The treatment relationship in peer-based and regular case management for clients with severe mental illness. The efficacy of a consumer case management team: 2-year outcomes of a randomized trial. Professional and paraprofessional group treatments for depression: a comparison of cognitive-behavioral and mutual support interventions. Psychiatric hospitalizations, arrests, emergency room visits, and homelessness of clients with serious and persistent mental illness: findings from a randomized trial of two ACT programs vs. usual care. Effects of participation in consumer-operated service programs on both personal and organizationally mediated empowerment: results of multisite study. Reducing rehospitalization of state mental patients. Peer management and support. Adding consumer-providers to intensive case management: does it improve outcome? A study of client-focused case management and consumer advocacy: the Community and Consumer Service Project. Effectiveness of peer support in reducing readmissions of persons with multiple psychiatric hospitalizations.
This study compared the quality of treatment relationships and engagement in peer-based and regular case management. It also assessed the value of positive relationship qualities in predicting motivation for and use of community-based services for persons with severe mental illness.
                One hundred thirty-seven adults with severe mental illness participated in a 2x2 prospective longitudinal randomized clinical trial with two levels of case management intervention (peer and regular) and two interviews (six and 12 months). Self-report questionnaires assessed treatment relationships, motivation, and service use, and providers rated participants' initial engagement and monthly attendance in treatment.
                Participants perceived higher positive regard, understanding, and acceptance from peer providers rather than from regular providers at six months only, with initially unengaged clients showing more contacts with case managers in the peer condition and decreasing contacts in the regular condition. Six-month positive regard and understanding positively predicted 12-month treatment motivation for psychiatric, alcohol, and drug use problems and attendance at Alcoholics and Narcotics Anonymous meetings.
                Early in treatment, peer providers may possess distinctive skills in communicating positive regard, understanding, and acceptance to clients and a facility for increasing treatment participation among the most disengaged, leading to greater motivation for further treatment and use of peer-based community services. Findings strongly suggest that peer providers serve a valued role in quickly forging therapeutic connections with persons typically considered to be among the most alienated from the health care service system. This article reports the results of a randomized trial of a team of case managers who are mental health consumers compared to a team of nonconsumer. Using a repeated measures MANOVA design, consumer case managers were found to be as effective as a team of nonconsumer case managers in maintaining the stability of severely mentally disabled clients served over a 2-year period. Implications for the employment of consumers in mental health services and the vocational capacity of persons with mental illness are discussed. The relative efficacy of professional and paraprofessional therapists in providing group cognitive-behavioral therapy (CBT) and mutual support group therapy (MSG) was examined. Depressed outpatients (N = 98) were randomly assigned to CBT or MSG led by either 2 professional or 2 paraprofessional therapists. Results suggest that nonprofessionals were as effective as professionals in reducing depressive symptoms and that clients in the CBT and MSG conditions improved equally. Clinically significant improvement was demonstrated for both conditions. However, following treatment, more patients in the professionally led CBT groups were classified as nondepressed and alleviated than in the paraprofessionally led CBT groups. Additionally, therapist adherence to manual-based treatments was associated with greater improvement in clinician-rated depressive symptoms in both conditions and skills in cognitive restructuring were associated with greater improvement among clients in CBT. This investigation examined several adverse outcomes in clients with serious mental illness in a randomized trial of Assertive Community Treatment (ACT) versus usual care.
                163 subjects were randomized to one of two ACT experimental conditions (staffed by consumers or non-consumers) or usual community care. Conditions were compared on psychiatric hospitalization, emergency room visit, arrest, and homelessness, within the two-year study period. Demographic, program, and client variables were examined for significant associations with outcomes.
                Significant differences were found between ACT and usual care in time to first arrest, but not hospitalization, homelessness or ER visits. Shorter time to first hospitalization was associated with male gender, diagnoses other than schizophrenia, high psychiatric symptomatology and lower provider case load. ER visits were associated with increased client symptomatology. Shorter times to homelessness were predicted by poorer therapeutic alliance between case manager and clients. Shorter time to first arrest was predicted by client minority status and enrollment in usual care.
                The paucity of significant main effects may have been due to a prolonged "start-up" phase of the ACT programs, poor ACT implementation, restricted availability of psychiatric hospital beds, or changes in usual care services delivered over the study period. The number of empowerment-oriented consumer-operated service programs (COSPs) in mental health has increased dramatically over the past decade; however, little empirical evidence exists about the effects of such programs on their intended outcomes. This study examined the effects of COSPs on various aspects of empowerment within the context of a multisite, federally funded, randomized clinical trial of COSPs. Results suggest that the individuals who received the consumer-operated services perceived higher levels of personal empowerment than those in the control intervention; overall, effect sizes were very modest when all sites were examined together in intent-to-treat analyses. However, we noted variations in outcomes by intensity of COSP use and also by study site, which suggest that specific programs had significant effects, while others did not. The implications of these results for the mental health field and for service providers and policy makers are discussed. nan Over the past decade, there has been increasing interest in the employment of mental health consumers in various roles as providers of services. Although integration of consumers into case management services has been studied, the roles of consumers have been poorly defined and the benefits have not been established. The goal of this study was to evaluate whether consumers enhance case management outcome through the provision of social support.
                This study compared consumer-assisted and non-consumer-assisted case management with standard clinic-based care. The consumer role focused on the development of social support by using peer staff who matched the profile of participants. A total of 203 clients with severe and persistent mental illness were randomly assigned to one of the three conditions and followed for 12 months.
                All three programs yielded the same general pattern of improvement over time for symptoms, health care satisfaction, and quality of life. Clients in the three programs also showed similar but small changes in measures of social network behavior. Consumer-assisted case management was unique in its use of peer-organized activities. Non-consumer-assisted case management made greater use of individual contacts with professional staff. Standard clinic-based care relied more on group and on individual therapy. Despite these variations in the pattern of services over a 12-month period, no one program emerged as categorically superior to the others.
                Although more research is needed to determine optimal roles for consumers in mental health service delivery, a randomized trial found no evidence that the presence of consumers enhances case management outcome. The study investigated the provision of client-focused services to community-based clients with schizophrenia and bipolar disorder. It hypothesised that the delivery of more client-focused services would improve client outcome in terms of functioning, disability and satisfaction with services. Client-focused services were developed using an empowerment model of case management and by the addition of consumer advocates.
                Clients referred for case management were randomly allocated to one of three groups: standard case management (n = 35), client-focused case management (n = 39), or client-focused case management plus consumer advocacy (n = 45). Measures of functioning, disability, quality of life, burden of care and service satisfaction were measured at baseline and 12 months. Outcome data were collected concerning number and duration of hospital readmission, crisis intervention and compliance with treatment and services.
                While there were no differences between the groups on quantitative measures of functioning, disability, quality of life, service satisfaction and burden of care, there were significant between-group differences on qualitative measures of satisfaction with services.
                Several methodological difficulties hampered interpretation of the findings. Although clients did not differ on outcome measures of functioning and disability, the group receiving client-focused case management reported greater satisfaction with service delivery. The study examined the feasibility and effectiveness of using peer support to reduce recurrent psychiatric hospitalizations.
                A randomized controlled design was used, with follow-up at nine months after an index discharge from an academically affiliated psychiatric hospital. Patients were 18 years or older with major mental illness and had been hospitalized three or more times in the prior 18 months. Seventy-four patients were recruited, randomly assigned to usual care (N=36) or to a peer mentor plus usual care (N=38), and assessed at nine months.
                Participants who were assigned a peer mentor had significantly fewer rehospitalizations (.89 ± 1.35 versus 1.53 ± 1.54; p=.042 [one-tailed]) and fewer hospital days (10.08 ± 17.31 versus 19.08 ± 21.63 days; p<.03, [one tailed]).
                Despite the study's limitations, findings suggest that use of peer mentors is a promising intervention for reducing recurrent psychiatric hospitalizations for patients at risk of readmission.
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.