Addressing the threat of loneliness and depression in older adults
Authors: Marcia Scazufca, Nadine Seward
Journal: The Lancet Healthy Longevity (2024)

WHO launched a new Commission on Social Connection in November, 2023, to address loneliness as a pressing global health threat.1WHOWHO Commission on Social Connection.https://www.who.int/groups/commission-on-social-connectionDate: November, 2023Date accessed: November 28, 2023Google Scholar Current estimates suggest that one in four older adults experience social isolation, putting them at increased risk of depression, stroke, anxiety, dementia, suicide, and early mortality.1WHOWHO Commission on Social Connection.https://www.who.int/groups/commission-on-social-connectionDate: November, 2023Date accessed: November 28, 2023Google Scholar The implementation of physical distancing requirements during the COVID-19 pandemic reduced levels of social networking, resulting in increased levels of loneliness, depression, and chronic health conditions.1WHOWHO Commission on Social Connection.https://www.who.int/groups/commission-on-social-connectionDate: November, 2023Date accessed: November 28, 2023Google Scholar, 2Steptoe A Di Gessa G Mental health and social interactions of older people with physical disabilities in England during the COVID-19 pandemic: a longitudinal cohort study.Lancet Public Health. 2021; 6: e365-e373Summary Full Text Full Text PDF PubMed Scopus (101) Google Scholar These events have raised awareness of the importance of the issue of loneliness and, consequently, research has now started to emerge on the usefulness of psychological therapies to improve social connections and loneliness, and reduce levels of depression in times of social isolation.1WHOWHO Commission on Social Connection.https://www.who.int/groups/commission-on-social-connectionDate: November, 2023Date accessed: November 28, 2023Google Scholar Before the pandemic, there was accumulating evidence on the effectiveness of collaborative care psychosocial programmes in mitigating depression and, in some instances, loneliness in older adults, based on face-to-face task-sharing approaches (delivered via trained lay people or non-specialist mental health providers).3Gilbody S Bower P Fletcher J Richards D Sutton AJ Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes.Arch Intern Med. 2006; 166: 2314-2321Crossref PubMed Scopus (1048) Google Scholar, 4Scazufca M Nakamura C Seward N et al.A task-shared, collaborative care psychosocial intervention for improving depressive symptomatology among older adults in a socioeconomically deprived area of Brazil (PROACTIVE): a pragmatic, two-arm, parallel-group, cluster-randomised controlled trial.Lancet Healthy Longev. 2022; 3: e690-e702Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar However, many of the challenges brought on by the pandemic highlighted the urgent need to develop evidence-based psychological interventions that do not involve face-to-face contact. Simon Gilbody and colleagues5Littlewood E McMillan D Chew Graham C et al.Can we mitigate the psychological impacts of social isolation using behavioural activation? Long-term results of the UK BASIL urgent public health COVID-19 pilot randomised controlled trial and living systematic review.Evid Based Ment Health. 2022; 25: e49-e57Crossref Scopus (2) Google Scholar piloted an intervention aimed at mitigating loneliness and depression in the UK, which showed promising results. The same research group has created a living systematic review (PROSPERO, CRD42021298788) that shows the overall effectiveness of cognitive and behavioural approaches for loneliness and depression in individuals aged older than 18 years. In The Lancet Healthy Longevity, Gilbody and colleagues6Gilbody S Littlewood E McMillan D et al.Behavioural activation to mitigate the psychological impacts of COVID-19 restrictions on older people in England and Wales (BASIL+): a pragmatic randomised controlled trial.Lancet Healthy Longev. 2024; 5: e97-107Google Scholar report the key findings of BASIL+, a robust, pragmatic randomised controlled trial conducted to evaluate the effectiveness of an innovative psychological intervention in mitigating depression and loneliness during the COVID-19 pandemic. BASIL+ was delivered via telephone over eight sessions to older adults (aged ≥65 years) with depression and chronic health conditions. Traditional approaches to behavioural activation encourage patients to engage in meaningful and enjoyable activities that help to improve symptoms of depression.7Samad Z Brealey S Gilbody S The effectiveness of behavioural therapy for the treatment of depression in older adults: a meta-analysis.Int J Geriatr Psychiatry. 2011; 26: 1211-1220Crossref PubMed Scopus (34) Google Scholar BASIL+ adapted the behavioural activation approach to encourage patients to engage in meaningful and enjoyable activities that specifically improve social connectedness due to the physical distancing requirements during the COVID-19 pandemic. The results of the short-term follow-up of the BASIL+ trial show that there are solutions available that can help improve levels of emotional loneliness and depression severity in an older population. However, the BASIL+ trial did not find evidence of improvements for the secondary outcomes of social loneliness, anxiety, and quality of life. Once results from the longer-term follow-up are available, we will understand whether the effects of this brief intervention are maintained. The challenges of implementing and evaluating BASIL+ cannot go unnoticed. First, the trial took place during the COVID-19 pandemic when health systems were not only overstretched but also ill prepared for the devastating impact of the pandemic on loneliness and depression in older people.2Steptoe A Di Gessa G Mental health and social interactions of older people with physical disabilities in England during the COVID-19 pandemic: a longitudinal cohort study.Lancet Public Health. 2021; 6: e365-e373Summary Full Text Full Text PDF PubMed Scopus (101) Google Scholar, 8Patel K Robertson E Kwong ASF et al.Psychological distress before and during the COVID-19 pandemic among adults in the United Kingdom based on coordinated analyses of 11 longitudinal studies.JAMA Netw Open. 2022; 5e227629 Crossref Scopus (88) Google Scholar Second, the trial enrolled older adults with multiple and interconnected health needs, including depression and at least two long-term conditions. Such a combination of health conditions places people at increased risk of negative social and health outcomes.9Donovan NJ Blazer D Social isolation and loneliness in older adults: review and commentary of a National Academies Report.Am J Geriatr Psychiatry. 2020; 28: 1233-1244Summary Full Text Full Text PDF PubMed Scopus (175) Google Scholar Given the interconnected health needs of this population and the associated complexity surrounding these issues, research is now needed to understand whether the BASIL+ intervention can be adapted into a collaborative care approach. As an example, a collaborative care component could be offered whereby the health worker delivering the remote sessions also refers patients to primary care to address any unmet health needs. Sessions could also incorporate materials to help patients better manage a healthy lifestyle. More research is also needed to understand whether BASIL+ is effective beyond the COVID-19 pandemic in older adults who are at risk of social isolation and loneliness. Robust, participatory, theory-informed implementation research can help to address many of these questions, facilitating widespread scale-up.10Seward N Hanlon C Hinrichs-Kraples S et al.A guide to systems-level, participatory, theory-informed implementation research in global health.BMJ Global Health. 2021; 6e005365 Crossref Scopus (13) Google Scholar The COVID-19 pandemic exposed how health systems globally were unprepared to prevent and care for the short-term and long-term consequences of social isolation imposed not only by health emergencies but also by chronic conditions in older adults. BASIL+ is an example of how psychological interventions integrated into the health system can help the most vulnerable populations experiencing social isolation. Climate change, violence, war, migration, and outbreaks of infectious diseases are increasingly becoming frequent events in our societies. We are also experiencing a rapidly ageing population that is at risk of social isolation due to disabilities and chronic health conditions. With the launch of the new WHO commission on Social Connection, the time is ripe for funding opportunities to implement and expand programmes at a global level. We declare no competing interests. Behavioural activation to mitigate the psychological impacts of COVID-19 restrictions on older people in England and Wales (BASIL+): a pragmatic randomised controlled trialBehavioural activation is an effective and potentially scalable intervention that can reduce symptoms of depression and emotional loneliness in at-risk groups in the short term. The findings of this trial add to the range of strategies to improve the mental health of older adults with multiple long-term conditions. These results can be helpful to policy makers beyond the pandemic in reducing the global burden of depression and addressing the health impacts of loneliness, particularly in at-risk groups. Full-Text PDF Open Access