Over the years, research has indicated associations between adverse social circumstances, such as poverty and socio-economic difficulties, lack of close social relationships, lack of employment and educational opportunities, and the development of mental health conditions. Similarly, a bi-directional relationship has been identified with mental health conditions leading to worse social outcomes. Effective interventions to improve social circumstances are considered a research priority, and the NIHR Mental Health Policy Research Unit (MHPRU) comes with some answers on the topic.
The MHPRU at University College London and King’s College London was established in 2017. Its aim is to help the Department of Health and Social Care and others involved in making nationwide plans for mental health services to make decisions based on good evidence. It makes expert views and evidence available to policymakers in a timely way and carries out research that is directly useful for policy. The MHPRU is managed by academics at UCL and KCL in partnership with the University of Greenwich. The MHPRU’s Lived Experience Working Group contributes to its work.
The MHPRU carried out a rapid evidence synthesis of reports on randomised controlled trials of interventions to improve social circumstances among adults with mental health conditions across eight social domains including housing and homelessness; money and basic needs; work and education; social isolation and connectedness; family, intimate and caring relationships; victimisation and exploitation; offending; and rights, inclusion and citizenship. The review was initiated in order to inform the UK Government about what interventions should be available more widely to improve people’s lives in each area of interest.
Effective interventions to improve social outcomes among people with mental health conditions are deemed a priority for research and policy.
Methods
The eight domains, and the specific questions within each, were created through consultation with government policymakers and a range of stakeholders, including people with personal experience of mental health difficulties, health and social care practitioners, and academics. The research team then sought systematic reviews and randomised controlled trails (RCTs) of any interventions relevant to any of the domains. Through this process, one systematic review (which incorporated 48 RCTs) and a further 102 individual RCT studies were found. The systematic review related to Individual Placement and Support (IPS) approaches to paid employment. Employment studies also comprised 28 of the RCTs, while the housing domain accounted for 18.
Results
The study found that by far the most robust and compelling evidence available related to gaining paid employment and to tackling homelessness.
Gaining paid employment: Individual Placement and Support
In the case of the former, Individual Placement and Support came out as a clear leader in terms of evidence of its effectiveness, particularly for people with a ‘severe mental illness’ but also among people with depression or anxiety. IPS emphasises rapid job search based on a person’s preferences, with support that continues when they start working.
IPS is based on eight key principles:
- Focus on open paid employment
- Eligibility is a choice and a right
- Integration of IPS with mental health or other clinical and support services
- Finding a preferred role
- Personalised benefits advice
- Rapid job search
- Employer engagement and job development
- Time-unlimited and individualised in-work support.
Tackling homelessness: Housing First
For the latter, the Housing First model provided the strongest evidence, where it was found to bring long term (for over two years) benefits to homeless people with severe mental illness diagnoses. The Housing First approach emphasises rapid placement in a tenancy, with wraparound support provided according to need (including for mental health or substance use). More information about the Housing First model and its application in England is available here: https://hfe.homeless.org.uk/.
The research produced fewer clear results beyond these two. For employment, they found little evidence for effective interventions to support reductions in sickness absence, and there was less evidence for housing support models other than Housing First. It is noted, however, that a Cochrane review (Nieuwenhuijsen 2020) found moderate evidence that a combination of work-directed and clinical interventions (such as psychological treatment), reduce sickness absence by an average of 25 days within the first year of follow-up. The most effective interventions combine targeting both the symptoms of poor mental health in the individual worker and elements of their workplace, for instance combining work-focused CBT with regular contact and communication from the line manager during sick leave.
The other six domains in the study also provided fewer clues for policymakers or commissioners of mental health services. Studies of interventions to prevent social isolation provided little evidence for effective approaches. There was only one RCT of support with money management and that showed little effect. And there were no RCTs at all relating to support with family relationships or parenting. Even though all eight domains are important to people living with mental health difficulties, six lack evidence to enable service providers to offer support with the best chance of working.
This review found that Individual Placement and Support and Housing First were the leading approaches supported by evidence to improve the social circumstances of people with mental health problems.
Conclusions
The article paints a disappointing picture of research into social needs for people with mental health difficulties. With just two exceptions, evidence relating to crucial questions about how people are supported to have a life with a mental illness is simply missing in the formal research literature. As the authors conclude:
…the overall picture from our review is of very large gaps in the evidence. Several social domains almost entirely lack an evidence base even though they are not only outcomes that are highly valued by service users and carers, but are also implicated as risk factors for onset and continuation of mental health conditions.
It does, nonetheless, provide invaluable evidence about where the existing research into social needs does give strong steers to policymakers and commissioners of mental health services, most notably about the importance of investing in IPS and Housing First. And it makes a powerful case for a stronger focus on meeting people’s social needs alongside traditional clinical interventions such as medication and psychological therapy. In the context of the Covid-19 pandemic, the cost of living crisis, the Black Lives Matter movement, and climate change, the message that citizenship, livelihood, safety, and equality are vital areas of concern for mental health services is a critical one for the government, the NHS and local councils alike to consider.
Although research gaps on the social needs of people with mental health conditions exist, the review provides invaluable evidence to invest in targeted interventions.
Strengths and limitations
The article provides a broad sweep across eight critical domains in people’s lives. Because the eight were selected through wide engagement – not invented in isolation – they represent important priorities for both research and service provision.
The major limitation of the study is that it does not look beyond RCT evidence. It is possible that a great deal more evidence is available from other sources, including service evaluations and peer-led research, which could shine a brighter light on many of the domains, and bring a stronger equality lens to it by exploring what works for specific groups of people. The absence of evidence one way or another for other social interventions shouldn’t be misinterpreted as implying they do not work – merely that the research economy has so far failed to embrace these important questions at the necessary scale to find their way into formal research literature.
The inclusion of literature beyond randomised controlled trials would bring a valuable perspective to the interpretation of the evidence.
Implications for practice
This study underlines once again the powerful case for the adoption at a scale of Individual Placement and Support (IPS), especially, but not solely, within secondary mental health services. The NHS Long Term Plan has already committed to expanding IPS nationwide so that more than 50,000 people are able to benefit from this intervention annually by 2024 (Hutchinson, 2022). It is now up to integrated care systems across England to ensure that they grasp this window of opportunity to build up their IPS services so that no one is denied the best chance to get into paid employment if and when they want to take it.
The study also makes it clear that Housing First has unfulfilled potential to support homeless people with mental health difficulties. Whether this approach or a modified version of it, might also be applicable for people facing housing insecurity but not street homeless is also worthy of consideration.
Given the similarities in approach between IPS and Housing First, the article itself makes three important points that can be drawn from their success:
- First, similarly to IPS and Housing First interventions, interventions which directly target the desired social circumstance, rather than providing an interim staged approach may result in greater benefit.
- Second, successful interventions identified in this review suggest that high-intensity support may be required to achieve improvements in social circumstances.
- Third, although we did not find a clear pattern of provision of multi-disciplinary team support, there is an indication that the enhanced and comprehensive care integration typical of both Housing First and IPS are important in producing positive outcomes.
The paucity of evidence in the other domains leads inevitably to the cliché that ‘more research is needed’. But this should not be at the expense of action in the here and now, while we wait for research to catch up.
Integrated care systems will rightly want to spend public money wisely, on interventions that matter to people and that have the best chance of producing benefits. The domains listed in the article could be a useful checklist for any commissioning body to identify what help it provides within each: including for different groups of people and communities within their local area.
This could very quickly highlight gaps, as well as identify to what extent existing provision coheres with the evidence (so far) of what works. But it can also help to shine a light on promising approaches and practice-based learning, especially where community and user-led organisations are meeting people’s social needs in ways that traditional research methodologies do not value or struggle to capture.
Ultimately, this study takes us closer to really value the social aspects of mental health care: the ways in which structural discrimination and injustice can be addressed in practice so that people with mental health difficulties have a fairer chance in life and the best possible support.
Commissioning bodies could be guided by the study to identify needed support across domains for different communities within a local area.
Statement of interest
The Centre for Mental Health works alongside the MHPRU to ensure the research is accessible and relevant to policymakers, practitioners, and the public.
Links
Primary paper
Other references
Hutchinson, J. (2022). Briefing 59: Individual Placement and Support. Centre for Mental Health.
Nieuwenhuijsen, K. et al. (2020). What are the best ways to help people with depression go back to work? Cochrane Review.
Photo credits
- Photo by Jon Tyson on Unsplash
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- Photo by J’Waye Covington on Unsplash
- Photo by Volodymyr Hryshchenko on Unsplash
