Abstract Aims While there is growing evidence for the effectiveness of peer support (PS) in improving psychosocial outcomes among individuals with severe mental health conditions, the mechanisms through which these effects occur remain insufficiently understood. This study examines whether social inclusion, hope and empowerment mediate the relationship between PS, personal recovery and health and social functioning. Methods Data were collected from 565 adults with severe mental health conditions who participated in the multicentre UPSIDES randomised controlled trial across six sites in Germany, Uganda, Tanzania, India and Israel. Participants in the intervention group received structured PS from trained peer workers over a 6- to 8-month period. Standardised, self-report measures of social inclusion, hope, empowerment and personal recovery, as well as clinician-rated health and social functioning, were administered at baseline, 4 months, end of intervention (8 months) and 12-month follow-up. Cross-lagged panel modelling was used to explore longitudinal associations and mediating pathways. Results The cross-lagged models showed strong autoregressive effects across all variables, indicating high temporal stability. There were no significant direct effects of PS on recovery or health and social functioning. However, mediation analysis identified significant indirect effects of PS on personal recovery via social inclusion ( β = 0.114, 95% confidence interval [CI] [0.049, 0.194], P < 0.05) and hope ( β = 0.037, 95% CI [0.001, 0.086], P < 0.05). Similar indirect effects were observed for health and social functioning (via social inclusion: β = −0.035, 95% CI [−0.064, −0.013]; via hope: β = −0.026, 95% CI [−0.052, −0.006]; both P < 0.05). Conclusions Findings suggest that PS affects recovery-related outcomes primarily through intermediate mechanisms of enhanced hope and social inclusion. These results support theoretical models positing indirect pathways of change in PS interventions and highlight the value of targeting social and psychological domains when designing and implementing PS in mental health services. Individuals with lower baseline levels of hope and social inclusion may particularly benefit from PS. Trial Registration Number: ISRCTN26008944

BackgroundRecovery colleges (RCs) facilitate peer-supported communities where people with lived experience of mental disruption learn collaboratively, aiming to foster empowerment and personal recovery. While existing (qualitative) research relates RC attendance to positive outcomes, high-quality multi-college quantitative studies evaluating RC effectiveness are scarce.AimsWe examine the extent to which RC attendance impacts empowerment (primary outcome) and other recovery-related outcomes.MethodIn this nonrandomised clinical trial (May 2022 to January 2025), RC partakers from four Dutch RCs were compared with controls over 2 years, in annual data collections. Linear mixed model analyses were conducted to investigate interactions between group and time. Exploratory analyses investigated distinguishing characteristics of RC partakers. This study was embedded in a larger project and was pre-registered (clinicaltrials.gov: #NCT05620212). Academic and experiential researchers collaborated in the design, recruitment, and analysis.ResultsThe sample comprised 91 RC partakers and 182 matched controls. RC partakers faced severe or persistent mental health challenges and attended RCs in multiple capacities (e.g., student and visitor/volunteer). Outcomes were mostly stable over time and did not differ between groups. Hence, no group-specific changes over time were found, as shown by interaction terms that were not statistically significant (e.g., empowerment: estimate T1*RC= 0.02, 95% CI= -0.08-0.13, estimate T2*RC= -0.001, 95% CI= -0.11-0.11).ConclusionsDespite promising qualitative evidence of RC effectiveness, our study found no differences between RC partakers and matched controls in quantitative recovery-related outcomes over time. Factors of influence may be possible pre-study effects, unmeasured confounding, or limitations in how standardised questionnaires capture recovery experiences. Methodologically, the findings raise questions about the operationalisation of effectiveness in the context of personal recovery and flexible, co-created practices such as RCs. Importantly, while this study could not establish measurable effectiveness, this does not automatically imply that RC attendance cannot meaningfully contribute to recovery.Plain Language Summary TitleStudy evaluating if recovery colleges have effects on recovery by comparing survey scores of people who do vs. do not attend them across two years.

Mental health challenges often emerge in young people, yet access to timely and flexible support remains limited. Serious games can be a mental health resource, but how they portray recovery-related elements and which mental health challenges shape these portrayals remains unclear. This scoping review mapped recovery-related portrayals in serious games for young people, with attention to characters, narratives, gameplay mechanics, and the portrayed mental health challenges. The review followed Joanna Briggs Institute guidance and the Participant, Concept, Context framework. Five databases were searched for English-language studies published from 2000 to May 2026. Studies were screened independently by two reviewers. Data were analyzed using qualitative content analysis informed by Dunlap and Kowert’s multidimensional portrayal framework and the CHIME framework. Eleven studies describing ten games were included. Most studies described dimensional portrayals in which psychological processes were integrated into characters, narratives, and gameplay mechanics. However, portrayals predominantly emphasized individual coping and CBT-based skills. Relational support, cultural grounding, and co-designed experiences were less frequently portrayed and less fully developed. The most portrayed mental health challenges were depression, anxiety, obsessive-compulsive disorder (OCD), eating disorders, and emotion regulation difficulties. Serious games tend to portray recovery as a de-contextualized and individual process of deficit amelioration. The sociocultural and growth-oriented aspects of recovery are neglected. Greater integration of social connection, cultural grounding, and co-designed experiences may improve their relevance and recovery-oriented value for young people. N/A

Aims and method Recovery Colleges are adult education initiatives supporting personal recovery for individuals with mental health difficulties. We characterised a national (England) inception cohort of mental health service users, students from the Recovery Colleges Characterisation and Testing 2 programme, and compared those attending different Recovery College types on sociodemographic, clinical, service use and student-reported outcomes over the 4 months prior to enrolment. Mixed-effects regression models were used to assess differences. Results The cohort comprised 498 students from 36 Recovery Colleges across England; 77.7% attended strengths-oriented Recovery Colleges. Mean age was 39 years (s.d. 12); most were female (72.1%) and White (81.5%). Common diagnoses were mood (31.3%) and anxiety disorders (29.7%). No significant differences were found between students attending strengths- versus community-oriented Recovery Colleges. Clinical implications Strengths- and community-oriented Recovery Colleges have similar service user student populations. Certain groups that may be underrepresented in Recovery Colleges and Recovery College research include older adults, men, those with developmental disorders and ethnic minority populations.

PurposeThe global spread of recovery colleges (RCs) demands culturally adapted fidelity measures to support international implementation and research. This study aims to translate, culturally adapt and pilot test the RECOLLECT Fidelity Measure and Checklists for Brazil, addressing the critical need for assessing RC fidelity in diverse contexts.Design/methodology/approachA rigorous five-step methodology was used for translation and cultural adaptation. This included initial and back-translation, consultation with original developers, multidisciplinary review and pilot testing of student and peer educator checklists within a Brazilian artistic-cultural recovery project.FindingsThis study produced a culturally adapted Brazilian Portuguese version of the instruments. Pilot data from the Checklists (descriptive, non-psychometric tools) showed that the adaptation mainly involved linguistic modifications for Brazilian relevance. The pilot demonstrated overall high fidelity to RC principles. However, the Co-production and Community Focus domains exhibited less alignment, suggesting areas for future Brazilian RC development.Originality/valueTo the best of the authors' knowledge, this research is the first adaptation and pilot testing of RC fidelity instruments for a Latin American context, providing culturally appropriate measures to inform future recovery research and practice in the region. This study provides the necessary foundational step of cultural adaptation, which is a prerequisite for future psychometric validation of the Fidelity Measure. These findings highlight the feasibility and importance of adapting fidelity measures to local contexts, especially in resource-scarce regions such as Brazil and Latin America.

Although peer support is increasingly used in mental health services worldwide, service users' experiences have been studied mostly in high-income countries. The current study examined service users' experiences of peer support in the UPSIDES Trial, delivered across diverse cultural and resource contexts, including high, middle and low-income countries. Semi-structured interviews were conducted with 33 service users across six study sites (Germany [two sites], Uganda, Tanzania, Israel, and India) and analyzed using thematic analysis to identify patterns in participants' experiences. To capture diverse perspectives, service users were purposively sampled based on pre-post changes in social inclusion and personal recovery, with participants randomly selected from the top and bottom 20% ('high' and 'low' responders). Four themes emerged: (1) adaptable settings and intervention flexibility; (2) 'active ingredients' such as mutuality, reciprocity, and role-modeling; (3) positive intra-personal, inter-personal, and behavioral outcomes; and (4) barriers, including mismatches, unmet expectations, unclear boundaries and challenges to continuity. The study highlights shared relational elements of peer support alongside context-specific adaptations. Findings reinforce its value as a complementary, person-centred service with global relevance, while pointing to challenges including improving matching, reducing dropout, and clarifying expectations. Site-specific aspects are discussed, offering insights for global implementation.

Abstract One-to-one peer support is widely used in mental health services, but the components associated with better outcomes remain unclear. We systematically reviewed randomised controlled trials and conducted additive component network meta-analyses to identify which components of one-to-one peer support worker interventions were associated with outcomes for adults using mental health services. CINAHL Ultimate, Embase, MEDLINE, PsycINFO, CENTRAL, ClinicalTrials.gov and ISRCTN were searched, supplemented by citation tracking, previous reviews and expert consultation. Interventions were coded for seven components: Training and development, Maintaining peer support worker wellbeing, Relationship-building, Social support, Emotional support, Practical support and Cultural adaptation. The review followed PRISMA-NMA reporting guidance and was registered with PROSPERO (CRD42022355291). Thirty-six trials randomised 6,645 participants across nine countries. Only quality of life and recovery yielded estimable component effects at one or more follow-up points. For quality of life, Practical support had a positive incremental estimate at 3 months (standardised mean difference 0.52, 95% confidence interval 0.17 to 0.87); no component showed clear evidence of benefit at 6 months; and at 12 months Social support had a positive estimate (1.57, 0.12 to 3.01), whereas Maintaining peer support worker wellbeing had a negative estimate (-1.66,-3.05 to-0.28). These estimates were not consistent across follow-up points. For recovery, Relationship-building had positive estimates at 6 months (0.90, 0.03 to 1.78) and 12 months (0.50, 0.29 to 0.72). Networks were sparse and often disconnected, and additivity could not be tested in disconnected networks. Current trials do not permit definitive prioritisation of peer-support components. Relationship-building was the most consistent candidate component, but all findings remain provisional. Future trials should prospectively specify, manipulate and measure component delivery.

As mental health research increasingly aims to generate societal impact, researchers operate at the intersection of innovation and ethical responsibility. Drawing on experiences from the cocreated NEON Young Norway Study on youth recovery narratives, this viewpoint identifies four ethical tensions that arise from the existing governance frameworks in youth digital mental health research: (1) balancing safeguarding against harm with youth participation, (2) protecting privacy without undermining authentic storytelling, (3) governing unpredictable outcomes of cocreated research, and (4) meeting ethical and legal standards while ensuring youth-friendly communication. These tensions highlight limitations in mental health research that adopts participatory and digital approaches, as this often struggles to accommodate iterative designs, narrative data, and cross-sector collaboration. We argue that responsible youth mental health research requires ethics to be understood as a dynamic, participatory practice that supports safe and equitable inclusion, rather than having a focus on risk prevention. Ethical governance, therefore, needs to evolve toward proportionate, context-sensitive approaches that can enable innovation while protecting young people's rights, agency, and voices.

Personal recovery is a mainstream concept in mental health research and practice in the West. The applicability of personal recovery to other cultural and economic contexts is not well understood. This study aimed to characterise the recovery narratives of people living with psychosis in rural Ethiopia. We carried out in-depth interviews with 13 individuals with psychosis, and repeated interviews after 12 months. We conducted an inductive narrative analysis. We first read transcripts to create a case history for each participant. We then identified text which spoke to the dimensions: (i) narrative form (genre and tone); (ii) narrative structure; and (iii) narrative ‘voices’ (characters and meta-narratives). We created a typology of narratives by grouping them into genres, before comparing findings between participants. Whilst there were some stories of change and hope (endeavour narratives), the majority were characterised by struggle (endurance narratives) or despair (entrapment narratives). The narratives were shaped by key characters (family, community, God, medication) and five meta-narratives: supporting family is the priority in life; working makes you well; people with mental illness are less than human; traumatic life events cause or worsen mental illness; and it is God's will that ultimately determines events. Contextual circumstances- poverty, lack of work opportunities, limited access to mental healthcare, and gender norms- were critically important in shaping the lives of our participants. These findings resonate with the critique that some recovery frameworks may be too positive, neat and individualistic to speak to the range of experiences of people with psychosis. Supporting mental health recovery in contexts such as Ethiopia involves addressing structural factors that impede recovery, such as poverty, poor access to medication, and stigma, in ways that are congruent with cultural norms.

Background By 2021, we found that 88 Recovery Colleges were operating in England. Recovery Colleges adhere to shared principles including adult education and co-production, but are also heterogeneous, varying in the populations they serve, their sources of funding and access to resources. Previous research has not explored the organisational factors that influence the set-up of Recovery Colleges, nor the factors which facilitate or pose challenges to their sustainable operation. Aims To identify how Recovery Colleges vary in their operation and to ascertain how organisational factors facilitate or hinder the set-up, running and sustainability of English Recovery Colleges. Method Semi-structured interviews with 31 Recovery College managers across England were analysed using framework analysis. Results Four themes were identified: Recovery College pioneers; Adapting to the local context; Degree of autonomy within the National Health Service; and Ongoing organisational work. Colleges were commonly established by key individuals from diverse backgrounds, leveraging their organisational positions and lived experience to facilitate implementation. Colleges were adapted to fit local contexts, shaped by factors including existing services, regional demographics and community resources. Colleges varied in their relations with key funders, with some operating comparatively autonomously and others tied closely to their ‘parent’ organisations. Sustaining college operations involved ongoing organisational work to respond to changing pressures. Conclusions Recovery Colleges exhibit consistent values and aims oriented around supporting recovery through education and co-production but are diverse in their operation. These colleges are highly complex interventions, and their sustainability requires organisational agility to manage competing pressures.

Social inclusion means being able to participate in activities valued within one's community or wider society as one would wish. People with severe mental illness (i.e., psychoses, bipolar disorder, and severe depression) experience some of the highest rates of social exclusion compared to people with other disabilities. This is the case regardless of the availability of specialist mental health services. Therefore, questions arise about the extent to which mental health services can and do prioritize social inclusion as a goal of service provision, and what strategies are needed outside of mental health services, at the levels of legislation and policy, statutory services, and civil society. In this paper we consider what social inclusion means in different cultures and contexts, since the value attached to different activities varies by culture and by life stage and gender. We discuss the subjective impact of low levels of social inclusion in terms of loneliness, and the evidence base for interventions to address it. We then turn to strategies to increase observable forms of social inclusion, considering them at the levels of legislation, services and other community assets. While evidence for some interventions is largely based on the Global North, we use evidence and examples from the Global South to the extent that we have found them. We also consider the predominant frameworks for social inclusion used in health services, followed by alternatives that may offer a more empowering approach to social inclusion for some people. We then describe strategies to reduce social exclusion through interventions to address stigma and discrimination, directed at key target groups or at population level. We make recommendations for policy makers, researchers, health professionals, and advocates based on the evidence and examples we have found, covering various forms of legislation, services and mental health research. Our conclusions identify the next steps for interventions, including development, evaluation, implementation or modification for better contextual adaptation.

In recent decades, personal recovery has emerged as a mental health paradigm, primarily within Global North and WEIRD (Western, Educated, Industrialized, Rich, and Democratic) contexts. However, its conceptualization in Global South countries like Brazil remains incipient. We aimed to synthesize qualitative studies on the recovery process among people with severe mental illness in Brazil and compare these findings with North American and European frameworks, particularly CHIME (Connectedness, Hope, Identity, Meaning, and Empowerment). Following ENTREQ (Enhancing Transparency in Reporting the Synthesis of Qualitative Research) and PICo (Population, Phenomenon of Interest, and Context), guidelines, we screened 1,224 studies; seven were included, representing a total of 83 participants. Quality was assessed using the RATS (Relevance, Appropriateness, Transparency, and Soundness) checklist; all studies achieved acceptable to high quality standards (scores 16-24), with a 91.4% inter-rater agreement rate. Four analytical themes emerged from 13 descriptive themes: Protagonism (Autonomy, Overcoming, Empowerment); Bond (Peer Support, Belonging, Connection with others, Welcoming); Awareness (Insight, Acceptance, Psychotic Episode, Stigma, Pathologization); and Hope. While findings align with universal aspects of recovery, cultural specificities arise from the central role of "Protagonism" and "Bond." These themes reflect the Brazilian cultural and historical background, emphasizing citizenship and a collectivist orientation over individualistic models. Unlike Global North frameworks focusing on internal psychological states, our findings highlight recovery as deeply rooted in social ties and political agency. We recommend future research and implementation efforts utilize locally salient terms to respect these cultural markers.

This qualitative narrative study explores how adults with lived experience of mental health difficulties draw on spirituality to make meaning and support recovery. Thirty participants were interviewed and asked to share their stories of spirituality, mental health and recovery. A narrative thematic analysis approach was developed to explore the superordinate theme of meaning making which comprised three interrelated themes: (1) Reframing, where spirituality enabled participants to adopt a bigger-picture perspective, evolve interpretations over time, and validate experiences; (2) Navigating mythos and logos, describing how symbolic, intuitive and experiential modes of understanding (mythos) were juxtaposed with rational, logical or scientific modes (logos) to support functional sense-making; and (3) Discerning spiritual guidance, in which intuition, synchronicity, dreams, visions and signs informed decisions, identity and coping as part of an evolving process of meaning making. Findings align with Meaning Making Framework theory, highlighting the integration of situational stressors into broader global meaning systems and the value of positive reappraisal. Mythos and logos were typically held in dynamic relationship to support coherence, agency and wellbeing, with mythos emerging as a powerful, often overlooked resource for meaning making via experiences of spiritual guidance. Drawing on findings across all three themes, the VALID (Validate, Attend, Lightly hold, Internal frameworks, Discern collaboratively) Framework for Spiritually Informed Practice is proposed. These are five evidence-derived principles offering practical orientations for engaging with spirituality at the intersection of mental health and recovery. The study offers novel, practice-relevant insights into spirituality as an intrinsic dimension of meaning-making in mental health recovery, highlighting the need to validate diverse spiritual experiences in mental health contexts.

Recovery Colleges are expanding internationally (264 identified in 31 countries across six continents), yet key tools for defining and assessing them were developed in high-income Anglophone contexts. We conducted a two-round international Delphi study using a cross-cultural de-centring approach to examine the cross-cultural applicability of the RECOLLECT Change Model and RECOLLECT Fidelity Measure, and to develop globally applicable and interoperable versions of these tools. In Round 1, 54 panellists from 20 countries rated item importance and cultural difficulty and provided free-text feedback, analysed using corpus-informed linguistic methods. Core principles were broadly endorsed, but “coproduction”, “recovery”, “professionals” and “shifting the balance of power” were interpreted inconsistently, revealing embedded assumptions about equality, autonomy and open-ended participation. Round 1 findings informed wording refinements tested in Round 2 with 41 panellists from 15 countries. All 11 revised items reached consensus for understandability and cultural appropriateness, strengthening the tools while preserving core Recovery College values.

IntroductionSome people with psychosis experience posttraumatic growth (PTG). PTG is defined as positive psychological changes which occurs after the experience of trauma or adversity, following an emotive struggle with the experience. There is some research into the process and domains of PTG in psychosis. However, limitations of the existing evidence base include a focus on experiences of first-episode psychosis, exclusive inclusion of participants who currently use clinical mental health services, and an emphasis on individual-level facilitators. Increasingly, psychosis is considered as a dimensional construct. The aim of this study was to address these gaps by using a dimensional understanding of psychosis to investigate the process of PTG in psychosis, and to validate the PROSPER framework.MethodSemi-structured qualitative interviews about the experience of PTG were conducted with 25 individuals with diagnosed or self-reported experiences of psychosis who self-identify with having experiences of PTG. Inductive and deductive thematic analysis was used to identify PTG processes, mechanisms and outcomes.ResultsParticipants described the experience of psychosis as a disruption to an individual’s life course, which is moderated by personal and trauma factors. All participants could describe experiences of PTG, but some participants reported difficulty identifying current experiences of PTG, indicating that PTG is a dynamic process. The process from the experience of psychosis to PTG was influenced by two mechanisms: cognitive factors and social/societal factors. All seven domains of the PROSPER framework were validated.ConclusionsExperiencing PTG in psychosis is possible. Further research to quantify the effects of mechanisms utilising longitudinal designs would assist to strengthen the evidence base. Interventions to support PTG in psychosis are indicated, targeting both individual and population levels.

Peer support is a recovery-oriented collaborative practice where individuals with lived experiences with mental health conditions engage in supporting others experiencing similar challenges. Becoming a peer support worker (PSW) includes a transition from being a service user to becoming a provider of care and personal roles and identity are challenged when adjusting to the new role. Through individual interviews, this study explored eight PSWs' personal stories of mental illness, recovery, and when the possibility of becoming a peer support worker emerged during this process. Thematic analysis led to four themes: 1) Struggles in everyday life, 2) Landmark events, 3) Turning points, and 4) Finding your way. The PSWs told deeply personal stories of how mental illness had impacted their lives. The themes display when the initial idea and then the ambition to become a PSW emerged during the process of recovery. This study provides insight into how the PSWs at different times-and in different ways-became aware of the possibility of using their personal experience to support others. At an overall level, these findings represent descriptions of individual processes in which the PSWs moved towards re-positioning their lived experiences with mental health challenges from deficit to asset.

The recovery movement has challenged long-standing professional pessimism about psychiatric prognoses. Yet, despite strong empirical evidence for the possibility of recovery from mental illness, the psychiatric profession has shown little change in attitude. Drawing on complexity thinking, the authors describe how diagnostic and therapeutic practices can create feedback loops that sustain perceptions of chronicity. Psychiatry's emphasis on rapid diagnosis and treatment initiation, coupled with neglect of dediagnosing and deprescribing, may inadvertently reinforce the belief that mental disorders are lifelong. They propose that the "art of undoing," such as deprescribing and revising diagnostic assessments, should be recognized as a core clinical skill and research target to break professional pessimism.

Background Recovery Colleges (RCs) support recovery through adult education, with preliminary evidence of positive effects on a range of outcomes. This study examined associations between RC enrolment and mental health service use at an index mental health provider, use of other National Health Service (NHS) hospital services for all causes, associated costs, and service user outcomes. Methods Our retrospective matched cohort study used a controlled before-and-after design. We used linkage with electronic health records to identify all mental health service user students enrolled at one RC. Students were matched with non-student service user controls on sociodemographic and clinical variables using caliper matching. Impacts of RC enrolment on service use were assessed using negative binomial regression models at six-month, 12-month, and five-year post-enrolment. People with lived experience were involved in the design, conduct, and reporting of this study. Outcomes Our sample comprised 1 435 students and 4 665 controls. We observed decreases in several types of mental health service use in students relative to controls at six months (e.g. adjusted Incidence Rate Ratios [aIRRs] for inpatient admissions 0·56, 95%CI 0·30 to 0·64) and 12 months (aIRR 0·60, 95%CI 0·44 to 0·81). At 12 months, students showed a £5 028 (95%CI -£8 223 to -£1 834) greater reduction in total costs per student compared with controls. This indicates that RCs offer an 8·4:1 financial return on investment. Students also showed relative reductions in all-cause hospital bed days at six months (aIRR 0·53, 95%CI 0·35 to 0·81) and 12 months (aIRR 0·66, 95%CI 0·46 to 0·96), with a £412 (95%CI -£1 085 to -£260) greater reduction in associated total costs at 12 months. Among students, reductions in Health of the Nation Outcome Scale (HoNOS) scores indicated consistent improvement in functioning over time. Interpretation Mental health service users who enrol in a RC have reduced subsequent mental and all-cause healthcare use, and reduced service-related costs compared with matched service users not using a RC. Service user outcomes are also improved. Funding National Institute for Health and Care Research. Evidence before this study Since the first one opened in England in 2009, Recovery Colleges (RCs) have spread globally. A 2025 review collating 2013-2024 evidence (64 papers) identified 11 studies investigating outcomes and four investigating service use. Quantitative evaluation of outcomes has used pre-post designs to investigate the impact of RCs on components of recovery, finding consistent evidence of benefit in relation to a number of outcomes including wellbeing, empowerment, hope, and social inclusion. Service use studies have indicated benefits from RC attendance, including increased employment and reduced hospital admissions and bed days, with preliminary evidence of associated cost savings. However, across all studies the evidence quality is low, with most outcome studies using small samples (mostly <100 students) and none using a separate control group. Consequently, change due to other factors such as measurement error or time cannot be discounted, so causation cannot be established. Added value of this study This is the largest study of its kind which utilises a methodologically rigorous approach to investigate the impact of RCs on service use, costs and outcomes. In 6 100 people, we identified a consistent positive impact for service user students, compared with optimally matched service user non-students, in relation to mental health service use at an index mental health provider (especially in-patient admissions) and wider all-cause hospital service use (especially bed days) at 12 months post-enrolment, resulting in relative cost savings for service users who are students compared with those who are not. Furthermore, we showed a relative beneficial impact for students on functioning consistently up to five years after RC enrolment. Implications of all the available evidence The evidence base for supporting RCs is significantly strengthened. Mental health service users who are students at RCs are likely to benefit, both in terms of clinical outcomes and reduced service use, compared to similar people not using the RC. Significant cost savings also arise, which we estimate as an 8·4:1 financial return on investment. Our study evidence supports ongoing investment in RCs with significant return on investment, especially in England. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This article is independent research funded by the NIHR (Programme Grants for Applied Research Recovery Colleges Characterisation and Testing (RECOLLECT) 2 NIHR200605) and part funded by the NIHR Maudsley Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and Kings College London ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Clinical Record Interactive Search (CRIS) system is a platform and governance framework allowing access to de-identified SLaM records for research. CRIS contains healthcare information for almost all people in contact with SLaM from January 1, 2007 and received research ethics committee approval as an anonymised data resource for secondary analyses (Oxford Research Ethics Committee C, reference 23/SC/0257). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data for this study were obtained via the Clinical Record Interactive Search (CRIS) system. CRIS provides researchers affiliated with the National Institute for Health Research (NIHR) Maudsley Biomedical Research Centre (BRC) secure access to de-identified electronic health records for approved research projects. Applications for access to de-identified data can be submitted through the NIHR BRC at the South London and Maudsley NHS Foundation Trust. Because the source data are derived from patient records, access is restricted to eligible researchers who have obtained the necessary ethical and institutional approvals. All requests are subject to review and authorization by the CRIS Oversight Committee. Further information about CRIS and its data access policies is available at: https://www.maudsleybrc.nihr.ac.uk/facilities/clinical-record-interactive-search-cris/.

This study developed and evaluated a new personal recovery scale—Global INSPIRE—in English and Japanese, and compared responses between Japan and the UK. Personal recovery—living a satisfying and meaningful life despite mental health challenges—has gained attention in mental health. The widely-used CHIME framework identifies five recovery processes: Connectedness, Hope, Identity, Meaning, and Empowerment. Full INSPIRE evaluates whether service users feel supported in each CHIME process. However, emerging cross-cultural evidence indicates differences in the priority placed on each CHIME domain. No tool exists to assess recovery priorities, hindering cross-cultural research. The 20-item self-completed Global INSPIRE was adapted from the Full INSPIRE to assess recovery priorities of both service users and non-service users. Participants in the UK (n = 512) and Japan (n = 507) completed the Global INSPIRE at baseline and two-week follow-up. Psychometric properties were evaluated, including reliability, test-retest stability, and discriminant validity with two established recovery scales—CORE-10 and QPR-15. Cross-national differences in recovery priorities were also examined. Both versions showed excellent reliability (α = 0.91 UK; 0.97 Japan), test-retest stability (4/5 processes UK, 5/5 Japan), and acceptable model fit (CFI = 0.80 UK; 0.85 Japan). Measurement invariance supported configural (CFI = 0.89) and metric invariance (CFI = 0.89) but not scalar invariance (CFI = 0.83). Discriminant validity was supported by weak correlations with CORE-10 and QPR-15. UK participants prioritised Hope, Meaning, and Empowerment, while Japanese participants prioritised Identity. Global INSPIRE is a reliable and culturally adaptable tool for assessing distinct recovery priorities. Future research should explore demographic differences and expand testing across diverse cultural contexts.