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. Author manuscript; available in PMC: 2025 May 1.
Published in final edited form as: Psychiatry Res. 2024 Feb 27;335:115826. doi: 10.1016/j.psychres.2024.115826

Associations of history of alcohol use disorder with loneliness, social support, and mental health during the COVID-19 pandemic

Jeremy W Luk a,*, Noa Leiter b, Bethany L Stangl b, Tommy Gunawan a,b, Melanie L Schwandt a, David Goldman a,c, Nancy Diazgranados a,†, Vijay A Ramchandani b,†
PMCID: PMC11229409  NIHMSID: NIHMS1978946  PMID: 38479194

Abstract

This study examined the effects of alcohol use disorder (AUD) and treatment history on changes in loneliness, social support, and mental health symptoms from before to during the pandemic, and tested loneliness and social support as mediators of the AUD-mental health associations. Participants (n = 427) enrolled in the NIAAA COVID-19 Pandemic Impact on Alcohol Study were categorized into three groups: healthy control (62.3%), nontreatment AUD (14.1%), and treatment AUD (23.7%). Multilevel generalized linear models were conducted to examine changes in loneliness, social support, and mental health symptoms by group. Path analyses tested the mediating roles of loneliness and social support. Loneliness increased during the pandemic, especially in the nontreatment AUD group. Social support decreased in the healthy control and AUD treatment group. Anxiety and depressive symptoms increased in the nontreatment AUD group. Individuals with a history of AUD regardless of treatment history reported greater loneliness, which was linked to higher anxiety and depressive symptoms. Loneliness, but not social support, mediated the AUD-mental health associations. Psychosocial interventions aimed at increasing positive social engagement among individuals with AUD may help alleviate feelings of loneliness and mitigate mental health symptoms. Study findings can also help improve preparedness for future public health crises.

Keywords: Alcohol Use Disorder, Loneliness, Social Support, Mental Health, COVID-19

1. Introduction

The COVID-19 pandemic has had a pervasive negative impact on mental wellbeing. Symptoms of depression and anxiety increased globally during the pandemic (Daniali et al., 2023; World Health Organization, 2022), and issues such as loneliness and lack of social support have received increased attention. Prior to the pandemic, loneliness already presented as a growing public health issue, with about half of U.S. adults endorsing experiencing loneliness (Cigna, 2020). A myriad of factors during the COVID-19 pandemic could have exacerbated existing concerns, including the social distancing measures and lockdowns imposed during the initial phase of the pandemic (Killgore et al., 2021; Schmits & Glowacz, 2022), as well as the adverse effects of COVID-related stressors on health and wellbeing (Graupensperger et al., 2022; Luk et al., 2023b). The gravity of this public health issue and the need for immediate action are evident through the advisory released in May 2023 by U.S. Surgeon General Dr. Vivek Murthy: “Our Epidemic of Loneliness and Isolation.” This advisory warns of the detrimental mental and physical health consequences of loneliness, including increased risk of anxiety, depression, heart disease, stroke, and dementia, and the need to build social connections to combat these risks (Office of the U.S. Surgeon General, 2023).

Research aimed at understanding changes in loneliness from before to during the pandemic is varied. Several studies report that levels of loneliness remained stable (Luchetti et al., 2020; Peng & Roth, 2022), whereas some report an increase (Kovacs et al., 2021; Lee et al., 2020; Macdonald & Hülür, 2021), and others a decrease (Bartrés-Faz et al., 2021). A recent meta-analytic review found an overall increase in loneliness from before to during the start of the pandemic, though the observed effects were small and heterogeneous (Ernst et al., 2022). This heterogeneity illustrates that certain populations may be more vulnerable to experiencing loneliness during the pandemic. For instance, adults who are younger or single, and individuals with lower household incomes or smaller social networks may be at heightened risk for loneliness (Bu et al., 2020; Rumas et al., 2021; Tutzer et al., 2021). Individuals with alcohol use disorder (AUD) are often socially marginalized due to stigma related to alcohol misuse (Room, 2005). These individuals have been identified as a vulnerable group disproportionately affected by the COVID-19 pandemic, as disruptions to AUD treatment and recovery support groups may have increased the likelihood of a relapse and associated medical complications (Murthy & Narasimha, 2021; Perumalswami et al., 2023; Yazdi et al., 2020). In one study, Lommer et al. (2022) investigated changes in loneliness among individuals with substance use across five months of the pandemic, finding that individuals with substance use disorders (SUD) experienced comparable levels of “severe loneliness” to individuals without SUD at baseline, but significantly more “severe loneliness” at the follow-up timepoint. Few investigations, however, have specifically studied changes in loneliness based on individuals’ history of AUD. This is of particular importance considering that loneliness has been associated with increased psychological distress (Horigian et al., 2021) and hazardous alcohol use during the pandemic (Wakabayashi et al., 2022).

As normal social contacts and interactions may have been disrupted during the COVID-19 pandemic (Freedman et al., 2022; Lee et al., 2022), it is critical to understand if access to social support has changed in tandem with these disruptions. Social support refers to tangible support made available within an individual’s social network and is a resilience factor that protects individuals from mental health problems (Laham et al., 2021). Research indicates that greater social support was associated with more positive mental health during the pandemic (Szkody et al., 2021; van den Berg et al., 2021). In terms of change over time, one study revealed stability in social support among the French general population during the pandemic (Laham et al., 2021), whereas other studies indicated an increase in social support among older US adults (Ang, 2022) and Chinese adults (Xu et al., 2020). Lommer et al. (2022) found that social support did not change significantly across five months of the pandemic, but that individuals without SUD reported higher perceived social support than those with SUD. Limited research has explored changes in social support according to individuals’ history of AUD and treatment status.

A history of AUD is associated with higher levels of anxiety and depressive symptoms (Lasserre et al., 2022; Ummels et al., 2022), but the mechanisms are unclear. Loneliness is a significant mediator that links various risk factors to mental health outcomes. For instance, loneliness mediated the associations of childhood trauma with adulthood psychopathology (Shevlin et al., 2015). Among college students, loneliness mediated the associations of low social skills with depression and anxiety (Moeller & Seehuus, 2019). Among older adults, loneliness mediated the associations of social and physical environment with mental health (Domènech-Abella et al., 2021). In a sample of healthcare students in Ecuador, loneliness was a mediator of the associations between psychological stress and mental health symptoms during the COVID-19 pandemic (Bonilla-Sierra et al., 2021). Several studies that examined loneliness and pandemic mental health also examined the role of social support as a protective factor (Bareket-Bojmel et al., 2021; Bentley et al., 2022; Pineda et al., 2022; Saltzman et al., 2020). Based on these prior studies, loneliness and social support are potential mediators of the AUD-mental health associations.

The current study had two complementary goals. First, extending a prior study examining the impact of AUD diagnosis and treatment history (AUD-treatment history) on alcohol-related and quality of life outcomes (Luk, Stangl, Gunawan, et al., 2023a), we examined group-specific changes in loneliness, social support, anxiety symptoms, and depression symptoms from before the COVID-19 pandemic to during the pandemic by AUD-treatment history. Second, we tested a mediation model in which loneliness and social support were conceptualized as mediators of the associations between AUD-treatment history and mental health symptoms. In terms of changes over time, we hypothesized an increase in loneliness, a decrease in social support, and increases in anxiety and depressive symptoms. In terms of mediational pathways, we hypothesized that individuals with a history of AUD would report higher loneliness and lower social support, which would in turn be linked to higher anxiety and depressive symptoms.

2. Methods

2.1. Participants

Data were drawn from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) COVID-19 Pandemic Impact on Alcohol Study (C19-PIA Study). Participants for this study were previously enrolled in the NIAAA Natural History Protocol between March 11, 2015 and December 8, 2022, a deep phenotyping study of individuals across the spectrum of alcohol use, including those who sought inpatient treatment for AUD at the National Institutes of Health (NIH) Clinical Center. Of 899 individuals who were reached by our research team, 589 consented and were enrolled in the C19-PIA Study (response rate = 65.5%), 305 (33.9%) declined to participate or were withdrawn, and 5 (0.6%) were ineligible or not suitable as they did not complete the Natural History Protocol. Out of the 589 participants enrolled in the C19-PIA Study in between June 3, 2020 and December 30, 2022, 162 were excluded from the current study due to missing data on AUD diagnosis (n = 15), mental health symptoms (n = 19), and loneliness or social support (n = 128), yielding an analytic sample of 427 participants.

The C19-PIA Study is an ongoing longitudinal study that recruits individuals from the NIAAA Natural History Protocol for participation on a rolling basis. Because the longitudinal component of the C19-PIA Study spans over a two-year period, participants who were more recently enrolled are still actively being followed over time. The current study utilized data from the baseline survey of the C19-PIA Study, during which participants reported their pre-pandemic and pandemic levels of loneliness, social support, and mental health symptoms either via phone interview or a combination of phone interview and web-based survey. Details about the study design and recruitment methods can be found in previous C19-PIA Study publications (Luk et al., 2023a, b). On average, the time lapsed from the Natural History Protocol to the C19-PIA Study baseline assessment was 689 days (SD = 654 days). Most participants (71.2%) in the Natural History Protocol were enrolled before the declaration of the pandemic by the World Health Organization (WHO) on March 11, 2020. The C19-PIA study was approved by the NIH Intramural Institutional Review Board and is registered in clinicaltrials.gov (NCT04391816).

2.2. Measures

Self-reported demographic characteristics including sex, race, ethnicity, marital status, household income, along with information regarding AUD-treatment status, were drawn from the NIAAA Natural History Protocol database (Luk et al., 2022). Self-reported age was assessed at the baseline of the C19-PIA Study. Measures of loneliness, social support, anxiety symptoms, and depressive symptoms were administered twice in the C19-PIA Study to determine pre-pandemic and current levels during the pandemic, as described below.

2.2.1. AUD-treatment status.

The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (First, 2015) evaluated AUD diagnosis (37.7% [n = 161] met criteria and 62.3% [n =266] did not). Of participants with a history of AUD, 62.7% (n = 101) sought inpatient treatment for AUD and 37.3% (n = 60) did not. This information was used to create three groups for analyses: “healthy control” group (62.3%; n = 266); “non-treatment AUD” group (14.1%; n = 60); and “treatment seeking AUD” group (23.7%; n = 101).

2.2.2. Loneliness.

Participants were asked to report their level of loneliness on the UCLA Loneliness Scale (Russell et al., 1978) during two time periods: (1) for the 3 months before the start of the COVID-19 pandemic, and (2) since the start of the pandemic. The UCLA Loneliness Scale is a 20-question measure of feelings of loneliness and social isolation. Response options include O (“I often feel this way”), S (“I sometimes feel this way”), R (“I rarely feel this way”), and N (“I never feel this way”). Responses are summed, yielding scores ranging from 20 to 80.

2.2.3. Social support.

Participants were asked to report their level of social support on the Lubben Social Network Scale-6 (LSNS-6; Lubben et al., 2006; Lubben, 1988) during two time periods: (1) for the 6 months before the start of the COVID-19 pandemic, and (2) since the start of the pandemic. The LSNS-6 is a 6-item measure assessing social networks and support from familial relationships and friendships. Response options range from 0 (“none”) to 5 (“nine or more”). Responses are summed, yielding scores ranging from 0 to 30.

2.2.4. Anxiety symptoms.

Participants were asked to report their level of anxiety symptoms on the Generalized Anxiety Disorder-7 Assessment (GAD-7; Spitzer et al., 2006) during two time periods: (1) the month before the pandemic, and (2) in the last month. Response options for each question range from 0 (“not at all”) to 3 (“nearly every day”), yielding sum scores ranging from 0 to 21.

2.2.5. Depressive symptoms.

Participants were asked to report their level of depressive symptoms on the Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001) during two time periods: (1) the month before the pandemic, and (2) in the last month. Response options for each question range from 0 (“not at all”) to 3 (“nearly every day”), yielding sum scores ranging from 0 to 27.

2.2.6. Cohort.

As the C19-PIA study sample had more participants who completed the NIAAA Natural History Protocol within the past 2 years, to adjust for variations in the time interval between participation in the NIAAA Natural History Protocol and the C19-PIA Study assessment, we created a three-level categorical variable: <1 year (43.8%; n = 187), 1-2 years (27.2%; n = 116), and 3-6 years (29.0%; n = 124).

2.2.7. Enrollment phase.

We created a five-level categorical variable to adjust for the development of the pandemic over time and variations in when participants completed the C19-PIA Study baseline assessment. “Phase I” went from the World Health Organization declaration of the pandemic on March 11, 2020 to the end of July (18.3%, n = 78); during this period, shutdowns, social distancing measures, and mask mandates were broadly implemented, with precautions gradually lessening as infection and death rates trended downward in July. “Phase II” went from August 1, 2020 to November 22, 2020 (27.2%, n = 116); during this period, mask mandates and gathering restrictions were mostly lifted, with an emphasis on the lower risk of infection in outdoor gatherings. “Phase III” went from November 23, 2020 to February 28, 2021 (23.9%, n = 102); during this period, COVID infections and deaths increased in the winter prompting the Centers for Disease Control and Prevention (CDC) to require face mask wearing at transportation hubs. “Phase IV” went from March 1, 2021 to November 30, 2021; during this period, access to COVID-19 vaccinations expanded, the CDC lifted social distancing measures and mask mandates for indoor gatherings with vaccinated people, but a new wave of infections (Delta variant) hit in the summer of 2021 (14.3%, n = 61). “Phase V” went from December 1, 2021 to December 30, 2022; during this period, the Omicron variant became predominant, booster vaccines were expanded to the public, and by the end of this period the Washington D.C. Metro area completely lifted precautionary measures (16.4%, n = 70).

2.3. Statistical analysis

First, multilevel generalized linear models (GLM) with robust standard errors (using vce(robust) in Stata) were used to examine changes in loneliness, social support, anxiety symptoms, and depressive symptoms from before the pandemic to during the pandemic, adjusting for age, sex, race, marital status, cohort, and enrollment phase. We included time x AUD-treatment status interaction terms in the multilevel GLM to test whether these changes across time varied by AUD-treatment status. Second, we conducted path analysis (using the MLR estimator in Mplus) to test loneliness and social support as mediators of the associations between history of AUD and mental health symptoms. Covariates in the path analysis model included age, sex, race, marital status, cohort, and enrollment phase. Four autoregressive paths for the mediators and outcomes (i.e., pre-pandemic loneliness to pandemic loneliness, pre-pandemic social support to pandemic social support, pre-pandemic anxiety symptoms to pandemic anxiety symptoms, and pre-pandemic depressive symptoms to pandemic depressive symptoms) were also estimated simultaneously. As 28.8% of study participants completed the Natural History Protocol after the WHO declaration of the pandemic on March 11, 2020, sensitivity analyses excluding these participants were conducted to examine if the main findings would be replicated. Descriptive statistics and results from the multilevel models were obtained from Stata 18 (StataCorp LLC, College Station, TX), and the path analysis was conducted in Mplus 8.4 (Muthén & Muthén, 1998-2017).

3. Results

3.1. Sample characteristics

Table 1 summarizes the characteristics of the overall sample by AUD status. The overall sample (N = 427) had a mean age of 42.0 (SD = 14.1) years, was 51.8% male, and was racially diverse (53.6% White, 31.9% Black, and 14.5% Other). Other self-reported race categories, including 29 Asian, 2 American Indian or Alaska Native, 12 Multiracial, and 19 Unknown Race, were combined for analyses due to small cell sizes. The sample was also heterogenous in terms of marital status and household income.

Table 1.

Sample characteristics of the overall sample and by AUD-treatment status

Overall Sample
(N = 427)		 Healthy Control
(n = 266; 62.3%)		 Non-Treatment AUD
(n = 60; 14.1%)		 Treatment Seeking AUD
(n = 101; 23.7%)
Frequency Percent Frequency Percent Frequency Percent Frequency Percent
Age
 18-34 years old 137 32.1 98 36.8 27 45.0 12 11.9
 35-54 years old 161 37.7 96 36.1 17 28.3 48 47.5
 55 years or older 129 30.2 72 27.1 16 26.7 41 40.6
Sex
 Female 206 48.3 145 54.5 25 41.7 36 35.6
 Male 221 51.8 121 45.5 35 58.3 65 64.4
Race
 White 229 53.6 143 53.8 30 50.0 56 55.5
 Black/African American 136 31.9 83 31.2 23 38.3 30 29.7
 Other 62 14.5 40 15.0 7 11.7 15 14.9
Ethnicity
 Not Hispanic or Latino 377 88.3 240 90.2 52 86.7 85 83.2
 Hispanic or Latino 31 7.3 19 7.1 4 6.7 8 7.9
 Unknown or not reported 19 4.5 7 2.6 4 6.7 8 7.9
Marital Status
 Single 271 63.5 180 67.7 38 63.3 53 52.5
 Married 95 22.3 61 22.9 12 20.0 22 21.8
 Other 61 14.3 25 9.4 10 16.7 26 25.7
Household Income
 < $20,000 104 24.7 47 17.9 15 25.0 42 42.4
 $20,000 – $74,999 177 42.0 113 43.1 25 41.7 39 39.4
 $75,000 + 140 33.3 102 39.9 20 33.3 18 18.2
Cohort
 <1 year 187 43.8 114 42.9 16 26.7 57 56.4
 1-2 years 116 27.2 68 25.6 23 38.3 25 24.8
 3-6 years 124 29.0 84 31.6 21 35.0 19 18.8
Enrollment Phase
 I - Spring 2020 78 18.3 44 16.5 7 11.7 27 26.7
 II - Summer to Fall 2020 116 27.2 63 23.7 23 38.3 30 29.7
 III - Fall to Spring 2021 102 23.9 75 28.2 15 25.0 12 11.9
 IV - Spring to Fall 2021 61 14.3 37 13.8 8 13.3 16 15.8
 V - Winter 2021 to Winter 2022 70 16.4 47 17.7 7 11.7 16 15.8
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Note. Age was self-reported at baseline of the C19-PIA Study. Six participants had missing data for household income and percentages for the participants with valid data were reported. Other self-reported race categories included 29 Asian, 2 American Indian or Alaska Native, 12 Multiracial, and 19 Unknown Race.

3.2. Changes in loneliness, social support, and mental health by AUD-treatment history

Changes in loneliness, social support, and mental health from before to during the pandemic are visually illustrated in Figure 1 using raincloud plots. Results from the full multilevel GLM adjusting for covariates are presented in Table 2. To probe the interaction effects of time and history of AUD-treatment, the simple slopes of time on the four outcomes of interest by AUD-treatment history are presented in Table 3.

Figure 1.

Figure 1.

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Loneliness, Social Support, and Mental Health Symptoms by AUD-Treatment Groups.

Raincloud plots are used to show data distributions (data points to the left and a half violin plot to the right). Plotted data points reflect observed (not model-predicted) values. The white dots represent the medians and the X symbols represent the means.

Table 2.

Multilevel GLM of time by AUD-treatment status interactions on loneliness, social support, and mental health symptoms

Loneliness Social Support Anxiety Symptoms Depressive Symptoms
b (95% CI) b (95% CI) b (95% CI) b (95% CI)
Intercept 39.18 (32.92, 45.44) 21.50 (19.37, 23.63) 4.17 (2.57, 5.78) 4.48 (2.82, 6.14)
Age (continuous) −0.03 (−0.15, 0.08) −0.07 (−0.11, −0.03) −0.03 (−0.06, 0.00) −0.03 (−0.06, 0.00)
Sex
 Female (referent) -- -- -- --
 Male −0.27 (−3.02, 2.48) −0.79 (−1.90, 0.32) −0.35 (−1.17, 0.48) −0.37 (−1.25, 0.50)
Race
 White (referent) -- -- -- --
 Black/African American −3.43 (−6.73, −0.12) −2.09 (−3.50, −0.68) −0.30 (−1.26, 0.66) −0.73 (−1.72, 0.26)
 Other −4.91 (−8.73, −1.09) −2.58 (−4.09, −1.08) −0.09 (−1.33, 1.14) −1.06 (−2.29, 0.18)
Marital Status
 Single (referent) -- -- -- --
 Married −5.80 (−9.06, −2.53) 2.54 (1.17, 3.90) −0.95 (−1.96, 0.06) −0.58 (−1.66, 0.50)
 Other −2.30 (−6.83, 2.24) 0.07 (−1.86, 1.99) −0.02 (−1.43, 1.38) 0.55 (−0.96, 2.05)
Cohort
 <1 year (referent) -- -- -- --
 1-2 years 2.04 (−2.40, 6.47) 1.12 (−0.71, 2.95) 0.53 (−0.87, 1.93) 0.99 (−0.43, 2.42)
 3-6 years −2.20 (−6.45, 2.05) 0.76 (−1.09, 2.61) −1.70 (−3.12, −0.29) −1.20 (−2.69, 0.29)
Enrollment Phase
 I - Spring 2020 (referent) -- -- -- --
 II - Summer to Fall 2020 0.19 (−4.53, 4.92) −1.63 (−3.66, 0.41) 1.51 (0.04, 2.98) 0.62 (−0.92, 2.17)
 III - Fall to Spring 2021 1.17 (−4.18, 6.51) −0.92 (−3.05, 1.21) 1.33 (−0.31, 2.96) 0.66 (−1.09, 2.40)
 IV - Spring to Fall 2021 2.31 (−3.00, 7.62) −1.30 (−3.35, 0.75) 1.27 (−0.32, 2.85) 0.42 (−1.24, 2.08)
 V – Winter 2021 to Winter 2022 1.13 (−3.88, 6.14) 1.01 (−1.01, 3.04) 0.74 (−0.55, 2.04) 0.84 (−0.63, 2.30)
Time
 T1 – Before Pandemic (referent) -- -- -- --
 T2 – During Pandemic 2.21 (0.93, 3.49) −0.88 (−1.24, −0.52) 0.40 (−0.08, 0.87) 0.53 (0.01, 1.05)
AUD-Treatment Status
 Healthy control (referent) -- -- -- --
 Non-treatment AUD 3.20 (−1.49, 7.89) −1.27 (−3.01, 0.46) 1.48 (0.03, 2.93) 2.31 (0.78, 3.84)
 Treatment AUD 7.29 (3.73, 10.85) 0.04 (−1.44, 1.53) 4.13 (2.82, 5.44) 5.40 (3.92, 6.88)
Interactions
 T2 x Non-treatment AUD 3.24 (−0.15, 6.63) 0.23 (−0.76, 1.22) 1.42 (0.10, 2.73) 1.87 (0.24, 3.50)
 T2 x Treatment AUD 0.66 (−2.10, 3.43) −0.20 (−1.09, 0.70) −1.30 (−2.75, 0.15) −2.13 (−3.91, −0.36)
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Note. Cohort reflects time lapsed from participation in the NIAAA Natural History Protocol to baseline of C19-PIA Study, coded into three categories due to uneven distribution across years. Significant associations were highlighted in bold. For the two-level by three-level interaction between time and AUD-treatment status, the following interaction terms were set as referent: Before Pandemic x Non-Treatment AUD, Before Pandemic x Treatment AUD.

Table 3.

Group-specific changes in loneliness, social support, and mental health symptoms from before to during the pandemic (N = 427)

Group-Specific Estimate A. Loneliness B. Social Support
b (95% CIs) p b (95% CIs) p
Healthy Control 2.21 (0.93, 3.49) 0.001 −0.88 (−1.24, −0.52) <0.001
Non-Treatment AUD 5.45 (2.31, 8.59) 0.001 −0.65 (−1.57, 0.27) 0.166
Treatment AUD 2.87 (0.42, 5.32) 0.021 −1.08 (−1.90, −0.26) 0.010
Group-Specific Estimate C. Anxiety Symptoms D. Depressive Symptoms
b (95% CIs) p b (95% CIs) p
Healthy Control 0.40 (−0.08, 0.87) 0.100 0.53 (0.01, 1.05) 0.045
Non-Treatment AUD 1.82 (0.59, 3.04) 0.004 2.40 (0.85, 3.95) 0.002
Treatment AUD −0.90 (−2.27, 0.46) 0.196 −1.60 (−3.30, 0.09) 0.064
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Note. Multilevel GLM controlled for age (continuous), sex, race, marital status, cohort, and enrollment phase. Regression coefficients were unstandardized. Significant associations were highlighted in bold.

Figure 1 Panel A shows that loneliness significantly increased from before to during the pandemic across all three groups. Relative to pre-pandemic, loneliness was 2.21 points higher in the healthy control group (95% CI = 0.93, 3.49), 5.45 points higher in the treatment seeking AUD group (95% CI = 2.31, 8.59), and 2.87 points higher in the non-treatment seeking AUD group (95% CI = 0.42, 5.32) during the pandemic. Panel B shows that social support significantly decreased by 0.88 points in the healthy control group (95% CI = −1.24, −0.52) and decreased by 1.08 points in the treatment AUD group (95% CI = −1.90, −0.26). Panel C shows that anxiety symptoms increased significantly by 1.82 points in the nontreatment AUD group only (95% CI = 0.59, 3.04). Panel D shows that depressive symptoms increased significantly by 0.53 points in the healthy control group (95% CI = 0.01, 1.05) and 2.40 points in the nontreatment AUD group (95% CI = 0.85, 3.95).

3.3. Testing the mediating roles of loneliness and social support

Mediation effects were tested within a path analysis framework. The mediation model provided good fit to the data (χ2 = 31.544, df = 16, p = 0.0115; RMSEA = 0.048; CFI = 0.989; TLI = 0.947; SRMR = 0.018). This model (Figure 2) adjusted for age, sex, race, marital status, cohort, enrollment phase, and the autoregressive paths for the two mediators and the two outcomes using pre-pandemic levels that were retrospectively reported. The inclusion of the autoregressive paths helped rule out the possibility that any observed mediation effects would be confounded by pre-existing mental health symptoms. There were no mediation effects via social support. All four mediation paths via loneliness were significant. Relative to the healthy control group, individuals in the nontreatment AUD group reported higher loneliness (b = 0.084, 95% CI = 0.011, 0.158), which in turn was associated with higher anxiety symptoms (b = 0.312, 95% CI = 0.223, 0.400) and depressive symptoms (b = 0.312, 95% CI = 0.225, 0.399). Similarly, relative to the healthy control group, individuals in the treatment AUD group reported higher loneliness (b = 0.079, 95% CI = 0.008, 0.151), which in turn was also associated with higher anxiety symptoms and depressive symptoms. The direct, indirect, and total effects of treatment-AUD history on mental health symptoms are presented in Supplemental Table 2. The proportion of variance in the outcomes mediated by loneliness ranged from 12.5% to 29.8%.

Figure 2.

Figure 2.

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Loneliness as a Mediator of the Associations between AUD-Treatment History and Mental Health Symptoms

Based on AUD and treatment history assessed in the NIAAA Natural History Protocol, individuals who were in the non-treatment AUD and treatment AUD groups were contrasted with the healthy control group as the referent comparison group. Loneliness, social support, and mental health symptoms were assessed in the NIAAA COVID-19 Pandemic Impact on Alcohol Study.

3.4. Sensitivity analyses

In the subsample of participants who completed the C19-PIA Study before the start of the COVID-19 pandemic (n = 304), the group-specific estimates of the effect of time on loneliness, anxiety symptoms, and depressive symptoms in the multilevel models were replicated (See Supplemental Table 3). For social support, healthy controls had a decrease in both the main analysis and the sensitivity analysis. The only finding that was no longer significant in the sensitivity analysis was the change in social support in the treatment AUD group, where the decrease was significant in the main analysis (b = −1.08, 95% CI = −1.90, −0.26, p = 0.010), but was not statistically significant in the sensitivity analysis (b = −1.20, 95% CI = −2.44, 0.03, p = 0.056). Due to model convergence difficulties in the smaller subsample, a simplified mediation model (removing the cohort and enrollment phase covariates and combining the non-treatment and treatment AUD groups) was specified in the sensitivity analysis (See Supplemental Table 4). Consistent with the main analysis, the sensitivity analysis showed that the effects of AUD on anxiety symptoms and depressive symptoms were mediated via loneliness (18.8% and 14.2% proportion mediated respectively), whereas social support was not a significant mediator.

4. Discussion

In the current study, we found an overall pattern of increases in loneliness and decreases in social support from before to during the COVID-19 pandemic. Increases in loneliness during the pandemic have been found in samples in the United States and internationally (Kovacs et al., 2021; Lee et al., 2020; Lommer et al., 2022; Macdonald & Hülür, 2021). Our results are also consistent with decreases in social support from before to during the pandemic in a sample of women in Mexico City (Rivera Rivera et al., 2021). Decreases in social support may be due to social distancing measures and lockdowns during the early phase of the pandemic and the consequential changing nature of social interactions (Perez-Brumer et al., 2022). One longitudinal study on social networks found significant decreases in network density and global network size from before to during the pandemic (Kovacs et al., 2021), which may have contributed to increases in loneliness and decreases in social support.

When investigating changes in these measures based on individuals’ history of AUD, we found that loneliness significantly increased for the healthy control group, the non-treatment AUD group, and the treatment AUD group, with the non-treatment AUD group experiencing the largest increase in loneliness. We also found that social support significantly decreased in the healthy control and treatment AUD groups. Our results align with a recent systematic review by Ingram, Kelly, Deane, et al. (2020) which found that individuals with SUD reported more loneliness when compared to the general population. It may be of particular concern that individuals in the non-treatment AUD group reported the largest increase over time, as loneliness is linked to substance use (Ingram, Kelly, Deane, et al., 2020; Stickley et al., 2014; Wakabayashi et al., 2022) and non-treatment seeking individuals may not have effective cope strategies to manage a sense of loneliness without turning to hazardous drinking.

Changes in anxiety symptoms and depressive symptoms from before to during the pandemic varied across treatment-AUD groups. Anxiety symptoms significantly increased in the non-treatment AUD group, but not the treatment AUD or the healthy control group. Depressive symptoms also increased in the healthy control and non-treatment AUD groups, but did not change significantly in the treatment AUD group. Importantly, even though the treatment AUD group did not experience an increase in anxiety and depressive symptoms during the pandemic, anxiety and depressive symptoms were still significantly higher in both the non-treatment AUD and the treatment AUD groups when compared to the healthy control group due to high pre-pandemic levels. This aligns with existing literature indicating the links between AUD diagnosis and mental health related factors (Kwako et al., 2019; Puddephatt et al., 2022). The persistently higher anxiety and depressive symptoms in the two AUD groups relative to the healthy control group across the time provided context for testing potential mediation by loneliness and social support, and highlighted the need to adjust for the autoregressive effects of pre-pandemic anxiety and depressive symptoms in the mediation model.

The present study used a mediation model to test if this association between history of AUD and higher levels of anxiety and depressive symptoms was in part due to feelings of loneliness or lack of social support. We found that loneliness mediated the AUD-mental health association, while social support did not. This extends the existing literature that has found loneliness to be a significant mediator between various risk factors and negative mental health outcomes (Moeller & Seehuus, 2019; Shevlin et al., 2015). Social support may not have been significant as a mediator because of the measure used in this study. The LSNS-6 measures social support from family and friends, but it does not capture other potential sources of support (Lubben et al., 2006), such as romantic partners, community members, and colleagues. In addition, other sources of support that might be especially relevant to those in recovery, such as sponsors and friends who do not use or misuse alcohol, were not assessed. More research on additional types of social support is needed to understand its potential mediating role in the association between AUD-treatment history and mental health outcomes.

Given that loneliness may be one mechanism through which individuals with AUD are at risk for increased anxiety and depressive symptoms, this study highlights the utility of targeting loneliness in efforts to reduce anxiety and depression symptoms. A meta-analysis on interventions to reduce loneliness revealed four primary intervention strategies, including (1) improving social skills, (2) enhancing social support, (3) increasing opportunities for social contact, and (4) addressing maladaptive social cognition, with addressing maladaptive social cognition being the most successful intervention (Masi et al., 2011). Promoting resilience and positive coping behaviors may also be helpful to individuals with AUD in the context of exposure to stress (McCabe et al., 2024). Psychosocial interventions may be most effective if they are tailored to individuals with AUD, such as the Groups for Belonging program (Ingram et al., 2020), and based on community-level considerations (Noone and Yang, 2022). Along with targeting loneliness, tailoring interventions to address quality of life issues among individuals with AUD and associated medical conditions are warranted (Luk et al., 2024). To improve the reach of interventions to those in need, increased use of telebehavioral health approaches may be considered (Attonito et al., 2021).

Despite the strengths of this study, it is not without limitations. First, the time lapse from the Natural History Protocol to the C19-PIA Study varied across participants. While we adjusted for variations in time lapse in the analyses using the cohort variable, unmeasured variations that were not captured by the cohort variable could have biased the study findings. Second, some participants (28.8%) completed the Natural History Protocol after the WHO declaration of the pandemic on March 11, 2020. For these individuals, their AUD-treatment history was not temporally before the start of the pandemic and would reflect cross-sectional associations among study variables. Third, AUD status was assessed in the Natural History Protocol and current AUD status was not reassessed as part of the C19-PIA Study. Thus, this study did not account for changes in AUD diagnosis that may have occurred in the interval between participation in the two protocols. Fourth, pre-pandemic measures of loneliness, social support, and mental health symptoms relied on retrospective reporting and may be prone to recall bias. Fifth, some potential participants were excluded from the current analysis because they did not consent to participation or due to missing data, which may contribute to selection bias. Finally, the study used a convenience sample that was geographically limited, therefore, the findings may not be broadly generalizable.

In conclusion, the current study utilized a unique sample to investigate patterns of change in loneliness, social support, anxiety symptoms, and depressive symptoms from before to during the COVID-19 pandemic based on AUD treatment status. We found an overall pattern of increases in loneliness and decreases in social support, with the non-treatment AUD group experiencing the largest increase in loneliness from before to during the pandemic. The non-treatment AUD group also experienced an increase in anxiety and depressive symptoms. Mediation analysis found that the association between AUD history and anxiety and depressive symptoms was mediated by loneliness, but not social support. These findings point to a need for clinical and community interventions targeting loneliness, especially among individuals with a history of AUD, in efforts to reduce mental health disparities during the COVID-19 pandemic and beyond.

Supplementary Material

1

Highlights.

  • A unique sample with individuals with and without alcohol use disorder was used.

  • Loneliness increased from before to during the pandemic for all groups.

  • Social support decreased among healthy controls and those who sought prior AUD treatment.

  • Loneliness mediated the associations between history of AUD and mental health outcomes.

  • Addressing loneliness among individuals with AUD may help alleviate burden of mental health challenges.

Footnotes

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Declaration of Interest Statement

The authors do not have any conflicts of interest to disclose.

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