Issues in Mental Health Nursing

ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: http://www.tandfonline.com/loi/imhn20

Supportive Peer Relationships and Mental Health

in Adolescence: An Integrative Review

Ashley Roach

To cite this article: Ashley Roach (2018): Supportive Peer Relationships and Mental
Health in Adolescence: An Integrative Review, Issues in Mental Health Nursing, DOI:
10.1080/01612840.2018.1496498

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Published online: 25 Sep 2018.

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ISSUES IN MENTAL HEALTH NURSING
https://doi.org/10.1080/01612840.2018.1496498

Supportive Peer Relationships and Mental Health in Adolescence:

An Integrative Review
Ashley Roach, MS, RN, CNL
University of Tennessee, College of Nursing, Knoxville, Tennessee, USA

ABSTRACT
In the United States, nearly one in five adolescents has a diagnosable mental health disorder.
Beginning in the teenage years, adolescents become less reliant on their parents for support and
begin to turn to their peer group for support; therefore, it is important to understand the role of
peers during this developmental time, especially in relation to mental health. The purpose of this
project is to review the literature regarding positive peer support and mental health in adoles-
cence. CINAHL, PubMed, and PsycINFO were used to conduct the review. The inclusive years of
the search were 2007–2017. A total of 15 studies were included for review. The results were con-
sistent over time and settings, demonstrating the positive role of peer support in adolescences
with mental health care needs. Following a synthesis of the literature, gaps in research and impli-
cations for practice and further research, are discussed.

Introduction mental illness have a higher dropout rate compared to all

In the United States, nearly one in five adolescents has a
diagnosable mental health disorder, 30% of high school stu-
dents have reported symptoms of depression, and 18% have
reported seriously considering suicide (Centers for Disease
Control and Prevention, 2016); Substance Abuse and Mental
Health Services Administration, 2014, 2015). The total num-
ber of adolescents is expected to grow to 45 million by 2050
(Health and Human Services Office of Adolescent Health,
2016) and the percentage of adolescents with mental health
disorders continues to rise (Centers for Disease Control and
Prevention, 2016; Substance Abuse and Mental Health
Services Administration, 2014, 2015). The growing numbers
of adolescents with mental health issues present a significant
health problem and there is a need to recognize the factors
that will improve health outcomes for these individuals. The
purpose of this integrative review is to examine the literature
related to supportive peer relationships in adolescents with
mental health care needs and to answer the question: what
impact do supportive peer relationship have on adolescents
in the context of depression, anxiety, and suicide?
Background
The growing number of adolescents with mental health care
needs presents a significant economic and social burden. The
annual cost to treat childhood mental health disorders is esti-
mated at $237 billion (National Research Council and
Institute of Medicine, 2009). Further, seventy percent of
youth in the juvenile justice system have a mental illness
(Shufelt & Cocozza, 2006). High school students with a
other disability groups (US Department of Education, 2014).
Suicide is currently the third leading cause of death for
individuals ages 10–14 and the second leading cause of death
for those who are 15- to 24-years old (Centers for Disease
Control and Prevention, 2015). While these numbers are stag-
gering, evidence supports that mental health disorders can be
treated, mitigated, and managed, but it takes early identifica-
tion and support from the people surrounding the adolescent
(National Research Council and Institute of Medicine, 2009).
Whereas the risk factors for depression, anxiety, and sui-
cide in adolescents have been the focus of much research,
less is known about the protective factors surrounding these
conditions (Beesdo, Knappe, & Pine, 2009; Kirkcaldy, Siefen,
Urkin, & Merrick, 2006; Merikangas, 2005; Strandheim
et al., 2014; Thapar, Collishaw, Pine, & Thapar, 2012).
Recently, the Interagency Working Group on Youth
Programs, representing 20 federal agencies, developed an
agenda to focus on positive youth development (PYD)
(Positive Youth Development, n.d.). PYD programs focus on
promoting protective factors such as supportive school,
community, and social environments to improve outcomes
for adolescents. One key protective factor is a healthy peer
network. Although peers can sometimes have a negative
influence on one another, (Prinstein, Boergers, & Spirito,
2001; Smith, Chein, & Steinberg, 2014) the focus of this
review is on the positive impact of peer relationships.
Significance
Beginning in the teenage years, adolescents become less
reliant on their parents for support and begin to turn to

CONTACT Ashley Roach aroach13@utk.edu University of Tennessee, College of Nursing, 1200 Volunteer Blvd, Knoxville, TN 37916, USA.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/imhn.
ß 2018 Taylor & Francis Group, LLC
2 A. ROACH
Figure 1. PRISMA diagram of literature search on peer support in adolescents with mental health conditions.
their peer group for support (American Psychological
Association, 2002; Furman & Buhrmester, 1992). This is a
normal part of the developmental process and often means
that adolescents feel more comfortable confiding in their
friends as opposed to their parents or other adults. Peers
and friends are on the frontlines of interacting with peers
with mental disorders; therefore, it is important to under-
stand the role of peers during this developmental time, espe-
cially in relation to mental health.
Methods
CINAHL, PubMed, and PsycINFO databases were used to
find primary research articles related to adolescent peer
relationships and suicide, depression, or anxiety. Key search
terms were “peer,” “adolescent,” “friendship,” “support,”
“mental health,” “suicide,” “depression,” and “anxiety.” To
capture the most recent literature, the inclusive years of the
search were 2007–2017. References lists of articles were also
reviewed to include all appropriate articles. Because of vari-
ation in adolescent peer relationships across cultures
(French, 2015; Rude & Herda, 2010), studies were limited to
those conducted in the United States and to those represent-
ing multiple races and ethnic groups, to understand the gen-
eral nature of peer influence in the United States. The
studies that were selected were those that concentrated on
the supportive role of peer relationships, rather than the
negative role of peer relationships. Studies focusing on
college students were excluded. Results of the search are
displayed in a Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) flowchart (Figure 1).
To assess the body of literature related to adolescent peer
support as a whole, all articles meeting the inclusion and
exclusion criteria were included in this integrative review.
The Matrix Method (Garrard, 2016) was used to organize
and synthesize the literature (Table 1).
Results
Search outcome
The original search resulted in 130 articles in CINAHL, 197
in PubMed, and 230 in PsycINFO. After removal of
duplicates, abstracts were read for inclusion and exclusion
criteria, and then limited to 70 for full-length article
review. Fifteen articles (n ¼ 15) were selected for the final
review. The search represented articles from the following
disciplines: social work (Anthony & Stone, 2010; Williams
& Anthony, 2015), psychology (Czyz, Liu, & King, 2012;
Gallagher, Prinstein, Simon, & Spirito, 2014; Jacobson &
Newman, 2016; Mackin, Perlman, Davila, Kotov, & Klein,
2017; Miller, Adams, Esposito-Smythers, Thompson, &
Proctor, 2014; Miller, Esposito-Smythers, & Leichtweis,
2015; Szwedo, Chango, & Allen, 2015), human development
and family studies (Newman, Newman, Griffen, O’Connor,
& Spas, 2007), psychiatry (Petrova, Wyman, Schmeelk-Cone,
Table 1. Results of matrix method review of literature on peer support in adolescents with mental health care needs.
Research
Author/Date Theoretical Framework Question/Hypotheses Methods
Newman et al. (2007) None provided What is the relationship Longitudinal cross-sectional. 9th graders experienced Parents, peers and
between each source Data collected over 2
of social support and years. Participants:
adjustment, especially N ¼ 104 eighth graders
depressive symptoms? and 101 ninth graders
from middle- to high-
income, predominantly
white community in
southern Rhode Island.
In year 2, 60 of the
original 8th graders were
surveyed as 9th graders.
Measures: Peer
support: Perceived Social
Support measure.
Depression: Reynolds
Adolescent
Depression Scale.
Anthony and Eco-interactional-devel- To examine risk and Cross-sectional design Friend support was sig-
Stone (2010) opmental perspective protective factors and Participants: N ¼ 20,749
contextual correlates middle and high school
of health and students Measures:
well-being Secondary analysis of
the public use sample of
the SSP
Weber et al. (2010) Lerner’s adolescent To examine the interre- Cross-sectional design Depressive symptoms
development, stress, lationships between Participants: N ¼ 154
and coping theory depressive symptoms adolescents, 86% white,
and perceived social ranged in age from
support, self-esteem, 14–18 years. Measures:
and optimism in this Depression: Reynolds
sample of rural Adolescent Depression
school-based Scale Peer
adolescents support: Perceived Social
Support Scale Self-
esteem: Rosenberg Self-
Esteem Scale Optimism:
Life Orientation
Test-Revised
Implications for
Results Conclusions Further Research Implications for Practice
Inclusion of different Development of
more depressive schools play import- populations interventions to
symptoms and lower ant roles in support- Further research on support peer connect-
levels of school ing adolescents transition to high edness during
belonging compared during transition to school influence on transition to
to 8th graders. high school. depressive symptoms. high school
Changes in parent Disruption of sense of Examination of social
support and peer belonging has impli- support over the high
support were signifi- cations for mental school years
cantly associated with health, physical
depressive symptoms health, and academic
in the transition to achievement.
high school.
Controlling for
gender, grades in
school, and other life
stressors, parent
support, peer support,
and school belonging
were negatively
associated with
depressive symptoms
in 9th grade.
Peer support, school, Further work to under- Interventions targeted at
nificantly associated and neighborhood stand the differences friend support
with mental health. factors are associated between adolescents
with well-being. reporting high and
low levels of
well-being
Social support may have Further research in Education interventions
were negatively a protective factor for clinical settings with to improve optimism,
correlated with peer depression and pro- adolescents self-esteem,
social support, family mote self-esteem, with depression social supports
social support, self- and optimism.
esteem,
and optimism.
(continued)
ISSUES IN MENTAL HEALTH NURSING
3
Table 1. Continued.
Author/Date Theoretical Framework Question/Hypotheses
Czyz et al. (2012) Emile Durkheim’s To examine the extent
Suicide: A Study in
Sociology; Thomas
Joiner’s Interpersonal
psychological theory
of suicide
Rew et al. (2013) Primary To determine the influ-
Socialization Theory
Kornienko and The Developmental To explore whether the
Santos (2014) Tradeoffs Model
Research
Methods
Longitudinal design- Adolescents who
to which post-hospi- Questionnaires given at
talization change in 3, 6, and 12 months
connectedness with post-hospitalization.
family, peers, and Participants: Hospitalized
nonfamily adults patients (n ¼ 338), 13- to
predict suicide 17 years old who had
attempts, severity of been psychiatrically
suicidal ideation, and hospitalized due to
depressive symptoms acute suicidal ideation
across a 12-month or attempt of suicide.
follow-up period Measures: Suicidal
among inpatient Ideation: Suicidal
suicidal adolescents Ideation
Questionnaire–Junior.
Depression: Children’s
Depression Rating
Scale–Revised Peer con-
nectedness: items from
the Perceived
Emotional ¼ Personal
Support Scale
Longitudinal design Data Adolescents' social con-
ence of parents and collected annually in
peers on adolescents’ participants’ junior and
health-promot- senior years of high
ing behaviors school. Participants: rural
youth (n ¼ 1081, mean
age ¼17 0.7; 43.5%
males; 44% Hispanic)
and their parents
Measures: Stress:
Adolescent Lifestyle
Questionnaire stress
management subscale.
Social connectedness:
Family Integration Scale
Longitudinal design, Data In males with high levels Males who were con-
association between collected at baseline and
social status processes 8 months Participants:
(i.e., friendship net- Adolescents (n ¼ 367)
work popularity) and attending sixth and sev-
depressive symptoms enth grades Measures:
was moderated by Depression: A shortened
socio-cognitive version of the Children’s
aspects of peer rela- Depression Inventory
tions (i.e., a fear of Social anxiety: Fear of
negative evaluation negative evaluation
by peers) and gender (FNE): an 8-item subscale
from the Social Anxiety
Scale for Adolescents.
Friendship network
popularity: friend-
ship nomination
4
Implications for
Results Conclusions Further Research Implications for Practice
Peer connectedness is a Further research on peer Education on the
reported greater protective factor for connectedness, par- importance of social
improvements in peer depressive symptoms ticularly in samples of connectedness as a
connectedness were and suicidal ideation. psychiatrically hospi- protective factor.
A. ROACH
half as likely to talized suicidal Assessment of
attempt suicide dur- adolescents adolescents’ peer
ing the 12-month relationships and pro-
period. Improved peer viding guidance to
connectedness was help them develop
associated with less more supportive,
severe depressive close, and confiding
symptoms for all relationships within
adolescents and with their peer structure.
less severe suicidal
ideation for female
individuals, but only
at the 3-month
assessment
time point.
Social connectedness is Further research is Assessment and facilita-
nectedness was a sig- plays an important needed to develop tion of adolescents’
nificant predictor for role in health promot- and test nursing health-promot-
all types of health- ing behaviors, includ- interventions based ing behaviors,
promoting behaviors ing mediating stress. on primary socializa-
except for safety. tion theory.
Further exploration of Depression prevention
social anxiety, friend- cerned about nega- social and behavioral interventions that
ship network popular- tive evaluations from factors in adolescents contain both interper-
ity was associated peers, friendship net- related to friendship sonal functioning and
negatively with work popularity was network popularity. cognitive-behavioral
increases in depres- associated negatively components and
sive symptoms. with increases in focus on friendship
Conversely, for depressive symptoms development.
females with high lev- during early adoles-
els social anxiety, cence. Conversely, for
friendship network females with high lev-
popularity was associ- els of fear of negative
ated positively with evaluation, friendship
increases in depres- network popularity
sive symptoms was associated posi-
tively with increases
in depressive symp-
toms during early
adolescence.
(continued)
Table 1. Continued.
Research Implications for
Author/Date Theoretical Framework Question/Hypotheses Methods Results Conclusions Further Research Implications for Practice
Gallagher et al. (2014) None provided Loneliness and low per- Longitudinal design. Data Adolescents with high Results are inconsistent Research on the mecha- Assessment of anxious
ceived close friend collected during psychi- levels of loneliness with prior research nisms by which lone- teens for heightened
and parental support atric hospitalization and experienced higher showing that social liness impacts levels of loneliness.
will each statistically at 9 and 18 months post levels of suicidal idea- anxiety in adolescents suicidal ideation. Interventions focused
mediate the relation- baseline Participants: tion at baseline and is associated with on the reduction of
ship between baseline N ¼ 144 adolescents age at 18 months. lower perceived social loneliness and
social anxiety symp- 12–15 Measures: Suicidal Adolescents with high support and that improving social skills
toms and ideation at baseline and and low level of lower perceived social
suicidal ideation. at the 18-month follow- loneliness experienced support is linked to
up time point: The a similar rate of suicidal ideation.
Suicidal Ideation decline of suicidal
Questionnaire Social ideation over time.
phobia and major Social support at 9
depression: months post-baseline
The Diagnostic Interview did not significantly
Schedule for Children predict 18-month
(DISC-IV-Adolescent suicidal ideation.
Report) Perceived social
support: The Social
Support Scale for
Children and
Adolescents (adminis-
tered at baseline and at
the 9-month follow-up)
Feelings of loneliness:
The Loneliness and
Social Dissatisfaction
Scale (administered at
baseline and at the 9-
month
follow-up time point)
Miller et al. (2014) Developmental-organiza- To explore the longitu- Longitudinal design Data Childhood Maltreatment Contrary to study Examination of the Assessment for history
tional model of child dinal associations of collected at ages 4, 6, 8, severity was unrelated hypotheses, strong nature of friendships of child maltreatment,
maltreatment. child maltreatment 12, 14, 16 and 18. to Friendships. Strong friendship quality was (i.e., prosocial, devi- depressive symptoms,
prior to age 12 in Participants: (n ¼ 884) Friendships predicted related to increased ant) and its effects on and perceived quality
relation to interper- Measures: Childhood increased odds of sui- odds of suicidal idea- suicidal ideation. of interpersonal rela-
sonal relationships maltreatment: self-report cidal ideation tion at age 18. tionships among
(age 16) and assessment that included Friendships predicted Authors speculated teens presenting with
subsequent suicidal descriptions of experien- subsequent that the stress of suicidal ideation
ideation in later ces. Friendships: a Depression. maintaining strong
adolescent (age 18). LONGSCAN-adapted ver- close friendships over
sion of the Network of time contributes to
Relationships Inventory the risk of suicidal
Suicidal ideation: self- ideation or that that
report at age 12 using the effects of support
one item from the from best friends
Trauma Symptoms varies among
Checklist for Children adolescents.
and one item from the
Youth Self Report At age
18, SI was assessed
ISSUES IN MENTAL HEALTH NURSING

(continued)
5
Table 1. Continued. 6
Research Implications for
Author/Date Theoretical Framework Question/Hypotheses Methods Results Conclusions Further Research Implications for Practice
using one item from the
Trauma Symptom and
one item from the
A. ROACH

Youth Self Report

Depression: self-report at
age 16 using the
Depression subscale
from the TSCC and at
18 using the Depression
subscale from the TSI
Szwedo et al. (2015) None provided To examine whether Longitudinal design. Data The interaction between Positive coping and self- Examination of variables Assessment of teens’
youths’ positive cop- collected at 15, 16, 17, romantic relationship perceived friendship with other social, eco- romantic relationship
ing and self-perceived 18, 19 and 21 years of involvement and competence may pro- nomic, and age status and interven-
friendship compe- age Participants: N ¼ 184 close friendship com- tect youth from demographics. tions to promote
tence would buffer adolescents (86 male petence at age 18 depressive symptoms friendships during
against depressive and 98 female) and a was not significant. in the context of dif- romantic
symptoms in romantic subsample of 62 target Youth experiencing ferent romantic relationships.
experiences. Higher adolescents and their relationship nonconti- experiences.
levels of positive cop- romantic partners, nuity who had higher
ing and self-perceived approximately 15-years- perceived friendship
friendship compe- old. Recruited from a competence reported
tence will buffer single public middle lower levels of resi-
romantically involved school drawing from dualized depressive
youth against resi- suburban and urban symptoms, compared
dualized increases in populations in the to youth with lower
depressive symptoms. southeastern United perceived friend-
Higher levels of posi- States Second visit: ship competence
tive coping and self- teens participated in a
perceived friendship 6-min interaction task
competence will buf- with their romantic part-
fer youth who experi- ner. Measures:
ence the Competence in close
noncontinuity of a friendships: the
romantic relationship Friendship Competence
against residualized subscale of the Harter
increases in depres- Self-Perception Profile
sive symptoms. for Adolescents
Depression: Kovacs’
Children’s Depression
Inventory Child
Depression Inventory
and the Beck Depression
Inventory Coping:
Emotional Repair scale
from the Trait Meta-
Mood Scale
Miller et al. (2015) The sociological theory To examine the relative Cross-sectional design Adolescents who per- Parent, friend, and Replication in commu- Assessment for percep-
of suicide, the psy- contributions of per- Participants: Adolescents ceived lower support school support is nity-based samples, tions of social support
chache theory of sui- ceptions of social sup- (n ¼ 143) admitted to a from school and close important in under- with larger more from close friends,
cide, and the port from parents, partial hospitalization friends reported the standing suicidal idea- diverse sample. family, and school
interpersonal-psycho- close friends, and program. Measures: greatest odds of sui- tion and behavior. Replication with lon- staff among clinical
logical theory of sui- school on current sui- Social support from cide attempt history. gitudinal design. youth. Interventions
cide (IPTS) cidal ideation and parents, close friends, that promote positive
(continued)
Table 1. Continued.
Research Implications for
Author/Date Theoretical Framework Question/Hypotheses Methods Results Conclusions Further Research Implications for Practice
suicide attempt his- and school: The Child prosocial peer support
tory in a clinical sam- and Adolescent Social networks.
ple of adolescents. Support Scale (CASSS)
Suicidal ideation: The
Scale for Suicidal
Ideation Suicidal
ideation, suicide plans,
gestures, and attempts,
non-suicidal self-injury:
The Self-Injurious
Thoughts and Behaviors
Interview DSM-4 emo-
tional and behavioral
disorders symptoms: The
Youth Inventory-4 (YI-4)
Pachucki et al. (2015) None provided How are network charac- Longitudinal design. Data Girls with more depres- Peer influence on mental Examination of different
teristics of young collected over a 3-month sive symptoms had health is not espe- forms of interaction
adolescents associ- period. Participants: interactions consistent cially strong in 6th and their relevance
ated with depressive N ¼ 40 (mean age 12.3) with social inhibition, grade, though in girls for child health.
symptoms and self- from a private K-8 while boys’ interac- with depressive symp- Examination of differ-
esteem? (2) How school in an urban set- tions suggest robust- toms exhibit ent social circles,
might network-based ting in California ness to depressive social inhibition. including neighbor-
social selection and Measures: Social status: symptoms. Girls hood and other extra-
social influence oper- the youth ladder instru- higher in self-esteem curricular activity
ate as mechanisms ment adapted from the tended towards friendships. .
that contribute to MacArthur Research greater sociability.
change in self-esteem Network on Socio-
or depres- Economic Status &
sive symptoms. Health Social interac-
tions: observationally
assessed during a 25-
minute lunch period
using wearable proximity
sensors using active
radio-frequency identifi-
cation Self-esteem: eight
questions drawn from
the DuBois Self-Esteem
Questionnaire.
Depressive symptoms:
10-item short form of
Kovacs’ Children’s
Depression Inventory
Petrova et al. (2015) Health belief model To examine the short- Cross-sectional design Peer leader presenta- Peer role models can Determining other what Incorporating peer lead-
term impact of posi- Participants: N ¼ 706 tions enhanced help serve as effective activities would pro- ers in suicide preven-
tive-themed suicide (84.8%) participated seeking acceptability, agents in suicide pre- vide positive suicide tion strategies.
prevention messaging from four high schools, attitudes about over- vention prevention messaging
delivered by adoles- three in a rural areas, coming barriers to communications. other key social-inter-
cent peer models one in a small metropol- helping suicidal personal protective
through Sources of itan region. Measures: youth, perceptions factors for suicide
ISSUES IN MENTAL HEALTH NURSING

Strength and to Coping with Distress and that adults can help Comparing peer
evaluate the added Suicide Concerns: Help suicidal youth, and leader delivered
(continued)
7

Table 1. Continued.
Research
Author/Date Theoretical Framework Question/Hypotheses
benefit of soliciting
active participation
from the tar-
get audience.
Williams and Ecodevelopmental The joint impact of posi- Cross-sectional design
Anthony (2015) framework tive family and peer
influences (i.e., family
togetherness, parental
behavioral expecta-
tions, friend support)
on adolescent func-
tioning (i.e., health
and well-being,
school misbehavior
Jacobson and None provided To investigate two pos- Longitudinal design, using
Newman (2016) sible mechanisms of
the relationship
between anxiety and
later depression: per-
ceptions of close rela-
tionships and
perceptions of group
relationships.
8
A. ROACH
Implications for
Methods Results Conclusions Further Research Implications for Practice
Seeking from Adults at the naming of specific messages vs. adult
School Reject Codes of trusted adults. –delivered messages.
Silence Maladaptive
Coping Sources of
Strength Coping Suicidal
ideation: Youth Risk
Behavior Survey
Friend support was sig- Positive peer relation- Examination of by differ- Interventions that work
Participants: A conveni- nificantly associated ships contribute to ent developmen- through multiple
ence sample with well-being adolescent health and tal periods layers of the
(n ¼ 37,354) of middle well-being. adolescents’ social
and high school stu- ecology Emphasizing
dents using the SSP the benefit of positive
Questionnaire. Measures: relational influences
Friend support: five
items from the Friend
Dimension questionnaire.
Well-being: specific
questions the SSP
questionnaire
Adolescent perceptions Perceptions of social Further examination of Interventions that facili-
Add Health, public use of both close and relationships are a how social relation- tate close relation-
dataset. Perceptions of group relationships mediating factor in ships are related to ships (or perceptions
close relationships meas- significantly mediated anxiety depression and anx- of close relationships)
ured 6 months later, and the relationship and depression. iety in adolescents. in adolescents, espe-
depression levels and between adolescent cially those with
diagnosis were meas- anxiety and adult lev- high anxiety
ured 12–14 years later. els of depression.
Participants: Nationally
representative sample of
adolescents (N ¼ 6504)
Measures: Group rela-
tionships and close
friendships: items from
the Add Health survey
Physiological symptoms
of anxiety: Six items
(continued)
Table 1. Continued.
Research Implications for
Author/Date Theoretical Framework Question/Hypotheses Methods Results Conclusions Further Research Implications for Practice
from the Add health sur-
vey Depression: Center
for Epidemiologic
Studies Depression Scale
(CES-D) and self-reported
depression diagnosis.
Mackin et al. (2017) VanOrden et al. and To examine the impact Longitudinal design, Data Peer support protected Social support, types of Research with a larger Interventions promoting
O’Connor, models of of social support on collected at baseline and against the effect of stressor and psychi- sample size and social support
theoretical models the association at 9 months. interpersonal life atric outcome should research distinguish-
of suicide between life stress Participants: N ¼ 550 stress on sui- be considered when ing between non-sui-
and prospectively adolescent females aged cidal symptoms examining the stress. cidal and suicidal
assessed suicidal 13.5–15.5 recruited from self-injury.
symptoms among as a part of the
adolescent girls. Adolescent Development
of Emotions and
Personality Traits
(ADEPT) project.
Assessments were con-
ducted by interview
completed self- report
questionnaires in-person
visit at our laboratory,
over the phone and self-
report questionnaires
about depressive symp-
toms were completed
online. Measures:
Adolescent life stress:
Stressful Life Events
Schedule for adolescents
Adolescent perception of
social support: Network
of Relationship Inventory
– Relationship and the
Multidimensional Scale
of Perceived Social
Support Adolescent
symptoms of suicidality
and dysphoria: Inventory
of Depression and
Anxiety Symptoms
ISSUES IN MENTAL HEALTH NURSING
9
10 A. ROACH
& Pisani, 2015), sociology (Kornienko & Santos, 2014), pedi-
atric medicine (Pachucki, Ozer, Barrat, & Cattuto, 2015),
and nursing (Rew, Arheart, Thompson, & Johnson, 2013;
Weber, Puskar, & Ren, 2010).
Study designs
All the resulting articles were quantitative studies, though
this was not a criterion for inclusion. Five were cross-sec-
tional surveys (Anthony & Stone, 2010; Miller et al., 2015;
Petrova et al., 2015; Weber et al., 2010; Williams &
Anthony, 2015) and nine were longitudinal cohort studies
(Czyz et al., 2012; Gallagher et al., 2014; Jacobson &
Newman, 2016; Kornienko & Santos, 2014; Mackin et al.,
2017; Miller et al., 2014; Newman et al., 2007; Pachucki
et al., 2015; Rew et al., 2013; Szwedo et al., 2015). One study
utilized both cross-sectional and longitudinal analysis
(Newman et al., 2007). Follow-up for longitudinal studies
varied from 3 months to 14 years.
Data collection methods
The majority of researchers used self-reported surveys,
observations, and/or questionnaires to collect data for their
studies (n ¼ 9). Participant consent or adult consent and
adolescent assent were obtained prior to collection.
Gallagher et al. (2014) used both interviews and self-report
instruments. Mackin et al. (2017) and Szwedo et al. (2015)
conducted interviews to collect data. Miller et al. (2014)
used data from Longitudinal Studies of Child Abuse and
Neglect (LONGSCAN), which involved a combination of
self-report questionnaires at in-person visits, over-the-phone
interviews and self-report questionnaires, and online self-
report questionnaires. Anthony and Stone (2010) and
Williams and Anthony (2015) conducted secondary analysis
from the School Support Profile (SSP) and Jacobson and
Newman (2016) used data from the National Longitudinal
Study of Adolescent Health (Add Health) survey.
Sampling
Researchers in three studies assessed participants from
inpatient hospital settings (Czyz et al., 2012; Gallagher et al.,
2014; Miller et al., 2015). The researchers in the other stud-
ies utilized community samples. The participants in the
studies reflect a national sampling. A national representative
sample was used by researchers in three of the studies.
(Anthony & Stone, 2010; Jacobson & Newman, 2016;
Williams & Anthony, 2015). Other studies were conducted
in a variety of settings across the nation. Participants from
these studies included adolescents from urban, suburban,
and rural settings, representing multiple socio-economic
classes, races, ethnicities, and genders. At study entry, the
age of participants in the studies ranged from 12 to
18 years.
Variable measurement
Peer support
Researchers used several tools to measure peer-related con-
cepts: peer connectedness, social support, close friendship,
friendship network, friendships, peer support, social status,
social interactions, social connectedness, friendship support,
and competence in close friendships (Table 1). The tools
had adequate reliability and validity (Bowen, Rose, & Ware,
2006; Canty-Mitchell & Zimet, 2000; Furman, 1996;
Goodenow, 1993; Lipski, Sifers, & Jackson, 2014; Muris,
Meesters, & Fijen, 2003; Slavin, 1991), with a few expections.
To measure the concept of close friendship, Jacobson and
Newman (2016) used two items from the Add Health. No
reports on reliability or validity of these items were found.
Kornienko and Santos (2014) measured friendship network
popularity by using friendship nomination, a method to calcu-
late the number of friends directly and indirectly involved in
the participants’ social network. This method was based on
self-report of friend and is a generally reliable method to assess
peer network; however reliability may be diminished with
smaller sample sizes (Marks, Babcock, Cillessen, & Crick,
2013). The reliability and validity of MacArthur Research
Network on Socio-Economic Status & Health and the Family
Integration Scale were not reported by the authors or found in
the literature (Pachucki et al., 2015; Rew et al., 2013).
Other measures
A variety of tools were used to assess the additional out-
come measures of depression, anxiety, life stress, self-esteem,
coping, optimism, well-being, suicide, and non-suicidal self-
injury (Table 1). All of these tools had acceptable psycho-
metric properties (Allgaier et al., 2012; Beck, Steer, Beck, &
Newman, 2009; Beck, Steer, & Carbin, 1988; Briere, 1996;
Briere, Elliott, Harris, & Cotman, 1995; DuBois, Felner,
Brand, Phillips, & Lease, 1996; Gillis, 1997; Gould et al.,
2004; Jacobson & Newman, 2014; Kovacs & Beck, 1977; La
Greca, 1998; Nock, Holmberg, Photos, & Michel, 2007;
Radloff, 1977; Reynolds, 2000; Rosenberg, 1965; Scheier,
Carver, & Bridges, 1994; Schmeelk-Cone, Pisani, Petrova, &
Wyman, 2012; Shaffer, Fisher, Lucas, Dulcan, & Schwab-
Stone, 2000; Shain, Naylor, & Alessi, 1990; Williamson et al.,
2003; Wyman et al., 2010). Suicide was conceptualized as
suicidal ideation, plans, and attempts and measured using
reliable and valid tools as well as self-report (Beck, Kovacs,
& Weissman, 1979; Brener et al., 2002; Pinto, McCoy, &
Whisman, 1997; Reynolds, 1992; Watson et al., 2007). Miller
et al. (2015) used the Self-Injurious Thoughts and Behaviors
Interview, which has strong reliability and validity, to assess
for non-suicidal self-injury, which has strong reliability
and validity.
Peer support and depression
Many researchers examined peer support and depression in
the adolescent population. Czyz et al. (2012) found that peer
connectedness improved depressive symptoms for adoles-
cents at 3, 6, and 12 months post psychiatric hospitalization

in a sample of 13- to 17-year old adolescents (n ¼ 338).
Jacobson and Newman (2016)’s analysis found the percep-
tion of both group and close friendships in adolescents pro-
vided a mediating effect on adult levels of depression, using
the Add Health data, which consisted of a nationally repre-
sentative sample of middle school and high school students
(n ¼ 6504). Results from Kornienko and Santos (2014)’s
study indicated that in males with high levels of social anx-
iety, an increase in friendship popularity was associated with
a decrease in depressive symptoms. However, the opposite
was true for females. Friendship popularity was associated
with an increase in depressive symptoms in females with
high levels of social anxiety. Data were collected at baseline
and 8 months and the sample consisted of sixth and seventh
grade students (n ¼ 367). Miller et al. (2014)’s work showed
that strong friendships predicted depression in adolescents
who were at risk or reported maltreatment. This finding was
inconsistent with the researcher’s hypothesis. Although data
in this study were collected at 4, 6, 8, 12, 14, 16, and 18
years of age, for the purposes of this study, data were ana-
lyzed at ages 16 and 18 years. Newman et al. (2007) specific-
ally assessed the transition of eighth graders (n ¼ 104) to
high school and found that changes in peer support were
associated with increased depressive symptoms during this
time. Pachucki et al. (2015) found that girls with more
depressive symptoms were more likely to display social
inhibition and girls with higher self-esteem were more likely
to have more social interactions and higher social status.
This study was limited to participants (n ¼ 40) at a small
private school in an urban setting in California. In the con-
text of non-continuity in romantic relationships, Szwedo
et al. (2015) found in adolescents (n ¼ 184), having a higher
level of perceived competence in close friendships buffered
against depressive symptoms compared with adolescents
who reported a lower level of competences in close friend-
ships. The sample was limited to middle school students
recruited from a single middle school in the southeastern
United States. Data were collected over time at the following
approximate ages: 15, 16, 17, 18, 19, and 21 years of age.
Weber et al. (2010) concluded from their research that social
support may be a protective factor against depressive symp-
toms, as depressive symptoms were negatively correlated
with peer social support. This finding represented adoles-
cents ages 14–18 (n ¼ 154) from a high school in rural,
western Pennsylvania.
Peer support and suicide
In addition to examining peer support and depression,
researchers also studied the correlation of peer support and
suicide. Czyz et al. (2012) found that adolescents were half
as likely to attempt suicide during a 12-month period post-
hospitalization for a suicidal ideation or suicide attempt if
they reported improvements in peer connectedness during
that same time period. At 3 months, improvements in peer
connectedness were also associated with a decrease in sui-
cidal ideation for female participants. In their study,
Gallagher et al. (2014) also assessed adolescents (n ¼ 144),
ISSUES IN MENTAL HEALTH NURSING 11
ages 12–15, during an acute psychiatric hospitalization and
at 9 and 18 months following the hospitalization. They
found that high levels of loneliness predicted higher levels of
suicidal ideation at baseline and 18 months. However, their
data indicated that social support at 9 months did not pre-
dict suicidal ideation at 18 months. Mackin et al. (2017)
found that peer support protected against suicidal symptoms
in adolescent females (n ¼ 550), ages 13–15, when assessed
at baseline and 9 months. Similar to predicting depressive
symptoms, Miller et al. (2014)’s analysis showed that strong
friendships predicted increased odds of suicidal ideation.
This is in contrast to Miller et al. (2015)’s work that indi-
cated adolescents who felt lower support from close friend-
ships had greater odds of a suicide attempt. In assessing the
effectiveness of peer-led suicide prevention education,
Petrova et al. (2015) determined that peer-led presentations
helped improve the acceptability of help-seeking behaviors
and coping related to suicide, and improved the perceptions
of adults as resources for suicidal youth. This was measured
using a follow-up questionnaire given to high school stu-
dents (n ¼ 706) immediately following the presentation. The
sample in this study included adolescents from both rural
high schools and a small metropolitan high school in a small
eastern state.
Peer support and other outcome measures
Other outcome measures of peer support have been exam-
ined such as anxiety, stress, and mental well-being. Jacobson
and Newman (2016) found that close friendships explained
16% of variation in anxiety-predicting depression in adoles-
cence. However, in their work, Gallagher et al. (2014) deter-
mined that social anxiety was not correlated with close
friend support. Mackin et al. (2017) found that peer support
acted as a protective factor against the effects of interper-
sonal life stress. When assessing social connectedness, Rew
et al. (2013) determined that social connectedness was a pre-
dictor for all types of health promoting behaviors, including
stress management. The sample in this study included rural
adolescents (n ¼ 1081) with a mean age of 17. Data were
collected in their junior and senior years of high school.
Anthony and Stone (2010) and Williams and Anthony
(2015) found that friend support was significantly associated
with mental health well-being in a cross-sectional analysis of
secondary data from middle school and high school students
(n ¼ 20,749 and n ¼ 37,354, respectively) from seven states
across the United States. In addition to being a protective
factor in depressive symptoms, Weber et al. (2010) con-
cluded that social support may also be a protective for self-
esteem and optimism.
Discussion
The results from this integrative review demonstrate the
important role of peer support in adolescents with mental
health care needs, specially related to suicide, depression,
and anxiety. The variety of data collection methods, includ-
ing interviews, questionnaires, observations, and the use of
12 A. ROACH
secondary data analysis provide multiple angles in which to
view adolescent peer support. These results were consistent
over time and across settings, including rural, urban, and
various geographic locations across the United States.
Although individual studies were limited by their sample
size (Newman et al., 2007; Pachucki et al., 2015), specific
location (Newman et al., 2007; Pachucki et al., 2015; Rew
et al., 2013; Szwedo et al., 2015), specific sample, i.e. hospi-
talized adolescents (Gallagher et al., 2014; Miller et al.,
2015), specific gender (Mackin et al., 2017), and use of ana-
lysis of secondary data (Anthony & Stone, 2010; Jacobson &
Newman, 2016; Williams & Anthony, 2015), the findings
were consistent in that peer support was a protective factor
against suicide, depression, anxiety, and stress, and was posi-
tively associated with mental well-being, self-esteem, and
optimism. The exceptions were in studies by Miller et al.
(2014) and Kornienko and Santos (2014). Participants in
these studies were adolescents who had confounding cir-
cumstances such as risk or history of maltreatment or
endorsed social anxiety. Miller et al. (2014) speculated that
for some adolescents maintaining close friendships over
time could increase stress and lead to increased depression
and suicidal ideation. It is evident that additional research is
needed to better understand the role of peer relationships in
adolescents with these complicating factors.
Researchers in these studies conceptualized peer support
differently and measured concepts with a variety of instru-
ments. This is perhaps reflective of the range of disciplines
represented in this review. However, because of the import-
ance of inter-professional collaboration and shared ideas
across disciplines, common terminology and concept clarifi-
cation is necessary to ensure that recommendations from
research are transferable across disciplines.
This review contained both cross sectional and longitu-
dinal studies to assess peer support. Suicidal ideation,
depression, and anxiety can result in self-harm and adverse
events, so recognizing the immediate factors that will buffer
against these conditions could help mediate undesirable out-
comes. Whereas, long-term effects of poor mental health
also have significant implications (Kieling et al., 2011;
Trzesniewski et al., 2006); therefore, it is also essential to
understand and optimize the protective factors that influ-
ence mental well-being over time (Coie et al., 1993). In the
longitudinal studies, peer support was consistently found to
be one of those factors (Czyz et al., 2012; Gallagher et al.,
2014; Jacobson & Newman, 2016; Mackin et al., 2017;
Newman et al., 2007; Pachucki et al., 2015; Rew et al., 2013;
Szwedo et al., 2015).
In this review, there were a lack of studies involving
interventions. The results from the one study that utilized
an educational intervention indicated that having a peer-led
suicide prevention discussion helped students identify sup-
portive adults from whom they would feel comfortable seek-
ing help (Petrova et al., 2015). Because the survey was
administered immediately after the educational intervention,
the long-term effects of the intervention are unknown and it
is impossible to determine whether adolescents indeed felt
comfortable seeking help from adults during actual times of
acute distress. Also, because this study involved a sample
from a specific geographic region, the result may not be
generalizable to broader populations. However, these limita-
tions highlight the need for more robust studies involving
peer-led mental health interventions.
Implications for research
Although the findings from this integrative review are
largely consistent, there are still gaps in knowledge that
need to be addressed. No studies that used qualitative
designs were found. While we know that peer support is
associated with positive mental well-being and can buffer
against the negative effects of poor mental health, the
mechanisms by which peer support impacts these factors
are unknown. It is unclear if it is the number of peers, the
amount of time spent with peers, or the nature of the peer
relationship that provides the positive impact. By better
understanding how peer support functions in adolescents
with mental health conditions, interventions can be devel-
oped and directly targeted to support and enhance positive
peer relationships. Research can then be conducted to test
the effectiveness of specific interventions for
this population.
In addition to a lack of understanding of the mechanism
of peer support, the impact of providing peer support on
the young person dealing with a depressed or suicidal friend
has not been examined. The concept of caregiver burden in
the adolescent population has largely focused on the role of
the parents, with a few studies examining the impact of
caregiver burden on siblings (Abrams, 2009; Alderfer &
Hodges, 2010; Shivers, McGregor, & Hough, 2017).
However, the idea that peers, who are often a source of pri-
mary support during adolescence, may experience the weight
of bearing one another’s burdens, is not well-understood
and investigation into this aspect of peer support
is warranted.
Only two studies were conducted by nurses (Rew et al.,
2013; Weber et al., 2010). Nurses work in a variety of set-
tings with adolescents and peers, including schools, camps,
community health clinics, and hospitals. Research is needed
to understand the role of peer support in adolescents in the
context of nursing and the impact that nurses can have on
the mental well-being of this population.
Implications for practice
It is clear from these findings that peer relationships play
an important role in adolescent mental health.
Professionals working with this population should be
mindful of this in practice. Although research is needed to
develop and understand interventions that target peer sup-
port, professionals should assess all adolescents for levels of
peer support, social connectedness, and interpersonal func-
tioning. Offering guidance to enhance those relationships
and providing tools to improve social skills and relation-
ship development, should be routinely incorporated into
practice with adolescents.

Conclusion
Positive peer support has the potential to be a protective
factor for adolescents with mental health care needs such as
anxiety, depression, and suicidal ideation. The benefits of
peer support can be both long-term and short-term and
nurses are well positioned to maximize these benefits
through holistic assessments and interventions that target
adolescents’ community of influence. Unfortunately, the
types of interventions and details are not well-understand.
Thus, additional research is needed to develop best practices
for adolescents with mental health conditions and
their peers.
Acknowledgments
The author would like to thank Dr. Sandra Thomas and Dr. Karen
Rose for their support during this work.
Disclosure statement
No potential conflict of interest was reported by the author.
ORCID
Ashley Roach http://orcid.org/0000-0002-6954-4677
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