‘An Epidemic of Loneliness and Despair’: How Wisdom Can Help

Q&A with Dilip V. Jeste, M.D.

University of California, San Diego

BBRF Scientific Council Member

2002 BBRF Distinguished Investigator

Dr. Jeste is the Senior Associate Dean for Healthy Aging and Senior Care, Distinguished Professor of Psychiatry and Neurosciences, Levi Memorial Chair in Aging, and Director of the Stein Institute for Research on Aging, at UC San Diego, and Co-Director of the UC San Diego-IBM Center on Artificial Intelligence for Healthy Living. He was previously Chief of the Units on Movement Disorders and Dementias at the National Institute of Mental Health. At UC San Diego he started a Geriatric Psychiatry program in 1986—today, one of the largest such programs in the world. He discusses many of the ideas raised in this Q& A in a new book, “Wiser.”

Dr. Jeste, you have said that we are currently in the middle of two epidemics, one being COVID, of course, but the other an epidemic of loneliness. You have written that loneliness acts as “a lethal behavioral toxin in our society.” Can you help us understand what you mean?

People don’t realize that this “other” epidemic of loneliness has been going on for the last couple of decades. One way to see this is through the average lifespan in the U.S., which had been increasing ever since the 1950s but started dropping a few years ago. This decrease is not because of new infections or new cancers. It is because of a marked increase in the numbers of opioid-related deaths and suicides, both of which are related to underlying loneliness. In 1999, there were 8,000 deaths from opioid overdoses. Last year, this number reached 50,000. Overall, the rate of suicide has increased by 30% in the U.S. from 1999–2017. The U.S. government estimates that 162,000 Americans die every year from loneliness and social isolation. That is greater than the number of Americans who die annually from lung cancer or from stroke.

The silent epidemic of loneliness doesn’t strike in a “crisis” sort of way, and yet it has been going on for 20 years. Stress is increasing. Loneliness is increasing.

These have been called “deaths of despair.”

Yes. And loneliness also contributes to other illnesses such as diabetes, obesity, heart disease, dementia, major depression, and generalized anxiety disorder. This is based on studies of several thousands of people who were followed over a period of years. We’re able to say that loneliness increases mortality by 30%. That is the same or greater than mortality attributed to smoking 15 cigarettes a day or mild to moderate obesity.

What factors in the way we live are responsible for the increase in loneliness?

Two important factors for increased stress and loneliness in the last 20 years are globalization and the rapid growth of technology.

And yet: advocates of globalization and enthusiasts of new technologies say that these two forces are actually connecting us, making the world smaller.

There is no question that globalization and technology have many good effects, but the good effects are often neutralized by downsides.

In the realm of technology, I suppose you could cite social media as not just “connecting” people, but also, for many, and especially young people, increasing peer pressure tremendously.

Exactly. Some social media contribute to psychopathology, whereby some people hurt others psychosocially.

The COVID pandemic adds a whole new layer to this because of the very fact that we need to be physically isolated.

Social distancing is absolutely critical to reduce the spread of the disease; however, that social distancing is also causing greater loneliness and social isolation, which is increasing the risk of suicide, substance use, obesity and so on.

When we think of people who are lonely, we often think of those who are old. Who is empirically most at risk of being lonely?

Loneliness is common across the board. Something to keep in mind is that especially in recent years, the level of stress, loneliness, and suicides has increased, especially in younger people, including teenagers. Loneliness is common at all ages; however, there are some ages at which it peaks. In one of the studies my colleagues and I recently published, we found that there were three peaks: people in their late-20s, mid-50s and late-80s.

What circumstances mark those peak years?

Adolescence is a difficult period for most people, but then you reach 21, and you are supposed to be an independent adult and make lots of major decisions. There is a lot of stress and tremendous peer pressure. And you may feel that you are worse off than your peers, because you are always comparing yourself with peers seemingly doing better. The 50s is the time of the classical mid-life crisis, when people start noticing higher blood pressure or other physical changes, and see retirement looming. Their kids have left home, leaving an empty nest. And then the late 80s, of course, is the period when, often, you don’t even have a spouse. You are worried about dementia. Your physical health is in decline and you may be disabled.

You study “wisdom,” which is a word that means different things to different people. But you use it in a particular way. You’re talking about wisdom as a concept that you’re trying to measure empirically and to apply therapeutically for people who experience loneliness. How did you get interested in the idea of wisdom?

We did a study of about 2,000 people in the general community, ages 20 to over 100, and we found that physical health starts declining around age 45–50. But mental health actually tends to improve over the entire span from ages 20 to 90. This is what I call the paradox of aging. This finding has now been replicated by several other studies. The 20s is a period of considerable stress, depression, anxiety, loneliness. But the good news is that things start getting better, emotionally, for many people. It’s not that the stress goes down, it’s that you get better at handling it—and that’s where the idea of “wisdom” comes from, as I use it.

How did you reach your definition of wisdom?

When I got interested in wisdom, the first thing I did was a literature review. We looked at all the scientific journal articles that had tried to define this term and found that wisdom is not understood universally as one thing. We found seven different components that were used across the studies on wisdom. These components are: pro-social behavior (i.e., empathy or compassion); emotional regulation; self-reflection; acceptance of uncertainty and diversity of perspectives; the ability to be decisive; the ability to give appropriate advice and support to others; and spirituality.

To do scientific research on this subject, you must define wisdom clearly and you must be able to measure it empirically. We developed a questionnaire that assesses people on a scale, the San Diego Wisdom Scale (SD-WISE). It measures each of these seven components. And we have four items for each of these subscales, so a total of 28 questions. The total score is called Jeste-Thomas Wisdom Index or JTWI.

Since you develop your definition based on studies published since the 1970s, does this mean that your idea of wisdom reflects only modern Western thinking?

We actually did a qualitative/ quantitative study of wisdom as discussed in an ancient Indian scripture, Bhagavad Gita. We looked at the word “wisdom” and its antithesis, “foolishness,” to see how often those words were used and in what context. For example, the Gita says that a wise person is somebody who is quite decisive when needed. That means that decisiveness is a component of wisdom. The Gita also says that a wise person is unselfish and looks out to other people’s needs (what I call “pro-social behaviors”). We were really surprised to find that the components of wisdom in the Gita are almost identical to our modern definition!

It seems there’s something almost eternal about this, or perpetual in human culture. Why do you think that is?

To me, it means that wisdom is biologically based. If it is based in biology in the brain, then it will not change over centuries and across cultures. We published a paper on the neurobiology of wisdom. We found that in the brain, the prefrontal cortex and the limbic striatum are involved in a major way in all of these wisdom components.

What you are saying is that there are probably biological correlates of the things that cause us to express in our behaviors the seven components of wisdom.

Exactly. Just as there are places in the brain that display abnormal functioning in conditions marked by a lack of wisdom—for example, antisocial personality.

Can wisdom be increased or inculcated?

Wisdom is a trait, and most traits are about 50% determined by genetics and 50% by environment and behavior. We recently published a meta-analysis of 57 randomized control trials interested in three of the components of wisdom that I’ve discussed: emotional regulation, empathy/compassion, and spirituality. About half of these studies showed significant improvement with the interventions they tested. Our analysis of these trials showed that components of wisdom can be increased. The question then becomes whether someone can increase the “whole”— living in a way that benefits themselves as well as others—from the behaviors and insights associated with wisdom.

Just a few months ago, my colleagues and I published a paper on that very question. It was a study of 89 older people in five retirement communities in three states. The purpose of the study was to increase resilience in these people, but we also were using the wisdom scale, and found a significant increase in the overall wisdom scale score—as well as an increase in resilience and decrease in stress.

What were the interventions that increased resilience?

We used psychosocial or behavioral interventions, group-based. These used the principles of cognitive behavioral therapy along with other approaches like keeping a “gratitude diary,” in which you record something every day that you are grateful for.

That helps to increase self-reflection.

Yes, and also empathy/compassion, because when you start acknowledging that people around try to help you, it increases your desire to help them too. Coming back to your original question, yes, wisdom components can be improved. Even overall wisdom.

How do we improve our own wisdom in practice?

What I call “practical wisdom” is something that you can actually do in everyday life. What we need to do is improve our self-reflection, empathy/ compassion, emotional regulation, acceptance of uncertainty, decisiveness, social advising, and spirituality.

The first step is to assess yourself in an unbiased way. You can start by going online and taking our SD-WISE questionnaire at: aging.ucsd.edu. You will respond to statements using a 1-5 scale, where you indicate the extent to which you agree with them. This way you can find out what components you are strong or weak in. We all have strengths and limitations. What we need is an unbiased evaluation. If we are to improve, we have to find out where we need help, right?

Would you agree that one condition of becoming wiser is that the individual has to want to do this?

People should want to improve. No question about that. But there are people who want to improve and don’t know how, and that’s why they give up.

Let’s talk to the people who want to improve but don’t know they can or what framework to use.

Let’s say you need to be more selfreflective. What do you do? Practical wisdom means wise decision-making in everyday life. Almost every decision I make should be made around the seven components to the extent possible. Let’s use as an example a recent fight with a good friend that is making me feel lonely. You can start with self-reflection: why did it happen? Did I do something wrong? Then secondly, emotional regulation. I’m being mad at him. But that doesn’t help, so I should control my anger. Third is empathy. Empathy is both cognitive and affective. What is my friend’s perspective? Where is he coming from? That doesn’t mean I have to agree with him, but it helps me a lot to understand his rationale. Then comes the acceptance of uncertainty. I can accept the fact that he may have a different value system and that’s okay. And finally, spirituality means being connected to something or someone that you don’t see or hear or feel, whether it is God, nature, or whatever. You won’t feel lonely if you are always connected. This is practical wisdom. We need to integrate it into all behaviors. In the beginning it takes time, but it should eventually become second nature.

Consider the hypothetical of an elderly person who has lost their spouse and many friends, and is feeling lonely. This is very common. Their world is getting smaller. Their physical health is declining. How can they apply practical wisdom to their life?

You can start with a kind of mindfulness, where you accept your emotions of grief and loneliness and what you are going through. You also get some perspective, realizing that you’re not the only one feeling that way. Another way is to think about the times you’ve felt lonely in the past and subsequently came out of it when you found new friends or hobbies. It didn’t last forever.

In senior living facilities, should staff organize programs that teach practical wisdom?

I think it is very important to have this type of training at all levels, provided by community staff. This is something that should start from kindergarten. I think we need it, in societal terms, because of the increased rates of suicides, that are now even happening in children as young as 10.

Our stress levels as a society keep on increasing. It becomes a vicious circle. Higher stress level leads to more depression. You don’t do as well, and then there’s more pressure. We need to change that. In our educational institutions, we emphasize hard skills. For example, in medical school we teach students how to be the best diagnostician and treatment-prescriber. We don’t teach them how to take care of themselves, how to empathize, how to have self-reflection or self-compassion. We need to teach people how to get social support and to support others.

You did a study of seniors in San Diego County who were living in a facility with hundreds of people like themselves. Yet, 63% said they felt lonely. You commented: “The study shows why solutions to loneliness such as increased engagement on social media or going into public spaces does not work for all people.... We must stop thinking that we can cure loneliness just by increasing people’s social relationships.” Tell us about this and how it relates to the concept of “Oneliness.”

Loneliness is subjective. This means you can be lonely in a crowd. Even if someone is in a group facility with many others like themselves, or on social media where they connect with hundreds, they can feel lonely. In contrast, an older person living by himself or herself can feel quite contented. This is “oneliness”—it refers to people who are happy or at least contented at being by themselves. It means not feeling isolated and distressed. Thus, you don’t have to be with others all the time. For those who are spiritual, it is always possible to feel connected. Even if you do not have spirituality, if you are alone, you can say, “This is good, actually. I can read something, or I can watch a movie or whatever.” The solution to loneliness is not outside the individual. The solution is inside.

Written By Fatima Bhojani and Peter Tarr, Ph.D.

Click here to read the Brain & Behavior Magazine's December 2020 issue