Factors include age, personality, time spent online

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be "The Informed Patient," with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Earlier this year, the U.S. surgeon general, Dr. Vivek Murthy, released a report calling attention to the public health crisis of loneliness, isolation and lack of connection. It's something that can affect mental, physical, and societal health in people of all ages.

For help understanding this report, I turn to child and adolescent psychiatrist, Dr. Hilary Gamble. She's an assistant professor of psychiatry and behavioral sciences at Upstate.

Welcome to "The Informed Patient," Dr. Gamble.

Hilary Gamble, MD: Thank you for having me.

Host Amber Smith: The surgeon general had to think this was important in order to issue an 82-page report called "Our Epidemic of Loneliness and Isolation." Do you think this is all because of the pandemic forcing us to socially distance?

Hilary Gamble, MD: Well, first of all, I'm so glad that we are broaching this topic. I think it's an important one to explore now, and also retrospectively. According to the report, 50% of all Americans said that they felt lonely prior to the pandemic. So while I think that the pandemic certainly worsened that sense of isolation and loneliness in our population, I think there was a certain amount of that that predated our pandemic.

The lockdown loneliness, I think, has been a particular stressor, obviously, and not just in the United States, but worldwide. A recent study in the U.K. presented data that helped us to better understand, I think, the added impact of the lockdown loneliness. And the researchers showed us that there was certainly an increase in the amount of loneliness that people experienced during, and relatively, post-pandemic, I guess you could say at this point. And also there is certainly an associated decline in mental health.

Host Amber Smith: Well, one of the things that preceded or was a out there before the pandemic is social media. How much of that plays into the creation of loneliness and isolation?

Hilary Gamble, MD: So I think social media, definitely, is a tricky subject. I think that it can sometimes facilitate social connection and also definitely detract from our connections between one another.

If we look at the data specifically of our teens, age 13 to 17, 95% of those adolescents are engaged with using social media in one form or another. I think it's become so commonplace in the way we perform our jobs, interact with school, touch base with family and friends who are maybe far apart or across the world. So definitely there have been some advantages.

Americans have reported that they spend roughly six hours a day on digital media and a third of Americans report being on some sort of digital media almost constantly. You know, I think to say that that hasn't impacted us socially would be remiss. I think the extent of the impact is difficult to fully understand. Because again, there are both pros and cons to the use of social media, and so I think in order to fully understand it, we have to dive into how each individual interacts with social media or with digital media in general.

Host Amber Smith: We've heard about growing numbers of kids in adolescence with depression or suicide attempts. Do you think these cases begin with feelings of loneliness that go unrecognized or untreated?

Hilary Gamble, MD: I think in some instances, yes, as someone who sees children and adolescents who present to our emergency department at Upstate, or who follows or sees new consults for kids in our Golisano Children's Hospital, I can tell you subjectively, loneliness, a sense of isolation or even a more general sense of feeling alone or like people don't understand what they're going through particularly in adolescence, I think can predispose to worsening mental health, for sure. In particular, we know via numerous studies that in teenagers isolation is a red flag that we child psychiatrists certainly pay attention to when we hear during an interview.

And, and that is something that perks our ears and certainly forces us to, I think, more thoroughly explore other symptoms that could be present that could potentially warrant increased interventions in that population.

Host Amber Smith: Is it common for you to hear from your patients that they feel insignificant or, like, they are dealing with the stress of life all alone?

Hilary Gamble, MD: Yes, I think so, particularly for those who have identified of a struggle of some sort, whether it be worries, social worries or performance worries in school, or a sense of feeling down and disconnected. I think that lack of feeling understood by someone else can really exacerbate one's sense of loneliness.

Host Amber Smith: Well, let's talk about what social connections mean and why they matter. But first, what counts as a social connection? Are we talking about family members, or friends and acquaintances, or phone call conversations? What is a social connection?

Hilary Gamble, MD: I think, boy, that is the question, isn't it? I think anything that enables us to interact with another person counts as a social connection or interaction, and I think because we all have our own individual needs for feeling social connected, it can look really differently from person to person. So I might have less of an innate need to feel connected to other people. I might be able to tolerate loneliness and be less adversely impacted by it than my sister, brother, parent. And they might have higher needs or wishes for social connection.

So I think that it's important, as we study loneliness and identify the impacts, and therefore theinterventions that could be helpful, that we make it individualized, based on one's particular needs and wishes.

Host Amber Smith: Do you think that some people are born to be more socially connected and outgoing, and others are just naturally more reclusive?

Hilary Gamble, MD: We know in child psychiatry that every person is born with a certain temperament. Now, the temperament certainly is not fixed in stone throughout one's life. We all know nature versus nurture here, and I think both elements play crucial roles in the development of a temperament and a personality.

And I think that depending on one's experience in life, whether someone is going through maybe the loss of a loved one or a family illness, or has a chronic medical illness, I think those can really raise the level, potentially, of the need for social connectedness versus someone who perceives things as going fairly well.

Now, that's not to say that people who perceive their lives as being very positive are immune to needing social connection. I don't mean that. I just mean that I think, again, as child psychiatrists, we think about development as a longitudinal entity that sort of ebbs and flows based on developmental level and the needs and the psychosocial stressors in one's life at the time.

Host Amber Smith: There seem to be people, though, who, when they're alone, they feel solitude versus anxiety because they're alone. What can we learn from those who feel the solitude that can help us be more like them?

Hilary Gamble, MD: So I think just like we all have our own temperaments, we all experience loneliness or solitude differently. For some people, I think solitude can be peaceful. Some people enjoy going for those quiet walks in the woods. Other people thrive by being surrounded by other people or animals, life of some sort.

And, again, that need might change. So sometimes we feel really overwhelmed or overstimulated. Maybe we've had a really busy week at work and a lot of demands placed on us. And maybe that would lead to us wanting a little bit of disconnection in order to reset ourselves so that we're ready to have additional connections in the future. So I think the work there is for each of us individually to take the pulse on our own needs and wants at the time, and allow ourselves the space to either seek out a social connection or not, to take some space for ourselves to reset.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking about loneliness and isolation with child and adolescent psychiatrist Dr. Hilary Gamble.

Now, what are the risks to physical health in people who are lonely and isolated?

Hilary Gamble, MD: I'm so glad that we're speaking about this topic in particular, and I have to admit that when I read the surgeon general's report, I found some of the statistics staggering. So I do want to just review a few of those, for the folks who are listening today. I think they're very important, and I think they really drive home the impact, the gravity of the situation that we're facing now.

So the surgeon general reported that loneliness is associated with a 26% increase in premature death, so death before we would expect it for a person. Lacking social connection is equivalent to smoking 15 cigarettes per day. And childhood isolation results in increased rates of obesity, hypertension, or high blood pressure, and hyperglycemia, or high blood glucose, blood sugar levels, later in adulthood.

So of course, we've spoken thus far about the direct or more immediate impacts on our mental health, like depression and anxiety symptoms, for example. But this data suggests that not only do we struggle with the mental impacts of isolation and social disconnectedness, but also our bodies physically store that pain and inflammation and can manifest really quite troubling symptoms later in life.

Host Amber Smith: So, do we know yet, do those physical symptoms and diseases disappear if the loneliness dissipates?

Hilary Gamble, MD: I would like to think, yes. I think at this point we're lacking in data to support a strong conviction either way. I think what we know about depression and anxiety so far suggests that the sooner it's treated, the sooner our bodies can return to baseline and be free of that chronic inflammation and stress, the better the long-term health outcomes.

Host Amber Smith: So what do you do to help a child or adolescent who complains about feeling lonely? How do you help them?

Hilary Gamble, MD: I think helping adolescents requires a "village" approach, for sure. You think of adolescence as a time in which teens in general are individuating from their families. And by that, I mean that adolescents at that stage start to form really strong peer relationships. And those relationships tend to strengthen as those with family become a little bit more strained. And this is a totally normal developmental stage and is really helpful later in life when you have to form adult-to-adult peer interactions and relationships.

I think sometimes it's difficult, I would imagine, for parents to stay attuned and present with adolescents during that process because naturally they're being pushed away. So my wish would be for parents to continue to stay present, and I realize that sounds vague. I think staying available and making it clear to the adolescent in words and in action that you will be a consistent presence, regardless of the adolescent's changes, can really provide a sense of security and validation for the child.

I think so often kids forget that their parents were also adolescents at one point, and we often hear, you know, "You don't know what it's like You've never been through this." And it's tempting to argue, right, and say, "I was a kid once, too." But the simple fact is their experience IS different than the parents' experience. And so to validate that maybe it's not harder or easier, but certainly different, I think, can have. A profound impact in allowing that child the opportunity to talk through the struggles. And for the parent to be available when needed, I think, is most important during that time.

Host Amber Smith: Now, some social connections aren't necessarily positive. I'm thinking about gangs or extremist groups that may manipulate their members. Are you concerned about lonely kids being pulled into groups like that?

Hilary Gamble, MD: So I think that predators -- right? That's what we're talking about -- certainly prey on the feeling of isolation, the feeling that "nobody gets me." And when you're in that lonely spot, you are certainly susceptible to anyone or anything that provides validation or a sense of belonging. And like you're suggesting, a sense of belonging can be a really positive thing for some youth, or it can be horribly negative.

And I think that, unfortunately, with social media, we have so many outlets for people with malintentions to reach youth and to pose as people who are superficially supportive but really have an ulterior motive. So I think the isolation is scary.

I give parents a prescription to be extra annoying when I fear that a child or adolescent is isolating or pulling away from social connections, whether it be with friends or family. And I tell the parent, when your child gets angry at you for knocking on their door, checking in, you just blame me. I'll take it. So I invite them to check in more often and to be present because that certainly will decrease the likelihood of their child being a victim.

Host Amber Smith: Let me ask you a little more about advice you have for children and adolescents and their parents if they're struggling with feelings of loneliness. Are there bad habits that encourage loneliness?

Hilary Gamble, MD: I think sometimes the process is insidious, meaning we don't notice it until it's a problem. It seems to be kind of inching along and then all of a sudden families get to a point where they notice they're disconnected from their child, or vice versa. And some of my work with children and families is to explore that process and wonder how we got to this point and what went awry. And there rarely is a simple answer.

Typically it's "Well, you know, I wasn't feeling well," or "I had a couple of down days, and so I stayed in my room, and I was on my video games more and more, and I snapped at my parents every time they came to check on me." And then the parent didn't want to annoy the child and make it worse. And fast-forward a few days or weeks, and now we're in a position where the child is really truly isolated and involved in who knows what online, potentially, and parents feeling at a loss as to what to do.

So again, I just say: Stay present. Raising children, as we know, is a marathon, not a sprint, right? And so a few days, a few difficult days, of pushing into your teenager's life in a respectful way, I think, can mitigate some of these unfortunate consequences and inadvertent consequences of trying to do the right thing, but backing off when, really, people might need you to be more present as a parent or as a family.

Another thing that we often remind each other of in child psychiatry is this idea -- and it sounds very simple -- but we always say, let's try to meet the family or the child where they're at, meaning not everyone is ready to have family dinner every night. Not everyone is at that point where they can handle that. Sometimes it's a couple of check-ins during the day. Sometimes it's one activity a week. And I think that, again, the individualized approach is important to figure out where the struggle is and therefore where a reasonable intervention might be warranted. And I think we have to be mindful to set the bar at a place where the youth can achieve.

Host Amber Smith: Are medications ever part of it?

Hilary Gamble, MD: Sure. When kids meet criteria for bona fide anxiety or depression or other mental health disorders, absolutely, medications are a part of our treatment. For the most part, and for most disorders that we commonly see in children and adolescents, psychotherapy is a main first intervention, our first-line intervention, we call it.

Sometimes if symptoms are more moderate or severe, we do recommend a combination of psychotherapy and medications, but of course the psychotherapy doesn't have side effects, right? Like the medications do. So we like to at least start with that for a period of time to see if we can help the youth explore maybe where some of those blocks are and come up with techniques to help to better cope with that pain that they're feeling inside.

Host Amber Smith: As a follow-up to what you were saying about family dinner, if the youth is so alienated that they can't bear to be together with their family, do they just eat in their room, or what does the family do for that?

Hilary Gamble, MD: I do have some teens that spend a lot of time in their room. I also see a lot of teens who have, like we said, these very strong friend connections. And sometimes they're spending increasing amount of time at friends' houses with other families, and that's not always a bad thing. So sometimes these other families can have really positive impacts. Sometimes these kids can serve as pseudo older brothers or sisters for their friend's younger siblings.

So there are all these dynamics that we better understand once we hear the story. Because on the surface you might hear, "My son's never home for dinner" or whatever, but we find out that that child has actually made a really strong connection with a great friend in school who has a wonderful family and there are little siblings, and he or she has served as, like, a wonderful older sibling figure for this family.

So, again, creating the narrative and giving space for that and better understanding the reason for the disconnection and what might be driving it, and if it truly is disconnection, or maybe just a different relationship. That can be very telling.

Host Amber Smith: Is it helpful to tell someone who complains of being lonely to get out there and volunteer or go join this or that? I mean, just the act of being around people. Is that going to help with the loneliness?

Hilary Gamble, MD: We have this old adage, right? Just smile and you'll feel better; it naturally takes less energy to smile than it does to frown, and all these kinds of sayings. When people are truly suffering with depression -- now, I'm getting a little bit clinical here -- but when people are truly depressed, they generally lack motivation and the ability to feel that joy. So while it may make you, as the suggester of the activity, feel better, like the person is getting out and doing something, that might not have intrinsic value to the person.

And once people start to recover, we notice, actually, that the people around them see the improvement first before the person feels better themselves, which speaks a little bit to what you're talking about here, I think. So, can the activity help? Yes. Physical activity, we know, can certainly lower stress hormones. However, the lack of motivation can stand in the way. And I think we just have to be mindful of the tendency for people who are already suffering to feel guilty about it.

And, like I said, when we set the bar or we make expectations, the important factor is to make sure that we're setting expectations that the person can achieve so that they build confidence and want to do even more next time. If we set the bar too high and they don't achieve it, then that actually could really exacerbate the symptoms, right, of feeling like a failure, feeling alone or not heard.

Host Amber Smith: Are there changes to society and the way we live today that you think could help overall with this crisis of loneliness?

Hilary Gamble, MD: Gosh, that's the million dollar question, isn't it? I wish I had a thorough or concrete answer to that. As we spoke in the very beginning of this talk, technology certainly has advantages and disadvantages. I think the balance here is of the utmost importance. So our technology has the opportunity to both augment and detract from our social connection.

We all use it differently, and if nothing else, I hope that maybe, after listening to this talk, people are able to have at least an honest dialogue about how they're using digital media, how they're using social media, and are they using it to augment social connectedness, or is it potentially detracting from the connectedness that they could feel with others?

Host Amber Smith: Well, Dr. Gamble, thank you so much for making time for this interview.

Hilary Gamble, MD: I appreciate you having me. Thank you very much.

Host Amber Smith: My guest has been Dr. Hilary Gamble. She's an assistant professor of psychiatry and behavioral sciences at Upstate.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.