Peer-delivered self-management programmes in mental health
Authors: Marcia Valenstein, Paul Pfeiffer
Journal: The Lancet (2018)

Facilitating recovery and full lives among people with serious mental illness is a priority for mental health services.1US Department of Health and Human Services AgenciesTransforming Mental Health Care in America: The Federal Action Agenda: First Steps. US Department of Health and Human Services Agencies, Washington, DC2006https://store.samhsa.gov/product/Transforming-Mental-Health-Care-in-America/SMA05-4060Date accessed: July 19, 2018Google Scholar, 2Shepherd G Boardman J Slade M Making recovery a reality. Centre for Mental Health, 2008https://www.centreformentalhealth.org.uk/making-recovery-a-realityDate accessed: July 19, 2018Google Scholar Reducing the use of acute care services is also important, for economic reasons and to maximise personal freedom, by treating people in the least restrictive setting possible. Peer support and self-management programmes are increasingly popular recovery-oriented services that have the potential to improve patient wellbeing, reduce relapse, and decrease burden on formal acute mental health services. In mental health settings, peer support refers to individuals who have lived experiences of mental health challenges and recovery who help others in treatment with similar challenges. Illness self-management programmes refer to structured efforts, often using a standardised curriculum, that engage people with mental health conditions in developing skills to manage emerging psychiatric symptoms and crisis situations, to avoid relapse, and enhance recovery.3Petros R Solomon P Reviewing illness self-management programs: a selection guide for consumers, practitioners, and administrators.Psychiatr Serv. 2015; 66: 1180-1193Crossref PubMed Scopus (10) Google Scholar Increasingly, peer supporters have been delivering self-management curriculums informed by their own experiences. However, despite the popularity of these approaches and widespread adoption in the UK, the USA, and elsewhere,4Farkas M Boevink W Peer delivered services in mental health care in 2018: infancy or adolescence?.World Psychiatry. 2018; 17: 222-224Crossref PubMed Scopus (11) Google Scholar the evidence supporting the efficacy of peer support and peer delivery of self-management curriculums is relatively thin.5Pitt V Lowe D Hill S et al.Consumer-providers of care for adult clients of statutory mental health services.Cochrane Database Syst Rev. 2013; 3 (CD004807.)PubMed Google Scholar, 6Lloyd-Evans B Mayo-Wilson E Harrison B et al.A systematic review and meta-analysis of randomised controlled trials of peer support for people with severe mental illness.BMC Psychiatry. 2014; 14: 39Crossref PubMed Scopus (232) Google Scholar, 7Fuhr DC Salisbury TT De Silva MJ et al.Effectiveness of peer-delivered interventions for severe mental illness and depression on clinical and psychosocial outcomes: a systematic review and meta-analysis.Soc Psychiatry Psychiatr Epidemiol. 2014; 49: 1691-1702Crossref PubMed Scopus (73) Google Scholar Some reviews note that peer support might slightly reduce the use of crisis or emergency services,5Pitt V Lowe D Hill S et al.Consumer-providers of care for adult clients of statutory mental health services.Cochrane Database Syst Rev. 2013; 3 (CD004807.)PubMed Google Scholar or improve empowerment, activation, or hope, with peer-delivered self-management curriculums showing promise.7Fuhr DC Salisbury TT De Silva MJ et al.Effectiveness of peer-delivered interventions for severe mental illness and depression on clinical and psychosocial outcomes: a systematic review and meta-analysis.Soc Psychiatry Psychiatr Epidemiol. 2014; 49: 1691-1702Crossref PubMed Scopus (73) Google Scholar, 8Chinman M George P Dougherty RH et al.Peer support services for individuals with serious mental illnesses: assessing the evidence.Psychiatr Serv. 2014; 65: 429-441Crossref PubMed Scopus (274) Google Scholar In The Lancet, Sonia Johnson and colleagues9Johnson S Lamb D Marston L et al.Peer-supported self-management for people discharged from a mental health crisis team: a randomised controlled trial.Lancet. 2018; 392: 409-418Summary Full Text Full Text PDF PubMed Scopus (45) Google Scholar report the results of a randomised controlled trial that strengthens the evidence base for peer-delivered self-management programmes. They assigned 441 patients receiving mental health care services from six UK crisis resolution teams either to usual care plus ten individual 1-h sessions over 4 months with peer support workers who helped patients complete a personal recovery workbook (the intervention group), or to usual care plus the same personal recovery workbook sent by post (the control group). The sessions with peer support workers were structured around completion of the workbook and included setting personal recovery goals, making plans to re-establish community functioning and support networks after a crisis, identifying early warning signs, planning to avoid or attenuate relapse, and planning strategies to maintain wellbeing once a crisis has abated. Patients assigned to the intervention were significantly less likely to be readmitted to acute care services in the 12 months following discharge from the crisis resolution team, with 29% (64/218) of patients in the intervention group versus 38% (83/216) of patients in the control group being readmitted (odds ratio 0·66, 95% CI 0·43–0·99; p=0·0438). There was also a significant difference in the time to readmission (median 112 days [IQR 42–242] vs 86 days [43–180]; hazard ratio 0·71, 95% CI 0·52–0·97; p=0·0291), although there were no significant differences in the number of acute care days in the year after enrolment. At 4 months, patients in the intervention group were more satisfied with their mental health care, and rated their self-recovery more highly than patients in the control group, although the latter finding was no longer significant after adjusting for predictors of missing data. There were no other statistically significant differences in any of the other secondary outcomes, including self-rated recovery, self-management skills, symptom severity, loneliness, or social network engagement, at either 4 months or 18 months. There is much to celebrate but also much left to do following the publication of these findings. The completion of a substantial, adequately powered randomised controlled trial with high ascertainment of the primary outcome and blinded raters is welcome. The finding of reduced readmissions is also welcome, given that implementation of peer support has proceeded apace despite the scarcity of substantial evidence regarding its efficacy. With the publication of this trial, peer-delivered self-management programmes might be considered one of the configurations of peer support with the strongest evidence. That said, the lack of a significant effect on almost all secondary outcomes and potential mediators leaves the mechanism of reduced readmissions unclear. We are left with a complex intervention that appears to reduce readmissions but with few insights into what the active or necessary parts of the intervention might be—eg, support and sharing of life experiences with the peer, engaging actively with the recovery workbook, or changes in self-management behaviours that were not apparent through the self-reported measure. Subsequent studies by these researchers outlining their qualitative work and implementation of the intervention might explain how and why the intervention had its effect on use of services. Because reduced acute care admissions might also include inappropriate avoidance of needed admissions, future research or implementation studies should include additional indicators of the need for acute services such as the severity of suicidal ideation, suicide attempts, or harm to others. This trial shows that a peer-delivered self-management programme that can reasonably be adopted in clinical practice reduces readmissions. Health services that use peer supporters should strongly consider having peers deliver structured self-management curriculums as part of their efforts to assist other individuals with mental health challenges, particularly those at high-risk for relapse. However, key questions remain regarding the components of peer-delivered self-management that are required for efficacy. There are also additional questions regarding the mechanisms underlying the intervention's efficacy and potential modifications of the intervention that might further reduce readmissions and increase its effect on other outcomes, such as symptoms, self-management skills, and wellbeing. MV declares no competing interests. PP has received grants from the US National Institute of Mental Health to study a peer support intervention for patients following psychiatric hospital admission. Peer-supported self-management for people discharged from a mental health crisis team: a randomised controlled trialOur findings suggest that peer-delivered self-management reduces readmission to acute care, although admission rates were lower than anticipated and confidence intervals were relatively wide. The complexity of the study intervention limits interpretability, but assessment is warranted of whether implementing this intervention in routine settings reduces acute care readmission. 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