TITLE: Peer Support Programs for Adults with Operational Injury and Their Families: A Review of the Clinical Evidence

DATE: 26 September 2012

CONTEXT AND POLICY ISSUES

Military service members deployed to military conflicts are prone to psychosocial problems such as post-traumatic stress disorder (PTSD), depression, sleep disturbances, or suicidal thoughts.1 A National Canadian Military Health Survey showed a significant association between traumatic event exposure and PTSD, depression and suicidal ideations among Canadian Forces personnel.2,3 Upon returning home, many encounter mental health problems due to additional financial, familial and societal hurdles and stress,4-7 resulting in a one-month prevalence of PTSD of 10.3% among Canadian veterans.8,9 The toll of multiple and prolonged deployments was also evident in the veterans families and children who might experience emotional or behavioral difficulties.10-12

Many initiatives, including peer-support programs, have been implemented to help veterans with mental health problems and their families.13-15 Peer-support programs such as Operational Stress Injury Social Support (OSISS), Vet-to-Vet and Buddy-to-Buddy were created based on the concept that the emotional and experiential ties that bind military service members, when used strategically, can help former veterans to assist returning citizen soldiers to recover their psychosocial health, and improve their social functioning and reintegration.16-19 One example of a peer-support program is the Vet-to-Vet program, developed at the Veterans Affairs (VA) Connecticut Healthcare System.17 This is a peer-provided model run by veterans who were themselves recipients of mental health services and who were trained and monitored by health care professionals. Vet-to-Vet meetings were held five days per week, with specific topic designated for each day, such as Awareness and Pride, Recovery Workshop, Writer’s Meeting, Wellness, and Mental Illness Anonymous. Interviews and mental health assessments based on different outcome measures were conducted at baseline and along the program, and changes over time were analyzed.

The objective of this study is to conduct a review of the clinical evidence regarding benefits and harms of peer-support programs for treatment of adults with operational stress injury and their family.

Disclaimer: The Rapid Response Service is an information service for those involved in planning and providing health care in . Rapid responses are based on a limited literature search and are not comprehensive, systematic reviews. The intent is to provide a list of sources and a summary of the best evidence on the topic that CADTH could identify using all reasonable efforts within the time allowed. Rapid responses should be considered along with other types of information and health care considerations. The information included in this response is not intended to replace professional medical advice, nor should it be construed as a recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for which little information can be found, but which may in future prove to be effective. While CADTH has taken care in the preparation of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect. CADTH is not liable for any loss or damages resulting from use of the information in the report.

Copyright: This report contains CADTH copyright material. It may be copied and used for non-commercial purposes, provided that attribution is given to CADTH.

Links: This report may contain links to other information available on the websites of third parties on the Internet. CADTH does not have control over the content of such sites. Use of third party sites is governed by the owners’ own terms and conditions.

RESEARCH QUESTIONS

1. What is the clinical evidence regarding benefits and harms of peer-support programs for treatment of adults with operational stress injury, including PTSD and depression?

2. What is the clinical evidence regarding benefits and harms of peer-support programs for partners and families of adults with operational stress injury, including PTSD and depression?

KEY MESSAGE

Evidence from the included study suggests that participation in peer support program may enhance personal well-being of veterans as measured by a variety of clinical outcome measures. Compared to veterans who did not participate in Vet-to-Vet peer-support program, veterans who participated in more than ten sessions scored significantly higher on measures of empowerment, and functional status. Their number of days of alcohol use was also significantly reduced. The change in severity of depression and PTSD symptoms was not significant following the intervention. There was no evidence found regarding benefits and harms of peer-support programs for partners and families of adults with operational stress injury, including PTSD and depression.

METHODS

Literature Search Strategy

A limited literature search was conducted on key resources including PubMed In Process, Ovid MEDLINE, Ovid PsychINFO, The Cochrane Library (2012, Issue 8), University of York Centre for Reviews and Dissemination (CRD) databases, Canadian and major international health technology agencies, as well as a focused Internet search. Methodological filters were applied to limit retrieval to health technology assessments, systematic reviews, meta-analyses, randomized controlled trials and non-randomized studies. Where possible, retrieval was limited to the human population. The search was also limited to English language documents published between January 1, 2002 and August 21, 2012.

Selection Criteria and Methods

One reviewer screened the titles and abstracts of the retrieved publications and examined the full-text publications for the final article selection. Selection criteria are outlined in Table 1.

Table 1: Selection Criteria Population Adults with operational stress injury Partners/families of adults with operational stress injury Intervention Peer-support programs Comparator No peer support Other active treatment Outcomes Clinical benefit (including reduction of distress, improved integration, engagement in formal treatment) Harms Study design Health technology assessment, systematic review, meta-analyses, randomized controlled trials (RCTs), non-RCTs

Peer Support Programs for Adults with Operational Stress Injury 2

Exclusion Criteria

Articles were excluded if they did not meet the selection criteria in Table 1, if they were published prior to January 2002, if they were duplicate publications of the same study, or if they were referenced in a selected systematic review.

Critical Appraisal of Individual Studies

The quality of the included studies was assessed using the Downs and Black checklist.20 Numerical scores were not calculated. Instead, the strengths and limitations of individual studies are summarized and presented.

SUMMARY OF EVIDENCE

Quantity of Available Evidence

The literature search yielded 248 citations. Five additional studies were identified by searching the grey literature. After screening of abstracts, 19 potentially relevant studies were selected for full-text review. One study was included in the review.

The PRISMA flowchart in Appendix 1 details the process of the study selection.

Summary of Study Characteristics

A detailed summary of the included study21 is provided in Appendix 2.

Study design

The included study was a prospective observational design, conducted in the United States, and published in 2008.

Population

The included study included 296 veterans with severe mental illness, divided into two cohorts: veterans receiving the peer support intervention (n = 218) and veterans prior to introduction of the peer support program (n = 78). A sub-group of those receiving peer support was also included for comparison, consisting of veterans who attended more than 10 peer-support sessions.

Interventions and comparators

The selected study compared veterans participating in the Vet-to-Vet program, a peer-support program developed by the Veterans Affairs (VA) Connecticut Healthcare System with veterans not receiving Vet-to-Vet support. Meetings occurred five days per week, with interviews conducted at one, three, and nine months after baseline assessment.

Outcomes

The primary outcome measures of the Vet-to-Vet study were recovery attitudes, confidence, general empowerment, and empowerment over illness. Secondary outcome measures included

Peer Support Programs for Adults with Operational Stress Injury 3

functional status, substance use, symptom severity, trauma history, general life satisfaction, and length of participation in Vet-to-Vet program.

Summary of Critical Appraisal

A summary of the critical appraisal conducted for selected study can be found in Appendix 3. The study was observational in design; there was no random assignment of participants, and there was no blinding of the interviewer to the cohort. Power calculation to determine adequate sample size was not performed. The study had hypothesis, interventions, and main outcomes clearly described. The strength of the study was in the diversity of different outcome measures.

Summary of Findings

Main findings of included studies are summarized in detail in Appendix 4.

What is the clinical evidence regarding benefits and harms of peer-support programs for treatment of adults with operational stress injury, including PTSD and depression?

One quasi-experimental prospective observational study21 examined the effectiveness of the Vet-to-Vet program on veterans with severe mental illness. Data suggest that participation in peer support program may enhance personal well-being of veterans as measured by a variety of clinical outcome measures.

Two consecutive cohorts of a total of 296 veterans with severe mental illness were included in the study. The first cohort (n = 78) included veterans before the implementation of the program, and the second cohort after (n = 218). A third cohort (n = 102) was also created to include a subset of the second cohort who participated in more than ten Vet-to-Vet sessions. The sample was predominantly male (95%) and white (66%). The veterans were either married currently or had been married in the past (72%), and about 30% had been homeless during the 30 days before the baseline assessment. Outcome measures were categorized into primary and secondary measures. Primary outcome measures included recovery attitudes, confidence, general empowerment, and empowerment over illness. Secondary outcome measures included functional status, substance use, symptom severity (general psychiatric symptoms and PTSD symptoms), trauma history, general life satisfaction, and participation in the Vet-to-Vet program. Follow-up interviews and evaluations were conducted at one month, three months, and nine months after the initial baseline assessment. The comparisons were made between the first cohort and the second cohort (intention-to-treat analyses), and between the first cohort and the third cohort (as-treated analyses).

Of the primary outcome measures, general empowerment had a statistically significant improvement within program participants in both intention-to-treat and as-treated analyses. Recovery attitudes and empowerment of illness had no statistically significant changes on both intention-to-treat and as-treated analyses. As opposed to the intention-to-treat analyses, the as- treated analyses showed veterans with more than ten peer-support sessions had a statistically significant increase in confidence than veterans without interventions. Of the secondary outcome measures, functional status had a statistically significant increase in Vet-to-Vet participants in both intention-to-treat and as-treated analyses. Severity of general psychiatric or PTSD symptoms had no statistically significant changes on both intention-to-treat and as- treated analyses. The number of days using alcohol had a statistically significant decrease

Peer Support Programs for Adults with Operational Stress Injury 4

among participants in both intention-to-treat and as-treated analyses (the clinical significance of the decrease was not reported), while the number of days using drugs was not affected. The difference in the length of participation in the program was statistically significant in as-treated analyses but was not in intention-to-treat analyses. Comparative data on general life satisfaction was not reported.

What is the clinical evidence regarding benefits and harms of peer-support programs for partners and families of adults with operational stress injury, including PTSD and depression?

There was no evidence found regarding benefits and harms of peer-support programs for partners and families of adults with operational stress injury, including PTSD and depression

Limitations

The robustness of the clinical evidence regarding benefits and harms of peer-support programs for treatment of adults with operational stress injury is limited due to the quantity and quality of the available published literature. The absence of randomization in the included study makes uncertain whether the increase in empowerment and confidence following participation in the peer-support program was not due to differences between groups. Findings were drawn from one study of US veterans, thus the generalizability of the conclusions to veterans in general was limited and may not be representative of Canadian veterans. Additionally, the study population was predominantly male (95%) limiting generalizability to female veterans. There was no evidence found regarding benefits and harms of peer-support programs for partners and families of adults with operational stress injury, including PTSD and depression.

CONCLUSIONS AND IMPLICATIONS FOR DECISION OR POLICY MAKING

Evidence from the included study suggests that participation in peer support program may enhance personal well-being of veterans as measured by a variety of clinical outcome measures such as empowerment, confidence, functional status and decreased alcohol use. More studies on different peer-support programs, in particular those with patient randomization, are needed to validate the roles and benefits of peer-support programs.

Despite the widespread adoption of peer support for veterans, the unique position of the help providers and the complex nature of the target population make the success of a peer-support program depend heavily on its structure and preparation. The Defense Centers of Excellence for Psychological Health and (DCoE) published a White Paper in 2011 on how to most efficiently utilize peer support in active-duty military or environments.22 Based on the evaluation of different programs, the White Paper stated:

“…five elements were found to be essential to a successful peer-to-peer program:

1. Adequate Planning and Preparation, including identifying needs of the target population and aligning program goals to meet those needs. 2. Clearly Articulated Policies to Avoid Confusion, especially around role boundaries and confidentiality. 3. Systematic Screening with Defined Selection Criteria for Peer Supporters, such as communication skills, leadership ability, character, previous experience or training, and individuals who can serve as positive role models.

Peer Support Programs for Adults with Operational Stress Injury 5

4. Leverage Benefits from “Peer” Status, such as experiential learning, social support, leadership, and improved self-confidence. 5. Enable Continued Learning through Structured Training, by providing an atmosphere for peer supporters to support each other and improve peer support skills.

In addition, the literature review and examination of exemplar programs points to several underlying features or “key ingredients” that appear to account for the special effectiveness of peer support interventions. These are (1) social support, (2) experiential knowledge, (3) trust, (4) confidentiality and (5) easy access.” (p1 and 2)

In the face of the lack of a consistent approach to implementing peer support, recommendations from an international consensus study in 2012 were developed and can be used for the design and implementation of peer-support programs in high-risk organizations such as emergency services and the military.23 These recommendations included determination of the goals of the program and the role of peer supporters; selection, training and accreditation of peer supporters; access to peer supporters; looking after peer supporters; and program evaluation.

Finally, with the increasing role of the Reserve Forces in operations abroad and the expansion of peacekeeping missions into military interventions, it is important for policy makers to realize that reservists and peacekeepers are also vulnerable to operational stress injury. Recent studies found that reservists were more likely to feel unsupported compared to Regular personnel upon coming home and had difficulties with social integration in the post deployment period.24 A systematic review of the literature on the relationship between deployment to a peacekeeping operation and mental disorders, distress and suicide found that a post deployment distress was consistently present in peacekeepers exposed to combat, and an increased likelihood of suicidal ideation.25 Policies that include targeted interventions such as social assistance including peer support and may therefore be needed for returning reservists and peacekeepers in dealing with potential emotional, behavioral and addiction problems.

PREPARED BY: Canadian Agency for Drugs and Technologies in Health Tel: 1-866-898-8439 www.cadth.ca

Peer Support Programs for Adults with Operational Stress Injury 6

REFERENCES

1. Riddle JR, Smith TC, Smith B, Corbeil TE, Engel CC, Wells TS, et al. Millennium Cohort: the 2001-2003 baseline prevalence of mental disorders in the U.S. military. J Clin Epidemiol. 2007 Feb;60(2):192-201.

2. Nelson C, Cyr KS, Corbett B, Hurley E, Gifford S, Elhai JD, et al. Predictors of posttraumatic stress disorder, depression, and suicidal ideation among Canadian Forces personnel in a National Canadian Military Health Survey. J Psychiatr Res. 2011 Nov;45(11):1483-8.

3. Belik SL, Stein MB, Asmundson GJ, Sareen J. Relation between traumatic events and suicide attempts in Canadian military personnel. Can J Psychiatry. 2009 Feb;54(2):93-104.

4. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA. 2006 Mar 1;295(9):1023-32.

5. Baker DG, Heppner P, Afari N, Nunnink S, Kilmer M, Simmons A, et al. Trauma exposure, branch of service, and physical injury in relation to mental health among U.S. veterans returning from Iraq and Afghanistan. Mil Med. 2009 Aug;174(8):773-8.

6. Seal KH, Metzler TJ, Gima KS, Bertenthal D, Maguen S, Marmar CR. Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002-2008. Am J Public Health [Internet]. 2009 Sep [cited 2012 Sep 7];99(9):1651-8. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724454

7. Richardson JD, Thompson JM, Boswall M, Jetly R. Horror comes home: veterans with posttraumatic stress disorder. Can Fam Physician [Internet]. 2010 May [cited 2012 Sep 7];56(5):430-73. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2868611

8. Richardson JD, Elhai JD, Pedlar DJ. Association of PTSD and depression with medical and specialist care utilization in modern peacekeeping veterans in Canada with health- related . J Clin Psychiatry. 2006 Aug;67(8):1240-5.

9. Richardson JD. Military-related PTSD in Canadian veterans. Canadian Psychiatry Aujourd'hui [Internet]. 2009 Feb [cited 2012 Aug 27];5(1). Available from: http://publications.cpa-apc.org/browse/documents/445

10. Chartrand M. Developmental and behavioral implications for military children with deployed parents. 2012 Apr 6 [cited 2012 Aug 27]. In: UpToDate [Internet]. Version 20.8. Waltham (MA): UpToDate; 1992 - . Available from: http://www.uptodate.com Subscripton required.

11. Lincoln A, Swift E, Shorteno-Fraser M. Psychological adjustment and treatment of children and families with parents deployed in military combat. J Clin Psychol. 2008 Aug;64(8):984- 92.

12. Palmer C. A theory of risk and resilience factors in military families. Mil Psychol. 2008;20(3):205-17.

Peer Support Programs for Adults with Operational Stress Injury 7

13. Tsai J, Harpaz-Rotem I, Pietrzak RH, Southwick SM. The role of coping, resilience, and social support in mediating the relation between PTSD and social functioning in veterans returning from Iraq and Afghanistan. Psychiatry. 2012;75(2):135-49.

14. Chinman M, Shoai R, Cohen A. Using organizational change strategies to guide peer support technician implementation in the Veterans Administration. Psychiatr Rehabil J. 2010;33(4):269-77.

15. Lester P, Mogil C, Saltzman W, Woodward K, Nash W, Leskin G, et al. Families overcoming under stress: implementing family-centered prevention for military families facing wartime deployments and combat operational stress. Mil Med. 2011 Jan;176(1):19- 25.

16. Military members and veterans [Internet]. In: Operational Stress Injury Social Support. Operational Stress Injury Social Support (OSISS); 2006 [cited 2012 Sep 10]. Available from: http://www.osiss.ca/engraph/index_e.asp?sidecat=1.

17. Resnick SG, Armstrong M, Sperrazza M, Harkness L, Rosenheck RA. A model of consumer-provider partnership: Vet-to-Vet. Psychiatr Rehabil J. 2004;28(2):185-7.

18. Hinojosa R, Hinojosa MS. Using military friendships to optimize postdeployment reintegration for male Operation Iraqi Freedom/Operation Enduring Freedom veterans. J Rehabil Res Dev. 2011;48(10):1145-58.

19. Greden JF, Valenstein M, Spinner J, Blow A, Gorman LA, Dalack GW, et al. Buddy-to- Buddy, a citizen soldier peer support program to counteract stigma, PTSD, depression, and suicide. Ann N Y Acad Sci. 2010 Oct;1208:90-7.

20. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health [Internet]. 1998 Jun [cited 2012 Aug 8];52(6):377-84. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1756728/pdf/v052p00377.pdf

21. Resnick SG, Rosenheck RA. Integrating peer-provided services: a quasi-experimental study of recovery orientation, confidence, and empowerment. Psychiatr Serv [Internet]. 2008 Nov [cited 2012 Aug 22];59(11):1307-14. Available from: http://ps.psychiatryonline.org/data/Journals/PSS/3862/08ps1307.pdf

22. Money N, Moore M, Brown D, Kasper K, Roeder J, Bartone P, et al. Best practices identified for peer support programs [Internet]. Arlington (VA): Defense Centers of Excellence For Psychological Health & Traumatic Brain Injury; 2011 Jan. [cited 2012 Aug 27]. Available from: http://www.dcoe.health.mil/Content/Navigation/Documents/Best_Practices_Identified_for_ Peer_Support_Programs_Jan_2011.pdf

23. Creamer MC, Varker T, Bisson J, Darte K, Greenberg N, Lau W, et al. Guidelines for peer support in high-risk organizations: an international consensus study using the Delphi method. J Trauma Stress. 2012 Apr;25(2):134-41.

Peer Support Programs for Adults with Operational Stress Injury 8

24. Harvey SB, Hatch SL, Jones M, Hull L, Jones N, Greenberg N, et al. Coming home: social functioning and the mental health of UK Reservists on return from deployment to Iraq or Afghanistan. Ann Epidemiol. 2011 Sep;21(9):666-72.

25. Sareen J, Stein MB, Thoresen S, Belik SL, Zamorski M, Asmundson GJ. Is peacekeeping peaceful? A systematic review. Can J Psychiatry. 2010 Jul;55(7):464-72.

Peer Support Programs for Adults with Operational Stress Injury 9

Appendix 1: Selection of Included Studies

248 citations identified from electronic literature search and screened (abstracts)

5 potentially relevant reports retrieved from other sources (grey literature, hand search) 234 citations excluded

19 potentially relevant articles retrieved for scrutiny (full text)

18 reports excluded

1 report included in review

Peer Support Programs for Adults with Operational Stress Injury 10

Appendix 2: Characteristics of Included Studies

Table A1: Characteristics of Included Clinical Trials First Author, Population, Intervention Comparator Clinical Outcomes Year, Number of Country, patients (n) Study Design

Resnik, 200821 Veterans with Vet-to-Vet program* No comparator Primary outcome US severe mental measure Quasi- illness (n = 296) Meetings occurred 5 days Changes over time on experimental per week. measures of prospective -without . recovery orientation observational intervention (Vet- Interviews conducted at (RAQ) study to-Vet program): 78 one month, three months, . confidence (MHCS) veterans (cohort 1) and nine months after the . general empowerment baseline assessment. (MDS) -with intervention . empowerment over (Vet-to-Vet illness (RAS) program): 218 veterans (cohort 2) Secondary outcome measures -subset of cohort 2 .functional status and participating in (ADLS, GAF) > 10 Vet-to-Vet . substance use (ASI) sessions: 102 . symptom severity veterans (cohort 2- (BPRS, PTSD PCL-S) V) . trauma history . general life satisfaction (LQLS) . participation in Vet-to- Vet program ADLS: Activities of Daily Living Scale; MDS: Making Decision Scale; ASI: Addiction Severity Index; BPRS: Brief Psychiatric Rating Scale; GAF: Global Assessment of Functioning; LQLS: Lehman Quality of Life Scale; MHCS: Mental Health Confidence Scale; RAQ: Recovery Attitudes Questionnaire; RAS: Recovery Assessment Scale; PTSD PCL-S: post straumatic stress disorder Check List-Stressor Specific Version; *Vet-to-Vet program: described under “Context and Policy” section

Peer Support Programs for Adults with Operational Stress Injury 11

Appendix 3: Summary of Critical Appraisal of Included Studies

Table A2: Summary of Critical Appraisal of Included Studies First Author, Strengths Limitations Publication Year Resnik, 200821 hypothesis clearly described absence of random assignment interventions of interest clearly absence of blinding of the interviewer to the described cohort diversity of outcome measures unclear whether power calculation was method of selection from source performed to determine adequate sample population and representation described size main outcomes, interventions, patient characteristics, and main findings clearly described estimates of random variability and actual probability values provided

Peer Support Programs for Adults with Operational Stress Injury 12

Appendix 4: Main Study Findings and Authors’ Conclusions

Table A3: Main Study Findings and Authors’ Conclusions First Author, Main Study Findings Authors’ Conclusions Publication Year Research question 1 (clinical evidence of peer-support programs for adults with operational stress injury) Resnik, 200821 “these data suggest that Intention-to-treat analyses participation in peer support may Cohort 1 Cohort 2 P-value enhance personal well-being, as (mean ± SD)* (mean ± SD) measured by both recovery- Recovery 4.05 ± 0.43 4.06 ± 0.44 ns oriented and more traditional attitudes clinical measures” (p 1307) (RAQ) Confidence 4.18 ± 1.06 4.36 ± 0.93 ns (MHCS) General 2.82 ± 0.40 2.92 ± 0.30 0.02 empowerme nt (MDS) Empowerme 2.59 ± 0.78 2.67 ± 0.63 ns nt over illness (RAS) Functional 37.78 ± 8.18 43.39 ± 8.14 <0.001 status (GAF) Functional 2.97 ± 0.73 3.07 ± 0.81 0.02 status (ADLS) Symptom 22.73 ± 12.97 21.94 ± ns severity 10.69 (BPRS) Symptom 38.93 ± 18.38 41.44 ± ns severity 18.85 (PTSD PCL- S) Substance use in the past 30 days (ASI)

-number of 1.02 ± 4.57 0.94 ± 3.02 0.001 days using alcohol

-number of 0.59 ± 4.08 0.68 ± 3.13 ns days using drugs

Completed 46/78 (60%) 153/218 ns review at 9 (70%) months (%)

As-treated analyses Cohort 1 Cohort 2-V P-value (mean ± SD) (mean ± SD) Recovery 4.05 ± 0.43 4.06 ± 47 ns attitudes (RAQ) Confidence 4.18 ± 1.06 4.46 ± 0.84 0.01

Peer Support Programs for Adults with Operational Stress Injury 13

Table A3: Main Study Findings and Authors’ Conclusions First Author, Main Study Findings Authors’ Conclusions Publication Year (MHCS) General 2.82 ± 0.40 2.93 ± 0.29 0.03 empowerme nt (MDS) Empowerme 2.59 ± 0.78 2.75 ± 0.63 ns nt over illness (RAS) Functional 37.78 ± 8.18 43.07 ± 6.97 0.001 status (GAF) Functional 2.97 ± 0.73 3.03 ± 0.77 0.05 status (ADLS) Symptom 22.73 ± 12.97 21.20 ± ns severity 10.31 (BPRS) Symptom 38.93 ± 18.38 40.51 ± ns severity 19.93 (PTSD PCL- S) Substance use in the past 30 days (ASI)

-number of 1.02 ± 4.57 0.67 ± 2.51 0.004 days using alcohol

-number of 0.59 ± 4.08 0.46 ± 3.23 ns days using drugs

Completed 46/78 (60%) 82/102 0.002 review at 9 (80%) months (%)

Research question 2 (clinical evidence of peer-support programs for partners and families)

No studies identified for this research question Cohort 1: veterans without interventions; cohort 2: veterans with interventions; Cohort 2 – V: subset of cohort 2 and attending more than 10 sessions; *: mean scores are from the combined averages from the three- and nine-month follow up period; ns: not significant; SD: standard deviation; ADLS: Activities of Daily Living Scale; MDS: Making Decision Scale; ASI: Addiction Severity Index; BPRS: Brief Psychiatric Rating Scale; GAF: Global Assessment of Functioning; MHCS: Mental Health Confidence Scale; RAQ: Recovery Attitudes Questionnaire; RAS: Recovery Assessment Scale; PTSD PCL-S: post-traumatic stress disorder Check List-Stressor Specific Version

Peer Support Programs for Adults with Operational Stress Injury 14