We conducted a Health Technology Assessment (HTA) to inform decisions related to the adoption, implementation, and evaluation of peer support programs for youth mental health. The main findings of this HTA show:
Youth recognize the value of peer support in their mental health recovery and wellness, and they view peer support as an accessible, convenient, and safe mental health resource. They also highlight the importance of representation and involvement of youth with diverse backgrounds and experiences in the design and evaluation of peer support programs to ensure equity, diversity, and inclusion.
Formal peer support programs (i.e., support is provided by trained peer support workers based at structured community- or health clinic–based organizations) might help a young person feel more comfortable to share information about their mental health issue and ask for help. The 2 studies we identified found that peer support may improve youth’s attitudes toward disclosure of mental illness, distress related to that disclosure, and help-seeking behaviour more than no peer support. However, because only a small amount of low-quality evidence is available, it is very uncertain whether peer support programs are as or more effective at supporting an individual in their recovery compared with programs without a peer support component.
The safety of peer support programs for the management of mental health concerns in youth is currently unknown (no research evidence was found).
Formal guidance for evaluating peer support programs for youth mental health is currently lacking and evaluation practices vary across programs in Canada. However, most programs share common evaluation practices. These include focusing on recovery-oriented outcomes, involving youth throughout the evaluation (to ensure relevance), and tailoring the evaluation to reflect the local program context.
When considering implementation of peer support programs for youth mental health, decision-makers may wish to allocate resources for ongoing program evaluation. Strengthened program evaluations can improve the understanding of the benefits and maximize the effectiveness of peer support programs. In addition, practice-based evidence from the evaluation of peer support programs can be used to further support the design and implementation of appropriate, equitable, and culturally competent programs.
The mental health of youth living in Canada is a serious public health concern that worsened during the COVID-19 pandemic. It is now estimated that the proportion of youth who are affected by a mental health challenge has reached or exceeded 60%. As a result, increasing numbers of youth need access to mental health support in Canada. However, social issues (e.g., fear of the stigma) and system-level issues (e.g., limited availability of public mental health services and lengthy wait lists) create barriers to accessing care. Health system decisionmakers across the country are considering options to improve the availability and provide timely access to mental health support for youth. Peer support is considered a promising option.
Peer support contributes to mental health recovery by connecting youth with a youth peer support worker who has a shared experience of mental health challenges. The peer support worker, who is typically a youth in a positive state of recovery with the skills and training to provide peer support, can guide and link the peer support user to mental health services and provide support for coping with mental health challenges. The peer support user can learn from the information, behaviour, or encouragement provided by the peer support worker.
Participation in peer support programs is typically voluntary and does not require a referral or formal diagnosis to receive care. In addition, peer support can be a standalone program or complement other mental health services.
Peer support programs are currently delivered through community, non-governmental organizations, and health care facilities in Canada; however, the effectiveness of these programs is not well-established. To inform decisions about adoption and implementation of peer support programs for youth mental health, decisionmakers want to know the clinical effectiveness and safety of these programs. In addition, they want to know how to evaluate peer support programs. This HTA provides evidence to support decisions related to the adoption, implementation, and evaluation of formal peer support programs for youth mental health.
For this HTA, we engaged youth advisors (peer support users and workers) who shared their perspectives with the research team at various stages of the project. We also conducted a systematic review of the available evidence on the clinical effectiveness and safety of peer support interventions compared with interventions without peer support for youth aged 12 to 25 years with mental health concerns (substance use was excluded) and an Environmental Scan of peer support program evaluations. For this review, we considered only formal peer support delivered by trained peer support workers with shared lived experience.
Four youth with lived experience of peer support helped the research team understand the context for the scientific evidence and the experiences of those accessing and providing peer support. We retrieved relevant publications for the review through a systematic search of multiple electronic databases and the grey literature. The Environmental Scan included a limited literature search of the published and grey literature and consultations with stakeholders from organizations that offer peer support services for youth mental health in Canada.
Engagement of peer support advisors: The advisors shared that peer support appeals to youth mainly because it offers a first point of contact and an accessible, convenient, safe, and low commitment mental health support service. The youth advisors agreed that outcomes related to their recovery journey (e.g., community integration, overall fulfillment, emotional regulation, empowerment, education, employment, and social connections) were central to their experiences with peer support. Because recovery is a process, the advisors proposed that the benefits of peer support could be measured over time rather than at a single time point. The advisors also highlighted the importance of representation and involvement of youth with diverse backgrounds and experiences in the design and evaluation of peer support programs. Issues related to safety, such as the importance of setting professional boundaries between peer support service users and workers, were also discussed.
Clinical effectiveness and safety: We identified 3 publications that reported results from 2 randomized controlled trials on outcomes related to personal recovery and clinical symptoms in youth. The limited available evidence suggests that peer support may be favourable over no peer support for some outcomes (e.g., attitudes to disclosure, disclosure-related distress, secrecy, help-seeking behaviour, health-related quality of life), whereas there may be little to no difference in the effect of peer support for other outcomes (e.g., depression, anxiety, hopelessness, social withdrawal, empowerment). However, the evidence is limited and very uncertain for all outcomes. Our review did not find any studies with information related to the safety of peer support programs for youth peer support users.
Environmental Scan on peer support program evaluation: We identified 6 reports (2 published reports from the literature search and 4 reports that were shared by stakeholders) with information related to peer support program evaluations for youth mental health in Canada and internationally. We also conducted 7 targeted consultations with Canadian stakeholders. The findings from the literature and stakeholder consultations indicate that evaluation practices vary across programs in Canada. This is mainly due to a lack of formal guidance and because evaluation practices are often tailored to understand the needs of the individual programs and the youth engaging with those programs.
Common approaches for program evaluation include measuring real-world practice impact, focusing on recovery outcomes, and involving youth in the design and conduct of evaluations (to ensure relevance). Funding considerations and resources required for regular and rigorous program evaluations are reported as common concerns across peer support programs.
Equity considerations when evaluating peer support programs: As discussed with stakeholders, evaluations of peer support programs can reflect program goals for inclusive and equitable access by involving youth in the evaluation design, using multiple methods for data collection to minimize barriers to feedback, ensuring that all evaluations are anonymous and data collection is confidential to ensure participant safety, avoiding the use of clinical language to minimize stigmatization, trying to identify potential inequities during participant intake to help address barriers to participation, and ensuring that evaluations are done in a culturally competent manner.