A new study published in the journal World Psychiatry provides a systematic review of the literature on social interventions for individuals with severe mental illness (SMI) since 2016. The findings, collated with narrative synthesis, concluded that social interventions have considerable benefits but are arguably the most complex to enact and require multi-level stakeholder commitment and investment for successful implementation.
The authors, led by Helen Killaspy, a professor of rehabilitation psychiatry at University College London, highlight the promise of social interventions as well as the current barriers and inconsistencies in the emerging literature:
“We aimed to identify the social interventions that are most effective in increasing the social and economic participation of people with SMI, yet many of the studies reported on interventions that took place within settings where participants mixed mainly with other service users. Whether this represents social participation depends on the definition of the term. There is growing evidence to suggest that loneliness is a driver of poor health and social outcomes and therefore any opportunities to support social connection should be valued.”
Research has shown that people with SMI are at greater risk of poverty, unemployment, and inadequate housing – all factors which negatively impact their social inclusion and exacerbate adverse mental health symptoms. These social conditions contribute to individuals living with SMI being some of the most marginalized in society.
While individuals living with SMI have challenging symptoms, a growing body of consumer-oriented literature validates the importance of personal recovery from mental illness. The personal recovery model is not defined by the presence or absence of symptoms but rather by valued social roles and relationships unique to the individual. Social interventions are vital in changing the status quo, disrupting social exclusion for individuals with SMI, and promoting personal recovery.
However, social interventions are complex and can be challenging to implement. Even the definition of social intervention remains vague, as some categorize family interventions under psychological therapies in one section and psychosocial interventions in another. Further, despite being referred to as “psychosocial,” these interventions rarely focus on enabling employment, education, and occupational activities. Instead, the term has tended to be a catch-all for any intervention that is not a medicinal or biomedical one. The authors explain:
“Due to their complexity, even when supported by good evidence, social interventions are typically more difficult to implement in practice compared with pharmacological (and even psychological) therapies and require commitment and support from multiple stakeholders across the policy and provider spectrum.”
To better understand models of care and interventions for individuals with SMI, the authors conducted a systematic review of 75 identified studies that reported on the effectiveness of community-based models of care and interventions with the broader aim of supporting social inclusion. The studies ranged from various countries, including Canada, the United States, Australia, India, Iran, China, France, and the United Kingdom.
The authors approached the data through narrative synthesis, which includes identifying patterns of results across the studies, exploration of whether the effects of an intervention vary according to the study population, identifying factors that may influence outcomes, and developing a theoretical framework underpinning specific intervention effects.
Through narrative synthesis, the authors found the importance of specific factors that influenced the findings across the studies that were important to consider. A unique result was the use of inconsistent terminology used to describe the interventions. This concern has been previously acknowledged, and a common taxonomy has been proposed. However, the findings from this review show that researchers are not yet following these suggestions.
Despite the difficulties with consistent terminology, the authors identified good evidence for the Housing First model, which is a homeless assistance approach that prioritizes providing permanent housing for individuals with SMI who often have co-occurring substance use histories so that individuals can pursue personal goals and improve their quality of life.
There was also good evidence for the Individual Placement and Support model, which focuses on employment for individuals with SMI. Supported education and social interventions delivered at the group or individual client level included community participation and family interventions, as well as peer-led interventions and social skills interventions.
While the authors highlight the importance of operationalizing definitions and studies, they also recognize the counterproductivity in “over-operationalizing” the work and losing the creativity needed to address the concerns of those living with SMI. The authors write:
“We found that interventions aiming to support the community participation of people with SMI demonstrated a high degree of innovation, with promising initial results. This is clearly an area of growing interest. However, research into which types of interventions are most effective and how to address implementation challenges is at a fledgling stage of development. However, one of the main strengths of these interventions is their diversity and creativity, so it may well be counterproductive to ‘over-operationalize.’”
In closing, the authors highlight the benefits of social interventions and acknowledge the complexity of implementing them in the mental health field, particularly since they require multi-level stakeholder commitment and investment for successful implementation. They provide direction for future work, including following a clear definition of what constitutes a social intervention through a standardized taxonomy.
Further, the authors discuss the importance of prioritizing social interventions compared to pharmacological and psychological interventions. Given reported non-adherence to psychotropic medications amongst people with SMI stands at 49%, and uptake of psychological interventions is reported to be under 20% in some cases, the authors urge that greater consumer involvement during the development of interventions may assist acceptability and participation.
Killaspy, H., Harvey, C., Brasier, C., Brophy, L., Ennals, P., Fletcher, J., & Hamilton, B. (2022). Community‐based social interventions for people with severe mental illness: A systematic review and narrative synthesis of recent evidence. World Psychiatry, 21(1), 96–123. https://doi.org/10.1002/wps.20940 (Link)