Within the context of mental health services, peer support describes a relationship between two or more people with lived experiences of mental health challenges and service use. Various approaches are taken to formalise these relationships, with a shared focus on the value of harnessing lived experience to provide intentional, reciprocal support as a peer. Rather than needing to have shared the exact same experiences, peer support values both commonalities and differences through unconditional acceptance. Core values of peer support include self-determination, autonomy, non-hierarchical structures, reciprocity, hope, and mutuality (Watson 2019).
Peer support can be structured (e.g. manualised intervention) or unstructured, be delivered in-person or remotely (e.g. via telephone or the internet), and can be one-on-one or group based. Group-based peer support can be ‘peer-led’, that is a peer facilitator guides the group, or ‘peer-to-peer support’ (e.g. mutual support group) where there is no facilitator.
In a recent systematic review and meta-analysis, Lyons and colleagues (2021) examined the evidence for peer support groups for adults (aged 18 and over) who experience mental health challenges.
The authors conducted a systematic review using high quality (Cochrane) methods, including a formal assessment of risk of bias for each trial using the Cochrane risk-of-bias tool for randomised trials.
The review included studies that were randomised controlled trials and tested intentional, group peer support interventions, delivered with or without a peer facilitator. The interventions had to be designed to promote recovery from mental health challenges, and so groups with a different focus (e.g. bereavement or physical health conditions) were excluded. Any groups facilitated or co-facilitated by a person in a non-peer role (e.g. healthcare professional) were also excluded.
Rather than focus on a specific mental disorder, the inclusion criteria reflected a broad definition of ‘mental health conditions’, including people who had used mental health services, been diagnosed with an axis 1 psychiatric disorder or assessed as meeting clinical threshold using a validated measure of psychiatric symptoms.
Outcomes of interest covered fell under four broad groupings; personal recovery, clinical recovery, acute mental health care services and social outputs.
Meta-analysis was undertaken where there were sufficient data available.
In total, n=8 trials with n=2,131 participants were included in the review; n=6 were included in the meta-analysis. All but one of the trials were conducted in the United States and the median mean age of participants was 46 years old. The duration of included interventions ranged between 3 weeks and 12 months.
Most (7/8) of the included trials used structured groups delivered by 1-3 peer facilitators. This meant it included an educational component with structured topics covered in ‘classes’, with four trials having a focus on the self-management of mental health conditions, and three on reducing the stigma associated with mental ill-health. The other trial used an unstructured, unmoderated online peer support group model although this trial was not included in the meta-analysis results.
Six trials had either high or unclear risk of bias. The main reasons for these ratings included attrition rates and blinding.
- The most frequently reported outcome was of recovery (5 trials), with meta-analysis finding a small effect of group peer support on overall personal recovery that was maintained at follow-up (up to 6 months).
- The finding was not replicated for other specific elements of personal recovery such as ‘hope’, ‘empowerment’, or ‘self-efficacy’.
- There was a very small effect of group peer support on psychiatric symptoms following intervention.
- There were no reportable outcomes for the domains of acute mental health care services and social outputs.
The authors concluded that they:
could not offer conclusive evidence for the effectiveness of group peer support for clinical and recovery outcomes.
This was in part due to the small number of studies, particularly as only two of the included studies were rated as having a low risk of bias.
The difficulty with measuring the concepts that peer support is designed to target was discussed by the authors in reference to recovery being a personally defined process whereby the meaning of recovery differs between individuals.
This may explain why broader measures of recovery used in the included trials were more able to capture overall improvement, but more narrow measures of the concepts of hope, empowerment and self-efficacy did not seemingly change.
Strengths and limitations
- High quality methods, including rigorous meta-analysis.
- Strict and limited inclusion criteria, thus reducing heterogeneity of intervention delivery.
- However, this narrow focus meant that at least one trial was excluded due to having a cluster RCT design. Peer support is typically embedded across an organisation, meaning a cluster design may be a useful design.
- Interventions that were multi-modal, that is included one-to-one as well as group elements, were also excluded. This type of intervention is likely to be particularly useful in this hard to engage cohort and so excluding these means some potentially helpful interventions were not evaluated.
- Limited evidence (one trial) identified that focused on unstructured peer support, so generalising findings to these type of groups needs to be particularly cautious.
- The median mean age of the participants was 46 years old, highlighting the lack of evidence in younger populations who may be at an earlier stage of experiencing mental health challenges.
Implications for practice
The authors of this review are correctly cautious of overstating the impact their findings should have on practice. In particular, there remains a lack of high-quality trials of mutual support group interventions, despite the growing popularity of this type of support in clinical practice internationally and substantive qualitative literature which details consistent personal benefits.
Overall, the results of this systematic review and meta-analysis suggest that the implementation of structured peer-delivered support groups in local settings may produce small improvements in the personal recovery of individuals accessing these services. To optimise the recovery principles which typically guide mental health services these days, intervention development and delivery should have individuals with lived experience playing a lead role.
Our active ingredients review: Peer support for youth anxiety and depression
Lyons and colleagues focused on reviewing the literature for adults, and the included studies had a median mean age of 46. Yet peer support may be particularly useful for young people. Whether they be friends, schoolmates or other acquaintances, peers play a crucial role in the development of young people. At a time when young people are forming and engaging in these relationships, mental illness is also most commonly emerging. Struggles with peers can contribute to poor mental health, just as positive relationships can help protect or mitigate against challenges with mental health. Although there has been some promising evidence for peer support helping with conditions like depression in adults (Pfeiffer et al 2011), little is known about whether or not peer support works for young people who experience two disorders common in youth, specifically anxiety and depression.
We wanted to find out whether or not peer support helped improve outcomes for youth depression and anxiety. We defined peer support as support from another young person who had experienced mental health challenges.
We sought to answer the following key questions:
- In which ways does peer support work for young people who experience anxiety and depression?
- In what contexts does peer support work for young people who experience anxiety and depression?
- For whom does peer support appear to work for, and why?
We conducted a systematic review of controlled trials (randomised and non-randomised) testing peer support for young people. Inclusion criteria included a participant mean age between 14-24 years, peer support provided by someone with relevant lived experience, and having at least one outcome measure related to depression or anxiety. 1,406 papers were identified for screening, and eight met the inclusion criteria. The team also consulted an international steering group of ten young people (aged between 18 and 24 years old, from four Australia, Canada, Ireland, and Singapore) and interviewed seven experts (representing peer work practice in Australia, Brazil, Canada, India, Kenya, Nigeria, the United States, and Zambia) throughout the review process.
Due to limited evidence there were insufficient data to answer the overall research questions. What we could glean from the literature to date was that peer support seems to be acceptable and safe for young people with depression and anxiety, who provided positive feedback about interventions overall. Only one study specifically measured adverse effects, and they found none. Trials were conducted in limited contexts; however, two studies successfully and safely tested online peer support interventions, which is particularly relevant given the COVID-19 pandemic and can increase accessibility in countries where mental health resources are scarce. The lack of evidence makes it difficult to understand the mechanism of action for peer support for young people with anxiety and depression.
How does peer support work?
To start addressing this gap, we drew on the findings of this review, previous literature from adults, and knowledge from our steering groups and expert interviews to propose a preliminary model for the mechanism of action regarding peer support for youth anxiety and depression. The purpose of this draft model was to synthesise empirical and experiential knowledge to stimulate discussion and inform future research in the area.
We proposed that peer support has the potential to address mental health challenges related to anxiety and depression (e.g. hopelessness, nervousness), associated challenges (e.g. loss of power and autonomy), impacts on functioning (e.g. disengagement from education), and help-seeking pathways. It does this through a range of practices underpinned by core values (e.g. building sense of self-worth through reciprocity and mutuality), that ultimately strengthen connections to other people, community, other sources of help, and a sense of identity, cumulatively improving recovery and wellbeing.
Despite the rapidly increasing popularity of peer support programs within and beyond mental health services, there is limited evidence to understand its effectiveness for young people.
The studies identified in this review reported that peer worker-delivered interventions were safe, acceptable, and cost-effective. However, local adaptation is required to reflect the characteristics of the young people engaging in these services, and the governance and support structures in place at a local level. The ability to safely deliver peer support online supports the prospect of scalability.
Current evidence is insufficient to draw any strong recommendations for practice. However, the lack of consistent reporting across research studies likely reflects gaps in practice. These gaps include role clarity and the degree to which peer support interventions are designed, implemented and tested in accordance with core peer support values.
The gap between the increasing number of programs happening in practice, and the relatively small amount of research is this area, represents an opportunity to capture existing knowledge. In order to better understand how peer support can help young people who experience mental health challenges, we need research that is designed with young people and harnesses the experiential knowledge of those delivering and receiving these programs.
Statement of interests
We do not have interests to declare.
Lyons, N., Cooper, C. & Lloyd-Evans, B. A systematic review and meta-analysis of group peer support interventions for people experiencing mental health conditions. BMC Psychiatry 21, 315 (2021).
Pfeiffer PN, Heisler M, Piette JD, Rogers MAM, Valenstein M. Efficacy of peer support interventions for depression: A meta-analysis. General Hospital Psychiatry. 2011;33(1):29-36.
Watson E. The mechanisms underpinning peer support: a literature review. J Ment Health. 2019;28(6):677-88