Getting by With a Little Help From Our Peers

We have been witnessing the tragic costs of COVID-19 on health and well-being, and an increased awareness of the racism that permeates much of our society. Urban residents and communities of color, particularly Black communities, have long faced health disparities leading to unequal access to care, differential treatment within the medical system, and poorer mental and physical health outcomes. As we have taken steps to protect ourselves against the virus, we have had to reduce social interactions with our families, friends, faith-based communities, neighborhoods, and other community supports. Our older adults have been particularly burdened by these social distancing requirements, as we see nursing homes and assisted living facilities on lockdown with older adults being confined to their rooms with no opportunity to socialize in person with friends or family. With limited technological savvy and challenges to hearing and vision, many older adults are alone, lonely and disconnected. Some older adults face increased vulnerability due to domestic and elder abuse. We are aware of the building evidence that loneliness increases the risks of physical, cognitive, and psychological morbidity.¹ In New York City, the Department for the Aging has seen an increase in the numbers of older adults who endorse loneliness from 43.8% of clients in January 2020 to 73.6% of clients in March 2020, a 30% rise in only 2 months (New York City Department for the Aging unpublished data).

In this issue, Conwell et al. describe a unique program that targets social disconnectedness and loneliness to prevent suicidal ideation and improve mental health outcomes by providing peer companionship.² The peer companionship program brings peer support available through a program within an aging service provider to older adults identified in primary care settings. The design crosses service silos to bring an existing low cost resource (peer companionship) to those older adults who need support in a medical setting. Participants with low social connectedness who worked with a peer experienced significantly greater reductions of depression, anxiety, and feelings that they are a burden on others. The authors note that the low implementation costs make wide dissemination more feasible, and that even small changes in mood and isolation can make a meaningful difference.

Well-trained peers are an underutilized resource, with growing evidence for their effectiveness at targeting a variety of health conditions both within settings and across settings. Within the aging service setting, Choi et al. used tele-behavioral activation delivered by lay coaches to target loneliness and depression in homebound elders and found the intervention to be effective.³ Raue et al. found that having peer coaches recruited at senior centers and trained to deliver a simplified behavioral activation protocol to senior center members was both feasible⁴ and acceptable.⁵ The benefits also extend to the peer companions themselves; serving as a peer educator for depressed older adults was reported to be satisfying and beneficial.⁶

Integration of peer support into medical settings may reduce access barriers and facilitate service setting transitions. With a workforce shortage in trained geriatric and primary care professionals, the Institute of Medicine and the National Council of Aging have acknowledged the need to identify nontraditional providers. Primary care provides an important touch point for accessing older adults who may not be linked to aging support services. Prescription of social interactions by recommending increased engagement in community activities is often underused due to poor links between health care practitioners and community-based services.⁷ Integrated peer support could increase social connections. Peer support also offers an opportunity to reduce health disparities in minority aging populations and increase access to healthcare and supportive services. Volunteer-led health programs can be effective to improve patient access to care and to reduce stigma of seeking mental health services.⁸ Peers may also support care transitions and have a significant impact on health related quality of life, particularly for Black and Latino and/or Hispanic elders who are living with a medical condition and co-occurring depression.⁹ While opportunities exist, peer programs face the challenges Conwell et al. report such as peer coach and/or companion recruitment, integration of peers into an existing service, as well as training and intervention fidelity.

What opportunities exist for peer mental health interventions in the near future given social distancing? In New York City agencies unable to provide in person services have set up regular wellness checks and reassurance calls that offer a unique chance to screen for mental health needs. Instituting wide reaching community screening with solid links to ongoing reassurance/support calls reduces the potential for seniors with needs to go undetected. These programs have enabled more seniors to discuss their concerns and these private conversations by telephone may even lessen the fears of stigma. They also offer a unique opportunity for peer interventions. Older adults whose mental health needs are greater are offered careful referrals to virtual (telephone or video) mental health services. In an unprecedented move, the Governor of New York State required insurance companies to waive co-pays for telehealth visits (https://www.governor.ny.gov/news/audio-rush-transcript-during-coronavirus-briefing-governor-cuomo-announces-department-financial) reducing yet another significant barrier to care for older adults. Perhaps the increased awareness of both the vulnerability of our older adults, and the systemic inequalities will offer us a chance to create and implement innovative programing. A comprehensive system of services could provide virtual peer support, referrals to virtual therapies, have reduced the barriers to mental health services, and design programs in multiple languages that can meet the needs of all communities. Increased partnerships between communities and academic researchers, across service sectors, and between diverse communities could be a positive byproduct of these challenging times.

Author Contributions

Jo Anne Sirey, Ph.D. and Elissa Kozlov, Ph.D. were involved in the planning and preparation of this commentary.

Acknowledgments

The authors have no conflicts to report.