The connecting adolescents to reduce relapse (CARR) trial: study protocol for a randomized controlled trial comparing the efficacy of Groups 4 Health and cognitive behaviour therapy in young people

Acceptability and Feasibility of an Intervention to Enhance Social Group Belonging: Evidence From Three Trials of Groups 4 Health

Groups 4 Health (G4H) is a group psychotherapy program that targets social group disconnection. An emerging evidence base supports its efficacy in reducing loneliness, depression, and social anxiety. However, to date there has been no formal analysis of its acceptability to clients and therapists, nor an investigation of its feasibility for wider implementation. This input from end users is crucial to ensure the program's wider suitability and to contribute to its improvement. This study drew data from three clinical trials, including 266 G4H clients and 68 G4H therapists. From the Phase III trial only, additional data were available from 90 clients in a dose-controlled cognitive-behavioral therapy (CBT) comparison group, and focus groups/interviews with 6 therapists and 13 clients. Client satisfaction was high, with all average ratings >7/10, significantly exceeding the CBT comparison group. Therapist satisfaction with each module was >5/7. Retention was >80%. Homework completion was high, with <10% of clients saying that they had not attempted the homework. Therapists and clients both emphasized the benefits arising from G4H, and the contribution of the group context itself as a vehicle to achieve positive outcomes.

Groups 4 Health versus cognitive-behavioural therapy for depression and loneliness in young people: randomised phase 3 non-inferiority trial with 12-month follow-up

BACKGROUND

Depression treatments are typically less effective for young people than for adults. However, treatments rarely target loneliness, which is a key risk factor in the onset, maintenance and development of depression.

AIMS

This study evaluated the efficacy of a novel loneliness intervention, Groups 4 Health (G4H), relative to the best-practice treatment of cognitive-behavioural therapy (CBT) in reducing loneliness and depression over a 12-month period (Australian New Zealand Clinical Trial Registry: ACTRN12618000440224).

METHOD

The study was a phase 3 randomised non-inferiority trial comparing G4H with dose-controlled group CBT. Participants were 174 people aged 15-25 years experiencing loneliness and clinically significant symptoms of depression, who were not in receipt of adjunct treatment. Participants were recruited from mental health services in Southeast Queensland, Australia. Randomisation was conducted using computer software. Follow-up assessments and statistical analyses were masked to allocation. Both interventions consisted of five 75 min group-based psychotherapy sessions. The primary outcomes were depression and loneliness, with a non-inferiority margin of 2.20 for depression.

RESULTS

The trial enrolled 174 participants between 24 April 2018 and 25 May 2019, with 84 in the G4H condition and 90 in the CBT condition. All randomised participants were included in the intention-to-treat analyses (n = 174). The pre-post effect sizes for depression were dG4H = -0.71 and dCBT = -0.91. For loneliness, they were dG4H = -1.07 and dCBT = -0.89. At 12-month follow-up, the absolute difference between groups on depression was 1.176 (95% CI -1.94 to 4.29) and on loneliness it was -0.679 (95% CI -1.43 to 0.07). No adverse effects were observed.

CONCLUSIONS

G4H was non-inferior to CBT for depression and showed a slight advantage over CBT for loneliness that emerged after treatment completion.

GROUPS 2 CONNECT: An online activity to maintain social connection and well-being during COVID-19

COVID-19 has had significant negative consequences for well-being. As well as the primary effects of the virus itself, secondary effects have resulted from the social isolation caused by the lockdowns imposed to slow the spread of the virus. Recognising the toxic effects of isolation, researchers, practitioners and policy-makers are conscious of the need to mitigate the negative effects of social distancing. Drawing on insights from a large body of research on the Social Identity Approach to Health, we devised an online activity-GROUPS 2 CONNECT (G2C)-aimed at helping people to maintain social connectedness when face-to-face interaction was not possible. Across four studies (N = 1021), we found that after completing the G2C activity, participants reported an increase in perceived quality of social connection, perceived ability to stay connected and well-being, with results showing that for two of the three longitudinal studies these uplifts were stable over time, and for all studies, the uplifts remained consistently higher for those who reported completing their social connection goals. These findings provide initial evidence of the value of G2C as a tool to support social connection, thereby reducing the risk of social isolation.

Loneliness as an active ingredient in preventing or alleviating youth anxiety and depression: a critical interpretative synthesis incorporating principles from rapid realist reviews

Loneliness is a relatively common problem in young people (14-24 years) and predicts the onset of depression and anxiety. Interventions to reduce loneliness thus have significant potential as active ingredients in strategies to prevent or alleviate anxiety and depression among young people. Previous reviews have focused on quantitative evidence and have not examined potential mechanisms that could be targets for intervention strategies. To build on this work, in this review we aimed to combine qualitative and quantitative evidence with stakeholder views to identify interventions that appear worth testing for their potential effectiveness in reducing loneliness, anxiety and depression in young people aged 14-24 years, and provide insights into the potential mechanisms of action. We conducted a Critical Interpretative Synthesis, a systematic review method that iteratively synthesises qualitative and quantitative evidence and is explicitly focused on building theory through a critical approach to the evidence that questions underlying assumptions. Literature searches were performed using nine databases, and eight additional databases were searched for theses and grey literature. Charity and policy websites were searched for content relevant to interventions for youth loneliness. We incorporated elements of Rapid Realistic Review approaches by consulting with young people and academic experts to feed into search strategies and the resulting conceptual framework, in which we aimed to set out which interventions appear potentially promising in terms of theoretical and empirical underpinnings and which fit with stakeholder views. We reviewed effectiveness data and quality ratings for the included randomised controlled trials only. Through synthesising 27 studies (total participants n = 105,649; range 1-102,072 in different studies) and grey literature, and iteratively consulting with stakeholders, a conceptual framework was developed. A range of 'Intrapersonal' (e.g. therapy that changes thinking and behaviour), 'Interpersonal' (e.g. improving social skills), and 'Social' Strategies (e.g. enhancing social support, and providing opportunities for social contact) seem worth testing further for their potential to help young people address loneliness, thereby preventing or alleviating depression and/or anxiety. Such strategies should be co-designed with young people and personalised to fit individual needs. Plausible mechanisms of action are facilitating sustained social support, providing opportunities for young people to socialise with peers who share similar experiences, and changing thinking and behaviour, for instance through building positive attitudes to themselves and others. The most convincing evidence of effectiveness was found in support of Intrapersonal Strategies: two randomised controlled studies quality-rated as 'good' found decreases in loneliness associated with different forms of therapy (Cognitive Behavioural Therapy or peer network counselling), although power calculations were not reported, and effect sizes were small or missing. Strategies to address loneliness and prevent or alleviate anxiety and depression need to be co-designed and personalised. Promising elements to incorporate into these strategies are social support, including from peers with similar experiences, and psychological therapy.

Groups 4 Health protects against unanticipated threats to mental health: Evaluating two interventions during COVID-19 lockdown among young people with a history of depression and loneliness

BACKGROUND

Decades of research indicate that when social connectedness is threatened, mental health is at risk. However, extant interventions to tackle loneliness have had only modest success, and none have been trialled under conditions of such threat.

METHOD

174 young people with depression and loneliness were randomised to one of two evidence-based treatments: cognitive behaviour therapy (CBT) or Groups 4 Health (G4H), an intervention designed to increase social group belonging. Depression, loneliness, and well-being outcomes were evaluated at one-year follow-up; COVID-19 lockdown restrictions were imposed partway through follow-up assessments. This provided a quasi-experimental test of the utility of each intervention in the presence (lockdown group) and absence (control group) of a threat to social connectedness.

RESULTS

At one-year follow-up, participants in lockdown reported significantly poorer wellbeing than controls who completed follow-up before lockdown, t(152)=2.41, p=.017. Although both CBT and G4H led to symptom improvement, the benefits of G4H were more robust following an unanticipated threat to social connectedness for depression (χ²(16)=31.35, p=.001), loneliness (χ²(8)=21.622, p=.006), and wellbeing (χ²(8)=22.938, p=.003).

LIMITATIONS

Because the COVID-19 lockdown was unanticipated, this analysis represents an opportunistic use of available data. As a result, we could not measure the specific impact of restrictions on participants, such as reduced income, degree of isolation, or health-related anxieties.

CONCLUSIONS

G4H delivered one year prior to COVID-19 lockdown offered greater protection than CBT against relapse of loneliness and depression symptoms. Implications are discussed with a focus on how these benefits might be extended to other life stressors and transitions.

Social identity makes group-based social connection possible: Implications for loneliness and mental health

This review argues that a distinctly positive form of social connection is made possible by the social identities that people derive from psychologically meaningful group memberships. These connections have important implications for mental health by virtue of their distinct capacity to furnish people with a sense of collective meaning, purpose, support, and efficacy. This analysis suggests that loneliness and its toxic effects arise in part from the challenges of achieving this distinct form of social connection in contemporary society. However, it also suggests that a good way to tackle loneliness and support mental health is by building, restoring, and sustaining social identities through meaningful group-based connections. We conclude by reflecting on the success of interventions that do precisely this - most notably Groups 4 Health.

Life Change, Social Identity, and Health

Life change affects health. Research aimed at understanding the consequences of life change has primarily focused on the important roles played by stress, social support, individual differences, and broader socioeconomic factors in shaping health outcomes, most notably mental health decline. In this review we extend these accounts by exploring social identity-based determinants of adjustment to life change. We do so by drawing on social identity theorizing and, in particular, the Social Identity Model of Identity Change (SIMIC). This points to the importance of multiple, maintained, new, and compatible group memberships as determinants of people's responses and adjustment to life change. We apply this model to understand the health consequences of adjustment to life change in four diverse areas: pursuit of higher education, migration, trauma and resilience, and recovery from illness and injury. Finally, we provide direction for future research on SIMIC and the health consequences of life change.