An interventional study of Supportive/reminder text messaging plus peer support and Supportive/reminder text messaging in Depression, Bipolar Disorder and Schizophrenia, sponsored by University of Alberta. Completed at 5 sites in Canada. Open to participants aged 18 Years to 65 Years. Per ClinicalTrials.gov, last updated 2021-04-14.
Sponsored by University of Alberta · Not applicable, Interventional, and Treatment
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.
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:
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:
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.
Exclusion Criteria:
Patients will be assigned a peer support worker who will visit them during the last week of their inpatient stay to introduce themselves and build rapport before patients are discharged into the community. The peer support workers will visit the participants up to eight times over a six month period. The peer support workers will offer the opportunity for interactive text message support for six months. In addition to peer support, participants in this arm of the study will receive daily supportive text messages from an automated online application and reminder text messages for their community clinic/program appointments.
Behavioral: Supportive/reminder text messaging plus peer support
Patients in the supportive/reminder text message only arm of the study will receive daily supportive text messages from the automated online application and reminder text messages for their community clinic/program appointments.
Behavioral: Supportive/reminder text messaging
Patients in the control arm of the study will receive the usual follow-up appointment offered to all patients who are discharged from acute care. However, they will not receive peer support or supportive/reminder text messages.
Patients will be assigned a peer support worker who will visit them during the last week of their inpatient stay to introduce themselves and build rapport before patients are discharged into the community. The peer support workers will visit the participants up to eight times over a six month period. The peer support workers will offer the opportunity for interactive text message support for six months. Patients will not receive daily supportive/reminder text messages
Behavioral: Peer support only
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
Core Outcome Measure
Core outcome measure has 34 question measure covering 5 sub-scales * Relation to self and others * Daily living and role functioning * Depression and anxiety * Impulsive and addictive behaviour * Psychosis Sub-scale and overall mean scores also range from 0 to 4. Four of the five subscale scores and the BASIS-32 average are computed by averaging the ratings for component items using the number of non-missing items as the denominator. The score range from 0 to 128
Time frame: 6 & 12 Weeks and 6 $ 12 Months
Changes in Health of Nations Outcome Scale (HoNOS) score from Baseline
HoNOS measures the symptom severity and social functioning across time. It has 12 items that measure behaviour, impairment, symptoms and social functioning. The items are rated on a scale of 0-4 and the results or changes in ratings are known as outcomes and may be attributed to services provided. The scores range from 0 to 48.
Time frame: 6 & 12 Weeks and 6 $ 12 Months
Perceived Discrimination Scale score
This is a 5 scale item with each scale scored either from 0-3, 0-4 or 0-6, with 38 questions. The score ranges from 0 to 145 with calculation of each scale mean, standard deviation and alpha for each patient.
Time frame: 6 & 12 Weeks and 6 & 12 Months
World Health Organization Quality of Life Brief instrument (WHOQOL-BREF) score
The WHOQOL-BREF produces a quality of life profile. It is possible to derive four domain scores. The mean score of items within each domain is used to calculate the domain score. Mean scores are then multiplied by 4 in order to make domain scores comparable with the scores used in the WHOQOL-100. Raw scores are then transformed to scores which range from 0-100 scale.
Time frame: 6 & 12 Weeks and 6 $ 12 Months
Patient Satisfaction/Experience Questionnaire
This scale has 10 questions with a Liket scale with five options for each question. The score range from 10 to 50
Time frame: 6 & 12 Months
Rates of Health services utilization
Rates of use, inpatient admissions and length of stay, readmissions, completed appointments, Emergency Department presentations, Emergency Medical Services use, community services appointments, crisis and urgent service calls, no show rates.
Time frame: 6 & 12 Months
Cost of Health services utilized
Cost of use, inpatient admissions and length of stay, re-admissions, completed appointments, Emergency Department presentations, Emergency Medical Services use, community services appointments, crisis and urgent service calls, and no show cost.
Time frame: 6 & 12 Months
Peer Support Worker Effectiveness
Will be assessed through qualitative interviews of key informants and focus group discussions
Time frame: 6 & 12 Months
Peer Support Worker Job satisfaction
Will be assessed through qualitative interviews of key informants and focus group discussions
Time frame: 6 & 12 Months
Peer Support Worker Acceptability
Will be assessed through qualitative interviews of key informants and focus group discussions
Time frame: 6 & 12 Months
Recovery Assessment Scale score for Peer Support workers
The Recovery Assessment Scale has 24 items. It is a Likert scale with 5 rating categories. "completely true" which are scored 1, 2, 3 and 4 respectively giving a range of scores from 38 to 152.
Time frame: 6 & 12 Months
Recovery Assessment Scale score
The Recovery Assessment Scale has 24 items. It is a Likert scale with 5 rating categories for consumers to select from: "untrue"; "a bit true"; "mostly true" and "completely true" which are scored 1, 2, 3 and 4 respectively giving a range of scores from 38 to 152.
Time frame: 6 & 12 Weeks and 6 &12 Months
Plan to share: No
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University of Alberta