Further Development and Initial Testing of RESTORE in Frontline Workers

Study Overview
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Brief Summary
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There is considerable need for psychological intervention targeting stressor-related mental health symptoms related to COVID-19. The investigators have developed an online self-directed transdiagnostic intervention to address this need called RESTORE: Recovering from Extreme Stressors Through Online Resources and E-health. The specific aims of this project are to refine and investigate the feasibility, initial safety, and efficacy of RESTORE for addressing mental health symptoms in first responders, health care workers (HCW), and Canadian Armed Forces members exposed to COVID-19-related traumatic or extreme stressors.

Detailed Description
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This uncontrolled pilot interventional study will examine the feasibility and preliminary efficacy of RESTORE. RESTORE is a guided self-directed online intervention to improve anxiety, depression, and posttraumatic stress disorder (PTSD) in individuals exposed to COVID-19 related traumatic or extreme stressors. RESTORE is based on evidence-based psychotherapies and has been designed to overcome many of the barriers associated with accessing evidence-based psychotherapies. The intervention will be iteratively refined over the course of the study. The guidance methods will also be refined and manualized over the course of the study The primary hypotheses are that RESTORE will be safe, feasible, and desirable to participants, and will lead to improvements in mental health symptom severity from baseline to post-intervention. Secondary hypotheses are that RESTORE will lead to significant improvements in perceived health, quality of life, and functioning from baseline to post-intervention. Participants will be assessed at baseline, pre-intervention, during the intervention (after module 4), immediately after the intervention, and 1 month after completion of the intervention.

Official Title
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Addressing Stress Responses on the Frontline-Further Development of RESTORE (Recovering From Extreme Stressors Through Online Resources and E-health)

Conditions
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Mental Health, PTSD, Anxiety, Depressive Symptoms

Intervention / Treatment
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* Behavioral: RESTORE: Recovering from Extreme Stressors Through Online Resources and E-health


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Canadian healthcare worker, first responder, or military member Experienced a traumatic or extremely stressful situation in the course of work related to COVID-19 ≥ 18 years of age Scores at above clinical threshold, as defined by the investigators, on at least one of: Patient Health Questionnaire-9 ([PHQ-9] score ≥ 10), Generalized Anxiety Disorder Scale-7 ([GAD-7] score ≥ 10), and/or Posttraumatic Stress Disorder Scale-5 ([PCL-5] score ≥ 33) Access to a computer or a tablet with high speed internet access, be able to clearly see the screen of a computer or tablet, and be fluent in English Ability to provide consent Exclusion Criteria: Elevated risk of suicide Currently enrolled in another intervention or treatment (e.g., cognitive behavioural therapy) for stress responses related to the COVID-19 pandemic

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Other
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: RESTORE intervention<br>Participants who screen eligible and consent will receive RESTORE with guidance. | Behavioral: RESTORE: Recovering from Extreme Stressors Through Online Resources and E-health<br>* RESTORE (www.restoreonline.ca) includes eight e-modules anticipated to be approximately 30-40 minutes each in length and intended to be completed over 4-8 weeks. The modules address cognitive and behavioural factors posited to cause and maintain psychological distress related to the COVID-19 pandemic. These include cognitions about the cause and meaning of stressors related to the pandemic, including self-blame, other blame and hindsight bias, as well as problematic beliefs related to safety, trust, and control. The modules also address the importance of: (1) expressing emotions that are natural to the events of the pandemic (e.g., sadness in the face of loss), (2) working through, rather than avoiding, thoughts, feelings and grief related to the pandemic, and (3) utilizing social supports. The modules consist of written materials, brief videos, and practice assignments delivered through the platform. RESTORE includes guidance via direct messaging and/or brief telephone calls.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in self-reported Post Traumatic Stress Disorder (PTSD) symptoms | The PTSD Checklist-5 (PCL-5); Weathers, Litz, Keane, Palemeri, Marx, & Schnurr, 2013) weekly version will provide a measure of change in self-reported PTSD symptoms over the course of intervention. Items are rated from 0 (not at all) to 4 (extremely). Items are summed to create a total score ranging from 0 to 80. A cutoff score of ≥ 33 can be used for screening for PTSD diagnosis (Weathers et al, 2013). | Baseline, pre-intervention; during the intervention (after module 4); immediately after the intervention; 1-month follow-up | 
| Change in Generalized Anxiety Disorder-7 (GAD-7) | A brief clinical measure to assess anxiety severity. Each item is rated on a 4-point scale from 0 (not at all) to 3 (nearly every day). A symptom severity score is calculated based on the sum of the 7 items, with scores ranging from 0 to 21. GAD-7 scores of 10 and 15 are the cut-off points for moderate and severe anxiety, respectively (Spitzer et., 2006). | Baseline, pre-intervention; during the intervention (after module 4); immediately after the intervention; 1-month follow-up | 
| Change in Patient Health Questionnaire-9 (PHQ-9) | A self-report measure of depression symptoms. Each of the 9 items is rated on a 4-point scale, ranging from 0 (not at all) to 3 (nearly every day). Items are summed to produce a total severity score ranging from 0 to 27, with higher scores indicating greater symptom severity. PHQ-9 scores ≥ 10 are considered indicative of moderate levels of depression (Manea et al., 2011). | Baseline, pre-intervention; during the intervention (after module 4); immediately after the intervention; 1-month follow-up | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Perceived Health, Functioning, and Quality of Life (QOL) | Single items will be used to measure perceived health, work functioning, and quality of life over the past month. Each item is rated on a 5-point scale, ranging from 1 (not at all satisfied/poor) to 5 (extremely satisfied/excellent). | Baseline, pre-intervention; during the intervention (after module 4); immediately after the intervention; 1-month follow-up | 
| Change in Trauma-Related Guilt Inventory (TRGI) | The TRGI is a 32-item self-report questionnaire designed to measure guilt experienced as a result of surviving a traumatic event. The inventory includes three scales: guilt cognitions, distress, and global guilt scales. | Baseline, pre-intervention; during the intervention (after module 4); immediately after the intervention; 1-month follow-up | 
| Change in Adapted Brief Grief Questionnaire | The Adapted Brief Grief Questionnaire is a 5-item self-report measure for screening for complicated grief (Shear et al., 2006). The items deal with difficulty accepting the death, interference in current life, troubling thoughts related to the death, avoidance of reminders of the loss, and feeling distant from others. Each item is scored from 0 to 2 (0 = not at all, 1 = somewhat, 2 = a lot). | Baseline, pre-intervention; during the intervention (after module 4); immediately after the intervention; 1-month follow-up | 
| Change in Perceived emotional social support | Perceived Emotional Social Support is a single item measure of emotional of social support received in the past week from family and friends (Stappenbeck et al., 2015). The item is rated on a 5-point Likert scale, with responses ranging from 1 (strongly disagree) to 5 (strongly agree). | Baseline, pre-intervention; during the intervention (after module 4); immediately after the intervention; 1-month follow-up | 
| Change in Adapted Expressions of Moral Injury Scale | The Adapted Expressions of Moral Injury Scale is an investigator-adapted version of the Expressions of Moral Injury Scale (EMES). The EMES is a brief measure assessing emotions, beliefs, and behaviours associated with moral injury (Koenig, Mantri, Wang, & Lawson, 2020). Each of the 11 items is rated on a 5-point scale, ranging from 1 (strongly disagree) to 5 (strongly agree). | Baseline, pre-intervention; during the intervention (after module 4); immediately after the intervention; 1-month follow-up | 
| Change in Mental Health Seeking Attitudes/Intention Scale | The Mental Health Seeking Attitudes/Intention Scale is an adapted 3-item measure to assess attitudes toward seeking help from a mental health professional (Hammer, Parent, & Spiker, 2018). Each of the items is rated on a 7-point scale, ranging from 1 (definitely false) to 7 (definitely true). | Baseline, pre-intervention; during the intervention (after module 4); immediately after the intervention; 1-month follow-up | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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COVID-19, eHealth intervention, mental health