Intervention Review

You have free access to this content

Consumer-providers of care for adult clients of statutory mental health services

  1. Veronica Pitt1,
  2. Dianne Lowe2,*,
  3. Sophie Hill3,
  4. Megan Prictor4,
  5. Sarah E Hetrick5,
  6. Rebecca Ryan3,
  7. Lynda Berends6

Editorial Group: Cochrane Consumers and Communication Group

Published Online: 28 MAR 2013

Assessed as up-to-date: 14 MAR 2012

DOI: 10.1002/14651858.CD004807.pub2


How to Cite

Pitt V, Lowe D, Hill S, Prictor M, Hetrick SE, Ryan R, Berends L. Consumer-providers of care for adult clients of statutory mental health services. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD004807. DOI: 10.1002/14651858.CD004807.pub2.

Author Information

  1. 1

    National Trauma Research Institute, The Alfred Hospital, Monash University, Melbourne, Victoria, Australia

  2. 2

    Australian Institute for Primary Care & Ageing, La Trobe University, Centre for Health Communication and Participation, Bundoora, VIC, Australia

  3. 3

    La Trobe University, Centre for Health Communication and Participation, Australian Institute for Primary Care & Ageing, Bundoora, VIC, Australia

  4. 4

    Australian Institute for Primary Care & Ageing, La Trobe University, Cochrane Consumers and Communication Review Group, Bundoora, VIC, Australia

  5. 5

    University of Melbourne, Orygen Youth Health Research Centre, Centre for Youth Mental Health, Melbourne, Victoria, Australia

  6. 6

    Turning Point Alcohol & Drug Centre, Fitzroy, VIC, Australia

*Dianne Lowe, Centre for Health Communication and Participation, Australian Institute for Primary Care & Ageing, La Trobe University, Bundoora, VIC, 3086, Australia. d.lowe@latrobe.edu.au.

Publication History

  1. Publication Status: New
  2. Published Online: 28 MAR 2013

SEARCH

 
Characteristics of included studies [ordered by study ID]
Bright 1999

MethodsRCT

Setting: Fee for service outpatient clinic, University of Memphis Department of Psychology, Memphis (TN), USA.

Funding: Not reported.

Recruitment (Clients): media advertisements, those eligible were added to clinic caseload as regular fee for service outpatients, with partial fee reimbursement for those who attended weekly sessions. Met inclusions: 146/400; of these 23 were excluded and 25 refused to take part (no reasons reported).

Recruitment (consumer-providers): Recruited from self-help groups in which they had participated or led.

Training/support: Both consumer-providers and professionals received 2-day training, using protocol and treatment manuals for cognitive behavioural therapy (CBT) and mutual support group therapy (MSG). Modules were: common interventions, cognitive behavioural techniques, and mutual support group methods. Therapists were paired with an opposite gender co-therapist with similar availability. Professionals were paired together as were consumer-providers. Further training/supervision was provided if therapists failed to adhere to the protocol (see 'fidelity' in Interventions section below).

Inclusion criteria (Clients): Age between 18-60 years, not currently in therapy, not currently on medication for mood disorders, no current drug or alcohol problems, minimum eighth-grade education, ability to read and complete pretreatment assessment questionnaire, score ten or higher on Hamilton Rating Scale for Depression, Structured Clinical Interview DSM-III-R Non-Patient Edition (SCID-NP) criteria for current episode of definite major depressive disorder, dysthymia, or depression not otherwise specified.

Exclusions (Clients): Diagnosis of bipolar disorder, alcoholism, drug abuse or dependence, organic brain syndrome, history of schizophrenia, depression with psychotic features, or mental retardation, receiving concurrent treatment, experiencing current active suicidal potential, or experiencing other need for immediate treatment.


ParticipantsClients: 98 participants (28.6% male). Mean age 45.8 (SD not reported). Range 21-72 years.

Principal mental health problem/diagnosis: Moderate to severe depressive symptoms.

Treatment currently receiving: None (participants were excluded if they were receiving concurrent treatment).

Description consumer-providers: Half of the consumer-providers (3 of 6) had led community-based self-help groups; and half of the professionals (4 of 8) had led self-help groups. All of the consumer-providers had participated in community-based self-help groups. Consumer-providers' average age was 36 years (28 years for the professional therapists). Diagnosis of consumer-providers: not reported.


InterventionsStudy aim: To assess the relative efficacy of professional and consumer-provider therapists in providing group CBT and MSG.

Intervention aim: To reduce clients' symptoms of depression and improve mood. Trialists hypothesised that clients in the professionally-led CBT group would demonstrate better skill acquisition in monitoring and modifying dysfunctional thoughts compared with clients in the consumer-led CBT group; and that clients in the consumer-provider MSG group would show greater self-disclosure than those in the professionally-led MSG group.

Role of consumer-providers: Involvement as therapists delivering CBT or MSG interventions.

Intervention (MSG): (n = 22) MSG therapy led by two paraprofessional consumer-providers (male and female) . Sessions involved informal exchanges of information between individuals faced with the same difficulties.

Intervention (CBT): (n = 21) CBT led by two paraprofessional consumer-providers (male and female). Sessions were based on Feeling Good Seminar Series 1 with accompanying participant workbook, The Feeling Good Handbook.

Control (CBT): (n = 27) CBT provided by two professional therapists (male and female).

Control (MSG): (n = 29) MSG led by two professional therapists (male and female).

Delivery: Ten weekly 90-minute sessions. Each pair of co-therapists (consumer-providers and professionals) conducted an MSG and CBT group concurrently.

Fidelity: Therapist sessions were supervised once weekly, and all therapy sessions were audio-taped and observed by trained raters. If the therapist failed to accomplish any of the four general objectives for the intended condition or if they included any of the four general objectives from the other treatment conditions, further training/supervision was provided.

Consumer involvement outside of the intervention: None.

Changes in trial protocol: Unclear.


OutcomesAssessments were conducted at baseline (pretreatment), weekly during the treatment phase, posttreatment (10 weeks), and 6 months follow up.

Hamilton Rating Score for Depression (HRSD)

Beck Depression Inventory (BDI)

Automatic Thoughts Questionnaire (ATQ)

Hopkins Symptoms Checklist-58 (HSCL-58)

Out-of-session practice: average time spent working on personal issues (MSG) or homework assignments (CBT) between sessions.

Therapy Compliance Checklist: observers rated therapy teams on four general objectives specific to CBT and four objectives specific to MSG. Each was rated as not present (0), subthreshold (+/-1), or present (+/-2), with positive indicating a match and negative indicating a mismatch between treatment intended and treatment delivered. Possible scores -8 to 8, higher scores better.


NotesFour-arm trial involved two relevant comparisons; 1) consumer-provider led CBT vs professional led CBT and 2) consumer-provider led MSG vs professional led MSG. Each comparison has been analysed separately. Direction of benefit was reversed for analysis of HSCL-58 and HRSD outcome data.

Power Calculation: Trialists estimated that N = 96 on the basis of an assumed attrition rate of 20%, a significance level of 0.05, power of 0.80 and an estimated moderate effect size of 0.30.

Thirty clients terminated therapy before completing 7 sessions and the analysed outcome data for BDI, HSRD, HSCL-58, and ATQ included only the 68 participants who attended at least 7 sessions and returned for the "posttest assessment". In some cases it may have been possible to collect and include posttest data from clients who attended less than 7 sessions and this may have been inappropriately excluded from the primary analysis. It is unclear what effect omission of data pertaining to these individuals would have on the outcomes.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk"patients were blocked for gender and BDI score and were randomly assigned either to CBT or MSG"

"Therapists negotiated among themselves on their practical availability to conduct a group at a given time...With these leaders then in place, group members were randomised to condition." (author communication)

Allocation concealment (selection bias)Unclear riskNo information provided.

Blinding (performance bias and detection bias)
Self-reported outcomes
High risk"...clients were informed that they would be randomly assigned to the professional/paraprofessional and CBT/MSG conditions" (author communication)

All outcomes involved participant responses who were not blinded to group assignments.

Blinding (performance bias and detection bias)
All other outcomes
Low risk"...outcome assessment was conducted by clinicians not involved in the trial who were blind to treatment assignment" (author communication) [However all outcomes were by self-report].

Incomplete outcome data (attrition bias)
up to 6 months
High risk"Thirty clients terminated therapy before completing seven sessions...We analysed outcome data from the BDI, the HSRD, the HSCL-58, and the ATQ for the 68 participants who attended at least seven therapy sessions and returned for the posttest assessment"

It is likely that in some cases it could have been possible to collect and include posttest data from clients that attended less than seven sessions and this may have been inappropriately excluded from the primary analysis.

Selective reporting (reporting bias)High riskSix month follow up data not reported.

Groups comparable at baseline?Low risk"...there were no pre-treatment differences in the professional/paraprofessional groups" (author communication)

No contamination between treatment groups?Low riskTherapy compliance was assessed to ensure the integrity of the intervention was maintained by the different group leaders across the separate treatment groups and it is unlikely there was any crossover of group leaders or participants attending a different session than the one they were assigned to.

Clarke 2000

MethodsRCT

Setting: Community-based mental health services in Portland (OR), USA in conjunction with consumer run drop in centre and subsequently case management services Mind Empowered Inc. (MEI), an assertive case management/supported housing program. MEI was entirely consumer operated and over 80% of the Board of Directors were consumers. MEI was the site for both the consumer-provider and non-consumer teams.

Funding: Center for Mental Health Services.

Recruitment (Clients): Clients being discharged from state and local hospitals or transferring to new service providers in the community were recruited by county mental health workers. Direct referrals from mental health agencies were also accepted. Research staff screened clients for eligibility. 180/189 met the inclusion criteria, two participants declined (no reasons reported).

Recruitment (Consumer-provider): Recruitment details not provided.

Training/support: Intensive training on the assertive community treatment (ACT) model provided to staff from both teams at the beginning of the study, and throughout the next several years.

Inclusion criteria: Adults in the Portland metropolitan area who met the Oregon definition of chronically mentally ill and priority 1 criteria. All had to be 18 years with a severe mental disorder as identified by a psychiatrist, a licensed clinical psychologist or a certified non medical examiner, and having a documented history of persistent psychotic symptoms (not caused by substance abuse), as well as impaired role functioning in two of three areas (social role, daily living skills, and social acceptability).

Exclusions: Mental retardation.


ParticipantsClients: 178 participants (60.7% male). Mean age 36.5 (SD 10.3).

Principal mental health problem/diagnosis: Schizophrenia (59.5%).

Other characteristics: Substance abuse (33,1%), homeless in past six months (30.7%), hospitalised in the last six months (60.7%), and at least one prior arrest (63.2%).

Treatment receiving: Not described.

Description consumer-providers: Self-identified mental health consumers with a DSM-III-R axis I diagnosis. Main diagnosis was bipolar disorder (n = 4, 50%), other diagnoses included major depression, schizoaffective disorder, or cyclothymia. Most held a Bachelor's degree.


InterventionsStudy aim: To examine time to first episode, and number of clients experiencing hospital use, incarceration, emergency room visits and homelessness in people randomised to ACT involving consumer-providers compared to ACT with professional staff or usual care.

Intervention aim: To decrease adverse outcomes such as episodes of hospital use, incarceration, ER visits and homelessness.

Trial duration: 3 years.

Role of consumer-provider: Case managers in ACT teams.

Both ACT teams shared a psychiatrist, nurse practitioner, and clinical director. Each team consisted of four full-time and one part-time case manager, including a team leader.

Intervention:(n = 57) Consumer-provider case managers in an ACT team. Average caseload was 4.6 clients per case manager.

Non-consumer ACT team: (n = 57) Professional case managers with no diagnosable mental illness. Most held a Masters degree. Average caseload was 5.4 clients per case manager.

Usual care: (n = 49) Participants received mental health services from agencies in the Portland metropolitan area.

Delivery: Clients in ACT groups frequently had three to five weekly contacts with their mental health providers.

Fidelity: Assessed with the Dartmouth ACT Fidelity Scale. Both ACT groups scored lower on all three scales compared with other states (Illinois and East Coast). Poor effectiveness may have been due to poor implementation based on lower fidelity.

Consumer involvement outside of the intervention: None.

Changes in trial protocol: None stated.


OutcomesInterviews conducted every 6 months up to 24 months post randomisation.

Case manager activity logs

Case manager time allocation

Location of services provided

Emergency room visits

Psychiatric hospitalisation


NotesData analysis involved comparison of the two ACT teams (Comparison 1) and did not include the usual care group.

Power calculation: Authors calculated sample sizes needed to detect significant effects for each major outcome. Sample size used was far too small to detect an effect for each outcome.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk"randomly assigned to one of three conditions"

Insufficient information provided to determine whether adequate sequence generation.

Allocation concealment (selection bias)Unclear riskNo information provided.

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskParticipants had to provide consent and were most likely aware of purpose of study.

Blinding (performance bias and detection bias)
All other outcomes
High riskProviders were aware of the different treatment being provided to participants.

Incomplete outcome data (attrition bias)
up to 6 months
Unclear riskFifteen participants were excluded from the analysis (11 never began assigned treatment, 3 engaged with non-study providers, and one subject had a developmental disability and was unable to complete the baseline interview). It is unclear whether missing data were balanced across treatment groups.

Incomplete outcome data (attrition bias)
post 6 months
Unclear riskFifteen participants were excluded from the analysis (11 never began assigned treatment, 3 engaged with non-study providers, and one subject had a developmental disability and was unable to complete the baseline interview). It is unclear whether missing data were balanced across treatment groups.

Selective reporting (reporting bias)Low riskData reported for all quantitative outcomes.

Groups comparable at baseline?Low risk"No significant baseline differences were found between study conditions on demographic or clinical characteristics"

No contamination between treatment groups?High risk"While none of the usual care CMHC's initially operated assertive outreach case management teams, over the study period some agencies adopted aspects of the ACT program"

Although located at separate locations, ACT teams involving consumer-providers or professionals only shared staff that participated in treatment planning and consultation across both groups.

Craig 2004

MethodsRCT

Setting: Assertive outreach team in inner London Borough (UK) that targets the most alienated and least engaged users across the sector providing outpatient services.

Funding: Not reported.

Recruitment (clients): Clients currently registered with assertive outreach teams were screened for eligibility. Ninety clients met inclusion criteria however the case management team prioritised 45 clients for initial allocation because of case load limits.

Recruitment (consumer-providers): No details provided.

Training/support: Originally 6 weeks training was provided to 3 part-time consumer-providers, however this was reduced substantially after unsuccessful retention of these consumer-providers. The revised training focused on the client's social care needs, and the consumer-provider role as client befrienders and advocates.

Inclusion criteria: Clients of assertive outreach team with severe mental illness and a history of poor engagement.

Exclusions: Clients of assertive outreach team that are well engaged with regular outpatient or depot clinic attendance, currently in prison, in the process of transfer to another team, or in long term hospital placements.


ParticipantsClients: 45 participants (66.7% male). Mean age 37.6 (SD 8.9), single (82%), live alone (56%).

Principal mental health diagnosis/problem: All participants were moderately symptomatic, with an average total BPRS score of 39.4 (range 25-64, higher scores worse) and suffered from chronic psychotic illnesses with paranoid schizophrenia the main diagnosis (87%).

Other diagnoses/problems: Significant drug or alcohol abuse (29%), history of violence (40%), or criminal record (9/45). Fourteen participants were hospitalised at least once in previous year for average 67 days, 11 of these admissions were involuntary.

Treatment currently receiving: Outpatient services.

Description consumer-providers: Two consumer-provider roles, both suffered severe mental illness and were unemployed for a number of years, but had previously held down jobs.


InterventionsStudy aim: To investigate the feasibility and impact of employing mental health services users as health care assistants (HCAs) within an assertive outreach team.

Intervention aim: To improve uptake and engagement with services, to decrease the number of unmet care needs, increase the size of the social network, and increase satisfaction with care.

Role of consumer-provider: Employed as full time HCAs (two positions), no other involvement in control of providing care, or development of program. Consumer-providers engaged with clients from the outset in a befriending social care and client advocate role.

Intervention: (n = 24) Assertive outreach team incorporating consumer-providers as HCAs. Consumer-providers reviewed welfare benefits and benefit uptake, encouraged attendance at clinic and vocational/social activities, led a recreational group at a church hall and helped clients with practical daily activities.

Control: (n = 21) Case management and assertive outreach team involving psychiatrists and case managers from a nursing background.

Duration: 12 months.

Fidelity: Not reported. Intervention content and delivery likely to be highly variable between clients (ie individualised care was one of the aims of the intervention). Training was provided to providers but it is not clear whether this aimed to standardise the delivery or content of the intervention.

Consumer involvement outside of the intervention: None.

Changes in trial protocol: Yes, original protocol recruited and trained three consumer-providers. None stayed with the program and two new consumer-providers were recruited and trained with a different emphasis on training and role.


OutcomesOutcomes assessed at baseline and 12 months follow up.

Life Skills Profile (LSP)

Significant Others Scale (SOS)

Camberwell Assessment of Need (CANSAS - staff version and client version)

Verona Service Satisfaction Scale (VSSS)

Service use


NotesPercentage values were used to estimate the number of people with events for dichotomous outcomes. Client assessment of unmet needs (CAN) was used as an outcome measure for client satisfaction (direction of benefit reversed so that higher scores are favourable). CAN staff assessment of unmet needs was used as an outcome measure for professional attitudes (ie staff assessment of client needs; direction of benefit reversed so that higher scores are favourable). Did not attend rates for clinic appointments are presented in analyses as use of mental health services (direction of benefit reversed so that higher scores indicate benefit).

Power calculation: Power calculation performed but not reported. Authors indicate that the study (pilot) was based on a sample size that was approximately half that suggested by the power calculation therefore the study was underpowered to detect significant differences between groups if they existed.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"...random number tables"

Allocation concealment (selection bias)Low risk"The case management team identified 45 clients for initial allocation and these were sequentially numbered and random number tables were used to allocate them"

"Participant allocation was carried out according to sequence allocation through a telephone call to an administrator who was independent of the clinical team and the research staff" (author communication)

Blinding (performance bias and detection bias)
Self-reported outcomes
High risk"All clients were told of the project, that allocation to meeting one of the HCAs was by randomisation"

Blinding (performance bias and detection bias)
All other outcomes
High risk"With the exception of attendance records, therefore, the major findings from the secondary outcome analysis are reliant on interviews with staff who were not blind to the intervention and had a vested interest in seeing it succeed"

Incomplete outcome data (attrition bias)
post 6 months
Low risk"12 participants either refused or provided incomplete baseline interviews and four of these also refused follow-up interview"

Attrition losses were balanced across treatment groups.

Selective reporting (reporting bias)Low riskProtocol not available. Data reported for all quantitative outcomes.

Groups comparable at baseline?Low risk"...intervention and comparison groups were well balanced with no substantial differences on any demographic variable at baseline"

No contamination between treatment groups?High risk"some of the clients in the standard care arm also attended the social occasions that the HCAs led"

Gordon 1979

MethodsRCT

Setting: Residential hospital in Florida, USA

Funding: Not reported.

Recruitment (clients): Recruited during last two weeks of nine-week residence at Florida Mental Health Institute; patients were involved in a previous study of a peer management peer-support program during their stay.

Recruitment (consumer-providers): Previous residential clients of Florida Mental Health Institute could apply to be Community Area Managers or a Network Director.

The consumer providers receive training and a Peer Counselling manual. The manuals provide instructions on solutions for such issues as employment, housing, recreation, patient crises and instability, and medical problems. Staff from the Community Network Development projects supervise and provide clinical back-up.

Inclusion criteria: Clients experiencing their first hospital admission or who had had less than four months' hospitalisation before the current hospitalisation for mental illness. No further details provided.

Exclusions: Not described.


ParticipantsClients: 80 clients (aged 18-45) recruited two weeks before discharge from a nine-week mental health early intervention program. No baseline data provided.

Principal mental health diagnosis/problem: Not provided.

Other diagnoses/problems: Not described.

Treatment currently receiving: Outpatient services.

Description consumer-providers: Former hospital inpatients, selected on the basis of overall emotional adjustment and motivation, and possession of a current driver's license, car and telephone. No further details provided.


InterventionsStudy aim: To assess the effectiveness of a Community Network Development (CND) program involving consumer-providers in reducing patient recidivism.

Intervention aim: To reduce rehospitalisation and community mental health service use.

Role of consumer-provider: to maintain contact with 20 to 50 local CND members; organise and lead weekly meetings; provide peer counseling' organise business or fund raising activities; assist group members in times of crisis; maintain positive attitude among group members.

Intervention: (n = not described) Prior to discharge, clients received support on transition to community life, including training on pre-employment skills, peer counseling, group leadership, and community living. After discharge, in addition to treatment as usual, clients were followed up by Community Area Managers staff who live locally (within 30 mins drive). Clients were encouraged to attend meetings which included a social activity (eg picnic, shopping etc). Support for transportation and social contact was encouraged between group members.

Control: (n = not described) Treatment as usual; traditional aftercare services with referring therapists or a local Community Mental Health Centre.

Duration: 10 months.

Fidelity: Not reported.

Consumer involvement outside of the intervention: None.

Changes in trial protocol: None described.


OutcomesOutcomes assessed at 10 months.

Rehospitalization.

Length of stay

Use of community mental health services


NotesNumbers randomised to each group were not specified. Therefore outcome data reported are unusable.

Paper published in Self-Help Reporter in March-April 1979 was not able to be obtained.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided.

Allocation concealment (selection bias)Unclear riskNo information provided.

Blinding (performance bias and detection bias)
All other outcomes
Unclear riskNo information provided on blinding of outcomes.

Incomplete outcome data (attrition bias)
post 6 months
Unclear riskData not provided in a usable format.

Selective reporting (reporting bias)Unclear riskAuthors provide data for outcomes, however, data are unusable as there is not information on numbers randomised to each group. It is also unclear if other outcomes were measured and not reported.

Groups comparable at baseline?Unclear riskNo baseline data provided.

No contamination between treatment groups?Unclear riskNo information provided.

Kaufmann 1995

MethodsRCT 

Setting: Community mental health centre (CHMC), Pittsburgh (PA), USA.

Funding: National Institute of Mental Health

Recruitment clients: Clients of urban community mental health centre who received treatment during a period of 27 months and met eligibility criteria were recruited to the study. Subjects were paid for completing research interviews. 823 participants met inclusion criteria, however 582 were excluded (they were either inpatients, enrolled in a partial hospital program that met at the same time as the self-help groups, or were already members of the self-help groups) and 151 refused to take part (2 after informed consent, 1 had incomplete data, and no reasons given for the remaining 148).

Recruitment consumer-providers: Not described.

Training/support: Investigators and staff at the self-help group and CMHCs collaborated together. All research contacts with self-help group members were made with the agreement of the membership of the self-help group and individual members could veto over researcher participation in the project. Vetoes involved excluding the recording of any activity at the drop-in centres, and limiting access to pre-arranged times. Biannual community Advisory Board meetings at the drop-in centres were conducted and researchers updated the Board on research project progress and members presented demonstrations and personal accounts of activities at self-help group meetings.

Inclusion criteria: Psychiatric diagnosis of schizophrenia, schizoaffective disorder or major mood disorder, normal intelligence, recent inpatient or outpatient psychiatric treatment.

Exclusions: Personality disorders.


ParticipantsClients: 90 participants (38.9% male). Mean age 42 (SD not reported), unemployed (87%), never married (51%).

Principal diagnosis: Schizophrenia (54.4%), schizoaffective disorder (13.3%), or major affective disorder (32.2%).

Treatment receiving: Inpatient or outpatient treatment at community mental health centres.

Description consumer-providers: Current and former psychiatric patients working at drop in centers operated under sponsorship of the community mental health centre.


InterventionsStudy aim: To test the effectiveness of self-help group on outcomes for people with severe and long-standing mental illness.

Intervention aim: To reduce symptoms in people with severe and long-standing mental illness.

Intervention: (n = 54) Participants referred to 1 of 3 self-help groups run by current and former psychiatric patients with a psychosocial rehabilitation clubhouse approach, in addition to usual care at the CMHC. A consumer outreach worker from the self-help groups also contacted experimental subjects, and offered to accompany them to their first group meeting. Group meetings occurred once a week at three community mental health sponsored and operated drop-in centres. The centres were not solely run by consumers, however they had at least one self-help group member in a paid staff position. Attendance at the drop in centre was voluntary.

Control: (n = 36) Participants not told about the self-help groups; encouraged to continue with their usual care at the community mental health centre.

Duration: Unclear, records at the self-help group were kept for 6 months.

Fidelity: Attendance at the drop in centre was voluntary. There was cross-over between groups (17% of both the treatment and control groups participated in self-help groups).

Consumer involvement outside of the intervention: Data collection. The research team provided a cash honorarium to those members who collected data for the research project.

Changes in trial protocol: Yes, post hoc design aimed at uncovering reasons for low participation in self-help activities in the study sample. Due to the overall low rates of participation, and the number of subjects who were cross-overs, the researchers decided to stop collecting follow-up outcome data and searched for factors in the sample's composition and the self-help group membership which might account for low participation.


OutcomesOutcomes assessed at baseline and six months.

Brief Psychiatric Rating Scale (BPRS)

Symptom Check List-90 (SCL-90)

Attendance


Notes9/54 experimental subjects (17%) participated in self-help group activities. 6/36 (17%) control subjects participated; hence there was no significant difference in participation rates between groups. Data were only reported comparing participators vs non-participators and did not compare the original randomised groups.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk"...randomly assigned"

Insufficient information provided to determine whether adequate sequence generation.

Allocation concealment (selection bias)Unclear riskNo information provided.

Blinding (performance bias and detection bias)
Self-reported outcomes
High risk"Subjects were told that they were volunteers in a study of self-help"

Participants not blind however, data assessors were not aware of group assignments.

Blinding (performance bias and detection bias)
All other outcomes
Unclear riskUnclear whether health professionals were blind to group assignments.

Incomplete outcome data (attrition bias)
up to 6 months
Low risk"Two subjects withdrew after initial consent, and one had incomplete data"

Selective reporting (reporting bias)High risk"...we stopped collecting follow up outcome data and searched for factors in the sample's composition and the self-help group membership which might account for low participation"

Data analysis compared participators to non-participators regardless of the groups they were assigned to by randomisation.

Groups comparable at baseline?Low risk"Analysis of baseline assessment data showed no statistically significant differences between experimental and control subjects"

No contamination between treatment groups?High risk"...there was no significant difference in rate of self-help group participation between experimental and control subjects"

Nine (17%) experimental subjects and six (17%) control subjects participated in self-help group activities.

O'Donnell 1999

MethodsRCT

Setting: Outpatient mental health services, Eastern Sydney Area Health Service (Australia).

Funding: Commonwealth Innovative Grants Program of the National Mental Health Strategy.

Recruitment clients: Inpatients or community health centre clients referred for case management were invited to participate. 530 clients met the inclusion criteria, 359 were excluded from participation, and 52 refused to take part (no reasons provided).

Recruitment consumer--providers: Recruited over a 14 month period through Eastern Area Mental Health. No other details reported.

Training/support: Consumer Consultants trained the consumer-providers and other advocates over a 3-day period on subjects including the Mental Health Act, patient rights, communication and listening skills, assertiveness, conflict resolution, and stress management. Mental Health staff provided training on the diagnosis and treatment of schizophrenia and bipolar disorder, psychosocial and family interventions, case management, rehabilitation, supportive accommodation services and other community resources. Advocates met individually with a Project Director monthly, and advocates met as a group once a month. After some time this was considered inadequate support, so phone debriefing was established with an experienced advocate.

Inclusion criteria: People aged 18-65 years, English-speaking, met DSM-IV criteria for schizophrenia, schizoaffective disorder, schizophreniform disorder or bipolar affective disorder, referred for case management by community health services within old Eastern Sydney Area Health Service.

Exclusions: Co-diagnosis of substance dependence disorder, current Community Treatment Order or Community Counselling Order, history of violence (unless associated with acute psychosis).


ParticipantsClients: 119 participants (57.1% male). Mean age 36 years (SD 9.8). Mean education 11.6 years. Predominately lived alone (39%), or with family (30%), and were supported by pension (72%), mean duration 80 months.

Principal mental health diagnosis/problem: Schizophrenia (66%); schizoaffective disorder (16%); schizophreniform disorder (6%); and bipolar (12%).

Stage of illness: Mean duration of illness was 117 months (SD 98.9, range 1-432), mean number of hospital admissions 6 (SD 6.4, range 1-30), and mean number of admissions per year 1 (SD 0.93, range 0-6).

Description consumer-providers: Six advocates and three reserve advocates were included that were either: 1) recovered individuals who had experienced mental illness themselves (consumer-providers); 2) siblings or carers of people who had experienced mental illness (secondary consumers); or 3) non-consumers who were interested in working with people with mental illness. During the project the focus changed to studying the effects of only primary consumers so advocates were replaced as positions opened with consumer-providers only.


InterventionsStudy aim: To redress the perceived hierarchical delivery of mental health services, in which the "service" has the authority and the client has little or none, with the services being imposed. The project aimed to empower the client by establishing parity between client and staff without legal imposition and involve clients in their rehabilitative process in a consensual manner that promoted respect, dignity and self-determination.

Intervention aim: To test if the delivery of client focused case management services compared with standard community practice would improve functioning, disability, quality of life, and service satisfaction for clients, as well as family burden of care outcomes. To test if consumer advocacy services in addition to client focused case management service delivery would improve outcomes, and whether clients who were more empowered by the use of client-focused approaches would be more satisfied and compliant with services received.

Role of consumer-provider: Employed as consumer advocates in case management teams, initially recruited to each work 3 hrs/week (based on Rozelle Hospital advocate program). Advocates were assigned 3-6 clients each for 12-month period.

Intervention: Client-focused case management (n = 45) plus consumer advocates (some consumer-providers). Consumer advocates provided self-advocacy for clients, encouraged client's self confidence, and were role models for clients during their recovery. They also communicated with case managers and participated in the development of recovery agreement meetings where requested by clients.

Control 1: Client-focused case management (n = 39). Case managers trained in the use of Rose's Advocacy Empowerment Model in clinical practice and familiar with solution-focused and narrative approaches to therapy. Involved customised recovery plans, with emphasis on client recovery goals. Recovery agreement meetings held between client, case manager, treating psychiatrist, family member or significant other, and sometimes consumer advocate to reinforce support for client achieving recovery goals.

Control 2: Standard case management (n = 35). Usual case management practices provided by existing community case managers.

Duration: 12 months.

Fidelity: Consumer advocacy and client participation was seemingly compromised as it was not possible to widely advertise or promote consumer advocacy or its potential benefits because the study was only open to clients in particular diagnostic categories. This meant consumer advocates had to explain their role and promote themselves to clients, and this reportedly had a disempowering effect on the advocates. Client-related illness (eg paranoid symptoms) also led to clients rejecting advocates before they could develop rapport.

Consumer involvement outside of the intervention: None.

Changes in trial protocol: Changed eligibility criteria from 55 to 65 years to increase potential participants. Siblings, carers or interested non-consumers, in addition to consumer-providers, were originally recruited as advocates but a post hoc decision meant that only consumer-providers were recruited to replace advocates that left during the project.


OutcomesOutcomes were assessed at baseline 6 months and 12 months.

Quality of Life Index for Mental Health (QOLIMH)

Health of the Nation Outcomes Scales (HoNOS)

Life Skills Profile (LSP)

Client Service Satisfaction Questionnaire (CSQ)

Service use


NotesData analysis involved comparison of the two client focused case management teams and did not include the usual care group (note that reported data in the article appears to be the client focused case management groups combined and compared to standard case management).

Power calculation: Not reported.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk"randomly assigned to one of three groups". Insufficient information to determine whether adequate sequence generation.

Allocation concealment (selection bias)Unclear riskNo information provided.

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskParticipants required to provide informed consent therefore unlikely to be blinded.

Blinding (performance bias and detection bias)
All other outcomes
Unclear riskUnclear whether outcome assessors were blinded.

Incomplete outcome data (attrition bias)
up to 6 months
Unclear riskSix month data not reported.

Incomplete outcome data (attrition bias)
post 6 months
Low riskLosses were unbalanced across treatment groups however reasons provided indicate this is an unlikely source of bias.

Selective reporting (reporting bias)High risk"Although subjects were also followed up at 6 months, the results for this stage will not be presented here as they add little to the study results"

Groups comparable at baseline?Low risk"...there were no significant differences between the three groups at baseline with respect to sociodemographic variables, illness factors or medication factors"

No contamination between treatment groups?Unclear riskIt is unclear whether any community peer support services were available to participants in the control groups.

Rivera 2007

MethodsRCT

Setting: Elmhurst Hospital Center, New York City (NYC), USA.

Funding: NYC Department of Health and Mental Hygiene, New York State Office of Mental Health, and the NYC Health and Hospitals Corporation.

Recruitment (clients): Research assistants recruited discharged inpatients with persistent and severe mental illness from inpatient units at a city hospital Jul 1997 - Dec 2000.

Recruitment (consumer-provider): Recruited from vocational training and peer advocacy programs, 369 /585 clients who met inclusion criteria consented to take part, 114 clients were excluded (mostly because they were discharged to alternative treatment settings), and 216 refused to take part (no reasons reported).

Training/support: Professional and consumer-provider intensive case management staff received similar orientation and training with additional elements to address their specific roles. Before working with clients, staff had 40 hours of training with competency testing. Staff also received 1 hr individual supervision and 1 hr group supervision, and 1.5 hours of training weekly for the duration of the project. Consumer-providers were supervised by a full-time and half-time social worker who met with them individually and in groups to solve problems and plan activities.

Inclusion criteria: Aged 18+ years, diagnosed psychotic or mood disorder on axis I, and two or more psychiatric hospitalizations in the previous 2 years.

Exclusions: None stated.


ParticipantsClients: 255 participants. Mean age 38.3 (SD 12.8). Never married (60%). Education 12.0 years (SD 3.0).

Principal mental health diagnosis/problem: Schizophrenia (29%), schizoaffective disorder (20%), bipolar (26%), depression (22%) or other psychotic disorder (3%).

Treatment receiving: Intensive case management or clinic care.

Description consumer-provider: Consumer-providers had history of multiple hospitalizations for mood or psychotic disorders, were eligible for disability benefits, relied on medication for stability and had between three to eight years of sobriety and stability in the community.


InterventionsStudy aim: To compare intensive case management involving consumer-providers or professionals with standard clinic-based care.

Intervention aim: To evaluate whether consumer-providers enhance case management outcomes through the provision of social support. Consumer-providers were expected to improve social networks for clients leading to positive changes in social function and quality of life.

Role of consumer-provider: Part of intensive case management team, responsible for developing social support and contribute to treatment planning case management meetings.

Intervention: (n = 70) Consumer-provider assisted strengths-based intensive case management which focused on client autonomy. Consumer-providers engaged clients in social activities and helped develop supportive social networks. They were guided by preferences of clients in planning activities which included home or community based one-on-one group social activities to help facilitate independent relationship building using natural community resources. They were instructed not to provide peer routine case management services. Consumer-providers also contributed to treatment planning and provided information about participants during weekly team meetings.

Standard care: (n = 66) Strengths-based intensive case management provided by 2 licensed clinical social workers. Individual care provided using natural community resources and backup from a team member. Caseloads limited to 20 participants. 24 hour telephone coverage. Participants encouraged to participate in cognitive-behavioural group therapy.

Clinic-based care: (n = 67) Doctoral-level psychologist and clinical social worker provided clinic-based services using a strengths-based approach. No 24-hour telephone coverage available.

Duration: 30 months.

Fidelity: No details reported.

Consumer involvement outside of the intervention: None.

Changes in trial protocol: None described.


OutcomesAssessments conducted at 6 and 12 months.

Lehman Quality of Life Inventory (QOLI)

Brief Symptom Inventory (BSI)

Pattison Network Inventory (PNI)

Behavioural Health Care Rating of Satisfaction (BHCRS)

Hours of activity with care providers

Hours of individual therapy

Hours of group therapy

Contacts with mobile crisis unit/case management

Days of hospitalisation

Outpatient clinic visits

Days of hospital treatment


NotesData collected from 1 to 6 months and 7 to 12 months were added together to give overall data for 12 months for health service use outcomes and hospital service use. The subjective social relations subscale of QOLI was used as the social outcome measure. Data analysis involved comparisons of the strengths based intensive case management teams involving consumer-providers and professionals and did not include the clinic based care group.

Power calculation: Trialists reported that approximately 150 participants divided among three groups would be needed to detect a moderate group effect with 80% power at the 0.05 alpha level. To detect treatment by time interactions of moderate size the same number of participants would yield 90% power at the 0.05 alpha level.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk"Participants were randomly assigned to one of the three treatment groups". No other information provided.

Allocation concealment (selection bias)Unclear riskNo information provided.

Blinding (performance bias and detection bias)
Self-reported outcomes
Unclear riskUnclear whether participants were aware of purpose of study.

Blinding (performance bias and detection bias)
All other outcomes
Low risk"Research assistants who were blind to the treatment assignments collected all interview data...Data were entered into a secure database by using unique identification numbers for participants"

Other outcomes probably blinded.

Incomplete outcome data (attrition bias)
up to 6 months
Low risk"...sample size was reduced from 255 to 203, mostly because some clients were discharged to long-term residential programs that would not allow enrolment in our clinic...Missing data contributed to small variations in sample sizes for the analyses"

Incomplete outcome data (attrition bias)
post 6 months
Low riskSame as above.

Selective reporting (reporting bias)Low riskAll outcome data reported.

Groups comparable at baseline?Low risk"There were no significant differences between treatment groups at baseline on the following variables: sex, race or ethnicity, age, education, marital status, and diagnosis"

No contamination between treatment groups?Unclear riskNo information provided.

Rogers 2007

MethodsRCT

Setting: 8 study sites in various states across the USA (3 in northeast, 1 on west coast, 2 in the south, and 2 in the Midwest). Experimental and control groups located at each site.

Funding: USA Department of Health and Human Services (DHHS), Substance Abuse and Mental Health Services Administration (SAM-HSA).

Recruitment (clients): Participants recruited from traditional mental health providers who partnered with consumer operated service programs (COSP). No details were provided on numbers eligible, excluded, or refused participation.

Recruitment (consumer-provider): Not described.

Inclusion criteria: Diagnosed serious and persistent mental illness (DSM Mental Disorder Axis I or II), 18 years or older, able to provide full and informed consent, actively attending traditional mental health provider within previous 12 months (at least 4 mental health services in past year and at least 1 in the past 4 months).

Exclusions: Unable to participate in research interviews, more than 3 visits to the COSPs under study in the past 6 months.


ParticipantsClients: 1827 participants (39.9% male). Mean age 42.7. College/Vocational Training (38.7%), married (12.6%), have children (52.8%), currently employed for pay or volunteer (29.3%), currently in own residence (57.9%), currently homeless (10.2%), social security income past 30 days (83.6%).

Principal diagnoses: Schizophrenia or psychotic disorder (50.4%), mood disorders (44.4%), anxiety disorders (3.7%), other (1.5%).

Stage of illness/problem: Mean age first psychiatric contact 23.0. Recent psychiatric hospitalisation (16.0%).

Other health problem: Physical disability (51.7%).

Description consumer-provider: Eight COSPs categorised as drop-in (n = 4), peer support and mentoring (n = 2), and education and advocacy (n = 2). Common ingredients across all COSPs included a focus on peer support, recovery education, empowerment, and tangible assistance for independent community living.


InterventionsStudy aim: To examine the effectiveness of COSPs on improving psychological, social, and objective and subjective functioning outcomes in individuals who receive traditional mental health services.

Intervention aim: To provide peer support, recovery education, empowerment, and tangible assistance for independent community living.

Role of consumer-provider: Services included drop-in (n = 4 sites), peer support and mentoring (n = 2 sites), and education and advocacy (n = 2 sites).

Intervention: Attendance at a COSP in addition to traditional mental health service. COSPs varied in the type of service provided such as drop-in, peer support and mentoring, and education and advocacy. Common ingredients across all COSPs included a focus on peer support, recovery education, empowerment, and tangible assistance for independent community living.

Control: Traditional mental health services provided by professionals or paraprofessionals including psychiatrists, social workers, psychologists, and residential providers.

Duration: 1998 to 2004.

Fidelity: Fidelity Assessment Common Ingredients Tool (FACIT).

Program Structure (possible score 10-48); drop-in 39.13, peer support 35.00, education and advocacy 42.00.

Environment (possible score 11-50); drop-in 42.38, peer support 34.00, education and advocacy 36.75.

Belief Systems (possible score 9-40); drop-in 34.75, peer support 35.50, education and advocacy 34.50.

Peer Support (possible score 8-35); drop-in 29.25, peer support 29.50, education and advocacy 23.25.

Education (possible score 5-25); drop-in 13.25, peer support 16.50, education and advocacy 23.75].

Advocacy (possible score 3-15); drop-in 8.00, peer support 12.00, education and advocacy 13.50. Authors note that they conducted two rounds of pilot testing of the assessment protocol and the standardised interviewer training to ensure accurate data collection.

Consumer involvement outside of the intervention: Consumer/survivors who represented the COSPs joined with other consumers on research teams to form a Consumer Advisory Panel as part of their participation in the federal study.

Changes in trial protocol: None described.


OutcomesAssessments conducted at baseline, 4, 8, and 12 months.

Making Decisions Empowerment (MDE)

Personal Empowerment (PE)

Organisationally Mediated Empowerment (OME)

Attendance: Dichotomous (any contact vs no contact) as well as categories based on frequency of utilisation (0 = no contact, 1 = > 0 and < 8.5 visits, 2 = > 8.5 visits).


NotesPercentage values were used to estimate number of people with events for dichotomous outcomes. Number of people assessed in each group was assumed to be the number of people randomised.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"Each site developed randomisation procedures that prevented "gaming", largely through the use of computer-generated random number tables"

Allocation concealment (selection bias)Unclear risk(see quote above) "...these procedures remained under the control of the researchers and not the interviewers or program staff"

It is unclear whether researchers had the opportunity to manipulate group assignments.

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskParticipants had to provide informed consent and were likely to be aware of purpose of study.

Blinding (performance bias and detection bias)
All other outcomes
Unclear riskUnclear whether mental health service providers, clinicians or research staff were blinded to group assignments.

Incomplete outcome data (attrition bias)
up to 6 months
Unclear riskData not provided.

Incomplete outcome data (attrition bias)
post 6 months
Unclear risk"The attrition rate from baseline to the end point of the study (12 months) was approximately 20.5 percent"

Insufficient information to determine whether an imbalance of losses across treatment groups or the potential impact of incomplete data on results.

Selective reporting (reporting bias)High riskComplete data set provided for baseline assessments of all outcomes however follow-up data are less comprehensive and appears to be selectively reported for a subset of participants or results that are based on the trialists' 'as treated' approach.

Groups comparable at baseline?Unclear risk"We found no significant differences in baseline scores for the MDE, PE Choice, PE Reduction in Chance, or OME for the entire sample by experimental condition"

However, baseline participant characteristics were not reported separately for each experimental condition therefore unable to judge whether there were any potential confounders between groups.

No contamination between treatment groups?High risk"..participants were able to continue to receive traditional mental health services and use COSPs regardless of their randomisation assignment...We found that 57 percent of those assigned to the intervention condition and 15 percent of those assigned to the control condition used the COSPs"

Sells 2006

MethodsRCT

Setting: 4 study sites across Connecticut, USA. 3 sites were state-operated mental health agencies; two urban and one rural. Fourth site was a nonprofit agency serving a rural population.

Funding: Yale Institution for Social and Policy Studies. Peer-based treatment sponsored by Connecticut Department of Mental Health and Addiction Services.

Recruitment (client): Prospective participants identified through mental health authorities were invited to a project interview. Consenting participants were paid $20 for completion of baseline interview.

Recruitment (consumer-providers): All peer staff worked as providers within the Connecticut Peer Engagement Specialists project, a four-site statewide investigation at public mental health centres in three Connecticut towns and through contract with a nonprofit agency in a fourth town. No details were provided on numbers eligible, excluded, or refused participation.

Training/support: Consumer-providers received 2 weeks training by professional and peer healthcare staff. Topics included outreach and engagement; ethical guidelines; local community resources; and record keeping. Consumer-providers received supervision from clinical supervisors. Regular providers worked on the same treatment teams as consumer-providers.

Inclusion criteria: Diagnosed serious mental illness (schizophrenia spectrum disorder, major mood disorder, or both) with a history of being difficult to engage in treatment (provider-assessed using Level of Care Utilization System) and inflicted or threatened to inflict serious physical injury upon another person within the last 5 years.

Exclusions: None stated.


ParticipantsClients: 137 participants (61.3% male). Mean age 41 (SD 9), range 20-63.

Principal diagnoses: Main diagnoses were psychotic disorder (61%) or major mood disorders (63%). Co-occurring disorders (70%).

Description consumer-providers: All 8 consumer-provider staff had publicly disclosed histories of severe mental illness and some had disclosed histories of co-occurring drug use disorders.


InterventionsStudy aim: To study the effects of consumer-provider case management services on treatment relationship dimensions and engagement for clients with severe mental illness early in the treatment process.

Intervention aim: Consumer-provider communications were expected to be more validating than invalidating compared to regular providers. It was hypothesised that invalidating communication from consumer-providers, but not from traditional providers, would be significantly associated with favourable client outcomes including significantly higher rates of enrolment and participation, lower rates of hospitalisation and incarceration, more days in stable housing and higher scores on quality of life and community integration measures compared to those in usual care.

Role of consumer-provider: Consumer-providers partnered with assertive community treatment teams. Consumer-providers delivered non clinical activities determined by the clients' interests. Consumer-provider caseload average was 10-12 clients (approximately half the case load of the control group).

Intervention: Mental health agency sites (n = 3) provided ACT with consumer-providers as case managers. Non-profit agency (n = 1) provided three integrated teams for case management, clinical, and psychosocial rehabilitation. Consumer-providers were assigned to psychosocial rehabilitation team. However consumer-provider peer specialists were not integrated within the teams and worked almost exclusively with their clients. They were not required to fulfil traditional case manager responsibilities and focused their time on clients.

Control: Regular community-based treatment provided at each study site without involvement of consumer-providers. Ideally, ACT staff worked as a team, sharing responsibility for meeting all of their clients’ basic needs while focusing primarily on medication and case management.

Duration: July 2001 to June 2003 (participants received 12 months of intervention).

Fidelity: 3 agency sites delivered ACT while the non-profit agency site used 3 different integrated teams: case management, clinical, and psychosocial rehabilitation.

Consumer involvement outside of the intervention: None.

Changes in trial protocol: None described.


OutcomesOutcomes assessed at baseline, 6 and 12 months.

Quality of Life (QOLI-B)

Barrett-Lennard Relationship Inventory (BLRI)

Attendance: Number of contacts in past 30 days

Service use


NotesCalculated the treatment effect of each BLRI subscale (positive regard, empathy, unconditionality) and presented the median treatment effect in the analysis for the client manager relationship outcome.

Power calculation: Not reported.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information provided.

Allocation concealment (selection bias)Unclear risk"After the client left the room, the researcher would randomly assign the individual to one of two groups."

Insufficient information to determine whether adequate concealment of allocation.

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskParticipants were aware of the purpose of the study.

Blinding (performance bias and detection bias)
All other outcomes
High riskProviders were not blinded.

Incomplete outcome data (attrition bias)
up to 6 months
Low risk"The discovery by researchers that ineligible clients had been enrolled resulted in an overhaul of the referral process and exclusion of several enrolled clients."

BLRI data: 54/68 participants assessed in consumer-provider group and 51/69 in control group. Losses balanced across groups.

Incomplete outcome data (attrition bias)
post 6 months
High riskBLRI data: 42/68 participants assessed in consumer-provider group and 32/69 in control group. Reasons for losses not provided. Losses not balanced across groups could bias results in either direction.

Selective reporting (reporting bias)High riskOnly reported on a subsample of 25 clients for attendance (those rated by clinicians as least engaged in treatment). Limited information provided for QOLI-B or service use.

Groups comparable at baseline?Unclear riskConditions of serious mental illness balanced across groups however, no further information provided about the characteristics of participants across treatment groups.

No contamination between treatment groups?Unclear risk"...all providers attended the same meetings and could freely interact and share practice activities."

Peer and regular providers were on the same treatment teams.

Sledge 2011

MethodsRCT

Setting: Yale-New Haven Psychiatric Hospital, acute care hospital, New Haven, Connecticut, USA.

Funding: Grant M123828 Eli Lilly; Connecticut Department of Mental Health and Addiction Services; George D and Esther S Gross Professor of Psychiatry endowment.

Recruitment (client): Prospective participants identified people admitted to the Yale-New Haven Psychiatric Hospital between 1 Nov 2006 and 1 Nov 2008.

Recruitment (consumer-provider): Recruited from formal job postings. No details were provided on numbers applied, eligible, excluded, or refused participation.

Training/support: Consumer-providers received training on fundamentals of recovery philosophy and promotion practices, local resources available, boundaries, safety, cultural competence, gender factors, trauma-informed care, motivational interviewing techniques. Training occurred over 16 days during four weeks, with homework. Received a salary from the state Department of Mental Health, under the supervision of staff at the Connecticut Department of Mental Health and Addiction Services. They did not report to or take direction from clinical staff who were directly responsible for patient care. They had ongoing supervision, including 90 minute, weekly team meeting, conducted by study supervisors and the mentors' direct supervisor.

Inclusion criteria: 18 years or older; two or more psychiatric hospitalisations in previous 18 months; documented DSM-IV diagnosis of schizophrenia, schizoaffective disorder, psychotic disorder not otherwise specified, bipolar disorder or major depressive disorder, and willing to accept random assignment.

Exclusions: unable to give signed, written consent; unable to speak English; unavailable because of imminent incarceration; primary DM-IV axis I diagnosis of substance abuse or dependence or an axis II diagnosis alone.


ParticipantsClients: 89 participants randomised, 15 withdrew consent leaving an intention to treat sample of 74 (intervention n = 38, 45% male; control n = 36, 58% male). Mean age: intervention: 42.4 years (SD 11.5); control: 38.7 years (SD 8.4) .

Principal diagnoses: Main diagnoses were psychotic disorder: intervention: 68%, control: 69%, and mood disorders: intervention: 32%, control 31%.

Description consumer-providers: All 8 consumer-providers were in recovery from a severe mental illness, openly self-identify as having a history of mental illness, demonstrated strong interpersonal skills, and willing to work in the community and complete a paid training program.


InterventionsStudy aim: To determine whether recovery mentor support services are effective in promoting recovery and social integration among psychiatrically disabled individuals who experience high rates of inpatient hospitalization.

Intervention aim: Consumer-provider were to deliver support for participants (peer companion model), with the aim to reduce inpatient hospitalizations.

Role of consumer-providers: Consumer-providers gave support for clients. Consumer-providers delivered non-clinical activities determined by the clients' interests. Consumer-provider caseload not described.

Intervention: Mentors were instructed not to aim for any specific goal other than to support their clients (n = 38). Recovery mentors were trained to use their own first-hand experiences as a basis on which to provide support to participants. Frequency of contact determined by mentee in collaboration with mentor. 13 of 38 intervention-group patients had no contact with their mentee. Data for 55% of intervention-group patients showed that mean frequency of contact was 13.43 contacts (SD 11.46), over nine months. Mean total hours of contact: 24.15 hours (SD 17.41).

Control: (n = 36) Direct clinical care received by both groups consisted of what was available to them through their own efforts and resources. Most of the clinical care was delivered in the public sector via community-based organizations that are funded by the DMHAS either through a state facility or grants to private, nonprofit community-based, mental healthcare centres. Generally clinical care consisted of medication, psycho-education and case management, and supportive psychotherapy.

Duration: Nov 2006 to Nov 2008.

Fidelity: 13 (34%) of clients had no contact with their mentor during study period despite being assigned to mentor arm.

Consumer involvement outside of the intervention: None.

Changes in trial protocol: None described.


OutcomesOutcomes assessed at 3 and 9 months.

Number of hospitalizations

Number of days in hospital

Trial protocol outcomes listed included:

Sense of community

Motivation for change

Social functioning

Hope

Self determination

Functional status

Treatment relationship


NotesContacted authors regarding secondary outcomes, who advised that data were collected and authors are currently drafting a manuscript for these outcomes.

Power calculation: Not reported.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"Randomization scheme generated with SAS statistical software with a 50-50 split between recovery mentor and treatment as usual for 120 participants."

Allocation concealment (selection bias)Low risk"Each randomized assignment was separated and placed in consecutive order in a sealed, numbered envelope by staff (who were not directly linked to the study) at the Program for Recovery and Community Health."

Blinding (performance bias and detection bias)
Self-reported outcomes
Unclear riskIt is unclear if participants were aware of the purpose of the study.

Blinding (performance bias and detection bias)
All other outcomes
High riskSupervisors of mentors also participated in some follow-up evaluations and were not blind to participants' treatment status.

Incomplete outcome data (attrition bias)
up to 6 months
Unclear riskNo 3-month data published as yet (at January 2013).

Incomplete outcome data (attrition bias)
post 6 months
High riskPrimary outcomes have been reported, it appears that data for all participants in the intention to treat sample have been reported. Authors note, however, they did not have verifiable data on whether patients were hospitalised at other facilities during the follow up period.

Selective reporting (reporting bias)Unclear riskSecondary outcomes listed in trial protocol not yet reported (at January 2013), including: Sense of community; Motivation for change; Social functioning; Hope; Self determination; Functional status; Treatment relationship.

Groups comparable at baseline?Low risk"The two groups did not differ on most variables at baseline", however, marital status was different between groups (intervention: 21% currently married; control 3% currently married).

No contamination between treatment groups?Unclear riskNot described.

Solomon 1995

MethodsRCT 

Setting: Community mental health centre Philadelphia, USA.

Funding: National Institute of Mental Health.

Recruitment (clients): All clients on the roster of a community mental health centre (July 1990 - July 1991) that met the criteria for intensive case management and who were at risk for hospitalisation were invited to participate. 128 eligible, 32 refused.

Recruitment (consumer-providers): Unclear.

Training/support: Both teams received training required by all intensive case managers within the mental health system. This includes a continuing education program. Both teams also received additional training on consumer issues, team building, and other topics pertinent to the service model.

Inclusion criteria: Diagnosed major mental illness, significant treatment history, Global Assessment Scale score of 40 or below (patients over 35 years old), or 60 or below (patients 35 years or younger).

Exclusions: None stated.


ParticipantsClients: 96 participants (52% male). Mean age 41 (SD 14.4). Never married (76%). Less than high school education (48%). Income source: supplemental security income (62%), social security disability income (16%).

Principal diagnosis: Schizophrenia (86%), major affective disorder (13%), or unspecified psychotic disorder (1%).

Other characteristics: Homeless in past year (11%) or during lifetime (21%). Arrest in past year (18%) or during lifetime (42%). Living arrangement: community rehabilitation facilities (24%), boarding homes (18%), with parents (17%). Complies with medication most or all of the time (91%). History includes state hospitalisation (18%), lifetime hospitalizations (7%). Mean age at first hospitalisation 27 (SD 5.8); mean baseline BPRS score 31 (SD 9.5), and mean income 479 (323.6).

Treatment receiving: Intensive case management.

Description consumer-providers: All consumer-providers had a major mental health disorder as defined in the DSM-III-R; at least one prior psychiatric hospitalisation and a minimum of 14 days psychiatric hospitalisation, or at least 5 psychiatric emergency service contacts over a year, regular contact with community mental health services, psychosocial services, or other outpatient treatment for a primary diagnosis of the mental illness. The consumer-provider team was older with a broader representation of educational experience, age and race than the control team.


InterventionsStudy aim: To determine if satisfaction with general mental health treatment would be greater for clients of the consumer-provider case management teams compared with clients of non-consumer case managers, and if individual characteristics of case managers may significantly affect satisfaction with treatment for clients of mental health services.

Intervention aim: Designed to compare the outcomes of clients served by two teams of case managers. To determine whether a team of mental health service consumer-providers delivered intensive case management services differently than a team of professional case managers.

Role of consumer-provider: Case management operated as a part of a consumer-run advocacy and service organisation which had a consumer director, 4 case managers (3 consumer-provider case managers and 1 non-consumer case manager). The non-consumer later left and was replaced with a consumer-provider. In the 2nd year, a full-time clinical director and part time psychiatrist were hired.

Intervention: (n = 48) Consumer-provider case management team. Team comprised 4 case managers that met 3 times a week. Each team member had their own clients. Case managers saw clients in their own environments and provided individualised social support for community living. Case management was based on the ACT model. Case managers routinely interacted with health professionals, community and social welfare staff, benefits administrators, families and housing providers to plan or monitor services.

Control: (n = 48) Non-consumer case management team. Team comprised 4 case managers that met biweekly and also met with another team of intensive case managers monthly. Also based on the ACT model.

Fidelity: Not described.

Consumer involvement outside of the intervention: None.

Changes in trial protocol: None described.


OutcomesOutcomes assessed at baseline and after one and two years follow up.

Lehman's Quality of Life Interview (QOLI)

Brief Psychiatric Rating Scale (BPRS)

Client satisfaction: 16 items on a 4 point scale (very helpful, helpful, somewhat helpful, not at all helpful). Scores ranged from 1-4, higher scores better

Working Alliance Inventory (WAI): client-assessed and case manager-assessed

Emergency service use

Hospital admission

Outpatient treatment services

Rehabilitation services

Service provision (time allocation and location of case management services)


NotesService provision and use of services (eg outpatient treatment services and rehabilitation services) were measured in units of time (one time unit is 15 minutes), reported values were converted and presented as number of hours in the final analysis.

Power calculation: Not described.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk"...randomly assigned"

Insufficient information to determine whether adequate sequence generation.

Allocation concealment (selection bias)Unclear riskNo information provided.

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskParticipants had to provide informed consent and were likely to be aware of purpose of study.

Blinding (performance bias and detection bias)
All other outcomes
Unclear risk"...researchers were not blinded to the intervention status of participants"

Incomplete outcome data (attrition bias)
up to 6 months
Low risk90/96 participants followed up. Reasons for losses were provided however it is unclear whether losses were balanced across groups. Unlikely to be a source of bias.

Incomplete outcome data (attrition bias)
post 6 months
Low riskAs above.

Selective reporting (reporting bias)High riskOutcome data presented as pooled results for entire sample rather than results for separate treatment groups.

Groups comparable at baseline?Low risk"There were no differences between the clients of the two teams on clinical characteristics, social indicators, social network, living arrangements, quality of life, and demographics, with the exception of gender...baseline variables found no significant differences by gender"

No contamination between treatment groups?Low riskBoth teams operated in the same catchment area but were based at different sites.

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Bedell 1980Allocation to treatment groups not randomised

Bruxner 2010Study suspended due to recruitment problems (correspondence with J Robinson July 2012)

Campbell 2004Intervention not integrated within statutory mental health setting (Consumer-operated services as an alternative to statutory mental health service)

Castelein 2008Intervention not integrated within statutory mental health setting (nurse and peer led self-help group); Comparison group differed on more factors than consumer-provider alone

Chatterjee 2011Lay health workers were not current or past consumers of mental health services (confirmed by communication with Chatterjee S, 2012)

Cook 2012aComparison group differed on more factors than consumer-provider alone

Cook 2012b(Identified from van Gestel 2012) Intervention not integrated within statutory mental health setting (peer-led course)

Davidson 2004Intervention not integrated within statutory mental health setting (independent social support). Also, befriending only (confirmed by correspondence with author).

Dennis 2003Intervention not integrated within statutory mental health setting (maternal child health)

Dennis 2009Intervention not integrated within statutory mental health setting (immunisation clinic)

Draine 1995Intervention not integrated within statutory mental health setting (forensic)

Dumont 2002Intervention not integrated within statutory mental health setting (consumer-run crisis hostel as an alternative to statutory mental health service)

Felton 1995Allocation to treatment groups was quasi-randomised

Forchuk 2005Comparison group differed on more factors than consumer-provider alone

Galanter 1988Intervention not integrated within statutory mental health setting (independent peer-led self-help group)

Greenfield 2008Comparison group differed on more factors than consumer-provider alone

Hartley 2011Allocation to treatment groups was quasi-randomised

Hunkeler 2000Intervention not integrated within statutory mental health setting (primary care)

Jonikas 2011Comparison group differed on more factors than consumer-provider alone

Kaufmann 1995aIntervention not specifically for mental health (employment)

Klein 1997Allocation to treatment groups was quasi-randomised

Krebaum 1999aRetrospective program evaluation, not prospective randomised trial (confirmed in correspondence with author, 12 July 2012)

Lafave 1996Comparison group differed on more factors than consumer-provider alone

Landers 2011Allocation to treatment groups was not randomised

Lehman 1997Comparison group differed on more factors than consumer-provider alone

Lehman 1999Intervention not specifically for mental health (homelessness)

Lehman 2002Intervention not specifically for mental health (employment support)

Liberman 1998Comparison group differed on more factors than consumer-provider alone

Liviniemi 2001No comparison group

Ludman 2007Intervention not integrated within statutory mental health setting (peer support education as an alternative to statutory mental health service)

Macias 2006Intervention not specifically for mental health (employment support)

McCorkle 2008Allocation to treatment groups was quasi-randomised

Powell 2001Intervention not integrated within statutory mental health setting (independent peer-led self-help group)

Quinlivan 1995Comparison group differed on more factors than consumer-provider alone

Reynolds 2004Comparison group differed on more factors than consumer-provider alone

Rowe 2007Intervention not integrated within statutory mental health setting (forensic)

Sacks 2008Participants not clients of a statutory mental health service (substance abuse)

Salyers 2010Comparison group differed on more factors than consumer-provider alone

Schmidt 2006Allocation to treatment groups was quasi-randomised

Seeman 2001Intervention not integrated within statutory mental health setting (perinatal)

Segal 2010Both intervention and comparison group involved consumer providers

Segal 2011Both intervention and comparison group involved consumer providers

Simon 2011Intervention not integrated within statutory mental health setting (research institute)

Stefancic 2007Intervention not specifically for mental health (housing)

Straughan 2006Intervention not integrated within statutory mental health setting (independent peer-led recovery group)

Sytema 2007Comparison group differed on more factors than consumer-provider alone

van Gestel 2012Intervention not integrated within statutory mental health setting (peer-led course); wait-list control group received no treatment at all (ie. not 'service as usual')

Young 2005Allocation to treatment groups was quasi-randomised

 
Characteristics of studies awaiting assessment [ordered by study ID]
Kroon 2011

MethodsRandomised controlled trial.

ParticipantsPeople with severe mental illness.

InterventionsA user-run recovery group and short recovery courses, added to care as usual.

OutcomesEmpowerment, mental health confidence, connectedness, quality of life, depressive symptoms.

NotesNeed additional information; emailed authors (May 2012) and awaiting response (January 2013).

Stone 1979

MethodsControlled study (no further details).

ParticipantsInpatients at Florida Mental Health Institute, aged between 18 and 54, with a minimum of three months' hospitalization or three different hospitals.

InterventionsSmall group, peer management inpatient treatment

OutcomesRehospitalization incidence and duration, staff satisfaction.

NotesUnable to obtain abstract for either reference. Southeastern Psychological Association (SEPA) was unable to provide additional information (January 2013).

 
Characteristics of ongoing studies [ordered by study ID]
Chinman 2012

Trial name or titlePEers Enhancing Recovery (PEER)

MethodsCluster RCT

ParticipantsVeterans with mental illness (US)

InterventionsBehavioral: Adding a Consumer Provider to Intensive Case Management Teams

OutcomesPrimary: Behaviour and Symptom Identification Scale (BASIS-24)

Secondary:

Mental Health Recovery Measure (MHRM)

Patient Activation Measure

Recovery Assessment: Person in Recovery Version

Illness Management and Recovery Scale: Client Self-Rating

Quality of Life Interview

Starting dateOctober 2008

Contact informationMatthew Chinman (chinman@rand.org)

NotesAuthors advised results data soon to be published (Jan 2013)

Tondora 2010

Trial name or titleCulturally responsive person-centred care for psychosis.

MethodsRandomised controlled trial.

ParticipantsSelf-identified as African and/or Latino, over 18 receiving outpatient services following psychosis. N = 290.

InterventionsStandard care plus facilitation of person-centred care (with peer mentor) compared to standard care, or standard care plus facilitation of person-centred care with peer mentor and community inclusion activities.

OutcomesSymptoms; clinical and functional status; quality of life; illness self-management; satisfaction with services.

Starting dateJanuary 2008

Contact informationRebecca Miller (rebecca.miller@yale.edu)

NotesFunded by National Institute of Mental Health. Trial complete, data not yet published. Awaiting response from authors on use of unpublished data (January 2013).

 
Comparison 1. Consumer-provider versus professional staff

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Quality of life: Life satisfaction subscale (subjective)1Mean Difference (IV, Random, 95% CI)Totals not selected

 2 Function: Daily activities subscale (subjective)1Mean Difference (IV, Random, 95% CI)Totals not selected

 3 Social: Social relations subscale (subjective)1Mean Difference (IV, Random, 95% CI)Totals not selected

 4 Symptoms2197Std. Mean Difference (IV, Random, 95% CI)-0.24 [-0.52, 0.05]

 5 Depression1Mean Difference (IV, Random, 95% CI)Totals not selected

    5.1 Self-report (BDI) at 10 weeks
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

    5.2 Observer-rated (HRSD) at 10 weeks
1Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 6 Satisfaction2213Std. Mean Difference (IV, Random, 95% CI)-0.22 [-0.69, 0.25]

 7 Client manager relationship2160Std. Mean Difference (IV, Random, 95% CI)0.22 [-0.10, 0.53]

 8 Use of mental health services in 12 months2Mean Difference (IV, Random, 95% CI)Totals not selected

    8.1 Rehabilitation services
2Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

    8.2 Outpatient contacts
2Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

 9 Attrition3331Risk Ratio (M-H, Random, 95% CI)0.80 [0.58, 1.09]

 10 Service provision: Caseload/personnelOther dataNo numeric data

 11 Service provision: Time allocationOther dataNo numeric data

 12 Service provision: Location of servicesOther dataNo numeric data

 13 Service provision: Case manager tasksOther dataNo numeric data

    13.1 Service categories
Other dataNo numeric data

    13.2 Administrative
Other dataNo numeric data

 14 Crisis/emergency service2Std. Mean Difference (Random, 95% CI)-0.34 [-0.60, -0.07]

 15 Hospital admissions1Risk Ratio (M-H, Random, 95% CI)Totals not selected

 16 Length of stay1Mean Difference (IV, Random, 95% CI)Totals not selected

 17 Professional's attitude: client manager relationship1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 
Analysis 1.10 Comparison 1 Consumer-provider versus professional staff, Outcome 10 Service provision: Caseload/personnel.
Service provision: Caseload/personnel

StudyDescriptionConsumer-providerProfessional staff

Bright 1999Caseload (Mutual support groups)n = 22n = 27

Bright 1999Caseload (Cognitive behavioural therapy groups)n = 21n = 27

Clarke 2000Average caseload4.6 clients/case manager5.4 clients/case manager

Rivera 2007Personnel4 x 0.5 EFT personnel (n = 70)2 x 1.0 EFT personnel (n = 66)

Sells 2006Average caseload10 to 12 clients/case manager20 to 24 clients/case manager

Solomon 1995Personnel4 personnel

(n = 48)
4 personnel

(n = 48)

 
Analysis 1.11 Comparison 1 Consumer-provider versus professional staff, Outcome 11 Service provision: Time allocation.
Service provision: Time allocation

StudyTime spent withConsumer-providerProfessional staffEffect measure

Clarke 2000Team40%40%not estimable

Clarke 2000Clients33%33%not estimable

Clarke 2000Alone25%25%not estimable

Clarke 2000Family/staff and

other agencies/operators
6%6%not estimable

Clarke 2000

Solomon 1995Face-to-face with clientmean 38.2 (SD 33.63), n=46mean 9.95 (SD 10.54), n = 45MD 28.25 hours [95% CI 18.06 to 38.45]

Solomon 1995Telephone with clientmean 5.90 (SD 6.44), n = 46mean 21.8 (SD 6.44), n = 45MD -15.90 hours [95% CI -18.55 to -13.25]

Solomon 1995Contact with client family/friendsmean 0.46 (SD 1.22), n = 46mean 13.62 (SD 18.38), n = 45MD -13.16 hours [95% CI -18.54 to -7.78]

Solomon 1995Contact with provider agency or staffmean 1.98 (SD 7.03), n = 46mean 25.56 (SD 23.87), n = 45MD -23.58 hours [95% CI -30.84 to -16.32]

Solomon 1995All case management servicesmean 83.79 (SD 63.71), n = 46mean 64.51 (SD 54.62), n = 45MD 19.28 hours [95% CI -5.08 to 43.63]

 
Analysis 1.12 Comparison 1 Consumer-provider versus professional staff, Outcome 12 Service provision: Location of services.
Service provision: Location of services

StudyLocationConsumer-providerProfessional staffEffect measure

Clarke 2000Out of office (eg client home or public place)61%73%not estimable

Clarke 2000Institution15%13%not estimable

Clarke 2000

Clarke 2000

Clarke 2000

Solomon 1995Officemean 13.01 (SD 13.77), n = 46mean 63.30 (SD 43.15), n = 45MD -50.29 hours [95% CI -63.51 to -37.07]

Solomon 1995Client's homemean 9.23 (SD 9.71), n = 46mean 5.21 (SD 8.34), n = 45MD 4.02 hours [95% CI 0.30 to 7.74]

Solomon 1995On the streetmean 4.89 (SD 8.32), n = 46mean 1.50 (SD 3.52), n = 45MD 3.39 hours [95% CI 0.77 to 6.01]

Solomon 1995Provider agencymean 28.44 (SD 37.29), n = 46mean 1.95 (SD 3.01), n = 45MD 26.49 hours [95% CI 15.68 to 37.30]

Solomon 1995Hospital (no difference in days hospitalised between groups)mean 1.08 (SD 2.55), n = 46mean 5.05 (SD 8.30), n = 45MD -3.97 hours [95% CI -6.50 to -1.44]

 
Analysis 1.13 Comparison 1 Consumer-provider versus professional staff, Outcome 13 Service provision: Case manager tasks.
Service provision: Case manager tasks

StudyCategoryConsumer-providerProfessional staff

Service categories

Clarke 2000Support/structure14%15%

Clarke 2000Treatment Plan3%6%

Clarke 2000Service Coordination8%8%

Clarke 2000Crisis1%1%

Clarke 2000Assess/monitor 6%7%

Clarke 2000Training (skill/job)1%3%

Clarke 2000Transporting3%5%

Clarke 2000Counselling3%3%

Clarke 2000Other3%2%

Administrative

Clarke 2000Travel11%11%

Clarke 2000Paperwork 13%14%

Clarke 2000Administration/Supervision15%8%

Clarke 2000Team meetings19%17%

Clarke 2000

Clarke 2000

Clarke 2000

Clarke 2000

Clarke 2000

 
Comparison 2. Consumer-provider as adjunct versus usual care alone

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Function1Mean Difference (IV, Random, 95% CI)Totals not selected

 2 Social1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 3 Satisfaction2Std. Mean Difference (Random, 95% CI)Subtotals only

    3.1 Service
2Std. Mean Difference (Random, 95% CI)0.76 [-0.59, 2.10]

    3.2 Staff
1Std. Mean Difference (Random, 95% CI)0.18 [-0.43, 0.79]

    3.3 Needs met
1Std. Mean Difference (Random, 95% CI)0.68 [0.05, 1.31]

 4 Use of mental health services: attendance at clinic appointments1Std. Mean Difference (Random, 95% CI)0.52 [-0.07, 1.11]

 5 Attrition3218Risk Ratio (M-H, Random, 95% CI)1.29 [0.72, 2.31]

 6 Any hospital admissions145Risk Ratio (M-H, Random, 95% CI)1.07 [0.55, 2.07]

 7 Number of hospital admissions174Mean Difference (IV, Fixed, 95% CI)-0.64 [-1.30, 0.02]

 8 Length of hospital stay2119Mean Difference (IV, Random, 95% CI)-13.41 [-32.09, 5.27]

 9 Professionals' attitude: client needs met145Mean Difference (IV, Random, 95% CI)1.56 [0.50, 2.62]

 
Table 1. Outcome measurement tools

ToolAbbreviationReference/sDescriptionOutcomeAssessorStudies

Lehman Quality of Life (also in Brief Version)QOLI (and QOLI-Brief)Lehman 1988

Lehman 1994
Subjective subscales: Life satisfaction, Daily activities, Family contact, Social relations, Finances, Health, Safety (score 1-7).

Objective subscales: Family contacts, Social relations (score 1-5), Daily activities, Finances (score 0-1).

Higher scores better.
Quality of lifeClient self-report (interview)Sells 2006, Rivera 2007, Solomon 1995

Quality of Life Index for Mental HealthQOLIMHBecker 1993A brief 25-item questionnaire
modified from the Quality of Life Index for Mental Health.
Quality of lifeClient self-reportO'Donnell 1999

Making Decisions EmpowermentMDERogers 199728 items (score 1-4). Responses are summed. Higher scores better (individual scale values reversed).EmpowermentClient self-reportRogers 2007

Personal EmpowermentPESegal 199520 items with two sub-scales; 1) choice and 2) reduction in chance. Choice sub-scale employs four point Likert scale . Reduction in Chance sub-scale employs five-point scale. Responses are summed. Higher scores better (individual scale values reversed).EmpowermentClient self-reportRogers 2007

Life Skills ProfileLSPRosen 1989A 39-item measure of function
and disability. Higher scores better.
FunctionCase managers and familiesCraig 2004

Significant Others ScaleSOSPower 1988Interview assesses size of social network and ratings of qualitative aspects of support provided by individuals in the network.SocialClient self-report (interview)Craig 2004

Hopkins Symptoms Checklist-58HSCL-58Derogatis 197458-items on a four-point scale. Higher scores worse. SymptomsClient self-reportBright 1999

Brief Symptom InventoryBSIDerogatis 1983Measures clinically relevant symptoms (score 1-5). Higher scores better.SymptomsClient self-reportRivera 2007

Brief Psychiatric Rating Scale (also expanded version)BPRSOverall 1962

Velligan 2005
18 items (expanded version has 24 items) rated on seven point scale. Higher scores worse.  SymptomsTrained interviewerKaufmann 1995, Solomon 1995,

Symptom Check List-90SCL-90Derogardis 1977Self-administered check list of 90 items rated on a five point scale (0 = not at all; 4 = extremely), eight sub scale scores were computed and three global indices, global severity index, positive symptoms distress index, and positive symptom total.SymptomsClient self-reportKaufmann 1995

Beck Depression InventoryBDIBeck 197921-item scale. Each item consists of four statements of depressive symptoms (score 0-3) and assesses respondents mood in the past week. Maximum score 63 (≥19 indicates significant depressive symptoms). Higher scores worse.DepressionClient self-reportBright 1999

Hamilton Rating Scale for Depression (revised)HRSDRehm 1985Observer-rated scale for depressive symptomatology following clinical interview taking into account patient behaviour in the immediate preceding week (score 0-52; 30 = severe illness). Higher scores worse.DepressionClinicianBright 1999

Behavioral Health Care Rating of SatisfactionBHCRSDow 1995Client satisfaction with clinical staff and services (score 1-6). Higher scores better.SatisfactionClientRivera 2007

Verona Service Satisfaction ScaleVSSSCozza 199754 questions that cover seven dimensions:
overall satisfaction, professionals’ skills and behaviour, information access, efficacy,
types of intervention and relative’s involvement. Higher scores better.
SatisfactionClientCraig 2004

Client Service Satisfaction QuestionnaireCSQLarsen 1979

Greenfield 1989
Modified nine-item scale. Higher scores better.SatisfactionClientO'Donnell 1999

Satisfaction with treatmentHoult 1983, modifying Stein 1980Interview based 16 item scale to measure client satisfaction with all MH treatment (not case management services alone) on a 4-point scale. Higher scores associated with greater satisfaction, authors note that they used a modified version of the instrument for assessing community treatment team approachSatisfactionTrained interviewerSolomon 1995

Camberwell Assessment of Needs CANPhelan 1995Sum score (possible score 0-22). Higher scores worse.SatisfactionCan be rated independently by staff and clientsCraig 2004

Barrett-Lennard Relationship InventoryBLRIBarrett-Lennard 196264 items, six point scale (1=definitely false, 6=definitely true). Higher score better.client-counselor relationshipclient self-reportSells 2006

Working Alliance InventoryWAIRalph 1992

Hovarth 1989
36 items (score 1-7) equally divided across 3 subscales: Goals, Tasks, and Bonds. Higher scores better.Client-manager relationshipClient and case managersSolomon 1995

 
Table 2. Missing data and outcome reporting bias

OutcomeStudies assessed outcomen studies with outcome data

(total N included in analysis)
n studies with incomplete data

(total N randomised)

COMPARISON 1 (n = 5)

Primary outcomes

QOL31 (130)2 (233)

Function31 (130)2 (233)

Social31 (130)2 (233)

Symptoms32 (197)1(96)

Depression21(67)1(96)

Satisfaction22 (213)0

Client manager relationship22 (160)0

Use of mental health services32 (227)1 (137)

Client attrition53 (333)2 (250)

Hospital admissions21 (114)1 (96)

Crisis/Emergency services32 (250)1 (96)

Length of stay21 (136)1 (96)

Secondary outcomes

Providers' attitudes11 (96)0

COMPARISON 2 (n = 6)

Primary outcomes

QOL101 (84)

Function31 (45)2 (208)

Social21 (45)1 (89)

Symptoms101 (90)

Sense of community101 (89)

Motivation for change101 (89)

Self-determination101 (89)

Hope101 (89)

Satisfaction22 (125)0

Client manager relationship101 (89)

Use of mental health services11 (45)0

Client attrition3 (218)3 (199)

Hospital admissions3 (199)1 (84)

Crisis/emergency services101 (84)

Length of stay43(199)1 (84)

Secondary outcomes

Providers' attitudes31 (45)2 (173)

 
Table 3. Included studies reported in multiple publications

StudyOther papers reporting study

Clarke 2000Herinckx 1997; Paulson 1996; Paulson 1999

Craig 2004Doherty 2004

Gordon 1979Edmunson 1982; Edmunson 1984; Gordon 1979b

O'Donnell 1999O'Donnell 1998

Rogers 2007Johnsen 2005

Sells 2006Jewell 2006; Sells 2008

Solomon 1995Solomon 1994a; Solomon 1994b; Solomon 1995b; Solomon 1995c; Solomon 1995d; Solomon 1996a; Solomon 1996b