Depression and anxiety are prevalent mental health challenges, with onset commonly occurring during adolescence and early adulthood (1). In an Australian survey of young people between 4–17 years of age, 6.9% had an anxiety disorder and 2.8% had major depressive disorder in the 12 months prior, which was associated with high levels of distress, self-harm, and impacts on schooling (2). Twelve-month prevalence continues to increases; for example, in an international survey of 14,000 University students, around 18.5% experienced depression and 16.7% anxiety (3). While some young people receive help from trained professionals, a large proportion experience barriers to accessing services or do not have their needs fully met by services (2). For those who do seek help, peers play a critical part in the help seeking process for young people, who often turn to friends and family first before accessing formal help (4).
The degree to which informal support from peers, such as friends and acquaintances, is helpful will depend on how capable and willing peers are to provide such support. Attempts have been made to formalise peer support for promoting mental health and wellbeing in educational settings (5). Although peer support can occur across multiple settings, there is a rapidly growing peer workforce in mental health services, especially in high income countries (6). Peer workers (also called peer support workers, peer practitioners and other terms) are positioned in mental health services and trained to draw on their lived experience of mental health challenges.
In contrast to other roles in the mental health system, the peer relationship is uniquely characterised by shared experience; the value of expertise through experience rather than clinical education and training; and reciprocity/ mutuality, whereby both individuals explicitly learn and benefit from the relationship (7). Peers are responsible for establishing and continually negotiating the ‘rules’ and power structures of the relationship, unlike a clinician-patient relationship (8). Five common mechanisms have been identified across various models of peer support: lived experience; love labour, which refers to assurance of the emotional safety and wellbeing of peers; liminality of the peer worker, describing their position between identities of ‘patient’ and ‘clinician’; strengths-focussed social and practical support, and the helper role of the peer worker, which can facilitate their own recovery (9).
However, mental health services are not always favourable settings for peer support. A number of barriers to implementation have been identified, including role confusion (i.e. employers and/or peer workers not knowing what the role is and how it fits within the service), role diffusion (i.e. spending time doing non-peer support tasks), co-optation (i.e. tasks becoming clinical in nature), professional stigma (i.e. negative attitudes from others and lack of credibility), and lack of support (i.e. availability of peer supervision, appropriate training and professional development) (10, 11).
Despite challenges, several reviews and meta-analyses have assessed the effectiveness of peer support interventions for adults with mental health challenges, finding that client and program characteristics varied widely (12–15). For example, peer workers delivered a range of services, such as peer education, peer support, mentoring, psychoeducation, and case management, in different settings and mediums (see Table 1 for examples of peer support). Regardless, peer support interventions appear to be effective at improving hope, empowerment, increasing patient activation and self-efficacy (12, 13). While one review (15) did not report a significant difference in hope, they suggest this could be attributed to the limited amount of included studies that focused on this, and differences in methodologies and outcome measures.
Table 1
Different Real-World Models of Peer Support
Model | Description | Delivery Methods | Specific Model Benefits | Example |
One-on-one | Peer Support given between two people. Most likely involving a professional third-party to link the two people together. | Face to face, Phone, Online | Tailored for the individual. | 1-on-1 Peer Support Appointments (Orygen; https://oyh.org.au/client-hub/peer-support-team/1-1-peer-support-appointments) |
Group peer-to-peer support | Groups share a lived experience. May be structured and organised, however, no formal facilitator. Can be independent or tied to a larger network. | Face to face, Online | Tailored to the shared lived experience. Can be informal and include social activities. | Grow (https://www.grow.org.au/) |
Peer-led groups | Peer-Leaders sharing their lived experience to support and educate others similar to themselves. Can be workshops or structured group peer support often tied to a larger network. | Face to face, Online | Tailored to the shared lived experience, may have educational aspects. | Hearing Voices Network (https://www.hearing-voices.org/) |
Groups co-facilitated by peer and traditionally qualified expert (e.g. clinician) | Often involves professional health services, where a group of people with a shared lived experience are supported by both an expert and peer. Can be structured and formal. | Face to face, Online | Tailored to both group and individual, may have educational and treatment aspects. | Headspace centres (https://headspace.org.au/headspace-centres/sunshine/youth-peer-support-at-headspace-sunshine/) |
Online peer support | Can be one on one or group format. May have professional involvement through moderators. Mostly peer-to-peer support through forums. | Online | Can be anonymous. | Side by Side (Mind; https://sidebyside.mind.org.uk/) |
Adapted from: https://www.nationalvoices.org.uk/peer-support-hub/peer-support-models-explained. |
NB: All models may be provided in either a traditional service (e.g. community mental health service) or peer-led service. |
Peer support interventions in adult populations generally did not impact quality of life, overall symptom severity, social inclusion (12), depression and anxiety symptoms (13), measures of hospitalisation (13), or service satisfaction (15). Mixed results were reported for several outcomes, including service use (12–15) and client ratings of the working relationship (14, 15). However, more recent evidence (16) has demonstrated a reduction in 12-month rate of readmission to acute care following a self-management program delivered by peer support workers after patients had left the care of mental health crisis teams. The intervention also increased time until first readmission. This recent evidence suggests that peer support may reduce hospitalisations, an important objective outcome for health services worldwide. Trachtenberg (2013) (17) found that peer support work significantly reduces hospital bed use, with the average financial savings outweighing additional costs of employing peer support workers (benefit:cost ratio of 4.76:1), highlighting the cost-effectiveness of peer support.
While these reviews focused on services for individuals with ‘severe mental illnesses’ (typically psychoses, bipolar disorder, severe depression), several meta-analyses have assessed peer support specifically for ‘common’ mental health disorders (e.g., depression and anxiety). Pfeiffer, Heisler (18) included studies comparing peer support versus treatment as usual (TAU) or group cognitive behavioural therapy (CBT) for adults experiencing depression. The peer support group demonstrated a greater reduction in depression scores compared to TAU, but not significantly different to CBT, suggesting possible efficacy at the level of established treatments (18). However, there was wide variability in patient populations, with many studies focusing on subpopulations, such as perinatal mothers. Similarly, Huang, Yan (19) reviewed randomised controlled trials (RCTs) of women with perinatal depression who received either peer support or TAU. For those who received peer support, depression scores were lower than controls, most participants reported intervention satisfaction, and it was cost-effective. Likewise, Field, Diego (20) reported that for women with prenatal depression who received group peer support or group interpersonal psychotherapy, both groups demonstrated significantly lower depression symptoms and cortisol levels (with a greater decrease in cortisol for the peer support group), despite the former group having a lower socio-economic status (SES), higher baseline depression scores, and shorter group sessions. Altogether, the available evidence suggests that peer work is a safe, effective, flexible and cost-effective intervention for adults, which promotes hope, empowerment, patient activation and self-efficacy, and reduces hospitalisations.
Previous work has focused foremost on adult populations, and there is a paucity of literature regarding young people. Using both peer-reviewed and grey literature, Gopalan and colleagues (2017) (21) undertook a United States-specific scoping review of youth peer support services and research for young people under 25 years old with emotional or behavioural problems. In total, 43 articles were identified (only three were randomised controlled trials), with a range of different peer support models, including differences in the program goals, the degree to which peer workers were involved, and the roles they undertook. There was also variation within the peer worker roles, including core competencies, training and supervision received by peer workers. Outside of the USA, the CHOICE project (22, 23) in Australia, studied the impact of youth peer workers supporting consumers (aged 16 to 25 years) to take part in shared decision making regarding their mental health treatment. Peer workers used a co-designed shared decision-making tool with clients before their appointment to see an intake worker (clinician). Young people receiving the intervention felt more involved in treatment decisions with intake workers compared to the comparison group. The project did not measure anxiety and depression symptoms, as the focus was on shared decision making related outcomes; however, it was conducted in a youth mental health service where the majority of clients present with anxiety and/or depression (headspace (24)). Overall, the findings support the use of peer support in promoting shared decision-making.
While the majority of work in this area has focused upon providing peer work within existing mental health services, an additional challenge is that many young people do not access formal services for their mental health concerns (25). Given that connections with peers are especially important during this developmental period, formal and informal peer support may represent an alternative avenue for young people to access support. For example, Reavley et al. (2011) (4) surveyed 275 young people with a mental health disorder in Australia to examine factors related to help-seeking and self-help behaviours. Participants most frequently sought help from family (77% of respondents) and close friends (73%), more so than general practitioners (53%). Peer workers may act as a bridge between, for example, untrained friends, and accessing mental health services.
Therefore, peer support is a strong candidate intervention for young people with depression and anxiety, since people in this age group experience high rates of these mental health concerns in particular, and they may be more receptive to seeking help from peers before or during engagement with formal services. The aim of this systematic review was to understand the effectiveness of peer support for youth depression and anxiety (aged 14–24) as either a primary or comorbid mental health complaint, including the contexts in which it works, who it does and does not work for, and how it works.