Effects of COVID-19 Mental Health Interventions among Community-based Children, Adolescents, and Adults: A Living Systematic Review of Randomised Controlled Trials

ABSTRACT Background Scalable interventions to address COVID-19 mental health are needed. Our objective was to assess effects of mental health interventions for community-based children, adolescents, and adults. Methods We searched 9 databases (2 Chinese-language) from December 31, 2019 to March 22, 2021. We included randomised controlled trials with non-hospitalised, non-quarantined participants of interventions to address COVID-19 mental health challenges. We synthesized results descriptively but did not pool quantitatively due to substantial heterogeneity of populations and interventions and concerns about risk of bias. Findings We identified 9 eligible trials, including 3 well-conducted, well-reported trials that tested interventions designed specifically for COVID-19 mental health challenges, plus 6 trials of standard interventions (e.g., individual or group therapy, expressive writing, mindfulness recordings) minimally adapted for COVID-19, all with risk of bias concerns. Among the 3 COVID-19-specific intervention trials, one (N = 670) found that a self-guided, internet-based cognitive-behavioural intervention targeting dysfunctional COVID-19 worry significantly reduced COVID-19 anxiety (standardized mean difference [SMD] 0.74, 95% CI 0.58 to 0.90) and depression symptoms (SMD 0.38, 95% CI 0.22 to 0.55) in Swedish general population participants. A lay-delivered telephone intervention for homebound older adults in the United States (N = 240) and a peer-moderated education and support intervention for people with a rare autoimmune condition from 12 countries (N = 172) significantly improved anxiety (SMD 0.35, 95% CI 0.09 to 0.60; SMD 0.31, 95% CI 0.03 to 0.58) and depressive symptoms (SMD 0.31, 95% CI 0.05 to 0.56; SMD 0.31, 95% CI 0.07 to 0.55) 6-weeks post-intervention, but these were not significant immediately post-intervention. No trials in children or adolescents were identified. Interpretation Internet-based programs for the general population and lay-or peer-delivered interventions for vulnerable groups may be effective, scalable options for public mental health in COVID-19. More well-conducted trials, including for children and adolescents, are needed. Funding Canadian Institutes of Health Research (CMS-171703; MS1-173070); McGill Interdisciplinary Initiative in Infection and Immunity Emergency COVID-19 Research Fund (R2-42). Registration PROSPERO (CRD42020179703); registered on April 17, 2020. RESEARCH IN CONTEXT Evidence before this study We searched for systematic reviews of randomised controlled trials of interventions to address mental health challenges in COVID-19. We used searches from our living systematic review, which were not limited by study design and reviewed citations through April 29, 2021 from MEDLINE, PsycINFO, CINAHL, EMBASE, Web of Science, China National Knowledge Infrastructure, Wanfang, medRxiv (preprints), and Open Science Framework Preprints (preprint server aggregator). We identified 4 systematic reviews of interventions for COVID-19 mental health with search dates between April and September 2020. None, however, included evidence from any completed randomised controlled trials on mental health interventions for community-based children, adolescents, or adults during COVID-19. Added value of this study Our systematic review is the only living systematic review on COVID-19 community-based mental health interventions registered in PROSPERO and, to the best of our knowledge, the first systematic review to synthesize evidence on completed randomised controlled trials of COVID-19 mental health interventions. The sheer volume of evidence being published in COVID-19 poses a barrier to effective synthesis and policy response. We reviewed over 45,000 citations in any language and distilled this to 9 verified eligible community-based trials. Of these, there were 3 well-conducted trials of interventions designed specifically to be scalable to address challenges of public mental health in COVID-19. One trial showed that internet-based cognitive behavioural therapy in the Swedish general population (N = 670) reduced COVID-19 anxiety and symptoms of depression. Trials that tested a lay-delivered telephone support intervention for homebound older adults in the United States (N = 240) and a peer-moderated group intervention for people with a rare autoimmune condition from 12 countries (N = 172) also found that they improved mental health outcomes, although not all outcomes were statistically significant. Implications of all the available evidence Effective, scalable, and feasibly delivered mental health interventions are needed for the general public and vulnerable groups as lockdown restrictions continue, even intermittently, and because COVID-19 mental health implications will likely persist beyond the pandemic. Although we identified only 3 high-quality trials, they demonstrated approaches that can be feasibly adopted to meet the needs of adults in the general public and vulnerable groups. The successful internet-based cognitive behavioural therapy intervention was made available to the Swedish general public free-of-charge following testing and suggests that online tools tailored for specific concerns in COVID-19 may represent an efficient way of addressing public mental health. Two lay-and peer-delivered interventions, consistent with pre-COVID-19 evidence, suggest that low-intensity, non-professionally delivered, support-oriented approaches can be leveraged among vulnerable groups. The absence of trials of interventions for children and adolescents underlines the need for evidence on scalable strategies for this population, including school-based approaches.

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