[Skip to Content]
[Skip to Content Landing]

Effect of Layperson-Delivered, Empathy-Focused Program of Telephone Calls on Loneliness, Depression, and Anxiety Among Adults During the COVID-19 PandemicA Randomized Clinical Trial

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Can a program of empathetic conversations delivered by laypeople via telephone reduce loneliness, depression, and anxiety in at-risk older adults?

Findings  In this randomized clinical trial of 240 older adults receiving services through a Meals on Wheels organization, a 4-week empathy-oriented telephone program delivered by rapidly trained lay callers during the coronavirus disease 2019 pandemic improved loneliness, depression, anxiety, and general mental health.

Meaning  In this study, loneliness, depression, and anxiety were rapidly reduced through layperson-delivered calls that focused on empathetic listening, suggesting a scalable approach to persistent mental health challenges of older adults.


Importance  Loneliness is a risk factor for many clinical conditions, but there are few effective interventions deployable at scale.

Objective  To determine whether a layperson-delivered, empathy-focused program of telephone calls could rapidly improve loneliness, depression, and anxiety in at-risk adults.

Design, Setting, and Participants  From July 6 to September 24, 2020, we recruited and followed up 240 adults who were assigned to receive calls (intervention group) or no calls (control group) via block randomization. Loneliness, depression, and anxiety were measured using validated scales at enrollment and after 4 weeks. Intention-to-treat analyses were conducted. Meals on Wheels Central Texas (MOWCTX) clients received calls in their homes or wherever they might have been when the call was received. The study included MOWCTX clients who fit their service criteria, including being homebound and expressing a need for food. A total of 296 participants were screened, of whom 240 were randomized to intervention or control.

Interventions  Sixteen callers, aged 17 to 23 years, were briefly trained in empathetic conversational techniques. Each called 6 to 9 participants over 4 weeks daily for the first 5 days, after which clients could choose to drop down to fewer calls but no less than 2 calls a week.

Main Outcomes and Measures  Primary outcome was loneliness (3-item UCLA Loneliness Scale, range 3-9; and 6-item De Jong Giervald Loneliness [De Jong] Scale, range 0-6). Secondary outcomes were depression (Personal Health Questionnaire for Depression), anxiety (Generalized Anxiety Disorder scale), and self-rated health (Short Form Health Survey Questionnaire).

Results  The 240 participants were aged 27 to 101 years, with 63% aged at least 65 years (n = 149 of 232), 56% living alone (n = 135 of 240), 79% women (n = 190 of 240), 39% Black or African American (n = 94 of 240), and 22% Hispanic or Latino (n = 52 of 240), and all reported at least 1 chronic condition. Of 240 participants enrolled, 13 were lost to follow-up in the intervention arm and 1 in the control arm. Postassessment differences between intervention and control after 4 weeks showed an improvement of 1.1 on the UCLA Loneliness Scale (95% CI, 0.5-1.7; P < .001; Cohen d of 0.48), and improvement of 0.32 on De Jong (95% CI, −0.20 to 0.81; P = .06; Cohen d, 0.17) for loneliness; an improvement of 1.5 on the Personal Health Questionnaire for Depression (95% CI, 0.22-2.7; P < .001; Cohen d, 0.31) for depression; and an improvement of 1.8 on the Generalized Anxiety Disorder scale (95% CI, 0.44 to 3.2; P < .001; Cohen d, 0.35) for anxiety. General physical health on the Short Form Health Questionnaire Survey showed no change, but mental health improved by 2.6 (95% CI, 0.81 to 4.4; P = .003; Cohen d of 0.46).

Conclusions and Relevance  A layperson-delivered, empathy-oriented telephone call program reduced loneliness, depression, and anxiety compared with the control group and improved the general mental health of participants within 4 weeks. Future research can determine whether effects on depression and anxiety can be extended to maximize clinical relevance.

Trial Registration  ClinicalTrials.gov Identifier: NCT04595708

Sign in to take quiz and track your certificates

Buy This Activity
Our websites may be periodically unavailable between 7:00pm CT February 4, 2023 and 1:00am CT February 5, 2023 for regularly scheduled maintenance.

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Maninder K. Kahlon, PhD, Dell Medical School, The University of Texas at Austin, 1501 Red River St, Austin, TX 78712 (mkahlon@austin.utexas.edu).

Accepted for Publication: January 22, 2021.

Published Online: February 23, 2021. doi:10.1001/jamapsychiatry.2021.0113

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Kahlon MK et al. JAMA Psychiatry.

Author Contributions: Drs Kahlon and Aksan had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Kahlon, Aubrey, Jacobs, Mundhenk, Tomlinson.

Acquisition, analysis, or interpretation of data: Kahlon, Aksan, Aubrey, Clark, Cowley-Morillo, Jacobs, Sebastian.

Drafting of the manuscript: Kahlon, Aksan, Clark, Cowley-Morillo, Tomlinson.

Critical revision of the manuscript for important intellectual content: Kahlon, Aksan, Aubrey, Clark, Jacobs, Mundhenk, Sebastian.

Statistical analysis: Aksan.

Obtained funding: Kahlon.

Administrative, technical, or material support: Kahlon, Clark, Cowley-Morillo, Jacobs, Sebastian.

Supervision: Kahlon, Aubrey, Clark, Jacobs.

Conflict of Interest Disclosures: Drs Kahlon, Aksan, Aubrey, and Clark reported grants from Episcopal Health Foundation during the conduct of the study. No other disclosures were reported.

Funding/Support: Funding came from Dell Medical School, University of Texas at Austin and from the Episcopal Health Foundation, Houston, Texas.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2.

Additional Contributions: We thank Meals on Wheels Central Texas (MOWCTX) and specifically Seanna Marceaux, MS, RDN, LD, Nayely Gutierrez, RDN, LD, and Lauren Sasser, MPH, for their collaboration and insights, and Keegan Kinney and Jenna Parro, MHA, for editing support.

National Academies of Sciences, Engineering, and Medicine.  Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Washington, DC: The National Academies Press; 2020. doi:10.17226/25663.
Cacioppo  JT , Hughes  ME , Waite  LJ , Hawkley  LC , Thisted  RA .  Loneliness as a specific risk factor for depressive symptoms: cross-sectional and longitudinal analyses.   Psychol Aging. 2006;21(1):140-151. doi:10.1037/0882-7974.21.1.140PubMedGoogle ScholarCrossref
Luchetti  M , Lee  JH , Aschwanden  D ,  et al.  The trajectory of loneliness in response to COVID-19.   Am Psychol. 2020;75(7):897-908. doi:10.1037/amp0000690PubMedGoogle ScholarCrossref
McGinty  EE , Presskreischer  R , Han  H , Barry  CL .  Psychological distress and loneliness reported by US adults in 2018 and April 2020.   JAMA. 2020;324(1):93-94. doi:10.1001/jama.2020.9740PubMedGoogle ScholarCrossref
Killgore  WDS , Cloonan  SA , Taylor  EC , Dailey  NS .  Loneliness: a signature mental health concern in the era of COVID-19.   Psychiatry Res. 2020;290:113117. doi:10.1016/j.psychres.2020.113117PubMedGoogle Scholar
Bu  F , Steptoe  A , Fancourt  D .  Loneliness during a strict lockdown: trajectories and predictors during the COVID-19 pandemic in 38,217 United Kingdom adults.   Soc Sci Med. 2020;265:113521. doi:10.1016/j.socscimed.2020.113521PubMedGoogle Scholar
van Tilburg  TG , Steinmetz  S , Stolte  E , van der Roest  H , de Vries  DH .  Loneliness and mental health during the COVID-19 pandemic: a study among Dutch older adults.   J Gerontol B Psychol Sci Soc Sci. 2020:gbaa111. doi:10.1093/geronb/gbaa111PubMedGoogle Scholar
McGinty  EE , Presskreischer  R , Anderson  KE , Han  H , Barry  CL .  Psychological distress and COVID-19–related stressors reported in a longitudinal cohort of US adults in April and July 2020.   JAMA. 2020;324(24):2555-2557. doi:10.1001/jama.2020.21231PubMedGoogle ScholarCrossref
Vahia  IV , Jeste  DV , Reynolds  CF  III .  Older adults and the mental health effects of COVID-19.   JAMA. 2020;324(22):2253-2254. doi:10.1001/jama.2020.21753PubMedGoogle ScholarCrossref
Masi  CM , Chen  HY , Hawkley  LC , Cacioppo  JT .  A meta-analysis of interventions to reduce loneliness.   Pers Soc Psychol Rev. 2011;15(3):219-266. doi:10.1177/1088868310377394PubMedGoogle ScholarCrossref
Choi  NG , Pepin  R , Marti  CN , Stevens  CJ , Bruce  ML .  Improving social connectedness for homebound older adults: randomized controlled trial of tele-delivered behavioral activation versus tele-delivered friendly visits.   Am J Geriatr Psychiatry. 2020;28(7):698-708. doi:10.1016/j.jagp.2020.02.008PubMedGoogle ScholarCrossref
Penning  MJ , Liu  G , Chou  PH .  Measuring loneliness among middle-aged and older adults: the UCLA and de Jong Gierveld loneliness scales.   Soc Indic Res. 2014;118:1147-1166. doi:10.1007/s11205-013-0461-1.Google ScholarCrossref
De Jong Gierveld  J , Van Tilburg  T .  The De Jong Gierveld short scales for emotional and social loneliness: tested on data from 7 countries in the UN generations and gender surveys.   Eur J Ageing. 2010;7(2):121-130. doi:10.1007/s10433-010-0144-6PubMedGoogle ScholarCrossref
Hughes  ME , Waite  LJ , Hawkley  LC , Cacioppo  JT .  A short scale for measuring loneliness in large surveys: results from two population-based studies.   Res Aging. 2004;26(6):655-672. doi:10.1177/0164027504268574PubMedGoogle ScholarCrossref
Schulz  KF , Altman  DG , Moher  D ; CONSORT Group.  CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials.   BMJ. 2010;340:c332. doi:10.1136/bmj.c332PubMedGoogle ScholarCrossref
De Jong Gierveld  J , Van Tilburg  TG .  A six-item scale for overall, emotional and social loneliness: confirmatory tests on new survey data.   Res Aging. 2006;28(5)582–598. doi:10.1177/0164027506289723.Google ScholarCrossref
Ware  J  Jr , Kosinski  M , Keller  SD .  A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity.   Med Care. 1996;34(3):220-233. doi:10.1097/00005650-199603000-00003PubMedGoogle ScholarCrossref
Shin  C , Lee  SH , Han  KM , Yoon  HK , Han  C .  Comparison of the usefulness of the PHQ-8 and PHQ-9 for screening for major depressive disorder: analysis of psychiatric outpatient data.   Psychiatry Investig. 2019;16(4):300-305. doi:10.30773/pi.2019.02.01PubMedGoogle ScholarCrossref
Spitzer  RL , Kroenke  K , Williams  JBW , Löwe  B .  A brief measure for assessing generalized anxiety disorder: the GAD-7.   Arch Intern Med. 2006;166(10):1092-1097. doi:10.1001/archinte.166.10.1092PubMedGoogle ScholarCrossref
Chiang  KJ , Chu  H , Chang  HJ ,  et al.  The effects of reminiscence therapy on psychological well-being, depression, and loneliness among the institutionalized aged.   Int J Geriatr Psychiatry. 2010;25(4):380-388. doi:10.1002/gps.2350PubMedGoogle ScholarCrossref
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience

Lookup An Activity


My Saved Searches

You currently have no searches saved.


My Saved Courses

You currently have no courses saved.