From the Editor

Anxiety provoking. That’s how a patient recently described the first few days of hospitalization in an unfamiliar environment and feeling unwell. Would peer support have helped?

In the first selection, Cecilie Høgh Egmose (of the University of Copenhagen) and her colleagues conduct a systematic review and meta-analysis for Psychiatric Services. In this study, they analyzed 49 RCTs involving more than 12,000 participants and with different types of services and peer support. They find: “peer support interventions generally but only slightly improve outcomes of personal recovery and slightly reduce symptoms of anxiety among individuals with any mental illness.” We look at the paper and its clinical implications.

In the second selection, writer Adele Waters interviews the incoming president of the UK’s Royal College of Psychiatrists in a front cover article for The BMJ. Dr. Lade Smith’s new position is like a British combination of two Canadian presidencies: of the Royal College of Physicians and Surgeons and of the Canadian Psychiatric Association. She has had a big career as an educator, clinician, and researcher. And Dr. Smith is clear in her advocacy: “The chronic underfunding of mental health care must be tackled urgently. We have the evidence to make the case. Investing in mental healthcare is cost effective, saves lives, and enhances our economy.”

And in the third selection, Drs. Vicky Stergiopoulos and Stephen Hwang (both of the University of Toronto) mull violence and Toronto’s transit system. In an essay for the Toronto Star, they push past the headlines and suggest that we address core issues. They write: “Simply adding police officers and security guards on the TTC will not be sufficient. This is not a TTC problem but, rather, a whole system problem.”


Selection 1: “The Effectiveness of Peer Support in Personal and Clinical Recovery—Systematic Review and Meta-Analysis” 

Cecilie Høgh Egmose, Chalotte Heinsvig Poulsen, Carsten Hjorthøj, et al.

Psychiatric Services, 8 February 2023  Online First

Efforts have been made worldwide to give mental health services a more recovery-oriented direction, by using a recovery-oriented practice as the dominant paradigm. In this paradigm, personal recovery is defined as ‘a way of living satisfying, hopeful, and reciprocal lives, together with others even though we may still experience distress…’ Personal recovery differs from clinical recovery, which has traditionally focused on the reduction of symptoms and increased levels of functioning. Recently, a meta-analysis has found a significant small-to-medium association between clinical recovery and personal recovery, suggesting that both perspectives should be considered in treatment and outcome monitoring of patients with severe mental illness…

Peer support, defined as ‘giving and receiving help founded on key principles of respect, shared responsibility, and mutual agreement of what is helpful’ delivered by individuals with lived experiences of mental illness, is regarded as a central element in recovery-oriented practices… [In] recent years, peer support has become widely used across different settings – for example, peers are employed as recovery mentors in psychiatric hospital health care, volunteer in mutual support groups in civil-society settings, and moderate online peer-to-peer interventions.

However, the evidence of the effectiveness of peer support is mixed and is primarily based on outcomes among individuals with severe mental illness.

So begins a paper by Egmose et al.

Here’s what they did:

“A systematic review of randomized controlled trials (RCTs) was conducted in PubMed, PsycInfo, CINAHL, Cochrane Library, and Web of Science. A meta-analysis of outcomes of personal and clinical recoveries at the end of interventions was conducted.”

Here what they found:

  • “49 RCTs with 12,477 participants with any mental illness were included.”
  • “Most of the trials had a high risk for bias” Only one was classified as “good” in terms of bias; the rest were “fair” or “poor.” (!)
  • “Peer support in general had a small positive effect on personal recovery (standard mean difference=0.20…) and decreased anxiety symptoms (SMD=−0.21…).” 
  • The positive effect for personal recovery was most seen for peer support offered in addition to hospital care.
  • “Evidence of efficacy of peer support provided independently of hospital settings or online is promising and requires more high-quality RCTs.”

A few thoughts:

1. This is an interesting study. It adds nicely to the evolving peer support literature. And the distinction between personal recovery and clinical recovery is thoughtful. Bonus: the first author has lived experience.

2. The paper in a sentence: peer support helped with personal recovery and anxiety, but not with clinical recovery.

3. The study draws on past studies, of course – but the authors find significant bias, colouring the final result.

4. The authors pulled together different types of peer support, creating a big pool of RCTs, including peer support in and out of hospital settings, those who receive compensation, and those working with online support groups. The approach meant an impressive number of studies were reviewed – but was the definition too broad?

5. How to interpret the results? The authors are cautious: “[B]efore we can recommend implementation of peer support in specific health care settings, co-created high quality trials measuring the effectiveness, including potential adverse effects, and the cost-effectiveness of the intervention are needed.”

6. There is something compelling about this work – as we move from patients being seen as passive members of the health care community to active partners in clinical care development, research, and service delivery.

The full Psych Services paper can be found here:

Selection 2: “To improve mental healthcare we first need to build respect for psychiatry”

Adele Waters

The BMJ, 22 February 2023

When Shubulade (Lade) Smith takes up the presidency of the Royal College of Psychiatrists (RCPsych) in July, she will be following her late father’s advice.

She didn’t have the role in her sights when the election campaign kicked off last year, because she was focused on making the regular journey from London to Manchester to visit her terminally ill father. As she sat by his bedside during their final days together, she kept being interrupted by texts encouraging her to run for the presidency. When she told him about the opportunity to lead her profession, he told her to ‘give it a go.’

After he died, she declared her intention to stand and, following a decisive vote by the membership (42.8%) in one of the largest election turnouts the college has had for decades (39.4% of the membership), she won and will become president in July.

So begins an article by Waters.

In this lively interview, Waters profiles incoming president of the UK’s Royal College of Psychiatry. Dr. Smith has a record of accomplishment, as the article notes: “researcher – a she has published more than 70 journal articles, book chapters, and research letters; educator – she is a visiting senior lecturer at the Institute of Psychiatry, Psychology, and Neuroscience, King’s College London; and policymaker – she is a director of the National Collaborating Centre for Mental Health. In November 2019 she was awarded psychiatrist of the year by RCPsych and a CBE.”

Dr. Smith talks about her enthusiasm for our field: “During the campaign I spoke to many psychiatrists. They had brilliant ideas and it was heartening to find out that they weren’t all bitter or burnt out. Yes, they were overworked – but they still had hope and optimism and enthusiasm. More than anything, they had real care and compassion for their patients and absolutely wanted the best for them. Everything they talked about was around what we can do to make things better.”

She reviews her plans for the Royal College which include twice-yearly debates to consider big topics. She also wants to continue trying to tackle inequities.

The article describes her background: she decided to become a doctor when, in her youth, she spent hours observing people at the Manchester Central Library. She excelled at school and was admitted to her first-choice medical school – only to struggle and fail exams since she was away from her strict Nigerian parents. She briefly considered a career in obstetrics, but decided on psychiatry during her first rotation. “It was a lightbulb moment. I realised what I loved was the connection to patients.”

The article closes with some of Dr. Smith’s comments from her recent campaign.

On psychiatry

“Psychiatrists are the backbone of our mental health system…”

On workforce

“For psychiatrists to provide the compassionate, person centred, equitable care that we were trained to do, we must tackle workforce shortages and chronic resource deficits. Working psychiatrists must regain job satisfaction…”

On equality

“All psychiatrists must feel valued and supported by the college to achieve their potential. I will continue to promote equality. I will improve systems to tackle workplace inequality faced by women, ethnic minority doctors, LGBTQ+ doctors, and doctors with disabilities, so that psychiatrists thrive in their workplace.”

A few thoughts:

1. This is an entertaining article. And Dr. Smith landing the cover of BMJ may be a first for a psychiatrist. That’s not her only first, of course: she’s the first Black woman to lead a UK royal college.

2. One day, I hope to sit down with Dr. Smith for a cup of coffee.

3. Though this article is written for a British publication about a British colleague, the issues also seem very relevant here.

The full BMJ interview can be found here:

Selection 3: “Rethinking crisis intervention at the TTC”

Vicky Stergiopoulos and Stephen Hwang

Toronto Star, 21 February 2023

Riding transit to work or school shouldn’t be a scary proposition, but that’s unfortunately the daily reality for far too many who take transit as a daily necessity.

This is not an issue of a subway station, or any other public space, being inherently unsafe. The issues that are plaguing our society are migrating onto the TTC. Violent incidents don’t occur in a vacuum.

The response to add 80 police officers and 50 in-house security personnel to address the recent violence on the TTC is predictable and follows the approach taken in many North American cities, but will it be effective?

So begins an essay by Drs. Stergiopoulos and Hwang.

They argue that the reasons for these problems are complex: 

“The leading factors that increase the risk of violent behaviour are trauma, victimization and abuse. Inadequate income, loss of employment and lack of access to basic necessities, such as housing and food, are also key predictors. When coupled with substance use or certain mental health conditions, these stressors increase the likelihood that an individual will commit acts of violence.” They continue: “Underfunding of social services, abdication of mental health supports and housing by senior levels of government, lack of supports for people who use drugs, and trauma from the pandemic are just some of the root causes that have led to the behaviours we are witnessing.”

They are cool to the idea of more police officers. “The presence of an officer in uniform may deter crime or stop an assault in progress, but with 75 subway stations, 192 bus routes, over 8,000 bus and streetcar stops serving 1.7 million daily passengers, the odds are long that a police officer will be on the scene at the moment they are needed. In addition, many situations on the transit system may be escalated rather than made better by police involvement.” 

Instead, they see a larger societal response. “Research shows that communities that provide early years programs, supports for at-risk youth, job training and employment, and decent affordable housing as well as other measures that address the social determinants of health have lower crime rates.”

And they advocate for an alternative to police. “A team of crisis workers who are trained to provide assistance to people with mental health issues may be better able to proactively identify and de-escalate potentially violent situations. Moreover, crisis workers can refer people to the care providers they need and ensure that the individual isn’t just being shuffled from the transit system to other spaces such as libraries and coffee shops.”

A few thoughts:

1. This is a good and important essay.

2. The suggestion of crisis workers is thoughtful.

3. We need more of this type of writing, helping inform the public – and, ultimately, shaping public opinion.

The full Star essay can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.