Group peer support boosts recovery in Danish community trial

Peer support is a widely recommended recovery-oriented intervention in which a person in recovery offers support to others living with mental health conditions (Davidson et al., 2006; World Health Organization, 2021), and is an approach we have regularly featured in these pages.

Peer support workers support their clients’ recovery by drawing on their own lived experience, employing positive self-disclosure, expanding social networks, and promoting hope, empowerment and self-efficacy (Fuhr et al., 2014; Corrigan et al., 2019). Over recent years it has been shown that clients of peer support workers report positive effects on different psychosocial and functional outcomes including recovery, social inclusion, and empowerment (White et al., 2020; Smit et al., 2023; Høgh Egmose et al., 2023; Cooper et al., 2024; Yim et al., 2023).

Peer support may be delivered in either one-to-one or group formats, or in a mix of both, as recently done in the UPSIDES study. The major share of evidence has been generated on one-to-one peer support, but there is insufficient evidence available from trials of group peer support.

While peer support has been implemented and evaluated in many countries, its spread and evidence-base in Denmark is limited, even though recovery-oriented mental health care plays an important role there. It is also rare to find trials of group-based and community-set peer support. A recently published randomised controlled trial sought to contribute to filling the evidence gap on group peer support in Denmark (Poulsen et al., 2025b).

Methods

The study was a randomised controlled trial in five Danish municipalities, which compared the PEER intervention added to service as usual (SAU) to SAU alone. Participants were municipality social service users and self-referrals. This means the sample was mixed with no exclusion criteria based on diagnosis, substance use, or suicidal ideation. The lived experience researchers and statistician were blinded to allocation; participants and volunteers were not. Researchers addressed missing data by running both complete case and multiple imputation analyses, adjusting for education level.

The intervention was a 10-week group course called “Paths to Everyday Life” (PEER). Beyond the 10‑week group programme, participants could receive up to six months of one‑to‑one companionship with a peer, helping them access community activities, education, employment, and services.

The intervention manual was built around the CHIME framework (Connectedness; Hope; Identity; Meaning; Empowerment; Leamy et al., 2011), with sessions covering sharing safely, boundaries, life values, relationships, storytelling, and developing individual plans. Sessions were delivered by peer volunteers who were well advanced in their own personal recovery. Volunteers received training and written guidance before the trial began, with ongoing supervision from local peer coordinators employed by the Peer Partnership Association NGO (Poulsen et al., 2022).

The primary outcome in the RCT was personal recovery measured with the Questionnaire about the Process of Recovery (QPR-15: Neil et al., 2009) which consists of 15 items, each scored on a 4-point scale. Secondary outcomes were empowerment (Empowerment Scale ES; Rogers et al., 1997), quality of life (The Manchester Short Assessment of Quality of Life MANSA: Priebe et al., 1999), and functioning (Work and Social Adjustment Scale WSAS: Mundt et al., 2002). An effect was defined as improvement between measurement at baseline and at the end of the intervention (three months later) on a given outcome scale.

Results

296 participants were included in the intention-to-treat analysis, split roughly equally between the PEER group (145) and service as usual alone (151).

The primary outcome: personal recovery

Personal recovery scores (measured using the QPR-15 questionnaire) were significantly higher in the PEER group at the end of the intervention:

• PEER group mean score: 37.3 (95% CI: 35.4 to 39.1)
• SAU group mean score: 32.1 (95% CI: 30.2 to 34.1)
• Mean difference: 5.1 points (95% CI: 2.4 to 7.8; p<0.001), with a small to medium effect size (Cohen’s d = 0.43), which reached the pre-specified threshold for being meaningful in practice.

 Secondary and exploratory outcomes

Some secondary outcomes also showed significant improvement in the PEER group:

• Work ability and social functioning improved (mean difference: -4.1 points on the WSAS scale; 95% CI: -6.7 to -1.6; p=0.002) – lower scores indicate better functioning
• Quality of life improved (mean difference: 3.6 points; 95% CI: 0.5 to 6.8; p=0.02)
• Hope and self-efficacy (exploratory outcomes) both improved significantly.

Empowerment, self-advocacy, and social network scores showed no significant differences between groups.

Engagement

Engagement was mixed. Of those who received PEER, only 46% attended eight or more of the ten group sessions. Just 10% took up the optional one-to-one peer support offer. The authors note this may reflect practical barriers or individual preferences rather than intervention failure. Even so, this raises questions about reach and how the intervention might be adapted to suit a wider range of participants.

Conclusions

The small-to-medium effect supports peer support’s role, aligning with prior RCTs (e.g. Puschner et al., 2025) and meta-analyses (e.g. Smit et al., 2023). The study also provides important new evidence for community and group-based peer interventions.

Strengths and limitations

This study has a number of strengths. First, the intervention has been fully described in a comprehensive manual, and has a strong theoretical foundation because it builds on an established recovery model (CHIME framework, Leamy et al., 2011).

Second, the development of the intervention was excellent, including co-design with ample involvement by people with lived experience, refinement through a pilot and qualitative evaluation before the main trial (Poulsen et al., 2025a). Third, the intervention has been implemented in collaboration between municipal social services, a mental‑health research centre, and an NGO (the Peer Partnership Association), and targets people with mental health conditions in community settings rather than only those with long‑term severe illness in hospital. This positioning reduces clashes with traditional clinical hierarchies that often create hostility or marginalisation of peer workers in hospital‑based schemes.

There are also some limitations. First, while it is reported that volunteers received structured training on core values such as hope, equality and empowerment, as well as on boundaries, expectations, and ideas for activities, a two-day training weekend seems short to adequately prepare peer support workers to provide high-quality services (Hiltensperger et al., 2025; Nixdorf et al., 2024; Charles et al., 2021) and at the same time participate in a complex randomised controlled trial.

Second, while the trial originally aimed to assess outcomes both at post-intervention and at a 6-month follow-up, funding was only secured for a 3-month follow-up. An application for a feasibility study of the individual companionship component as a substitute for the longer follow-up was also unsuccessful. This means the durability of any gains in personal recovery beyond the immediate post-intervention period is unknown. Also the lack of an adequate evaluation of the individual companionship element limits the study’s ability to explore mechanisms related to that part of the intervention.

Third, while a small qualitative study identified some mechanisms of change (Egmose et al., 2024), a full mixed-methods process evaluation including fidelity has not been carried out. This would be useful to further substantiate why and for whom PEER is effective and suitable, and allow for a deeper understanding of how outcomes can vary across different contexts.

Finally, a full health economic evaluation has not yet been completed, leaving a gap for policy implementation decisions.

Implications for practice

PEER’s relative success reflects doing many of the implementation basics well, i.e. clear model, community location, and outcomes that match what peer support is designed to change. However, much of its success might be due to the specific context. Next steps should be scaling up the programme in Denmark, to add real-world evidence and demonstrating that PEER works outside a research setting.

Scaling PEER‑like programmes elsewhere will depend on reproducing enabling conditions in different health and welfare systems. For example, PEER’s success relies on structured training, local peer coordinators, and regular supervision, requiring sustained funding for coordinators and training infrastructure, which many systems lack (Charles et al., 2020; Charles et al., 2021; Ibrahim et al., 2020).

Further, replicating PEER in systems with less established recovery orientation and stronger professional hierarchies may meet more resistance than in the Danish context, where co‑production and user involvement are relatively institutionalised. PEER also assumes the existence of municipal social services, accessible community activities, and NGOs able to host and coordinate volunteers. In settings with weaker welfare systems, limited community resources, or fragile NGOs, this may be hard to reproduce.

Finally, using volunteer peers may support scalability by emphasising low costs. However, not paying peer support workers risks undermining the professionalisation of peer work; signalling that lived experience expertise is valued and can support career progression into further employment.

Regardless of these challenges this study offers hope as well as evidence for anyone seeking to encourage the development of community-based peer alternatives, and the authors are to be commended for completing a rigorous RCT in challenging circumstances.

Statement of interests

Bernd Puschner has no conflicts to declare. AI was used to support the review and development of drafts and in the editing process.

Edited by

Edited by Simon Bradstreet.

Links

Primary paper

Chalotte Poulsen, Cecilie Egmose, Bea Ebersbach, Carsten Hjorthøj, Lene Eplov (2025). The “Paths to everyday life” peer support intervention for adults with mental health difficulties versus service as usual in a Danish community setting – results from a randomized two-armed, multi-site, superiority trial. BMC Psychiatry 25, 695.

Other references

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