[Successful Implementation of Peer Support for People with Severe Mental Illness in Germany: a Theory of Change Approach]. / Eine Theory of Change zur erfolgreichen Implementierung von Peer-Begleitung für Menschen mit schweren psychischen Erkrankungen in Deutschland.

OBJECTIVE: Peer support is an established intervention in which people with mental illness receive support by trained peer support workers who have already overcome a mental health crisis. The implementation of peer support is complex due to interacting factors and can be achieved through the participatory Theory of Change method. Aim of this study is to develop a cross-site Theory of Change for the sustainable implementation of UPSIDES peer support in Germany. METHODS: Based on site-specific Theories of Change workshops from Ulm and Hamburg in which 47 participants took part, a cross-site Theory of Change was designed and verified in three follow-up workshops with 12 participants. Participants' professional and experiential backgrounds were diverse, including peer support workers, hospital directors and managers, mental health professionals (psychiatrists, psychotherapists, nurses), and researchers. RESULTS: The first pathway of the cross-site Theory of Change focuses on the training of peer support workers, whereas the second pathway emphasizes recognition and integration by mental health institutions and professionals. The third pathway specifies the building of a cross-professional care network to integrate various peer support services. Procedures to approach prospective peer clients are depicted in the fourth pathway. The fifth path addresses the clarification of the role description of peer support workers and the implementation in other institutions through cooperation. DISCUSSION: Many of the identified implementation steps have been validated in comparable studies. The development of this Theory of Change by bringing together multiple perspectives of key stakeholders is an important basis for the sustainable implementation of UPSIDES peer support. Furthermore, it may serve as a blueprint for the implementation of similar interventions to advance scaling-up of evidence-based user-led and recovery-oriented interventions. CONCLUSION: The Theory of Change approach is a well-accepted and feasible method, which can be recommended for the implementation of complex interventions such as UPSIDES peer support.

Study protocol of a randomized controlled trial evaluating home treatment with peer support for acute mental health crises (HoPe).

BACKGROUND: Home treatment (HT) is a treatment modality for patients with severe mental illness (SMI) in acute mental crises. It is frequently considered equivalent to psychiatric inpatient treatment in terms of treatment outcome. Peer Support (PS) means that people with lived experience of a mental illness are trained to support others on their way towards recovery. While PS is growing in international importance and despite a growing number of studies supporting its benefits, it is still not comprehensively implemented into routine care. The HoPe (Home Treatment with Peer Support) study investigates a combination of both - HT and PS - to provide further evidence for a recovery-oriented treatment of psychiatric patients. METHODS: In our randomized controlled trial (RCT), HT with PS is compared with HT without PS within a network of eight psychiatric clinical centers from the North, South and East of Germany. We investigate the effects of a combination of both approaches with respect to the prevention of relapse/recurrence defined as first hospitalization after randomization (primary outcome), disease severity, general functioning, self-efficacy, psychosocial health, stigma resistance, recovery support, and service satisfaction (secondary outcomes). A sample of 286 patients will be assessed at baseline after admission to HT care (data point t0) and randomized into the intervention (HT + PS) and control arm (HT). Follow-Up assessments will be conducted 2, 6 and 12 months after admission (resulting in three further data points, t1 to t3) and will be analyzed via intention-to-treat approach. DISCUSSION: This study may determine the positive effects of PS added to HT, prove additional evidence for the efficacy of PS and thereby facilitate its further implementation into psychiatric settings. The aim is to improve quality of mental health care and patients' recovery as well as to reduce the risk of relapses and hospitalizations for patients with SMI. TRIAL REGISTRATION: The trial is registered with ClinicalTrials.gov: NCT04336527 , April 7, 2020.

Typology of modifications to peer support work for adults with mental health problems: systematic review.

BACKGROUND: Peer support work roles are being implemented internationally, and increasingly in lower-resource settings. However, there is no framework to inform what types of modifications are needed to address local contextual and cultural aspects. AIMS: To conduct a systematic review identifying a typology of modifications to peer support work for adults with mental health problems. METHOD: We systematically reviewed the peer support literature following PRISMA guidelines for systematic reviews (registered on PROSPERO (International Prospective Register of Systematic Reviews) on 24 July 2018: CRD42018094832). All study designs were eligible and studies were selected according to the stated eligibility criteria and analysed with standardised critical appraisal tools. A narrative synthesis was conducted to identify types of, and rationales for modifications. RESULTS: A total of 15 300 unique studies were identified, from which 39 studies were included with only one from a low-resource setting. Six types of modifications were identified: role expectations; initial training; type of contact; role extension; workplace support for peer support workers; and recruitment. Five rationales for modifications were identified: to provide best possible peer support; to best meet service user needs; to meet organisational needs, to maximise role clarity; and to address socioeconomic issues. CONCLUSIONS: Peer support work is modified in both pre-planned and unplanned ways when implemented. Considering each identified modification as a candidate change will lead to a more systematic consideration of whether and how to modify peer support in different settings. Future evaluative research of modifiable versus non-modifiable components of peer support work is needed to understand the modifications needed for implementation among different mental health systems and cultural settings.

A systematic review of influences on implementation of peer support work for adults with mental health problems.

PURPOSE: The evidence base for peer support work in mental health is established, yet implementation remains a challenge. The aim of this systematic review was to identify influences which facilitate or are barriers to implementation of mental health peer support work. METHODS: Data sources comprised online databases (n = 11), journal table of contents (n = 2), conference proceedings (n = 18), peer support websites (n = 2), expert consultation (n = 38) and forward and backward citation tracking. Publications were included if they reported on implementation facilitators or barriers for formal face-to-face peer support work with adults with a mental health problem, and were available in English, French, German, Hebrew, Luganda, Spanish or Swahili. Data were analysed using narrative synthesis. A six-site international survey [Germany (2 sites), India, Israel, Tanzania, Uganda] using a measure based on the strongest influences was conducted. The review protocol was pre-registered (Prospero: CRD42018094838). RESULTS: The search strategy identified 5813 publications, of which 53 were included. Fourteen implementation influences were identified, notably organisational culture (reported by 53% of papers), training (42%) and role definition (40%). Ratings on a measure using these influences demonstrated preliminary evidence for the convergent and discriminant validity of the identified influences. CONCLUSION: The identified influences provide a guide to implementation of peer support. For services developing a peer support service, organisational culture including role support (training, role clarity, resourcing and access to a peer network) and staff attitudes need to be considered. The identified influences provide a theory base to prepare research sites for implementing peer support worker interventions.

[Models of peer support in psychiatric care]. / Einsatzmöglichkeiten von Peerbegleitung in der psychiatrischen Versorgung.

In the past decades, psychiatric care has changed from the traditional medical model to a more person-centered and recovery-focused approach. In this process, peer support workers are essential, because with their lived experience of crisis and recovery they are able to spread hope.This article gives an overview of the recent literature describing the current change model of peer support, reporting the evidence of peer support, as well as the current stage of implementation of peer support in different psychiatric contexts.An overview of the current state of research, selected by the authors, based on repeated systematic literature searches in peer support research projects, is given. Additionally, some examples of user involvement from the Hamburg EX-IN Curriculum, trialogs between sufferers, relatives and professionals, as well as the so-called psychosis seminars are described in more detail.Peer support has shown promising results in one-to-one and group settings, case management, crisis interventions, and the reduction of coercive measures.Although there are promising results of peer support in various clinical contexts, multiple challenges in the implementation of peer support are reported. They need to be overcome by the inclusion of all staff members in the change process of the system in order to further develop user-oriented and recovery-oriented psychiatric care.

Knowledge on types of treatment pressure. A cross-sectional study among mental health professionals.

Treatment pressure restricts patients' voluntary and autonomous decisions. Yet interventions involving treatment pressure are widely used in mental health and psychosocial services. This cross-sectional study explored whether mental health professionals' knowledge on five types of treatment pressure (no coercion, persuasion or conviction, leverage, threat, and formal coercion) was associated with sociodemographic, professional and contextual factors. A more positive attitude towards interventions involving treatment pressure was associated with underrating the level of those interventions compared with a predefined default value. The treatment setting and professional group played a minor role in 'leverage' and 'formal coercion' types of treatment pressure, respectively.

Effectiveness of a peer-supported crisis intervention to reduce the proportion of compulsory admissions in acute psychiatric crisis interventions in an outreach and outpatient setting: study protocol for an exploratory cluster randomised trial combined with qualitative methods.

INTRODUCTION: Compulsory admissions are associated with feelings of fear, humiliation and powerlessness. The number of compulsory admissions in Germany and other high-income countries has increased in recent years. Peer support has been shown to increase the self-efficacy of individuals with mental health conditions in acute crises and to reduce the use of coercive measures in clinical settings. The objective of this study is to reduce the number of compulsory admissions by involving peer support workers (PSWs) in acute mental health crises in outreach and outpatient settings. METHODS AND ANALYSIS: This one-year intervention is an exploratory, cluster randomised study. Trained PSWs will join the public crisis intervention services (CIS) in two of five regions (the intervention regions) in the city of Bremen (Germany). PSWs will participate in crisis interventions and aspects of the mental health services. They will be involved in developing and conducting an antistigma training for police officers. The remaining three regions will serve as control regions. All individuals aged 18 and older who experience an acute mental health crisis during the operating hours of the regional CIS in the city of Bremen (around 2000 in previous years) will be included in the study. Semistructured interviews will be conducted with PSWs, 30 patients from control and intervention regions, as well as two focus group discussions with CIS staff. A descriptive comparison between all participants in the intervention and control regions will assess the proportion of compulsory admissions in crisis interventions during the baseline and intervention years, including an analysis of temporal changes. ETHICS AND DISSEMINATION: This study was approved by the Ethics Committee of the University of Bremen (file 2022-09) on 20 June 2022. The results will be presented via scientific conferences, scientific journals and communicated to policy-makers and practitioners. TRIAL REGISTRATION NUMBER: DRKS00029377.

Development of the UPSIDES global mental health training programme for peer support workers: Perspectives from stakeholders in low, middle and high-income countries.

BACKGROUND: Peer support in mental health is a low-threshold intervention with increasing evidence for enhancing personal recovery and empowerment of persons living with severe mental health conditions. As peer support spreads globally, there is a growing need for peer support training programmes that work well in different contexts and cultures. This study evaluates the applicability and transferability of implementing a manualised multi-national training programme for mental health peer support workers called UPSIDES from the perspective of different local stakeholders in high-, middle-, and low-income countries. METHOD: Data from seven focus groups across six study sites in Africa (Tanzania, Uganda), Asia (India, Israel), and Europe (Germany 2 sites) with 44 participants (3 service users, 7 peer support workers, 25 mental health staff members, 6 clinical directors and 3 local community stakeholders) were thematically analysed. RESULTS: 397 codes were identified, which were thematically analysed. Five implementation enablers were identified: (i) Enhancing applicability through better guidance and clarity of training programme management, (ii) provision of sufficient time for training, (iii) addressing negative attitudes towards peer support workers by additional training of organisations and staff, (iv) inclusion of core components in the training manual such as communication skills, and (v) addressing cultural differences of society, mental health services and discrimination of mental health conditions. DISCUSSION: Participants in all focus groups discussed the implementation of the training and peer support intervention to a greater extent than the content of the training. This is in line with growing literature of difficulties in the implementation of peer support including difficulties in hiring peer support workers, lack of funding, and lack of role clarity. The results of this qualitative study with stakeholders from different mental health settings worldwide emphasises the need to further investigate the successful implementation of peer support training. All results have been incorporated into the manualisation of the UPSIDES peer support training.

Societal and organisational influences on implementation of mental health peer support work in low-income and high-income settings: a qualitative focus group study.

OBJECTIVES: Despite the established evidence base for mental health peer support work, widespread implementation remains a challenge. This study aimed to explore societal and organisational influences on the implementation of peer support work in low-income and high-income settings. DESIGN: Study sites conducted two focus groups in local languages at each site, using a topic guide based on a conceptual framework describing eight peer support worker (PSW) principles and five implementation issues. Transcripts were translated into English and an inductive thematic analysis was conducted to characterise implementation influences. SETTING: The study took place in two tertiary and three secondary mental healthcare sites as part of the Using Peer Support in Developing Empowering Mental Health Services (UPSIDES) study, comprising three high-income sites (Hamburg and Ulm, Germany; Be'er Sheva, Israel) and two low-income sites (Dar es Salaam, Tanzania; Kampala, Uganda) chosen for diversity both in region and in experience of peer support work. PARTICIPANTS: 12 focus groups were conducted (including a total of 86 participants), across sites in Ulm (n=2), Hamburg (n=2), Dar es Salaam (n=2), Be'er Sheva (n=2) and Kampala (n=4). Three individual interviews were also done in Kampala. All participants met the inclusion criteria: aged over 18 years; actual or potential PSW or mental health clinician or hospital/community manager or regional/national policy-maker; and able to give informed consent. RESULTS: Six themes relating to implementation influences were identified: community and staff attitudes, resource availability, organisational culture, role definition, training and support and peer support network. CONCLUSIONS: This is the first multicountry study to explore societal attitudes and organisational culture influences on the implementation of peer support. Addressing community-level discrimination and developing a recovery orientation in mental health systems can contribute to effective implementation of peer support work. The relationship between societal stigma about mental health and resource allocation decisions warrants future investigation. TRIAL REGISTRATION NUMBER: ISRCTN26008944.

Proportionate translation of study materials and measures in a multinational global health trial: methodology development and implementation.

OBJECTIVES: Current translation guidelines do not include sufficiently flexible translation approaches for different study materials. We aimed to develop a proportionate methodology to inform translation of all types of study materials in global health trials. DESIGN: The design included three stages: (1) categorisation of study materials, (2) integration of existing translation frameworks and (3) methodology implementation (Germany, India, Israel, Tanzania and Uganda) and refinement. PARTICIPANTS: The study population comprised 27 mental health service users and 27 mental health workers who were fluent in the local language in stage 7 (pretesting), and 54 bilingual mental health service users, aged 18 years or over, and able to give consent as judged by a clinician for step 9 (psychometric evaluation). SETTING: The study took place in preparation for the Using Peer Support in Developing Empowering Mental Health Services (UPSIDES) randomised controlled trial (ISRCTN26008944). PRIMARY OUTCOME MEASURE: The primary outcome measure was the Social Inclusion Scale (SIS). RESULTS: The typology identifies four categories of study materials: local text, study-generated text, secondary measures and primary measure. The UPSIDES Proportionate Translation Methodology comprises ten steps: preparation, forward translation, reconciliation, back translation, review, harmonisation, pretesting, finalisation, psychometric evaluation and dissemination. The translated primary outcome measure for the UPSIDES Trial (SIS) demonstrated adequate content validity (49.3 vs 48.5, p=0.08), convergent validity and internal consistency (0.73), with minimal floor/ceiling effects. CONCLUSION: This methodology can be recommended for translating, cross-culturally adapting and validating all study materials, including standardised measures, in future multisite global trials. The methodology is particularly applicable to multi-national studies involving sites with differing resource levels. The robustness of the psychometric findings is limited by the sample sizes for each site. However, making this limitation explicit is preferable to the typical practice of not reporting adequate details about measure translation and validation. TRAIL REGISTRATION NUMBER: ISRCTN26008944.

Effectiveness of a contact-based anti-stigma intervention for police officers.

INTRODUCTION: Police force interaction rates with individuals with mental health conditions are on the rise. International research reveals that the presence of a mental health condition increases the risk for detention and use of force by police officers. Stigmatization of individuals with mental health conditions as dangerous and unpredictable is assumed to have an impact on the likelihood of police use of force. The following study examines a trialogical intervention to reduce stigmatization of individuals with a diagnosis of schizophrenia in a police officer sample. METHOD: 1318 police officers participated in a trialogical contact-based intervention with the aim to reduce stigmatizing attitudes and beliefs. Emotional reactions, stereotypes and social distance were assessed prior to and after the intervention in a one-group design. RESULTS: Negative stereotypes were positively associated with social distance in individuals with a diagnosis of schizophrenia and were positively associated with anxiety. Dependent sample t-test revealed reduced anxiety towards individuals with a diagnosis of schizophrenia, less negative stereotypes, and less social distance post intervention. All results were significant, and all effect sizes showed a small to moderate effect. CONCLUSIONS: Trialogical contact-based, short-term anti-stigma interventions appear to reduce stigmatizing attitudes towards individuals with mental health conditions in a large police force sample. A missing control group is a key study limitation. Further research is needed to examine the effectiveness of the intervention in a randomized-controlled trial. However, the results clearly suggest that anti-stigma interventions could be beneficially introduced into police training.

[Do we Choose the Right Measures to Avoid Coercion? - A Survey of Service Users who Experienced Coercion About Potentially Helpful Milder Measures]. / Wählen wir die richtigen Mittel zur Zwangsvermeidung?

AIM: We investigated which milder measures service users perceive as helpful to prevent coercive measures and in which extent these measures are offered. METHODS: A sample of 155 former service users who experienced coercion was recruited and questioned via online or paper pencil survey. RESULTS: On average, participants reported to have received 4.7 from a total of 25 milder measures. The measures, which where most frequent rated as potentially helpful where "crisis talks", "considering needs" and "showing interest". The analysis showed a negative relation between the frequency of offered measures and the frequency these measures where rated as potentially helpful. 86 % of the participants reported low satisfaction with treatment overall. CONCLUSION: It seems, that in escalating situations service users do not receive the measures they perceive as helpful. In order to prevent the use of coercive measures staff members should focus on crisis talks and a need-orientated, empathic interaction.

Psychometric evaluation of the German version of the Opening Minds Stigma Scale for Health Care Providers (OMS-HC).

BACKGROUND: Healthcare professionals can be a source of stigma and discrimination for people with mental illness, and anti-stigma programs are needed for this target group. However, there is no validated German language scale to assess attitudes of healthcare professionals towards people with mental illness. This study had the aim to validate the German language version of the Opening Minds Stigma Scale for Health Care Providers (OMS-HC), a self-report measure of stigmatizing attitudes. METHODS: Staff (n = 392) on general psychiatric inpatient wards (excluding child, forensic and geriatric psychiatry) at five psychiatric hospitals in Switzerland (n = 3) and Germany (n = 2) participated in the study. The internal consistency of the OMS-HC was examined as well as its factor structure using exploratory and confirmatory factor analyses. To assess the scale's concurrent validity, we used the Social Distance Scale. RESULTS: Internal consistency for the OMS-HC total score was good (α = 0.74), acceptable for the subscales Attitudes (α = 0.62) and Social Distance (α = 0.69), and poor for the Disclosure subscale (α = 0.55). The original three-factor structure fit our data well. The OMS-HC total score and the Social Distance subscale score were significantly correlated with the Social Distance Scale, supporting concurrent validity. CONCLUSION: The German version of the OMS-HC demonstrated satisfactory psychometric properties and can be recommended for future research and intervention evaluation.

Initial Training for Mental Health Peer Support Workers: Systematized Review and International Delphi Consultation.

BACKGROUND: Initial training is essential for the mental health peer support worker (PSW) role. Training needs to incorporate recent advances in digital peer support and the increase of peer support work roles internationally. There is a lack of evidence on training topics that are important for initial peer support work training and on which training topics can be provided on the internet. OBJECTIVE: The objective of this study is to establish consensus levels about the content of initial training for mental health PSWs and the extent to which each identified topic can be delivered over the internet. METHODS: A systematized review was conducted to identify a preliminary list of training topics from existing training manuals. Three rounds of Delphi consultation were then conducted to establish the importance and web-based deliverability of each topic. In round 1, participants were asked to rate the training topics for importance, and the topic list was refined. In rounds 2 and 3, participants were asked to rate each topic for importance and the extent to which they could be delivered over the internet. RESULTS: The systematized review identified 32 training manuals from 14 countries: Argentina, Australia, Brazil, Canada, Chile, Germany, Ireland, the Netherlands, Norway, Scotland, Sweden, Uganda, the United Kingdom, and the United States. These were synthesized to develop a preliminary list of 18 topics. The Delphi consultation involved 110 participants (49 PSWs, 36 managers, and 25 researchers) from 21 countries (14 high-income, 5 middle-income, and 2 low-income countries). After the Delphi consultation (round 1: n=110; round 2: n=89; and round 3: n=82), 20 training topics (18 universal and 2 context-specific) were identified. There was a strong consensus about the importance of five topics: lived experience as an asset, ethics, PSW well-being, and PSW role focus on recovery and communication, with a moderate consensus for all other topics apart from the knowledge of mental health. There was no clear pattern of differences among PSW, manager, and researcher ratings of importance or between responses from participants in countries with different resource levels. All training topics were identified with a strong consensus as being deliverable through blended web-based and face-to-face training (rating 1) or fully deliverable on the internet with moderation (rating 2), with none identified as only deliverable through face-to-face teaching (rating 0) or deliverable fully on the web as a stand-alone course without moderation (rating 3). CONCLUSIONS: The 20 training topics identified can be recommended for inclusion in the curriculum of initial training programs for PSWs. Further research on web-based delivery of initial training is needed to understand the role of web-based moderation and whether web-based training better prepares recipients to deliver web-based peer support.

Effects of contact-based, short-term anti-stigma training for medical students : Results from a randomized controlled trial.

BACKGROUND: Mental health stigma (MHS) places a burden on those affected that far exceeds psychosocial harms. Contact-based anti-stigma work has been found effective for several target groups. For medical students however, its efficacy remains unclear. AIM: The purpose of this study was to examine the efficacy of contact-based, trialogic anti-stigma training for medical students. METHODS: A randomized controlled trial (RCT) was conducted, controlling for standard clinical placement in psychiatry. External validity was maximized by including all students (n = 204) who started their 6­week obligatory psychiatry course during the study period between March and July 2018. Assessments were conducted at the beginning of each of the two covered terms and immediately postintervention. RESULTS: Students who received the anti-stigma training displayed significantly less stigmatizing attitudes after the intervention, measured using the MICA (Mental Illness-Clinicians' Attitudes) scale as primary outcome. Analogous findings were noted for social distance and stereotypes, whereas these could not be observed for emotional reactions. All significant changes were independent of gender and age. CONCLUSION: The positive results underpin the research in this field and point towards the inclusion of comparable interventions in regular student curricula. Given the limitation of a missing late follow-up, however, further research regarding the persistence of stigma reduction is needed.

Peer support for people with severe mental illness versus usual care in high-, middle- and low-income countries: study protocol for a pragmatic, multicentre, randomised controlled trial (UPSIDES-RCT).

BACKGROUND: Peer support is an established intervention involving a person recovering from mental illness supporting others with mental illness. Peer support is an under-used resource in global mental health. Building upon comprehensive formative research, this study will rigorously evaluate the impact of peer support at multiple levels, including service user outcomes (psychosocial and clinical), peer support worker outcomes (work role and empowerment), service outcomes (cost-effectiveness and return on investment), and implementation outcomes (adoption, sustainability and organisational change). METHODS: UPSIDES-RCT is a pragmatic, parallel-group, multicentre, randomised controlled trial assessing the effectiveness of using peer support in developing empowering mental health services (UPSIDES) at four measurement points over 1 year (baseline, 4-, 8- and 12-month follow-up), with embedded process evaluation and cost-effectiveness analysis. Research will take place in a range of high-, middle- and low-income countries (Germany, UK, Israel, India, Uganda and Tanzania). The primary outcome is social inclusion of service users with severe mental illness (N = 558; N = 93 per site) at 8-month follow-up, measured with the Social Inclusion Scale. Secondary outcomes include empowerment (using the Empowerment Scale), hope (using the HOPE scale), recovery (using Stages of Recovery) and health and social functioning (using the Health of the Nations Outcome Scales). Mixed-methods process evaluation will investigate mediators and moderators of effect and the implementation experiences of four UPSIDES stakeholder groups (service users, peer support workers, mental health workers and policy makers). A cost-effectiveness analysis examining cost-utility and health budget impact will estimate the value for money of UPSIDES peer support. DISCUSSION: The UPSIDES-RCT will explore the essential components necessary to create a peer support model in mental health care, while providing the evidence required to sustain and eventually scale-up the intervention in different cultural, organisational and resource settings. By actively involving and empowering service users, UPSIDES will move mental health systems toward a recovery orientation, emphasising user-centredness, community participation and the realisation of mental health as a human right. TRIAL REGISTRATION: ISRCTN, ISRCTN26008944. Registered on 30 October 2019.

[Competencies and Role Experiences of Peer Support - A Participatory Research Report]. / Kompetenzen und Rollen(-erwartungen) von Genesungsbegleitern in der psychiatrischen Versorgung ­ Ein partizipativer Forschungsbericht.

OBJECTIVE: This study explores the peer support providers' competencies and role experiences. METHODS: A multiple coding approach has been used to collaboratively analyze and discuss ethnographic material. RESULTS: Compared to other professionals, peer support provider engage with patients in a more open and less classificatory way. Their role is often unclear and defined by both more flexibility and dependencies. CONCLUSIONS: It is important to clearly define the competencies and roles of peer support providers and balance them with the expectations of the other professionals.

Using Peer Support in Developing Empowering Mental Health Services (UPSIDES): Background, Rationale and Methodology.

BACKGROUND: Peers are people with lived experience of mental illness. Peer support is an established intervention in which peers offer support to others with mental illness. A large proportion of people living with severe mental illness receive no care. The care gap is largest in low- and middle-income countries, with detrimental effects on individuals and societies. The global shortage of human resources for mental health is an important driver of the care gap. Peers are an under-used resource in global mental health. OBJECTIVES: To describe rationale and methodology of an international multicentre study which will scale-up peer support for people with severe mental illness in high-, middle-, and low-income countries through mixed-methods implementation research. METHODS: UPSIDES is an international community of research and practice for peer support, including peer support workers, mental health researchers, and other relevant stakeholders in eight study sites across six countries in Europe, Africa, and Asia. During the first two years of UPSIDES, a series of qualitative studies and systematic reviews will explore stakeholders' perceptions and the current state of peer support at each site. Findings will be incorporated into a conceptual framework to guide the development of a culturally appropriate peer support intervention to be piloted across all study sites. All intervention and study materials will be translated according to internationally recognised guidelines.Expected Impact: UPSIDES: will leverage the unique expertise of people with lived experience of mental illness to strengthen mental health systems in high-, middle- and low-income countries. UPSIDES will actively involve and empower service users and embed patient-centeredness, recovery orientation, human rights approaches, and community participation into services. The focus on capacity-building of peers may prove particularly valuable in low-resource settings in which shortages of human capital are most severe.

Embracing Psychosis: A Cognitive Insight Intervention Improves Personal Narratives and Meaning-Making in Patients With Schizophrenia.

Schizophrenia is a complex psychiatric disorder with unknown and presumably heterogeneous etiology. While the disorder can have various outcomes, research is predominantly "deficit-oriented" emphasizing the hardship that the disorder inflicts on sufferers as well as their families and society. Beyond symptom reduction, imparting patients with hope and meaning in life is increasingly considered an important treatment target, which may raise self-esteem, and reduce self-stigma and suicidal ideation. The present study compared a psychotherapeutic treatment aimed at improving cognitive insight, individualized metacognitive intervention (MCT+), with an active control in order to elucidate if personal meaning-making and hope can be improved in patients with psychosis across time. A total of 92 patients were randomized to either individualized metacognitive therapy (MCT+) or CogPack (neuropsychological training) and followed up for up to 6 months. The "Subjective Sense in Psychosis Questionnaire" (SUSE) was administered which covers different salutogenetic vs pathogenetic views of the disorder, valence of symptom experiences and the consequences of psychosis. Patients in the MCT+ group showed a significant positive shift in attitudes towards the consequences of their illness over time relative to patients in the active control condition. There was some evidence that MCT+ also enhanced meaning-making. The perceived negative consequences of psychosis were highly correlated with depression and low self-esteem, as well as suicidality. The study shows that a cognitive insight training can improve meaning-making in patients and help them come to terms with their diagnosis.