Serious mental illness (SMI) is the second most costly medical disorder treated in the VHA. Despite these expenditures, clinical outcomes for these patients are often poor due to a combination of low quality care and severe cognitive and functional impairments. While these problems are multifaceted, studies outside the VHA have shown that the use of different types of peer support-those with SMI in recovery providing assistance and role modeling to others with SMI-can often improve and augment public care. This is because peer support addresses factors that contribute to poor outcomes at the patient level (reduce social isolation; facilitate patient involvement in community-based services and supports) and at the system level (increase patient access; move services toward recovery orientation). Thus, while there exists many empirical studies, a thorough and concise systematic review of peer support is a critical first step in understanding more fully both its history and its future promise for the VHA. The importance of such a review is highlighted by peer support's inclusion in the VHA Mental Health Strategic Plan ("Recommendation 2.3.. Develop Peer Support Program as an adjunct to mental health services..").
To conduct a thorough evidence-based review of peer support to determine which types ought to be disseminated broadly in the VHA.
Peer support lacks a precise definition and its literature is published in a range of disciplines, journals, and formats. Thus, we will first conduct a conference call with 4-5 national experts to collaboratively decide the fundamental question "what constitutes peer support" and to help narrow the databases, key terms, and domains to include in our search. The national experts will be those who have either conducted peer support research or implemented peer support programs from both within and outside of the VHA. We will also include VHA sys-tem policymakers to ensure coordination with VHA Leadership and Field.
We will search diverse databases such as Medline, HealthSTAR, EMBASE, PSYCHLIT, MANTIS, SciSearch, Social SciSearch, Social Science Abstracts, Soci-ology Abstracts, Current Contents, Allied and Complementary Medicine, the Current Index to Statistics, and the Methodology Register of the Cochrane Library, among others. Unpublished or "grey literature" such as conference abstracts, reports from foundations and government agencies, or relevant dissertations will be identified with the help of the national experts, as well as through the Cochrane registry of clinical trials, the International Register of Trials, and the Health Care Quality Improvement Projects database. Then based on the conference call of national experts, we will create a one-page screening form of inclusion/exclusion criteria to determine whether the initial pool of studies identified meet the consensus definition of peer support. At a second more detailed stage of screening, we will apply other inclusion criteria based on such dimensions as study design, area of the study, or outcomes measured.
Criteria such as the Evidence Pyramid are commonly used to assess the quality of evidence in conventional, often randomized, controlled trials (RCTs). However, a review of peer support will necessarily include non-RCT data and will be quite dependent on descriptive, observational and qualitative studies. Also, given the high degree of heterogeneity in the peer support literature, standard meta-analytic aproaches will not be as useful and more creative approaches will be required. An alternative approach we will use here is to present the studies in a common format-an "evidence table"-that displays essential dimensions to facilitate cross study comparisons. The table is a matrix, with rows representing individual studies, and columns containing domains such as study de-sign and participant attrition rates; a description of the study population; the community setting and participants; a description of the intervention; and specific outcome measures. There will also be an emphasis on implementation issues as described in these studies to build an understanding of how to implement peer support, in addition to assessing its efficacy. Although no statistical inference will be drawn, a systematic review and presentation of the literature would be a major contribution. The final product will be a report containing the evidence table, study summaries, and recommendations to inform policy-makers and clinical managers about alternatives as they make decisions regarding implementation of peer support.
This is a new project and results have not yet been obtained.
In order to improve outcomes for veterans with SMI, VHA mental health services are being encouraged to become more recovery-oriented and peer support is a key component to that transition. However, guidance is needed about what types of peer support are most effective and would be best suited for veterans. As VISNs begin to enact the peer support components of the Strategic Plan, this report will provide managers with the information they need to choose the most appropriate peer support intervention to help align their services with the recovery model. Using the MIRECC's education unit, we will work with Mental Health QUERI to disseminate the evidence report, including presenting it to Central Office for use in setting national priorities and to individual facilities to support local program development.
None at this time.
Mental, Cognitive and Behavioral Disorders
Treatment - Observational