Effective, Scalable Interventions for Tackling Population Mental Health

The pandemic triggered an increase in the incidences of mental health problems across the globe. It also revealed a need to identify what mental health service provision, available at population-level, is effective.

A population-level problem naturally requires solutions that can be rolled out at scale.

Since January 2022, the EPPI-Centre (UCL), which is part of the the International Public Policy Observatory (IPPO) collaboration, has been conducting a systematic review of the most effective, scalable interventions to address anxiety and depression, shown to have surfaced during the COVID-19 pandemic.

The policy briefing that follows draws on the findings from IPPO’s review of the evidence for looking at a problem that naturally requires solutions that can be rolled out at scale. We’ve also put together a policy overview, to give you a sense of the landscape of work.

You can watch the launch of our systematic review and a discussion of its findings on November 17, 2022 below.

What did we want to know?

What are the most effective, scalable interventions to address widespread mental health issues that have surfaced during the COVID-19 pandemic?

This entailed conducting a multi-component review to answer the following questions on:

  • the nature and extent of mental health issues arising during COVID-19
  • the effectiveness of population-level mental health interventions and the factors potentially influencing scale-up of mental health interventions

What did we find?

Rates of depression, anxiety and PTSD are higher than they were before the pandemic. Overall, there is review-level evidence that psychological interventions, delivered at population-level, can have a positive impact on preventing and treating depression, anxiety, and PTSD.

Reviews of school-based interventions report evidence of positive effect on:

  • CBT for the universal and targeted prevention of anxiety at primary schools
  • CBT and CBT with psychoeducation for universal prevention of anxiety and depression in secondary schools
  • Mindfulness/relaxation for universal prevention of anxiety in secondary schools
  • Cognitive–behavioural with IPT for universal prevention of depression in secondary schools
  • Third wave CBT (e.g. ACT) for universal prevention of depression
  • Psychological therapies for indicated prevention of anxiety and depression in secondary schools

No evidence of difference was found between intervention and control groups for

  • Universal or targeted prevention of depression in primary schools
  • Targeted prevention of anxiety or depression in secondary schools

Reviews of digital intervention for children report evidence of positive effect on:

  • CBT-based interventions delivered via the internet, smartphone or mobile apps for treating depression and anxiety

Reviews of community-based interventions for children report evidence of positive effect on:

  • CBT for treating anxiety and depression
  • Psychotherapy for treating depression
  • A range of trauma-informed CBT and psychotherapeutic approaches for treating PTSD

No evidence of difference was found between intervention and control groups for treatment of PTSD when delivering supportive counselling or family therapy.

Reviews of workplace interventions report evidence of positive effect on:

  • Mindfulness training intervention for universal prevention of anxiety and depression.
  • Psychoeducation for universal prevention of depression
  • Cognitive behavioural interventions, and self-help interventions combined with exercise for indicated prevention of depression.

Reviews of digital intervention for adults report evidence of positive effect on:

  • CBT and ACT based smartphone apps for preventing and treating anxiety
  • Compositive psychological interventions for treatment of anxiety (e.g. iCBT, iACT)
  • Internet-based CBT for treatment of anxiety, depression and PTSD
  • They also report no evidence of difference for CBT and ACT based smartphone apps for treatment of PTSD when comparted to control groups

Reviews of community-based interventions for children report evidence of positive effect on:

  • Stress Control Programmes for preventing anxiety and depression
  • IAPT and CBT based psychological therapies for treating anxiety and depression

How to achieve scale-up?

Primary studies provided evidence on scaling up of mental health and psychosocial interventions. The evidence suggest that programmes may be more likely to achieve scale-up if they:

Intervention characteristics:

  • Increase access to services across time and place by digitising interventions and making them available online
  • Expand the workforce by task shifting or task sharing from specialists to non-specialists
  • Use technology and online provision to train non specialists and speed up workforce availability
  • Enable self-referral and make mental health interventions more open access

Resource related factors:

  • Secure policy support and government funding for scaling by demonstrating evidence of impact
  • Identify when additional resource is needed for scale-up to support greater implementation success
  • Match service level to needs by identifying care pathways, signposting, or stepped care
  • Integrate mental health services into primary care to make more efficient use of resources

Working together:

  • Employ effective leaders to gain lasting buy-in from stakeholders on scale-up of services
  • Include knowledgeable local champions to promote new services at set- up and maintenance
  • Gain the buy in of multi-stakeholders, including the implementers of programmes

Programme fidelity (to ensure scale up happens as intended):

  • Provide training fidelity and knowledge transfer to provide skills for consistency in provision
  • Use guidelines, templates, manuals to provide a common shareable framework for delivery

Monitoring and Evaluation:

  • Use benchmarks and indicators to measure progress against and support future investment
  • Include ongoing evaluation of the quality and feasibility of services and track scale-up progress
  • Standardise training and adopt recognised accreditation models to disseminate the programme more widely and implement best practice while seeking greater reach

Test the acceptability of an intervention prior to scale-up

  • Assess acceptability to implementers to anticipate potential organisational changes needed
  • Assess acceptability to service users to ensures services are meeting needs and reach

Contextual factors:

  • Engage with the socio-political context of programme implementation to assess and ensure fit
  • Consider cultural factors and adaption needs by integrating local knowledge and practices with evidence-based programmes to contribute to contextually appropriate service delivery.

Combine supply side and demand side approaches

  • Use resource mapping to identify population needs and service gaps.
  • Take proactive efforts to raise awareness of the programmes in the target community
  • Minimising barriers to service use through campaigns to reduce stigma towards mental ill health

What are the implications for policy and practice?

The evidence-base for the effectiveness of population-mental health and psychosocial interventions continues to gain traction. However, if effective mental health and psychosocial interventions are to be made available at population-level, they need to be scaled appropriately.

Policy and practice support for scale-up is critical in this endeavour, and more so when scaling requires intervention, organisational and system-level changes. Government commitment in the form of policy initiatives and resource allocation is key to ensuring the sustainable impact of scaled intervention. Feasibility and cost-effectiveness analysis, prior to scale-up and throughout implementation, could also help inform the success of scale-up strategies.

There is consistent evidence on the effectiveness of community-based population-level mental health services for treating symptoms of anxiety, depression and PTSD. Large-scale nationwide programmes, such as Increasing Access to Psychological Services (IAPT), which provides a stepped-care approach to maximise availability of services to need (e.g., low to high intensity CBT, counselling interpersonal therapy) is now very well established in England and Wales.  The rollout of similar public mental health care in other regions would require significant government policy buy-in to enable and maintain any infrastructure changes needed. It would also require an investment in human resource to establish a trained and competent workforce and support and any organisational culture changes identified.

The review-level evidence for school-based prevention interventions is mixed. While findings suggest that universal and targeted prevention can work to delay the onset or worsening of anxiety symptoms in primary schools, replication of results were not found for depression.  Similarly, findings for interventions delivered in secondary schools suggested that CBT-based approaches work for universal prevention of anxiety and depression, but not targeted prevention. While there is evidence of effectiveness for indicated prevention in adolescents. To address this, it might be useful to consider taking a stepped care approach in schools. For example, providing universal prevention interventions for all students alongside targeted individualised support for children and young people with elevated symptoms. The school will continue to be a site in which to reach large numbers of children and young people, but more understanding of how interventions need to be tailored to meet their needs as they develop is required.

There are a variety of effective universal and indicated workplace prevention interventions for depression and anxiety. Sustained, long-term investment in occupation-based mental health interventions by employers, ensuring they are both acceptable and accessible to employees, continues to be an important route when seeking to reach a large proportion of the adult population and support ongoing mental health efforts in light of the pandemic.  The workplace also provides an opportunity to implement key scale up-strategies, such as: adopting effective leadership and deploying champions to promote mental health initiatives, engaging with multi-sectoral partners to provide on and off-site services (e.g., employee assistance programmes), using benchmarks and indicators to measure progress against and incorporating ongoing evaluation of the quality and feasibility of services to track effectiveness and scale-up progress.

Although the evidence-base for the effectiveness of digital and mobile app interventions is currently modest, with greater effect sizes for internet-delivered interventions with professional input, the potential scale-up of specialist and non-specialist online psychological support and increasing transnational reach of mental health provision remains. Thus, further consideration of the role of digital mental health, in the prevention and treatment of mental health symptoms as part of a stepped-care approach to service delivery is warranted. Online platforms also provide a resource efficient way to reach and train a workforce necessary for the delivery of mental health services, on and offline, including provision of supervision and cascading of best practice to ensure fidelity. This of course, is particularly salient in the context of COVID-19 and any future infectious disease crises, as many mental health services remain virtual as we continue to use a hybrid model of working.

As highlighted, there is consistent evidence of improving intervention reach and scale-up of mental health services through stepped care models of provision. That is, where low intensity and brief interventions are offered as a first-line approach, with more intensive interventions made available for those with more severe needs.  Taking a stepped care approach can be supported by task-shifting, where lower severity mental health needs can be shifted to non-specialists, (with referral to specialists at higher level of needs if required), enabling greater access to mental health services that would otherwise be the case if providers needed extensive training.

However, in most scale-up scenarios, there will be a need to substantially enlarge the mental health workforce to scale interventions to effectively target large populations with prevention needs and smaller populations of people who require more intensive treatments. This can be supported by using guidelines, templates, manuals to provide a common intervention framework and ensure intervention fidelity, as stated, by utilising digital platforms to support and train the workforce and speed up their availability.

In the aftermath of COVID-19, the key to the scale up of mental health provision is being aware of and meeting demand needs. National and regional policy and practice initiatives can achieve scale-up by setting up strategic partnerships, with multi-stakeholders, which integrates local knowledge alongside knowledge of evidence-based mental health interventions. Doing so, can inform the maximisation of resources, how best to adapt interventions, and build a strong leadership team and trained workforce to implement services, as closely as intended to achieve intended reach. In the long-term, these mental health strategic partnerships can contribute knowledge on how to scale and deliver mental health programmes at population level and support best practice for similar initiatives in the future.

How did we get these results?

This project contained three stages. First, we conducted an overview of systematic reviews on prevalence published between 2021-2022 identified from the IPPO Living Map. Second, we conducted an overview of systematic reviews on population mental health and psychosocial intervention sampling general populations. Third we conducted an analysis of primary studies on scale-up of interventions. Descriptive data on characteristics and findings were extracted and synthesised narratively and in tables.