Using Peer Mentors to Deliver Depression Care

Recruitment of peer mentors. We will recruit peer mentors from a community organization who
are in recovery and are recommended by the organization and have had basic training in
supportive listening and experience working with persons in the community in need of mental
health support. We will recruit 10 peer mentors, striving for a balance of men and women, and
accounting for attrition, so that at least 5 peer mentors will participate in the project.
The study doctor will meet and interview interested peers to screen for eligibility criteria,
motivation and aptitude. Persons who do not meet criteria for continued participation in the
study will be referred to other volunteer opportunities when appropriate.

Recruitment of patients. Twenty patient participants will be recruited through the internal
medicine and psychiatry clinics at Johns Hopkins Bayview Medical Center as well as the
community. A research assistant will screen patients for depressive symptoms with the Patient
Health Questionnaire-9 (PHQ-9). Patients meeting eligibility criteria will give written
informed consent. Eligible patients will be scheduled for another appointment to meet with
the study doctor in a private room at offices in the clinical campus.

Training of peer mentors. The PI and research assistant will conduct 5 sessions totaling 20
hours of training for the peer mentors. Training will refine the peer mentor's social support
behaviors, which include the use of effective communication skills, rapport building, active
listening, and sharing of experiential knowledge, and expression of empathy. Issues of
cultural interviewing, cultural competence, patient confidentiality, DSM-IV diagnosis,
differentiation of peer and professional roles and patient safety will be addressed.
Knowledge regarding how mental health and illness presents itself in old age and the specific
developmental problems older adults face will be provided. Training will include review of
written materials, lectures, discussion of case studies and role play. Upon completion of the
training, peer mentors will be assessed for mental health knowledge and interpersonal skills
and those who pass muster will be matched with patients.

The peer mentor role: Activities of the peer mentor with the patient will be structured by
the following principles which are derived from important elements of both peer support and
psychotherapy and our preliminary work:

Principles to structure peer mentor interactions with patients

1. Establish a working relationship

2. Establish goals of meetings with patient

3. Provide active listening, empathy, reciprocity, mutual respect, provision of emotional
support Provide support and encourage work toward patient-identified goals to relieve
depression

4. Work on patient-identified goals by engaging multiple techniques as appropriate: sharing
appropriate coping strategies eg. positive thinking, experiential knowledge, problem
solving, consideration of different perspectives.

5. Provide psychoeducation. Discuss the kinds of depression services available,
medications, psychotherapy Acknowledge socioeconomic contributors to depression

6. Provide information on community resources

7. Connect to professional clinical services if appropriate The psychiatrist role: Peer
mentors will meet with the candidate who is a psychiatrist on a weekly basis. The
psychiatrist will provide: (1) clinical leadership and structure by reinforcing the
principles of the peer-patient meetings; and (2) supervision and coaching which will
involve encouragement, continuing education, training and skill enhancement for the peer
mentor. The psychiatrist will guide the peer mentor to ensure that a positive social
experience is being provided and to manage the patient in a way that ensures the
realization of the patient's goal. The peer mentor will share impressions of patient
progress and receive any guidance needed from the psychiatrist.

Study procedures. After patient consent is obtained, the psychiatrist will meet with the
patient for a clinical interview so that the psychiatrist can form an impression of the
patient and provide relevant guidance to the peer mentor. The patient will then be matched
with a peer mentor. The peer mentor will contact the patient by telephone to schedule a
meeting and meet with the peer mentor at his home or in the clinic. The peer mentor will meet
the patient weekly for 8 one-hour sessions. The peer mentors will meet individually on a
weekly basis with the psychiatrist during the study period in a collaborative and supervisory
effort regarding the care of the patient Data Analysis. Analysis will involve both
quantitative and qualitative methods. We will identify measured factors related to engagement
and depression response and remission so that we can understand how the delivery model may
need to be tailored or modified. This analysis will consider depression response and
remission and engagement as dependent variables, with other variables as predictors or effect
modifiers. We will also carry out debriefing interviews with peers and patients in order to
look for themes that will call attention to factors that are most salient to patients and
peers.

Quantitative analysis. Influential variables will be identified in the statistical models
according to association with the dependent variables, namely 1) engagement in depression
care defined as two or more sessions attended with the peer mentor, and 2) decrease in
depressive symptoms which will be treated as a continuous variable.

Qualitative analysis. We will collect qualitative data to obtain the perspective of peer
mentors and patients themselves regarding study processes and mediators from their point of
view. Two semi-structured interviews with patients and peer mentors will be conducted by the
PI at 4 weeks and upon completion of the study. The purpose will be to obtain feedback
regarding positive and negative aspects of the peer delivery model which will provide
perspectives different from the expert and valuable for that reason.

ANALYSIS OF PROCESS We will analyze the process of the peer mentor-patient interactions by 1)
conducting an interaction analysis which will provide quantitative associations between
communication elements and outcomes to determine which elements are salient to the
effectiveness of the peer delivery model, and 2) conducting a qualitative analysis of the
voice recordings to assess how the peer mentors implement the critical elements and how
patients respond to them. The analyses of process will serve to determine the content of the
training for peer mentors, the activities peers will perform with patients and manual
development.

The Roter Interaction Analysis System (RIAS) is a widely used system for interaction
assessment in medical contexts. The RIAS has demonstrated predictive validity to patient
satisfaction, patient recall, and improvements in levels of emotional distress. Combined with
quantitative process and outcome measures of care, statistical analysis can establish
associations between specific communicative thematic categories and patient outcomes.

Data Analysis. We will evaluate the specific interactions between peer and patient employing
the RIAS to investigate the specific interactions that are associated with engagement and
depression response and remission so that we can refine the training required for peers and
develop measures tapping effective interaction strategies. We will also carry out open-ended
interviews with patients that complement the RIAS analysis to assess how the peer mentors
implement the critical elements and how patients respond.

Quantitative analysis. The voice recordings to be analyzed with the RIAS in Phase 2 are
obtained from two sources: (1) 28 voice recordings of peer mentor-patient interactions were
obtained in our preliminary work and (2) 160 voice recordings of peer mentor-patient
interactions will be obtained in the pilot study proposed in this application. The PI will
work with Dr. Roter's laboratory for consultation where coding, reliability testing, and data
entry into an SPSS file will occur. We will draw upon our conceptual model as well as
incorporate the results of the quantitative and qualitative analysis regarding mediators to
construct peer mentor and patient communication profiles which will then be linked to
outcomes. Those elements which are associated with outcomes should be the focus of peer
mentor training and be integrated into the manual. We will use linear regression to assess
the presence, strength, and statistical associations between RIAS categories and outcomes.

Qualitative analysis. The goal of qualitative analysis of the voice recordings will be to
enrich the inferences we make using RIAS data to capture the nuances of what is occurring in
the peer mentor-patient relationship. The PI and the research assistant will listen to the
voice recordings of peer mentor-patient interactions at weeks 1, 4, and 8. They will mark and
transcribe sections in the voice recordings that show how interaction elements such as
affective exchange take place between the peer mentor and patient, and those sections that
provide examples of variations in the methods the peer mentors use and the responses of the
patients. The transcriptions will be coded and analyzed for themes. This analysis will
contextualize the results of the RIAS analysis and provide knowledge about peer mentor
communication and behavior.

Manual development: Knowledge obtained from the study will be developed into a manual which
will form the basis for a larger peer mentor study.

Inclusion Criteria:

Peer mentors: Inclusion criteria:

1. 50 years and older,

2. able to give informed consent;

3. received basic training in behavioral health,

4. history of depression.-

Patients:

1. 50 years and older;

2. clinically significant depression (defined above);

3. able to communicate in English;

4. willing to give informed consent

Exclusion Criteria:

Peer mentors: Exclusion criteria:

1. meet current diagnostic criteria for Minor or Major Depressive Disorder;

2. meet current diagnostic criteria for a psychotic disorder;

3. meet current diagnostic criteria for substance abuse or dependence.

Patients:

1. meet diagnostic criteria for mania or hypomania;

2. meet diagnostic criteria for psychotic syndrome;

3. meet diagnostic criteria for alcohol abuse or dependence;

4. acutely suicidal or psychotic; and,

5. a score on the Mini-Mental State Examination (MMSE) <24.