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Peer support may curb readmission to mental health crisis units

Fewer people given this type of support readmitted within a year

Caroline White

Friday, 03 August 2018

Peer support from people who have lived through mental health conditions themselves may help curb the likelihood of readmission for those who have recently left acute mental health care, suggests a randomised controlled trial* of more than 400 people in England published in The Lancet.

In the UK, more than half of people admitted to acute care are readmitted within a year, and there is no good evidence on how these readmissions can be reduced.

Support from people who have experienced mental health problems is used in the UK and USA in programmes such as the NHS’ Implementing Recovery through Organisational Change and the USA’s Wellness Recovery Action Plan.

The current study is the first randomised trial to assess the effectiveness of this approach.

“People discharged from community crisis services are often readmitted to acute care. Not only does this impede recovery, but also consumes resources that might otherwise be dedicated to longer-term improvements in functioning and quality of life,” says lead researcher, Professor Sonia Johnson, of University College London.

“Peer support workers could provide support and encouragement that is particularly warm and empathetic because it is rooted in personal experience, as well as providing service users with a role model for their recovery,” she added.

The researchers compared advice on self-management advice in a workbook with help from a support worker who had also experienced mental ill health among people discharged from one of six crisis resolution teams in England.

Participants had a range of diagnoses, including schizophrenia, bipolar disorder, psychosis, depression, anxiety disorder, post-traumatic stress, and personality disorder. Everyone continued with treatment and usual care throughout the study.

Participants either received a personal recovery workbook (220 people) or peer support plus the workbook (221 people).

The workbook included sections on setting personal recovery goals; re-establishing their place in the community and support networks; identifying early warning signs and taking steps to avoid or delay relapse; and planning strategies to maintain wellbeing. Participants were asked to record observations and plans in each of these areas.

Those who received support from a person who had also experienced mental health problems were offered 10 weekly one-hour sessions. The support worker listened to their problems and shared the skills and coping strategies they had learnt during their own recovery. Support workers received training beforehand in listening skills, cultural awareness, self-disclosure, and confidentiality.

The authors monitored participants’ health records to find out if they had been readmitted to acute inpatient wards, crisis resolution teams, crisis houses, or acute day care services, within one year, and interviewed participants about their experiences after four and 18 months.

After a year, readmission to acute care was lower in the peer support group, with 29% (64/218) of participants readmitted compared with 38% (83/216) given just the workbook.

Some 72% (160/221) of those offered the support and workbook attended at least three meetings with their peer support worker, and a third (65/198) attended all 10.

Similar numbers of participants in both groups read the booklet, but more people in the intervention group used it to make written plans (58-64% compared with 28-44%).

During the study 71 serious incidents occurred, but none was thought to be down to the study.

“Our study provides the most robust evidence for the effectiveness of any peer-provided support in a UK secondary mental health setting,” continues Professor Johnson.

“Our novel findings are potentially important as the intervention is acceptable to patients and feasible for service managers and users who would like to avoid relapse and readmission to acute care.”

The authors note that it wasn’t possible to identify which part of the intervention was associated with the improvement in outcomes. And a high proportion of people in the comparison group used the booklet, and readmission rates in this group were below the national average, which may suggest that the booklet is effective on its own too.

In a linked comment**, Drs Marcia Valenstein and Paul Pfeiffer, of the University of Michigan, write: “There is much to celebrate but also much left to do following the publication of these findings. 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.”

But they add: “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.”

*Johnson S, Lamb D, Louise Marston L, et al. Peer-supported self-management for people discharged from a mental health crisis team: a randomised controlled trial. The Lancet, Volume 392, Issue 10145, doi:10.1016/S0140-6736(18)31470-3
**Valenstein M and Pfeiffer P. Peer-delivered self-management programmes in mental health. The Lancet, volume 392, issue 10145, doi: 10.1016/S0140-6736(18)31718-5

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