The dizzying spread of coronavirus disease 2019 (COVID-19), as well as the ensuing social distancing restrictions and public health interventions, have contributed to an epidemic of another sort: loneliness. The most at-risk population, adults aged over 80 years, face estimated fatality risks from the virus of 9.3% compared with just 0.2% in the general population.1

Under ordinary circumstances, where individuals have control over the number and quality of their interactions, the costs of perceived social isolation are already high. As studies have repeatedly documented, social isolation contributes to elevated blood pressure, morning spikes in cortisol levels, and disrupted sleep.2 Furthermore, experiments mimicking social isolation contributed to significant declines in cognitive performance and increases in cognitive impairments in undergraduate students, even during a single brief course-related study.3 Perceived social isolation or loneliness is a better predictor of mortality after heart attack than other cardiovascular risk factors.4 Moreover, healthy students during a brief summer vacation showed slower rates of wound healing than their less isolated peers.5

In the long term, social isolation may well impose increased mortality risks on society’s most at-risk populations for mortality from cancer and cardiovascular disease, as well as from COVID-19. In fact, as Michelle Riba, MD, from the department of psychiatry, University of Michigan, Ann Arbor, stated in an interview, “many groups of people may feel particularly vulnerable due to the lockdown [from] COVID-19.” She noted that impacted groups could include “elderly people who live in nursing homes where visitation is limited, elderly or other people who live alone, people who are in immunocomprised states, and [those] who already had mental disorders.”

The Lonely Crowd

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This current period of social isolation will also exacerbate the epidemic of loneliness identified by a 2019 University of Michigan study on healthy aging in which 34% of adults aged 50 to 80 years reported feeling lonely. Among the increasing number of households of adults living alone—now 42% of US adults—60% reported feeling a lack of companionship and 41% felt isolated. Notably, 28% of people who reported feeling lonely ranked their health as either fair or poor in contrast to the 13% who rarely felt socially isolated.6 Even though social interactions and networks decline with advancing age, relationships forged later in life tend to be of better quality, featuring greater emotional closeness and less negativity than those in younger populations.7 Thus the impacts of current social isolation policies may fall heavily on older adults, further compromising their ability to fight infection if they become ill with COVID-19.2,5

The current period of self-isolation will disproportionately affect the elderly population, whose prior social contacts occurred largely at community centers or places of worship, all now closed due to the pandemic. “Those who do not have close family or friends, and rely on the support of voluntary services or social care, could be placed at additional risk, along with those who are already lonely, isolated, or secluded,” according to a recent correspondence published in The Lancet.8 In addition, social isolation, even removed from the sudden enforced isolation resulting from COVID-19 lockdowns, can lead to increased cases of psychosis, delusions, and suicidal behavior, as well as higher numbers of hospitalizations.9

A Future Epidemic of PTSD?

Earlier quarantines give us some indications of the potential fallout from extended periods of isolation. After being quarantined during the epidemic of sudden acute respiratory syndrome (SARS), individuals who were quarantined or had relatives who contracted SARS were 2 to 3 times more likely to report high levels of posttraumatic stress disorder (PTSD) symptoms than the rest of the population.10

For months following quarantine for SARS in both China and Canada, members of the isolated population still practiced avoidance of crowds and vigilant hand washing, in addition to delays in returns to normalcy more broadly.11 Even parents quarantined with children were not immune to feelings resulting from self-isolation, and scores of PTSD symptoms were 4 times higher in children who had been quarantined. Moreover, 28% of adults who had been quarantined displayed sufficiently severe symptoms of PTSD to warrant a diagnosis of a trauma-related mental health disorder.12

Quarantines that last 10 days or longer may result in increased probabilities that individuals show symptoms of PTSD in the weeks and months after quarantines ceased.13 The costs are even steeper among quarantined healthcare workers, and for 3 years after the SARS epidemic, healthcare workers were significantly more likely to experience dependency on alcohol or substance abuse than the general population affected by SARS.14

Social networks such as WhatsApp and Facebook can help reduce the social isolation of the most at-risk populations already suffering from loneliness. Furthermore, audiovisual connections such as Skype, Facetime, or Zoom can help these populations participate in virtual choirs, listen to performances, or meet with neighbors.15 However, some of society’s loneliest members, now cocooned for an indefinite period of time, lack access to sufficient broadband or the technological savvy to set up virtual meetings, counters Dr Riba. “It is important for these folks, if they can, to let their loved ones know what is needed and for us to reach out to them by phone, or email or message how we can help,” Dr Riba noted, “We can help by picking up groceries, making meals, calling each day to make sure they are okay. It’s important for people to receive regular check-ins.”

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Videoconferencing and “Warm” Distancing

These critical measures can at least reduce some of the harms inflicted by long stretches of self-isolation, thus improving long term health. Furthermore, these efforts can reduce negative feelings of isolation and depression,11 which will undoubtedly affect already lonely individuals cut off from social contact by the COVID-19 pandemic.

With so many services already migrating to a telemedicine model during the pandemic,16 psychotherapy via video conferencing is clearly a timely, safe, and apt solution to mitigate the social isolation, fear, and exacerbation of existing psychiatric conditions.17 In fact, video conferencing—now available via smartphones, tablets, and computers—creates a “warm” distance for patients with anxiety and mood disorders and has been shown by a systematic review to be an effective form of therapy.18 Other studies have demonstrated the efficacy of therapist-guided psychotherapy via the Internet.19

Until recently, however, psychotherapy via telemedicine has been hindered by presuppositions about the need to establish therapeutic connections initially through face-to-face interventions, despite research showing the potential for virtual therapeutic alliances.20 This resistance to adopting new technologies is in line with estimates that healthcare innovations require an average of 16 years before their widespread adoption and acceptance.21

Nevertheless, the dramatic impacts of a novel virus and pandemic have brought about swift adoptions of telemedicine in other aspects of medicine, which should eliminate remaining resistance to psychotherapy by video conference.17 With patients facing indefinite social isolation, exacerbated by fears of contracting a novel virus, telemedicine may prove a much-needed lifeline for new and established patients alike.


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