From RCPsych Insight: Class acts

Each month we will highlight a story from RCPsych Insight magazine which reflects the work being done in mental health services around the UK.

This article looks at what is being done to combat loneliness.

Full article

Imagine you like to run but find it difficult to stick to a schedule. One charity, GoodGym, has come up with a solution that also contributes to improving the quality of life of socially isolated older adults. Volunteer runners are matched with older people, or ‘coaches’ as they are referred to. Then, at a prearranged time, the volunteer runs to the older person’s home, pays them a social visit (and has a rest) and then runs home afterwards.

In addition to making a rewarding personal connection, volunteers feel highly motivated to adhere to their running schedules and the coaches benefit from spending time in the volunteers’ company, that otherwise would have been spent alone.

Half a million older people go at least five or six days a week without seeing or speaking to anyone, according to Age UK, and there are an estimated 1.2 million chronically lonely older people in the UK. While the subjective experience of loneliness is, of course, not in itself indicative of pathology – rather, a natural reaction to unmet social needs – it has very serious health consequences that should not be overlooked.

Loneliness is on par with smoking

“Far from being a trivial concern, loneliness is associated with an increase in mortality on a par with smoking and worse than obesity,” says Dr Amanda Thompsell, chair of RCPsych’s Old Age Faculty. Being lonely is also predictive of mental distress, with the potential to increase both psychological and physiological stress levels, increasing the likelihood of heart disease, dementia, anxiety, depression and suicidality. “And critically, among older people,” she adds, “it has been shown to be a risk factor for the progression of frailty.”

The College’s Old Age Faculty has produced a joint Position Statement with the British Geriatrics Society on loneliness and social isolation. Among their priorities is the need for increased identification and prevention. But reaching lonely individuals in the first place is one of the key challenges.

Taking full advantage of people’s existing points of contact with healthcare services is a practical starting point. A 2018 study found that older patients who live on their own are heavy users of health services.

“This means that we, as healthcare professionals, have opportunities to intervene and stop patients’ physical and mental health from deteriorating.

But very often, no one is picking up on loneliness – yet it could be so easy,” says Dr Thompsell.

Bereavement – particularly of a spouse – poor health, reduced mobility, frailty and any limits placed on independence are clear things to watch out for. And existing mental health problems, by their nature, can create and add to loneliness and social isolation, exacerbating the condition.

Older bereaved people ‘less likely to seek help’

Dr Thompsell points to the fact that older bereaved people are less likely to seek help and less likely to be referred for bereavement support than younger people, on top of being more likely to

have worse mental health as a result of bereavement. “And yet, talking therapies can be highly effective for older people,” she says.

Fewer than one in five people aged over 60 have received counselling following a death even though NHS guidance states that “older people, especially those with depression, are as likely to benefit from talking therapies as everyone else”.

In fact, recovery rates for those who have been through the Improving Access to Psychological Therapies (IAPT) programme are often better for people aged 65 and over than those who are younger. “It is essential that we ensure that ageism does not prevent older people from accessing the services they need,” says Dr Thompsell.

Making a difference

Social prescribing is another important strategy for tackling loneliness. But not all provision is suitable for older people, and appropriate consideration must be made of an older person’s mobility or ability to handle large group-based activities, in addition to their personal preferences and demographic. Anecdotally, programmes that promote the feeling of making a difference to

others seem to have the most impact. The Downshall intergenerational project in Ilford, for example, sees older people visiting a primary school and helping the children with their reading and other activities.

Increased prioritisation of loneliness is included in the NHS Long-Term Plan, which Dr Thompsell welcomes, but she and the Old Age Faculty are concerned about the provision and continuity of services. The Plan aims to put 1,000 social prescribing link workers in place by the end of 2020/21.

But many social prescribing and befriending schemes are in the hands of small local charities. “Sometimes, these services close after only a matter of months,” says Dr Thompsell. “By the time you’ve printed out the leaflets, they’re already out of date.”

Solutions cannot be short term

Continuity of services and the ability to plan are fundamental. “Psychiatrists have a role in advocating for these wherever they can and explaining to local commissioning groups that short-termism for loneliness services simply isn’t helpful,” says Dr Thompsell.

Psychiatrists can also play a part in prevention by promoting awareness of the needs of older people who are experiencing, or are at risk of, mental health problems. Although the impact of loneliness on mental and physical health is gaining increased political and media attention, it is yet to be embedded in many everyday healthcare considerations, and more broadly in the culture.

Psychiatrists can help just by having a conversation with their multidisciplinary and multispeciality colleagues, as well as with medical students and trainees.

“Arming ourselves with the facts on loneliness, keeping up to date with what services are available locally, and building and maintaining strong relationships with providers are some of the best ways we can contribute,” says Dr Thompsell.

“Of course, not everyone who is lonely needs to see a psychiatrist. But if an older person has risk factors for loneliness, we can do more to offer support and encourage our healthcare colleagues to do the same. Asking simple questions such as: ‘Are you seeing people as much as you’d like? Do you feel lonely? Does that bother you?’ could open up a conversation that otherwise might not have happened.”

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