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Mental health
Protocol
Home-based and community-based activities that can improve mental wellness: a protocol for an umbrella review
  1. Joseph H Puyat1,
  2. Mana Mohebbian1,
  3. Aanchel Gupta2,
  4. Ursula Ellis3,
  5. Harmanpreet Ranote4,
  6. Alberto Almeida5,
  7. Lisa Ridgway6,
  8. Fidel Vila-Rodriguez4,
  9. Arminee Kazanjian1
  1. 1School of Population and Public Health, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
  2. 2Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  3. 3Woodward Library, The University of British Columbia, Vancouver, British Columbia, Canada
  4. 4Department of Psychiatry, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
  5. 5BC Mental Health and Substance Use Services, Vancouver, British Columbia, Canada
  6. 6BC Support Unit, Vancouver, British Columbia, Canada
  1. Correspondence to Dr Joseph H Puyat; jpuyat{at}cheos.ubc.ca

Abstract

Introduction Mental disorders affect about 13% of the world’s population. While evidence-based mental health treatments are available, a significant number of persons with mental illnesses are untreated or do not receive adequate mental healthcare due to various reasons, including costs, stigma and the desire to self-manage symptoms. In the past few years, there has been an increase in the body of evidence regarding leisure activities and mental wellness. However, there is currently no published overview of the state of the evidence on these activities and their potential preventive and therapeutic effects on mental health.

Methods and analysis Using Joanna Briggs Institute (JBI) review guidelines, an umbrella review will be undertaken to synthesise findings from systematic reviews and meta-analyses on the mental health benefits of home-based and community-based activities. MEDLINE, PsycInfo, Embase, CINAHL, Web of Science, Epistemonikos, Cochrane Database of Systematic Reviews, JBI Database of Systematic Reviews and Implementation Reports will be searched for potentially relevant systematic reviews and meta-analyses published from January 1991 to present. Title/abstract screening, full-text review, data extraction and assessment of methodological quality will each be performed independently by two reviewers. A third review author will be available to resolve discrepancies in any of the review tasks. To assess the quality of potentially eligible reviews, the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses will be used. Findings will be presented in table form and will be summarised by study population, type of home-based or community-based activity or intervention, and type of mental health outcomes. Overall assessment of the strength of existing evidence from eligible systematic reviews will be provided following the grading of recommendation, assessment, development and evaluation approach.

Ethics and dissemination No ethical approval is required. Results of this umbrella review will be published in a peer-reviewed journal.

PROSPERO registration number CRD42021266989.

  • mental health
  • anxiety disorders
  • adult psychiatry
  • public health
  • social medicine
  • protocols & guidelines
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2022-065564

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    Strengths and limitations of this study

    • An umbrella review approach will help identify gaps in knowledge about the effectiveness of a variety of leisure activities in promoting mental health.

    • Screening, full-text review, data extraction and assessment of methodological quality will be conducted independently by two reviewers.

    • A final summary of the type of home-based or community-based activity or intervention and mental health outcomes, will be presented in a table format with three-colour visual indicators.

    • A limitation is that the umbrella review will only include review studies published in the English language and exclusion of non-English studies may affect review findings.

    • It is possible that emerging evidence on specific types of activities that have not been systematically reviewed will be excluded from this umbrella review.

    Introduction

    Mental disorders affect the lives of many individuals around the world, causing significant suffering to patients and their families. Based on most recent estimates, each year about 970 million people (uncertainty interval: 900 916 247 to 1 044 361 550) or 13% (uncertainty interval: 12% to 14%) of the world’s population experience various mental disorders.1 The economic burden caused by mental disorders is also substantial. A report from 2010 has put the global economic cost of mental disorders at US$2.5 trillion, with cost projections increasing to US$6.0 trillion by 2030.2 Mental disorders have also become the leading cause of disability3 and also the greatest contributor (35%) to global economic losses (US$47 trillion) due to non-communicable diseases.2

    Evidence-based treatments for various mental disorders, such as pharmacotherapy or psychotherapy, have been available for quite some time now and represent what are commonly known as conventional mental healthcare in many parts of the world. Despite the availability of mental health treatments, a substantial proportion of people with mental disorders do not receive the care or treatment they need.4 For example, in the USA, of the 44.7 and 20.1 million Americans who need mental health and substance use treatment, only about 10%–30% received treatment.5 Similarly, of the people experiencing mental health challenges in Australia and Canada, about 41% and 49% do not receive professional help.6 Even more concerning is the finding that about one-half of people who receive mental health treatment do not receive minimally adequate care.7

    Reasons for not receiving evidence-based mental healthcare include patient-level factors such as low perceived need and a desire to self-manage one’s mental health conditions, which have been reported as particularly important determinants of health-seeking and treatment adherence among individuals experiencing mild to moderate symptoms.8 Among those with severe symptoms, the most salient structural barriers include inability to pay for treatment, difficulty securing appointments and inaccessible treatment locations.8

    In addition to conventional therapies, other approaches based on leisure activities such as physical activity, yoga and relaxation for improving mental wellness have increased in popularity, along with the number of studies that constitute the evidence-base.9 10 The non-clinical activities included in these approaches are not meant to replace clinical interventions but can be designed to either complement conventional mental healthcare or help prevent the development of mental health conditions and promote resiliency in the population. Many of these activities are generally well accepted by the public, have either low or minimal costs, and are already supported by community organisations and institutions.

    To date, there is currently no published rigorous overview of the state of evidence on these activities and their potential preventive and therapeutic effects on mental health. Our search of various electronic databases indicates that there is also no ongoing umbrella review on this topic registered in the International Prospective Register of Systematic Review (PROSPERO), Joanna Briggs Institute (JBI) Systematic Review Register, Open Science Framework Registries and Cochrane Database of Systematic Reviews. An umbrella review, also known as an overview of studies or a meta-review, is needed to synthesise and mobilise the growing number of systematic reviews that document the mental health benefits of a wide range of home-based and community-based activities such as physical activity, outdoor activities and creative arts.11–13 Because umbrella reviews are based on systematic reviews, an umbrella review approach14 15 will allow for the synthesis of the breadth of knowledge in this area based on the highest quality of evidence.

    Findings from an umbrella review that provides evidence on the effectiveness of a range of leisure activities on promoting mental well-being in the general public can have a number of potential applications. First, the evidence can be used to inform future revisions of clinical practice guidelines and care pathways for mental health treatments to include a wide range of activities with known levels of therapeutic and preventive effects. Such a resource will increase clinicians’ confidence in prescribing activities with measured effects to match patients’ needs, preferences and lifestyles, which all contribute to treatment adherence. Additionally, when conducted in group settings and in local communities, these activities can be the cornerstone of many social prescribing programmes that are gaining attention in many countries such as the UK, USA and Canada.16–18 Social prescribing, which was first pioneered in the UK and is currently developing its evidence base, is a promising evidentiary approach to improving the physical and mental well-being of patients in primary care settings by linking them to non-medical interventions or activities in the community that promotes social connectedness.16

    Second, findings from an umbrella review will facilitate decision-making with regard to investment in public infrastructures, such as multi-use laneways, affordable gyms, yoga studios, accessible green or walkable spaces, and online resources that promote and provide guidance on various types of activities. Leisure activities, in general, tend to be more accessible than traditional psychosocial interventions. However, there may still be issues regarding affordability and cost that may affect the accessibility of these activities. Investment, therefore, in infrastructure, as well as in subsidies to support these activities will pay off at the population level in terms of promoting mental health in society, and mitigating years of life lost associated with mental disorders.19

    Finally, and in the context of a population health framework that recognises the need to provide different approaches to subpopulations with varying mental health needs,20 findings from this umbrella review will offer a larger segment of the population with complementary and alternative means to improve and promote their mental wellness. As specified by a population health approach to mental health,20 there is a relatively smaller proportion of people with moderate to severe and complex mental disorders that requires significant and intensive clinical services from mental health specialists and other professionals providing ‘conventional’ mental health treatment. Findings from this umbrella review are likely to have limited applicability to this segment of the population. However, beyond this small subpopulation are the vast majority who experience or are at risk of developing mild symptoms. This larger group is less likely to benefit from conventional treatment, as can be inferred from findings about antidepressant therapy and mild to moderate depression.21 22 Individuals in this larger group are also less likely to seek conventional treatment or support due to stigma associated with receiving care from mental health professionals. This larger segment of the population stands to derive significant benefit from this umbrella review of the different types of leisure activities that can be performed at home or in the community and that have preventive and therapeutic effects on mental well-being.

    Objectives

    This protocol is for an umbrella review that aims to summarise and provide an overview of the findings from published systematic reviews and meta-analyses of the benefits of home-based and community-based activities on various mental health conditions. The umbrella review will be conducted following the Methodology for JBI Umbrella Reviews.14 15

    Methods and analysis

    Inclusion criteria

    We will include systematic reviews that are relevant to our research question in terms of study population, intervention, comparator group and outcome (table 1).

    View this table:
    Table 1

    Inclusion criteria based on PICO elements

    Study population

    The target population consists of the following groups: (1) general population; (2) people at risk of developing mental disorders; (3) people with mild to moderate mental disorders and (4) people with severe mental disorders.

    Interventions

    Systematic reviews that examine the impact on mental health of any form of leisure activities will be considered. Leisure activities are defined as everything people do in their free time or voluntarily, and mainly for enjoyment.23 24 These activities are generally not work-related and also not considered biologically necessary for survival25 of the individual or the human species. Leisure activities encompass a wide range of behaviours such as reading for enjoyment, practicing meditation or relaxation exercises, participating in arts and crafts, engaging in sports or physical activities, listening to music, volunteering in community activities or engaging in any hobbies, to name a few. Leisure activities examined as the primary intervention, for example, as an intervention for the general population or for those with mild to moderate symptoms; or, as an adjunctive therapy for people with severe mental illness will be considered.

    Comparator interventions

    Systematic reviews that examine the impact of leisure activities on mental health in comparison with usual care (ie, psychological or pharmacological therapies) or another type of leisure activities will be considered. Comparator interventions consisting of multiple interventions will also be considered.

    Mental health outcomes

    Systematic reviews that examined self-reported or clinician-assessed outcomes will be included. These outcomes could be in the form of changes in well-being or resilience in the general population; changes in risk of developing mental disorders among at-risk groups and changes in symptoms of mental disorders or quality of life among those with mental disorders. Improvement in mental well-being and reduction in mental disorder symptoms due to engagement in leisure activities, as well as their opposite or unintended effects will also be considered.

    Search strategy

    A search strategy was developed and tested with the help of a professional librarian. MEDLINE (Ovid), PsycInfo (EBSCO), Embase (Ovid), CINAHL, Science Citation Index and Social Sciences Citation Index (Web of Science) and Epistemonikos will be searched for potentially relevant systematic reviews and meta-analyses. Systematic reviews of qualitative and quantitative studies will be included. We will also search repositories of systematic reviews, including the Cochrane Database of Systematic Reviews, JBI Database of Systematic Reviews and Implementation Reports, and Epistemonikos. Search terms for identifying systematic reviews26 will be adapted in conjunction with clusters of terms for various leisure activities such as “exercise”, “mindfulness” or “music”, and terms related to mental wellness, such as “mental health”, “stress”, “loneliness”, “depression” and “anxiety”. A copy of the full draft of the Ovid MEDLINE search strategy can be found in online supplemental appendix A. Forward and backward citation searching will be conducted on included studies using Citation Chaser (https://estech.shinyapps.io/citationchaser/).

    We will exclude systematic reviews on any type of activities, including sleeping or eating, that are biologically necessary for the survival of an individual or the human species. We will exclude scoping reviews as these are conducted for different purposes than systematic reviews.27 Additionally, we will exclude systematic reviews that were: (1) published before January 1991; (2) have a primary focus on psychopharmacological (eg, antidepressants) or psychological (eg, CBT and counselling) therapies and (3) not published in English or do not have English translations. We will keep track of all potentially relevant reviews that were identified during screening but were excluded from full review due to lack of English translations or because they have not yet been published in peer-reviewed journals.

    Screening, quality assessment and data extraction

    References will be exported from databases and imported into SUMARI and deduplicated. Title/abstract screening, full-text review, data extraction and assessment of methodological quality will each be performed independently by two reviewers. A third review author will be available to help resolve discrepancies in any of the review tasks.

    To evaluate the quality of potentially eligible reviews, we will use the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses (see online supplemental appendix B).15 The checklist contains 11 questions answerable by ‘Yes’, ‘No’, ‘Unclear’ and ‘Not applicable’ responses. Only reviews that were assessed with a ‘Yes’ response to the following questions in the checklist will be included in the umbrella review: ‘(1) Is the review question clearly and explicitly stated?; (2) Were the inclusion criteria appropriate for the review question?; (3) Was the search strategy appropriate?; (4) Were the sources and resources used to search for studies adequate?; (5) Were the criteria appropriate for appraising studies appropriate?’.

    We will use the JBI Data Extraction Form for Review for Systematic Reviews and Research Syntheses15 to extract the following data from each included systematic reviews: citation details, study objectives, type of review, analytic approach to synthesise the evidence, number of included studies, search period, databases searched, participant details, setting and context, quality assessment tool, intervention or leisure activities examined, comparator interventions, relevant outcomes reported and major findings (see online supplemental appendix C). Consistent with umbrella reviews’ main objective of providing an easily interpretable overview of findings from systematic reviews, no primary studies will be included or retrieved.15 Consequently, no data (eg, effect estimates and SEs or CIs) from original studies will be extracted.

    The critical appraisal tool and data extraction form will be piloted with three review studies before they are used independently by the reviewers. Any discrepancies in quality assessment and data extraction will be discussed and resolved through a consensus process. To facilitate the entire review process, we will use the JBI SUMARI platform,28 which contains the JBI standardised tools for study appraisal and data collection. Registration for this umbrella review was made at the International Prospective Register of Systematic Reviews.

    Data summary and summary of evidence

    A narrative synthesis of the findings will be conducted to summarise the findings. A flowchart (see figure 1) following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines29 will be included to describe the results of the umbrella review process. Key characteristics of and the main findings from all eligible reviews will be presented in a table format. As well, a summary of the methodological quality ratings for all included reviews will be presented to provide an overall picture of the quality of the individual reviews informing the results of the umbrella review.

    Figure 1
    Figure 1

    PRISMA flow diagram29 summarising the process for identifying and screening systematic review studies for inclusion in the full review. During identification, various bibliographic databases will be searched and the total number of potentially eligible reviews (n=) from each database will be reported in the first box. Duplicate and other excluded entries will be recorded in the second box. At screening, the total number of entries (n=) screened, retrieved and appraised will be recorded on the first set of boxes while the number of entries excluded and the reasons for exclusion will be recorded in the second set of boxes. The final box will record the total number of entries (n=) that will be included in the umbrella review.

    Findings from meta-analyses will be presented in table form and will be summarised by study population (eg, adult general population, youth and children at risk of developing mental disorders, individuals with severe mental disorders), type of home-based or community-based activity or intervention, type of comparator (eg, usual care or other types of leisure activities) and mental health outcomes (eg, improvement in mental well-being, quality of life, reduction in symptoms of mental disorders). For example, pooled effect size estimates from review studies on yoga and its effects on anxiety, depression and other mental health outcomes will be summarised in separate rows and columns. Each pooled effect size estimates will also be accompanied by columns that indicate the number of studies, the number of participants and the results of heterogeneity assessments reported by the review study.

    Qualitative findings from systematic reviews will also be presented in a table form containing a description of the context examined, a verbatim quote of the synthesised finding, and a brief interpretation of the synthesised finding.14

    A final summary of the evidence will be presented in a table form containing the specific names of the activities, the reviews that constitute the existing evidence, and a visual indicator, based on JBI umbrella review guidelines,14 that uses three colours to indicate the state of the evidence for each activity and outcome reviewed. Green will be used to signify that the existing evidence is consistently or overwhelmingly supportive of the health-promoting effect of the activity (eg, exercise) on a specific mental health outcome (eg, depression). Orange will be used to indicate that the current evidence for effectiveness is mixed, while red will be used to indicate the current evidence shows a lack of beneficial effects or evidence that the activity results in poorer or worse mental health outcomes.

    An overall state of the evidence assessments will be provided following the grading of recommendation, assessment, development and evaluation (GRADE) approach.30 GRADE assessments for systematic reviews of randomised controlled trials will be based on risk of bias, consistency, directness of effects, precision and evidence of publication bias. For systematic reviews of non-randomised studies, GRADE assessments will be based on the magnitude of effect, evidence of dose–response associations and adjustments for all plausible confounders.31 Finally, GRADE assessments of qualitative syntheses will be provided following the GRADE-CERQual guidelines, which give considerations to a review’s methodological limitation, coherence, data adequacy and relevance.32

    We will run the search strategy on a regular basis and update the umbrella review to incorporate systematic reviews published within 5 years of the most recent publication of the umbrella review results.

    Patient and public involvement

    The development of this umbrella review protocol was part of a year-long collaboration that included patient partners (LR and AA) from the BC Support Unit and the BC Mental Health and Substance Use Services. Their lived experience and insights helped shape the research question and the plan to address it through an umbrella review. These partners contributed to the conceptualisation of this review protocol, provided feedback on the final draft and provided approval to be included as coauthors of this manuscript. They and other patient partners will be encouraged and provided the necessary support to participate in the future conduct of this umbrella review and in the dissemination and use of research findings. Patient partners’ continued, meaningful participation will help ensure that the research findings are relevant and are translated into policy and practice, to improve mental health for everyone.33

    Study limitations

    A knowledge synthesis based on an umbrella review of systematic reviews can fill the need for a reliable source of knowledge to anyone interested in the breadth of high-quality evidence available on home-based and community-based activities that can promote mental wellness. Some limitations inherent to umbrella reviews, however, need to be considered. First, umbrella review results are based on systematic reviews, which are in turn, based on the availability of published high-quality primary studies. As previously noted by other researchers,34–36 there is a persistent bias against publishing studies with null or weak results. This publication bias could make the evidence-base for a specific activity stronger than it actually is had rigorous studies with null or weak results been published and subsequently included in systematic reviews. We will examine and reduce the impact of publication bias in our synthesis of findings by highlighting when the assessment for publication bias is lacking or is suggestive of the presence of a strong publication bias. Second, it is possible that newer types of activities or activities that have rarely been investigated in primary studies may not have been the subject of systematic reviews. This could result in a synthesis that excludes emerging evidence on relatively newer types of activities. To ensure that the umbrella review is current, our team will update the umbrella review on a regular basis to include evidence from systematic reviews on newer activities. Third, it is possible that multiple independent reviews could include the same set of studies and present a misleading impression that a large evidence base exists. To mitigate the impact of this limitation, our synthesis will include notes about the degree of overlap across reviews, if any, on our summary tables. Finally, due to lack of resources, our umbrella review will include only review studies published in the English language. There is some evidence that exclusion of non-English studies can affect the results of systematic reviews.37

    Ethics statements

    Patient consent for publication

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    Supplementary materials

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    Footnotes

    • Contributors JHP wrote the initial draft and secured funding for and contributed to the conceptualisation and design of this protocol. MM, AG and HR contributed to the writing, preparation of the final manuscript, and selection of review tools included in the protocol. UE helped develop the search strategy, contributed to the methodology and provided critical feedback. LR and AA contributed to the conceptualisation of the review protocol, as patient partners, and provided critical feedback. FV-R and AK contributed to the conceptualisation of the protocol and provided critical feedback. All authors reviewed and approved the final version of the submitted manuscript.

    • Funding This work was supported by Michael Smith Foundation for Health Research (Grant #: C2-2020-1419).

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.