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Original research
Five-year changes in loneliness and mental health among adults 41–85 years: the Doetinchem Cohort Study
  1. Tijmen Maas1,
  2. Gerrie-Cor Herber1,
  3. W M Monique Verschuren2,
  4. H Susan J Picavet1
  1. 1Centre for Nutrition, Prevention and Health Services, National Institute of Public Health and the Environment, Bilthoven, Netherlands
  2. 2National Institute for Public Health and the Environment, Bilthoven, Netherlands
  1. Correspondence to Dr H Susan J Picavet; susan.picavet{at}rivm.nl

Abstract

Background Both loneliness and mental health represent important public health themes with stable or even worsening population figures. The association between loneliness and mental health is cross-sectionally well-established, but longitudinal studies are scarce. The aim of this study is to explore the individual changes in loneliness and mental health and the relation between these changes.

Methods We used data from wave 5 (years: 2007–2012, n: 4016) and wave 6 (years: 2013–2017, n: 3437) of the Doetinchem Cohort Study, consisting of participants aged 41–86 years. Loneliness was measured using the De Jong-Gierveld 6-item Loneliness Scale and mental health was measured with the 5-item Mental Health Inventory. We assessed changes in loneliness and mental health over a 5-year period. Generalised estimating equations and linear regression were performed to determine the longitudinal association. Associations were adjusted for various sociodemographic, lifestyle and health factors.

Results Over a 5-year period, 23.4% experienced a change in loneliness and 9.7% in mental health.

Higher levels of loneliness were significantly associated with poor mental health both cross-sectionally and over time (β:−3.56, 95% CI: −3.79 to −3.32). Increasing feelings of loneliness were associated with worsening mental health, and decreasing feelings of loneliness were associated with improving mental health (β:−2.35, 95% CI: −2.61 to −2.08).

Conclusion The high rate of individual changes in loneliness, combined with the association between changes in loneliness and changes in mental health, shows a possible potential in improving poor mental health by designing public health interventions aimed at reducing feelings of loneliness.

  • COHORT STUDIES
  • EPIDEMIOLOGY
  • GERONTOLOGY
  • HEALTH
  • SOCIAL SCIENCES

Data availability statement

Data are available upon reasonable request. The data of the Doetinchem Cohort Study cannot be placed in a public repository due to legal and ethical constraints. The participants’ informed consent did not include consent to public availability of the data. However, the data are available upon request, by contacting the scientific committee of the Doetinchem Cohort Study by email: Doetinchemstudie@rivm.nl.

http://creativecommons.org/licenses/by-nc/4.0/

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, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/jech-2024-222099

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Loneliness and mental health represent important public health themes, but insight into individual changes in loneliness and mental health and the longitudinal relation between loneliness and mental health is scarce.

    WHAT THIS STUDY ADDS

    • More than 1 out of 5 older adults show changes in loneliness over a 5-year period, and almost 1 out of 10 show a change in mental health.

    • Loneliness and mental health are clearly intertwined, both cross-sectionally and longitudinally.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • Tackling loneliness in public health interventions may have the potential to promote mental health.

    Introduction

    Loneliness refers to an unpleasant and distressing feeling where one perceives the quantity or quality of their social relations as inadequate,1 which can lead to poor mental health.2 In 2012, 39% of the adult Dutch population (18 years and older) experienced loneliness, which increased to 46% in 2016.3 Loneliness may vary over time at the individual level.4

    Poor mental health is also often found, with 12% of the Dutch population (of 12 years and over) experiencing poor mental health in 2016.5 Mental health is defined by the WHO as ‘a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community’.6 There is little known on changes in mental health in the long term (1 year or longer), neither on the population level nor on the individual level. However, during the COVID-19 pandemic, several studies were set up examining mental health over time,7–9 though mainly focusing on mean-level changes in mental health.

    There is a clear association between loneliness and mental health, as suggested by many cross-sectional and some longitudinal studies.10–12 These studies mainly focused on the association between loneliness and mental health disorders, with little attention on general mental health measures, for example, as defined by the 5-item Mental Health Inventory (MHI-5), which is often used in cohort studies. Because of the large proportions of the population experiencing loneliness and poor mental health and the high association between the two, it seems also relevant to explore the changes in loneliness and in mental health and the longitudinal relation between the two.3 5 Insight in this can be used to develop public health interventions targeting people experiencing both loneliness and poor mental health. Therefore, the aim of this study is to explore individual changes in loneliness and mental health and the longitudinal association between loneliness and mental health among adults aged 41–86 years, measured twice with a 5-year interval (2007–2012 and 2013–2017).

    Methods

    Study design, participants and data collection

    This study used data from the Doetinchem Cohort Study, a prospective cohort study aimed at the role of lifestyle on health. Based on a sex-age stratified random sample of the general population aged 20–59 years of Doetinchem in the first wave (1987–1991), 12 404 adults were measured with a response rate of 62%. A random two-thirds selection of those (n=7768) was reinvited for wave 2 in 1993–1997 (n=6117), wave 3 in 1998–2002 (n=4918), wave 4 in 2003–2007 (n=4520), wave 5 in 2008–2012 (n=4016) and wave 6 in 2013–2017 (n=3477).13 For the current study, data from wave 5 (here baseline) and wave 6 were used because loneliness was introduced in the protocol from wave 5. A total of 5368 adults were invited for wave 5 and wave 6, with 4166 adults participating in either or both waves after excluding non-respondents. Measurements included questionnaires and a physical examination at the regional public health service.

    Measurements

    Loneliness—Loneliness was measured using the 11-item De Jong-Gierveld Loneliness Scale in wave 5 and the shortened 6-item scale in wave 6.14 Both versions have equivalent validity and reliability.14 We analysed the 6-item version for both waves, which consists of three positive and three negative formulated items derived from the 11-item version, with answering categories ‘yes’, ‘more or less’, or ‘no’. Responses indicating loneliness were assigned a point. Loneliness scores range from 0 to 6, with higher scores indicating loneliness. The 6-item scale uses a cut-off value of 1 to distinguish between lonely and not lonely. Depending on the analysis in this paper, loneliness was computed as a continuous variable (range 0–6), dichotomous variable (0–1: not lonely and 2–6: lonely), a categorical variable consisting of four patterns (ie, not lonely in both waves/not lonely in wave 5 and lonely in wave 6/lonely in wave 5 and not lonely in wave 6/lonely in both waves) and as a change score variable (range −6 to 6) by subtracting the continuous scores of wave 5 from wave 6.

    Mental health—Mental health was measured using the MHI-5, a valid and reliable tool for measurements in the general population. The MHI-5 comprises five questions on depressive symptoms and anxiety symptoms in the past month. The items were scored on a 6-point Likert scale, with 1 being ‘all of the time’ and 6 being ‘none of the time’. The total score was computed with a standard linear transformation after reverse coding items 1 and 2 and rescaled to a score between 0 and 100. A higher score indicated better mental health, using a cut-off value of 60 to distinguish between poor and good mental health.15 Depending on the analysis, mental was computed as a continuous variable (range 0–100), dichotomous variable (≤60: poor mental health and≥61: good mental health), a categorical variable consisting of four patterns across waves similar to loneliness and as a change score variable (range −100 to +100) similarly computed as loneliness.

    Covariates

    Besides sex and age, we used as covariates: marital status, household composition, educational attainment, physical activity and chronic diseases, all questionnaire-based. Marital status was defined as married (reference category) and unmarried, including widowhood, never married and divorced. Household composition included living with others, including children, parents, partners or other adults (reference category) and living alone. Educational attainment consisted of three categories: intermediate secondary education or lower (low; reference category); intermediate vocational or higher secondary education (medium) and higher vocational education or university (high). Physical activity was measured using an extensive questionnaire of hours spent on activities and defined as physically active (reference category) and physically inactive.16 Based on the Dutch guidelines and the observation that physical activity is often over-reported,17 we used a cut-off point of 3.5 hours of leisure-time physical activity of at least moderate intensity. Chronic disease was included as having no chronic diseases (reference category) and one or more chronic diseases, including stroke, cerebral vascular accident, lung disease (asthma and chronic obstructive pulmonary disease), cancer and diabetes.

    Data analyses

    Analyses were done with SAS Studio (V.3.8). Descriptives were used to characterise the study population at baseline and evaluate the numbers showing changes or not in loneliness or mental health in four patterns.

    The longitudinal association between loneliness and mental health was explored as follows:

    First, a cross-tabulation analysis contrasting the four patterns of changes in loneliness and mental health between wave 5 and 6. To assess whether the stability and changes in loneliness were related to stability and changes in mental health, the observed and predicted values were displayed, and a χ² test was used to test for independence.

    Second, we used generalised estimating equations (GEE) analysis, including continuous loneliness and mental health scores at wave 5 and 6. Results are presented of the crude model and the adjusted model including sociodemographic, lifestyle and health factors. Also, sex, age (cut-off of 60 years) and household composition were tested as effect modifiers.

    Third, the association between the change scores in loneliness and mental health was analysed using linear regression. Change scores were classified as: (1) neutral: stability in the score of either loneliness or mental health over time, (2) positive: an increase in loneliness/mental health score and (3) negative: a decrease in loneliness/mental health score. Three models were run, a crude model, a second model adjusting for baseline scores of loneliness and mental health and a third model with additional adjustment for sociodemographic, lifestyle and health factors.

    Results

    In total, 4166 participants with data on loneliness and mental health in wave 5 and/or wave 6 were included in the analyses. More than half of the study population were women (52.7%) and the mean age at baseline was 59 years (±9.6 years) (table 1). About one-fifth were unmarried (19.7%), 13.8% lived alone and 46.0% had a low education. Less than half did not adhere to the guidelines of physical activity in leisure time (44.6%) and one-third suffered from one or more chronic diseases (32.2%). The proportion experiencing loneliness remained stable over the waves (30.4% and 30.2%). Similar results were found for mental health, where 7.8% of the study population experienced poor mental health in wave 5 and 8.7% in wave 6.

    View this table:
    Table 1

    Descriptive characteristics of the study population (N=4166)

    Loneliness and mental health over time

    Changes in loneliness were experienced by 23.4% of the study population, with 11.8% experiencing loneliness in wave 5 but not in wave 6, and 11.6% becoming lonely in wave 6 (figure 1). Stable lonely was found for 18.6% and 58.0% was stable not lonely. Changes in mental health were found for 9.7%, with 4.4% changing from poor to good and 5.3% from good to poor. Stable poor was found for 3.4% and 86.9% had stable good mental health.

    Figure 1
    Figure 1

    Stability and changes in loneliness and mental health of participants in the Doetinchem Cohort Study over a 5-year period.

    Longitudinal association between loneliness and mental health

    Cross-tabulation of (changes in) mental health and loneliness over a 5-year period is presented in table 2. The observed values were found to differ statistically significantly from the predicted values, as shown by the χ² test (X2: 396.17, p<0.001), portraying a relationship between the categories of loneliness and mental health. In particular, the diagonal is interesting: it shows that stability in being not lonely and in good mental health is more often found together than based on independence (55.1% vs 50.8%). The same holds for stable loneliness and stable poor mental health (2.3% vs 0.6%), changing to loneliness and changing to poor mental health (1.4% vs 0.6%) and changing to being not lonely and changing to good mental health (0.8% vs 0.5%).

    View this table:
    Table 2

    Loneliness and mental health patterns of participants in the Doetinchem Cohort Study

    Table 3 shows the results of the GEE analysis. A higher loneliness score was associated with a lower mental health score both over time and cross-sectionally, with a β of −3.75 (95% CI: −3.98 to −3.51), which remained unchanged after adjustment for various sociodemographic, lifestyle and health factors (β: −3.56, 95% CI: −3.79 to −3.32). Furthermore, sex, age and household composition did not show to be significant effect modifiers.

    View this table:
    Table 3

    Longitudinal association of loneliness and mental health, GEE model

    The association between changes in loneliness and changes in mental health is presented in table 4. The crude model shows a statistically significant association, where a single-point increase in the loneliness change score was associated with a decrease in the mental health change score of 1.66 points (95% CI: −1.92 to −1.40). When adjusting for the baseline scores of mental health and loneliness, the association became slightly stronger (β:−2.34, 95% CI: −2.59 to −2.08). Finally, this association remained after additional adjustment of sociodemographic, lifestyle and health factors at baseline (β:−2.35, 95% CI: −2.61 to −2.08).

    View this table:
    Table 4

    Association between loneliness and mental health change score, linear regression

    Discussion

    The analysis of a sample of the general population aged 41–86 years showed that almost a quarter experienced a change in feelings of loneliness over a 5-year period, and almost 1 out of 10 reported a change in mental health. Higher levels of loneliness were found to be associated with poor mental health both cross-sectionally and over time.

    Loneliness over time

    The majority of our study population remained stable in loneliness (76.6%), which aligns with earlier findings that showed 70% of older Dutch adults remained unchanged in their loneliness score over 7 years.18 Evidence implies that loneliness has a trait-like nature, meaning that some individuals will inevitably experience more loneliness throughout life than others, irrespective of their situation.4 This might explain the stability in loneliness among our study population.

    Furthermore, almost one-quarter of our study population reported a change in loneliness, which was equally distributed in direction. Earlier observations are not fully comparable to our findings.18 A 7-year longitudinal study among older Dutch adults found that reduced feelings of loneliness between multiple waves were experienced by 10–13% of the participants and increased feelings of loneliness by 11–18%.18 Unlike our study, it was not specified whether the changes in loneliness resulted in participants becoming lonely or recovering from loneliness during the study period. The changeability of loneliness found in our study might be explained by the fact that the study population predominantly consisted of older adults (50 years and older). Older adults are more likely to experience loneliness due to transitions of late adulthood, such as death of a partner, bereavement, retirement, living alone, physical and cognitive disabilities, diminishing social networks and loss of social roles.19 20 Simultaneously, older adults are more likely to experience a reduction in feelings of loneliness. Widowed or divorced older adults can find new intimate others, retirement can create opportunities to expand the social network by engaging in activities, the birth of grandchildren could increase social interaction frequencies and demanding chronic diseases could increase social support.21–24

    Mental health over time

    The majority of the study population experienced stable mental health (90.3%). Similar to loneliness, depressive symptoms have been found to have a trait-like nature.25 Given mental health is dependent on both depressive and anxiety symptomology, the depression’s trait-like nature would partially explain the stability in mental health.

    One out of 20 (5.3%) changed from good to poor mental health over a period of 5 years and 4.4% vice versa. Comparison of these findings with previous studies is difficult as most recent studies were conducted in the context of the COVID-19 pandemic, which differed considerably from the current study’s prepandemic context.7–9 One prepandemic longitudinal study assessed changes in mental health among US adults aged 25–75 years over a 10-year period.26 This study found that 9.2% of the study population changed from a ‘languishing’ mental health to ‘moderate’ or ‘flourishing’ mental health, and 9.5% changed from ‘flourishing’ mental health to ‘moderate’ or ‘languishing’ mental health.26 The changes in mental health in this study were larger than our observations, which may be due to the different age group, the different time frame and the use of a different definition of mental health. Experiencing a change to poor mental health can be induced by cognitive impairments, loss of close ones, bereavement, poor physical health, reduced social network and decreased frequency of contact with the social network.27–29 On the other hand, experiencing changes to good mental health could be explained by increased performances of physical activities, healthier dietary habits, improved sleep quality and increased job control in the workplace.30–33

    Longitudinal association between loneliness and mental health

    Our study showed that there is a strong intertwining of (changes in) loneliness and (changes in) mental health, cross-sectional and longitudinal and independent of various sociodemographic, lifestyle and health factors. Similar findings were shown by studies examining the association between loneliness and (elements of) mental health. In those studies, loneliness was found to be longitudinally associated with depressive symptoms after 2, 11 and 12 years of follow-up, even after adjustment for similar covariates as used in our study.19 34 35 Considering anxiety, experiencing higher levels of loneliness were found to increase the likelihood of being diagnosed with generalised anxiety disorder after 2 years of follow-up.36 The relation between decreasing feelings of loneliness and improving mental health could partially be explained by the fact that individuals experiencing loneliness are prone to re-engage in social interactions,34 which subsequently increases their social network, assuming their social environment is available and qualitatively adequate.37 This aligns with earlier findings, showing that decreasing feelings of loneliness were reciprocally associated with social network expansion, and decreasing feelings of loneliness were associated with decreasing depressive symptoms.34 In contrast, individuals experiencing depression are more likely to perceive the social support of close relationships as inadequate, inducing feelings of loneliness.12 Sometimes loneliness is not viewed as a unidimensional concept, but two are distinguished: emotional loneliness, the absence or loss of close emotional ties or intimate individuals, and social loneliness, the undesirable absence of an engaging or wide social network.38 Emotional loneliness was shown to be associated with depression,39 whereas social loneliness was found to be associated with anxiety.40

    Strengths of this study include a population sample, good overall response rates and a broad age range. The study also has several limitations. The study population consisted solely of participants living in Doetinchem and lacking ethnic groups.13 Also, selective loss to follow-up is present, giving a more healthy study population.13 Those who were lonely or had poor mental health in wave 5 participated less frequently in wave 6 (being 19% and 29%, respectively) compared with those who were not lonely or had good mental health. This resulted in the underestimation of the prevalence of loneliness and poor mental health. In addition, we are aware that mental health entails a much broader range of experiences than the short MHI-5 questionnaire that has a focus on depression and anxiety symptomatology. Our findings cannot be interpreted as causal or give insight into the directionality. We see it as a description of longitudinal developments that coincide.

    However, the association between loneliness (changes) and mental health (changes) suggests that successful interventions for one element may also be profitable for the other. Earlier findings showed bidirectionality in the association between loneliness and mental health,36 so successful intervention on both components may be effective for the other. In particular, the varying character of loneliness may be interpreted as a possible potential in improving mental health by designing public health interventions aimed at reducing feelings of loneliness.

    To inform public health further, future studies may focus on the following aspects. First, more research is needed to gain insight into causality and directionality of the associations between changes in loneliness and changes in mental health. Second, it is important to gain insight into the long-term individual changes in the various elements of loneliness (emotional and social loneliness) and of mental health (depressive symptoms and anxiety symptoms) to assess their changeability in the long run and what the (causal) role is of lifestyle, health or environmental factors.

    In conclusion, substantial individual changes in loneliness and mental health were present over a 5-year period, although the largest part of the population showed stability in loneliness and mental health. Loneliness and mental health are clearly linked, both cross-sectionally and longitudinally. Tackling loneliness may present a target for promoting mental health.

    Data availability statement

    Data are available upon reasonable request. The data of the Doetinchem Cohort Study cannot be placed in a public repository due to legal and ethical constraints. The participants’ informed consent did not include consent to public availability of the data. However, the data are available upon request, by contacting the scientific committee of the Doetinchem Cohort Study by email: Doetinchemstudie@rivm.nl.

    Ethics statements

    Patient consent for publication

    Ethics approval

    The study was conducted according to the principles of the World Medical Association Declaration of Helsinki and in accordance with the Medical Research Involving Human Subject Act (WMO). For wave 5, approval was given on 31 December 2007, and for wave 6, on 24 January 2013 by the METC of University Medical Centre of Utrecht (UMCU) with protocol number 7/233 (and CCMO number 19158.041.07). Participants gave informed consent to participate in the study before taking part.

    Acknowledgments

    We thank the respondents, epidemiologists and fieldworkers of the Municipal Health Service in Doetinchem for their contribution to the data collection for this study.

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    Footnotes

    • Contributors HSJP, G-CH and TM developed the idea for the analyses. All authors participated in writing the manuscript and approved the final version. TM carried out the data analyses. HSJP and WMMV participated in the data collection. HSJP is the guarantor. None of the authors has conflicts of interest.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

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