MEDICINE, SCIENCE AND SOCIETY
A Friend, Not an Apple, A Day Will Help Keep the Doctor Away LEON
EISENBERG,
I yield to no we/man in my fondness for apples. Nor do I lightly threaten the fabric of American society by casting doubt upon its folk wisdom. Yet a proper respect for the truth demands the acknowledgement that, however firm the belief, we still lack convincing proof that apples diminish the need for medical care. It is all the more remarkable, then, to discover that friends may do what apples cannot. “Discover” is not quite the right word. Most experienced clinicians are familiar with the lonely and unhappy patient who frequents the office with functional complaints; with the accelerated aging of the widow or widower whose children do not visit: and with the breakdown in health that too often accompanies retirement and withdrawal from lifelong social networks. Yet few physicians have been willing to take seriously what many would insist they knew all along, once confronted by the evidence. What is new is the cumulative impact of systematic studies which document a relationship between social isolation and illness. The point of this sermon, thinly disguised as an editorial, is to review a few of those studies as a consciousnessraising exercise; I contend that assessing social interconnectedness is essential to accurate medical diagnosis and effective treatment. The British sociologist, George W. Brown, and his colleagues, in an epidemiologic study of psychiatric disturbance among women in London [l], found that having an intimate and confiding [but not necessarily sexual) relationship with a husband or boyfriend reduced the likelihood of depressive symptoms in the presence of life stress ordinarily provocative of such symptoms. However, other less intense friendship patterns did not seem to yield a similar protective effect against depression. Extending this finding, Miller and Ingham [z] surveyed 337 subjects sampled from the list of one general
M.D.
practice in an urban residential area of Edinburgh. Members of the patient panel, half chosen because they had just consulted their doctor and half drawn from a group who had not been seen for at least three months, were asked about symptoms and about friendship patterns. The nine symptoms selected for inquiry were categorized as psychologic [tiredness, anxiety, depression and irritability] or physical (backache, headache, palpitations, dizziness and breathlessness). At the same interview, the subjects were asked whether they had a confidant (someone they could in full trust discuss serious personal matters with) and whether they had acquaintances in the neighborhood and at the workplace. Although mean symptom levels in current patients were higher than in nonattenders, the trends within both samples were similar (so similar, in fact, as to raise interesting questions about the transition to patienthood). The major finding was that, for the women, having a confidant and having friends were associated with significantly lower psychologic and physical symptom levels. For the men, the trends were in the same direction: only a few reached statistical significance, perhaps because of the smaller number: two thirds of the sample were women. In an Australian study by Henderson et al. [3] of a random sample (142 subjects) of the general population of Canberra, both psychiatric morbidity and social interactions were assessed by standardized interview schedules. A strong inverse relationship was found between social bonds and the presence of neurotic symptoms-sufficiently strong that 47 per cent of the variance in the General Health Questionnaire (GHQ] score was explained by the factors derived from the measure of social bonds. In an extension of this study to a much larger sample (753 subjects), Henderson and his colleagues [4] identified main effects on GHQ scores significant at the 0.001 level for both social bonding and
Dr. kkenberg is Maude and Lilfiun Presley Professor oj Psychiutry ot the He is the author of many.papers on child development. psychophurmacology With Professor Arthur Kleinmun of the Ilniversity of Wushington, he is “‘l’he Relevance of Sociul Science for Medicine” to be published by Reidel quests for reprints should be addressed to Dr. Leon f&enberg. Children’s .NU 1,ongwood Avenue, Boston. Mussuchusetts 02115.
April 1676
I furvurd Medicof School. und sociul psychiutry. editing u volume entitled in the winter of 1979. ReI fospital Medico1 Center,
The American Journal of Medicine
Volume 66
551
MEDICINE, SCIENCE AND SOCIETY-EISENBERG
life stress; that is, the greater the life stress, the higher the symptom score; the closer the social bonds, the lower the symptom score. When the level of adversity (as measured by life events] is held constant, there is a statistically significant decline in GHQ score with increasing levels of social bonds. Henderson’s Social Psychiatry Research Unit has also contrasted 50 nonpsychotic psychiatric patients with 50 matched controls on the size and utilization of each individual’s “primary group” (those with whom one has interaction and commitment). Patients had fewer good friends and fewer contacts with persons outside the household: they believed that they had received insufficient support from those who meant the most to them. Thus far, I have summarized recent evidence demonstrating an association between relative social isolation and increase in psychiatric morbidity. Some may be tempted to respond: “So, what’s new? What else would you expect from neurotics? Didn’t Groucho Marx tell us all we needed to know a long time ago with the aphorism: ‘I wouldn’t join a club that would have me as a member!’ Besides, what does all this have to do with real disease?” I have discussed elsewhere, and will not repeat here, just what is “real” in disease and illness [5]. Suffice it to note that, by conservative estimate, psychiatric disorders account for no less than one in seven patients in a general practice; moreover, they occur at a higher rate in patients with concomitant physical illness. Perhaps more persuasive to sceptics will be the evidence that what is true for psychiatric morbidity is also so for mortality from other diseases; namely, higher rates among the socially isolated. Berkman and Syme [6] have reported the findings of a nine year mortality follow-up study on 4,726 adults between the ages of 30 and 69 years in Alameda County, California. At the time of the initial enrollment of subjects in 1965, data were collected on self-reported health status, socioeconomic status, health practices (such as smoking, obesity, alcohol consumption and the health practice index of Belloc and Breslow) and health services. At the same time, study subjects were asked in detail about four sources of social contact: marriage, contacts with close friends and relatives, church membership, and informal and formal group associations. Age- and sex-specific mortality rates over the nine year period demonstrated a significantly lower mortality for subjects reporting each of these social ties. Relative risks for those with the fewest social contacts, when compared with those with the most social contacts, were 2.3 for men and 2.8 for women! The association between social disconnectedness and mortality persisted after taking into account initial health status, social class, health practices and utilization of health services, although each of those factors in turn influenced mortality. A composite social network index correlated negatively
552
April 1979
The American Journal of Medicine
not only with over-all mortality but also with four separate causes of death: ischemic heart disease, cancer, cerebrovascular and circulatory diseases. There is by now a very considerable literature on the effects of stressful life circumstances on morbidity, both psychiatric and nonpsychiatric, and on mortality [7] although methodologic issues continue to be controversial [8,9]. The evidence, reviewed here, that social bonding increases host resistance adds further support to the concept that the social environment is an important determinant of health status. The precise mechanisms remain to be identified. Candidate physiologic pathways include neural, hormonal and immunologic control systems; psychologically, both social stress and social support influence coping behavior, how change is assessed and the strategies of adaptive response to it
[lOI. Despite the uncertainty of the intervening mechanisms, it would seem prudent for the physician to inquire about a patient’s social bonds as part of a comprehensive diagnostic assessment in order to design a treatment plan responsive to the patient’s needs. There are, of course, no pharmacies available to fill a prescription for “spouses, confidants and friends, p.r.n.” but the physician is himself or herself one source of social support, And physicians can serve to link patients with community agencies and mutual help groups, and can encourage them to affiliate with church and social organizations which match their interests. Some patients lack friends because they lack the social skills needed to make and keep them; group therapy may be helpful in this regard. Some are isolated because of the disintegration of the community; the physician must be an advocate for better community ‘services. Difficult as remedy may be, the point remains that social isolation is in itself a pathogenic factor in disease production. Mechanisms of social bonding are as ancient as the evolution of our species; their disruption has devastating impact. Good friends are an essential ingredient for good health. As to apples, well, let them be, for:
Volume 66
“When Newton saw an apple fall, he found A mode of proving that the earth turn’d round In a most natural whirl, called ‘gravitation;’ And thus is the sole mortal who could rapple, Since Adam, with a fall or with an app9e.” (Ryron: Don Juan X, i) REFERENCES Brown GW, Bhrolchain MN, Harris T: Social class and psychiatric disturbance among women in an urban population, Sociology 9: 225, 1975. Miller PMcC, Ingham JG: Friends, confidants and symptoms. Sot Psychiat 11: 51.1976. Henderson S, Byrne DG, Duncan-Jones P, et al: Social bonds in the epidemiology of neurosis: a preliminary communication. Br J Psychiat 132:463,1978.
~lEI)ICINE. SCIENCE AND SOCIETY-EISENBERG
4. Henderson S, Duncan-Jones P, Byrne DG, et al.: Social bonds, adversity and neurosis. Presented at the World Psychiatric Association Section Committee on Epidemiology and Community Psychiatry, Triennial Meeting, St. Louis, October 18-20,1978. To be published. 5. Eisenberg L: Disease and illness: distinctions between professional and popular ideas of sickness. Culture, Med Psychiat 1: 9.1977. 6. Berkman LF, Syme SL: Social networks, host resistance, and mortality: a nine year follow-up of Alameda County residents. Am J Epidemiol (in press]. 7. Klerman GL, Izen JE: The effects of bereavement and grief
on physical health and general well-being. Adv Psychosom Med 9: 63 1977. 8. Tennant C, Bebbington P: The social causation of depression: a critique of the work of Brown and his colleagues. Psycho1 Med 8: 565.1978. 9. Brown GW, Harris T: Social origins of depression: a reply. Psycho1 Med 8: 577,1978. 10. Hamburg DA, Adams JE, Brodie HKH: Coping behavior in stressful circumstances: some implications for social psychiatry. Further Explorations in Social Psychiatry [Kaplan BH. Wilson RN, Leighton AH, eds], New York, Basic Books, 1976. p 158.
April 1979 The American Journal of Medicine
Volume 66
553
A Friend, Not an Apple, A Day Will Help Keep the Doctor Away LEON
EISENBERG,
I yield to no we/man in my fondness for apples. Nor do I lightly threaten the fabric of American society by casting doubt upon its folk wisdom. Yet a proper respect for the truth demands the acknowledgement that, however firm the belief, we still lack convincing proof that apples diminish the need for medical care. It is all the more remarkable, then, to discover that friends may do what apples cannot. “Discover” is not quite the right word. Most experienced clinicians are familiar with the lonely and unhappy patient who frequents the office with functional complaints; with the accelerated aging of the widow or widower whose children do not visit: and with the breakdown in health that too often accompanies retirement and withdrawal from lifelong social networks. Yet few physicians have been willing to take seriously what many would insist they knew all along, once confronted by the evidence. What is new is the cumulative impact of systematic studies which document a relationship between social isolation and illness. The point of this sermon, thinly disguised as an editorial, is to review a few of those studies as a consciousnessraising exercise; I contend that assessing social interconnectedness is essential to accurate medical diagnosis and effective treatment. The British sociologist, George W. Brown, and his colleagues, in an epidemiologic study of psychiatric disturbance among women in London [l], found that having an intimate and confiding [but not necessarily sexual) relationship with a husband or boyfriend reduced the likelihood of depressive symptoms in the presence of life stress ordinarily provocative of such symptoms. However, other less intense friendship patterns did not seem to yield a similar protective effect against depression. Extending this finding, Miller and Ingham [z] surveyed 337 subjects sampled from the list of one general
M.D.
practice in an urban residential area of Edinburgh. Members of the patient panel, half chosen because they had just consulted their doctor and half drawn from a group who had not been seen for at least three months, were asked about symptoms and about friendship patterns. The nine symptoms selected for inquiry were categorized as psychologic [tiredness, anxiety, depression and irritability] or physical (backache, headache, palpitations, dizziness and breathlessness). At the same interview, the subjects were asked whether they had a confidant (someone they could in full trust discuss serious personal matters with) and whether they had acquaintances in the neighborhood and at the workplace. Although mean symptom levels in current patients were higher than in nonattenders, the trends within both samples were similar (so similar, in fact, as to raise interesting questions about the transition to patienthood). The major finding was that, for the women, having a confidant and having friends were associated with significantly lower psychologic and physical symptom levels. For the men, the trends were in the same direction: only a few reached statistical significance, perhaps because of the smaller number: two thirds of the sample were women. In an Australian study by Henderson et al. [3] of a random sample (142 subjects) of the general population of Canberra, both psychiatric morbidity and social interactions were assessed by standardized interview schedules. A strong inverse relationship was found between social bonds and the presence of neurotic symptoms-sufficiently strong that 47 per cent of the variance in the General Health Questionnaire (GHQ] score was explained by the factors derived from the measure of social bonds. In an extension of this study to a much larger sample (753 subjects), Henderson and his colleagues [4] identified main effects on GHQ scores significant at the 0.001 level for both social bonding and
Dr. kkenberg is Maude and Lilfiun Presley Professor oj Psychiutry ot the He is the author of many.papers on child development. psychophurmacology With Professor Arthur Kleinmun of the Ilniversity of Wushington, he is “‘l’he Relevance of Sociul Science for Medicine” to be published by Reidel quests for reprints should be addressed to Dr. Leon f&enberg. Children’s .NU 1,ongwood Avenue, Boston. Mussuchusetts 02115.
April 1676
I furvurd Medicof School. und sociul psychiutry. editing u volume entitled in the winter of 1979. ReI fospital Medico1 Center,
The American Journal of Medicine
Volume 66
551
MEDICINE, SCIENCE AND SOCIETY-EISENBERG
life stress; that is, the greater the life stress, the higher the symptom score; the closer the social bonds, the lower the symptom score. When the level of adversity (as measured by life events] is held constant, there is a statistically significant decline in GHQ score with increasing levels of social bonds. Henderson’s Social Psychiatry Research Unit has also contrasted 50 nonpsychotic psychiatric patients with 50 matched controls on the size and utilization of each individual’s “primary group” (those with whom one has interaction and commitment). Patients had fewer good friends and fewer contacts with persons outside the household: they believed that they had received insufficient support from those who meant the most to them. Thus far, I have summarized recent evidence demonstrating an association between relative social isolation and increase in psychiatric morbidity. Some may be tempted to respond: “So, what’s new? What else would you expect from neurotics? Didn’t Groucho Marx tell us all we needed to know a long time ago with the aphorism: ‘I wouldn’t join a club that would have me as a member!’ Besides, what does all this have to do with real disease?” I have discussed elsewhere, and will not repeat here, just what is “real” in disease and illness [5]. Suffice it to note that, by conservative estimate, psychiatric disorders account for no less than one in seven patients in a general practice; moreover, they occur at a higher rate in patients with concomitant physical illness. Perhaps more persuasive to sceptics will be the evidence that what is true for psychiatric morbidity is also so for mortality from other diseases; namely, higher rates among the socially isolated. Berkman and Syme [6] have reported the findings of a nine year mortality follow-up study on 4,726 adults between the ages of 30 and 69 years in Alameda County, California. At the time of the initial enrollment of subjects in 1965, data were collected on self-reported health status, socioeconomic status, health practices (such as smoking, obesity, alcohol consumption and the health practice index of Belloc and Breslow) and health services. At the same time, study subjects were asked in detail about four sources of social contact: marriage, contacts with close friends and relatives, church membership, and informal and formal group associations. Age- and sex-specific mortality rates over the nine year period demonstrated a significantly lower mortality for subjects reporting each of these social ties. Relative risks for those with the fewest social contacts, when compared with those with the most social contacts, were 2.3 for men and 2.8 for women! The association between social disconnectedness and mortality persisted after taking into account initial health status, social class, health practices and utilization of health services, although each of those factors in turn influenced mortality. A composite social network index correlated negatively
552
April 1979
The American Journal of Medicine
not only with over-all mortality but also with four separate causes of death: ischemic heart disease, cancer, cerebrovascular and circulatory diseases. There is by now a very considerable literature on the effects of stressful life circumstances on morbidity, both psychiatric and nonpsychiatric, and on mortality [7] although methodologic issues continue to be controversial [8,9]. The evidence, reviewed here, that social bonding increases host resistance adds further support to the concept that the social environment is an important determinant of health status. The precise mechanisms remain to be identified. Candidate physiologic pathways include neural, hormonal and immunologic control systems; psychologically, both social stress and social support influence coping behavior, how change is assessed and the strategies of adaptive response to it
[lOI. Despite the uncertainty of the intervening mechanisms, it would seem prudent for the physician to inquire about a patient’s social bonds as part of a comprehensive diagnostic assessment in order to design a treatment plan responsive to the patient’s needs. There are, of course, no pharmacies available to fill a prescription for “spouses, confidants and friends, p.r.n.” but the physician is himself or herself one source of social support, And physicians can serve to link patients with community agencies and mutual help groups, and can encourage them to affiliate with church and social organizations which match their interests. Some patients lack friends because they lack the social skills needed to make and keep them; group therapy may be helpful in this regard. Some are isolated because of the disintegration of the community; the physician must be an advocate for better community ‘services. Difficult as remedy may be, the point remains that social isolation is in itself a pathogenic factor in disease production. Mechanisms of social bonding are as ancient as the evolution of our species; their disruption has devastating impact. Good friends are an essential ingredient for good health. As to apples, well, let them be, for:
Volume 66
“When Newton saw an apple fall, he found A mode of proving that the earth turn’d round In a most natural whirl, called ‘gravitation;’ And thus is the sole mortal who could rapple, Since Adam, with a fall or with an app9e.” (Ryron: Don Juan X, i) REFERENCES Brown GW, Bhrolchain MN, Harris T: Social class and psychiatric disturbance among women in an urban population, Sociology 9: 225, 1975. Miller PMcC, Ingham JG: Friends, confidants and symptoms. Sot Psychiat 11: 51.1976. Henderson S, Byrne DG, Duncan-Jones P, et al: Social bonds in the epidemiology of neurosis: a preliminary communication. Br J Psychiat 132:463,1978.
~lEI)ICINE. SCIENCE AND SOCIETY-EISENBERG
4. Henderson S, Duncan-Jones P, Byrne DG, et al.: Social bonds, adversity and neurosis. Presented at the World Psychiatric Association Section Committee on Epidemiology and Community Psychiatry, Triennial Meeting, St. Louis, October 18-20,1978. To be published. 5. Eisenberg L: Disease and illness: distinctions between professional and popular ideas of sickness. Culture, Med Psychiat 1: 9.1977. 6. Berkman LF, Syme SL: Social networks, host resistance, and mortality: a nine year follow-up of Alameda County residents. Am J Epidemiol (in press]. 7. Klerman GL, Izen JE: The effects of bereavement and grief
on physical health and general well-being. Adv Psychosom Med 9: 63 1977. 8. Tennant C, Bebbington P: The social causation of depression: a critique of the work of Brown and his colleagues. Psycho1 Med 8: 565.1978. 9. Brown GW, Harris T: Social origins of depression: a reply. Psycho1 Med 8: 577,1978. 10. Hamburg DA, Adams JE, Brodie HKH: Coping behavior in stressful circumstances: some implications for social psychiatry. Further Explorations in Social Psychiatry [Kaplan BH. Wilson RN, Leighton AH, eds], New York, Basic Books, 1976. p 158.
April 1979 The American Journal of Medicine
Volume 66
553
