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. Author manuscript; available in PMC: 2022 Jul 22.
Published in final edited form as: Early Interv Psychiatry. 2020 Sep 4;15(4):914–921. doi: 10.1111/eip.13036

Roles of peer specialists and use of mental health services among youth with serious mental illness

Victoria D Ojeda 1, Nev Jones 2, Michelle R Munson 3, Emily Berliant 1, Todd P Gilmer 1
PMCID: PMC9305632  NIHMSID: NIHMS1823117  PMID: 32888260

Abstract

Aim:

To examine whether roles of peer specialists affect service use among Black, Latinx and White youth ages 16–24 with serious mental illness (SMI) in Los Angeles and San Diego Counties.

Methods:

Administrative data from 2015 to 2018 was used to summarize service use among 6329 transition age youth age 16–24 with SMI who received services from 76 outpatient public mental health programs with peer specialists on staff. Roles of peer specialists were assessed via a program survey. Generalized linear models were used to assess the relationship between peer specialist characteristics and service use outcomes (ie, outpatient and inpatient).

Results:

Having a transition age youth peer specialist on staff (vs older peer specialists) and having peer specialists that provide four or more services (vs fewer services) was associated with an increase in annual outpatient visits in both counties (P = <.001 each). In Los Angeles County, having three or more peer specialist trainings (vs fewer trainings) was associated with lower use of inpatient services (P < .001). In San Diego County, having a transition age youth peer specialist and peer specialists that provide four or more services was associated with lower use of inpatient services (P < .001 each).

Conclusions:

Types of peer support and number of types of peer services were associated with mental health service utilization. Detailed examination of the roles of peer specialists is merited to identify the specific pathways that improve outcomes.

Keywords: peer specialist, serious mental illness, mental health services

1 |. INTRODUCTION

Youth with serious mental illness (SMI) often face exceptional challenges as they move into early adulthood, including transitions from child- to adult-serving systems, emancipation from foster care and service needs that are often inadequately met (Cusick, Havlicek, & Courtney, 2012; Davis, 2003; Munson & McMillen, 2009; Vostanis, 2005). SMIs, as defined by federal and state mental health authorities in the United States, include schizophrenia-spectrum disorders, severe bipolar disorder and severe major depression that result in serious functional impairment, which substantially interfere with or limit one or more major life activities (MHSA, 2020). SMI impact a large number of transition age youth. The National Survey on Drug Use and Health reported that approximately 2.6 million young adults experienced SMI in the past year (SAMHSA, 2018). Recent research also reveals that the prevalence of suicidality and major depressive episodes among young adults have increased steadily over last decade (Twenge, Carter, & Campbell, 2017), with rates of suicide increasingly sharply in recent years for particular racial/ethnic subgroups including African American (Al-Mateen & Rogers, 2018) and Native American/Native Alaskan youth (Ivey-Stephenson, Crosby, Jack, Haileyesus, & Kresnow-Sedacca, 2017). Documented rates of SMI among young adults have been found to be high when compared with older and younger age cohorts (Kessler et al., 2010; Twenge et al., 2017).

Compared with youth without SMI, youth with SMI have lower levels of educational attainment, and higher rates of unemployment, poverty, unplanned pregnancy, substance use, homelessness and justice system involvement (Davis, Banks, Fisher, & Grudzinskas, 2004; Davis & Vander Stoep, 1997; Vander Stoep et al., 2000; Wagner & Newman, 2012). Concerns about the mental health system’s ability to engage, retain and treat youth with SMI have prompted calls for agerelevant and culturally appropriate services (Edlund et al., 2002; Manteuffel, Stephens, Sondheimer, & Fisher, 2008; Pottick, Bilder, Vander Stoep, Warner, & Alvarez, 2008).

Conceptual frameworks identify common determinants of engagement among youth, including beliefs about treatment, stigma and trust (Lal & Malla, 2015; Munson et al., 2012). Peer support services may improve engagement of youth by providing culturally and developmentally appropriate supports that build on mutuality, empathy, hope and trust (Gopalan, Lee, Harris, Acri, & Munson, 2017; Grant, Simmons, & Davey, 2018; Simmons, Batchelor, Dimopoulos-Bick, & Howe, 2017; Solomon, 2004). Peer providers (or peer specialists) possess unique knowledge and expertise based on lived experience and training. They can have enhanced credibility with youth and possess an ability to serve as role models for resilience/recovery (Coates & Howe, 2014; Howe, Batchelor, & Bochynska, 2011; Swanton, Collin, Burns, & Sorensen, 2007). Peer specialists report that their most important roles involve developing relationships with clients, and both peer specialists and clients report that shared lived experience is a key element in establishing those bonds (Cabral, Strother, Muhr, Sefton, & Savageau, 2014; Simmons et al., 2020).

Systematic reviews and meta-analyses of peer support among adults have come to differing conclusions (Davidson, Bellamy, Guy, & Miller, 2012; Lloyd-Evans et al., 2014; Reif et al., 2014). As commentators have noted, challenges with evaluating effectiveness include the diverse array of roles and responsibilities adopted by peer providers, particularly in naturalistic community based settings (Jones, Teague, Wolf, & Rosen, 2020; Salzer, Schwenk, & Brusilovskiy, 2010) and lack of consensus and consistency in the operationalizations of peer roles and selection and measurement of outcomes in research trials (Chinman et al., 2016; King & Simmons, 2018). Overall, evidence tends to be stronger for manualized peer-led interventions such as Wellness Recovery Action Planning (WRAP), a group based structured intervention revolving around the development of a symptom self-management and advance crisis plan (Cook et al., 2010; Cook, Copeland, et al., 2012a). Research on the implementation of peer services consistently identify numerous barriers and areas in which support for peer roles is lacking, including role ambiguity, low pay and lack of benefits, poor or inadequate supervision and lack of opportunities for growth or advancement (Cabral et al., 2014; Jones, Kosyluk, Gius, Wolf, & Rosen, 2019).

With respect to youth peer support more specifically, the relative importance of shared characteristics and experiences between peer providers and youth served—including age, race/ethnicity and involvement with other systems, including juvenile justice and child welfare—remains empirically unaddressed; and youth-specific peer provider credentials remain underdeveloped and underevaluated relative to adult certifications (Walker, Baird, & Welch, 2018).

In this study, we build on this limited research to examine the roles of peer specialists among publicly funded outpatient youth and young adult mental health programs in Los Angeles and San Diego counties. We examine the presence of peer specialists, their age and we quantify the range and number of services provided. We also quantify the training of peer specialists in evidence-based practices. We estimate the effect of these peer specialist roles on use of mental health services, hypothesizing that youth who receive services from programs in which peer specialists provide a greater range of services and who receive trainings in more practices will have a more favourable service profile, which we define as higher use of outpatient services and lower use of inpatient services. In the present study we use the term youth to describe transition-age youth regardless of age of onset or past use of services.

2 |. METHODS

2.1 |. Study sample

Administrative data provided by the Los Angeles county Department of Mental Health and the San Diego county Department of Behavioural Health Services were used to identify Black, Latinx and White transition age youth ages 16–24 receiving services premised on a diagnosis of SMI (as defined by the state of California) (2020) who received outpatient mental health services in three fiscal years, from July 1, 2015 to June 30, 2018. Data include date of birth, gender and race and ethnicity; outpatient service use information including dates of service, diagnosis codes and procedure codes; and inpatient service use information including admission and discharge dates.

We organized data by fiscal year. Age was calculated as of January 1 of the fiscal year. Procedure codes identified outpatient services including case management, medication management, rehabilitation and therapy. We calculated the number of outpatient visits as the number of unique days during which one of these services was received. We similarly calculated the number of unique inpatient admissions during the fiscal year. Diagnoses were examined across the fiscal years and the study team hierarchically assigned a diagnosis based on a schizophrenia, bipolar disorder, or major depression; for example, if a youth received a diagnosis for both schizophrenia and depression, a diagnosis of schizophrenia was assigned.

Youth were assigned to the outpatient program in which they received the highest number of outpatient services during the year; ties were handled by random assignment. The focus of the study was on nonteam-based outpatient mental health programs; that is, those providing services such as medication management, counselling and vocational supports without centralized care coordination. In order to help accurately identify programs serving predominantly youth we limited the sample to sites that served at least 20 youth during any given fiscal year. We excluded programs which reported employment of peer specialists for less than 3 years, in order to ensure that peer specialists could have been accessed by participants throughout the 3-year study period.

2.2 |. Program survey

We implemented a computer-assisted self-administered (CASI) survey using Qualtrics, a HIPAA-compliant cloud-based survey software (Provo, UT) to collect program-level data. Contact information was obtained for the programs in which youth were identified as receiving outpatient services. Programs were contacted by phone to describe the study and to identify the appropriate persons to respond to the survey. Proposed program responders held a leadership position and had broad knowledge of the program including the array of services provided and the use of peer specialists; responders were typically program managers.

The program survey was conducted from August 1, 2018 and January 10, 2019. Proposed responders received personalized survey links and nonresponders or persons with incomplete surveys received weekly emailed reminders. Responders were also offered the option of completing an interviewer-administered survey on a day/time of their choosing. Electronic informed consent was provided by responders prior to responding to the survey. We sent survey requests to 335 programs; of these, 183 programs (54.6%) responded to the survey and 76 of respondents (45.1%) reported a peer specialist on staff. This study used survey data regarding the array of available services, the characteristics of peer specialists including age, gender and race/ethnicity, the services provided by peer specialists and whether peer specialists received training in specific evidence-based practices.

2.3 |. Analysis methods

Regression analyses were used to estimate the relationship between outpatient mental health visits and inpatient mental health services and the roles peer specialist, adjusting for age, gender, race/ethnicity, clinical diagnosis and the array of services available from the outpatient program. The annual number of outpatient mental health services was estimated using generalized linear models assuming a gamma distribution and a log link function (Blough, Madden, & Hornbrook, 1999; Manning & Mullahy, 2001). The probability of having an inpatient mental health service was estimated using logistic regression. Standardized estimates of the effects of specific characteristics of peer specialists on annual outpatient visits and the probability of inpatient admission among programs were calculated using recycled predictions (Basu & Rathouz, 2005).

Standard errors for each of the estimates were calculated using the nonparametric bootstrap with clustering at the program level and P-values were computed using the percentile method from the empirical distributions of the results from 1000 replicates (Efron, 1993). This study was approved by the Human Subjects Research Protections Program at the University of California, San Diego, Los Angeles Department of Mental Health and San Diego County Department of Behavioural Health Services in accordance with the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996.

3 |. RESULTS

3.1 |. Outpatient program sample

Table 1 shows the characteristics of 76 outpatient mental health programs that provided services to transition age youth age 16–24 living with SMI that had peer specialists on staff.

TABLE 1.

characteristics of programs with peer specialists that provide services to transitional age youth in Los Angeles and San Diego counties

Overall
 Los Angeles county
 San Diego county
N % N % N % P-value
Overall 76 44 32
Age of peer
 Age 16–24 29 38.2 19 53.2 10 31.3 .290
 Age 25–30 35 46.0 21 47.7 14 43.8 .731
 Age 31+ 47 61.8 27 61.4 20 62.5 .920
Services provided by peer specialists
 Peer-led counselling 34 44.7 14 31.8 20 62.5 .008
 Peer-led education 44 57.9 21 47.7 23 71.9 .035
 Peer support groups 46 60.5 28 63.6 18 56.3 .515
 Peer mentoring 58 76.3 38 86.4 20 62.5 .016
 Peer recovery champions or coaches 15 19.7 9 20.5 6 18.8 .854
 Peer-run crisis intervention 14 18.4 6 13.6 8 25.0 .207
 Peer-run crisis residential 5 6.6 3 6.8 2 6.3 .921
 Peer-led drop in centre 9 11.8 8 18.2 1 3.1 .045
 Peer-led activity groups/community outings 47 61.8 32 72.7 15 46.9 .022
Number of services provided by peer specialists
 Peers provide four or more services 38 50.0 20 45.5 18 56.3 .353
Peer specialists trained in evidence based practices (EBPs)
 Applied suicide intervention skills training (ASIST) 7 9.2 6 13.6 1 3.1 .118
 Building recovery of individual dreams and goals through education and support (BRIDGES) 1 1.3 1 2.3 0 0 .391
 Individual placement and support (IPS) 8 10.5 4 9.1 4 12.5 .633
 Mental health first aid 40 52.6 28 63.6 12 37.5 .024
 Motivational interviewing 50 65.8 26 59.1 24 75.0 .149
 Permanent supported housing 12 15.8 10 22.7 2 6.3 .052
 Seeking safety 29 38.2 16 36.4 13 40.6 .706
 Supported education 7 9.2 5 11.4 2 6.3 .447
 Transition to independence process (TIP) 7 9.2 5 11.4 2 6.3 .447
 Wellness and recovery action plan (WRAP) 33 43.4 16 36.4 17 53.1 .146
Number of trainings available to peer specialists
 Trainings available in three or more EBPs 39 51.3 22 50.0 17 53.1 .788
Services available from program in addition to behavioural health
 Basic services (eg, ID, transportation, laundry) 43 56.6 30 68.2 14 40.1 .017
 Benefits management 25 32.9 20 45.5 5 15.6 .006
 Education support 52 68.4 33 75.0 19 59.4 .148
 Employment support 59 77.6 39 88.6 20 62.5 .007
 Family services (eg, family therapy, parenting skills) 45 59.2 30 68.2 15 46.9 .062
 Financial skills 40 52.6 26 59.1 14 43.8 .186
 Housing support 58 76.3 39 88.6 19 59.4 .003
 Physical health services 23 30.3 17 38.6 6 18.8 .062
Number of services available from program
 Program provides five or more services 34 44.8 24 54.6 10 31.3 .044
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About one-third of programs with peer specialists on staff employed peer specialists who were themselves transition aged (16–24; N = 29, 38.2%); 35 programs (46.0%) had peer specialists who were close in age (25–30) and 47 (61.8%) had peer specialist who were over 30 years of age. Peer specialists provided a wide range of services. The most commonly were peer support groups (N = 46, 60.5%), peer mentoring (N = 58, 76.3%) and peer-led activity groups or community outings (N = 47, 61.8%). Among one half of programs, peer specialists provided four or more types of services.

Peer specialists were trained in multiple ‘evidenced based practices’ as defined by US federal mental health authorities (Ojeda et al., 2016). The most common trainings received by peer specialists included Mental Health First Aid (MHFA; N = 40, 52.6%), Motivational Interviewing (N = 50, 65.8%) and Wellness and Recovery Action Plans (WRAP; N = 33, 43.4%). Peer specialists in approximately one half of programs, received trainings in three or more evidenced based practices.

Programs provided a wide range of services in addition to those more narrowly targeting clinical behavioural health issues. The most common of these services were supports designed to address basic needs (eg, transportation, laundry), education and employment and housing. Approximately one third of programs provided five or more additional services.

Although there were some differences in peer specialist trainings and services and in Los Angeles vs San Diego counties, there were no significant difference in the overall number of services provided or trainings received by peer staff.

3.2 |. Youth study sample

Table 2 shows the characteristics of the 6329 youth in the sample who received services from 76 outpatient mental health programs in Los Angeles (N = 3928, 62.1%) and San Diego (N = 2401, 37.9%) counties. The mean age was 19.9 (SD = 2.7); 3387 (53.5%) were female; 1179 (18.6%) were Black, 3967 (62.7%) were Latinx and 1183 (18.7%) were non-Latinx White. About 1344 (21.2%) received a diagnosis of schizophrenia, 1595 (25.2%) bipolar disorder and 3390 (53.6%) major depression.

TABLE 2.

Characteristics of transitional age youth receiving services in outpatient programs with peer specialists in Los Angeles and San Diego counties

Overall
 Los Angeles county
 San Diego county
N % N % N % P-value
Overall 6329 3928 2401
Age group <.001
 Age 16–17 1766 27.9 1241 31.6 525 21.9
 Age 18–19 1291 20.4 811 20.7 480 20.0
 Age 20–21 1207 19.1 693 17.6 514 21.4
 Age 22–23 1231 19.5 698 17.8 533 22.2
 Age 24–25 834 13.2 485 12.4 349 14.5
Gender <.001
 Female 3387 53.5 2179 55.5 1208 50.3
 Male 2942 46.5 1749 44.5 1193 49.7
Race/Ethnicity <.001
 Black 1179 18.6 837 21.3 342 14.2
 Latinx 3967 62.7 2696 68.6 1271 52.9
 Non-Latinx White 1183 18.7 395 10.1 788 32.8
Diagnosis <.001
 Schizophrenia 1344 21.2 591 15.1 753 31.4
 Bipolar disorder 1595 25.2 831 21.2 764 31.8
 Major depression 3390 53.6 2506 63.8 884 36.8
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There were significant differences among youth in our sample between the two counties (Table 2). Youth in Los Angeles county were somewhat older, more likely to be female, and more likely to be Black or Latinx, but were less likely to be diagnosed with schizophrenia or bipolar disorder than youth in San Diego county (P ≤ .001 each). Table 3 shows annual mean numbers of outpatient mental health visits and the annual probability of inpatient mental health services use. Youth in Los Angeles county had a significantly greater number of outpatient visits, and youth in San Diego county had a higher probability of inpatient admission (P < .001 each). Given these significant differences in youths’ characteristics, we decided to analyse the data separately by county.

TABLE 3.

Standardized estimates of mental health outpatient visits and probability of inpatient mental health service use among transitional age youth by county

Mental health outpatient visits
 Inpatient mental health service use
County Mean visits SE P-value Probability of use SE P-value
Overall 14.5 1.4 13.8 4.0
Los Angeles County 15.3 1.6 11.1 5.0
San Diego County 13.1 .8 <.001 16.9 2.2 <.001
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3.3 |. Peer specialist roles and service use

Table 4 shows standardized estimates of service use associated with peer specialist characteristics, stratified by county. Youth receiving services in programs that included transition age youths as peers (vs having only older peers on staff) had the greatest number of outpatient mental health services annually: 12.43 (SE = 1.3) visits higher in Los Angeles county and 8.4 (SE = .7) visits higher in San Diego county (P < .001 each). Outpatient service use was higher among programs in both counties where peer specialists provided four or more services (vs fewer types of services) and when programs provided five or more services in addition to behavioural health services (P ≤ .001 each). Outpatient service use was higher among programs in San Diego county where peer specialists received trainings in three or more evidenced based practices (vs having trainings available for fewer practices) (P ≤ .001).

TABLE 4.

Standardized effects of peer specialists characteristics on numbers of mental health outpatient visits and probability of inpatient mental health service use among transitional age youth in programs with peer specialists

Effect on mental health outpatient visits
 Effect on inpatient mental health service use
County Mean visits SE P-value Probability of use SE P-value
Los Angeles county
 Peer age 16–24 12.4 1.3 <.001 −.2 1.1 .403
 Peers provide four or more services 9.4 1.0 <.001 1.3 1.2 .877
 Peers trained in three or more EBPs −.1 .9 .548 −4.5 1.1 <.001
 Programs provide five or more services 6.1 1.0 <.001 −.2 1.3 .449
San Diego county
 Peer age 16–24 8.4 .7 <.001 −6.5 1.8 <.001
 Peers provide four or more services 4.0 .6 <.001 −7.1 2.2 <.001
 Peers trained in three or more EBPs 2.4 .6 <.001 −2.4 1.6 .061
 Programs provide five or more services 6.3 1.0 <.001 −12.3 1.9 <.001
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The effect of peer specialist characteristics on inpatient mental health service use was less consistent by county. In Los Angeles county, having three or more trainings was associated with a lower probability of using inpatient services (P < .001). In San Diego county, having a youth peer specialist, peer specialists that provide four or more services and programs that provided five or more services in addition to behavioural health services was associated with declines in inpatient services (P < .01 each).

4 |. CONCLUSIONS

In this article, we examined the relationship between peer specialist roles and peer service characteristics and the use of outpatient and inpatient mental health services among Black, Latinx and White youth with SMI in Los Angeles and San Diego Counties. We found that peer specialists provided a wide range of services, that the number of types of services varied, and that peers received varying trainings in a wide range of evidenced-based or supported practices. We found that having young adults on staff as peer specialists, providing multiple types of peer programming and having access to multiple trainings was associated with increased use of outpatient mental health services. We also found that access to peer specialists was associated with reduced inpatient mental health services use, although this association were not consistent across the two counties. Our differential findings by county speak to the importance of context and the importance of examining interventions, including peer support, by county or administrative catchment area.

Peer support services are designed to support individuals through challenges and crises, ideally preventing hospitalization, a commitment which potentially offers youth a greater chance of remaining in the community, as opposed to inpatient settings. These outcomes also are suggestive of the potential for peer support services to offer cost savings to agencies and health care systems in California, and potentially other states and regions.

Building on previous research, this study supports the importance of structured training, support and supervision for peer support specialists as the field moves forward in the 21st Century. For example, findings suggest that additional training, as well as greater structure attached to peer roles, as operationalized through a higher number (and array) of peer-delivered services, may increase the impact and benefits of peer service components. While some of the specific EBPs represented in the survey were peer-developed (eg, WRAP) others were not (MHFA). In many California counties, and presumably other national and international jurisdictions, administrative policy places a strong emphasis on training in ‘EBPs’, presumably helping to account for training and delivery of nonpeer-specific interventions. Additional research would be helpful in teasing out the influence of different trainings and interventions, distinguishing between those explicitly designed for peer delivery, and explicitly aligned with a peer support ethos, vs those designed for nonpeer providers. It would also be important to unpack the extent to which nonpeer interventions may be adapted in order to better align with peer support values, and the role of supervisors in guiding potential adaptation(s). In addition, the general dearth of well-researched peer-developed interventions also contributes to the use or substitution of generic EBPs and underscores the need for substantive increases the funding of rigorous research and development projects that focus on peer-led interventions.

There are considerable implications for the field of peer support services and their potential to influence outcomes for youth with SMI. A major finding here is that greater investment in peer roles in the context of youth mental health services, including training and breadth of peer services offerings, in turn positively impacting service utilization, operationalized here as increased outpatient and decreased inpatient service use. These findings mirror several adult system of care studies in which peer support has likewise been associated with increased outpatient services and reduced psychiatric hospitalization (Castellanos, Capo, Valderrama, Jean-Francois, & Luna, 2018; Landers & Zhou, 2014). An important next step is the investigation of (potential) causal relationships between altered service utilization patterns and client-level outcomes. To date, virtually all evidence concerning the effectiveness of peer support has stemmed from specific clinical trials, often focused on narrow interventions, such as WRAP (Cook et al., 2010; Cook, Copeland, et al., 2012a) (Cook et al., 2010; Cook, Copeland, et al., 2012a) or BRIDGES (Cook, Steigman, et al., 2012b), that fail to encapsulate the breadth and diversity of real-world peer provider roles. Documenting improved outcomes in large, real-world implementation settings and unpacking mechanisms of action in these settings, is critical.

This article had a few limitations. Our analyses focused on commonly used mental health services that were captured in administrative data. We may have missed changes in other types of services that were not captured in the data such as nonclinical, psychosocial interventions. We did not have data on mental health outcomes or functioning, or targets such as resilience and self-efficacy that are often a focus of peer support. We measured peer support using a point in time survey of program managers, and our study design compared programs where peers has more involved roles—providing a wider range of services and receiving more trainings—than programs where peers had fewer roles; although we were able to control for a range of services provided by the programs, it is possible that programs where peers were more involved in service delivery differ from programs where peers were less involved in ways that we did not measure yet could affect outcomes (Alberta, Ploski, & Carlson, 2012; Jones et al., 2020).

Despite these limitations, the present study provides useful information using a large sample of youth with SMI. Our data show that certain characteristics of peer-specialists are associated with improved patterns of mental health services use, including increased use of outpatient and reduced use of inpatient mental health services. Future research should consider the context in which peer specialist services are delivered and the considerations that affect the types of peer roles that are implemented, services offered and quality of trainings and supervision.

Funding information

This work was supported by grant R01MD011528 from the National Institute on Minority Health and Health Disparities.

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