The 2023 Surgeon General’s US Advisory “Our Epidemic of Loneliness and Isolation” brings attention to a growing problem in the US.1 Loneliness is a feeling that has comparable impacts to those of obesity and smoking 15 cigarettes a day on a person’s health and premature mortality.2 In the US, approximately 50% of people in the general population report loneliness;1 however, some sub-groups may have even higher rates. People with serious mental illness (SMI; defined as a schizophrenia spectrum disorder, bipolar disorder, and treatment-refractory major depressive disorder) experience significant impairment in psychosocial functioning throughout their lifespan. Research has suggested that people with SMI experience approximately twice the rate of loneliness as the general population.3 However, to date, the prevalence of loneliness in people with SMI is not known. This study explores the prevalence of loneliness among adults with SMI in a supportive housing setting.
Methods
The Bridge, a supportive housing agency with 350+ scattered site apartments and 24 residences across Manhattan, Brooklyn, and the Bronx, surveyed all residents age 50+ years using the self-report Older Adult Needs Assessment (OANA). Secondary data analyses were conducted on OANA data from April 1 to April 30, 2023. Data included 565 adults with SMI who completed the valid, reliable 3-item UCLA loneliness measure4, which ranges from 3 to 9. Consisting with scoring in previous studies three to five were categorized as “not lonely,” and scores of six to nine were “lonely.”5
Data were collected at The Bridge residences electronically by residential staff. Participants’ demographic and primary ICD diagnosis data (F2x and F3x) were extracted from electronic health records electronically by staff. Descriptive statistics were used to assess the demographic characteristics of the sample. Missing data (0.9%) were omitted through listwise deletion. Logistic regression was used to determine the association of sociodemographic and clinical factors with loneliness in older community-dwelling adults with SMI. Analyses were conducted using SPSS 18. This secondary data analysis was approved by Dartmouth Health’s institutional review board. The study employs the Strengthening the Reporting of Observational Studies in Epidemiology reporting guidelines.
Results
The mean age of respondents was 63.21 (6.24); range 55-89 years. The highest rates of loneliness were reported among men (63.5%), Black Americans (51.8%), people with schizophrenia spectrum disorder (59.1%), and people in congregate housing (70.8%).
A logistic regression was performed to ascertain associations of age, gender, race, SMI diagnosis, and housing type with the likelihood of being lonely among participants. The aforementioned factors, however, were not associated with being lonely. An analysis stratified by gender demonstrated that Hispanic females were less likely to feel lonely (adjusted odds ratio [AOR], 0.08; 95% confidence interval [CI], 0.006-0.971) and women residing in scattered site housing were associated with a higher likelihood of being lonely (AOR, 2.31; 95% CI, 1.13-4.71).
Discussion
Rates of loneliness in people with SMI are consistent with estimates in the general population4. High-risk groups for loneliness include Black Americans, people with schizophrenia, people residing in congregate housing, and women residing in scattersite housing was associated with higher likelihood of being lonely. Unlike the general population, age did not significantly impact loneliness, indicating the experience of SMI may trump traditional social determinants of health. People with SMI have identified loneliness as a top unmet need 5 and a cause of early mortality in people with SMI, and is a critical intervention area6.
Limitations of the study include data from a single supportive housing system that may not be generalizable. Database limitations limit knowledge of factors that could affect loneliness, such as severity or duration of SMI.
Table 1.
Sociodemographic characteristics of the included sample (n=519)
| Not Lonely (n=382) | Lonely (n=137) | Total (n=519) | P-value | |
|---|---|---|---|---|
| Age, mean (SD) | 63.24 (6.1) | 63.12 (6.5) | 63.21 (6.24) | 0.856 |
| Gender, n (%) | 0.578 | |||
| Female | 150 (39.2%) | 50 (36.4%) | 200 (38.5%) | |
| Male | 230 (60.3%) | 87 (63.6%) | 317 (61%) | |
| Trans-Male | 0 (0%) | 0 (0%) | 0 (0%) | |
| Trans-Female | 2 (.5%) | 0 (0%) | 2 (.3%) | |
| Race, n (%) | 0.415 | |||
| Black American | 228 (59.6%) | 71 (51.8%) | 299 (57.6%) | |
| White | 82 (21.4%) | 34 (24.8%) | 116 (22.4%) | |
| Hispanic | 58 (15.4%) | 27 (19.7%) | 85 (16.4%) | |
| Other | 14 (3.6%) | 5 (3.6%) | 19 (3.6%) | |
| Primary Diagnosis | 0.835 | |||
| Schizophrenia spectrum disorder | 233 (60.9%) | 81 (59.2%) | 314 (60.5%) | |
| Bipolar Disorder | 56 (14.7%) | 23 (16.8%) | 79 (15.2%) | |
| Major Depressive Disorder | 93 (24.4%) | 33 (24%) | 126 (24.3%) | |
| Supportive Housing Site | 0.231 | |||
| Congregate | 249 (65.2%) | 97 (70.8%) | 346 (66.6%) | |
| Scattersite | 133(34.8%) | 40 (29.2%) | 173 (33.4%) |
Note: “Lonely” was defined as a score of 6-9 and “not lonely” was defined as a score of 3-5 using the 3-item UCLA loneliness scale; Primary diagnosis was defined as most recent SMI diagnosis. Scattersite housing is multiple housing units in different locations. Congregate housing is a shared living arrangement that combines housing and services for older adults and people with disabilities.
Table 2.
Factors associated with loneliness in adults with SMI by gender (N=519)
| Variable | Odds Ratio | 95% C.I. | P-value | ||
|---|---|---|---|---|---|
|
| |||||
| Lower | Upper | ||||
| Male | |||||
| Housing | Congregate (Reference) | ||||
| Scattersite | 0.903 | 0.519 | 1.571 | 0.717 | |
| Age | Age | 0.943 | 0.943 | 1.022 | 0.369 |
| White (Reference) | |||||
| Race | Black American | 2.107 | 0.524 | 8.315 | 0.287 |
| Hispanic | 1.661 | 0.448 | 6.163 | 0.448 | |
| Other | 2.543 | 0.617 | 10.485 | 0.197 | |
| SMI Diagnosis | Major Depressive Disorder (Reference) | ||||
| Bipolar | 0.933 | 0.573 | 1.519 | 0.78 | |
| Schizophrenia | 1.125 | 0.644 | 1.963 | 0.679 | |
| Female | |||||
| Housing | Congregate (Reference) | ||||
| Scattersite | 2.307 | 1.131 | 4.707 | 0.022* | |
| Age | Age | 1.014 | 0.961 | 1.071 | .606 |
| White (Reference) | |||||
| Race | Black American | 0.105 | 0.008 | 1.363 | 0.085 |
| Hispanic | 0.079 | 0.006 | 0.971 | 0.047* | |
| Other | 0.140 | 0.011 | 0.011 | 0.136 | |
| SMI Diagnosis | Major Depressive Disorder (Reference) | ||||
| Bipolar | 1.754 | 0.725 | 4.246 | 0.213 | |
| Schizophrenia | 1.991 | 0.865 | 4.581 | 0.105 | |
Note: “Other” is defined as Native American and multiple races.
Acknowledgments
This project was funded CLIN-STAR, Grant/Award Number: U24AG065204; NIMH, Grant/Award Number: K01MH117496
Sponsor’s Role
This project was supported Dr. Fortuna’s Clin-STAR award and an NIH K01 award (K01 MH117496). Dr. Rhee was supported in part by the National Institute on Aging (NIA) (#R21AG070666; R21AG078972), National Institute of Mental Health (#R21MH117438), National Institute on Drug Abuse (#R21DA057540) and Institute for Collaboration on Health, Intervention, and Policy (InCHIP) of the University of Connecticut in the past 3 years.
Footnotes
Conflicts of Interest
KLF reports a conflict with Social Wellness and Emissary Health, Inc. GE reports a conflict with EBSCO, Abridge, and Fora Health. TGR, RH, JW, LL, PR has no conflict of interest related to the current study.
Data Sharing Statement
Data from this vulnerable population and supportive housing site is not permitted to be shared to do the sensitive nature of the data from this historically marginalized population.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data from this vulnerable population and supportive housing site is not permitted to be shared to do the sensitive nature of the data from this historically marginalized population.