Diverse elements comprising studies of peer support complicate evidence synthesis.

BACKGROUND: Innovative approaches to care, such as peer support, are needed to address the substantial and frequently unmet needs of people with serious mental illnesses such as schizophrenia. Although peer support services continue to expand in mental healthcare, findings of effectiveness from systematic reviews are mixed. However, the studies evaluated in these reviews consisted of diverse elements which the review methods neglected to consider. AIMS: This review aims to demonstrate the substantial diversity in intervention components and measured outcomes among studies of peer support and lay the groundwork for more focused reviews of individual intervention components. METHODS: As part of a realist review of the literature, here we synthesize evidence in a way that examines the substantial diversity in intervention components and measured outcomes comprising studies of peer support. RESULTS: Seven categories of outcomes were represented, including recovery, symptoms and functioning, and care utilization. Importantly, seven distinct intervention components were represented in 26 studies: "being there," assistance in self-management, linkage to clinical care and community resources, social and emotional support, ongoing support, explicit utilization of shared lived experience or peer support values, and systems advocacy. Reflecting diversity in approaches, no study reported all intervention components, and no component was found among all studies. IMPLICATIONS: Peer support services constitute a category of intervention approaches far too varied to evaluate as a single entity. Results suggest intervention components deserving more focused research, including assistance in self-management, "being there," and explicit utilization of shared lived experience or peer support values. PRISMA/PROSPERO: As this article reports results from a realist review of the literature, we did not follow the PRISMA guidance which is suitable for systematic reviews. We did follow the Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidelines.This review was not registered on PROSPERO as it is not a systematic review.

Systemic Racism as a Determinant of Health Inequities for People With Substance Use Disorder.

This Viewpoint describes how systemic racism is a determinant of inequities in treatment for people with substance use disorder and suggests an antiracism framework in addiction practice.

Care integration goes Beyond Co-Location: Creating a Medical Home.

How to successfully integrate mental health and primary care remains a critically important question given the continued morbidity and early mortality of people with serious mental illness. This study investigated integration in a community mental health center (MHC) primarily treating people with SMI in a large, urban northeastern city where an on-site primary care center (PCC) was opened resulting in co-located mental health and primary care services being provided. Using focus groups and online surveys this study asked participants about their thoughts and interactions with the on-site PCC. Participants included staff from clinical, non-clinical, and leadership roles in the mental health center (MHC; PCC staff; and MHC clients who did not use the on-site PCC). MHC staff also offered their thoughts about and experiences with the on-site PCC one year and two years after the on-site PCC opened through an on-line survey. In both methods, staff reported limited awareness and expectations of the PCC in the first year. Staff indicated that successful care integration goes beyond co-location and peer health navigation can enhance integration. Finally, staff discussed desires for enhancing care integration and co-located services into a medical home that included communicating across medical records and providers at different agencies. Our results suggest that, in addition to the previously researched three C's of care integration (consultation, coordination, and collaboration), two more C's were essential to successful care integration: co-location and communication. Communication across medical records and providers at different agencies was an essential component of care integration, and co-location added increased ability to communicate across providers.

Breaking through social determinants of health: Results from a feasibility study of Imani Breakthrough, a community developed substance use intervention for Black and Latinx people.

Racial and ethnic disparities in substance use intervention design, implementation, and dissemination have been recognized for years, yet few intervention programs have been designed and conducted by and for people who use substances. Imani Breakthrough is a two-phase 22-week intervention developed by the community, run by facilitators with lived experience and church members, that is implemented in Black and Latinx church settings. This community-based participatory research (CBPR) approach is a concept developed in response to a call for action from the State of Connecticut Department of Mental Health and Addiction Services (DMHAS) with funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) to address rising rates of death due to opioid overdose, and other negative consequences of substance misuse. After nine months of didactic community meetings, the final design involved twelve weeks of education in a group setting related to the recovery process, including the impact of trauma and racism on substance use, and a focus on citizenship and community participation and the 8 dimensions of wellness, followed by ten weeks of mutual support, with intensive wraparound support and life coaching focused on the social determinants of health (SDOH). We found the Imani intervention was feasible and acceptable, with 42 % of participants retained at 12 weeks. In addition, in a subset of participants with complete data, we found a significant increase in both citizenship scores and dimensions of wellness from baseline to week 12, with the greatest improvements in the occupational, intellectual, financial, and personal responsibility dimensions. As drug overdose rates among Black and Latinx people who use substances continue to increase, it is imperative that we address the inequities in the SDOH that contribute to this disparity gap so that we can develop interventions tailored to the specific needs of Black and Latinx people who use drugs. The Imani Breakthrough intervention shows promise as a community-driven approach that can address these disparities and promote health equity.

The role of substance use treatment in reducing stigma after release from incarceration: A qualitative analysis.

BACKGROUND: People with substance use disorders (SUD) who have been involved in the legal system often experience stigma upon reentry into the community after incarceration. Although substance use treatment can sometimes be a source of stigma, it may also reduce stigma by facilitating connections with providers, reducing distress, or helping people feel more integrated in their community. However, research has rarely examined the potential for treatment to reduce stigma. METHODS: This study examined stigma experiences and the degree to which substance use treatment reduced stigma among 24 people with SUDs who were receiving care in an outpatient treatment facility after release from incarceration. Qualitative interviews were conducted and analyzed using a content analysis approach. RESULTS: Participants reported negative self-judgements as well as perceiving negative judgments from the community upon reentry. With regard to stigma reduction, themes emerged around substance use treatment repairing strained family relationships and reducing participants' self-stigma. Aspects of treatment that reportedly reduced stigma included the treatment facility having a nonjudgmental atmosphere, patients trusting the staff, and working with peer navigators who had lived experience of SUD and incarceration. CONCLUSIONS: Results from this study suggest that substance use treatment has the potential to decrease the negative impacts of stigma upon release from incarceration, which continues to be a major barrier. Though more research on stigma reduction is needed, we suggest some preliminary considerations for treatment programs and providers.

Comparisons Between Young, Middle-Aged, and Older Adult Sexual and Gender Minority Male Sexual Assault Survivors.

OBJECTIVE: This study compared sexual abuse histories and depressive symptoms between younger, middle-aged, and older sexual and gender minority (SGM) male survivors. DESIGN: Participants completed a brief, online screener as part of a large comparative effectiveness psychotherapy trial. SETTING: SGM males 18 years or older, residing in the U.S. or Canada, were recruited online. PARTICIPANTS: This study included younger (aged 18-39; n = 1,435), middle-aged (aged 40-59; n = 546), and older (aged 60+; n = 40) SGM men who reported a history of sexual abuse/assault. MEASUREMENTS: Participants were asked about their sexual abuse history, experience of other traumas, symptoms of depression, and past 60-day mental health treatment engagement. RESULTS: Older SGM men reported a lower rate of occurrence of adult sexual assault, exposure to other traumas, and depression. However, older and younger groups did not differ on any childhood sexual assault variable, the frequency of or number of attackers for adult sexual assault, the frequency of accidents and other injury traumas, or the occurrence or frequency of mental health treatment. Trauma load, including childhood and adult sexual assault, were more strongly related to current depressive symptoms than age group. CONCLUSION: While there were some age-based or cohort differences in the rates of sexual trauma, the clinical response of both groups was similar. Implications for working clinically with middle-aged and older SGM men with untreated sexual assault-related mental health difficulties are discussed, including outreach and availability of gender- and older-inclusive survivor treatment and resources.

Strategies for the Management of Voices Shared in a Brazilian Hearing Voices Group.

Hearing Voices peer support groups allow people to construct understandings of their voices. The groups focus on supporting voice hearers in reducing distress associated with voices through an array of strategies. This study sought to describe the voice management strategies shared in a hearing voices peer support group within a Brazilian public mental health service. In this qualitative study we recorded 10 group meetings. Transcripts were coded and analyzed using thematic analysis. The findings indicated five themes, described as: (1) strategies used to avoid distressing experiences; (2) strategies for managing the voices; (3) strategies for seeking social support; (4) strategies for creating a sense of belonging in the community; and (5) strategies related to spirituality and religiosity. These strategies appear to be essential in helping voice hearers feel less alone, reducing the amount of distress associated with hearing voices, and developing coping strategies. These groups provide people who hear voices with the opportunity to share their stories with peers in a group setting, construct new understandings about the experience, and learn strategies for managing their voices. Accordingly, there are great possibilities for the use of these groups within mental health services throughout Latin America.

Training Male Sexual Abuse Survivors as Peer Leaders to Deliver Motivational Interviewing and Trauma-Informed Affirmative Care.

This paper provides a description and evaluation of training male sexual abuse survivors to deliver Motivational Interviewing (MI) and Motivational Interviewing with Trauma-Informed Affirmative Care (MI-AC) online to sexual and gender minority (SGM) men with sexual assault histories and depression. After a search and selection process, 26 men with lived experience of sexual abuse received MI training that included the use of role-playing, video demonstrations, and practice followed by weekly supervision while co-leading groups. Peer leaders completed several measures pre and post training, including beliefs about MI and self-reported learning of MI and satisfaction with the training. A sample of MI and MI-AC audio sessions were independently rated for adherence and competence. Peer leaders' beliefs about MI changed over time, while self-rated skill level stayed consistent. Peer leaders demonstrated good adherence to the MI and MI-AC conditions. Results suggest that men with lived experience of sexual trauma effectively learned to deliver MI and/or MI-AC to SGM male survivors in online groups. These interventions have the potential to expand the reach of limited services for this population as well as reduce their depression and assist in SGM men with histories of sexual abuse entering into formal mental health services.

"That Was a State of Depression by Itself Dealing with Society": Atmospheric racism, mental health, and the Black and African American faith community.

Despite increased societal focus on structural racism, and its negative impact on health, empirical research within mental health remains limited relative to the magnitude of the problem. The current study-situated within a community-engaged project with members of a predominantly Black and African American church in the northeastern US-collaboratively examined depressive experience, recovery, and the role of racism and racialized structures. This co-designed study featured individual interviews (N = 11), a focus group (N = 14), and stakeholder engagement. A form of qualitative, phenomenological analysis that situates psychological phenomena within their social structural contexts was utilized. Though a main focal point of the study was depressive and significantly distressing experience, participant narratives directed us more towards a world that was structured to deplete and deprive-from basic neighborhood conditions, to police brutality, to workplace discrimination, to pervasive racist stereotypes, to differential treatment by health and social services. Racism was thus considered as atmospheric, in the sense of permeating life itself-with social, affective, embodied, and temporal dimensions, alongside practical (e.g., livelihood, vocation, and care) and spatial (e.g., neighborhood, community, and work) ones. The major thematic subsections-world, body, time, community, and space-reflect this fundamental saturation of racism within lived reality. There are two, interrelated senses of structural racism implicated here: the structures of the world and their impact on the structural dimensions of life. This study on the atmospheric nature of racism provides a community-centered complement to existing literature on structural racism and health that often proceed from higher, more population level scales. This combined literature suggests placing ever-renewed emphasis on addressing the causes and conditions that make this kind of distorted world possible in the first place.

Racial and ethnic mental health disparities in U.S. Military Veterans: Results from the National Health and Resilience in Veterans Study.

Despite military veterans having a higher prevalence of several common psychiatric disorders relative to non-veterans, scarce population-based research has examined racial/ethnic differences in these disorders. The aim of this study was to examine racial/ethnic differences in the prevalence of psychiatric outcomes in a population-based sample of White, Black, and Hispanic military veterans, and to examine the role of intersectionality between sociodemographic variables and race/ethnicity in predicting these outcomes. Data were analyzed from the National Health and Resilience in Veterans Study (NHRVS), a contemporary, nationally representative survey of 4069 US veterans conducted in 2019-2020. Outcomes include self-report screening measures of lifetime and current psychiatric disorders, and suicidality. Results revealed that Hispanic and Black veterans were more likely than White veterans to screen positive for lifetime posttraumatic stress disorder (PTSD; 17.8% and 16.7% vs. 11.1%, respectively); Hispanic veterans were more likely than White veterans to screen positive for lifetime major depressive disorder (22.0% vs. 16.0%); Black veterans were more likely than White veterans to screen positive for current PTSD (10.1% vs. 5.9%) and drug use disorder (12.9% vs. 8.7%); and Hispanic veterans were more likely than Black veterans to report current suicidal ideation (16.2% vs. 8.1%). Racial/ethnic minority status interacted with lower household income, younger age, and female sex in predicting greater likelihood of some of these outcomes. Results of this population-based study suggest a disproportionate burden of certain psychiatric disorders among racial/ethnicity minority veterans, and identify high-risk subgroups that can be targeted in prevention and treatment efforts.

Brazilian immigrants in the United States and mental health: An integrative review.

BACKGROUND: Brazilian immigrants are becoming a more visible minority and, although different from other Latinos (in a linguistic, cultural, historical, and ethnic sense), are usually either counted as Latinos, not included in the Latino samples or simply overlooked in research studies. It is essential to understand the stress and pressures they undergo and appreciate their singular perspective and culturally-infused experiences to meet their needs and improve their mental healthcare and quality of life in the United States. AIM: The aim of this review is to understand and describe the experience of Brazilian immigrants in the U.S., related to mental health, assessing what studies have addressed and what is still needing to be researched. METHOD: We carried out an integrative review of peer-reviewed articles published between 2011 and 2022 using PychInfo, PubMed, and Proquest, addressing mental health of Brazilian immigrants in the United States. RESULTS: A total of 10 articles were included revealing the interest of a variety of fields and uncovering three themes: (1) mental healthcare needs (especially warmth and understanding of culture), (2) common sources of support and stress in the community and work, and (3) Socioeconomic aspects related to their mental health, including discrimination, work-life balance, neighborhood cohesion, and acculturation. CONCLUSIONS: Results may be useful to practitioners, researchers, and policy makers, who should be attentive to client's familiarity with the English language, their sources of support, spirituality, specific Brazilian traits, their feeling of 'being invisible', life in community, and their previous experiences with healthcare in Brazil.

A Mixed Methods Study Examining Citizenship Among Youth With Mental Health Challenges.

Introduction: Multiple stakeholders have recently called for greater research on the barriers to citizenship and community belonging faced by people with mental health challenges. Citizenship has been defined as a person's access to the rights, roles, responsibilities, resources and relationships that help people feel a sense of belonging. Factors that may impact citizenship include financial precarity; intersecting forms of marginalization and oppression (e.g., racism); and the mental health care people receive. Research has yet to examine experiences of citizenship among youth with mental health challenges. To address this gap, this study will examine how youth experience citizenship; predictors of citizenship; how citizenship shapes recovery; and the degree to which youth are receiving citizenship-oriented care. Methods: The research objectives will be evaluated using a multiphase mixed methods research design. Quantitative data will be collected cross-sectionally using validated self-report questionnaires. Qualitative data will be collected using a hermeneutic phenomenological method using semi-structured interviews and focus groups. Analyses: Multiple stepwise regression analyses will be used to determine predictors of citizenship and if of citizenship predict recovery. Pearson correlations will be computed to determine the relationship between participants' perceived desire for, and receipt of citizenship-oriented care. Phenomenological analysis will be used to analyze qualitative data. Findings will then be mixed using a weaving method in the final paper discussion section. Conclusion: Findings from this study may support the development of citizenship-oriented healthcare in Canada.

Generativity among people with lived experience of mental illness and distress.

Generativity refers to the contributions that people make toward the betterment of others, communities, and future generations. Engaging in generativity may add purpose and meaning to one's life, elements which people with mental illness often feel is relevant for their recovery. Despite its importance, what is known about how people with mental health problems engage in generativity, and the relationship between generativity and recovery is unclear. Addressing this knowledge gap may inform recovery-oriented interventions; and may help shift stigmatizing views that people with mental illnesses are a burden on society. This study explored generativity and its relationship to recovery among people with mental illnesses. The objectives were evaluated using a mixed methods sequential explanatory design over two phases. During the quantitative phase, participants completed questionnaires measuring generativity, recovery, and distress. During the qualitative phase, participants interpreted and elaborated upon the quantitative results. Phase one participants endorsed many items reflecting generativity. Generativity was correlated with overall recovery scores, as well as with domains reflecting no domination by symptoms (r = .32), a willingness to ask for help (r = .46), and personal confidence and hope (r = .48). Phase two participants discussed how the quantitative results resonated with their own experiences; their own generative behaviors, which included ephemeral and concrete forms of generativity; and how engaging in generativity improved their recovery. People with lived experience of mental illness make important contributions to the lives of other people and their communities; and these contributions can support recovery. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Citizenship, Social Justice and Collective Empowerment: Living Outside Mental Illness.

Citizenship is emerging as one of the world's leading models to shift mental health care from artificial psychiatric settings into more natural community settings by incorporating human rights. This paper describes a four-session roundtable series entitled Citizenship, Social Justice, and Collective Empowerment: Living Outside Mental Illness. These roundtables were part of the New England Mental Health Technology Transfer Center Network (MHTTC). They were built on the conviction that people who have lived experiences of mental health challenges and engaged in making community connections should be at the center of teaching about those experiences. Presenters shared their experiences about how they navigated stigma and discrimination on their way to community inclusion, belonging, and empowerment. The common theme across the series was the citizenship framework. The citizenship framework has inspired people to become involved in an individual and collective dynamic experience that connects them with the 5R's of rights, responsibilities, roles, resources, relationships, and a sense of belonging in society. The outcomes from the discussion on the webinars demonstrated that peer support could be a promising intervention to increase the sense of belonging in the community.

Effective Peer Employment Within Multidisciplinary Organizations: Model for Best Practice.

This study sought a clearer understanding of organizational mechanisms reinforcing effective peer employment and organizational change from the perspectives of peer workers, non-peer staff and management in multidisciplinary mental health and substance use recovery services. Findings were used to develop a model for organizational best practice for peer employment and associated organizational change to promote recovery-oriented and person-directed services. Qualitative research was undertaken, involving 132 people participating in 14 focus groups and eight individual interviews. These people were employed across five U.S. multidisciplinary organizations providing mental health and substance use recovery services and deemed by a panel of experts to provide effective employment of peer workers. Study findings include the articulation of an interactive working model of best practice, comprising organizational commitment, organizational culture and effective organizational strategies necessary for a "whole-of-organization" approach to support authentic peer work and enable organizational transformation, to actualize recovery-oriented values and person-driven services. Strategies include Human Resources engagement, peers in positions of senior organizational authority, recurring whole of workforce training, along with peer training and peer-led supervision. Findings suggest whole-of-organization commitment, culture and practice are essential for the organizational transformation needed to support effective employment of peers in multidisciplinary environments.

To disclose or not to disclose? Peer workers impact on a culture of safe disclosure for mental health professionals with lived experience.

The presence of peer workers in multi-disciplinary environments has rapidly increased in recent years, yet the impact of peer work on other mental health roles is largely unknown. This article explores the presence of peer workers within multi-disciplinary environments, with a specific focus on the possible impact of this presence on the culture of disclosure for mental health professionals with lived experiences of mental health challenges. Semi-structured focus groups and interviews were conducted with 132 participants at five organizations across the United States. Participants self-identified as being employed in a range of roles including management, mental health professionals, designated peer workers, and designated peer leadership positions. Findings suggest intentionally employing peers and using peer values to address stigma toward mental health professionals improves the culture of disclosure. In work environments where peer-led initiatives were featured, mental health professionals felt safer disclosing their own lived experience to their colleagues and supervisors. Recommendations include the use of parallel strategies to promote the perceived value of peers and to implement peer-led training for both supervisors and professionals to model a workplace culture that promotes and supports self-disclosure in the organization. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Implementation of peer support in mental health services: A systematic review of the literature.

Peer support within mental health services has a growing evidence base and aligns with current policies of recovery-oriented care. Despite these advantages, widespread implementation of peer support remains limited, likely due to various methodological and implementation issues. Researchers have noted the importance of utilizing an implementation framework to understand best practices for implementation. Therefore, the purpose of the current study was to synthesize the existing literature on the implementation of peer support interventions and identify barriers and facilitators using an implementation framework. The Consolidated Framework for Implementation Research (CFIR) was used to organize the literature obtained in the systematic search and synthesize best practices for implementation. The systematic search identified 19 published articles that were coded for relevant information including implementation barriers and facilitators. The review highlighted a number of important elements for implementation within the CFIR domains, including clear role definition, a flexible organizational culture, and education for peer and nonpeer staff. Implementation barriers included an organizational culture without a recovery focus, allied practitioners' beliefs about peer support, and an unclear peer role. The results of this review provide a summary of best practices for the implementation of peer support in mental health services that can be used by researchers and service providers in future implementation. These practices should continue to be tested and reworked as the climate of recovery-oriented services within mental health organizations evolves. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Generativity among persons providing or receiving peer or mutual support: A scoping review.

OBJECTIVE: People with lived experience of mental illness or distress can help others recover through peer or mutual support. One way they may help others recover is by fostering generativity, which refers to one's concern for and contributions toward the betterment of others, including future generations (e.g., through caregiving, engaging in civics). Generativity may add purpose to one's life, benefit society, and improve areas which persons with lived experience feel are important for their recovery. Despite its importance, the state of knowledge on experiences and facilitators of generativity, as well as the impact that engaging in generativity has on the lives of persons engaged in peer or mutual support, is unclear. METHOD: A librarian-assisted scoping review of the literature was conducted in five steps: identifying the research question and relevance; selecting studies; charting data; and coding and summarizing the results. RESULTS: Out of 11,862 articles that were screened, only 18 met eligibility criteria. Most studies were conducted in the United States and included White/Caucasian participants. Our synthesis produced themes related to generative actions, which included helping others, changing organizations and systems, and sharing personal stories. Themes describing facilitators of generativity included individual-level and organizational-level factors. One theme reflecting the positive psychosocial impact of engaging in generativity was produced. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Findings from this study point to several knowledge gaps to be investigated in future research and can facilitate the implementation of peer support initiatives aimed at fostering generativity, which may in turn promote recovery. (PsycInfo Database Record (c) 2022 APA, all rights reserved).