In a 1995 review of 20 years of research on the issue, Harvard social epidemiologist Lisa Berkman, PhD, found that “people who are isolated are at increased mortality risk from a number of causes. . . . Recent studies indicate that social support is particularly related to survival after myocardial infarction.”

The connection between poor social support and poor recovery from heart attack is complex, but it may well be depression. Depression is associated with a three- to fourfold increase in cardiac mortality within 18 months of a heart attack, according to studies by Frasure-Smith et al. published in the Journal of the American Medical Association in 1993 and Circulation in 1995. The same researchers examined depression and social support in 887 MI patients, and their results (published in the April 2000 issue of Circulation) linked social isolation and depression with mortality. Interestingly, however, the study showed that social isolation was generally not closely linked with depression, although being married or living with others did lessen the likelihood of depression. While social networks weren’t found to prevent depression, the study did find that depressed patients who had high levels of social support were less likely to experience a depression-related increase in post-MI mortality. The project also identified three factors that helped mitigate depression: a higher perception of social support, more close friends and relatives with whom the patient had regular monthly contact, and living with one or more persons. “Very high levels of support appear to buffer the impact of depression on mortality,” the researchers wrote.

When they lack close relationships, older people particularly are at risk for depression, dementia, and entry into a nursing home. A Swedish study published in the April 15th issue of the Lancet followed approximately 1,200 elderly people without dementia for an average of three years, and found that those with a limited or poor social network had a 60% increased risk of developing dementia. And a 1994 study examining more than 2,800 elderly people in New Haven, CT, previously confirmed the common-sense conclusion that those who enjoyed regular contact in a close family network were less likely to enter nursing homes.

Research published last year in Health Psychology found a possible connection between social isolation and cancer: the study showed that men with high levels of stress and poor social support had increased levels of prostate-specific antigen in their blood—and thereby an increased risk of prostate cancer.

In an editorial published last year in JAMA, David Spiegel, MD, of the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine, summarized the overwhelming value of social support in improving and maintaining health. “Being well integrated socially reduces all-cause age-adjusted mortality by . . . twofold, about as much as having low-versus-high serum cholesterol levels or being a nonsmoker,” he wrote.

The effect has been shown in recoveries from heart attacks, strokes, and hip fractures, among other health crises. Researchers speculate that emotional support in a time of crisis calms the patient, reducing the stress that can prompt harmful physiological responses. Relaxation can boost immune and neuroendocrine system responses that support healing, Mendes de Leon suggests. According to Arthur Stone, PhD, professor of psychiatry at the State University of New York in Stony Brook, the biological response involves a feedback loop between the brain and the body. “Social factors influence biological factors and vice versa,” Stone explains. “When our brain produces certain types of hormones and activates organs . . . the organs produce their own chemical mediators that go back up to the brain. Everything’s influencing everything else.”

A sense of embeddedness, or belonging, may also have an impact on longevity. “On a day-to-day basis we may not need the presence of someone to whom we want to convey our deepest worries and fears,” says Mendes de Leon, “but the improved longevity may be a function of ‘How much do I feel integrated in my social environment?’ The feeling of some social embeddedness is important to the health of older people.”

Having friends can also motivate people to remain physically active, and the research suggests that those with more diverse social networks generally take better care of themselves: they smoke less, exercise more, and sleep better, says Sheldon Cohen, PhD, professor of psychology at Carnegie Mellon University in Pittsburgh.

Patients being treated for HIV fare better when they have a network of friends and others to support them, perhaps because they’re more likely to take their medicine when others are there to remind them, says Sheryl L. Catz, PhD, assistant professor of psychiatry and behavioral medicine at the Medical College of Wisconsin. Catz was lead author of a paper examining HIV patients and their social networks. “Our findings suggest that patients with limited emotional support should receive mental health and support services not only to improve psychological functioning but also, potentially, to enhance treatment adherence.”

An intriguing study of Cohen’s published in 1997 in JAMA showed that healthy volunteers exposed to a common-cold virus were less likely to get sick if they had a diverse social network. The finding could not be explained by the subjects’ health habits alone, such as smoking, sleeping poorly, or low vitamin C intake.

“At this point we’ve been unable to clearly identify what the difference is either biologically or psychologically that made the subjects healthier,” Cohen says. “These aren’t easy connections to make,” he says, noting that “it took us 10 to 12 years to make a plausible connection between stress and colds.”

Although Cohen is reluctant to make certain claims about the physiological mechanisms involved, he says the evidence clearly shows that social isolation puts patients at risk, and that part of primary care should be attending to a patient’s social networks. “A clinician certainly could encourage patients to participate in groups, whether through social activities or religious groups or spending more time with friends,” he suggests.

Marvel, who has studied physician-patient interaction extensively, says doctors or patients raise the topic of social support in office visits only about 15% of the time.

The greatest concern of physicians is probably that they won’t have time for an extended discussion of the patient’s emotional life. “The doctor thinks, ‘If I do ask those questions, I may open up a can of worms, and it’s going to take me a long time to have that discussion,’” Marvel says.

But allowing a patient the opportunity to discuss social and emotional issues enables primary care doctors to find out whether an isolation issue will interfere with treatment and, if it will, to suggest an intervention such as a support group or a referral to a counselor. Furthermore, the simple act of discussing the issue with a doctor may make the patient feel better.

It’s possible to open up such a discussion without taking on more than can be handled in an office visit, Marvel says. He suggests using the BATHE technique, outlined by Marian R. Stuart and Joseph A. Lieberman III in The Fifteen Minute Hour, a book that adapts psychotherapy techniques to brief primary care encounters. BATHE stands for background, affect, trouble, handling, and empathy.

The technique involves asking the patient an open-ended question, such as, “What is going on in your life,” and listening attentively and supportively to the patient’s response. Pay attention to the patient’s affect, or mood. Is she depressed, lonely, or anxious? If so, focus the discussion on what is bothering her. Find out how she is coping with or handling the situation, ensuring that she has someone to support her emotionally. Finally, empathize with her by acknowledging how she’s feeling. The BATHE technique provides an opportunity for a brief, focused interview over which the practitioner maintains control.

“In my experience, when physicians use this set of structured questions, they feel a little more in control even though they’re exploring the psychosocial realm,” says Marvel. “It won’t be an endless discussion, and yet you get to that issue of whether the patient is coping and handling the problem.”

Physicians can also simply offer an empathetic ear. “The most therapeutic part of this approach is having somebody listen,” says Marvel. “That’s more important than offering the patient a solution.”

Physicians can limit their inquiries about social support to patients with problems or symptoms that suggest social isolation is an issue, such as patients who schedule frequent appointments—particularly for unexplained physical problems—and those who are depressed or have chronic illness.

Another way, short of an in-depth interview, to find out if patients are isolated is to include a couple of questions about social support on the patient intake form or questionnaire. Furthermore, reception staff and nurses often have casual conversations with patients, and they can be instructed to pass along relevant information about patients who might need extra help.

Another technique is to encourage patients to bring an advocate—a friend or relative—along on medical appointments. “In the past some physicians have seen that as a nuisance,” says Carolina Yahne, PhD, a psychology professor and research associate at the University of New Mexico Center on Alcoholism, Substance Abuse, and Addiction. “But the physician who encourages that . . . can elicit the support of the patient’s help network.”

Other recommendations a doctor can make include the following:

• Refer the patient to a support group focused on his chronic illness or age group.
• Suggest talking with a counselor, social worker, or minister.
• Recommend getting a pet.
• Ask about religious affiliation and contacts in the patient’s religious community.
• Offer a follow-up appointment to further discuss the problem.

It’s useful to keep on hand listings of social support resources in the community so an easy referral can be made. For instance, have a list of community agencies that deal with the elderly, including adult day care programs, legal and housing assistance, and Medicare counseling. Keep extra copies that the physician or office staff can hand to patients who need help.

Shorter stays in the hospital and increasing evidence that patients’ social needs affect their health have made connections between primary care physicians and social workers more important, Webb says. She adds, “This has put a major strain on primary care doctors to try to ensure that patients get the needed support to improve their health and recover from illness.”

The pressure has been particularly intense on medical groups in urban, inner-city areas where patients tend to have more psychosocial problems and high-risk behaviors, such as poor housing, smoking, and substance abuse.

Social workers can provide patients with education, links to community resources, emotional support, coping skills for life-threatening medical conditions, psychological counseling, and support for their family members.

Many primary care doctors are more comfortable making a referral to a licensed social worker because they feel uncomfortable probing into a patient’s personal life, Webb says. “I’ve worked with residents on biopsychosocial issues, and there is a high level of discomfort. They wonder, ‘How do I raise these questions?’”

In her own work with primary care practices, Webb has often heard patients and their families say that they felt intimidated and were discouraged from asking the doctor medical questions. “I would come back to the doctor to follow up and he’d say, ‘I didn’t have a clue they didn’t get what they needed,’” Webb relates. “The physician would feel a lot of relief knowing that what he or she had said was explained the best it could be and that follow-up was being done.”

Some practices find it worthwhile to pool their money and hire a social worker. Increasingly, insurance plans are paying for the behavioral counseling related to medical diagnoses such as heart disease and other chronic illnesses. Another option is to refer patients to independent licensed clinical social workers who will bill for their services separately.

One often-overlooked resource for physicians is the patient’s spiritual network, psychologist Yahne says, whether it’s a formal church or simply the patient’s own belief in prayer. “Physicians have traditionally not called on that,” she says.

Referral to other professionals—social workers, psychologists, and clergy, for instance—can be lifesavers for busy primary care doctors. “You need to call in everything you’ve got,” Yahne says.

Professionals aren’t the only ones who can help. Soliciting the help of family members, and encouraging them to visit a hospitalized patient, is also helpful, says Mendes de Leon. “You can positively reinforce that to the family and say, ‘It’s great you can come to visit, and I’m sure the patient appreciates it,’” he suggests. “Those kinds of simple remarks can go a long way.”

For a busy primary care doctor, remembering to keep apprised of a patient’s social connectedness may be difficult, but researchers say it’s worthwhile. “We have to start teaching primary care physicians, or at least making them aware that this kind of emotional support is important to patients,” Mendes de Leon contends. “It doesn’t take a lot of time or a lot of expertise. Quickly checking on the emotional status of your patient is only the humane thing to do.”