions for reducing social isolation and loneliness [ 67 ]. Lastly, we argue that policies would be meaningless if there are no concrete funding streams allocated towards evidence generation, intervention design and implementation and the evaluation thereof. Because our review could not identify clear funding streams for all countries, we strongly encourage policy makers to make the funding streams transparent within their loneliness policies.

Limitations

The primary limitation of our scoping review was concerned with identifying documents from countries that did not provide information in English. That limitation was partially overcome by the use of Google’s website translator. Another limitation is the reliance on machine translation for the identified documents. Documents were translated into English from German, Danish, Finnish, French, Dutch and Norwegian using DeepL. For German and French, the quality of the translation was checked by the author team and considered sufficient to meet our study aim. The cross-sectional design of our scoping review also does not account for how a country’s policy may have changed over time. This is a general issue in policy evaluation. That limitation can be overcome by conducting this review every two to four years. Another challenge with our study is that the data reflect the existence of policies and not the effectiveness of their implementation. Further, only funding that was explicitly allocated to reducing loneliness and social isolation was considered. We acknowledge that other initiatives that received governmental funding pledges, such as establishing community centres for older adults, might also reduce feelings of loneliness. However, it is beyond the scope of the current paper to identify which initiatives specifically reduce loneliness and how much funding has been allocated to them, especially as evidence on which interventions have proven successful are scarce. Additionally, there may be other funding streams we are not aware of or that might have been part of other documents (e.g., state budgets) not included in this analysis.

More work is needed to assess if the various proposed interventions are implemented and successful. Evaluating interventions is crucial if we want to effectively use the pledged funding, to identify what tools (online or other) are being developed to promote loneliness interventions on national and regional levels and to map out the role of the emerging national loneliness networks.

Our study provides the first comprehensive overview of the national loneliness policy landscape across 52 countries, highlighting the increasing prioritisation of loneliness and social isolation as significant public health and societal issues. While the momentum in addressing loneliness is evident, with most policies being informed by scientific evidence, gaps remain, particularly around intervention strategies and their effectiveness. Our findings urge policymakers to not only sustain this momentum but to also strengthen their strategies by incorporating rigorous, evidence-based intervention evaluations and fostering international collaborations for knowledge sharing. This approach can enhance the understanding and addressing of loneliness, ensuring interventions are well-targeted, effective, and scalable. By addressing these issues, policymakers can more effectively manage loneliness by directing funds to develop and implement interventions that impact the individual (e.g. through therapy or befriending services, thereby improving public health outcomes) and the community and society by making them genuinely inclusive, thereby increasing social cohesion.

Availability of data and materials

The references to the documents supporting the conclusions of this article are provided in Table  1 . Should a link have expired, contact the corresponding author for a pdf version of the translated and original document in question.

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Acknowledgements

The authors thank the following students for assisting with compiling the dataset of government documents: Selma Akbas and Laura Baldini. The authors also thank the following students for assisting with the first round of document coding: Kim Aleppo, Izma Ahmed, Angela Benson, Emma Marchong, Sathana Sivanantham, Keyi Le, Yaxuan Shi, Ruifeng Ding and Yiming Bi. The authors would also like to thank Mahmoud M M Al Ammouri for creating the map displayed as Fig.  2 . The lead author also thanks Claudia Kessler from Public Health Services based in Switzerland for insightful discussions on the Danish and Dutch national loneliness policies.

This research was unfunded. Nina Goldman is supported by the Swiss National Science Foundation (SNSF), Bern (Grant #: 214225). Austen El-Osta is supported by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration (ARC) Northwest London. The views expressed are those of the authors and not necessarily those of the SNSF, NHS, NIHR or the Department of Health and Social Care. AEO is the guarantor.

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Nina Goldman, Devi Khanna and Marie Line El Asmar contributed equally to this work.

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Manchester Institute of Education, University of Manchester, Ellen Wilkinson Building, Devas Street, Manchester, M13 9PL, United Kingdom

Nina Goldman, Devi Khanna & Pamela Qualter

School of Public Heath, Faculty of Medicine, Imperial College London, Charing Cross Hospital, Reynolds Building, St Dunstan’s Road, London, W6 8RF, United Kingdom

Nina Goldman & Austen El-Osta

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All authors contributed substantially to this study: Conception (N.G., A.EO.) and design of the work (N.G., A.EO., P.Q.); Data collection (N.G.); Data analysis and interpretation (N.G., D.K., M.L.EA.); Drafting the article (N.G., D.K., M.L.EA.); Critical revision of the article (P.Q., A.EO.); Final approval of the version to be submitted (N.G., D.K., M.L.EA., A.EO., P.Q.)

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The authors span multiple nationalities and levels of seniority. All authors are based at three UK institutions (University of Manchester, Imperial College London and Hampshire Hospitals NHS Foundation Trust). The lead author is a human geographer researching loneliness from a spatial perspective, the second author has a background in international social and public policy, the third author is a medical doctor conducting mixed methods research in the area of public health, the fourth author is the UK's leading scientific expert on child and adolescent loneliness and the last author is a mixed methods public health researcher and is principal investigator of the Measuring Loneliness in the UK (INTERACT) study.

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Goldman, N., Khanna, D., El Asmar, M.L. et al. Addressing loneliness and social isolation in 52 countries: a scoping review of National policies. BMC Public Health 24 , 1207 (2024). https://doi.org/10.1186/s12889-024-18370-8

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The History of Loneliness

By Jill Lepore

The female chimpanzee at the Philadelphia Zoological Garden died of complications from a cold early in the morning of December 27, 1878. “Miss Chimpanzee,” according to news reports, died “while receiving the attentions of her companion.” Both she and that companion, a four-year-old male, had been born near the Gabon River, in West Africa; they had arrived in Philadelphia in April, together. “These Apes can be captured only when young,” the zoo superintendent, Arthur E. Brown, explained, and they are generally taken only one or two at a time. In the wild, “they live together in small bands of half a dozen and build platforms among the branches, out of boughs and leaves, on which they sleep.” But in Philadelphia, in the monkey house, where it was just the two of them, they had become “accustomed to sleep at night in each other’s arms on a blanket on the floor,” clutching each other, desperately, achingly, through the long, cold night.

The Philadelphia Zoological Garden was the first zoo in the United States. It opened in 1874, two years after Charles Darwin published “The Expression of the Emotions in Man and Animals,” in which he related what he had learned about the social attachments of primates from Abraham Bartlett, the superintendent of the Zoological Society of London:

Many kinds of monkeys, as I am assured by the keepers in the Zoological Gardens, delight in fondling and being fondled by each other, and by persons to whom they are attached. Mr. Bartlett has described to me the behavior of two chimpanzees, rather older animals than those generally imported into this country, when they were first brought together. They sat opposite, touching each other with their much protruded lips; and the one put his hand on the shoulder of the other. They then mutually folded each other in their arms. Afterwards they stood up, each with one arm on the shoulder of the other, lifted up their heads, opened their mouths, and yelled with delight.

Mr. and Miss Chimpanzee, in Philadelphia, were two of only four chimpanzees in America, and when she died human observers mourned her loss, but, above all, they remarked on the behavior of her companion. For a long time, they reported, he tried in vain to rouse her. Then he “went into a frenzy of grief.” This paroxysm accorded entirely with what Darwin had described in humans: “Persons suffering from excessive grief often seek relief by violent and almost frantic movements.” The bereaved chimpanzee began to pull out the hair from his head. He wailed, making a sound the zookeeper had never heard before: Hah-ah-ah-ah-ah . “His cries were heard over the entire garden. He dashed himself against the bars of the cage and butted his head upon the hard-wood bottom, and when this burst of grief was ended he poked his head under the straw in one corner and moaned as if his heart would break.”

Nothing quite like this had ever been recorded. Superintendent Brown prepared a scholarly article, “Grief in the Chimpanzee.” Even long after the death of the female, Brown reported, the male “invariably slept on a cross-beam at the top of the cage, returning to inherited habit, and showing, probably, that the apprehension of unseen dangers has been heightened by his sense of loneliness.”

Loneliness is grief, distended. People are primates, and even more sociable than chimpanzees. We hunger for intimacy. We wither without it. And yet, long before the present pandemic, with its forced isolation and social distancing, humans had begun building their own monkey houses. Before modern times, very few human beings lived alone. Slowly, beginning not much more than a century ago, that changed. In the United States, more than one in four people now lives alone; in some parts of the country, especially big cities, that percentage is much higher. You can live alone without being lonely, and you can be lonely without living alone, but the two are closely tied together, which makes lockdowns, sheltering in place, that much harder to bear. Loneliness, it seems unnecessary to say, is terrible for your health. In 2017 and 2018, the former U.S. Surgeon General Vivek H. Murthy declared an “epidemic of loneliness,” and the U.K. appointed a Minister of Loneliness. To diagnose this condition, doctors at U.C.L.A. devised a Loneliness Scale. Do you often, sometimes, rarely, or never feel these ways?

I am unhappy doing so many things alone. I have nobody to talk to. I cannot tolerate being so alone. I feel as if nobody really understands me. I am no longer close to anyone. There is no one I can turn to. I feel isolated from others.

In the age of quarantine, does one disease produce another?

“Loneliness” is a vogue term, and like all vogue terms it’s a cover for all sorts of things most people would rather not name and have no idea how to fix. Plenty of people like to be alone. I myself love to be alone. But solitude and seclusion, which are the things I love, are different from loneliness, which is a thing I hate. Loneliness is a state of profound distress. Neuroscientists identify loneliness as a state of hypervigilance whose origins lie among our primate ancestors and in our own hunter-gatherer past. Much of the research in this field was led by John Cacioppo, at the Center for Cognitive and Social Neuroscience, at the University of Chicago. Cacioppo, who died in 2018, was known as Dr. Loneliness. In the new book “ Together: The Healing Power of Human Connection in a Sometimes Lonely World ” (Harper Wave), Murthy explains how Cacioppo’s evolutionary theory of loneliness has been tested by anthropologists at the University of Oxford, who have traced its origins back fifty-two million years, to the very first primates. Primates need to belong to an intimate social group, a family or a band, in order to survive; this is especially true for humans (humans you don’t know might very well kill you, which is a problem not shared by most other primates). Separated from the group—either finding yourself alone or finding yourself among a group of people who do not know and understand you—triggers a fight-or-flight response. Cacioppo argued that your body understands being alone, or being with strangers, as an emergency. “Over millennia, this hypervigilance in response to isolation became embedded in our nervous system to produce the anxiety we associate with loneliness,” Murthy writes. We breathe fast, our heart races, our blood pressure rises, we don’t sleep. We act fearful, defensive, and self-involved, all of which drive away people who might actually want to help, and tend to stop lonely people from doing what would benefit them most: reaching out to others.

The loneliness epidemic, in this sense, is rather like the obesity epidemic. Evolutionarily speaking, panicking while being alone, like finding high-calorie foods irresistible, is highly adaptive, but, more recently, in a world where laws (mostly) prevent us from killing one another, we need to work with strangers every day, and the problem is more likely to be too much high-calorie food rather than too little. These drives backfire.

Loneliness, Murthy argues, lies behind a host of problems—anxiety, violence, trauma, crime, suicide, depression, political apathy, and even political polarization. Murthy writes with compassion, but his everything-can-be-reduced-to-loneliness argument is hard to swallow, not least because much of what he has to say about loneliness was said about homelessness in the nineteen-eighties, when “homelessness” was the vogue term—a word somehow easier to say than “poverty”—and saying it didn’t help. (Since then, the number of homeless Americans has increased.) Curiously, Murthy often conflates the two, explaining loneliness as feeling homeless. To belong is to feel at home. “To be at home is to be known,” he writes. Home can be anywhere. Human societies are so intricate that people have meaningful, intimate ties of all kinds, with all sorts of groups of other people, even across distances. You can feel at home with friends, or at work, or in a college dining hall, or at church, or in Yankee Stadium, or at your neighborhood bar. Loneliness is the feeling that no place is home. “In community after community,” Murthy writes, “I met lonely people who felt homeless even though they had a roof over their heads.” Maybe what people experiencing loneliness and people experiencing homelessness both need are homes with other humans who love them and need them, and to know they are needed by them in societies that care about them. That’s not a policy agenda. That’s an indictment of modern life.

In “ A Biography of Loneliness: The History of an Emotion ” (Oxford), the British historian Fay Bound Alberti defines loneliness as “a conscious, cognitive feeling of estrangement or social separation from meaningful others,” and she objects to the idea that it’s universal, transhistorical, and the source of all that ails us. She argues that the condition really didn’t exist before the nineteenth century, at least not in a chronic form. It’s not that people—widows and widowers, in particular, and the very poor, the sick, and the outcast—weren’t lonely; it’s that, since it wasn’t possible to survive without living among other people, and without being bonded to other people, by ties of affection and loyalty and obligation, loneliness was a passing experience. Monarchs probably were lonely, chronically. (Hey, it’s lonely at the top!) But, for most ordinary people, daily living involved such intricate webs of dependence and exchange—and shared shelter—that to be chronically or desperately lonely was to be dying. The word “loneliness” very seldom appears in English before about 1800. Robinson Crusoe was alone, but never lonely. One exception is “Hamlet”: Ophelia suffers from “loneliness”; then she drowns herself.

Modern loneliness, in Alberti’s view, is the child of capitalism and secularism. “Many of the divisions and hierarchies that have developed since the eighteenth century—between self and world, individual and community, public and private—have been naturalized through the politics and philosophy of individualism,” she writes. “Is it any coincidence that a language of loneliness emerged at the same time?” It is not a coincidence. The rise of privacy, itself a product of market capitalism—privacy being something that you buy—is a driver of loneliness. So is individualism, which you also have to pay for.

Alberti’s book is a cultural history (she offers an anodyne reading of “Wuthering Heights,” for instance, and another of the letters of Sylvia Plath ). But the social history is more interesting, and there the scholarship demonstrates that whatever epidemic of loneliness can be said to exist is very closely associated with living alone. Whether living alone makes people lonely or whether people live alone because they’re lonely might seem to be harder to say, but the preponderance of the evidence supports the former: it is the force of history, not the exertion of choice, that leads people to live alone. This is a problem for people trying to fight an epidemic of loneliness, because the force of history is relentless.

Before the twentieth century, according to the best longitudinal demographic studies, about five per cent of all households (or about one per cent of the world population) consisted of just one person. That figure began rising around 1910, driven by urbanization, the decline of live-in servants, a declining birth rate, and the replacement of the traditional, multigenerational family with the nuclear family. By the time David Riesman published “ The Lonely Crowd ,” in 1950, nine per cent of all households consisted of a single person. In 1959, psychiatry discovered loneliness, in a subtle essay by the German analyst Frieda Fromm-Reichmann. “Loneliness seems to be such a painful, frightening experience that people will do practically everything to avoid it,” she wrote. She, too, shrank in horror from its contemplation. “The longing for interpersonal intimacy stays with every human being from infancy through life,” she wrote, “and there is no human being who is not threatened by its loss.” People who are not lonely are so terrified of loneliness that they shun the lonely, afraid that the condition might be contagious. And people who are lonely are themselves so horrified by what they are experiencing that they become secretive and self-obsessed—“it produces the sad conviction that nobody else has experienced or ever will sense what they are experiencing or have experienced,” Fromm-Reichmann wrote. One tragedy of loneliness is that lonely people can’t see that lots of people feel the same way they do.

“During the past half century, our species has embarked on a remarkable social experiment,” the sociologist Eric Klinenberg wrote in “ Going Solo: The Extraordinary Rise and Surprising Appeal of Living Alone ,” from 2012. “For the first time in human history, great numbers of people—at all ages, in all places, of every political persuasion—have begun settling down as singletons.” Klinenberg considers this to be, in large part, a triumph; more plausibly, it is a disaster. Beginning in the nineteen-sixties, the percentage of single-person households grew at a much steeper rate, driven by a high divorce rate, a still-falling birth rate, and longer lifespans over all. (After the rise of the nuclear family, the old began to reside alone, with women typically outliving their husbands.) A medical literature on loneliness began to emerge in the nineteen-eighties, at the same time that policymakers became concerned with, and named, “homelessness,” which is a far more dire condition than being a single-person household: to be homeless is to be a household that does not hold a house. Cacioppo began his research in the nineteen-nineties, even as humans were building a network of computers, to connect us all. Klinenberg, who graduated from college in 1993, is particularly interested in people who chose to live alone right about then.

I suppose I was one of them. I tried living alone when I was twenty-five, because it seemed important to me, the way owning a piece of furniture that I did not find on the street seemed important to me, as a sign that I had come of age, could pay rent without subletting a sublet. I could afford to buy privacy, I might say now, but then I’m sure I would have said that I had become “my own person.” I lasted only two months. I didn’t like watching television alone, and also I didn’t have a television, and this, if not the golden age of television, was the golden age of “The Simpsons,” so I started watching television with the person who lived in the apartment next door. I moved in with him, and then I married him.

This experience might not fit so well into the story Klinenberg tells; he argues that networked technologies of communication, beginning with the telephone’s widespread adoption, in the nineteen-fifties, helped make living alone possible. Radio, television, Internet, social media: we can feel at home online. Or not. Robert Putnam’s influential book about the decline of American community ties, “Bowling Alone,” came out in 2000, four years before the launch of Facebook, which monetized loneliness. Some people say that the success of social media was a product of an epidemic of loneliness; some people say it was a contributor to it; some people say it’s the only remedy for it. Connect! Disconnect! The Economist declared loneliness to be “the leprosy of the 21st century.” The epidemic only grew.

This is not a peculiarly American phenomenon. Living alone, while common in the United States, is more common in many other parts of the world, including Scandinavia, Japan, Germany, France, the U.K., Australia, and Canada, and it’s on the rise in China, India, and Brazil. Living alone works best in nations with strong social supports. It works worst in places like the United States. It is best to have not only an Internet but a social safety net.

Then the great, global confinement began: enforced isolation, social distancing, shutdowns, lockdowns, a human but inhuman zoological garden. Zoom is better than nothing. But for how long? And what about the moment your connection crashes: the panic, the last tie severed? It is a terrible, frightful experiment, a test of the human capacity to bear loneliness. Do you pull out your hair? Do you dash yourself against the walls of your cage? Do you, locked inside, thrash and cry and moan? Sometimes, rarely, or never? More today than yesterday? ♦

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Growing body of research shows importance of addressing loneliness, social isolation

by Michael Eisenstein, Johns Hopkins University Bloomberg School of Public Health

Too much time alone can take a toll on the mind—and for older adults, the consequences can be particularly severe.

"Individuals who experience isolation have higher levels of negative cardiovascular outcomes, functional limitations, cognitive health, and a 30% increased mortality risk as indicated in certain studies," says Thomas Cudjoe, MD, MPH, an assistant professor at the Johns Hopkins School of Medicine.

Indeed, increased risk of mortality from social isolation has been compared to smoking 15 cigarettes a day .

At the societal level, roughly 1 in 4 people over 65 are socially isolated, which could potentially affect the health and well-being of millions of Americans, according to research from Cudjoe and colleagues. Another cost: Medicare spends $6.7 billion annually in added cost of care for socially isolated older Americans, according to a 2017 AARP report .

While the COVID-19 pandemic may have forced the issue of social isolation onto everybody's radar, it has been a long-standing problem for older Americans. As we grow older, it can be all too easy to lose touch with both family and the friends we've acquired over a lifetime. Aging also leads to inevitable physical decline, including disabilities that can make it more difficult to get out of the house and engage with the outside world.

Hearing loss, for example, can make communication challenging and can take the pleasure out of activities like dining out or going to the movies, cutting off important avenues of social stimulation "Two-thirds of older adults have age-related hearing loss ," says Alison Huang, Ph.D. '22, MPH '14, a senior research associate in Epidemiology. A 2024 study by Huang and colleagues found that loss of hearing is associated with a 28% greater risk of social isolation over time.

Cudjoe points out that other factors can further exacerbate this problem. "I'm particularly interested in how poverty influences social connections , and how this burden potentially is different than for people who are higher income," he says.

Both loneliness (the subjective feeling of being isolated) and social isolation (the objective lack of social contact) can have negative impacts on health and longevity. Some effects are indirect, arising from reduced access to or utilization of health care services by isolated individuals.

"Someone who is socially isolated, you could envision might have more difficulty keeping their prescriptions refilled all the time, or more difficulty accessing the health care system if they're dependent on others for transportation," says Cynthia Boyd, MD, MPH, director of the Division of Geriatric Medicine and Gerontology at the School of Medicine and professor in Health Policy and Management and Epidemiology.

In a 2018 study , Boyd, Cudjoe, and others examined the impact of self-reported loneliness on the long-term health of more than 2,000 patients who had previously been hospitalized for heart failure. The study found that people experiencing high levels of loneliness were at more than three-fold greater risk of death and 68% greater risk of hospitalization over the course of a year than those with low levels of loneliness.

Mental health is also a casualty, and isolation can heighten the risk of depression, anxiety, and cognitive decline . In a 2022 study of dementia, Cudjoe and colleagues tracked more than 5,000 elderly Americans over the course of nine years, and found that those experiencing objectively measured social isolation faced a nearly 30% greater risk of developing dementia during this span.

Boyd sees a potential vicious circle here. "Having cognitive impairment may then make it harder for you to maintain connections or get feedback from things that might keep you from feeling lonely," she says. This could in turn further exacerbate the progression of cognitive decline.

Creating effective interventions for loneliness and isolation remains a challenge, but there may be greater opportunities to intervene when isolation is directly tied to some form of disability.

For example, Huang says that relatively few hearing-impaired adults—between 10% and 20%—use hearing aids , but a clearer demonstration between auditory function and mental health may help motivate people to seek treatment. "I think it's an interesting way of thinking about isolation interventions," says Huang, who is now in the midst of a clinical trial to assess whether treatments for hearing-impairment help preserve cognitive health in older adults .

She also points out that the design of more accommodating environments—for example, restaurants and cafes with walls that dampen noise rather than echoing and amplifying it—might offer more welcoming environments for hearing-impaired people to socialize.

Another potential strategy involves "social prescriptions," in which clinicians match people with group activities or help them coordinate opportunities for regular interaction with other people, either in-person or virtually via platforms like Zoom.

But there are limited data demonstrating benefits from such social prescriptions, and their implementation requires careful evaluation of why a given individual feels isolated and what kinds of treatments are accessible and enjoyable to them. "We really have to have a comprehensive and holistic approach ," says Boyd.

Cudjoe agrees, and believes it is important to not approach isolation and loneliness as monolithic problems in the elderly community, but instead to work with individuals to identify and meet their needs.

In his view, this includes educating both clinicians and the general public about the importance of connection, and designing environments where patients can readily obtain the level of social connection that they need and want in their lives. "We shouldn't have a paternal or authoritarian kind of approach to this, but support people in the goals that they have," says Cudjoe.

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The Loneliness Curve

New research suggests people tend to be lonelier in young adulthood and late life. But experts say it doesn’t have to be that way.

By Christina Caron

When Surgeon General Vivek Murthy went on a nationwide college tour last fall, he started to hear the same kind of question time and again: How are we supposed to connect with one another when nobody talks anymore?

In an age when participation in community organizations , clubs and religious groups has declined, and more social interaction is happening online instead of in person, some young people are reporting levels of loneliness that, in past decades, were typically associated with older adults.

It’s one of the many reasons loneliness has become a problem at both the beginning and end of our life span. In a study published last Tuesday in the journal Psychological Science, researchers found that loneliness follows a U-shaped curve: Starting from young adulthood, self-reported loneliness tends to decline as people approach midlife only to rise again after the age of 60, becoming especially pronounced by around age 80.

While anyone can experience loneliness, including middle-aged adults , people in midlife may feel more socially connected than other age groups because they are often interacting with co-workers, a spouse, children and others in their community — and these relationships may feel stable and satisfying, said Eileen K. Graham, an associate professor of medical social sciences at the Northwestern University Feinberg School of Medicine and the lead author of the study.

As people get older, those opportunities can “start to fall away,” she said. In the study, which looked at data waves spanning several decades, starting as early as the 1980s and ending as late as 2018, participants at either end of the age spectrum were more likely to agree with statements such as: “I miss having people around me” or “My social relationships are superficial.”

“We have social muscles just like we have physical muscles,” Dr. Murthy said. “And those social muscles weaken when we don’t use them.”

When loneliness goes unchecked, it can be dangerous to our physical and mental health, and has been linked to problems like heart disease, dementia and suicidal ideation.

Dr. Graham and other experts on social connection said there were small steps we could take at any age to cultivate a sense of belonging and social connection.

Do a relationship audit.

“Don’t wait until old age to discover that you lack a good-quality social network,” said Louise Hawkley, a research scientist who studies loneliness at NORC, a social research organization at the University of Chicago . “The longer you wait, the harder it gets to form new connections.”

Studies suggest that most people benefit from having a minimum of four to six close relationships, said Julianne Holt-Lunstad, a professor of psychology and neuroscience and the director of the Social Connection and Health Lab at Brigham Young University.

But it’s not just the quantity that matters, she added, it’s also the variety and the quality.

“Different relationships can fulfill different kinds of needs,” Dr. Holt-Lunstad said. “Just like you need a variety of foods to get a variety of nutrients, you need a variety of types of people in your life.”

Ask yourself: Are you able to rely on and support the people in your life? And are your relationships mostly positive rather than negative?

If so, it’s a sign that those relationships are beneficial to your mental and physical well-being, she said.

Join a group.

Research has shown that poor health, living alone and having fewer close family and friends account for the increase in loneliness after about age 75.

But isolation isn’t the only thing that contributes to loneliness — in people both young and old, loneliness stems from a disconnect between what you want or expect from your relationships and what those relationships are providing.

If your network is shrinking — or if you feel unsatisfied with your relationships — seek new connections by joining a community group, participating in a social sports league or volunteering , which can provide a sense of meaning and purpose, Dr. Hawkley said.

And if one type of volunteering is not satisfying, do not give up, she added. Instead try another type.

Participating in organizations that interest you can offer a sense of belonging and is one way to accelerate the process of connecting in person with like-minded people.

Cut back on social media.

Jean Twenge, a social psychologist and the author of “Generations,” found in her research that heavy social media use is linked to poor mental health — especially among girls — and that smartphone access and internet use “ increased in lock step with teenage loneliness .”

Instead of defaulting to an online conversation or merely a reaction to someone’s post, you can suggest bonding over a meal — no phones allowed.

And if a text or social media interaction is getting long or involved, move to real-time conversation by texting, “Can I give you a quick call?” Dr. Twenge said.

Finally, Dr. Holt-Lunstad suggested asking a friend or family member to go on a walk instead of corresponding online. Not only is taking a stroll free, it also has the added benefit of providing fresh air and exercise.

Take the initiative.

“Oftentimes when people feel lonely, they may be waiting for someone else to reach out to them,” Dr. Holt-Lunstad said. “It can feel really hard to ask for help or even just to initiate a social interaction. You feel very vulnerable. What if they say no?”

Some people might feel more comfortable contacting others with an offer to help, she added, because it helps you focus “outward instead of inward.”

Small acts of kindness will not only maintain but also solidify your relationships, the experts said.

For example, if you like to cook, offer to drop off food for a friend or family member, Dr. Twenge said.

“You’ll not only strengthen a social connection but get the mood boost that comes from helping,” she added.

Christina Caron is a Times reporter covering mental health. More about Christina Caron

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Loneliness grows as we age

International study finds consistent patterns and factors associated with loneliness.

Loneliness in adulthood follows a U-shaped pattern: it's higher in younger and older adulthood, and lowest during middle adulthood, reports a new Northwestern Medicine study that examined nine longitudinal studies from around the world.

The study also identified several risk factors for heightened loneliness across the whole lifespan, including social isolation, sex, education and physical impairment.

"What was striking was how consistent the uptick in loneliness is in older adulthood," said corresponding author Eileen Graham, associate professor of medical social sciences at Northwestern University Feinberg School of Medicine. "There's a wealth of evidence that loneliness is related to poorer health, so we wanted to better understand who is lonely and why people are becoming lonelier as they age out of midlife so we can hopefully start finding ways to mitigate it."

Lacking connection can increase the risk for premature death to levels comparable to smoking daily, according to the office of the U.S. Surgeon General, who one year ago called for action to address America's loneliness epidemic. Graham said her findings underscore the need for targeted interventions to reduce social disparities throughout adulthood to hopefully reduce levels of loneliness, especially among older adults.

Perhaps one day general practitioners could assess levels of loneliness during regular wellness visits to help identify those who might be most at risk, Graham said.

The study will be published April 30 in the journal Psychological Science.

Factors associated with higher persistent loneliness

The study found individuals with higher persistent loneliness were disproportionately women, more isolated, less educated, had lower income, had more functional limitations, were divorced or widowed, were smokers, or had poorer cognitive, physical or mental health.

'How does loneliness change across the lifespan?'

The study replicated this U-shaped pattern across nine datasets from studies conducted in the U.K., Germany, Sweden, the Netherlands, Australia, Israel and more. Only one of the datasets was from the U.S., which Graham said points to how widespread the loneliness epidemic is globally.

"Our study is unique because it harnessed the power of all these datasets to answer the same question -- 'How does loneliness change across the lifespan, and what factors contribute to becoming more or less lonely over time?'," she said.

All of the nine longitudinal studies were conducted before the onset of the COVID-19 pandemic, when many researchers found loneliness became even more pronounced.

Why is middle adulthood less lonely?

While this study didn't specifically examine why middle-aged adults are the least lonely, Graham said it could be because the many demands on a middle-aged person's life often involve social interactions, such as being married, going to work and making friends with the parents of children's friends.

But the relationship between social interaction and loneliness is complex. "You can have a lot of social interaction and still be lonely or, alternatively, be relatively isolated and not feel lonely," Graham said.

As for younger adulthood being a lonelier time, Graham and the study's co-author Tomiko Yoneda said the study data start right at the end of adolescence, when young adults are often navigating several important life transitions (e.g., education, careers, friend groups, relationship partners and families).

"As people age and develop through young adulthood into midlife, they start to set down roots and become established, solidifying adult friend groups, social networks and life partners," said Yoneda, assistant professor of psychology at University of California, Davis. "We do have evidence that married people tend to be less lonely, so for older adults who are not married, finding ongoing points of meaningful social contact will likely help mitigate the risk of persistent loneliness."

• Mental Health Research
• Healthy Aging
• Staying Healthy
• Social Psychology
• Relationships
• Child Psychology
• Adolescence
• Social cognition
• Lactose intolerance
• Social psychology
• Adult attention-deficit disorder
• Social movement
• Calorie restricted diet

Story Source:

Materials provided by Northwestern University . Original written by Kristin Samuelson. Note: Content may be edited for style and length.

Journal Reference :

• Eileen K. Graham, Emorie D. Beck, Kathryn Jackson, Tomiko Yoneda, Chloe McGhee, Lily Pieramici, Olivia E. Atherton, Jing Luo, Emily C. Willroth, Andrew Steptoe, Daniel K. Mroczek, Anthony D. Ong. Do We Become More Lonely With Age? A Coordinated Data Analysis of Nine Longitudinal Studies . Psychological Science , 2024; DOI: 10.1177/09567976241242037

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