A Pandemic on Top of an Epidemic

Former U.S. Surgeon General Vivek H. Murthy declared a loneliness epidemic in 2017, triggering a plethora of headlines. Now, many are asking whether steps like shelter-at-home and social distancing that are necessary to control the COVID-19 pandemic will exacerbate that loneliness epidemic and increase physical and behavioral health disorders and mortality.

In an interview with Boston public radio station WBUR earlier this year, Murthy noted research using “rigorous scales” has found that “more than 20 percent... of the adult population in America admits to struggling with loneliness.” According to the federal Health Resources and Services Administration (HRSA), being lonely increases the chance of dying by 45 percent, making it as dangerous as obesity and cigarette smoking. Studies link loneliness and isolation to problems with the immune system and to increased risks for heart disease, stroke, cancer, and depression. Although living through a pandemic is not officially listed as a qualifying trauma in the official psychiatric diagnostic manual (DSM-5), there is evidence that social isolation and quarantine can provoke many symptoms characteristic of posttraumatic stress disorder (PTSD).

Loneliness May Not Be of Epidemic Proportions

Not everyone agrees that there is in fact a loneliness epidemic, however. A 2019 article looked at the data about loneliness and concluded that overall they don’t support the notion of an ongoing loneliness epidemic. “There is an epidemic of headlines that claim we are experiencing a ‘loneliness epidemic,’ writes Esteban Ortiz-Ospina, “but there is no empirical support for the fact that loneliness is increasing, let alone spreading at epidemic rates.” Although many authors point to an increase in the last century of the number of Americans who live alone as evidence that loneliness must be increasing, it is also important not to conflate social isolation with loneliness. For example, many people who live alone do not report feeling lonely.

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Regardless of whether loneliness is an epidemic or not, it is clear that more people than perhaps ever in the last century are undergoing enforced social isolation, forced to stay away from school, work, family, and friends. And experts do agree that even if loneliness is not as widespread in the U.S. as the dramatic headlines might suggest, it is a risk factor for multiple poor health outcomes.

Hence, the risk that social isolation and loneliness will produce health problems even beyond the ultimate resolution of the COVID-19 epidemic is a reasonable concern. From a behavioral health viewpoint, a recent paper in Lancet Psychiatry states that “A major adverse consequence of the COVID-19 pandemic is likely to be increased social isolation and loneliness… which are strongly associated with anxiety depression, self-harm, and suicide attempts across the lifespan.” A review of previous quarantine situations, like those during outbreaks of H1N1 influenza, SARS, and Ebola also raised the possibility of increased alcohol abuse and a particularly adverse effect of loneliness on the elderly. Most ominous in this regard are studies linking social isolation and loneliness to an increased risk for suicide, leading three authors to call the link between suicide and COVID-19 a “perfect storm” in an article last month in JAMA Psychiatry.

Thus, it is clear that attention must be given to the development of loneliness that will affect an unknown number of people subjected to forced isolation during the pandemic. For these people, the effects of being isolated on their health and well-being may well last for months or even years after the pandemic is officially declared resolved.

How to Combat Loneliness

Multiple authors have already weighed in on ways to mitigate the loneliness effects of social distancing. For many of these interventions, however, there are limited data about effectiveness. For example, we do not know the extent to which socializing via video platforms like Zoom with friends and family works to relieve some of the adverse effects of loneliness. One study from the University of Pennsylvania actually showed that cutting down on social media reduces loneliness, but that was done before technology became our only way of staying connected. Elderly people who are also lonely may not be fluent with video conferencing platforms.

What can we do? People vary in how they experience loneliness and there are many interventions that have been tried to ameliorate loneliness. This makes it hard to make firm, evidence-based statements about what might work, especially when we are facing a unique situation such as the current pandemic. From studies that are available, we would recommend the following as possibly effective interventions:

1. Attempt to schedule a regular one-on-one meeting with an isolated individual by video conference or telephone. This can be once per week or more frequent, but should be on a predefined schedule.
2. Use the internet as much as possible to establish social contacts, but limit its use for acquiring news about the pandemic.
3. Encourage group activities by video conference. There are innumerable opportunities now to join in groups from a diverse range of interests and the isolated person can be encouraged to join one or more activity and discussion groups online, even if he or she only listens.
4. A pet may help.

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We cannot vouch that these will ultimately be proven effective if and when high-quality studies are done but given the state of the evidence they seem among the most promising. We need to make sure people understand that while on the one hand emotional distress is expected at this time and shared with a huge group of people, it is still painful, and everyone’s distress has unique elements. Knowing that the pain is a shared phenomenon may help—but dismissing it as “just what everybody is experiencing” will not.

When people use telemedicine for any reason, a clinician should inquire about mental health issues and distress and query whether the individual has social support. Telemental health is also now increasingly available for people who need more intense and professional interventions.

We conclude that there is reason to doubt that loneliness is a true “epidemic” at this time, but it is likely to emerge as a significant comorbidity from this pandemic and pose all kinds of long-term threats to health and well-being. At the very least, we must be certain that we are identifying people who are suffering from loneliness and do our best to relieve their discomfort and establish some social contact for them.