Social isolation is a globally significant public health issue that has become more prominent during the pandemic. It is an objective state characterized by a lack of social contacts, whereas loneliness is the subjective feeling of social isolation and a perceived inconsistency between the actual and desired level of social connection. Some people experience loneliness stemming from social isolation, while others can experience loneliness without being socially isolated. Social connection is a protective factor that benefits health outcomes, while a lack of social connection is a risk factor that harms health outcomes. A former United States (U.S.) surgeon general refers to the risks associated with social isolation and loneliness as an epidemic (Holt-Lunstad, 2020). There is an urgent need for public health mitigation measures that combat the detrimental impact of loneliness on physical and mental health.
Social isolation and loneliness pose a major threat to public health. The physical effects include decreased levels of protective hormones, increased inflammatory activity, increased heart rate and blood pressure, increased risk of cardiovascular disease, increased risk of mortality, impaired repair of blood vessel walls, altered nutritional rhythms, neuroendocrine dysfunction, which compromises sleep quality, and weakened immune function, which makes individuals more susceptible to infections (Leigh-Hunt et al., 2017). These effects are the result of an abnormal physiological stress response to loneliness and behavioral changes triggered by social isolation. Due to their inadequate medical support and exposure to healthy behavioral norms, lonely individuals are more likely to engage in risky health behaviors such as unprotected sex, smoking, excess alcohol consumption, overeating, sedentary lifestyles, and noncompliance with medical prescriptions, all of which contribute to preventable deaths. A small social network with little medical support exacerbates the link between loneliness, risky health behaviors, and adverse health outcomes (Hwang et al., 2020). An understanding of these mechanisms is necessary to implement effective public health interventions.
Social isolation takes a disproportionate physical health toll on the elderly by decreasing disaster resilience. Social isolation, in conjunction with functional limitations and medical equipment, makes elders more vulnerable to natural disasters. Elders are more likely to live alone and less likely to know neighbors. They are less likely to make a plan and build a kit and less aware of preparedness and emergency response guidelines. They are more likely to be disconnected from emergency response information due to their lack of technological skills. Social cohesion allows elders to receive information, medical support, and transportation services in the case of an interruption of power or services. Emergency preparedness includes social participation, communication and information, community and health services, and transportation. Public health officials and policymakers should devise strategies to engage elders in preparedness education and increase their social cohesion (Shih et al., 2018).
In addition to physical effects, social isolation and loneliness have detrimental psychological and cognitive effects. Social isolation and loneliness increase the risk of social withdrawal, low self-esteem, toxic stress, depression, suicide, and dementia. A meta-analysis found that the quality of social relationships is more important than the quantity of them to subjective mental well-being. Two other systematic reviews found that large social networks with high quality relationships protected against major depression and poststroke depression. A systematic review of immigrant women in the perinatal period found an association between social isolation and adverse mental health outcomes after childbirth, including anxiety, stress, and regret (Leigh-Hunt et al., 2017). Evidence from previous pandemics and infectious outbreaks shows the harmful effects of social isolation. After the 2009 influenza A (H1N1) pandemic in the U.S., 28% of quarantined parents reported symptoms of trauma-related mental health disorders compared with 6% of parents not quarantined, and post-traumatic stress scores were four times higher in quarantined children than those who were not quarantined (Razi et al., 2020).
The coronavirus pandemic exacerbates the psychological impacts of social isolation. To break the chain of transmission, the government implemented restrictive measures such as stay-at-home orders, isolation, social distancing, lockdowns, and closure of workplaces, entertainment venues, and educational institutes. Negative psychological effects of quarantine include post-traumatic stress symptoms, anger, fear, anguish, and confusion. Stressors during quarantine include separation from loved ones, fears of infection, longer quarantine duration, inadequate basic supplies, inadequate information, frustration, and boredom. Post-quarantine stressors include financial instability and stigma, both of which are risk factors for anxiety, anger, and other symptoms of psychological disorders months after quarantine. One study found that quarantined staff were more likely to be stigmatized and experience detachment from others, anxiety, exhaustion, insomnia, irritability, poor concentration and indecisiveness, deteriorating work performance, and reluctance to work (Brooks et al., 2020).
As people grapple with the reality of social isolation during the pandemic, they experience depression, loneliness, and interpersonal disconnection. Reactive depression occurs when negative emotions become intense and overwhelming. Depression harms the ability to set and achieve goals, solve problems, and function effectively. Characteristics of depression include sadness, resignation, renunciation, negative thoughts, decreased self-sufficiency, and an increased tendency to give up, complain, and delegate tasks. As psychological and environmental stress levels increase, relationships deteriorate. Instead of connecting people, restrictive measures create hostility and conflict between groups. This triggers xenophobia and widens deep divisions within society. People who experience prolonged social isolation and deep disconnection due to a lack of an adequate social network are more likely to develop depressive symptoms. Conversely, people who spend an unusually high amount of time together in confined spaces due to stay-at-home orders are vulnerable to conflicts and domestic violence, both of which are risk factors for depression (Pietrabissa and Simpson, 2020).
Perceived social isolation has led to an increase in substance use and suicide during the coronavirus pandemic, which has become a serious mental health crisis. Adolescent solitary substance use, which is associated with poorer mental health outcomes than social substance use, has increased during the pandemic. In a June 2020 survey, 13% of adults reported new or increased substance use due to stress from social isolation, and 11% of adults reported experiencing suicidal thoughts in the past 30 days. Early 2020 data show that drug overdose deaths were most evident from March to May 2020, which was when pandemic-related lockdowns began in the U.S. A May 2020 analysis projects that by 2029, there will be additional deaths due to alcohol or drug misuse and suicide, both of which are associated with social isolation and the economic downtown (Panchal et al., 2021).
Each population experiences different psychological effects of the coronavirus pandemic. Children and teens experience anxiety, distress, and social isolation from the shift to online learning and disruptions in their social routines. Changes in children’s behavior include difficulties with attention and concentration, excessive crying, increased sadness, depression, or worry, changes in eating habits, and unexpected headaches and pain. Elders and people with disabilities, who are more likely to contract the virus and develop severe symptoms, experience stress, trauma, anxiety, distress, and depression from physical isolation (Javed et al., 2020). Risk factors for social isolation and loneliness among elders include loss of loved ones, family dispersal, poor health, decreased mobility and income, and decreased inter-generational living (Fakoya et al., 2020). Elders rely on younger family members for their physical and social needs, and self-isolation harms the family system. Elders and people with disabilities living in nursing homes face serious mental health issues. Changes in their behavior include emotional outbursts, irritating and shouting behavior, and changes in their eating and sleeping habits (Javed et al., 2020).
The pandemic is also a source of social isolation. Front-line workers and previously coronavirus-infected individuals experience social distancing and stigmatization when they are perceived as potential virus carriers, which can trigger feelings of anger, sadness, and frustration (Javed et al., 2020). Stressors for healthcare workers include long working hours, death of their colleagues and patients, high patient load, unavailability of proper coronavirus medication, and unavailability of protective gears and supplies (Javed et al., 2020). The pandemic harms the homeless population, who experience drug addiction, less access to healthcare services, unavailability of proper sanitation facilities, and an inability to maintain social distancing in congregate settings. Additionally, people with mental health disorders are affected and suffer from the pandemic, as discrimination and stigmatization increase infection severity and disease transmission.Less awareness of the risk and understanding of protective measures, cognitive impairment, and confined psychiatric wards decrease treatment efficacy (Javed et al., 2020). Public health mitigation measures must address the unique mental health challenges of each population.
The public health mitigation measures that can reduce social isolation and loneliness are grouped into two levels of public health prevention: primary prevention, which prevents disease or injury before it occurs, and secondary prevention, which decreases the impact of a disease that has already occurred. Primary prevention involves researching the psychological impact of the pandemic on at-risk populations such as students, parents, healthcare workers, and teachers and providing online psychological counseling. Secondary prevention involves decreasing social isolation by using digital devices to provide more opportunities for social interactions. The three components of this plan include developing new psychological treatments and forms of online communication, teaching psychotherapists how to use online devices, and discussing the benefits of telepsychology with the general population (Saladino et al., 2020). One specific public health intervention that falls under secondary prevention is group psychotherapy. Online group psychotherapy allows individuals with anxiety, depression, loneliness, grief and substance abuse to receive psychological support, engage in social interactions, and feel a sense of belonging during the pandemic. Online group therapy is beneficial because it improves access to services in underserved areas and protects the safety of people who are isolating to slow the spread of the virus (Marmarosh et al., 2020).
The government plays an integral role in mitigating the short and long-term psychological consequences of social isolation and loneliness during the pandemic. U.S. governors are creating hotlines, using technology to promote virtual connections, and implementing unique interventions for vulnerable populations. The federal government and private sector have also established programs to help populations experiencing social isolation and loneliness. The U.S. Department of Veterans Affairs National Center for PTSD developed Covid Coach, an application that provides resources on wellbeing exercises, coping strategies, and tips to reduce loneliness. AARP provides resources for reducing loneliness and improving social connections through its Connect2Affect program, which offers a free connectedness risk assessment. ConnectiCare developed the Peace of Mind initiative, which uses nurse care managers to provide vulnerable populations with telephone-based mental health services. NovuHealth established a Healthy Connections program, which involves asking individuals about their emotional and mental health needs and directing them to the appropriate services. Other steps the government can take to reduce loneliness include increasing access to critical services and changing telehealth and workforce policies to meet rising demands. (“Strategies to Address Social Isolation and Loneliness During COVID-19”, 2020).
Non-governmental organizations (NGOs) also have a hand in public health mitigation strategies for social isolation and loneliness. The World Health Organization provides mental health and resiliency tools for the general population, healthcare workers, team leaders or healthcare facility managers, caregivers of children, older adults, people with medical conditions and their caregivers, and people in isolation. All individuals can reduce social isolation and loneliness by checking on and helping other people in their community. Altruism benefits both the helper and the person receiving support. Healthcare workers can address mental health conditions by providing patients with medical and psychosocial support. Healthcare facility managers can establish a buddy system, which will allow workers to provide one another with social support. Caregivers of children can keep children close to their family and help children express their feelings in a positive way. Older adults, people with medical conditions, and their caregivers can receive medical and psychological assistance from their social contacts. People in isolation can maintain their social connections via email, social media, telephone, or video conference (“Mental Health and Psychosocial Considerations During the COVID-19 Outbreak”, 2020). These techniques will reduce social isolation and loneliness in various populations.
Public health mitigation measures should consider the relationship between social isolation and the social determinants of health. A public health nonprofit organization in New York City called Public Health Solutions found that older adults living in public housing were experiencing higher rates of social isolation because they were unable to use the Internet for health visits, access to food, medications, and social support. This organization is collaborating with the New York City Housing Authority to provide older adults with improved Internet access, hardware and software, and technology instruction. Other mitigation challenges include the lack of time available during routine care visits to screen for and discuss social isolation and loneliness and the lack of direct reimbursement for population health and preventive care interventions under the fee-for service payment systems (Escalante et al., 2021). Public health officials should collaborate with healthcare providers and policymakers to overcome these challenges.
Social isolation and loneliness are serious public health issues that affect a significant number of people in the U.S. and the world. Research has shown that the health effects of loneliness are comparable to those of smoking and obesity. Loneliness increases the risk of inflammation, immune system problems, cardiovascular disease, hypertension, cognitive decline, premature morbidity, low self-esteem, anxiety, depression, and suicide. The coronavirus pandemic has increased the prevalence of social isolation and loneliness. Public health officials can collaborate with non-governmental organizations and local, state, and federal government agencies to develop interventions that meet the mental health needs of target populations, such as the homeless, elderly, healthcare workers, people with disabilities, caregivers, and children. Mitigation strategies include conducting research on the effects of loneliness, educating the public about ways to reduce loneliness, using digital devices for communication purposes, establishing group online psychotherapy programs, and addressing the social determinants to health. Addressing social isolation and loneliness is one part of the comprehensive effort to address mental health during the pandemic. Public health interventions that foster social connections and reduce loneliness will allow individuals to achieve and maintain optimal long-term physical and psychological health.
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