A Pandemic On Top of an Epidemic

Is There a Loneliness Epidemic and Will COVID-19 Make it Worse?

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%…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%, 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).

         Neuroscientists have weighed in on possible mechanisms for the adverse effects of feeling chronically lonely on health. A study in mice showed that solitary isolation led to decreases in the size of neurons in the two brain regions studied, increases in the stress hormone cortisol, and decreases in a brain growth factor called BDNF. In humans, a study using functional magnetic brain imaging (fMRI) showed much less activity in a brain region necessary for experiencing reward, the ventral striatum, in lonely people than non-lonely people. In a not yet peer-reviewed report, scientists compared the effects of an acute social isolation challenge (10 hours of sitting alone in a nearly empty room) to food deprivation and found that the same region of the brain, the substantia nigra, was activated by both conditions. The substantia nigra sends neural projections to the ventral striatum to trigger the release of the neurotransmitter dopamine, which is associated with both craving and reward. Thus, craving food and craving social contact appear to cause similar brain activity and social isolation leaves the brain in a state of deprivation reminiscent of extreme hunger.

Social isolation and loneliness may lead to decreased activity in the brain’s reward pathway that goes from the substantia nigra (shown here in the middle of the brain slice) to the ventral striatum (shown here just above the substantia nigra) (source: Shutterstock).

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.

         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.

Although neurological signs and symptoms have been noted to be part of the COVID-19 illness for some patients, the paper notes that right now we do not know if and how the novel coronavirus that causes COVID-19 (SARS-CoV-2) gets into the brain. But “post-infectious fatigue and depressive syndromes have been associated with other epidemics and it seems possible that the same will be true of the COVID-19 pandemic.” Indeed, a survey has shown that 84% of Americans believe that if social distancing continues longer than they expect, it will adversely affect their mental health. 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.

         In a Perspective essay in the New England Journal of Medicine, Betty Pfefferbaum and Carol S. North remind us that “After disasters, most people are resilient and do not succumb to psychopathology. Indeed, some people find new strengths.” But they go on to warn that a variety of negative emotions are inevitable the longer social distancing rules remain in effect. “In the current pandemic,” they write, “home confinement of large swaths of the population for indefinite periods, differences among the stay-at-home orders issued by various jurisdictions, and conflicting messages from government and public health authorities will most likely intensify distress.” While we all are likely to suffer some emotional distress during and even after the pandemic, a subset of us will feel profoundly lonely and prone to the physical and emotional disorders known to be associated with loneliness.

It is not known what interventions may help decrease loneliness while practicing social isolation but using the internet to establish social contacts could be helpful (source: Shutterstock).

         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 so unique a situation 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

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 reasons, a clinician should inquire about mental health issues and distress and query whether the individual has social support. Telementalhealth 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.

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