Peer support has rapidly emerged as a core component of mental health services, particularly in high-income countries. As mental health systems globally shift towards recovery-oriented models of care with a particular focus on lived experience inclusion, peer work is increasingly recognised not only as a complementary service, but also as a central part of mental health reform. Governments in Australia, the UK, Canada, the United States, and several Southeast Asian nations have begun integrating peer support into policy frameworks, reflecting the value and legitimacy being placed on peer-led support services.
Despite this growth, research into peer support often focuses on clinical outcomes rather than more fitting recovery-oriented measures such as social inclusion, empowerment, and hope, where positive outcomes are more likely. The UPSIDES trial (Using Peer Support In Developing Empowering mental health Services) is a landmark international trial that explores the effectiveness of peer support across high, middle and lower-income countries and across several different social, political, and economic contexts. It asks: can peer support improve social inclusion and recovery for people experiencing mental ill health?
Can peer support improve social inclusion and recovery for people experiencing mental ill health?
Methods
The UPSIDES randomised control trial recruited participants aged 18-60 years old with a ‘severe mental health condition’ across six sites: Germany (2), Uganda, Tanzania, Israel and India. Participants were randomised to receive either the UPSIDES peer support intervention alongside treatment as usual, or treatment as usual alone. Treatment as usual consisted of a mix of in-patient, out-patient, and community services with variation across the sites. This variation reflected the different mental health service contexts that peer support was delivered in. Peer support was delivered in community mental health settings in both German sites and in Israel, while in India, Tanzania, and Uganda, peer support was delivered within the context of psychiatric hospitals.
To support sites and peer support workers, a conceptual framework, training manual, and implementation manual was developed by all UPSIDES partners. Training for peer workers consisted of 12 core modules exploring the peer support role. Peer support was delivered by trained peer workers with lived experience of mental ill health. Peer support workers were adults aged 18-60 who were self-identified as being in recovery and had not been admitted to a hospital for at least 3 months before training. Peer support workers delivered individual and group sessions over a period of six months, with a minimum of three contacts during the time.
Outcomes were measured using validated self-report scales, with social inclusion as the primary outcome and hope, empowerment, recovery, health and social functioning as secondary outcomes. The primary outcome was measured using the Social Inclusion Scale (SIS; Secker et al 2009), which focuses on participants sense of social isolation with other people and within the community, their relationships with others, and sense of acceptance within their social contexts.
Peer support was tested across six sites in five countries.
Results
In total, 615 participants took part in the UPSIDES trial. They were mostly in their late 30s, identified as women, single, and had completed secondary education. Diagnoses of participants were primarily depression and psychosis, for an average (mean) of 15 years indicating that many participants had long term experiences of mental health challenges.
On average, participants received seven peer support sessions, mostly one-on-one and lasting over 30 minutes each. A total of 1,559 peer support sessions were delivered across all sites.
Primary outcome
While the overall social inclusion score did not reach statistical significance, subscales for social isolation and social acceptance showed significant improvements. The results suggest that peer support may help reduce feelings of isolation. However, the authors noted that increased effort of research staff in retaining participants due to the concurrent COVID-19 pandemic and social restrictions in place may have supported participants to feel appreciated.
Secondary outcomes
Empowerment and hope improved significantly for those who received peer support. Recovery measures showed an observable effect without reaching statistical significance. No improvements were found for health and social functioning.
615 participants had on average seven peer support sessions.
Conclusion
This study is the first randomised controlled trial to be conducted across diverse geographic and cultural contexts, spanning both high-income and low- and middle-income countries. By collecting data from diverse health systems, resource settings, and population needs, it represents relevant evidence that can inform equitable and context-appropriate interventions.
The UPSIDES study demonstrates that peer support is feasible and impactful across diverse settings particularly if implementation support is provided to services, and when peer support workers are provided training, guidance and support in a way that is flexible enough to be responsive to the unique social, cultural and organisational contexts in which they are working in (Hiltensperger et al 2024). The foundations of UPSIDES in adhering to recovery-oriented principles and adaptability to local contexts make it a promising model for reform in mental health globally.
The foundations of UPSIDES in adhering to recovery-oriented principles and adaptability to local contexts make it a promising model for reform in mental health globally.
Strengths and limitations
Strengths
- The UPSIDES manual was produced collaboratively between all the participating sites and partners and was adapted for each setting while maintaining core values and principles around peer support.
- The trial spanned varied social, political, and economic contexts, showcasing the viability of peer support globally.
- The outcomes identified to measure the success of the intervention were compatible with the relational, non-clinical ways of working used by lived experience workers.
Historically reporting of peer support interventions have lacked clarity about the nature of the peer worker, peers, intervention components, and professional supports for the peer workers to maintain a lived experience perspective (King and Simmons 2018). This lack of clarity has meant that a range of different intervention designs and frameworks have all been called peer support, but might not be lived experience developed and led. For example, using peers to deliver an intervention not grounded in lived experience and peer support principles and values, but instead delivering psychoeducational programs based on a medical or deficit model of mental health and wellbeing. This study is significant because it clearly articulated how the intervention was adapted for the local context whilst retaining the core principles and values of peer support, that is, the components of the intervention that are expected to lead to positive outcomes for peers. These resources are publicly available via the UPSIDES website.
The study measured social inclusion focused on relationships, rather than including broader factors such as education, employment, finances, or housing as others have done (e.g., Filia et al 2022). This focus makes sense for this trial given that participants received an average of seven sessions, and outcomes were measured over an eight-month period. Within that timeframe, changes in structural markers like securing housing or employment are unlikely, whereas improvements in relational domains are more likely. At the same time, it’s important to note that this narrower focus does not capture the full scope of social inclusion. Stronger relationships are an important foundation, but genuine social inclusion also depends on opportunities in education and work, financial security, and stable housing. The UPSIDES trial provides valuable insight into shorter-term, relational changes, while also highlighting the need for future research to examine whether such interventions can ultimately support those broader and longer-term outcomes.
Limitations
- Variability in implementation and support structures for peer support workers across sites as well as the method of peer support. Some sites had options between one-on-one and group peer support while other sites exclusively delivered group peer support which may not work for all participants.
- A lack of consistency between sites of what the treatment as usual consisted of particularly as this varied across a range of settings.
The experiences of people accessing community based mental health services and mental health services within psychiatric hospitals are often significantly different. These differences can be in the environment, the autonomy of service users, the focus of support and the outcomes that these services aim to achieve for those who access them. A key limitation of the UPSIDES study was the variability of these settings that peer support was delivered within and what treatment as usual was for participants. While it was observed that there were beneficial outcomes to the group that received peer support compared to those who did not, it is difficult to determine whether the observed effects were due to the intervention itself, or other factors that may be unique to the settings in which peer support was delivered. The authors acknowledge in the paper potential factors such as increased researcher support due to COVID social distancing restrictions, as well the differences in how peer support was delivered.
To better understand the effectiveness of peer support, future studies should account for the variability in the ways that support is delivered or for the UPSIDES intervention to be trialled in more controlled settings with consistency in regards to what treatment as usual may look like. However, it is important to acknowledge that the differences may also be reflective of what recovery-oriented services currently look like in different settings.
A key limitation was variability in settings and treatment as usual
Implications for practice
As peer support continues to grow in mental health systems worldwide, it is essential to reflect on its purpose within mental health services, and the intended outcomes of peer support for the people who access it. Measuring outcomes aligned with peer support values, rather than symptom reduction or adherence to psychiatric treatment is a strength of this study and one that is essential for the success of similar trials seeking to measure the efficacy of peer support as either a standalone service or as a complement to existing services. However, it is also important to recognise that the primary outcome of social inclusion was not realised. Secondary recovery-related outcomes did achieve statistical significance, which is in line with wider evidence, perhaps providing more support for the potential role of hope and empowerment as a core element of peer support.
A worthy initiative as part of the UPSIDES trial was the emphasis on co-creation of program resources while leaving enough room for each site to adapt the program to its own individual contexts. Services users across different settings ultimately have different experiences of mental ill health, but also the legal, social, and economic positions in which receiving treatment or support for mental ill health may place them. As such, a universalist approach to implementing, training, and conceptualising peer support is likely to work against the needs of service users who experience different challenges and experiences according to their context.
Peer support must be measured by outcomes that reflect its core values—hope, empowerment, and inclusion—rather than symptom reduction.
Links
Primary paper
Puschner B, Nakku J, Hiltensperger R, Wolf P, Adler Ben-Dor I, Bugeiga F, Charles A, Gai Meir L, Garber-Epstein P, Goldfarb Y, Grayzman A, Hadas-Grundman S, Haun M, Heuer I, Iboma B, Kalha J, Kamwaga L, Korde P, Kotera Y, Krumm S, Kulkarni A, Kwebiiha E, Kyara J, Lachman M, Mahlke C, Mayer B, Moran G, Mpango R, Mtei R, Müller-Stierlin A, Nanyonga R, Ngakongwa F, Niwemuhwezi J, Nixdorf R, Nugent L, Pathare S, Ramesh M, Ryan G, Schulz G, Wagner M, Waldmann T, Wenzel L, Shamba D, Slade M. Effectiveness of peer support for people with severe mental health conditions in high-, middle- and low-income countries: multicentre randomised controlled trial. Br J Psychiatry. 2025 Jun 27:1
Other references
Filia K, Gao CX, Jackson HJ, Menssink J, Watson A, Gardner A, Cotton SM, Killackey E. Psychometric properties of a brief, self-report measure of social inclusion: the F-SIM16. Epidemiol Psychiatr Sci. 2022 Jan 21;31:e8
Hiltensperger R, Ryan G, Ben-Dor I, Charles A, Epple E, Kalha J, Korde P, Kotera Y, Mpango R, Moran G, Mueller-Stierlin A, Nixdorf R, Ramesh M, Shamba D, Slade M, Puschner B, Nakku J. Implementation of peer support for people with severe mental health conditions in high-, middle- and low-income-countries: a theory of change approach. BMC health services research. 2024. 24:480.
King AJ, Simmons MB. A Systematic Review of the Attributes and Outcomes of Peer Work and Guidelines for Reporting Studies of Peer Interventions. Psychiatr Serv. 2018 Sep 1;69(9):961-977.
Secker J, Hacking S, Kent L, et al. Development of a measure of social inclusion for arts and mental health project participants. J Ment Health 2009;18:65–72.