Beutel et al.

BMC Psychiatry (2017) 17:97

DOI 10.1186/s12888-017-1262-x

RESEARCH ARTICLE Open Access

Loneliness in the general population:

prevalence, determinants and relations to
mental health
Manfred E. Beutel1, Eva M. Klein1, Elmar Brähler1, Iris Reiner1, Claus Jünger3, Matthias Michal1, Jörg Wiltink1,
Philipp S. Wild3,4,5, Thomas Münzel2,5, Karl J. Lackner6 and Ana N. Tibubos1*

Abstract
Background: While loneliness has been regarded as a risk to mental and physical health, there is a lack of current
community data covering a broad age range. This study used a large and representative German adult sample to
investigate loneliness.
Methods: Baseline data of the Gutenberg Health Study (GHS) collected between April 2007 and April 2012
(N = 15,010; 35–74 years), were analyzed. Recruitment for the community-based, prospective, observational cohort
study was performed in equal strata for gender, residence and age decades. Measures were provided by self-report
and interview. Loneliness was used as a predictor for distress (depression, generalized anxiety, and suicidal ideation)
in logistic regression analyses adjusting for sociodemographic variables and mental distress.
Results: A total of 10.5% of participants reported some degree of loneliness (4.9% slight, 3.9% moderate and 1.7%
severely distressed by loneliness). Loneliness declined across age groups. Loneliness was stronger in women, in
participants without a partner, and in those living alone and without children. Controlling for demographic variables
and other sources of distress loneliness was associated with depression (OR = 1.91), generalized anxiety (OR = 1.21)
and suicidal ideation (OR = 1.35). Lonely participants also smoked more and visited physicians more frequently.
Conclusions: The findings support the view that loneliness poses a significant health problem for a sizeable part of the
population with increased risks in terms of distress (depression, anxiety), suicidal ideation, health behavior and health
care utilization.
Keywords: Loneliness, Depression, Anxiety, Suicidal ideation, Partnership, Prevalence

Background availability in the environment [4]. Moreover, loneliness is

Social relationships and social integration are crucial for an emotional state, reflecting the subjective experience of
emotional fulfilment and development over the life span suffering from social isolation [5].
[1]. As social beings, humans have a basic “need to belong" Research on loneliness over the life span concluded that
e.g., [2]. Social isolation refers to a lack of social contact, loneliness was highest in late adolescence, gradually de-
which can be objectively quantified (e.g. living alone, with- creasing during middle adulthood, and then increasing for
out a partnership). Loneliness, however, is usually defined late adulthood [6, 7]. In the German Ageing Survey, men
subjectively as a painfully experienced absence of social and women from 40 to 85 years participated in three
contact, belongingness, or a sense of isolation [3]. It refers waves from 1996 to 2008 in order to find out whether the
to a perceived discrepancy between social needs and their extent of loneliness of adults in the second half of their
lives has changed in Germany. The prevalence of lonely
subjects was estimated at 3 to 7% and declined gradually
* Correspondence: AnaNanette.Tibubos@unimedizin-mainz.de
1
Department of Psychosomatic Medicine and Psychotherapy, University
with age, particularly in the oldest group (70-85 years;[8]).
Medical Center of the Johannes Gutenberg University Mainz, Zahlbacher Str. With regard to sociodemographic variables, loneliness has
8, D-55131 Mainz, Germany been linked to indicators of social integration such as
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Beutel et al. BMC Psychiatry (2017) 17:97 Page 2 of 7

romantic relationships, perceived social support and ac- multiple health risk behaviors. In the Health and Retire-
ceptance [9]. Unmarried individuals indicated feeling lone- ment Study [23], the authors found that loneliness was sig-
lier than married individuals [4]. Childlessness had no nificantly and positively associated with physician visits
effect on loneliness in older adults [4]. Yet, living alone among persons aged 60 years and older. Three major path-
was not per se associated with loneliness, instead a smaller ways have been discussed by which loneliness affects health
social network was an indicator of loneliness, both in men [21]: (1) Health risk behaviors such as smoking and physical
and women [10]. However, the significance of gender in inactivity, (2) defective immune function and increase of
experiencing loneliness is contested: In a study conducted blood pressure, (3) psychological variables such as reduced
by Tesch-Römer et al. [8] men reported more loneliness self-esteem and decreased coping.
than women (from middle to late adulthood). In the Notably, as most studies have used US samples and fo-
KORA Age study which is based on a random sub-sample cused on late adulthood investigating health-related asso-
of a German community sample of over 4000 adults in ciations of loneliness [8, 10, 23], current prevalence data
the age range of 64-94 years from southern Germany, are limited for research on the link of loneliness to mental
Zebhauser et al. [10] found that the mean level of loneli- health beyond late adulthood for European populations, in
ness did not differ between men and women; only in the particular in Germany. The purpose of this study was to
oldest participants (>85 years) loneliness was higher in determine prevalence and determinants of loneliness in
women. As a result, findings are somewhat difficult to in- men and women of the general population from 35 to
tegrate due to the heterogeneity of measures ranging from 74 years and to identify associations with mental health,
single items inquiring “if a person feels lonely…” to health behavior and health care utilization. Therefore, the
broadly used scales such as the original UCLA loneliness purposes of the present study were (1) to assess the preva-
scale with 20 items [11] or the Loneliness scale by de Jong lence and determinants of different degrees of loneliness
Gierveld and Van Tilburg [12] with 11 items. in men and women, and to determine its associations to
Loneliness has been associated with many negative men- (2) mental health, (3) health behavior and (4) health care
tal health outcomes [13, 14] such as depression, suicidality, utilization in a large German community sample across
reduced positive emotions, poor sleep quality and general the age range from 35 to 74 years.
health, as well as physiological changes (e.g., increased cor-
tisol awakening response and pro-inflammatory gene ex- Methods
pression). Additionally, loneliness was associated with Study sample
depression, low life satisfaction, and low resilience - particu- This study investigated the cross-sectional baseline data of
larly in men [10]. It has therefore been considered a major the Gutenberg Health Study (GHS) from April 2007 to
source of psychological stress [15], especially when April 2012 (N = 15,010). As specified by Wild et al. [24],
combined with depression [16]. Especially, the distinction the GHS is a population-based, prospective, observational
of loneliness from depressive symptoms has been focused single-center cohort study in the Rhein-Main-Region in
by Cacioppo and colleagues [17, 18]. Accordingly, the rela- western Mid-Germany. The sample was drawn at random
tion between loneliness and depressive symptoms are recip- from the local registries of the city of Mainz and the adja-
rocal, emphasizing that both constructs are intimately cent district of Mainz-Bingen. Recruitment was performed
related but distinct. stratified in equal strata for gender, residence and for age
Loneliness also aggravates the morbidity and mortality of decades. Eligible participants were aged 35 to 74 years and
cardiovascular, cerebrovascular, and other chronic diseases gave their written informed consent. We excluded 5.8% of
[15]. It has also been related to cognitive decline and Alz- the sample due to insufficient knowledge of German lan-
heimer’s disease in aging. In a recent meta-analysis, lack of guage, physical or mental inability to participate. The re-
functional and structural social integration predicted a 50% sponse rate amounted to 60.3%. It was defined as the
increase in mortality, which is comparable to traditional recruitment efficacy proportion, i.e. the number of per-
risk factors [19]. It has remained an issue of debate whether sons with participation in or appointment for the baseline
loneliness independently predicts mortality risk after adjust- examination divided by the sum of number of persons
ing for health status, health behavior, depression, and social with participation in or appointment for the baseline
isolation [20]. A recent meta-analysis of longitudinal data examination plus those with refusal and those who were
on 35,925 participants by Valtorta et al. [21] found a 29% not contactable [28]. Mean age was 54.9 (±11.1); 49.4%
increase for incident coronary heart disease and 32% for were female.
stroke in those with poor social relationships. This effect
was in the range of other recognized psychosocial risk fac- Materials and assessment
tors such as job strain. In the English Longitudinal Study of Cardiovascular risk factors and clinical variables, venous
Ageing (ELSA), Shankar et al. [22] found that loneliness blood samples, blood pressure, and anthropometric mea-
was associated with physical inactivity, smoking, and surements were ascertained in the course of the 5-h

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Beutel et al. BMC Psychiatry (2017) 17:97 Page 3 of 7

baseline-examination in the study center by certified the past 2 weeks, adding up to a sum score between 0
medical technical assistants according to standard oper- and 27 points. According to [25], caseness was defined
ating procedures. by a PHQ-8 sum score of ≥10, achieving a sensitivity of
88% and a specificity of 88% for major depression.
Measures and questionnaires Generalized anxiety was assessed with the two
All measures used in our analyses are displayed in Table screening items of the short form of the GAD-7
1, categorized in sociodemographic variables, health re- (Generalized Anxiety Disorder [GAD]-7 Scale; [26]).
lated variables, measures of distress, and loneliness. On the two screening items of the GAD-7, subjects
Loneliness was assessed by a single item “I am frequently rated “Feeling nervous, anxious or on edge” and “Not
alone /have few contacts” rated as 0 = no, does not apply, being able to stop or control worrying”. According to
1 = yes it applies, but I do not suffer from it, 2 = yes, it ap- [27], the sum score of the answers (0 = not at all,
plies, and I suffer slightly, 3 = yes, it applies, and I suffer 1 = several days, 2 = over half the days, and 3 = nearly
moderately, 4 = yes, it applies, and I suffer strongly. Loneli- every day) assesses generalized anxiety with good sen-
ness was recoded combining 0 and 1 = no loneliness or dis- sitivity (86%) and specificity (83%).
tress; 2 = slight, 3 = moderate, and 4 = severe loneliness. Following the study by Michal et al. [27], we measured
Mental health measures comprised depression, general- suicidal ideation by the item “In the last 2 weeks, have you
ized anxiety, panic, suicidality, depersonalization and Type had thoughts that you would be better off dead or of hurt-
D personality (also known as Distressed Personality). ing yourself in some way?” of the PHQ-9 (PHQ-9; [25, 28]).
The Patient Health Questionnaire (PHQ-8; 25), quan- Significant suicidal ideation was defined when suicidal idea-
tifies depression by the frequency of being bothered by tion was present for several days over the past two weeks
each of the 9 diagnostic criteria of major depression over or more (0 = not at all to 3 = nearly every day).

Table 1 Different degrees of subjective loneliness in a German representative sample: Sociodemographic characteristics, health
related variables, and distress
No Slight Moderate Severe p-value*
loneliness loneliness loneliness loneliness
N (%) 13,124 (89.5) 720 (4.9) 569 (3.9) 248 (1.7)
Sociodemographic variables
Age (years) 55.1 ± 11.1 53.4 ± 10.6 53.0 ± 11.0 53.1 ± 11.1 < 0.0001
Women 48.3 54.9 64.1 66.5 < 0.0001
Partnership 84.7 55.4 54.3 42.1 < 0.0001
Children 85.6 76.3 81.1 77.3 < 0.0001
Living alone 11.7 36.7 36.1 48.5 < 0.0001
Socioeconomic status 13.1 ± 4.4 12.4 ± 4.4 12.0 ± 4.4 11.4 ± 4.0 < 0.0001
Unemployment 38.7 36.1 40.5 45.5 n.s.
Health related variables
Smoker 18.5 26.1 27.4 31.8 < 0.0001
2
BMI (kg/m ) 27.3 ± 4.9 27.6 ± 5.6 27.1 ± 5.4 28.4 ± 6.5 n.s.
Alcohol gram/day 11.4 ± 16.7 10.3 ± 18.4 9.9 ± 17.8 8.5 ± 19.6 < 0.0001
Antidepressant 4.5 11.0 15.0 24.8 < 0.0001
Anxiolytic 0.8 2.3 1.6 3.3 < 0.0001
Visited physician past month 41.9 48.3 52.3 63.4 < 0.0001
Inpatient treatment past year 13.0 14.7 19.5 21.1 < 0.0001
Distress
Current depression (PHQ-8 ≥ 10) 5.2 19.3 30.5 52.6 < 0.0001
Generalized anxiety (GAD) > = 3 4.8 12.9 25.7 40.2 < 0.0001
Panic attack (past 4 weeks) 4.6 10.2 13.6 30.0 < 0.0001
Suicidal ideation 5.6 18.9 26.4 41.8 < 0.0001
Type D 20.5 46.5 54.7 55.1 <0.0001
Note: *chi2 or Kruskal Wallis test; numerical values with standard deviation are mean scores, values without standard deviation are percentages

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Beutel et al. BMC Psychiatry (2017) 17:97 Page 4 of 7

Panic was assessed by a single item “Did you have a panic those without loneliness. SES declined with increasing
attack in the last 4 weeks”. Response mode was dichotom- loneliness. No significant increases were found for previ-
ous: 0 = “no, does not apply”, 1 = “yes it applies” [29]. ous unemployment, although there was a descriptive
The German version of the Type-D or Distressed Per- trend of a positive link between feeling lonely and previ-
sonality scale (ds14; [30] )assesses a pattern consisting of ous unemployment.
significant negative affectivity (≥10) in conjunction with Concerning health behavior, the proportion of current
significant social inhibition (≥10) with 7 items each. smokers almost doubled with increasing loneliness.
Health behavior included smoking, which was dichoto- There was no association with BMI. The average alcohol
mized into non-smokers (never smoker and ex-smoker) consumption was negatively linked to loneliness. Regard-
and smokers (occasional smoker, i.e. cigarette/day, and ing health care utilization, there were strong increases in
smoker, i.e. cigarette/day). the intake of anxiolytics and antidepressants among
Health care utilization was also assessed according to lonely participants. The majority of participants (63%)
the number and kind of physicians visited in the past with a strong degree of loneliness had visited a physician
month and the number of inpatient treatments in the (vs. 42% with no feelings of loneliness), and 21% (vs.
past year. We further inquired the intake of antidepres- 13%) had had inpatient treatments. Regarding mental
sants and anxiolytics during the past month. Health care health, more than half of the loneliest participants were
utilization variables were recoded (yes/no). also depressed (vs. 5% in the group with feelings of lone-
liness), and over 40% in this group reported anxiety and
Computer-assisted personal interview suicidal ideation (which increased from 6% to 42%) and
During the computer-assisted personal interview (cf. [24]) 30% panic attacks in the past 4 weeks. Type D increased
participants were asked about their alcohol consumption. considerably with the degree of loneliness.
As defined by Lampert & Kroll, socioeconomic status Figure 1 presents the proportions of (at least slightly)
(SES) ranges from 3 (lowest) to 27 (highest SES). Add- lonely participants across the age range, separately for
itionally, the question “Do you live with your partner in a men and for women living with or without a partner at
household together?” (no/yes) was administered. the time the participants were interviewed.
Among those living with a partner, loneliness was
Statistical analysis much lower; few men (1.4 to 2.7%) reported feeling
We reported absolute numbers, percentages, or means lonely, whereas more than twice as many women re-
with standard deviations. Comparisons between groups ported feeling lonely (up to 5.9%). In contrast, about 10-
(no, slight, moderate and severe loneliness) were done 20% of the participants living alone indicated feeling
with Kruskal Wallis test or Chi2 tests. lonely. Women living alone in the age range 35-44 years
In order to investigate the association between loneli- (20.7% vs. 13.9%) and 55-64 years (19.3% vs. 11.6%) were
ness and depression (PHQ-8 ≥ 10), generalized anxiety considerably more affected by loneliness than men. In
(GAD-2 ≥ 3) and suicidal ideation, loneliness was used as the age range of 45-54 years (14.2% vs. 15.4%) and 65-
a predictor in multiple generalized linear models with a 74 years (10.7% vs. 10.6%), no significant gender differ-
binominal distribution and a log link function adjusted for ences were observed when participant lived alone.
sociodemographic variables. P-values are based on 2- Among those living alone, the highest proportion of
tailed tests. No adjustments for multiple testing were per- loneliness was found in the youngest group of women in
formed, as this was an exploratory study. Due to the large the range from 35 to 44 years (20.7%), whereas men
number of tests, we recommend to interpret p-values with tended to report heightened loneliness in the range from
caution taking effect estimates into account. Statistical 45 to 54 years (15.4%).
analyses were performed using SAS for Windows 9.4 TS Table 2 shows significant predictors of distress - separ-
Level 1 M1 (SAS Institute Inc.) Cary, NC, USA. ately for depression, anxiety, and suicidal ideation. In
addition to loneliness, age, gender, partnership, socioeco-
Results nomic status, generalized anxiety, panic attacks, and de-
Table 1 compares participants with different degrees of pression were included as predictors in each regression
loneliness based on sociodemographic features, health model. Loneliness as one of the predictors of the first re-
related variables, and distress. A total of 10.5% reported gression model almost doubled the likelihood of depres-
some degree of loneliness: 4.9% were slightly, 3.9% mod- sion (OR = 1.91). As we expected, generalized anxiety and
erately and 1.7% severely distressed by feeling lonely. panic attacks were highly associated with depression, too.
Overall, mean age of lonely participants was lower. Additional factors contributing to a strong overall predic-
Loneliness was more frequent in women, in participants tion (c = .90) were lower age and SES. Similarly, loneliness
without a partner or without children. Almost four times also positively predicted anxiety (OR = 1.21), in addition
as many lonely participants lived alone compared to to lower age, SES, female gender, increased panic attacks,

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Beutel et al. BMC Psychiatry (2017) 17:97 Page 5 of 7

Fig. 1 Loneliness across the age range in a German representative sample: men and women living alone or living with partner

and depression. Prediction of suicidal ideation by loneli- Living alone was an important determinant of loneliness in
ness was also substantial (OR = 1.35) in addition to higher men and women. However, the relationship between loneli-
age, lower SES, generalized anxiety, panic and depression ness, gender and living alone appeared to be complex. Simi-
(overall model, c = .87). lar to previous findings [10] different patterns of loneliness
were observed with regard to age and gender. On the one
Discussion hand, younger women (below 45 years of age) living with-
In a large community sample covering middle to late adult- out a partner were more affected by loneliness than men.
hood (35 to 74 years), we found that one in 10 (10.5%) par- On the other hand, middle-aged men (between 45 and
ticipants reported some degree of loneliness. As in previous 64 years) were slightly more affected than women. Living
studies e.g. ([7, 8]), loneliness declined with age. Loneliness without a partner had a stronger impact on younger
was more frequent in women, in participants without a women and middle-aged men. Finally, in the oldest age
partnership, without children and in those living alone. So- group from 65 to 74 years, loneliness declined and no
cioeconomic status declined with increasing loneliness. longer differed between men and women living alone.

Table 2 Prediction of depression, suicidal ideation, and anxiety in a German representative sample by loneliness controlling for
demographic variables and other sources of distress (N = 15,010)
Depression (PHQ-8) Anxiety (GAD-2) Suicidal ideation
Variables OR 95% CI p-value OR 95% CI p-value OR 95% CI p-value
Loneliness 1.91 1.74-2.09 < 0.0001 1.21 1.09-1.34 0.0002 1.31 1.19-1.44 <0.0001
Age 0.99 0.98-0.99 0.0004 0.98 0.98-0.99 0.0002 1.03 1.02-1.03 <0.0001
Women 0.94 0.80-1.10 0.4209 1.25 1.06-1.49 0.01 0.92 0.79-1.08 0.3127
Partnership 0.92 0.76-1.11 0.3731 1.02 0.83-1.25 0.8771 0.80 0.67-0.95 0.0117
Socioeconomic status 0.94 0.92-0.96 < 0.0001 0.97 0.97-0.98 0.0043 0.96 0.95-0.98 0.0001
Generalized anxiety 2.91 2.73-3.11 < 0.0001 - 1.30 1.21-1.39 <.0001
Panic attack 2.98 2.42-3.67 < 0.0001 2.69 2.17-3.34 < 0.0001 1.49 1.19-1.86 0.0005
depression - 1.46 1.42-1.49 < 0.0001 1.29 1.26-1.32 < 0.0001
c-statistic 0.90 0.91 0.87
Note: OR Odds ratio, 95% CI = 95% confidence interval

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Beutel et al. BMC Psychiatry (2017) 17:97 Page 6 of 7

Interestingly, when living with someone, loneliness was yet. As we did not directly assess the size and quality of
comparatively low. However, about twice as many women social networks, we cannot estimate the effect of social
in partnerships (up to 5.9%) reported feeling lonely in com- isolation in our study which is a confounding variable
parison to men (1.4% to 2.7%). Additionally, our data show when investigating loneliness. In line with previous find-
that living with a partner is linked to loneliness in almost ings [34, 35] our data suggests that younger age groups
all men and to a slightly lesser extent in women. It might are more affected by loneliness. Thus, the investigation
alternatively reflect a reporting bias such as men are less of the prevalence of loneliness and its impact on mental
likely to admit to being lonely [31]. health in individuals under 35 years old would be desir-
Feeling lonely was associated with distress: More than able. While our findings may be taken as indicative for
half of the loneliest participants were also depressed (vs. the validity of our measure of loneliness, we concede
5% in the group without loneliness). Generalized anxiety, that we only used a single item to measure loneliness.
panic attacks and suicidality were strongly associated with The results of our study, which are overall in line with
loneliness, suicidal ideation increased dramatically from findings in research on loneliness using comprehensive
6% to 42%. There was also a large increase of Type D be- questionnaires, indicate a first step of the external valid-
havior pattern. This may be due to the previously de- ity of a 1-item-measure of loneliness as reasonable alter-
scribed relationship deficits in lonely persons and their native to loneliness scales, especially for large-scale
tendency to experience negative affect [14]. Loneliness surveys. Future studies will have to prove other aspects
remained a clear predictor for depression [17], anxiety of validity of this measure by directly comparing it with
and suicidal ideation when we took into account demo- other loneliness scales.
graphic variables and other types of mental distress; odds
ratios for depression were 1.9; for suicidal ideation and Conclusions
generalized anxiety, 1.35 and 1.21, respectively. I.e., there Our findings support the view that loneliness poses a
was still a 31% increase in suicidality when taking the significant health problem for a sizeable part of the
major demographic and mental health predictors (depres- population with increased risks in terms of distress (de-
sion and anxiety) into account. The association between pression, anxiety), suicidal ideation, health behavior and
loneliness and suicidality supports the theory [32] that health care utilization.
thwarted belongingness and perceived burdensomeness
are major determinants of suicidality (see also [33]). Acknowledgement
Regarding health care behavior, the majority of partici- We express our gratitude to the study participants and staff of the Gutenberg
Health Study.
pants (63%) with a strong degree of loneliness had vis-
ited a physician (vs. 42% without loneliness), and 21% Funding
had had inpatient treatments. The Gutenberg Health Study is funded through the government of
Overall, our findings support the view that loneliness Rhineland-Palatinate („Stiftung Rheinland-Pfalz für Innovation“, contract AZ
961-386261/733), the research programs “Wissen schafft Zukunft” and “Center
poses significant health risks in terms of reduced mental for Translational Vascular Biology (CTVB)” of the Johannes Gutenberg-
health (depression, anxiety) and increased suicidal idea- University of Mainz, and its contract with Boehringer Ingelheim and PHILIPS
tion [10, 21]. Loneliness also contributed to smoking as Medical Systems, including an unrestricted grant for the Gutenberg Health
Study. The funders had no role in study design, data collection and analysis,
an indicator for an unhealthy lifestyle, but not to other decision to publish, or preparation of the manuscript.
risk factors such as alcohol use or diet (BMI). More
physician visits, inpatient treatments, and intake of psy- Availability of data and materials
chotropic medication may be due to subjects` reduced For approved reasons, some access restrictions apply to the data underlying
these findings. Data sets contain identifying participant information, which is
mental health. Taken together, these findings support not suitable for public deposition. Access to the local database is available
the view that loneliness should be regarded and inquired upon request to the corresponding author.
about as a relevant health [14] variable on its own.
Strengths of this study reside in the large sample size Authors’ contributions
All authors have made substantial contributions to this work, and they have
and the use of standardized self-report instruments to been involved in drafting or revising the manuscript. They have read and
measure distress. Interpretation of our findings is limited approved the final manuscript. Conceived and designed the studies: MEB
by the cross-sectional character of our study which does ANT EMK EB IR CJ MM JW PW TM KL. Performed the studies: MEB PW KL.
Analyzed the data: CJ ANT EMK. Contributed materials, respectively analysis
not permit causal conclusions. Loneliness may contrib- tools: MEB ANT EMK EB IR CJ MM JW PW TM KL. Wrote the paper: MEB ANT
ute to distress and suicidality, however, depressive and EMK EB IR CJ MM JW PW TM KL.
anxiety disorders may lead individuals to refrain from
social contact out of inhibition and fear. This question Competing interests
The authors declare that they have no competing interests.
of causality has been addressed for depression in a longi-
tudinal study [17] indicating a reciprocal relationship. Consent for publication
No similar studies are available for anxiety disorders, Not applicable.

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Beutel et al. BMC Psychiatry (2017) 17:97 Page 7 of 7

Ethics approval and consent to participate angiotensin–aldosterone-system (RAAS). Psychoneuroendocrinology. 2012;

The GHS and its procedure, including the present analyses, were approved by 37(2):230–7.
the ethics committee of the Statutory Medical Board of Rhineland-Palatinate, 17. Cacioppo JT, Hughes ME, Waite LJ, Thisted RA. Loneliness as a Specific Risk
Germany (reference no. 837.020.07; original vote: 22.3.2007, latest update: Factor for Depressive Symptoms: Cross-Sectional and Longitudinal Analyses.
20.10.2015). Participation was voluntary and written informed consent was Psychol Aging. 2006;21(1):140–51.
obtained from each subject upon entry into the study. 18. Cacioppo JT, Hawkley LC, Ernst JM, Burleson M, Berntson GG. Nouriani. Loneliness
within a nomological net: An evolutionary perspective Journal of Research in
Personality. 2006;40:1054–85.
Publisher’s Note 19. Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: a
Springer Nature remains neutral with regard to jurisdictional claims in meta-analytic review. PLoS Med. 2010;7(7):e1000316.
published maps and institutional affiliations. 20. Ong AD, Uchino BN, Wethington E. Loneliness and Health in Older Adults:
A Mini-Review and Synthesis Gerontology. 2016;62:443–9.
Author details 21. Valtorta NK, Kanaan M, Gilbody S, Ronzi S, Hanratty B. Loneliness and social
1
Department of Psychosomatic Medicine and Psychotherapy, University isolation as risk factors for coronary heart disease and stroke: systematic
Medical Center of the Johannes Gutenberg University Mainz, Zahlbacher Str. review and meta-analysis of longitudinal observational studies. Heart. 2016;
8, D-55131 Mainz, Germany. 2Center for Cardiology, Cardiology I, University 102(13):1009–16. heartjnl-2015-308790.
Medical Center of the Johannes Gutenberg University, Mainz, Germany. 22. Shankar A, McMunn A, Banks J, Steptoe A. Health Psychology. Loneliness,
3
Preventive Cardiology and Preventive Medicine, Center for Cardiology, social isolation, and behavioral and biological health indicators in older
University Medical Center of the Johannes Gutenberg University, Mainz, adults. 2011;30(4):377-85.
Germany. 4Center for Thrombosis and Hemostasis, University Medical Center 23. Gerst-Emerson K, Jayawardhana J. Loneliness as a Public Health Issue: The
of the Johannes Gutenberg University, Mainz, Germany. 5German Center for Impact of Loneliness on Health Care Utilization Among Older Adults. Am J
Cardiovascular Research (DZHK), partner site Rhine Main, Mainz, Germany. Public Health. 2015;105(5):1013–9.
6
Institute for Clinical Chemistry and Laboratory Medicine, University Medical 24. Wild PS, Zeller T, Beutel M, Blettner M, Dugi KA, Lackner KJ, et al. Die
Center of the Johannes Gutenberg University, Mainz, Germany. Gutenberg Gesundheitsstudie. Bundesgesundheitsbl Gesundheitsforsch
Gesundheitsschutz. 2012;55(6):824–30.
Received: 12 November 2016 Accepted: 9 March 2017 25. Löwe B, Kroenke K, Herzog W, Gräfe K. Measuring depression outcome with
a brief self-report instrument: sensitivity to change of the Patient Health
Questionnaire (PHQ-9). J Affect Disord. 2004;81(1):61–6.
References 26. Löwe B, Decker O, Müller S, Brähler E, Schellberg D, Herzog W, et al.
1. Hughes ME, Waite LJ, Hawkley LC, Cacioppo JT. A short scale for measuring Validation and standardization of the Generalized Anxiety Disorder Screener
loneliness in large surveys results from two population-based studies. (GAD-7) in the general population. Med Care. 2008;46(3):266–74.
Research on aging. 2004;26(6):655–72. 27. Michal M, Wiltink J, Till Y, Wild PS, Münzel T, Blankenberg S, et al. Type-D
2. Baumeister RF, Leary MR. The need to belong: desire for interpersonal personality and depersonalization are associated with suicidal ideation in
attachments as a fundamental human motivation. Psychol Bull. 1995;117(3):497. the German general population aged 35–74: results from the Gutenberg
3. Mushtaq R, Shoib S, Shah T, Mushtaq S. Relationship between loneliness, Heart Study. J Affect Disord. 2010;125(1):227–33.
psychiatric disorders and physical health? A review on the psychological 28. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version
aspects of loneliness. Journal of clinical and diagnostic research: JCDR. 2014; of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental
8(9):WE01. Disorders. Patient Health Questionnaire. JAMA. 1999;282(18):1737–44.
4. Hawkley LC, Capitanio JP. Perceived social isolation, evolutionary fitness and 29. Löwe B, Gräfe K, Zipfel S, Spitzer RL, Herrmann-Lingen C, Witte S, et al.
health outcomes: a lifespan approach. Phil Trans R Soc B. 2015;370(1669): Detecting panic disorder in medical and psychosomatic outpatients:
20140114. comparative validation of the Hospital Anxiety and Depression Scale, the
5. Weiss RS. Reflections on the present state of loneliness research. Journal of Patient Health Questionnaire, a screening question, and physicians'
Social Behavior and Personality. 1987;2(2):1–16. diagnosis. J Psychosom Res. 2003;55(6):515–9.
6. Luhmann M, Hawkley LC. Age Differences in Loneliness From Late 30. Denollet J. DS14: standard assessment of negative affectivity, social
Adolescence to Oldest Old Age. Dev Psychol. 2016;62(6):943–59. inhibition, and Type D personality. Psychosom Med. 2005;67(1):89–97.
7. Hawkley LC, Cacioppo JT. Loneliness Matters: A Theoretical and Empirical 31. Borys S, Perlman D. Gender Differences in Loneliness Personality and Social
Review of Consequences and Mechanisms. Ann Behav Med. 2010;40(2):218–27. Psychology Bulletin. 1985;11(1):63–74.
8. Tesch-Römer C, Wiest M, Wurm S, Huxhold O. Einsamkeittrends in der 32. Joiner TE. Why people die by suicide. Cambridge: Harvard University Press; 2005.
zweiten Lebenshälfte. Z Gerontol Geriatr. 2013;46(3):237–41. 33. Gallagher M, Prinstein MJ, Simon V, Spirito A. Social anxiety symptoms and
9. Adam EK, Chyu L, Hoyt LT, Doane LD, Boisjoly J, Duncan GJ, et al. Adverse suicidal ideation in a clinical sample of early adolescents: examining
adolescent relationship histories and young adult health: cumulative effects loneliness and social support as longitudinal mediators. J Abnorm Child
of loneliness, low parental support, relationship instability, intimate partner Psychol. 2014;42(6):871–83.
violence, and loss. The Journal of adolescent health : official publication of 34. Vanhalst J, Goossens L, Luyckx K, Scholte RH, Engels RC. The development
the Society for Adolescent Medicine. 2011;49(3):278–86. of loneliness from mid- to late adolescence: trajectory classes, personality
10. Zebhauser A, Hofmann-Xu L, Baumert J, Häfner S, Lacruz M, Emeny R, et al. traits, and psychosocial functioning. J Adolesc. 2013;36(6):1305–12.
How much does it hurt to be lonely? Mental and physical differences 35. Marcoen A, Goossens L, Caes P. Lonelines in pre-through late adolescence:
between older men and women in the KORA-Age Study. International Exploring the contributions of a multidimensional approach. Journal of Youth
journal of geriatric psychiatry. 2014;29(3):245–52. and Adolescence. 1987;16(6):561–77.
11. Russell D, Peplau LA, Cutrona CE. The revised UCLA Loneliness Scale:
Concurrent and discriminant validity evidence. J Pers Soc Psychol. 1980;
39(3):472–80.
12. de Jong Gierveld J, van Tilburg T. Manual of the Loneliness Scale. VU
University Amsterdam, Department of Social Research Methodology1999.
13. Victor CR, Yang K. The prevalence of loneliness among adults: a case study
of the United Kingdom. The Journal of psychology. 2012;146(1-2):85–104.
14. Heinrich L, Gullone E. The clinical significance of loneliness: A literature
review. Clin Psychol Rev. 2006;26:695–718.
15. Friedler B, Crapser J, McCullough L. One is the deadliest number: the
detrimental effects of social isolation on cerebrovascular diseases and
cognition. Acta Neuropathol. 2015;129(4):493–509.
16. Häfner S, Baumert J, Emeny R, Lacruz M, Bidlingmaier M, Reincke M, et al. To
live alone and to be depressed, an alarming combination for the renin–

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:

1. use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
2. use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
3. falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
4. use bots or other automated methods to access the content or redirect messages
5. override any security feature or exclusionary protocol; or
6. share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at

onlineservice@springernature.com