We identified 8819 articles from the search of five databases. We conducted full text screening of 175 articles, finding 31 to be eligible. One other article was identified through reviewing the reference lists, bringing the total to 32 included articles (Fig. 1).
A total of 1945 participants were involved in the 32 studies, with individual sample sizes ranging from 4 to 300. Twenty-six studies had fewer than 100 participants. The target populations involved individuals with depressive symptoms (n = 12) (45,46,47,48,49,50,51,52,53,54,55,56), psychotic symptoms (n = 7) (57,58,59,60,61,62,63), trauma (n = 4) (64,65,66,67), social anxiety disorder (n = 2) (68,69), suicidal intent (n = 1) (70) and elevated levels of distress (n = 1) (71). Five other studies involved participants with a variety of mental health conditions, including bipolar disorder, mood disorders and affective disorders (72,73,74,75,76). Some studies recruited individuals from more than one diagnostic group, for example individuals with diagnosis of schizophrenia, major depressive disorder, or bipolar disorder (72), or individuals with schizophrenia or affective disorder (74).
Of the total of 32 studies, 16 (50%) were feasibility or pilot studies (45,47,48,51,52,53,55,57,59,60,61,63,66,68,69,73). Most were uncontrolled, pre-post measures pilot studies and four were pilot RCTs (48,51,59,63). We grouped these studies as feasibility studies as their primary aim was to assess the feasibility and preliminary evidence of conducting future definitive trials utilizing the same interventions (77). All feasibility studies also reported effectiveness outcomes. Seven other studies (21.9%) (46,49,58,65,67,72,76) used the single-group/pre-post measures design. Nine included studies were effectiveness trials (28.1%) (50,54,56,62,64,70,71,74,75), of which three were fully powered RCTs and six were RCTs that were not fully powered; all with the primary aim of assessing intervention effectiveness. Overall, nine of 32 studies used mixed methods (36%).
Twelve studies were carried out in the United States (48,49,52,54,55,56,63,64,66,72,74,75), eleven in Australia (45,47,53,57,60,61,68,69,71,73,76), two in Netherlands (59,62), one in China (67), one in Iran (50), one in Korea (65), one in Portugal (58), one in Sri Lanka (70), one in Taiwan (46) and one in the United Kingdom (51). Only four studies (12.5%) were conducted between 2000–2010 (47,55,56,63); the others were conducted between years 2011–2020, among which 21 studies were conducted within the last five years (2016–2020) at the time of conducting this review.
The interventions evaluated used technology to relay therapeutic content, to provide social support and as a tool for distance follow-up or monitoring. Although there were interventions designed specifically to reduce loneliness (n = 2) (60,68), most aimed to promote the well-being of participants, such as improving social functioning or mental and physical health outcomes. In these studies, social isolation was not the primary outcome, but was included among a range of psychosocial outcomes instead. Only four studies explicitly stated their primary and secondary outcomes – among these, one listed loneliness and perceived social support among their primary outcomes (61), and another listed objective social participation (62). Other studies did not explicitly differentiate between primary and secondary outcomes, although six studies did lay out their primary objectives/hypotheses (45,49,60,68,74,75).
Of the 32 studies, 29 assessed subjective social isolation, two measured objective social isolation (62,65) and one assessed both subjective and objective social isolation outcomes (69). Overall, loneliness and perceived social support were the most assessed dimensions of social isolation, whereas for objective social isolation specifically, social network size and time spent with others were assessed. Commonly used validated outcome measures included the: University of California Los Angeles Loneliness Scale (UCLA-LS) (n = 7) (46,47,57,60,61,68,69), Medical Outcomes Trial-Social Support Scale (MOS-SSS) (n = 7) (48,53,63,66,70,74,75), Social Provisions Scale (SPS) (n = 4) (51,57,61,72), Multidimensional Scale of Perceived Social Support (MSPSS) (n = 3) (52,64,73) and Social Connectedness Scale (SCS) (n = 2) (45,69). Seven studies used more than one social isolation measure (48,49,53,57,61,63,69). Four studies used unvalidated outcome measures including single-item measures, multiple-item measures and questionnaires administered via the Experience Sampling Method (ESM) (48,54,59,62). Detailed characteristics of studies, including study aims, sample sizes, study designs and outcome measures, are outlined in Table 1 (feasibility studies), Table 2 (single-group studies) and Table 3 (effectiveness trials).
Table 2
the study characteristics of single-group studies, stratified by study design
Single-group study(s) (n = 4)
|
Author, year, country
|
Participants
|
Setting
|
Aim
|
Follow up
|
Outcome measure(s)
|
Wang, 2016, China
|
Individuals with experience(s) of traumatic event in the previous 3–60 months and reported 2 or more PTSD symptoms
|
- Urban sample: Internet advertisements
- Rural sample: counselling centre in Sichuan province
|
(1) how urban and rural participants used the CMTR program, including general program usage and program adherence, (2) how program use was related to demographics (ie, sex, age, highest level of education attained, marital status, and annual family income), health problems (ie, PTSD and depressive symptom severity, trauma duration), psychological factors (ie, coping self-efficacy), and social factors (ie, social functioning impairment and social support after trauma) before the intervention, and (3) how program use was associated with change in outcomes after the treatment and at 3-months’ follow-up
|
Long-term follow up: 3-month
|
- Social isolation outcomes: Crisis Support Scale
- Other outcomes: PTSD symptoms, depressive symptoms, trauma coping self-efficacy, social functioning and program use
|
Lee, 2018, Korea
|
Individuals (aged 20–65 years) diagnosed with PTSD following workplace accidents
|
Seoul National University Hospital and the Complex Regional Pain Syndrome Association in Korea
|
To investigate the effectiveness of an online imagery-based program for treating the psychiatric symptoms of patients with PTSD related to workplace accidents.
|
End of treatment: 4-week
|
- Social isolation outcomes: social support network via Functional Social Support Questionnaire (FSSQ)
- Other outcomes: depressed mood, anxiety symptoms, PTSD symptoms, positive changes that occur after traumatic event, suicidal ideation
|
Goodwin, 2018, USA
|
Individuals (aged 18 years or older) with depressed mood or anhedonia and has visited primary care clinic in the previous 6 months
|
Primary care offices in urban and suburban areas in the USA
|
To examine helpfulness and safety of the Psycho-Babble
|
End of treatment: 6-week
|
- Social isolation outcomes: loneliness via loneliness item of Center for Epidemiologic Studies Depression Scale (CES-D-10), perceived social support via Perceived Social Support from Friends scale
- Other outcomes: depression, self-efficacy, hopelessness, self-harm ideation, program ratings, rate of concerning content on the ISG
|
De Almeida, 2018, Portugal
|
Individuals (aged over 18 years) diagnosed with schizophrenia and attend psychosocial rehabilitation services
|
Outpatient mental health services centre in Portugal
|
To present the acceptability and model of analysis of weCOPE app
|
End of treatment: 8-week
|
- Social isolation outcomes: Social Support Satisfaction Scale
- Other outcomes: recovery, empowerment, self-efficacy, personal and social performance, positive and negative symptoms
|
Mixed-methods study(s) (n = 3)
|
Author, year, country
|
Participants
|
Setting
|
Aim
|
Control group
|
Follow up
|
Data collection method
|
Quantitative: outcome measure(s)
|
Qualitative
|
Loi, 2016, Australia
|
Older adults
|
Aged care specialized facility accommodating adults with a variety of psychiatric conditions
|
To investigate a structured training program on using the internet via touch technology (TT) to residents with psychiatric conditions living in residential care facility.
|
None
|
End of treatment: 6-week
|
- Social isolation outcomes: social isolation via Hawthorne Friendship scale
- Other outcomes: self-esteem, familiarity of use and attitudes toward the Internet (via Internet questionnaire using 5-point Likert Scales)
|
Open-ended questions on the post-Internet questionnaire
|
Chen, 2020, Taiwan
|
Older adults (aged 65 years or above) with depressed mood
|
Long-term care facilities with more than 100 beds in Southern Taiwan
|
To investigate the effect of a social robot intervention on depression, loneliness, and quality of life of older adults in long-term care and to explore participants’ experiences and perceptions after the intervention.
|
None
|
- Mid-term follow-up: A week before 8-week observation (T1), end of 8-week observation (T2), mid-point of 8-week intervention (T3)
- End of treatment: end of 8-week intervention (T4)
|
- Social isolation outcomes: loneliness via UCLA-LS-3
- Other outcomes: depressed mood, quality of life
|
Individual semi-structured interview to explore participants’ experience and perceptions of participating in the Paro intervention
|
Aschbrenner, 2016, USA
|
Adults (aged 21 or older) with a chart diagnosis of schizophrenia, schizoaffective disorder, MDD, or bipolar disorder; on stable pharmacological treatment and had body mass index (BMI) over 30
|
An urban community mental health center in southern New Hampshire, USA
|
To explore peer-to-peer support among individuals participating in a group lifestyle intervention that included social media to enhance in person weight management sessions.
|
None
|
End of treatment: 24-week
|
- Social isolation outcomes: social support from group members (Social Provisions Scale-Short Form SPS-10)
- Other outcomes: perceptions of the group environment
|
- Qualitative focus group interviews to elicit participants’ perceptions of peer-to-peer support throughout the overall intervention
|
Table 3
the study characteristics of effectiveness trials, stratified by study design
Fully powered randomized controlled trials (n = 3)
|
Author, year, country
|
Participants
|
Setting
|
Intervention
|
Control/comparator condition
|
Follow up
|
Outcome measure(s)
|
Pot-Kolder 2018, Netherlands
|
Adults (aged 18–65) with a DSM-IV diagnosis of psychotic disorder, paranoid ideation in the past month and avoidance of shops, streets, public transport or restaurants
|
Dutch mental health centres
|
To establish the effectiveness of VR-CBT, compared with treatment as usual, in improving the quantity and quality of social participation in patients with psychotic disorders who experience paranoid ideation and social avoidance.
|
VR-CBT + treatment as usual (TAU) vs. waiting list + TAU only control group
|
- End of treatment: 3-month
- Long-term follow up: 6-month
|
- Social isolation outcomes: amount of time spent with other people (assessed with Experience Sampling Method on a 7-point Likert Scale)
- Other outcomes: momentary paranoia, perceived social threat, momentary anxiety, safety behaviour, paranoid thoughts, social interaction anxiety, social functioning, depression, quality of life and cognitive biases
|
Moeini, 2019, Iran
|
- Female students (aged 15–18 years) with mild to moderate depression levels
|
Female high schools within Hamadan City, west of Iran.
|
To examine the effectiveness of a web-based intervention for depressive symptoms in female adolescents; Application of the SCT that to our knowledge is one of the first studies of this type.
|
Intervention vs. no-treatment control
|
- Mid-term follow up: 12-week
- End of treatment: 24-week
|
- Social isolation outcomes: perceived social support via Farsi version of Perceived Social Support Scale-Revised (PSSS-R)
- Other outcomes: depressive symptoms, self-efficacy, outcome expectations, self-regulation, website satisfaction and usage
|
Kaplan, 2011, USA
|
Individuals diagnosed with schizophrenia spectrum or affective disorder
|
Mental health provider agencies, websites and e-newslists targeting individuals with mental illnesses
|
To examine the impact of unmoderated, unstructured Internet peer support on the well-being of individuals with psychiatric disabilities.
|
Peer support listserv vs. peer support bulletin board vs. waitlist control
|
- Mid-term follow up: 4-month
- End of treatment: 12-month
|
- Social isolation outcomes: MOS-SSS
- Other outcomes: recovery assessment quality of life, empowerment, depression and anxiety symptoms
|
Randomized comparative trials (n = 2)
|
Author, year, country
|
Participants
|
Setting
|
Intervention
|
Control/comparator condition
|
Follow up
|
Outcome measure(s)
|
Van Voorhees, 2008, USA
|
Young people (aged 14–21 years) with persistent sub-threshold depression
|
Primary care practice sites in four USA states
|
To determine which primary care approach is more efficacious in reducing vulnerability of major depressive disorder as measured by pre/post changes in vulnerability factors.
|
CATCH-IT with brief advice from primary care physician (PCP-BA) vs. CATCH-IT with motivational interview (PCP-MI)
|
End of treatment: 4–8 weeks post-enrolment
|
- Social isolation outcomes: perceived family social support and perceived peer social support from the National Longitudinal Study of Adolescent Health (ADHEALTH)
- Other outcomes: symptoms of other mental disorders with binary questions, depressive symptoms, closeness to parents, social acceptance, closeness to classmates and level of school impairment related to depressed mood
|
Saulsberry, 2013, USA
|
Young people (aged 14–21 years) with persistent sub-threshold depression
|
Primary care sites across Southern and Midwestern USA
|
To determine one-year follow up outcomes of the CATCH-IT intervention
|
CATCH-IT PCP-MI vs. CATCH-IT PCP-BA
|
Long-term follow up: 1-year
|
- Social isolation outcomes: loneliness (single item rated on a 4-point scale)
- Other outcomes: depressive symptoms clinically significant depressive episodes, self-harm ideation and hopelessness
|
Author, year, country
|
Participants
|
Setting
|
Intervention
|
Control/comparator condition
|
Follow up
|
Outcome measure(s)
|
Marasinghe 2012, Sri Lanka
|
Individuals aged 15–74 years, having been admitted to the hospital after self-harm attempt and with significant suicidal intent
|
Colombo South Teaching Hospital, Sri Lanka.
|
To test whether a Brief Mobile Treatment (BMT) intervention can improve outcomes relative to usual care among suicide attempters
|
Immediate vs. delayed brief mobile treatment (IBMT vs. DBMT)
|
- Long-term follow up: 6- and 12-month
|
- Social isolation outcomes: Medical Outcomes Study-Social Support Scale (MOS-SSS)
- Other outcomes: suicidal intent, depressive symptoms, alcohol use, drug use
|
Kaplan, 2014, USA
|
Mothers over the age of 18 with a diagnosis of a mood or schizophrenia spectrum disorder
|
Websites and e-news lists of the Temple University Collaborative and partners
|
To explore the effect of an Internet educational intervention for mothers with serious mental illness.
|
Intervention vs active control
|
End of treatment: 3-month
|
- Social isolation outcomes: MOS-SSS
- Other outcomes: parenting efficacy, parenting skills, coping skills, parental stress
|
Interian, 2016, USA
|
- Veterans: veterans of Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF), with a positive screen on the PTSD Checklist (PCL) (≥50)
- Family member/partner: designated by participants
|
VA New Jersey Health Care System
|
To assess a brief Internet-based intervention that provided Veterans’ families with psychoeducation on postdeployment readjustment
|
Control group VS intervention group
|
Long-term follow up: 2-month
|
- Social isolation outcomes (Veterans): perceived family support via Multidimensional Scale of Perceived Social Support (MSPSS)
- Other outcomes (Veterans): mental health service use, perceived criticism
- Other outcomes (family members): perceived criticism, family empowerment, perceived efficacy to carry out tasks targeted by the intervention (assessed with a 7-item measure)
|
Mixed-methods trial(s) (n = 1)
|
Author, year, country
|
Participants
|
Setting
|
Aim
|
Control group
|
Follow up
|
Data collection method
|
Quantitative:outcome measure(s)
|
Qualitative
|
Ellis, 2011, Australia
|
Undergraduate students (aged
18–25 years) suffering from low-to-moderate levels of distress
|
Department of Psychology and Faculty of Health Sciences at The University of Sydney
|
To assess the efficacy of a brief online CBT intervention (MoodGYM) compared with an online support group (MoodGarden) in decreasing symptoms of depression and anxiety, and improving dysfunctional thoughts, social support, and CBT literacy in young adults.
|
Online CBT (MoodGym) vs. online peer support (MoodGarden) vs. no-treatment control
|
End of treatment: 3-week
|
- Social isolation outcomes: Online Social Support Scale (OSSS)
- Other outcomes: depression, anxiety, stress, automatic negative thoughts
|
- Open-ended questions to evaluate the best and worst aspects of the intervention
|
To answer our research questions, we structured our findings based on 1) nature of the interventions evaluated, 2) quality assessment, and 3) strength of evidence. We describe the different intervention types and their main components in the first section, and then summarise the available evidence on feasibility and on effectiveness.
Types of intervention
Characteristics of all interventions are outlined in Table 4, stratified by types of intervention.
Table 4
characteristics of interventions, stratified by types of interventions
Author, year
|
Study design
|
Intervention
|
Duration
|
Web-based programmes (n = 16)
|
Wang, 2016
|
Single-group
|
- The Chinese version of My Trauma Recovery (CMTR): web-based self-help intervention program
− 6 modules offering education and exercises for trauma recovery-related topics
|
1 month
|
Rotondi, 2005
|
Feasibility (pilot RCT)
|
- Web-based psychoeducation programme (the Schizophrenia Guide software) that provided online group therapy with individual patients or with support persons and educational materials
- Online therapy groups were with a) support persons only, b) PWS only, c) multifamily therapy group for both PWS and support persons
|
(duration of intervention not specified)
|
Rice, 2020
|
Feasibility (single-group)
|
- Entourage –online social anxiety intervention based on the Moderated Online Social Therapy (MOST) model (positive psychology, mindfulness and strength-based theories)
- Features: an interface for users to build social connections; therapy comics and modules; a problem-solving discussion board
- The therapy content is individually tailored to each participant by clinical moderators who can suggest specific content based on individual users' treatment needs and goals.
- Participants continued their in-person therapy at the same time at their local headspace centre
|
12 weeks
|
Rice, 2018
|
Feasibility (single-group)
|
- Rebound – an online social therapy intervention programme based on the MOST model
- Integrates social networking and individually-tailored interactive psychosocial interventions; helped users to identify key personal strengths using interactive online card-sort task and encourage users to put their strengths into action
|
12 weeks
|
O’Mahen, 2014
|
Feasibility (pilot RCT)
|
- Netmums – a guided internet behavioural activation (BA) treatment
- Online programme supplemented by resources on the Netmum website, online peer support and weekly phone call support from mental health workers
|
12 sessions
|
Moeini, 2019
|
RCT
|
- The DAD (Dorehye Amozeshie Dokhtaran) website: depression improvement program
- Based on Social Cognition Theory constructs
− 7 modules in multimedia format with online assistance from psychiatrists, daily mood assessments and supplementary resources
|
6 months
|
Ludwig, 2020
|
Feasibility (single-group)
|
- An online social media platform (‘Horyzons’) that integrates therapeutic content from CBT, positive psychology, mindfulness and meditation that can be used independently
- To foster positive social connections among users, allowusers to discuss specific issues, receive support or suggestions and guided through problem-solving steps; track personal goals and share progress.
- User content and activity suggestions are tailored to users’ individual strengths and goals
|
12 weeks
|
Lee, 2018
|
Single-group
|
- Online imagery-based program
- First phase: help patients to become more aware of their sensory experiences; second phase: mediate early-life trauma; third phase: address recent trauma; fourth phase: restore positive belief in oneself
- Appropriate sound-enhanced imagery experiences aided relaxation and increased emotional impact of each treatment session
|
4 weeks
|
Kaplan, 2014
|
RCT
|
- Internet-based parenting intervention
- Experimental condition: online parenting course based in CBT techniques; peer support listserv via email
- Active control condition: access to website with educational factsheets
- Both groups continued to receive their usual health-care services
|
3 months
|
Kaplan, 2011
|
RCT
|
- Listserv: unmoderated, unstructured Internet peer support Listserv (anonymous communication via group e-mail)
- Bulletin board: unmoderated peer support
|
12 months
|
Interian, 2016
|
RCT
|
- ‘Family of Heroes’ (FoH): Brief internet intervention
- The training uses avatar characters that deliver psychoeducation and engage in simulated conversations concerning post-deployment stress and mental health treatment.
- Stimulated conversations help family members choose statements that convey empathy and soften tone of conversation. Each conversational scenario focused on: de-escalating an argument, renegotiating household responsibilities, and encouraging VA mental health treatment-seeking.
|
1 hour
|
Goodwin, 2018
|
Single-group
|
- Psycho-Babble website: Internet Support Group (ISG) for depression
- Provide fact-based information on mental health and access to a well-established ISG for primary care patients
- Content based on National Institute of Mental Health (NIMH) and MoodGYM online intervention
|
6 weeks
|
Ellis, 2011
|
Feasibility (pilot RCT)
|
- Online CBT (MoodGym): 5-module (over 3 sessions) self-help program to reduce dysfunctional thinking, overcome negative feelings and identify relaxation strategies
- Online peer support (MoodGarden): online mental health resource offering peer-based support and information on self-management, participants can also share their experiences on a message board
|
3 weeks
|
Campbell, 2019
|
Feasibility (single-group)
|
− 6 KHL Circles (groups) conducted over a 12-month period
- For each Circle, KHL Counselors posted psychoeducational material about family discord weekly and encouraged discussion activity and interaction between participants to address issues within the topics.
|
8 weeks
|
Bailey, 2020
|
Feasibility (single-group)
|
- Affinity: enhanced online social networking intervention
- Follows the MOST model: peer social networking, problem-solving forum, therapeutic content delivered via comics
|
8 weeks
|
Alvarez-Jimenez, 2018
|
Feasibility (single-group)
|
- MOMENTUM program: strengths and mindfulness-based intervention
- Merges interactive psychosocial intervention modules and online social networking
- Content suggestions for each user tailored weekly based on user's needs, interests and strengths.
- Participants continued treatment within PACE Clinic
|
2 months
|
Phone-based interventions (n = 7)
|
Price, 2014
|
Feasibility (single-group)
|
- Daily automated messages were sent to participants after their discharge from the hospital using the Connecting to Help After Trauma (CHAT) program
- Themes of messages included re-experiencing, avoidance and hypervigilance to provide informational support and to assess trauma symptoms after their injury
|
15 days
|
Pfeiffer, 2016
|
Feasibility (single-group)
|
- Automated phone call intervention
- Participants received weekly visits or phone calls from family/friend or a peer support specialist
- Patient monitoring and feedback facilitated by weekly automated phone calls. The phone system utilized interactive voice response technology (IVR) – based on patients’ responses to the assessments via the system, their support persons will guide their phone interactions with the patients
- Continued usual outpatient mental healthcare after discharge
|
6 months
|
Lim, 2020
|
Feasibility (single-group)
|
- +Connect app: users are to complete tasks which were delivered via: text and images, Shared Experience Videos featuring young people with lived experiences, Expert Videos featuring academics introducing core concepts, Actor Videos featuring actors modelling social behaviours.
- The app is gamified to increase engagement. There is also a mood evaluation tracker
|
6 weeks
|
Lim, 2019
|
Feasibility (single-group)
|
-+Connect app
|
6 weeks
|
Hanssen, 2020
|
Feasibility (pilot RCT)
|
- Schizophrenia Mobile Assessment and RealTime feedback application (SMARTapp)
- The app was personalised for all participants, according to their personal preferences (answered at baseline) so they could access their coping strategies, comforting thoughts and relaxing activities at any time in-app
- All participants completed up to six short Experience Sampling Method (ESM) questionnaires daily.
|
3 weeks
|
Gjerdingen, 2013
|
Feasibility (pilot RCT)
|
- Peer telephone support: peer supporters provided educational, emotional and comparison support
- Postpartum doula group: face-to-face postpartum doula services (24 hours of services over 6 weeks), including education regarding infant care, practical support and emotional support
- It was expected that all 3 groups would receive usual depression treatment from their health care providers
|
3 months
|
De Almeida, 2018
|
Single-group
|
- weCOPE mobile application
− 4-module intervention – symptom monitoring, problem-solving, anxiety-management and goal setting
|
8 weeks
|
Blended interventions (n = 7)
|
Van Voorhees, 2008
|
RCT
|
- CATCH-IT (Competent Adulthood Transition with Cognitive-Behavioral and Interpersonal Training) programme: based on Behavioural Activation, Cognitive Behavioural Therapy (CBT), Interpersonal Psychotherapy (IPT) techniques and a community resiliency concept
- Teaches adolescents how to reduce behaviours that increase vulnerability for depressive disorders and increase behaviours that are thought to protect against depression
|
14 modules
|
Van Voorhees, 2005
|
Feasibility (single-group)
|
- Online programme based on Cognitive Behavioural Therapy (CBT), Interpersonal Therapy (IPT)
- Initial motivational interview (MI) and follow-up MI with a primary care physician (PCP)
|
11 modules
|
Saulsberry, 2013
|
RCT
|
CATCH-IT internet-based program
|
14 modules
|
Marasinghe, 2012
|
RCT
|
- Mobile follow-up treatment of 12 months
- Face-to-face component: mediation and interventions to increase social support, reduce alcohol use
- Online components: phone calls at various follow-up time points post-discharge to assess suicidality and mood, plan intervention, provide guidance for social support; access to audio messages; weekly motivational messages up to 26 weeks
- The BMT was administered in addition to usual care throughout the study
|
12 months
|
Loi, 2016
|
Single-group
|
- Internet program based on a local program for older adults (Internet for Seniors)
- Training program to teach older adults Internet-using skills, sending or receiving emails. Apple iPads were used as the Touchscreen Technology
|
6 weeks
|
Dow, 2008
|
Feasibility (single-group)
|
- Participants were trained for basic computer operation, Internet searching, sending/receiving emails, virus protection and avoiding dangers.
- Participants were given a recycled personal computer to keep after the study
- The intervention was carried out in person, in groups
|
4 weeks
|
Aschbrenner, 2016
|
Single-group
|
- Group-based lifestyle intervention
- Face-to-face component: weekly in-person weight management sessions, optional twice weekly group exercise sessions
- Digital component (introduced in week 6): use of technology and social media (private Facebook group) to facilitate monitoring and peer support. Participants to post content related to healthy eating and exercise or described personal successes or challenges towards achieving lifestyle goals. Study staff regularly posted content related to topics covered in the group sessions, reminders to exercise, and tips for healthy eating
|
24 weeks
|
Socially assistive robot intervention(s) (n = 1)
|
Chen, 2020
|
Single-group
|
− 24-hour Personal Assistive Robot (Paro) intervention:
- Each participant given a Paro to keep for the intervention stage, they were free to choose when to interact with it, to take the Paro outside or put it aside.
- Paro is a kind of animal companion robot and has the appearance of a baby harp seal. It is equipped with tactile sensors that monitor sound, light and touch. It can show human-like emotional reactions
|
8 weeks of observation (usual care) and 8 weeks of intervention
|
Virtual reality intervention(s) (n = 1)
|
Pot-Kolder, 2018
|
RCT
|
- Sessions of virtual-reality-based cognitive behavioural therapy (VR-CBT)
- Participants move within four virtual social environments (street, bus, café and supermarket) which were individualised to match their paranoid fears of the patient.
- Patients and therapists communicated during VR sessions to explore suspicious thoughts and drop safety behaviours during social situations.
|
16 sessions over 8–12 weeks
|
1. Web-based interventions
In this review, we adopted the definition of a web-based interventions as ‘a primarily self-guided intervention programme that is executed by means of a prescriptive online programme operated through a website and used by consumers seeking health- and mental-health related assistance’ (78). Overall, 16 out of 32 studies (50%) utilized web-based programmes, including eight feasibility/pilot studies (45,51,53,57,61,63,69,73), three pre-post measure studies (49,65,67), and five effectiveness trials (50,64,71,74,75). Of the eight feasibility studies, two were pilot RCTs that mainly aimed to examine feasibility and acceptability outcomes (51,63). All studies delivered web-based programmes in a multicomponent format.
Access to therapeutic content, peer support and clinical/peer moderation were frequently reported as part of the intervention. Therapeutic content was delivered in forms of therapy courses or modules consisting of core concept explanations, skill- or strength-building exercises and psychoeducational resources. Some also incorporated interactive content in forms of online games or comic strips (45,53,57,61,69). All studies provided therapeutic content to various degrees, including studies that assessed internet peer support groups (49,71,74). As an example, Goodwin et al. (n = 34) (49) mainly investigated the role of online peer support via an established Internet Support Group (ISG) called the ‘Psycho-Babble’. Participants, with depressive symptoms, were given access to an Internet portal that contained the ISG as well as fact-based content related to mental health and depression.
Peer support was also a common element, incorporated in forms of group discussion forums, online chatrooms, existing social media (e.g., Telegram®) and email listservs. Online peer support was the main element investigated in three studies (49,71,74) whereas nine other studies also incorporated peer support as part of the interventions, but not as the main element (45,50,51,53,57,61,69,73). Participants were able to interact with peers who had experienced the same difficulties using the online platforms under safety monitoring from the researchers. This was proposed to promote a sense of community, thus fostering social support and mental wellbeing.
We also identified eight studies that explicitly reported embedding moderation by peers (45,50,51,53,57,61,69,73); six of these also incorporated clinical moderation by professionals (45,53,57,61,69,73). The researchers reported the role of peer moderators to be promoting engagement and providing support when needed. Expert moderators were tasked with providing clinical guidance, monitoring the clinical status of participants and monitoring the safety of the online environment. Most other studies also made mention of monitoring from experts or clinicians. Among the three studies that did not report clinical or peer moderation, one was an underpowered RCT by Kaplan and colleagues (n = 60) (75) which aimed to examine unmoderated and unstructured internet support for participants with schizophrenia or affective disorders. In the other two studies, interventions were designed as self-help, take-home resources (65,67), thus the research focus was on assessing treatment courses that could be entirely self-facilitated by the participants. There was no mention of expert moderation/monitoring or additional social support component in either of these studies. For example, Lee et al.’s study (n = 35) (65), conducted in South Korea, consisted of an online imagery-based program that was developed based on the cognitive model of PTSD. The main therapeutic objective was to utilize guided imagery techniques to help participants modify traumatic memories. Training sessions were made up of auditory guidance and background music to enhance imagery experience, supplemented by mind-body training techniques such as relaxation and meditation.
Apart from two studies (63,73), the online programmes were individual-level interventions and were self-directed by the participants. Campbell et al.’s study (n = 105) (73), the only feasibility study that recruited more than 100 participants, used an online platform (‘Kids Helpline Circle’) to conduct group counselling with young adults with mild depressive or anxiety symptoms. Rotondi et al. (n = 30) (63) conducted therapy groups facilitated by mental health professionals using online bulletin boards. This feasibility study involved persons with schizophrenia and provided problem-solving group therapy to the participants and their family members. In both studies, while the online counselling/therapy was facilitated by the researchers, participants had access to other aspects of the intervention that also contained psychoeducational resources.
In ten of the 16 studies (62.5%), researchers aimed to develop their interventions based on specific theoretical frameworks, including Cognitive Behavioural Therapy (CBT) (71,75), Social Cognitive Theory (SCT) (50), Behavioural Activation (BA) (51) and the cognitive model of PTSD (65). It is also noteworthy that the web-based programmes (‘MOMENTUM’, ‘Affinity’, ‘Horyzons’, ‘Rebound’ and ‘Entourage’) in five feasibility studies (45,53,57,61,69) were based on the MOST (Moderated Online Social Therapy) model developed by Orygen, a mental health organization based in Australia. The MOST model has its theoretical basis in Self-Determination Theory, positive psychology and mindfulness (79). The interventions incorporated self-help therapy modules, a moderated social network, and personalised suggestions for therapy content from clinicians. Behavioural prompts were also included as a feature of persuasive systems – recommendations for behaviour change were given to users to implement in the real world. These interactive online platforms aimed to foster self-efficacy and social support for users in a safe environment. They are intended to supplement face-to-face treatments, therefore participants in these studies are recruited from local clinics and continued their in-person treatments during the study periods.
2. Telephone-based programmes
We identified seven studies, including six feasibility studies (48,52,59,60,66,68) and one single-group study (58) that delivered interventions using mobile telephones. Of the six feasibility studies, two were pilot RCTs with the primary aim to test feasibility and acceptability outcomes (48,59). More specifically, four utilized smartphone apps (58,59,60,68), two used telephone calls (48,52), and the other used text messages (66). Studies that utilized smartphone apps mentioned monitoring by clinical professionals while the others did not. Although each intervention provided certain degrees of therapeutic support that had their basis in concepts such as positive psychology, the theoretical basis for the formation of these interventions was not outlined in detail.
Of these studies, six studies shared a common component of symptom assessment and monitoring (52,58,59,60,66,68). Symptom monitoring was a feature in Hanssen and colleagues’ (n = 64) (59) pilot feasibility RCT conducted with individuals with schizophrenia in the Netherlands. The researchers assessed the SMARTapp (Schizophrenia Mobile Assessment and RealTime feedback application), which was mainly designed for participants to carry out real-time monitoring of their symptoms by answering multiple questionnaires daily using the app. The app was personalized for the users at baseline assessment – e.g., users had in-app access to their preferred relaxation activities or comforting thoughts at any time. Participants in the intervention group received additional personalized feedback (suggestions for a certain activity or behaviour change) from the SMARTapp based on their questionnaire responses, whereas those in the control group used the app without individual feedback. In another study, Price et al (n = 29) (66) assessed a symptom-monitoring intervention utilizing text messages. Recruited after experiencing a traumatic injury, participants received daily messages that contained assessments of different symptom domains, including social support, hypervigilance and re-experiencing. Symptom assessment and monitoring was the main objective for these studies. The main aim of the + Connect app, which was used in two other feasibility studies (60,68), was to reduce loneliness by conveying evidence-based concepts of positive psychology to users, in order to build on their strengths and empower them to engage in meaningful social interactions. Content was delivered in a multimedia format (via short videos or via text and images) and participants had to answer content-based quizzes afterwards. Through answering questions, completing daily mood tracking and progressing through various levels of content, participants also obtained points and badges. The addition of this gamification element was intended to promote participants’ engagement.
Social support was integrated in the two studies utilizing phone calls (48,52). In a pilot feasibility RCT, Gjerdingen et al. (n = 39) (48) compared the effects of support from peer volunteers via phone calls versus in-person support from certified postpartum doulas versus usual care. In contrast, Pfeiffer et al. (n = 48) (66) assessed a more complex digital intervention: the researchers used an automated telephone monitoring system to assess veteran patients’ depressive symptoms and medication adherence, while also providing social support to the participants via weekly phone calls/meetings with either a friend, a family member or a trained and certified peer specialist, depending on the participant’s choice. The automated phone system utilized interactive voice response technology (IVR) and consisted of scripted voice recordings to which participants responded. The family member/friend received a report on the participant’s responses and tips on how to interact with the participant during the meetings, while the peer specialist was instructed to guide interactions based on the participants’ responses using their own skills.
3. Blended interventions
A total of seven studies employed a blended approach by combining digital with face-to-face components in therapy. These were two feasibility studies (47,55), two single-group studies (72,76) and three effectiveness trials (54,56,70). The role of the digital component varied – some studies utilized technology as the main instrument to convey therapeutic content (n = 3) (54,55,56) while in others it served as a monitoring/follow-up tool (n = 2) (70,72). Two other studies (47,76) conducted in-person, group training sessions during which participants were trained to use a computer and the Internet. As an example, Dow and colleagues (n = 14) (47) conducted a computer-training programme for rural carers with subsyndromal depressive symptoms. Participants were given a recycled personal computer and trained on how to use the computer, send and receive emails and to navigate the Internet. It was proposed that such training programmes may facilitate more social connections for the participants as they learn to connect with others online, thus reducing social isolation.
Another three studies – a feasibility study (55) and two randomized comparative trials (not fully powered) (54,56) – examined the effects of using face-to-face motivational interviews (MI) to complement the web-based programme (Competent Adulthood Transition with Cognitive-behavioural and Interpersonal Training – CATCH-IT), which was based on CBT and Interpersonal Therapy (IPT) principles. The web-based programme was the main component, while an in-person, 10- to 15-minute MI was conducted once before and once after the online intervention. CATCH-IT was used for depression prevention with adolescents who had been experiencing persistent sub-threshold depressive symptoms, whereas the role of MI was proposed to enhance the users’ willingness for behaviour change, leading to increased effectiveness of the internet intervention.
It was unclear from the description of most studies whether there was any moderation for the digital component. In contrast, Aschbrenner and colleagues (n = 25) (72) reported safety monitoring of the private Facebook group that participants were introduced to in their lifestyle intervention. This was a group intervention designed to promote the overall well-being of participants via weekly weight management sessions and the use of social media. Along with Marasinghe et al,’s (n = 68) (70) RCT, the digital components in this study were implemented during more than half of the intervention period and served as an adjunct to complement the face-to-face intervention. The main purpose of the technology components was to monitor or facilitate participants’ self-monitoring of symptoms, as well as provide informational and social support.
Although there was some level of description regarding the theoretical basis of each individual component, the theoretical basis of using a blended approach of these components was unclear.
4. Social robots
Socially assistive robots are designed to interact with people in a socio-emotional way during interpersonal interactions to improve recovery and health outcomes (80). Recently social robots have been increasingly utilized to alleviate psychological distress and reduce social isolation among elderly adults with dementia (81). In this review, we identified one single-group study conducted by Chen et al. (n = 20) (46) who delivered a social robot intervention involving elderly adults with depression. Participants were each allocated an animal companion robot (Personal Assistive RobOt – ‘Paro’) to keep throughout the intervention. They were encouraged to interact with it through touch and verbally, whenever they preferred to. Paro is shaped like a baby harp seal, equipped with tactile sensors and could show human-like emotional reactions. Paro and other animal robot interventions are aimed at encouraging human-animal interactions that can improve psychological and social functioning through the comfort and emotional attachment derived from close interactions and commitment to the animal companion robot.
5. Virtual reality
Virtual reality (VR) is utilized in therapy by allowing participants to complete therapeutic exercises in the virtual social world with the guidance of a therapist. In a fully powered RCT, Pot-Kolder and colleagues (n = 116) (62) assessed the effectiveness of a virtual-reality-based CBT (VR-CBT) to enhance positive social participation (operationalised as time spent with others) among individuals with psychotic disorders who experienced paranoid ideation and social avoidance. Participants communicated with therapists in each session where they were exposed to virtual simulations of social situations. Based on individualised case formulations, each participant experienced exposure to different social environmental cues that elicited paranoid thoughts and safety behaviours. The participants worked with the therapists during these sessions to explore and challenge their safety behaviours and negative thoughts.
Quality assessment
Out of the 16 included feasibility studies (all of which provided data collected with aim of assessing effectiveness) we judged six to be at moderate risk of bias, five at low risk of bias and five at high risk of bias. None of these studies accounted for confounders in the study design or data analysis. Of these 16 studies, five did not report complete outcome data (completion rates below 80%) and one did not specify completion rates.
Of the seven single-group, pre-post measures studies, four were judged to be at moderate risk of bias, two at low risk of bias and one at high risk of bias. Of these seven studies, two did not report complete outcome data and three did not specify completion rates.
There were three fully powered RCTs, one of each judged to be at high, moderate and low risk of bias respectively. The six other randomised trials that were not fully powered were all judged to be at moderate risk of bias. Eight out of nine randomized trials described methods of randomization. However, descriptions of concealment and blinding were unclear or missing on six randomized trials. Out of nine randomized trials, all specified completion rates but three did not report complete outcome data. Results of quality assessment are presented in Supplementary File 2.
Strength of evidence
Although the heterogeneity of studies and lack of studies assessing social isolation as the primary outcome (in contrast, being included among a range of outcomes instead) make it difficult to form firm conclusions, we present a summary of the efficacy and feasibility outcomes of the included studies to provide a preliminary overview of the current state of evidence, categorised by respective study designs. We also outlined the participants’ characteristics, effectiveness and feasibility outcomes (for feasibility studies only) as well as intervention duration in Tables 5, 6 and 7 (for feasibility studies, single-group/pre-post measures studies and effectiveness trials respectively).
Table 5
results of the feasibility studies, stratified by study design
Author, year
|
N (n allocated to intervention, control)
|
Mean age (years)
|
Gender (% female)
|
Intervention effect on social isolation outcomes
|
Randomized trial(s) (n = 4)
|
Rotondi, 2005
|
30 PWS (i = 16, c = 14), 21 support persons (i = 11, c = 10)
|
37.5 (PWS), 51.52 (support persons)
|
70% (PWS), 66.7% (support persons)
|
- Comparing baseline and 3-month follow up, PWS in the telehealth group showed a trend towards greater social support (F(1, 27) = 3.79, p = .062). For support persons, there were no significant differences for social support (F(1, 18) = 0.36).
|
O’Mahen, 2014
|
83 (i = 41, c = 42)
|
Not specified
|
100%
|
- At 17-week follow up, there were no between-group differences in perceived support scores (95% CI: -1.79 to 2.03, p = 0.27), effect size is medium (d = 0.50, 95% CI 1.02 to − 0.02).
|
Hanssen, 2020
|
− 64
- Final data analysis: 50 (i = 27, c = 23)
|
37.9 (i), 40.3 (c)
|
33.3% (i), 39.1% (c)
|
- There was no group-by-time interaction and no group effect on loneliness
- Statistically significant decrease in loneliness scores over time in both groups (b=-0.004, 95%CI: -0.007 to -0.0009, p = 0.01, d=-0.11).
|
Gjerdingen, 2013
|
39 (doula group = 12, telephone support group = 13, c = 14)
|
29.7 overall
|
100%
|
- No significant group differences in social support comparing baseline to 6-month follow up
|
Non-randomized trial(s) (n = 2)
|
Pfeiffer, 2017
|
48 (family/friend group = 19, specialist group = 29)
|
50.1 overall
|
25% overall
|
- No statistically significant differences between time points were found on perceived social support.
- There were also no statistically significant differences between groups at 3 or 6 months for perceived social support
|
Lim, 2019
|
20 (young people with SAD = 9, students with no mental health conditions = 11)
|
21 (SAD), 20.36 (students)
|
44.44% (SAD), 45.45% (students)
|
- SAD: loneliness scores decreased in a linear trend from baseline to 3-month follow up
- Student: loneliness scores decreased from baseline to post-intervention and 3-month follow up
- Across the entire group, loneliness showed mean negative slope (M = − 3.82, 95% CI: -5.54 to -2.17). On average, participants’ loneliness scores decreased by 7.64 points by follow-up (d = 0.94).
|
Single-group study(s) (n = 10)
|
Van Voorhees, 2005
|
14
|
Age range: 18–24 years overall
|
42.9% overall
|
- At post-intervention, there was a trend of increasing social support scores (d = 0.27, CI: -0.73, 1.24, p = 0.13)
|
Rice, 2020
|
89
|
19.8 overall
|
47.2% overall
|
- Comparing baseline and post-intervention, statistically significant improvements were found on social connectedness (d = 0.63, p < .001), significant decreases in loneliness (d = 0.63, p < .001). Changes in social network were not significant.
|
Rice, 2018
|
42
|
18.5 overall
|
50% overall
|
- Comparing baseline and post-intervention, there was no significant increase in social connectedness (p = 0.711) or social support (p = 0.470)
|
Price, 2014, USA
|
31
|
37.1 overall
|
45.2% overall
|
- There was no reported analysis on differences of social support, but from the descriptive statistics table there is around a 2-point decrease on social support comparing baseline to 1-month follow up and baseline to 3-month follow up
|
Ludwig, 2020
|
24
|
25.16 overall
|
36.8% overall
|
- Loneliness scores showed moderate reductions from baseline to mid-treatment (6-week) (d = 0.27).
- Changes in participants' perceived social support increased from baseline to 6-week and post-treatment (12-week) (d = 0.03 and d = 0.10), although modest and not maintained at 16 weeks.
|
Lim, 2020
|
12
|
20.5 overall
|
25% overall
|
- The mean of slopes indicated loneliness scores were more likely to reduce after intervention (M = − 0.34, SD = 0.24).
- Participants could be expected to have scores that are about 0.3 standard deviations lower at post-treatment, and about 0.6 standard deviations lower at 3-month follow-up than at baseline
|
Dow, 2008
|
14
|
65.5 overall
|
86% overall
|
- There was a decrease of loneliness scores for 11 participants
|
Campbell, 2019
|
105
|
16.2 overall
|
81.9% overall
|
- Due to the drop-off in response rates between the baseline survey (105/105, 100%) and final survey (8/105, 7.6%), data quality was too low to conduct meaningful analysis.
|
Bailey, 2020
|
20
|
21.7 overall
|
55% overall
|
- Comparing baseline and post-intervention, differences on social connectedness were not statistically significant
|
Alvarez-Jimenez, 2018
|
14
|
20.3 overall
|
78% overall
|
- Statistically significant improvements were found in subscales of social support at post-intervention: attachment (d = 0.70, p = 0.05) and guidance (d = 0.75, p = 0.03).
− 33% of participants had a reliable decline on loneliness
|
Table 6
results of the single-group studies
Author, year
|
N (n allocated to intervention, control)
|
Mean age (years)
|
Gender (% female)
|
Intervention effect on social isolation outcomes
|
Single-group study(s) (n = 7)
|
Wang, 2016
|
146 (urban = 56, rural = 90)
|
Age range: 16–70 overall
|
67.86% (urban), 82.22% (rural)
|
- At post-intervention, the use of the relaxation module was associated with negative change in social support (b=-0.10, p = 0.04). Use of the triggers, self-talk, unhelpful coping and mastery tools modules were not associated with significant changes in social support
- Total number of days using the program was positively correlated with social support scores (r = 0.22, p < 0.01)
|
Loi, 2016
|
5
|
69.9 overall
|
40% overall
|
- There were no significant differences before and after the intervention for social isolation (t=-2.434, p = 0.072)
|
Lee, 2018
|
35
|
48.1 overall
|
14.3% overall
|
- Patients did not show significant improvements on FSSQ (t = 0.197, p = 0.84) at post-treatment
|
Goodwin, 2018
|
34
|
32.53 overall
|
79.41% overall
|
- No significant changes were found in loneliness (p = 0.51) or social support (p = 0.91) at post-treatment
|
De Almeida, 2018
|
9
|
38.11 overall
|
22% overall
|
- Statistically significant improvement at post-treatment was found in social support (p = 0.021). Improvements were also found in subscales (intimacy: p = 0.012; satisfaction with family: p = 0.026).
|
Chen, 2020
|
20
|
81.1 overall
|
65% overall
|
- Comparing T2 to T4, statistically significant decreases in loneliness scores were found over time (F(3, 57) = 61.7, p < 0.001).
- There were significant differences in every time point comparison: T2 vs T3 t = 8.84, p < 0.001, d = 1.95; T2 vsT4 t = 8.47, p < 0.001, d = 2.50; T3 vs T4 t = 2.48, p = 0.023, d = 0.75.
|
Aschbrenner, 2016
|
25
|
48.6 overall
|
56% overall
|
- The global score for the assessing perceived social support from the group was high (M = 30.8 SD = 5.5).
|
1. Feasibility and pilot studies
While their primary stated purpose was to obtain data to test the feasibility of conducting a full trial, all 16 feasibility studies aimed to provide data relevant to effectiveness. In a pilot RCT, Hanssen and colleagues (n = 64) (59) found statistically significant decreases in loneliness scores across all participants using the SMARTapp intervention, but no difference was found between the intervention and control groups, hence effectiveness is unclear. Rotondi and colleagues (n = 51) (63) showed a non-significant trend towards greater perceived social support for participants in the web-based intervention group compared to the control group. The other two pilot RCTs (48,51) did not report significant findings.
Although Van Voorhees and colleagues (n = 14) (55) found a non-significant trend toward increasing social support scores among participants, this was a single- group study that did not include a control group to compare the effects of the online CATCH-IT intervention and so does not pertain to effectiveness. Using an online intervention based on the MOST model (‘Entourage’) and single-group design, Rice and colleagues (n = 89) (69) showed statistically significant improvements in social connectedness and loneliness among participants at post-intervention compared to baseline, but no significant differences on social network scores; the lack of a control group means no conclusions can be drawn regarding effectiveness. Three studies did not report tests of significance but reported improvements in social isolation outcomes using different statistical tests (60,61,68), such as latent trajectory models. The other seven single-group feasibility studies reporting effectiveness data did not find significant differences in social isolation outcomes (45,52,53,57) or did not report statistical analysis testing for significant differences (47,66,73).
Table 7
results of the effectiveness trials, stratified by study design
Author, year
|
N (n allocated to intervention, control)
|
Mean age (years)
|
Gender (% female)
|
Intervention effect on social isolation outcomes
|
Fully powered randomized controlled trial(s) (n = 3)
|
Pot-Kolder, 2018
|
116 (i = 58, c = 58)
|
36.5 (i), 39.5 (c)
|
31% (i), 28% (c)
|
- VR-CBT did not significantly increase the amount of time spent with other people at post-treatment compared to baseline (d = 0.25; 95% CI: − 0.064 to 0.344, p = 0.178), but it did at 6-mont follow-up compared with baseline (d = 0.50, 95% CI: 0.072 to 0.502, p = 0.009).
- Time spent with others decreased by 2.4% in the control group between baseline and follow up, whereas it marginally increased by 0.3% in VR-CBT
|
Moeini, 2019
|
128 (i = 64, c = 64)
|
16.2 (i), 16.5(c)
|
100%
|
- In the intervention group, there was a statistically significant increase in social support from baseline to 24-week (p = 0.002).
- Compared to the control group, improvements in social support from baseline to 12 weeks were found to be statistically significant (p = 0.011).
|
Kaplan, 2011
|
300 (i = 200, c = 100)
|
47 overall
|
66.5% (i), 64% (c)
|
- There were no differences between conditions on social support scores (F(1,298) = 0.08; p = 0.93).
- Across the entire sample, there was a statistically significant improvement on social support scores (F(1,298) = 3.16; p = 0.04)
|
Randomized comparative trial(s) (n = 2)
|
Van Voorhees, 2008
|
83 (motivational group = 43, brief advice group = 40)
|
17.44 overall
|
56.18% overall
|
- For perceived social support by peers, significant pre-post differences found across entire sample (p < 0.001), but no differences between groups (p = 0.62). Individually, both groups demonstrated increases with moderate to large effect sizes (MI: 0.76, 95% CI: 0.18, 1.32 p < 0.001; BA: 1.39, 95% CI: 0.75, 1.99, p < 0.001; all: 1.09, 95% CI: 0.64, 1.52)
- There was no change in the perceived family support scale
|
Saulsberry, 2013
|
83 (MI = 43, BA = 40); 58 overall at one-year follow up
|
17.26 overall
|
57% overall
|
- Significant decline in the mean rating of loneliness for the entire sample from baseline to one-year follow-up (ES = 0.49, 95% CI: 0.18, 0.79, p < 0.001). Individually, in both groups there were significant declines in the mean loneliness score from baseline to one-year follow-up (MI: ES = 0.43, 95% CI: 0.00, 0.85, p = 0.01; BA: ES = 0.54, 95% CI: 0.08, 0.98, p = 0.01).
|
Randomized controlled trial(s) (not fully powered) (n = 4)
|
Marasinghe, 2012
|
68 (i = 34, c = 34)
|
30 (i-male), 34(i-female), 29 (c-male), 31 (c-female)
|
50%
|
- Scores on social support improved significantly across time in both conditions
- The BMT group also showed a significant improvement of social support when compared to the control group
|
Kaplan, 2014
|
60 (i = 31, c = 29)
|
37 (i), 36 (c)
|
100%
|
- No significant differences were found between intervention and control groups on social support (t = 0.05, p = 0.96, d = 0.02)
|
Interian, 2016
|
103 dyads formed of veterans and family members (i = 50, c = 53)
|
- Veterans: <29 years (32.3%), 30–36 years (36.5%), 37 or older (31.3%)
- Family members: <29 years (35.2%), 30–36 (24.2%), 37 or older (40.7%)
|
- Veterans: 18.8%
- Family members: 85.7%
|
- Across time, participants in the intervention group were significantly more likely to report a decrease in perceived family support (p = 0.04) compared to the control group
|
Ellis, 2011
|
39 (MoodGym = 13, MoodGarden = 13, c = 13)
|
19.67 overall
|
77% overall
|
- Online social support significantly improved for the MoodGarden (online peer support) group compared with both MoodGym (online CBT) and control (MoodGarden vs.control: t = 2.31, p = .03; MoodGarden vs. MoodGym: t = 3.62, p = .00).
|
Feasibility outcomes from the studies generally favoured proceeding to a full trial, as most studies (n = 11) (45,47,48,51,53,57,59,60,61,68,69) reported satisfactory retention rates at above 70%. Among these, all studies utilizing web-based programmes based on the MOST model (n = 5) (45,53,57,61,69) reported retention rates over 80%. Another pilot feasibility RCT conducted by Gjerdingen et al. (n = 39) (48) compared the effects of telephone peer support vs face-to-face postpartum doula support and reported retention rates to be over 90%. However, the only feasibility study that recruited more than 100 participants reported a dropout rate as high as 92.4% (73). The study sought to assess an online group counselling platform (Kids Helpline Circle).
Acceptability outcomes were difficult to compare as different scales and methods of rating were utilized in each study. Generally, satisfaction ratings and feedback regarding the usefulness/helpfulness of the interventions were favourable, but there were also some mixed findings. For example, participants in Hanssen’s study (n = 64) (59), with retention rate over 70%, rated the SMARTapp as easy to use (94%) and appealing (95%) but also annoying (38% in the comparison group and 73% in the intervention group) due to the frequent reminder beeps to prompt questionnaire completion. In two out of seven studies (28.6%) that involved both digital and face-to-face components, researchers reported lower satisfaction ratings for the digital component. This was observed in Van Voorhees and colleagues’ blended intervention (n = 14) (55) and Gjerdingen et al’s (n = 39) (48) study comparing telephone peer support vs face-to-face postpartum doula support. Lastly, eight feasibility studies also assessed safety outcomes (45,49,53,57,60,68,69,74). None reported adverse events that were attributed to the interventions assessed. All eight studies reported that all participants reported feeling safe while using the interventions.
Our reporting of findings from feasibility studies was intended to help identify new approaches for future research. Whilst findings demonstrate the variety of potentially feasible and acceptable interventions to be tested in large-scale trials, we cannot form firm conclusions about the interventions’ effectiveness in improving social connectedness and loneliness.
2. Uncontrolled studies providing pre/post comparisons
Mixed findings were demonstrated from the seven single-group studies. Chen and colleagues (n = 20) (46) found significant decreases in loneliness scores among the elderly participants in the middle of, and at the end of, the 8-week social robot intervention compared to pre-intervention. De Almeida and colleagues (n = 9) (58), using the weCOPE application, also demonstrated statistically significant increases in social support among individuals with schizophrenia over eight weeks. Due to the lack of control groups in these studies, the findings should be taken, at best, as an indicator for a possibility of an intervention effect.
Among the other studies, one did not conduct a statistical test of significance (72), while three did not find significant changes in the social isolation outcomes (49,65,76). Wang and colleagues (67) reported correlations between usage and social support scores. Using a web-based intervention (the Chinese version of My Trauma Recovery - CMTR), the authors found statistically significant negative findings: decreases in social support scores correlated with increased uses of one of the program modules (the relaxation module), but only on the first day of the intervention, and there was no control group to compare this to. There were no significant correlations between social support scores and the use other five modules. Of all the studies, there was no report of adverse events related to the respective interventions. Together these studies do not provide strong evidence to support any of the interventions evaluated given that they lack control or comparison conditions.
3. Effectiveness trials
Three fully powered RCTs showed varying findings. Moeini et al. (n = 128) (50) reported statistically significant improvements in social support among female adolescents with mild to moderate depressive symptoms in the intervention group compared to controls after a 24-week web-based intervention (Dorehye Amozeshie Dokhtaran – DAD). Conversely, studies from Pot-Kolder et al. (n = 116) (62) and Kaplan et al. (n = 300) (74) reported no significant differences between treatment and control groups. Pot-Kolder et al. (62) conducted a VR-CBT intervention with participants with psychotic disorder, while Kaplan et al. (74) involved individuals diagnosed with schizophrenia or an affective disorder to compare social support outcomes between three conditions: Internet peer support via a listserv, Internet peer support via a bulletin board, and a waitlist control condition.
Two randomized comparative trials that were not fully powered used blended interventions. Both trials did not find significant differences between the comparison groups. Involving adolescents at high risk of depression, Van Voorhees and colleagues (n = 83) (56) compared CATCH-IT with motivational interviewing (MI) and CATCH-IT with brief advice. Similarly, Saulsberry et al. (n = 83) (54) examined the effects of CATCH-IT with MI vs CATCH-IT with brief advice in a one-year follow up study of a RCT that also investigated the CATCH-IT intervention. As these studies did not report significant differences between intervention and control groups, we cannot reach conclusions about clinical effectiveness of the interventions.
The four pilot RCTs included also reported mixed findings. Kaplan et al. (n = 60) (75) reported no significant differences in social isolation outcomes after an online parenting intervention involving mothers with mood disorder and schizophrenia. In a web-based intervention involving university students with elevated levels of distress, Ellis and colleagues (n = 39) (71) found that perceived social support scores among participants in the online peer support group were significantly improved compared to online CBT and no-treatment control groups. Using a blended intervention involving individuals with suicidal ideation, Marasinghe et al. (n = 68) (70) also reported significant improvements in social support in the intervention group compared to waitlist control. However, this study did not clarify their threshold of significance or p-value. Lastly, Interian and colleagues (n = 206) (64) found that the veteran participants in the intervention group were significantly more likely to report a decrease in perceived family support compared to the control group. This was demonstrated at a 2-month follow up after a single-session one-hour web-based intervention (‘Family of Heroes’). Clear conclusions cannot be drawn due to the small sample sizes and lack of power calculations in the trials. Regarding safety, none of these four pilot RCTs reported adverse events related to the interventions in each study.