A systematic review and meta-analysis of group peer support interventions for people experiencing mental health conditions

Effectiveness of Peer Support Programs for Severe Mental Illness: A Systematic Review and Meta-Analysis

(1) Background: While medication and various forms of psychotherapy are common treatments for severe mental illness, peer support programs have also proven to be effective in managing mental disorders. These programs, which involve individuals with similar experiences in navigating mental health challenges, aim to improve coping skills and foster supportive community networks. However, despite the prevalent mention of peer support programs, especially those with supervision, there has been no systematic review or meta-analysis of peer support supervision. This study aimed to systematically review and meta-analyze the forms and effectiveness of peer support programs for individuals with severe mental illnesses. (2) Methods: A literature search focusing on randomized controlled trials (RCTs) published between February 2003 and January 2024 was conducted. (3) Results: Sixteen RCTs meeting the inclusion criteria and involving a total of 4008 participants were reviewed. These studies utilized various peer support program strategies, with eight studies included in the qualitative analysis. The combined effect sizes for depressive symptoms (d = 0.12; 95% CI, -0.14, 0.37; p = 0.37), empowerment (d = 1.17; 95% CI, -0.81, 3.15; p = 0.25), quality of life (d = 0.70; 95% CI, -0.12, 1.52; p = 0.09), psychiatric symptoms (d = -0.05; 95% CI, -0.20, 0.10; p = 0.54), and self-efficacy (d = 0.20; 95% CI, 0.05, 0.36; p = 0.01) were assessed. (4) Conclusions: Our analysis emphasizes the need for further studies on peer support programs for individuals with severe mental illness, particularly those focused on self-efficacy outcomes across diverse geographic locations involving more countries and with larger scales to bolster the strength of the evidence.

Shaping and shifting schemas on supervised injectable opioid treatment: findings from a cross-sectional qualitative study in two German treatment facilities

BACKGROUND

Supervised injectable opioid treatment (SIOT) is a promising alternative for people living with opioid use disorder (OUD) who have not sufficiently benefitted from oral opioid substitution treatment. Yet, SIOT utilization remains limited in Germany. We propose that this is due to beliefs, or schemas, on SIOT among people living with OUD. Drawing from medical sociology and social psychology, this study explores the emergence and evolution of such schemas on SIOT.

METHODS

We conducted semi-structured interviews with 34 individuals currently in or eligible for SIOT in two German outpatient treatment facilities and paralleled an inductive qualitative content analysis with the exploration of individual cases.

RESULTS

The analysis revealed that peer-to-peer interaction and individuals' practical experiences in therapy are crucial in constructing and changing idiosyncratic and shared schemas of SIOT. When facing ambiguous information, cognitive strategies like subtyping served to mitigate uncertainty.

CONCLUSION

This research has important practical implications for integrating experiential knowledge into clinical care and improve information sharing among people living with OUD. A nuanced understanding of the complex network of informal advice-seeking and -giving among people living with OUD is indispensable to adequately expand treatment modalities of proven effectiveness.

Evaluation of lived experience Peer Support intervention for mental health service consumers in Primary Care (PS-PC): study protocol for a stepped-wedge cluster randomised controlled trial

BACKGROUND

The demand for mental health services in Australia is substantial and has grown beyond the capacity of the current workforce. As a result, it is currently difficult for many to access secondary healthcare providers. Within the secondary healthcare sector, however, peer workers who have lived experience of managing mental health conditions have been increasingly employed to intentionally use their journey of recovery in supporting others living with mental health conditions and their communities. Currently, the presence of peer workers in primary care has been limited, despite the potential benefits of providing supports in conjunction with GPs and secondary healthcare providers.

METHODS

This stepped-wedge cluster randomised controlled trial (RCT) aims to evaluate a lived experience peer support intervention for accessing mental health care in primary care (PS-PC). Four medical practices across Australia will be randomly allocated to switch from control to intervention, until all practices are delivering the PS-PC intervention. The study will enrol 66 patients at each practice (total sample size of 264). Over a period of 3-4 months, 12 h of practical and emotional support provided by lived experience peer workers will be available to participants. Scale-based questionnaires will inform intervention efficacy in terms of mental health outcomes (e.g., self-efficacy) and other health outcomes (e.g., healthcare-related costs) over four time points. Other perspectives will be explored through scales completed by approximately 150 family members or carers (carer burden) and 16 peer workers (self-efficacy) pre- and post-intervention, and 20 medical practice staff members (attitudes toward peer workers) at the end of each study site's involvement in the intervention. Interviews (n = 60) and six focus groups held toward the end of each study site's involvement will further explore the views of participants, family members or carers, peer workers, and practice staff to better understand the efficacy and acceptability of the intervention.

DISCUSSION

This mixed-methods, multi-centre, stepped-wedge controlled study will be the first to evaluate the implementation of peer workers in the primary care mental health care sector.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12623001189617. Registered on 17 November 2023, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=386715.

Experiences of a peer group for people diagnosed with borderline personality disorder: A qualitative interview study

There is a notable lack of literature evaluating peer support for people with a diagnosis of borderline personality disorder (BPD). Peer-led groups have been shown to positively impact outcomes related to empowerment, hope, and self-efficacy beliefs for consumers diagnosed with serious mental illness and may also be a helpful option for those experiencing personality disorder symptoms. We outline the coproduction of a peer group for people with a lived experience of BPD and a qualitative analysis of feedback post-group participation. Twenty-two consumers participated in post-group interviews and described their experiences of peer support. Interview transcripts were coded, and three main themes were identified: growth and change, connection and feeling understood, and creating safety. The findings suggested that participation in a coproduced peer support group for people with a diagnosis of BPD facilitated positive personal transformation as well as opportunities to develop connection through shared experiences in a safe environment grounded in mutuality. These themes were particularly powerful for participants because they countered previous experiences of not feeling safe, understood, or equal when seeking treatment. These findings support the acceptability of implementing a coproduced group for people diagnosed with BPD in a community mental health setting.

Use of Online Communities among People with Type 2 Diabetes: A Scoping Review

PURPOSE OF REVIEW

People with diabetes require continuous self-monitoring and face numerous decisions in their day-to-day lives. Therefore, on many occasions, they need more support than that provided by health professionals. In this context, peer support in online diabetes communities could be a useful tool. The purpose of the review is to describe, analyze and synthesize the available evidence on the use and health out-comes of online communities for people with type 2 diabetes mellitus. A scoping review was conducted in accordance with the Joanna Briggs Institute guidelines. Searches were performed PubMed, Web of Science, CINHAL, Scopus and Cochrane databases.

RECENT FINDINGS

From 1821 identified documents, 6 articles were included. These studies explored the characteristics of diabetes online communities and the population features. Besides, the results were classified according to whether they were clinical, psychosocial, or addressed people's experiences with the online community. The analysis underscores their value in facilitating communication, improving diabetes management, and enhancing psychosocial well-being. Future investigations should prioritize longitudinal assessments to elucidate the sustained impact of community engagement and optimize user participation for enhanced patient outcomes. The growing relevance of new technologies has led to a significant number of individuals with chronic illnesses seeking peer support. Online health communities have emerged as virtual spaces where individuals with shared health interests interact and form relationships. Within these digital spaces, individuals can engage in peer interaction, observe behaviors, and mutually benefit, potentially leading to improved attitudes toward the disease.

Mutual Aid Groups for Loneliness, Psychosocial Disability, and Continuity of Care

The objective of the present study was to evaluate the effectiveness of mutual help groups in continuity of care, loneliness and psychosocial disability in a Colombian context. For this, a quasi-experimental design is used, with pre- and post-intervention assessments due to non-randomized participant allocation. The study involved 131 individuals with mental disorders. The Psychosocial Disability Scale, The Alberta Scale of Continuity of Services in Mental Health, the UCLA Scale and the Zarit Caregiver Burden Scale were employed. The intervention was based on the core components of mutual aid groups. Significant differences (p < 0.001) were observed for the study variables, particularly in Loneliness, Continuity of Care, and various domains of psychosocial disability. A large effect size was found for these variables after the intervention. Most variables exhibited a moderate to large effect. This study demonstrates the effectiveness of mutual groups facilitated by mental health personnel at the primary care level.

The effectiveness, implementation, and experiences of peer support approaches for mental health: a systematic umbrella review

BACKGROUND

Peer support for mental health is recommended across international policy guidance and provision. Our systematic umbrella review summarises evidence on the effectiveness, implementation, and experiences of paid peer support approaches for mental health.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, The Campbell Collaboration, and The Cochrane Database of Systematic Reviews (2012-2022) for reviews of paid peer support interventions for mental health. The AMSTAR2 assessed quality. Results were synthesised narratively, with implementation reported using the CFIR (Consolidated Framework for Implementation Research). The protocol was registered with PROSPERO (registration number: CRD42022362099).

RESULTS

We included 35 reviews (426 primary studies, n = 95-40,927 participants): systematic reviews with (n = 13) or without (n = 13) meta-analysis, or with qualitative synthesis (n = 3), scoping reviews (n = 6). Most reviews were low or critically low (97%) quality, one review was high quality. Effectiveness was investigated in 23 reviews. Results were mixed; there was some evidence from meta-analyses that peer support may improve depression symptoms (particularly perinatal depression), self-efficacy, and recovery. Factors promoting successful implementation, investigated in 9 reviews, included adequate training and supervision, a recovery-oriented workplace, strong leadership, and a supportive and trusting workplace culture with effective collaboration. Barriers included lack of time, resources and funding, and lack of recognised peer support worker (PSW) certification. Experiences of peer support were explored in 11 reviews, with 3 overarching themes: (i) what the PSW role can bring, including recovery and improved wellbeing for service users and PSWs; (ii) confusion over the PSW role, including role ambiguity and unclear boundaries; and (iii) organisational challenges and impact, including low pay, negative non-peer staff attitudes, and lack of support and training.

CONCLUSIONS

Peer support may be effective at improving some clinical outcomes, self-efficacy, and recovery. Certain populations, e.g. perinatal populations, may especially benefit from peer support. Potential strategies to successfully implement PSWs include co-production, clearly defined PSW roles, a receptive hierarchical structure and staff, appropriate PSW and staff training with clinical and/or peer supervision alongside safeguarding. Services could benefit from clear, coproduced, setting specific implementation guidelines for PSW. PSW roles tend to be poorly defined and associations between PSW intervention content and impacts need further investigation. Future research should reflect the priorities of providers/service users involved in peer support.

Whole-family programmes for families living with parental mental illness: a systematic review and meta-analysis

Several interventions have been developed to support families living with parental mental illness (PMI). Recent evidence suggests that programmes with whole-family components may have greater positive effects for families, thereby also reducing costs to health and social care systems. This review aimed to identify whole-family interventions, their common characteristics, effectiveness and acceptability. A systematic review was conducted according to PRISMA 2020 guidelines. A literature search was conducted in ASSIA, CINAHL, Embase, Medline, and PsycINFO in January 2021 and updated in August 2022. We double screened 3914 abstracts and 212 papers according to pre-set inclusion and exclusion criteria. The Mixed Methods Appraisal Tool was used for quality assessment. Quantitative and qualitative data were extracted and synthesised. Randomised-control trial data on child and parent mental health outcomes were analysed separately in random-effects meta-analyses. The protocol, extracted data, and meta-data are accessible via the Open Science Framework ( https://osf.io/9uxgp/ ). Data from 66 reports-based on 41 independent studies and referring to 30 different interventions-were included. Findings indicated small intervention effects for all outcomes including children's and parents' mental health (dc = -0.017, -027; dp = -0.14, -0.16) and family outcomes. Qualitative evidence suggested that most families experienced whole-family interventions as positive, highlighting specific components as helpful, including whole-family components, speaking about mental illness, and the benefits of group settings. Our findings highlight the lack of high-quality studies. The present review fills an important gap in the literature by summarising the evidence for whole-family interventions. There is a lack of robust evidence coupled with a great need in families affected by PMI which could be addressed by whole-family interventions. We recommend the involvement of families in the further development of these interventions and their evaluation.

A systematic review of peer support interventions for student mental health and well-being in higher education

BACKGROUND

Higher education institutions (HEIs) are seeking effective ways to address the rising demand for student mental health services. Peer support is widely considered a viable option to increase service capacity; however, there are no agreed definitions of peer support, making it difficult to establish its impact on student mental health and well-being.

AIMS

This systematic review aims to better understand and evaluate peer support in HEIs.

METHOD

Five databases, OpenGrey and Grey Matters were searched in May 2021. Included studies were quantitative, longitudinal (with and without a control) or cross-sectional with a control. The vote-counting method was used for synthesis. The risk of bias was assessed with the National Institutes of Health Quality Assessment Tool.

RESULTS

Three types of peer support were represented in 28 papers: peer-led support groups, peer mentoring and peer learning. Peer learning and peer mentoring had more positive, significant results reported for the outcomes of anxiety and stress. Peer-led support groups were the only type targeting students with mental health difficulties.

CONCLUSIONS

The heterogeneity of measures and outcomes prevents firm conclusions on the effectiveness of peer support for mental health and well-being. Most studies were rated 'poor' or 'fair' in their risk of bias. There is not a solid evidence base for the effectiveness of peer support. Nonetheless, HEIs can use the terminology developed in this review for shared discussions that guide more robust research and evaluation of peer support as an intervention.

Integration of a peer practitioner in a hospital unit for patients with psychotic disorders: an exploratory qualitative study

Introduction

Studies on the integration of peer mental health practitioners (PMHP) in hospitals are sparse, despite significant benefits being reported for patients and professionals. The integration of PMHP requires the consideration of several parameters and a change in the culture of care. This study aims to understand the impact of the integration of a PMHP in a hospital unit caring for patients with psychiatric disorders.

Methods

A qualitative content analysis of three focus groups with the interdisciplinarity team were conducted. A consulting PMHP was integrated into the entire research process.

Results

Data analysis revealed five main themes: the importance of integration, benefits for patients linked to the identification process, benefits for the team and institution, potentials risks, and perspectives.

Discussion

The study was conducted in a hospital setting with patients suffering from severe psychiatric disorders associated with behavioral disturbances. The benefits reported in the results outline the feasibility of PMHP integration in an acute psychiatric care setting. Nevertheless, further formalization of the PMHP role is required to minimize possible areas of tension between respective fields of activity of each professional.

The effectiveness of peer support for individuals with mental illness: systematic review and meta-analysis

BACKGROUND

The benefits of peer support interventions (PSIs) for individuals with mental illness are not well known. The aim of this systematic review and meta-analysis was to assess the effectiveness of PSIs for individuals with mental illness for clinical, personal, and functional recovery outcomes.

METHODS

Searches were conducted in PubMed, Embase, and PsycINFO (December 18, 2020). Included were randomized controlled trials (RCTs) comparing peer-delivered PSIs to control conditions. The quality of records was assessed using the Cochrane Collaboration Risk of Bias tool. Data were pooled for each outcome, using random-effects models.

RESULTS

After screening 3455 records, 30 RCTs were included in the systematic review and 28 were meta-analyzed (4152 individuals). Compared to control conditions, peer support was associated with small but significant post-test effect sizes for clinical recovery, g = 0.19, 95% CI (0.11-0.27), I2 = 10%, 95% CI (0-44), and personal recovery, g = 0.15, 95% CI (0.04-0.27), I2 = 43%, 95% CI (1-67), but not for functional recovery, g = 0.08, 95% CI (-0.02 to 0.18), I2 = 36%, 95% CI (0-61). Our findings should be considered with caution due to the modest quality of the included studies.

CONCLUSIONS

PSIs may be effective for the clinical and personal recovery of mental illness. Effects are modest, though consistent, suggesting potential efficacy for PSI across a wide range of mental disorders and intervention types.

Systematic review on the involvement and engagement of patients as advisers for the organisation of organ transplantation services

OBJECTIVES

This systematic review aims to derive practical lessons from publications on patient involvement and engagement in the organisation of organ transplantation services.

DESIGN

This systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses. Inclusion criteria for the analysis of publications in English cited in the databases PubMed and Web of Science until 6 December 2022 required that patients participated as advisers in the organisation of organ transplantation services. Quality assessment was performed using the Guidance for Reporting Involvement of Patients and the Public (GRIPP) 2 small form and the Critical Appraisal Skills Programme (CASP) tool for the assessment of the risks of bias.

RESULTS

Deployed search strings identified 2263 records resulting in a total of 11 articles. The aims and strategies, deployed methods, observed effects, observed barriers and proposed improvements for the future varied vastly. All reported that well-developed programmes involving and engaging patients at an organisational level provide additional benefits for patients and foster patient-centred care. Lessons learnt include: (1) to empower patients, the information provided to them should be individualised to prioritise their needs; (2) financial as well as organisational resources are important to successfully implement patient involvement and engagement; (3) systematic feedback from patients in organisational structures to health providers is required to improve clinical workflows and (4) the consideration of ethical issues and the relationship between investigators and participating patients should be clarified and reported.

CONCLUSIONS

Actionable management recommendations could be derived. The quantitative impact on clinical outcome and economic clinical process improvements remains to be investigated. Study quality can be improved using the GRIPP 2 guidance and the CASP tool.

PROSPERO REGISTRATION NUMBER

CRD42022186467.

Evaluating the Effectiveness of a Psychological and Adventure-based Multicomponent Therapeutic Program for Victims of Intimate Partner Violence: A Pilot Study

Intimate partner violence (IPV) is a global health problem with different negative consequences for women's mental health. This pilot study aims to evaluate the efficacy of a multicomponent intervention for battered women using a comparison group design to analyze improvement in self-esteem, self-concept, self-efficacy, body dissatisfaction, and depression. The intervention consisted of an eight-session multicomponent intervention program based on the combination of group psychological therapy and adventure activities. The study sample originally consisted of 34 women IPV victims. Self-report psychological assessment was conducted during the pre-test and post-test while interviews were conducted during the post-test among the experimental group. The results of this pilot study suggest the efficacy of the cognitive-behavioral multicomponent intervention on self-esteem, self-efficacy, and depression in the IPV victims from the experimental group. We conclude that these findings support the efficacy of this psychological intervention program. Practical implications and suggestions are also discussed.

Inclusion as Assimilation, Integration, or Co-optation? A Post-Structural Analysis of Inclusion as Produced Through Mental Health Research on Peer Support

In the last 20 years, research on the inclusion of peer support within mental health settings has burgeoned, paralleling the broad adoption of service user inclusion within policy as a moral imperative and universally beneficial. Despite the seemingly progressive impetus behind inclusion, increasingly peer support workers talk of exhaustion working within mental health systems, the slow rate of change to oppressive values and practices, and ongoing experiences of workplace exclusion. Such experiences suggest differences in the way in which inclusion is produced across different stakeholder groups and contexts. In this article, we adopt Bacchi's 'what's the problem represented to be?' approach to identify how mental health research, often understood as an a-political activity, produces versions of inclusion. We argue current research predominantly produces inclusion as 'assimilation' and 'integration'. We use critical inclusion, mental health, and survivor scholarship to evaluate the effects these productions have for peer support and peer support workers, finding that both problematise peer support workers and those seeking support. We consider possibilities for more liberatory productions of inclusion, building on the notion of inclusion as 'co-optation'. Our analysis points to the need for researchers to engage with an uncomfortable reflexivity to enable more emancipatory possibilities regarding inclusion and peer support.

Challenges faced when living with schizophrenia in the community: A narrative inquiry

BACKGROUND

Schizophrenia is a chronic and severe mental disorder. People with schizophrenia have transferred from hospital-based care to community-based care with the support of mental health legal policies. Challenges faced in the community should be emphasized. Limited qualitative studies have explored the challenges of living with schizophrenia.

AIMS

To explore the challenges of people living with schizophrenia in the community.

METHODS

A narrative method was used, including semi-structured, face-to-face interviews. Thematic analysis approach was used to analyze data.

RESULTS

Ten clients and their family members participated in the study. Analysis revealed three main themes related to their challenges in the community: deficits in self-management of illness; insufficient community mental health care; and the influence of policy. These challenges prevent those with schizophrenia from effectively managing their illness, returning to a productive role in society, and improving their quality of life.

CONCLUSIONS

There are challenges in mental health rehabilitation and social reintegration of individuals with schizophrenia. There is a need for continuous community mental rehabilitation services, appropriate policy support, and the need to educate the public to reduce social bias and discrimination which allows individuals with schizophrenia to assume a productive role in the community.

Towards evidence-based and inclusive models of peer support for long covid: A hermeneutic systematic review

Since the first wave of COVID-19 in March 2020 the number of people living with post-COVID syndrome has risen rapidly at global pace, however, questions still remain as to whether there is a hidden cohort of sufferers not accessing mainstream clinics. This group are likely to be constituted by already marginalised people at the sharp end of existing health inequalities and not accessing formal clinics. The challenge of supporting such patients includes the question of how best to organise and facilitate different forms of support. As such, we aim to examine whether peer support is a potential option for hidden or hardly reached populations of long COVID sufferers with a specific focus on the UK, though not exclusively. Through a systematic hermeneutic literature review of peer support in other conditions (57 papers), we evaluate the global potential of peer support for the ongoing needs of people living with long COVID. Through our analysis, we highlight three key peer support perspectives in healthcare reflecting particular theoretical perspectives, goals, and understandings of what is 'good health', we call these: biomedical (disease control/management), relational (intersubjective mutual support) and socio-political (advocacy, campaigning & social context). Additionally, we identify three broad models for delivering peer support: service-led, community-based and social media. Attention to power relations, social and cultural capital, and a co-design approach are key when developing peer support services for disadvantaged and underserved groups. Models from other long-term conditions suggest that peer support for long COVID can and should go beyond biomedical goals and harness the power of relational support and collective advocacy. This may be particularly important when seeking to reduce health inequalities and improve access for a potentially hidden cohort of sufferers.

Documenting a Decade of Exponential Growth in Employer Demand for Peer Support Providers

The past decade has seen peer support providers increasingly incorporated as part of a recovery-oriented approach to behavioral health (BH) services for mental illness and substance use disorder. Despite this, there are few data sources to track this sector of the BH workforce, and understanding of peer support provider supply, demand, distribution, and associated factors is limited. In this retrospective, observational study, the authors analyzed job postings from 2010 to 2020 to assess employer demand for peer support providers and the factors associated with its growth, using a labor market data set from Emsi Burning Glass. The authors identified peer support job postings using a three-pronged, stepwise approach. Then, bivariate regression analyses using robust standard errors were conducted to examine state-level relationships between the number of peer support job postings per 100,000 population and Medicaid policies and indicators of states' BH infrastructure. The authors identified approximately 35,000 unique postings, finding the number increased 17-fold between 2010 and 2020. Bivariate analysis found significant state-level associations between peer support job postings and Medicaid expansion, as well as states' mean number of mental health facilities. This analysis represents the first to quantify employer demand for peer support providers, clearly demonstrating robust growth over time. Findings underscore the importance of continuing to develop data on this workforce to better understand factors driving its growth.

The Effectiveness of Peer Support in Personal and Clinical Recovery-Systematic Review and Meta-Analysis

OBJECTIVE

Peer support has been shown to support personal recovery from mental illness. It is unclear whether the effects of peer support across different mental illnesses depend on the organizational setting. The authors reviewed the effectiveness of peer support for both personal recovery and clinical recovery of adults with any mental illness and evaluated the effectiveness of peer support in different settings.

METHODS

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.

RESULTS

In total, 49 RCTs with 12,477 participants with any mental illness were included. Most of the trials had a high risk for bias. Results of the meta-analysis indicated that peer support in general had a small positive effect on personal recovery (standard mean difference [SMD]=0.20; 95% CI=0.11-0.29) and decreased anxiety symptoms (SMD=-0.21; 95% CI=-0.40 to -0.02), with most trials evaluating peers added to mental health-related hospital services. No data for peers in established service roles were available for the meta-analysis. Peer-designed interventions developed to be provided independently of hospital services and delivered in community settings had a modest effect on self-advocacy. A small nonsignificant effect on personal recovery for peer support delivered online was also observed.

CONCLUSIONS

The effect on personal recovery from mental illness was most evident in peer support added to hospital services. High-quality RCTs with comparable cocreated interventions and clear descriptions of mechanisms of change are needed to further investigate peer support efficacy.

Peer-led recovery groups for people with psychosis in South Africa (PRIZE): protocol for a randomised controlled feasibility trial

BACKGROUND

The available care for people with psychosis in South Africa is inadequate to support personal recovery. Group peer support interventions are a promising approach to foster recovery, but little is known about the preferences of service users, or the practical application of this care model, in low- and middle-income countries (LMIC). This study aims to assess the acceptability and feasibility of integrating peer-led recovery groups for people with psychosis and their caregivers in South Africa into existing systems of care, and to determine key parameters in preparation for a definitive trial.

METHODS

The study is set in Nelson Mandela Bay Metropolitan district of the Eastern Cape Province, South Africa. The design is an individually randomised parallel group feasibility trial comparing recovery groups in addition to treatment as usual (TAU) with TAU alone in a 1:1 allocation ratio. We aim to recruit 100 isiXhosa-speaking people with psychosis and 100 linked caregivers. TAU comprises anti-psychotic medication-focused outpatient care. The intervention arm will comprise seven recovery groups, including service users and caregiver participants. Recovery groups will be delivered in two phases: a 2-month phase facilitated by an auxiliary social worker, then a 3-month peer-led phase. We will use mixed methods to evaluate the process and outcomes of the study. Intervention acceptability and feasibility (primary outcomes) will be assessed at 5 months post-intervention start using qualitative data collected from service users, caregivers, and auxiliary social workers, along with quantitative process indicators. Facilitator competence will be assessed with the GroupACT observational rating tool. Trial procedures will be assessed, including recruitment and retention rates, contamination, and validity of quantitative outcome measures. To explore potential effectiveness, quantitative outcome data (functioning, unmet needs, personal recovery, internalised stigma, health service use, medication adherence, and caregiver burden) will be collected at baseline, 2 months, and 5 months post-intervention start.

DISCUSSION

This study will contribute to the sparse evidence on the acceptability and feasibility of peer-led and recovery-oriented interventions for people with psychosis in LMIC when integrated into existing care systems. Results from this feasibility trial will inform preparations for a definitive trial and subsequent larger-scale implementation.

TRIAL REGISTRATION

Pan-African Clinical Trials Register PACTR202202482587686. Registered on 28 February 2022.  https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=21496 .

Psychosocial Exoskeletons: Normal Development, Psychopathological and Sociopathological Phenomena, and Therapeutic Applications

In medical therapeutics, exoskeleton refers to external protections, supports, and appliances. By analogy, psychosocial exoskeletons can be envisioned as assistive psychological and social structures that brace and extend individuals' coping abilities. This article considers the utility of defining "psychosocial exoskeletons" as a framework to encompass psychological and social devices that enhance coping, and "therapeutic psychosocial exoskeletons" as devices assisting psychiatric treatment. Clinical observations were augmented via selective narrative review using PubMed and PsychInfo.A range of psychological and social devices were identified that constitute psychosocial exoskeletons. In extremes, psychosocial exoskeletons may prescribe comprehensive lifestyles including dress, rites, taboos, and acceptable relationships. These devices may enhance normal or psychopathological development.Therapeutic psychosocial exoskeletons consist of intentionally prescribed psychotherapeutic and sociotherapeutic interventions assembled to address patient-centered problems. Elements may include counseling and psychotherapies, peer-based recovery programs, institutional programs, and social interventions involving financial assistance, supported employment, pets, and other practical resources.

Implementing the figure of peer support workers in mental health: an international perspective from the context of its implementation in Catalonia

In the context of debates surrounding the training of mental health peer support workers and their incorporation into the Catalan Health System, this article presents a literature review complemented by interviews carried out between 2020 and 2021 with both international and Spanish experts. Based on the information obtained, content analysis of elements of their training and integration within the health system was performed. German-speaking countries offer the most homogeneous training and recruitment programs. In the case of English- and French-speaking countries, non-profit or third sector organizations are usually in charge of training programs and recruitment. Various experiences with training programs exist in the Ibero-American world, although they are not recognized as professional qualifications. Recommendations are offered for the development of this figure in Catalonia, which include advancing towards professional training with recognition as health care providers, as well as contracting options from both socio-health or health care providers or from third sector entities.

Recovery 101: A Community Psychoeducation Program on Mental Health Recovery and Peer Support Services Created by an Academic Psychiatrist and Delivered by Peers

OBJECTIVE

Despite the ongoing growing interest and established benefits of mental health recovery and peer support services, little is known about the effects of mental health recovery and peer support services specifically in community education programs. Seeking to further expand this scope, this article details the development, implementation, and evaluation of a recovery and peer services community psychoeducation program created by an academic psychiatrist and delivered by trained mental health peers.

METHODS

A community psychoeducation intervention on recovery and peer services was provided in 2 different series: 5-session and 1-session series. Participants in the intervention were recruited from 2 local nonprofit recovery-oriented organizations and a public mental health service agency. Surveys were administered before and after each presentation session and analyzed both quantitatively and qualitatively.

RESULTS

Quantitative survey items covering knowledge, awareness, interest, and likelihood of involvement in peer services for recovery all showed statistically significant gains from before to after the sessions. The qualitative data provided information about the participants' interests in the program in terms of knowledge of recovery, self-improvement, advocacy, resources, support, and nonspecific positive comments.

CONCLUSIONS

An essential contribution of the program was to introduce participants to recovery and peer services. It also provided them with foundational knowledge that placed participants in a position to begin to practice the concepts of recovery. According to the participants' comments in the surveys, the program imbued a sense of hope and motivation; support and fellowship; and, importantly, role modeling and wisdom from the presenters.

Implementation of peer-support services in Asia: A scoping review

WHAT IS KNOWN ON THE SUBJECT

Peer-support services was started in the 1970s psychiatric survivor movement in the United States of America (USA) due to the lack of transitional support for deinstitutionalized psychiatric patients. Delivered by peer-support workers (PSWs) with lived experiences of mental health conditions, peer-support workers use their experiential knowledge to help others with similar conditions. The paradigm shifts in mental health recovery has led to an increase in interest on peer-support services among the Asia countries. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The diversity political and cultural differences in Asia makes it a unique for people to understand the mental health ecosystem that exist within. This review is timely as it provides the insights into the current state of peer-support services for mental health consumers in Asia and the future research on them. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: First, this review provided a broad overview on the current types of peer-support services and their implementation in Asia. Second, emphasized the importance and value of peer-support services for individuals with mental health conditions in their journey towards recovery. Third, important to build a more positive image for peer-support workers by assigning more clarity to their roles and systematizing training to hone their skills in providing peer support.

ABSTRACT

Introduction The increasing recognition and need for recovery-oriented services led to the heightened interests of peer-support services globally, including Asia. However, little is known about the peer-support services in Asia as compared to the West, where peer-support services primarily originated from and are well established. Aim To examine available evidence on the implementation of peer-support services for such consumers in Asia. Method This scoping review was based on the Arksey & O'Malley's framework. A comprehensive search was performed across seven electronic databases. The grey literature was also searched through Open Grey and ProQuest Dissertation and Theses, alongside hand searching of the reference of the studies. Articles searched was from January 2000 to December 2021. Results Three main themes were identified to provide an overview on peer-support services for mental health consumers in Asia: the delivery of such services in Asia; Asian consumers' perceptions of them; and factors affecting their implementation. Discussion Given their relative novelty in Asia, findings from this review represent useful insights for organizations and policy administrators when formulating such services. Implications for Practice Future research should also focus on evaluating the effectiveness of such services in Asia and comparing their outcomes with other regions.

Co-creating safe spaces: Study protocol for translational research on innovative alternatives to the emergency department for people experiencing emotional distress and/or suicidal crisis

INTRODUCTION

Safe spaces are an alternative to emergency departments, which are often unable to provide optimum care for people experiencing emotional distress and/or suicidal crisis. At present, there are several different safe space models being trialled in Australia. However, research examining the effectiveness of safe space models, especially in community settings, is rare. In this paper, we present a protocol for a study in which we will investigate the implementation, effectiveness, and sustainability of safe space models as genuine alternatives for people who might usually present to the emergency department or choose not to access help due to past negative experiences.

MATERIAL AND METHODS

We will use a mixed methods, co-designed study design, conducted according to the principles of community-based participatory research to obtain deep insights into the benefits of different safe space models, potential challenges, and facilitators of effective practice. We developed the study plan and evaluation framework using the RE-AIM framework, and this will be used to assess key outcomes related to reach, effectiveness, adoption, implementation, and maintenance. Data collection will comprise quantitative measures on access, use, satisfaction, (cost) effectiveness, distress, and suicidal ideation; and qualitative assessments of service implementation, experience, feasibility, acceptability, community awareness, and the fidelity of the models to service co-design. Data will be collected and analysed concurrently throughout the trial period of the initiatives.

DISCUSSION

This study will enable an extensive investigation of safe spaces that will inform local delivery and provide a broader understanding of the key features of safe spaces as acceptable and effective alternatives to hospital-based care for people experiencing emotional distress and/or suicidal crisis. This study will also contribute to a growing body of research on the role and benefits of peer support and provide critical new knowledge on the successes and challenges of service co-design to inform future practice.

Common Humanity as an Under-acknowledged Mechanism for Mental Health Peer Support

Mental health peer support (PS) is a relational approach to recovery. Service users are helped through a relationship focused on connection with a PS worker who shares similar experiences. Despite the strong evidence base, the mechanisms of action for mental health PS are under-researched. Several theories have been proposed to explain the mechanisms, including social comparison theory (SCT). SCT highlights the benefits arising from emphasising differences between a service user and the PS worker. An unintended consequence is that connection between them may be reduced. We propose common humanity (CH) as an under-acknowledged mechanism of action. CH is an experience recognising that there are other people living with similar suffering, and helps us regulate emotions. A CH-informed connection-based PS relationship may help a service user in different ways from a SCT-informed comparison-based PS relationship. Future PS research can investigate emotional self-regulation to establish whether CH-related outcomes arise from PS.

What is the volume, diversity and nature of recent, robust evidence for the use of peer support in health and social care? An evidence and gap map

Background

Peer support interventions involve people drawing on shared personal experience to help one another improve their physical or mental health, or reduce social isolation. If effective, they may also lessen the demand on health and social care services, reducing costs. However, the design and delivery of peer support varies greatly, from the targeted problem or need, the setting and mode of delivery, to the number and content of sessions. Robust evidence is essential for policymakers commissioning peer support and practitioners delivering services in health care and community settings. This map draws together evidence on different types of peer support to support the design and delivery of interventions.

Objectives

The aim of this map was to provide an overview of the volume, diversity and nature of recent, high quality evidence on the effectiveness and cost-effectiveness of the use of peer support in health and social care.

Search Methods

We searched MEDLINE, seven further bibliographic databases, and Epistemonikos for systematic reviews (in October 2020), randomised controlled trials (in March 2021) and economic evaluations (in May 2021) on the effectiveness of peer support interventions in health and social care. We also conducted searches of Google Scholar, two trial registers, PROSPERO, and completed citation chasing on included studies.

Selection Criteria

Systematic reviews, randomised controlled trials and economic evaluations were included in the map. Included studies focused on adult populations with a defined health or social care need, were conducted in high-income countries, and published since 2015. Any measure of effectiveness was included, as was any form of peer support providing the peer had shared experience with the participant and a formalised role.

Data Collection and Analysis

Data were extracted on the type of peer support intervention and outcomes assessed in included studies. Standardised tools were used to assess study quality for all studies: assessing the methodological quality of systematic reviews 2 for systematic reviews; Cochrane risk of bias tool for randomised controlled trials; and consensus health economic criteria list for economic evaluations.

Main Results

We included 91 studies: 32 systematic reviews; 52 randomised controlled trials; and 7 economic evaluations. Whilst most included systematic reviews and economic evaluations were assessed to be of low or medium quality, the majority of randomised controlled trials were of higher quality. There were concentrations of evidence relating to different types of peer support, including education, psychological support, self-care/self-management and social support. Populations with long-term health conditions were most commonly studied. The majority of studies measured health-related indicators as outcomes; few studies assessed cost-effectiveness. Studies were unevenly distributed geographically, with most being conducted in the USA. Several gaps were evident regarding the delivery of peer support, particularly the integration of peers and professionals in delivering support and interventions of longer duration.

Authors' Conclusions

Although there is evidence available to inform the commissioning and delivery of peer support in health and social care, there are also clear gaps that need to be addressed to further support provision, particularly regarding cost-effectiveness. The effectiveness of peer support in different countries, with varying health and social care systems, is a priority for future research, as is the integration of peers with professionals in delivering peer support.

Effectiveness and implementation outcomes for peer-delivered mental health interventions in low- and middle-income countries: a mixed-methods systematic review

PURPOSE

This review aimed to evaluate interventions led by peer counselors (PCs) for adults with common mental disorders in low- and middle-income countries (LMICs) along indices of overall effectiveness and key implementation outcomes (acceptability, feasibility, cost, fidelity, sustainability).

METHODS

This review followed a mixed-methods systematic review design. MEDLINE/PubMed, Embase, PsycINFO, and Global Health databases were searched for PC-led interventions for adults in LMICs targeting depressive and/or anxiety disorders or PTSD. Quantitative data was narratively synthesized, and qualitative data was thematically synthesized separately. The results from the qualitative and quantitative syntheses were then combined in a cross-study synthesis.

RESULTS

Twenty-four papers describing thirteen PC-led interventions were included for review. Narrative synthesis results indicated mixed effectiveness of PC-led interventions in reducing depressive, anxiety, PTSD symptoms and high PC competency. Thematic synthesis revealed five descriptive themes: (1) Preferred PC characteristics; (2) Incentives and motivation for PCs; (3) Barriers to PC-led intervention implementation; (4) Helpful supervision/training practices; and (5) Overall high acceptability of PC-led interventions. Cross-study synthesis revealed high acceptability, feasibility, and fidelity, but cost and sustainability outcomes were underreported in included papers.

CONCLUSION

PC-led interventions seem to show initial promise in terms of effectiveness, acceptability, feasibility, cost, fidelity, and sustainability. Future research should focus on standardizing measurements of implementation outcomes to facilitate cross-study analysis. Additional empirical attention should be paid to underrepresented implementation outcomes (e.g., cost, sustainability). Finally, researchers should adopt a participatory approach that elevates the perspectives of PCs throughout all stages of the implementation process.

Stigma and Peer-Led Interventions: A Systematic Review and Meta-Analysis

Purpose

The main purpose of our systematic review was to investigate the effect of peer-led intervention on self-stigma in individuals with mental health problems. Secondary purpose was investigating the impact of peer intervention on clinical symptoms, recovery-related outcomes, and disclosure-related outcomes.

Methods

Five electronic databases were searched from 1975 to 2021. Literature databases were searched for randomized controlled trials. From the perspective of key outcomes, a meta-analysis of the effects of peer-led interventions on changing stigma was conducted.

Results

A meta-analysis of randomized controlled trials targeting different target groups with mental health problems (e.g., adolescents, college students, family members of mentally ill persons, unemployed persons, etc.) was conducted. It was found that, at the end of the intervention, intervention had a positive effect on main outcomes such as self-stigma and stress from stigma. As for secondary outcomes, there was no significant influence on clinical symptoms. There was a positive effect on rehabilitation and empowerment, but without a statistical significance. There was a statistically significant effect on self-efficacy and professional help seeking. There was a statistically significant effect on confidentiality and disclosure-related distress in the Honest Open Proud (HOP) subgroup. There was no significant influence on confidentiality and withdrawal in the non-HOP subgroup.

Conclusion

Peer-led intervention can reduce self-stigma and stigma pressure and might improve recovery and empowerment. It increases self-efficacy and willingness to seek professional help, but has no significant effect on clinical symptoms and withdrawal. HOP intervention has positive effects on disclosure-related confidentiality and pain.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO, identifier: CRD42021287584.

Acute psychiatric care: approaches to increasing the range of services and improving access and quality of care

Acute services for mental health crises are very important to service users and their supporters, and consume a substantial share of mental health resources in many countries. However, acute care is often unpopular and sometimes coercive, and the evidence on which models are best for patient experience and outcomes remains surprisingly limited, in part reflecting challenges in conducting studies with people in crisis. Evidence on best ap-proaches to initial assessment and immediate management is particularly lacking, but some innovative models involving extended assessment, brief interventions, and diversifying settings and strategies for providing support are potentially helpful. Acute wards continue to be central in the intensive treatment phase following a crisis, but new approaches need to be developed, evaluated and implemented to reducing coercion, addressing trauma, diversifying treatments and the inpatient workforce, and making decision-making and care collaborative. Intensive home treatment services, acute day units, and community crisis services have supporting evidence in diverting some service users from hospital admission: a greater understanding of how best to implement them in a wide range of contexts and what works best for which service users would be valuable. Approaches to crisis management in the voluntary sector are more flexible and informal: such services have potential to complement and provide valuable learning for statutory sector services, especially for groups who tend to be underserved or disengaged. Such approaches often involve staff with personal experience of mental health crises, who have important potential roles in improving quality of acute care across sectors. Large gaps exist in many low- and middle-income countries, fuelled by poor access to quality mental health care. Responses need to build on a foundation of existing community responses and contextually relevant evidence. The necessity of moving outside formal systems in low-resource settings may lead to wider learning from locally embedded strategies.

Commenting and connecting: A thematic analysis of responses to YouTube vlogs about borderline personality disorder

Borderline Personality Disorder (BPD) is an often misunderstood and stigmatized mental health difficulty. Increasingly, social media has been used as a forum to share dialogue on such difficulties. This research analysed YouTube comments in response to personal vlogs about living with BPD. The key term 'Living with Borderline Personality Disorder Vlog' was inputted into a YouTube Ireland search, results were displayed by relevance and the top four vlogs that met the criteria were chosen for analysis. A total of 1197 comments (approximately 55,574 words) were analysed using inductive thematic analysis (Braun and Clarke, 2006). Five distinct themes were identified: 1) Sharing advice, support and encouragement, 2) Vlogs destigmatizing, informing and educating, 3) Solidarity, relatability and personal connection, 4) Intense, unstable intrapersonal and interpersonal functioning, 5) Prompting disclosures about mental health struggles. The vlogs gave people insight and understanding, increasing empathy towards those suffering with BPD or with their mental health. The overall picture drawn from the data was one of solidarity, support, de-stigmatization, normalization, sharing, comfort and encouragement. Further research into people's attitudes towards BPD, their opinions and knowledge of the disorder, may help make important changes, inform policies and practice, and ultimately improve the lives of those living with the disorder.

De-escalation of conflict in forensic mental health inpatient settings: a Theoretical Domains Framework-informed qualitative investigation of staff and patient perspectives

Background

Violence and other harms that result from conflict in forensic inpatient mental health settings are an international problem. De-escalation approaches for reducing conflict are recommended, yet the evidence-base for their use is limited. For the first time, the present study uses implementation science and behaviour change approaches to identify the specific organisational and individual behaviour change targets for enhanced de-escalation in low and medium secure forensic inpatient settings. The primary objective of this study was to identify and describe individual professional, cultural and system-level barriers and enablers to the implementation of de-escalation in forensic mental health inpatient settings. The secondary objective was to identify the changes in capabilities, opportunities and motivations required to enhance de-escalation behaviours in these settings.

Methods

Qualitative design with data collection and analysis informed by the Theoretical Domains Framework (TDF). Two medium secure forensic mental health inpatient wards and one low secure mental health inpatient ward participated. 12 inpatients and 18 staff participated across five focus groups and one individual interview (at participant preference) guided by a semi-structured interview schedule informed by the TDF domains. Data were analysed via Framework Analysis, organised into the 14 TDF domains then coded inductively within each domain.

Results

The capabilities required to enhance de-escalation comprised relationship-building, emotional regulation and improved understanding of patients. Staff opportunities for de-escalation are limited by shared beliefs within nursing teams stigmatising therapeutic intimacy in nurse-patient relationships and emotional vulnerability in staff. These beliefs may be modified by ward manager role-modelling. Increased opportunity for de-escalation may be created by increasing service user involvement in antipsychotic prescribing and modifications to the physical environment (sensory rooms and limiting restrictions on patient access to ward spaces). Staff motivation to engage in de-escalation may be increased through reducing perceptions of patient dangerousness via post-incident debriefing and advanced de-escalation planning.

Conclusions

Interventions to enhance de-escalation in forensic mental health settings should enhance ward staff’s understanding of patients and modify beliefs about therapeutic boundaries which limit the quality of staff-patient relationships. The complex interactions within the capabilities-opportunities-motivation configuration our novel analysis generated, indicates that de-escalation behaviour is unlikely to be changed through knowledge and skills-based training alone. De-escalation training should be implemented with adjunct interventions targeting: collaborative antipsychotic prescribing; debriefing and de-escalation planning; modifications to the physical environment; and ward manager role-modelling of emotional vulnerability and therapeutic intimacy in nurse-patient relationships.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-022-00735-6.