title: Consumer-providers of care for adult clients of statutory mental health services.
abstract: BACKGROUND
  In mental health services, the past several decades has seen a slow but steady trend towards employment of past or present consumers of the service to work alongside mental health professionals in providing services. However the effects of this employment on clients (service recipients) and services has remained unclear.We conducted a systematic review of randomised trials assessing the effects of employing consumers of mental health services as providers of statutory mental health services to clients. In this review this role is called 'consumer-provider' and the term 'statutory mental health services' refers to public services, those required by statute or law, or public services involving statutory duties. The consumer-provider's role can encompass peer support, coaching, advocacy, case management or outreach, crisis worker or assertive community treatment worker, or providing social support programmes.
  
  
  OBJECTIVE
  To assess the effects of employing current or past adult consumers of mental health services as providers of statutory mental health services.
  
  
  METHODS
  We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2012, Issue 3), MEDLINE (OvidSP) (1950 to March 2012), EMBASE (OvidSP) (1988 to March 2012), PsycINFO (OvidSP) (1806 to March 2012), CINAHL (EBSCOhost) (1981 to March 2009), Current Contents (OvidSP) (1993 to March 2012), and reference lists of relevant articles.
  
  
  METHODS
  Randomised controlled trials of current or past consumers of mental health services employed as providers ('consumer-providers') in statutory mental health services, comparing either: 1) consumers versus professionals employed to do the same role within a mental health service, or 2) mental health services with and without consumer-providers as an adjunct to the service.
  
  
  METHODS
  Two review authors independently selected studies and extracted data. We contacted trialists for additional information. We conducted analyses using a random-effects model, pooling studies that measured the same outcome to provide a summary estimate of the effect across studies. We describe findings for each outcome in the text of the review with considerations of the potential impact of bias and the clinical importance of results, with input from a clinical expert.
  
  
  RESULTS
  We included 11 randomised controlled trials involving 2796 people. The quality of these studies was moderate to low, with most of the studies at unclear risk of bias in terms of random sequence generation and allocation concealment, and high risk of bias for blinded outcome assessment and selective outcome reporting.Five trials involving 581 people compared consumer-providers to professionals in similar roles within mental health services (case management roles (4 trials), facilitating group therapy (1 trial)). There were no significant differences in client quality of life (mean difference (MD) -0.30, 95% confidence interval (CI) -0.80 to 0.20); depression (data not pooled), general mental health symptoms (standardised mean difference (SMD) -0.24, 95% CI -0.52 to 0.05); client satisfaction with treatment (SMD -0.22, 95% CI -0.69 to 0.25), client or professional ratings of client-manager relationship; use of mental health services, hospital admissions and length of stay; or attrition (risk ratio 0.80, 95% CI 0.58 to 1.09) between mental health teams involving consumer-providers or professional staff in similar roles.There was a small reduction in crisis and emergency service use for clients receiving care involving consumer-providers (SMD -0.34 (95%CI -0.60 to -0.07). Past or present consumers who provided mental health services did so differently than professionals; they spent more time face-to-face with clients, and less time in the office, on the telephone, with clients' friends and family, or at provider agencies.Six trials involving 2215 people compared mental health services with or without the addition of consumer-providers. There were no significant differences in psychosocial outcomes (quality of life, empowerment, function, social relations), client satisfaction with service provision (SMD 0.76, 95% CI -0.59 to 2.10) and with staff (SMD 0.18, 95% CI -0.43 to 0.79), attendance rates (SMD 0.52 (95% CI -0.07 to 1.11), hospital admissions and length of stay, or attrition (risk ratio 1.29, 95% CI 0.72 to 2.31) between groups with consumer-providers as an adjunct to professional-led care and those receiving usual care from health professionals alone. One study found a small difference favouring the intervention group for both client and staff ratings of clients' needs having been met, although detection bias may have affected the latter. None of the six studies in this comparison reported client mental health outcomes.No studies in either comparison group reported data on adverse outcomes for clients, or the financial costs of service provision.
  
  
  CONCLUSIONS
  Involving consumer-providers in mental health teams results in psychosocial, mental health symptom and service use outcomes for clients that were no better or worse than those achieved by professionals employed in similar roles, particularly for case management services.There is low quality evidence that involving consumer-providers in mental health teams results in a small reduction in clients' use of crisis or emergency services. The nature of the consumer-providers' involvement differs compared to professionals, as do the resources required to support their involvement. The overall quality of the evidence is moderate to low. There is no evidence of harm associated with involving consumer-providers in mental health teams.Future randomised controlled trials of consumer-providers in mental health services should minimise bias through the use of adequate randomisation and concealment of allocation, blinding of outcome assessment where possible, the comprehensive reporting of outcome data, and the avoidance of contamination between treatment groups. Researchers should adhere to SPIRIT and CONSORT reporting standards for clinical trials.Future trials should further evaluate standardised measures of clients' mental health, adverse outcomes for clients, the potential benefits and harms to the consumer-providers themselves (including need to return to treatment), and the financial costs of the intervention. They should utilise consistent, validated measurement tools and include a clear description of the consumer-provider role (eg specific tasks, responsibilities and expected deliverables of the role) and relevant training for the role so that it can be readily implemented. The weight of evidence being strongly based in the United States, future research should be located in diverse settings including in low- and middle-income countries.
authors.affiliation: National Trauma Research Institute, The Alfred Hospital, Monash University, Melbourne, Australia.
authors.forename: Veronica
authors.initials: V
authors.lastname: Pitt
authors.forename: Dianne
authors.initials: D
authors.lastname: Lowe
authors.forename: Sophie
authors.initials: S
authors.lastname: Hill
authors.forename: Megan
authors.initials: M
authors.lastname: Prictor
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Hetrick
authors.forename: Rebecca
authors.initials: R
authors.lastname: Ryan
authors.forename: Lynda
authors.initials: L
authors.lastname: Berends
mesh_terms: D000328:Adult; D019090:Case Management; D003376:Counseling / Q000379:methods / Q000458:organization & administration; D004651:Employment; D006801:Humans; D001523:Mental Disorders / Q000628:therapy*; D008605:Mental Health Services / Q000331:legislation & jurisprudence / Q000458:organization & administration*; D010344:Patient Advocacy; D010358:Patient Participation / Q000379:methods* / Q000639:trends; D010379:Peer Group; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic; D012944:Social Support
references.citation: Arch Gen Psychiatry. 1997 Nov;54(11):1038-43
references.pmid: 9366661
references.citation: BMJ. 2010 Mar 23;340:c332
references.pmid: 20332509
references.citation: Community Ment Health J. 2011 Jun;47(3):252-66
references.pmid: 20512528
references.citation: Am J Psychiatry. 1998 Aug;155(8):1087-91
references.pmid: 9699698
references.citation: Psychiatr Serv. 2011 May;62(5):541-4
references.pmid: 21532082
references.citation: J Prim Prev. 2007 Jul;28(3-4):265-79
references.pmid: 17592778
references.citation: Schizophr Bull. 2012 Jun;38(4):881-91
references.pmid: 21402724
references.citation: Psychiatr Serv. 1997 Aug;48(8):1042-7
references.pmid: 9255837
references.citation: Psychiatr Serv. 2007 Jul;58(7):955-61
references.pmid: 17602012
references.citation: Community Ment Health J. 1996 Feb;32(1):47-67
references.pmid: 8635317
references.citation: Aust N Z J Psychiatry. 1998 Dec;32(6):873-9
references.pmid: 10084353
references.citation: Psychiatr Serv. 2005 Aug;56(8):967-75
references.pmid: 16088014
references.citation: Community Ment Health J. 2013 Jun;49(3):260-9
references.pmid: 22167660
references.citation: Mod Probl Pharmacopsychiatry. 1974;7(0):79-110
references.pmid: 4607278
references.citation: Arch Fam Med. 2000 Aug;9(8):700-8
references.pmid: 10927707
references.citation: J Am Psychiatr Nurses Assoc. 2011 Jan-Feb;17(1):37-44
references.pmid: 21659293
references.citation: Acta Psychiatr Scand. 2008 Jul;118(1):64-72
references.pmid: 18595176
references.citation: Arch Gen Psychiatry. 2002 Feb;59(2):165-72
references.pmid: 11825138
references.citation: Psychiatr Serv. 2012;63(5):477-81
references.pmid: 22388475
references.citation: BMC Psychiatry. 2010 May 25;10:37
references.pmid: 20500881
references.citation: Psychiatr Serv. 2011 Aug;62(8):915-21
references.pmid: 21807831
references.citation: Aust N Z J Psychiatry. 1983 Jun;17(2):160-7
references.pmid: 6578788
references.citation: Can J Psychiatry. 2003 Mar;48(2):115-24
references.pmid: 12655910
references.citation: New Dir Ment Health Serv. 1998 Fall;(79):65-77
references.pmid: 9766164
references.citation: Community Ment Health J. 1995 Jun;31(3):229-38
references.pmid: 7621660
references.citation: J Fla Med Assoc. 1979 Sep;66(9):927-33
references.pmid: 479803
references.citation: Gen Hosp Psychiatry. 2011 Jan-Feb;33(1):29-36
references.pmid: 21353125
references.citation: Br J Psychiatry. 1999 Apr;174:346-52
references.pmid: 10533554
references.citation: Psychiatr Q. 1995 Fall;66(3):249-61
references.pmid: 7568532
references.citation: J Psychiatr Ment Health Nurs. 2005 Feb;12(1):51-6
references.pmid: 15720497
references.citation: Psychiatr Serv. 1997 Oct;48(10):1297-306
references.pmid: 9323749
references.citation: J Psychiatr Ment Health Nurs. 2004 Feb;11(1):82-8
references.pmid: 14723643
references.citation: Arch Gen Psychiatry. 1980 Apr;37(4):392-7
references.pmid: 7362425
references.citation: Psychiatr Serv. 2008 Nov;59(11):1315-21
references.pmid: 18971408
references.citation: Acta Psychiatr Scand. 2007 Aug;116(2):105-12
references.pmid: 17650271
references.citation: Cochrane Database Syst Rev. 2006 Jul 19;(3):CD004563
references.pmid: 16856050
references.citation: Br J Psychiatry. 1995 Nov;167(5):589-95
references.pmid: 8564313
references.citation: Psychiatr Serv. 2010 Sep;61(9):944-5
references.pmid: 20810597
references.citation: BMJ. 2002 Nov 30;325(7375):1265
references.pmid: 12458241
references.citation: Psychiatr Serv. 2010 Sep;61(9):905-10
references.pmid: 20810589
references.citation: J Psychiatr Ment Health Nurs. 2005 Oct;12(5):556-64
references.pmid: 16164506
references.citation: J Nerv Ment Dis. 1994 Mar;182(3):179-84
references.pmid: 8113778
references.citation: J Behav Health Serv Res. 1998 Nov;25(4):397-411
references.pmid: 9796162
references.citation: J Rehabil Res Dev. 2007;44(6):785-99
references.pmid: 18075937
references.citation: Am J Community Psychol. 2008 Sep;42(1-2):135-44
references.pmid: 18626766
references.citation: Community Ment Health J. 2011 Feb;47(1):106-12
references.pmid: 19551502
references.citation: Psychiatr Serv. 1995 Oct;46(10):1037-44
references.pmid: 8829785
references.citation: Qual Life Res. 1993 Aug;2(4):239-51
references.pmid: 8220359
references.citation: Psychiatr Serv. 1998 Apr;49(4):498-503
references.pmid: 9550240
references.citation: J Ment Health. 2011 Aug;20(4):392-411
references.pmid: 21770786
references.citation: Community Ment Health J. 1996 Feb;32(1):33-40
references.pmid: 8635315
references.citation: Psychiatr Rehabil J. 2011 Fall;35(2):87-9
references.pmid: 22020837
references.citation: Acta Psychiatr Scand. 2003 Jun;107(6):410-4
references.pmid: 12752016
references.citation: Community Ment Health J. 1995 Jun;31(3):215-27
references.pmid: 7621659
references.citation: Aust N Z J Psychiatry. 1999 Oct;33(5):684-93
references.pmid: 10544992
references.citation: Psychiatr Serv. 1996 Jul;47(7):757-9
references.pmid: 8807692
references.citation: Psychiatr Serv. 2006 Oct;57(10):1406-15
references.pmid: 17035557
references.citation: J Ment Health Adm. 1995 Spring;22(2):135-46
references.pmid: 10142127
references.citation: Community Ment Health J. 2001 Jun;37(3):215-29
references.pmid: 11440423
references.citation: Schizophr Bull. 1989;15(2):325-37
references.pmid: 2749191
references.citation: Community Ment Health J. 1988 Summer;24(2):151-6
references.pmid: 3402199
references.citation: J Clin Psychol. 1980 Jul;36(3):716-22
references.pmid: 7410570
references.citation: J Ment Health Adm. 1995 Spring;22(2):126-34
references.pmid: 10142126
references.citation: Psychiatr Serv. 2008 Nov;59(11):1322-7
references.pmid: 18971409
references.citation: J Consult Clin Psychol. 1999 Aug;67(4):491-501
references.pmid: 10450619
references.citation: Trials. 2011 Jan 13;12:12
references.pmid: 21226970
references.citation: BMJ. 2013 Jan 08;346:e7586
references.pmid: 23303884
references.citation: Psychiatr Serv. 2007 Jun;58(6):802-9
references.pmid: 17535940
references.citation: BMJ. 2009 Jan 15;338:a3064
references.pmid: 19147637
references.citation: Cochrane Database Syst Rev. 2008 Oct 08;(4):CD006903
references.pmid: 18843736
references.citation: Am J Psychiatry. 1988 Oct;145(10):1248-53
references.pmid: 3421346
references.citation: Psychiatry Res. 2005 Jun 30;135(3):217-28
references.pmid: 15993949
references.citation: Psychiatr Serv. 1999 May;50(5):693-5
references.pmid: 10332908
references.citation: Community Ment Health J. 1994 Apr;30(2):165-76
references.pmid: 8013213
references.citation: Community Ment Health J. 2011 Feb;47(1):99-105
references.pmid: 19308728
references.citation: Psychiatr Serv. 2012 Jan;63(1):54-60
references.pmid: 22227760
references.citation: Psychiatr Rehabil J. 2001 Summer;25(1):3-11
references.pmid: 11529450
references.citation: BMJ. 2002 Nov 30;325(7375):1263
references.pmid: 12458240
references.citation: Hosp Community Psychiatry. 1994 Aug;45(8):793-7
references.pmid: 7982695
references.citation: Cochrane Database Syst Rev. 2011 May 11;2011(5):
references.pmid: 24143128
references.citation: Clin Trials. 2010 Aug;7(4):368-79
references.pmid: 20571133
references.citation: Psychol Med. 1983 Aug;13(3):595-605
references.pmid: 6622612
references.citation: Can Ment Health. 1989 Jun;37(2):22-5
references.pmid: 10294598
references.citation: Psychiatr Serv. 2007 Aug;58(8):1065-72
references.pmid: 17664517
references.citation: Community Ment Health J. 2008 Oct;44(5):359-66
references.pmid: 18481176
references.citation: Hosp Community Psychiatry. 1991 May;42(5):494-8
references.pmid: 2060914
references.citation: Hosp Community Psychiatry. 1993 Jul;44(7):675-8
references.pmid: 8354507
references.citation: Psychiatr Serv. 2006 Aug;57(8):1179-84
references.pmid: 16870970
references.citation: World Psychiatry. 2012 Jun;11(2):123-8
references.pmid: 22654945
references.citation: Psychiatr Serv. 2011 Jun;62(6):666-9
references.pmid: 21632737
references.citation: BMC Health Serv Res. 2012 Feb 16;12:42
references.pmid: 22340662
references.citation: Br J Clin Psychol. 1988 Nov;27(4):349-58
references.pmid: 3214688
references.citation: Cochrane Database Syst Rev. 2010 Mar 17;(3):CD004015
references.pmid: 20238326
references.citation: J Psychiatr Res. 1985;19(1):31-41
references.pmid: 3989736
references.citation: J Subst Abuse Treat. 2008 Jan;34(1):48-60
references.pmid: 17574795
references.citation: Community Ment Health J. 1996 Feb;32(1):41-6
references.pmid: 8635316
references.citation: Eval Program Plann. 1979;2(3):197-207
references.pmid: 10245370
references.citation: Ment Health Serv Res. 2000 Sep;2(3):155-64
references.pmid: 11256724
references.citation: Psychiatr Rehabil J. 2010 Spring;33(4):269-77
references.pmid: 20374985
references.citation: J Consult Clin Psychol. 2003 Oct;71(5):890-900
references.pmid: 14516237
references.citation: Psychiatr Serv. 1995 Apr;46(4):365-71
references.pmid: 7788458
references.citation: Epidemiol Psichiatr Soc. 1997 Sep-Dec;6(3):173-83
references.pmid: 9575029
references.citation: Community Ment Health J. 1999 Jun;35(3):251-69
references.pmid: 10401895
references.citation: Community Ment Health J. 2010 Aug;46(4):319-29
references.pmid: 20077006
references.citation: Schizophr Res. 2012 Apr;136(1-3):36-42
references.pmid: 22130108