COVID-19 and Social Isolation Endangering Psychological Health of Older Adults: Implications for Telepsychiatry

1.1 Shielding, social isolation, loneliness, and psychological health

COVID-19 containment measures, including the shielding strategies, are significantly more aversive for older adults [19, 20]. The effect of shielding induced social isolation can be explained by two core constructs of psychological well-being (PWB), including purpose in life and personal growth [23, 24]. Aging involves a decline in these constructs, which may translate into social isolation and loneliness [23, 24]. Social isolation is an objective state of being physically separated from others, whereas loneliness is perceived or subjective isolation [19, 25]. In other words, living alone does not mean social isolation. At the same time, it is possible for someone to feel alone (loneliness) despite being surrounded by people [14]. In the U.S., nearly one-fourth of the older population live alone, but they are not socially isolated [19]. Social isolation and loneliness are among the main drivers of physical and psychosocial health outcomes among older adults [25, 26]. However, unique contributions to social isolation and loneliness remain equivocal [20, 21]. Loneliness is a long-standing public health concern among older populations and poses a comparable mortality threat as other well-established risk factors, such as smoking, physical inactivity, and obesity [25]. Loneliness can alter the cell mechanisms to promote inflammation, thereby increasing the susceptibility to infections [19]. Individuals with robust social integrations and supporting web are more likely to have better survival and emotional well-being compared to those being socially disconnected or lonely [27, 28]. Additionally, prolonged duration of loneliness has elevated psychological symptoms, substance abuse, and suicide rates among older adults [27, 28].

1.2 Stressors and contributing factors

Social connectedness or relationships influence mental health by stress-buffering and the mechanisms of the main effect [26, 27, 28, 29]. Stress buffering assumes the association of social integration with the psychological health of individuals under stress conditions. In contrast, the main effects model is based on the belief that social ties improve mental health irrespective of the presence or absence of stress [26, 27, 28, 29]. Stressors, including impaired physical health status, reduced mobility, lack of independence, the presence of comorbid conditions, retirement, confinement to home, fear of losing close relative, spouse bereavement, are cited as contributing factors of social isolation and adverse psychological health outcomes among the older adults [27, 28, 29]. In the context of COVID-19, the grief of losing loved ones, fear of dying with no family members around are the amplifying factors of social isolation [23, 27, 28, 29]. Given the high contagious nature of the SARS-CoV-2, hospitals and nursing institutions have restricted the entry of the visitors, resulting in older adults dying in isolation, leaving behind their partners with the agony of loss and separation [28, 29]. Due to the high prevalence of COVID-19, and the interplay between biological, environmental, and social factors, the impact on the psychological well-being of older people is likely to escalate in the foreseeable future. Therefore, addressing the social, healthcare, and emotional needs of the older population should take precedence to improve the psychological health outcomes.

1.3 Shielding, social isolation, and healthcare utilization

As an indirect benefit, shielding may help in reducing the demand for hospital beds by mitigating COVID-19 transmission among individuals with pre-existing chronic conditions [7]. More often, chronic conditions require hospital admissions for performing specialized treatments, thus increasing health care utilization and associated expenditures [30]. Besides, cognitive impairment and depressive symptoms, resulting from chronic loneliness, were reported as significant sources of increased hospital utilization trends among the older population [30]. Nearly 1 in 3 older adults found to have chronic loneliness and had multiple physician offices, visits, emergency visits, and inpatient hospital stays [25, 26, 27, 28, 29, 30, 31]. Socially isolated individuals, especially older adults, tend to utilize more medical services to stimulate interpersonal interactions for satisfying their social needs [31].

1.4 The spectrum of psychological morbidities

COVID-19 has the potential to trigger a myriad of mental health problems among older adults. Some of the salient ones are discussed here. The first one is depression, which is characterized by low mood, diminished interest in activities, loss or gain of weight, decrease or increase in appetite, sleep irregularities, psychomotor agitation or retardation, tiredness, feelings of worthlessness accompanied by unwarranted guilt, reduced ability to think or focus, being indecisive, recurrent thoughts of death, suicidal ideation or a suicide attempt with a particular plan [32]. Several reports revealed higher levels of depression among older adults during COVID-19 [33, 34]. The second one is the potential precipitation of manic episodes in bipolar patients [34]. These episodes include a long period of joy or excessive happiness, extreme irritability, agitation, talking rapidly, jumping from one idea to another, having racing thoughts, being easily distractible, increasing goal-directed activities, such as taking on new projects, being restless, sleeping less than usual, having an unrealistic belief in one’s abilities, and impulsive behavior such as spending sprees, impulsive sex, and hasty business investments [35]. The third set of mental health problems can manifest as anxiety disorders, some of which are particularly relevant during COVID-19, including panic disorder and agoraphobia, posttraumatic stress disorder (PTSD), and generalized anxiety disorder. Bouts of anxiety or panic attacks are discrete periods of intense fear or discomfort that develops abruptly and peaks within 10 minutes. Additionally, panic disorder is accompanied by the subjective feelings of heart racing, shaking, dizziness, shortness of breath, sometimes chest pain, a fear of losing control, fear of dying, derealisation, depersonalization, dizziness, and paraesthesia [32]. PTSD is related to a traumatic experience and is characterized by three actions: re-experiencing the trauma, avoiding stimuli related to trauma, and experiencing symptoms of increased autonomic activation such as insomnia, irritability, and hypervigilance [35]. Finally, generalized anxiety disorder is associated with frequent and lasting worry, which is not in synchrony with the actual circumstances. Anxiety can get accentuated among older adults during COVID-19 [35, 36].

1.5 Psychosocial impact of COVID-19 among older adults

COVID-19 pandemic has a devastating effect on the psychological well-being of older adults. According to the national survey of 1468 U.S. adults, the prevalence of psychological distress among older adults ($>$ 55 years) was 7.3%, compared to the 3.9% reported during pre-pandemic circumstances in 2018 [36, 37]. Reportedly, loneliness has increased by 3% during COVID-19, which suggests that loneliness is not the sole risk factor of psychological morbidities [36, 37]. Another Spain based study cited loss of loved ones, hospitalization of a family member, fear of dying, financial insecurity, low socioeconomic status, and raial disparities as potential risk factors, which may be attributed to the greater psychological distress among older adults [28, 29, 36, 37]. In the United Kingdom, the prevalence of psychological distress increased from 18.9% to 27.3%, of which individuals with pre-existing chronic conditions, low-income households, and those belong to Asian ethnicity form a sizable proportion [36, 37]. It is important to emphasize that these findings were only limited to community-dwelling older adults; the psychological impact of COVID-19 among institutionalized older adults remains the subject of investigation till today.

1.6 Risk factors

The impact on physical health is closely tied with multiple aspects of the psychological constructs [22, 23, 24]. For instance, older adults with debilitating conditions may experience loss of autonomy and a decline in social interactions. Given the physical limitations, they lose the ability to engage in social activities, which eventually reduces the size of their social support system. In determining the risk factors of mental health in the context of COVID-19, one should be mindful of accounting potential effect modifiers, mediators, and confounders such as a change in lifestyle or daily routine, type of living arrangement (residential vs. institution), fear of losing loved ones, fear of dying, lack of economic resources, and limited communication capabilities, etc.[22, 26, 28, 29] The exploration of these factors marks avenues for future research to inform policies aimed to promote the psychological well-being of older adults in the wake of COVID-19.

1.7 Influence of COVID-19 on social capital

Social capital is a sociological construct that explains the functioning of social groups using two components of community participation that entails what people do (such as contacts with friends, neighbors, civic engagement, etc.) and social cohesion consisting of what people feel (such as belongingness, social trust, cooperation, etc.) [38, 39, 40]. This construct is especially vital for the well-being of older populations [40, 41, 42]. However, the COVID-19 pandemic has lowered both the community participation and social cohesion aspects of social capital, thereby negatively affecting the well-being, especially among older adults. There is a need to enhance the feeling of community participation and social cohesion among the older population during the COVID-19 crisis. Social cohesion can be improved by making phone calls, using online forums and listservs, utilizations of text messaging, telepsychiatry services, and other such means.

1.8 Prevention and treatment of mental health problems for older adults in the COVD-19 pandemic

Primary prevention strategies of mental health problems in older adults during COVID-19 interventions should aim to build positive factors such as hardiness, sense of coherence, optimism, social support, self-esteem, and self-efficacy, physical activity [42, 43, 44, 45, 46]. These can be delivered through web-based educational interventions by mental health educators or psychiatrists through telepsychiatry. For secondary prevention of mental health problems in older adults during COVID-19, screening and early treatments are essential, for these telepsychiatry interventions are vital, followed by psychopharmacological and psychotherapeutic interventions. Details of psychopharmacological and psychotherapeutic interventions are beyond the scope of this commentary. However, it cannot be overemphasized that telepsychiatry can play a pivotal role in addressing the gaps both in the delivery of primary and secondary prevention of mental health problems among older adults.

1.9 Strategies to improve social connectivity

First, it is essential to understand that ”physical distancing” and ”social distancing” are not interchangeable terms. It is possible to practice physical distancing while being socially integrated. Public health interventions to build community-based and family networks for providing social and emotional support will be beneficial in improving the psychological well-being of the older population. The association of social support with improved mental health has already been acknowledged by previous studies [46, 47]. Also, there is enough supporting evidence, which emphasizes the effectiveness of peer support groups among the older population for satisfying the social needs of those experiencing loneliness [47, 48]. Access to telepsychiatry services with psychological assistance tools (like talk therapy) can be beneficial in addressing the psychological needs and help in improving the mental well-being of the older population. Access to digital technologies and increased participation of older people in the digital society will help in strengthening social inclusion among the older population. The gap in computer literacy across generations (also known as the digital divide) can pose the challenge, for which intergenerational technology learning can be viewed as a potential solution [47, 48, 49]. The evidence-based interventions using the fourth-generation Multi-Theory Model (MTM) can also be developed to increase the uptake of technology among older adults [50].

1.10 Challenges and barriers for the adoption of telepsychiatry

Telepsychiatry (or e-psychiatry) services have helped people to access psychological assistance tools (e.g., cognitive behavioral therapy) while maintaining a pharmaceutical medication regimen among patients utilizing psychotropic drugs to support mental well-being [51]. However, barriers in the adoption of telepsychiatry vary widely worldwide [52]. The principal barriers include technological issues, resistance to change, cost, age (which is relevant to your topic), and level of digital literacy, time, socioeconomic status, level of education, digital literacy, language barriers, unavailability of electronic devices or phones among patients, and internet connectivity and resistance to change identified by previous studies conducted in the U.S., U.K., Belgium, Australia, Netherlands, Africa, Iran, Saudi Arabia, and India [53, 54, 55, 56, 57, 58, 59, 60]. One of the main barriers to telepsychiatry is ensuring prospective patients have access to internet-accessible technology and poor internet connectivity or lacking access completely; it a significant obstacle in telemedicine.

A 2017 survey by the Pew Research Center exploring technology use among older adults found that nearly 51% of older adults in the U.S. (aged 65 and older) reported having access to high-speed broadband [61]. Technology adoption varied significantly with socioeconomic status or income status [61, 62]. Nearly 87% of older adults who are affluent had internet access compared to only 27% among those with lower income ( $<$ 30,000 /year) [61]. The level of income was positively correlated with the ownership of smartphones [61]. Socioeconomic risk factors affect older adults more than younger adults due to the fixed-income constraints faced by many older adults, who may no longer be working. Many retired or widowed older adults may not have enough money to access internet-capable technology. Resistance to technology is another factor that influences the rates of technology acceptance and utilization [63].

People living in urban areas have fewer barriers to health services than those living in rural areas. Rural-dwelling older adults will have less access to physicians, must travel much farther for health services, and may also be lacking access to community mental health services [63]. Also, those who are living in rural areas are less likely than those in urban areas to access the internet due to technological access limitations [60]. In the U.S., 19 million people living in rural or tribal areas (6% of the population), are lacking access to high-speed broadband internet, according to the U.S. Federal Communications Commission (FCC) report of 2020 [64]. Consistent with this report, per the Telecom Regularity Authority of India, only 28% of people residing in rural areas had access to the internet, illustrating the challenge posed in telemedicine [60]. These financial and technological access issues are substantial barriers that require infrastructure investments and technology acquisition assistance that is not currently available in the middle of the COVID-19 pandemic.

Other issues include stigmatization, privacy, and digital literacy. Particularly with the telepsychiatry, accessing mental health care still has a stigma for many people. Some older adults may feel uncomfortable using telepsychiatry for their mental health needs due to concerns over privacy, confidentiality, or quality of the interaction [60]. But some patients may feel more comfortable sharing personal information from the privacy of their own homes, instead of in a doctor’s office setting that may feel less private. Also, digital literacy and computer use skills may not be as advanced in this population, potentially requiring assistance in setting up the hardware needed for effective telemedicine appointments (such as a computer, webcam, and microphone) [61]. It is essential to understand these barriers and challenges to improve support for older adults around the use of technology and telemedicine. Intergenerational pieces of training and peer support interventions will play instrumental roles in overcoming these obstacles.