Peer Support Experience for Patients Discharged From Acute Psychiatric Care
Condition: Depression; Bipolar Disorder; Schizophrenia
MeSH terms: Schizophrenia; Bipolar Disorder
Study type: Interventional

Summary: 
      The aim of the project is to conduct a four arm randomized controlled pilot trial to evaluate
      the effectiveness of an innovative peer support program that incorporates leadership
      training, mentorship, recognition, reward systems and supportive/reminder text messaging for
      patients discharged from acute (hospital) care. Methods and analysis: This is a prospective,
      rater-blinded, four arm randomized controlled trial. 180 patients discharged from acute
      psychiatric care in Edmonton, Alberta, Canada will be randomized to one of four conditions:
      treatment as usual follow-up care, enrollment in usual follow-up care plus daily
      supportive/reminder text messages, enrollment in a peer support system plus daily
      supportive/reminder text messages or enrollment in a peer support system without daily
      supportive text messages. Patients in each group will complete evaluation measures (e.g.,
      recovery, general symptomatology, functional outcomes) at baseline, six and twelve weeks &
      six and 12 months. Service utilization data and data regarding the experience of the peer
      support workers will also be collected. Data will be analyzed with descriptive statistics,
      repeated measures, and correlational analyses. We hypothesize that patients enrolled in the
      peer support system plus daily supportive/reminder text messages condition will achieve
      superior outcomes in comparison to other groups. Peer support worker experience will be
      derived from exploratory data analysis.
    

Detailed description: 
      Background and Rationale Peer support is emotional, social and practical help provided by
      non-professionals to assist people with sustaining health behaviours. The peer support
      workers share a similar condition as patients, effectively manage their condition, and have
      received training to provide support. Peer support is provided to people with psychological
      health complaints by peer supporter workers with lived experience, and the position of peer
      support worker may include activities such as advocacy, connecting patients with resources,
      and experiential sharing, among others .

      Peer support is consistent with the recovery paradigm in mental health, and is differentiated
      from psychiatric models of traditional diagnosis and treatment. The purported mechanisms
      through which peer support may function are through experiential knowledge sharing, modeling
      of adaptive coping strategies, social comparison, and enhancing social support. Moreover,
      peer support may be particularly useful for clients who have difficulty engaging in
      conventional services . It may be the case that peer support systems can serve as an entry
      point into the healthcare system for 'hardly reached' individuals and at the very least,
      serve as a means of providing supportive services for those who would otherwise not engage in
      treatment. In addition, providing peer support may offer benefits to the peer supporter
      her/himself, by enhancing feelings of competence and personal value .

      Peer support is valued in recovery-oriented models of mental health and is becoming
      increasingly implemented organizationally [see Myrick and del Vecchio for a discussion]. Many
      studies have reported positive effects of peer support, including lower inpatient service
      use, better relationships with providers, and increased engagement. However, a recent
      rigorous evaluation of randomized controlled trials (RCTs) of peer support studies reported
      that outcomes were generally mixed and often non-significant. In their review, the authors
      noted a high degree of bias and methodological limitations in the studies they reviewed, and
      concluded that "peer support programmes should be implemented within the context of high
      quality research projects wherever possible".

      In addition to methodological improvements of research on peer support, there is a need to
      further develop the peer support workforce. Identified areas of development for peer support
      programs include: how to define "peerness", role clarity and integration with existing
      systems, credentialing, and workforce development. Within our local context, in the province
      of Alberta, Canada, peer support for patients has been in existence for many years. Anecdotal
      evidence suggests there is low uptake and high attrition for peer support worker roles within
      the province. There has been a drive to develop curricula and organizational infrastructure
      to formally train and support peer support workers. Administrators who have worked with peer
      support workers suggest the lack of adequate incentives may contribute to peer support
      workforce challenges. Relatedly, there are often limited incentives for mental health
      professionals to provide supervision and mentorship for peer support workers locally.

      In summary, the existing literature suggests there is opportunity for innovation in peer
      support programs, and there is a need for rigorous methodology to better evaluate outcomes
      from peer support programs. There is also a need to further develop the peer support
      workforce. The current paper describes a randomized controlled trial that is designed to
      systematically evaluate a novel peer support model termed the "Edmonton Peer Support System"
      (EPSS), which incorporates innovative features of service delivery (i.e., an incentive-based
      model of training, text messaging) and rigorous methodological design to minimize bias and
      confounds (e.g., comprehensive measures of outcome; methodological design features including
      longitudinal, prospective, three arm parallel design, and rater-blinding).

      One of the innovative features of this study is the incorporation of text messaging. Text
      messaging is a relatively low cost, high impact, and easily scalable program that uses
      existing technology, is devoid of geographic barriers, and is easily accessible to end users.
      There is evidence that supportive text messaging demonstrates positive effects in terms of
      symptom improvement and patient satisfaction. For example, patients with depression and
      comorbid alcohol use disorder showed significantly lower depressive symptoms on standardized
      self-report than a similar patient group who did not receive messages [large effect
      size)(9)]. A second randomized trial demonstrated similar results [(Cohen's d= 0.67)(10)]. In
      terms of satisfaction, over 80% of subscribers reported that a texting program improved their
      mental health.

      There is also evidence that reminder text messaging improves appointment attendance rates.
      For example, in a systematic review and meta-analysis of eight randomized controlled trials
      involving 6615 participants, the authors found moderate quality evidence from seven studies
      (5841 participants) that mobile text message reminders improved the rate of attendance at
      healthcare appointments compared to no reminders [risk ratio (RR) 1.14 (95% confidence
      interval (CI) 1.03 to 1.26)]. They also found that text messaging reminders were similar to
      telephone reminders in terms of their effect on attendance rates, yet cost less than
      telephone reminders.

      Another innovative feature of this study is the incorporation of a peer support incentive
      system. As discussed, the peer support workforce has been identified as an area in need of
      development, including role clarity, integration with healthcare professionals, and
      credentialing. Specifically, a lack of a "career ladder" or a clear movement within positions
      of peer support work has been identified, with movement possible laterally (but not upward)
      within many program structures. In this project, peer support workers will participate in an
      incentive based system that formally recognizes performance. The EPSS is structured as
      follows:

        -  Peer support workers are people with lived mental health experience who are at a point
           in their personal recovery where they consistently demonstrate the ability to share
           their individual story in a manner that inspires hope and builds relationships with
           others. Peer support workers who are employed by Alberta Health Services (AHS), our
           provincial health authority, will be invited to enroll as foundational members of the
           EPSS.

        -  Members will be provided with formalized training developed within our health region,
           involving knowledge training, practice, and ongoing meetings throughout offering the
           program to assist peer support workers in adhering to principles consistent with a peer
           support framework and recovery philosophy and problem-solving concerns or challenges
           that may arise. Peer support workers will receive clinical support/mentorship from
           mental health therapists.

        -  Patient beneficiaries of EPSS will receive supportive face-to-face visits, phone calls,
           and interactive text message support from their peer support workers. They will also
           receive reminder text messages for their appointments.

        -  Patient beneficiaries will be enrolled as associate members of the EPSS and will be
           provided with training to act as peer support workers when they are an advanced stage in
           their recovery. At this time they can apply for AHS peer support worker roles as
           available.

        -  Contributions of peer support workers will be recognized via attainment of different
           levels of membership (e.g. "star" levels) and certificates of recognition (bearing logos
           of collaborating institutions) at formal ceremonies. Star-level recognition will be
           categorized into: Silver Star Memberships (five stars), Gold Star Memberships (ten
           stars), and Star Fellowships (twenty stars).

        -  Contributions of mental health therapists towards supporting/mentoring peer support
           workers will also be recognized through star memberships and certificates at formal
           ceremonies.

      The hope of EPSS is to increase compassion and decrease stigma, foster multi-disciplinary
      teamwork, incorporate client/caregiver experiences, and strengthen service provider skills
      and abilities. Our proposed EPSS will provide training for those with mental health
      challenges that will enable them to contribute providing compassionate care for mental health
      patients. This program philosophy is aligned with regional goals relating to improvement of
      mental health services in our province.

      Aim and Objectives The aim of the project is to evaluate the effectiveness of an EPSS which
      incorporates leadership training, mentorship, recognition, reward systems and
      supportive/reminder text messaging for patients discharged from acute (hospital) care. The
      client outcomes will be organized according to: recovery variables (e.g., recovery, stigma),
      functional variables (quality of life, employment), symptom variables (psychological
      symptoms, general outcomes), and service variables (e.g., heath service utilization, cost,
      satisfaction), as further described in Methods and Analysis. Peer support worker outcomes
      will also be evaluated, including effectiveness, job satisfaction, acceptability, and
      recovery.

      The objectives of the project include:

        1. To compare mean changes in recovery, functional outcomes, clinical symptoms, and service
           variables after six weeks, twelve weeks, six months and twelve months for patients in
           each of the three arms: those discharged from acute care and enrolled in peer support
           system plus daily supportive/reminder text messages; those with usual follow-up care
           plus daily supportive/reminder text messages, and those receiving usual follow-up care.

        2. To assess job satisfaction, acceptability, and recovery of peer support workers at six
           and twelve months.

        3. To assess job satisfaction among mental health therapists offering support and
           mentorship for peer support workers.

      Hypothesis The investigators hypothesize that patients enrolled in the peer support system
      plus daily supportive/reminder text messages will achieve superior outcomes compared to
      patients enrolled in the other arms of the study on each outcome measure used. In turn,
      patients enrolled in peer support will have superior outcomes to patients enrolled in the
      treatment as usual condition.

      Data Analysis:

      Initially, we aimed to deploy intention-to-treat analysis, whereby patient data are analyzed
      according to their original assigned groups, regardless of time spent in the study. However,
      after randomization and due to clinical logistic reasons, a significant number of patients
      did not receive access to the Peer Support Worker service in the two intervention arms of
      Peer Support Worker. Thus we have made a strategic decision to adapt the protocol to a
      Controlled Observational Study and to change the analysis approach to as-treated, rather than
      intention-to-treat to maximize the investigational value of the study without compromising or
      biasing outcomes.
    

Intervention name(s): Supportive/reminder text messaging plus peer support; Supportive/reminder text messaging; Peer support only
Intervention type(s): Behavioral; Behavioral; Behavioral
Intervention description(s): Regular supportive/reminder text message will be delivered to patients who will also receive face to face and interactive text message support from peer support workers; Regular supportive/reminder text message will be delivered to patients who will NOT receive any face to face or interactive text message support from peer support workers; face to face support from peer support workers but no interactive or daily supportive/reminder text messages
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: This will be a longitudinal, prospective, parallel design, three arm, rater-blinded randomized clinical trial with a recruitment period of six months and an observation period of 12 months for each participant.
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment