Initial evidence review - Strategies for encouraging psychological and emotional resilience in response to loneliness 2019

It is now widely accepted that loneliness is influenced by a combination of psychological factors, including attitudes to participating in social interactions and mental health problems, as well as environmental factors such as living far from family and friends and life events and transitions such as bereavement and moving away from home. Despite increased recognition of the importance of individual-level processes and meanings that influence the experience of loneliness, there is a gap in our knowledge of how best to address the psychological factors that contribute to chronic loneliness. In this report, we aim to synthesise information from a range of sources in order to identify the psychological pathways to loneliness and relevant psychological barriers to accessing strategies which target social isolation. The report highlights promising interventions that have potential to target the psychological aspects of loneliness. It makes a series of recommendations to improve understanding and delivery of effective psychological interventions to address loneliness and how the interaction between such strategies and community-based interventions. We conducted an extensive scoping review of the academic literature, including online database searches and broader searches reviewing conference abstracts and reports from the Third Sector. We obtained expert opinions by speaking to relevant stakeholders including people with lived experiences of loneliness, charitable organisations working with people who are experiencing chronic loneliness, and those involved in developing and evaluating interventions to tackle loneliness. Much of the work focused on older adults but we also looked at interventions delivered across the age range. We report the findings from this work, including an overview of the wide range of psychological factors which might explain why some people who are chronically lonely struggle to engage with community strategies and other sources of support that are available. These factors include having mental health problems, personality characteristics and having unhelpful beliefs and behaviours related to social interactions. We recommend that interventions that target either the psychological or social aspects of loneliness should not be provided in isolation, and that multi-modal interventions are likely to be most successful. Further research evidence is needed to evaluate the feasibility, acceptability, effectiveness and cost-effectiveness of delivering psychological interventions in conjunction with community-based strategies. Social prescribing is a potential opportunity for the successful delivery of psycho-social interventions. For example, integration of psychological and community-based support could be promoted by including directories of psychological support in guides to community based resources, and by connecting social prescribing link workers with their local improving access to psychological therapies services. The social psychological approaches such as the Groups 4 Health model (Haslam et al., 2019; Haslam, Cruwys, Haslam, Dingle & Chang, 2016) show promise and potentially could bridge psychological and social understandings of loneliness. There is preliminary research evidence that interventions that address the psychological factors involved in loneliness can be successful, and there are various approaches to addressing these factors across the UK, although many initiatives have not yet been fully evaluated. The strongest research evidence was found for cognitive behavioural interventions, and there are some promising developments, including digital initiatives which are designed to change individuals’ thoughts and feelings about loneliness, that are worthy of further evaluation. We would also recommend that acceptance and commitment therapy is formally evaluated as an intervention for loneliness. We noted that the research base in this area is still underdeveloped and more work is needed to demonstrate which interventions are most accessible to people who are chronically lonely and can feasibly be delivered within NHS and community settings. Research into the potential adverse effects of psychological interventions, individual differences in responsiveness and the longer term impact on loneliness is also needed. It is likely that including measures of loneliness in evaluations of interventions for social anxiety and grief and in routine work with older adults in improving access to psychological therapies services would yield data that will contribute to the growing evidence base in this area. We hope that bringing together the research evidence and expert opinion in this report will increase awareness of the wide range of psychological factors implicated in loneliness and lead to further provision of psychological interventions for loneliness, in combination with community based support for social isolation

Smoking cessation for people with severe mental illness (SCIMITAR+) : a pragmatic randomised controlled trial

BACKGROUND: People with severe mental illnesses such as schizophrenia are three times more likely to smoke than the wider population, contributing to widening health inequalities. Smoking remains the largest modifiable risk factor for this health inequality, but people with severe mental illness have not historically engaged with smoking cessation services. We aimed to test the effectiveness of a combined behavioural and pharmacological smoking cessation intervention targeted specifically at people with severe mental illness. METHODS: In the smoking cessation intervention for severe mental illness (SCIMITAR+) trial, a pragmatic, randomised controlled study, we recruited heavy smokers with bipolar disorder or schizophrenia from 16 primary care and 21 community-based mental health sites in the UK. Participants were eligible if they were aged 18 years or older, and smoked at least five cigarettes per day. Exclusion criteria included substantial comorbid drug or alcohol problems and people who lacked capacity to consent at the time of recruitment. Using computer-generated random numbers, participants were randomly assigned (1:1) to a bespoke smoking cessation intervention or to usual care. Participants, mental health specialists, and primary care physicians were unmasked to assignment. The bespoke smoking cessation intervention consisted of behavioural support from a mental health smoking cessation practitioner and pharmacological aids for smoking cessation, with adaptations for people with severe mental illness-such as, extended pre-quit sessions, cut down to quit, and home visits. Access to pharmacotherapy was via primary care after discussion with the smoking cessation specialist. Under usual care participants were offered access to local smoking cessation services not specifically designed for people with severe mental illnesses. The primary endpoint was smoking cessation at 12 months ascertained via carbon monoxide measurements below 10 parts per million and self-reported cessation for the past 7 days. Secondary endpoints were biologically verified smoking cessation at 6 months; number of cigarettes smoked per day, Fagerström Test for Nicotine Dependence (FTND) and Motivation to Quit (MTQ) questionnaire; general and mental health functioning determined via the Patient Health Questionnaire-9 (PHQ-9), the Generalised Anxiety Disorder-7 (GAD-7) questionnaire, and 12-Item Short Form Health Survey (SF-12); and body-mass index (BMI). This trial was registerd with the ISRCTN registry, number ISRCTN72955454, and is complete. FINDINGS: Between Oct 7, 2015, and Dec 16, 2016, 526 eligible patients were randomly assigned to the bespoke smoking cessation intervention (n=265) or usual care (n=261). 309 (59%) participants were male, median age was 47·2 years (IQR 36·3-54·5), with high nicotine dependence (mean 24 cigarettes per day [SD 13·2]), and the most common severe mental disorders were schizophrenia or other psychotic illness (n=343 [65%]), bipolar disorder (n=115 [22%]), and schizoaffective disorder (n=66 [13%]). 234 (88%) of intervention participants engaged with the treatment programme and attended 6·4 (SD 3·5) quit smoking sessions, with an average duration of 39 min (SD 17; median 35 min, range 5-120). Verified quit data at 12 months were available for 219 (84%) of 261 usual care and 223 (84%) of 265 intervention participants. The proportion of participants who had quit at 12 months was higher in the intervention group than in the usual care group, but non-significantly (34 [15%] of 223 [13% of those assigned to group] vs 22 [10%] of 219 [8% of those assigned to group], risk difference 5·2%, 95% CI -1·0 to 11·4; odds ratio [OR] 1·6, 95% CI 0·9 to 2·9; p=0·10). The proportion of participants who quit at 6 months was significantly higher in the intervention group than in the usual care group (32 [14%] of 226 vs 14 [6%] of 217; risk difference 7·7%, 95% CI 2·1 to 13·3; OR 2·4, 95% CI 1·2 to 4·6; p=0·010). The incidence rate ratio for number of cigarettes smoked per day at 6 months was 0·90 (95% CI 0·80 to 1·01; p=0·079), and at 12 months was 1·00 (0·89 to 1·13; p=0·95). At both 6 months and 12 months, the intervention group was non-significantly favoured in the FTND (adjusted mean difference 6 months -0·18, 95% CI -0·53 to 0·17, p=0·32; and 12 months -0·01, -0·39 to 0·38, p=0·97) and MTQ questionnaire (adjusted mean difference 0·58, -0·01 to 1·17, p=0·056; and 12 months 0·64, 0·04 to 1·24, p=0·038). The PHQ-9 showed no difference between the groups (adjusted mean difference at 6 months 0·20, 95% CI -0·85 to 1·24 vs 12 months -0·12, -1·18 to 0·94). For the SF-12 survey, we saw evidence of improvement in physical health in the intervention group at 6 months (adjusted mean difference 1·75, 95% CI 0·21 to 3·28), but this difference was not evident at 12 months (0·59, -1·07 to 2·26); and we saw no difference in mental health between the groups at 6 or 12 months (adjusted mean difference at 6 months -0·73, 95% CI -2·82 to 1·36, and 12 months -0·41, -2·35 to 1·53). The GAD-7 questionnaire showed no difference between the groups (adjusted mean difference at 6 months -0·32 95% CI -1·26 to 0·62 vs 12 months -0·10, -1·05 to 0·86). No difference in BMI was seen between the groups (adjusted mean difference 6 months 0·16, 95% CI -0·54 to 0·85; 12 months 0·25, -0·62 to 1·13). INTERPRETATION: This bespoke intervention is a candidate model of smoking cessation for clinicians and policy makers to address high prevalence of smoking. The incidence of quitting at 6 months shows that smoking cessation can be achieved, but the waning of this effect by 12 months means more effort is needed for sustained quitting. FUNDING: National Institute for Health Research Health Technology Assessment Programme

A bespoke smoking cessation service compared with treatment as usual for people with severe mental ill health: the SCIMITAR+ RCT

BackgroundThere is a high prevalence of smoking among people with severe mental ill health (SMI). Helping people with SMI to quit smoking could improve their health and longevity, and reduce health inequalities. However, those with SMI are less likely to access and engage with routine smoking cessation services than the general population.ObjectivesTo compare the clinical effectiveness and cost-effectiveness of a bespoke smoking cessation (BSC) intervention with usual stop smoking services for people with SMI.DesignA pragmatic, two-arm, individually randomised controlled trial.SettingPrimary care and secondary care mental health services in England.ParticipantsSmokers aged ≥ 18 years with SMI who would like to cut down on or quit smoking.InterventionsA BSC intervention delivered by mental health specialists trained to deliver evidence-supported smoking cessation interventions compared with usual care.Main outcome measuresThe primary outcome was self-reported, CO-verified smoking cessation at 12 months. Smoking-related secondary outcomes were self-reported smoking cessation, the number of cigarettes smoked per day, the Fagerström Test for Nicotine Dependence and the Motivation to Quit questionnaire. Other secondary outcomes were Patient Health Questionnaire-9 items, Generalised Anxiety Disorder Assessment-7 items and 12-Item Short-Form Health Survey, to assess mental health and body mass index measured at 6 and 12 months post randomisation.ResultsThe trial randomised 526 people (265 to the intervention group, 261 to the usual-care group) aged 19 to 72 years (mean 46 years). About 60% of participants were male. Participants smoked between 3 and 100 cigarettes per day (mean 25 cigarettes per day) at baseline. The intervention group had a higher rate of exhaled CO-verified smoking cessation at 6 and 12 months than the usual-care group [adjusted odds ratio (OR) 12 months: 1.6, 95% confidence interval (CI) 0.9 to 2.8; adjusted OR 6 months: 2.4, 95% CI 1.2 to 4.7]. This was not statistically significant at 12 months (p = 0.12) but was statistically significant at 6 months (p = 0.01). In total, 111 serious adverse events were reported (69 in the BSC group and 42 in the usual-care group); the majority were unplanned hospitalisations due to a deterioration in mental health (n = 98). The intervention is likely (57%) to be less costly but more effective than usual care; however, this result was not necessarily associated with participants’ smoking status.LimitationsFollow-up was not blind to treatment allocation. However, the primary outcome included a biochemically verified end point, less susceptible to observer biases. Some participants experienced difficulties in accessing nicotine replacement therapy because of changes in service provision. Efforts were made to help participants access nicotine replacement therapy, but this may have affected participants’ quit attempt.ConclusionsPeople with SMI who received the intervention were more likely to have stopped smoking at 6 months. Although more people who received the intervention had stopped smoking at 12 months, this was not statistically significant.Future workFurther research is needed to establish how quitting can be sustained among people with SMI.Trial registrationCurrent Controlled Trials ISRCTN72955454.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 50. See the NIHR Journals Library website for further project information