By Marvin Ross
Peer support is considered the flavour of the month in treating those with mental illness yet the research on its efficacy is negative. In an era where evidence based medicine is supposed to dictate what should be best practices in the care and treatment of patients, this is very out of character and concerning.
In 2019, the Cochrane Review conducted an evaluation of peer support but was unable to demonstrate its value. For those unfamiliar with Cochrane it is “a systematic review (that) attempts to identify, appraise and synthesize all the empirical evidence that meets pre-specified eligibility criteria to answer a specific research question. Researchers conducting systematic reviews use explicit, systematic methods that are selected with a view aimed at minimizing bias, to produce more reliable findings to inform decision making.”
In that review, they looked at 13 studies that compared peer review plus standard care to just standard care. Those studies involved close to 2500 people. The reviewers had serious concerns about the biases of many of the studies and particularly with the blinding. In any study, the researchers should not know which participants are in which group. It should be blind to them to ensure total objectivity rather than any hint of possible bias. They stated that they had “concerns regarding blinding of participants and outcome assessment, attrition and selective reporting (which) were especially serious, as about a quarter of the included studies were at high risk of bias for these domains.”
What they found was that peer support made no difference on hospital admissions or that “there were
- no useable data for our other prespecified important outcomes:
- days in hospital,
- clinically important change in global state (improvement),
- clinically important change in quality of life for peer supporter and service user, or
- increased cost to society.”
The latest meta-analysis of peer support was just published in Psychiatric Services in February by a group of Danish researchers. What was interesting about that study was that they differentiated between personal recovery and clinical recovery. Personal recovery is “a way of living satisfying, hopeful, and reciprocal lives, together with others even though we may still experience distress…” We learn to make do with what we’ve got and get on with life as best we can. Clinical recovery is the reduction of symptoms and functional improvements
This research included 49 random control trials and 12,477 subjects but most had a high risk for bias. Only one of the studies could be classified as good. Peer support did have a small improvement for personal recovery and reduction of anxiety but nothing else. There were no clinical improvements which are not surprising.
The authors concluded that before we can “recommend implementation of peer support in specific health care settings, co-created high quality trials measuring the effectiveness, including potential adverse effects, and the cost-effectiveness of the intervention are needed.”
These findings are consistent with what the blog The Mental Elf found in 2014 in reporting on a meta-analysis of peer support for those with serious mental illness. The conclusion in that study was that the impact was negligible but where there was an effect, the quality of the study was poor.
Repeated meta-analyses continue to fail proving the efficacy of peer support but peer support continues to expand and be promoted which I fail to understand. Health professionals base what they do on the concept of evidence and their use of evidence based medicine (EBM). The definition of that is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.The aim of EBM is to integrate the experience of the clinician, the values of the patient, and the best available scientific information to guide decision-making about clinical management.”
The studies presented above fail to do that. As the Mental Elf stated, any intervention must be:
Acceptable: to the people it is aimed at
Feasible: that it is possible to implement, realistic and achievable
Generalisable: it can work with similar populations in different geographical areas or settings
Clinically effective: has a positive impact on service user outcomes
Cost Effective: there is a return on investment
Equity of access: it’s available to all those who could benefit from it
Peer support has not been proven to do any of that so why is it pushed and why are we wasting scarce dollars to have it.