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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.

Abstract

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

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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.

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