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Mitigating the psychological effects of social isolation during the covid-19 pandemic

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1904 (Published 21 May 2020) Cite this as: BMJ 2020;369:m1904

Read our latest coverage of the coronavirus pandemic
  1. Mohammad S Razai, academic clinical fellow in primary care1,
  2. Pippa Oakeshott, professor of general practice1,
  3. Hadyn Kankam, academic foundation trainee2,
  4. Sandro Galea, dean and professor3,
  5. Helen Stokes-Lampard, professor of GP education and chair of the National Academy for Social Prescribing4
  1. 1Population Health Research Institute, St George University of London, London, UK
  2. 2St George’s University Hospital NHS Foundation Trust, London, UK
  3. 3Boston University School of Public Health, Boston, Massachusetts, USA
  4. 4Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
  1. Correspondence to: M S Razai mrazai{at}sgul.ac.uk

What you need to know

  • Primary care could provide unique relationship-based continuity of care to patients with psychological effects from social isolation during the current covid-19 pandemic

  • Such patients could be identified with existing simple and validated screening tools

  • Telephone or online video consultations are safe and effective for providing support for mental health in primary care, including counselling, coaching, and befriending. Video consultations can provide additional visual information and therapeutic presence and are particularly useful for anxious patients

  • Social prescribing can improve the social and psychological wellbeing of patients by drawing from community resources such as the arts (for example, singing in a virtual choir, dancing, or online drawing classes). It can be delivered by trained non-clinical staff in primary care

A 76 year old woman who lives alone requests a telephone consultation. She is in strict self isolation because of her severe chronic obstructive pulmonary disease. She has a history of anxiety and mild depression and says she cannot stop watching the news and is terrified she will catch coronavirus and die. She has a neighbour who helps her with essential shopping and a younger sister who lives abroad. She had previously complained of feeling lonely. She has no acute physical health complaints and is eating and drinking adequately.

During the covid-19 pandemic, physical distancing measures (also called social distancing) have been implemented in many countries to interrupt viral transmission and delay the spread of infection. These measures range from mandatory quarantine to voluntary self isolation and have come at a cost of socially isolating many people, putting their mental and emotional health at risk. Key areas of social interaction, connection, and support have been affected by the closure of pubs, restaurants, libraries, sports facilities, and community centres for the elderly, in addition to the cancellation of sporting events, weddings, and funerals. The World Health Organization and the UK government have issued guidance on the management of mental health aspects of covid-19.12

This article offers an approach to identifying and managing adults impacted by the psychological effects of social isolation during the covid-19 pandemic, and to mitigate the adverse effects of physical distancing.

What are the psychological impacts of social isolation?

Evidence from previous infectious outbreaks and pandemics demonstrates the deleterious mental health and psychological effects of social isolation.345 For example, high psychological distress was reported by 34% of quarantined horse owners during equine influenza outbreak compared with 12% in the general population.6 After the 2009 influenza A (H1N1) pandemic in the US, post-traumatic stress scores were four times higher in quarantined children than in those who were not quarantined, and 28% of quarantined parents reported symptoms of trauma related mental health disorders compared with 6% of parents not quarantined.7 After release from quarantine due to SARS, many people reported avoiding those coughing and sneezing (54%) and avoiding crowded (26%) and public spaces (21%) for several weeks.8

Anxiety, low mood, stress, fear, frustration, and boredom may be precipitated by covid-19 and its consequences, including restriction of movement; loss of social connections and employment; loss of financial income; fear of contagion; or concern about lack of access to basic needs such as medicines, food, or water. These symptoms may be appropriate reactions to extreme circumstances but may hinder patients’ ability to function.

Loneliness is a subjective unpleasant experience and refers to dissatisfaction with the discrepancy between an individual’s preferred and actual social relationships.9 It is a psychological manifestation of social isolation—commonly experienced at times of change—and is associated with adverse impacts on mental and physical health, including premature death at rates comparable to obesity and smoking.1011 People with serious underlying physical and mental health conditions, those who are socioeconomically disadvantaged, or are elderly are at increased risk of loneliness (box 1).1213

Box 1

People at risk of psychological harm from social isolation during the covid-19 pandemic5

  • People with pre-existing physical and mental health conditions (such as anxiety, depression, and obsessive-compulsive disorder)

  • Older people living alone or in institutions such as care homes and special needs facilities

  • Disabled individuals, especially those with learning and communication disabilities

  • People with recent bereavement, hospitalisation, or illness

  • Individuals infected with covid-19 who are stigmatised in the community

  • Those subject to domestic violence, which is likely to be made worse during quarantine

  • People with drug and/or alcohol use disorders

  • Individuals with caretaking responsibilities, including childcare during extended school closures

  • People who are unemployed or those who have lost income during the pandemic

  • People living alone with limited social capital and support network

  • Individuals under mandatory quarantine and those in strict self isolation due to serious physical health conditions (shielding)

  • Young people (due to closure of schools and colleges and sports and entertainment facilities)

  • Refugees, internally displaced people, and undocumented migrants

RETURN TO TEXT

How to approach patients

Primary care doctors providing patient-centred, longitudinal care are in a unique position to provide psychological support and treatment during the current pandemic,1415 since continuity of care is associated with lower mortality rates and better patient outcomes.16 Patients struggling with mental health impacts of social isolation can present for any reason and may or may not openly report distressing psychological symptoms. Furthermore, one in five patients consult general practitioners for primarily social problems rather than medical.17

If not mentioned outright by patients, the decision of who to screen for psychological distress requiring intervention should be based on clinical judgment, prior knowledge of the patient, and individual risk factors (box 1). Initially, open-ended questions can be used to explore biopsychosocial issues: worsening sleep, screen time, mood, or eating or increased substance use may be cause for concern, signalling the potential need for additional screening. Though many may experience mental health symptoms during the covid-19 pandemic, people with risk factors for significant psychological harm may experience more severe or debilitating symptoms that require intervention (box 1).

Screening for depression and anxiety

There are no specific screening tools to cover all the mental health and psychological impacts of covid-19. Previous studies on the mental health impacts of outbreaks and pandemics have used pre-existing questionnaires.5 Validated screening questions such as those in box 2 are already used to assess for anxiety and depression in primary care. Further assessment including evaluating suicide risk (asking about suicidal thoughts, plan and intent), will be guided by patient responses. Clinicians could use validated tools such as the Columbia Suicide Severity Rating Scale.19

Box 2

Patient Health Questionnaire-4 (PHQ-4) screening questions for anxiety and depression18

Over the last two weeks, how often have you been bothered by the following problems:

  1. Feeling nervous, anxious or on edge?

  2. Not being able to stop or control worrying?

  3. Little interest or pleasure in doing things?

  4. Feeling down, depressed, or hopeless?

To score answers, the responses should be coded as follows:

View this table:

Add the scores for each question together to give a possible total score from 0 to 12, with categories of psychological distress being:

  • Scores 0-2 = None

  • Scores 3-5 = Mild

  • Scores 6-8 = Moderate

  • Scores 9-12 = Severe

  • Anxiety subscale = Sum of items 1 and 2 (score range 0 to 6)

  • Depression subscale = Sum of items 3 and 4 (score range 0 to 6)

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Screening for distressing loneliness

We suggest using the rigorously tested UCLA Loneliness Scale to assess for distressing loneliness (box 3), which has been shown to be reliable when completed via telephone consultation.20 It is also applicable in different cultural settings.2122 If physically distancing to any extent, many patients could score 6 or above on the scale.

Box 3

The UCLA Loneliness Scale20

  1. How often do you feel that you lack companionship?

  2. How often do you feel left out?

  3. How often do you feel isolated from others?

To score answers, the responses should be coded as follows:

View this table:

Add the scores for each question together to give a possible total score from 3 (least lonely) to 9 (most lonely)23:

  • Scores 3-5 = Not lonely

  • Scores 6-9 = Lonely

RETURN TO TEXT

What evidence based strategies exist for managing the psychological impacts of the covid-19 pandemic?

The cornerstones of mental health treatment remain the same as in the pre-pandemic period. Patients may need reassurance, appropriate safety-netting, and self care advice, as from WHO (box 4). Decisions regarding mental health interventions for patients will depend on the severity of symptoms and screening results, pre-existing mental health conditions, available social resources, patient wishes, and the estimated risk of adverse health outcomes. As in typical practice, specialist advice or referral to mental health services may be required.

Box 4

WHO advice for people in isolation1

  • Stay connected and maintain your social networks

  • Keep your daily routines or create new ones if circumstances change

  • During social distancing, stay connected to friends, family, and community members via telephone, email, social media, or video conference

  • During times of stress, pay attention to your own needs and feelings

  • Engage in healthy activities that you enjoy and find relaxing

  • Exercise regularly, keep regular sleep routines, and eat healthy food

  • A near constant stream of news reports can cause anyone to feel anxious or distressed. Seek information updates and practical guidance at specific times during the day from health professionals or reliable sources such as the WHO

  • Avoid listening to or following rumours that make you feel uncomfortable

RETURN TO TEXT

The use of online, self-guided cognitive behavioural therapy (CBT) is well established and at least as effective as face-to-face CBT for many mental health conditions, including anxiety and depression.2425 Patients with severe symptoms or pre-existing mental health conditions may need referral to community mental health services or to secondary care through routine referral pathways.

Two additional evidence based strategies could reduce psychological harm during the pandemic: remote telephone or video consultations and social prescribing.

Use of remote telephone or video consultations during social isolation

Containing the spread of covid-19 has entailed a dramatic shift from face-to-face to remote consulting for primary care and mental health providers. There is strong evidence for the acceptability, safety, and effectiveness of telephone and online video consultations in healthcare settings for improving mental health.26 In a study assessing depression in low-income elderly patients, telehealth problem solving therapy was as effective as face-to-face therapy, for example.27 Patients with medically unexplained symptoms experienced reduced anxiety and depression symptoms when psychotherapy was delivered via the internet compared with the usual face-to-face treatment.28

Telephone consulting is a familiar tool that has been widely used in primary care for decades but is limited by the lack of non-verbal cues.29 Video consultations provide therapeutic presence and additional visual information and may be particularly useful for anxious patients.303132 There is also evidence that videoconferencing with a smartphone for nursing home residents reduces subjective feelings of loneliness.33 However, effective use of video consultations and other web based technologies may be limited in resource-poor or rural settings, in populations with low health literacy, and in some older adults.

After identifying patients—including those with anxiety, depression, and loneliness—through screening, video consultations can be used both for initial consultation and subsequent therapeutic sessions such as befriending, problem solving, counselling, and coaching by clinicians or trained social prescribers in primary care (box 5).

Box 5

Use of remote general practice consultations to mitigate psychological harm during the covid-19 pandemic (based on Calgary-Cambridge communication model34)

Set up

Check the patient’s medical record for risk factors for mental health problems and loneliness such as living alone, being elderly, or having pre-existing mental or physical health conditions. Have online self help websites for mental health and loneliness on hand.

Connect

Check the quality of audio and video link, confirm you are speaking to the right patient, check the patient’s location and ensure their privacy and comfort, and confirm that the patient is happy to continue.

Communicate

Develop rapport, explore the patient’s ideas and concerns and what they hope to get out of this session, listen attentively and sensitively, ask open questions, and avoid jargon and information overload. Screen for anxiety, depression, and loneliness. Explore social, spiritual, and psychological concerns, and agree on a problem list. Offer routine mental health and psychological support as appropriate. If there is no diagnosable mental health condition on initial contact, refer or signpost to social prescribing support (box 6), which can advise on a range of actions including diet, physical activity, and maintaining social connections using digital resources. Social prescribing can also be used for mental health in parallel with other interventions.

Conclude

Summarise key concerns and ask if the patient has any further questions. Agree a plan, including a date for review.

RETURN TO TEXT

The role of social prescribing in a pandemic

Social prescribing is the use of non-medical interventions such as the arts, physical activity, or other community engagement (for example, singing in a choir, dancing, exercise classes or painting classes) to address broader determinants of health and improve wellbeing by drawing on existing assets and resources in communities.35 Multiple studies have shown that social prescribing such as engagement with the arts is a cost effective approach that could help prevent a range of physical and mental health conditions.36 While covid-19 prevents meetings in person, many activities and voluntary services have moved to digital platforms. Emerging interest in social prescribing373839 could be harnessed during the current pandemic to accelerate recruitment of trained staff. For example, in the UK, several initiatives are placing social prescribers across primary care networks.37 Box 6 outlines how social prescribing might mitigate the adverse psychological impact of social isolation.

Box 6

Use of social prescribing by primary care during the covid-19 pandemic3540

  • A social prescriber provides information and support, and signposts to statutory and voluntary resources. This may include an introduction to community support networks and regular review (moderate support). Social prescribers who are suitably qualified may also provide online welfare calls, mental health reviews, counselling and coaching with a personalised intensive review (high support). This can include helping individuals lose weight, maintain physical fitness, eat a healthier diet, and gain online qualifications.

  • Where appropriate, draw on the existing local community and voluntary assets (such as volunteers helping vulnerable individuals with shopping) rather than forming new organisations. This could include using online platforms for mental health support, mindfulness, and meditation (see box 7), and virtual singing, dancing, and yoga groups.

  • If you have a patient advocacy or participation group in your area, involve them in your discussions and ask for their support.

  • Focus on individuals with the greatest needs, such as those most at serious risk of adverse psychological and mental health harm due to covid-19 and ask what matters to them.

  • Develop a clear and simple referral pathway to a social prescriber.

  • Discuss regularly with your primary care organisation the need for planning and encouraging the uptake of social prescription and be proactive in developing strong links with local agencies (box 7).

  • Ask patients for feedback and ensure you monitor and audit your social prescribing service.

  • Consider having a dedicated clinical or non-clinical social prescriber (such as Link workers in the UK) and if appropriate give them access to patients’ records and include them in your multidisciplinary team meetings and communicate with them regularly (if applicable).

RETURN TO TEXT

Despite its ubiquity, only one in two adults aged 75 years and older uses the internet.41 Thus, alternative methods of engagement must be sought for this group. A telephone call could establish what resources are available to the patient, and where online tools are not accessible, the clinician or social prescriber could advise the patient on simple exercise routines, recommend appropriate radio or television programmes, or signpost them to accessible forms of health and wellbeing activities.42 Physical activity is of particular importance as there are benefits for both physical and mental health. Community volunteers can aid with social prescribing, shopping, regular telephone conversations, and home visits while maintaining physical distancing advice. Such schemes are already operational in certain countries, such as the NHS Volunteer Responders in the UK (box 7).

Box 7

Examples of online mental and physical health support during the pandemic

Examples of social prescribing support

RETURN TO TEXT

Conclusion

Social isolation during the covid-19 pandemic is likely to have adverse psychological effects, particularly in high risk individuals. Primary care has unique strengths, including continuity of care, that lend themselves to alleviating psychological harm via evidence based approaches including video consultations and social prescribing.

Once her symptoms and history were reviewed, the patient in the case history was offered reassurance, and self care advice. Counselling and cognitive behavioural therapy were delivered remotely, and a social prescriber was also involved. This improved her wellbeing and reduced her loneliness.

Education into practice

  • Do you have a local policy for identifying and screening patients at risk of psychological harm due to the covid-19 pandemic?

  • What community assets do you have to help mitigate the effect of social isolation on mental health and loneliness?

  • What remote connection facilities do you have in your practice and what do you need to set up one today?

How patients were involved in the creation of this article

A patient read the manuscript and provided feedback on the relevance and usefulness of the screening questions, especially for loneliness. She believed social prescribing such as remote video or telephone welfare calls and counselling make a positive difference in overcoming anxiety and loneliness.

How this article was made

This article uses best available evidence, recent research papers, and the latest advice from the WHO.

Search strategy

We used web-based systematic reviews, other relevant published research and latest guidelines. Additional resources were drawn from our personal datasets.

Acknowledgments

We thank the BMJ editors and independent peer reviewers for their helpful comments and feedback.

Footnotes

  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Patient consent: Patient consent not required (patient anonymised, dead, or hypothetical).

  • Provenance and peer review: Commissioned, based on an idea from the author; externally peer reviewed.

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