Description of the condition
Schizophrenia is a chronic, disruptive, mental illness that frequently contributes to a wide variety of functional disabilities, especially within social and occupational domains (Harvey 2012). The worldwide estimate for the life-time prevalence of schizophrenia ranges from 1.4 to 4.6 per 1000 persons; the annual incidence rate lies between 0.16 and 0.42 per 1000 persons, with onset often occurring in adolescence and early adulthood (Jablensky 2000). The psychopathology of schizophrenia is often described in terms of the severity of positive (e.g. hallucinations and disorganised speech) and negative (e.g. blunted affect and social withdrawal) symptoms. While antipsychotic medications remain the core treatment for controlling the symptoms of schizophrenia, they are associated with a range of undesirable side effects on cardiovascular, endocrine and other bodily systems, resulting in poor treatment adherence (Kane 2010).
About 30% of people with schizophrenia have persistent and severe negative symptoms that tend to be resistant to medication. Termed ‘deficit syndrome', persistent negative symptoms are characterised by lack of initiative, interests and social fluency, poor verbal communication, concentration and loss of interpersonal function (Nasrallah 2011; Tandon 2009). Together with progressive deterioration in various cognitive functions (e.g. problems in working memory and information processing, reasoning and problem solving, and social cognition), there are considerable and wide varieties of functional impairments which can severely compromise overall psychosocial functioning, social integration and quality of life (Mohamed 2008). These factors may all eventually reduce treatment efficacy in individuals with schizophrenia.
The total societal costs of schizophrenia, including treatment, rehabilitation, community care services, and loss of productivity, were estimated at more than USD 60 billion per annum in the USA, UK and other developed countries in the 20th century (Mangalore 2007; Wu 2005). People with schizophrenia have severe social and occupational disability (30%) and are at higher risks of other mental (e.g. 25% to 30% have depression) and physical health (e.g. 20% to 25% have cardiovascular disease) problems (De Hert 2009), have a two-to-three-times higher all-cause mortality rate and are 12 times more likely to die by suicide than the general population (Goff 2005; Wildqust 2010).
Description of the intervention
Peer support is broadly defined as “a system of giving and receiving help founded on key principles of respect, shared responsibility, and mutual agreement of what is helpful” (Mead 2001). Dennis 2003 defined 'peer support' within a healthcare context as ".... the provision of emotional, appraisal and informational assistance by a created social network member who possesses experiential knowledge of a specific behaviour or stressor and similar characteristics as the target population" (Doull 2005). Peers can be referred to those people who share common characteristics with a specific individual or group, affiliating and empathising with and supporting each other to promote health and deal with life problems. The emphasis is on the idea that 'peers' are considered to be equal (Dennis 2003); in contrast to the traditional healthcare system of mental health services, which distinguishes between providers (i.e. trained professionals) and consumers (e.g. people with schizophrenia and families/friends), peer-support programmes are built on collaborative, mutual and equal partnerships of participants who share their experiences (or expertise) in different stages of recovery.
Peer-support programmes for individuals with schizophrenia are mainly classified into three main categories, according to how they run the services and the roles played by their coordinators or facilitators (Ahmed 2012). One category of support programmes is led by peer specialists who are employed in the healthcare setting to advocate for the consumers, provide supportive services to the consumers and their families, and offer advice to the mental healthcare team. The other two categories are the mutual/self-help groups and the consumer-led services, respectively, which share similarities in operating the principles of peer support to service other consumers outside of formal healthcare settings, working with relatively fewer resources and less professional support from the mental healthcare system. The latter is the more structured programme in terms of its system, structure and group sessions, and involves itself more with leadership of the coordinators and facilitators, or both who are often either volunteers and committed or hired to be the service providers. However, all categories of peer-support programmes emphasise interactive mutual peer or social learning. In response to individual groups’ and group members’ needs, their content can range from psychoeducation about schizophrenia and its symptom management, medication adherence, stress reduction and coping strategies, to problem solving approaches, and the strengthening of family and community support resources, as well as vocational and social skills training (Chien 2009).
How the intervention might work
Peer support has become an increasingly important strategy in healthcare systems that are encountering limited manpower and resources on one hand and, on the other, continuously increasing costs of managing complex and chronic illnesses such as severe mental disorders. Peer support has been widely used to improve physical and psychosocial health and enhance behavioural change and self-care in diverse chronic illness conditions, as well as in population groups in need of support (Cheah 2001). A peer-support programme can provide a platform where fellow patients and those already recovered from schizophrenia, or another mental illness, can share their individual experiences of the illness and management strategies in everyday life in a way that is not commonly offered in traditional healthcare settings where mental health professionals may often dominate services. In contrast to traditional healthcare settings, often stigmatised by the general public, the environment of a peer-support group fosters a sense of emotional support, information exchange, companionship, and reassurance and appraisals among group members (Ahmed 2012, Dennis 2003). Through interpersonal sharing, modelling and assistance within or outside of group sessions, it is believed that these supportive strategies can effectively combat hopelessness and behavioural problems relating to schizophrenia, and empower participants to continue treatment and resume key roles in real life (Chien 2009; Davidson 1999). However, research has shown inconsistent findings on whether social or peer support enhances self-care ability and medication adherence in people with mental illness (Pistrang 2008) and other chronic illnesses such as diabetic mellitus (Toljamo 2001).
While most peer-support groups mainly target those who are in the early stages of recovery, the benefits of these group programmes are not limited only to those who receive the peer-support service, but also extend to those who provide peer support to others (Miyamoto 2012). The peer-support providers who are assigned the roles of coordinator or facilitator of the group can successfully rebuild their self-efficacy through having the chance to serve other people with similar conditions. They may even collaborate with professionals to deliver appropriate services to other group members in need. Through active participation in service provision, they themselves increase their knowledge of disease management and enhance various skills that are important to daily functioning (Arnstein 2002).
Why it is important to do this review
Recent systematic reviews and practice guidelines have recommended that, in adjunction to psychopharmacological treatment, psychosocial interventions designed to support people with schizophrenia and their families should also be used to improve individual's rehabilitation, reintegration into the community and recovery from the illness (Pharoah 2010, NICE 2009). There is now an increasing body of evidence concerning the effects of a range of psychosocial interventions for schizophrenia, including psychoeducation (Xia 2011), cognitive-behavioural therapy (Turkington 2004, Morrison 2009) and family intervention (Pharoah 2010). While psychosocial intervention have indicated significant positive effects on reducing relapse and readmission rates, and enhancing medication compliance, most have not demonstrated consistent and conclusive results in improving other psychosocial health conditions of people with schizophrenia. Therefore, the design or testing of alternative approaches to psychosocial intervention for these individuals should be considered. Guided by the consumer movement and recovery model in mental health care, peer support is one such approach to psychosocial intervention that places emphasis on promoting the overall wellness and empowerment of people with schizophrenia through establishing partnerships between those with the condition throughout the whole journey of recovery (Ahmed 2012). While there are few controlled trials investigating physical health outcomes after peer-support group interventions, the results of a few quasi-experimental and cohort studies have indicated that peer support is associated with significant improvements in body weight, level of physical activity and general physical health in individuals with schizophrenia and other severe mental illnesses (Davidson 1999; Lawn 2008), and diabetes (Dale 2012) and other chronic illnesses (Rowe 2007; Stice 2004).
With its emphasis on the experiences of people with schizophrenia, their needs and perspectives in treatment planning, peer-support programmes have led to growing interest in the role that those who are experiencing difficulties with recovery can play in enlightening the social reintegration and enhancing the rehabilitation process of others with similar mental health problems (Ahmed 2012). Recently, the number of peer-support programmes for schizophrenia care has increased rapidly in developed countries such as the USA and Canada. Nevertheless, there is no systematic review on the impetus for this alternative treatment approach and its effects on mental condition and relapse, medication adherence, and a wide variety of outcomes such as psychosocial and occupational functioning, social skills, self-efficacy, overall wellness and quality of life in people with schizophrenia (Miyamoto 2012).
This review focuses on peer-support programmes and their use varies across cultures. There are no systematic reviews on this topic in the area of schizophrenia; and only one literature review has been published on the effects of support groups for various kinds of mental health problems (Pistrang 2008). The findings of this review will enhance our knowledge of the effectiveness of peer-support interventions and the various models for the delivery of peer-support interventions across cultures. The costs and benefits of these programmes can then be systematically evaluated.