Early Intervention in Mental Health for Adolescents and Young Adults: A Systematic Review

Method

We used the PRISMA methodology (Moher et al., 2009) in conducting this review. The search terms were developed not only to capture pertinent articles but also to make sure that the terms relevant to the specific thesaurus of each database were included. Table 1 lists the search terms included in this systematic review.

A medical research librarian with experience in completing systematic review searches conducted the search and confirmed and improved the search strategies. Databases and sites searched included MEDLINE, PsycINFO, CINAHL, and OTseeker. In addition, consolidated information sources, such as the Cochrane Database of Systematic Reviews, were included in the search; these databases are peer-reviewed summaries of journal articles and provide a system for clinicians and scientists to conduct systematic reviews of selected clinical questions and topics. Moreover, reference lists from articles included in related systematic reviews were examined for potential articles, and selected journals were hand searched to ensure that all appropriate articles were included.

Two of the authors (Roush and Downing) conducted the remainder of the review, beginning by independently reviewing citations and abstracts of the articles identified by the medical research librarian to determine whether to obtain the full-text article for further consideration. The two authors discussed discrepancies until they reached agreement. The same process was used to evaluate the full text of potential articles. They then recorded a summary of each article in an evidence table, rated each article for risk of bias, and determined themes presented by the articles. AOTA staff and the EBP Project consultant reviewed the evidence table to ensure quality control. Supplemental Table 1 (available online at http://otjournal.net; navigate to this article, and click on “Supplemental”) is the evidence table for the systematic review.

Inclusion criteria specific to this review were as follows: participants age 12–35 at entry; ≤2 yr of active symptoms at entry; diagnosis of psychosis, depression, or anxiety disorder; and focus on functional outcomes rather than symptoms. Personality disorder diagnoses were excluded. General inclusion criteria of the larger systematic review that included this question were as follows: peer-reviewed scientific literature published in English, intervention approaches within the scope of practice of occupational therapy for the target diagnoses, and publication between 1995 and 2016. The review excluded data from presentations, conference proceedings, non–peer-reviewed research literature, dissertations, and theses.

Studies included in the review provide Level I, II, and III evidence. Ratings of the strength of the evidence are based on the guidelines of the U.S. Preventive Services Task Force (2017), defined as follows:

Results

Of the 25,775 citations and articles found by the research librarian, 512 were reviewed by the authors for relevance to this study question. An additional 158 articles were identified by hand search. A total of 234 full-text articles were assessed, and 30 met the inclusion criteria (see Figure 1): 22 articles provided Level I evidence, 6 provided Level II evidence, and 2 provided Level III evidence. Critical appraisal of the evidence revealed four primary categories of intervention: cognitive remediation (CR), cognitive–behavioral therapy (CBT), supported education and supported employment (SE/E), and family psychoeducation (FPE).

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Figure 1.

Flow diagram for studies included in the systematic review.

Discussion

The results of this review provide occupational therapy practitioners with emerging evidence to guide practice in early intervention for adolescents and young adults with SMI. Four interventions were identified—(1) CR, (2) CBT, (3) SE/E, and (4) FPE—that address improvement and maintenance of occupational performance in adolescents and young adults at high risk for schizophrenia or after a first episode of psychosis.

It is well documented that cognitive changes occur in the early stages of psychosis and in other SMIs such as depression (B. Y. H. Lam et al., 2014; R. W. Lam et al., 2014). This review found moderate evidence for the use of CR interventions to improve cognition and general functioning across occupations in the early stages of mental illness. CBT has a growing body of evidence supporting its effectiveness for youth with depression, CHR, or FEP in preventing the progression of SMI, reducing symptoms, and promoting occupational functioning.

It is also well documented that people with SMI have low employment rates and earn less than their peers without mental illness. The more serious their mental illness, the less likely they are to work, which decreases their opportunities for developing social relationships and building occupational skills (Luciano & Meara, 2014). Recent research has demonstrated strong evidence that vocational support during the CHR and FEP phases of a psychotic illness can promote positive social and occupational outcomes in competitive employment and academics (Baksheev et al., 2012; Bond et al., 2015; Killackey et al., 2008).

Occupational therapy practitioners have the necessary skills and training to provide vocational support to youth with CHR and FEP, particularly when following the evidence-based IPS model (Major et al., 2010; Porteous & Waghorn, 2007). This review found moderate evidence for the effectiveness of supported employment in improving the employment rates of those with CHR and FEP. The evidence for engagement in supported education was mixed.

FPE in various formats has been extensively researched for decades with a variety of diagnostic populations, but most often with people with schizophrenia and other psychotic disorders. Strong evidence indicates that FPE is effective in preventing relapse and rehospitalization and improves problem-solving skills and functional outcomes for people with serious, persistent mental illness (Lucksted et al., 2012). Strong evidence also exists that FPE for youth with CHR and FEP and their families can have positive results, such as symptom reduction, relapse prevention, and improved social and occupational functioning.

Implications for Occupational Therapy Practice and Research

Occupational therapy practitioners, with their roots in mental health and human development, can uniquely add to early intervention teams with their strong focus on function through occupational engagement (AOTA, 2014). This systematic review has the following implications for occupational therapy practice and research:

Limitations

Systematic reviews are limited by the quality of the individual studies reviewed. The studies in this review had limitations in randomization, allocation concealment, and blinding of participants and researchers and risk of attrition bias. Many studies had multiple interventions, so identifying the direct effect of one particular intervention was often difficult. Although functional status was referenced in all of the included studies, the methods of measuring functional status varied greatly, making it difficult to generalize results. Lastly, the vast majority of the studies were not conducted by occupational therapy practitioners, and the specific role of occupational therapy in providing the interventions was not the focus of the studies.

Conclusion

Research demonstrates that specific interventions with clients in the earliest stages of SMI can offset cognitive impairments and improve functioning and social relationships. Occupational therapy practitioners have the specialized training and skills necessary to provide occupation-based individual and group interventions. Evidence-based practices, such as CR, CBT, FPE, and SE/E, are approaches occupational therapy practitioners should consider to make vital contributions to early intervention teams. However, more occupational therapy–focused research is needed to conclusively demonstrate the role of occupational therapy in early intervention for clients with SMI.

Supplemental Material