ABSTRACT
Background Older adults were more likely to be socially isolated during the COVID-19 pandemic, with risk of depression and loneliness. Behavioural Activation (BA) could feasibly maintain mental health in the face of COVID isolation. Methods We undertook a multicentre randomised controlled trial [BASIL+ ISRCTN63034289] of BA to mitigate depression and loneliness among older people. BA was offered by telephone to intervention participants (n=218). Control participants received usual care, with existing COVID wellbeing resources (n=217). Findings Participants engaged with 5.2 (SD 2.9) of 8 remote BA sessions. Adjusted mean difference (AMD) for depression (PHQ-9) at 3 months [primary outcome] was -1.65 (95% CI -2.54 to -0.75, p<0.001). There was an effect for BA on emotional loneliness at 3 months (AMD -0.37, 95% CI -0.68 to -0.06, p=0.02), but not social loneliness (AMD -0.05, 95% CI -0.33 to 0.23, p=0.72). Other secondary outcomes at 3 months were anxiety (GAD-7: AMD -0.67, 95% CI -1.43 to 0.09, p=0.08) and quality of life (SF12 mental component: AMD 1.99, 95% CI 0.22 to 3.76, p=0.03; physical component: AMD -0.50, 95% CI -2.14 to 1.10, p=0.53). BASIL+ trial results were incorporated into a living systematic review [PROSPERO CRD42021298788], and we found strong evidence of an impact of behavioural and/or cognitive strategies on depression [random effects pooled standardised mean difference -0.32, 95% CI -0.48 to -0.16, 10 studies, n=1,210 participants] and loneliness [random effects pooled standardised mean difference -0.44, 95%CI -0.64 to -0.24, 13 studies, n=1,421 participants] in the short-term (<6 months). Interpretation BA is an effective intervention that reduces depression and some aspects of loneliness in the short term. This adds to the range of strategies to improve population mental health, particularly among older adults with multiple long-term conditions. These results will be helpful to policy makers in preventing depression and loneliness beyond the pandemic. Funding NIHR RP-PG-0217-20006
Subject(s)
Anxiety Disorders , Adjustment Disorders , Depressive Disorder , COVID-19ABSTRACT
BackgroundBehavioural and cognitive interventions remain a credible approach in preventing loneliness and depression. There was a need to rapidly generate and assimilate trial-based data during COVID-19. ObjectivesWe undertook a COVID-19 parallel pilot RCT of behavioural activation for depression and loneliness [the BASIL-C19 trial ISRCTN94091479]. We also assimilate these data in a COVID-19 living systematic review [PROSPERO CRD42021298788]. MethodsPrimary care participants (>=65 years) with long-term conditions were computer randomised to Behavioural Activation (n=47) versus care-as-usual (n=49). The single blinded primary outcome was the PHQ-9. Secondary outcomes included loneliness (De Jong Gierveld Scale). Data from the BASIL-C19 trial were included in a random effects meta-analysis of depression and loneliness. FindingsThe 12 months adjusted mean difference for PHQ-9 was -0.70 (95% CI -2.61 to 1.20) and for loneliness was -0.39 (95% CI -1.43 to 0.65). Secondary 12-month trial outcomes suggested evidence of benefit for behavioural activation. The BASIL-C19 meta-analysis (13 trials) found short-term reductions in depression (standardised mean difference [SMD]=-0.31, 95%CI -0.51 to -0.11) and loneliness (SMD=-0.48, 95%CI -0.70 to -0.27). There were few long-term trials, but there was evidence of some benefit (loneliness SMD=-0.20, 95%CI -0.40 to -0.01; depression SMD=-0.20, 95%CI -0.47 to 0.07). DiscussionWe found a signal of effect in reducing loneliness and depression in the BASIL trial. Living meta-analysis provides strong evidence of short-term benefit for loneliness and depression. Clinical implicationsScalable behavioural and cognitive approaches should be considered as population-level strategies for depression and loneliness on the basis of the living systematic review. FundingThis study was funded by National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research (PGfAR) RP-PG-0217-20006. Author summaryO_ST_ABSWhy was this study done?C_ST_ABS Older people with long-term conditions have been impacted by COVID-19 pandemic restrictions and have experienced social isolation. In turn, this puts them at risk for depression and loneliness, and these are bad for health and wellbeing. Psychosocial approaches, such as behavioural activation, could be helpful. Trial-based evidence is needed to demonstrate if it is possible to prevent the onset, or mitigate the impact, of loneliness and depression. There are few studies of brief psychosocial interventions to mitigate depression and loneliness, and it is important to know how emerging trial-based data adds to existing evidence. What did the researchers do and find? There was preliminary evidence that levels of loneliness were reduced at 3 months when behavioural activation was offered. At longer term (12-month) follow-up there were signals of ongoing positive impact. When BASIL-C19 data were assimilated into a living systematic review there is clear evidence of impact of brief psychological interventions on depression and loneliness in the short-term. More research into the longer-term impact is needed. What does all this mean? Behavioural activation now shows evidence of benefit which will be useful for policy makers in offering support to people who are socially isolated. This research knowledge will be useful once the COVID-19 pandemic has passed, since loneliness is common in older populations and effective scalable solutions will be needed to tackle this problem. As new trial-based data emerges, our living systematic review and meta-analysis will be updated since this is an area of active research.
Subject(s)
COVID-19 , Depressive DisorderABSTRACT
Purpose Population surveys underrepresent people with severe mental ill health. This paper aims to explore perceived social support and loneliness and factor associations during the Covid-19 pandemic in a sample of individuals with severe mental ill health. Design/methodology/approach We sampled an already existing cohort of people with severe mental ill health. Researchers contacted participants by phone or by post to invite them to take part in a survey about how the pandemic restrictions had impacted health, Covid-19 experiences, perceived social support, employment and loneliness. Loneliness was measured by the three item UCLA loneliness scale. Findings In the pandemic sub-cohort, 367 adults with a severe mental ill health diagnosis completed a remote survey. 29-34% of participants reported being lonely. Loneliness was associated with being younger in age (adjusted OR = -.98, p = .02), living alone (adjusted OR = 2.04, p = .01), high levels of social and economic deprivation (adjusted OR = 2.49, p = .04), and lower perceived social support ( B = -5.86, p < .001). Living alone was associated with lower perceived social support. Being lonely was associated with a self-reported deterioration in mental health during the pandemic (adjusted OR = 3.46, 95%CI 2.03-5.91). Practical implications Intervention strategies to tackle loneliness in the severe mental ill health population are needed. Further research is needed to follow-up the severe mental ill health population after pandemic restrictions are lifted to understand perceived social support and loneliness trends. Originality Loneliness was a substantial problem for the severe mental ill health population before the Covid-19 pandemic but there is limited evidence to understand perceived social support and loneliness trends during the pandemic.
Subject(s)
COVID-19 , Intellectual DisabilityABSTRACT
Aims: To explore: how satisfied people with severe mental illness (SMI) are with the support received during the pandemic; understand any difficulties encountered when accessing both mental health and primary care services; consider ways to mitigate these difficulties; and assess the perceived need for future support from mental health services. Materials and Methods: A representative sample was drawn from a large transdiagnostic clinical cohort of people with SMI, which was recruited between April 2016 and March 2020. The sample was re-surveyed a few months after the beginning of the restrictions. Descriptive frequency statistics were used to analyse the quantitative data. The free text responses were analysed thematically. Results: 367 participants responded to the survey. Two thirds were receiving support from mental health services with the rest supported in primary care or self-managing. A quarter thought they would need more mental health support in the coming year. Half had needed to used community mental health services during the pandemic and the majority had been able to get support. A minority reported that their mental health had deteriorated but they had either not got the supported they wanted or had not sought help. The biggest service change was the reduction in face-to-face appointments and increasing use of phone and video call support. Nearly half of those using mental health services found this change acceptable or even preferred it; acceptability was influenced by several factors. Participants were more likely to be satisfied with support received when seen in person. Discussion: Although most participants were satisfied with the mental health support they had received, a minority were not. This, couple with findings on future need for mental health support has implications for post pandemic demand on services. Remote care has brought benefits but also risks that it could increase inequalities in access to services.
Subject(s)
COVID-19 , Intellectual DisabilityABSTRACT
Background Older adults with long-term conditions have become more socially isolated (often due to advice to shield to protect them from COVID-19) and are thus at particular risk of depression and loneliness. There is a need for brief scalable psychosocial interventions to mitigate the psychological impacts of social isolation. Behavioural Activation is a plausible intervention, but a trial is needed. Methods We undertook an external randomised pilot trial (ISRCTN94091479) designed to test recruitment, retention and engagement with, and the acceptability and preliminary effects of the intervention. Participants aged [≥] 65 years with two or more long-term conditions were recruited between June and October 2020. Behavioural Activation was offered to intervention participants (n=47), and control participants received usual care (n=49). Findings Remote recruitment was possible and 45/47 (95.7%) randomised to the intervention completed one or more sessions (median 6 sessions). 90 (93.8%) completed the one month follow-up, and 86 (89.6%) completed the three month follow-up. The between-group comparison for the primary clinical outcome at one month was an adjusted between group mean difference of -0.50 PHQ-9 points (95% CI -2.01 to 1.01), but only a small number of participants had completed the intervention at this point. At three months, the PHQ-9 adjusted mean difference was 0.19 (95% CI -1.36 to 1.75). When we examined loneliness, the between-group difference in the De Jong Gierveld Loneliness scale at one month was 0.28 (95% CI -0.51 to 1.06), and there was statistically significant between group difference at three months (-0.87; 95% CI -1.56 to -0.18). Participants who withdrew had minimal depressive symptoms at entry. Interpretation Behavioural Activation is a plausible intervention to mitigate the psychological impacts of COVID-19 isolation for older adults. The intervention can be delivered remotely and at scale, but should be reserved for older adults with evidence of depressive symptoms. The significant reduction in loneliness is unlikely to be a chance finding, and this will now be confirmed in a fully powered RCT. Funding This study was funded by National Institute for Health Research (NIHR) Programme Grants for Applied Research (PGfAR) RP-PG-0217-20006
Subject(s)
COVID-19 , Depressive Disorder , Tooth, ImpactedABSTRACT
Background People with severe mental ill health (SMI) experience a mortality gap of 15-20 years. COVID-19 has amplified population health inequalities, and there is concern that people with SMI will be disproportionately affected. Understanding how health risk behaviours have changed during the pandemic is important when developing strategies to mitigate future increases in health inequalities. Methods We sampled from an existing cohort of people with SMI. Researchers contacted participants by phone or post to invite them to take part in a survey about how the pandemic had affected them. We asked people about their health risk behaviours and how these had changed during the pandemic. We created an index of changed behaviours, comprising dietary factors, smoking, lack of exercise, and drinking patterns. By creating data linkages, we compared their responses during pandemic restrictions to responses they gave prior to the pandemic. Outcomes 367 people provided health risk data. 47.5% of participants reported taking less physical activity during the pandemic and of those who smoke 54.5% reported smoking more heavily. Self-reported deterioration in physical health and younger age were significantly associated with an increase in health risk behaviours (adjusted OR for physical health 1.59, 95%CI 1.22-2.07; adjusted OR for Age 0.99, 95%CI 0.98-1.00). Interpretation COVID-19 is likely to amplify health inequalities for people with SMI. Health services should target health risk behaviours for people with SMI to mitigate the immediate and long lasting impacts of the COVID-19 pandemic. Funding Medical Research council, Yorkshire and Humber Applied Research Collaboration, Wellcome and UKRI.
Subject(s)
COVID-19 , Intellectual DisabilityABSTRACT
Smoking rates are higher for people who use mental health services which contributes substantially to health inequalities. Smoking can lead to worse COVID-19 outcomes, yet it remains unclear whether smoking has changed for people who use mental health services. We examined smoking patterns in a large clinical cohort of people with SMI before and during the pandemic. We found high levels of nicotine dependence and heavier patterns of smoking. Whilst some people had reported quitting, it is likely that smoking inequalities have become further entrenched. Mental health services should seek to mitigate this modifiable risk and source of poor health.