People discharged from mental health crisis teams are less likely to re-enter acute services within a year if they receive self-management support. The support in this study was provided by a peer worker, someone with experience of mental illness. The peer worker used a workbook to provide information and talk through recovery goals. The study compared this with those who had received the workbook by post.
Participating adults had a range of mental illnesses and had been managed by six crisis resolution teams in England before being discharged to community mental health services or primary care. NHS Trusts employed peer support workers with experience of using mental health services to deliver up to ten individual sessions and to help individuals complete the workbook.
This NIHR-funded study of 440 people shows a moderate effect of peer support in reducing readmissions from about 40% to less than 30%. However, there was no clear impact on self-rated recovery. It is the first UK trial and the most promising evidence so far available for peer support in this context.
Services may be encouraged to consider peer support, as recommended by NICE. However, it would be ideal to look at cost and cost-effectiveness before this intervention is rolled out into routine practice.
Why was this study needed?
Around 200 crisis resolution and home treatment teams in England and Wales provide intensive support at home to adults during a mental health crisis, with £400 million spent by the NHS on the service in 2017/18. As an alternative to in-hospital admissions, this crisis care may save healthcare costs while giving greater independence to patients. Yet over half of crisis team patients are readmitted to hospital within a year of discharge, and evidence is limited on how to promote recovery.
In parallel, mental health services are increasingly employing peer support workers, despite little evidence on the effectiveness of peer support. These are people who have recovered from a mental illness and wish to help others through their personal experience.
This research aimed to assess the effectiveness of an adapted self-management workbook for service users to better manage their mental illness and plan recovery with and without peer support.
What did this study do?
This trial randomised 440 adults to receive up to 10 sessions with a peer support worker who helped them complete a workbook or the workbook without support. The intervention began within a month of discharge from the crisis team, and the usual community-based mental healthcare continued. Around a quarter of the ethnically diverse sample had depression, and around a third had psychosis. The trial excluded patients presenting a high risk to others.
Peer support workers delivered an average of seven of the possible ten one hour face to face sessions within four months. They used their own experiences to facilitate workbook completion, listen supportively and share recovery strategies.
Admissions data came from hospital records. Participants and researchers completed validated scales during interviews at four months and 18 months after entering the trial.
Unavoidably, participants and services were aware of treatment allocation, but researchers were kept unaware of the allocation as far as possible.
What did it find?
- Within a year, 29% of people allocated to the peer support group had been readmitted to acute mental healthcare, compared with 38% of people receiving the workbook by post without peer support (adjusted odds ratio 0.66, 95% confidence interval [CI] 0.43 to 0.99). The peer support group had a longer period before any first readmission occurred, (112 days versus 86 days, hazard ratio 0.71, 95% CI 0.52 to 0.97).
- There was no difference between the intervention and control groups in the number of days of acute mental health care readmission within a year (mean 13 days for the intervention group vs 19 days for the control group, incident rate ratio 0.90, 95% CI 0.66 to 1.23). There was also no difference in the number of contacts with other members of the community based mental health teams.
- At four months, participants receiving peer support reported being slightly more satisfied with mental health services overall, with an average rating of 26 out of 32 on the Client Satisfaction Questionnaire, than those in the control group who had an average rating of 24 (mean difference 1.96, 95% CI 1.03 to 2.89).
- There were no differences between the intervention and control groups in self-rated recovery, illness management, social networks, loneliness, or psychiatric symptoms rated by researchers through interview.
- Around 60% of people receiving peer support said they had used the workbook to make written plans, compared with 28 to 44% in the control group. Similar proportions (around 85%) said they had read it.
What does current guidance say on this issue?
NICE recommended in 2014 that peer support should be considered to improve the quality of life for people with psychosis and schizophrenia. Peer support workers should remain in stable recovery, receive training and whole team support, and be mentored by an experienced peer support worker. NICE, however, noted weak clinical and cost effectiveness evidence at that time for peer support, and the possibility of adverse outcomes for peer support workers.
The Royal College of Psychiatrists’ Home Treatment Accreditation Scheme (2015), states that the home treatment team should have access to peer support workers.
An earlier NIHR-funded study on peer support workers in mental health provides a useful overview and context.
What are the implications?
Peer support with the workbook following an acute admission to a crisis team appears to lengthen the time to readmission. The positive effect could be due to the increased encouragement to use the workbook and set goals or the general increase in support and empathy peer workers provide. The lack of an effect on some related factors that would be important in preventing relapse, such as self-rated recovery, is perhaps disappointing.
We do not know how peer support compares to professional support. But an effect in this hard to manage group is important and might encourage further training for peer workers and refinement of the workbook intervention. This large trial provides new evidence on structured self-management support. This should be of interest to commissioners, mental health teams and service users.
Citation and Funding
Johnson 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(10145):409-18.
This project was funded by the National Institute for Health Research Programme Grants for Applied Research (project number 0109-10078).
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Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre