Introduction
Job loss, debt and financial difficulties are associated with an increased risk of mental illness, self-harm and suicide (Fitch et al. Reference Fitch, Hamilton, Bassett and Davey2011; Haw et al. Reference Haw, Hawton, Gunnell and Platt2015). During periods of economic recession the numbers of people affected by these and other problems rise and levels of depression, self-harm and suicide increase (Stuckler et al. Reference Stuckler, Basu, Suhrcke, Coutts and McKee2009; Katikireddi et al. Reference Katikireddi, Niedzwiedz and Popham2012; Chang et al. Reference Chang, Stuckler, Yip and Gunnell2013; Corcoran et al. Reference Corcoran, Griffin, Arensman, Fitzgerald and Perry2015). Interventions to help mitigate the effect of job loss and debt on mental health are an important element of policy response to periods of recession. Ecological studies indicate that factors such as government spending on active labour market programmes and unemployment protection schemes may counter the effect of recession on suicide rates (Stuckler et al. Reference Stuckler, Basu, Suhrcke, Coutts and McKee2009; Norström & Grönqvist, Reference Norström and Grönqvist2014) and austerity measures such as reassessment of individuals’ eligibility for benefit could have the opposite effect (Barr et al. Reference Barr, Taylor-Robinson, Stuckler, Loopstra, Reeves, Wickham and Whitehead2015). However, there have been few evaluations of specific interventions targeted at individuals.
A number of policy documents (WHO, 2011; van Stolk et al. Reference van Stolk, Hofman, Hafner and Janta2014) have summarized some of the limited randomized controlled trial (RCT) evidence of the effects on mental health of interventions for people who have lost their jobs, most notably studies of the JOBS programmes in the USA (Caplan et al. Reference Caplan, Vinokur, Price and van Ryn1989; Vinokur et al. Reference Vinokur, Price and Schul1995b ) and the Työhön job search programme in Finland (Vuori et al. Reference Vuori, Silvonen, Vinokur and Price2002). Two reviews assessed the evidence on ‘job search’ interventions and included data from randomized and non-randomized studies (Audhoe et al. Reference Audhoe, Hoving, Sluiter and Frings-Dresen2010; Liu et al. Reference Liu, Huang and Wang2014). Both reported that job search interventions improved depression and employment (Audhoe et al. Reference Audhoe, Hoving, Sluiter and Frings-Dresen2010; Liu et al. Reference Liu, Huang and Wang2014). However, to our knowledge, no systematic reviews have assessed evidence of the effectiveness of the range of interventions, including job-search programmes, designed to ameliorate the impact of job loss, unemployment and economic hardship on mental health.
Our aim was to systematically review the evidence from randomized controlled trials of interventions given to the general population to reduce the effects of economic hardship on mental health. Our focus was on studies conducted in general population samples of working age individuals, rather than those focusing on specific high-risk samples, such as individuals with serious mental illness (Kukla & Bond, Reference Kukla and Bond2009; Tsang et al. Reference Tsang, Fung, Leung, Li and Cheung2010; Burke-Miller et al. Reference Burke-Miller, Razzano, Grey, Blyler and Cook2012; Nieuwenhuijsen et al. Reference Nieuwenhuijsen, Faber, Verbeek, Neumeyer-Gromen, Hees, Verhoeven, van der Feltz-Cornelis and Bültmann2014). We also excluded studies on select population groups (e.g. single mothers) where we felt policy responses and interventions would be tailored specifically for the particular needs of those populations and were not generalizable to a general population (Wiggins et al. Reference Wiggins, Oakley, Roberts, Turner, Rajan, Austerberry, Mujica and Mugford2004; Forgatch & DeGarmo, Reference Forgatch and DeGarmo2007). This review will be of use to policy makers, researchers planning future intervention studies and public health practitioners working in local authorities.
Method
Criteria for considering studies for this review
We included randomized controlled trials (RCTs) and cluster randomized trials of public health or health service interventions designed to mitigate the effects of unemployment, debt or austerity measures in the general population. We included only studies with a measure of mental health as an outcome, such as studies with measures of either mental disorder or mental health symptom scales. Examples of types of intervention include: group support or workshops to provide people with job search skills and resilience to the impact of rejected applications; advice type interventions (e.g. Citizens Advice Bureau) to help people navigate their way through benefits systems and/or access relevant support or to provide debt advice; interventions aimed at training frontline staff in job centres or benefits agencies or debt collection agencies to identify individuals who have mental health problems and help them respond appropriately. We excluded studies focused on people with serious mental illness, as this is a distinct subgroup of the population requiring specific intervention types; people not of working age; rehabilitation interventions for people with somatic or mental health problems that either aimed to help them get back into work, or to prevent them from losing their job if they were currently employed; and interventions aimed at selected specific groups of the working population (e.g. single mothers). We also excluded studies if the authors did not report any measure of mental health. A protocol for the review was registered in advance on the PROSPERO website, we prepared the review following Cochrane methods and using PRISMA reporting guidelines (Liberati et al. Reference Liberati, Altman, Tetzlaff, Mulrow, Gøtzsche, Ioannidis, Clarke, Devereaux, Kleijnen and Moher2009; Higgins & Green, Reference Higgins and Green2011; Moore et al. Reference Moore, Gunnell, Metcalfe, Kapur and Hawton2015).
Search
We searched MEDLINE, PsycINFO, Embase on Ovid; the Cochrane Library including CENTRAL on Wiley Interscience; and Science and Social Science Citation Index, and Arts and Humanities Citation Index on Web of Science. All databases were searched from inception to 27 May 2015 and re-run on 16 January 2016. We excluded letters, editorials, and conference proceedings for which there were no full-text papers. We searched the reference lists of, and ran a citation search on, all included studies. We used a combination of MeSH terms and text words for mental health combined with terms for economic hardship, unemployment, job insecurity credit advice and financial worries. We used filters for selection of RCTs taken from the Cochrane Handbook (Lefebvre et al. Reference Lefebvre, Mannheimer, Glanville, Higgins and Green2011). We did not exclude studies based on language (see Supplementary Appendix 1 for full details of the searches).
Eligibility, data collection and assessment of risk of bias
We screened the titles and abstracts and eligibility of full-text reports independently and in duplicate (D.G. and T.H.M.M.) using a form to check the criteria and discussing any discordant decisions until consensus was reached. All authors extracted data and assessed risk of bias, independently and in duplicate, recording these on a data extraction form (D.G., T.H.M.M., K.H., N.K., C.M.). Disagreements were discussed until consensus was reached, with recourse to a third reviewer if necessary. To investigate bias we used the Cochrane Risk-of-Bias tool (Higgins et al. Reference Higgins, Altman, Sterne, Higgins and Green2011). Domains assessed included quality of the random sequence generation, concealment of allocation, description of drop-outs and withdrawals, blinding (of participants, research personnel and outcome assessment) and selective outcome reporting. (See Supplementary Appendices for details of data extracted, eligibility and risk of bias assessment.)
Synthesis
We planned to examine the treatment effect direction and consistency by providing a systematic narrative, structured summary of the evidence (tables and descriptive text) from the studies based on type of intervention and participants. There were insufficient data reported in the studies to prepare a meta-analysis for ‘job-club’ type interventions; the remaining interventions were too heterogeneous in terms of interventions to attempt to pool data. We categorized type of interventions on a post-hoc basis as described in our protocol because we were unclear what range of interventions, setting and participants we would identify (Moore et al. Reference Moore, Gunnell, Metcalfe, Kapur and Hawton2015).
Results
Our search identified 2389 records (see Fig. 1). The 11 RCTs included 5303 participants and were reported in 26 papers (see Fig. 1). There was considerable heterogeneity in terms of type of intervention, and participants, study size (see Table 1, Fig. 2, Supplementary Appendix 2 and Supplementary Appendix 3). Six studies were from the USA, two from the UK, and one each from Spain, Australia and Finland. Five studies – four in the USA (Caplan et al. Reference Caplan, Vinokur, Price and van Ryn1989; Rife, Reference Rife1992; Gustafson, Reference Gustafson1995; Vinokur et al. Reference Vinokur, Price and Schul1995b ) and one in Finland (Vuori et al. Reference Vuori, Silvonen, Vinokur and Price2002) – examined the effect of ‘job-club’ type interventions for unemployed people to cope with job loss and assisted them into new employment, two studies assessed the effects of cognitive behavioural therapy (CBT) for unemployed people (Proudfoot et al. Reference Proudfoot, Guest, Carson, Dunn and Gray1997; Harris et al. Reference Harris, Lum, Rose, Morrow, Comino and Harris2002), one study investigated the effects of expressive writing (Spera et al. Reference Spera, Buhrfeind and Pennebaker1994), a second the effect of guided mental imagery (Joseph & Greenberg, Reference Joseph and Greenberg2001), and a third the effects of emotional competencies training (Hodzic et al. Reference Hodzic, Ripoll, Bernal and Zenasni2015a ). Another study evaluated debt advice for people in debt (Pleasence & Balmer, Reference Pleasence and Balmer2007).
Study selection.
Visualization of study characteristics. Ranges for age and length of unemployment were presented when data were available.
Details of interventions and participants
a Although Spera et al. (Reference Spera, Buhrfeind and Pennebaker1994) had three arm study with n = 63 participants we are using data from just two study arms (n = 41) the people in one of the groups (no writing) were not allocated during the randomization procedure (Spera et al. Reference Spera, Buhrfeind and Pennebaker1994). CES-D Centre of epidemiologic studies depression scale.
We excluded 110 reports (see Fig. 1 and Supplementary Appendix 4). Twenty papers describing RCTs were excluded because they did not report any mental health data (see Supplementary Appendix 4); five reports because the population, i.e. single or new mothers on benefits, would necessarily have interventions tailored to suit their circumstances (Wiggins et al. Reference Wiggins, Oakley, Roberts, Turner, Rajan, Austerberry, Mujica and Mugford2004; Forgatch & DeGarmo, Reference Forgatch and DeGarmo2007; Morris & Hendra, Reference Morris and Hendra2009; Jagannathan et al. Reference Jagannathan, Camasso and Sambamoorthi2010; Kneipp et al. Reference Kneipp, Kairalla, Lutz, Pereira, Hall, Flocks, Beeber and Schwartz2011); one report providing loans (Fernald et al. Reference Fernald, Hamad, Karlan, Ozer and Zinman2008); and two reports where the intervention was increasing access to healthcare insurance (Finkelstein et al. Reference Finkelstein, Taubman, Wright, Bernstein, Gruber, Newhouse, Allen, Baicker and Or2012; Baicker et al. Reference Baicker, Taubman, Allen, Bernstein, Gruber, Newhouse, Schneider, Wright, Zaslavsky, Finkelstein, Carlson, Edlund, Gallia and Smith2013), as these interventions were unlikely to be suitable for a general population.
Despite searching for and including people in the general population all participants in the included studies were unemployed, with mean durations of unemployment ranging from 2.3 to 33 months (see Fig. 2). Three studies recruited professionals or management-level staff (Spera et al. Reference Spera, Buhrfeind and Pennebaker1994; Proudfoot et al. Reference Proudfoot, Guest, Carson, Dunn and Gray1997; Pleasence & Balmer, Reference Pleasence and Balmer2007). Mean age ranged from 32 (Vinokur et al. Reference Vinokur, Price and Schul1995b ) to 58 (Rife, Reference Rife1992) years and gender balance varied from 13% male (Hodzic et al. Reference Hodzic, Ripoll, Bernal and Zenasni2015a ) to 98% male (Spera et al. Reference Spera, Buhrfeind and Pennebaker1994).
Most studies were assessed as at high or unclear ‘risk of bias’ so the numerical outcomes need to be interpreted with some caution. Information needed to assess bias was not reported in several studies and participants in all 11 studies would have been aware of the intervention they were given and so all the studies were at high risk of bias for that domain (see Fig. 3).
Risk of bias. ✓ Domain was judged to be low risk of bias; ×, domain was judged to be at high risk of bias; ?, it was not possible to assess the risk of bias for this domain; ait is not possible to obscure the type of intervention in studies such as these as the participants are aware of the intervention they are receiving, therefore all studies are rated at high risk-of-bias; bemployment outcome was complex, dichotomised to working enough and not working enough however 14% of people did not meet these criteria and were not included in the outcome assessment; cstopped early high drop out; ddifference in baseline of people exposed to relaxation techniques. CBT, Cognitive behavioural therapy.
Ten of 11 studies described the personnel delivering the intervention the exception was Rife (Reference Rife1992), while just two, JOBS II and Työhön, described their training (Vinokur et al. Reference Vinokur, Price and Schul1995b ; Vuori et al. Reference Vuori, Silvonen, Vinokur and Price2002). Two studies, JOBS I and JOBS II reported supervision for their staff (Vinokur et al. Reference Vinokur, Price, Caplan, van Ryn and Curran1995a , Reference Vinokur, Price and Schul b ). Four studies, JOBS I, JOBS II, Työhön and Harris et al. (Reference Harris, Lum, Rose, Morrow, Comino and Harris2002) reported use of a manual (Caplan et al. Reference Caplan, Vinokur, Price and van Ryn1989; Vinokur et al. Reference Vinokur, Price and Schul1995b ; Harris et al. Reference Harris, Lum, Rose, Morrow, Comino and Harris2002; Vuori et al. Reference Vuori, Silvonen, Vinokur and Price2002) and three (JOBS I, JOBS II and Työhön) included an assessment of fidelity to treatment (Caplan et al. Reference Caplan, Vinokur, Price and van Ryn1989; Vinokur et al. Reference Vinokur, Price and Schul1995b ; Vuori et al. Reference Vuori, Silvonen, Vinokur and Price2002) (see Supplementary Appendix 5).
‘Job-club’ interventions
Five studies, reported in 17 papers, assessed the effects of ‘job-club’ interventions. Four of these compared ‘job-club’ to written, self-administered job-search materials (JOBS I, JOBS II, Työhön and Gustafson, 1995) and one, Rife et al. compared ‘job club’ to usual unemployment centre services. The JOBS I intervention (Caplan et al. Reference Caplan, Vinokur, Price and van Ryn1989; Vinokur et al. Reference Vinokur, Price and Caplan1991a , Reference Vinokur, van Ryn, Gramlich and Price b , Reference Vinokur, Price, Caplan, van Ryn and Curran 1995a ; Price et al. Reference Price, Van Ryn and Vinokur1992; Vanryn & Vinokur, Reference Vanryn and Vinokur1992) (n = 1122) delivered job skills training seminars to groups of 16–20 people in eight sessions of 3 h (Table 1, Fig. 2 and Supplementary Appendix 3). The JOBS I intervention was modified in JOBS II (n = 1771) to focus more on enhancement of personal control, sense of mastery and job-search self-efficacy; sessions were reduced from eight sessions over 2 weeks in JOBS I to daily 4 h sessions provided over 5 days in JOBS II and training of group facilitators was also increased (Vinokur et al. Reference Vinokur, Price and Schul1995b , Reference Vinokur, Price and Caplan1996, 2000; Vinokur & Schul, Reference Vinokur and Schul1997). Both JOBS I and JOBS II excluded people with any signs of mental illness (JOBS I; Caplan et al. Reference Caplan, Vinokur, Price and van Ryn1989) or depression scores of >3 on Hopkins Symptom checklist 90, (JOBS II; Vinokur et al. Reference Vinokur, Price and Schul1995b ) at baseline. Vuori et al. (Reference Vuori, Silvonen, Vinokur and Price2002) adapted the JOBS II intervention for use in Finland (n = 1261), named it Työhön (‘let's get to work’), and recruited people with a longer history of unemployment (11 months v. 3-4 months in JOBS I and JOBS II). Unlike the two JOBS trials a high proportion (78%) of participants were female (Vuori et al. Reference Vuori, Silvonen, Vinokur and Price2002; Vuori & Silvonen, Reference Vuori and Silvonen2005; Vuori & Vinokur, Reference Vuori and Vinokur2005). Rife et al. (n = 52) provided practical job skills training workshops two afternoons per week for 12 weeks (Rife, Reference Rife1992; Rife & Belcher, Reference Rife and Belcher1994) and Gustafson et al. (n = 16) delivered job skills training interventions similar to JOBS I for eight 3 h sessions over 2 weeks (Gustafson, Reference Gustafson1995).
The ‘job club’ intervention delivered in JOBS I had no effect on levels of anxiety or depression at 6 weeks or 4 months (see Table 2). A post-hoc subgroup analysis showed that the participants with higher risk of developing depression, based on the 25% of participants with highest baseline risk of depression, economic hardship and social assertiveness (Price et al. Reference Price, Van Ryn and Vinokur1992) benefited most from the intervention (interaction: p = 0.01). In high-risk participants depression scores were reduced at 6 weeks [difference in means: −0.26, 95% confidence interval (CI) −0.48 to −0.04; interaction: F = 6.07 p = 0.01], 4 months (difference in means: −0.36, 95% CI −0.59 to −0.13; interaction: F = 12.14 p = 0.001) and 28 months (difference in means: −0.25, 95% CI −0.50 to 0.0; interaction: F = 6.05 p = 0.01) by up to almost 0.5 s.d. on the depression subscale of the Hopkins Symptom Checklist 90 (HSCL-90; see Table 2). JOBS I had no effect on employment at the same time points (see Table 3) (Caplan et al. Reference Caplan, Vinokur, Price and van Ryn1989; Price et al. Reference Price, Van Ryn and Vinokur1992; Vinokur et al. Reference Vinokur, Price and Caplan1991a , Reference Vinokur, van Ryn, Gramlich and Price b , 1995a; Vanryn & Vinokur, Reference Vanryn and Vinokur1992).
Mental health outcomes by Intervention type
BHS, Beck Hopelessness Scale; CES-D, Centre of Epidemiologic Studies Depression Scale; ES, Effect size; GDS, Geriatric Depression Scale; GHQ-12, General Health Questionnaire - 12 items. Self-report measure of psychological morbidity (Goldberg et al. Reference Goldberg, Gater, Sartorius, Ustun, Piccinelli, Gureje and Rutter1997); GHQ-30, General Health Questionnaire 30 Item. Self-report measure of psychological morbidity; HSCL-90, Hopkins Symptom Checklist 90 Subscale – 11 items adapted for use in Finland (Vuori et al. Reference Vuori, Silvonen, Vinokur and Price2002). The measure of depressive symptoms was a 10-item Finnish scale (Salokangas et al. Reference Salokangas, Stengard and Poutanen1994) based on the Hopkins Checklist (Derogatis et al. Reference Derogatis, Lipman, Rickels, Uhlenhuth and Covi1974) Cronbach's α coefficients were 0.92 at T1 and 0.92 at T4; Log R, Logistic regression; LR, Linear Regressions; LSS-Opt, Life satisfaction scale subscale optimism; MD, difference in means; MF ANOVA, multifactorial ANOVA; MVM, multivariate model, Pleasence & Balmer (Reference Pleasence and Balmer2007). The authors state ‘We fitted a multivariate model fitting STAI-6 and EQ-5D scores simultaneously as normal response variables’ The effect sizes they report are changes from baseline to follow-up at 20 weeks; MW-U, Mann–Whitney U; ns, not reaching the statistical significance of a p value ⩽0.05; OR, odds ratio; POM, Profile of Mood States Questionnaire; PSS, Perceived Stress Scale; RD, risk difference; SF-36, Short-Form-36 Health Survey Questionnaire (Ware et al. Reference Ware, Kosinski and Keller1994); SLRC, Standardized linear regression coefficient; For the Työhön study the s.d. for the HSCL-90 were reported as 6 for the intervention or 6.5 for the control. Therefore a change in 0.06 of a s.d. represents a change in score of 0.36 of a point on the HSCL-90 scale). For the JOBS II study no s.d. is provided for the HSCL-90; SMUHQ, Southern Methodists University Health Questionnaire (Watson & Pennebaker, Reference Watson and Pennebaker1989); STAI, Stait Trait Anxiety Scale (reduction in score = benefit range 20–80 score of >42 = case). Gustafson 1995; 6 week data (Gustafson, Reference Gustafson1995): Harris 2002; 3–4 month data (Harris et al. Reference Harris, Lum, Rose, Morrow, Comino and Harris2002): Hodzic 2015; 1 month and 6 month data (Hodzic et al. Reference Hodzic, Ripoll, Bernal and Zenasni2015a ): JOBS I; 6 week, 4 month data (Vinokur et al. Reference Vinokur, Price and Caplan1991a ), 28 month data (Vinokur et al. Reference Vinokur, van Ryn, Gramlich and Price1991b ), low risk and high risk data all time points (Price et al. Reference Price, Van Ryn and Vinokur1992): JOBS II; 2 month and 6 month data (Vinokur et al. Reference Vinokur, Price and Schul1995b ), 2 year data (Vinokur et al. Reference Vinokur, Schul, Vuori and Price2000): Joseph 2001; 2 week and 2 month data (Joseph, Reference Joseph1999, Joseph & Greenberg, Reference Joseph and Greenberg2001): Rife 1992; 12 week data (Rife, Reference Rife1992): Työhön; 6 month data (Vuori et al. Reference Vuori, Silvonen, Vinokur and Price2002); 24 month data (Vuori & Silvonen, Reference Vuori and Silvonen2005): Pleasance 2007; 0-5 month (Pleasence & Balmer, Reference Pleasence and Balmer2007): Proudfoot 1997; 7 week data (Proudfoot et al. Reference Proudfoot, Gray, Carson, Guest and Dunn1999, Proudfoot et al. Reference Proudfoot, Guest, Carson, Dunn and Gray1997): Spera 1994 (Spera et al. Reference Spera, Buhrfeind and Pennebaker1994).
a Risk difference calculated using methods described in Deeks & Higgins (Reference Deeks and Higgins2010) Statistical algorithms in Review Manager 5.2 (Deeks & Higgins, Reference Deeks and Higgins2010).
b Mean difference calculated using methods described in Salanti (Reference Salanti2013) Statistical algorithms for the Calculator in Review Manager 5.2 (Salanti, Reference Salanti2013).
c Data from Price et al. (Reference Price, Van Ryn and Vinokur1992). Participants were at high or low risk of depression. NB People scoring ⩾3 on pre-test depression were excluded from the analysis.
d Two-way ANCOVA (analysis of covariance) baseline depression and hours of employment as covariates and stratified by predicted risk of depression score (75% low risk; 25% high risk) (Price et al. Reference Price, Van Ryn and Vinokur1992).
e Generalized linear model analysis of variance (ANOVA) 4.10 = F of interaction of risk (high or low) and condition (intervention or control) (Vinokur et al. Reference Vinokur, Price and Schul1995b ).
f CIDI (Composite Index of Depression Inventory). Defines the occurrence of major depressive episode (MDE). A less stringent definition of ‘probable’ MDE was defined by dichotomizing a score of 0–6 = 0 or no diagnosis whilst 7–8 = 1 or probable diagnosis MDE.
g ANCOVA (analysis of covariance) with pre-test scores as covariates.
h Harris et al. do not present the p values for the t tests for SF-36 MCS. The t test is for baseline to follow-up within groups, i.e. not comparing groups. The authors report a χ2 analysis to test for differences between groups but these data were not presented. They also prepare an ANCOVA using baseline values as covariates – and do not present these data.
i Only 31% of the intervention group received debt advice. 10% of the control group sought and obtained debt advice.
j Although the Spera et al. (Reference Spera, Buhrfeind and Pennebaker1994) study had three arms (n = 63) only two of the arms (Writing and No writing n = 41) were allocated at random. While we are reporting only from these two study arms the ANOVA analyses include all three arms.
Employment, debt and debt awareness outcomes by intervention type
BLRA, Binary logistic regression analysis; BLRC, binary logistic regression coefficient; Contract, contract employment; FT, full time; NRM, normal response model; MD, difference in means; OR, odds ratio; PT, part time; RD, risk difference; Temp, temporary. Gustafson 1995; 6 week data (Gustafson, Reference Gustafson1995): Harris 2002; 3 to 4 month data (Harris et al. Reference Harris, Lum, Rose, Morrow, Comino and Harris2002); Hodzic 2015; 6 month and 1 year data (Hodzic et al. Reference Hodzic, Ripoll, Lira and Zenasni2015b ): JOBS I; 6 week, 4 month data (Vinokur et al. Reference Vinokur, Price and Caplan1991a ), 28 month data (Vinokur et al. Reference Vinokur, van Ryn, Gramlich and Price1991b ): JOBS II 2 month and 6 month data (Vinokur et al. Reference Vinokur, Price and Schul1995b ); 2 year data (Vinokur et al. Reference Vinokur, Schul, Vuori and Price2000): Joseph 2001; 2 week and 2 month data (Joseph, Reference Joseph1999; Joseph & Greenberg, Reference Joseph and Greenberg2001): Rife 1992; 12 week data (Rife, Reference Rife1992): Työhön 6 month data (Vuori et al. Reference Vuori, Silvonen, Vinokur and Price2002); 24 month data (Vuori & Silvonen, Reference Vuori and Silvonen2005): Pleasence 2007; 0 to 5 month data (Pleasence & Balmer, Reference Pleasence and Balmer2007): Proudfoot 1997; 4 month (Proudfoot et al. Reference Proudfoot, Guest, Carson, Dunn and Gray1997); Spera, 1994; (Spera et al. Reference Spera, Buhrfeind and Pennebaker1994).
a Risk difference calculated using methods described in Deeks & Higgins (Reference Deeks and Higgins2010) Statistical algorithms in Review Manager 5.2 (Deeks & Higgins, Reference Deeks and Higgins2010).
b Mean difference calculated using (Salanti, Reference Salanti2013). Statistical algorithms for the Calculator in Review Manager 5.2.
c Employed >20 h per week and considered to be ‘working enough’.
d Employment in JOBS I was defined as working 20 h per week or more PLUS working as many hours as they needed.
e Multivariate analysis of variance (MANOVA).
f Some employment related activity, i.e. temporary, part-time, unpaid, paid, casual or full-time employment or enrolment in part or full-time study.
g Although the Spera et al. (Reference Spera, Buhrfeind and Pennebaker1994) study had three arms (n = 63) only two of the arms (Writing and No writing n = 41) were allocated at random. While we are reporting only from these two study arms for the ANOVA analyses include all three arms. For this analysis only data from 40 participants were available.
h ANOVA across all three intervention arms shows there are significant variation in number employed (F 2,59 = 3.72 p = 0.03).
i ORM Ordinal regression model was fitted across the five categories (much better, better, the same, worse, and much worse) and there were no differences between categories by intervention type. When the data were looked at for each category, only one was significant, the people who had the intervention were more likely to score their perception of debt as ‘better’ Wald text χ2 = 5.92, p = 0.015.
JOBS II evaluated a modified version of JOBS I and stratified participants at baseline according to their risk of depression (high or low). The authors reported a small improvement of depressive symptoms at 2 years for those who received the intervention (standardized linear regression coefficient −0.06, p < 0.05) (see Table 2). As in JOBS I, stronger effects of approximately 0.2 s.d. improvements were seen in participants at high risk of depression (around 40% of the trial participants) (interaction: F 1,1331 = 4.10, p = 0.043). There was no effect on the Composite Index of Depression Inventory (CIDI), a 9-point scale of likelihood of major depressive episode (MDE) (linear regression: −0.04 s.d. p > 0.05). However, using the more stringent criteria of probable (90% likely) to have a MDE (scores of 7 or 8 on CIDI) fewer people in the intervention group had probable MDE at 2 years compared to those in the control (odds ratio 0.61, p < 0.05). This intervention was also associated with improved employment at this time point (Vinokur et al. Reference Vinokur, Price and Schul1995b , Reference Vinokur, Price and Caplan1996, Reference Vinokur, Schul, Vuori and Price2000; Vinokur & Schul, Reference Vinokur and Schul1997). In the Finnish version of JOBS II, Työhön (‘Let's get to work’), there were improved psychological symptoms (GHQ-12) at 6 months and improved depression symptoms at 6 months and 24 months, although, as described above for JOBS II, the actual size of the reduction in depressive symptoms was small. No analyses stratified by baseline depression risk were reported. In the Työhön study there was no effect on employment at 6 or 24 months (see Tables 2 and 3) (Vuori et al. Reference Vuori, Silvonen, Vinokur and Price2002; Vuori & Silvonen, Reference Vuori and Silvonen2005; Vuori & Vinokur, Reference Vuori and Vinokur2005). Rife and colleagues assessed the effects of a similar intervention, more focussed on practical skills training, and reported that the people in the intervention group showed an improvement in depressive symptoms on the Geriatric Depression Scale at 3 months (p < 0.05) and more of this group were employed compared to the control group (65% v. 26% p < 0.01) (see Tables 2 and 3) (Rife, Reference Rife1992; Rife & Belcher, Reference Rife and Belcher1994). Gustafson's small (n = 16) trial found no effect of the ‘job club’ intervention on anxiety scores or employment (see Table 2), but was under-powered (Gustafson, Reference Gustafson1995). The trials and subgroups where the greatest improvements were seen in employment were those in which participants experienced the greatest improvement in depression (Rife, Reference Rife1992; Rife & Belcher, Reference Rife and Belcher1994; Vinokur et al. Reference Vinokur, Price and Schul1995b ).
CBT interventions
Two studies assessed the effect of group CBT on long-term unemployed individuals. The intervention content was similar in both trials, including cognitive restructuring, behaviour modification and homework assignments. However, Proudfoot et al. (Reference Proudfoot, Guest, Carson, Dunn and Gray1997) provided sessions of 3 h per week for 7 weeks (21 h) compared to Harris et al. (Reference Harris, Lum, Rose, Morrow, Comino and Harris2002) who provided 11 h over 2 days (see Table 1 and Supplementary Appendix 3). Both studies used an active comparator arm [social support programme that included homework (Proudfoot et al. Reference Proudfoot, Guest, Carson, Dunn and Gray1997) and a 2-day senior certificate in first aid (Harris et al. Reference Harris, Lum, Rose, Morrow, Comino and Harris2002)] to mimic the attention provided to participants in the intervention arm. The populations were quite different; Proudfoot et al. (n = 289) enrolled long-term (>12 months) unemployed professionals who were mostly (83%) male, whereas Harris et al. (n = 195) targeted long-term unemployed individuals in disadvantaged areas who were of lower socioeconomic status and were 55% male (see Table 1) (Harris et al. Reference Harris, Lum, Rose, Morrow, Comino and Harris2002; Proudfoot et al. Reference Proudfoot, Guest, Carson, Dunn and Gray1997).
Proudfoot et al. reported that CBT improved mental health (GHQ-30) scores (difference in means: -1.44, 95% CI −3.20 to 0.32, p < 0.05) at 7 weeks but found no effect on the proportion of participants meeting thresholds for a psychiatric ‘case’ (defined as a score >5 on GHQ-30) in the intervention group (21%) compared to the control group (23%) (p = 0.78; see Table 2). However, people receiving CBT were more likely to be employed at 7 weeks compared to those in the control group (34% v. 13%, p = 0.0006; see Table 3) (Proudfoot et al. Reference Proudfoot, Guest, Carson, Dunn and Gray1997). The second, smaller CBT trial of Harris et al. (Reference Harris, Lum, Rose, Morrow, Comino and Harris2002) showed no effect on employment or the mental health indicators (Harris et al. Reference Harris, Lum, Rose, Morrow, Comino and Harris2002); if anything there was evidence of an adverse effect on measures of hopelessness (difference in means: −2.04, 95% CI 0.66 to 3.42) and optimism (difference in means: −2.6, 95% CI −4.10 to 1.10; see Table 2), although there were baseline differences between the study arms with higher levels of self-esteem (Table 2) and shorter durations of unemployment (Table 3) in the control compared to the intervention arm (Harris et al. Reference Harris, Lum, Rose, Morrow, Comino and Harris2002).
Other interventions
Four other interventions have been evaluated in single trials of 41–402 participants. Telephone debt advice to people (n = 402) who were in debt (recruited from unemployment offices) had no effect on measures of anxiety (Table 2) or on numerous measures of indebtedness (see Table 3) (Pleasence & Balmer, Reference Pleasence and Balmer2007), but only 31% of participants in the intervention group actually received debt advice and 10% of the control (no intervention) group independently sought debt advice (Pleasence & Balmer, Reference Pleasence and Balmer2007). One study (n = 41) provided unemployed people with opportunities for expressive writing (20 min over 5 days where they could disclose effects of unemployment) compared to control writing (Spera et al. Reference Spera, Buhrfeind and Pennebaker1994). Expressive writing had no effect on symptoms of anxiety at 3 months (Table 2) but appeared to improve employment (Table 3) (Spera et al. Reference Spera, Buhrfeind and Pennebaker1994). Joseph and colleagues (n = 76) assessed the effects of guided imagery (20 min over six sessions) that allowed participants to visualize their success at finding and obtaining employment and also included relaxation techniques compared to control imagery (see Table 2) (Joseph, Reference Joseph1999; Joseph & Greenberg, Reference Joseph and Greenberg2001). People who received guided imagery were more likely to be in employment at 7 weeks but there was no effect on depression (Tables 2 and 3) (Joseph, Reference Joseph1999; Joseph & Greenberg, Reference Joseph and Greenberg2001). Finally, a trial (n = 75) of the provision of group emotional competency training for unemployed people compared to no intervention did not present an analysis of the effects emotional competency training on mental health but calculation of the difference in means and 95% CIs showed no effect on (GHQ-12), nor on symptoms of depression, anxiety or stress (see Table 2) (Hodzic et al. Reference Hodzic, Ripoll, Bernal and Zenasni2015a ).
Discussion
Main findings
There is consistent evidence from large RCTs in different settings, including three trials with more than 1000 participants, that intensive 1- to 2-week ‘job club’ interventions for unemployed people reduce the risk of depression. The most clinically relevant effects are seen among participants at increased risk of developing depression (around a quarter of participants); in this group, effect sizes of up to 0.5 s.d. improvements in depression scores were seen. Improvement in depression was seen for up to 2 years, although effects on employment were mixed. Larger effects on depression were seen in trials/subgroups with the greatest increases in employment.
The only other intervention investigated in more than one trial was group CBT. There was good evidence of a short-term (3 months) effect on depression symptoms and re-employment in the larger trial that delivered CBT over 7 weeks, though no effect on psychiatric ‘caseness’ (Proudfoot et al. Reference Proudfoot, Guest, Carson, Dunn and Gray1997). The second showed no beneficial effects (Harris et al. Reference Harris, Lum, Rose, Morrow, Comino and Harris2002). Differences between these two trials may reflect differences in participants [professionals (Proudfoot et al. Reference Proudfoot, Guest, Carson, Dunn and Gray1997) v. people from disadvantaged areas (Harris et al. Reference Harris, Lum, Rose, Morrow, Comino and Harris2002)] and timing/intensity of the intervention [21 h provided weekly over 7 weeks (Proudfoot et al. Reference Proudfoot, Guest, Carson, Dunn and Gray1997) v. 11 h provided over 2 days (Harris et al. Reference Harris, Lum, Rose, Morrow, Comino and Harris2002)].
There is limited evidence for other interventions, but these were all evaluated in single trials with small sample sizes (Spera et al. Reference Spera, Buhrfeind and Pennebaker1994; Joseph & Greenberg, Reference Joseph and Greenberg2001; Hodzic et al. Reference Hodzic, Ripoll, Bernal and Zenasni2015a ) or limited uptake of the intervention (Pleasence & Balmer, Reference Pleasence and Balmer2007).
Risk of bias was a problem for many of the studies with a third of the items rendered not assessable because the items were not reported. Taking into account the high risk of bias of the studies we have to interpret the strength of the evidence with some caution. Studies varied in the quality of reporting important details of interventions. In four a manual was used (Caplan et al. Reference Caplan, Vinokur, Price and van Ryn1989; Vinokur et al. Reference Vinokur, Price and Schul1995b ; Harris et al. Reference Harris, Lum, Rose, Morrow, Comino and Harris2002; Vuori et al. Reference Vuori, Silvonen, Vinokur and Price2002) and three included an assessment of fidelity to treatment (Caplan et al. Reference Caplan, Vinokur, Price and van Ryn1989; Vinokur et al. Reference Vinokur, Price and Schul1995b ; Vuori et al. Reference Vuori, Silvonen, Vinokur and Price2002). Detailed descriptions of interventions and assessments made to assess fidelity to treatment should be described in future studies (Craig et al. Reference Craig, Dieppe, Macintyre, Michie, Nazareth and Petticrew2008).
Evidence of improvement in depressive symptoms in intervention group participants coincided in some studies with higher levels of re-employment (JOBS II high-risk group and Proudfoot et al.) (Vinokur et al. Reference Vinokur, Price and Schul1995b ; Proudfoot et al. Reference Proudfoot, Guest, Carson, Dunn and Gray1997, Reference Proudfoot, Gray, Carson, Guest and Dunn1999; Vinokur et al. Reference Vinokur, Schul, Vuori and Price2000); however, in some studies this was not the case (JOBS I and Työhön) (Vinokur et al. Reference Vinokur, van Ryn, Gramlich and Price1991b ; Price et al. Reference Price, Van Ryn and Vinokur1992; Vuori et al. Reference Vuori, Silvonen, Vinokur and Price2002; Vuori & Silvonen, Reference Vuori and Silvonen2005). Some studies looked for aspects of the intervention that might contribute to the change in outcome (mediating effects). There was some evidence in JOBS II that reduced depressive symptoms were associated with reduction of financial strain and reemployment (Vinokur & Schul, Reference Vinokur and Schul1997). Job search preparedness (self-efficacy and inoculation against setbacks) reduced depressive symptoms and improved employment in JOBS I and Työhön but the authors do not present an analysis on effects of employment on mental health for JOBS I (Vanryn & Vinokur, Reference Vanryn and Vinokur1992; Vuori & Vinokur, Reference Vuori and Vinokur2005). Työhön authors did identify a link between reduced financial strain and reduction in depressive symptoms (Vuori & Vinokur, Reference Vuori and Vinokur2005).
Strengths and limitations
To the best of our knowledge this is the first comprehensive review of RCT evidence of interventions targeted at alleviating the impact on mental health of unemployment and debt in general population samples. Two reviews with a narrower focus solely on ‘job search’ interventions, which included evidence from non-randomized studies, reported that ‘job search’ interventions reduced depression and anxiety and improved employment (Audhoe et al. Reference Audhoe, Hoving, Sluiter and Frings-Dresen2010; Liu et al. Reference Liu, Huang and Wang2014). A strong evidence base in this area is important to inform policy responses to future recessions as these are associated with rises in unemployment, debt, depression, and suicidal behaviour. Our review facilitates an overview of the types of interventions considered to date, providing pointers to what works best to inform future research in this field.
The main limitation is the relatively sparse literature in this field. The only intervention evaluated in large trials in different settings was the ‘job club’ intervention and results for these trials are not presented in such a way as to enable meta-analysis. Thus identifying what works for whom and when was not possible from this data set. There is some evidence from a systematic review that included non-randomized studies that job-search interventions only appeared to improve employment if they included components that developed skills and enhanced motivation, although mediating effects on mental health were not investigated (Liu et al. Reference Liu, Huang and Wang2014). In JOBS II there was some evidence that the intervention had the greatest effects on mental health among those individuals with low levels of mastery (a composite measure based on self-esteem, self-efficacy and locus of control measures) at baseline, but such effects have not been investigated systematically (Vinokur et al. Reference Vinokur, Schul, Vuori and Price2000). Suicide (incidence 11.4/1 00 000) and attempted suicide (4/1000), possibly the most severe effect of economic hardship, are thankfully relatively rare (WHO, 2014, 2016); reported trials are underpowered to detect any effect on these indicators and were not evaluated in the studies we reviewed. Our focus was on trials evaluating mental health, the key risk factor for suicide and we assumed that interventions having an impact on mental health will in turn influence suicide attempts and suicide. The studies we identified used a range of outcome measures (GHQ-12, GHQ-30, SF-36, GDS, PSSS, Beck Hopelessness scale, POMS, CIDI, CES-D HSCL-90, STAI) designed to measure different aspects of mental health and ranging from disorder specific scales (e.g. CES-D) to screens for common mental disorder (GHQ-12). We excluded 20 reports of RCTs because they did not report any measures for mental health and we would recommend that any future trialists investigating interventions for debt and unemployment collect and publish such outcomes.
A priori we decided not to review the literature on specific groups, e.g. people with severe mental illness and single mothers, although some of the included trials did focus on population subgroups [e.g. unemployed professionals (Proudfoot et al. Reference Proudfoot, Guest, Carson, Dunn and Gray1997), long-term unemployed living in deprived areas (Harris et al. Reference Harris, Lum, Rose, Morrow, Comino and Harris2002)]. Literature in this area is rather old and largely focused on the unemployed/job loss. The one trial of debt advice had to be stopped early because of high levels of loss to follow-up (Pleasence & Balmer, Reference Pleasence and Balmer2007; Pleasence, Reference Pleasence2008).
Findings in the context of the wider literature
The focus of our review has been on the relatively few RCTs in this field. Conducting trials in the context of economic recession is challenging as the rapid rises in job loss and debt require timely policy responses. Timescales for obtaining research funding to conduct RCTs, and time delays in obtaining research ethics approval (Salman et al. Reference Salman, Beller, Kagan, Hemminki, Phillips, Savulescu, Macleod, Wisely and Chalmers2014), means that by the time a trial is funded the most acute period of economic difficulty may have passed. Three previous systematic reviews have all remarked upon the absence of evidence of health benefits for public health interventions for people on low income. One found 10 RCTs on income supplementation by searching medical and sociological literature but none had measured any aspect of health (Connor et al. Reference Connor, Rodgers and Priest1999). A broader search including grey literature for welfare advice delivered in a healthcare setting found 55 studies (one RCT) and concluded that income was improved but could not comment on health (Adams et al. Reference Adams, White, Moffatt, Howel and Mackintosh2006). A third searched medical literature for vocational interventions for unemployed and found weak evidence of no effect on mental health (Audhoe et al. Reference Audhoe, Hoving, Sluiter and Frings-Dresen2010).
Several observational studies have investigated the impact of different policy responses to periods of recession and provide additional pointers to effective interventions. Stuckler et al.’s analysis of the association of changes in unemployment with changes in suicide mortality in 26 European Union countries between 1970 and 2007 indicates that government spending on active labour market programmes mitigated the effect rises in unemployment on suicide (Stuckler et al. Reference Stuckler, Basu, Suhrcke, Coutts and McKee2009). Components of active labour market programmes include classroom or on the job training, job search assistance or sanctions for failing to search, subsidized private sector employment and subsidized public sector employment. Notably, some elements of these programmes were included in the ‘job club’ (interventions described above) (Caplan et al. Reference Caplan, Vinokur, Price and van Ryn1989; Vinokur et al. Reference Vinokur, Price and Caplan1991a , Reference Vinokur, van Ryn, Gramlich and Price b , 1995a; Price et al. Reference Price, Van Ryn and Vinokur1992; Vanryn & Vinokur, Reference Vanryn and Vinokur1992).
Two recent ecological studies conducted during the 2008 recession provide evidence of the beneficial effects of providing generous welfare benefits to people who are out of work. An analysis of US state-level suicide data showed that states providing more generous unemployment benefits experienced lower recession-related rises in suicide than those providing less generous welfare support (Cylus et al. Reference Cylus, Glymour and Avendano2014). In an ecological analysis of data from 30 countries, there was a graded association between a country's spending on unemployment protection and the effect of unemployment rises on suicide (Norström & Grönqvist, Reference Norström and Grönqvist2014).
Future research agenda
Whilst some authors did report their RCTs with reference to CONSORT guidelines (Pleasence & Balmer, Reference Pleasence and Balmer2007; Schultz et al. 2010) we would urge authors of future studies to follow this lead to allow accurate assessments of risk-of bias and clarity of analysis and treatment effects (Turner et al. Reference Turner, Shamseer, Altman, Weeks, Peters, Kober, Dias, Schulz, Plint and Moher2012). Some trials had low recruitment rates and, given the likely financial difficulties faced by research participants in this field, trialists could attempt to increase participation by providing incentives or compensation for participants’ time, as five of the 11 studies in this review did (see Supplementary Appendix 3).
Recent research into suicides occurring during a period of recession indicated that those whose suicide appeared to be related to consequences of recession were largely still in work, cohabiting, with financial dependents but had no contact with secondary-care psychiatric and little recent contact with primary-care services (Coope et al. Reference Coope, Donovan, Wilson, Barnes, Metcalfe, Hollingworth, Kapur, Hawton and Gunnell2015). This indicates the need for research into how best to (a) identify those at risk of adverse mental health outcomes during recession, and (b) intervene to reduce risk among those not in contact with services. In the UK's recent recession, policy responses included training front-line job centre and debt collection staff (Fitch & Davey, Reference Fitch and Davey2010; Domokos, Reference Domokos2011). Evaluation of these and similar interventions would inform responses to future recessions. From a healthcare perspective, pragmatic trials in primary care such as the DeCoDer trial will provide useful additional evidence for primary care type interventions to address economic hardship and depression and anxiety (DECODER, 2014). In addition the impact of training primary-care and specialist mental health staff in appraising financial difficulties and signposting them to appropriate statutory and voluntary sector organizations may be worthwhile and form the basis of future evaluative research (Adams et al. Reference Adams, White, Moffatt, Howel and Mackintosh2006; Harris & Harris, Reference Harris and Harris2009; Barnes et al. Reference Barnes, Gunnell, Davies, Hawton, Kapur, Potokar and Donovan2016). Future RCTs could usefully include measures to help identify what intervention works for whom and why. They might specifically build on work by studies in this review and measure mediating effects e.g. self-efficacy, debt management skills etc. Stratification to create a priori subgroups of participants would help identify which groups were benefitting or not from the intervention. Other potential subgroups could include age, socioeconomic position, or gender. Nested qualitative research could be used to identify potential barriers and facilitators to intervention uptake and adherence among participants and be useful in helping to identify time critical aspects of the intervention, e.g. were participants successful at gaining employment, managing debt, etc. because their mood lifted or vice versa? Researchers could try to publish across both socio-legal and medical disciplines and future systematic reviews should search both literature sources.
Conclusions
There is reasonably consistent evidence from large RCTs that short, 1- to 2-week ‘job club’ interventions can reduce depressive symptoms in high-risk, unemployed people up to 2 years. Evidence for CBT is mixed and for other interventions it is limited. Further high-quality RCTs are urgently needed. Such trials might usefully focus on interventions to help individuals with financial difficulties and debt, as most of the literature to date as focussed on provision of help to the unemployed, although the two issues are closely inter-related.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S0033291716002944.
Acknowledgements
T.H.M.M. and A.R.’s time was supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care West (CLAHRC West) at University Hospitals Bristol NHS Foundation Trust. D.G., K.H., N.K. and C.M. are supported by NIHR under its Programme Grants for Applied Research scheme (RP-PG-0610-10026). D.G. and K.H. are NIHR senior investigators. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
Declaration of Interest
D.G., C.M., K.H. and N.K. all report grants from National Institute of Health Research during the conduct of the study; T.H.M.M. and A.R.’s salaries were from NIHR CLAHRC West during the conduct of the study.
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