- Email: [email protected]
Peer counseling in depression care: A pilot study in a psychiatric inpatient setting
Accepted Manuscript
Peer counseling in depression care: A pilot study in a psychiatric inpatient setting Elisabeth Kohls , Juliane Hug , Marlen Stahl , Pia Driessen , Christel Roemer , Elke Wollschlaeger , Katrin Moldenhauer , Christine Rummel-Kluge PII: DOI: Reference:
S0165-1781(18)31174-0 https://doi.org/10.1016/j.psychres.2018.10.058 PSY 11834
To appear in:
Psychiatry Research
Received date: Revised date: Accepted date:
20 June 2018 18 October 2018 23 October 2018
Please cite this article as: Elisabeth Kohls , Juliane Hug , Marlen Stahl , Pia Driessen , Christel Roemer , Elke Wollschlaeger , Katrin Moldenhauer , Christine Rummel-Kluge , Peer counseling in depression care: A pilot study in a psychiatric inpatient setting, Psychiatry Research (2018), doi: https://doi.org/10.1016/j.psychres.2018.10.058
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ACCEPTED MANUSCRIPT Highlights
It is a pilot on acceptance and effects of peer-counseling in patients and peers
Patients described the peer-intervention as a positive experience
Patients especially valued the counselor’s personal experiences
A significant improvement of self-rated mood after the counseling was found
Overall findings suggest inpatient peer-counselling as a useful, additional offer
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RUNNING HEAD: Peer counseling in depression care
Peer counseling in depression care:
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A pilot study in a psychiatric inpatient setting
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Elisabeth Kohlsa, Juliane Hugb*, Marlen Stahla, Pia Driessenb, Christel Roemerc, Elke Wollschlaegerc, Katrin Moldenhauerc & Christine Rummel-Klugea
Department of Psychiatry and Psychotherapy, University Leipzig, Leipzig, Germany
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European Alliance Against Depression (EAAD), Leipzig, Germany
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Leipzig Alliance Against Depression e. V., Leipzig, Germany
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*Corresponding author: Juliane Hug, European Alliance Against Depression (EAAD), Semmelweisstraße 10, Haus 13, 04103 Leipzig, Germany; Tel.: (0049) 341 97 24 565; Fax: (0049) 341 97 24 539; E-mail address: [email protected]
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ACCEPTED MANUSCRIPT Abstract To evaluate in a pilot study whether peer counseling is feasible and accepted for inpatients with depression. A one-to-one peer counseling intervention was implemented in an inpatient psychiatric department. Patients were invited to ask questions concerning their illness. Three trained counselors with a history of depressive episodes supervised peers. The patients evaluated the counseling and their mood. The peer counselors evaluated the counseling; in addition their depression stigma was assessed. Twenty-nine patients (F32 or
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F33 according to ICD-10, mean age 43 years, 58% female, hospitalized for three weeks minimum) participated. Main topics addressed were ‘the patient himself’ and ‘treatment options, offers and services in the local area’. 94% would recommend peer counseling, 72% would like to take part again. Self-rated mood was significantly higher after than before the
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counseling. The findings suggest that peer counseling is a useful, additional offer for inpatients with depression as it appears to meet needs yet not addressed. Patients especially valued the counselor’s personal experiences. Routine care of depression can be enhanced with peer counseling, e.g. by smoothing the transition from inpatient to outpatient treatment. Further, RCTs on peer counseling in depression should be conducted
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prospectively.
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Keywords: peer counseling; depression; inpatient; patient education
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1. Introduction The ‘peer to peer’ approach – getting help from someone who is or was in the same situation – is very common in different situations of life (Rummel-Kluge et al., 2008). It has been well established for several somatic conditions (e.g. cancer) and in the area of health promotion (e.g. breastfeeding), but less applied in psychiatric care. ‘Peer counseling’ is considered as a method for providing information, advice, and emotional support on an
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illness or a medical condition by individuals who are affected themselves. In contrast to most self-help interventions, peer counselors are trained and supervised during the counseling period (e.g. (Rudy et al., 2001; Heisler and Piette, 2005; Giese-Davis et al., 2006). The World Health Organization (WHO) also advocates the participation of consumers in psychiatry
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(World Health Organization, 2003).
Depression is the most prominent single cause of disability worldwide; with an estimated 4.3 million years of healthy living lost each year (Wittchen et al., 2011). Depression has a high lifetime prevalence within the international range of 6.3 - 10.3%, a large comorbidity (Baumeister and Härter, 2007), mortality (Ustün et al., 2004) and a considerable economic
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impact (Chisholm et al., 2016). Even though a range of effective treatments is available (Hollon et al., 2002; Malhi et al., 2015), patients encounter difficulties with the transition
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from inpatient to outpatient treatment. A smooth transition from an inpatient setting is particularly challenging, as treatment continuity (e.g. uninterrupted prescription of
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antidepressants or timely continuation of psychotherapy) is of primary importance to prevent relapse (Holzinger et al., 2017). Peer counseling represents a promising means of
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overcoming some of the barriers. Within the last decade, peer counseling has been applied and tested as a supplementary treatment of severe mental illnesses like schizophrenia and
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bipolar disorders (Sells et al., 2006; Min et al., 2007; Sledge et al., 2011). A German pilot study (Rummel-Kluge et al., 2008) examined the effects of peer counseling in patients with schizophrenia (N = 88, hospitalized for five weeks). The vast majority of patients would have recommended peer counseling to others. To our knowledge, peer counseling has only been applied and tested in association with depression in three studies to date: Dennis (Dennis, 2003) studied a sample of 42 mothers with a high-risk for post-partum depression (PPD). The vast majority (87.5%) was satisfied with the peer support experience and depressive symptomatology significantly decreased at 4- and 8-week follow up. In the second study (Ho, 2007) studied depressed elderly subjects (N = 30) that participated in a peer counseling 4
ACCEPTED MANUSCRIPT programme, which was found to have improved their perceived health status and level of depression. Third, Garcia and colleagues (Garcia et al., 1997) studied seniors with depression, suicidal thoughts and other emotional crises. 13 consultants with an average age of 65 years participated in the 72-hour consultancy training. The study results suggested a significant reduction of depressive symptoms of the counselors after the training. These few studies are limited to nursing approach or telephone peer support. To our knowledge, to
providing support by a trained and supervised ‘expert’.
1.1 Objectives
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date there have been no studies addressing patients whilst being in inpatient treatment and
The present pilot study seeks to examine the extent to which peer counseling is feasible in
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clinical setting for depressed patients by answering the following research questions: 1. Patients’ experience:
How do patients assess the counseling immediately after the counseling and at two-month follow-up?
Which topics are addressed by the patients during the counseling?
Is there an association between the symptom severity and the evaluation of the peer
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counseling?
Does peer counseling affect the mood of patients?
Does peer counseling affect the peer counselors’ attitude toward depression?
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2. Counselors’ experience:
2. Methods
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2.1 Characteristics of the peer counselors and the intervention
The peer counselors (N = 3) in this study were females (46, 57 and 63 years old) who had experienced several depressive episodes in the past years. Additionally, two out of the three peer counselors had previous experience with peer counseling. Additionally, all peer counselors were engaged volunteers in the ‘Leipzig Alliance Against Depression’, a regional non-profit association. It aims at improving care for people with depression and to prevent suicidal behavior by cooperating with GPs and mental health care specialist, raising awareness via a PR campaign, training stakeholders and supporting local self-help groups and initiatives. The peer counselors had been carefully selected by a senior psychiatrist 5
ACCEPTED MANUSCRIPT based on their knowledge about depression treatment and local care provision, their current health status, their motivation and their wish to support others. All peer counselors were in a remission state during the study duration (and minimum two years before), two on current antidepressant medication. The peer counselors were trained in a two-day workshop regarding depression, treatment of depression, special offers (e.g. self-help programmes) in the local area, organizational and ethical aspects, as well as communication skills. The peer
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counseling (translated title: ‘Patients consult Patients - Where to go with my depression’) was offered twice a week for 60 minutes each, of which 45 minutes were scheduled for counseling time and 15 minutes for data assessment and evaluation. The service was disseminated by posters and patients were informed by their treating physician and the nursing staff. Neither the peer counselors, nor the patients taking part in the peer
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counseling received financial remuneration. A written informed consent was obtained from all patients and confidentiality agreements from counselors prior to study inclusion. The study has been approved by the Ethical Advisory Board, University Leipzig, Medical Faculty. 2.2 Patients and treatment-as-usual
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Potential participants for this pilot study were all patients treated on the depression ward at the University Hospital Leipzig, Department of Psychiatry, Germany. All patients received
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standard psychiatric care, including pharmacological and psychotherapeutic treatment, daily consultation with their treating physicians, a primary nursing system, and regular contact
therapy).
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with a social worker, group psychoeducation, and other group therapies (e.g. occupational
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2.3 Topics covered in the counseling sessions
The counseling sessions aimed to be supportive and focused on the provision of outpatient
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treatment options, self-help and self-management services and additional services the patient could take up after discharge. Requests, concerns, and general questions related to the illness were other topics that arose during the counseling. During the consultation, the peer counselor was required to answer the questions of the patient, to report his own experiences and to provide support, or – in case that she did not feel competent to answer a specific question – to refer the patient to the appropriate team member, e.g. the treating physician, social worker, psychologist, or nursing staff.
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ACCEPTED MANUSCRIPT 2.4 Evaluation and assessments
Assessments took place (see table 1 for overview) before the counselor training (T0), after the counselor training (T1), 1-2 days prior to the counseling (T2), immediately before the counseling (T3), immediately after the counseling (T4), and two months after the counselling (T5). 2.4.1 Patients
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Sociodemographic data: Recorded based on the clinical files (pre-counseling).
Patients’ mood and symptom severity: The patients rated their mood immediately before and after the counseling session via the Zerssen Mood Scale (abbreviated as BS; German original title: “Zerssen Befindlichkeits-Skala”) for T3 (BS-T3) and T4 (BS-T4) (Zerssen D.,
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1975). The questionnaire measures the subject's subjective state of health or the short-term change of state of health. The 28 test items of the scale consist of two property words of opposite meaning (for example, "serious" and "cheerful"). They capture levels of mood, drive, self-esteem and vitality. The internal consistencies lie between at 0.90 and 0.91.
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Further, the Patient Health Questionnaire (PHQ-9) was administered at T3 and T5. It measures each of the nine DSM-IV criteria from “0” (not at all) to “3” (nearly every day). It
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can be used as both diagnostic and severity measure (area under the curve in ROC analysis is 0.95 (Kroenke et al., 2001) and its validity and sensitivity to change have been shown
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repeatedly (Löwe et al., 2004; Martin et al., 2006). Assessment of the counseling session by the patient: The ‘Short Inventory for Individual
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Psychotherapy and Counseling’ (Krampen, 2002) (German original title: Stundenbogen für die Allgemeine und Differentielle Einzelpsychotherapie für Patienten (STEPP)) consists of
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twelve items to be rated on a 7-point Likert scale (1: do not agree at all - 7: agree completely) and was administered at T4 and at T5 (STEPP Follow-up). For our pilot study, the STEPP questionnaire was slightly modified in terms of wording (e.g. ‘therapy session’ replaced by ‘counseling session’) and complemented by three additional items (what did patients like/not like; whether patients would recommend the counseling to other patients; and for T5: whether patients would like to participate again (after discharge)). The questionnaire comprises three complementary subscales: relationship perspective (STEPPR), problem-solving perspective (STEPP-P) and clarification perspective (STEPP-C). The
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ACCEPTED MANUSCRIPT internal reliability consistencies of the STEPP subscales lie between 0.76 and 0.91, the profile reliabilities are 0.66 and 0.71. To analyze the features of the counseling that were perceived positively and negatively and to assess content-related topics covered, qualitative content analysis according to Mayring
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(Mayring, 2008, 2015) was conducted, leading to inductive answer categories.
2.4.2 Counselors
Attitude toward depression: The Depression Stigma Scale (DSS; (Griffiths et al., 2004) was administered to assess counselors’ attitudes toward depression. The DSS consists of two subscales – the Personal Stigma subscale and the Perceived Stigma subscale – each of them
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comprising nine items. Participants respond to each item via a five-point Likert scale ranging from “strongly disagree” (score 1) to “strongly agree” (score 5). Scale scores are calculated by summing scale items, with higher scores indicating more stigmatizing attitudes. The counselors’ personal and perceived depression stigma (DSS) (20) was investigated before
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(T0) and after the peer counselors’ training (T1).
Assessment of the counseling session by the counselor: Before and after the counseling,
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peer counselors filled in a short protocol form (PF) with 17 items addressing the following questions and aspects (multiple choice or open questions):
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PF-T3: Demographic data of the patient, data about inpatient treatment, data about
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organizational aspects (contact, time of counseling, location, etc.). PF-T4: Data about inpatient and planned outpatient treatment (discharge date, details of planned outpatient treatment), own initiative in participation (yes/no), concerns and
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questions of the patient in free text format, summary of recommendations and advice given to the patient, including (if applicable) referral, assessment of whether the concerns of the patients were completely addressed (yes/no/partially), assessment of whether the counseling was helpful for the patient (yes/no/unsure), duration of the counseling in minutes. 2.4.3 Study coordinator
Further, the study coordinator filled out a protocol form (PF-S) 1-2 days before the counseling session was scheduled and at T5 (Follow-up, content of the questions adapted 8
ACCEPTED MANUSCRIPT respectively). At T2 assessment, the protocol consisted of 16 items with open and multiplechoice questions addressing: sociodemographic data of the patient, data about inpatient treatment (admission data, details of treatment), and questions about recruitment for the study, information about the study and data security. Further, informed consent of the patient was obtained in written form and informational material about the study handed out to the patient. At T5, the protocol consisted of three items and assessed details of the
[Please insert table 1 here]
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2.5 Statistical analysis
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outpatient treatment or support the patient has or is using after discharge.
Statistical analysis was performed using IBM SPSS Statistics version 24.0. Descriptive methods were used for statistical analysis of sociodemographic and feedback data from patients and peer counselors. Parametric (t-test) and non-parametric (Mann-Whitney U and Wilcoxon rank sum) tests were used for the investigation of associations. The level of
3. Results 3.1 Participating patients
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statistical significance was Alpha = 0.05 and all tests were two-tailed.
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For participation in the study, N = 53 patients were potentially eligible in the respective recruitment period (Figure 1). Due to a lack of interest, N = 17 patients were excluded and
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no other exclusion criteria applied. In total, N = 36 patients reported previous treatment based on a depressive episode (F32 ICD-10) or recurrent depressive disorder (F33 ICD-10)
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and were included in the study to take part in the peer counseling.
[Please insert figure 1 here]
Out of these, seven patients took part in the counseling and the post-survey assessment, but will be excluded from the further analysis due to divergent primary diagnoses (bipolar affective disorder (F31), schizoaffective disorders (F25), and adjustment disorders (F43)), based on the medical records (checked retrospectively via the hospital SAP system for quality check and confirmation of the self-reported diagnosis at the end of the assessments). 9
ACCEPTED MANUSCRIPT For the analysis of this study, only patients whose patient file confirmed the self-reported diagnosis (N = 29) had been included. In the 2-month follow-up, N = 24 participated. In total, twenty-nine patients (diagnosis: F32 or F33; mean age 43 years, 58% female, mean hospitalization three weeks) had been included into the analysis. 3.2 Duration, scheduling and acceptability of the counseling sessions
Counseling sessions took place between January 13th and May 16th 2014, on two days a
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week from 6.30 pm onwards. The mean duration of counseling was M = 58.5 minutes (SD = 13.7; Min. = 35; Max. = 90). In 82.2% of cases, patients and counselors were able to start their sessions in time. More than two thirds (65.5%) of counseling sessions were finished in time. One session was interrupted.
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The outright majority of patients (94%) would recommend this peer counseling to others and 72% of the patients would like to take part again.
One peer counselor made use of the supervision offered by a senior clinician.
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3.3 Patient’s mood before and after the counseling session
Means, standard deviations and t-values of the sum scores of the BS at T3 and T4 are
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displayed in table 2. The patients’ mood rating (assessed with the BS) after the peer counseling was statistically significantly lower (with lower scores indicating increased mood) than before the meeting with the counselor, investigated with a t-test for dependent
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samples (t(28) = 5.38, p < 0.01).
[Please insert table 2 here]
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3.4 Evaluation of the counseling session directly after the session (T4) and at follow-up (T5) by the patient (STEPP questionnaire)
The sum scores of the STEPP subscales: clarification perspective, problem-solving perspective and relationship perspective and respective means and standard deviations are displayed in table 3. The main topics addressed were ‘the patient himself’ and ‘frontline services in Leipzig‘. [Please insert table 3 here]
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ACCEPTED MANUSCRIPT The sum score of the clarification perspective (STEPP-C) can be any value between five and 35. In comparison to the standard sample and with respect to the confidence interval, the tvalues of the C-scale (STEPP-C) indicate an average assessment of the counseling at T4 and T5. A calculation of Wilcoxon rank sums did not show any statistically significant differences between C-scale ratings at T4 and T5 (p = 1.00). The sum score of the problem-solving perspective (STEPP-P) can be any value between four
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and 28. When comparing the means displayed in table 3 to the standard sample and respecting the confidence intervals, these t-values of the P-scale (STEPP-P) indicate an average assessment of the counseling at T4 and T5. A calculation of Wilcoxon rank sums did not show any statistically significant differences between P-scale ratings at T4 and T5 (p =
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0.95).
The extent to which patients felt understood and supported was assessed by the relationship perspective (STEPP-R). The sum score can be any value between three and 21. Compared to the standard sample, the t-values of the relationship perspective (STEPP-R) at T4 speak for an above average assessment of the relationship between counselor and
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patient, whilst the limits of the confidence interval include the possibility of average, also far above average values. The t-value for assessing the relationship between patient and
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counselor at T5 can be considered as average, compared to the standard sample, whilst the limits of the confidence interval include the possibility of above average values as well. A
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calculation of Wilcoxon rank sums revealed statistically significant differences in the
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evaluation of the relationship perspective between T4 and T5 (p < 0.05). 3.4.1 Association of symptom severity and evaluation of the counseling session
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The symptom severity of the patient (PHQ-9) before the counseling (T3: M = 15.42, SD = 6.22; Min. = 5; Max. = 27) and the evaluation of the peer counseling (STEPP questionnaire; T4: M = 62.17 (SD = 12.27; Min. = 36.00; Max. = 82) was not significantly associated (R(26) = -0.082, p = 0.680). Further, two quartile-based extreme groups based on the PHQ-9 sum score were defined (N = 8 patients with slight/moderate depressive symptoms, M = 7.75; SD = 2.76; N = 10 patients with severe depressive symptoms, M = 21.90; SD = 2.42) and compared regarding the evaluation of the counseling session, yielding no significant difference (Mann-Whitney U test; p = 0.897).
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3.5 Topics and suggestions during the consultation
The topics and questions addressed by patients during the counseling were assessed in twelve inductively composed categories according to Mayring. The most frequently discussed topic was the patient himself in order to report personal matters. Patients mainly talked about their current feelings, individual views on what causes and triggers depression,
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symptoms, and conflicts with their environment and social network. The second most frequently discussed topic was the availability of treatment options, offers and services in Leipzig. According to the overall theme of the counseling, 48.3% of patients used the sessions to gather information about the local health care system (i.e. available self-help groups, psychotherapists). In total, 41.4% of patients obtained information on depression
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treatment in general.
Nearly a quarter of the patients (24.1%) reported their current personal situation in the clinic (i.e. internal hospital structures, satisfaction with the treatment) or their personal professional background. 17.2% of the patients used the conversation to share know-how.
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General information on depression (e.g., causes, and symptoms) and comorbidities were
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also discussed.
3.6 Patients feedback: positive and negative features of the counseling (T4 and T5)
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At T4 and T5, patients were assessed on what they liked and disliked about the counseling. Answers were clustered in categories according to Mayring (Mayring, 2008, 2015). The
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categories and the number of patients who gave particular positive and negative feedback
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on the counseling are shown in table 4.
[Please insert table 4 here]
3.7 Attitude toward depression of the counselors
Before and after the 2-day training workshop, peer counselors reached a mean of M = 5 (SDbefore = 2.00; SDafter = 3.67) on the DSS personal subscale. On the DSS perceived subscale, they reached a mean of M = 24 (SD = 1.73) before, and M = 23.33 (SD = 3.51) after the counselor training.
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4. Discussion Peer counseling has been proven to be successful as a complementary treatment option for somatic illnesses like breast cancer, HIV and diabetes. It has already shown benefits in the
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treatment of psychiatric disorders such as schizophrenia (Rummel-Kluge et al., 2008) but has rarely been implemented and evaluated in other fields of psychiatric care. For depression, however, we identified a particular need for further research, as it accounts for one of the most burdensome mental disorders with, at the same time, the largest room for improvement.
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To our knowledge this is the first study investigating the acceptance and effects of peercounseling for inpatients with depression at the end of their hospitalization, provided by patients with a personal history of depression.
The participants in our study (N = 29) described the peer-intervention as a positive
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experience and the vast majority (94.4%) would recommend it to others. Most patients would have liked to attend another peer counseling session and felt well
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understood and supported.
The peer counselors’ personal experience was perceived as especially enriching.
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Throughout the counseling, patients felt they could address all problems and questions related to the illness in the broadest sense. Depression severity (based on PHQ-9 scores) prior to the counseling session had no
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effect on how the counseling was rated by patients. We therefore assume that
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counseling is equally accepted among higher impaired patients as well.
We found a significant improvement of self-rated mood (assessed with the BS scale)
in patients after the sessions compared to prior to the counseling.
4.1 Patients
The patients mainly used peer counseling to share their experiences with the illness and to receive information, especially about depression treatment and local self-help options. However, it is not clear whether they took up one of these options after being discharged.
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ACCEPTED MANUSCRIPT Further research should focus on whether counselling can produce an actual behavioural change. We did not find negative effects of peer-delivered services. The patients’ overall positive evaluation of the peer counseling supports the hypothesis that peer support is equally beneficial for patients with somatic and mental illnesses. This further explains the increasing tendency of implementing peer support for a growing number of illnesses. Our finding that the majority of patients would recommend peer-counseling
Doughty and Tse, 2011; Bock and Heumann, 2014).
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sessions and would like to take part again goes in line with previous studies in the field (e.g.
During counseling, patients feel well-understood and supported on the short and long-term. The results of our pilot study indicate that the relationship between the patient and the
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counselor is crucial for this effect. Peer counselors have the potential to act as a role model as gatekeepers toward post-inpatient treatment options and recovery. 4.2 Counselors
The counselor needs a thorough knowledge of both, the illness itself and its treatment. We
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also recommend a stable state of mental health. The peer counselors in the present study reported overall positive attitudes toward depression before the counseling (assessed with
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the DSS). However, the perceived stigma (stigma believed to be present in the general public about depression) was rated more negative, which might be due to having experienced
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negative attitudes from others in the past. Moreover, we assume that next to the positive evaluation from patients, the counselors
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themselves will benefit e.g. by increased self-confidence on the long term or feelings of appreciation. Because counselors are subject to a substantial burden, they shall receive
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adequate training and regular supervision. The integration of peer-delivered services can effectively complement inpatient treatment and facilitate the transition from inpatient to outpatient care in the context of depression. Peer-delivered services are a good approach for counselors and patients to interact on the same level in order to exchange information and experiences. By learning from someone with a personal experience, patients might be more prone to change their attitudes, e.g. on antidepressant treatment or psychotherapy, and adopt strategies that have been helpful for the counselor in the past. This could possibly result in an improvement of symptoms, 14
ACCEPTED MANUSCRIPT compliance, and quality of life (Rummel-Kluge et al., 2008) and should therefore be part of future research.
Furthermore, web-based peer support programmes (next to the classical face-to-face delivery) will most likely increase in line with the general rise of E-mental-health interventions as well. Some promising research is already underway in this area (e.g.
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(Bernecker et al., 2017; Hageman et al., 2017)).
4.3 Strengths and limitations
As this represents a pilot and feasibility study, a number of limitations have to be taken into account: The preliminary nature of the findings have to be stressed due to the small study
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sample sizes (N = 29 patients and N = 3 counselors), as well as the application of subjective measurement instruments, where bias due to socially desirable responses cannot be excluded, and the lack of a formal control condition. Regarding the improvement of selfrated mood, we cannot unravel the actual effects of peer counseling from the effects of
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psychiatric treatment-as-usual (as received by all participants of this study). However, this is to our knowledge the first pilot and feasibility study for peer counseling for patients with
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depression in the context of inpatient treatment. We believe that the concept of inpatient peer counseling meets a yet unattended need in psychiatry in general and in depression in
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4.4 Conclusion
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particular.
The findings suggest that peer-counseling is a potentially useful and an additional offer for inpatients with depression. The results of this pilot study show that peer counseling in the
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clinical treatment of depression is feasible and acceptable, both for patients and peer counselors. The patients reported satisfaction with the consultation and felt well understood, supported and perceived the session as enriching. A vast majority would recommend peer-delivered services for depression treatment and would participate again. The patients’ self-reported mood after the consultation was significantly higher than before and the counselors were able to address their concerns and questions. We did not find evidence of burden on the counselors. Our data suggest that peer-counseling is a useful tool
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ACCEPTED MANUSCRIPT for inpatients with depression as it appears to meet as yet unattended needs even after inpatient treatment including psychotherapy and medication. Peer-counseling in depression should be considered as a potentially useful intervention in addition to routine clinical care. For further studies the authors recommend a randomized controlled trial, a further extension of the counselors’ training, an improved recruitment or enrolment strategy and
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the regular supervision of all peer counselors. Further research with a randomized controlled study seems worthwhile in order to evaluate the concept further and identify implementation barriers and success factors as well as medium- and long term outcomes on symptoms and help-seeking behaviour. While peer interventions are currently implemented and evaluated for a broad range of health outcomes and serious somatic disorders like HIV,
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breast cancer and diabetes, the clinical and research agenda should switch their focus towards depression. Disclosures
Acknowledgements
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None for EK, MS, PD, JH, CR, EW and KM. CRK received lecture honoraria from Servier and Jansen.
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We confirm that all patient- and personal identifiers have been removed or disguised so the patients described are not identifiable and cannot be identified through the details of the
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story. We confirm that the peer counselors have read this manuscript and have given permission for it to be published in the current format. We cordially thank all peer
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counselors and patients for their participation. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors
Author contributions Author CRK, EK and MS designed the study and wrote the protocol. Author JH and MS performed the literature searches. Authors MS and EK undertook the statistical analysis, 16
ACCEPTED MANUSCRIPT authors EK, JH and PD wrote the first draft of the manuscript, and EK, JH and PD performed the interpretation of the data. MS, CR, EW and KM collected/obtained data. CR, EW and KM conducted the peer counseling sessions. CRK revised the manuscript critically for important content, wrote the final draft of the manuscript and performed proof reading, also MS, CR, EW and KM. All authors were included in interpreting the data and revising the manuscript critically for important intellectual content. They all gave final approval to the submitted
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version of the manuscript.
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Baumeister, H., Härter, M., 2007. Prevalence of mental disorders based on general population surveys. Social psychiatry and psychiatric epidemiology 42 (7), 537–546. 10.1007/s00127-0070204-1. Bernecker, S.L., Banschback, K., Santorelli, G.D., Constantino, M.J., 2017. A web-disseminated selfhelp and peer support program could fill gaps in mental health care: lessons from a consumer survey. JMIR mental health 4 (1), e5. 10.2196/mental.4751. Bock, T., Heumann, K., 2014, November 29. Reduziert die Begleitung durch Peer-Berater das Risiko der Rehospitalisierung? Erste Ergebnisse des Hamburger Peer-Projekts im Psychnet-Programm. [Does peer counseling reduce the risk of rehospitalization? First results of the Hamburg peer project in the Psychnet programme.] In T. Bock & T. Becker (Chair), Versorgungsforschung und Versorgungsmodelle. Symposium conducted at the DGPPN Congress, Berlin, Germany. Chisholm, D., Sweeny, K., Sheehan, P., Rasmussen, B., Smit, F., Cuijpers, P., et al., 2016. Scaling-up treatment of depression and anxiety: A global return on investment analysis. The Lancet Psychiatry 3 (7), 603-604. 10.1016/S2215-0366(16)30024-4. Dennis, C.-L., 2003. The effect of peer support on postpartum depression: A pilot randomized controlled trial. Canadian journal of psychiatry. Revue canadienne de psychiatrie 48 (2), 115–124. 10.1177/070674370304800209. Doughty, C., Tse, S., 2011. Can consumer-led mental health services be equally effective? An integrative review of CLMH services in high-income countries. Community mental health journal 47 (3), 252–266. 10.1007/s10597-010-9321-5. Garcia, Y.E., Metha, A., Perfect, M.C., McWhirter, J.J., 1997. A SENIOR PEER COUNSELING PROGRAM: EVALUATION OF TRAINING AND BENEFITS TO COUNSELORS. Educational Gerontology 23 (4), 329–344. 10.1080/0360127970230403. Giese-Davis, J., Bliss-Isberg, C., Carson, K., Star, P., Donaghy, J., Cordova, M.J., et al., 2006. The effect of peer counseling on quality of life following diagnosis of breast cancer: An observational study. Psycho-oncology 15 (11), 1014–1022. 10.1002/pon.1037. 17
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Hageman, P.A., Pullen, C.H., Hertzog, M., Pozehl, B., Eisenhauer, C., Boeckner, L.S., 2017. Web-Based Interventions Alone or Supplemented with Peer-Led Support or Professional Email Counseling for Weight Loss and Weight Maintenance in Women from Rural Communities: Results of a Clinical Trial. Journal of obesity 2017, 1602627. 10.1155/2017/1602627. Heisler, M., Piette, J.D., 2005. "I help you, and you help me": Facilitated telephone peer support among patients with diabetes. The Diabetes educator 31 (6), 869–879. 10.1177/0145721705283247. Ho, A.P.Y., 2007. A peer counselling program for the elderly with depression living in the community. Aging & mental health 11 (1), 69–74. 10.1080/13607860600735861. Hollon, S.D., Thase, M.E., Markowitz, J.C., 2002. Treatment and Prevention of Depression. Psychological science in the public interest : a journal of the American Psychological Society 3 (2), 39–77. 10.1111/1529-1006.00008. Holzinger, F., Fahrenkrog, S., Roll, S., Kleefeld, F., Adli, M., Heintze, C., 2017. Discharge management strategies and post-discharge care interventions for depression - Systematic review and metaanalysis. Journal of affective disorders 223, 82–94. 10.1016/j.jad.2017.07.026. Krampen, G., 2002. Stundenbogen für die allgemeine und differentielle Einzelpsychotherapie (STEP). Hogrefe, Göttigen. Kroenke, K., Spitzer, R.L., Williams, J.B., 2001. The PHQ-9: Validity of a brief depression severity measure. Journal of general internal medicine 16 (9), 606–613. Löwe, B., Unützer, J., Callahan, C.M., Perkins, A.J., Kroenke, K., 2004. Monitoring depression treatment outcomes with the patient health questionnaire-9. Medical care 42 (12), 1194–1201. Malhi, G.S., Bassett, D., Boyce, P., Bryant, R., Fitzgerald, P.B., Fritz, K., et al., 2015. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. The Australian and New Zealand journal of psychiatry 49 (12), 1087–1206. 10.1177/0004867415617657. Martin, A., Rief, W., Klaiberg, A., Braehler, E., 2006. Validity of the Brief Patient Health Questionnaire Mood Scale (PHQ-9) in the general population. General hospital psychiatry 28 (1), 71–77. 10.1016/j.genhosppsych.2005.07.003. Mayring, P., 2008. Qualitative Inhaltsanalyse: Grundlagen und Techniken, 10th ed. Beltz, Weinheim. Mayring, P., 2015. Qualitative Inhaltsanalyse: Grundlagen und Techniken, 12th ed. Beltz, Weinheim. Min, S.-Y., Whitecraft, J., Rothbard, A.B., Salzer, M.S., 2007. Peer support for persons with cooccurring disorders and community tenure: A survival analysis. Psychiatric rehabilitation journal 30 (3), 207–213. Rudy, R.R., Rosenfeld, L.B., Galassi, J.P., Parker, J., Schanberg, R., 2001. Participants' perceptions of a peer-helper, telephone-based social support intervention for melanoma patients. Health communication 13 (3), 285–305. 10.1207/S15327027HC1303_4. Rummel-Kluge, C., Stiegler-Kotzor, M., Schwarz, C., Hansen, W.-P., Kissling, W., 2008. Peer-counseling in schizophrenia: Patients consult patients. Patient education and counseling 70 (3), 357–362. 10.1016/j.pec.2007.11.001. Sells, D., Davidson, L., Jewell, C., Falzer, P., Rowe, M., 2006. The treatment relationship in peer-based and regular case management for clients with severe mental illness. Psychiatric services (Washington, D.C.) 57 (8), 1179–1184. 10.1176/ps.2006.57.8.1179. Sledge, W.H., Lawless, M., Sells, D., Wieland, M., O'Connell, M.J., Davidson, L., 2011. Effectiveness of peer support in reducing readmissions of persons with multiple psychiatric hospitalizations. Psychiatric services (Washington, D.C.) 62 (5), 541–544. 10.1176/ps.62.5.pss6205_0541.
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Ustün, T.B., Ayuso-Mateos, J.L., Chatterji, S., Mathers, C., Murray, C.J.L., 2004. Global burden of depressive disorders in the year 2000. The British journal of psychiatry : the journal of mental science 184, 386–392. Wittchen, H.U., Jacobi, F., Rehm, J., Gustavsson, A., Svensson, M., Jonsson, B., et al., 2011. The size and burden of mental disorders and other disorders of the brain in Europe 2010. European neuropsychopharmacology : the journal of the European College of Neuropsychopharmacology 21 (9), 655–679. 10.1016/j.euroneuro.2011.07.018. World Health Organization, 2003. Advocacy for Mental Health. WHO, Geneva. Zerrsen D., 1975. Die Befindlichkeitsskala. Beltz, Weinheim.
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Figure 1. Flow chart of the recruitment of patients in two steps and inclusion and exclusion criteria (F32 = depressive episode. F33 = recurrent depressive disorder. F31 = bipolar affective disorder. F25 = schizoaffective disorders. F43 = adjustment disorders).
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ACCEPTED MANUSCRIPT Table 1: Overview assessment time points and instruments for evaluation
T2
T3
T4
Counselor
Attitudes toward depression
After the counselors training workshop 1-2 days before the counseling session
Depression Stigma Scale (DSS-T1) Protocol formstudy coordinator (PF-S) Protocol form, PF-T3
Counselor
Attitudes toward depression
Study coordinator
Sociodemographic data, data about treatment, IC of the patient
Counselor
Organizational aspects of the counseling, sociodemographic data
PHQ-9 BS-T3 Protocol form PF-T4
Patient
STEPP BS-T4 Protocol formstudy coordinatorfollow-up (PF-S) PHQ-9 STEPP Follow-up
Patient
Depressive symptoms Mood Data on inpatient and planned outpatient treatment, summary of content of the counseling session Assessment of the counseling session Mood Data on outpatient treatment, organizational aspects
Before the counseling session
After the counseling session
Follow-up 2 months after the counseling session
Counselor
Study coordinator
Patient
Depressive symptoms assessment of the counseling sessionfollow-up
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T5
Assessment
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T1
Filled out by
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T0
Instruments/ abbreviation Before the Depression counselors Stigma Scale training workshop (DSS-T0)
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Time point
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Table 2: Means of the sum scores and t-values of the BS Mood Scale at T3 and T4 BS-T3 (N = 29)
BS-T4 (N= 29)
Before the counseling session
After the counseling session
Sum score
t-value
M
SD
Mt
34.69
14.13
70.58
Sum score SDt 13.06
t-value
M
SD
Mt
SDt
25.72
15.45
62.73
13.39
Note: Sum score = scale sum value. t-value = standard values with M = 50, SD = 10. Mt = mean t-value. SDt = mean standard deviation of the t-value.
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Table 3: Means and standard deviation of the sum scores of the STEPP subscales at T4 and T5 STEPP at T4 (N = 29) Sum scores
STEPP at T5 (N = 23)
t-values
Sum scores
t-values
SD
Mt
SDt
M
SD
Mt
SDt
STEPP-Ca
22.31
7.10
49.14
9.37
21.70
8.96
49.78
12.38
STEPP-Pb
20.59
4.67
52.07
10.22
18.65
STEPP-Rc
19.28
2.39
66.72
15.66
17.57
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6.00
49.13
10.83
3.89
57.83
17.95
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Note: Sum score = scale sum value. t-value = standard values with M = 50, SD = 10. Mt = mean t-value. SDt = mean standard deviation of the t-value. a Subscale of the STEPP questionnaire: clarification perspective. b Subscale of the STEPP questionnaire: problem-solving perspective. c Subscale of the STEPP questionnaire: relationship perspective.
Positive features of the counseling
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Table 4: Feedback on the counseling provided by patients
Negative features of the counseling More perceived benefits at later point in time (N = 2)
Openness of the counselor (N = 9)
Disturbances by other patients and noises on the ward (N = 2)
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Personal experience of the counselor (N = 12)
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Understanding of the counselor (N = 9) Advice given by the counselor (N = 8)
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Empathy of the counselor (N = 7) Encouragement and conveying of hope (N = 6) Active listening (N = 5) Others (N = 17)
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ACCEPTED MANUSCRIPT Table 5: Personal and perceived stigma of the counselors before and after the counselor training T0
T1
M
SD
Min.
Max.
M
SD
Min.
Max.
DSS-Personala
5.00
2.00
3.00
7.00
5.00
3.67
1.00
5.00
DSS-Perceivedb
24.00
1.73
22.00
25.00
23.33
3.51
20.00
27.00
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Note: This table shows the personal and perceived stigma of the counselors at T0 (before the counselor training) and at T1 (after the counselor training). a DSS-Personal = subscale personal stigma. b DSS-Perceived = subscale perceived stigma.
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Peer counseling in depression care: A pilot study in a psychiatric inpatient setting Elisabeth Kohls , Juliane Hug , Marlen Stahl , Pia Driessen , Christel Roemer , Elke Wollschlaeger , Katrin Moldenhauer , Christine Rummel-Kluge PII: DOI: Reference:
S0165-1781(18)31174-0 https://doi.org/10.1016/j.psychres.2018.10.058 PSY 11834
To appear in:
Psychiatry Research
Received date: Revised date: Accepted date:
20 June 2018 18 October 2018 23 October 2018
Please cite this article as: Elisabeth Kohls , Juliane Hug , Marlen Stahl , Pia Driessen , Christel Roemer , Elke Wollschlaeger , Katrin Moldenhauer , Christine Rummel-Kluge , Peer counseling in depression care: A pilot study in a psychiatric inpatient setting, Psychiatry Research (2018), doi: https://doi.org/10.1016/j.psychres.2018.10.058
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Highlights
It is a pilot on acceptance and effects of peer-counseling in patients and peers
Patients described the peer-intervention as a positive experience
Patients especially valued the counselor’s personal experiences
A significant improvement of self-rated mood after the counseling was found
Overall findings suggest inpatient peer-counselling as a useful, additional offer
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RUNNING HEAD: Peer counseling in depression care
Peer counseling in depression care:
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A pilot study in a psychiatric inpatient setting
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Elisabeth Kohlsa, Juliane Hugb*, Marlen Stahla, Pia Driessenb, Christel Roemerc, Elke Wollschlaegerc, Katrin Moldenhauerc & Christine Rummel-Klugea
Department of Psychiatry and Psychotherapy, University Leipzig, Leipzig, Germany
b
European Alliance Against Depression (EAAD), Leipzig, Germany
c
Leipzig Alliance Against Depression e. V., Leipzig, Germany
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*Corresponding author: Juliane Hug, European Alliance Against Depression (EAAD), Semmelweisstraße 10, Haus 13, 04103 Leipzig, Germany; Tel.: (0049) 341 97 24 565; Fax: (0049) 341 97 24 539; E-mail address: [email protected]
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ACCEPTED MANUSCRIPT Abstract To evaluate in a pilot study whether peer counseling is feasible and accepted for inpatients with depression. A one-to-one peer counseling intervention was implemented in an inpatient psychiatric department. Patients were invited to ask questions concerning their illness. Three trained counselors with a history of depressive episodes supervised peers. The patients evaluated the counseling and their mood. The peer counselors evaluated the counseling; in addition their depression stigma was assessed. Twenty-nine patients (F32 or
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F33 according to ICD-10, mean age 43 years, 58% female, hospitalized for three weeks minimum) participated. Main topics addressed were ‘the patient himself’ and ‘treatment options, offers and services in the local area’. 94% would recommend peer counseling, 72% would like to take part again. Self-rated mood was significantly higher after than before the
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counseling. The findings suggest that peer counseling is a useful, additional offer for inpatients with depression as it appears to meet needs yet not addressed. Patients especially valued the counselor’s personal experiences. Routine care of depression can be enhanced with peer counseling, e.g. by smoothing the transition from inpatient to outpatient treatment. Further, RCTs on peer counseling in depression should be conducted
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prospectively.
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Keywords: peer counseling; depression; inpatient; patient education
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1. Introduction The ‘peer to peer’ approach – getting help from someone who is or was in the same situation – is very common in different situations of life (Rummel-Kluge et al., 2008). It has been well established for several somatic conditions (e.g. cancer) and in the area of health promotion (e.g. breastfeeding), but less applied in psychiatric care. ‘Peer counseling’ is considered as a method for providing information, advice, and emotional support on an
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illness or a medical condition by individuals who are affected themselves. In contrast to most self-help interventions, peer counselors are trained and supervised during the counseling period (e.g. (Rudy et al., 2001; Heisler and Piette, 2005; Giese-Davis et al., 2006). The World Health Organization (WHO) also advocates the participation of consumers in psychiatry
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(World Health Organization, 2003).
Depression is the most prominent single cause of disability worldwide; with an estimated 4.3 million years of healthy living lost each year (Wittchen et al., 2011). Depression has a high lifetime prevalence within the international range of 6.3 - 10.3%, a large comorbidity (Baumeister and Härter, 2007), mortality (Ustün et al., 2004) and a considerable economic
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impact (Chisholm et al., 2016). Even though a range of effective treatments is available (Hollon et al., 2002; Malhi et al., 2015), patients encounter difficulties with the transition
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from inpatient to outpatient treatment. A smooth transition from an inpatient setting is particularly challenging, as treatment continuity (e.g. uninterrupted prescription of
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antidepressants or timely continuation of psychotherapy) is of primary importance to prevent relapse (Holzinger et al., 2017). Peer counseling represents a promising means of
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overcoming some of the barriers. Within the last decade, peer counseling has been applied and tested as a supplementary treatment of severe mental illnesses like schizophrenia and
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bipolar disorders (Sells et al., 2006; Min et al., 2007; Sledge et al., 2011). A German pilot study (Rummel-Kluge et al., 2008) examined the effects of peer counseling in patients with schizophrenia (N = 88, hospitalized for five weeks). The vast majority of patients would have recommended peer counseling to others. To our knowledge, peer counseling has only been applied and tested in association with depression in three studies to date: Dennis (Dennis, 2003) studied a sample of 42 mothers with a high-risk for post-partum depression (PPD). The vast majority (87.5%) was satisfied with the peer support experience and depressive symptomatology significantly decreased at 4- and 8-week follow up. In the second study (Ho, 2007) studied depressed elderly subjects (N = 30) that participated in a peer counseling 4
ACCEPTED MANUSCRIPT programme, which was found to have improved their perceived health status and level of depression. Third, Garcia and colleagues (Garcia et al., 1997) studied seniors with depression, suicidal thoughts and other emotional crises. 13 consultants with an average age of 65 years participated in the 72-hour consultancy training. The study results suggested a significant reduction of depressive symptoms of the counselors after the training. These few studies are limited to nursing approach or telephone peer support. To our knowledge, to
providing support by a trained and supervised ‘expert’.
1.1 Objectives
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date there have been no studies addressing patients whilst being in inpatient treatment and
The present pilot study seeks to examine the extent to which peer counseling is feasible in
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clinical setting for depressed patients by answering the following research questions: 1. Patients’ experience:
How do patients assess the counseling immediately after the counseling and at two-month follow-up?
Which topics are addressed by the patients during the counseling?
Is there an association between the symptom severity and the evaluation of the peer
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counseling?
Does peer counseling affect the mood of patients?
Does peer counseling affect the peer counselors’ attitude toward depression?
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2. Counselors’ experience:
2. Methods
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2.1 Characteristics of the peer counselors and the intervention
The peer counselors (N = 3) in this study were females (46, 57 and 63 years old) who had experienced several depressive episodes in the past years. Additionally, two out of the three peer counselors had previous experience with peer counseling. Additionally, all peer counselors were engaged volunteers in the ‘Leipzig Alliance Against Depression’, a regional non-profit association. It aims at improving care for people with depression and to prevent suicidal behavior by cooperating with GPs and mental health care specialist, raising awareness via a PR campaign, training stakeholders and supporting local self-help groups and initiatives. The peer counselors had been carefully selected by a senior psychiatrist 5
ACCEPTED MANUSCRIPT based on their knowledge about depression treatment and local care provision, their current health status, their motivation and their wish to support others. All peer counselors were in a remission state during the study duration (and minimum two years before), two on current antidepressant medication. The peer counselors were trained in a two-day workshop regarding depression, treatment of depression, special offers (e.g. self-help programmes) in the local area, organizational and ethical aspects, as well as communication skills. The peer
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counseling (translated title: ‘Patients consult Patients - Where to go with my depression’) was offered twice a week for 60 minutes each, of which 45 minutes were scheduled for counseling time and 15 minutes for data assessment and evaluation. The service was disseminated by posters and patients were informed by their treating physician and the nursing staff. Neither the peer counselors, nor the patients taking part in the peer
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counseling received financial remuneration. A written informed consent was obtained from all patients and confidentiality agreements from counselors prior to study inclusion. The study has been approved by the Ethical Advisory Board, University Leipzig, Medical Faculty. 2.2 Patients and treatment-as-usual
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Potential participants for this pilot study were all patients treated on the depression ward at the University Hospital Leipzig, Department of Psychiatry, Germany. All patients received
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standard psychiatric care, including pharmacological and psychotherapeutic treatment, daily consultation with their treating physicians, a primary nursing system, and regular contact
therapy).
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with a social worker, group psychoeducation, and other group therapies (e.g. occupational
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2.3 Topics covered in the counseling sessions
The counseling sessions aimed to be supportive and focused on the provision of outpatient
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treatment options, self-help and self-management services and additional services the patient could take up after discharge. Requests, concerns, and general questions related to the illness were other topics that arose during the counseling. During the consultation, the peer counselor was required to answer the questions of the patient, to report his own experiences and to provide support, or – in case that she did not feel competent to answer a specific question – to refer the patient to the appropriate team member, e.g. the treating physician, social worker, psychologist, or nursing staff.
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ACCEPTED MANUSCRIPT 2.4 Evaluation and assessments
Assessments took place (see table 1 for overview) before the counselor training (T0), after the counselor training (T1), 1-2 days prior to the counseling (T2), immediately before the counseling (T3), immediately after the counseling (T4), and two months after the counselling (T5). 2.4.1 Patients
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Sociodemographic data: Recorded based on the clinical files (pre-counseling).
Patients’ mood and symptom severity: The patients rated their mood immediately before and after the counseling session via the Zerssen Mood Scale (abbreviated as BS; German original title: “Zerssen Befindlichkeits-Skala”) for T3 (BS-T3) and T4 (BS-T4) (Zerssen D.,
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1975). The questionnaire measures the subject's subjective state of health or the short-term change of state of health. The 28 test items of the scale consist of two property words of opposite meaning (for example, "serious" and "cheerful"). They capture levels of mood, drive, self-esteem and vitality. The internal consistencies lie between at 0.90 and 0.91.
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Further, the Patient Health Questionnaire (PHQ-9) was administered at T3 and T5. It measures each of the nine DSM-IV criteria from “0” (not at all) to “3” (nearly every day). It
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can be used as both diagnostic and severity measure (area under the curve in ROC analysis is 0.95 (Kroenke et al., 2001) and its validity and sensitivity to change have been shown
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repeatedly (Löwe et al., 2004; Martin et al., 2006). Assessment of the counseling session by the patient: The ‘Short Inventory for Individual
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Psychotherapy and Counseling’ (Krampen, 2002) (German original title: Stundenbogen für die Allgemeine und Differentielle Einzelpsychotherapie für Patienten (STEPP)) consists of
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twelve items to be rated on a 7-point Likert scale (1: do not agree at all - 7: agree completely) and was administered at T4 and at T5 (STEPP Follow-up). For our pilot study, the STEPP questionnaire was slightly modified in terms of wording (e.g. ‘therapy session’ replaced by ‘counseling session’) and complemented by three additional items (what did patients like/not like; whether patients would recommend the counseling to other patients; and for T5: whether patients would like to participate again (after discharge)). The questionnaire comprises three complementary subscales: relationship perspective (STEPPR), problem-solving perspective (STEPP-P) and clarification perspective (STEPP-C). The
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ACCEPTED MANUSCRIPT internal reliability consistencies of the STEPP subscales lie between 0.76 and 0.91, the profile reliabilities are 0.66 and 0.71. To analyze the features of the counseling that were perceived positively and negatively and to assess content-related topics covered, qualitative content analysis according to Mayring
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(Mayring, 2008, 2015) was conducted, leading to inductive answer categories.
2.4.2 Counselors
Attitude toward depression: The Depression Stigma Scale (DSS; (Griffiths et al., 2004) was administered to assess counselors’ attitudes toward depression. The DSS consists of two subscales – the Personal Stigma subscale and the Perceived Stigma subscale – each of them
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comprising nine items. Participants respond to each item via a five-point Likert scale ranging from “strongly disagree” (score 1) to “strongly agree” (score 5). Scale scores are calculated by summing scale items, with higher scores indicating more stigmatizing attitudes. The counselors’ personal and perceived depression stigma (DSS) (20) was investigated before
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(T0) and after the peer counselors’ training (T1).
Assessment of the counseling session by the counselor: Before and after the counseling,
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peer counselors filled in a short protocol form (PF) with 17 items addressing the following questions and aspects (multiple choice or open questions):
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PF-T3: Demographic data of the patient, data about inpatient treatment, data about
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organizational aspects (contact, time of counseling, location, etc.). PF-T4: Data about inpatient and planned outpatient treatment (discharge date, details of planned outpatient treatment), own initiative in participation (yes/no), concerns and
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questions of the patient in free text format, summary of recommendations and advice given to the patient, including (if applicable) referral, assessment of whether the concerns of the patients were completely addressed (yes/no/partially), assessment of whether the counseling was helpful for the patient (yes/no/unsure), duration of the counseling in minutes. 2.4.3 Study coordinator
Further, the study coordinator filled out a protocol form (PF-S) 1-2 days before the counseling session was scheduled and at T5 (Follow-up, content of the questions adapted 8
ACCEPTED MANUSCRIPT respectively). At T2 assessment, the protocol consisted of 16 items with open and multiplechoice questions addressing: sociodemographic data of the patient, data about inpatient treatment (admission data, details of treatment), and questions about recruitment for the study, information about the study and data security. Further, informed consent of the patient was obtained in written form and informational material about the study handed out to the patient. At T5, the protocol consisted of three items and assessed details of the
[Please insert table 1 here]
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2.5 Statistical analysis
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outpatient treatment or support the patient has or is using after discharge.
Statistical analysis was performed using IBM SPSS Statistics version 24.0. Descriptive methods were used for statistical analysis of sociodemographic and feedback data from patients and peer counselors. Parametric (t-test) and non-parametric (Mann-Whitney U and Wilcoxon rank sum) tests were used for the investigation of associations. The level of
3. Results 3.1 Participating patients
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statistical significance was Alpha = 0.05 and all tests were two-tailed.
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For participation in the study, N = 53 patients were potentially eligible in the respective recruitment period (Figure 1). Due to a lack of interest, N = 17 patients were excluded and
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no other exclusion criteria applied. In total, N = 36 patients reported previous treatment based on a depressive episode (F32 ICD-10) or recurrent depressive disorder (F33 ICD-10)
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and were included in the study to take part in the peer counseling.
[Please insert figure 1 here]
Out of these, seven patients took part in the counseling and the post-survey assessment, but will be excluded from the further analysis due to divergent primary diagnoses (bipolar affective disorder (F31), schizoaffective disorders (F25), and adjustment disorders (F43)), based on the medical records (checked retrospectively via the hospital SAP system for quality check and confirmation of the self-reported diagnosis at the end of the assessments). 9
ACCEPTED MANUSCRIPT For the analysis of this study, only patients whose patient file confirmed the self-reported diagnosis (N = 29) had been included. In the 2-month follow-up, N = 24 participated. In total, twenty-nine patients (diagnosis: F32 or F33; mean age 43 years, 58% female, mean hospitalization three weeks) had been included into the analysis. 3.2 Duration, scheduling and acceptability of the counseling sessions
Counseling sessions took place between January 13th and May 16th 2014, on two days a
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week from 6.30 pm onwards. The mean duration of counseling was M = 58.5 minutes (SD = 13.7; Min. = 35; Max. = 90). In 82.2% of cases, patients and counselors were able to start their sessions in time. More than two thirds (65.5%) of counseling sessions were finished in time. One session was interrupted.
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The outright majority of patients (94%) would recommend this peer counseling to others and 72% of the patients would like to take part again.
One peer counselor made use of the supervision offered by a senior clinician.
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3.3 Patient’s mood before and after the counseling session
Means, standard deviations and t-values of the sum scores of the BS at T3 and T4 are
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displayed in table 2. The patients’ mood rating (assessed with the BS) after the peer counseling was statistically significantly lower (with lower scores indicating increased mood) than before the meeting with the counselor, investigated with a t-test for dependent
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samples (t(28) = 5.38, p < 0.01).
[Please insert table 2 here]
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3.4 Evaluation of the counseling session directly after the session (T4) and at follow-up (T5) by the patient (STEPP questionnaire)
The sum scores of the STEPP subscales: clarification perspective, problem-solving perspective and relationship perspective and respective means and standard deviations are displayed in table 3. The main topics addressed were ‘the patient himself’ and ‘frontline services in Leipzig‘. [Please insert table 3 here]
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ACCEPTED MANUSCRIPT The sum score of the clarification perspective (STEPP-C) can be any value between five and 35. In comparison to the standard sample and with respect to the confidence interval, the tvalues of the C-scale (STEPP-C) indicate an average assessment of the counseling at T4 and T5. A calculation of Wilcoxon rank sums did not show any statistically significant differences between C-scale ratings at T4 and T5 (p = 1.00). The sum score of the problem-solving perspective (STEPP-P) can be any value between four
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and 28. When comparing the means displayed in table 3 to the standard sample and respecting the confidence intervals, these t-values of the P-scale (STEPP-P) indicate an average assessment of the counseling at T4 and T5. A calculation of Wilcoxon rank sums did not show any statistically significant differences between P-scale ratings at T4 and T5 (p =
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0.95).
The extent to which patients felt understood and supported was assessed by the relationship perspective (STEPP-R). The sum score can be any value between three and 21. Compared to the standard sample, the t-values of the relationship perspective (STEPP-R) at T4 speak for an above average assessment of the relationship between counselor and
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patient, whilst the limits of the confidence interval include the possibility of average, also far above average values. The t-value for assessing the relationship between patient and
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counselor at T5 can be considered as average, compared to the standard sample, whilst the limits of the confidence interval include the possibility of above average values as well. A
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calculation of Wilcoxon rank sums revealed statistically significant differences in the
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evaluation of the relationship perspective between T4 and T5 (p < 0.05). 3.4.1 Association of symptom severity and evaluation of the counseling session
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The symptom severity of the patient (PHQ-9) before the counseling (T3: M = 15.42, SD = 6.22; Min. = 5; Max. = 27) and the evaluation of the peer counseling (STEPP questionnaire; T4: M = 62.17 (SD = 12.27; Min. = 36.00; Max. = 82) was not significantly associated (R(26) = -0.082, p = 0.680). Further, two quartile-based extreme groups based on the PHQ-9 sum score were defined (N = 8 patients with slight/moderate depressive symptoms, M = 7.75; SD = 2.76; N = 10 patients with severe depressive symptoms, M = 21.90; SD = 2.42) and compared regarding the evaluation of the counseling session, yielding no significant difference (Mann-Whitney U test; p = 0.897).
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3.5 Topics and suggestions during the consultation
The topics and questions addressed by patients during the counseling were assessed in twelve inductively composed categories according to Mayring. The most frequently discussed topic was the patient himself in order to report personal matters. Patients mainly talked about their current feelings, individual views on what causes and triggers depression,
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symptoms, and conflicts with their environment and social network. The second most frequently discussed topic was the availability of treatment options, offers and services in Leipzig. According to the overall theme of the counseling, 48.3% of patients used the sessions to gather information about the local health care system (i.e. available self-help groups, psychotherapists). In total, 41.4% of patients obtained information on depression
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treatment in general.
Nearly a quarter of the patients (24.1%) reported their current personal situation in the clinic (i.e. internal hospital structures, satisfaction with the treatment) or their personal professional background. 17.2% of the patients used the conversation to share know-how.
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General information on depression (e.g., causes, and symptoms) and comorbidities were
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also discussed.
3.6 Patients feedback: positive and negative features of the counseling (T4 and T5)
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At T4 and T5, patients were assessed on what they liked and disliked about the counseling. Answers were clustered in categories according to Mayring (Mayring, 2008, 2015). The
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categories and the number of patients who gave particular positive and negative feedback
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on the counseling are shown in table 4.
[Please insert table 4 here]
3.7 Attitude toward depression of the counselors
Before and after the 2-day training workshop, peer counselors reached a mean of M = 5 (SDbefore = 2.00; SDafter = 3.67) on the DSS personal subscale. On the DSS perceived subscale, they reached a mean of M = 24 (SD = 1.73) before, and M = 23.33 (SD = 3.51) after the counselor training.
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ACCEPTED MANUSCRIPT [Please insert table 5 here]
4. Discussion Peer counseling has been proven to be successful as a complementary treatment option for somatic illnesses like breast cancer, HIV and diabetes. It has already shown benefits in the
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treatment of psychiatric disorders such as schizophrenia (Rummel-Kluge et al., 2008) but has rarely been implemented and evaluated in other fields of psychiatric care. For depression, however, we identified a particular need for further research, as it accounts for one of the most burdensome mental disorders with, at the same time, the largest room for improvement.
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To our knowledge this is the first study investigating the acceptance and effects of peercounseling for inpatients with depression at the end of their hospitalization, provided by patients with a personal history of depression.
The participants in our study (N = 29) described the peer-intervention as a positive
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experience and the vast majority (94.4%) would recommend it to others. Most patients would have liked to attend another peer counseling session and felt well
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understood and supported.
The peer counselors’ personal experience was perceived as especially enriching.
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Throughout the counseling, patients felt they could address all problems and questions related to the illness in the broadest sense. Depression severity (based on PHQ-9 scores) prior to the counseling session had no
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effect on how the counseling was rated by patients. We therefore assume that
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counseling is equally accepted among higher impaired patients as well.
We found a significant improvement of self-rated mood (assessed with the BS scale)
in patients after the sessions compared to prior to the counseling.
4.1 Patients
The patients mainly used peer counseling to share their experiences with the illness and to receive information, especially about depression treatment and local self-help options. However, it is not clear whether they took up one of these options after being discharged.
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ACCEPTED MANUSCRIPT Further research should focus on whether counselling can produce an actual behavioural change. We did not find negative effects of peer-delivered services. The patients’ overall positive evaluation of the peer counseling supports the hypothesis that peer support is equally beneficial for patients with somatic and mental illnesses. This further explains the increasing tendency of implementing peer support for a growing number of illnesses. Our finding that the majority of patients would recommend peer-counseling
Doughty and Tse, 2011; Bock and Heumann, 2014).
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sessions and would like to take part again goes in line with previous studies in the field (e.g.
During counseling, patients feel well-understood and supported on the short and long-term. The results of our pilot study indicate that the relationship between the patient and the
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counselor is crucial for this effect. Peer counselors have the potential to act as a role model as gatekeepers toward post-inpatient treatment options and recovery. 4.2 Counselors
The counselor needs a thorough knowledge of both, the illness itself and its treatment. We
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also recommend a stable state of mental health. The peer counselors in the present study reported overall positive attitudes toward depression before the counseling (assessed with
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the DSS). However, the perceived stigma (stigma believed to be present in the general public about depression) was rated more negative, which might be due to having experienced
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negative attitudes from others in the past. Moreover, we assume that next to the positive evaluation from patients, the counselors
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themselves will benefit e.g. by increased self-confidence on the long term or feelings of appreciation. Because counselors are subject to a substantial burden, they shall receive
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adequate training and regular supervision. The integration of peer-delivered services can effectively complement inpatient treatment and facilitate the transition from inpatient to outpatient care in the context of depression. Peer-delivered services are a good approach for counselors and patients to interact on the same level in order to exchange information and experiences. By learning from someone with a personal experience, patients might be more prone to change their attitudes, e.g. on antidepressant treatment or psychotherapy, and adopt strategies that have been helpful for the counselor in the past. This could possibly result in an improvement of symptoms, 14
ACCEPTED MANUSCRIPT compliance, and quality of life (Rummel-Kluge et al., 2008) and should therefore be part of future research.
Furthermore, web-based peer support programmes (next to the classical face-to-face delivery) will most likely increase in line with the general rise of E-mental-health interventions as well. Some promising research is already underway in this area (e.g.
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(Bernecker et al., 2017; Hageman et al., 2017)).
4.3 Strengths and limitations
As this represents a pilot and feasibility study, a number of limitations have to be taken into account: The preliminary nature of the findings have to be stressed due to the small study
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sample sizes (N = 29 patients and N = 3 counselors), as well as the application of subjective measurement instruments, where bias due to socially desirable responses cannot be excluded, and the lack of a formal control condition. Regarding the improvement of selfrated mood, we cannot unravel the actual effects of peer counseling from the effects of
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psychiatric treatment-as-usual (as received by all participants of this study). However, this is to our knowledge the first pilot and feasibility study for peer counseling for patients with
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depression in the context of inpatient treatment. We believe that the concept of inpatient peer counseling meets a yet unattended need in psychiatry in general and in depression in
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4.4 Conclusion
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particular.
The findings suggest that peer-counseling is a potentially useful and an additional offer for inpatients with depression. The results of this pilot study show that peer counseling in the
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clinical treatment of depression is feasible and acceptable, both for patients and peer counselors. The patients reported satisfaction with the consultation and felt well understood, supported and perceived the session as enriching. A vast majority would recommend peer-delivered services for depression treatment and would participate again. The patients’ self-reported mood after the consultation was significantly higher than before and the counselors were able to address their concerns and questions. We did not find evidence of burden on the counselors. Our data suggest that peer-counseling is a useful tool
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ACCEPTED MANUSCRIPT for inpatients with depression as it appears to meet as yet unattended needs even after inpatient treatment including psychotherapy and medication. Peer-counseling in depression should be considered as a potentially useful intervention in addition to routine clinical care. For further studies the authors recommend a randomized controlled trial, a further extension of the counselors’ training, an improved recruitment or enrolment strategy and
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the regular supervision of all peer counselors. Further research with a randomized controlled study seems worthwhile in order to evaluate the concept further and identify implementation barriers and success factors as well as medium- and long term outcomes on symptoms and help-seeking behaviour. While peer interventions are currently implemented and evaluated for a broad range of health outcomes and serious somatic disorders like HIV,
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breast cancer and diabetes, the clinical and research agenda should switch their focus towards depression. Disclosures
Acknowledgements
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None for EK, MS, PD, JH, CR, EW and KM. CRK received lecture honoraria from Servier and Jansen.
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We confirm that all patient- and personal identifiers have been removed or disguised so the patients described are not identifiable and cannot be identified through the details of the
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story. We confirm that the peer counselors have read this manuscript and have given permission for it to be published in the current format. We cordially thank all peer
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counselors and patients for their participation. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors
Author contributions Author CRK, EK and MS designed the study and wrote the protocol. Author JH and MS performed the literature searches. Authors MS and EK undertook the statistical analysis, 16
ACCEPTED MANUSCRIPT authors EK, JH and PD wrote the first draft of the manuscript, and EK, JH and PD performed the interpretation of the data. MS, CR, EW and KM collected/obtained data. CR, EW and KM conducted the peer counseling sessions. CRK revised the manuscript critically for important content, wrote the final draft of the manuscript and performed proof reading, also MS, CR, EW and KM. All authors were included in interpreting the data and revising the manuscript critically for important intellectual content. They all gave final approval to the submitted
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version of the manuscript.
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Hageman, P.A., Pullen, C.H., Hertzog, M., Pozehl, B., Eisenhauer, C., Boeckner, L.S., 2017. Web-Based Interventions Alone or Supplemented with Peer-Led Support or Professional Email Counseling for Weight Loss and Weight Maintenance in Women from Rural Communities: Results of a Clinical Trial. Journal of obesity 2017, 1602627. 10.1155/2017/1602627. Heisler, M., Piette, J.D., 2005. "I help you, and you help me": Facilitated telephone peer support among patients with diabetes. The Diabetes educator 31 (6), 869–879. 10.1177/0145721705283247. Ho, A.P.Y., 2007. A peer counselling program for the elderly with depression living in the community. Aging & mental health 11 (1), 69–74. 10.1080/13607860600735861. Hollon, S.D., Thase, M.E., Markowitz, J.C., 2002. Treatment and Prevention of Depression. Psychological science in the public interest : a journal of the American Psychological Society 3 (2), 39–77. 10.1111/1529-1006.00008. Holzinger, F., Fahrenkrog, S., Roll, S., Kleefeld, F., Adli, M., Heintze, C., 2017. Discharge management strategies and post-discharge care interventions for depression - Systematic review and metaanalysis. Journal of affective disorders 223, 82–94. 10.1016/j.jad.2017.07.026. Krampen, G., 2002. Stundenbogen für die allgemeine und differentielle Einzelpsychotherapie (STEP). Hogrefe, Göttigen. Kroenke, K., Spitzer, R.L., Williams, J.B., 2001. The PHQ-9: Validity of a brief depression severity measure. Journal of general internal medicine 16 (9), 606–613. Löwe, B., Unützer, J., Callahan, C.M., Perkins, A.J., Kroenke, K., 2004. Monitoring depression treatment outcomes with the patient health questionnaire-9. Medical care 42 (12), 1194–1201. Malhi, G.S., Bassett, D., Boyce, P., Bryant, R., Fitzgerald, P.B., Fritz, K., et al., 2015. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. The Australian and New Zealand journal of psychiatry 49 (12), 1087–1206. 10.1177/0004867415617657. Martin, A., Rief, W., Klaiberg, A., Braehler, E., 2006. Validity of the Brief Patient Health Questionnaire Mood Scale (PHQ-9) in the general population. General hospital psychiatry 28 (1), 71–77. 10.1016/j.genhosppsych.2005.07.003. Mayring, P., 2008. Qualitative Inhaltsanalyse: Grundlagen und Techniken, 10th ed. Beltz, Weinheim. Mayring, P., 2015. Qualitative Inhaltsanalyse: Grundlagen und Techniken, 12th ed. Beltz, Weinheim. Min, S.-Y., Whitecraft, J., Rothbard, A.B., Salzer, M.S., 2007. Peer support for persons with cooccurring disorders and community tenure: A survival analysis. Psychiatric rehabilitation journal 30 (3), 207–213. Rudy, R.R., Rosenfeld, L.B., Galassi, J.P., Parker, J., Schanberg, R., 2001. Participants' perceptions of a peer-helper, telephone-based social support intervention for melanoma patients. Health communication 13 (3), 285–305. 10.1207/S15327027HC1303_4. Rummel-Kluge, C., Stiegler-Kotzor, M., Schwarz, C., Hansen, W.-P., Kissling, W., 2008. Peer-counseling in schizophrenia: Patients consult patients. Patient education and counseling 70 (3), 357–362. 10.1016/j.pec.2007.11.001. Sells, D., Davidson, L., Jewell, C., Falzer, P., Rowe, M., 2006. The treatment relationship in peer-based and regular case management for clients with severe mental illness. Psychiatric services (Washington, D.C.) 57 (8), 1179–1184. 10.1176/ps.2006.57.8.1179. Sledge, W.H., Lawless, M., Sells, D., Wieland, M., O'Connell, M.J., Davidson, L., 2011. Effectiveness of peer support in reducing readmissions of persons with multiple psychiatric hospitalizations. Psychiatric services (Washington, D.C.) 62 (5), 541–544. 10.1176/ps.62.5.pss6205_0541.
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Ustün, T.B., Ayuso-Mateos, J.L., Chatterji, S., Mathers, C., Murray, C.J.L., 2004. Global burden of depressive disorders in the year 2000. The British journal of psychiatry : the journal of mental science 184, 386–392. Wittchen, H.U., Jacobi, F., Rehm, J., Gustavsson, A., Svensson, M., Jonsson, B., et al., 2011. The size and burden of mental disorders and other disorders of the brain in Europe 2010. European neuropsychopharmacology : the journal of the European College of Neuropsychopharmacology 21 (9), 655–679. 10.1016/j.euroneuro.2011.07.018. World Health Organization, 2003. Advocacy for Mental Health. WHO, Geneva. Zerrsen D., 1975. Die Befindlichkeitsskala. Beltz, Weinheim.
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Figure 1. Flow chart of the recruitment of patients in two steps and inclusion and exclusion criteria (F32 = depressive episode. F33 = recurrent depressive disorder. F31 = bipolar affective disorder. F25 = schizoaffective disorders. F43 = adjustment disorders).
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ACCEPTED MANUSCRIPT Table 1: Overview assessment time points and instruments for evaluation
T2
T3
T4
Counselor
Attitudes toward depression
After the counselors training workshop 1-2 days before the counseling session
Depression Stigma Scale (DSS-T1) Protocol formstudy coordinator (PF-S) Protocol form, PF-T3
Counselor
Attitudes toward depression
Study coordinator
Sociodemographic data, data about treatment, IC of the patient
Counselor
Organizational aspects of the counseling, sociodemographic data
PHQ-9 BS-T3 Protocol form PF-T4
Patient
STEPP BS-T4 Protocol formstudy coordinatorfollow-up (PF-S) PHQ-9 STEPP Follow-up
Patient
Depressive symptoms Mood Data on inpatient and planned outpatient treatment, summary of content of the counseling session Assessment of the counseling session Mood Data on outpatient treatment, organizational aspects
Before the counseling session
After the counseling session
Follow-up 2 months after the counseling session
Counselor
Study coordinator
Patient
Depressive symptoms assessment of the counseling sessionfollow-up
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PT
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T5
Assessment
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T1
Filled out by
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T0
Instruments/ abbreviation Before the Depression counselors Stigma Scale training workshop (DSS-T0)
M
Time point
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Table 2: Means of the sum scores and t-values of the BS Mood Scale at T3 and T4 BS-T3 (N = 29)
BS-T4 (N= 29)
Before the counseling session
After the counseling session
Sum score
t-value
M
SD
Mt
34.69
14.13
70.58
Sum score SDt 13.06
t-value
M
SD
Mt
SDt
25.72
15.45
62.73
13.39
Note: Sum score = scale sum value. t-value = standard values with M = 50, SD = 10. Mt = mean t-value. SDt = mean standard deviation of the t-value.
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Table 3: Means and standard deviation of the sum scores of the STEPP subscales at T4 and T5 STEPP at T4 (N = 29) Sum scores
STEPP at T5 (N = 23)
t-values
Sum scores
t-values
SD
Mt
SDt
M
SD
Mt
SDt
STEPP-Ca
22.31
7.10
49.14
9.37
21.70
8.96
49.78
12.38
STEPP-Pb
20.59
4.67
52.07
10.22
18.65
STEPP-Rc
19.28
2.39
66.72
15.66
17.57
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M
6.00
49.13
10.83
3.89
57.83
17.95
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Note: Sum score = scale sum value. t-value = standard values with M = 50, SD = 10. Mt = mean t-value. SDt = mean standard deviation of the t-value. a Subscale of the STEPP questionnaire: clarification perspective. b Subscale of the STEPP questionnaire: problem-solving perspective. c Subscale of the STEPP questionnaire: relationship perspective.
Positive features of the counseling
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Table 4: Feedback on the counseling provided by patients
Negative features of the counseling More perceived benefits at later point in time (N = 2)
Openness of the counselor (N = 9)
Disturbances by other patients and noises on the ward (N = 2)
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Personal experience of the counselor (N = 12)
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Understanding of the counselor (N = 9) Advice given by the counselor (N = 8)
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Empathy of the counselor (N = 7) Encouragement and conveying of hope (N = 6) Active listening (N = 5) Others (N = 17)
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ACCEPTED MANUSCRIPT Table 5: Personal and perceived stigma of the counselors before and after the counselor training T0
T1
M
SD
Min.
Max.
M
SD
Min.
Max.
DSS-Personala
5.00
2.00
3.00
7.00
5.00
3.67
1.00
5.00
DSS-Perceivedb
24.00
1.73
22.00
25.00
23.33
3.51
20.00
27.00
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M
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Note: This table shows the personal and perceived stigma of the counselors at T0 (before the counselor training) and at T1 (after the counselor training). a DSS-Personal = subscale personal stigma. b DSS-Perceived = subscale perceived stigma.
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