BACKGROUND/RATIONALE:
Although effective treatments are available for depression, remission is often incomplete and relapse is common. Thus, many patients must cope with longer term depressive symptoms that decrease their quality of life and compromise functioning. As with other chronic conditions, frequent, proactive, and supportive contacts may assist depressed patients in maintaining the motivation and self-management skills needed to reach valued life goals despite continuing symptoms.

Peer-support interventions that supplement usual mental health care, allow for frequent contacts, build on key elements of chronic illness care, mutual self-help, and recovery may be beneficial for patients dealing with depressive symptoms over the longer term.

OBJECTIVE(S):
Patients with chronic, clinically significant depressive symptoms may benefit from peer interventions that emphasize reciprocal support and facilitate self-management. We conducted a randomized controlled trial (RCT) that compared the effectiveness of telephone- delivered mutual peer-support to enhanced usual care for VA patients in depression treatment. Our primary aims were to evaluate the intervention on: a) functional status, b) quality of life, c) depressive symptoms, and d) suicidal ideation. We also evaluated the intervention effects on recovery orientation.

METHODS:
Patients were eligible for participation if: they were in mental health treatment at one of four study VA medical centers or their associated Community Based Outpatient Clinics; were not attending mental health services or self-help programs outside VA; had a clinician-confirmed depression diagnosis; had at least one adequate antidepressant or psychotherapy trial within the prior 24 months; were seen less than bi-weekly; had current PHQ-9 scores > 10 or WSAS scores > 10; and the ability to communicate by telephone. Of 7,476 patients screened using administrative data and record review, 3,131 met initial eligibility criteria. Patients' clinicians gave permission to contact 1,810 patients, but 378 were not reachable. 352 of the patients contacted by telephone were ineligible on secondary screening and 617 declined participation. Thus, 443 eligible patients were enrolled and completed initial baseline assessments, with 200 being randomized to the mutual peer support intervention (DIAL-UP) and 243 to the enhanced usual care (EUC).

During intervention implementation, there was a shut-down of the calling system for 8 weeks due to "unusual activity" on the University secure server and the subsequent installment of additional security features. This led to substantial interruptions in the peer intervention for 56 individuals who were excluded from the main study analyses.

Patients in the enhanced usual care group received their usual mental health care, a copy of the Depression Helpbook and bi-weekly study mailings with depression management tips. Patients in the peer-support intervention (DIAL-UP) received their usual mental health care, the enhancements above, and: a) brief guidance on being an effective peer partner; b) access to a specialized telephone platform with free calls to partners; c) a peer-support manual that contained self-management and recovery principles and discussion topics; and d) access to mental health staff for back-up and advice. Participants in DIAL-UP were asked to contact their partner once a week.

Study measures were collected at baseline, 3, 6, and 12 months, with 6 months considered the primary end-point. Functional and quality of life measures included the Medical Outcomes Study Short Form-36 for use among Veterans (VR-36), The Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q-SF). Symptomatic measures included Beck Depression Inventory - 2nd Edition (BDI-II). Suicidal ideation and behaviors were measured with the Beck Suicide Scale and mental health recovery orientation was measured using the Mental Health Recovery Measure.

Follow up measures were obtained for 84% of patients at 3 months; 89% at 6 months; and 88% at 12 months.

We conducted "intent to treat" analyses that took the paired nature of the data into consideration. Bivariate analyses were completed using Genmod with a single independent variable and pair IDs as clusters. Multivariable analyses were completed using mixed model analyses, with baseline clinical and functional measures as covariates.

FINDINGS/RESULTS:
The study population was 80.6% male and had a mean age of 54.9 years (SD=10.8); 75.7% were white. At baseline, patients had substantial levels of depressive symptoms (mean BDI-II score of 25.4 (SD =10.7) and substantial functional limitations (mean VR-36 mental health component score of 33.1 (SD=10.3) and physical component score of 35.9 (SD=10.6). They also had low Quality of Life Scores (mean Q-LES-Q-SF of 38.8 (SD=8.9). Randomization was successful in balancing baseline characteristics, with no significant baseline differences between groups in demographics or clinical and functional status.

Of the 144 patients (72 pairs) randomized to the intervention arm, 18% of the pairs completed 0-1 calls, 22% completed 2-5 calls; 28% completed 6-11 calls, and 32% completed 12 or more calls during the 6 months of telephone platform access. Pairs in which both patients had moderate to severe levels of depression were less likely to continue with calls.

There were no significant differences in the primary study outcomes by study group at the 6 month end-point. Patients in both study groups showed improvement in depressive symptoms with decreases in mean BDI-II score of 7.0 points in the intervention group and 6.7 points in the EUC group (adjusted estimate =-.5, p=.6). Functional scores showed minor improvements in both groups, with VR-36 MCS scores increasing by 3.8 points in the intervention group and 3.9 in the EUC group (adjusted estimate=.2, p=.9). VR-36 PCS scores showed little change (adjusted estimate =.-.3, p=.7). Quality of life scores increased slightly in both groups (adjusted estimate=.9, p=.3), while Beck Suicide Scale scores decreased in both groups (adjusted estimate=-.003, p=.99) and MHRM scores increased in both groups (adjusted estimate=.12, p=.95). Analyses addressing the intervention effects on the relative effectiveness of the intervention among subgroups of depressed patients are ongoing.

IMPACT:
Study findings do not provide support for the efficacy of a telephone-delivered reciprocal peer support for VA patients with chronic depression. The study intervention paired patients who were both symptomatic and actively receiving VA mental health treatment, and there was a deliberate effort not to professionalize peers providing reciprocal support, with an emphasis on natural, less structured interactions. Depression severity appeared to impact continued participation in peer calls. Given study findings and the growing literature on the efficacy of varying peer-support structures, VA researchers and policy makers might consider using professionalized, regularly supervised peers who have a reasonable symptomatic remission. Efficacy may also be increased when peers deliver a more structured curriculum.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Valenstein M, Pfeiffer PN, Brandfon S, Walters H, Ganoczy D, Kim HM, Cohen JL, Benn-Burton W, Carroll E, Henry J, Garcia E, Risk B, Kales HC, Piette JD, Heisler M. Augmenting Ongoing Depression Care With a Mutual Peer Support Intervention Versus Self-Help Materials Alone: A Randomized Trial. Psychiatric services (Washington, D.C.). 2016 Feb 1; 67(2):236-9. [view]
2. Pfeiffer PN, Heisler M, Piette JD, Rogers MA, Valenstein M. Efficacy of peer support interventions for depression: a meta-analysis. General hospital psychiatry. 2011 Jan 1; 33(1):29-36. [view]
3. Leggett A, Ganoczy D, Zivin K, Valenstein M. Predictors of Pharmacy-Based Measurement and Self-Report of Antidepressant Adherence: Are Individuals Overestimating Adherence? Psychiatric services (Washington, D.C.). 2016 Jul 1; 67(7):803-6. [view]
4. Pfeiffer PN, Brandfon S, Garcia E, Duffy S, Ganoczy D, Myra Kim H, Valenstein M. Predictors of suicidal ideation among depressed Veterans and the interpersonal theory of suicide. Journal of affective disorders. 2014 Jan 1; 152-154:277-81. [view]

Conference Presentations

1. Travis J, Roeder K, Walters H, Pfeiffer P, Valenstein MT. Tele-Mental Health. Poster session presented at: VA MIRECC Annual Best Practices in Mental Health Conference; 2009 Jul 22; Baltimore, MD. [view]
2. Pfeiffer PN. Two social support interventions for depression: peer support and Carepartners. Paper presented at: American Psychiatric Association Annual Meeting; 2011 May 14; Honolulu, HI. [view]

DRA: Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational
Keywords: Depression, Psychiatric health care delivery, Self-care
MeSH Terms: none