Can we mitigate the psychological impacts of social isolation using behavioural activation? Long-term results of the UK BASIL Urgent Public Health COVID-19 pilot randomised controlled trial and living systematic review
Authors: Littlewood Elizabeth , McMillan Dean , Chew-Graham Carolyn A. , Bailey Della , Gascoyne Samantha , Sloan Claire , Burke Lauren , Coventry Peter , Crosland Suzanne , Fairhurst Caroline , Henry Andrew , Hewitt Catherine , Baird Kalpita , Ryde Eloise , Shearsmith Leanne , Traviss-Turner Gemma , Woodhouse Rebecca , Webster Judith , Meader Nick , Churchill Rachel , Eddy Elizabeth , Heron Paul , Hickin Nisha , Shafran Roz , Almeida Osvaldo P. , Clegg Andrew , Gentry Tom , Hill Andrew , Lovell Karina , Dexter Smith Sarah , Ekers David , Gilbody Simon 
Published: June 2022

Background

Behavioural and cognitive interventions remain a credible approach in preventing loneliness and depression. There was a need to rapidly generate and assimilate trial-based data during COVID-19.

Objectives

We undertook a COVID-19 parallel pilot RCT of behavioural activation for depression and loneliness [the BASIL-C19 trial ISRCTN94091479]. We also assimilate these data in a COVID-19 living systematic review [PROSPERO CRD42021298788].

Methods

Primary care participants (>=65 years) with long-term conditions were computer randomised to Behavioural Activation (n=47) versus care-as-usual (n=49). The single blinded primary outcome was the PHQ-9. Secondary outcomes included loneliness (De Jong Gierveld Scale). Data from the BASIL-C19 trial were included in a random effects meta-analysis of depression and loneliness.

Findings

The 12 months adjusted mean difference for PHQ-9 was -0.70 (95% CI -2.61 to 1.20) and for loneliness was -0.39 (95% CI -1.43 to 0.65). Secondary 12-month trial outcomes suggested evidence of benefit for behavioural activation.

The BASIL-C19 meta-analysis (13 trials) found short-term reductions in depression (standardised mean difference [SMD]=-0.31, 95%CI -0.51 to -0.11) and loneliness (SMD=-0.48, 95%CI -0.70 to -0.27). There were few long-term trials, but there was evidence of some benefit (loneliness SMD=-0.20, 95%CI -0.40 to -0.01; depression SMD=-0.20, 95%CI -0.47 to 0.07).

Discussion

We found a signal of effect in reducing loneliness and depression in the BASIL trial. Living meta-analysis provides strong evidence of short-term benefit for loneliness and depression.

Clinical implications

Scalable behavioural and cognitive approaches should be considered as population-level strategies for depression and loneliness on the basis of the living systematic review.

Funding

This study was funded by National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research (PGfAR) RP-PG-0217-20006.

Author summary

Why was this study done?

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Older people with long-term conditions have been impacted by COVID-19 pandemic restrictions and have experienced social isolation. In turn, this puts them at risk for depression and loneliness, and these are bad for health and wellbeing. Psychosocial approaches, such as behavioural activation, could be helpful.

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Trial-based evidence is needed to demonstrate if it is possible to prevent the onset, or mitigate the impact, of loneliness and depression.

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There are few studies of brief psychosocial interventions to mitigate depression and loneliness, and it is important to know how emerging trial-based data adds to existing evidence.

What did the researchers do and find?

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There was preliminary evidence that levels of loneliness were reduced at 3 months when behavioural activation was offered.

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At longer term (12-month) follow-up there were signals of ongoing positive impact.

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When BASIL-C19 data were assimilated into a living systematic review there is clear evidence of impact of brief psychological interventions on depression and loneliness in the short-term. More research into the longer-term impact is needed.

What does all this mean?

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Behavioural activation now shows evidence of benefit which will be useful for policy makers in offering support to people who are socially isolated.

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This research knowledge will be useful once the COVID-19 pandemic has passed, since loneliness is common in older populations and effective scalable solutions will be needed to tackle this problem.

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As new trial-based data emerges, our living systematic review and meta-analysis will be updated since this is an area of active research.