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NIHR Signal Peer support may reduce readmissions following mental health crises

Published on 13 November 2018

doi: 10.3310/signal-000673

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.

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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).

Bibliography

Gillard S, Edwards C, Gibson S et al. New ways of working in mental health services: a qualitative, comparative case study assessing and informing the emergence of new peer worker roles in mental health services in England. 2014. Health Serv Deliv Res. 2014;2(19).

Milton A, Lloyd-Evans B et al. Development of a peer-supported, self-management intervention for people following mental health crisis. BMC Res Notes. 2017;10:588.

Mind. Peer support. London: Mind; 2016.

NHS website. Dealing with a mental health crisis or emergency. London: Department of Health; 2016.

NICE. Psychosis and schizophrenia in adults: prevention and management. CG178. London: National Institute for Health and Care Excellence; 2014.

NIHR. Forward thinking: NIHR research on support for people with severe mental illness. Themed Review. Southampton: NIHR Dissemination Centre; 2018.

Perkins R and Rinaldi M. Taking back control: a guide to planning your own recovery. London: South West London and St George’s Mental Health NHS Trust; 2007.

RCPsych. Home Treatment Accreditation Scheme (HTAS). Standards for home treatment teams - second edition. Edited by Hodge S and Buley N. London: Royal College of Psychiatrists College; 2015.

Repper J et al. Peer support workers: a practical guide to implementation. ImROC Briefing. London: Centre for Mental Health and NHS Confederation Mental Health Network; 2013.

Trachtenberg M, Parsonage M et al. Peer support in mental health care: is it good value for money? London: Centre for Mental Health; 2013.

Valenstein M and Pfeiffer P. Peer-delivered self-management programmes in mental health. Lancet. 2018;392:364-65.

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).

Bibliography

Gillard S, Edwards C, Gibson S et al. New ways of working in mental health services: a qualitative, comparative case study assessing and informing the emergence of new peer worker roles in mental health services in England. 2014. Health Serv Deliv Res. 2014;2(19).

Milton A, Lloyd-Evans B et al. Development of a peer-supported, self-management intervention for people following mental health crisis. BMC Res Notes. 2017;10:588.

Mind. Peer support. London: Mind; 2016.

NHS website. Dealing with a mental health crisis or emergency. London: Department of Health; 2016.

NICE. Psychosis and schizophrenia in adults: prevention and management. CG178. London: National Institute for Health and Care Excellence; 2014.

NIHR. Forward thinking: NIHR research on support for people with severe mental illness. Themed Review. Southampton: NIHR Dissemination Centre; 2018.

Perkins R and Rinaldi M. Taking back control: a guide to planning your own recovery. London: South West London and St George’s Mental Health NHS Trust; 2007.

RCPsych. Home Treatment Accreditation Scheme (HTAS). Standards for home treatment teams - second edition. Edited by Hodge S and Buley N. London: Royal College of Psychiatrists College; 2015.

Repper J et al. Peer support workers: a practical guide to implementation. ImROC Briefing. London: Centre for Mental Health and NHS Confederation Mental Health Network; 2013.

Trachtenberg M, Parsonage M et al. Peer support in mental health care: is it good value for money? London: Centre for Mental Health; 2013.

Valenstein M and Pfeiffer P. Peer-delivered self-management programmes in mental health. Lancet. 2018;392:364-65.

Peer-supported self-management for people discharged from a mental health crisis team: a randomised controlled trial

Published on 14 August 2018

Johnson, S.,Lamb, D.,Marston, L.,Osborn, D.,Mason, O.,Henderson, C.,Ambler, G.,Milton, A.,Davidson, M.,Christoforou, M.,Sullivan, S.,Hunter, R.,Hindle, D.,Paterson, B.,Leverton, M.,Piotrowski, J.,Forsyth, R.,Mosse, L.,Goater, N.,Kelly, K.,Lean, M.,Pilling, S.,Morant, N.,Lloyd-Evans, B.

Lancet Volume 392 Issue 10145 , 2018

BACKGROUND: High resource expenditure on acute care is a challenge for mental health services aiming to focus on supporting recovery, and relapse after an acute crisis episode is common. Some evidence supports self-management interventions to prevent such relapses, but their effect on readmissions to acute care following a crisis is untested. We tested whether a self-management intervention facilitated by peer support workers could reduce rates of readmission to acute care for people discharged from crisis resolution teams, which provide intensive home treatment following a crisis. METHODS: We did a randomised controlled superiority trial recruiting participants from six crisis resolution teams in England. Eligible participants had been on crisis resolution team caseloads for at least a week, and had capacity to give informed consent. Participants were randomly assigned to intervention and control groups by an unmasked data manager. Those collecting and analysing data were masked to allocation, but participants were not. Participants in the intervention group were offered up to ten sessions with a peer support worker who supported them in completing a personal recovery workbook, including formulation of personal recovery goals and crisis plans. The control group received the personal recovery workbook by post. The primary outcome was readmission to acute care within 1 year. This trial is registered with ISRCTN, number 01027104. FINDINGS: 221 participants were assigned to the intervention group versus 220 to the control group; primary outcome data were obtained for 218 versus 216. 64 (29%) of 218 participants in the intervention versus 83 (38%) of 216 in the control group were readmitted to acute care within 1 year (odds ratio 0.66, 95% CI 0.43-0.99; p=0.0438). 71 serious adverse events were identified in the trial (29 in the treatment group; 42 in the control group). INTERPRETATION: Our 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. FUNDING: National Institute for Health Research.

Expert commentary

People living with severe mental health problems sometimes experience crises, requiring acute care and treatment. In developed mental health systems acute care is provided by staff in community-based crisis resolution services, and by staff working in psychiatric hospitals.

Reducing crises from happening is an important goal for mental health services. This study shows that structured, peer-supported, self-management is a promising intervention which can reduce rates of readmission to acute care.

This is a valuable finding, suggesting a clear and important role for peer workers and underpinning the case for a structured approach to mental health self-help.

Dr Ben Hannigan, Professor of Mental Health Nursing, Cardiff University

Expert commentary

Training in self-management offered following discharge has the potential to keep people in recovery for longer. However, research in this area is difficult to conduct, and so this well conducted randomised controlled trial is important.

Furthermore, the findings suggest that the intervention can be delivered routinely in practice.

The study design does not allow conclusions to be drawn on whether using peer support workers had benefits over other types of support worker. Additionally, the wide confidence intervals mean that the intervention may have had a very small effect on readmissions. The authors address these points in their discussion.

Norman Young, Nurse Consultant and Senior Associate Lecturer, Cardiff and Vale UHB and Cardiff University​

The commentator declares no conflicting interests