Reducing loneliness and depression in older adults during COVID-19 with an online support program

Loneliness is a feeling experienced when the quantity and quality of our social relationships do not meet our expectations [1]. It is a subjective feeling that does not necessarily relate to the number of people surrounding us. According to Weiss [2], loneliness can be considered a multifaceted construct comprised of a social and an emotional dimension. Social loneliness emerges from the absence of an available and satisfying social network that can provide a sense of belonging and is connected to social factors such as having close friendships, companionship, and the size of one’s social network. Emotional loneliness refers to the absence of one or more attachment figures with whom one could establish a close connection, and the desired level of intimacy or confidence is not achieved.

Being lonely has been associated with all-cause mortality [3], higher rates of morbidity, worse physical health [4], a faster rate of cognitive decline [5], and impaired functional status and quality of life [6]. Loneliness is related to increases in anxiety and depressive symptomatology (and their comorbidities), particularly in people with poor social support [7, 8]. In recent years, we have witnessed an increasing prevalence of loneliness, with nearly a third of individuals in developed countries experiencing its impact [9]. According to a recent meta-analysis including data from 2000 to 2019, loneliness prevalence in Europe ranges from 5.3% in young adults to 11.9% in older adults [10].

A previous longitudinal study with a 7-year follow-up performed by our research team, identified social support and loneliness as potential targets in people with major depressive disorder (MDD). We reported that lower social support predicted higher subsequent levels of loneliness, which in turn predicted higher probabilities of MDD in a sample of older adults (50 years or older) with MDD at baseline [11]. Moreover, having a small social network has a negative impact on depression in lonely people [12], so increasing social support by creating opportunities for successful social interactions may reduce depressive symptomatology [13, 14].

The effect of socially disruptive measures on social relationships in the context of the COVID-19 pandemic increased feelings of loneliness [15, 16] and the prevalence of mental health problems among older adults [17, 18]. In addition, aging can be accompanied by events that can limit social participation, such as the loss of people from our social environment, retirement, and health problems. This vital transition implies a personal and social adaptation of the individual to a new social role or personal situation, being a stressful moment that can lead to non-desired loneliness [19].

The highly prevalent late-life loneliness [20], accompanied by its adverse health effects, calls for a heightened focus on the development of effective interventions to address this escalating public health issue. It is important that interventions offer new social opportunities while also prompting a shift in how individuals approach and perceive social relationships on a broader scale. Moreover, such interventions must be adapted to the social restrictions needed to contain the spread of COVID-19 pandemic, which highlighted the need to explore remote delivery methods. The adaptation of these interventions is not only relevant in the pandemic context but can also be employed in future similar situations or for individuals unable to physically travel to the intervention site (e.g., due to distance or mobility issues). Additionally, online interactions enable better reconciliation with daily activities and can also help facilitate initial contacts for individuals who have difficulties establishing social relationships, especially in face-to-face settings.

Considering the different targets we can address to reduce loneliness, there are mainly four types of interventions. We can target the community or social support level by (1) enhancing social skills, (2) providing social support, or (3) increasing opportunities for social interaction. Additionally, interventions can target the individual or psychological level by (4) addressing maladaptative social cognition (e.g., cognitive behavioural therapy to identify and reframe negative perceptions and thoughts of loneliness) [21]. Cohen-Mansfield & Perach [22] concluded in their review that combining multiple approaches seems to be the most promising strategy to reduce loneliness.

The most effective tools to deliver interventions targeting social support and aimed at alleviating loneliness are group-based interventions with educational inputs or support activities for specific groups of older people and with the presence of facilitators who encourage the participation of participants in decision-making [23–25]. However, the studies that applied it used heterogeneous health measures, obtaining both positive and negative results [26, 27]. Thus, the health effects of loneliness interventions are promising but inconclusive to date.

Likewise, systematic reviews on interventions to reduce loneliness that include online interventions [28, 29] suggest that new technologies can be considered a promising tool, but although most interventions report some effectiveness in reducing social isolation and loneliness, the quality of the evidence is generally weak. According to a recent scoping review of reviews [30], it is crucial to acknowledge that there is no universal approach to addressing loneliness and, as a result, interventions should be tailored to meet the unique needs of each participant. In this regard, modular interventions offer greater flexibility to adapt to the specific needs of each participant.

In the pandemic context, studies based on previous research and using a rigorous methodology were needed, so we designed a psychosocial online intervention following the assumption that interventions addressing loneliness to improve mental health should follow a modular structure and have a dual focus: (i) sharing experiences and promoting peer support to overcome feelings of loneliness and (ii) increasing the chances of establishing successful social relationships.

The design of the intervention took into account previous programs with similar aims that showed promising results in psychosocial well-being (including mental health, social support, and loneliness), such as the "Circle of Friends" [31, 32], conducted in Finland, and in the Spanish context "Paths: from loneliness to participation" [27, 33] and "Feeling good" [34]. These programs were conducted through face-to-face group sessions. In the present project, its main components were adapted to an online format.

Therefore, we aim to assess the feasibility of an online psychosocial group-based pilot intervention named “Breaking Loneliness, Opening Community” (BLOC). The intervention followed a pre-post evaluation design aimed at testing the following hypotheses: 1) the intervention has a positive effect on participants’ feelings of loneliness, and 2) it contributes to improving social support, symptoms of depression and anxiety, quality of life, and self-reported health of the participants.

The study sample (N = 27) was mainly composed of females (74%) and the mean age was 74.26 years (66–88 years) (Table 1). Most participants had achieved a secondary education level (48%) and were married or in a relationship (33%). Significantly more women dropped out at post-intervention (p<0.05), while no significant differences were observed in the remaining sociodemographic variables. The means of the outcome variables improved from T1 to T2: quality of life, perceived health, and social support increased, while loneliness, and depressive and anxiety symptoms decreased. In the case of depressive symptoms and emotional loneliness, this improvement was statistically significant (p<0.05) with medium to large effect sizes (Table 1).

The estimated means presented in Table 2 show statistically significant decreases in depressive symptoms and emotional loneliness (p<0.01). Emotional loneliness decreased by 0.84 points on a scale of 0 to 6, and depressive symptoms decreased by 2.30 points on a scale of 0 to 24.

Most of the participants used their own computer (59.3%) or their mobile phone (29.6%) to carry out the sessions. The link to the Zoom session was mainly sent by e-mail (66.7%) or WhatsApp (29.6%). The drop-out rate was 22%. The post-intervention interview was done to the 21 participants who had at least completed one session (81% assistance to ≥5 sessions).

Qualitatively, participants positively evaluated the intervention and found in the group a space for personal growth, where they could meet new people and express themselves with confidence and security. Most participants gave their group peers their phone number to keep in touch and some even met face-to-face to do social activities.

The ‘Breaking Loneliness, Opening Community’ (BLOC) pilot intervention aimed to promote the participants’ development of coping strategies to cope with feelings of loneliness while reflecting on the social meaning of loneliness in late life and, conversely, to increase social support by being a group-based intervention. Our study sample, on average, presented moderate levels of loneliness and mild depressive symptoms at baseline, which agrees with previous literature reporting their frequent co-occurrence [46–48]. Following the intervention, participants exhibited a decrease in loneliness, notably showing a substantial reduction in emotional loneliness (p<0.01). Furthermore, the statistically significant (p<0.01) decrease in participants’ depressive symptoms highlights the importance of an intervention that can reduce depressive symptomatology, especially given the increase in the prevalence of depression during the COVID-19 pandemic [49], which already placed a substantial burden prior to the pandemic.

The intervention had a high assistance rate for the majority of the sessions and a low drop-out rate, indicators that, together with the positive qualitative evaluation of the participants, reflect the acceptability and participants’ motivation to participate in the intervention. Females were more prone to participate in the study, which aligns with previous studies that have reported that among older adults, the digital gender gap has been compensated in recent years, and now females use more internet for social contact [50, 51].

However, contrary to what we expected, we did not obtain significant changes in the outcomes related to social relationships in an objective sense (i.e., increase in social support or a reduction in social loneliness). In the present study, to recruit participants, a call was made to those individuals who “wanted to connect more and better with others”, reflecting a desire to improve their social support at that time. Almost 60% of the sample reported loneliness, having a 44% of the sample moderate loneliness (de Jong score between 3–8) and 15% severe loneliness (de Jong: 9–11), reflecting a need to enhance their social relationships and highlighting a deficiency in either the individual or community dimensions of social interactions. Nevertheless, most participants (67%) had a moderate level of social support (OSSS-3: 9–11). This could suggest that participants likely have access to social support, and that difficulties in connection might more commonly stem from the qualitative or individual aspects of their social relationships. Our sample scored higher in the dimension of emotional loneliness compared to social loneliness at baseline, which aligns with previous studies showing a peak in emotional loneliness in older adulthood, while social loneliness is more stable across adulthood and drops at later stages of life [52, 53]. The significant decrease in emotional loneliness after the intervention could be due to the participants finding a confidence and intimate environment in the intervention group, where they gave each other support and understanding when sharing their thoughts and feelings. In this way, even though perhaps their social network was already satisfactory, they did not have the necessary closeness and emotional support that the group provided them.

The content of the intervention relied on the idea that we need to address the new needs derived from the pandemic and, at the same time, attend to pre-existing unmet mental health needs from before the pandemic. A significant reduction in depressive symptomatology was identified after the intervention, with the study sample going from having mild depressive symptoms before the intervention to minimal symptomatology afterward. Therefore, interventions providing peer support groups to combat loneliness and, at the same time, increasing the likelihood of establishing satisfying social relationships might help to reduce the burden of depression among older adults and reduce the significant economic costs associated with it [54].

Interventions overcoming social distancing restrictions through online tools and targeting vulnerable population sectors (e.g., older adults) can become essential to lessen the collateral consequences of the COVID-19 pandemic on social behaviour and mental health. The present pilot study tested a promising online psychology tool to reduce emotional loneliness and depressive symptoms, with a high rate of assistance to most of the sessions and a low drop-out rate. A future randomized controlled trial is needed to explore the impact of the present intervention on a larger sample of older adults.

The authors would like to express special gratitude to all the participants for their generous contribution, which made this study possible.

Following what was approved by the Ethics Comitee, data from the BLOC project are available for use for specific research questions, provided that an agreement is made up. Research proposals should be sent to the "Impact and prevention of mental disorders" Research Group (https://www.irsjd.org/en/research/35/impact-and-prevention-of-mental-disorders↗), through the following institutional email: ParcSanitari.edadconsalud@sjd.es. Files with data published in this publication are freely available for replication purposes and can be obtained using the same analysis proposal form. The "Impact and prevention of mental disorders" Research Group will review all requests for data to ensure that proposals do not violate privacy regulations and are in keeping with informed consent that is provided by all participants.

This study was supported by “Fundació CMJ Godó”. Aina Gabarrell‐Pascuet's work is supported by the Secretariat of Universities and Research of the Generalitat de Catalunya and the European Social Fund (2023 FI-3 00187). Joan Domènech‐Abella has a “Juan de la Cierva” research contract awarded by the Spanish Ministry of Science and Innovation (MCIU: FJC2019‐038955‐I). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.