Living alone and mental health: parallel analyses in longitudinal population surveys and electronic health records prior to and during the COVID-19 pandemic

ABSTRACT Objectives To describe the mental health gap between those who live alone and those who live with others, and to examine whether the COVID-19 pandemic had an impact on this gap. Design Ten population based prospective cohort studies, and a retrospective descriptive cohort study based on electronic health records (EHRs). Setting UK Longitudinal population-based surveys (LPS), and primary and secondary care records within the OpenSAFELY-TPP database. Participants Participants from the LPS were included if they had information on living status in early 2020, valid data on mental ill-health at the closest pre-pandemic assessment and at least once during the pandemic, and valid data on a key minimum set of covariates. The EHR dataset included 16 million adults registered with primary care practices in England using TPP SystmOne software on 1st February 2020, with at least three months of registration, valid address data, and living in households of <16 people. Main outcome measures In the LPS, self-reported survey measures of psychological distress and life satisfaction were assessed in the nearest pre-pandemic sweep and three periods during the pandemic: April-June 2020, July-October 2020, and November 2020-March 2021. In the EHR analyses, outcomes were morbidity codes recorded in primary or secondary care between March 2018 and January 2022 reflecting the diagnoses of depression, self-harm, anxiety, obsessive compulsive disorder, eating disorders, and severe mental illnesses. Results The LPS consisted of 37,544 participants (15.2% living alone) and we found greater psychological distress (SMD: 0.09 (95% CI: 0.04, 0.14) and lower life satisfaction (SMD: -0.22 (95% CI: -0.30, -0.15) in those living alone pre-pandemic, and the gap between the two groups stayed similar after the onset of the pandemic. In the EHR analysis of almost 16 million records (21.4% living alone), codes indicating mental health conditions were more common in those who lived alone compared to those who lived with others (e.g., depression 26 and severe mental illness 58 cases more per 100,000). Recording of mental health conditions fell during the pandemic for common mental health disorders and the gap between the two groups narrowed. Conclusions Multiple sources of data indicate that those who live alone experience greater levels of common and severe mental illnesses, and lower life satisfaction. During the pandemic this gap in need remained, however, there was a narrowing of the gap in service use, suggesting greater barriers to healthcare access for those who live alone. Summary Box What is already known on the topic? Households with one individual are an increasing demographic, comprising over a quarter of all households in the UK in 2021. However, the mental health gap between those who live alone compared to those who live with others is not well described and even less is known about the relative gaps in need and healthcare-seeking and access. The pandemic and associated restrictive measures further increased the likelihood of isolation for this group, which may have impacted mental health. What this study adds? We present comprehensive evidence from both population-based surveys and electronic health records regarding the greater levels of mental health symptoms and in recorded diagnoses for common (anxiety, depression) and less common (OCD, eating disorders, SMIs) mental health conditions for people living alone compared to those living with others. Our analyses indicate that mental health conditions are more common among those who live alone compared to those who live with others. Although levels of reported distress increased for both groups during the pandemic, healthcare-seeking dropped in both groups, and the rates of healthcare-seeking among those who live alone converged with those who live with others for common mental health conditions. This suggests greater barriers for treatment access among those that live alone. The findings have implications for mental health service planning and efforts to reduce barriers to treatment access, especially for individuals who live on their own.