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

TLDR: In this article, the authors conducted a systematic review on COVID-19 community-based mental health interventions registered in PROSPERO and to the best of their knowledge, the first systematic review to synthesize evidence on completed randomised controlled trials of COVID19 mental health intervention.

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

Figures

Table 1. Characteristics of Included Trials

Figure 3. Forest Plot, Intervention Effects on Depression in Trials Designed Specifically for COVID-19

Table 2. Risk of Bias of Included Trials

Table 3. Reporting Quality of Interventions Based on TIDieR Checklist

Figure 2. Forest Plot, Intervention Effects on Anxiety in Trials Designed Specifically for COVID-19

Figure 1. PRISMA 2020 Flow Diagram: Searches through March 22, 2021

Full text

Mental Health Interventions in COVID-19
1
!
Effects of COVID-19 Mental Health Interventions among Community-based Children,
Adolescents, and Adults: A Living Systematic Review of Randomised Controlled Trials
Olivia Bonardi
1
; Yutong Wang
1
; Kexin Li, BSc
1
; Xiaowen Jiang, BA
1
; Ankur Krishnan, MSc
1
;
Chen He, MScPH
1
; Ying Sun, MPH
1
; Yin Wu, PhD
1,2
; Jill T. Boruff, MLIS
3
; Sarah Markham,
PhD
4
; Danielle B. Rice, MSc
1,5
; Ian Thombs-Vite
1
; Amina Tasleem
1,5
;
Tiffany Dal Santo
1,5
;
Anneke Yao
1,5
; Marleine Azar, MSc
1
; Branka Agic, MD
6,7
; Christine Fahim, PhD
8
; Michael S.
Martin, PhD
9,10
; Sanjeev Sockalingam, MD
6,11
; Gustavo Turecki, MD
2,12
; Andrea Benedetti,
PhD
13-15
Brett D. Thombs, PhD
1,2,5,13,14,16,17
1
Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec,
Canada;
2
Department of Psychiatry, McGill University, Montreal, Quebec, Canada;
3
Schulich
Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal,
Quebec, Canada;
4
Department of Biostatistics and Health Informatics, King's College London,
London, UK;
5
Department of Psychology, McGill University, Montreal, Quebec, Canada;
6
Centre
for Addiction and Mental Health, Toronto, Ontario, Canada;
7
Dalla Lana School of Public Health,
University of Toronto, Toronto, Ontario, Canada
8
Li Ka Shing Knowledge Institute, Unity Health
Toronto, Toronto, Ontario, Canada;
9
School of Epidemiology and Public Health, University of
Ottawa; Ontario, Canada;
10
Correctional Service of Canada, Ottawa, Ontario, Canada;
11
Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada;
12
McGill Group for
Suicide Studies, Douglas Mental Health University Institute, McGill University, Montreal,
Quebec, Canada;
13
Department of Epidemiology, Biostatistics, and Occupational Health, McGill
University, Montreal, Quebec, Canada;
14
Department of Medicine, McGill University, Montreal,
Quebec, Canada;
15
Respiratory Epidemiology and Clinical Research Unit, McGill University
Health Centre, Montreal, Quebec, Canada;
16
Department of Educational and Counselling
. CC-BY-NC 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 7, 2021. ; https://doi.org/10.1101/2021.05.04.21256517doi: medRxiv preprint
NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.

Mental Health Interventions in COVID-19
2
!
Psychology, McGill University, Montreal, Quebec, Canada;
17
Biomedical Ethics Unit, McGill
University, Montreal, Quebec, Canada;
Corresponding author:
Brett D. Thombs, PhD; Jewish General Hospital; 4333 Cote Ste Catherine Road; Montreal,
Quebec, Canada, H3T 1E4; Tel (514) 340-8222 ext. 25112; E-mail: brett.thombs@mcgill.ca
ORCID: 0000-0002-5644-8432
Word Count: 3,500
. CC-BY-NC 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 7, 2021. ; https://doi.org/10.1101/2021.05.04.21256517doi: medRxiv preprint

Mental Health Interventions in COVID-19
3
!
ABSTRACT
Background: Scalable interventions to address COVID-19 mental health are needed. Our
objective was to assess effects of mental health interventions for community-based children,
adolescents, and adults.
Methods: We searched 9 databases (2 Chinese-language) from December 31, 2019 to March
22, 2021. We included randomised controlled trials with non-hospitalised, non-quarantined
participants of interventions to address COVID-19 mental health challenges. We synthesized
results descriptively but did not pool quantitatively due to substantial heterogeneity of
populations and interventions and concerns about risk of bias.
Findings: We identified 9 eligible trials, including 3 well-conducted, well-reported trials that
tested interventions designed specifically for COVID-19 mental health challenges, plus 6 trials of
standard interventions (e.g., individual or group therapy, expressive writing, mindfulness
recordings) minimally adapted for COVID-19, all with risk of bias concerns. Among the 3
COVID-19-specific intervention trials, one (N = 670) found that a self-guided, internet-based
cognitive-behavioural intervention targeting dysfunctional COVID-19 worry significantly reduced
COVID-19 anxiety (standardized mean difference [SMD] 0.74, 95% CI 0.58 to 0.90) and
depression symptoms (SMD 0.38, 95% CI 0.22 to 0.55) in Swedish general population
participants. A lay-delivered telephone intervention for homebound older adults in the United
States (N = 240) and a peer-moderated education and support intervention for people with a
rare autoimmune condition from 12 countries (N = 172) significantly improved anxiety (SMD
0.35, 95% CI 0.09 to 0.60; SMD 0.31, 95% CI 0.03 to 0.58) and depressive symptoms (SMD
0.31, 95% CI 0.05 to 0.56; SMD 0.31, 95% CI 0.07 to 0.55) 6-weeks post-intervention, but these
were not significant immediately post-intervention. No trials in children or adolescents were
identified.
. CC-BY-NC 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 7, 2021. ; https://doi.org/10.1101/2021.05.04.21256517doi: medRxiv preprint

Mental Health Interventions in COVID-19
4
!
Interpretation: Internet-based programs for the general population and lay- or peer-delivered
interventions for vulnerable groups may be effective, scalable options for public mental health
in COVID-19. More well-conducted trials, including for children and adolescents, are needed.
Funding: Canadian Institutes of Health Research (CMS-171703; MS1-173070); McGill
Interdisciplinary Initiative in Infection and Immunity Emergency COVID-19 Research Fund (R2-
42).
Registration: PROSPERO (CRD42020179703); registered on April 17, 2020.
. CC-BY-NC 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 7, 2021. ; https://doi.org/10.1101/2021.05.04.21256517doi: medRxiv preprint

Mental Health Interventions in COVID-19
5
!
RESEARCH IN CONTEXT
Evidence before this study: We searched for systematic reviews of randomised controlled
trials of interventions to address mental health challenges in COVID-19. We used searches from
our living systematic review, which were not limited by study design and reviewed citations
through April 29, 2021 from MEDLINE, PsycINFO, CINAHL, EMBASE, Web of Science, China
National Knowledge Infrastructure, Wanfang, medRxiv (preprints), and Open Science
Framework Preprints (preprint server aggregator). We identified 4 systematic reviews of
interventions for COVID-19 mental health with search dates between April and September
2020. None, however, included evidence from any completed randomised controlled trials on
mental health interventions for community-based children, adolescents, or adults during COVID-
19.
Added value of this study: Our systematic review is the only living systematic review on
COVID-19 community-based mental health interventions registered in PROSPERO and, to the
best of our knowledge, the first systematic review to synthesize evidence on completed
randomised controlled trials of COVID-19 mental health interventions. The sheer volume of
evidence being published in COVID-19 poses a barrier to effective synthesis and policy
response. We reviewed over 45,000 citations in any language and distilled this to 9 verified
eligible community-based trials. Of these, there were 3 well-conducted trials of interventions
designed specifically to be scalable to address challenges of public mental health in COVID-19.
One trial showed that internet-based cognitive behavioural therapy in the Swedish general
population (N = 670) reduced COVID-19 anxiety and symptoms of depression. Trials that tested
a lay-delivered telephone support intervention for homebound older adults in the United States
(N = 240) and a peer-moderated group intervention for people with a rare autoimmune condition
from 12 countries (N = 172) also found that they improved mental health outcomes, although
not all outcomes were statistically significant.
. CC-BY-NC 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 7, 2021. ; https://doi.org/10.1101/2021.05.04.21256517doi: medRxiv preprint

Frequently asked questions

Q1. What contributions have the authors mentioned in the paper "Mental health interventions in covid-19 1 effects of covid-19 mental health interventions among community-based children, adolescents, and adults: a living systematic review of randomised controlled trials" ?

Bonardi et al. this paper conducted a systematic review of mental health interventions in the SARS-CoV-2 coronavirus disease ( COVID-19 ) pandemic and found that mental health challenges may include loneliness, boredom, grief and loss, depression, stress, worry, fear, burnout and anxiety. 

Q2. What is the way to address the effects of COVID-19?

24 DISCUSSIONScalable, feasibly delivered interventions are needed to address community mental healthimplications of COVID-19 that will likely persist beyond the pandemic. 

Q3. What funding was provided for the living systematic review?

The living systematic review was funded by the Canadian Institutes of Health Research (CMS-171703; MS1-173070) and McGill Interdisciplinary Initiative in Infection and Immunity Emergency COVID-19 Research Fund (R2-42). 

Q4. What are the factors that appear to be associated with greater likelihood of effectiveness?

factors that appear to be associated with greater likelihood of effectiveness include shared experiences or characteristics among participants and the ability of participants to speak freely and develop relationships. 

Q5. What are the common types of interventions for COVID-19?

The authors identified 9 eligible trials, including 3 well-conducted, well-reported trials that tested interventions designed specifically for COVID-19 mental health challenges, plus 6 trials of standard interventions (e.g., individual or group therapy, expressive writing, mindfulness recordings) minimally adapted for COVID-19, all with risk of bias concerns. 

Q6. How many well-designed interventions were identified for COVID-19?

The authors identified 3 wellconducted trials of potentially scalable interventions designed to address COVID-19 mental health in the general public24 and among people vulnerable in COVID-19 due to age and preexisting medical conditions. 

Q7. What were the risk of bias items in the trial?

Among the 6 trials,25-30 one trial25 had 3 high risk ratings, and the other 5 trials26-30had between 4 and 6 unclear or high ratings out of 7 risk of bias items. 

Q8. how many trials were excluded after title and abstract review?

Of these, 45,536were excluded after title and abstract review and 146 after full-text review, leaving 95 trials, of which 59 evaluated interventions for people hospitalised or quarantined due to COVID-19, 10 assessed single-session interventions without subsequent follow-up, 4 were non-randomised trials, and 13 were not verified by authors (6 without author contact information in publication or online; 7 no response), leaving 9 eligible, verified RCTs for inclusion22-30 (Figure 1). 

Q9. What did the researchers find to be the effective intervention for COVID-19?

The authors identified 6 trials that tested delivery of standard psychological interventions withoutsignificant adaptation for COVID-19, including individual or group-based cognitive behavioural therapy,25,28 expressive writing,26,29 and self-guided mindfulness apps or audio recordings. 

Q10. Why did the authors not pool results across trials?

The authors did not pool results across trials because of substantial heterogeneity of populations, interventions, and outcomes and concerns about risk of bias.