Peer Interventions in Severe Mental Illnesses: A Systematic Review and its Relation to Occupational Therapy

Figures & data

Figure 1. Flow diagram of article inclusion and exclusion process. From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097

Table 1. Summary of fIndings.

Article	Author/Year	Level of evidence/Study design/Participants/Inclusion criteria/Country	Intervention and control groups	Outcome measures	Statistically significant results
1	(Chinman et al., 2015) https://doi.org/10.1007/s11414-013-9343-1	Level I RCT N = 238 M age = not reported Female= 10% (n = 28) Intervention group: 122–M age = 54.59 ± 9.19 yr.–Female = 10% (n = 12) Control group: 116–M age = 51.89 ± 11.13 yr.–Female = 13% (n = 16) Inclusion criteria: SMI + rehospitalitations Country: US	Peer intervention: training + Case management Duration: 1 year Environment: community Control group: usual care	Baseline and 1-year follow QOLI BASIS-R Patient Activation Measure (PAM) BASIS-R Mental health recovery: RSA MHRM IIMR	PAM (p < 0.05) MHRM (p < 0.01) BASIS-R – (p < 0.02)
2	(Cook et al., 2012) https://doi.org/10.1016/j.schres.2011.10.016	Level I RCT N = 428 M age = 42.8 ± 10.9 yr. Female = 556% (n = 238) Intervention group: n = 212–M age = 42.7 ± 9.9 yr. – Female= 53.8% (n = 114) Control group: n = 216 – M age= 43.0 ± 11.8 yr. –Female= 57.4% (n = 124) Inclusion criteria: SMI Country: US	Peer intervention: Education program Duration: 8 weeks Environment: community Control: standard	Baseline − 8 weeks − 6 months (follow up) Symptom: BSI Recovery mental health: RAS SHS	RAS: (p<.01) SHS: (p<.01)
3	(Corrigan et al., 2018) https://doi.org/10.1176/appi.ps.201700241	Level I RCT N = 110 M age = not reported Female = 58% (n = 64) Intervention group: n = 55–M age = 48.6 ± 9.9 yr.–Female = 51% (n = 28) Control group: M age = 42.7 ± 11.9 yr.–Female = 66% (n = 36) Inclusion criteria: latinos + SMI Country: US	Peer intervention: case management. Duration: 12 months Environment: community Control group: usual care	Baseline and at four, eight, and 12 months QLS Mental health recovery: Empowerment Scale RAS	RAS (F = 12.5, df = 3 and 286, p,.01)) Empowerment Scale (F = 2.9, df = 3 and 318, p,.05) QLS (F = 3.3, df = 3 and 311, p,.05)
4	(Druss et al., 2018) https://doi.org/10.1176/appi.ps.201700352	Level I RCT N = 400 M age = not reported Female = 63% (n = 255) Intervention group: n = 198–M age = 49.74 ± 8.72 yr.–Female = 67% (n = 132) Control group: n = 202–M age = 49.69 ± 9.51 yr.–Female = 61% (n = 123) Inclusion criteria: SMI + comorbidity Country: US	Peer intervention: Education program Environment: community Control: usual care	Baseline, 3-month and 6- month follow-up. SF-36: physical component summary (PCS) and mental component summary Medical self-management: PAM Medication adherence: MMAS Block Fat-Sugar-Fruit-Vegetable Screener Mental health recovery RAS	Physical Component Summary (p = 0.046) and Mental Component Summary (p = 0.039) of the SF-36. Mental Health recovery (p = 0.02)
5	(Jewell, Falzer, Davidson, Rowe, & Sells, 2006) https://doi.org/10.1176/ps.2006.57.8.1179	RCT N = 137 M age = 41 ± 9 yr. Female = 38.68% (n = 53) Intervention group: n = 68 Control group: n = 69 Inclusion criteria: SMI + substance use disorder Country: US	Peer intervention: Case management Environment: community Control: usual care	Baseline − 6 months − 12 months Relationship: BLRI Addiction: ASI	BLRI at 6 months: Positive regard (p < 0.05)–Unconditionality (p < 0.05) BLRI at 12 months: Positive regard (p < 0.01) – Empathy (p < 0.04) – Unconditionality (p < 0.02)
6	(Johnson et al., 2018) https://doi.org/10.1016/S0140-6736(18)31470-3	Level I RCT N = 441 M age = 40 ± 12.5 yr. Female = 60% (n = 263) Intervention group: n = 221 – M age = 40 ± 13 yr.–Female= 60% (n = 132) Control group: n = 220–M age = 40 ± 12 yr.–Female = 60% (n = 131) Inclusion criteria: SMI Country: UK	Peer intervention: education program Environment: community Remuneration: not reported Control group: usual care	Baseline, 4 months, 18 months follow-up Symptom severity: BPRS IMRS Loneliness Scale Lubben Social Network Scale Client Satisfaction Questionnaire readmission of participants to an acute service Mental health recovery: Questionnaire on the Process of Recovery	Satisfaction with mental health services at 4 months (p < 0.001)
7	(Kelly et al., 2017) https://doi.org/10.1016/j.schres.2016.10.031	Level I RCT N=151 M age= 45.63 ± 10.95 yr. Female = 53.6% (n = 81) Intervention group: n = 76 – M age = 44.80 ± 11.30 yr. – Female = 46.1% (n = 35) Control group: n = 75–M age = 46.47 ± 10.59 yr.–Female = 61.3% (n = 46) Inclusion criteria: SMI Country: US	Peer intervention: case management Duration: 6 months Environment: community Control: usual care	Baseline − 6 months − 12 months Pain: SF-12 Self-management attitudes and behaviors: Mental Health Confidence Scale Routine health screening Health service utilization Satisfaction with primary care provider: Engagement with the Healthcare Provider Scale	Significant difference in helth service utilization: (p < 0.05) Healthcare Provider Scale (p < 0.019) Improved detection of chronic health conditions (0.048) Reductions in pain (p < 0.031) Increased confidence in consumer self-management of healthcare (p < 0.009)
8	(Mahlke et al., 2017) https://doi.org/10.1016/j.eurpsy.2016.12.007	Level I RCT N = 216 M age = 41.48 ± 12.82 yr. Female = 57% (n = 124) Intervention group: n = 114–M age = 41.22 ± 12.32 yr.–Female = 56% (n = 65) Control group: n = 102–M age = 41.79 ± 13.43 yr.–Female = 58% (n = 59) Inclusion criteria: a primary diagnosis of SMI Country: Germany	Peer intervention: case management Duration: 12 months Environment: community Control intervention: usual care	Baseline, 6 and 12-month follow-up GSE EuroQol Questionnaire EQ5D Clinical Global Impression scale GSE number of days spent in hospital GAF	EQ5D, (95% CI: 0.82–358 10.49, p = 0.04).
9	(Muralidharan et al., 2019) https://doi.org/10.1176/appi.ps.201800162	Level I RCT N=242 M age=57.8 ± 7.7 yr. Intervention group: n = 124–M age = 58.5 ± 7.6 yr.–Female = 14% Control group: n = 118–M age = 57.0 ± 7.8 yr.–Female = 13% Inclusion criteria: SMI + comorbidity Country: US	Peer intervention: education program Duration: 3 months Environment: community Control intervention: usual care	Baseline, posttreatment, and 3 months follow-up SF-12 BASIS-24 Self-Management Self-Efficacy scale PAM MHLCS IMSM MMAS Recovery mental health: MARS	SF-12 (t = 2.15, p=.032) Self-management Self-Efficacy Scale (t = 4.10, p,0.001) PAM (t = 2.08, p = 0.038) MHLCS (t = 2.01, p = 0.045) BASIS-24 (t=–2.02, p = 0.044); IMSM–physical activity–(t = 2.55, p = 0.011) IMSM -relationship quality- (t = 22.45, p = 0.015)
10	(Resnick & Rosenheck, 2010) https://doi.org/10.2975/33.4.2010.262.268	Level I RCT N = 218 M age = 48.7+/−8.9 yr. Female = 5.4% (n = 12) Intervention group: n = 108 – M age = 48.9+/−8.5 yr. – Female = 8.3% (n = 9) Control group: n = 110/–M age: 48.4+/−9,3 yr. – Female = 2.7% (n = 3) Inclusion criteria: SMI + participation in CRP Country: US	Peer intervention: education program Duration: 9 months Environment: community Control: usual care	Using multiple regression analysis, baseline variables were examined as predictors of attendance in Vet-to-Vet over the 9-month study period Employment General life satisfaction Functioning: GAF Activities of Daily Living Scale money spent on drugs or alcohol in the prior 30 days BPRS Recovery of mental health: recovery attitudes confidence feelings of mastery over mental illness General empowerment	The study identified significant correlations between baseline variables and a continuous measure of program attendance: Activities of daily living (r=-0.21, p = 0.03) Recovery orientation (r=-0.20, p = 0.03) General empowerment (r=-0.20, p = 0.04) Attendance at CRP at the one-month interview (r = 0.25, p = 0.01), Number of meetings attended prior to study entry (r = 0.30, p = 0.002)
11	(Rogers et al., 2016) https://doi.org/10.1037/prj0000208	Level I RCT N=113 M age = not reported Female = 55% (n = 63) Intervention group: n = 63–M age: 38.7 ± 13 yr.–Female: 53.97% (n = 34) Control group: n = 50–M age:40.9 ± 12 yr.–Female: 58% (n = 29) Inclusion criteria: SMI Country: US	Peer intervention: case management Duration: 6 months Environment: community Control group: intervention by inviting each participant to partake of all services offered by the peer-run agency	Baseline, 3-month and 6- month follow-up. BQOL ISEL BASIS-24 Recovery mental health: RAS	BQOL (p < 0.05) BASIS-24 (p < 0.05)
12	(Rowe et al., 2007) https://doi.org/10.1176/ps.2007.58.7.955	Level I RCT N = 114 M age = 39.8 ± 8.8 yr. Female = 32% (n = 36) Intervention group: n = 73 Control group: n = 41 Inclusion criteria: SMI + criminal charges Country: US	Peer intervention: case management – education program Duration: 12 months Environment: community Control: standard services	Three interviews (baseline, six months, and 12 months). Criminal justice data Addiction: ASI	Low levels of alcohol consumption at (p < 0.005) Decreased nonalcohol drug use (p < 0.05) Reduced criminal justice charges (p < 0.05)
13	(Sledge et al., 2011) https://10.1176/ps.62.5.pss6205_0541	Level I RCT N=74 M age= Female = 48.64% (n = 36) Intervention group: n = 38–M age = 42.16 ± 12.0 yr. – Female = 55% Control group: n = 36 – M age = 38.06 ± 9.3 yr – Female = 42% Inclusion criteria: SMI + rehospitalitations Country: US	Peer intervention: case management Duration: 9 months Environment: community Control intervention: usual care	Number of hospitalizations and hospital days during the nine-month study period Number of hospitalizations Hospital days	Fewer rehospitalizations (p = 0.042) fewer hospital days (p < 0.03)
14	(van Gestel-Timmermans, Brouwers, van Assen, & van Nieuwenhuizen, 2012) https://doi.org/10.1176/appi.ps.201000450	Level I RCT N = 333 M age = not reported Female = 66.07% (n = 271) Intervention group: n = 168–age: 43 ± 11 yr. – women: 68% Control group: n = 165 – age: 44 ± 10 yr. – women: 64% Inclusion criteria: SMI + rehospitalitations. Country: The Netherlands	Peer intervention. education program Duration: 12 sessions Environment: community Control group: Participants in the control group enrolled in the course at six months	Assessments took place at baseline, after three months (at the end of the course), and after six months. Employment Quality of life: MANSA Self-efficacy: MHCS BPRS Recovery mental health: HHI Dutch Empowerment Scale Loneliness Scale	Significant differences (positive results) on empowerment, hope, and self-efficacy beliefs (p < 0.01)
15	(Weissman, Covell, Kushner, Irwin, & Essock, 2005) https://doi.org/10.1007/s10597-005-5001-2	Level II Case control N = 32 M age= 48 ± 8 yr. 100% male Intervention group: n = 17 Control group: n = 15 Inclusion criteria: Homeless A + SMI Country: US	Peer intervention: case management Duration: 12 months Environment: community Control: usual case management	Interviewed participants at baseline, 4, 8, and 12 months: Employment Housing General life satisfaction Social Relationships Functioning: GAF Activities of Daily Living Scale Symptoms: HSCL-25 Addictions	without statistical significance
16	(Wrobleski et al., 2015) https://doi.org/10.1177/0008417414551784	Level 1 RCT N = 21 M age= 53.18 Woman= 85.71% (n = 18) Intervention group: n = 12; age: 56.18 Control group: n = 9; age: 48.65 Inclusion criteria: SMI Country: Canada	Peer intervention: training + case management Duration: 60 hr of classroom training and a 40-hr practicum Environment: community Control group: standard occupational therapy + 52 hr of MHW support	Quantitative pretest-posttest control group design and qualitative exit interviews Quality of Life Interview–Brief Version	General life satisfaction (p = 0.003) Satisfaction with finances (p = 0.004) Daily activities (p = 0.05)
17	(Yamaguchi et al., 2017) https://doi.org/10.1176/appi.ps.201600544	Level I RCT N=56 M age = not reported Woman = not reported Intervention group: n = 26 Control group: n = 27 Inclusion criteria: SMI Country: Japan	Peer intervention: case management Duration: 6 months Environment: psychiatric hospitalization Control group: usual care	Baseline and 6- month follow-up WHO-QOL26 DIEPSS BPRS Japanese version of PAM MMAS IPC STAR SDM-18 CSQ-8J GAF Mental health recovery: SISR	SDM-18 (p= <0.001) IPC (p= <0.01) DIEPSS (p < 0.02) STAR-patient (p < 0.02)

SMI: severe mental illness; GAF: global assessment functioning; HSCL-25 = Hopkins symptom checklist; PSW: peer supporter worker; ASI = addiction severity index; CRP = community reintegration program; BPRS: brief psychiatric rating scale; MANSA: Manchester short assessment; HHI: health hope index; MHCS: mental health confidence scale; BSI: brief symptom inventory; SHS: state hope scale; BLRI: barret-lennard relationship inventory; HARP: health and recovery peer; SF-36 = short-form health survey -36; PAM: patient activation measure; RAS: recovery assessment scale; BQOL: brief quality of life; BASIS-24 = behavior and symptom identification scale; ISEL: interpersonal support evaluations list; WHO-QOL26; world health organization quality of live; DIEPSS = drug-induced extrapyramidal symptom scale; MMAS; morisky medication adherence; IPC: interpersonal process of care; DIEPSS: Drug-Induced Extra-pyramidal Symptom Scale; STAR: scale to assess therapeutic relationship; SDM-18 = shared decision-making-18; CSQ-8J; client satisfaction questionnaire-8 japanese version; SISR: self-identified stage of recovery; QLS: quality of life scale; QOLI: quality of life instrument; MHRM: mental health recovery measure; IMR: illness management and recovery; MHC: mental health confidence; GSE: general self-efficacy; EQ5D: euroQol questionnaire; SF-12 = short form health survey-12; MHLCS: multidimensional health locus of control scale; IMSM: instrument to measure self-management; MARS: Maryland assessment of recovery scale; MHW = mental health worker.

Table 2. Risk-of-Bias Table.

Citation	Selection bias			Blinding of participants and personnel (performance bias)		Blinding of outcome assessment (detection bias)		Incomplete outcome data (attrition bias)	Selective reporting (reporting bias)
	Random sequence generation	Allocation concealment	Baseline difference between intervention group	Blinding of participants during the trial	Blinding of personnel during the trial	Patient-reported outcomes	Objective outcomes
(Chinman et al., 2015)	+	+	+	−	−	+	+	+	+
(Cook et al., 2012)	+	+	+	−	−	+	+	?	+
(Corrigan et al., 2018)	+	+	+	−	−	?	?	+	+
(Druss et al., 2018)	+	+	+	−	−	+	+	+	+
(Jewell et al., 2006)	+	?	+	−	−	?	?	?	+
(Johnson et al., 2018)	+	+	+	−	−	+	+	+	+
(Kelly et al., 2017)	+	+	+	−	−	?	?	?	+
(Mahlke et al., 2017)	+	+	+	−	−	+	+	?	+
(Muralidharan et al., 2019)	+	?	+	−	−	?	?	+	+
(Resnick & Rosenheck, 2010)	+	?	+	−	−	+	+	+	+
(Rogers et al., 2016)	+	?	+	−	−	?	?	+	+
(Rowe et al., 2007)	+	?	+	−	−	+	+	+	+
(Sledge et al., 2011)	+	?	+	−	−	+	+	?	−
(van Gestel-Timmermans et al., 2012)	+	+	+	−	−	?	?	−	+
(Weissmanet al., 2005)	+	?	+	−	−	?	?	+	−
(Wrobleski et al., 2014)	+	?	+	−	−	?	?	+	+
(Yamaguchi et al., 2017)	+	?	+	−	−	?	?	?	+

Note. Categories for risk of bias are as follows: Low risk of bias (+), unclear risk of bias (?), high risk of bias (–). Scoring for overall risk of bias assessment is as follows: 0–3 minuses, low risk of bias (L); 4–6 minuses, moderate risk of bias (M); 7–9 minuses, high risk of bias (H).

Citation. Table format adapted from Higgins, J. P. T., Sterne, J. A. C., Savović, J., Page, M. J., Hróbjartsson, A., Boutron, I., … Eldridge, S. (2016). A revised tool for assessing risk of bias in randomized trials. Cochrane Database of Systematic Reviews 2016, Issue 10 (Suppl. 1), 29–31. https://doi.org//10.1002/14651858.CD201601.

Table 3. Outcome Measures with Statistical Value Grouped by Outcome Domains According to Occupational Therapy Practice Framework Outcome Domains.

	Occupational performance	Prevention	Health and wellness	Quality of life	Occupational justice	N
Chinman et al., 2015			BASIS-R	PAM	MHRM	3
Cook et al., 2012				SHS	RAS	2
Corrigan et al., 2017				QLS	Empowerment Scale; RAS	3
Druss et al., 2018				SF-36	RAS	2
Jewell et al., 2006				BLRI		1
Johnson et al., 2018	Client satisfaction					1
Kelly et al., 2017	Healthcare Provider Scale	Access primary care health services; emergency care		SF-12		4
Mahlke et al., 2017				EQ5D		1
Muralidharan et al., 2019			BASIS-24	PAM; SF-12; Self-management Self-Efficacy Scale; MHLCS		5
Resnick & Rosenheck, 2010	Activities of Daily Living Scale				Empowerment; Recovery Attitude Scale	3
Rogers et al., 2016			BASIS-24	BQOL		2
Rowe et al., 2007		Criminal justice charge	ASI			2
Sledge et al., 2011		Rehospitalizations; hospital days				2
van Gestel-Timmermans et al., 2012				HHI	Dutch Empowerment Scale	2
Weissman et al., 2005						0
Wrobleski et al., 2015				Quality of Life Interview–Brief Version		1
Yamaguchi et al., 2017	SDM-18; IPC; STAR-patient		DIEPSS			4
Total	6	5	5	14	8	38

BLRI: Barret-Lennard Relationship Inventory; SF-36: Short-Form Health Survey-36; PAM: Patient Activation Measure; RAS: Recovery Assessment Scale; BQOL: Brief Quality Of Life; BASIS-24: Behavior And Symptom Identification Scale; DIEPSS: Drug-Induced Extrapyramidal Symptom Scale; IPC: Interpersonal Process Of Care; STAR: Scale to Assess Therapeutic Relationship; SDM-18: Shared Decision-Making-18; QLS: Quality of Life Scale; QOLI: Quality of Life Instrument; MHRM: Mental Health Recovery Measure; EQ5D: Euroqol Questionnaire; SF-12: Short Form Health Survey-12; MHLCS: Multidimensional Health Locus of Control Scale; IMSM: Instrument to Measure Self-Management; HHI: Health Hope Index; MHRM: Mental Health Recovery Measure.

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