Randomised controlled trials of occupational therapy interventions for adults with a mental health condition or dementia: A systematic review of study methods and outcome measurement

Introduction High-quality randomised controlled trials (RCTs) of interventions are essential for determining whether an intervention is effective. However, many RCTs that examine the effectiveness of occupational therapy interventions for adults with mental health conditions or dementia have methodological limitations that reduce confidence in their results. We aimed to systematically review the quality of methods and outcome measures used in RCTs of occupational therapy interventions for adults with a mental health condition or dementia. This will inform future research in this area and enable practitioners to appraise the evidence when selecting interventions. Method We searched peer-reviewed English language publications from 2000 to 2021 in MEDLINE, PsycINFO, ASSIA, CINAHL and e-thos, and hand-searched 12 journals. We included papers that met pre-specified inclusion criteria, appraised quality using a validated tool and extracted data. We conducted a narrative synthesis. Results Of thirty-three included papers, 26 reported full or pilot RCTs, two reported secondary analysis or secondary outcomes of included RCTs, three reported process evaluations and two reported economic evaluations. Methodological limitations were found in many studies and outcome measures varied in their psychometric quality. Conclusion High-quality RCTs of occupational therapy interventions are needed for adults with mental health conditions and dementia. Researchers should follow international guidelines for rigorously developing and evaluating interventions and reporting studies. Practitioners should critically apply RCT evidence when selecting occupational therapy interventions.Output Status: Forthcoming/Available Onlin

Digital interventions for subjective and objective social isolation among individuals with mental health conditions: a scoping review

Background: Social isolation encompasses subjective and objective concepts. Both are associated with negative health consequences and are more prevalent among people with mental health problems than among the general population. To alleviate social isolation, digital interventions have potential as accessible alternatives or adjuncts to face-to-face interventions. This scoping review aimed to describe the types of digital interventions evaluated for feasibility, acceptability and effectiveness in alleviating social isolation among individuals with mental health problems, and to present an overview of the quantitative evidence yielded to inform future intervention design. // Methods: We searched five electronic databases for quantitative and mixed methods studies published between January 2000 and July 2020. Studies were included if they evaluated digital interventions for individuals with mental health conditions, had subjective and/or objective social isolation as their primary outcome, or as one of their outcomes if no primary outcome was specified. Feasibility studies were included if feasibility outcomes were the primary outcomes and social isolation was among their secondary outcomes. A narrative synthesis was conducted to present our findings. The protocol was registered on Open Science Framework (doi:https://doi.org/10.17605/OSF.IO/CNX8A). // Results: Thirty-two studies were included for our review: 16 feasibility studies, seven single-group studies and nine effectiveness trials. There was great variation in the interventions, study designs and sample populations. Interventions included web-based programmes, phone-based programmes, blended interventions, socially assistive robots and virtual reality interventions. Many were feasibility studies, or otherwise not fully powered to detect an effect if one were present, thus preventing clear conclusions about clinical effectiveness. Satisfactory feasibility outcomes indicated potential for future trials to assess these interventions. // Conclusion: Our scoping review identified a range of digital approaches utilized to alleviate social isolation among individuals with mental health disorders. Conclusions regarding clinical effectiveness cannot be reached due to variability of approaches and lack of large-scale randomized controlled trials. To make clear recommendations for digital social isolation interventions, future research needs to be based on rigorous methods and larger samples. Future studies should also focus on utilizing theory-driven approaches and improving existing approaches to advance the field

Digital interventions for subjective and objective social isolation among individuals with mental health conditions: a scoping review

Background: Social isolation encompasses subjective and objective concepts. Both are associated with negative health consequences and are more prevalent among people with mental health problems than among the general population. To alleviate social isolation, digital interventions have potential as accessible alternatives or adjuncts to face-to-face interventions. This scoping review aimed to describe the types of digital interventions evaluated for feasibility, acceptability and effectiveness in alleviating social isolation among individuals with mental health problems, and to present an overview of the quantitative evidence yielded to inform future intervention design. // Methods: We searched five electronic databases for quantitative and mixed methods studies published between January 2000 and July 2020. Studies were included if they evaluated digital interventions for individuals with mental health conditions, had subjective and/or objective social isolation as their primary outcome, or as one of their outcomes if no primary outcome was specified. Feasibility studies were included if feasibility outcomes were the primary outcomes and social isolation was among their secondary outcomes. A narrative synthesis was conducted to present our findings. The protocol was registered on Open Science Framework (doi:https://doi.org/10.17605/OSF.IO/CNX8A). // Results: Thirty-two studies were included for our review: 16 feasibility studies, seven single-group studies and nine effectiveness trials. There was great variation in the interventions, study designs and sample populations. Interventions included web-based programmes, phone-based programmes, blended interventions, socially assistive robots and virtual reality interventions. Many were feasibility studies, or otherwise not fully powered to detect an effect if one were present, thus preventing clear conclusions about clinical effectiveness. Satisfactory feasibility outcomes indicated potential for future trials to assess these interventions. // Conclusion: Our scoping review identified a range of digital approaches utilized to alleviate social isolation among individuals with mental health disorders. Conclusions regarding clinical effectiveness cannot be reached due to variability of approaches and lack of large-scale randomized controlled trials. To make clear recommendations for digital social isolation interventions, future research needs to be based on rigorous methods and larger samples. Future studies should also focus on utilizing theory-driven approaches and improving existing approaches to advance the field

Making activism a participatory, inclusive and developmental process: a research programme involving mental health service users

Understanding real-world experiences and issues is a priority for research funders, yet there are challenges in directly engaging with people for evaluation and investigation of the professional services they receive. Much professional work takes place within institutional restrictions, arising from legislation, policy and local practices. Collaborative research is therefore complex but relevant for improving services. This research programme started in 2002 with focus group research, led by occupational therapists based in a local National Health Service trust and a university, followed by eight further projects including a Photovoice project. This programme and our perspectives from reflections suggest we do not always know who we are, what we want or who cares about research outcomes, but it is important to embrace the potential of activism, to energise and focus people for positive action, wherever they are based

Reflections on the coproduction of a crisis-focused intervention for inpatient settings underpinned by a Cognitive Behavioural Therapy for psychosis (CBTp) model

Background: Psychological interventions delivered in inpatient settings have rarely been coproduced with those who receive them. The aim of this study is to outline the coproduction process which led to the development of an adapted inpatient intervention underpinned by a Cognitive Behaviour Therapy for psychosis model. / Method: Our coproduction group was comprised of experts by experience, family and carers, multi-disciplinary clinicians, and researchers. The group met monthly to develop the intervention and focused on eight key areas of the intervention, including therapist values, assessment, formulation, coping strategies, crisis/safety plans, and discharge plans. / Results: The coproduction panel highlighted the importance of flexible delivery of the intervention, developing a trusting relationship with the therapist, advocacy, prioritising patient safety on the ward, managing the impacts of inpatient care, preparing for discharge, and having family, carer and community involvement. Challenges of the coproduction process included having a pre-existing intervention model that was being adapted rather than coproducing a new one, discussing emotionally charged issues, and having limited time to coproduce the intervention. / Discussion: Coproduction brought immense value to the development of this intervention, ensuring it was culturally competent and suitable for the inpatient setting. Further research should be undertaken exploring the coproduction process applied to clinical research

A scoping review of interventions using occupation to improve mental health or mental wellbeing in adolescent populations

Introduction. Occupation-based interventions could help to address a growing mental health crisis among young people and adolescents. To develop new interventions and avoid research waste, a review of the academic literature is needed that systematically identifies and describes interventions designed to improve the mental health and wellbeing of 11–25 year-olds. Aim. The scoping review aims to systematically review the academic, literature to identify and describe key characteristics of intervention studies using occupation to improve adolescents’ and young people’s mental health and wellbeing, exploring the range of interventions, reviewing reporting quality and illuminating gaps for further research. Method. An iteratively developed scoping review protocol informs a systematic database search and review of the literature. Core characteristics are extracted and described, using the TIDIER guidelines and the CASP assessment tool. Results. Five occupational therapy-based interventions, and 69 other occupation-based studies representing a wide breadth of approaches, outcomes and settings were identified. Conclusions. Robust development, testing and reporting of occupation-based and occupation-focused intervention studies to promote and support mental health and wellbeing in adolescents and young people are needed. Interventions should be co-designed, developmentally appropriate and scaffold development. However, better agreement is needed about core outcomes measurement in this area

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

Applying Theory to Explain the Influence of Factors External to an Organization on the Implementation of an Evidence-Based Intervention

Despite its widely acknowledged influence on implementation, limited research has been done on how the external environment (i.e., outer setting) determines when organizations adopt and implement new interventions. Determinant frameworks identify several outer setting-level factors such as funding streams, inter-organizational relationships, and peer pressure. However, these frameworks do not explain how or why outer-setting factors influence implementation. To advance research in this area, we argue for the importance of deriving theory-based propositions from organization theory to explain how outer setting factors influence organizations. Drawing on the work of the Organization Theory in Implementation Science (OTIS) project, we identified 20 propositions from five classic organization theories—Complexity Theory, Contingency Theory, Institutional Theory, Resource Dependence Theory, and Transaction Cost Economics. We then applied those propositions to hypothesize relationships among outer setting factors, implementation strategies, and implementation outcomes in five case studies of evidenced-based tobacco control interventions. The five case studies address the implementation of smoke-free policies, community health worker-led tobacco education and cessation programs, 5 A's (Ask, Advise, Assess, Assist, and Arrange), point-of-sale tobacco marketing policy interventions, and quitlines. The case studies illustrate how propositions may be used to guide the selection and testing of implementation strategies. Organization theories provide a menu of propositions that offer guidance for selecting and optimizing high-leverage implementation strategies that target factors at the level of outer setting. Furthermore, these propositions suggest testable hypotheses regarding the mechanisms underlying the influence of outer-setting factors on how and why organizations adopt and implement interventions

Exploring the experiences of loneliness in adults with mental health problems: a participatory qualitative interview study

Background Loneliness is associated with many mental health conditions, as both a potential causal and an exacerbating factor. Richer evidence about how people with mental health problems experience loneliness, and about what makes it more or less severe, is needed to underpin research on strategies to help address loneliness. Methods Our aim was to explore experiences of loneliness, as well as what helps address it, among a diverse sample of adults living with mental health problems in the UK. We recruited purposively via online networks and community organisations, with most interviews conducted during the COVID-19 pandemic. Qualitative semi-structured interviews were conducted with 59 consenting participants face-to-face, by video call or telephone. Researchers with relevant lived experience were involved at all stages, including design, data collection, analysis and writing up of results. Findings Analysis led to identification of four overarching themes: 1. What the word “lonely” meant to participants, 2. Connections between loneliness and mental health, 3. Contributory factors to continuing loneliness, 4. Ways of reducing loneliness. Central aspects of loneliness were lack of meaningful connections with others and lack of a sense of belonging to valued groups and communities. Some drivers of loneliness, such as losses and transitions, were universal, but specific links were also made between living with mental health problems and being lonely. These included direct effects of mental health symptoms, the need to withdraw to cope with mental health problems, and impacts of stigma and poverty. Conclusions The multiplicity of contributors to loneliness that we identified, and of potential strategies for reducing it, suggest that a variety of approaches are relevant to reducing loneliness among people with mental health problems, including peer support and supported self-help, psychological and social interventions, and strategies to facilitate change at community and societal levels. The views and experiences of adults living with mental health problems are a rich source for understanding why loneliness is frequent in this context and what may address it. Co-produced approaches to developing and testing approaches to loneliness interventions can draw on this experiential knowledge

Associations between constructs related to social relationships and mental health conditions and symptoms: an umbrella review

BACKGROUND: Loneliness and social isolation are increasingly recognised as prevalent among people with mental health problems, and as potential targets for interventions to improve quality of life and outcomes, as well as for preventive strategies. Understanding the relationship between quality and quantity of social relationships and a range of mental health conditions is a helpful step towards development of such interventions. PURPOSE: Our aim was to give an overview of associations between constructs related to social relationships (including loneliness and social isolation) and diagnosed mental conditions and mental health symptoms, as reported in systematic reviews of observational studies. METHODS: For this umbrella review (systematic review of systematic reviews) we searched five databases (PsycINFO, MEDLINE, EMBASE, CINAHL, Web of Science) and relevant online resources (PROSPERO, Campbell Collaboration, Joanna Briggs Institute Evidence Synthesis Journal). We included systematic reviews of studies of associations between constructs related to social relationships and mental health diagnoses or psychiatric symptom severity, in clinical or general population samples. We also included reviews of general population studies investigating the relationship between loneliness and risk of onset of mental health problems. RESULTS: We identified 53 relevant systematic reviews, including them in a narrative synthesis. We found evidence regarding associations between (i) loneliness, social isolation, social support, social network size and composition, and individual-level social capital and (ii) diagnoses of mental health conditions and severity of various mental health symptoms. Depression (including post-natal) and psychosis were most often reported on, with few systematic reviews on eating disorders or post-traumatic stress disorder (PTSD), and only four related to anxiety. Social support was the most commonly included social construct. Our findings were limited by low quality of reviews and their inclusion of mainly cross-sectional evidence. CONCLUSION: Good quality evidence is needed on a wider range of social constructs, on conditions other than depression, and on longitudinal relationships between social constructs and mental health symptoms and conditions