Does loneliness contribute to the increased risk of depression in older adults who are sexual minorities or have chronic physical health problems?
Depression is a common mental health problem and there is evidence that rates of depression are rising among older adults.1,2 As we age, depression can be more difficult to diagnose and many people never get treatment.1 We need to identify modifiable causes of depression among older adults, so we can design interventions to target these causes in the general population.
Around a third of older adults in the UK report loneliness.3 We know that older adults who experience loneliness are more likely to develop depression in the future.4 Certain older adults have a higher risk of depression than others, for example those who are lesbian, gay or bisexual (LGB) and those who have chronic physical health problems.5 However, we have a poor understanding of what causes the increased risk of depression in these groups. Interventions for loneliness, such as community groups, could reduce or prevent depressive symptoms in these groups, if there was evidence that loneliness was a causal link in this pathway.
Although loneliness might contribute to the increased risk of depression in older adults who are LGB or have chronic physical health problems, few studies have tested this hypothesis.
Aims and objectives
We conducted two studies to address the following research questions:
1.1 Are LGB older adults at increased risk of future loneliness compared with heterosexuals?
1.2 To what extent does loneliness contribute to increased risk of future depression in LGB compared with heterosexual older adults?
2.1 Are older adults with chronic physical health problems (illness or injuries) at increased risk of future loneliness compared with the rest of the population?
2.2 To what extent does loneliness contribute to increased risk of future depression in older adults with physical health problems compared with the rest of the population?
We used the English Longitudinal Study of Ageing (ELSA), a representative sample of adults aged 15 and over. More than 18,000 people have taken part in ELSA since it started in 2002, with the same people re-interviewed every two years.
We used data on sexual orientation and physical health at one point in time (2012), loneliness two years later (2014), and depression two years after that (2016). To test whether being LGB or having physical health problems was associated with an increased risk of loneliness two years later, we used linear regression models. To test the extent to which loneliness contributed to the increased risk of depression in these groups we conducted causal mediation analyses. We performed these analyses before and after adjusting for a range of variables that might confound these associations.
Study 1: the role of loneliness in the association between sexual orientation and future symptoms of depression
We used data from 6794 participants who provided data on sexual orientation at the sixth follow-up point of the ELSA study. We used a binary variable (LGB or heterosexual) due to small numbers in certain sexual minority groups.
We found that, compared with heterosexuals, LGB older adults scored higher on depressive symptoms two years later (mean difference: 0.26, 95% Confidence Interval 0.10 to 0.42). We also found that sexual minority older adults had higher levels of loneliness than heterosexuals (mean difference: 0.18 95%CI 0.08 to 0.27). In our mediation analysis, loneliness accounted for 20% of the association between sexual orientation and depressive symptoms two years later.
Study 2: the role of loneliness in the association between chronic physical illness and future symptoms of depression
We used data from 4,793 participants. The physical illnesses we investigated included: arthritis, cancer, diabetes, cardiovascular disease, stroke, and chronic obstructive pulmonary disease. We created a binary variable to indicate whether people had at least one of these physical illnesses or not.
We found that depressive symptoms four years later were 21% higher (incident rate ratio = 1.21, 95%CI = 1.03-1.42) in people who had physical illness compared with those who did not. However, we found no evidence of that loneliness two years later was higher among people who had physical illness compared with those who did not. There was no evidence that these associations differed according to the type of physical illness people had, or the number of physical illnesses they had. We therefore concluded that loneliness was not a potential mechanism underlying the increased risk of depression in older adults with physical illnesses. As a result, we did not conduct tests of causal mediation.
Strengths and limitations
The main strengths of our study include:
- The large sample which was representative of the English population of older adults.
- The repeated measurements of loneliness and depression over multiple time-points.
- The rich set of potential confounding variables including genetic data.
The main limitations of our study include:
- We can never be certain of causality when using observational datasets.
- We created a binary variable for sexual orientation which did not allow us to investigate more specific orientations separately (e.g. lesbian, gay, bisexual).
- ELSA did not collect information on whether people were transgender, gender diverse or non-binary.
- Most of the physical illnesses were either arthritis or cardiovascular disease. This may have limited the conclusions we could make about other chronic physical illnesses with smaller numbers, such as stroke and COPD.
- Like most cohort studies there were missing data, which can introduce bias. However, we conducted an analysis where we replaced missing data using statistical methods and the results did not differ.
Conclusions and implications for practice
Our findings suggest that increased risk of depression in LGB compared with heterosexual older adults is due, in part, to higher levels of loneliness. About half of older gay and bisexual men and more than a quarter of lesbians and bisexual women live alone, compared with less than a fifth of heterosexuals.6 Sexual minority older adults are more likely than heterosexuals to be single, to not have children and to have lost loved ones (e.g. to HIV or suicide).7,8 They are also less likely to see their family. 9 Stigma and discrimination are likely to play an important role.10 Fears about being their true selves might lead to a lack of meaningful connections and a sense of social invisibility. Community interventions which provide safe inclusive spaces where LGB older adults can build meaningful connections could reduce loneliness in this group, and prevent future symptoms of depression.
We found that chronic physical illness increases the risk symptoms of depression in older adults. However, we found no evidence that this occurs because physical illness leads to loneliness. We found no evidence of an association between the physical illnesses we examined and loneliness. Our evidence suggests that reducing loneliness among older adults with chronic physical illness is unlikely to prevent future depression.
Involvement of people with lived experience
The idea for our study on physical health problems and loneliness was developed by Stephen Lee, a member of the Loneliness and Social Isolation in Mental Health Network Co-production Group, who has experience of loneliness and depression. Stephen worked with us as part of the research team on this project.
We also worked with older adults from the Befriending scheme run by Opening Doors London (ODL), the biggest charity providing support services for LGBT+ people over 50 in the UK. We would like to thank members of ODL for their input into the interpretation of our findings on sexual orientation, loneliness and depression.
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