|Year : 2021 | Volume
| Issue : 2 | Page : 63-69
Loneliness in older people: Spiritual practices as an alternative pathway to action, a treatise from India
Consultant Geriatric Psychiatrist, Kolkata, India, International Psychogeriatric Association, Kolkata, India
|Date of Submission||16-Sep-2021|
|Date of Decision||25-Oct-2021|
|Date of Acceptance||11-Nov-2021|
|Date of Web Publication||31-Jan-2022|
Dr. Debanjan Banerjee
Department of Psychiatry, Geriatric Psychiatry Unit, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Loneliness is an abstract construct defined in multiple ways. It is a feeling of disconnectedness, emotional isolation, and subjective feeling of lacking social relationships. Research shows loneliness to be common in older people, which, in turn, is a potent risk factor for various physical and psychosocial health conditions. Chronic loneliness is a predisposing factor for suicide, worsens cognitive outcomes, and impairs quality of living. Conventionally, aging is associated with “loss of vitality” and the “desperate need to retain older abilities.” In contrast to these concepts, eastern views center around acceptance, “letting go” and aging with a greater sense of purpose. Traversing loneliness with self-esteem is viewed over a consistent resistance against loneliness. Self-acceptance, wisdom, and understanding the processes of emotional aging can foster hope and resilience which help navigate the inevitable loneliness that may arise in old age due to a multitude of factors. Spirituality has various intersections with mental well-being, however, it is often considered to be an esoteric concept. In this paper, we provide an Indian understanding of accepting and dealing with loneliness through the daily implementation of spiritual practices in life as well as mental health interventions. The four ashramas of Hinduism are discussed with special relevance to Vanaprastha Ashrama (forest-dweller), which signifies renunciation and acceptance associated with aging. The actionable areas with respect to spirituality and its philosophical underpinnings in mitigating loneliness in older people are also highlighted.
Keywords: Hope, India, loneliness, older people, sense of purpose, social isolation, spirituality
|How to cite this article:|
Banerjee D. Loneliness in older people: Spiritual practices as an alternative pathway to action, a treatise from India. J Geriatr Ment Health 2021;8:63-9
|How to cite this URL:|
Banerjee D. Loneliness in older people: Spiritual practices as an alternative pathway to action, a treatise from India. J Geriatr Ment Health [serial online] 2021 [cited 2022 Dec 2];8:63-9. Available from: https://www.jgmh.org/text.asp?2021/8/2/63/336909
| Prologue: The Premise of Loneliness|| |
“The whole conviction of my life now rests upon the belief that loneliness, far from being a rare and curious phenomenon, is the central and inevitable fact of human existence.”
This time-tested quote by Thomas Wolfe from his essay God's Lonely Man (1930) takes an existential view to explore how every living being passes through the phase of “loneliness” at some time or other in his/her life., Wolfe stresses on the fact that being lonely exists on a spectrum rather than being dichotomous and while parts of it are unavoidable and beneficial, in extreme and prolonged cases, it may have adverse consequences on one's health and well-being. Loneliness has been described as “inability to realize the meaning in one's own life,” “feelings of disconnectedness,” and “a subjective yet negative feeling of lacking social relationships.”, It has been associated with heart disease, stroke, diabetes, depression, anxiety, suicide, and dementia, even though the causality is unclear.,,, While loneliness is the “subjective feeling of being isolated,” social isolation is the objective state of cherishing few social relationships or infrequent social interactions. Poor interpersonal relationships, poverty, social inequalities, and familial discord can all contribute to social isolation. According to the Centre for Disease Control and Prevention, social isolation and resultant loneliness can double the risk of all-cause premature deaths, especially after middle ages. Further, it also adds to morbidity and poor quality of life, with depression and anxiety being common mediating factors. Loneliness increases hospitalization risks, prolongs hospital stays in chronic medical conditions, and doubles the hospital visits in old age. These physical effects have assumed increasing importance even in public discourse and social media, the New York Times featuring several headlines in the past few years, “How Social Isolation is Killing us,” “The Surprising Effects of Loneliness on Health,” and “Combating an Epidemic of Loneliness,” to name a few.,
An important aspect is that loneliness does not necessarily depend on the “physical presence” of people around and that it is distinct from solitude, which refers to a pleasant state of seclusion. Together with the renewed academic discourse of psychological health, research on loneliness and related interventions has also boomed in the recent past, courtesy the Coronavirus Disease 2019 (COVID-19) pandemic and consequent social distancing. Travel restrictions, fear of the infection, quarantine measures, COVID-appropriate behaviors, and xenophobia have all “frenzied speed of modern society to a grinding halt and literally crushed the wings of unlimited social interaction.” The heightened mortality and morbidity in older age coupled with ageist stereotypes have obligated older people to isolate themselves from the rest of the world to reduce infection risk. Most residential facilities and old age homes have banned visitors for prolonged periods due to the COVID risk and group activities within the residence have been compromised, all leading to the loneliness burden. Recently, Basu in his editorial outlined the biopsychosocial approach to loneliness during the COVID-19 pandemic, cautioning against the “medicalization and pathologization” of a subjective mental state being misinterpreted as a psychiatric condition. Understanding loneliness as an illness using mechanistic biological models creates the illusion of pharmacological targets, thereby underestimating the “essential role of social connection and mental health in understanding, preventing, and mitigating loneliness and the related consequences.” While dealing with this multidimensional and abstract construct, mental health professionals need to come out of the reductionistic categorical approach and start considering it as a continuum.
| Rethinking Loneliness in Older People|| |
The seminal work of Weiss Loneliness: the Experience of Emotional and Social Isolation categorized it into social (lack of a social network), emotional (lack of deep nurturing bonds with others), and familial/romantic (deficits in interpersonal relationships) types. Aging and frailty are two independent risk factors for loneliness, with increased risk of physical morbidities, psychosocial adversities, and mortality in the lonely elderly. Living alone, neglect and socioeconomic vulnerability among older people pose the most important risks. As per a report from the National Academics of Sciences, Engineering, and Medicine (NASEM), more than one-third of adults above 45 years feel lonely, and nearly 25% of those aged 65 years and above are considered to be socially isolated, which has serious significant health risks. Nearly 24% of community-dwelling older people are considered socially isolated based on the National Health and Aging Trends Study. Kaiser Family Foundation in 2018 reported that one-fifth of the U. S. adults felt “lonely, lack of companionship, left out or isolated from others,” and this proportion increased with age. Social isolation is associated with a 50%, 29%, and 30% risk of developing all-cause dementia, incident coronary artery disease, and stroke, respectively.
The proportion of individuals above 60 years age in our country is ever-rising. Nearly every article on geriatric care starts by highlighting how this proportion is going to double and triple within the next few decades. In India, besides the rapid population aging, socioecological conditions (living alone and living with nonrelations), breaking down of intergenerational bonds, heightened dependency ratio, widowhood, and economic dependency are the usual harbingers of loneliness in old age., The other contributing factors are social support/networks, place of residence, family dynamics, transportation facilities, and population migration. 3.68 million women and 1.23 million men are supposedly living alone and facing loneliness based on the NSSO of India condition of aged, 2004. These numbers have only increased over the years. Tiwari while discussing loneliness in the Indian context mentions about the aspects of “experience of separateness, mental health status, frailty, social networks, and frequency/degree of loneliness” to assess it in clinical settings.
Now let's arrive at questions in hand: how do we alleviate loneliness, especially in older people who are the most vulnerable? How to lead the path from devious, painful loneliness that is desolate and worrisome to solitude that is filled with tranquility and peace?
Poetic as it seems, the primal answer to loneliness has always been at the base of human existence: “the need and ability to be at peace with oneself,” something which has been long engulfed by the insatiable quests of globalization. For ages, various specific interventions have been suggested targeting loneliness whereas lifestyle modifications which can deal with the loneliness of daily lives have been neglected. The role of empathy perceived social support, and communication in the elderly are also under-emphasized. A recent randomized clinical trial by Kahlon et al. showed the efficacy of layperson-delivered empathy-focused telephonic conversation on loneliness, anxiety, and depression during the COVID-19 pandemic. Marcus Riley in BOOMING: a Life-Changing Philosophy for Aging Well highlights aging as one of “humanity's greatest triumphs” even though it is inevitably associated with feeling lonely. Riley further adds, “the key to living later life to the full is
- Being engaged
- Passionate and capable of adapting to changing circumstances
- Good health
- Sufficient finances, and
- Living everyday as a flesh and blood rebuttal of ageism in the society and workplace.”
This brings us to a different take on loneliness in older adults altogether. Instead of considering it as a “separate pathological entity” that deserves a “special treatment,” why not deal with it as it comes in the usual process of aging. The answer probably lies in our own roots and traditions.
| In Search for Shelter in Our Roots|| |
Contrary to the common approaches, there are alternatives that need to be examined to address the loneliness of old age in particular. Maybe we should deviate from the western ideas of resisting and fighting the process of aging and associated loneliness by improvising resources and building on the resources of the culture and societal strengths to the eastern philosophy of acceptance and “letting go when it's time.”
The central aspect of eastern religions is to see the aging process as natural progression of life stages, aptly described by the concept of ASHRAMAS.,
The basis or central theme of all Indian or eastern religions, Hindu, Buddhist, or Jain is the idea of “Tyaga or renunciation.” This powerful concept has withstood civilizations for years. It has been linked to the last two ashrams (stages of life) according to Hinduism, that is, Vaanaprastha (Forest Dweller) and Sanyas (Ascetic). Dr. N. N. Wig in his classical writing mentions about the applicability of Vaanaprastha in modern society. It is stated that after completing the religious and family (earthly) obligations of a Grahasthi (house owner) ashram, one must leave the residence and proceed to the forest (thus, the name Vanaprastha; Vana meaning forest). The spouse can accompany the person for this journey. The literal translation of “living in the forest” definitely does not hold true in today's socioeconomic context but rather refers to “maturity, wisdom, acceptance, and solitude” as a person ages. In today's world, can someone give up all their responsibilities at an age of 50 or 60 years? Apparently, it seems implausible. However, in other words, a gradual yet resolved “detachment” from the various earthly needs with a positive acceptance of aging seem a probable take in the modern day.
In contrast to the western concept of resisting aging, in India, the older people are often looked up to as “wise, experienced, and mature.”, Hence, the concept of Vaanaprastha can be applied for a healthy aging approach where one can slowly prepare oneself for old age rather than a consistent lamenting about the “loss” associated with it. This, however, is not antagonistic to the desire of being “young and evergreen,” which is another way of life. On the other hand, when aging brings in multiple biopsychosocial vulnerabilities, it is indeed impossible to pretend to stay young or constantly strive and compete to battle age. Rather, this alternative approach enables us to gradually prepare ourselves for the “inevitable” process of aging so that we can handle it gracefully with a peace of mind., Reconciliation with aging has been shown to be one of the components of healthy longevity in longitudinal aging studies which improves self-esteem and fosters resilience. Both these factors can help mitigate loneliness in later life. Eastern philosophy adds that transition in ages and integration into the social environment (essential in avoiding a lonely state of mind) is impossible by changing surroundings alone. Ultimate happiness, sense of life-satisfaction, and peace of mind can be achieved by changing oneself as well., Again, the authors do not advocate any particular way here but only mention the possible pathways to take. It is eventually the personal choice of each individual as to what path they wish to tread, and none is absolute.
As Blaise Pascal mentions, “All of humanity's problems stem from man's inability to sit quietly in a room alone,” Manu Smriti also describes how eastern traditions aim for being with oneself (“oneliness” instead of “loneliness”), optimism and hope which are associated with “letting go of one's abilities in a graded yet respectful manner rather than lamenting for the loss.” This resonates with Weiss' concept of emotional loneliness which he postulated to arise from maladaptive coping and unhealthy attachment patterns. Spirituality has been considered to be one of the most important factors in coping, resilience, hardiness building, and stress-reduction strategies. It assumes increasing importance with age, in end-of-life care and during grief. Faith, finding meaning, and spiritual practices have also been used as predictors of wellbeing, psychological resilience, and adjustment in cases of terminal illnesses including cancer.,
Koenig states, “spirituality is distinguished from all other things – humanism, values, morals, and mental health – by its connection to that what is sacred, the transcendent.” This search for the transcendent often leads to a destination in the later stages of life as per Hinduism that involves a need to “seek outside the self.” This helps maintain ecological connections of the “self” with the nature to enable a realization of an “ultimate truth/reality” that can be extremely individualized. While in western traditions, this is referred to as God, Allah, or Higher Power, in eastern faith, it is Brahman (or heightened “self-conscious”). What we are discussing now is highly abstract and heterogeneous and hence definitely not the subject of a systematic review or randomized controlled trial. However, studies related to spirituality and mental health have revealed the effect of the former in mitigating social/emotional loneliness mediated by coping with adversity, building positive emotions, enabling happiness, fostering hope and optimism, bringing in a meaning to life, enhancing self-esteem and sense of self-control, strengthening positive character traits, and fighting stress.,, In fact, religion, health care, and medicine have had numerous intersections throughout history, with the distinctions still blurred in many cultures. Needing to be in control of all relationships and failure to do so for various reasons often lead to painful feelings of loneliness. At times, emotional bonds are wrecked even in a crowded environment, due to neglect, abuse, or discord. While spirituality may not be a direct answer to these issues, eastern traditions always focus on the need of collectivism versus individualism that enables social cohesion, a concept known in mitigating chronic loneliness.,, Also known as “group cohesiveness,” social cohesion is related to multifaceted bonds that link people together. Irrespective of the religious beliefs and morals, the common features based on our traditions that help in the transition from loneliness to solitude are as follows:
- Voluntary withdrawal from the routine hustle of live and trying to unify emotionally with nature
- Deliberately attempting to reduce one's needs to maintain a balance with the available resources
- Acceptance of aging and associated limitations, enjoying the positive constructs and wisdom of age, reduced need to be in control
- Contribution to the society and focusing on social welfare to the extent possible
- Pursuit of spirituality.
| Practicing Spirituality in Daily Life|| |
Religion and spirituality are vital components of health and well-being. The practice of spirituality can be very individualized and is beyond the scope of this article. Certain possible and practical approaches in daily life are enumerated here [Table 1]. Meditation can be a potential tool for general well-being. It comes from the word “medere” which means “whole,” the same source from where “healing” takes its origin. The very concept of “meditation” is taken in a very esoteric meaning. However, it has been referred to as a “disciplined way of reflecting on self, one's relationship with the world, present and future path of life, and meaning/greater purpose in life.” The techniques range from practices of concentration, awareness, or altered state of consciousness based on any directional or nondirectional stimulus. Meditation is similar but not akin to mindfulness which is defined as “awareness that arises when paying attention to the present moment nonjudgmentally.” It is also associated with sense of acceptance and positive aging. Sense of purpose, resilience, and acceptance has been hypothesized to “rejuvenate” inflammation processes, cellular senescence, and metabolic degeneration, thereby helping in the frailty of aging. Based on data from the Health and Retirement Study, one of the classical longitudinal studies of aging, sense of purpose in life was associated significantly better objective (physical) measures of frailty in older adults. Compassion and empathy in day-to-day activities are other doable attributes of spirituality. Trzeciak et al. talks about “compassionomics” and the benefits that it has in a variety of health conditions. Although compassion and empathy are abstract entities and cannot really be measured, they can easily be implemented in daily actions and conversations. Empathy has shown to boost resilience, relieve burnout, and reverse cost crisis in healthcare. Finally, lets look at the practices of forgiveness and leisure. Forgiveness has strong causal link with health and “wholeness” in later life and consists of empathizing, acceptance, altruism, and commitment. Studies have shown significant positive correlation between self-forgiveness, spiritually motivated forgiveness, and psychosocial well-being. It has shown to be a moderator for reducing inward anger and suicidal behavior. On the other hand, leisure practices have been studied as activities with anti-depressant effects which improved emotional well-being. A recent narrative review by Fancourt et al. conceptualizes the bio-psycho-socio-cultural impact of leisure activities on health through a multileveled theoretical framework. Leisure and self-acceptance have been shown to be related with beneficial effects on depression, anxiety, and general psychological well-being., Social support, social engagement, and wisdom have been shown as other attributes of spirituality that counteracts loneliness and burnout in later age. As Dr. Tanya T. Nguyen (Department of Psychiatry, University of California, San Diego) mentioned,
“To many people, wisdom remains a fuzzy concept that's difficult to operationalize and measure. It's analogous to the concepts of consciousness, emotions, and cognitions, which at one point were considered nonscientific, but today we accept them as biological and scientific entities.”
To simplify the understanding of the pathway of loneliness associated with aging, spiritual pathways based on Indian traditions and teachings help in striving for the “essential reality of our being or the Brahman” which reinforces our impermanence and helps us unify with the larger cosmos against the daily illusions of life. Isavasyam idam sarvam is one of the most discussed premises of the Upanishads that refer to the entire existence being surrounded by an ultimate truth, parts of which exist in every being. This forms the basis of one's connection with the holistic truth and thus enables a sense of purpose and achievement., To put it simply, “How does one feel lonely if he/she is connected to a larger purpose that is partly constituted by him/her!” Interestingly, this is not exclusively an eastern idea. Riley mentions the need for a “spiritual vitality” to accept and cherish solitude. A path analysis model study from Portugal showed the mediating effect of spiritual practices between aging and perceived social connectedness as well as life satisfaction. A pragmatic group intervention trial in the senior housing communities of the U. S. involved savoring, acceptance, gratitude, and engagement in value-based activities to improve resilience and reduce loneliness. The authors highlighted need for these principles to be incorporated for similar communities worldwide irrespective of religious beliefs. Wu, while discussing social isolation and loneliness in older people in the setting of COVID-19 pandemic, mentions the need of self-connections as an essential component of emotional network and resilience. An integrative research review by Counted et al. shows both direct and indirect effect of relational spirituality on quality of life as a coping model in multiple health conditions and advocates for complementary alternative health therapy. The “sense of a larger purpose” has been a recurrent theme of coping in India during the pandemic. A recent qualitative exploration of the needs and adversities of Indian frontline physicians stressed on this resilience framework. This nation-wide study found that the physicians “navigated their adversities” through an “identity” which is reliant on self-esteem, purpose, altruism, and the “need to do a greater good amidst crisis.” Western interventions targeting loneliness in the older communities have shown that the most effective ones are based on active participation of the individuals, belief system, and multisystemic approach including healthy lifestyle modifications. The NASEM specifically stress on the role of education, policy priorities, addressing the social determinants of health, health-care staff training, public health campaigns, and improving knowledge-attitude-practice related to loneliness. The central tone of all these strategies is, however, grounded in self-esteem, self-help, restoring social identity, and regaining the sense of purpose, all of which are not very different from the philosophies we just discussed.
| Epilogue: The Way Forward|| |
This idea is not against the need to be physically and mentally fit with age but rather a complementary process of acceptance, solitude, and being at peace with oneself, something that is long due for humanity. Loneliness is a phase, a process that is a function of time at various stages of life. There are no interventions that are absolute as according to Wolfe “Loneliness is there to stay,” but spirituality and adopting our roots probably can help to anchor a scaffolding to prevent its adverse consequences by encouraging the sensation of “self” and social connectedness through the existential “sense of purpose.” Hence, in many ways, the Vanaprastha Ashram is that time of life where loneliness strikes the most and a spiritual journey may help with a gradual withdrawal from routine materialistic pathways. This can have multiple facets in daily life in varying degrees: a sincere and intense desire to change oneself with time, company of life-minded people, self-reflection of the inner narratives, and spiritual discussion., All of these, in turn, help form the “larger sense of purpose” and help one staying connected, which is vital to counteract the loneliness of old age. This may be one of the many strategies, but surely a strategy worth trying and studying further, especially in the Indian context. Shearer and Russel while translating the Upanishads in English mentioned,
“At the heart of this phenomenal world, within all its changing forms dwells the unchanging Divine. So go beyond the changing and enjoying the inner cease to take yourself what to others are riches.”
Recently, the author of this article has mentioned certain actionable points to imbibe the practice of spirituality in loneliness mitigating interventions. Those points are expanded in [Table 2]. The evaluation and implementation of such strategies stay subject of further population-based research.
|Table 2: Approach to spirituality-based interventions in old age for dealing with loneliness|
Click here to view
The recent success, especially during the past 7 years of yoga/meditation as a mental health intervention, gives hope for similar integration of spirituality. The author would also like to recognize that there is scope for other nonpharmacological interventions such as voluntary groups in each locality, volunteers linking with older persons, online support, and lifestyle modifications for similar examination, inclusion to address the issues of loneliness. To reiterate where this article started, navigating loneliness needs to be considered as an integral process of healthy aging rather than something alienated. Very recently, the National Institute of Health-WIDE Strategic Plan for 2021–2025 stressed on the importance of lifestyle interventions, healthy diet, and autonomy in healthy brain aging, preventing cellular senescence and mitigating the vascular risks for dementia. These are areas to pursue in the coming years and decades as populations age and loneliness becomes an essential part of life of all individuals that they have to navigate.
My sincere thanks to Dr. R. S. Murthy (Retired Professor, NIMHANS, Bengaluru) for his excellent insights, wisdom, and guidance in materializing the content of this paper.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hartley L. Theme in Thomas Wolfe's “the lost boy” and “god's lonely man”. Ga Rev 1961;15:230-5.
Préher G. A cosmos of his own: Loss, ghosts and loneliness in Thomas Wolfe's fiction. Thomas Wolfe Rev 2011;35:22-39.
Rokach A. Loneliness Updated: An Introduction. Loneliness Updated: Recent research on loneliness and how it affects our lives. Edited by Rokach A. Routledge (Taylor & Francis Books). New York. 2013; 1-8.
Heinrich LM, Gullone E. The clinical significance of loneliness: A literature review. Clin Psychol Rev 2006;26:695-718.
Bekhet AK, Zauszniewski JA, Nakhla WE. Loneliness: A concept analysis. In: Nursing Forum. Vol. 43. Malden, USA: Blackwell Publishing Inc.; 2008.
Routasalo P, Pitkala KH. Loneliness among older people. Rev Clin Gerontol 2003;13:303-11.
Cacioppo JT, Hawkley LC, Crawford LE, Ernst JM, Burleson MH, Kowalewski RB, et al
. Loneliness and health: Potential mechanisms. Psychosom Med 2002;64:407-17.
Ong AD, Uchino BN, Wethington E. Loneliness and health in older adults: A mini-review and synthesis. Gerontology 2016;62:443-9.
Tomaka J, Thompson S, Palacios R. The relation of social isolation, loneliness, and social support to disease outcomes among the elderly. J Aging Health 2006;18:359-84.
Banerjee D, Rai M. Social isolation in Covid-19: The impact of loneliness. Int J Soc Psychiatry 2020;66:525-7.
D'cruz M, Banerjee D. “An invisible human rights crisis”: The marginalization of older adults during the COVID-19 pandemic-an advocacy review. Psychiatry Res 2020;292:113369.
Basu D. Ah, look at all the lonely people will social psychiatry please stand up for ministering to loneliness? World Soc Psychiatry 2021;3:1.
Weiss RS. Loneliness: The Experience of Emotional and Social Isolation. Cambridge, MA: The MIT Press; 1973.
National Academies of Sciences, Engineering, and Medicine. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Washington, DC: National Academies Press; 2020.
Cudjoe TK, Roth DL, Szanton SL, Wolff JL, Boyd CM, Thorpe RJ Jr. The epidemiology of social isolation: National health and aging trends study. J Gerontol B Psychol Sci Soc Sci 2020;75:107-13.
McGinty EE, Presskreischer R, Han H, Barry CL. Psychological distress and loneliness reported by US adults in 2018 and April 2020. JAMA 2020;324:93-4.
Paslithil A. An Aging Indian Population: Issues and Problems. In: Proceedings of the Indian History Congress 2009 Jan 1. Vol. 70. Indian History Congress; 2009. p. 1095-99.
Bhatia SP, Swami HM, Thakur JS, Bhatia V. A study of health problems and loneliness among the elderly in Chandigarh. Indian J Community Med 2007;32:255. [Full text]
Jeyalakshmi S, Chakrabarti S, Gupta N. Situation Analysis of the Elderly in India. Central Statistics Office, Ministry of Statistics and Programme Implementation, Government of India Document; 2011.
National Sample Survey Organization. Morbidity, Health Care and the Condition of the Aged-NSS 60th
Round (January-June) National Sample Survey Organization, Ministry of Statistics and Program Implementation, Government of India, Report No. 507 (60/25.0/1); 2004.
Tiwari SC. Loneliness: A disease? Indian J Psychiatry 2013;55:320.
] [Full text]
Kahlon MK, Aksan N, Aubrey R, Clark N, Cowley-Morillo M, Jacobs EA, et al
. Effect of layperson-delivered, empathy-focused program of telephone calls on loneliness, depression, and anxiety among adults during the COVID-19 pandemic: A randomized clinical trial. JAMA Psychiatry 2021;78:616-22.
Riley M. Booming: A Life-Changing Philosophy for Ageing Well. Ventura Press. Sydney. 2018.
Wig NN. Relevance of Vaanaprastha Ashram in Modern Times. In: The Joy of Mental Health. Some popular writings of Dr. N.N. Wig. Compiled and Edited by Dr. K.J.S. Chatrath. Mental Health Forum Servants of the People Society Chandigarh; 2004.
Murthy RS. From local to global-contributions of Indian psychiatry to international psychiatry. Indian J Psychiatry 2010;52 Suppl 1:S30-7.
Suryavanshi P. Vedic ashrams of life: A step towards successful ageing and accepting death gracefully. Indian J Gerontol 2016;30:
Saraswathi TS, Mistry J, Dutta R. Reconceptualizing lifespan development through a Hindu perspective. In L. A. Jensen (Ed.), Bridging cultural and developmental approaches to psychology: New syntheses in theory, research, and policy (pp. 276–300). Oxford University Press. Oxford. 2011.
Sharma A. Relevance of Ashrama System in Comtemporary Indian Society; 2007.
Pascal B. Blaise Pascal: Thoughts, letters, and minor works. Edited by Eliot CW. Translated Trotter WF, Booth ML, Wight OW. Cosimo, Inc. New York. 2007.
Tiwari SC, Pandey NM. The Indian concepts of lifestyle and mental health in old age. Indian J Psychiatry 2013;55 Suppl 2:S288.
Yanez B, Edmondson D, Stanton AL, Park CL, Kwan L, Ganz PA, et al
. Facets of spirituality as predictors of adjustment to cancer: Relative contributions of having faith and finding meaning. J Consult Clin Psychol 2009;77:730.
Purnell JQ, Andersen BL. Religious practice and spirituality in the psychological adjustment of survivors of breast cancer. Couns Values 2009;53:165-82.
Koenig HG. Religion, spirituality, and health: The research and clinical implications. ISRN Psychiatry 2012;2012:278730.
Koenig HG. Spirituality and mental health. Int J Appl Psychoanal Stud 2010;7:116-22.
Weber SR, Pargament KI. The role of religion and spirituality in mental health. Curr Opin Psychiatry 2014;27:358-63.
Goleman D. Meditation and consciousness: An Asian approach to mental health. Am J Psychother 1976;30:41-54.
Kabat-Zinn J. Mindfulness-based stress reduction (MBSR). Constructivism Human Sci 2003;8:73-83.
Schuman-Olivier Z, Trombka M, Lovas DA, Brewer JA, Vago DR, Gawande R, et al
. Mindfulness and behavior change. Harv Rev Psychiatry 2020;28:371-94.
Mahmoodi H, Nahand FJ, Shaghaghi A, Shooshtari S, Jafarabadi MA, Allahverdipour H. Gender based cognitive determinants of medication adherence in older adults with chronic conditions. Patient Prefer Adherence 2019;13:1733-44.
Kim ES, Kawachi I, Chen Y, Kubzansky LD. Association between purpose in life and objective measures of physical function in older adults. JAMA Psychiatry 2017;74:1039-45.
Trzeciak S, Mazzarelli A, Booker C. Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference. Pensacola, FL: Studer Group; 2019.
VanderWeele TJ. Is forgiveness a public health issue? Am J Public Health 2018;108:189-90.
Long KN, Chen Y, Potts M, Hanson J, VanderWeele TJ. Spiritually motivated self-forgiveness and divine forgiveness, and subsequent health and well-being among middle-aged female nurses: An outcome-wide longitudinal approach. Front Psychol 2020;11:1337.
Hirsch JK, Webb JR, Jeglic EL. Forgiveness as a moderator of the association between anger expression and suicidal behaviour. Ment Health Relig Cult 2012;15:279-300.
Fullagar S. Leisure practices as counter-depressants: Emotion-work and emotion-play within women's recovery from depression. Leisure Sci 2008;30:35-52.
Fancourt D, Aughterson H, Finn S, Walker E, Steptoe A. How leisure activities affect health: A narrative review and multi-level theoretical framework of mechanisms of action. Lancet Psychiatry 2021;8:329-39.
Nimrod G, Kleiber DA, Berdychevsky L. Leisure in coping with depression. J Leisure Res 2012;44:419-49.
Green M, Elliott M. Religion, health, and psychological well-being. J Relig Health 2010;49:149-63.
Rao AV, Krishnamurtis J. Teachings-relevance to mental health. Indian J Psychiatry 1995;37:155-60.
Lima S, Teixeira L, Esteves R, Ribeiro F, Pereira F, Teixeira A, et al
. Spirituality and quality of life in older adults: A path analysis model. BMC Geriatr 2020;20:259.
Treichler EB, Glorioso D, Lee EE, Wu TC, Tu XM, Daly R, et al
. A pragmatic trial of a group intervention in senior housing communities to increase resilience. Int Psychogeriatr 2020;32:173-82.
Wu B. Social isolation and loneliness among older adults in the context of COVID-19: A global challenge. Glob Health Res Policy 2020;5:27.
Counted V, Possamai A, Meade T. Relational spirituality and quality of life 2007 to 2017: An integrative research review. Health Qual Life Outcomes 2018;16:75.
Banerjee D, Sathyanarayana Rao TS, Kallivayalil RA, Javed A. Psychosocial framework of resilience: Navigating needs and adversities during the pandemic, a qualitative exploration in the Indian frontline physicians. Front Psychol 2021;12:622132.
Shearer A, Russell P. The Upanishads (Harper Colophon Books). New York, USA: Harper and Row; 1979. p. 25.
Murthy RS, Banerjee D. Loneliness in older people: From analysis to action. World Soc Psychiatry 2021;3:120.
[Table 1], [Table 2]