enhancing depression care with peer mentors what they do ... · no longer only smi •minority...

Enhancing Depression Care with Peer Mentors

What they do and how they do it

Jin Hui Joo, MD MADivision of Geriatric Psychiatry and Neuropsychiatry

I. Context

II. Peer pilot study

III. Peer communication

• Population healthShort on capacity

• Primary careNo longer only SMI

• Minority older adultsDisparities, increased risk

• Lack of engagement, increase repertoire

Context

Bartels et al., 2004

Need – PRISM-ELow engagement

Katon 1995; Akincigi, 2007; Barrett 2008

Traditional treatmentsLow engagement and adherence

• Adherence to medications28-60% stop before 6 months

• Adherence to psychotherapy 20-57% dropout after first session

Pfeiffer, 2010

Meta-analysis of peer support interventions

27 studies, 2 without control group

SMG: 0.5043 (p< .0001, 95 % CI 0.3675, 0.6412

Equivalent to a reduction of 4.64 points on the BDI-II

Bryan, 2015

Meta-analysis of peer interventions

Gaps in knowledge

• Little evidence on models of care, peer role, process of training and supervision.

• Most evidence on peer support groups.

• Few on elderly.

I. Context

II. Peer Enhanced Depression Care

Pilot Study

III. Results

IV. Discussion

Existing workforce

What are peer mentors?

• Older adult

• In recovery

• Experiential knowledge

• Trained and supervised

• Focused on depression care

• One to one

Case management

Psychotherapy

Stand alone treatment

Peer Mentoring on the Spectrum

Davidson et al 2006

Psychosocial support

Interpersonal emotion

regulation• Socioaffective needs

• Cognitive needs

• Action needs

Peer support• Coping skills from life

experience

Social learning• Modeling – influence

through example

• Self-efficacy

Conceptual Framework

Solomon 2004; Gross 2003; Bandura 1986

Peer MentorInterventionist

Mental Health

ProfessionalSupervision and training

Informal therapeutic relationship

PatientNot engaged in specialty mental health care

Community-based

PEERS Model

Primary Care Clinic

Recruitment

• 6 peer mentors

– with history of depression and treatment and 5+ years in recovery

• 30 patients

– 50+ years of age and older

– Not receiving care

– PHQ-9 > 5

1. Build relationshipTrust and confidence

2. Active listeningListen more and talk less

3. Socioemotional supportRespond to patient’s emotional distress

4. Identify goal and encourage changeAsk patient to try a new behavior or coping strategy

Training and supervision

Focus:Within a trusting and caring relationship, help older adult see, learn and try things in a different way. Practical and time-limited.

Peer Role

Relationship

building

Work on goals

to relieve depression

Link to resources and

professional care

Training

Supervision

8 Peer-Patient meetingsMatching

Audiorecorded

Clinical Eval

Patient

Peer mentor

PEERS – Process

I. Context


I. Results

III. Peer communication

Characteristics n (%)

Age in years (mean ± standard deviation) 68.9 ± 6.6 years

Women 23 (85)

Ethnicity

Black or African American 20 (74)

White 6 (22)

Other 1 (4)

Education

Grade 1 to 8 2 (7)

1-4 years of high school or GED 8 (30)

1-3 years of community college or technical school 11 (41)

4 years of college or more 6 (22)

Marital status

Married 7 (26)

Divorce/Separated/Widowed 18 (67)

Not married but living with partner 2 (7)

Total medical problems

0 1 (4)

1-2 8 (30)

≥3 18 (67)

History of major depressive episode 22 (81)

History of counseling 14 (52)

On antidepressants currently 8 (30)

Patient characteristics of 27 patients 30 recruited, 27 completed

PHQ-9Scores

Meetings over time

85% experienced decrease in PHQ-9 scores

Depression Outcomes

Depression scores over 12 months

Depression and other measures assessed before meeting with the peer mentor and after 8 weeks of meetings. Median and interquartile range of depression scores are provided for comparison due to the small sample size.

Outcomes

Working alliance and depression

• Two patients referred during the study.

• One AA man asked for referral for counseling post-study.

• 12 patients with PHQ>5 post-study declined referral.

Use of mental health services

• Suggests peer support programs can decrease depressive outcomes

• Potential mediators:

– Working alliance

– Coping skills

– Loneliness

– Hope

Summary

I. Context


III. Study results

IV. Peer communication

Concerns about Peer Support

• Social conversation?

• Patient-focused or peer-focused?

• Inappropriate advice?

• Helping relationship?

What are peer mentors doing? Health communication analysis

Communication Analysis

• 3 peer mentors and 23 patients.

• Sixty-nine audio recordings coded using the Roter Interaction Analysis System

Beginning Middle End

(N = 23, Obs = 23) (N = 23, Obs = 23) (N = 23, Obs = 23) Pa

All peer counselor talk (mean ± SD)

363 ± 152 288 ± 113 291 ± 109 0.04

a The statistical significance of individual variables was assessed with the Cochran-Mantel-Haenszel χ2 tests with df = 2.

Within-peer clustering was not taken into account in the statistical test.

Verbal dominanceIs the peer listening?


(N = 23, Obs = 23) (N = 23, Obs = 23) (N = 23, Obs = 23) Pa


363 ± 152 288 ± 113 291 ± 109 0.04

Ratio of patient/peer talk – verbal dominance

1.95 2.31 2.31 0.08



Verbal dominanceWho’s talking more?


(N = 23, Obs = 23) (N = 23, Obs = 23) (N = 23, Obs = 23) Pa


363 ± 152 288 ± 113 291 ± 109 0.04

Ratio of patient/peer talk – verbal dominance

1.95 2.31 2.31 0.08

Patient centered communication (mean ± SD)

22.2 ± 23.0 47.6 ± 55.7 42.1 ± 65.9 0.02



Verbal dominanceWho’s listening and who’s talking?

What are they talking about?

Kinds of peer talk

1. Build relationshipTrust and confidence, patient-centered

2. Active listeningListen more and talk less

3. Socioemotional supportRespond to patient’s emotional distress, show concern

4. Identify goal and encourage changeAsk patient to try a new behavior or coping strategy

Training and supervision

Peer mentor talk and working alliance and depression

Selection, training and supervision

• Peer mentors can communicate informally with patients, provide positive social support, focused on patient benefit.

• Not intrinsic qualities of peers, but made possible through selection, training and supervision.

Example of self-disclosure

“But as a I start talking to other people,

I did go to a psychiatrist and I did go through

a long period of therapy.

And one of the things I came out with is that

I'm a workaholic. But I have to take time for

me. Because if I don't take time for me,

everybody that's standing on my shoulders is

just going to fall.

So I'm telling you that story to see how it

relates to your story cause you got a lot of

people on your shoulders, too.”









just going to fall.




Struggle









just going to fall.




Struggle

Treatment









just going to fall.




Struggle

Treatment

Learning









just going to fall.




Struggle

Treatment

Learning

Suggestion

Limitations & challenges

• A feasibility study

• One size does not fit all

• Offers another method of delivery of psychosocial support with potential impact on clinical outcomes

Implications

• Promising workforce

• Non-clinical approach to depression

• Underserved, minority groups

Jin Hui Joo, MD MADivision of Geriatric Psychiatry and Neuropsychiatry

Thank you!

enhancing depression care with peer mentors what they do ... · no longer only smi •minority...

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