Depression is a global concern and is predicted to become the leading, serious, and chronic noncommunicative disease by 2030 [
Social participation is defined in the occupational therapy profession as “the interweaving of occupations to support desired engagement in community and family activities as well as those involving peers and friends, … and that support social interdependence” [
The literature review revealed that nonpharmacological treatment is the preferred treatment option by the majority of people with depression [
To manage depression and improve mental and social health, individuals with depression need to work themselves and cooperate with other people in the community and society. Therefore, supportive social participation and rehabilitation processes of adults with depression are typically motivated by the recovery and active management of their illness in terms of personal and social well-being [
The objective of this research was to review intervention programs that support the social participation of adults with depression and their effectiveness. This systematic review only included research studies of nonpharmacological treatment that resulted in behavioral and emotional changes in social participation for the primary focus and also included other effective factors resulting from the intervention programs such as life satisfaction and QoL as relevant to achieve the objective.
This systematic review followed the guideline of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [
The level of evidence.
Level | Type of evidence |
---|---|
Level I | Systematic reviews, meta-analyses, randomized controlled trials |
Level II | Two groups, nonrandomized studies (e.g., cohort, case-control) |
Level III | One group, nonrandomized (e.g., before and after, pretest and posttests) |
Level IV | Descriptive studies that include analysis of outcomes (single-subject design, case series) |
Level V | Case reports and expert opinion that include narrative literature reviews and consensus statements |
Adapted from Sackett’s evidence-based medicine [
The Patient/Problem, Intervention, Comparison, Outcome (PICO) method [
The inclusion criteria in the initial stage of screening were peer-reviewed scientific articles on adults with depression aged 20 to 60 years old, published in English between January 2010 and December 2018. Searching articles and hand searches were completed in one month. This review included only journal articles and excluded non-peer-reviewed research literature, presentations, conference proceedings, and dissertations. The researchers only considered intervention programs directly provided to persons with depression. The research team considered studies concerning persons with depression and physical comorbidity for inclusion as these individuals face many barriers to social participation. All documents and information were logged and validated by the researchers (SP, RS, AT, JJ, SA, and TS).
The exclusion criteria were as follows: (1) study with other groups of participants unrelated to the purpose of this research, which consisted of (1.1) animal or drug study, (1.2) development of assessment tool, (1.3) family, caregiver, stakeholder, and other groups (e.g., occupational therapy practitioner or students), (1.4) nonspecific participants (e.g., severe mental illness or psychosis), and (1.5) individuals aged <20 or >60 years; (2) different research types of evidence, such as (2.1) qualitative study and (2.2) studies not categorized as evidence-based medicine levels I–III; (3) social participation not being the central aspect in the research; and (4) not an intervention program for persons with depression.
Studies were searched and identified independently through databases by SP and TS, using sets of key terms, and additional hand searches were conducted by SP and JJ. Retrieved studies underwent title and abstract screening, performed independently by SP and JJ. Studies were dismissed at this stage if they did not match the screening criteria, as were the studies with social participation defined remarkably differently from this. In case of any doubt, SA, who has higher qualification and research experience, made the final decision after thorough deliberation and critical thinking. Reference lists of the studies included were also reviewed to ensure their relevance. Next, SP retrieved the full text of the remaining articles, arranged, categorized, and grouped the studies into a spreadsheet before assessing the strength of evidence and risk of bias. The other researchers double-checked each stage.
The researchers provided a narrative synthesis of the findings. It was structured around the types of intervention programs, characteristics of the target population, and types of outcomes. The guidelines from the U.S. Preventive Services Task Force [
Strength of evidence (level of certainty).
Strength | Description |
---|---|
Strong | (i) Two or more level I studies |
Moderate | (i) At least one level I high-quality study or multiple moderate-quality studies (level II, level III, etc.) |
Low | (i) Small number of low-level studies, flaws in the studies, etc. |
Reference: the U.S. Preventive Services Task Force [
The search found 1,135 studies in the screening process. Among these, ten studies (Berget et al. 2011 [
PRISMA flow diagram.
Study characteristics, activities or treatment program, and strength of evidence.
Author/Ref | Level of evidence/research design | Participants, age ranges, and sample size | Outcome measures | Activity or treatment program | Result | Strength of evidence |
---|---|---|---|---|---|---|
Berget et al. 2011 [ | Level I/RCT | Score change; SB, SA, SSMA in BDI & STAI | Depression significantly decreased between baseline and six-month follow-up in both treatment and control groups, but no significant difference was observed in depression scores between the treatment and control group at any point in time. | Strong | ||
Graven et al. 2011 [ | Level I/systematic review | RCT articles only | PEDro scale rating | Group 1: compared intervention group to usual care or placebo control ( | A total of 54 studies were classified into nine types. | Strong |
Ammerman et al. 2013 [ | Level I/RCT | Measure at pre-, post-, and three-month follow-up treatments | Psychological distress decreased (broad improvement) at posttreatment and follow-up. IH-CBT increased social support (affiliative and belongingness aspects), whereas tangible support was not significant. | Strong | ||
Nagy et al. 2017 [ | Level I/systematic review | WMHCIDI | (1) Peer support, e.g., sharing and empathizing with others | 22 of 24 studies used a combination of approaches. | Strong | |
Chen et al. 2019 [ | Level I/RCT | Four-time score measure; baseline (T0)—after the program (T1, T2, T3) | Less fear of social interactions, less avoidance of social interactions, and improved physical function during the three months after the intervention. | Strong | ||
Strøm et al. 2019 [ | Level I/RCT | HADS | No significant difference within the treatment and the control group regarding changes in HADS at three-month follow-up. | Strong | ||
Kern et al. 2019 [ | Level I/RCT | BDI-II weekly, during the baseline, six-month follow-up assessments | Greater improvement in hedonic capacity, environmental reward, and social impairment was associated with greater reductions in depression over six months. | Strong | ||
Rogers et al. 2014 [ | Level III/pre- and posttest | Brief self-report questionnaire | Sports-oriented intervention using surfing in an experiential and skill-based program | Clinically meaningful improvement in PTSD severity ( | Moderate | |
Cruwys et al. 2014 [ | Level III/two longitudinal intervention studies | Both treatment programs contributed to a decline in depression. | Moderate | |||
Croezen et al. 2015 [ | Level III/one group longitudinal study | Depressive symptom (EURO-D scale) | Study activities: | The prevalence of depressive symptoms declined between waves 1 and 2 but increased between waves 2 and 4. | Moderate |
Abbreviation: ADL: activity of daily living; AAT: animal-assisted therapy; BA: behavioral activation; BAI: Beck Anxiety Inventory; BCPHE: behavior change program and health education; BDI: Beck Depression Inventory; BES: best evidence synthesis; BSI: Brief Symptom Inventory; CBT: cognitive behavioral therapy; DASS: Depression Anxiety Stress Scales; EPDS: Edinburgh Postnatal Depression Scale; HADS: Hospital Anxiety and Depression Scale; HFA: Healthy Families America; HNC: head and neck cancer; IH-CBT: in-home cognitive behavioral therapy; ISEL: Interpersonal Support Evaluation List; ISG: Internet Support Group; KPS: Karnofsky Performance Scale; LBPRS: low back pain rating scale; LSAS: Liebowitz Social Anxiety Scale; MDD: major depressive disorder; NFP: nurse-family partnership; ODI: Oswestry disability index; PEDro: Physiotherapy Evidence Database; PLF: instrumented posterolateral fusion; PTSD: posttraumatic stress disorder; QoL: quality of life; SA: score after; SB: score before; SCID-I: Structured Clinical Interview for DSM-IV Axis I Disorders, January 2007 version; SHV: standard home visiting; SNI: Social Network Index; SSMA: score six months after; STAI: the Spielberger State Anxiety Inventory; UW-QoL: University of Washington Quality of Life Scale; WMHCIDI: World Mental Health Composite International Diagnostic Interview; w-SPIINA: web-based spine platform featuring interaction and information by animation; ZSRDS: Zung Self-Rating Depression Scale.
In the analysis and synthesis of results, seven of the ten studies (Berget et al. 2011 [
Two major categories of intervention were found with 13 specific programs (Table
Two major categories of intervention.
Programs | Authors |
---|---|
Occupational-based intervention (OBI) | |
Animal-assisted therapy (AAT) | Berget et al. 2011 [ |
Sport or exercise program (SEP) | Graven et al. 2011 [ |
Religious activity (RA) | Croezen et al. 2015 [ |
Group-based activity (GBA) | Nagy et al. 2017 [ |
Skill-building program (SBP) | Nagy et al. 2017 [ |
Other social and community supportive program (OSCSP), which covers peer support (PS) and linking community resource (LCR) | Nagy et al. 2017 [ |
Cognitive behavioral therapy-based intervention (CBT-BI) | |
Web-based program (WBP) | Strøm et al. 2019 [ |
Clinical psychotherapy group (CPG) | Cruwys et al. 2014 [ |
Behavioral change program and health education (BCPHE) | Chen et al. 2019 [ |
In-home cognitive behavioral therapy and home visit (IH-CBT+HV) | Ammerman et al. 2013 [ |
Behavioral activation for depression and lifestyle intervention (BADLI) | Kern et al. 2019 [ |
Psychoeducation (PsyE) | Nagy et al. 2017 [ |
Psychotherapy (PsyT) | Nagy et al. 2017 [ |
These programs sought the following four outcomes: behavioral change of social participation (
The results of four programs showed positive behavioral changes in social participation. First, AAT (Berget et al. 2011 [
Third, BCPHE (Chen et al. 2019 [
All programs of OBI and CBT-BI presented a reduction of depressive symptoms. Furthermore, SEP (Graven et al. 2011 [
Four programs, SBP, SEP, PS, and GBA from Nagy et al. 2017 [
SEP (Graven et al. 2011 [
A strong level of certainty was found in seven studies (Berget et al. 2011 [
The risk of bias was rated for studies individually (Tables
Risk-of-bias table for considering nonsystematic reviews.
Citation | Selection Bias | Performance bias | Detection bias | Attrition bias | Reporting bias | ||
---|---|---|---|---|---|---|---|
Random sequence generation | Allocation concealment | Blinding of participants and personnel | Blinding of outcome assessment: self-reported outcomes | Blinding of outcome assessment: objective outcomes | Incomplete outcome data | Selective reporting | |
Berget et al. 2011 [ | + | + | + | ? | ? | + | + |
Ammerman et al. 2013 [ | + | + | + | ? | ? | + | + |
Chen et al. 2019 [ | + | + | + | ? | ? | + | + |
Strøm et al. 2019 [ | + | — | — | — | — | + | + |
Kern et al. 2019 [ | + | — | ? | ? | ? | + | + |
Rogers et al. 2014 [ | — | — | — | — | — | + | + |
Cruwys et al. 2014 [ | — | — | — | — | — | + | + |
Croezen et al. 2015 [ | — | — | — | ? | ? | + | + |
Categories for risk of bias: +: low risk of bias; ?: unclear risk of bias; –: high risk of bias; NA: not applicable. Risk-of-bias table format followed the guideline from
Risk-of-bias table for considering systematic review (AMSTAR).
Citation | (1) | (2) | (3) | (4) | (5) | (6) | (7) | (8) | (9) | (10) | (11) |
---|---|---|---|---|---|---|---|---|---|---|---|
Graven et al. 2011 [ | + | + | + | + | + | + | + | + | + | + | + |
Nagy et al. 2017 [ | + | + | + | + | + | + | + | + | + | + | + |
Note 1. Categories for risk of bias: +: low risk of bias; ?: unclear risk of bias; –: high risk of bias; NA: not applicable. Risk-of-bias table format followed the Development of AMSTAR by Shea et al. [
This review revealed that not every treatment program affects all behavioral changes in social participation, reduces depression or depressive symptoms, improves life satisfaction, and improves QoL. It could not be determined which program was the most effective due to the diversity of participants’ programs and characteristics. The programs within the systematic reviews included in this study (SEP (Graven et al. 2011 [
AAT (Berget et al. 2011 [
CPG (Cruwys et al. 2014 [
Strong evidence was presented in most programs; however, an essential factor of the considerable rating level of certainty depended on whether their assessment tools were suitable or further study was needed. The assessment risk of bias was low in systematic review studies. The studies were considered as having nonsystematic reviews if they had a high risk of bias, except for some RCT studies. However, some parts of the RCT studies had a high risk of bias regarding advantages for the participants because they could not design the study with blinded personnel in treatment and outcome measurement. This systematic review provides a comprehensive appraisal of the effectiveness of intervention programs that support social participation for adults with depression and advocate the necessity of occupational therapy and healthcare services in the nonpharmacological treatment for depression in both clinical and community settings.
This review gathered and classified the intervention programs to support social participation in adults with depression; however, this study’s limitations should also be considered. Accordingly, the researchers focused more on nonpharmacological treatment in support of social participation and evidence in occupational therapy research, and several articles showed limitations after screening. Expanding databases and years of searching relate to a change of results when reviewing. Interpretation of the findings from several intervention programs was carefully performed because of the variation in examining intervention, diagnosis, and age range of the participants. The age of participants was accepted if the articles concerned only adolescents aged 16 years and above [
This study reviewed the evidence of nonpharmacological treatments that illustrate intervention programs and their effect on social participation for adults with depression. Programs were categorized as OBI or CBT-BI and summarized in order to demonstrate the effectiveness of interventions. Four programs (AAT, SEP, RA, and BCPHE) demonstrated visible behavioral changes in social participation. All intervention programs reported decreasing depressive symptoms. Four intervention programs (SBP, SEP, PS, and GBA) illustrated life satisfaction, whereas only CPG promoted QoL. Based on the result of this review, AAT, SEP, and BCPHE are recommended. A combined treatment with a flexible and suitable application for covering higher benefits in promoting social participation, reducing depression, and contributing to life satisfaction and QoL is recommended for other programs.
The reviewing data used to support the findings of this study are included within the article.
The authors declare no conflict of interest regarding the publication of this paper.
The authors would like to acknowledge the Tokyo Human Resources Fund for City Diplomacy for granting scholarship to the primary investigator during her pursuit of a Ph.D. in Occupational Therapy at the Tokyo Metropolitan University.