ectiveness of Following Mediterranean Diet Recommendations ...
The¢e¡ectiveness¢of interventions¢for reducing¢subjective¢ and … · 2020. 6. 18. · and...
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Vol.:(0123456789) 1 3 Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876 https://doi.org/10.1007/s00127-019-01800-z REVIEW The effectiveness of interventions for reducing subjective and objective social isolation among people with mental health problems: a systematic review Ruimin Ma 1 · Farhana Mann 1 · Jingyi Wang 1 · Brynmor Lloyd‑Evans 1 · James Terhune 1 · Ahmed Al‑Shihabi 2 · Sonia Johnson 1,3 Received: 13 November 2018 / Accepted: 17 October 2019 / Published online: 19 November 2019 © The Author(s) 2019 Abstract Purpose Subjective and objective social isolation are important factors contributing to both physical and mental health problems, including premature mortality and depression. This systematic review evaluated the current evidence for the effectiveness of interventions to improve subjective and/or objective social isolation for people with mental health problems. Primary outcomes of interest included loneliness, perceived social support, and objective social isolation. Methods Three databases were searched for relevant randomised controlled trials (RCTs). Studies were included if they evaluated interventions for people with mental health problems and had objective and/or subjective social isolation (includ- ing loneliness) as their primary outcome, or as one of a number of outcomes with none identified as primary. Results In total, 30 RCTs met the review’s inclusion criteria: 15 included subjective social isolation as an outcome and 11 included objective social isolation. The remaining four evaluated both outcomes. There was considerable variability between trials in types of intervention and participants’ characteristics. Significant results were reported in a minority of trials, but methodological limitations, such as small sample size, restricted conclusions from many studies. Conclusion The evidence is not yet strong enough to make specific recommendations for practice. Preliminary evidence suggests that promising interventions may include cognitive modification for subjective social isolation, and interventions with mixed strategies and supported socialisation for objective social isolation. We highlight the need for more thorough, theory-driven intervention development and for well-designed and adequately powered RCTs. Keywords Loneliness · Perceived social support · Objective social isolation · Mental health · Systematic review · Intervention Introduction Subjective social isolation and objective social isolation are conceptually distinct [1] and often only moderately corre- lated [2]. The terms loneliness and perceived social support both refer to people’s subjective perception of their social world (i.e. subjective social isolation) [1, 3]. Loneliness is defined as the unpleasant experience that occurs when there is a subjective discrepancy between desired and per- ceived availability and quality of social interactions [4]. Perceived social support is the self-rated adequacy of the social resources available to a person [5]. Well-established and widely used measures of loneliness are available, such as the UCLA Loneliness Scale [6]. Objective social isola- tion, meanwhile, involves having little social contact with other people [7] and can be objectively defined based on This article is part of the focused issue ‘Loneliness: contemporary insights on causes, correlates, and consequences’. * Sonia Johnson [email protected] 1 Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London W1T 7NF, England, UK 2 UCL Medical School, University College London, 74 Huntley Street, London WC1E 6BT, England, UK 3 Camden and Islington NHS Foundation Trust, St. Pancras Hospital, 4 St. Pancras Way, London NW1 0PE, England, UK
Transcript of The¢e¡ectiveness¢of interventions¢for reducing¢subjective¢ and … · 2020. 6. 18. · and...
Vol.:(0123456789)1 3
Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876 https://doi.org/10.1007/s00127-019-01800-z
REVIEW
The effectiveness of interventions for reducing subjective and objective social isolation among people with mental health problems: a systematic review
Ruimin Ma1 · Farhana Mann1 · Jingyi Wang1 · Brynmor Lloyd‑Evans1 · James Terhune1 · Ahmed Al‑Shihabi2 · Sonia Johnson1,3
Received: 13 November 2018 / Accepted: 17 October 2019 / Published online: 19 November 2019 © The Author(s) 2019
AbstractPurpose Subjective and objective social isolation are important factors contributing to both physical and mental health problems, including premature mortality and depression. This systematic review evaluated the current evidence for the effectiveness of interventions to improve subjective and/or objective social isolation for people with mental health problems. Primary outcomes of interest included loneliness, perceived social support, and objective social isolation.Methods Three databases were searched for relevant randomised controlled trials (RCTs). Studies were included if they evaluated interventions for people with mental health problems and had objective and/or subjective social isolation (includ-ing loneliness) as their primary outcome, or as one of a number of outcomes with none identified as primary.Results In total, 30 RCTs met the review’s inclusion criteria: 15 included subjective social isolation as an outcome and 11 included objective social isolation. The remaining four evaluated both outcomes. There was considerable variability between trials in types of intervention and participants’ characteristics. Significant results were reported in a minority of trials, but methodological limitations, such as small sample size, restricted conclusions from many studies.Conclusion The evidence is not yet strong enough to make specific recommendations for practice. Preliminary evidence suggests that promising interventions may include cognitive modification for subjective social isolation, and interventions with mixed strategies and supported socialisation for objective social isolation. We highlight the need for more thorough, theory-driven intervention development and for well-designed and adequately powered RCTs.
Keywords Loneliness · Perceived social support · Objective social isolation · Mental health · Systematic review · Intervention
Introduction
Subjective social isolation and objective social isolation are conceptually distinct [1] and often only moderately corre-lated [2]. The terms loneliness and perceived social support both refer to people’s subjective perception of their social world (i.e. subjective social isolation) [1, 3]. Loneliness is defined as the unpleasant experience that occurs when there is a subjective discrepancy between desired and per-ceived availability and quality of social interactions [4]. Perceived social support is the self-rated adequacy of the social resources available to a person [5]. Well-established and widely used measures of loneliness are available, such as the UCLA Loneliness Scale [6]. Objective social isola-tion, meanwhile, involves having little social contact with other people [7] and can be objectively defined based on
This article is part of the focused issue ‘Loneliness: contemporary insights on causes, correlates, and consequences’.
* Sonia Johnson [email protected]
1 Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London W1T 7NF, England, UK
2 UCL Medical School, University College London, 74 Huntley Street, London WC1E 6BT, England, UK
3 Camden and Islington NHS Foundation Trust, St. Pancras Hospital, 4 St. Pancras Way, London NW1 0PE, England, UK
840 Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
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quantitative measures of social network size or the frequency of social contacts with others [8]. A summary table of com-monly used measures of subjective and objective social iso-lation is provided in Appendix 1.
In a UK survey, approximately one in five of the general population reported being lonely in the preceding 2 weeks [9]. For people with mental health problems, the odds of being lonely were eight times greater than for the general population, and the odds were increased 20-fold for those with two or three diagnoses (e.g. depression and schizo-phrenia), compared to those without any diagnosis [10]. Objective social isolation, including having fewer friends [11] and being less likely to date [12], is also more com-mon among people with mental health problems than in the general population. Loneliness has adverse health effects, such as an impaired immune system [13], elevated blood pressure [14], depression [15], and cognitive decline [16]. Moreover, loneliness is associated with poorer quality of life [17] and personal recovery [18], and with more severe mental health symptoms [19]. Similarly, a number of nega-tive health outcomes have been found to be associated with objective social isolation, for example, increased all-cause mortality rate [20], poor physical health outcomes [21, 22], worse psychotic symptoms [23, 24], depressive symp-toms [24], and higher risk of dementia [25]. Conversely, social support that is perceived as sufficient is associated with less severe psychiatric symptoms, higher functioning, better personal recovery, greater self-esteem and empower-ment, and improved quality of life [26]. These associations between subjective and objective social isolation and poorer outcomes [27–30] make interventions designed to alleviate social isolation of high interest. Subjective social isolation has recently been increasingly recognised as a treatment priority for people with serious mental illness [31]. By targeting both subjective and objective social isolation as main outcomes in the current review, we aimed to establish the extent of the current evidence base for interventions for each of these potential treatment targets and to understand the similarities or differences between the characteristics of interventions that work for subjective and for objective social isolation.
Some authors have previously systematically reviewed interventions for subjective social isolation [30, 32–35] and objective social isolation [36–38] (Appendix 2). The most recent systematic review focused on subjective social isolation among people with mental health problems was published in 2005 [35]. Three more recent systematic reviews focused on aspects of objective social isolation: one reviewed interventions to increase network size in psycho-sis [37] and the other two examined interventions targeting social participation in people with mental health problems [36, 38]. Thus, there is no up-to-date systematic review of evidence for a full range of interventions to alleviate
subjective and/or objective social isolation among people with a mental health diagnosis.
Masi’s meta-analysis in 2011 [34] has been considered one of the most comprehensive reviews to date examining interventions for loneliness, identifying four main types of intervention. However, Masi’s review included only 20 RCTs and included all populations, not only people with mental health problems. Thus, our paper adds to knowledge from Masi’s review by providing an up-to-date synthesis of interventions for loneliness in people with mental health problems, using a typology of interventions targeting lone-liness and related constructs recently developed by Mann and her team [39]. This typology distinguishes among the following: (1) interventions involving changing maladaptive cognitions about others (e.g. cognitive-behavioural therapy or reframing); (2) social skills training and psychoeduca-tion programmes (e.g. family psychoeducation therapy); (3) supported socialisation (e.g. peer support groups, social recreation groups); and (4) wider community approaches (e.g. social prescribing and asset-based community develop-ment approaches). These community approaches maximise individuals’ engagement with social resources and/or aim to develop social resources at the level of whole communities.
Methods
We conducted the current systematic review to evaluate the evidence for the effectiveness of interventions designed to alleviate subjective social isolation (including loneliness and perceived social support) and/or objective social isolation among people with mental health problems.
Inclusion criteria
Types of study
Only randomised controlled trials (RCTs) were included, with no restrictions on publication dates, the country of ori-gin or language.
Participants
People primarily diagnosed with mental health conditions were included, including depression, anxiety, post-traumatic disorder, psychosis/schizophrenia or bipolar disorders. Any method of identifying or diagnosing people as mentally ill was acceptable. There was no restriction on the age of the participants. However, studies where the samples were peo-ple with a primary diagnosis of intellectual disability, autistic spectrum disorders, dementia, any other organic illnesses, substance misuse or physical health problems were excluded, even if some had comorbid mental health diagnoses.
841Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
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Interventions
This review included interventions which were designed to alleviate subjective or/and objective social isolation for people with mental health problems. Papers were included if subjective or objective social isolation was a primary out-come and excluded if they were secondary outcomes, with another clearly specified primary outcome. Trials were also included if a clear distinction was not made between primary and secondary outcomes, with subjective and/or objective social isolation as one of a number of main outcomes.
Comparison
We included trials where the control group received treat-ment-as-usual, however defined, no treatment or a waiting-list control. We also included trials which compared differ-ent active treatment groups.
Outcomes
The primary outcomes were subjective social isolation (including loneliness and perceived social support) and objective social isolation. End-of-treatment outcomes, medium-term outcomes (i.e. up to one year beyond the end-of-treatment time point) and longer-term follow-up out-comes (i.e. more than one year beyond the end-of-treatment time point) were reported separately. The following second-ary outcomes were also examined: health status, quality of life, and service use.
Search strategy
Three databases were systematically searched for relevant literature: Medline, Web of Science and PsycINFO. Three groups of search terms were combined: (1) subjective and objective social isolation (e.g. loneliness); (2) mental disor-ders (e.g. psychosis, depression, post-traumatic stress dis-order) and (3) trials (e.g. RCT). For detailed search terms, please see Appendix 3. Reference lists from included stud-ies, relevant systematic reviews, and meta-analyses were hand-searched. Grey literature was searched through Open-Grey by using keywords ‘loneliness’, ‘perceived social sup-port’ and ‘social isolation’.
Data extraction
RM and FM reviewed all titles and abstracts, AA screened half of the papers we retrieved, and final decisions regarding whether a paper should be included or not were made by all three independent reviewers. The primary reviewer (RM) reviewed all full-text papers retrieved, and inter-rater reli-ability was also evaluated as good between reviewers during
the screening process. The final list of included papers was confirmed only when RM, FM, and AA agreed on all papers. Any differences were resolved in consultation with a further independent reviewer (SJ). Data were extracted by RM and FM by using a standardised form developed for the review, including items related to publication year and country, study design, experimental settings, participants, the nature of the intervention, follow-up details, primary and secondary outcomes, any exclusions of participants, and the reasons for these, confounders, and risk of bias.
Quality assessment
The Cochrane Risk of Bias tool [40] was used for the qual-ity assessment. Each included paper was assessed by two reviewers (RM and FM/JT) regarding the following domains: sequence generation, allocation concealment, blinding of participants, personnel and outcome assessors, incomplete outcome data, selective outcome reporting and other sources of bias. For each paper, a final decision for each domain was made only if both assessors agreed. If there was disagree-ment, a third independent assessor (SJ) was consulted.
Synthesis plan
A narrative synthesis was conducted for this systematic review based on the principles from the ESRC’s Guid-ance on the Conduct of Narrative Synthesis in Systematic Reviews [41]. The included trials were grouped into three categories: (1) trials that included subjective social isola-tion as an outcome (primary or one of several, with none specified as primary); (2) trials that included objective social isolation as an outcome; and (3) trials that included both outcomes. Due to the expected heterogeneity in samples and intervention types from this broad review, meta-analysis was judged to be inappropriate.
Results
The initial literature search retrieved 5220 papers in total, of which 30 were found to be eligible for inclusion. The PRISMA flow diagram (Fig. 1) shows details of the screen-ing process.
The 30 trials involved 3080 participants in total, with individual trial sample sizes ranging from 21 to 357. Nine-teen trials had fewer than 100 participants. The median number was 88, and the interquartile range (IQR) was 104. Authors from nine trials specified sample size calculations. The search was conducted in July 2017 and all trials were published between 1976 and 2016. Thirteen trials were conducted in the US, 11 in Europe, 3 in Israel, 2 in China, and 1 in Canada. Thirteen interventions were conducted
842 Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
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individually, nine interventions were delivered in groups, four involved individual and group support, and four were implemented online. Ten trials compared different active treatments, four of which had no control group. The remain-ing 20 trials compared intervention groups with a control group: 13 involved treatment-as-usual groups, 5 involved waiting-list controls, and 2 involved no-treatment controls.
Interventions to reduce subjective social isolation
Fifteen trials included subjective social isolation as pri-mary outcome, or as one of several outcomes with none specified as primary (Table 1).
Two trials included only end-of-treatment outcomes [42, 43]. The follow-up period of the other 13 trials ranged from 1 week
to 36 months beyond the end of treatment. The Multidimen-sional Scale of Perceived Social Support (MSPSS) and UCLA Loneliness Scale were frequently administered. The measures used in 14 trials have been shown to have good validity and reliability, but one trial [44] did not use a well-established scale. Nine trials involved people with common mental illnesses (e.g. depression), three involved people with severe mental illnesses (e.g. schizophrenia), and three included people with a variety of mental health diagnoses. The majority of the trials had small sample sizes (< 100); only four trials had more than 200 partici-pants. Five trials included a sample size calculation.
Three trials involved online interventions, one trial com-bined online intervention and telephone support, four tri-als implemented face-to-face group intervention, five used face-to-face individual therapy, and the remaining two
Fig. 1 PRISMA diagram for literature search
843Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
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Tabl
e 1
Tria
ls th
at in
clud
ed su
bjec
tive
soci
al is
olat
ion
as o
utco
me
Mai
n au
thor
, sam
ple
and
setti
ngIn
terv
entio
n ca
tego
risat
ion
Inte
rven
tion
nam
e an
d du
ra-
tion
Follo
w-u
pSo
cial
isol
atio
n an
d ot
her
outc
ome
mea
sure
sSu
bjec
tive
soci
al is
olat
ion
outc
omes
Gro
up-b
ased
inte
rven
tion
Has
son-
Oha
yon
[42]
—21
0 ad
ults
with
seve
re m
enta
l ill
ness
Psyc
hiat
ric c
omm
unity
reha
-bi
litat
ion
cent
re in
Isra
el
(sec
onda
ry c
are
setti
ng)
Psyc
hoed
ucat
ion,
soci
al sk
ills
train
ing
Illne
ss M
anag
emen
t and
Re
cove
ry P
rogr
amm
e vs
. tre
atm
ent-a
s-us
ual c
ontro
l gr
oup
Dur
atio
n: 8
mon
ths
End-
of-tr
eatm
ent f
ollo
w-u
p (8
mon
ths)
Subj
ectiv
e so
cial
isol
atio
n ou
tcom
e: th
e M
ultid
imen
-si
onal
Sca
le o
f Per
ceiv
ed
Soci
al S
uppo
rt (M
SPSS
) [5
7]O
ther
out
com
e: p
erso
nal
reco
very
No
sign
ifica
nt c
hang
es in
pe
rcei
ved
soci
al su
ppor
t for
ei
ther
gro
up. p
> 0.
05a
Silv
erm
an [4
3]—
96 a
dults
w
ith v
arie
d A
xis I
dia
g-no
ses
Acu
te c
are
psyc
hiat
ric u
nit
in a
Uni
vers
ity h
ospi
tal,
the
Mid
wes
tern
regi
on in
th
e U
S (s
econ
dary
car
e se
tting
)
Psyc
hoed
ucat
ion
Live
edu
catio
nal m
usic
ther
-ap
y (c
ondi
tion
A),
reco
rded
ed
ucat
iona
l mus
ic th
erap
y (c
ondi
tion
B),
educ
atio
n w
ithou
t mus
ic (c
ondi
-tio
n C
), re
crea
tiona
l mus
ic
ther
apy
with
out e
duca
tion
(con
ditio
n D
)D
urat
ion:
24
wee
ks
End-
of-tr
eatm
ent f
ollo
w-u
p (2
4 w
eeks
)Su
bjec
tive
soci
al is
olat
ion
outc
ome:
the
MSP
SS [5
7]N
o si
gnifi
cant
bet
wee
n-gr
oup
diffe
renc
e in
tota
l per
ceiv
ed
soci
al su
ppor
t for
con
ditio
n A
vs.
B, c
ondi
tion
A a
nd B
vs
. con
ditio
n C
, as w
ell a
s for
co
nditi
on A
and
B v
s. D
(all
p > 0.
05)
(F (3
.87)
= 1.
50, p
= 0.
22)
Parti
al e
ffect
size
= 0.
028
for
supp
ort f
rom
sign
ifica
nt
othe
r, 0.
015
for s
uppo
rt fro
m
fam
ily, 0
.094
for s
uppo
rt fro
m fr
iend
s, an
d 0.
049
for
tota
l sup
port
Onl
y a
sign
ifica
nt b
etw
een-
grou
p di
ffere
nce
betw
een
cond
ition
A v
s. D
on
a fr
iend
su
bsca
le, 9
5% C
I (0.
47,
10.4
0), a
djus
ted p =
0.02
, m
ean
diffe
renc
e = 5.
34 B
oevi
nk [4
4] -
163
adul
ts
with
men
tal i
llnes
sM
enta
l hea
lth c
are
orga
nisa
-tio
ns (c
omm
unity
trea
t-m
ent t
eam
and
shel
tere
d ho
usin
g or
gani
satio
ns) i
n th
e N
ethe
rland
s (se
cond
-ar
y ca
re se
tting
)
Supp
orte
d so
cial
isat
ion
Tow
ard
Reco
very
, Em
pow
-er
men
t and
Exp
erie
ntia
l Ex
perti
se (T
REE
) + ca
re-a
s-us
ual v
s. ca
re-a
s-us
ual c
on-
trol g
roup
Dur
atio
n: 1
04 w
eeks
for
early
star
ters
and
52
wee
ks
for l
ate
star
ters
1 m
ediu
m-te
rm fo
llow
-up:
12
mon
ths (
post-
base
line)
1 lo
ng-te
rm fo
llow
-up:
24
mon
ths (
post-
base
line)
Subj
ectiv
e so
cial
isol
atio
n ou
tcom
e: th
e D
e Jo
ng-
Gie
rvel
d Lo
nelin
ess S
cale
[5
8]O
ther
out
com
es: q
ualit
y of
Li
fe; p
sych
iatri
c sy
mpt
oms
No
betw
een-
grou
p di
ffere
nce
in
lone
lines
s, 95
% C
I (−
0.31
, 0.
30) (
effec
t siz
e lin
ear
tread
B =
− 0.
053,
p =
0.98
), st
anda
rdis
ed e
ffect
size
was
−
0.00
1 fo
r eac
h ye
ar o
f exp
o-su
re to
TR
EE p
rogr
amm
e
844 Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
Tabl
e 1
(con
tinue
d)
Mai
n au
thor
, sam
ple
and
setti
ngIn
terv
entio
n ca
tego
risat
ion
Inte
rven
tion
nam
e an
d du
ra-
tion
Follo
w-u
pSo
cial
isol
atio
n an
d ot
her
outc
ome
mea
sure
sSu
bjec
tive
soci
al is
olat
ion
outc
omes
Egg
ert [
45]—
105
high
sc
hool
stud
ents
with
poo
r gr
ades
(mod
erat
e or
seve
re
depr
essi
on)
5 ur
ban
high
scho
ols i
n th
e U
S (g
ener
al p
opul
atio
n se
tting
)
Supp
orte
d so
cial
isat
ion,
so
cial
skill
s tra
inin
g an
d w
ider
com
mun
ity
appr
oach
es
Ass
essm
ent p
roto
col p
lus
1-se
mes
ter P
erso
nal
Gro
wth
Cla
ss (P
GC
I) v
s. A
sses
smen
t pro
toco
l plu
s a
2-se
mes
ter P
erso
nal G
row
th
Cla
ss (P
GC
II) v
s. an
ass
ess-
men
t pro
toco
l-onl
yD
urat
ion:
5 m
onth
s or 9
0 cl
ass d
ays i
n le
ngth
for
PGC
I, an
d 10
mon
ths o
r 19
0 cl
ass d
ays i
n le
ngth
fo
r PG
CII
2 m
ediu
m-te
rm fo
llow
-ups
: 5
and
10 m
onth
s (po
st-ba
selin
e)
Subj
ectiv
e so
cial
isol
atio
n ou
tcom
es: p
erce
ived
soci
al
supp
ort w
as m
easu
red
by
calc
ulat
ing
aver
age
ratin
gs
acro
ss 6
net
wor
k su
ppor
t so
urce
s. In
strum
enta
l and
ex
pres
sive
supp
ort p
rovi
ded
by e
ach
netw
ork
supp
ort
sour
ce (e
.g. f
amily
, frie
nds)
w
as a
lso
rate
d on
a sc
ale
Oth
er o
utco
me:
dep
ress
ive
sym
ptom
s
All
3 gr
oups
show
ed in
crea
sed
netw
ork
soci
al su
ppor
t F li
n-ea
r (1,
100)
= 32
.08,
p <
0.00
1N
o si
gnifi
cant
bet
wee
n-gr
oup
diffe
renc
e be
twee
n al
l gro
ups
F lin
ear (
1,10
0) =
1.98
, p =
0.14
3
Indi
vidu
al-b
ased
inte
rven
tion
Zan
g [4
6]—
30 a
dults
age
d 28
–80
with
pos
t-tra
umat
ic
stres
s dis
orde
r (PT
SD)
Bei
chua
n C
ount
y in
Chi
na
(gen
eral
pop
ulat
ion
set-
ting)
Cha
ngin
g co
gniti
ons
Nar
rativ
e Ex
posu
re T
hera
py
(NET
) vs.
Nar
rativ
e Ex
posu
re T
hera
py R
evis
ed
(NET
-R) v
s. w
aitin
g-lis
t co
ntro
l gro
upD
urat
ion:
2 w
eeks
for N
ET
and
1 w
eek
for N
ET-R
gr
oup
End-
of-tr
eatm
ent f
ollo
w-u
p (2
wee
ks fo
r NET
, 1 w
eek
for N
ET-R
)2
med
ium
-term
follo
w-u
ps:
1 w
eek
(for N
ET) o
r 2
wee
ks (f
or N
ET-R
), an
d 3
mon
ths
Subj
ectiv
e so
cial
isol
atio
n ou
tcom
e: th
e M
SPSS
[57]
Oth
er o
utco
mes
: anx
iety
and
de
pres
sive
sym
ptom
s; P
TSD
sy
mpt
oms
Bot
h N
ET a
nd N
ET-R
show
ed
effec
ts o
n pe
rcei
ved
soci
al
supp
ort a
fter t
reat
men
t, bu
t no
sign
ifica
nt b
etw
een-
grou
p di
ffere
nce
betw
een
the
two
grou
ps (F
(2,2
6) =
0.14
, p >
0.05
)N
o si
gnifi
cant
bet
wee
n-gr
oup
diffe
renc
e be
twee
n ei
ther
tre
atm
ent g
roup
(NET
and
N
ET-R
) and
the
wai
ting-
list
cont
rol i
n pe
rcei
ved
soci
al
supp
ort (
both
p >
0.05
) Z
ang
[47]
—22
adu
lts a
ged
37–7
5 w
ith P
TSD
Bei
chua
n C
ount
ry in
Chi
na
(gen
eral
pop
ulat
ion
set-
ting)
Cha
ngin
g co
gniti
ons
NET
inte
rven
tion
vs. w
aitin
g-lis
t con
trol g
roup
Dur
atio
n: 2
wee
ks
End-
of-tr
eatm
ent f
ollo
w-u
p (2
wee
ks)
2 m
ediu
m-te
rm fo
llow
-ups
: 2
wee
ks, a
nd 2
mon
ths
Subj
ectiv
e so
cial
isol
atio
n ou
tcom
e: th
e M
SPSS
[57]
Oth
er o
utco
mes
: sub
ject
ive
leve
l of d
istre
ss; d
epre
ssiv
e sy
mpt
oms
No
sign
ifica
nt b
etw
een-
grou
p di
ffere
nce
in p
erce
ived
soci
al
supp
ort (F
(1,1
9) =
4.25
, p =
0.05
, d =
0.33
)
Gaw
rysi
ak [4
8]—
30 a
dults
ag
ed ≥
18 w
ith d
epre
ssio
nA
pub
lic S
outh
easte
rn U
ni-
vers
ity in
the
US
(gen
eral
po
pula
tion
setti
ng)
Psyc
hoed
ucat
ion,
soci
al sk
ills
train
ing
and
supp
orte
d so
cial
isat
ion
Beh
avio
ural
Act
ivat
ion
Trea
tmen
t for
Dep
ress
ion
(BA
TD) v
s. no
-trea
tmen
t co
ntro
l gro
upD
urat
ion:
sing
le se
ssio
n la
sted
90 m
in
1 m
ediu
m-te
rm fo
llow
-up:
2
wee
ksSu
bjec
tive
soci
al is
olat
ion
outc
ome:
the
MSP
SS [5
7]O
ther
out
com
es: d
epre
s-si
ve sy
mpt
oms;
anx
iety
sy
mpt
oms
No
sign
ifica
nt b
etw
een-
grou
p di
ffere
nce
in p
erce
ived
soci
al
supp
ort (F
(1,2
8) =
3.11
, p =
0.08
, d =
0.70
)
845Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
Tabl
e 1
(con
tinue
d)
Mai
n au
thor
, sam
ple
and
setti
ngIn
terv
entio
n ca
tego
risat
ion
Inte
rven
tion
nam
e an
d du
ra-
tion
Follo
w-u
pSo
cial
isol
atio
n an
d ot
her
outc
ome
mea
sure
sSu
bjec
tive
soci
al is
olat
ion
outc
omes
Con
oley
[49]
—57
fem
ale
psyc
holo
gy u
nder
grad
uate
stu
dent
s with
mod
erat
e de
pres
sion
Uni
vers
ity P
sych
olog
y de
partm
ent i
n th
e U
S (g
en-
eral
pop
ulat
ion
setti
ng)
Cha
ngin
g co
gniti
ons
Refr
amin
g vs
. sel
f-co
ntro
l vs.
wai
ting-
list c
ontro
l gro
upD
urat
ion:
2 w
eeks
End-
of-tr
eatm
ent f
ollo
w-u
p (2
wee
ks)
1 m
ediu
m-te
rm fo
llow
-up:
2
wee
ks
Subj
ectiv
e so
cial
isol
atio
n ou
tcom
e: th
e Re
vise
d U
nive
rsity
of C
alifo
rnia
Los
A
ngel
es (U
CLA
) Lon
eli-
ness
Sca
le [5
9]; T
he C
ausa
l D
imen
sion
Sca
le [6
0]O
ther
out
com
e: d
epre
ssiv
e sy
mpt
oms
No
sign
ifica
nt tr
eatm
ent e
ffect
w
as fo
und
(F (2
,108
) = 0.
60,
p > 0.
05b )
Bjo
rkm
an [5
0]—
77 a
dults
ag
ed 1
9–51
with
seve
re
men
tal i
llnes
sC
ase
man
agem
ent s
ervi
ce in
Sw
eden
(sec
onda
ry c
are
setti
ng)
Soci
al sk
ills t
rain
ing
The
case
man
agem
ent s
ervi
ce
vs. s
tand
ard
care
Dur
atio
n: u
ncle
ar
2 lo
ng-te
rm fo
llow
-ups
: 18
and
36 m
onth
sSu
bjec
tive
soci
al is
olat
ion
outc
ome:
the
abbr
evia
ted
vers
ion
of th
e In
terv
iew
Sc
hedu
le fo
r Soc
ial I
nter
ac-
tion
(ISS
I) [6
1]O
ther
out
com
es: p
sych
iatri
c sy
mpt
oms;
qua
lity
of li
fe;
use
of p
sych
iatri
c se
rvic
es
No
sign
ifica
nt b
etw
een-
grou
p di
ffere
nce
betw
een
two
grou
ps in
soci
al o
utco
mes
(p
> 0.
05)c
Mix
ed-fo
rmat
(gro
up- a
nd in
divi
dual
-bas
ed)
Men
dels
on [5
1]—
78
depr
esse
d w
omen
age
d 14
–41
who
wer
e ei
ther
pr
egna
nt o
r had
a c
hild
le
ss th
an 6
mon
ths o
ldH
ome
visi
ting
prog
ram
me
in B
altim
ore
City
in th
e U
S (g
ener
al p
opul
atio
n se
tting
)
Cha
ngin
g co
gniti
ons
Stan
dard
hom
e vi
sitin
g se
rvic
es +
The
Mot
her
and
Bab
ies (
MB
) cou
rse
vs. s
tand
ard
hom
e vi
sitin
g se
rvic
es +
info
rmat
ion
on
perin
atal
dep
ress
ion
Dur
atio
n: 6
wee
ks
End-
of-tr
eatm
ent f
ollo
w-u
p (6
wee
ks)
2 m
ediu
m-te
rm fo
llow
-ups
: 3
and
6 m
onth
s
Subj
ectiv
e so
cial
isol
atio
n ou
tcom
e: th
e In
terp
erso
nal
Supp
ort E
valu
atio
n Li
st (I
SEL)
[62]
No
sign
ifica
nt b
etw
een-
grou
p di
ffere
nce
in p
erce
ived
soci
al
supp
ort, β =
6.67
, SE
= 0.
03,
p < 0.
10d
Mas
ia-W
arne
r [52
]—35
hi
gh sc
hool
stud
ents
with
so
cial
anx
iety
dis
orde
r2
paro
chia
l hig
h sc
hool
s in
New
Yor
k, U
S (g
ener
al
popu
latio
n se
tting
)
Psyc
hoed
ucat
ion/
soci
al
skill
s tra
inin
g, su
ppor
ted
soci
alis
atio
n an
d ch
angi
ng
cogn
ition
s
Skill
s for
Soc
ial a
nd A
ca-
dem
ic S
ucce
ss v
s. w
aitin
g-lis
t con
trol g
roup
Dur
atio
n: 3
mon
ths
End-
of-tr
eatm
ent f
ollo
w-u
p (3
mon
ths)
1 m
ediu
m-te
rm fo
llow
-up:
9
mon
ths
Subj
ectiv
e so
cial
isol
atio
n ou
tcom
e: L
onel
ines
s Sca
le
[63]
Oth
er o
utco
mes
: anx
iety
sy
mpt
oms;
soci
al p
hobi
c sy
mpt
oms;
dep
ress
ive
sym
ptom
s
No
sign
ifica
nt tr
eatm
ent e
ffect
, eff
ect s
ize =
0.20
e , p >
0.05
Onl
ine
inte
rven
tion
Kap
lan
[53]
—30
0 ad
ults
w
ith sc
hizo
phre
nia
spec
-tru
m o
r affe
ctiv
e di
sord
erO
nlin
e in
the
US
(gen
eral
po
pula
tion
setti
ng)
Supp
orte
d so
cial
isat
ion
Expe
rimen
tal p
eer s
uppo
rt lis
tser
v vs
. exp
erim
enta
l pe
er su
ppor
t bul
letin
boa
rd
vs. w
aitin
g-lis
t con
trol g
roup
Dur
atio
n: 1
2 m
onth
s
2 m
ediu
m-te
rm fo
llow
-ups
: 4
and
12 m
onth
s (po
st-ba
selin
e)
Subj
ectiv
e so
cial
isol
atio
n ou
tcom
e: th
e M
edic
al O
ut-
com
es S
tudy
(MO
S) S
ocia
l Su
ppor
t Sur
vey
[64]
Oth
er o
utco
mes
: per
sona
l re
cove
ry; q
ualit
y of
life
; ps
ychi
atric
sym
ptom
s
No
sign
ifica
nt b
etw
een-
grou
p di
ffere
nce
on M
OS
(F (1
,298
) = 0.
08, p
= 0.
93),
also
not
sign
ifica
nt w
hen
two
expe
rimen
tal g
roup
s com
-pa
red
to th
e co
ntro
l gro
up
sepa
rate
ly (p
> 0.
05)
846 Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
Tabl
e 1
(con
tinue
d)
Mai
n au
thor
, sam
ple
and
setti
ngIn
terv
entio
n ca
tego
risat
ion
Inte
rven
tion
nam
e an
d du
ra-
tion
Follo
w-u
pSo
cial
isol
atio
n an
d ot
her
outc
ome
mea
sure
sSu
bjec
tive
soci
al is
olat
ion
outc
omes
Rot
ondi
[54]
—30
pat
ient
s ag
ed ≥
14 w
ith sc
hizo
-ph
reni
a or
schi
zoaff
ectiv
e di
sord
erIn
- and
out
-pat
ient
psy
chia
t-ric
car
e un
its a
nd p
sych
i-at
ric re
habi
litat
ion
cent
res
in P
ittsb
urgh
, Pen
nsyl
vani
a (s
econ
dary
car
e se
tting
)
Psyc
hoed
ucat
ion
Tele
heal
th in
terv
entio
n vs
. us
ual c
are
grou
pD
urat
ion:
unc
lear
2 m
ediu
m-te
rm fo
llow
-ups
: 3
and
6 m
onth
s (po
st-ba
selin
e)
Subj
ectiv
e so
cial
isol
atio
n ou
tcom
e: th
e in
form
atio
nal
supp
ort a
nd e
mot
iona
l sup
-po
rt su
bsca
les o
f the
instr
u-m
ent t
hat w
as d
evel
oped
by
Kra
use
and
Mar
kide
s [65
]
No
sign
ifica
nt b
etw
een-
grou
p di
ffere
nce
on p
erce
ived
soci
al
supp
ort (F
(1,2
7) =
3.79
, p =
0.06
2)
O’M
ahen
[55]
—83
wom
en
aged
> 18
with
maj
or
depr
essi
ve d
isor
der
(MD
D)
Onl
ine
in th
e U
K (g
ener
al
popu
latio
n se
tting
)
Psyc
hoed
ucat
ion
and
sup-
porte
d so
cial
isat
ion
Net
mum
s Hel
ping
with
D
epre
ssio
n (H
WD
) vs.
treat
men
t-as-
usua
l con
trol
grou
pD
urat
ion:
unc
lear
End-
of-tr
eatm
ent f
ollo
w-u
p (u
ncle
ar)
1 m
ediu
m-te
rm fo
llow
-up:
6
mon
ths
Subj
ectiv
e so
cial
isol
atio
n ou
tcom
e: th
e So
cial
Pro
vi-
sion
Sca
le [6
6]O
ther
out
com
es: d
epre
s-si
ve sy
mpt
oms;
anx
iety
sy
mpt
oms
No
sign
ifica
nt b
etw
een-
grou
p di
ffere
nce
in p
erce
ived
sup-
port
betw
een
the
inte
rven
tion
and
cont
rol g
roup
(95%
CI
1.02
, − 0.
02),
med
ium
effe
ct
size
= 0.
50 (p
= 0.
27)
Inte
rian
[56]
—10
3 ve
tera
ns
with
PTS
DO
nlin
e in
the
US
(prim
ary
care
setti
ng)
Psyc
hoed
ucat
ion
and
chan
g-in
g co
gniti
ons
The
Fam
ily o
f Her
oes
inte
rven
tion
vs. n
o-tre
at-
men
t con
trol g
roup
Dur
atio
n: u
ncle
ar
1 m
ediu
m-te
rm fo
llow
-up:
2
mon
ths (
post-
base
line)
Subj
ectiv
e so
cial
isol
atio
n ou
tcom
e: th
e fa
mily
sub-
scal
e of
the
MSP
SS [5
7]
Inte
rven
tion
grou
p re
porte
d a
high
er c
hanc
e of
hav
ing
a de
crea
sed
perc
eive
d fa
mily
su
ppor
t ove
r tim
e th
an th
e co
ntro
l gro
up (p
= 0.
04)f
a Effec
t siz
e, c
onfid
ence
inte
rval
and
act
ual p
val
ue n
ot av
aila
ble
in th
e pa
per
b Con
fiden
ce in
terv
al a
nd a
ctua
l p v
alue
not
avai
labl
e in
the
pape
rc Eff
ect s
ize,
con
fiden
ce in
terv
al a
nd a
ctua
l p v
alue
not
avai
labl
e in
the
pape
rd Eff
ect s
ize
and
confi
denc
e in
terv
al n
ot av
aila
ble
in th
e pa
per
e Con
fiden
ce in
terv
al a
nd a
ctua
l p v
alue
not
avai
labl
e in
the
pape
rf Eff
ect s
ize
not a
vaila
ble
in th
e pa
per
847Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
combined both group and individual formats. Interventions in two trials involved supported socialisation, four trials evaluated psychoeducation/social skills training, four had cognition modification elements, and five trials mixed dif-ferent intervention types. The duration of the interventions ranged from 1 week to 104 weeks, while such information was missing in four trials and one trial involved only a single intervention session (Appendices 4 and 5).
Regarding quality assessment, method of randomisation was mentioned in half of the trials. Information on alloca-tion concealment, missing data, and blinding were not suf-ficiently described in most trials. For detailed quality assess-ments, please see Appendix 6.
Of the ten trials that compared an active intervention with a control group [42, 44, 47, 48, 50–52, 54–56], none of the authors reported a significant between-group differ-ence. In the five trials comparing at least two different active interventions [43, 45, 46, 49, 53], only Silverman and col-leagues [43] found significant between-group differences, reporting a greater improvement in perceived social support from friends (measured by MSPSS friend subscale) in an intervention group involving both music therapy and psych-oeducation than in other treatment groups (e.g. music alone). However, differences were not found in other outcomes and this trial did not involve a waiting-list or treatment-as-usual control. As most trials had small samples and lacked sample size calculations, clear conclusions cannot be drawn from negative results.
Eleven out of 15 trials included measures of other rel-evant outcomes [42, 44–50, 52, 53, 55]. Of these 11 trials, positive outcomes were reported by authors of seven trials. Improved depressive symptoms were reported in trials of interventions with mixed strategies with the following par-ticipant groups: adults in the community [48], urban high schoolers [45], and women with major depressive disorders [55]. Another mixed intervention had an effect on social avoidance and social phobia among high school students [52]. A diagnostically mixed participant group exhibited improved progress towards personal recovery and personal goals with psychoeducation/social skills training [42], and a mixed sample who received supported socialisation [44] also reported an improvement in quality of life. However, results on some outcomes in some of the trials did not show significant differences: an intervention with positive results for depression did not improve anxiety [48]; a case manage-ment service was not associated with any change in quality of life [50]; an online intervention for people with schizo-phrenia did not lead to any differences in quality of life or symptoms [53].
Interventions to reduce objective social isolation
Eleven trials included objective social isolation as pri-mary outcome, or as one of several outcomes with none identified as primary (Table 2).
Of 11 trials, one trial [67] only included end-of-treatment outcomes. The follow-up period of the other ten trials ranged from 4 weeks to 2 years beyond the end-of-treatment. In eight trials, validated objective social isolation scales were used. In one trial, objective social isolation was measured by sum-marising the number, frequency, and type of social connec-tions [73], one trial combined both methods [70], and we could not establish the validity of the measure used in another trial because too little detail was provided [71]. Three trials included people with common mental health problems, six trials involved people with severe mental illnesses, and two trials included diagnostically mixed populations. Most trials involved fewer than 100 participants, and only two had more than 200. Three trials included a sample size calculation.
Seven trials were implemented in an individual format, three were group-based interventions, and one involved both group and individual sessions, plus telephone support. Two trials involved a psychoeducation component/social skills training, one included supported socialisation opportuni-ties, the intervention type of another trial was unclear, and the other seven trials involved interventions with multiple components. The duration of the interventions ranged from 12 weeks to 2 years where this was specified, but such infor-mation was not given in four trials (Appendices 4 and 5).
A description of the randomisation process was only included in three trials. Allocation concealment detail was described in five trials. Authors of seven trials did not report how they dealt with missing data. For detailed quality assessments, please see Appendix 6.
Of the six trials that compared an active treatment group with a control group [67–69, 71, 73, 76], findings of four trials suggested superior outcomes for their intervention groups over their control groups on objective social isola-tion measures: a psychoeducation programme for adults with schizophrenia [67], a social network intervention for people diagnosed with schizophrenia spectrum disorders [73], a preventive senior centre group for seniors with mild depres-sion [69], and Social Cognition and Interaction Training (SCIT) for patients with various diagnoses [68]. One trial involving social education for people with schizophrenia and one trial involving home assessment teams for people with mood disorders did not lead to any improvements in objec-tive social isolation [71, 76].
Of the five trials that compared different active interven-tions [70, 72, 74, 75, 77], positive findings were reported in two trials. One trial included systematic desensitisation and social skills training interventions: both were found to be superior to the control group for increasing social contacts in
848 Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
Tabl
e 2
Tria
ls th
at in
clud
ed o
bjec
tive
soci
al is
olat
ion
as o
utco
me
Mai
n au
thor
, sam
ple
and
setti
ngIn
terv
entio
n ca
tego
-ris
atio
nIn
terv
entio
n na
me
and
dura
-tio
nFo
llow
-up
Obj
ectiv
e so
cial
isol
atio
n an
d ot
her o
utco
me
mea
sure
sO
bjec
tive
soci
al is
olat
ion
outc
ome
Gro
up-b
ased
inte
rven
tion
Atk
inso
n [6
7]—
146
regi
stere
d pa
tient
s with
sc
hizo
phre
nia
Com
mun
ity c
linic
in so
uth
Gla
sgow
, UK
(sec
onda
ry
care
setti
ng)
Psyc
hoed
ucat
ion
The
educ
atio
n gr
oup
vs.
wai
ting-
list c
ontro
l gro
upD
urat
ion:
20
wee
ks
End-
of-tr
eatm
ent f
ollo
w-
up (2
0 w
eeks
)1
med
ium
-term
follo
w-
up: 3
mon
ths
Obj
ectiv
e so
cial
isol
atio
n ou
tcom
e:
a m
odifi
ed S
ocia
l Net
wor
k Sc
hedu
le (S
NS)
[78]
Oth
er o
utco
mes
: qua
lity
of li
fe;
psyc
hiat
ric sy
mpt
oms;
ove
rall
func
tioni
ng
Sign
ifica
nt b
etw
een-
grou
p di
ffere
nce
in
the
tota
l num
ber o
f con
tact
s afte
r the
in
terv
entio
n (t
= 4.
4, p
< 0.
001)
and
at
follo
w-u
p (t
= 3.
6, p
< 0.
001)
.Si
gnifi
cant
bet
wee
n-gr
oup
diffe
renc
e in
the
num
ber o
f con
fidan
ts a
fter t
he
inte
rven
tion
(t =
3, p
= 0.
004)
and
at
follo
w-u
p (t
= 2.
8, p
= 0.
006)
Sign
ifica
nt b
etw
een-
grou
p di
ffere
nce
over
tim
e fro
m p
ost-g
roup
(t =
2.8,
p =
0.00
7) to
follo
w-u
p (t
= 2.
5,
p = 0.
02)
Has
son-
Oha
yon
[68]
—55
ad
ults
age
d 21
–62
with
va
rious
men
tal i
llnes
s3
psyc
hiat
ric re
habi
litat
ion
agen
cies
and
the
Uni
ver-
sity
Com
mun
ity C
linic
in
Bar
-Ila
n U
nive
rsity
, Isr
ael
(sec
onda
ry c
are
setti
ng)
Wid
er c
omm
unity
ap
proa
ches
, psy
ch-
oedu
catio
n/so
cial
sk
ills t
rain
ing
and
chan
ging
cog
nitio
ns
Soci
al C
ogni
tion
and
Inte
ract
ion
Trai
ning
(S
CIT
) + so
cial
men
torin
g vs
. soc
ial m
ento
ring
only
Dur
atio
n: u
ncle
ar
1 m
ediu
m-te
rm fo
llow
-up
: 6 m
onth
sO
bjec
tive
soci
al is
olat
ion
outc
ome:
th
e so
cio-
enga
gem
ent a
nd
inte
rper
sona
l-com
mun
icat
ion
subs
cale
s of t
he S
ocia
l Fun
ctio
n-in
g Sc
ale
(SFS
) [79
]
Expe
rimen
tal g
roup
show
ed si
g-ni
fican
tly m
ore
impr
ovem
ent i
n so
cial
eng
agem
ent t
han
the
con-
trols
(F (1
,53)
= 28
.9, p
< 0.
001,
eff
ect s
ize =
0.35
), bu
t no
sign
ifi-
cant
bet
wee
n-gr
oup
diffe
renc
e fo
r th
e in
terp
erso
nal c
omm
unic
atio
n su
bsca
le (F
(1,5
3) =
0.55
, p =
0.46
4,
effec
t siz
e = 0.
01)
Bøe
n [6
9]—
138
seni
ors
with
mild
dep
ress
ion
2 M
unic
ipal
dist
ricts
in
easte
rn a
nd w
este
rn O
slo,
N
orw
ay (g
ener
al p
opul
a-tio
n se
tting
)
Supp
orte
d so
cial
isa-
tion
and
wid
er c
om-
mun
ity a
ppro
ache
s
A p
reve
ntiv
e se
nior
cen
tre
grou
p pr
ogra
mm
e vs
. w
aitin
g-lis
t con
trol
Dur
atio
n: 1
yea
r
End-
of-tr
eatm
ent f
ollo
w-
up (1
yea
r)O
bjec
tive
soci
al is
olat
ion
outc
ome:
th
e O
slo-
3 So
cial
Sup
port
Scal
e [8
0]a
Oth
er o
utco
mes
: dep
ress
ive
sym
p-to
ms;
life
satis
fact
ion
Bot
h gr
oups
had
an
incr
ease
d le
vel o
f so
cial
supp
ort,
but g
reat
er im
prov
e-m
ent i
n th
e in
terv
entio
n gr
oup
than
th
e co
ntro
l gro
up, d
= 0.
12, 9
5% C
I (−
0.47
, 0.8
1).
Indi
vidu
al-b
ased
inte
rven
tion
Sol
omon
[70]
—96
adu
lts
with
schi
zoph
reni
a or
m
ajor
affe
ctiv
e di
sord
ers
A c
omm
unity
men
tal h
ealth
ce
ntre
in th
e U
S (s
econ
d-ar
y ca
re se
tting
)
Supp
orte
d so
cial
isa-
tion
and
wid
er c
om-
mun
ity a
ppro
ache
s
Con
sum
er m
anag
emen
t tea
m
vs. n
on-c
onsu
mer
man
age-
men
t tea
mD
urat
ion:
unc
lear
2 m
ediu
m-te
rm fo
llow
-up
s: 1
mon
th a
nd 1
yea
r (p
ost-b
asel
ine)
Obj
ectiv
e so
cial
isol
atio
n ou
t-co
mes
: fam
ily a
nd so
cial
con
-ta
cts;
Pat
tison
’s S
ocia
l Net
wor
k Sc
ale
[81]
Oth
er o
utco
mes
: use
of s
ervi
ces;
qu
ality
of l
ife; p
sych
iatri
c sy
mpt
oms
No
sign
ifica
nt b
etw
een-
grou
p di
ffer-
ence
in so
cial
net
wor
ks (p
> 0.
05)b
On
aver
age,
par
ticip
ants
iden
tified
2.7
2 pe
rson
s in
thei
r soc
ial n
etw
ork,
1.5
5 po
sitiv
e ne
twor
k m
embe
rs a
nd 1
.60
fam
ily m
embe
rs
Abe
rg-W
isted
t [71
]—40
ad
ults
with
schi
zoph
reni
a or
long
-term
psy
chot
ic
diso
rder
The
Kun
gsho
lmen
sect
or in
St
ockh
olm
, Sw
eden
(sec
-on
dary
car
e se
tting
)
Psyc
hoed
ucat
ion/
soci
al sk
ills t
rain
ing
The
inte
nsiv
e ca
se m
anag
e-m
ent p
rogr
amm
e vs
. sta
nd-
ard
serv
ices
Dur
atio
n: 2
yea
rs
One
long
-term
follo
w-u
p:
2 ye
ars (
post-
base
line)
Obj
ectiv
e so
cial
isol
atio
n ou
tcom
e:
the
num
ber o
f peo
ple
in p
artic
i-pa
nts’
soci
al li
fe w
as m
easu
red
by a
stan
dard
ised
pro
cedu
re
deve
lope
d fro
m w
ork
with
chi
ld
psyc
hiat
ric p
atie
nts [
82]
Oth
er o
utco
mes
: qua
lity
of li
fe;
serv
ice
use
Soci
al n
etw
ork
of th
e ex
perim
enta
l gr
oup
incr
ease
d, w
hile
it d
ecre
ased
fo
r the
con
trol g
roup
, but
no
sig-
nific
ant b
etw
een-
grou
p di
ffere
nce
(p >
0.00
4)c
849Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
Tabl
e 2
(con
tinue
d)
Mai
n au
thor
, sam
ple
and
setti
ngIn
terv
entio
n ca
tego
-ris
atio
nIn
terv
entio
n na
me
and
dura
-tio
nFo
llow
-up
Obj
ectiv
e so
cial
isol
atio
n an
d ot
her o
utco
me
mea
sure
sO
bjec
tive
soci
al is
olat
ion
outc
ome
Stra
vyns
ki [7
2]—
22 a
dults
ag
ed 2
2–57
with
diff
use
soci
al p
hobi
a an
d av
oida
nt
pers
onal
ity d
isor
der
The
Mau
dsle
y ho
spita
l in
Lond
on, U
K (s
econ
dary
ca
re se
tting
)
Soci
al sk
ills t
rain
ing
and
chan
ging
cog
ni-
tions
Soci
al sk
ills t
rain
ing
vs.
Soci
al sk
ill tr
aini
ng +
cogn
i-tiv
e m
odifi
catio
nD
urat
ion:
14
wee
ks
End-
of-tr
eatm
ent f
ollo
w-
up (1
4 w
eeks
)1
med
ium
-term
follo
w-
up: 6
mon
ths
Obj
ectiv
e so
cial
isol
atio
n ou
t-co
me:
obj
ectiv
e so
cial
isol
atio
n su
bsca
le o
f the
Stru
ctur
ed a
nd
Scal
ed In
terv
iew
to A
sses
s Mal
-ad
justm
ent (
SSIA
M) [
83]
Oth
er o
utco
me:
dep
ress
ive
sym
p-to
ms
No
sign
ifica
nt b
etw
een-
grou
p di
ffer-
ence
in so
cial
isol
atio
n, a
ll gr
oups
re
porte
d le
ss e
xper
ienc
e of
soci
al
isol
atio
n ov
er ti
me p >
0.05
d
Ter
zian
[73]
—35
7 ad
ults
ag
ed <
45 d
iagn
osed
as
on th
e sc
hizo
phre
nia
spec
-tru
m b
y th
e IC
D-1
0th
47 c
omm
unity
men
tal h
ealth
se
rvic
es (S
PT) i
n Ita
ly
(sec
onda
ry c
are
setti
ng)
Supp
orte
d so
cial
isa-
tion
and
wid
er c
om-
mun
ity a
ppro
ache
s
Soci
al n
etw
ork
inte
rven
-tio
n + us
ual t
reat
men
ts v
s. us
ual t
reat
men
tsD
urat
ion:
3–6
mon
ths
1 m
ediu
m-te
rm fo
llow
-up:
1
year
(pos
t-bas
elin
e)1
long
-term
follo
w-u
p:
2 ye
ars (
post-
base
line)
Obj
ectiv
e so
cial
isol
atio
n ou
tcom
e:
soci
al n
etw
orks
mea
sure
d by
di
ffere
nt p
aram
eter
s of r
elat
ion-
ship
s wer
e as
sess
ed, a
ll w
ere
sum
mar
ised
into
a sc
ore
Oth
er o
utco
mes
: psy
chia
tric
sym
p-to
ms;
hos
pita
lisat
ion
over
the
follo
w-u
p ye
ar
In th
is p
aper
, a so
cial
net
wor
k im
prov
emen
t was
defi
ned
as
an in
crea
se in
the
num
ber,
freq
uenc
y,
impo
rtanc
e or
clo
sene
ss o
f rel
atio
n-sh
ips,
and
an o
vera
ll so
cial
net
wor
k im
prov
emen
t was
defi
nied
as a
n im
prov
emen
t in
intim
ate
or w
orki
ng
rela
tions
hips
. Sig
nific
ant b
etw
een-
grou
p di
ffere
nces
in th
e im
prov
emen
t of
soci
al n
etw
ork
and
over
all s
ocia
l ne
twor
k im
prov
emen
t wer
e fo
und
An
impr
ovem
ent i
n so
cial
net
wor
k w
as
foun
d at
yea
r 1 in
25%
of p
atie
nts i
n co
ntro
l gro
up a
nd 3
9.9%
of p
atie
nts
in th
e ex
perim
enta
l gro
up (O
R 2
.0,
95%
CI 1
.3–3
.1; A
OR
2.4
, 95%
CI
1.4–
3.9)
At y
ear 1
, an
over
all s
ocia
l net
wor
k im
prov
emen
t was
repo
rted
for 3
0.8%
of
the
rout
ine
grou
p an
d 44
.5%
of t
he
expe
rimen
tal g
roup
(OR
1.8
, 95%
CI
1.2–
2.8;
AO
R 2
.1, 9
5% 1
.3–3
.4)
Thes
e di
ffere
nces
rem
aine
d si
gnifi
cant
at
yea
r 2 fo
r soc
ial n
etw
ork
impr
ove-
men
t (31
.5%
in th
e co
ntro
l gro
up a
nd
45.5
% in
the
expe
rimen
tal g
roup
, OR
1.
8, 9
5% C
I 1.1
–2.8
; AO
R 2
.1, 9
5%
CI 1
.3–3
.5) a
nd fo
r ove
rall
soci
al n
et-
wor
k im
prov
emen
t (33
.3%
for r
outin
e gr
oup,
47.
9% fo
r the
exp
erim
enta
l gr
oup,
OR
1.8
, 95%
CI 1
.2–2
.9; A
OR
2.
2, 9
5% C
I 1.3
–3.5
)
850 Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
Tabl
e 2
(con
tinue
d)
Mai
n au
thor
, sam
ple
and
setti
ngIn
terv
entio
n ca
tego
-ris
atio
nIn
terv
entio
n na
me
and
dura
-tio
nFo
llow
-up
Obj
ectiv
e so
cial
isol
atio
n an
d ot
her o
utco
me
mea
sure
sO
bjec
tive
soci
al is
olat
ion
outc
ome
Sol
omon
[74]
—96
adu
lts
with
schi
zoph
reni
a or
m
ajor
affe
ctiv
e di
sord
ers
A c
omm
unity
men
tal h
ealth
ce
ntre
in th
e U
S (s
econ
d-ar
y ca
re se
tting
)
Supp
orte
d so
cial
isa-
tion
and
wid
er c
om-
mun
ity a
ppro
ache
s
Con
sum
er c
ase
man
agem
ent
team
vs.
nonc
onsu
mer
m
anag
emen
t tea
mD
urat
ion:
2 y
ears
2 m
ediu
m-te
rm fo
llow
-up
s: 1
mon
th a
nd 1
yea
r (p
ost-b
asel
ine)
1 lo
ng-te
rm fo
llow
-up:
2
year
s (po
st-ba
selin
e)
Obj
ectiv
e so
cial
isol
atio
n ou
tcom
e:
Patti
son’
s Soc
ial N
etw
ork
[81]
Oth
er o
utco
mes
: qua
lity
of li
fe;
psyc
hiat
ric sy
mpt
oms
No
sign
ifica
nt b
etw
een-
grou
p di
f-fe
renc
e in
soci
al o
utco
me;
als
o no
si
gnifi
cant
tim
e an
d co
nditi
on e
ffect
(F (1
2,78
) = 1.
19, p
> 0.
05e )
Mar
zilli
er [7
5]—
21 a
dults
ag
ed 1
7–43
with
a d
iagn
o-si
s of p
erso
nalit
y di
sord
er
or n
euro
sis
The
Mau
dsle
y H
ospi
tal i
n Lo
ndon
, UK
(sec
onda
ry
care
setti
ng)
Soci
al sk
ills t
rain
ing
and
chan
ging
cog
ni-
tions
Syste
mat
ic D
esen
sitis
atio
n (S
D) v
s. So
cial
Ski
lls T
rain
-in
g (S
ST) v
s. w
aitin
g-lis
t co
ntro
lD
urat
ion:
3.5
mon
ths
End-
of-tr
eatm
ent f
ollo
w-
up (3
.5 m
onth
s)1
med
ium
-term
follo
w-
up: 6
mon
ths
Obj
ectiv
e so
cial
isol
atio
n ou
tcom
e:
Revi
sed-
Soci
al D
iary
and
Sta
nd-
ardi
sed
inte
rvie
w S
ched
ule
[75]
Oth
er o
utco
mes
: anx
iety
dis
orde
rs;
men
tal s
tate
; per
sona
lity
asse
ss-
men
t
No
betw
een-
grou
p di
ffere
nce
betw
een
SST
and
SD in
soci
al a
ctiv
ities
and
so
cial
con
tact
s (p >
0.05
)SS
T ha
d a
grea
ter i
mpr
ovem
ent i
n th
e ra
nge
of so
cial
act
iviti
es (F
(1
,18)
= 7.
56, p
< 0.
025)
and
soci
al
cont
acts
(F (1
,18)
= 9.
47, p
< 0.
0.01
) th
an th
e w
aitin
g-lis
t gro
upSD
had
a g
reat
er in
crea
se in
soci
al
cont
acts
than
the
wai
ting-
list g
roup
(F (1
,18)
= 12
.46,
p <
0.00
1) C
ole
[76]
—32
adu
lts w
ith
maj
or d
epre
ssio
n, d
ys-
thym
ic d
isor
der o
r oth
er
affec
tive
diso
rder
St. M
ary’
s Hos
pita
l in
Mon
treal
, Can
ada
(prim
ary
care
setti
ng)
Non
spec
ific
type
(int
erve
ntio
n gr
oup
rece
ived
a
psyc
haitr
ic a
sses
s-m
ent a
t hom
e,
com
pare
d to
a
stan
dard
trea
tmen
t gr
oup
who
rece
ived
an
ass
essm
ent a
t cl
inic
)
Hom
e as
sess
men
t gro
up v
s. cl
inic
ass
essm
ent g
roup
(tr
eatm
ent-a
s-us
ual)
Dur
atio
n: u
ncle
ar
3 m
ediu
m-te
rm fo
llow
-up
s: 4
, 8 a
nd 1
2 w
eeks
(p
ost-b
asel
ine)
Obj
ectiv
e so
cial
isol
atio
n ou
tcom
e:
Soci
al R
esou
rces
(SR
) sub
scal
e fro
m T
he O
lder
Am
eric
ans
Rese
arch
and
Ser
vice
Cen
tre
Instr
umen
t (O
AR
S) [8
4]O
ther
out
com
es: m
enta
l sta
te;
psyc
hiat
ric sy
mpt
oms
No
sign
ifica
nt b
etw
een-
grou
p di
ffer-
ence
s in
soci
al re
sour
ces (p >
0.05
)f
Mix
ed fo
rmat
(gro
up- a
nd in
divi
dual
-bas
ed)
Riv
era
[77]
—20
3 ad
ults
w
ith a
psy
chot
ic o
r moo
d di
sord
er o
n ax
is I
An
inpa
tient
uni
t in
a ci
ty
hosp
ital i
n N
ew Y
ork,
US
(sec
onda
ry c
are
setti
ng)
Supp
orte
d so
cial
isa-
tion
Peer
-ass
isted
car
e vs
. N
onco
nsum
er a
ssist
ed v
s. st
anda
rd c
are
vs. c
linic
-ba
sed
care
Dur
atio
n: u
ncle
ar
2 m
ediu
m-te
rm fo
llow
-up
s: 6
and
12
mon
ths
(pos
t-bas
elin
e)
Obj
ectiv
e so
cial
isol
atio
n ou
tcom
e:
a m
odifi
catio
n of
the
Patti
son
Net
wor
k In
vent
ory
[85]
Oth
er o
utco
mes
: qua
lity
of li
fe;
psyc
hiat
ric sy
mpt
oms
Onl
y pe
er-a
ssist
ed g
roup
show
ed a
n in
crea
se in
soci
al c
onta
cts f
rom
ba
selin
e to
12-
mon
th fo
llow
-up
(F (2
, 118
) = 7.
25, p
< 0.
01, e
ffect
si
ze =
0.11
)N
o si
gnifi
cant
bet
wee
n-gr
oup
dif-
fere
nce
in o
ther
net
wor
k m
easu
res
(p >
0.05
)
a Due
to th
e fa
ct th
at th
e O
slo-
3 sc
ale
focu
ses p
rimar
ily o
n th
e pr
actic
al a
spec
ts o
f soc
ial s
uppo
rt, B
øen’
s stu
dy w
as c
onsi
dere
d as
a st
udy
only
of o
bjec
tive
soci
al is
olat
ion
b Effec
t siz
e, c
onfid
ence
inte
rval
s, an
d ac
tual
p v
alue
not
avai
labl
e in
the
pape
rc Eff
ect s
ize,
con
fiden
ce in
terv
als,
and
actu
al p
val
ue n
ot av
aila
ble
in th
e pa
per;
the
sign
ifica
nt le
vel u
sed
in th
is st
udy
was
p <
0.00
4d Eff
ect s
ize
not a
vaila
ble
in th
e pa
per
e Effec
t siz
e, c
onfid
ence
inte
rval
, and
act
ual p
val
ue n
ot av
aila
ble
in th
e pa
per
f Effec
t siz
e, c
onfid
ence
inte
rval
, and
act
ual p
val
ue n
ot av
aila
ble
in th
e pa
per
851Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
a sample with personality or mood disorders, although there was no between-group difference between the two active treatment groups [75]. Rivera and colleagues [77] reported an increased contact with staff for participants receiving a consumer-provided programme, compared to non-consumer support. However, Solomon and colleagues [70, 74] also compared consumer versus non-consumer provided men-tal health care in their two studies and found no significant differences between the groups, or compared to a control group, in social network size or clinical outcomes. Stravy-nski and colleagues examined whether adding a cognitive modification component to social skills training for people with social phobia and/or avoidant personality disorders improved its effectiveness [72], but found no significant difference between groups. Therefore, the overall evidence regarding the effectiveness of consumer-provided intensive case management for objective social isolation is unclear.
Other relevant outcomes were included in 10 out of 11 trials [67, 69–77]. Of these ten trials, positive findings were reported in four trials: improved mental state was reported by Rivera and his team, who evaluated a supported sociali-sation intervention for adults with schizophrenia, other psy-chotic disorders or mood disorders [77]; reduced depression and social avoidance were reported by Stravynski and col-leagues, who evaluated a mixture of strategies for people with social phobia and/or avoidant personality disorder [72]. Atkinson and colleagues also reported a greater quality of life when psychoeducation/social skills training was offered to people with schizophrenia [67], and fewer emergency vis-its were also reported for a cohort of people with schizo-phrenia and psychotic symptoms receiving psychoeducation/social skills training [71]. However, Solomon and her team found no differences in psychiatric symptoms or service use for participants who received consumer-led case manage-ment [70, 74], and no clinical differences were reported by Terzian and colleagues in a social network intervention for people with schizophrenia [73].
Interventions targeting both subjective and objective social isolation
Four trials included both subjective and objective social iso-lation as outcomes (Table 3).
One trial [86] only included end-of-treatment outcomes. The follow-up period was between 2 weeks and 6 months in the other three trials [87–89]. Measures with established reliability and validity were used in three trials, but the measure in one trial [86] was developed by the team and not clearly described. One trial included people with common mental health problems, two included people with severe mental illness, and one included people with a variety of different mental health diagnoses. Two trials had fewer than
100 participants and only one had more than 200. A sample size calculation was included in one trial.
One trial involved an individual intervention, two trials involved group interventions, and one trial combined indi-vidual, group and phone elements. The length of interven-tions ranged from 3 to 8 months. One trial was of a supported socialisation intervention, two of cognitive modification, and another used a mixture of strategies (Appendices 4 and 5).
Two trials were judged as at low risk of bias for sequence generation, two trials were at low risk for allocation conceal-ment, and only one trial included a strategy for missing data. All trials were at high risk of bias for their blinding process and other sources of bias, but all were at low risk for selec-tive outcome reporting (Appendix 6).
In all four trials, an intervention group was compared to either a waiting-list or a treatment-as-usual control group. Significant between-group differences in subjective social isolation were demonstrated in three out of four trials: a peer support group for adults with psychosis [86], a group-based intervention involving showing humorous movies for adults with schizophrenia [87], and in-home cognitive behavioural therapy for women with major depressive disorders [88]. Of the three trials in which a significant effect on subjective isolation was reported, significant effects on objective social isolation were also reported in two trials [86, 87]. Schene and colleagues [89] did not find any significant between-group differences for either outcome in a diagnostically mixed sample receiving psychiatric day treatment, compared to standard inpatient care.
In terms of other relevant outcomes, reduction in symp-toms were reported by authors in three out of four trials: by Schene and colleagues who examined a mixture of strategies for people with a range of diagnoses [89], by Ammerman and his team who evaluated an intervention with a cognitive modification component for women with depression [88], and by Castelein and colleagues, who evaluated a supported socialisation intervention for people with schizophrenia [86]. Castelein and colleagues also reported additional benefits for quality of life.
Overall results
Table 4 summarises the results for each type of intervention for subjective and objective social isolation, including the ones targeting both subjective and objective social isolation.
Of all the trials that included a subjective social isolation measure (i.e. combining 15 trials including only a subjec-tive social isolation measure and the four trials targeting both subjective and objective social isolation—19 trials in total), positive results were reported in two out of the six trials that examined interventions with a cognition modifi-cation component, one out of the three trials of supported socialisation, and one out of the four trials of social skills
852 Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
training/psychoeducation programmes. Authors who evalu-ated mixed intervention strategies found no significant posi-tive results. None of the trials evaluated wider community approaches alone.
Regarding all the trials which included an objective social isolation measure (i.e. 15 trials), findings from one out of the two trials that involved changing cognitions, one out of the two trials that examined social skills training and psychoeducation, three out of the eight trials with a mixed intervention strategy, as well as all trials (i.e. two trials) that provided supported socialisation, suggested improvements in objective social isolation. No included trials for objec-tive social isolation involved wider community approaches alone. Small samples and lack of sample size calculations need to be borne in mind throughout.
In many of the included trials, subjective and/or objective social isolation was one of several outcomes (with no clearly specified primary outcome), and for some trials, strategies to reduce social isolation were part of an often much broader service improvement approach (e.g. [70, 74, 76, 89]). Just six trials [43, 72, 73, 75, 86, 87] had a measure of social isolation as the clearly stated primary outcome. Four out of these six trials included either a waiting-list or a treatment-as-usual control group [73, 75, 86, 87], and findings from all of these indicated a superior effect of their intervention compared to the control condition on the trials’ objective social isolation outcomes. In these trials, one intervention involved mixed strategies for adults with schizophrenia [73]; one involved supported socialisation for adults with schizo-phrenia/psychosis [86]; one compared two treatment groups (i.e. systematic desensitisation and social skills training) to a waiting-list control in a sample of people with personality disorders or neurosis [75]; and another trial investigated an intervention with a cognitive modification component for adults with schizophrenia [87]. Similar to Marzillier’s trial [75], Stravynski and colleagues [72] also offered cognitive modification and social skills training to a comparable sam-ple. Stravynksi’s trial involved a very small sample and the authors failed to find any additional improvement when a cognitive modification element was added to their social skills training. In one trial of four active conditions with-out a control group, for people with varied Axis I mental health diagnoses (e.g. depression, bipolar disorders) [43], the authors reported a positive effect of its psychoeduca-tion component over other intervention groups (e.g. music alone), though only on one outcome: perceived social sup-port from friends. In most trials in which subjective or objec-tive social isolation was specifically targeted as the primary outcome, and interventions were tailored accordingly, posi-tive results were reported: this specific focus may be impor-tant for intervention effectiveness.
Discussion
With growing interest in tackling subjective and objective social isolation due to the negative health impact of both issues, we conducted the current systematic review to sum-marise evidence from RCTs for interventions with subjec-tive and/or objective social isolation as main outcome(s) in people with mental health problems. Given the quality and sample size of many included studies, conclusions need to be cautious. The strategies found were extremely diverse. A tendency not to clearly specify primary outcomes in earlier trials meant that some of the trials meeting our criteria were broad socially oriented programmes in which social isola-tion measures were among a number of outcomes. The great diversity of interventions and low quality of reporting in some trials made meta-analysis inappropriate.
A small number of mainly small trials (in a mixture of populations) provided some evidence that perceived social support may be increased by interventions that involve cog-nitive modification (e.g. [88]), although there were also some trials, generally with short follow-ups in which an effect was not found (e.g. [46, 47]). Small sample sizes and lack of sample size calculations make it difficult to draw firm conclusions from the negative studies. In terms of psychoe-ducation/social skills training programmes (e.g. [42, 43]), no clear supporting evidence was found for subjective social isolation, although an evaluation of one educational inter-vention found positive results on one subscale [43]. Again, the lack of large well-powered trials with clearly focused interventions makes definitive conclusions hard to draw.
There is also evidence supporting some of the interven-tions targeting objective social isolation (e.g. [67–69]). How-ever, studies included a wide range of types of intervention, none of which can be identified as clearly more effective than others. Group-based interventions and interventions involving supported socialisation appeared to have more evidence supporting their effectiveness in reducing objec-tive social isolation than they do for subjective social isola-tion. All objective social isolation interventions delivered in a group format demonstrated effectiveness, compared to only two out of eight individual-based interventions, though again, lack of power and of clear theory-driven methods for alleviating isolation diminish our confidence in making firm negative conclusions. For people with mental health problems (especially people with psychosis), initiating and maintaining good social relationships can be disrupted by several difficulties, including self-stigma, psychiatric symp-toms, and societal discrimination [94]. Therefore, group-based interventions may offer a pathway to initiating social contacts and practising social skills in a relatively safe envi-ronment. It is of note that a good quality multicentre trial of peer support groups from the Netherlands, in which the
853Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
Tabl
e 3
Tria
ls th
at in
clud
ed b
oth
subj
ectiv
e an
d ob
ject
ive
soci
al is
olat
ion
as o
utco
mes
Mai
n au
thor
s, sa
m-
ple
and
setti
ngIn
terv
entio
n ca
tego
risa-
tion
Inte
rven
tion
nam
eFo
llow
-up
Subj
ectiv
e/ob
ject
ive
soci
al is
olat
ion
and
othe
r ou
tcom
e m
easu
res
Subj
ectiv
e so
cial
isol
a-tio
n ou
tcom
esO
bjec
tive
soci
al is
olat
ion
outc
omes
Gro
up-b
ased
inte
rven
tion
Cas
tele
in [8
6]—
106
adul
ts a
ged ≥
18
with
schi
zoph
reni
a or
rela
ted
psyc
hotic
di
sord
ers
4 m
enta
l hea
lth c
entre
s in
the
Net
herla
nds
(sec
onda
ry c
are
set-
ting)
Supp
orte
d so
cial
isat
ion
Car
e as
usu
al +
Gui
ded
Peer
Sup
port
Gro
up
(GPS
G) v
s. a
wai
ting-
lis
t (W
L) c
ondi
tion
Dur
atio
n: 8
mon
ths
End-
of-tr
eatm
ent f
ollo
w-
up (8
mon
ths)
Subj
ectiv
e so
cial
isol
a-tio
n ou
tcom
e: th
e So
cial
Sup
port
List
(SSL
) [90
]O
bjec
tive
soci
al is
olat
ion
outc
ome:
Per
sona
l N
etw
ork
Que
stion
naire
(P
NQ
) [86
]O
ther
out
com
es: q
ualit
y of
life
; scr
eeni
ng fo
r ps
ycho
sis
Expe
rimen
tal g
roup
had
a
sign
ifica
ntly
gre
ater
in
crea
se in
este
em
supp
ort (p =
0.02
), co
mpa
red
to W
La
Expe
rimen
tal g
roup
had
a
sign
ifica
ntly
gre
ater
im
prov
emen
t in
soci
al
cont
acts
with
pee
rs a
fter
the
sess
ions
(p =
0.03
), co
mpa
red
to W
L
Gel
kopf
[87]
—34
ad
ults
with
chr
onic
sc
hizo
phre
nics
by
DSM
-III
-R7
chro
nic
schi
zoph
reni
a w
ards
in Is
rael
(sec
-on
dary
car
e se
tting
)
Cha
ngin
g co
gniti
ons
Vid
eo p
roje
ctio
n of
hu
mor
ous m
ovie
s vs
. tre
atm
ent-a
s-us
ual
cont
rol g
roup
Dur
atio
n: 3
mon
ths
1 m
ediu
m-te
rm fo
llow
-up
: 2 w
eeks
Subj
ectiv
e so
cial
isol
a-tio
n ou
tcom
e: th
e So
cial
Sup
port
Que
s-tio
nnai
re 6
(SSQ
6) [9
1]O
bjec
tive
soci
al is
olat
ion
outc
omes
: 2 m
easu
res
of so
cial
net
wor
k su
m u
p th
e si
ze a
nd
disp
ersi
on; 4
mea
sure
s as
sess
the
sour
ce o
f the
su
ppor
t
A si
gnifi
cant
ly g
reat
er
impr
ovem
ent i
n th
e ex
perim
enta
l gro
up
than
the
cont
rol g
roup
, in
per
ceiv
ed a
mou
nt
of su
ppor
t fro
m st
aff
(F =
7.90
, p <
0.01
), em
otio
nal s
uppo
rt (F
= 4.
80, p
< 0.
05),
and
instr
umen
tal s
uppo
rt,
(F =
4.94
, p <
0.05
)N
o si
gnifi
cant
resu
lts in
sa
tisfa
ctio
n to
war
ds
the
supp
ort (F
= 1.
90,
p > 0.
05b )
A si
gnifi
cant
ly g
reat
er
impr
ovem
ent i
n th
e ex
perim
enta
l gro
up th
an
the
cont
rol g
roup
in th
e nu
mbe
r of s
uppo
rters
(F
= 4.
87, p
< 0.
05)
Indi
vidu
al-b
ased
inte
rven
tion
Am
mer
man
[88]
—93
fe
mal
es a
ged
from
16
–37
with
MD
DA
com
mun
ity-b
ased
ho
me
visi
ting
pro-
gram
me
in S
outh
-w
este
rn O
hio
and
Nor
ther
n K
entu
cky
in th
e U
S (g
ener
al
popu
latio
n se
tting
)
Cha
ngiin
g co
gniti
ons
In-H
ome
Cog
nitiv
e B
ehav
iour
al T
hera
py
(IH
-CB
T) +
hom
e vi
sit-
ing
vs. h
ome
visi
t alo
neD
urat
ion:
abo
ut 5
mon
ths
End-
of-tr
eatm
ent f
ollo
w-
up (5
mon
ths)
1 m
ediu
m-te
rm fo
llow
-up
: 3 m
onth
s
Subj
ectiv
e so
cial
is
olat
ion
outc
ome:
In
terp
erso
nal S
uppo
rt Ev
alua
tion
List
(ISE
L)
[62]
Obj
ectiv
e so
cial
isol
atio
n ou
tcom
e: S
ocia
l Net
-w
ork
Inde
x (S
NI)
[92]
Oth
er o
utco
me:
psy
chia
t-ric
sym
ptom
s
IH-C
BT
grou
p re
porte
d a
grea
ter i
ncre
ase
in so
cial
supp
ort
(p <
0.00
1) th
an S
HV.
Sm
all e
ffect
size
for
soci
al su
ppor
t (0.
38)
at p
ost-t
reat
men
t, an
d m
oder
ate
effec
t siz
e (0
.65)
at f
ollo
w-u
p
No
sign
ifica
nt b
etw
een-
grou
p di
ffere
nce
in
netw
ork
size
(F =
1.88
, p >
0.05
), ne
twor
k di
ver-
sity
(F =
0.63
, p >
0.05
), an
d em
bedd
ed n
etw
orks
(F
= 2.
23, p
> 0.
05)c
854 Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
supported socialisation intervention led to increased social contact, did not improve subjective social isolation [8]. The supported socialisation interventions in our review did not have clear effects on subjective social isolation either. It thus seems possible that supported socialisation is more effec-tive in reducing objective than subjective social isolation. There are two possible explanations: first, a lack of social relationships may not be the only factor contributing to sub-jective social isolation: social cognitions may also play a significant role [95]; second, organised groups may simply not be an effective way to help lonely people initiate mean-ingful friendships, start intimate relationships, or maintain or improve current relationships. However, most included studies were small and not informed by power calculations, so few definite conclusions can be drawn.
Some (e.g. [68, 69]), but not all (e.g. [70, 72]), interven-tions with multiple components appeared to have substantial impacts on improving objective social isolation. Solomon and her colleagues [70, 74] failed to find any significant between-group difference in their two trials, which dem-onstrated comparable effectiveness of consumer-provided and non-consumer provided support in terms of clinical and psychosocial outcomes. However, it must be noted that multi-component interventions often had multiple outcomes and multiple aims extending beyond alleviating social isola-tion: they met our inclusion criteria because social isolation was among a number of outcomes, with no specified pri-mary outcome. Psychoeducation programmes/social skills training were evaluated in only two trials [67, 71]: only Atkinson found a significant change on their social isola-tion outcome, so the effectiveness of this type of intervention remains unclear. It is possible that, as suggested by Mann and colleagues [39], social skills training is more suitable for client groups who are preparing to attend wider community groups, or that it works best when combined with other types of interventions (e.g. [68]).
Cognitive modification has not been shown to be effec-tive for objective social isolation: of the two trials using this technique to target objective social isolation [87, 88], significant changes were only observed in one trial [87] with a short follow-up period and a small sample size. In another trial [72], cognitive modification showed no additional ben-efits when added to social skills training, but the sample was very small and firm conclusions could not be drawn.
We did not find any relevant trial on interventions focus-ing on the wider community approaches alone, such as the social prescribing and community asset-development approaches described by Mann and her team [39]. It is possi-ble that interventions where the focus is at community-level are difficult to evaluate via individually randomised trials, but such trials are potentially feasible for individual-level approaches such as social prescribing.
Tabl
e 3
(con
tinue
d)
Mai
n au
thor
s, sa
m-
ple
and
setti
ngIn
terv
entio
n ca
tego
risa-
tion
Inte
rven
tion
nam
eFo
llow
-up
Subj
ectiv
e/ob
ject
ive
soci
al is
olat
ion
and
othe
r ou
tcom
e m
easu
res
Subj
ectiv
e so
cial
isol
a-tio
n ou
tcom
esO
bjec
tive
soci
al is
olat
ion
outc
omes
Mix
ed fo
rmat
(gro
up- a
nd in
divi
dual
-bas
ed)
Sch
ene
[89]
—22
2 ad
ults
age
d >
60
with
var
ious
men
tal
diso
rder
sU
nive
rsity
Psy
chi-
atric
Clin
ic o
f the
A
cade
mic
Hos
pita
l in
Utre
cht,
the
Net
her-
land
s (se
cond
ary
care
se
tting
)
Psyc
hoed
ucat
ion/
soci
al
skill
s tra
inin
g, a
nd su
p-po
rted
soci
alis
atio
n
Psyc
hiat
ric d
ay tr
eatm
ent
vs. i
npat
ient
trea
tmen
t (tr
eatm
ent-a
s-us
ual)
Dur
atio
n: o
n av
erag
e 37
.6
wee
ks fo
r day
trea
t-m
ent,
and
24.9
wee
ks
for i
npat
ient
trea
tmen
t
End-
of-tr
eatm
ent
follo
w-u
p (o
n av
erag
e 37
.6 w
eeks
for d
ay
treat
men
t, 24
.9 w
eeks
fo
r inp
atie
nt tr
eatm
ent)
1 m
ediu
m-te
rm fo
llow
-up
: 6 m
onth
s
Subj
ectiv
e an
d ob
ject
ive
soci
al is
olat
ion
out-
com
es: S
ocia
l Net
wor
k an
d So
cial
Sup
port
Que
stion
naire
(SN
SS)
[93]
Oth
er o
utco
mes
: men
tal
stat
e; p
sych
iatri
c sy
mp-
tom
s; so
cial
dys
func
-tio
n
No
sign
ifica
nt b
etw
een-
grou
p di
ffere
nce
in so
cial
supp
ort
(F =
0.20
, p >
0.05
), an
d no
cha
nge
over
tim
e (F
= 1.
25, p
> 0.
05)d
No
sign
ifica
nt b
etw
een-
grou
p di
ffere
nce
in
netw
ork
scop
e (F
= 0.
05,
p > 0.
05) a
nd n
etw
ork
cont
acts
(F =
0.02
, p >
0.05
)
a Effec
t siz
e an
d co
nfide
nce
inte
rval
not
avai
labl
e in
the
pape
rb Eff
ect s
ize,
con
fiden
ce in
terv
al a
nd a
ctua
l p v
alue
not
avai
labl
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ize,
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nd a
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rd Eff
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pape
r
855Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
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Limitations
To the best of our knowledge, this systematic review is the first to provide an overall synthesis of evidence on the effectiveness of interventions for subjective and/or objective social isolation across a range of mental health diagnoses. But it has important limitations. First, we included trials in which subjective and/or objective social isolation was either a primary outcome or one of a list of outcomes with none specified as primary. This means that we have excluded some trials which might offer relevant evidence based on secondary outcomes, and we have included trials where social isolation is one of a list of outcomes, but may not have been clearly the principal target of the intervention. Few of the included trials involved theory-driven interventions for which social isolation was the clear main target. Second, the conclusions we have drawn are limited by the heterogeneity of the intervention types and patient groups, and the low methodological quality of many included trials. Each type of intervention was only evaluated in a small number of tri-als and the content of programmes varied greatly. Factors such as lack of information on randomisation processes and allocation concealment resulted in high ratings for risk of bias in many of the studies. Many studies were essentially feasibility or pilot trials, with small sample sizes and no underpinning power calculations: thus no clear conclusions could be drawn from either positive or negative results from these studies, including several trials comparing two or more
active interventions. As expected, variations between stud-ies regarding interventions, study participants and outcomes measurement methods precluded meta-analysis. Addition-ally, four trials did not include a well-established outcome measure (e.g. [45, 73]). Last, although there were no restric-tions on the language of the included trials and no filter of language was used during the literature search, no eligible trials in other languages were retrieved. Great efforts were made to retrieve all relevant papers, but some trials in other languages may have been missed.
Research implications
Compared with objective social isolation and social support, the concept of loneliness has only recently been subjected to scientific research. This review identified few trials that included loneliness as their main outcome, and none yielded positive results. Recently published pilot trials have estab-lished that loneliness is a feasible target for intervention in severe mental illness, either through face-to-face or digital programmes [31, 96]. However, there is still a pressing need to evaluate interventions for loneliness scientifically in large-scale RCTs, given growing enthusiasm for these approaches. We have thus identified an important gap in the literature.
Some trials focusing on objective social isolation and perceived social support were retrieved, but some advances need to be made to develop a substantial body of evidence in this area. First, most trials were vague in articulating
Table 4 Summary of different types of intervention and results: objective and subjective social isolation
Type of intervention Comparison Outcomes for subjective isolation Outcomes for objective isolation
Changing cognitions Intervention versus TAU or no treatment
2/4 studies found significant posi-tive results
1/2 studies found significant positive results
two or more active treatments 0/2 studies found significant positive results for one form of intervention over others
N/A
Social skills training and/or psych-oeducation
Intervention versus TAU or no treatment
0/3 studies found significant posi-tive results
1/2 studies found significant positive results
Two or more active treatments 1/1 studies found significant positive results for one form of intervention over others
N/A
Supported socialisation Intervention versus TAU or no treatment
1/2 studies found significant posi-tive results
1/1 studies found significant positive results
Two or more active treatments 0/1 studies found significant positive results for one form of intervention over others
1/1 studies found significant positive results for one form of intervention over others
Wider community approaches Intervention versus TAU or no treatment
N/A N/A
Two or more active treatments N/A N/AMixed approaches (interventions
with mixed components)Intervention versus TAU or no
treatment0/5 studies found significant posi-
tive results3/4 studies found significant
positive results2 or more active treatments 0/1 studies found significant
positive results for one form of intervention over others
0/4 studies found significant positive results for one form of intervention over others
856 Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
a theoretical basis. The development of a clear theory of change is now regarded as an important step in the devel-opment of complex health interventions [97, 98]. Develop-ing such theoretical models could helpfully be informed by a richer understanding of experiences of subjective and objective social isolation among people with mental health problems and their views about what may alleviate these. Thus a co-produced approach to intervention development may result in interventions with a more robust theoretical basis and a closer fit to recipients’ needs. Second, greater advances are likely to be made in this area if future trials can specify interventions in greater detail, and if future sys-tematic reviews use clear systems, such as those applied in this review, to categorise interventions. We found that the descriptions of most interventions were typically vague, and most involved several components and delivery meth-ods. Thus the main components of each intervention were often unclear, and exactly which elements contributed to any positive outcomes was difficult to determine. However, this should not limit the development of future interventions with multiple components (e.g. interventions combining cognitive modification with addressing social/environmental barriers to social participation and developing social relationships). Cacioppo and colleagues [99] proposed that loneliness is a multi-dimensional concept, and there is a clear distinc-tion between intimate, relational, and collective loneliness. Thus, as a complex multi-faceted phenomenon, loneliness may well need to be addressed through multiple means.
Computer/mobile technology has become a popular for-mat for the implementation of interventions in the medi-cal field. Online interventions, including online support groups or chatrooms, may potentially be an effective way to provide social support [100]. However, only four trials targeting online interventions were retrieved in the current review and none has shown positive effects. Authors from existing systematic reviews [101, 102] conclude that there is great future potential for the development and utilisation of mobile apps in the mental health field. Meta-analyses have also demonstrated the use of online interventions as an acceptable and practical method to deliver healthcare for people with depression and anxiety [103, 104]. Another sys-tematic review examined the feasibility of web- and phone-based interventions for people with psychosis: authors sup-ported the feasibility of such interventions, and reported a range of positive outcomes in some of the studies included, including improved social connectedness and socialisation [105]. However, only few trials included in this review were RCTs and social isolation was not generally a primary out-come so that studies were not eligible for inclusion in the current review. One pilot trial has also investigated a novel online intervention called HORYZONS for young people with First Episode Psychosis (FEP), and participants became more socially connected after using HORYZONS [106].
Currently, a full trial utilising a single-blind RCT design to evaluate the effectiveness of this intervention over an 18-month follow-up period is taking place for young peo-ple with FEP [107]. In another recent feasibility trial [96], authors developed a digital smartphone application (app) named +Connect, which sought to utilise a positive psychol-ogy intervention (PPI) for young adults with early psychosis. The programme was found to be effective in reducing loneli-ness from baseline to 3-month post-intervention follow-up. Programme users also highlighted the benefits in their social lives of positive reinforcement provided by the app. Thus, although digital interventions have been insufficiently tested in substantial RCTs to date, it is feasible to implement such interventions for people with severe mental health problems in order to reduce loneliness, and there is a need for future research to develop and further examine digital interven-tions on a larger scale. Additionally, the successful imple-mentation of interventions involving positive psychology in the two pilot trials from Lim and her colleagues [31, 96] supports the idea that subjective social isolation is increas-ingly recognised as a primary treatment outcome for people with psychosis in the mental health field, and future research should also focus on the development and examination of new types of intervention that target loneliness directly for people with mental health problems.
Other forms of intervention that are so far untested but with potential to have effects on loneliness and social isola-tion include “friends interventions”, which involve patients’ friends in treatment with the aim of strengthening relation-ships [108] and other interventions aimed at reinvigorating or restoring existing relationships [109]. By focusing on existing social networks, this type of intervention has poten-tial to improve the quality of social relationships already established prior to mental health diagnosis. Beyond the individual level, there is also potential for the development and robust evaluation of the impact on people with mental health problems of interventions on a larger scale, for exam-ple, aimed at developing social connections within groups, communities or neighbourhoods, or at maximising the use of existing community assets [39]. Interventions involving wider communities have been seen as crucial in providing social opportunities for people with mental health problems to engage with their local communities and increase their sense of belonging and self-confidence [39]. Indirect inter-ventions targeting upstream factors that contribute to social isolation [110–113] are potentially effective, such as pro-grammes to improve housing and reduce poverty.
Clinical implications
There is substantial evidence demonstrating the signifi-cant impact of objective and subjective social isolation on health. However, lack of empirical evidence on the efficacy
857Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
of targeted interventions means that we cannot yet make clear recommendations for interventions. As argued in a recent Lancet editorial [114], there is a need for life science funding prioritising under-researched social, behavioural, and environmental determinants of health. Subjective and objective social isolation are among the social determinants of health that have received insufficient attention. Some of the research we report does provide a starting point for fur-ther work: in a few studies there is some evidence of effec-tiveness, while other studies with small samples have at least demonstrated that interventions are feasible and acceptable.
To conclude, based on this systematic review, current evidence does not yet clearly support scaled-up implemen-tation of any types of intervention for subjective or objec-tive social isolation in mental health services. Even though cognitive modification shows some promise for subjective social isolation, and interventions with mixed approaches and supported socialisation have also demonstrated their effectiveness for objective social isolation, quality of these trials limited our confidence in publicising their effective-ness. Therefore, innovation in intervention development and more high-quality research is needed. We also note that there is much innovative and interesting practice in this field that is not currently underpinned by research, especially in the voluntary sector: defining, establishing the theoretical premises for and evaluating existing models may thus be a promising direction.
Acknowledgements SJ and BLE are partly supported by the NIHR Mental Health Policy Research Unit the UKRI Loneliness and Social Isolation in Mental Health Cross-Disciplinary Network, the UCLH NIHR Biomedical Research Centre and the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames. FM is a Wellcome Clinical Research Training Fellow.
Author contributions SJ, BLE and RM conceived the review. SJ and BLE commented on search strategy and review protocol, JW recommended search terms. RM developed the search strategy and created review protocol, conducted the literature search, wrote and co-ordinated the drafts. RM, FM and AA independently contributed to the screening process. RM and FM extracted data. RM, FM and JT independently assessed the methodological quality of each included paper. RM screened reference lists of included studies and relevant systematic reviews and meta-analyses. SJ involved in any disagree-ment between reviewers in the screening process. SJ, BLE, FM and JW contributed comments to the drafts. All authors read and approved the final manuscript.
Compliance with ethical standards
Conflict of interest The authors state that they have no conflicts of in-terest.
Open Access This article is distributed under the terms of the Crea-tive Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribu-tion, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
Appendix 1: Measures and scales for subjective and objective social isolation
Measures Description For which populations
Subjective social isolation
The University of California at Los Angeles (UCLA) Loneliness Scale [115]
A unidimensional scale to assess the frequency and intensity of one’s lonely experiences, 20 items
General population (e.g. elderly, lonely stu-dents, immigrants)
People with mental health problems (e.g. psy-chiatric inpatients, people with depression)
UCLS-8 [6] A short-form of UCLA Loneliness Scale, 8 items
General population (e.g. university students, adolescents, elderly sample)
People with mental health problems (e.g. people with depression, mixed sample with various diagnoses)
The De Jong-Gierveld Loneli-ness Scale [116]
A 11-item scale measures the feeling of severe loneliness, contains 5 positive and 6 negative items
A short-form contains 6 items of the original De Jong-Gierveld Loneliness Scale (3 items for emotional loneliness and 3 items for social loneliness)
General population (e.g. national survey sam-ples from several countries, elderly Chinese)
People with mental health problems (e.g. mixed samples with various diagnoses)
Multidimensional Scale of Perceived Social Support (MSPSS) [57]
A 12-item scale to measure perceived overall amount of social support and support from significant other/friends/family
General population (e.g. Chinese university students, young adults, adults with physical disabilities)
People with mental health problems (e.g. people with post-traumatic stress disorder, women with severe depressive symptoms)
858 Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
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Measures Description For which populations
Objective social isolation
Social Network Index (SNI) [92]
A 12-item scale, measures the number of people one has regular contact with
General population (e.g. women with breast cancer, people with severe traumatic brain injury, African-Americans in urban area)
People with mental health problems (e.g. old adults with depressive symptoms, people with post-traumatic stress disorder)
The Pattison Psychosocial Kinship Inventory (PPKI) [117]
Measures the number of people and rela-tionships one considers as important
General population (e.g. dysfunctional fami-lies)
People with mental health problems (e.g. adults with schizophrenia, people with psychosis)
Measures focus on both domains
Lubben Social Network Scale (LSNS-6)
A revised version, contains 6 items, evaluates the quantity and quality of one’s relationship with family and friends
General population (e.g. community-dwelling elderly, Korean American caregivers)
People with mental health problems (e.g. mixed samples with different diagnoses, depressed immigrants)
Social Network Schedule (SNS) [78]
A 6-item scale, measures both quan-titative (i.e. the size of one’s social network, the frequency of social communication and the time one spent on socialisation) and qualitative (i.e. quality and intimacy of one’s social relationships, the intensity of social interactions) aspects of one’s social connections
People with mental health problems (e.g. people with non-organic psychosis, people with intellectual disability)
Medical Outcomes Study (MOS) Social Support Scale [64]
A 19-item survey measures dimensions of social support: emotional/infor-mational, tangible, affectionate and positive social interactions
General population (people with heart failure in Hong Kong, mothers with children in treatment)
People with mental health problems (e.g. adults with schizophrenia spectrum or affec-tive disorder)
Interview Schedule for Social interaction (ISSI) [61]
50 items, measures the availability and perceived adequacy of attachment and social integration
General population (e.g. patients with rheuma-toid arthritis, people from Canberra suburbs)
People with mental health problems (e.g. outpatients with schizophrenia, inpatient male offenders)
Appendix 2: Existing systematic reviews and meta‑analyses
Authors (pub-lished years)
Published years of included studies
Review method
Included partici-pants
How interventions were categorised
Number of studies
Types of study included
Subjective social isolation interventions Findlay [30] 1982–2002 Systematic
reviewOlder people (1) Increase social support
(2) Psychoeducation/social skills training
17 RCTs, non-randomised comparison studies
Cattan et al. [32] 1970–2002 Systematic review
Older people (1) Social skills training(2) Provide social support(3) Psychoeducation/social
skills training
30 RCTs, non-randomised comparison studies
Dickens et al. [33]
1976–2009 Systematic review
Older people (1) Increase social opportuni-ties
(2) Provide social support(3) Psychoeducation/social
skills training(4) Address maladaptive social
cognitions
32 RCTs, non-randomised comparison studies
859Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
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Authors (pub-lished years)
Published years of included studies
Review method
Included partici-pants
How interventions were categorised
Number of studies
Types of study included
Masi et al. [34] 1970–2009 Meta-analysis
Adults, ado-lescents and children
(1) Increase social opportuni-ties
(2) Provide social support(3) Address maladaptive social
cognitions(4) Provide social skill train-
ings
50 RCTs, non-randomised comparison studies
Perese and Wolf [35]
Unclear Narrative synthesis
People with mental health problems
Social network interventions: include support groups, psychosocial clubs, self-help groups, mutual help groups and volunteer groups
36 Unclear
Objective social isolation interventions Newlin et al. [36] Up to September
2014Systematic
Review and modified narrative synthesis
People with mental health problems
All types of psychosocial interventions
16 RCTs, non-randomised comparison stud-ies and qualitative studies
Anderson et al. [37]
2008–2014 Systematic review
People with psy-chosis
All types of social network interventions
5 RCTs
Webber and Fendt-Newlin [38]
2002–2016 Narrative synthesis
People with mental health problems
Social participation interven-tions: include social skills training, supported com-munity engagement, group-based community activities, employment interventions and peer support interven-tions
19 RCTs, non-randomised comparison stud-ies, and qualitative studies
Appendix 3: Search terms in Medline and PsycINFO
Same terms were used for the search in Web of Science with minor changes.
# Search term
1 loneliness.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol sup-plementary concept word, rare disease supplementary concept word, unique identifier]
2 Loneliness.mp. or Loneliness/3 lonely.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supple-
mentary concept word, rare disease supplementary concept word, unique identifier]4 (social support adj5 (subjective or personal or perceived or quality)).mp. [mp = title, abstract, original title, name of substance word,
subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
5 Confiding relationship*.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
6 Social isolation.mp. or Social Isolation/7 Social network*.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol
supplementary concept word, rare disease supplementary concept word, unique identifier]8 socially isolated.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol
supplementary concept word, rare disease supplementary concept word, unique identifier]9 1 or 2 or 3 or 4 or 5 or 6 or 7 or 810 Mental Disorders/11 Alcoholism/or Middle Aged/or Child Behaviour Disorders/or Child/or Adolescent/or Stress Disorders, Post-Traumatic/or Adult/or
Depression/or Mental Disorders/or mental health problems.mp. or Substance-Related Disorders/
860 Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
# Search term
12 Bipolar Disorder/or Psychotic Disorders/or Aged/or Stress, Psychological/or Middle Aged/or Community Mental Health Services/or Adult/or Mental Disorders/or mental illnesses.mp. or Schizophrenia/
13 mental.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supple-mentary concept word, rare disease supplementary concept word, unique identifier]
14 Psychiatr*.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol sup-plementary concept word, rare disease supplementary concept word, unique identifier]
15 Schizo*.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supple-mentary concept word, rare disease supplementary concept word, unique identifier]
16 Psychosis.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol sup-plementary concept word, rare disease supplementary concept word, unique identifier]
17 Depress*.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol sup-plementary concept word, rare disease supplementary concept word, unique identifier]
18 Suicid*.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supple-mentary concept word, rare disease supplementary concept word, unique identifier]
19 Mania*.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supple-mentary concept word, rare disease supplementary concept word, unique identifier]
20 Manic.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supple-mentary concept word, rare disease supplementary concept word, unique identifier]
21 Bipolar.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supple-mentary concept word, rare disease supplementary concept word, unique identifier]
22 Anxiety.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supple-mentary concept word, rare disease supplementary concept word, unique identifier]
23 Personality disorder*.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
24 Eating disorder*.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
25 Anorexia.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol sup-plementary concept word, rare disease supplementary concept word, unique identifier]
26 Bulimia.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supple-mentary concept word, rare disease supplementary concept word, unique identifier]
27 PTSD.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supple-mentary concept word, rare disease supplementary concept word, unique identifier]
28 Post-traumatic stress disorder*.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]
29 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 2830 9 and 2931 Clinical trial.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol sup-
plementary concept word, rare disease supplementary concept word, unique identifier]32 Controlled study.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol
supplementary concept word, rare disease supplementary concept word, unique identifier]33 Randomized controlled trial.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading
word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]34 Randomised controlled trial.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading
word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier]35 RCT.mp. [mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplemen-
tary concept word, rare disease supplementary concept word, unique identifier]36 31 or 32 or 33 or 34 or 3537 30 and 36
861Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
App
endi
x 4:
Cha
ract
eris
tics
of i
nclu
ded
tria
ls
Mai
n au
thor
Setti
ngPa
rtici
pant
sFo
llow
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Soci
al is
olat
ion
outc
omes
Oth
er o
utco
mes
Inte
rven
tion
type
Subj
ectiv
e so
cial
isol
atio
n tri
als
Kap
lan
[53]
Onl
ine
inte
rven
tion,
US
300
adul
ts w
ith a
dia
gno-
sis o
f a sc
hizo
phre
nia
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trum
or a
n aff
ectiv
e di
sord
er
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ediu
m-te
rm fo
llow
-up
s: 4
and
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mon
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e)
The
Med
ical
Out
com
es
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y (M
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Soc
ial
Supp
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y [6
4]
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nal r
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ery
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ualit
y of
Life
(3) P
sych
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c sy
mpt
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Supp
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Has
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Isra
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210
adul
ts w
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ent f
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ultid
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sion
al S
cale
of
Per
ceiv
ed S
ocia
l Su
ppor
t [57
]
Pers
onal
reco
very
Psyc
hoed
ucat
ion/
soci
al
skill
s tra
inin
g
Rot
ondi
[54]
In- a
nd o
utpa
tient
psy
-ch
iatri
c ca
re u
nits
and
ps
ychi
atric
reha
bilit
a-tio
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ntre
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ttsbu
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Pe
nnsy
lvan
ia
30 p
atie
nts a
ged
≥ 14
w
ith sc
hizo
phre
nia
or
schi
zoaff
ectiv
e di
sord
er
2 m
ediu
m-te
rm fo
llow
-up
s: 3
and
6 m
onth
s (p
ost-b
asel
ine)
The
info
rmat
iona
l sup
-po
rt an
d em
otio
nal
supp
ort s
ubsc
ales
of
the
instr
umen
t tha
t was
de
velo
ped
by K
raus
e an
d M
arki
des [
65]
N/A
Psyc
hoed
ucat
ion
Silv
erm
an [4
3]A
cute
car
e ps
ychi
atric
un
it, a
uni
vers
ity h
os-
pita
l, th
e M
idw
este
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on, U
S
96 a
dults
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var
ied
Axi
s I d
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of-tr
eatm
ent f
ollo
w-
upTh
e M
ultid
imen
sion
al
Scal
e of
Per
ceiv
ed
Soci
al S
uppo
rt (M
SPSS
) [57
]
N/A
Psyc
hoed
ucat
ion
Boe
vink
[44]
Men
tal h
ealth
car
e or
gani
satio
ns, t
he
Net
herla
nds
163
adul
ts w
ith v
ar-
ied
men
tal i
llnes
s1
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ium
-term
follo
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up: 1
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onth
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ne lo
ng-te
rm fo
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-up:
24
mon
ths (
post-
base
line)
The
De
Jong
-Gie
rvel
d Lo
nelin
ess S
cale
[58]
(1) Q
ualit
y of
Life
(2) P
sych
iatri
c sy
mpt
oms
Supp
orte
d so
cial
isat
ion
Zan
g [4
6]B
eich
uan
Cou
nty,
Chi
na30
age
d 28
–80
with
PT
SDEn
d-of
-trea
tmen
t fol
low
-up
2 m
ediu
m-te
rm fo
llow
-up
s: 1
wee
k or
2 w
eeks
, an
d 3
mon
ths
The
Mul
tidim
ensi
onal
Sc
ale
of P
erce
ived
So
cial
Sup
port
(MSP
SS) [
57]
(1) A
nxie
ty a
nd d
epre
s-si
ve sy
mpt
oms
(2) P
TSD
sym
ptom
s
Cha
ngin
g co
gniti
ons
Zan
g [4
7]B
eich
uan
Cou
nty,
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na22
age
d 37
–75
with
PT
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d-of
-trea
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t fol
low
-up
2 m
ediu
m-te
rm fo
llow
-up
s: 2
wee
ks a
nd
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onth
s
The
Mul
tidim
ensi
onal
Sc
ale
of P
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ived
So
cial
Sup
port
(MSP
SS) [
57]
(1) S
ubje
ctiv
e le
vel o
f di
stres
s(2
) Dep
ress
ive
sym
ptom
s
Cha
ngin
g co
gniti
ons
Gaw
rysi
ak [4
8]A
pub
lic S
outh
easte
rn
univ
ersi
ty, U
S30
age
d ≥ 18
with
dep
res-
sion
1 m
ediu
m-te
rm fo
llow
-up
: 2 w
eeks
The
Mul
tidim
ensi
onal
Sc
ale
of P
erce
ived
So
cial
Sup
port
(MSP
SS) [
57]
(1) D
epre
ssiv
e sy
mpt
oms
(2) A
nxie
ty sy
mpt
oms
Psyc
hoed
ucat
ion/
soci
al
skill
s tra
inin
g an
d su
p-po
rted
soci
alis
atio
n
862 Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
Mai
n au
thor
Setti
ngPa
rtici
pant
sFo
llow
-up
Soci
al is
olat
ion
outc
omes
Oth
er o
utco
mes
Inte
rven
tion
type
Bjo
rkm
an [5
0]C
ase
man
agem
ent s
er-
vice
, Sw
eden
77 a
dults
age
d 19
–51
with
seve
re m
enta
l ill
ness
2 lo
ng-te
rm fo
llow
-ups
: 18
and
36
mon
ths
The
abbr
evia
ted
vers
ion
of th
e In
terv
iew
Sch
ed-
ule
for S
ocia
l Int
erac
-tio
n (I
SSI)
[61]
(1) P
sych
iatri
c sy
mpt
oms
(2) Q
ualit
y of
life
Soci
al sk
ills t
rain
ing
Men
dels
on [5
1]B
altim
ore
City
, US
78 d
epre
ssed
wom
en a
ged
14–4
1 w
ho e
ither
wer
e pr
egna
nt o
r had
a c
hild
le
ss th
an 6
mon
ths o
ld
End-
of-tr
eatm
ent f
ollo
w-
up2
med
ium
-term
follo
w-
ups:
3 a
nd 6
mon
ths
The
Inte
rper
sona
l Sup
-po
rt Ev
alua
tion
List
(ISE
L) [6
2]
N/A
Cha
ngin
g co
gniti
ons
O’M
ahen
[55]
Onl
ine
inte
rven
tion,
UK
83 w
omen
age
d >
18
with
MD
DEn
d-of
-trea
tmen
t fol
low
-up
1 m
ediu
m-te
rm fo
llow
-up
: 6 m
onth
s
The
Soci
al P
rovi
sion
Sc
ale
[66]
(1) D
epre
ssiv
e sy
mpt
oms
(2) A
nxie
ty sy
mpt
oms
Psyc
hoed
ucat
ion
and
sup-
porte
d so
cial
isat
ion
Con
oley
[49]
Psyc
holo
gy D
epar
tmen
t, U
S57
fem
ale
psyc
holo
gy
unde
rgra
duat
e stu
dent
s w
ith m
oder
ate
depr
es-
sion
End-
of-tr
eatm
ent f
ollo
w-
up1
med
ium
-term
follo
w-
up: 2
wee
ks
The
Revi
sed
UC
LA
Lone
lines
s Sca
le [5
9]Th
e C
ausa
l Dim
ensi
on
Scal
e [6
0]
Dep
ress
ive
sym
ptom
sC
hang
ing
cogn
ition
s
Egg
ert [
45]
5 ur
ban
high
scho
ols,
US
105
high
scho
ol st
uden
ts
with
poo
r gra
des (
mod
-er
ate
or se
vere
dep
res-
sion
)
2 m
ediu
m-te
rm fo
llow
-up
s: 5
and
10
mon
ths
(pos
t-bas
elin
e)
Perc
eive
d so
cial
supp
ort:
mea
sure
d by
cal
cula
t-in
g av
erag
e ra
tings
ac
ross
six
netw
ork
supp
ort s
ourc
es.
The
instr
umen
tal a
nd
expr
essi
ve su
ppor
t pr
o-vi
ded
by e
ach
supp
ort
sour
ce w
as a
lso
rate
d
Dep
ress
ive
sym
ptom
sSu
ppor
ted
soci
alis
atio
n,
soci
al sk
ills t
rain
ing,
an
d w
ider
com
mu-
nity
app
roac
hes
Mas
ia-W
arne
r [52
]Tw
o pa
roch
ial h
igh
scho
ols,
New
Yor
k ci
ty, U
S
35 h
igh
scho
ol st
uden
ts
with
soci
al a
nxie
ty
diso
rder
End-
of-tr
eatm
ent f
ollo
w-
up1
med
ium
-term
follo
w-
up: 9
mon
ths
Lone
lines
s Sca
le [6
3](1
) Anx
iety
sym
ptom
s(2
) Soc
ial p
hobi
c sy
mp-
tom
s(3
) Dep
ress
ive
sym
ptom
s
Psyc
hoed
ucat
ion/
soci
al
skill
s tra
inin
g, su
ppor
ted
soci
alis
atio
n an
d ch
ang-
ing
cogn
ition
s In
teria
n [5
6]O
nlin
e in
terv
entio
n, U
S10
3 ve
tera
ns w
ith P
TSD
1 m
ediu
m-te
rm fo
llow
-up
: 2 m
onth
s (po
st-ba
selin
e)
The
fam
ily su
bsca
le o
f th
e M
ultid
imen
sion
al
Scal
e fo
r Per
ceiv
ed
Soci
al S
uppo
rt [5
7]
N/A
Psyc
hoed
ucat
ion
and
chan
ging
cog
nitio
ns
Obj
ectiv
e so
cial
isol
atio
n tri
als
Sol
omon
[70]
A c
omm
unity
men
tal
heal
th c
entre
, US
96 a
dults
with
schi
zo-
phre
nia
or m
ajor
affe
c-tiv
e di
sord
ers
2 m
ediu
m-te
rm fo
llow
-up
s: 1
mon
th a
nd 1
yea
r (p
ost-b
asel
ine)
(1) F
amily
and
soci
al
cont
acts
(2) P
attis
on’s
Soc
ial
Net
wor
k sc
ale
[81]
(1) U
se o
f ser
vice
s(2
) Qua
lity
of L
ife(3
) Psy
chia
tric
sym
ptom
s
Supp
orte
d so
cial
isat
ion
and
wid
er c
omm
unity
ap
proa
ches
Abe
rg-W
isted
t [71
]Th
e K
ungs
holm
en se
ctor
, St
ockh
olm
, Sw
eden
40 a
dults
with
schi
zo-
phre
nia
or lo
ng-te
rm
psyc
hotic
dis
orde
r, di
agno
sed
by D
SM-
III-
R sc
hizo
phre
nic
diso
rder
s
1 lo
ng-te
rm fo
llow
-up:
2
year
s (po
st-ba
selin
e)Th
e nu
mbe
r of p
eopl
e in
par
ticip
ants’
soci
al
life
was
mea
sure
d by
a
stan
dard
ised
pro
cedu
re
deve
lope
d fro
m w
ork
with
chi
ld p
sych
iatri
c pa
tient
s [82
]
(1) Q
ualit
y of
life
(2) S
ervi
ce u
sePs
ycho
educ
atio
n/so
cial
sk
ills t
rain
ing
863Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
Mai
n au
thor
Setti
ngPa
rtici
pant
sFo
llow
-up
Soci
al is
olat
ion
outc
omes
Oth
er o
utco
mes
Inte
rven
tion
type
Stra
vyns
ki [7
2]M
auds
ley
Hos
pita
l, Lo
ndon
, UK
22 a
dults
age
d 22
–57
with
diff
use
soci
al p
ho-
bia
and/
or av
oida
nt p
er-
sona
lity
diso
rder
End-
of-tr
eatm
ent f
ollo
w-
up1
med
ium
-term
follo
w-
up: 6
mon
ths
Stru
ctur
ed a
nd S
cale
d In
terv
iew
to A
sses
s M
alad
justm
ent
(SSI
AM
) [83
]
Dep
ress
ive
sym
ptom
sSo
cial
skill
s tra
inin
g an
d ch
angi
ng c
ogni
tions
Atk
inso
n [6
7]C
omm
unity
clin
ic, S
outh
G
lasg
ow, U
K14
6 re
giste
red
patie
nts
with
schi
zoph
reni
aEn
d-of
-trea
tmen
t fol
low
-up
1 m
ediu
m-te
rm fo
llow
-up
: 3 m
onth
s
A m
odifi
ed S
ocia
l Net
-w
ork
Sche
dule
(SN
S)
[78]
(1) Q
ualit
y of
life
(2) P
sych
iatri
c sy
mpt
oms
(3) O
vera
ll fu
nctio
ning
Psyc
hoed
ucat
ion
Ter
zian
[73]
47 c
omm
unity
men
tal
heal
th se
rvic
es (S
PT),
Italy
357
adul
ts a
ged <
45
diag
nose
d as
schi
zo-
phre
nia
spec
trum
dis
or-
der b
y th
e IC
D-1
0th
1 m
ediu
m-te
rm fo
llow
-up
: 1 y
ear (
post-
base
-lin
e)1
long
-term
follo
w-u
p:
2 ye
ars (
post-
base
line)
Soci
al n
etw
ork:
diff
eren
t pa
ram
eter
s of r
elat
ion-
ship
s wer
e as
sess
ed, a
ll w
ere
sum
mar
ized
into
a
scor
e
(1) P
sych
iatri
c sy
mpt
oms
(2) H
ospi
talis
atio
n ov
er
the
follo
w-u
p ye
ar
Supp
orte
d so
cial
isat
ion
and
wid
er c
omm
unity
ap
proa
ches
Has
son-
Oha
yon
[68]
3 ps
ychi
atric
reha
bilit
a-tio
n ag
enci
es a
nd th
e U
nive
rsity
Com
mun
ity
Clin
ic, B
ar-I
lan
Uni
ver-
sity
, Isr
ael
55 a
dults
age
d 21
–62
with
var
ious
seri-
ous m
enta
l illn
ess
1 m
ediu
m-te
rm fo
llow
-up
: 6 m
onth
sSo
cial
Fun
ctio
ning
Sca
le
(SFS
) [79
]N
/AW
ider
com
mun
ity
appr
oach
es, p
sych
oe-
duca
tion/
soci
al sk
ills
train
ing
and
chan
ging
co
gniti
ons
Riv
era
[77]
A c
ity h
ospi
tal,
New
Yo
rk, U
S20
3 ad
ults
with
a p
sy-
chot
ic o
r moo
d di
sord
er
on a
xis I
2 m
ediu
m-te
rm fo
llow
-up
s: 6
and
12
mon
ths
(pos
t-bas
elin
e)
A m
odifi
catio
n of
the
Patti
son
Net
wor
k In
vent
ory
[85]
(1) Q
ualit
y of
life
(2) P
sych
iatri
c sy
mpt
oms
Supp
orte
d so
cial
isat
ion
Sol
omon
[74]
A c
omm
unity
men
tal
heal
th c
entre
, US
96 a
dults
with
schi
zo-
phre
nia
or m
ajor
affe
c-tiv
e di
sord
ers
2 m
ediu
m-te
rm fo
llow
-up
s: 1
mon
th a
nd 1
yea
r (p
ost-b
asel
ine)
1 lo
ng-te
rm fo
llow
-up:
2
year
s (po
st-ba
selin
e)
Patti
son’
s Soc
ial N
etw
ork
[81]
(1) Q
ualit
y of
Life
(2) P
sych
iatri
c sy
mpt
oms
Supp
orte
d so
cial
isat
ion
and
wid
er c
omm
unity
ap
proa
ches
Mar
zilli
er [7
5]Th
e M
auds
ley
Hos
pita
l, U
K21
adu
lts a
ged
17–4
3 w
ith a
dia
gnos
is o
f pe
rson
ality
dis
orde
r or
neur
osis
End
of tr
eatm
ent f
ollo
w-
up1
med
ium
-term
follo
w-
up: 6
mon
ths
Revi
sed-
Soci
al D
iary
and
St
anda
rdis
ed In
terv
iew
Sc
hedu
le [7
5]
(1) A
nxie
ty d
isor
ders
(2) M
enta
l sta
te(3
) Per
sona
lity
asse
ss-
men
t
Soci
al sk
ills t
rain
ing
and
chan
ging
cog
nitio
ns
Bøe
n [6
9]2
mun
icip
al d
istric
ts,
easte
rn a
nd w
este
rn
Osl
o, N
orw
ay
138
seni
ors w
ith
mild
dep
ress
ion
End-
of-tr
eatm
ent f
ollo
w-
upTh
e O
slo-
3 So
cial
Sup
-po
rt Sc
ale
[80]
(1) D
epre
ssiv
e sy
mpt
oms
(2) L
ife sa
tisfa
ctio
nSu
ppor
ted
soci
alis
atio
n an
d w
ider
com
mun
ity
appr
oach
es C
ole
[76]
St. M
ary’
s hos
pita
l, M
ontre
al, C
anad
a32
adu
lts w
ith m
ajor
de
pres
sion
, dys
thym
ic
diso
rder
or o
ther
affe
c-tiv
e di
sord
er
3 m
ediu
m-te
rm fo
llow
-up
s: 4
, 8 a
nd 1
2 w
eeks
(p
ost-b
asel
ine)
The
Old
er A
mer
ican
s Re
sear
ch a
nd S
ervi
ce
Cen
tre In
strum
ent
(OA
RS)
[84]
(1) M
enta
l sta
te(2
) Sym
ptom
sN
/A
864 Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
Mai
n au
thor
Setti
ngPa
rtici
pant
sFo
llow
-up
Soci
al is
olat
ion
outc
omes
Oth
er o
utco
mes
Inte
rven
tion
type
Tria
ls fo
r bot
h su
bjec
tive
and
obje
ctiv
e so
cial
isol
atio
n S
chen
e [8
9]U
nive
rsity
Psy
chia
tric
Clin
ic o
f the
Aca
dem
ic
Hos
pita
l, U
trech
t, th
e N
ethe
rland
s
222
adul
ts a
ged >
60
with
var
ious
men
tal
diso
rder
s
End-
of-tr
eatm
ent f
ollo
w-
up1
med
ium
-term
follo
w-
up: 6
mon
ths
Subj
ectiv
e so
cial
isol
a-tio
n ou
tcom
e: S
ocia
l N
etw
ork
and
Soci
al
Supp
ort Q
uesti
onna
ire
(SN
SS) [
93]
Obj
ectiv
e so
cial
isol
a-tio
n ou
tcom
e: S
ocia
l N
etw
ork
and
Soci
al
Supp
ort q
uesti
onna
ire
(SN
SS) [
93]
(1) M
enta
l sta
te(2
) Psy
chia
tric
sym
ptom
s(3
) Soc
ial d
ysfu
nctio
n
Psyc
hoed
ucat
ion/
soci
al
skill
s tra
inin
g, a
nd su
p-po
rted
soci
alis
atio
n
Cas
tele
in [8
6]4
men
tal h
ealth
cen
tres,
the
Net
herla
nds
106
adul
ts a
ged ≥
18 w
ith
schi
zoph
reni
a or
rela
ted
psyc
hotic
dis
orde
rs
End-
of-tr
eatm
ent f
ollo
w-
upSu
bjec
tive
soci
al is
ola-
tion
outc
ome:
The
So
cial
Sup
port
List
(SSL
)O
bjec
tive
soci
al is
olat
ion
outc
ome:
Per
sona
l N
etw
ork
Que
stion
naire
(P
NQ
) [86
]
(1) Q
ualit
y of
Life
(2) S
cree
ning
for p
sy-
chos
is
Supp
orte
d so
cial
isat
ion
Gel
kopf
[87]
7 ch
roni
c sc
hizo
phre
nic
war
ds, I
srae
l34
adu
lts w
ith a
dia
gno-
sis o
f chr
onic
schi
zo-
phre
nia,
bas
ed o
n D
SM-I
II-R
1 m
ediu
m-te
rm fo
llow
-up
: 2 w
eeks
Subj
ectiv
e so
cial
isol
a-tio
n ou
tcom
e: T
he
Soci
al S
uppo
rt Q
ues-
tionn
aire
6 (S
SQ6)
[91]
Obj
ectiv
e so
cial
isol
atio
n ou
tcom
es:
(1) 2
mea
sure
s of s
ocia
l ne
twor
k su
m u
p th
e si
ze a
nd d
ispe
rsio
n(2
) 4 m
easu
res a
sses
s the
so
urce
of t
he su
ppor
t
N/A
Cha
ngin
g co
gniti
ons
Am
mer
man
[88]
Sout
hwes
tern
Ohi
o an
d N
orth
ern
Ken
tuck
y, U
S93
fem
ales
age
d fro
m 1
6 to
37
with
MD
DEn
d-of
-trea
tmen
t fol
low
-up
1 m
ediu
m-te
rm fo
llow
-up
: 3 m
onth
s
Subj
ectiv
e so
cial
is
olat
ion
outc
ome:
In
terp
erso
nal S
uppo
rt Ev
alua
tion
List
(ISE
L)
[62]
Obj
ectiv
e so
cial
isol
atio
n ou
tcom
e: S
ocia
l Net
-w
ork
Inde
x (S
NI)
[92]
Psyc
hiat
ric sy
mpt
oms
Cha
ngin
g co
gniti
ons
865Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
App
endi
x 5:
Cha
ract
eris
tics
of i
nter
vent
ions
Mai
n au
thor
Inte
rven
tion
and
cont
rol g
roup
Mod
e of
del
iver
yN
umbe
r of s
essi
ons +
dura
-tio
n of
eac
h se
ssio
n + du
ra-
tion
of in
terv
entio
n
Inte
rven
tion
desc
riptio
nsC
hara
cter
istic
s of i
nter
vent
ion
prov
ider
s
Subj
ectiv
e so
cial
isol
atio
n
Kap
lan
[53]
Expe
rimen
tal p
eer s
uppo
rt lis
tser
v vs
. exp
erim
enta
l pee
r su
ppor
t bul
letin
boa
rd v
s. w
aitin
g-lis
t con
trol g
roup
Onl
ine
Unc
lear
, ove
rall
dura
tion
of
the
study
was
12
mon
ths
Expe
rimen
tal p
eer s
uppo
rt lis
tser
v:
parti
cipa
nts c
omm
unic
ated
ano
ny-
mou
sly w
ith e
ach
othe
r via
a g
roup
di
strib
utio
n em
ail l
istEx
perim
enta
l pee
r sup
port
bulle
tin
boar
d: p
artic
ipan
ts w
ere
instr
ucte
d on
how
to c
reat
e ac
coun
t and
log
in
to b
oard
The
onlin
e co
mm
unic
atio
n of
bot
h lis
tser
v an
d bu
lletin
boa
rd g
roup
wer
e so
lely
pe
er d
irect
ed, b
ut te
chni
cal s
uppo
rt w
as
prov
ided
via
pho
ne o
r em
ail
Has
son-
Oha
yon
[42]
Illne
ss M
anag
emen
t and
Rec
ov-
ery
Prog
ram
me
vs. t
reat
men
t-as
-usu
al
Face
-to-fa
ce se
s-si
ons (
grou
p)W
eekl
y se
ssio
ns, a
n ho
ur
each
sess
ion
Dur
atio
n of
the
inte
rven
tion
was
8 m
onth
s
Inte
rven
tion
grou
p: Il
lnes
s Man
age-
men
t and
Rec
over
y Pr
ogra
mm
e is
a st
anda
rised
cur
ricul
um-b
ased
pr
ogra
mm
e, w
hich
pro
vide
s ess
entia
l in
form
atio
n an
d sk
ills t
o pe
ople
with
se
vere
men
tal i
llnes
s. Th
e in
form
atio
n an
d sk
ills p
rovi
ded
are
desi
gned
to
help
pat
ient
s man
age
thei
r illn
ess a
nd
wor
k to
war
ds th
eir p
erso
nal r
ecov
-er
y go
als.
In th
is st
udy,
edu
catio
nal
hand
outs
in H
ebre
w w
ere
prov
ided
to
par
ticip
ants
, foc
used
prim
arily
on
self-
man
agem
ent,
pers
onal
goa
ls,
soci
al su
ppor
t, m
edic
atio
n us
e, re
laps
e pr
even
tion,
and
cop
ing
with
psy
chia
t-ric
sym
ptom
s
Inte
rven
tions
wer
e le
d by
two
clin
icia
ns,
one
of w
hom
had
wee
kly
train
ing
sess
ions
. For
the
first
8 m
onth
s of
inte
rven
tion,
clin
icia
ns a
ttend
ed m
onth
ly
supe
rvis
ion
sess
ions
Rot
ondi
[54]
Tele
heal
th in
terv
entio
n vs
. usu
al
care
gro
upO
nlin
eU
ncle
arIn
terv
entio
n gr
oup:
incl
udin
g on
line
ther
apy
grou
ps, a
sk q
uesti
ons a
nd
rece
ive
answ
ers,
a lib
rary
of p
revi
ous
ques
tions
, act
iviti
es in
the
com
mun
ity,
new
s ite
ms,
and
educ
atio
nal r
eadi
ng
mat
eria
ls
The
3 th
erap
y gr
oups
wer
e fa
cilit
ated
by
mas
ter o
f soc
ial w
ork
and
PhD
clin
i-ci
ans,
they
wer
e al
l tra
ined
in th
e m
oni-
torin
g an
d m
anag
emen
t of w
eb-b
ased
in
terv
entio
ns
866 Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
Mai
n au
thor
Inte
rven
tion
and
cont
rol g
roup
Mod
e of
del
iver
yN
umbe
r of s
essi
ons +
dura
-tio
n of
eac
h se
ssio
n + du
ra-
tion
of in
terv
entio
n
Inte
rven
tion
desc
riptio
nsC
hara
cter
istic
s of i
nter
vent
ion
prov
ider
s
Silv
erm
an [4
3]Li
ve e
duca
tiona
l mus
ic th
erap
y (C
ondi
tion
A) v
s. re
cord
ed
educ
atio
nal m
usic
ther
apy
(Con
ditio
n B
) vs.
educ
atio
n w
ithou
t mus
ic (C
ondi
tion
C)
vs. r
ecre
atio
nal m
usic
ther
apy
with
out e
duca
tion
(Con
ditio
n D
)
Face
-to-fa
ce se
s-si
ons (
grou
p)24
wee
kly
sess
ions
, 45
min
pe
r ses
sion
Dur
atio
n of
inte
rven
tion:
24
wee
ks
Con
ditio
n A
: liv
e m
usic
, a sc
ripte
d ed
ucat
iona
l lyr
ic a
naly
sis s
essi
on
usin
g so
ng ly
rics t
hat f
ocus
ed o
n so
cial
supp
ort
Con
ditio
n B
: rec
orde
d m
usic
, a sc
ripte
d ed
ucat
iona
l lyr
ic a
naly
sis s
essi
on
abou
t lyr
ics t
hat f
ocus
ed o
n so
cial
su
ppor
tC
ondi
tion
C: W
ithou
t mus
ic, a
scrip
ted
educ
atio
nal s
essi
on w
ithou
t mus
ic
conc
erni
ng su
ppor
t and
cop
ing
Con
ditio
n D
: inv
estig
ator
led
the
grou
p in
pla
ying
rock
and
roll
bing
o, n
o sc
ripte
d ed
ucat
iona
l ses
sion
A c
ertifi
ed m
usic
ther
apist
with
mor
e th
an
12 y
ears
of c
linic
al p
sych
iatri
c ex
peri-
ence
con
duct
ed th
erap
y se
ssio
ns
Boe
vink
[44]
TREE
+ C
AU
vs.
CAU
(wai
ting-
list c
ontro
l)Fa
ce-to
-face
ses-
sion
s (gr
oup)
The
early
star
ters
: eac
h se
s-si
on la
sted
2 h,
met
eve
ry
two
wee
ksD
urat
ion
of th
e in
terv
entio
n:
104
wee
ksTh
e La
te st
arte
rs: e
ach
ses-
sion
laste
d 2
h, m
et e
very
tw
o w
eeks
;D
urat
ion
of th
e in
terv
entio
n:
52 w
eeks
TREE
mod
el:
(1) T
rain
ing
cour
se ‘s
tart
with
reco
very
’(2
) Dev
elop
ing
stren
gth
(3) A
one
-day
reco
very
trai
ning
cou
rse
The
reco
very
self-
help
wor
king
gro
ups
wer
e fa
cilit
ated
by
two
seni
or p
eer w
ork-
ers,
and
two
men
tal h
ealth
car
e m
anag
-er
s fac
ilita
ted
the
train
ing
cour
se
Zan
g [4
6]N
ET v
s. N
ET-R
vs.
wai
ting-
list
cont
rol
Face
-to-fa
ce
sess
ions
(ind
i-vi
dual
)
NET
gro
up: ≥
4 se
ssio
ns,
60–9
0 m
in p
er se
ssio
n,
twic
e w
eekl
yD
urat
ion
of in
terv
entio
n:
2 w
eeks
NET
-R g
roup
: ≥ 3
sess
ions
, 60
–120
min
per
sess
ion,
an
d ea
ch se
ssio
n w
as
1–2
days
apa
rt;D
urat
ion
of in
terv
entio
n:
1 w
eek
For b
oth
grou
ps, t
he n
arra
tive
was
re
cord
ed a
nd c
orre
cted
in su
bseq
uent
re
adin
g se
ssio
nsN
ET g
roup
: cre
ated
a d
etai
led
biog
-ra
phy
that
focu
sed
on tr
aum
atic
ex
perie
nces
NET
-R g
roup
: a m
odifi
ed v
ersi
on o
f N
ET; t
he p
artic
ipan
ts fi
rst c
onstr
ucte
d an
ear
thqu
ake
narr
ativ
e an
d th
en a
n au
tobi
ogra
phy
All
treat
men
ts w
ere
carr
ied
out b
y th
e fir
st au
thor
and
one
fem
ale
psyc
holo
gica
l co
unse
llor;
they
bot
h sp
eak
Chi
nese
and
ha
ve th
e C
hine
se n
atio
nal p
sych
olog
i-ca
l cou
nsel
lor c
ertifi
cate
(mas
ter)
and
al
so w
ere
train
ed in
the
use
of N
ET a
nd
NET
-RW
eekl
y ca
se a
nd p
erso
nal s
uper
visi
ons
wer
e co
nduc
ted;
the
coun
sello
rs w
ere
also
supe
rvis
ed b
efor
e th
ey h
ave
cont
act
with
par
ticip
ants
Zan
g [4
7]N
ET v
s. w
aitin
g-lis
t con
trol
grou
pFa
ce-to
-face
se
ssio
ns (i
ndi-
vidu
al)
NET
gro
up: 4
sess
ions
, 60
–90
min
per
sess
ion
Dur
atio
n of
inte
rven
tion:
2
wee
ks
NET
gro
up: c
reat
ed a
chr
onol
ogic
al
repo
rt of
bio
grap
hy w
ith a
focu
s on
traum
atic
exp
erie
nces
. A w
ritte
n re
port
of th
eir b
iogr
aphy
was
pro
vide
d in
the
last
sess
ion
The
team
was
led
by th
e fir
st au
thor
, con
-si
sted
of 3
fem
ale
ther
apist
s, an
d th
ey a
ll sp
eak
Chi
nese
, and
all
have
the
Chi
nese
na
tiona
l psy
chol
ogic
al c
ouns
ello
r cer
tifi-
cate
(Mas
ter)
Ther
apist
s wer
e tra
ined
for N
ET an
d th
ey
wer
e tut
ored
und
er su
perv
ision
bef
ore t
hey
wor
k w
ith p
artic
ipan
ts. W
eekl
y ca
se an
d pe
rson
al su
perv
ision
s wer
e also
carri
ed o
ut
867Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
Mai
n au
thor
Inte
rven
tion
and
cont
rol g
roup
Mod
e of
del
iver
yN
umbe
r of s
essi
ons +
dura
-tio
n of
eac
h se
ssio
n + du
ra-
tion
of in
terv
entio
n
Inte
rven
tion
desc
riptio
nsC
hara
cter
istic
s of i
nter
vent
ion
prov
ider
s
Gaw
rysi
ak [4
8]BA
TD v
s. no
trea
tmen
t con
trol
Face
-to-fa
ce
sess
ion
(indi
-vi
dual
)
Sing
le se
ssio
n la
sted
90 m
inBA
inte
rven
tion:
edu
catio
n, a
sses
smen
ts
of v
alue
s and
goa
ls, c
onstr
uct a
n ac
tivity
hie
rarc
hy, s
elec
tion
of v
alue
-ba
sed
beha
viou
rs, e
stab
lish
struc
ture
d be
havi
oura
l goa
ls, a
nd b
ehav
iour
al
chec
kout
form
One
mal
e do
ctor
al st
uden
ts in
clin
ical
ps
ycho
logy
was
trai
ned
in B
ATD
and
co
nduc
ted
the
indi
vidu
alis
ed in
terv
iew
Bjo
rkm
an [5
0]Th
e ca
se m
anag
emen
t ser
vice
vs
. sta
ndar
d ca
reFa
ce-to
-face
se
ssio
ns (i
ndi-
vidu
al)
1.45
per
wee
k du
ring
the
first
18 m
onth
s, an
d th
e ca
se
man
ager
spen
t on
aver
-ag
e 1.
9 h
in c
lient
con
tact
s ev
ery
wee
kD
urat
ion
of in
terv
entio
n:
uncl
ear
The
case
man
agem
ent s
ervi
ce: m
oder
-at
ely
focu
sed
on sk
ills t
rain
ing,
stro
ng
emph
asis
on
cons
umer
inpu
t
All
staff
had
exp
erie
nces
in w
orki
ng in
so
cial
serv
ices
, psy
chia
tric
serv
ices
or
voca
tiona
l reh
abili
tatio
n. T
he te
am c
on-
siste
d of
two
regi
stere
d nu
rses
and
two
soci
al w
orke
rs. S
uper
visi
on w
as d
one
by
a ps
ychi
atris
t and
a p
sych
olog
ist
Men
dels
on [5
1]St
anda
rd h
ome
visi
ting
ser-
vice
s + M
B c
ours
e vs
. sta
ndar
d ho
me
visi
ting
serv
ices
+ in
for-
mat
ion
on p
erin
atal
dep
ress
ion
Face
-to-fa
ce
sess
ions
(gro
up
and
indi
vidu
al)
6 w
eekl
y se
ssio
ns, 2
h e
ach
sess
ion
Dur
atio
n of
inte
rven
tion:
6
wee
ks
Inte
rven
tion
grou
p: S
essi
ons c
over
co
re c
ogni
tive
beha
viou
ral c
once
pts,
incl
udin
g pl
easa
nt a
ctiv
ities
, tho
ught
s, an
d co
ntac
t with
oth
ers
A li
cens
ed c
linic
al so
cial
wor
ker o
r clin
i-ca
l psy
chol
ogist
O’M
ahen
[55]
Net
mum
sHW
D v
s. tre
atm
ent-
as-u
sual
Onl
ine
and
tel-
epho
ne su
ppor
t12
-ses
sion
trea
tmen
t onl
ine
cour
se, w
eekl
y te
leph
one
supp
ort s
essi
ons o
f 20
–30
min
Dur
atio
n of
eac
h se
ssio
n an
d in
terv
entio
n: u
ncle
ar
Net
mum
sHW
D: i
nclu
ding
a c
ore
beha
viou
ral a
ctiv
atio
n (B
A) m
odel
, a
rela
pse
prev
entio
n se
ssio
n, p
lus t
wo
optio
nal m
odul
es. A
lso
a ch
at ro
om
that
was
mod
erat
ed b
y pe
er su
ppor
t-er
s, an
d w
eekl
y su
ppor
ted
phon
e ca
ll fro
m m
enta
l hea
lth w
orke
rs
Men
tal h
ealth
supp
orte
rs w
ith u
nder
-gr
adua
te d
egre
es a
nd 1
yea
r of c
linic
al
qual
ifica
tion
in p
sych
olog
ical
ther
apie
sPe
er su
ppor
ters
had
pre
viou
s tra
inin
g in
low
-inte
nsity
BA
, rec
eive
d 5
days
of
trai
ning
in h
igh-
inte
nsity
per
inat
al-
spec
ific
BA a
ppro
ach
Con
oley
[49]
Refr
amin
g vs
. sel
f-co
ntro
l vs.
wai
ting
list
Face
-to-fa
ce
sess
ions
(ind
i-vi
dual
)
2 se
ssio
ns w
ith 1
wee
k ap
art,
each
sess
ion
30 m
inD
urat
ion
of in
terv
entio
n:
2 w
eeks
Inte
rven
tion
grou
ps: a
imed
to in
crea
se
unde
rsta
ndin
g in
lone
lines
s. Fi
rst h
alf
of th
e se
ssio
n co
nsist
ed o
f lon
elin
ess
and
refle
ctiv
e re
spon
ses,
the
seco
nd
half
incl
uded
eith
er 3
–5 p
ositi
ve
refr
amin
g di
rect
ives
for r
efra
min
g su
bjec
ts, a
nd se
lf-co
ntro
l dire
ctiv
es
for s
elf-
cont
rol s
ubje
cts
Two
mal
e do
ctor
al st
uden
ts w
ith 3
-yea
r co
unse
lling
exp
erie
nce,
rece
ived
trai
n-in
g in
bot
h in
terv
entio
ns
868 Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
Mai
n au
thor
Inte
rven
tion
and
cont
rol g
roup
Mod
e of
del
iver
yN
umbe
r of s
essi
ons +
dura
-tio
n of
eac
h se
ssio
n + du
ra-
tion
of in
terv
entio
n
Inte
rven
tion
desc
riptio
nsC
hara
cter
istic
s of i
nter
vent
ion
prov
ider
s
Egg
ert [
45]
PGC
I vs.
PGC
II v
s. an
ass
ess-
men
t pro
toco
l-onl
yFa
ce-to
-face
ses-
sion
s (gr
oup)
PGC
I: m
et d
aily
, 55
min
per
m
eetin
gD
urat
ion
of in
terv
entio
n:
5 m
onth
s or 9
0 cl
ass d
ays
in le
ngth
PGC
II: m
et d
aily
, 55
min
per
m
eetin
gD
urat
ion
of in
terv
entio
n:
10 m
onth
s or 1
80 c
lass
da
ys in
leng
th
Bot
h PG
CI a
nd P
GC
II: s
mal
l gro
up
wor
k fo
cuse
d on
soci
al su
ppor
t; w
eekl
y m
onito
ring
of a
ctiv
ities
; and
lif
e sk
ills t
rain
ing
PGC
I: em
phas
ised
bon
ding
to P
GC
gr
oup,
incl
uded
trai
ning
to g
ive
and
rece
ive
soci
al su
ppor
t; fo
cuse
d on
m
otiv
atin
g to
cha
nge
and
acqu
ire
esse
ntia
l ski
lls, a
nd re
hear
sing
real
-lif
e is
sues
in th
e gr
oup
setti
ng w
ith a
m
ain
focu
s on
prob
lem
s with
frie
nds,
teac
hers
and
par
ents
PGC
II: e
mph
asis
ed b
road
er sc
hool
bo
ndin
g, in
clud
ed tr
aini
ng to
tran
sfer
sk
ills t
o re
al li
fe si
tuat
ions
, pro
vidi
ng
and
seek
ing
soci
al su
ppor
t, an
d de
vel-
opin
g he
alth
-pro
mot
ing
soci
al a
ctiv
i-tie
s to
redu
ce th
e ne
gativ
e im
pact
s of
suic
idal
thou
ghts
and
beh
avio
urs,
ange
r and
/or d
epre
ssio
n, a
nd d
rug
invo
lvem
ent
The
inte
rven
tions
wer
e de
liver
ed b
y tra
ined
scho
ol st
aff w
ho fu
nctio
ned
as
grou
p le
ader
s
Mas
ia-W
arne
r [5
2]Sk
ills f
or S
ocia
l and
Aca
dem
ic
Succ
ess v
s. w
aitin
g-lis
t gro
upFa
ce-to
-face
se
ssio
ns (g
roup
an
d in
divi
dual
)
12 w
eekl
y gr
oup
scho
ol se
s-si
ons (
40 m
in);
2 br
ief i
ndi-
vidu
al m
eetin
gs (1
5 m
in);
2 m
onth
ly g
roup
boo
ster
sess
ions
; and
4 w
eeke
nd
soci
al e
vent
s (90
min
)D
urat
ion
of in
terv
entio
n:
3 m
onth
s
12 g
roup
sess
ions
: 1 p
sych
oedu
catio
nal
sess
ion,
1 re
alist
ic th
inki
ng se
ssio
n, 4
so
cial
skill
s tra
inin
g se
ssio
ns, 5
exp
o-su
re se
ssio
ns, a
nd 1
rela
pse
prev
entio
n se
ssio
nIn
divi
dual
mee
tings
: met
with
gro
up
lead
ers a
t lea
st tw
ice,
aim
to id
entif
y in
divi
dual
trea
tmen
t goa
ls a
nd p
rob-
lem
solv
ing
Soci
al e
vent
s: m
et a
nd p
ract
iced
pr
ogra
mm
e sk
ills w
ith p
eers
in th
eir
com
mun
ity
A b
ehav
iour
ally
trai
ned
clin
ical
psy
chol
o-gi
st an
d a
clin
ical
psy
chol
ogy
grad
uate
stu
dent
co-
led
all g
roup
sPe
er a
ssist
ants
: nom
inat
ed b
y te
ache
rs a
nd
adm
inist
rato
rs, h
elp
with
exp
osur
es a
nd
skill
pra
ctic
e
Inte
rian
[56]
The
Fam
ily o
f Her
oes i
nter
ven-
tion
vs. c
ontro
l gro
upO
nlin
e1
h on
line
inte
rven
tion
Dur
atio
n of
inte
rven
tion:
un
clea
r
The
Fam
ily o
f Her
oes I
nter
vent
ion:
pr
ovid
ed p
sych
oedu
catio
n an
d sti
mul
ated
con
vers
atio
ns re
gard
ing
post-
depl
oym
ent s
tress
and
men
tal
heal
th tr
eatm
ent;
and
thre
e co
nver
sa-
tion
scen
ario
s
N/A
869Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
Mai
n au
thor
Inte
rven
tion
and
cont
rol g
roup
Mod
e of
del
iver
yN
umbe
r of s
essi
ons +
dura
-tio
n of
eac
h se
ssio
n + du
ra-
tion
of in
terv
entio
n
Inte
rven
tion
desc
riptio
nsC
hara
cter
istic
s of i
nter
vent
ion
prov
ider
s
Obj
ectiv
e so
cial
isol
atio
n tri
als
Sol
omon
[70]
Con
sum
er m
anag
emen
t tea
m v
s. no
n-co
nsum
er m
anag
emen
t te
am
Face
-to-fa
ce
sess
ions
(ind
i-vi
dual
)
Unc
lear
Bot
h co
nsum
er a
nd n
on-c
onsu
mer
man
-ag
emen
t tea
m fo
llow
ed a
n as
serti
ve
com
mun
ity tr
eatm
ent m
odel
(1) P
rovi
ded
activ
ities
: hou
sing
, reh
a-bi
litat
ion
and
soci
al a
ctiv
ities
(2) C
ase
man
ager
s pro
vide
d as
sist
ance
an
d su
ppor
ted
clie
nts,
supe
rvis
ed b
y co
nsum
er su
perv
isor
Requ
irem
ents
for c
onsu
mer
man
age-
men
t tea
m: h
ave
maj
or m
enta
l hea
lth
prob
lem
s, ≥
1 p
revi
ous p
sych
iatri
c ho
spita
lisat
ion,
a m
inim
um o
f 14
days
of
psy
chia
tric
hosp
italis
atio
n, o
r at l
east
5 ps
ychi
atric
em
erge
ncy
serv
ice
cont
acts
w
ithin
a y
ear
Requ
irem
ents
for n
on-c
onsu
mer
cas
e m
anag
emen
t tea
m: c
onsi
sted
of m
enta
l he
alth
pro
fess
iona
ls a
nd re
cent
col
lege
gr
adua
tes
Abe
rg-W
isted
t [7
1]Th
e in
tens
ive
case
man
age-
men
t pro
gram
me
vs. s
tand
ard
serv
ices
Face
-to-fa
ce
sess
ions
(ind
i-vi
dual
)
1 h
indi
vidu
al m
eetin
g ev
ery
othe
r wee
k; p
sych
iatri
c nu
rse/
nurs
e as
sist
ant m
et
with
pat
ient
s at l
east
4 h
per w
eek.
Cris
is in
terv
en-
tion
serv
ices
wer
e av
aila
ble
24 h
eve
ry d
ay a
nd 7
day
s a
wee
k.D
urat
ion
of in
terv
entio
n:
2 ye
ars
Inte
rven
tion
grou
p:(1
) The
team
pro
vide
d as
serti
ve o
ut-
reac
h; p
atie
nts r
ecei
ved
skill
trai
ning
an
d in
struc
tion
in c
ritic
al li
fe ta
sk(2
) Spe
cific
serv
ices
als
o pr
ovid
ed
base
d on
indi
vidu
al n
eeds
and
ass
ess-
men
ts(3
) Fam
ily p
sych
oedu
catio
n an
d su
ppor
t
The
team
con
siste
d of
a p
sych
olog
ist/
psyc
hiat
rist,
a ps
ychi
atric
soci
al w
orke
r, a
soci
al se
rvic
e offi
cer,
and
a ps
ychi
atric
nu
rse/
nurs
e as
sist
ant
Stra
vyns
ki [7
2]So
cial
skill
s tra
inin
g vs
. Soc
ial
skill
trai
ning
+ co
gniti
ve
mod
ifica
tion
Face
-to-fa
ce
sess
ions
(ind
i-vi
dual
)
12 se
ssio
ns, 9
0 m
in p
er
sess
ion
Dur
atio
n of
inte
rven
tion:
14
wee
ks
Soci
al sk
ills t
rain
ing:
focu
sed
on in
di-
vidu
al n
eeds
by
disc
ussi
ng sp
ecifi
c so
cial
targ
ets;
tech
niqu
es in
clud
ed
instr
uctio
ns, m
odel
ling,
role
-reh
ears
al,
feed
back
, sel
f-m
onito
ring,
and
hom
e-w
ork
Soci
al sk
ill tr
aini
ng +
cogn
itive
mod
ifi-
catio
n: p
revi
ously
des
crib
ed e
lem
ents
fo
r soc
ial s
kills
trai
ning
. For
cog
nitiv
e m
odifi
catio
n, p
artic
ipan
ts a
naly
sed
a di
stres
sing
eve
nt in
five
step
s: (1
) ac
tivat
ing
even
t with
des
crip
tions
; (2
) irr
atio
nal b
elie
fs; (
3) e
mot
iona
l co
nseq
uenc
es; (
4) d
ispu
te; (
5) p
lan
for
new
act
ions
Prov
ided
by
one
psyc
hiat
rist
Atk
inso
n [6
7]Th
e ed
ucat
ion
grou
p vs
. wai
ting-
list c
ontro
lFa
ce-to
-face
ses-
sion
s (gr
oup)
1.5
h pe
r ses
sion
Dur
atio
n of
inte
rven
tion:
20
wee
ks
The
educ
atio
n gr
oup:
sess
ions
gen
eral
ly
cove
red
schi
zoph
reni
a to
pics
, and
al
tern
ated
bet
wee
n an
info
rmat
ion
ses-
sion
and
a p
robl
em-s
olvi
ng se
ssio
n
Led
by c
omm
unity
psy
chia
tric
nurs
es,
occu
patio
nal t
hera
pists
and
regi
strar
s. Tr
aini
ngs w
ere
also
pro
vide
d
870 Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
Mai
n au
thor
Inte
rven
tion
and
cont
rol g
roup
Mod
e of
del
iver
yN
umbe
r of s
essi
ons +
dura
-tio
n of
eac
h se
ssio
n + du
ra-
tion
of in
terv
entio
n
Inte
rven
tion
desc
riptio
nsC
hara
cter
istic
s of i
nter
vent
ion
prov
ider
s
Ter
zian
[73]
Soci
al n
etw
ork
inte
rven
-tio
n + us
ual t
reat
men
ts v
s. us
ual t
reat
men
ts
Face
-to-fa
ce
(indi
vidu
al)
Unc
lear
info
rmat
ion
rega
rd-
ing
inte
rven
tion
sess
ions
Dur
atio
n of
inte
rven
tion:
3–
6 m
onth
s
Soci
al n
etw
ork
inte
rven
tion:
par
tici-
pant
s wer
e he
lped
to id
entif
y th
eir
poss
ible
are
as o
f int
eres
t, an
d so
cial
ac
tiviti
es w
ere
sugg
este
d
Prov
ided
by
a st
aff m
embe
r or n
atur
al
faci
litat
ors s
uch
as fa
mili
es, n
eigh
bour
s, or
vol
unte
ers
Has
son-
Oha
yon
[68]
Soci
al C
ogni
tion
and
Inte
rac-
tion
Trai
ning
(SC
IT) +
soci
al
men
torin
g vs
. soc
ial m
ento
ring
only
Face
-to-fa
ce se
s-si
ons (
grou
p)SC
IT in
terv
entio
n: 1
h
wee
kly
sess
ion
Soci
al m
ento
ring
serv
ice:
3
wee
kly
mee
tings
Dur
atio
n of
inte
rven
tion:
un
clea
r
Parti
cipa
nts r
ecei
ved
soci
al, l
eisu
re,
supp
ort,
and
empl
oym
ent s
ervi
ces,
as
wel
l as s
tand
ard
serv
ices
SCIT
inte
rven
tion
grou
p: b
esid
es
inte
rven
tion,
they
als
o re
ceiv
ed e
duca
-tio
nal h
ando
uts,
vide
os, a
nd sl
ides
All
rece
ived
the
sam
e so
cial
men
tor-
ing
serv
ices
to su
ppor
t pra
ctic
al st
eps
tow
ard
achi
evin
g pe
rson
ally
mea
ning
-fu
l goa
ls
Soci
al m
ento
rs w
ere
staff
of p
sych
iatri
c re
habi
litat
ion
agen
cies
Lead
clin
icia
ns re
ceiv
ed tr
aini
ng a
nd
ongo
ing
supe
rvis
ion.
All
clin
icia
ns h
ad
expe
rienc
es in
pro
vidi
ng p
sych
iatri
c re
habi
litat
ion
serv
ices
and
com
plet
ed a
SC
IT w
orks
hop
Riv
era
[77]
Peer
-ass
isted
car
e vs
. Non
con-
sum
er a
ssist
ed v
s. st
anda
rd
care
vs.
clin
ic-b
ased
car
e
Face
-to-fa
ce se
s-si
ons (
grou
p &
in
divi
dual
), an
d ph
one
calls
Unc
lear
info
rmat
ion
rega
rd-
ing
inte
rven
tion
sess
ions
an
d du
ratio
nB
ut te
leph
one
cove
rage
is
24 h
Peer
ass
isted
car
e gr
oup:
pro
fess
ion-
als p
rovi
ded
conv
entio
nal c
risis
m
anag
emen
t, th
erap
eutic
serv
ices
and
co
ncre
te se
rvic
es; p
arap
rofe
ssio
nal
cons
umer
s fac
ilita
ted
soci
al n
etw
orks
an
d pr
ovid
ed so
cial
supp
ort t
hrou
gh
activ
ities
, hom
e vi
sits
and
pho
ne c
alls
Clin
ic b
ased
car
e gr
oup:
onl
y pr
ovid
ed
office
-bas
ed se
rvic
es
All
prof
essi
onal
s wer
e lic
ense
d cl
inic
al
soci
al w
orke
rs, a
lso
rece
ived
trai
ning
an
d su
perv
isio
nsC
onsu
mer
s had
a h
istor
y of
mul
tiple
ho
spita
lisat
ions
for m
ood
or p
sych
otic
di
sord
ers,
wer
e el
igib
le fo
r dis
abili
ty
bene
fits,
relie
d on
med
icat
ion,
but
had
3–
8 ye
ars o
f sob
riety
and
stab
ility
. The
y ha
d th
e sa
me
train
ings
as p
rofe
ssio
nal,
and
wer
e su
perv
ised
by
soci
al w
orke
r
871Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
Mai
n au
thor
Inte
rven
tion
and
cont
rol g
roup
Mod
e of
del
iver
yN
umbe
r of s
essi
ons +
dura
-tio
n of
eac
h se
ssio
n + du
ra-
tion
of in
terv
entio
n
Inte
rven
tion
desc
riptio
nsC
hara
cter
istic
s of i
nter
vent
ion
prov
ider
s
Sol
omon
[74]
Con
sum
er c
ase
man
agem
ent
team
vs.
nonc
onsu
mer
man
-ag
emen
t tea
m
Face
-to-fa
ce
sess
ions
(ind
i-vi
dual
)
The
cons
umer
team
: Thr
ee
times
per
wee
kTh
e no
ncon
sum
er te
am: m
et
biw
eekl
yD
urat
ion
of th
e in
terv
entio
n:
2 ye
ars
Cas
e m
anag
ers o
ffere
d in
divi
dual
ised
so
cial
supp
ort f
or c
omm
unity
livi
ng,
activ
ities
incl
uded
goa
ls re
late
d to
in
com
e, li
ving
situ
atio
n, so
cial
and
fa
mily
rela
tions
, and
psy
chia
tric
treat
-m
ent
Requ
irem
ents
for c
onsu
mer
cas
e m
anag
-er
s: h
ave
a m
ajor
men
tal h
ealth
dis
orde
r; at
leas
t one
prio
r psy
chia
tric
hosp
i-ta
lisat
ion
and
a m
inim
um o
f 14
days
of
psyc
hiat
ric h
ospi
talis
atio
n, o
r at l
east
5 ps
ychi
atric
em
erge
ncy
serv
ice
cont
acts
ov
er a
1-y
ear p
erio
d; re
gula
r con
tact
in
com
mun
ity m
enta
l hea
lth se
rvic
es, p
sy-
chos
ocia
l ser
vice
s, or
oth
er o
utpa
tient
tre
atm
ent
Con
sum
er te
am: 3
con
sum
er m
anag
-er
s and
1 n
onco
nsum
er c
ase
man
ager
in
itial
ly, l
ater
, the
non
cons
umer
mem
ber
was
repl
aced
by
a co
nsum
er, a
nd a
clin
i-ca
l dire
ctor
and
a p
sych
iatri
st st
arte
d in
volv
ed. C
onsu
mer
man
gers
rece
ived
su
perv
isio
ns a
nd su
ppor
tN
onco
nsum
er te
am: a
ll no
ncon
sum
er
man
ager
s, tw
o sp
ecia
lists
star
ted
invo
lved
at t
he se
cond
yea
r. M
anag
ers
rece
ived
supe
rvis
ions
and
supp
ort
The
inte
rvie
wer
: a tr
aine
d pr
ofes
sion
al
rese
arch
wor
ker i
ndep
ende
nt o
f ser
vice
pr
ovid
ers.
Inte
nsiv
e, e
xper
ient
ial
train
ing
was
pro
vide
d in
bot
h th
e B
rief
Psyc
hiat
ric R
atin
g Sc
ale
(BPR
S) a
nd
Add
ictio
n Se
verit
y In
dex
(ASI
) M
arzi
llier
[75]
Syste
mat
ic D
esen
sitis
atio
n (S
D)
vs. S
ocia
l Ski
lls T
rain
ing
(SST
) vs.
wai
ting-
list c
ontro
l
Face
-to-fa
ce
sess
ions
(ind
i-vi
dual
)
15 4
5-m
in se
ssio
ns, o
nce
a w
eek,
occ
asio
nally
twic
e a
wee
kD
urat
ion
of in
terv
entio
n: 3
an
d ha
lf m
onth
s
Syste
mat
ic d
esen
sitis
atio
n: in
clud
ed
rela
xatio
n tra
inin
g an
d hi
erar
chy
con-
struc
tion,
pra
ctic
e in
bot
h im
agin
atio
n an
d re
ality
Soci
al sk
ills t
rain
ing:
com
bine
d el
e-m
ents
of b
oth
asse
rtive
and
soci
al
skill
s tra
inin
g, in
clud
ed ro
le p
layi
ng,
mod
ellin
g, a
nd p
ract
ice
in re
al-li
fe
and
with
vol
unte
ers
Ass
essm
ents
wer
e do
ne b
y 2
inde
pend
ent
asse
ssor
s; o
ne w
as a
trai
ned
psy-
chol
ogist
, and
the
othe
r was
a se
nior
ps
ychi
atris
tTh
e th
erap
ist w
as a
trai
ned
clin
ical
psy
-ch
olog
ist w
ith e
xper
ienc
e in
beh
avio
ural
tre
atm
ents
Bøe
n [6
9]A
pre
vent
ive
seni
or c
entre
gro
up
prog
ram
me
vs. c
ontro
lFa
ce-to
-face
ses-
sion
s (gr
oup)
Wee
kly
grou
p m
eetin
gs, 3
h
per m
eetin
g, a
bout
35–
38
times
tota
lly;
Dur
atio
n of
inte
rven
tion:
1
year
The
expe
rimen
tal g
roup
: inc
lude
d gr
oup
mee
ting,
phy
sica
l tra
inin
g pr
ogra
mm
e,
and
a se
lf-he
lp g
roup
. Tra
nspo
rtatio
n an
d w
arm
mea
ls w
ere
also
pro
vide
d
The
team
con
siste
d of
vol
unte
ers;
all
com
plet
ed a
trai
ning
cou
rse
and
wer
e su
perv
ised
by
a re
giste
red
nurs
e an
d an
ex
perie
nced
seni
or c
entre
lead
er
Col
e [7
6]H
ome
asse
ssm
ent g
roup
vs.
clin
ic a
sses
smen
t gro
upFa
ce-to
-face
se
ssio
ns (i
ndi-
vidu
al)
Unc
lear
Unc
lear
Stud
y ps
ychi
atris
ts (M
C o
r DR
) ass
esse
d pa
rtici
pant
s
872 Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
Mai
n au
thor
Inte
rven
tion
and
cont
rol g
roup
Mod
e of
del
iver
yN
umbe
r of s
essi
ons +
dura
-tio
n of
eac
h se
ssio
n + du
ra-
tion
of in
terv
entio
n
Inte
rven
tion
desc
riptio
nsC
hara
cter
istic
s of i
nter
vent
ion
prov
ider
s
Tria
ls fo
r bot
h su
bjec
tive
and
obje
ctiv
e so
cial
isol
atio
n S
chen
e [8
9]Ps
ychi
atric
day
trea
tmen
t vs.
inpa
tient
trea
tmen
tVa
ried:
mos
tly
face
-to-fa
ce
sess
ions
or
phon
e in
terv
iew
(g
roup
and
in
divi
dual
)
Day
trea
tmen
t: le
ngth
of
prog
ram
me
varie
dA
vera
ge d
urat
ion
of in
terv
en-
tion:
37.
6 w
eeks
Inpa
tient
trea
tmen
t: le
ngth
of
prog
ram
mes
var
ied
Ave
rage
dur
atio
n of
inte
rven
-tio
n: 2
4.9
wee
ks
Nin
e m
ain
grou
ps o
f tre
atm
ent
prog
ram
mes
: (1)
indi
vidu
al p
sych
o-th
erap
y or
supp
ortiv
e th
erap
y; (2
) in
divi
dual
cou
nsel
ling;
(3) g
roup
ps
ycho
ther
apy;
(4) s
ocio
ther
apy;
(5)
fam
ily c
ouns
ellin
g; (6
) occ
upat
iona
l th
erap
y; (7
) psy
chom
otor
ther
apy;
(8)
dram
a th
erap
y; (9
) sec
onda
ry e
nviro
n-m
enta
l act
iviti
esEx
tra c
are
for d
ay c
linic
par
ticip
ants
af
ter o
ffice
hou
rs, s
uch
as p
hone
cal
l or
face
-to-fa
ce ta
lks w
ith re
side
nt o
n du
ty in
the
clin
ic, o
r use
of c
linic
al
bed
Soci
al p
sych
iatri
c nu
rses
, psy
chia
trists
, an
d ps
ycho
logi
sts
Cas
tele
in [8
6]C
are
as u
sual
+ G
PSG
vs.
a w
ait-
ing-
list
cond
ition
Face
-to-fa
ce se
s-si
ons (
grou
p)90
min
per
sess
ion,
16
biw
eekl
y se
ssio
nsD
urat
ion
of in
terv
entio
n:
8 m
onth
s
Peer
supp
ort g
roup
: inc
lude
d ab
out
10 p
atie
nts,
patie
nts d
ecid
ed th
e to
pic
of e
ach
sess
ion,
dis
cuss
ing
daily
life
ex
perie
nces
in p
airs
and
gro
ups
Nur
ses g
uide
d th
e pe
er g
roup
s with
min
i-m
al in
volv
emen
t
Gel
kopf
[87]
Vid
eo p
roje
ctio
n of
hum
orou
s m
ovie
s vs.
cont
rol g
roup
Face
-to-fa
ce se
s-si
ons (
grou
p)Th
e ex
perim
enta
l gro
up: f
our
times
dai
ly (5
day
s a w
eek)
Dur
atio
n of
inte
rven
tion:
3
mon
ths
The
expe
rimen
tal g
roup
: exp
osed
exc
lu-
sive
ly to
com
edie
sTh
e co
ntro
l gro
up: 1
5% o
f the
film
s w
ere
com
edie
s; o
ther
s are
diff
eren
t ty
pes o
f film
s
A p
sych
olog
y stu
dent
was
invo
lved
to
ans
wer
que
stion
s dur
ing
expe
rimen
tal
testi
ng
Am
mer
man
[88]
IH-C
BT
+ ho
me
visi
ting
vs.
hom
e vi
sit a
lone
Face
-to-fa
ce
sess
ions
(ind
i-vi
dual
)
15 w
eekl
y se
ssio
ns, 6
0 m
in
per s
essi
on w
ith a
boo
ster
sess
ion
1 m
onth
afte
r tre
at-
men
tD
urat
ion
of in
terv
entio
n:
abou
t 5 m
onth
s
IH-C
BT:
prim
arily
targ
eted
dep
ress
ion
redu
ctio
n, c
onsi
sted
of b
ehav
iour
al
activ
atio
n, id
entifi
catio
n of
aut
o-m
atic
thou
ghts
and
sche
mas
, tho
ught
re
struc
tura
tion,
and
rela
pse
prev
entio
n
2 lic
ense
d m
aste
r lev
el so
cial
wor
kers
, re
ceiv
ed w
eekl
y su
perv
isio
n, a
revi
ew
of a
udio
tape
d se
ssio
ns a
nd a
self-
repo
rt ch
eckl
ist
873Social Psychiatry and Psychiatric Epidemiology (2020) 55:839–876
1 3
Appendix 6: Quality assessment
First author (pub-lication year)
Sequence genera-tion
Allocation con-cealment
Blinding Incomplete out-come data
Selective outcome reporting
Other sources of bias
Kaplan [53] Low risk Unclear High risk Unclear Low risk Low riskHasson-Ohayon
[42]Low risk Unclear High risk Unclear Low risk High risk
Rotondi [54] Unclear Unclear High risk Unclear Low risk High riskSilverman [43] Unclear Unclear High risk Unclear Low risk Low riskBoevink [44] Low risk Unclear High risk Unclear Low risk Low riskZang [46] Low risk Unclear High risk Unclear Low risk High riskZang [47] Low risk Unclear High risk Unclear Low risk High riskGawrysiak [48] Unclear Unclear High risk Unclear Low risk Low riskBjorkman [50] Low risk Low risk High risk Unclear Low risk High riskMendelson [51] Unclear Unclear High risk Unclear Low risk High riskO’Mahen [55] Low risk Low risk High risk Low risk Low risk Low riskConoley [49] Unclear Unclear High risk Unclear Low risk High riskEggert [45] Unclear Unclear High risk Unclear Low risk High riskMasia-Warner [52] Unclear Unclear High risk Low risk Low risk High riskInterian [56] Low risk Unclear High risk Unclear Low risk High riskSolomon [70] Unclear Unclear High risk Low risk Low risk High riskAberg-Wistedt
[71]Unclear Unclear High risk Unclear Low risk High risk
Atkinson [67] Unclear Unclear High risk Unclear Low risk High riskTerzian [73] Unclear Low risk High risk Unclear Low risk High riskHasson-Ohayon
[68]Unclear Unclear High risk Unclear Low risk High risk
Rivera [77] Unclear Low risk High risk Low risk Low risk Low riskSolomon [74] Unclear Unclear High risk Low risk Low risk High riskMarzillier [75] Low risk Low risk High risk Unclear Low risk High riskStravynski [72] Unclear Unclear High risk Unclear Low risk High riskBøen [69] Low risk Low risk High risk Unclear Low risk High riskCole [76] Low risk Low risk High risk Low risk Low risk High riskSchene [89] Unclear Unclear High risk Unclear Low risk High riskCastelein [86] Low Risk Low risk High risk Unclear Low risk High riskGelkopf [87] Low risk Unclear High risk Unclear Low risk High riskAmmerman [88] Unclear Low risk High risk Low risk Low risk High risk
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