PROJECT SUMMARY The development of appropriate and effective community-based care for people living with severe mental illness (SMIs) continues to be a global challenge, especially in low-and-middle income countries (LMICs). A particularly damaging cycle emerges when people with SMIs are admitted to hospital for acute psychiatric treatment, discharged back into community settings without appropriate support, only to be readmitted again due to psychiatric relapse. This “revolving door” phenomenon is a multilevel challenge to mental health systems, including in countries such as South Africa, with little to no formal community-based support systems for people living with SMIs. However, promising evidence has been produced that Critical Time Intervention (CTI), a time- limited psychosocial intervention with origins in the prevention of homelessness in the USA, could potentially improve individual and system outcomes by providing support to vulnerable service users during the difficult transition period from hospital to community settings. The proposed research project aims to build on a CTI version that draws from community health workers and peer support workers, adapted for low-resource settings in South America, to develop and pilot a locally appropriate intervention program for South Africa. Specifically, we will draw from partner project data, supplemented by additional qualitative research and collated to provide a contextual basis from which to adapt the CTI approach, its content and materials. In particular, we will seek out specific community resources that could be included in the development of support networks, including existing peer support groups, and, importantly, the involvement of traditional health practitioners. We will then conduct a pilot feasibility cohort study in the uMgungundlovu District Municipality in KwaZulu-Natal, South Africa. We will recruit and train five teams that each include an auxiliary social worker and a peer support worker to provide CTI support to 40 people with SMIs who are being discharged to community settings following acute psychiatric hospitalization. Quantitative and qualitative process measures in terms of the Consolidated Framework for Implementation Research (CFIR), and outcome measures in terms of Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) will be gathered at several intervals throughout the CTI piloting period. Our primary outcome will be the reduction in psychiatric readmission over a 16-month study period, relative to the previous 16-month period. Along with several secondary outcomes, these measures will provide the necessary data to establish feasibility, appropriateness, and limited effectiveness of the adapted CTI, and lay a foundation for further trial research.

PROJECT NARRATIVE Despite commendable progress in developing mental health systems in low-and-middle income countries, critical gaps remain, particularly the development of community-based systems of support for people living with severe mental illness (SMIs). This application will adapt and pilot an evidence-based program – Critical Time Intervention – in a South African district in order to determine its feasibility, appropriateness and limited effectiveness in reducing readmission following discharge from acute psychiatric hospitalization. By generating preliminary data on the real-world implementation of an adapted CTI in South Africa, this application seeks to build on an existing foundation of research partnerships and local government collaboration to develop a transitional support intervention that could yield significant and tangible impacts on people living with SMIs in low-resource communities.