Effectiveness of community interventions for protecting and promoting the mental health of working-age adults experiencing financial uncertainty: a systematic review

Mental health preparedness and response to epidemics focusing on COVID-19 pandemic: a qualitative study in Iran

BACKGROUND

During epidemics, the number of individuals whose mental health is affected is greater than those affected by the infection itself. This is because psychological factors have a direct relationship with the primary causes of the disease and mortality worldwide. Therefore, an increasing investment in research and strategic actions for mental health is essential globally, given the prevalence of infectious diseases. The aim of this study was to elucidate and describe the strategies for mental health preparedness and response during epidemics, with a focus on the COVID-19 pandemic in Iran.

METHODS

A qualitative study was conducted in Iran from 2022 to 2023. Purposeful Sampling was employed, continuing until data saturation was achieved. Data collection involved semi-structured interviews and observational notes with 20 managers and experts possessing expertise, experience, and knowledge in mental health. Ultimately, the participants' opinions, based on their experiences, were analyzed using the qualitative content analysis method with a conventional approach, resulting in the categorization of data into codes, subcategories, and categories.

RESULTS

The study revealed participants' opinions and experiences, categorized into two overarching categories: Preparedness, Policy-Making, and Planning Strategies (with four subcategories), and Response Strategies (comprising thirteen subcategories).

CONCLUSION

The opinions and experiences of managers and experts in this study revealed that an appropriate mental health response during pandemics requires preparedness before the occurrence of such crises and the implementation of suitable response strategies after the occurrence. Managers, policymakers, and decision-makers in this field should pay attention to the solutions derived from the experiences of such crises to respond more preparedly in the future.

The social determinants of mental health and disorder: evidence, prevention and recommendations

People exposed to more unfavourable social circumstances are more vulnerable to poor mental health over their life course, in ways that are often determined by structural factors which generate and perpetuate intergenerational cycles of disadvantage and poor health. Addressing these challenges is an imperative matter of social justice. In this paper we provide a roadmap to address the social determinants that cause mental ill health. Relying as far as possible on high-quality evidence, we first map out the literature that supports a causal link between social determinants and later mental health outcomes. Given the breadth of this topic, we focus on the most pervasive social determinants across the life course, and those that are common across major mental disorders. We draw primarily on the available evidence from the Global North, acknowledging that other global contexts will face both similar and unique sets of social determinants that will require equitable attention. Much of our evidence focuses on mental health in groups who are marginalized, and thus often exposed to a multitude of intersecting social risk factors. These groups include refugees, asylum seekers and displaced persons, as well as ethnoracial minoritized groups; lesbian, gay, bisexual, transgender and queer (LGBTQ+) groups; and those living in poverty. We then introduce a preventive framework for conceptualizing the link between social determinants and mental health and disorder, which can guide much needed primary prevention strategies capable of reducing inequalities and improving population mental health. Following this, we provide a review of the evidence concerning candidate preventive strategies to intervene on social determinants of mental health. These interventions fall broadly within the scope of universal, selected and indicated primary prevention strategies, but we also briefly review important secondary and tertiary strategies to promote recovery in those with existing mental disorders. Finally, we provide seven key recommendations, framed around social justice, which constitute a roadmap for action in research, policy and public health. Adoption of these recommendations would provide an opportunity to advance efforts to intervene on modifiable social determinants that affect population mental health.

How, when, and why is social class linked to mental health and wellbeing? A systematic meta-review

RATIONALE

Meta-reviews synthesising research on social class and mental health and wellbeing are currently limited and focused on specific facets of social class (e.g., social capital) or mental health and wellbeing (e.g., mental health disorders), and none sought to identify mechanisms in this relationship.

OBJECTIVES

The present meta-review sought to (1) assess the overall relationship between social class and mental health and wellbeing, (2) determine the mechanisms that act in this relationship, and (3) evaluate the strength of evidence available.

METHODS

The protocol was prospectively registered on PROSPERO (CRD42021214731). We systematically searched twelve databases in September 2022 and identified 149 eligible reviews from 38,257 records screened. Quality of evidence was assessed with the JBI levels of evidence and risk of bias with the ROBIS tool.

RESULTS

A large but low-quality evidence base points to class-based inequalities in mental health and wellbeing, with the strongest available evidence linking lower social positions to an increased risk of depression. In terms of different facets of stratification, the best available evidence suggests that deprivation (e.g., poverty), socioeconomic status, income, and subjective social status are consequential for individuals' mental health and wellbeing. However, high-quality evidence for the roles of education, occupation, other economic resources (e.g., wealth), and social capital is currently limited. Most reviews employed individual-level measures (e.g., income), as opposed to interpersonal- (e.g., social capital) or community-level (e.g., neighbourhood deprivation) measures. Considering mechanisms, we found some evidence for mediation via subjective social status, sense of control, and experiences of stress and trauma. There was also some evidence that higher socioeconomic status can provide a buffer for neighbourhood deprivation, lower social capital, and lower subjective social status.

CONCLUSIONS

Future research employing experimental or quasi-experimental methods, and systematic reviews with a low risk of bias, are necessary to advance this area of research.

How co-locating public mental health interventions in community settings impacts mental health and health inequalities: a multi-site realist evaluation

BACKGROUND

Public mental health interventions are non-clinical services that aim to promote wellbeing and prevent mental ill health at the population level. In England, the health, social and community system is characterised by complex and fragmented inter-sectoral relationships. To overcome this, there has been an expansion in co-locating public mental health services within clinical settings, the focus of prior research. This study evaluates how co-location in community-based settings can support adult mental health and reduce health inequalities.

METHODS

A qualitative multi-site case study design using a realist evaluation approach was employed. Data collection took place in three phases: theory gleaning, parallel testing and refining of theories, and theory consolidation. We collected data from service users (n = 32), service providers (n = 32), funders, commissioners, and policy makers (n = 11), and members of the public (n = 10). We conducted in-depth interviews (n = 65) and four focus group discussions (n = 20) at six case study sites across England, UK, and two online multi-stakeholder workshops (n = 20). Interview guides followed realist-informed open-ended questions, adapted for each phase. The realist analysis used an iterative, inductive, and deductive data analysis approach to identify the underlying mechanisms for how community co-location affects public mental health outcomes, who this works best for, and understand the contexts in which co-location operates.

RESULTS

Five overarching co-location theories were elicited and supported. Co-located services: (1) improved provision of holistic and person-centred support; (2) reduced stigma by creating non-judgemental environments that were not associated with clinical or mental health services; (3) delivered services in psychologically safe environments by creating a culture of empathy, friendliness and trust where people felt they were being treated with dignity and respect; (4) helped to overcome barriers to accessibility by making service access less costly and more time efficient, and (5) enhance the sustainability of services through better pooling of resources.

CONCLUSION

Co-locating public mental health services within communities impacts multiple social determinants of poor mental health. It has a role in reducing mental health inequalities by helping those least likely to access services. Operating practices that engender inter-service trust and resource-sharing are likely to support sustainability.

Current evidence and opportunities in child and adolescent public mental health: a research review

BACKGROUND

A public mental health lens is increasingly required to better understand the complex and multifactorial influences of interpersonal, community and institutional systems on the mental health of children and adolescents.

METHODS

This research review (1) provides an overview of public mental health and proposes a new interactional schema that can guide research and practice, (2) summarises recent evidence on public mental health interventions for children and adolescents, (3) highlights current challenges for this population that might benefit from additional attention and (4) discusses methodological and conceptual hurdles and proposes potential solutions.

RESULTS

In our evidence review, a broad range of universal, selective and indicated interventions with a variety of targets, mechanisms and settings were identified, some of which (most notably parenting programmes and various school-based interventions) have demonstrated small-to-modest positive effects. Few, however, have achieved sustained mental health improvements.

CONCLUSIONS

There is an opportunity to re-think how public mental health interventions are designed, evaluated and implemented. Deliberate design, encompassing careful consideration of the aims and population-level impacts of interventions, complemented by measurement that embraces complexity through more in-depth characterisation, or 'phenotyping', of interpersonal and environmental elements is needed. Opportunities to improve child and adolescent mental health outcomes are gaining unprecedented momentum. Innovative new methodology, heightened public awareness, institutional interest and supportive funding can enable enhanced study of public mental health that does not shy away from complexity.

Financial adversity and subsequent health and wellbeing during the COVID-19 pandemic in the UK: A qualitative interview study

Aims

There are concerns that the economic impacts of the COVID-19 pandemic, including employment inactivity and job loss, will have consequences for the UK population's health and wellbeing. However, there is limited qualitative research into how financial adversity contributes to poor health outcomes in this context. This study aimed to explore forms of financial adversity experienced during the pandemic and their subsequent impacts for health and wellbeing.

Methods

Qualitative semi-structured interviews with 20 people who experienced a form of financial adversity during the pandemic and six service providers employed in social welfare support services. Data were analysed using reflexive thematic analysis.

Results

Two main sources of financial adversity were identified: reductions in household incomes and increased living costs which engendered emotional and physical burdens. Coping strategies included increased financial borrowing, support from informal and formal networks and cutting back on energy use, food and non-essential items.

Conclusion

Our study highlighted exposure to multiple financial adversities because of the pandemic and how these experiences led to poor mental and physical health. The findings underline the importance of measures attending to the immediate needs of individuals, including accessible, co-located financial and psychological services, as well as broader measures that seek to reduce social and economic inequalities.

Money Matters: Time for Prevention and Early Intervention to Address Family Economic Circumstances

Child poverty is associated with poorer physical and mental health, negative educational outcomes and adverse long-term social and psychological consequences, all of which impact on service demand and expenditure. Until now, however, prevention and early intervention practice has tended to focus on enhancing inter-parental relationships and parenting skills (e.g., via relationship skills education, home visiting, parenting programs, family therapy) or child language, social-emotional and life skills (e.g., early childhood education, school-based programs, youth mentoring). Programs often target low-income neighborhoods or families but rarely address poverty directly. While there is substantial evidence for the effectiveness of such interventions in improving child outcomes, null results are not uncommon and even positive effects are often small, short-term, and difficult to replicate. One avenue to enhance intervention effectiveness is to improve families' economic circumstances. There are several arguments for this refocusing. It is arguably unethical to focus on individual risk without acknowledging or seeking to address (where relevant) families' social and economic contexts, while the stigma and material constraints associated with poverty can make it harder for families to engage with psychosocial support. There is also evidence that increasing household income improves child outcomes. Although national policies to alleviate poverty are important, it is increasingly recognized that practice-based initiatives have a role to play (e.g., income maximization, devolved budgets, money management support). However, knowledge about their implementation and effectiveness is relatively thin. For instance, there is some evidence that co-located welfare rights advice in healthcare settings can improve recipients' financial circumstances and health, but it is mixed and of limited quality. Moreover, there is little rigorous research on whether and how such services affect mediators (parent-child interactions, parenting capacity) and/or child physical and psychosocial outcomes directly. We call for prevention and early intervention programs to attend more to families' economic circumstances, and for experimental studies to test their implementation, reach and effectiveness.

Primary Mental Health Care in a New Era

Clinical experience and scientific studies highlight the pivotal role that primary health care services have and should have as a gateway to the health care system and as a first point of contact for patients with mental disorders, particularly-but not exclusively-for patients with a disorder in the spectrum of common mental disorders [...].

Perceived manageability of debt and mental health during the COVID-19 pandemic: A UK population analysis

OBJECTIVES

This study examined the association between perceived manageability of debt and risk of depression, anxiety, and mental health help-seeking among a nationally representative sample of adults living in the United Kingdom (UK).

METHODS

Data was derived from the COVID-19 Psychological Research Consortium (C19PRC) Study Wave 6 (August/September 2021) which examined the psychological, social, and economic effects of the COVID-19 pandemic on the UK adult population. Bivariate and logistic regression analyses were conducted to determine the association between different levels of perceived debt manageability (i.e., "easily manageable", "some problems", "quite serious problems", "very serious problems", "cannot manage at all") and mental health related outcomes.

RESULTS

Almost a quarter of the sample (24%, n = 494) reported debt management problems, and debt manageability associated with higher levels of anxiety, depression, and mental health help-seeking. After adjusting for demographic variables (e.g. income, receipt of benefits), logistic regression analysis demonstrated a dose-response association between increasing levels of debt manageability problems and mental health outcomes. Specifically, adjusted odds ratios for anxiety ranged from 2.28 ('some problems') to 11.18 ('very serious problems'), for depression ranged from 2.80 ('some problems') to 16.21 ('cannot manage at all'), and for mental health help-seeking ranged from 1.69 ('some problems') to 3.18 ('quite serious problems', 'very serious problems').

CONCLUSION

This study highlights that debt manageability problems represent a robust predictor of depression, anxiety, and mental-health help seeking.

The Role of Unemployment, Financial Hardship, and Economic Recession on Suicidal Behaviors and Interventions to Mitigate Their Impact: A Review

Understanding the social determinants and risk factors for suicidal behaviors underlies the development of effective suicide prevention interventions. This review focused on recently published literature (2010 onwards), with the aim to determine the role of economic factors (at the individual and population level) on suicidal behaviors and ideation as well as the effectiveness of interventions addressing these factors in reducing suicidal behaviors and ideation. Where available, literature examining the economic impact of COVID-19 was highlighted. Economic recession and unemployment are associated with increased risk of suicidal behavior at the population and individual level. Additionally, personal financial problems such as debt and financial strain are associated with increased risk of suicidal behavior and ideation at the individual level. Regarding interventions, unemployment benefits, employment protection legislation, higher minimum wage and active labor market programs may reduce suicide at the population level. However, it is not clear what impact they have at the individual level, nor in relation to suicide attempts, self-harm, or suicidal ideation. There was a lack of evidence as to the effectiveness of financially focused suicide prevention interventions at either level. Current findings were contextualized within, and advance, prominent social theoretical models. Recommendations focused on future areas of research, including the unfolding economic impact of COVID-19, as well as the co-design and evaluation of tailored interventions and/or gatekeeper training for those in the financial and welfare sector, and enhanced early education aimed at increasing financial literacy in young people before onset or exacerbation of financial hardship.

The Acceptability and Initial Effectiveness of “Space From Money Worries”: An Online Cognitive Behavioral Therapy Intervention to Tackle the Link Between Financial Difficulties and Poor Mental Health

Background

Previous research has shown a strong relationship between financial difficulties and mental health problems. Psychological factors such as hope and worry about finances appear to be an important factor in this relationship.

Objective

To develop an online based psychological intervention (Space from Money Worries) to tackle the psychological mechanisms underlying the relationship between poor mental health and financial difficulties, and to conduct an initial evaluation of the acceptability and preliminary efficacy of the intervention.

Materials and Methods

30 participants accessing Increasing Access to Psychological Therapies (IAPT) services completed GAD-7 to measure anxiety and PHQ-9 to measure depression upon signing up to the online intervention and again 4 to 8 weeks after this. Participants also completed a measure of perceived financial distress/wellbeing and a “Money and Mental Health Scale” constructed for the evaluation.

Results

Overall, 77% (n = 23) completed the intervention and follow-up assessments. Intent to Treat Analysis showed that there were statistically significant improvements in symptoms of depression, anxiety, improved perceived financial wellbeing and reduced scores on the money and mental health scale. The vast majority of participants rated each module positively.

Conclusions

Space from Money Worries appears to be acceptable and may lead to improvements in mental health, perceived financial wellbeing and a reduced relationship between financial difficulties and poor mental health. However, future research with a larger sample and a control group are needed to confirm that these changes are due to the intervention.

Mental Health Inequalities During COVID-19 Outbreak: The Role of Financial Insecurity and Attentional Control

The COVID-19 pandemic and subsequent lockdowns negatively impacted the mental health of populations. This impact is not equally distributed and increases existing mental health inequalities. Indeed, government restrictions and the economic consequences of the pandemic affect more the less educated and less wealthy people. However, psychological processes implicated in this increase of mental health inequalities during the COVID-19 pandemic remain unexplored. The present study (N=591) tested the role of financial insecurity and attentional control in the relation between socioeconomic status and mental health, along with the influence of trait anxiety. Based on Structural Equation Modelling, findings showed a mediation effect of financial insecurity, but not of attentional control, in the relationship between socioeconomic status and mental health. In addition, exploratory analyses suggested that financial insecurity also mediated the effect of attentional control on mental health. Results of the present research point at the importance of understanding psychological processes implicated in the effect of economic crises on mental health inequalities.

Community interventions for improving adult mental health: mapping local policy and practice in England

BACKGROUND

Public mental health (PMH) aims to improve wellbeing and prevent poor mental health at the population level. It is a global challenge and a UK priority area for action. Communities play an important role in the provision of PMH interventions. However, the evidence base concerning community-based PMH interventions is limited, meaning it is challenging to compare service provision to need. Without this, the efficient and equitable provision of services is hindered. Here, we sought to map the current range of community-based interventions for improving mental health and wellbeing currently provided in England to inform priority areas for policy and service intervention.

METHOD

We adopted an established mapping exercise methodology, comparing service provision with demographic and deprivation statistics. Five local authority areas of England were selected based on differing demographics, mental health needs and wider challenging circumstances (i.e. high deprivation). Community-based interventions were identified through: 1) desk-based research 2) established professional networks 3) chain-referral sampling of individuals involved in local mental health promotion and prevention and 4) peer researchers' insight. We included all community-based, non-clinical interventions aimed at adult residents operating between July 2019 and May 2020.

RESULTS

407 interventions were identified across the five areas addressing 16 risk/protective factors for PMH. Interventions for social isolation and loneliness were most prevalent, most commonly through social activities and/or befriending services. The most common subpopulations targeted were older adults and people from minority ethnic backgrounds. Interventions focusing on broader structural and environmental determinants were uncommon. There was some evidence of service provision being tailored to local need, though this was inconsistent, meaning some at-risk groups such as men or LGBTQ+ people from minority ethnic backgrounds were missed. Interventions were not consistently evaluated.

CONCLUSIONS

There was evidence of partial responsiveness to national and local prioritising. Provision was geared mainly towards addressing social and individual determinants of PMH, suggesting more integration is needed to engage wider service providers and policy-makers in PMH strategy and delivery at the community level. The lack of comprehensive evaluation of services to improve PMH needs to be urgently addressed to determine the extent of their effectiveness in communities they serve.