The COVID-19 pandemic has resulted in unprecedented research efforts worldwide, with groups around the globe turning their efforts to understanding all aspects of this once in a century event. The specific impact that the pandemic and ensuing lockdowns have had on mental health is still unfolding. A population-based study from Australia reported that 78% of adult respondents experienced worsening mental health since the outbreak (Newby et al., Reference Newby2020), while another large population-based study from the UK found that by 1 month into the UK lockdown, clinically significant levels of mental distress had increased at a rate that was higher than expected even after accounting for previous upward trends (Pierce et al., Reference Pierce2020). Similarly, a recent systematic review found that female gender, younger age (< 40 years), presence of psychiatric or chronic illness, and unemployment were risk factors for worsening anxiety, depression, and post-traumatic stress disorder during the pandemic (Xiong et al., Reference Xiong2020). Although the relationship between mental health and lockdowns due to COVID-19 is still evolving internationally, there are important policy implications around the impact of COVID-19 on mental health. Governments must consider interventions to protect the public from increased psychiatric symptoms where possible, and to do so, they need to focus on realistic and modifiable risk factors.
It is well established that self-reported loneliness and physical activity, two potentially modifiable lifestyle factors, are related to increased psychiatric symptoms such as depression and anxiety (Beutel et al., Reference Beutel2017; Mammen and Faulkner, Reference Mammen and Faulkner2013). Recently, researchers have attempted to understand the relationship between government-mandated lockdowns, feelings of loneliness, level of physical activity, and mental health. In one study, loneliness during COVID-19, as measured by the UCLA Loneliness Scale, was associated with depression and suicidal ideation (Killgore et al., Reference Killgore2020), and in another, adults who engaged in more physical activity during COVID-19 reported less depression on the PHQ-9 and less anxiety on the GAD-7 (Pieh et al., Reference Pieh, Budimir and Probst2020). These findings are important given loneliness and physical activity are two potentially modifiable risk factors that are likely to be impacted by government restrictions during the pandemic. Notably, no study to date has considered the impact of these two variables on mental health within the same sample nor has a study considered mental health trajectories from pre-pandemic to mid-pandemic in relation to physical activity and loneliness during lockdown.
The study by Creese et al. (Reference Creese2020) in this issue attempts to fill these gaps by investigating whether self-reported loneliness and decreased levels of physical activity were associated with worse trajectories of mental health (i.e. more depression and anxiety) for older adults during the COVID-19 pandemic compared to mental health trajectories pre-pandemic. To do so, the authors considered changes in participants’ pre- versus mid-pandemic depression and anxiety scores by modeling linear increases from 2015 to 2019 and from 2019 to 2020. The study involved 3,281 adults aged 50 years or older recruited from the ongoing UK PROTECT study. Participants were categorized as “lonely” versus “not lonely” and having “decreased” versus “similar/increased” physical activity based on responses to the UCLA Loneliness Scale and self-reported changes in physical activity, respectively. Depression was measured using the PHQ-9 and anxiety was measured using the GAD-7. People who reported feeling lonely in 2020 showed a steeper rate of decline in mental health (i.e. more depression and anxiety symptoms) from 2019 to 2020 than from 2015 to 2019, compared to those who did not report feeling lonely. Similarly, a steeper decline in mental health was found for the older adults who reported a decrease in physical activity in 2020, compared to those who reported similar/increased physical activity. However, the rate of increase in anxiety specifically was not as pronounced for those who had a history of psychiatric illness, perhaps reflecting a ceiling effect in the latter group.
This study adds important insights into the potential impact of COVID-19 on middle-aged and older adults’ mental health and is the first step in understanding how mandated lockdown or quarantine periods may impact people who felt lonely and who were less physically active in 2020. A unique strength of the study was the availability of pre-pandemic mental health data over 5 years, allowing the authors to model the rate of linear change in depression and anxiety symptoms over time, and draw conclusions about the specific impact of COVID-19, while controlling for risk factors such as gender, employment, and psychiatric history. The study utilized well-established scales for their measures of depression, anxiety, and loneliness and had unique and valuable pre- and mid-pandemic PHQ-9 and GAD-7 scores. This allowed the authors to utilize a large sample to draw conclusions about the patterns of change from the 5 years before COVID-19 compared to 2019–2020, while controlling for covariates which are known risk factors. As mentioned earlier, it is crucial for governments to understand who is at risk for worsening mental health and which modifiable variables can be targeted for intervention. This study by Creese contributes to this open question.
While the study had several strengths in relation to tracking mental health symptoms from pre- to mid-pandemic, some limitations deserve mention. Firstly, it may be tempting to argue that COVID-19 is the direct cause of loneliness and reduced physical activity for some, rendering these individuals particularly vulnerable to worsening mental health during isolation. However, no case for causality can be drawn from these data nor is there an ability to distinguish directionality as the authors do not have pre-pandemic measures of loneliness or physical activity. It is therefore not possible to comment on whether the pandemic caused loneliness and reduced activity, and in turn worse mental health for some, or whether preexisting loneliness and/or a history of less physical activity mediated the impact of COVID-19 on mental health for these individuals. Secondly, Creese et al. did not collect data on the type, duration, or intensity of physical activity. This leaves an open question as to the type and amount of physical activity required to maintain good mental health during a pandemic. Finally, the current study only utilized a measure of generalized anxiety and did not provide details about psychiatric history. Thus, it is unknown whether individuals with certain mental health conditions such as illness anxiety disorder or obsessive-compulsive disorder (American Psychiatric Association, 2013) may be more vulnerable to experiencing a worsening of symptoms during lockdowns. Future studies with pre-pandemic longitudinal data on loneliness and physical activity should seek to conduct similar analyses to Creese and colleagues, while controlling for these variables, to tease apart the direction of the relationship between loneliness, physical activity, and mental health during COVID-19. If and where possible, studies should also consider whether the type of physical activity and/or type of mental health condition moderates these effects.
The risk of COVID-19 infection is greatest among older adults, and for this reason, they have been among the first to go into and last to come out of lockdown. As a result, older adults are more likely to experience acute and severe social isolation and associated deleterious mental health impacts (Hwang et al., Reference Hwang2020), such as loneliness, worsening mental health, and psychological distress during COVID-19 (Forlenza and Stella, Reference Forlenza and Stella2020; Frenkel-Yosef et al., Reference Frenkel-Yosef, Maytles and Shrira2020). Creese and colleagues’ study is helpful in identifying older adults who may be most at risk of experiencing worse depression and anxiety during – and potentially after – the pandemic. That is, older adults who self-report feeling lonely and doing less physical activity than previously should be a target group for geriatric providers, policy-makers, and community groups. Further, family members and older adults themselves may take note of these risk factors and consider ways to lessen the impact of social distancing on social and mental health by finding alternative methods for staying connected and physically active (Hwang et al., Reference Hwang2020; Vernooij-Dassen et al., Reference Vernooij-Dassen, Verhey and Lapid2020).
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The COVID-19 pandemic has resulted in unprecedented research efforts worldwide, with groups around the globe turning their efforts to understanding all aspects of this once in a century event. The specific impact that the pandemic and ensuing lockdowns have had on mental health is still unfolding. A population-based study from Australia reported that 78% of adult respondents experienced worsening mental health since the outbreak (Newby et al., Reference Newby2020), while another large population-based study from the UK found that by 1 month into the UK lockdown, clinically significant levels of mental distress had increased at a rate that was higher than expected even after accounting for previous upward trends (Pierce et al., Reference Pierce2020). Similarly, a recent systematic review found that female gender, younger age (< 40 years), presence of psychiatric or chronic illness, and unemployment were risk factors for worsening anxiety, depression, and post-traumatic stress disorder during the pandemic (Xiong et al., Reference Xiong2020). Although the relationship between mental health and lockdowns due to COVID-19 is still evolving internationally, there are important policy implications around the impact of COVID-19 on mental health. Governments must consider interventions to protect the public from increased psychiatric symptoms where possible, and to do so, they need to focus on realistic and modifiable risk factors.
It is well established that self-reported loneliness and physical activity, two potentially modifiable lifestyle factors, are related to increased psychiatric symptoms such as depression and anxiety (Beutel et al., Reference Beutel2017; Mammen and Faulkner, Reference Mammen and Faulkner2013). Recently, researchers have attempted to understand the relationship between government-mandated lockdowns, feelings of loneliness, level of physical activity, and mental health. In one study, loneliness during COVID-19, as measured by the UCLA Loneliness Scale, was associated with depression and suicidal ideation (Killgore et al., Reference Killgore2020), and in another, adults who engaged in more physical activity during COVID-19 reported less depression on the PHQ-9 and less anxiety on the GAD-7 (Pieh et al., Reference Pieh, Budimir and Probst2020). These findings are important given loneliness and physical activity are two potentially modifiable risk factors that are likely to be impacted by government restrictions during the pandemic. Notably, no study to date has considered the impact of these two variables on mental health within the same sample nor has a study considered mental health trajectories from pre-pandemic to mid-pandemic in relation to physical activity and loneliness during lockdown.
The study by Creese et al. (Reference Creese2020) in this issue attempts to fill these gaps by investigating whether self-reported loneliness and decreased levels of physical activity were associated with worse trajectories of mental health (i.e. more depression and anxiety) for older adults during the COVID-19 pandemic compared to mental health trajectories pre-pandemic. To do so, the authors considered changes in participants’ pre- versus mid-pandemic depression and anxiety scores by modeling linear increases from 2015 to 2019 and from 2019 to 2020. The study involved 3,281 adults aged 50 years or older recruited from the ongoing UK PROTECT study. Participants were categorized as “lonely” versus “not lonely” and having “decreased” versus “similar/increased” physical activity based on responses to the UCLA Loneliness Scale and self-reported changes in physical activity, respectively. Depression was measured using the PHQ-9 and anxiety was measured using the GAD-7. People who reported feeling lonely in 2020 showed a steeper rate of decline in mental health (i.e. more depression and anxiety symptoms) from 2019 to 2020 than from 2015 to 2019, compared to those who did not report feeling lonely. Similarly, a steeper decline in mental health was found for the older adults who reported a decrease in physical activity in 2020, compared to those who reported similar/increased physical activity. However, the rate of increase in anxiety specifically was not as pronounced for those who had a history of psychiatric illness, perhaps reflecting a ceiling effect in the latter group.
This study adds important insights into the potential impact of COVID-19 on middle-aged and older adults’ mental health and is the first step in understanding how mandated lockdown or quarantine periods may impact people who felt lonely and who were less physically active in 2020. A unique strength of the study was the availability of pre-pandemic mental health data over 5 years, allowing the authors to model the rate of linear change in depression and anxiety symptoms over time, and draw conclusions about the specific impact of COVID-19, while controlling for risk factors such as gender, employment, and psychiatric history. The study utilized well-established scales for their measures of depression, anxiety, and loneliness and had unique and valuable pre- and mid-pandemic PHQ-9 and GAD-7 scores. This allowed the authors to utilize a large sample to draw conclusions about the patterns of change from the 5 years before COVID-19 compared to 2019–2020, while controlling for covariates which are known risk factors. As mentioned earlier, it is crucial for governments to understand who is at risk for worsening mental health and which modifiable variables can be targeted for intervention. This study by Creese contributes to this open question.
While the study had several strengths in relation to tracking mental health symptoms from pre- to mid-pandemic, some limitations deserve mention. Firstly, it may be tempting to argue that COVID-19 is the direct cause of loneliness and reduced physical activity for some, rendering these individuals particularly vulnerable to worsening mental health during isolation. However, no case for causality can be drawn from these data nor is there an ability to distinguish directionality as the authors do not have pre-pandemic measures of loneliness or physical activity. It is therefore not possible to comment on whether the pandemic caused loneliness and reduced activity, and in turn worse mental health for some, or whether preexisting loneliness and/or a history of less physical activity mediated the impact of COVID-19 on mental health for these individuals. Secondly, Creese et al. did not collect data on the type, duration, or intensity of physical activity. This leaves an open question as to the type and amount of physical activity required to maintain good mental health during a pandemic. Finally, the current study only utilized a measure of generalized anxiety and did not provide details about psychiatric history. Thus, it is unknown whether individuals with certain mental health conditions such as illness anxiety disorder or obsessive-compulsive disorder (American Psychiatric Association, 2013) may be more vulnerable to experiencing a worsening of symptoms during lockdowns. Future studies with pre-pandemic longitudinal data on loneliness and physical activity should seek to conduct similar analyses to Creese and colleagues, while controlling for these variables, to tease apart the direction of the relationship between loneliness, physical activity, and mental health during COVID-19. If and where possible, studies should also consider whether the type of physical activity and/or type of mental health condition moderates these effects.
The risk of COVID-19 infection is greatest among older adults, and for this reason, they have been among the first to go into and last to come out of lockdown. As a result, older adults are more likely to experience acute and severe social isolation and associated deleterious mental health impacts (Hwang et al., Reference Hwang2020), such as loneliness, worsening mental health, and psychological distress during COVID-19 (Forlenza and Stella, Reference Forlenza and Stella2020; Frenkel-Yosef et al., Reference Frenkel-Yosef, Maytles and Shrira2020). Creese and colleagues’ study is helpful in identifying older adults who may be most at risk of experiencing worse depression and anxiety during – and potentially after – the pandemic. That is, older adults who self-report feeling lonely and doing less physical activity than previously should be a target group for geriatric providers, policy-makers, and community groups. Further, family members and older adults themselves may take note of these risk factors and consider ways to lessen the impact of social distancing on social and mental health by finding alternative methods for staying connected and physically active (Hwang et al., Reference Hwang2020; Vernooij-Dassen et al., Reference Vernooij-Dassen, Verhey and Lapid2020).