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In times of pandemics, social distancing, isolation, and quarantine have precipitated depression, anxiety, and substance misuse. Scientific literature suggests that patients living with mental health problems or illnesses (MHPIs) who interact with peer support workers (PSWs) experience not only the empathy and connectedness that comes from similar life experiences but also feel hope in the possibility of recovery. So far, it is the effect of mental health teams or programs with PSWs that has been evaluated.
This paper presents the protocol for a web-based intervention facilitated by PSWs. The five principal research questions are whether this intervention will have an impact in terms of (Q1) personal-civic recovery and (Q2) clinical recovery, (Q3) how these recovery potentials can be impacted by the COVID-19 pandemic, (Q4) how the lived experience of persons in recovery can be mobilized to cope with such a situation, and (Q5) how sex and gender considerations can be taken into account for the pairing of PSWs with service users beyond considerations based solely on psychiatric diagnoses or specific MHPIs. This will help us assess the impact of PSWs in this setting.
PSWs will lead a typical informal peer support group within the larger context of online peer support groups, focusing on personal-civic recovery. They will be scripted with a fixed, predetermined duration (a series of 10 weekly 90-minute online workshops). There will be 2 experimental subgroups—patients diagnosed with (1) psychotic disorders (n=10) and (2) anxiety or mood disorders (n=10)—compared to a control group (n=10). Random assignment to the intervention and control arms will be conducted using a 2:1 ratio. Several instruments will be used to assess clinical recovery (eg, the Recovery Assessment Scale, the Citizenship Measure questionnaire). The COVID-19 Stress Scales will be used to assess effects in terms of clinical recovery and stress- or anxiety-related responses to COVID-19. Changes will be compared between groups from baseline to endpoint in the intervention and control groups using the Student paired sample t test.
This pilot study was funded in March 2020. The protocol was approved on June 16, 2020, by the Research Ethics Committees of the Montreal Mental Health University Institute. Recruitment took place during the months of July and August, and results are expected in December 2020.
Study results will provide reliable evidence on the effectiveness of a web-based intervention provided by PSWs. The investigators, alongside key decision makers and patient partners, will ensure knowledge translation throughout, and our massive open online course (MOOC),
ClinicalTrials.gov NCT04445324; https://clinicaltrials.gov/ct2/show/NCT04445324
PRR1-10.2196/22500
In recent pandemics, social distancing, isolation, and quarantine have precipitated depression and anxiety [
In response to this situation, this feasibility study of a trial offers a transitional measure of online social support for people suffering from (1) psychotic disorders or (2) anxiety or mood disorders, and to assess its effects in terms of both personal-civic recovery and clinical recovery. Transitional peer support groups will be organized and led by trained peer support workers (PSWs). PSWs are persons with first-hand lived experience of mental health problems or illnesses and who are further along in their own recovery journey. Upon training, they can provide supportive services when hired to fill such a paid specialty position, as now recommended by recovery-oriented best practices guidelines [
In Canada, the incremental economic burden of mental health problems or illnesses (MHPIs), which incorporates the use of medical resources and productivity losses due to long-term and short-term disability, as well as reductions in health-related quality of life, is estimated to be more than $50 billion per year. By calculating all health services utilization, long-term and short-term work loss, and health-related quality of life and their dollar valuations, Lim et al [
As a social movement echoing the historical claims of other social movements since the 1960s and 1970s, including the antipsychiatry movement, the origins of recovery in mental health are now fairly well documented [
The experience of living in recovery is particularly useful for sharing among peers who are coping, and/or have coped, with similar issues. The commonality is the struggle and emotional pain that can accompany the feeling of loss and/or hopelessness due to the consequences of MHPIs, rather than in relation to a specific symptom or psychiatric diagnosis. This commonality might also be in relation to sex and gender considerations [
The principal research questions are whether our novel PSWs-facilitated online intervention will have an impact in terms of (Q1) clinical recovery potential and (Q2) personal-civic recovery potential. We also question (Q3) how these potentials can be impacted by the COVID-19 pandemic and (Q4) how the lived experience of people in recovery can be mobilized to cope with the situation. Finally, we also explore (Q5) how sex and gender considerations can be taken into account for the pairing of PSWs with service users beyond considerations based solely on psychiatric diagnoses or specific MHPIs [
The main problem that this feasibility study of a trial addresses is that the scientific literature on the attribution of a specific effect of paid PSWs, in terms of clinical and personal-civic recovery potentials among persons living with psychotic disorders and/or anxiety and mood disorders, is sparse. Indeed, although we already know that patients served by case management teams with PSWs have shown greater treatment engagement, more satisfaction with their life situation and finances, and fewer life problems than compared to case management alone [
In 2014, Lloyd-Evans et al [
A quasi-experimental group design was used by Felton at al [
As part of the development of a new training program for PSWs, a joint undergraduate program of the Department of Psychiatry and the Vice-Deanery for Health Sciences at the Faculty of Medicine of the University of Montreal, we systematically searched the literature for examples of evidence-based PSWs interventions we could replicate and train our students to conduct. A recovery-oriented group intervention by PSWs that we became familiar with over the years is the Citizenship Enhancement Project [
A result of PSWs’ online group intervention efficacy in terms of both clinical and personal-civic recovery potentials for people living with psychotic disorders, and/or anxiety and mood disorders, would privilege the role of PSWs in recovery-oriented peer-to-peer support groups. The study will impact the conceptualization of recovery- and citizenship-oriented mental health care, clinical training, and in mental health treatment resource allocation and for informing nonspecialized clinicians as well as the public. Indeed, an embedded observational and qualitative study performed with postgraduate students and patient research partners will improve the understanding of the experiential knowledge translation and knowledge sharing dynamics among participating patients living with MHPIs and among PSWs. Decision making will also be informed for the definition of a university mission for all psychiatric facilities of the University of Montreal’s Integrated University Health and Social Services Network (IUHSSC). This network advances the integration of the university mission of care, teaching, and research, by facilitating knowledge translation and technology assessment in order to improve access to evidence-based care. This is a vast integrated network of health and social services organizations and public establishments with a university vocation, including those psychiatric facilities where PSWs do their final internship before being eventually hired. The territory of this network represents 46% of the population of the province of Quebec and the three Integrated University Health and Social Services Centers affiliated with the University of Montreal are partners of this study. Since 2015, the IUHSSC organization is the gateway to the public service system where the Quebec population can turn in case of health problems and/or psychosocial problems, including MHPIs. Due to their university affiliation, their mission is to contribute to academic training as well as to the development and dissemination of scientific knowledge. The study will inform the PSWs’ training program by generating a better understanding of the specific effects attributable to the PSW group intervention.
In 1994, Daniel Fisher, a person with lived experience of several psychiatric hospitalizations prior to becoming a psychiatrist and renowned author and speaker, released an empowerment model of recovery based on the principles that emerged from the lived experience of persons living with MHPIs. Among those principles is
Finally, recovering citizenship means that while recovery is replenishing its social roots, it also reminds citizenship, with its emphasis on the person’s rightful place in society, of the person’s unique journey to citizenship and life as a citizen.
Social interaction, which is essential to community membership, involves the development and maintenance of reciprocal relationships between members of a community, each of whom are, in principle, equal cocitizens to each other [
Indeed, the Mental Health Commission of Canada considers that “involvement within community” is an integral component of a definition of personal recovery. We thus combined the Recovery Assessment Scale [
A criterion for being recruited as a PSW will be to have successfully completed at least 180 hours of training within the microprogram (eg, undergraduate courses PST1000-Recovery & Global Health + PST1001-Ethics of Recovery for PSWs). We have published on the “reversed flipped class” approach in use in this 1-year-long microprogram where senior PSWs take turns as recovery experts and teaching partners, and by which patients/students learn from each other in a peer support–like atmosphere by reflecting on their lived experience of recovery [
The “signatures” of MHPIs is a term formulated by the American National Institute of Mental Health to designate the broad range of genetic, biological, psychological, and social factors that may “sign” a specific mental disorder, depending on an individual’s sex, history, lifestyle habits, etc [
When a person shows up at the Emergency Department of IUSMM for the first time, he or she is systematically approached by a research nurse after a first medical authorization is granted for that person to be approached (sometimes this authorization is not granted for medical or security reasons). The research nurse then explains the objectives of the Signature Bank project and invites the person to participate. Those who agree to participate sign the Information and Consent Form (T1), fill out a series of questionnaires, including ones on sociodemographics; consent to the taking of biological samples; and asked if they are willing to be contacted for other research purposes (like our own study). Then, as with any other IUSMM patients, they are evaluated by the Evaluation and Liaison Module during their hospital stay. A diagnostic is established or confirmed by ward psychiatrists and coded according to the WHO International Classification of Disease–10th Revision (ICD-10) [
Inclusion criteria include patients recruited from the Signature Bank data collection project diagnosed with (1) schizophrenia and psychotic disorders (ICD F20-F29), or with (2) anxiety or mood disorders (ICD F30-F49), (3) aged 18 years old or more, and (4) who have already consented to be contacted by telephone to be invited by our team to participate in this pilot study. Exclusion criteria include (1) active suicidal intentions, (2) marked cognitive impairment, and (3) no access to an electronic device with a webcam and microphone to participate in the online transitional peer support group.
Trained PSWs will learn with participants via a series of 10 colearning workshops that they will organize and facilitate as focus group panels in a manner to simulate a typical peer support group [
Peer support groups bring together people who have similar concerns so they can explore solutions to overcome shared challenges and feel supported by others who have had similar experiences and who may better understand each other’s situation. Peer support groups may be considered by group members as alternatives to, or complementary to, traditional mental health services. They are run by members for members so the priorities are directly based on their needs and preferences. Peer support groups should ideally be independent from mental health and social services, although some services may facilitate and encourage the creation of peer support groups.
The objective is to prevent the deterioration, in times of pandemic, of the participants’ recovery potential. It is also a question of stimulating this potential by encouraging them to share their worries and their coping strategies in relation to the current acute situation. More generally, they will be asked to project themselves beyond this situation and to discuss future challenges of inclusion and social participation (eg, by attending already existing peer support groups) in the short or long term, and of which they will have become aware of during the intervention. This is why this intervention is considered to be transitional. Their own goals during the pandemic may be different from those post pandemic, and the effects of the response may also be different. However, similar to Taylor et al [
To generate a collective narrative [
Upon reception of the signed Information and Consent forms by email, consecutive referrals will be randomly allocated by computer algorithm to one of the two modalities at point of entry into the study on acceptation into the protocol using a computerized program (eg, randomization.com). At this entry point, the participant will have been evaluated, diagnosed, met inclusion criteria, and given formal consent for the randomization procedure. To ensure a balance in the allocation for the strata and thus control the risk of a secular trend in the composition of groups, random block sizes in a random order will be used (3, 6, 9, etc). Participants will thus be randomly allocated to the trial arm (n=20, 2 groups of 10) or control arm (n=10), and will be identified by a randomly assigned identification number. Among those allocated to the experimental groups, 10 patients with psychotic disorders will be randomly selected to be part of the transitional support group for patients with psychotic disorders, and 10 patients with anxiety or mood disorders will be randomly selected to be part of the transitional self-help group for patients with anxiety or mood disorders. It will be the same for the control group; 5 patients with psychotic disorders will be randomly selected to be part of the control group for patients with psychotic disorders, and 5 patients with anxiety or mood disorders will be randomly selected to be part of the control group for patients with anxiety or mood disorders. In both cases, those who have not been selected will be placed on a substitute list in the event of withdrawal of a selected patient, who will be replaced at random by one of the corresponding substitutes.
The groups will be studied together and separately: the experimental group for patients with psychotic disorders (n=10) will be compared to the control group for patients with psychotic disorders (n=5); the experimental group for patients with anxiety or mood disorders (n=10) will be compared to the control group for patients with anxiety or mood disorders (n=5); and the combined experimental group for patients with psychotic disorders and for patients with anxiety or mood disorders (n=20; 2×10) will be compared to the combined control group for patients with psychotic disorders and anxiety or mood disorders (n=10).
This study will be reported following the CONSORT (Consolidated Standards of Reporting Trials) guidelines [
IUSMM clinical staff will receive no information on how participants scored on the Recovery Assessment Scale and Citizenship Measure questionnaires. PSWs will receive no information on participants’ results related to clinical recovery measures routinely taken for the Signature Bank. The PSWs will be separated from the outpatient clinic therapists and will sign agreements not to discuss cases.
Several instruments have been developed by clinicians and academics to assess clinical recovery. Based on their life narratives and to assess personal-civic recovery, measurement tools have also been developed through community-based participatory research and validated by persons living with MHPIs (eg, the Recovery Assessment Scale and the Citizenship Measure questionnaires). As users of mental health services typically tend to prefer interventions to help them recover, reintegrate with society, and achieve their personal goals [
The COVID-19 Stress Scales (36 items) and the measures of personal-civic recovery (47 items) will be repeated, along with the following measures of clinical recovery, which are routinely collected among all Signature Bank participants:
Anxiety: Anxiety State-Trait Anxiety Inventory Form Y6, 6 items (STAI-Y6) [
Depression: Depression Patient Health Questionnaire, 9 items (PHQ-9) [
Alcohol dependence: Alcohol Use Disorders Identification Test, 10 items (AUDIT-10) [
Drug dependence: Drug Abuse Screening Test, 10 items (DAST-10) [
Psychosis: Psychosis Screening Questionnaire, 12 items (PSQ) [
Social functioning: WHO Disability Assessment Schedule, 12 items (WHODAS 2.0) [
Research and clinical observations suggest that during times of pandemic many people exhibit stress- or anxiety-related responses that include fear of becoming infected, fear of coming into contact with possibly contaminated objects or surfaces, fear of foreigners who might be carrying infection (ie, disease-related xenophobia), fear of the socioeconomic consequences of the pandemic, compulsive checking of and reassurance seeking related to possible pandemic-related threats, and traumatic stress symptoms about the pandemic (eg, nightmares, intrusive thoughts). Taylor et al developed the 36-item COVID-19 Stress Scales to measure these features, as they pertain to COVID-19. The COVID-19 Stress Scales were developed to better understand and assess COVID-19–related distress. A stable 5-factor solution was identified, corresponding to scales assessing COVID-19–related stress and anxiety symptoms: (1) concerns related to danger and contamination (12 items, Cronbach α=0.94); (2) concerns about economic consequences (6 items, Cronbach α=0.90); (3) xenophobia (6 items, Cronbach α=0.92); (4) traumatic stress symptoms (6 items, Cronbach α=0.93), and (5) compulsive checking and reassurance seeking (6 items, Cronbach α=0.83). In collaboration with the original authors (ie, Steven Taylor), we have translated the COVID-19 Stress Scales into French, and it can be completed using a 5-point Likert scale.
Salzer and Brusilovskiy [
The Citizenship Measure was developed through a community-based participatory research design in response to a prompt (
When completing the Recovery Assessment Scale and Citizenship Measure questionnaires, participants will be asked to rate on a 5-point Likert scale (1=strongly disagree, 5=strongly agree) the extent to which the respective statements apply to them since the COVID-19 pandemic (in French:
As of February 2020, 2136 IUSMM patients have been enrolled in the Signature Bank since the year 2012, including 822 individuals with psychotic disorders, and 853 with anxiety and/or mood disorders. The study was approved by the local ethics committee in accordance with the Declaration of Helsinki, and the Signature Bank’s management framework provides further details on recruitment and consent forms. Between August 26, 2019, and February 26, 2020 (6 months), a preliminary validation study [
Baseline characteristics will be summarized, including for the measures of clinical recovery (see the
Each workshop and the corresponding debriefing session among PSWs will be transcribed verbatim. The data analysis team will employ thematic analysis [
Biological sex is a categorical construct comprised of genes, anatomy, gonads, and hormones that make up male and female differences [
Declaration of Helsinki protocols are being followed, and patients will give written informed consent. The study was approved on June 16, 2020, by the Research Ethics Committees of the Montreal Mental Health University Institute (#2020-1948). For all participants of the Signature Bank, including those participating in the research presented in this manuscript, an overseeing mental health expert have ruled that all adult patients were deemed ethically and medically capable of consenting for their participation.
This pilot study was funded in March 2020. Recruitment took place during the months of July and August 2020.
Distributions of participants in the pilot study.
Characteristic | Participants, n (%) | |
|
|
|
|
Participants with AMDa | 31 (33.7) |
|
Participants with PDb | 61 (66.3) |
|
54 (58.7) | |
|
Participants with AMD (n=31) | 23 (74.2) |
|
Participants with PD (n=61) | 31 (50.8) |
|
36 (66.7) | |
|
Participants with AMD (n=23) | 17 (73.9) |
|
Participants with PD (n=31) | 19 (61.3) |
|
32 (88.8) | |
|
Participants with AMD (n=17) | 16 (94.1) |
|
Participants with PD (n=19) | 19 (100.0) |
|
24 (80.0) | |
|
Participants with AMD in the experimental group (n=10) | 7 (70.0) |
|
Participants with PD in the experimental group (n=10) | 10 (100.0) |
|
Participants with AMD or PD in the control group (n=10) | 7 (70.0) |
aAMD: anxiety and mood disorders
bPD: psychotic disorders.
cICF: Information and Consent Form.
Calendar of activities.
Date | Activity | |
|
Convergent and Concurrent Validity Between Clinical Recovery and Personal-Civic Recovery | Effects of Online and Recovery-Oriented Peer Support Groups Facilitated by Peer Support Workers |
|
ClinicalTrials.gov ID NCT04125030 | ClinicalTrials.gov ID NCT04445324 |
September 2019 to March 2020 |
Study suspended due to the COVID-19 pandemic 92 eligible participants completed the study |
—a |
April-May 2020 | — |
Writing and submission of the research protocol to the institutional review board |
June 2020 | — |
Institutional review board approval of research protocol |
July 2020 |
Submission of the study protocol for publication in a peer-reviewed journal |
Submission of the study protocol for publication in a peer-reviewed journal |
August 2020 | — |
Recruitment of study participants among those 92 from the previous validation study Precompletion of measures (T1) |
September to October 2020 |
Publication of the research protocol [ |
10 weekly peer support groups for patients with psychotic disorders 10 weekly peer support groups for patients with anxiety or mood disorders |
November 2020 |
Data analyses |
Postcompletion of measures (T2) Addenda to study protocol Submission of the revised study protocol for publication |
December 2020 |
Submission of the study’s main conclusions for publication in an open access peer-reviewed journal |
Data analyses Submission of the study’s main conclusions for publication in an open access peer-reviewed journal |
aNot applicable.
Qualitative and quantitative results will be provided to all stakeholders and knowledge users, and posted on our massive open online course (MOOC) platform. Several PSWs and engaged service users take turns as teaching partners in
MOOCs are free interactive step-by-step courses developed by universities with the aim of reaching an unlimited number of participants and to create a community of lifelong e-learners (electronic learners). PSWs will be involved in the presentation and discussion of the findings, and acknowledged as coauthors in the publications, whenever appropriate, including within the MOOC (second edition). Indeed, the MOOC will be used as a knowledge translation platform for ongoing discussion among registrants, and updated with the findings of this pilot study in particular. Undoubtedly, the COVID-19 pandemic has disrupted many aspects of academic medical missions [
Cumulative total of MOOC (massive open online course) registrants during the first 20 weeks of 2020. WHO: World Health Organization.
Weekly variations in new registrants to the MOOC (massive open online course) during the first 20 weeks of 2020. WHO: World Health Organization.
In 2017, before the current COVID-19 crisis, Bendezu-Quispe and colleagues [
Moreover, millions of people worldwide experienced moderate to severe levels of stress- or anxiety-related symptoms in response to COVID-19. This is true for the general population [
Some psychiatrists even warn of a “tsunami” of mental illness due to problems arising during lockdown. They are particularly concerned that children and older adults are not receiving the support they need because of school closures, self-isolation, and fear of hospitals [
Beyond the current acute context, this feasibility study of a trial and corresponding future RCT, plus the MOOC as an innovative knowledge translation strategy, have the potential to demonstrate the relevance of this online group intervention of PSWs for many more current and future patients. Indeed, the Quebec Ministerial Mental Health Action Plan currently in force mentions the Assertive Community Treatment teams as potential models for the inclusion PSWs. Several reviews concluded that Assertive Community Treatment is more effective than standard services in reducing hospital use and increasing community tenure, and numerous practice guidelines endorsed this model as an evidence-based practice for the treatment of psychotic disorders like schizophrenia [
Profile of MOOC registrants after the first year (N=1553).
Alcohol Use Disorders Identification Test, 10 items
Canadian Medical Educational Directives for Specialists
Consolidated Standards of Reporting Trials
Drug Abuse Screening Test, 10 items
electronic learner
International Classification of Disease–10th Revision
Institut universitaire en santé mentale de Montréal
mental health problems or illness
massive open online course
Patient Health Questionnaire, 9 items
Psychosis Screening Questionnaire, 12 items
peer support worker
randomized controlled trial
Anxiety State-Trait Anxiety Inventory Form Y6, 6 items
World Health Organization
WHO Disability Assessment Schedule, 12 items
This study is funded by Fonds de Recherche du Québec – Santé (award number 251842), the Centre de recherche of Institut universitaire en santé mentale de Montréal, and the Équipe de recherche et d’action en santé mentale et culture. The funding bodies played no direct role in the design of the study; collection, analysis, and interpretation of the data; and in writing the manuscript.
None declared.