Cognitive Therapy and Research

https://doi.org/10.1007/s10608-021-10252-2

ORIGINAL ARTICLE

Evaluating the Interactive Effect of COVID‑19 Worry and Loneliness

on Mental Health Among Young Adults
Nubia A. Mayorga1 · Tanya Smit1 · Lorra Garey1 · Alexandra K. Gold4 · Michael W. Otto4 · Michael J. Zvolensky1,2,3

Accepted: 13 July 2021

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract
Background Young adults are overrepresented in terms of adverse mental health problems related to COVID-19. Emerging
work has identified worry about the consequences and trajectory of COVID-19 and loneliness as important factors in mental
health during the pandemic. However, the main and interactive effects of worry about COVID-19 and loneliness have not
been explored in one overarching model in relation to mental health problems among young adults.
Methods The present study therefore evaluated loneliness and COVID-19 related worry in terms of anxiety, stress, and
depression among young adults (209 college students, 76.1% female, Mage = 22.99 years, SD = 5.25) recruited to participate
in an online survey study.
Results Results indicated a significant interaction between COVID-19 worry and loneliness for each criterion variable
(depression: b = .01, SE = .003, t = 2.86, p = .01; anxiety: b = .01, SE = .002, t = 2.36, p = .02; stress: b = .01, SE = .003, t = 2.54,
p = .01), such that worry was more strongly related to each mental health outcome among those that endorsed higher levels
of loneliness.
Conclusion The current findings suggest loneliness is related to negative mental health symptoms among young adults
experiencing COVID-19 related worry. The current findings provide initial empirical evidence for the impact of COVID-
19 worry on mental health among young adults experiencing loneliness. Future research may benefit from exploring how
COVID-19 worry and loneliness interplay over time.

Keywords COVID-19 · Worry · Loneliness · Young Adults · Pandemic · Mental Health · Depression · Anxiety · Stress

Introduction COVID-19-related medical complications (February 2021;

WHO Coronavirus Disease (COVID-19) Dashboard). In
Coronavirus disease 2019 (COVID-19) has had a detrimen- addition to COVID-19-related physical health problems,
tal physical and mental health impact globally (Resnick there has been a significant increase in mental health symp-
et al., 2020; Troyer et al., 2020; Zvolensky et al., 2020). In toms and disorders associated with the COVID-19 pandemic
the United States (U.S.), over 20 million people have been (Gallagher et al., 2020; Salari et al., 2020), particularly
infected with COVID-19 and over 400,000 have died from among populations ‘at risk’ for elevated psychological dis-
tress, such as young adults (aged 18–25; Minds, 2020).
Young adults have endorsed some of the highest rates of
* Michael J. Zvolensky
[email protected] depression, anxiety, and overall stress during the pandemic
(Kujawa et al., 2020). For instance, up to 60% of young
1
Department of Psychology, University of Houston, 3695 adults have reported symptoms of psychological distress in
Cullen Blvd., 126 Heyne Building, Houston, TX 77204, response to the outbreak of COVID-19 (Martinez & Nguyen,
USA
2020). Among college students, approximately 45% have
2
Department of Behavioral Science, The University of Texas reported “high” levels of psychological impact (i.e., symp-
MD Anderson Cancer Center, Houston, TX, USA
toms associated with negative mental health outcomes),
3
HEALTH Institute, University of Houston, Houston, TX, 17.4% of students endorsed increased anxiety, and 14.6% of
USA
students reported greater stress (N = 2534; Browning et al.,
4
Department of Psychology & Brain Sciences, Boston 2021). Other national surveys have suggested young adults
University, Boston, MA, USA

13
Vol.:(0123456789)
 Cognitive Therapy and Research

have experienced up to a 55% increase in stress related to pandemic, stay-at-home orders and social distancing guide-
COVID-19 (Palsson & Ballou, 2020; Stress in A ­ mericaTM, lines may increase the risk of loneliness (Marroquín et al.,
2020: Stress in the Time of COVID-19, Volume One, 2020). 2020). Importantly, the experience of loneliness that occurs
Demographic and behavioral factors associated with the as a consequence to the COVID-19 pandemic may span
pandemic, such as sex, financial stress, disruption of routine, beyond the physical separation from others but encompasses
boredom, and other daily life stressors (e.g., virtual school) a lack of emotionally intimate connection with friends and
have been identified as factors related to observed mental family. Some work has found that the association between
health stress among young adults (Ettman et al., 2020; Pan- loneliness and depression among young adults is especially
chal et al., 2020). Although these data provide initial evi- strong during the COVID-19 pandemic (Liu et al., 2020).
dence for sociodemographic factors related to poor mental Recent non-COVID-19 research has indicated that the effect
health outcomes among this group, non-COVID-19 related of loneliness on negative mental health outcomes may be
research on anxiety and depression among young adults has exacerbated by other vulnerability factors, such as worry
emphasized the importance of identifying individually-based (Anyan et al., 2020). The extent to which such synergistic
and targetable mechanisms that amplify the severity of men- patterns extend to mental health outcomes during the pan-
tal health symptoms (Bentley et al., 2018; Ehring & Behar, demic, however, remain unknown.
2020; Wolitzky-Taylor et al., 2016). Theoretically, individual differences in worry about
Individual differences in worry may serve to amplify COVID-19 may be more strongly related to negative mental
emotional vulnerability states among young adults dur- health symptoms among college students who experience
ing the pandemic. Worry reflects a relatively stable state loneliness. Specifically, worry may provide the individual
of apprehension and negative expectations about future with a false sense of control, as they “prepare” themselves
events (Borkovec, 1985) and is targetable through interven- for various aversive future events (Dugas et al., 2004). Worry
tion (Topper et al., 2017). Worry is a risk factor for depres- is differentiated from loneliness that reflects anxious appren-
sion and related negative emotional symptoms (Muris et al., hension about future events whereas loneliness reflects s a
2005). Among young adults, higher levels of worry are asso- state of emotional discomfort that an individual faces at the
ciated with increased depression (Zvolensky et al., 2019), realization of desiring social connection and the inability to
anxiety (Gana et al., 2001), and stress (Roussis & Wells, attain it. In this sense, loneliness may increase the salience
2008; Wells & Carter, 2001). Emerging work investigating for worrying as the individual is depleted of pre-COVID-19
COVID-19 related worry (i.e., worry that is rooted in the adaptive coping strategies (e.g., social gatherings, seek-
uncertainty that surrounds the trajectory and consequences ing advice from peers; Hoffart et al., 2020) and worry may
of COVID-19) has shown that worry about the pandemic increase the intensity of loneliness as it may amplify the
is associated with poorer mental health (Kleinberg et al., emotional distress they fear will continue in the future.Thus,
2020; Wang et al., 2020) and greater substance use (Rogers these factors have the potential to interact with one another
et al., 2020). Additionally, worry during the pandemic is to in terms of stress, anxiety, and depression among young
related to higher anxiety, anxiety sensitivity, and depres- adults, such that those who are higher in worry and higher in
sion (Baiano et al., 2020), and COVID-19 stress syndrome loneliness may be more likely to experience increased stress,
is conceptualized, in part, on the basis of the tendency to increased anxiety, and increased depression.
worry about pandemic-related factors (Taylor, 2020). Cer- The aim of the current study was to evaluate the potential
tain demographic factors (e.g., sex; Van der Vegt & Klein- interactive effect of individual differences in worry and lone-
berg, 2020) have been shown to influence the degree of liness on anxiety, stress, and depression among young adults.
experienced worry, but no work has evaluated the relation It was hypothesized that greater levels of COVID-19 related
between individual differences in COVID-19 related worry worry and loneliness would be related to higher levels of
and other emotional vulnerability factors that contribute to anxiety, stress, and depression symptoms.
worse psychological outcomes among young adults.
Loneliness represents another emotional vulnerability
factor that may be relevant to explore among young adults Method
in the context of anxiety, depression, and stress during
the COVID-19 pandemic. Loneliness is characterized as Participants
a negative emotional factor that arises when there is per-
ceived discrepancy between current and desired states of The present study included 209 college students (76.1%
an individual’s social relationships (David Perlman, 1982). female, M age = 22.99 years, SD = 5.25, range = 18–31)
Greater levels of loneliness are associated with greater anxi- recruited to participate in an online survey study for course
ety (Moeller & Seehuus, 2019) and depression (Cacioppo credit. Participants had to be currently enrolled in a psychol-
et al., 2006; Stessman et al., 2014). During the COVID-19 ogy course, had to be at least 18 years old, and had to be able

13
Cognitive Therapy and Research

to provide informed consent. Exclusion criteria included COVID‑19 Worry Index

being a non-English speaker (to ensure comprehension of
the study questions). The COVID-19 Worry Index is a 15-item measure created
The present sample consisted of White/Caucasian by the current research team (Zvolensky et al., 2020) and is
(40.7%) individuals, followed by 25.4% Asian, 12.4% Black/ based off of established measures of worry (Meyer et al.,
African American, 8.1% ‘Other’, 7.2% ‘more than one race,’ 1990). This measures assesses worry specific to the COVID-
0.5% Alaska Native or Native American, and 0.5% Native 19 pandemic across various topics, including but not limited
Hawaiian or Pacific Islander; 5.3% of the sample declined to to, health (e.g., “I worry that I am going to become seriously
provide their race. Regarding ethnicity, 37.8% of participants ill due to COVID-19”), social relationships (“I am worried
identified as being Spanish/Hispanic/Latinx. Eight partici- I will lose friends due to social distancing”), and finances
pants (4.8%) reported ever being diagnosed with COVID-19. (“I am worried I will not be able to financially provide for
Regarding education, 8.4% were freshman (1st year), 16.4% myself or my family during this time”; Wilson et al., 2020).
were sophomore (2nd year), 31.4% were junior (3rd year), For each item, participants were asked to rate how worried
35.8% were senior (4th year), 5.3% were 5th year or higher, they feel about each item on a scale from 1 (Not at all) to
and 2.7% declined to answer. Regarding employment, 54.5% 10 (A great deal). A total COVID-19 worry score was used
of the sample reported being currently employed. in the current study as the predictor in all models and this
subscale demonstrated excellent internal consistency in the
Measures current sample (Cronbach’s α = 0.93).

Demographics Questionnaire Depression Anxiety Stress Scales (DASS‑21)

Participants provided demographic information such as their The DASS-21(Antony et al., 1998) is 21-item self-report
gender, age, race, ethnicity, and education. Age (Lorem measure assessing symptoms of anxiety and depression.
et al., 2017), employment-related stress (McDonough, Participants are asked to rate several statements on a scale
2000), gender (Abrams et al., 2019), race, and ethnicity from 0 (Did not apply to me at all) to 3 (Applied to me very
(Spanish/Hispanic/Latinx or non-Spanish/HispanicLatinx; much, or most of the time). This measure yields three scales:
General, 2001; Hooper et al., 2020) were all included as the depression scale, which measures dysphoric mood (e.g.,
covariates within the model. “I felt that life was meaningless”), the anxiety scale, which
measures symptoms of physical arousal, panic attacks, and
Employment‑Related Stress fear (e.g., “I felt scared without any good reason”), and the
stress scale, which measures symptoms related to tension,
A single item created by the current research team (i.e., How irritability, and overreacting to stressful events (e.g., “I was
stressed are you about your current employment situation?”) intolerant of anything that kept me from getting on with
aimed to assess the stress related to an individual’s employ- what I was doing”). The three DASS-21 scales were uti-
ment status. Participants rated this item on a scale from 1 lized as the criterion variables in our models and demon-
(Not at all) to 10 (Extremely). Employment-related stress strated good to excellent internal consistency (depression:
was included in all models as a covariate. Cronbach’s α = 0.93; anxiety: Cronbach’s α = 0.88; stress:
Cronbach’s α = 0.88).
UCLA Loneliness Scale (Version 3)
Data Analysis
The UCLA Loneliness Scale (Russell, 1996) is a 20-item
self-report measure assessing loneliness, conceptualized as Analyses were conducted using SPSS version 25. First,
an unpleasant subjective internal experience during which sample descriptive statistics and zero-order correlations
an individual perceives their social network as being insuf- among study variables were examined. Second, to evaluate
ficient (Daniel Perlman & Peplau, 1982). Participants are main and interactive effects of COVID-19 worry and lone-
asked to rate how often they relate to a series of items per- liness, three separate hierarchical regression analyses were
taining to loneliness (e.g., “How often do you feel that you conducted for anxiety, depression, and stress as criterion
lack companionship?”) on a 1 (Never) to 4 (Always) scale. variables. Covariates entered in the first step of each model
The scale yields a total score, and higher scores indicate included age, employment-related stress, gender, race, and
higher levels of loneliness. Past work has demonstrated that ethnicity (Spanish/Hispanic/Latinx or non-Spanish/His-
the UCLA Loneliness Scale has sound psychometric proper- panicLatinx). Race and ethnicity were dichotomized as fol-
ties (Hartshorne, 1993). In the current sample, the loneliness lows: race (0 = White, 1 = Non-White) and ethnicity (0 = Not
total score was used (Cronbach’s α = 0.72). Spanish/Hispanic/Latinx, 1 = Spanish/Hispanic/Latinx). In

13
 Cognitive Therapy and Research

Table 1  Descriptive statistics and correlations among variables

Mean/n SD/% 1 2 3 4 5 6 7 8 9

1. Depression 11.30 11.17 –

2. Anxiety 8.78 9.54 0.67*** –
3. Stress 13.12 10.29 0.78*** 0.74*** –
4. COVID-19 worry 47.89 19.55 0.26*** 0.35*** 0.32*** –
5. Loneliness (UCLA) 45.75 13.05 0.57*** 0.37*** 0.48*** 0.22** –
6. Age 23.17 5.59 −0.16* −0.09 −0.09 −0.03 −0.11 –
7. Employment-related stress 2.59 1.29 0.23** 0.26*** 0.21** 0.48*** 0.19** 0.10 –
8. Gender (% Female) 125 (n) 75.8% 0.07 0.06 0.15* 0.21** 0.10 0.10 0.19** –
9. Race (% Non-White) 127 (n) 56.2% −0.04 −0.07 0.05 −0.06 −0.05 0.13 0.04 0.10 –
10. Ethnicity (% Hispanic) 64 (n) 38.8% −0.03 0.02 −0.02 −0.002 −0.01 −0.07 −0.07 −0.13 −0.53***

N = 165; ***p < .001, **p < .01, *p < .05. Depression, Anxiety, and Stress: Depression, Anxiety, and Stress Scales – 21 (DASS-21; Antony et al.,
1998); COVID-19 worry: COVID-19 Worry Index; Loneliness: UCLA Loneliness Scale (Russell, 1996); Employment-related stress: “How
stressed are you about your current employment situation?” 1 (Not at all) to 10 (Extremely); Gender: 0 = Male, 1 = Female; Race: 0 = White,
1 = Non-White; Ethnicity: 0 = Not Spanish/Hispanic/Latinx, 1 = Spanish/Hispanic/Latinx

step 2, COVID-19 worry and loneliness were simultane- significantly and positively related (r = 0.22, 4% shared var-
ously entered. In step 3, the interaction of COVID-19 worry iance with one another, p = 0.02). The criterion variables
and loneliness was added. Planned simple slope post hoc were interrelated (range of r’s 0.67–0.78, p < 0.001).
analyses were conducted using high and low values (e.g. ± 1
SD from the mean) of the moderator variable to examine Primary Analyses
the association of COVID-19 worry and depression, anxi-
ety, and stress as a function of loneliness. In addition, the For depression, covariates entered in the first step accounted
Johnson–Neyman (JN) technique (Aiken et al., 1991) was for a significant (statistically significant) amount of vari-
used to statistically identify regions of values in COVID-19 ance on the criterion variable (F[5, 203] = 4.09, p = 0.001,
worry where the effect of loneliness was statistically signifi- R2 = 0.09; see Table 2). Employment stress (p < 0.001)
cant, per recommendations of Hayes (2013). Simple slopes and age (p = 0.01) each had a significant effect. Step two
and the JN procedure were conducted using the PROCESS accounted for significantly more variance in depression
macro for SPSS (Hayes, 2012). Effect sizes for interactions (ΔR2 = 0.28, p < 0.001) and a significant main effect emerged
were evaluated using unique variance explained (∆R2). for COVID-19 worry. Step three accounted for significantly
Lastly, to supplement our results, analyses were re-run using more variance in depression (ΔR2 = 0.03, p = 0.01). There
unadjusted models.1 was a significant interaction of COVID-19 worry and loneli-
ness (p = 0.01). Simple slope analysis revealed COVID-19
worry related to depressive symptoms among those at higher
Results levels of loneliness (b = 0.17, SE = 0.05, p < 0.001); COVID-
19 worry was not related to depressive symptoms among
Descriptive Statistics those at lower levels of loneliness (b = -0.01, SE = 0.05,
p = 0.80; see Fig. 1).
Descriptive statistics and bivariate correlations are pre- For anxiety, covariates entered in the first step accounted
sented in Table 1. COVID-19 worry was significantly and for a significant amount of variance (F[5, 203] = 3.46,
positively related to depression (r = 0.29, p < 0.001), anxiety p = 0.01, R 2 = 0.08; see Table 2). Employment stress
(r = 0.35, p < 0.001), and stress (r = 0.32, p < 0.001). Loneli- (p < 0.001) was a significant predictor. Step two accounted
ness was significantly and positively related to depression for significantly amount more variance in anxiety
(r = 0.57, p < 0.001), anxiety (r = 0.37, p < 0.001), and stress (ΔR2 = 0.14, p < 0.001) and a significant main effect emerged
(r = 0.48, p < 0.001). COVID-19 worry and loneliness were for COVID-19 worry. Step three accounted for significantly
more variance in anxiety (ΔR2 = 0.02, p = 0.01). There was a
significant interaction of COVID-19 worries and loneliness
1
Results were consistent with the original pattern of findings in that (p = 0.02). Simple slope analysis revealed that COVID-19
for all criterion variables, COVID-19 worry and loneliness contrib- worry related to anxiety symptoms among those at higher
uted to statistical significant overall model fit and the interaction of
COVID-19 and loneliness explained a significant amount of variance levels of loneliness (b = 0.19, SE = 0.05, p < 0.001); COVID-
in for the criterion variables. 19 worry was not related to anxiety symptoms among those

13
Cognitive Therapy and Research

Table 2  Regression model

Depression

B SE t p sr2 R2 change
Step 1 0.09
Employment stress 2.02 0.57 3.52 < 0.001 0.06
Age −0.38 0.14 −2.75 0.01 0.03
Gender 1.31 1.73 0.78 0.45 0.003
Race −0.12 0.47 −0.25 0.81 < 0.001
Ethnicity 0.66 1.72 0.38 0.70 0.001
Step 2 0.28
COVID-19 worry 0.08 0.04 2.12 0.04 0.01
Loneliness 0.44 0.05 8.91 < 0.001 0.25
Step 3 0.03
COVID-19 worry*Loneliness 0.01 0.003 2.86 0.01 0.02
Anxiety

b SE t p sr2 R2 change
Step 1 0.08
Employment stress 1.79 0.49 3.67 < 0.001 0.06
Age −0.19 0.19 −1.59 0.11 0.01
Gender 0.74 1.47 0.50 0.62 0.001
Race −0.32 0.40 −0.81 0.42 0.003
Ethnicity 0.05 1.46 0.04 0.97 < 0.001
Step 2 0.14
COVID-19 worry 0.11 0.03 3.40 0.001 0.04
Loneliness 0.21 0.05 4.51 < 0.001 0.08
Step 3 0.02
COVID-19 worry*Loneliness 0.01 0.002 2.37 0.02 0.15
Stress

b SE t p sr2 R2 change
Step 1 0.07
Employment stress 1.53 0.54 2.84 0.01 0.19
Age −0.25 0.13 −1.87 0.06 0.017
Gender 2.86 1.63 1.75 0.08 0.12
Race 0.33 0.44 0.75 0.45 0.05
Ethnicity 0.63 1.62 0.39 0.70 0.03
Step 2 0.22
COVID-19 worry 0.11 0.04 3.00 0.003 0.03
Loneliness 0.33 0.05 6.76 < 0.001 0.16
Step 3 0.02
COVID-19 worry*Loneliness 0.01 0.003 2.54 0.01 0.02

N = 319; New variables are represented in each step, however, all previous variables were retained

at lower levels of loneliness (b = 0.04, SE = 0.04, p = 0.32; Step three accounted for significantly more variance in stress
see Fig. 2). (ΔR2 = 0.02, p = 0.01). There was a significant interaction
For stress, covariates entered in the first step accounted for of COVID-19 worries and loneliness (p = 0.01). Simple
a significant amount of variance (F[5, 1203] = 3.19, p = 0.01, slope analysis revealed that COVID-19 worry related to
R2 = 0.07; see Table 2). Employment stress (p = 0.01) was stress symptoms among those at higher levels of loneliness
the only significant predictor. Step two accounted for sig- (b = 0.19, SE = 0.05, p < 0.001); COVID-19 worry was not
nificantly more variance in stress (ΔR2 = 0.22, p < 0.001), related to stress symptoms among those at lower levels of
and COVID-19 worry emerged as a significant predictor. loneliness (b = 0.03, SE = 0.05, p = 0.55; see Fig. 3).

13
 Cognitive Therapy and Research

Fig. 1  Interaction of COVID-

19 worry and loneliness on
depression

Fig. 2  Interaction of COVID-19

worry and loneliness on anxiety

Discussion worry and loneliness evidenced the greatest levels of emo-

tional distress. These results highlight the synergistic role
This study aimed to investigate the interactive effect of indi- of COVID-19 worry and loneliness beyond the respective
vidual differences in COVID-19 related worry and loneliness main effects for the studied mental health variables. The
in relation to depression, anxiety, and stress among young size of the observed significant interaction effects was small,
adults. Findings were consistent with our initial hypotheses. according to conventional standards (Cohen et al., 2013).
Specifically, there was a significant interactive effect for However, given the magnitude of variance accounted for at
COVID-19 worry and loneliness for each criterion variable, steps 1 and 2 (ranging from 22% to 37% of variance), it is
accounting for an additional 2–3% of the variance explained noteworthy that the interactive effects enhanced the model’s
over the theoretically relevant covariates of age, employ- predictive power (Abelson, 1985). Thus, the overall pattern
ment-related stress, gender, race, and ethnicity. Inspection of findings were consistent with theoretical models suggest-
of the forms of the significant interactions indicated that ing that there may indeed be clinically relevant interplay
individuals reporting co-occurring high levels of COVID-19 between COVID-19 worry and loneliness in regard to nega-
tive emotional symptoms among young adults.

13
Cognitive Therapy and Research

Fig. 3  Interaction of COVID-19

worry and loneliness on stress

It is important to note that these data form part of a pre- COVID-19 worry is related to negative mental health out-
liminary model and suggest COVID-19 worry on mental comes among young adults (Rogers et al., 2020).
health during the pandemic is likely to be exacerbated in These findings have important clinical implications.
the presence of increased loneliness among young adults. Results suggest worry about the outcomes and consequences
As the ongoing pandemic and associated regulations that of the current pandemic may be a risk factor for anxiety,
limit social interactions are likely to continue for some stress, and depression, particularly in the context of loneli-
time (“Study Sees Need for Some Social Distancing into ness. Thus, interventions could seek to address COVID-19
2022 to Curb Coronavirus,” 2020), worry and loneliness related worry and loneliness in one overarching therapeutic
may remain elevated in the general population. Therefore, model. For example, there may be value in providing psy-
ongoing work may benefit from continued investigation of choeducation for young adults on the interactive nature of
worry and loneliness as factors impacting mental health worry related to the pandemic and the loneliness that may
outcomes both during and after the pandemic. exacerbate such worry. Along with psychoeducation, clini-
In terms of main effects, COVID-19 related worry cians may seek to provide young adults with strategies to
emerged as an independent predictor and related to symp- lower levels of worry (e.g., structuring worry time, cognitive
toms of increased stress, anxiety, and depression. These restructuring) and promote activities that combat loneliness
data suggest that among young adults, worry within the (e.g., outdoor activities, virtual or socially distant interac-
context of the ongoing pandemic may exacerbate risk for tions with friends, peer support and disclosure; Steger &
negative mental health outcomes. This association has Kashdan, 2009). However, it is important to consider ele-
been evident in the general population (Rogers et al., vated levels of loneliness and worry may encompass a rela-
2020), but had yet to be investigated specifically among tively “normal” response to a pandemic and the restrictions
young adults. Of note, even though loneliness was related that accompany the pandemic. Indeed, elevated levels of
to worry in terms of the criterion symptoms, loneliness worry may serve a protective function in terms of prompting
alone did not reach statistical significance as a main effect individuals to adhere to guidelines and updated restrictions.
predictor when evaluated in the context of worry. This Young adults may likely benefit from a nuanced and bal-
pattern of associations supports the conceptualization of anced perspective of theseemotional states, in which worry
loneliness as both sharing variance with and also moderat- and loneliness are normalized as responses, while monitor-
ing the more primary effects of worry. The current sample ing the threshold for “elevated” worry and loneliness.
reported a level of loneliness that would be elevated com- The present study has limitations that warrant comment
pared to normative data (Morhan-Martin and Schumacher, and can serve to better inform future work in this area.
2003), underscoring the prevalence of loneliness during First, the study utilized cross sectional data. This type of
the pandemic and suggesting that greater attention could data collection impedes interpretation of temporal associa-
be focused on this construct. In terms of COVID-19 worry, tions across studied variables. Future prospective research
the current results extend past work by highlighting that is therefore needed to provide better insight into the

13
 Cognitive Therapy and Research

longitudinal nature of the interplay between the COVID-19 versions of the Depression Anxiety Stress Scales in clinical groups
worry and loneliness. Second, data was collected based on and a community sample. Psychological Assessment, 10(2), 176.
Baiano, C., Zappullo, I., & Conson, M. (2020). Tendency to worry
self-report. Future work may seek to employ multimethod and fear of mental health during Italy’s COVID-19 lockdown.
methodology to decrease shared method variance. Third, International Journal of Environmental Research and Public
COVID-19 related worry was evaluated as a unidimen- Health, 17(16), 5928.
sional construct. Future work may benefit from investigat- Bentley, K. H., Boettcher, H., Bullis, J. R., Carl, J. R., Conklin, L. R.,
Sauer-Zavala, S., Pierre-Louis, C., Farchione, T. J., & Barlow,
ing whether certain “areas” of worry are more pronounced D. H. (2018). Development of a single-session, transdiagnostic
among young adults (e.g., finances, health). These investiga- preventive intervention for young adults at risk for emotional
tions may provide a more nuanced understanding of the risk disorders. Behavior Modification, 42(5), 781–805.
level for negative mental health symptoms associated with Borkovec, T. D. (1985). Worry: A potentially valuable concept.
Behaviour Research and Therapy, 23(4), 481–482.
specific worries. Finally, no information was gathered on the Browning, M. H., Larson, L. R., Sharaievska, I., Rigolon, A., McAn-
regulations and social practices of the sample. Evaluating irlin, O., Mullenbach, L., Cloutier, S., Vu, T. M., Thomsen, J.,
to what degree social distancing restrictions are enforced, & Reigner, N. (2021). Psychological impacts from COVID-19
whether individuals engage in virtual gatherings, and the among university students: Risk factors across seven states in
the United States. PloS One, 16(1), e0245327.
level of compliance with distancing guidelines may provide Cacioppo, J. T., Hughes, M. E., Waite, L. J., Hawkley, L. C., & Thisted,
a better understanding on the levels of worry and loneliness R. A. (2006). Loneliness as a specific risk factor for depressive
among young adults. symptoms: Cross-sectional and longitudinal analyses. Psychology
Overall, the current findings provide initial empirical and Aging, 21(1), 140–151. https://​doi.​org/​10.​1037/​0882-​7974.​
21.1.​140
evidence for the impact of COVID-19 worry on mental Cohen, J., Cohen, P., West, S. G., & Aiken, L. S. (2013). Applied
health among young adults experiencing loneliness. Future multiple regression/correlation analysis for the behavioral sci-
research may benefit from exploring how COVID-19 worry ences. Routledge.
and loneliness interplay over time. Dugas, M. J., Schwartz, A., & Francis, K. (2004). Brief report: Intol-
erance of uncertainty, worry, and depression. Cognitive Therapy
and Research, 28(6), 835–842.
Ehring, T., & Behar, E. (2020). Transdiagnostic view on worrying
Funding Research reported in this publication was supported by the and other negative mental content. Generalized Anxiety Disor-
National Institute on Minority Health and Health Disparities (NIMHD) der and Worrying: A Comprehensive Handbook for Clinicians
of the National Institutes of Health (NIH) to the University of Houston and Researchers, 43–68.
under Award Number U54MD015946. The content is solely the respon- Ettman, C. K., Abdalla, S. M., Cohen, G. H., Sampson, L., Vivier,
sibility of the authors and does not necessarily represent the official P. M., & Galea, S. (2020). Prevalence of depression symptoms
views of the National Institutes of Health. in US adults before and during the COVID-19 pandemic. JAMA
Network Open, 3(9), e2019686–e2019686.
Declarations Gallagher, M. W., Zvolensky, M. J., Long, L. J., Rogers, A. H., &
Garey, L. (2020). The impact of covid-19 experiences and asso-
ciated stress on anxiety, depression, and functional impairment
Conflict of interest Nubia A. Mayorga, Tanya Smit, Lorra Garey, Al- in American adults. Cognitive Therapy and Research, 44(6),
exandra K. Gold, Michael W. Otto, Michael J. Zvolensky declare that 1043–1051.
they have no conflict of interest is evident for the content of this manu- Gana, K., Martin, B., & Canouet, M.-D. (2001). Worry and anxi-
script, the authors would like to acknowledge the following relation- ety: Is there a causal relationship? Psychopathology, 34(5),
ship. Dr. Otto receives compensation as a consultant for Big Health. 221–229.
General, U. S. (2001). Mental health: Culture, race, and ethnicity. A
Animal Rights No animal studies were carried out by the authors for supplement to mental health: A report of the surgeon general.
this article. US Department of Health and Human Services.
Hartshorne, T. S. (1993). Psychometric properties and confirmatory
Informed Consent All participants provided informed consent prior to factor analysis of the UCLA Loneliness Scale. Journal of Per-
participating in this research study. sonality Assessment, 61(1), 182–195.
Hayes, A. F. (2012). PROCESS: A versatile computational tool for
observed variable mediation, moderation, and conditional process
modeling.
References Hayes, N. (Ed.). (2013). Doing qualitative analysis in psychology. Psy-
chology Press.
Abelson, R. P. (1985). A variance explanation paradox: When a little Hoffart, A., Johnson, S. U., & Ebrahimi, O. V. (2020). Loneliness
is a lot. Psychological Bulletin, 97(1), 129. and social distancing during the COVID-19 pandemic: Risk
Abrams, L. R., Kalousova, L., & Fleischer, N. L. (2019). Gender dif- factors and associations with psychopathology. Frontiers in
ferences in relationships between sociodemographic factors and Psychiatry, 11, 1297.
e-cigarette use with smoking cessation: 2014–15 current popula- Hooper, M. W., Nápoles, A. M., & Pérez-Stable, E. J. (2020).
tion survey tobacco use supplement. Journal of Public Health. COVID-19 and racial/ethnic disparities. Jama.
https://​doi.​org/​10.​1093/​pubmed/​fdz017 Kleinberg, B., van der Vegt, I., & Mozes, M. (2020). Measuring
Antony, M. M., Bieling, P. J., Cox, B. J., Enns, M. W., & Swinson, R. emotions in the covid-19 real world worry dataset.
P. (1998). Psychometric properties of the 42-item and 21-item Kujawa, A., Green, H., Compas, B. E., Dickey, L., & Pegg, S. (2020).
Exposure to COVID-19 pandemic stress: Associations with

13
Cognitive Therapy and Research

depression and anxiety in emerging adults in the United States. Stress in AmericaTM 2020: Stress in the Time of COVID-19, Volume
Depression and Anxiety, 37(12), 1280–1288. One. (n.d.). Retrieved November 11, 2020, from https://w ​ ww.a​ pa.​
Liu, C. H., Zhang, E., Wong, G. T. F., & Hyun, S. (2020). Factors org/​news/​press/​relea​ses/​stress/​2020/​report
associated with depression, anxiety, and PTSD symptomatology Study sees need for some social distancing into 2022 to curb corona-
during the COVID-19 pandemic: Clinical implications for US virus. (2020, April 14). STAT​. https://​www.​statn​ews.​com/​2020/​
young adult mental health. Psychiatry Research, 290, 113172. 04/​14/​some-​social-​dista​ncing-​may-​be-​needed-​into-​2022-​to-​keep-​
Lorem, G. F., Schirmer, H., Wang, C. E. A., & Emaus, N. (2017). coron​avirus-​in-​check-​new-​study-​says/
Ageing and mental health: Changes in self-reported health due Taylor, S. (2020). COVID stress syndrome: Clinical and nosological
to physical illness and mental health status with consecutive considerations. Current Psychiatry Reports, 23(4), 1–7.
cross-sectional analyses. British Medical Journal Open, 7(1), Topper, M., Emmelkamp, P. M., Watkins, E., & Ehring, T. (2017).
e013629. https://​doi.​org/​10.​1136/​bmjop​en-​2016-​013629 Prevention of anxiety disorders and depression by targeting exces-
Marroquín, B., Vine, V., & Morgan, R. (2020). Mental health dur- sive worry and rumination in adolescents and young adults: A
ing the COVID-19 pandemic: Effects of stay-at-home policies, randomized controlled trial. Behaviour Research and Therapy,
social distancing behavior, and social resources. Psychiatry 90, 123–136.
Research, 293, 113419. Troyer, E. A., Kohn, J. N., & Hong, S. (2020). Are we facing a crashing
Martinez, A., & Nguyen, S. (2020). The Impact of Covid-19 on College wave of neuropsychiatric sequelae of COVID-19? Neuropsychi-
Student Well-Being. atric symptoms and potential immunologic mechanisms. Brain,
McDonough, P. (2000). Job insecurity and health. International Jour- Behavior, and Immunity.
nal of Health Services, 30(3), 453–476. https://​doi.​org/​10.​2190/​ Van der Vegt, I., & Kleinberg, B. (2020). Women worry about fam-
BPFG-​X3ME-​LHTA-​6RPV ily, men about the economy: Gender differences in emotional
Minds, A. (2020). COVID-19 impact on college student mental health. responses to COVID-19. International Conference on Social
Activeminds. Org. Informatics, 397–409.
Moeller, R. W., & Seehuus, M. (2019). Loneliness as a mediator for Wang, C., Pan, R., Wan, X., Tan, Y., Xu, L., Ho, C. S., & Ho, R.
college students’ social skills and experiences of depression and C. (2020). Immediate psychological responses and associated
anxiety. Journal of Adolescence, 73, 1–13. factors during the initial stage of the 2019 coronavirus disease
Muris, P., Roelofs, J., Rassin, E., Franken, I., & Mayer, B. (2005). (COVID-19) epidemic among the general population in China.
Mediating effects of rumination and worry on the links between International Journal of Environmental Research and Public
neuroticism, anxiety, and depression. Personality and Individual Health, 17(5), 1729.
Differences, 39(6), 1105–1111. Wells, A., & Carter, K. (2001). Further tests of a cognitive model
Palsson, O. S., & Ballou, S. (n.d.). The U.S. National Pandemic Emo- of generalized anxiety disorder: Metacognitions and worry in
tional Impact Report. 37. GAD, panic disorder, social phobia, depression, and nonpatients.
Panchal, N., Kamal, R., Orgera, K., Cox, C., Garfield, R., Hamel, L., Behavior Therapy, 32(1), 85–102. https://d​ oi.o​ rg/1​ 0.1​ 016/S ​ 0005-​
& Chidambaram, P. (2020). The implications of COVID-19 for 7894(01)​80045-9
mental health and substance use. Kaiser Family Foundation. WHO Coronavirus Disease (COVID-19) Dashboard. (n.d.). Retrieved
Perlman, Daniel, & Peplau, L. A. (1982). Theoretical approaches to November 1, 2020, from https://​covid​19.​who.​int
loneliness. Loneliness: A Sourcebook of Current Theory, Research Wilson, J. M., Lee, J., Fitzgerald, H. N., Oosterhoff, B., Sevi, B., &
and Therapy, 123–134. Shook, N. J. (2020). Job insecurity and financial concern dur-
Perlman, D. (1982). Loneliness: A sourcebook of current theory, ing the COVID-19 pandemic are associated with worse mental
research, and therapy (Vol. 36). Wiley. health. Journal of Occupational and Environmental Medicine,
Resnick, A., Galea, S., & Sivashanker, K. (2020). Covid-19: The pain- 62(9), 686–691. https://d​ oi.o​ rg/1​ 0.1​ 097/J​ OM.0​ 00000​ 00000​ 01962
ful price of ignoring health inequities. BMJ Opinion, 18. Wolitzky-Taylor, K., McBeth, J., Guillot, C. R., Stone, M. D., Kirkpat-
Rogers, A. H., Shepherd, J. M., Garey, L., & Zvolensky, M. J. (2020). rick, M. G., Zvolensky, M. J., Buckner, J. D., & Leventhal, A. M.
Psychological factors associated with substance use initiation dur- (2016). Transdiagnostic processes linking anxiety symptoms and
ing the COVID-19 pandemic. Psychiatry Research, 293, 113407. substance use problems among adolescents. Journal of Addictive
Roussis, P., & Wells, A. (2008). Psychological factors predicting stress Diseases, 35(4), 266–277.
symptoms: Metacognition, thought control, and varieties of worry. Zvolensky, M. J., Garey, L., Rogers, A. H., Schmidt, N. B., Vujanovic,
Anxiety, Stress, & Coping, 21(3), 213–225. A. A., Storch, E. A., Buckner, J. D., Paulus, D. J., Alfano, C., &
Russell, D. W. (1996). UCLA loneliness scale (Version 3): Reliability, Smits, J. A. (2020). Psychological, addictive, and health behavior
validity, and factor structure. Journal of Personality Assessment, implications of the COVID-19 pandemic. Behaviour Research and
66(1), 20–40. Therapy, 134, 103715.
Salari, N., Hosseinian-Far, A., Jalali, R., Vaisi-Raygani, A., Rasoul- Zvolensky, M. J., Kauffman, B. Y., Bogiaizian, D., Viana, A. G., Bakh-
poor, S., Mohammadi, M., Rasoulpoor, S., & Khaledi-Paveh, B. shaie, J., & Peraza, N. (2019). Worry among Latinx college stu-
(2020). Prevalence of stress, anxiety, depression among the gen- dents: relations to anxious arousal, social anxiety, general depres-
eral population during the COVID-19 pandemic: A systematic sion, and insomnia. Journal of American College Health, 1–8.
review and meta-analysis. Globalization and Health, 16(1), 1–11.
Steger, M. F., & Kashdan, T. B. (2009). Depression and everyday social Publisher’s Note Springer Nature remains neutral with regard to
activity, belonging, and well-being. Journal of Counseling Psy- jurisdictional claims in published maps and institutional affiliations.
chology, 56(2), 289.
Stessman, J., Rottenberg, Y., Shimshilashvili, I., Ein-Mor, E., & Jacobs,
J. M. (2014). Loneliness, health, and longevity. Journals of Ger-
ontology Series A: Biomedical Sciences and Medical Sciences,
69(6), 744–750.

13