Last week, the Jo Cox Commission on Loneliness (2017) report provided us with a timely reminder that anyone can feel isolated. Of course, this can happen especially to people living with long-term mental or physical illness. Often, what people need, is simply a friend. Having someone to engage with and carry out social activities with. This can do wonders for self-esteem and mental health.

Sadly, statistics show that over 50% of people with mental health problems regularly feel lonely and isolated (Perese & Wolf, 2005). A recent Mental Elf blog highlighting research by Sweet et al., (2017) further highlights the importance of social networks, for preventing and managing mental health problems.

Befriending interventions aim to lessen these feelings of isolation by recruiting volunteers to ‘befriend’ patients, spend time with them and support them. To date, research investigating befriending is limited. But what does exist, is promising.

A recent study by Siette, Cassidy and Priebe (2017) has provided a comprehensive review of the current state of the research on befriending interventions for different patients with various types of conditions.

Methods

The authors carried out a systematic review and meta-analysis. They searched nine databases and grey literature sources for interventions delivered to individuals of all ages, ethnicities, genders and nationalities, irrespective of their health status and defined a befriending intervention as any intervention where the main aim is “building a ‘friendship’ and providing social support”. Their literature searches looked for a range of physical and mental health indications including depression, anxiety, mental illness, cancer, physical illness and dementia. To be included in the analysis, the interventions had to be delivered by volunteers (not family members), be free and be delivered by someone who did not have the same health condition as the patient.

Three reviewers independently checked the full text papers of all retrieved articles to decide whether they should be included in the meta-analysis and data from each study was then extracted independently by two authors. Each included trial was assessed for bias (a measure of the quality of a study) using the Cochrane Collaboration Risk of Bias tool (Higgins et al., 2011).

Results

A total of 14 trials (2,411 participants) were included in the final analysis.

The included studies tested the effectiveness of befriending interventions for patients in different populations such as depressed elderly participants who required physical and emotional support, women with anxiety and depression, individuals with severe mental illness, and carers in dementia.

The quality of included studies were graded as follows:

Study Quality	Number of Studies	Study Details
High	7	Charlesworth et al. (2008) Harris et al. (1999) McCorkle et al. (2008) Mountain et al. (2014) Rantanen et al. (2015) Walshe et al. (2016) White et al. (2012)
Medium	3	Davidson et al. (2004) McNeil et al. (1991) Sheridan et al. (2015)
Low	4	Coe et al. (2013) Heller et al. (1991) Hughes et al. (1999) MacIntyre et al. (1999)

Befriending interventions varied in frequency, length of contact and method of delivery. The befriending schemes shared a core component of nurturing a social relationship between a volunteer and patient who, together, participate in social and recreational activities.

In their final meta-analysis, the authors included a mixture of randomised controlled studies and non-randomised studies such as case series.

The authors compared befriending and usual care with no treatment and reported that only patient-reported primary outcomes gave what they describe as a significant effect (p=0.05), with a standardised mean difference (SMD) of 0.18 (95% CI -0.002 to 0.36, I²=26%).  Note, however, that the confidence interval dips below zero.  The results may not be statistically significant, and could be due to chance variation.

Furthermore, the authors describe this as a “rather small effect size”.  Clearly the clinical significance of this effect should be considered as well as the statistical significance of the data.

Quality of life demonstrated that befriending showed what the authors describe as a “borderline significant effect” (p=0.08); there was an SMD of 0.24 (95% CI 0.52 to -0.03, I²=57%). No effect was shown on depression, loneliness, social support measure and well-being.

The patient-reported outcomes included measures across depression, social support, social network, mental well-being, quality of life and social functioning.

Conclusion

The authors claim their review shows that current evidence supports the notion that befriending interventions should be delivered as an effective treatment for individuals with a wide range of physical and mental health problems.

They conclude:

Befriending interventions achieve an overall improvement benefit in patient-reported primary outcomes, although with a rather small effect size.

Strengths and limitations

There are many strengths to commend in this review:

• First and foremost, this was one of the first all-encompassing examination of all existing studies of befriending on a range of different outcomes related to mental health and general wellbeing.
• Another strength was that the authors tried to avoid potential biases that some studies tend to have when they emphasise seemingly ‘important’ outcomes that were not actually of their main interest. They achieved this by choosing only outcomes that the patient reported rather than outcomes that studies reported.
• The reviewers also ensured that their analyses (between befriending and the outcome measures they were interested in) were divided independently for comparison. In doing so, they were able to compare differences of the associations between befriending and relevant outcomes that they were interested in.

There are also various limitations that should be taken into consideration:

• The reviewers reported significant effects (patient-reported primary outcomes and quality of life) where the confidence interval crossed the line of no effect.
• Patient-reported outcomes are not the same thing as patient-important outcomes.
• It was a post-hoc decision to focus on patient-reported outcomes (this was checked via email with the first author as the review protocol was not published online), which brings into question the validity of this finding.
• The authors acknowledged that they were unable to collect data about the participant engagement across time with the befriending intervention. It may be possible that participants were initially engaged but dropped out when their illness increased in severity. This impacts (and partly indicates) the effectiveness of a befriending intervention and also limits the ability to summarise an optimal length of time required for delivery of the befriending intervention in order for it to be effective.
• This review included several different patient-reported outcomes that showed overall improvement after intervention, but there were significant overlaps between these outcomes. For example depression, quality of life and well-being were all used as independent outcome measures, but could describe the same construct. This may overestimate the effectiveness of the intervention.
• Lastly, the authors acknowledge that the conclusion from this study may not be applicable on an individual level as the extracted studies differ greatly in terms of methods of delivering the intervention, length of intervention and the health conditions of the patients. Therefore, the underlying mechanism and how precisely befriending programmes can facilitate social integration and recovery for particular individuals is rather unclear.

Implications for practice

Qualitative reviews do suggest that befriending interventions support patients’ engagement in social activities, and are described as a useful complement to clinical practice due to their user acceptability and potential ability to influence mental health outcomes.

One of the issues raised in the study relates to the ambiguity regarding the reported outcomes. As identified by the authors, measuring a range of outcomes including depression and loneliness in patients who may not have a problematic baseline score of these, may dilute the seen effects. According to the stress buffering hypothesis, those who perceive themselves as having adequate social support can draw on this in stressful situations to alleviate its impact (Cohen & Wills, 1985). Therefore, for those patients who perceive their existing social support as being sufficient, a befriending intervention may not provide any additional mental or physical health benefits. What appears to be of more importance for clinical practice is identifying those patients who perceive their social support to be insufficient and may benefit more from a befriending intervention.

Despite finding insignificant effects for befriending on clinician-related outcomes, the authors claim to have found a significant effect in patient-reported outcomes (see above for clarification on this point). A significant effect in patient-reported outcomes would suggest that the benefits of befriending to patients’ recovery may play a valuable role, which is not necessarily observed through symptom-measurement. Future research should seek to investigate a specific model for the hypothesised effect of befriending and choose an appropriate outcome measure in order to investigate its impact with more clarity.

Factors to consider when developing/delivering befriending interventions

For the time being, the authors suggest some practical factors for consideration when developing and delivering befriending interventions:

• The key focus of the partnership should be to build a genuine friendship in which the pair are well-matched and collaboratively develop realistic outcomes within a supportive and sustainable context
• This is facilitated through befriender training, which would involve participants’ expectations, attitudes and behaviour, and target mutuality and reciprocity to establish an empathic relationship
• Temporality should also be considered, for instance intervening in the first phase of illness or providing longer befriender commitments to provide greater social support.

Factoring these considerations into current befriender models may have a positive effect on intervention impact.

Primary paper

Other references

Cohen, S., & Wills, T. A. (1985). Stress, Social Support and the Buffering Hypothesis. Psychological Bulletin, 98, 310-357.

Jo Cox Commission on Loneliness (2017) Combatting loneliness one conversation at a time A call to action (PDF).

Higgins, J. P. T., Altman, D. G., & Sterne, J. A. C. (2011). Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, Green S, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Retrieved from www.handbook.cochrane.org

Mental Elf blog based on Sweet et al. (2017). Retrieved from: https://www.nationalelfservice.net/mental-health/schizophrenia/personal-well-being-networks-for-severe-mental-illness-the-importance-of-being-social/

Perese, E. F., & Wolf, M. (2005). Combating Loneliness among Persons with Severe Mental Illness: Social Network Interventions’ Characteristics, Effectiveness and Applicability. Issues in Mental Health Nursing, 26(5), 591-609.

Sweet, D., Byng, R., Webber, M., Enki, D. G., Porter, I., Larsen, J., Huxley, P., & Pinfold, V. (2017). Personal well-being networks, social capital and severe mental illness: exploratory study. The British Journal of Psychiatry, 1-10.

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• Derek Harper CC BY 2.0
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