INFLUENTIAL PUBLICATION

Community Interventions to Promote Mental Health

and Social Equity
Enrico G. Castillo, Roya Ijadi-Maghsoodi, Sonya Shadravan, Elizabeth Moore, Michael O. Mensah III, Mary Docherty,
Maria Gabriela Aguilera Nunez, Nicolás Barcelo, Nichole Goodsmith, Laura E. Halpin, Isabella Morton, Joseph Mango,
Alanna E. Montero, Sara Rahmanian Koushkaki, Elizabeth Bromley, Bowen Chung, Felica Jones, Sonya Gabrielian,
Lillian Gelberg, Jared M. Greenberg, Ippolytos Kalofonos, Sheryl H. Kataoka, Jeanne Miranda, Harold A. Pincus,
Bonnie T. Zima, Kenneth B. Wells

Purpose of Review: We review recent community on whole communities or involving multiple non-healthcare
interventions to promote mental health and social equity. sectors. Findings from many studies reinforce the interplay
We define community interventions as those that involve among mental health, interpersonal relationships, and social
multi-sector partnerships, emphasize community members determinants of health.
as integral to the intervention, and/or deliver services in
community settings. We examine literature in seven topic Summary: There is evidence for the effectiveness of com-
areas: collaborative care, early psychosis, school-based munity interventions for improving mental health and some
interventions, homelessness, criminal justice, global mental social outcomes across social-ecological levels. Studies
health, and mental health promotion/prevention. We adapt indicate the importance of ongoing resources and train-
the social-ecological model for health promotion and provide ing to maintain long-term outcomes, explicit attention
a framework for understanding the actions of community to ethics and processes to foster equitable partnerships,
interventions. and policy reform to support sustainable healthcare-
community collaborations.
Recent Findings: There are recent examples of effective
interventions in each topic area. The majority of interventions Focus 2020; 18:60–70; doi: 10.1176/appi.focus.18102
focus on individual, family/interpersonal, and program/ (Reprinted with permission from Current Psychiatry Reports
institutional social-ecological levels, with few intervening 2019; 21:35)

Introduction This review focuses on recent developments in commu-

Families, workplaces, schools, social services, institutions, nity interventions to promote mental health. We highlight
and communities are potential resources to support health. major developments and trends, rather than providing a com-
In 1948, the World Health Organization defined health as a prehensive systematic review. Our review defines community
“state of complete physical, mental and social well-being and interventions as those that involve multi-sector partnerships,
not merely the absence of disease or infirmity” (1). Multi- include community members (e.g., lay health workers) as part
sector and community-based mental healthcare approaches of the intervention, and/or involve the delivery of services in
can help address health and social inequities by promoting community settings (e.g., schools, homes). We include inter-
social well-being and addressing structural determinants of ventions focused on traditional mental health outcomes (e.g.,
mental health (public policies and other upstream forces depression remission) and studies that include a wider range of
that influence the social determinants of mental health). outcomes including mental health-related knowledge, quality
A 2015 Cochrane review described three assumptions of life, and social well-being. We do not include substance use
that underlie community interventions (2). The first is an interventions, which warrant a separate review.
awareness of the multiple forces that exist at all social- To complete our review, we enlisted a large team of ex-
ecological levels (i.e., individual, interpersonal, organizational/ perts and trainees with experience in pertinent intervention
institutional, community, and policy) that facilitate or obstruct areas. Our review focuses on interventions published in peer-
mental health (3). The second is investment in community reviewed medical journals from 2015 to 2018, with additional
participation to provide resources and inform interventions, studies identified through reference mining and expert rec-
recognizing expertise outside of the healthcare system. The ommendations. We concentrate on seven topic areas, chosen
third is prioritization of community mental health and social for their salience and quality of evidence in recent literature:
outcomes. multi-sector collaborative care, early psychosis interventions,

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school-based interventions, homeless services, criminal justice, co-morbid substance use disorders and serious mental ill-
global mental health, and mental health promotion and sec- nesses in the study (25, 26). At 6-month follow-up, partici-
ondary prevention. We selected studies for their design, out- pants in CEP (n 5 514) compared to RS (n 5 504) had
comes, and/or impact (Appendix A). These were chosen significantly improved health-related quality of life, in-
from a larger number of relevant community interven- creased physical activity, reduced homelessness risk factors,
tions (Appendix B). and reduced behavioral health hospitalizations (18). Sub-
group analyses and follow-up studies at 12 and 36 months
support some significant beneficial effects of CEP over RS,
with main effects seen predominantly during the first
Multi-Sector Collaborative Care
6 months post-intervention and diminishing over time
Collaborative care models in mental health have historical (25, 27–34, 35).
roots in the Chronic Care Model (CCM) of chronic disease Since CPIC, only a handful of collaborative care studies
management (4, 5). The CCM envisioned a combination of have included non-healthcare partners (36–38, 39). Hankerson
health system reforms and community-based resources to et al. conducted depression screenings in three predomi-
support the ability of healthcare settings to improve out- nantly African American Christian “mega churches”
comes for those with chronic illnesses (4). Many collabo- ($ 2000 worshippers per weekend) in New York City, using
rative care studies, often for depression, have focused on a community coalition approach, including faith-based
incorporating mental health services to varying degrees organizations and local government (38). Investigators
within primary care settings (6–10). Adaptations exist for screened 122 community members at 3 church events in
other target populations (e.g., children) and settings (e.g., 2012. Notably, 19.7% of those screened reported moderate
obstetrics/gynecology practices, mental health clinics) (5, depression (PHQ-9 $ 10), in which the authors noted is
11–13). Studies have noted the importance of community higher than is seen in African American community samples.
organizations and social services, particularly when in- Moreover, none of the participants who screened positive
equities play a large role in determining outcomes and requested community mental health referrals, even though
require services beyond the healthcare sector, for exam- these were offered, demonstrating the importance of
ple for underresourced populations and natural disasters churches as sites for depression screening, counseling (i.e.,
(5, 14, 15, 16, 17). Mental Health First Aid), and referral (38, 39).
Community Partners in Care (CPIC) was a depression
collaborative care study that involved 95 programs in five
sectors: outpatient primary care, outpatient mental health,
Early Intervention Services for Psychosis
substance use treatment services, homeless services, and
other community services (e.g., senior centers, churches) There is a large and growing body of literature on co-
(18). A 2015 Cochrane review identified CPIC as the only ordinated specialty care programs for people with early
“high-quality study” that “specifically evaluated the added psychosis, including the RAISE Early Treatment Program/
value of a community engagement and planning intervention NAVIGATE and OnTrackNY (40–47, 48). Germane to our
(i.e. a coalition-led intervention) over and above resource community intervention focus, several early psychosis in-
enhancement and community outreach” (2) (page 32). CPIC terventions summarized in a 2014 review by Nordentoft
was a group-level randomized study that compared two et al. adapted Assertive Community Treatment (ACT), an
program-level quality improvement interventions: Commu- evidence-based service delivery model that emphasizes
nity Engagement and Planning (CEP) and Resources for outreach-based services (48, 49).
Services (RS). RS programs received a depression care toolkit Secher et al. published the 10-year follow-up results of
with technical assistance and consultation to implement a the Danish OPUS trial, a two-site RCT of a 2-year ACT-
community-wide approach to depression care. CEP programs based assertive early intervention (50). Services were
received the same resources within a multi-sector coalition delivered by a multidisciplinary team (psychiatrist, psy-
approach to co-leading, implementing, and monitoring multi- chologists, nurses, social workers, vocational therapist,
sector depression services (e.g., encouraging community physiotherapist, 10:1 patient-to-staff ratio) in patients’
programs to be active in psychoeducation and screening, with homes, other community locations, or clinic, based on
streamlined referrals to clinics and social services) (19). patients’ preferences. Intensive services at this early
CPIC’s community-partnered participatory research ap- critical stage were hypothesized to yield lasting effects by
proach and development of community partnerships are de- teaching individuals the skills to best manage their psy-
scribed in detail in several articles (19–24). chotic illnesses. OPUS results at 2 years showed signifi-
Unlike many collaborative care studies, CPIC focused on cant positive outcomes compared to services as usual:
a predominantly under-resourced racial/ethnic minority decreased positive and negative psychotic symptoms, re-
sample (n 5 1018, 46% African American, 41% Latino, 74% duced substance use, improved treatment adherence, lower
with family incomes below federal poverty level) and had antipsychotic medication dosage, higher treatment satis-
few exclusion criteria, enrolling many participants with faction, and reduced family burden. At 10-year follow-up,

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however, most of these outcome differences had dissipated. manualized program that teaches emotional regulation,
Investigators conclude that longer duration of specialized anxiety management, and problem solving, led by trained
assertive early intervention treatment, booster sessions, or school staff or other designated health leaders. Forty-one
the addition of an early detection program to reduce dura- schools were randomized to three arms (n 5 1343):
tion of untreated psychosis would aid the consolidation of health-led FRIENDS, school-led FRIENDS, and a com-
early treatment gains. parison group of Personal, Social, and Health Education
An initiative by a London Early Intervention Service (PSHE, emotional regulation, and self-awareness skills
(EIS) sought to decrease duration of untreated psychosis and with less focus on anxiety management) which was pro-
increase referrals from the community through early psy- vided by school staff. Health-led FRIENDS was more ef-
chosis psychoeducational workshops with 36 community fective in decreasing social anxiety, generalized anxiety,
organizations (e.g., housing and social services, youth ser- and total Revised Children’s Anxiety and Depression Scale
vices, cultural and faith groups, police, colleges, employment scores as compared to school-led FRIENDS and PSHE.
agencies) (51). EIS staff conducted 41 half-day workshops at There were no intervention effects on math, reading, or
community organizations; monthly follow-up meetings and writing standardized assessment test scores.
an additional session were offered; EIS promotional mate- Several studies implemented preventive interventions in
rials were made available; and EIS referral processes were the pre-kindergarten years. One such study evaluated de-
streamlined for community organizations, including a link- velopmental trajectories of youth, including behavioral, so-
age worker as a community liaison. Although the majority of cial, and learning measures over a 5-year period after
community staff were in contact with people experiencing receiving an enriched Head Start Curriculum (60). This
early psychosis in the past year (59.4%) and attitudes toward study is notable for its goal to address disparities and for the
EIS as a first referral destination improved (37% pre- to 68% measures used to evaluate effects on development, which
post-workshop), the study results were negative. Comparing included social and learning behaviors and interpersonal
EIS referrals in the year pre-/post-interventions, there was relationships. In this RCT, 25 Head Start Centers were
no significant difference in duration of untreated psychosis stratified and randomly assigned to receive usual Head Start
(295 vs. 396 days, p 5 0.715) and, contrary to expectations, vs. REDI intervention. REDI comprised dialogic reading,
referred patients experienced significantly more contacts sound games, an interactive alphabet activity, and imple-
with intermediate healthcare/non-healthcare programs in mentation of the Preschool Promoting Alternative Thinking
their pathway to EIS treatment (2.06 vs. 2.45 steps, p 5 Strategies curriculum focused on social emotional skills,
0.002), reflecting a less streamlined referral process. In with added professional development for teachers. Out-
follow-up interviews, the authors note the barriers of mental comes were obtained for 325 children who were followed
health stigma, high community staff turnover, and resistance for 5 years post-preschool. Children in the Head Start REDI
by EIS clinic staff to community-based work. Similar to intervention vs. control group were significantly more likely
CPIC, both of these studies suggest the importance of re- to follow optimal developmental trajectories in social be-
sources to sustain lasting change. havior, aggressive-oppositional behavior, learning engage-
ment, attention problems, student-teacher closeness, and
peer rejection. This and other studies illustrate the im-
portance of intervening at the levels of the classroom and
School-Based Interventions
whole school.
Research shows that youth, especially under-resourced
youth, are most likely to receive mental healthcare in
Homeless Services
schools, given barriers to obtaining community mental
health services (52, 53). School infrastructures also allow Individuals experiencing homelessness are at increased risk
for large-scale implementation of prevention interventions for mental illness, trauma, suicide, and medical comorbid-
(54). Given the number of factors involved in delivering ities, along with a reduced life expectancy compared with
school interventions, however, experts urge consideration of the general population (61–64). The recent focus on Housing
policies, school culture and climate, and leadership struc- First in community-based research on homelessness largely
ture when delivering interventions (55, 56). Academic out- reflects an increasing embrace of that model (65). Housing
comes can be difficult for researchers to collect given the First is an approach to providing permanent housing with-
unique requirements of Family Educational Rights and out requirements for pre-placement sobriety or treatment
Privacy Act and HIPAA (57). Further, developing sus- participation (65). Studies have demonstrated that Housing
tainable interventions in schools that are truly responsive First yields quicker and more sustained housing retention
to the needs of students may require years of building compared to continuum housing approaches (transitional
academic-community partnerships (58). housing 1/- sobriety or treatment requirements) (66).
Skryabina et al. assessed educational outcomes in an RCT In the Canadian At Home/Chez Moi study, a multi-city
of a universal school-based cognitive behavioral therapy RCT of the Housing First model compared with usual care,
prevention program, called FRIENDS (59). FRIENDS is a Aubry et al. followed 950 homeless or precariously housed

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adults with serious mental illness (67). The study found that judge, public defender, and district attorney. Over a year,
participants in Housing First, compared with usual care, FACT enrollees had significantly fewer convictions (0.4 6
more quickly entered housing (within 73 vs. 220 days), 0.7 vs 0.9 6 1.3, p 5 .023), days in jail (21.5 6 25.9 vs 43.5 6
retained housing for longer durations (281 vs. 115 days), 59.2, p 5 .025), and more days in outpatient mental health
and rated the quality of their housing more positively at 2-year treatment (305.5 6 92.1 versus 169.4 6 139.6, p , .001)
follow-up. They also had significantly higher gains in com- compared to treatment as usual.
munity functioning and quality of life in the first year. A pilot study examined a social worker-administered
Several family-focused studies addressed homelessness. decision-making intervention for police encountering
Nath examined the impact of drop-in homeless service people with mental illness (78). During the study period,
centers for children in New Delhi, India (68). They found any police officer who ran a background check on a
that for every month of attendance at a drop-in center, detained enrollee was notified of enrollee participation in
children experienced 2.1% fewer ill health outcomes per the program and was given the option to call a linkage
month and used 4.6% fewer substances. Shinn et al. focused specialist, usually a social worker employed by a com-
on social and mental health outcomes in children within munity mental health agency. Linkage specialists pro-
newly homeless families with mental health or substance use vided mental health history (e.g., treatment participation,
disorders (69). They compared usual care with a family- medication history) and treatment referral options.
adapted critical time intervention, which combined housing While this feasibility study lacked statistical power, the
and case management to connect families leaving shelters authors suggest that these results show the promise
with community services. Youth in both groups exhibited of a cross-sector approach to reducing arrests in this
reductions in psychosocial and mental health symptoms population.
over time. Children ages 6–10 and 11–16 receiving the Other interventions addressed risk factors for justice in-
intervention compared to usual care were less likely at volvement like lack of insurance, unemployment, emotional
24-month follow-up to self-report school troubles (i.e., regulation, and academic achievement (79–81, 82, 83). Two
suspension, being sent to the principal’s office, and being quasi-experimental studies focused on healthcare access,
sent home with a note). Other studies have begun to analo- examining the downstream service use and recidivism ef-
gously assess homeless interventions for broader social fects of expedited Medicaid enrollment for recent prison
outcomes, including community functioning, arrests, public releasees with schizophrenia or bipolar disorder in Wash-
and other service use (e.g., food banks, shelters, prison ington State (n 5 3086) (79, 80). Twelve months post-
time), employment, and income (70–74). Future studies implementation, 81% of the expedited group and 43% of the
would benefit from expanded exploration of social out- services as usual group were enrolled in Medicaid, (p , .01).
comes that are important to individuals who have expe- Community mental health (69% vs. 37%, p , .01), outpatient
rienced homelessness. primary care (64% vs. 42%, p , .01), and emergency room
use (55% vs. 35%, p , .01) significantly increased in the
intervention group compared to services as usual. Un-
Criminal Justice
expectedly, there was a significantly greater proportion of
Nearly 40% of jail and prison inmates self-report a history of those in the intervention versus comparison group that
mental illness, and this prevalence is higher among those spent any days in jail (43 vs. 34%, p , .01) and state prison
with more arrests and time served in a correctional facility (56% vs. 46%, p , .01), with no significant difference in the
(75). Community interventions in collaboration with the proportion with any arrests (59% vs. 54%) at follow-up. The
criminal justice system are well positioned to address health investigators suggest that while healthcare access is an
disparities experienced by justice-involved populations and important determinant for mental health, future inter-
the vulnerabilities to justice involvement experienced by ventions and policies must intentionally address the larger
those with mental illness in the community. The studies ecosystem of social/structural determinants of criminal
below collaborated with the justice system to alter in- justice involvement.
stitutional (e.g., police, court) processes for those with
mental illness and/or addressed upstream social and struc-
Global Mental Health
tural recidivism risk factors (76).
In Monroe County, New York, adults with psychotic Global mental health is “an area for study, research and
disorders charged with misdemeanors were conditionally practice that places a priority on improving health and
released and randomized to usual treatment (n 5 35) or achieving equity in health for all people worldwide” (84)
Forensic Assertive Community Treatment (FACT) (n 5 35) (pg. 1995). We reviewed community interventions in in-
(77). FACT employed high-fidelity ACT services with the ternational settings, acknowledging the shared social,
following adaptations: a 6-h training in criminal justice structural, and mental health challenges that exist across
collaboration for clinicians, screening for criminogenic risk nations. Many of the reviewed studies involve lay health
factors among enrollees, weekly court appearances, and worker (LHW) interventions (85, 86–90). Barnett et al.
meetings to discuss barriers to success with the supervising in their 2018 review of LHW interventions describe that

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LHWs elevate demand for services by increasing awareness strength of social network, and community engagement, and
of services and mental health literacy and by reducing stigma “individual healing” indicators: PTSD, anxiety, and de-
and barriers to care (85). Further, LHW interventions in- pression symptoms (n 5 2383). They found that TRCs
crease the supply of services in under-resourced areas by yielded improvements in societal healing, but worsened
enlarging the workforce of culturally appropriate providers. individuals’ health (worsened psychological health, de-
In 2017, Patel et al. published the first trial of a psycho- pression, anxiety, and PTSD). The authors suggest policy
logical intervention in primary care delivered by LHWs for implications such as integrated counseling in TRCs, re-
moderate/severe depression in a low/middle income coun- ducing delays in holding TRCs after war, and exploring
try (91). In that RCT, 495 participants in Goa, India, were alternative post-conflict unification methods.
assigned to the Healthy Activity Program (HAP) plus En-
hanced Usual Care (EUC) intervention or EUC alone (usual
care plus depression screenings and guideline-based pri-
Mental Health Promotion and Prevention
mary care treatment of depression). In order to deliver the
HAP (6–8 sessions on principles of behavioral activation), Communities That Care (CTC) is a community-level pre-
counselors received a 3-week training and 6-month intern- vention planning and implementation system with primary
ship under supervision of local mental health workers, who foci on preventing youth (school grades 6–9) substance use,
were trained by an expert on behavioral activation. At violence, and delinquency and secondary foci on depression,
3 months, HAP participants demonstrated significantly re- suicide, and other mental health outcomes. The CTC system
duced depression symptom severity, suicidal ideation, dis- involves five phases: identification of community stake-
ability, days out of work, and intimate partner violence and holders, formation of a community coalition, development of
significantly higher rates of depression remission and im- a community profile to identify risk and protective factors
proved behavioral activation compared to the EUC group. related to youth health and behavior problems, creation of a
A study in the Eastern Cape, South Africa, was the first to community action plan, and implementation and evaluation
examine the effectiveness of a child abuse prevention program (95). Communities implement evidence-based programs
for adolescents in a low/middle income country (92). Most of from the Building Healthy Youth Development registry,
the participating adolescents and caregivers (n 5 115 dyads) maintained by the University of Colorado Boulder’s Center
from six under-resourced rural and peri-urban communities for the Study of Prevention and Violence (96). The Com-
were referred to the study by non-governmental organiza- munity Youth Development Study was a community-
tions, schools, clinics, chieftans, and social workers based on a randomized study of CTC involving 24 communities (n .
history of family conflicts. Sixty percent of adolescent par- 14,000) in Colorado, Illinois, Kansas, Maine, Oregon, Utah,
ticipants at baseline had either an HIV-positive caregiver or and Washington State (97–99). CTC has also been imple-
were orphaned by AIDS, 63% experienced pre-intervention mented in Pennsylvania and rural Massachusetts (100–102).
child abuse, and 50% of caregivers at base-line endorsed in- In CTC versus control communities, results showed im-
timate partner violence. Participants completed a 12-week proved individual outcomes at eighth grade: reduced sub-
parenting program delivered by local childcare workers. The stance use, delinquency, and violence; later initiation of
study yielded significant improvements in social outcomes: alcohol use, tobacco use, and delinquency; and lower prev-
reduced child abuse (63.0% to 29.5%, p , .001), reduced ad- alence of risky behaviors (past-year delinquency, past
olescent delinquency/aggressive behavior, reduced witnessed 2-week delinquency, and past-month alcohol and tobacco
violence by adolescents, improved positive and involved par- use) (103). Many of these results persisted to grades 10–12,
enting (adolescent and caregiver self-report), and improved despite few CTC programs focused on these grade levels.
social support (adolescent and caregiver self-report). The Fewer results (greater lifetime abstinence from antisocial
study also demonstrated significantly improved mental health behavior; greater lifetime abstinence from drug use and vi-
outcomes, specifically decreased caregiver substance use, olence in male but not female participants) persisted to age
reduced adolescent and caregiver depression, and re- 19 (103, 104).
duced parenting stress. These findings illustrate the in- CTC investigators recently published follow-up results
terplay among social determinants, family dynamics, and for participants at age 21 (n 5 4002, 91% of the initial sample
caregiver-adolescent mental health. from grades 5–6), 11 years after initial CTC implementation
Multiple recent studies consider the effects of war and (103). By age 21, CTC vs. control communities showed in-
broad structural forces on mental health (87–89, 93). Cilliers creased likelihood of lifetime abstinence from alcohol, to-
et al. assessed the individual and community mental and bacco, and marijuana use (ARR 1.49; 95% CI 1.03, 2.16),
social well-being outcomes associated with truth and rec- increased abstinence from antisocial behavior (ARR 1.18,
onciliation commissions (TRCs) in 200 Sierra Leone villages 95% CI 1.02, 1.37), and decreased lifetime incidence of vio-
(94). TRCs are community forums created to uncover lence (ARR 0.89, 95% CI 0.79, 0.99). In male participants,
wrongdoing by governments or other actors in the aftermath CTC versus control communities also showed increased
of major conflicts. The authors measured “societal healing” likelihood of sustained abstinence from tobacco, marijuana,
indicators, including forgiveness of perpetrators, trust, and inhalant use.

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Social protection studies investigate mental health and of mental health services by leveraging trusted relationships.
other outcomes associated with direct provision of resources For example, Patel et al. demonstrated the successful de-
in the forms of cash and food transfers (105, 106, 107, 108, livery of behavioral activation for depression by LHWs
109). A neighborhood cluster RCT in Ecuador investigated through relatively brief training to a population with sig-
the effects of such resources on mental well-being and in- nificant barriers to healthcare access (91). Some studies
timate partner violence (106, 109). Colombian refugees and adapted evidence-based models (e.g., Forensic Assertive
low-income households in northern Ecuador were ran- Community Treatment) to deliver treatments in non-
domized to cash, food vouchers, food, or control arms. traditional locations, such as jails, churches, and senior
Treatment arms received the equivalent of $40 per month centers (77). Many individual-level interventions also si-
per household for 6 months, which represents 11% of pre- multaneously acted at the organizational/institutional level.
transfer monthly consumption. Food vouchers were re- In the successful RCT of Head Start REDI, teachers were
deemable at local supermarkets for a pre-approved list of provided with professional development and mentoring
nutritious foods. Food transfers were in the form of rice, to deliver an enriched curriculum (60).
lentils, vegetable oil, and canned sardines. Pooled results A second group of interventions intervened at the in-
from all treatment arms showed the intervention signifi- terpersonal level (e.g., parent and family interventions). The
cantly decreased the probability of controlling behaviors and effective child abuse prevention program in South Africa
physical and/or sexual violence by 6 to 7 percentage points focused on the parent-child dyad through individual and
compared to controls, with even greater reductions in the joint sessions (92). Additionally, a strength of this in-
prevalence of any physical/sexual violence for women with tervention was its delivery by local child care workers. A
low baseline ratings of household decision-making power third group of interventions functioned at the organiza-
(106). Qualitative interviews with participants indicated that tional/institutional level by enhancing the processes by
improved family well-being, reduced marital stress and which non-healthcare programs serve those with mental
conflict, and women’s increased freedom of movement illness. These interventions enlisted non-healthcare entities
and decision-making power contributed to the decrease and trusted community leaders to be active in mental
in violence. Similar studies include a large cluster RCT of healthcare, such as providing a depression screening in-
cash transfers in Kenya’s program for at-risk youth and a tervention in churches (38, 39). Several successful school-
cluster RCT of greening urban vacant land; both showed based interventions operated at the organizational level,
significant improvements in depression outcomes com- such as Warschburger and Zitzmann’s universal school-
pared to control communities. These studies highlight the based prevention program for eating disorders in Germany
importance of addressing social inequities to achieve mental and other whole school approaches (111, 112).
health gains in under-resourced communities (107, 110). We found only a small number of studies that intervened
at the level of whole communities. Most interventions
reviewed here included one non-healthcare sector collabo-
Discussion rator as opposed to collaborating with communities more
Actions of community interventions by social-ecological level. broadly. Examples of community-level interventions include
The community interventions above (Appendix A), drawn CPIC, which involved 95 organizations in 5 sectors to de-
from a larger selection (Appendix B), highlight the suc- velop community-wide plans for managing depression, and
cesses and promise of these interventions to promote CTC that supports communities to develop multi-sector
mental health and broader outcomes at all social-ecological coalitions to prevent youth substance use, violence, and
levels: individual, interpersonal/family, organizational/ delinquency (35, 103). Other studies acted at the community
institutional, community, and policy (3). Community level by directly providing or influencing resources on a large
involvement is represented in varied ways in the form of scale, through cash/food transfers or land revitalization efforts
individuals (lay health workers), settings (churches, schools), (94, 105, 106, 107, 108,109, 110).
leaders (community-based participatory research), and multi- A fifth group of interventions are health and public pol-
sector coalitions (35, 37, 38, 39, 85, 86–90, 91, 103). icies. Policies that promote mental health equity are beyond
Many studies examined the interplay among mental health the scope of this review but are detailed in our recent review
services, social and structural determinants, and mental on this topic (113). Policies as varied as mental health in-
health outcomes. Some explicitly assessed social outcomes surance parity, assisted outpatient treatment statutes, quality
like intimate partner violence, housing retention, academic metrics for social determinants of health, value-based pay-
performance, parent-child interactions, “societal healing,” and ment reforms, and the integration of funds and services for
other contributors to mental and social well-being (67, 92, 94, 111). health and social care have the potential to improve access to
Figure 1 summarizes the actions of community inter- treatment and improve outcomes (114–117, 118, 119–121).
ventions by social-ecological level to promote mental health Policies facilitating multi-sector health collaborations in-
and social well-being. We found that most interventions clude the Accountable Health Communities model, Cal-
reviewed promoted mental health at the individual level. ifornia’s Whole Person Care pilots, the Certified Community
LHW interventions extend access and increase acceptability Behavioral Health Clinics Demonstration Program, New

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FIGURE 1. Overview of community intervention processes by social-ecological level (adapted from McElroy, KR, Bibeau D, Steckler
A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q. 1988;15:351–377)a

a
A color version of the figure, as originally published, appears in the online version of this article (focus.psychiatryonline.org).

York’s Home and Community-based Services, the UK’s Social Ethical considerations. Ethical considerations are of impor-
Impact Bonds Trailblazers, and the National Health Service tance to many community interventions given the focus on
England’s social prescribing teams (122–127). Nation-level ef- marginalized and under-resourced populations (24, 133).
forts to promote shared values for mental and social well-being Research on interventions for at-risk individuals with stig-
are Australia’s mental health anti-stigma campaign, the US Na- matized conditions (e.g., incarceration, homelessness)
tional Prevention Strategy’s focus on emotional well-being, and should build trust with participants and recognize structural
the UK’s Campaign to End Loneliness (128–130). Thrive NYC is forces that place them at higher risk for these conditions
an example of large-scale action to promote mental health at (e.g., discriminatory policing and housing policies), to avoid
the civic level, with a budget of $850 million and 54 initiatives inadvertently worsening stigma. Involving community
across all public agencies and departments, with special em- stakeholders in equitable arrangements for interventions
phases on community partnerships and prevention (131, 132). and research requires the necessary time and processes to

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