Online peer support for mental health in individuals with post-acute sequelae of COVID-19: A pre-post pilot study with mixed methods

Online peer support for mental health in individuals with post-acute sequelae of COVID-19: A pre-post pilot study with mixed methods | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Online peer support for mental health in individuals with post-acute sequelae of COVID-19: A pre-post pilot study with mixed methods Megumi Hazumi, Michi Miyake, Mayumi Kataoka, Kentaro Usuda, Daisuke Nishi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4249778/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective This pilot examined the effect of online peer support on mental health problems among individuals with post-acute sequelae of COVID-2019 (PASC). Methods A single-arm pre-post design of online peer support design consisting of eight sessions of 1 h per week with three to six participants and two facilitators per group was performed. Participants were recruited from online communities, social media, and medical clinics for the PASC between May and August 2023. The degrees of depression, anxiety, loneliness, social withdrawal, and self-esteem were measured pre- and post-intervention. Participants’ statements during the sessions were analyzed using thematic analyses. Results Of the 18 participants, 3 dropped out of the interventions, and 17 (including 2 participants who dropped out) completed the pre- and post-intervention questionnaires. Depression severity significantly decreased in the paired t-test and linear mixed model. The following interactions were extracted: conveying the same feelings, dealing with difficulties, showing empathy, enhancing the atmosphere, and adapting to suit health conditions. Impressions extracted from participating in the interventions included feelings of emotional support, a sense of bonding, changes in perspective, changes in behaviors or new actions through participation, inadequacy during sessions, and adverse effects associated with participation. Conclusion Online peer support may be helpful in treating depression in individuals with PASC. Psychology Post-acute sequelae of COVID-19 peer support depression pre-post intervention mixed method COVID-19 Figures Figure 1 Introduction Post-acute sequelae of coronavirus disease 2019 (COVID-19) (PASC) is defined as the maintenance, relapse, or emergence of symptoms beyond 4 weeks after COVID-19 infection, such as fatigue, brain fog, dizziness, and gastrointestinal symptoms (Nalbandian et al., 2021 ; Thaweethai et al., 2023 ). Of the individuals with COVID-19, 12.44% had at least one symptom of PASC (Bello-Chavolla et al., 2024 ). The burden of health loss is substantial, with 35–69% of PASC persisting for over 2 years (Bowe et al., 2023 ). Several studies have shown that individuals with PASC are more likely to experience mental health problems. A meta-analysis indicated that 23% of patients with PASC experienced mental health problems (Seighali et al., 2024 ). Several cross-sectional surveys have reported an association between the presence of PASC and mental health problems (Hazumi et al., 2022 ; Hejazian et al., 2024 ; Li et al., 2024 ; Malheiro et al., 2024 ). Given that mental health problems exert not only a socioeconomic burden but also prolong PASC (Greenberg et al., 2021 ; Hazumi et al., 2024 ; König et al., 2020 ), decreasing mental health problems among individuals with PASC is crucial. In addition to psychological intervention(McGregor et al., 2024 ; Navas-Otero et al., 2024 ), physical rehabilitation(McGregor et al., 2024 ; Philip et al., 2022 ), exercise(Espinoza-Bravo et al., 2023 ; Jimeno-Almazán et al., 2023 , 2022 ), and non-invasive cognitive stimulation(Hausswirth et al., 2023 ; Klírová et al., 2024 ; Noda et al., 2023 ), online peer support is suggested to be useful for mental health problems in individuals with PASC when conducted with trained facilitators. Online peer support, recommended by several national health organizations for PASC as a strategy to address psychosocial aspects, consists of regular meetings via online video systems for individuals experiencing similar difficulties (Centers for Disease Control and Prevention, 2024 ; National Institute for Health and Care Excellence, 2020 ). Considering the difficulties that individuals with PASC may face in commuting to medical institutions because of their symptoms(Ladds et al., 2020 ), participating in online peer support may be a more practical option than face-to-face peer support. According to a qualitative study, participants complemented the treatment gap by obtaining insights, behavioral engagement, diversity, social connection, and delivering or obtaining support through a peer support group(Day, 2022 ; R. Hughes et al., 2020 ). The effects of peer support on mental health have also been demonstrated in other populations. Several meta-analyses have reported its effects on various chronic conditions, such as tinnitus (Nyenhuis et al., 2013 ), cancer (Ziegler et al., 2022 ), and diabetes (Liang et al., 2021 ). Online peer support during the COVID-19 pandemic has also been reported to be helpful for mental health in populations other than those with PASC(Suresh et al., 2021 ). Particularly, peer support groups with trained facilitators have been shown to increase the effects, as indicated by systematic reviews of peer support groups for breast cancer and major depressive disorder(Hu et al., 2019 ; Ibrahim et al., 2020 ) and a systematic review identifying accelerators of peer support groups(Shorey & Chua, 2023 ). However, to our knowledge, the effects of regular online peer support group meetings with trained facilitators on individuals with PASC have not yet been examined. A systematic review indicated that few studies have examined the effect of online peer support for PASC via regular meetings with trained facilitators (Kataoka et al., 2024 ). To date, two studies have reported that self-management programs containing online peer support sessions improve psychosocial problems. (Vaes et al., 2021 ; Wright et al., 2022 ). However, the intervention did not control for peer support sessions, such as the number, duration, and interval of sessions, and examined the effect of sessions alone. Hence, the effects of the peer support group sessions remain unclear. Moreover, although some experiences through peer support groups for PASC have been identified(Day, 2022 ), it may be incomprehensive owing to the lack of information regarding theoretical saturation, especially in negative experiences and the interactions between individuals during peer support sessions preceding obtaining such experiences remain unclear. Therefore, this study aimed to examine the effect of online peer support at regular meetings with trained facilitators on the mental health of individuals with PASC. Additionally, subjective experiences and impressions of online peer support sessions and interactions during sessions were examined using qualitative methods to explore the elements that impact the effect. Materials and Methods Study design This pilot study employed a pre- and post-single-arm design of online peer support for over 8 weeks. Participants responded to online questionnaires using Microsoft Forms three times: upon participant agreement, before starting the intervention, and after finishing the intervention. Participants' statements during all intervention sessions were also recorded using the Zoom recording system, which was used to hold the groups and collect them for qualitative analyses. This study was approved by the ethics committee of the National Center of Neurology and Psychiatry (A2023-010) and registered in the Japan Registry of Clinical Trials (jRCT1030230154). The study procedure followed the principles of the Declaration of Helsinki, and informed consent was obtained from all patients. Participants Recruitment was performed from May 2023 to August 2023 by posting recruitment advertisements on several social network services, such as anonymous online communities for PASC, including three LINE open chat groups containing approximately 100–900 members and a Facebook group containing approximately 30 members, X, and at a medical clinic for PASC. Regardless of the number of sessions attended and discontinuation of participation, participants who completed all three questionnaires received prepaid cards worth JPY 3,000 as rewards. Inclusion criteria were a) 18 years old or older, b) self-reported as having PASC, c) a Patient-Health Questionnaire-9 (PHQ-9) score ≥ 5, d) access to an online environment and devices, and e) having talking environment, such as private rooms. Exclusion criteria were a) difficulty in attending all sessions at the time of obtaining consent and b) the score of the item regarding suicidal intention at PHQ-9 ≥ 2. Participants who were absent from more than half the sessions were identified as dropouts. The sample size was required to be 18 or more, based on the sample size criteria for pilot studies(Lewis et al., 2021 ). Measurements Patient health questionnaire-9 (PHQ-9) The PHQ-9 was used for assessing the severity of depression, the primary outcome. It consisted of nine items with 4-level Rikert scales (0–3)(Kroenke et al., 2001 ; Kumiko Muramatsu et al., 2018 ). A total score of 5 or more indicated mild depression. This scale was collected at participant agreement, pre-intervention, and post-intervention. General anxiety disorder-7 (GAD-7) The GAD-7 was used to assess the severity of anxiety (a secondary outcome). It consisted of seven items with 4-level Rikert scales (0–3)(K. Muramatsu, 2009 ; Spitzer et al., 2006 ). Higher scores indicate severe anxiety. Data were collected at pre-intervention and post-intervention. Three-item loneliness scale A three-item loneliness scale was used to assess the severity of subjective loneliness (a secondary outcome), consisting of three items with 3-level Rikert scales (1–3)(M. E. Hughes et al., 2004 ; Igarashi, 2019 ). Higher scores indicate severe loneliness. Data were collected at pre-intervention and post-intervention. Luben social network scale (LSNS) The LSNS was used to assess the severity of social withdrawal (a secondary outcome). It comprises six items with 6-level Rikert scales (0–6)(Kurimoto et al., 2011 ; J. Lubben et al., 2006 ; J. E. Lubben, 1988 ). Higher scores indicate severe social withdrawal. Data were collected at pre-intervention and post-intervention. The Rothenberg self-esteem scale This scale, consisting of 10 items with 4-level Rikert scales (1–4), was used to assess the degree of self-esteem (a secondary outcome). Higher scores indicate higher self-esteem(Mimura & Griffiths, 2007 ; Rosenberg, 1965 ). Data were collected at pre-intervention and post-intervention. Others Age(Hejazian et al., 2024 ), sex (male, female, or others)(Colizzi et al., 2024 ), psychiatric history, duration since infection(Bota et al., 2024 ), vaccination for COVID-19(Demko et al., 2024 ), and time of participation in peer support group sessions were collected as covariates. These items were obtained during the participant agreement. Intervention Online peer support consisted of eight sessions, 1 h per session per week. All sessions were conducted using Zoom (Zoom Video Communications, Inc.). At the time of enrollment, each group consisted of three to six participants and two facilitators (MM and MH): a psychiatric nurse and a clinical psychotherapist lectured and supervised by a peer support supecialist at every sessions. The details of these sessions are listed in Table 1. The talk topics of each session were decided by the participants and facilitators in session #1 and before each session based on the pooled desired talk topics raised by the participants in the pre-intervention questionnaire. Examples of talk topics were as follows: how to deal with PASC, psychological distress regarding PASC, difficulty in doing work and household duties, no way to know when PASC will heal, change of life from before to after PASC, and self-image of PASC. The ground rules of the groups were shared with participants before session #1 to promote safe and warm communication. These ground rules included refraining from disclosing group discussions to individuals outside the group without permission, avoiding the promotion of specific treatments or folk remedies, and refraining from discussions related to politics, ideology, and religion. Participants could attend sessions in ways and lengths that facilitated their attendance, considering the PASC, such as leaving the session, late attendance, and lying down. Analyses After Cohen’s d for estimating the effect size and the Shapiro–Wilk tests for confirming normality were calculated, the pre-post changes in the outcomes were confirmed via paired t-tests. Sensitivity analyses were also performed using the linear mixed model, which confirmed the change after adjusting for loss-to-follow-up and covariates, including age, sex, psychiatric history, duration after infection, vaccination for COVID-19, and the time of participation. Intention-to-treat (ITT) and per-protocol analyses were conducted. Participants who were absent from the session more than four times were identified as dropouts. The data of participants who were lost to follow-up were excluded using paired t-tests and included in the linear mixed method. Quantitative analyses were performed using Stata 18.0. Statistical significance was set at p < 0.05. A thematic analysis approach was employed for qualitative data, focusing on interactions while participating in peer support groups and thoughts on participating in peer peer-support groups (Braun & Clarke, 2006 ). First, two authors (MH and MM) independently coded the anonymized transcripts generated from the statement records after repeatedly reading them. Second, they reviewed their coding and refined it based on their discussions, as needed, to address discrepancies. Third, the codes were sorted into potential themes and subthemes through an iterative process, with both authors (MH and MM) collaboratively examining the relevance and relationships between the codes. After several weeks, the draft themes, subthemes, and relevant codes were reviewed and refined as required by MH and MM for precision and reliability. Finally, the other authors reviewed themes, subthemes, and associated transcripts. Microsoft Excel was used for qualitative analyses. Results Participants As shown in Fig. 1, 18 of 23 enrolled individuals responded to the pre-intervention questionnaire, and 15 completed the interventions after 3 dropped out, although 17 responded to the post-intervention questionnaire. Table 2 presents participant characteristics. The mean age was 41.61 (Standard Deviation [SD] = 9.50), and 33.3% of the patients were male. The average number of sessions attendance was 5.94 (SD = 2.36). Pre-post intervention change The Shapiro–Wilk test for depression, anxiety, loneliness, social withdrawal, and self-esteem showed no significant differences (W = 0.97, p = 0.36; W = 0.97, p = 0.53; W = 0.96, p = 0.22; W = 0.96, p = 0.22; W = 0.96, p = 0.17). Table 3 shows Cohen’s d and the results of t-tests. Paired t-tests showed a significant change in the severity of depression regardless of ITT and per-protocol analysis (Pre = 13.33 ± 6.15, Post = 11.12 ± 4.55, t = 2.26, p = 0.04; Pre = 14.6 ± 5.96, Post = 11.73 ± 4.5, t = 2.29, p = 0.04). Cohen’s d was − 0.53 and − 0.45 at per-protocol analysis and ITT analysis. Significant changes in outcomes other than depression were not observed. S1 Appendix presents the results of sensitivity analyses. A significant change in the severity of depression was observed in crude or adjusted ITT analyses (coefficient=-2.42, Standard Error [SE] = 1.12, 95% confidence interval [CI]=-4.60–-0.23, p = 0.03, Akaike's information criterion [AIC] = 210.77, Bayesian information criterion [BIC] = 216.99; coefficient=-2.47, SE = 1.11, 95% CI=-4.66–-0.28, p = 0.03, AIC = 205.27, BIC = 220.82). Similar results were obtained from per-protocol analyses (Coefficient=-2.87, SE = 1.25, 95% CI=-5.32–-0.42, p = 0.02, AIC = 180.31, BIC = 185.92; Coefficient=-2.87, SE = 1.25, 95% CI=-5.32–-0.42, p = 0.02, AIC = 164.45, BIC = 178.47). No significant changes in outcomes, other than depression, were observed. Qualitative experiences For interactions while participating in peer support groups, 5 themes with 10 subthemes were extracted (Table 4). These themes include 1) Interactions conveying the same feelings, such as having the same experiences and opinions. 2) Interactions on how to deal with difficulties through proposals for coping strategies, information exchange, and prompting alternative thinking. 3) Interactions showing empathy, including encouragement and praise. 4) Interactions that enhance the atmosphere of groups, including idle talk and the presentation of differing opinions. 5) Interactions that accommodate physical conditions. Participants reported experiencing six themes with 16 subthemes after participating in peer support groups (Table 5). These themes include 1) Emotional support, such as feeling relieved through talking, being pleased by empathy from others, and learning that others have the same feelings. 2) Building a sense of bond, such as feeling the group’s existence as a support or sense of solidarity, and the pleasure of speaking honestly and encouraging someone. 3) Change in perspective, such as gaining new insights, becoming more positive, and viewing oneself objectively. 4) Changes in behavior or new actions, such as becoming a catalyst for taking new actions and gaining new information and strategies. 5) Feelings of inadequacy during sessions, such as struggling with approaching others and desiring more information exchange. 6) Adverse effects associated with participation, including negative feelings about the group ending, tension, and fatigue during attendance. Discussion To the best of our knowledge, this is the first study to examine changes in mental health conditions among individuals with PASC through online peer support conducted at regularly scheduled times with trained facilitators. A significant change in depression severity was observed from pre-intervention to post-intervention. Interactions during online peer support were extracted as follows: conveying the same feelings, dealing with difficulties, showing empathy, enhancing the atmosphere, and adapting to suit health conditions. Participants reported impressions of peer support groups, including emotional support, a sense of bonding, a change in perspective, a change in behavior, and new actions through participation. However, they also felt inadequate during the sessions and experienced adverse effects associated with participation. A small to moderate effect on depression severity was observed from pre-intervention to post-intervention, indicating that regularly scheduled online peer support with trained facilitators may be mildly effective for individuals with PASC. This result was consistent with multi-component peer support group programs for PASC (Kataoka et al., 2024 ; Vaes et al., 2021 ; Van Herck et al., 2021 ; Wright et al., 2022 ), as well as those for other populations during the COVID-19 pandemic and other chronic conditions(Liang et al., 2021 ; Nyenhuis et al., 2013 ; Suresh et al., 2021 ; Ziegler et al., 2022 ). Although the possibility of depression improvement being caused by the passage of time cannot be denied, online peer support may be practical for the mental health of patients with PASC. Qualitative analyses revealed interactions for conveying the same experiences, empathy, proposal of coping strategies and information, enhancing the atmosphere by idle talk, presenting different opinions, and accommodating their conditions, which were indicated to occur during the sessions. Additionally, individuals with PASC reported experiencing emotional support, a sense of bonding, and a change in perspective and behaviors through online peer support, as well as negative impressions, such as feelings of inadequate responses, and adverse effects, such as negative impressions about group ending and fatigue during attendance. Impressions of a sense of bonding and emotional support were consistent with impressions extracted in previous studies (Day, 2022 ; R. Hughes et al., 2020 ). Impressions such as a sense of bonding and emotional support may promote depression improvement, based on the study indicating that such impressions reduce mental health problems in different populations (Cornwell & Waite, 2009 ; Green et al., 2022 ; Ozaki et al., 2012 ). Moreover, interactions like conveying the same experiences and empathy may promote impressions like emotional support and to reduce depression, as sharing experiences and showing empathy generally promote bonding and emotional healing (Jong et al., 2015 ). The impression of changes in perspective and behavior may also have positive effects on depression, considering that Cognitive Behavior Therapy aims to promote changes in perspectives and behaviors that worsen depression to alternative ones. The interaction like the proposal of coping strategies and information and the presentation of different opinions, might contribute to changes in behaviors and perspectives. On the other hand, negative impressions like feelings of inadequate responses and adverse effects, such as negative feelings about group ending and fatigue during attendance, were newly identified in this study to our knowledge. These impressions may interefere depression improvement through online peer supports, as inadequate supportive communication and perceived isolation affect mental health(Clausing et al., 2023 ; Cornwell & Waite, 2009 ). Furthermore, online peer support may overcome the limitations of medical resources and accessibility for PASC(Ladds et al., 2020 ). Disseminating online peer support for PASC is essential to establish communities that deliver services. Additional care may be implemented based on negative impressions, such as negative feelings toward ending the group sessions, fatigue after attending, and feelings of inadequate response. For example, regular sessions without an ending, sessions with a shorter duration, and consultation services for frustration experienced during the sessions can be proposed. This study had some limitations. First, we acknowledge that the change in depression observed in this study may have been caused by time elapsed rather than online peer support due to the single-arm design. However, a similar significant change was observed after adjusting for time elapsed after infection. Additionally, there were sampling biases, such as being limited to individuals with high adherence because of voluntary agreement and having characteristics such as being close to online communities and social media. Representativeness was limited because of the small sample size. Moreover, the accuracy of the presence of PASC was limited, considering that PASC was self-reported and was not diagnosed by physicians. Participants may have impressions other than what they stated, especially impressions that were difficult to express in the presence of other participants (e.g., negative impressions of others’ attitudes). Qualitative analyses were performed with minimal subjective bias; however, complete elimination of such bias is difficult. Conclusion This single-arm pilot study suggests that online peer support with regular sessions and trained facilitators may be effective for depression among individuals with PASC. To confirm this effect robustly, a two-arm randomized controlled trial and a study examining the long-term effects should be conducted in the future. Declarations Funding This work was supported by an Intramural Research Grant for Neurological and Psychiatric Disorders of the National Center of Neurology and Psychiatry (grant number 4-3). 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J., Janssen, D. J. A., & Spruit, M. A. (2021). Severe fatigue in long COVID: Web-based quantitative follow-up study in members of online long COVID support groups. Journal of Medical Internet Research , 23 (9), e30274. Wright, H., Turner, A., Ennis, S., Percy, C., Loftus, G., Clyne, W., Matouskova, G., & Martin, F. (2022). Digital Peer-Supported Self-Management Intervention Codesigned by People With Long COVID: Mixed Methods Proof-of-Concept Study. JMIR Formative Research , 6 (10), e41410. Ziegler, E., Hill, J., Lieske, B., Klein, J., Dem, O. von, Knesebeck, & Kofahl, C. (2022). Empowerment in cancer patients: Does peer support make a difference? A systematic review. Psycho-Oncology , 31 (5), 683–704. Tables Table 1 Details of the online peer support sessions # 1 • Announcement of the aim and the experience process of the peer support group and the ground rules by facilitators • Self-introduction • Determination of talk topics for #2 to 7 • Free discussion • State impressions on the session one by one • Announcement of the next session by facilitators # 2–7 • Announcement of the aim and process of the peer support group and the ground rules by facilitators • State recent conditions one by one • Discussion regarding the topic and free discussion • State impressions on the session one by one • Announcement of the next session by facilitators # 8 • Announcement of the aim and process of the peer support group and the ground rules by facilitators • State recent conditions one by one • Discussion regarding the thoughts on participating in the past sessions • State impression on the session one by one • Announcement of asking to respond to the post-intervention questionnaires by facilitators Table 2 Participants characteristics Mean or n (n = 18) SD or % Age 41.61 9.50 Sex (male) 6 33.3% Psychiatric history 12 66.7% Duration after infection (m) 12.11 6.73 Vaccination 16 88.9% Times of attendance 5.94 2.36 1 1 5.6% 2 2 11.1% 3 0 0% 4 1 5.6% 5 3 16.7% 6 1 5.6% 7 3 16.7% 8 (all sessions) 7 38.9% SD, Standard Deviation Table 3 Pre-post intervention change Pre Post Cohen’s d Paired t-test mean SD mean SD t p Intention-to-treat analyses Depression 13.33 6.15 11.12 4.55 -0.45 2.26 0.04 Anxiety 8.72 5.48 7.94 4.32 -0.19 1.03 0.16 Loneliness 6.11 1.78 6.29 2.08 0.03 -0.16 0.88 Social withdrawal 9.28 5.74 9.64 5.74 0.03 -0.34 0.74 Self-esteem 27.00 4.92 25.65 3.97 -0.25 1.19 0.25 Per-protocol analyses Depression 14.6 5.96 11.73 4.5 -0.53 2.29 0.04 Anxiety 9.73 5.32 8.6 4.01 -0.23 1.03 0.32 Loneliness 6.33 1.59 6.33 2.09 0 0.00 1.00 Social withdrawal 9.07 6.06 9.4 5.85 0.06 -0.61 0.55 Self-esteem 27.07 5.26 25.67 4.13 -0.29 1.26 0.23 SD, Standard Deviation Table 4 Themes and statement examples regarding interactions while attending peer-support groups Themes Subthemes Statement example Interactions while participating in peer-support groups Interactions that convey having the same feelings Claims of having the same experiences "When I think about it carefully, until around this March, for about a year after I got sick, I was in exactly the same condition as you." Supports for others’ opinion "I also truly thought that maintaining my mental state was the most challenging part..." Interactions for dealing with their difficulties Proposals of coping strategies "If you have the environment to rest and adjust your physical condition, based on my experience, I think the risk of your condition worsening is reduced; that's what I thought after listening." Information exchanges "(In response to a question about the experience with self-E Epipharyngeal Abrasive Therapy, a self-care practice) I bought cotton swabs and tried it, but somehow I couldn't properly insert them into my nose, so I stopped." promoting alternative thinking "…, so I think that maybe you should really acknowledge your own efforts, your perseverance, and give yourself some credit for that." Interactions of showing empathy Sympathy " XXX-san, I think it must be frustrating not knowing the cause… " Encouragement "So, XXX-san, I don't think you should feel pathetic at all." Praise "Listening to XXX-san's story, I thought it was amazing how you've been inventive in dealing with various things..." Interactions that enhance the atmosphere Idle talk "Your icon of the Java sparrow plushie is super cute." Presentation of a differing opinion "(In response to the opinion that it might be cured in 30 years) …, leading to growing old and dying with a disabled body. " Interactions adapting to suit health conditions "It becomes quite tough to look at the screen for a long time, so I often close my eyes. " XXX-san, the names of the participants Table 5 Themes and statement examples regarding thoughts on participating in the peer-support groups Themes Subthemes Statement example Emotional supports Feeling relieved through talking "After I had a chance to speak, I felt a bit lighter." Pleased by the empathy of others "I'm really grateful that you understand and empathize with me as if it were your own issue. The pleasure of finding out others have the same feelings "It was really good to have this kind of opportunity, as it's been difficult to meet people who are going through similar experiences." Building a sense of bonding The group's existence as a support "I was especially looking forward to later sessions, …, naturally, it feels like my mood has lifted a bit in anticipation of this day." Feeling a sense of solidarity "For 2 months, I've felt a strong sense of camaraderie with XXX-san and XXX-san, as if we've been working together in tandem..." Being able to speak honestly "Since I've been lying to everyone around me, it was a relief that I didn't have to tell any lies today. Glad to encourage someone "Currently, I'm the one receiving a lot of encouragement, but the fact that I can encourage others is something that really makes me happy." Change in perspective Gaining new insights "I've received a really good perspective, wondering if even now, there might be things I can do aimed at growth, personal growth." becoming more positive "At first, I was really down, like I couldn't see the goal, or I didn't know what to do, but now, I feel more like thinking about what I could try doing next or what to experiment with." Viewing oneself objectively "Through an objective lens, I've come to reaffirm, by listening to everyone's stories, that there indeed are times when I can't move much and that it's a phase where I'm unable to be active." Change in behavior or new actions Becoming a catalyst for taking new actions "Hearing about how everyone spends their time, I thought about creating moments to step away from social media and try different ways to spend my time. Gaining new information and strategies "I'm glad to have learned even a little about everyone's current symptoms and how they communicate to others." Feelings of inadequate responses during sessions Struggling with how to approach others "Because of that, I was a bit unsure about how to join in the conversation or at what point it would be okay to chime in." Wishing for more exchange of information "I did think it would have been better if we could have set something like this up sooner and had the opportunity to exchange various pieces of information earlier." Adverse effects associated with participation Negative feelings about the group ending "I'm definitely anxious about the future, feeling as if I'm losing allies around me; that's what I think." Feelings of tension and fatigue during participation "Actually, I might have been a bit nervous last week too, because I was extremely tired after the meeting ended, and, yes, I ended up feeling quite drained and had to rest for the rest of the afternoon." XXX-san, the names of the participants Additional Declarations The authors declare potential competing interests as follows: Supplementary Files SupplementaryAJCP.docx Pre and post-intervention change based on linear mixed methods Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4249778","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":289930684,"identity":"d40e42c5-e25c-4bec-8889-aa0b76560788","order_by":0,"name":"Megumi Hazumi","email":"","orcid":"https://orcid.org/0000-0002-1625-6962","institution":"National Center of Neurology and Psychiatry","correspondingAuthor":false,"prefix":"","firstName":"Megumi","middleName":"","lastName":"Hazumi","suffix":""},{"id":289931059,"identity":"ab20af40-b1f0-4983-9d94-424b3c737b4f","order_by":1,"name":"Michi 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methods\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"SupplementaryAJCP.docx","url":"https://assets-eu.researchsquare.com/files/rs-4249778/v1/33a54d8727240dded722df06.docx"}],"financialInterests":"The authors declare potential competing interests as follows: ","formattedTitle":"\u003cp\u003eOnline peer support for mental health in individuals with post-acute sequelae of COVID-19: A pre-post pilot study with mixed methods\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePost-acute sequelae of coronavirus disease 2019 (COVID-19) (PASC) is defined as the maintenance, relapse, or emergence of symptoms beyond 4 weeks after COVID-19 infection, such as fatigue, brain fog, dizziness, and gastrointestinal symptoms (Nalbandian et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Thaweethai et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e). Of the individuals with COVID-19, 12.44% had at least one symptom of PASC (Bello-Chavolla et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e). The burden of health loss is substantial, with 35\u0026ndash;69% of PASC persisting for over 2 years (Bowe et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e). Several studies have shown that individuals with PASC are more likely to experience mental health problems. A meta-analysis indicated that 23% of patients with PASC experienced mental health problems (Seighali et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e). Several cross-sectional surveys have reported an association between the presence of PASC and mental health problems (Hazumi et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e; Hejazian et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e; Li et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e; Malheiro et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e). Given that mental health problems exert not only a socioeconomic burden but also prolong PASC (Greenberg et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Hazumi et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e; K\u0026ouml;nig et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e), decreasing mental health problems among individuals with PASC is crucial.\u003c/p\u003e\n\u003cp\u003eIn addition to psychological intervention(McGregor et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e; Navas-Otero et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e), physical rehabilitation(McGregor et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e; Philip et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e), exercise(Espinoza-Bravo et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e; Jimeno-Almaz\u0026aacute;n et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e), and non-invasive cognitive stimulation(Hausswirth et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e; Kl\u0026iacute;rov\u0026aacute; et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e; Noda et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e), online peer support is suggested to be useful for mental health problems in individuals with PASC when conducted with trained facilitators. Online peer support, recommended by several national health organizations for PASC as a strategy to address psychosocial aspects, consists of regular meetings via online video systems for individuals experiencing similar difficulties (Centers for Disease Control and Prevention, \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e; National Institute for Health and Care Excellence, \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). Considering the difficulties that individuals with PASC may face in commuting to medical institutions because of their symptoms(Ladds et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e), participating in online peer support may be a more practical option than face-to-face peer support. According to a qualitative study, participants complemented the treatment gap by obtaining insights, behavioral engagement, diversity, social connection, and delivering or obtaining support through a peer support group(Day, \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e; R. Hughes et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). The effects of peer support on mental health have also been demonstrated in other populations. Several meta-analyses have reported its effects on various chronic conditions, such as tinnitus (Nyenhuis et al., \u003cspan class=\"CitationRef\"\u003e2013\u003c/span\u003e), cancer (Ziegler et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e), and diabetes (Liang et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e). Online peer support during the COVID-19 pandemic has also been reported to be helpful for mental health in populations other than those with PASC(Suresh et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e). Particularly, peer support groups with trained facilitators have been shown to increase the effects, as indicated by systematic reviews of peer support groups for breast cancer and major depressive disorder(Hu et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; Ibrahim et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e) and a systematic review identifying accelerators of peer support groups(Shorey \u0026amp; Chua, \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eHowever, to our knowledge, the effects of regular online peer support group meetings with trained facilitators on individuals with PASC have not yet been examined. A systematic review indicated that few studies have examined the effect of online peer support for PASC via regular meetings with trained facilitators (Kataoka et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e). To date, two studies have reported that self-management programs containing online peer support sessions improve psychosocial problems. (Vaes et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Wright et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e). However, the intervention did not control for peer support sessions, such as the number, duration, and interval of sessions, and examined the effect of sessions alone. Hence, the effects of the peer support group sessions remain unclear. Moreover, although some experiences through peer support groups for PASC have been identified(Day, \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e), it may be incomprehensive owing to the lack of information regarding theoretical saturation, especially in negative experiences and the interactions between individuals during peer support sessions preceding obtaining such experiences remain unclear.\u003c/p\u003e\n\u003cp\u003eTherefore, this study aimed to examine the effect of online peer support at regular meetings with trained facilitators on the mental health of individuals with PASC. Additionally, subjective experiences and impressions of online peer support sessions and interactions during sessions were examined using qualitative methods to explore the elements that impact the effect.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis pilot study employed a pre- and post-single-arm design of online peer support for over 8 weeks. Participants responded to online questionnaires using Microsoft Forms three times: upon participant agreement, before starting the intervention, and after finishing the intervention. Participants' statements during all intervention sessions were also recorded using the Zoom recording system, which was used to hold the groups and collect them for qualitative analyses.\u003c/p\u003e\n\u003cp\u003eThis study was approved by the ethics committee of the National Center of Neurology and Psychiatry (A2023-010) and registered in the Japan Registry of Clinical Trials (jRCT1030230154). The study procedure followed the principles of the Declaration of Helsinki, and informed consent was obtained from all patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRecruitment was performed from May 2023 to August 2023 by posting recruitment advertisements on several social network services, such as anonymous online communities for PASC, including three LINE open chat groups containing approximately 100\u0026ndash;900 members and a Facebook group containing approximately 30 members, X, and at a medical clinic for PASC. Regardless of the number of sessions attended and discontinuation of participation, participants who completed all three questionnaires received prepaid cards worth JPY 3,000 as rewards. Inclusion criteria were a) 18 years old or older, b) self-reported as having PASC, c) a Patient-Health Questionnaire-9 (PHQ-9) score\u0026thinsp;\u0026ge;\u0026thinsp;5, d) access to an online environment and devices, and e) having talking environment, such as private rooms. Exclusion criteria were a) difficulty in attending all sessions at the time of obtaining consent and b) the score of the item regarding suicidal intention at PHQ-9\u0026thinsp;\u0026ge;\u0026thinsp;2. Participants who were absent from more than half the sessions were identified as dropouts.\u003c/p\u003e\n\u003cp\u003eThe sample size was required to be 18 or more, based on the sample size criteria for pilot studies(Lewis et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasurements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient health questionnaire-9 (PHQ-9)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe PHQ-9 was used for assessing the severity of depression, the primary outcome. It consisted of nine items with 4-level Rikert scales (0\u0026ndash;3)(Kroenke et al., \u003cspan class=\"CitationRef\"\u003e2001\u003c/span\u003e; Kumiko Muramatsu et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). A total score of 5 or more indicated mild depression. This scale was collected at participant agreement, pre-intervention, and post-intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGeneral anxiety disorder-7 (GAD-7)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe GAD-7 was used to assess the severity of anxiety (a secondary outcome). It consisted of seven items with 4-level Rikert scales (0\u0026ndash;3)(K. Muramatsu, \u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e; Spitzer et al., \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e). Higher scores indicate severe anxiety. Data were collected at pre-intervention and post-intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThree-item loneliness scale\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA three-item loneliness scale was used to assess the severity of subjective loneliness (a secondary outcome), consisting of three items with 3-level Rikert scales (1\u0026ndash;3)(M. E. Hughes et al., \u003cspan class=\"CitationRef\"\u003e2004\u003c/span\u003e; Igarashi, \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). Higher scores indicate severe loneliness. Data were collected at pre-intervention and post-intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLuben social network scale (LSNS)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe LSNS was used to assess the severity of social withdrawal (a secondary outcome). It comprises six items with 6-level Rikert scales (0\u0026ndash;6)(Kurimoto et al., \u003cspan class=\"CitationRef\"\u003e2011\u003c/span\u003e; J. Lubben et al., \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e; J. E. Lubben, \u003cspan class=\"CitationRef\"\u003e1988\u003c/span\u003e). Higher scores indicate severe social withdrawal. Data were collected at pre-intervention and post-intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Rothenberg self-esteem scale\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis scale, consisting of 10 items with 4-level Rikert scales (1\u0026ndash;4), was used to assess the degree of self-esteem (a secondary outcome). Higher scores indicate higher self-esteem(Mimura \u0026amp; Griffiths, \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e; Rosenberg, \u003cspan class=\"CitationRef\"\u003e1965\u003c/span\u003e). Data were collected at pre-intervention and post-intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOthers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAge(Hejazian et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e), sex (male, female, or others)(Colizzi et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e), psychiatric history, duration since infection(Bota et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e), vaccination for COVID-19(Demko et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e), and time of participation in peer support group sessions were collected as covariates. These items were obtained during the participant agreement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOnline peer support consisted of eight sessions, 1 h per session per week. All sessions were conducted using Zoom (Zoom Video Communications, Inc.). At the time of enrollment, each group consisted of three to six participants and two facilitators (MM and MH): a psychiatric nurse and a clinical psychotherapist lectured and supervised by a peer support supecialist at every sessions. The details of these sessions are listed in Table\u0026nbsp;1. The talk topics of each session were decided by the participants and facilitators in session #1 and before each session based on the pooled desired talk topics raised by the participants in the pre-intervention questionnaire. Examples of talk topics were as follows: how to deal with PASC, psychological distress regarding PASC, difficulty in doing work and household duties, no way to know when PASC will heal, change of life from before to after PASC, and self-image of PASC. The ground rules of the groups were shared with participants before session #1 to promote safe and warm communication. These ground rules included refraining from disclosing group discussions to individuals outside the group without permission, avoiding the promotion of specific treatments or folk remedies, and refraining from discussions related to politics, ideology, and religion. Participants could attend sessions in ways and lengths that facilitated their attendance, considering the PASC, such as leaving the session, late attendance, and lying down.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter Cohen\u0026rsquo;s d for estimating the effect size and the Shapiro\u0026ndash;Wilk tests for confirming normality were calculated, the pre-post changes in the outcomes were confirmed via paired t-tests. Sensitivity analyses were also performed using the linear mixed model, which confirmed the change after adjusting for loss-to-follow-up and covariates, including age, sex, psychiatric history, duration after infection, vaccination for COVID-19, and the time of participation. Intention-to-treat (ITT) and per-protocol analyses were conducted. Participants who were absent from the session more than four times were identified as dropouts.\u003c/p\u003e\n\u003cp\u003eThe data of participants who were lost to follow-up were excluded using paired t-tests and included in the linear mixed method. Quantitative analyses were performed using Stata 18.0. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\n\u003cp\u003eA thematic analysis approach was employed for qualitative data, focusing on interactions while participating in peer support groups and thoughts on participating in peer peer-support groups (Braun \u0026amp; Clarke, \u003cspan class=\"CitationRef\"\u003e2006\u003c/span\u003e). First, two authors (MH and MM) independently coded the anonymized transcripts generated from the statement records after repeatedly reading them. Second, they reviewed their coding and refined it based on their discussions, as needed, to address discrepancies. Third, the codes were sorted into potential themes and subthemes through an iterative process, with both authors (MH and MM) collaboratively examining the relevance and relationships between the codes. After several weeks, the draft themes, subthemes, and relevant codes were reviewed and refined as required by MH and MM for precision and reliability. Finally, the other authors reviewed themes, subthemes, and associated transcripts. Microsoft Excel was used for qualitative analyses.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Fig.\u0026nbsp;1, 18 of 23 enrolled individuals responded to the pre-intervention questionnaire, and 15 completed the interventions after 3 dropped out, although 17 responded to the post-intervention questionnaire.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;2 presents participant characteristics. The mean age was 41.61 (Standard Deviation [SD]\u0026thinsp;=\u0026thinsp;9.50), and 33.3% of the patients were male. The average number of sessions attendance was 5.94 (SD\u0026thinsp;=\u0026thinsp;2.36).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePre-post intervention change\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Shapiro\u0026ndash;Wilk test for depression, anxiety, loneliness, social withdrawal, and self-esteem showed no significant differences (W\u0026thinsp;=\u0026thinsp;0.97, p\u0026thinsp;=\u0026thinsp;0.36; W\u0026thinsp;=\u0026thinsp;0.97, p\u0026thinsp;=\u0026thinsp;0.53; W\u0026thinsp;=\u0026thinsp;0.96, p\u0026thinsp;=\u0026thinsp;0.22; W\u0026thinsp;=\u0026thinsp;0.96, p\u0026thinsp;=\u0026thinsp;0.22; W\u0026thinsp;=\u0026thinsp;0.96, p\u0026thinsp;=\u0026thinsp;0.17).\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;3 shows Cohen\u0026rsquo;s d and the results of t-tests. Paired t-tests showed a significant change in the severity of depression regardless of ITT and per-protocol analysis (Pre\u0026thinsp;=\u0026thinsp;13.33\u0026thinsp;\u0026plusmn;\u0026thinsp;6.15, Post\u0026thinsp;=\u0026thinsp;11.12\u0026thinsp;\u0026plusmn;\u0026thinsp;4.55, t\u0026thinsp;=\u0026thinsp;2.26, p\u0026thinsp;=\u0026thinsp;0.04; Pre\u0026thinsp;=\u0026thinsp;14.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.96, Post\u0026thinsp;=\u0026thinsp;11.73\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5, t\u0026thinsp;=\u0026thinsp;2.29, p\u0026thinsp;=\u0026thinsp;0.04). Cohen\u0026rsquo;s d was \u0026minus;\u0026thinsp;0.53 and \u0026minus;\u0026thinsp;0.45 at per-protocol analysis and ITT analysis. Significant changes in outcomes other than depression were not observed.\u003c/p\u003e\n\u003cp\u003eS1 Appendix presents the results of sensitivity analyses. A significant change in the severity of depression was observed in crude or adjusted ITT analyses (coefficient=-2.42, Standard Error [SE]\u0026thinsp;=\u0026thinsp;1.12, 95% confidence interval [CI]=-4.60\u0026ndash;-0.23, p\u0026thinsp;=\u0026thinsp;0.03, Akaike's information criterion [AIC]\u0026thinsp;=\u0026thinsp;210.77, Bayesian information criterion [BIC]\u0026thinsp;=\u0026thinsp;216.99; coefficient=-2.47, SE\u0026thinsp;=\u0026thinsp;1.11, 95% CI=-4.66\u0026ndash;-0.28, p\u0026thinsp;=\u0026thinsp;0.03, AIC\u0026thinsp;=\u0026thinsp;205.27, BIC\u0026thinsp;=\u0026thinsp;220.82). Similar results were obtained from per-protocol analyses (Coefficient=-2.87, SE\u0026thinsp;=\u0026thinsp;1.25, 95% CI=-5.32\u0026ndash;-0.42, p\u0026thinsp;=\u0026thinsp;0.02, AIC\u0026thinsp;=\u0026thinsp;180.31, BIC\u0026thinsp;=\u0026thinsp;185.92; Coefficient=-2.87, SE\u0026thinsp;=\u0026thinsp;1.25, 95% CI=-5.32\u0026ndash;-0.42, p\u0026thinsp;=\u0026thinsp;0.02, AIC\u0026thinsp;=\u0026thinsp;164.45, BIC\u0026thinsp;=\u0026thinsp;178.47). No significant changes in outcomes, other than depression, were observed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative experiences\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor interactions while participating in peer support groups, 5 themes with 10 subthemes were extracted (Table\u0026nbsp;4). These themes include 1) Interactions conveying the same feelings, such as having the same experiences and opinions. 2) Interactions on how to deal with difficulties through proposals for coping strategies, information exchange, and prompting alternative thinking. 3) Interactions showing empathy, including encouragement and praise. 4) Interactions that enhance the atmosphere of groups, including idle talk and the presentation of differing opinions. 5) Interactions that accommodate physical conditions.\u003c/p\u003e\n\u003cp\u003eParticipants reported experiencing six themes with 16 subthemes after participating in peer support groups (Table\u0026nbsp;5). These themes include 1) Emotional support, such as feeling relieved through talking, being pleased by empathy from others, and learning that others have the same feelings. 2) Building a sense of bond, such as feeling the group\u0026rsquo;s existence as a support or sense of solidarity, and the pleasure of speaking honestly and encouraging someone. 3) Change in perspective, such as gaining new insights, becoming more positive, and viewing oneself objectively. 4) Changes in behavior or new actions, such as becoming a catalyst for taking new actions and gaining new information and strategies. 5) Feelings of inadequacy during sessions, such as struggling with approaching others and desiring more information exchange. 6) Adverse effects associated with participation, including negative feelings about the group ending, tension, and fatigue during attendance.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo the best of our knowledge, this is the first study to examine changes in mental health conditions among individuals with PASC through online peer support conducted at regularly scheduled times with trained facilitators. A significant change in depression severity was observed from pre-intervention to post-intervention. Interactions during online peer support were extracted as follows: conveying the same feelings, dealing with difficulties, showing empathy, enhancing the atmosphere, and adapting to suit health conditions. Participants reported impressions of peer support groups, including emotional support, a sense of bonding, a change in perspective, a change in behavior, and new actions through participation. However, they also felt inadequate during the sessions and experienced adverse effects associated with participation.\u003c/p\u003e\n\u003cp\u003eA small to moderate effect on depression severity was observed from pre-intervention to post-intervention, indicating that regularly scheduled online peer support with trained facilitators may be mildly effective for individuals with PASC. This result was consistent with multi-component peer support group programs for PASC (Kataoka et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e; Vaes et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Van Herck et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Wright et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e), as well as those for other populations during the COVID-19 pandemic and other chronic conditions(Liang et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Nyenhuis et al., \u003cspan class=\"CitationRef\"\u003e2013\u003c/span\u003e; Suresh et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e; Ziegler et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e). Although the possibility of depression improvement being caused by the passage of time cannot be denied, online peer support may be practical for the mental health of patients with PASC.\u003c/p\u003e\n\u003cp\u003eQualitative analyses revealed interactions for conveying the same experiences, empathy, proposal of coping strategies and information, enhancing the atmosphere by idle talk, presenting different opinions, and accommodating their conditions, which were indicated to occur during the sessions. Additionally, individuals with PASC reported experiencing emotional support, a sense of bonding, and a change in perspective and behaviors through online peer support, as well as negative impressions, such as feelings of inadequate responses, and adverse effects, such as negative impressions about group ending and fatigue during attendance. Impressions of a sense of bonding and emotional support were consistent with impressions extracted in previous studies (Day, \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e; R. Hughes et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). Impressions such as a sense of bonding and emotional support may promote depression improvement, based on the study indicating that such impressions reduce mental health problems in different populations (Cornwell \u0026amp; Waite, \u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e; Green et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ozaki et al., \u003cspan class=\"CitationRef\"\u003e2012\u003c/span\u003e). Moreover, interactions like conveying the same experiences and empathy may promote impressions like emotional support and to reduce depression, as sharing experiences and showing empathy generally promote bonding and emotional healing (Jong et al., \u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e). The impression of changes in perspective and behavior may also have positive effects on depression, considering that Cognitive Behavior Therapy aims to promote changes in perspectives and behaviors that worsen depression to alternative ones. The interaction like the proposal of coping strategies and information and the presentation of different opinions, might contribute to changes in behaviors and perspectives. On the other hand, negative impressions like feelings of inadequate responses and adverse effects, such as negative feelings about group ending and fatigue during attendance, were newly identified in this study to our knowledge. These impressions may interefere depression improvement through online peer supports, as inadequate supportive communication and perceived isolation affect mental health(Clausing et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e; Cornwell \u0026amp; Waite, \u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eFurthermore, online peer support may overcome the limitations of medical resources and accessibility for PASC(Ladds et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). Disseminating online peer support for PASC is essential to establish communities that deliver services. Additional care may be implemented based on negative impressions, such as negative feelings toward ending the group sessions, fatigue after attending, and feelings of inadequate response. For example, regular sessions without an ending, sessions with a shorter duration, and consultation services for frustration experienced during the sessions can be proposed.\u003c/p\u003e\n\u003cp\u003eThis study had some limitations. First, we acknowledge that the change in depression observed in this study may have been caused by time elapsed rather than online peer support due to the single-arm design. However, a similar significant change was observed after adjusting for time elapsed after infection. Additionally, there were sampling biases, such as being limited to individuals with high adherence because of voluntary agreement and having characteristics such as being close to online communities and social media. Representativeness was limited because of the small sample size. Moreover, the accuracy of the presence of PASC was limited, considering that PASC was self-reported and was not diagnosed by physicians. Participants may have impressions other than what they stated, especially impressions that were difficult to express in the presence of other participants (e.g., negative impressions of others\u0026rsquo; attitudes). Qualitative analyses were performed with minimal subjective bias; however, complete elimination of such bias is difficult.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis single-arm pilot study suggests that online peer support with regular sessions and trained facilitators may be effective for depression among individuals with PASC. To confirm this effect robustly, a two-arm randomized controlled trial and a study examining the long-term effects should be conducted in the future.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by an Intramural Research Grant for Neurological and Psychiatric Disorders of the National Center of Neurology and Psychiatry (grant number 4-3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDaisuke Nishi reports personal fees outside of the submitted work from Startia, Inc., en-Power, Inc., MD.net, and Takeda Pharmaceutical Company, Ltd. MH, MM, MK, and KU have no conflicts of interest to disclose regarding this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: DN and MH. Data collection: MH, MM, and MK. 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Princeton University Press.\u003c/li\u003e\n\u003cli\u003eSeighali, N., Abdollahi, A., Shafiee, A., Amini, M. J., Teymouri Athar, M. M., Safari, O., Faghfouri, P., Eskandari, A., Rostaii, O., Salehi, A. H., Soltani, H., Hosseini, M., Abhari, F. S., Maghsoudi, M. R., Jahanbakhshi, B., \u0026amp; Bakhtiyari, M. (2024). The global prevalence of depression, anxiety, and sleep disorder among patients coping with Post COVID-19 syndrome (long COVID): a systematic review and meta-analysis. \u003cem\u003eBMC Psychiatry\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(1). https://doi.org/10.1186/s12888-023-05481-6\u003c/li\u003e\n\u003cli\u003eShorey, S., \u0026amp; Chua, J. Y. X. (2023). Effectiveness of peer support interventions for adults with depressive symptoms: a systematic review and meta-analysis. \u003cem\u003eJournal of Mental Health (Abingdon, England)\u003c/em\u003e, \u003cem\u003e32\u003c/em\u003e(2), 465\u0026ndash;479.\u003c/li\u003e\n\u003cli\u003eSpitzer, R. L., Kroenke, K., Williams, J. B. W., \u0026amp; Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder. \u003cem\u003eArchives of Internal Medicine\u003c/em\u003e, \u003cem\u003e166\u003c/em\u003e, 1092\u0026ndash;1097.\u003c/li\u003e\n\u003cli\u003eSuresh, R., Alam, A., \u0026amp; Karkossa, Z. (2021). Using peer support to strengthen mental health during the COVID-19 pandemic: A review. \u003cem\u003eFrontiers in Psychiatry\u003c/em\u003e, \u003cem\u003e12\u003c/em\u003e, 714181.\u003c/li\u003e\n\u003cli\u003eThaweethai, T., Jolley, S. E., Karlson, E. W., Levitan, E. B., Levy, B., McComsey, G. A., McCorkell, L., Nadkarni, G. N., Parthasarathy, S., Singh, U., Walker, T. A., Selvaggi, C. A., Shinnick, D. J., Schulte, C. C. M., Atchley-Challenner, R., Alba, G. A., Alicic, R., Altman, N., Anglin, K., \u0026hellip; RECOVER Consortium. (2023). Development of a Definition of Postacute Sequelae of SARS-CoV-2 Infection. \u003cem\u003eJAMA: The Journal of the American Medical Association\u003c/em\u003e, \u003cem\u003e329\u003c/em\u003e(22), 1934\u0026ndash;1946.\u003c/li\u003e\n\u003cli\u003eVaes, A. W., Go\u0026euml;rtz, Y. M. J., Van Herck, M., Machado, F. V. C., Meys, R., Delbressine, J. M., Houben-Wilke, S., Gaffron, S., Maier, D., Burtin, C., Posthuma, R., van Loon, N. P. H., Franssen, F. M. E., Hajian, B., Simons, S. O., van Boven, J. F. M., Klok, F. A., Spaetgens, B., Pinxt, C. M. H., \u0026hellip; Spruit, M. A. (2021). Recovery from COVID-19: a sprint or marathon? 6-month follow-up data from online long COVID-19 support group members. \u003cem\u003eERJ Open Research\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(2), 00141\u0026ndash;02021.\u003c/li\u003e\n\u003cli\u003eVan Herck, M., Go\u0026euml;rtz, Y. M. J., Houben-Wilke, S., Machado, F. V. C., Meys, R., Delbressine, J. M., Vaes, A. W., Burtin, C., Posthuma, R., Franssen, F. M. E., Hajian, B., Vijlbrief, H., Spies, Y., van \u0026rsquo;t Hul, A. J., Janssen, D. J. A., \u0026amp; Spruit, M. A. (2021). Severe fatigue in long COVID: Web-based quantitative follow-up study in members of online long COVID support groups. \u003cem\u003eJournal of Medical Internet Research\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(9), e30274.\u003c/li\u003e\n\u003cli\u003eWright, H., Turner, A., Ennis, S., Percy, C., Loftus, G., Clyne, W., Matouskova, G., \u0026amp; Martin, F. (2022). Digital Peer-Supported Self-Management Intervention Codesigned by People With Long COVID: Mixed Methods Proof-of-Concept Study. \u003cem\u003eJMIR Formative Research\u003c/em\u003e, \u003cem\u003e6\u003c/em\u003e(10), e41410.\u003c/li\u003e\n\u003cli\u003eZiegler, E., Hill, J., Lieske, B., Klein, J., Dem, O. von, Knesebeck, \u0026amp; Kofahl, C. (2022). Empowerment in cancer patients: Does peer support make a difference? A systematic review. \u003cem\u003ePsycho-Oncology\u003c/em\u003e, \u003cem\u003e31\u003c/em\u003e(5), 683\u0026ndash;704.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eDetails of the online peer support sessions\u003c/div\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e# 1\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026bull; Announcement of the aim and the experience process of the peer support group and the ground rules by facilitators\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026bull; Self-introduction\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026bull; Determination of talk topics for #2 to 7\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026bull; Free discussion\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026bull; State impressions on the session one by one\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026bull; Announcement of the next session by facilitators\u003c/div\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e# 2\u0026ndash;7\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026bull; Announcement of the aim and process of the peer support group and the ground rules by facilitators\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026bull; State recent conditions one by one\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026bull; Discussion regarding the topic and free discussion\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026bull; State impressions on the session one by one\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026bull; Announcement of the next session by facilitators\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e# 8\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026bull; Announcement of the aim and process of the peer support group and the ground rules by facilitators\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026bull; State recent conditions one by one\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026bull; Discussion regarding the thoughts on participating in the past sessions\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026bull; State impression on the session one by one\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026bull; Announcement of asking to respond to the post-intervention questionnaires by facilitators\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eParticipants characteristics\u003c/div\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eMean or n\u003c/div\u003e\n\u003cdiv class=\"SimplePara\"\u003e(n\u0026thinsp;=\u0026thinsp;18)\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSD or %\u003c/div\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eAge\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e41.61\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e9.50\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSex (male)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e6\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e33.3%\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePsychiatric history\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e12\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e66.7%\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eDuration after infection (m)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e12.11\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e6.73\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eVaccination\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e16\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e88.9%\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eTimes of attendance\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e5.94\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e2.36\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e5.6%\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e11.1%\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0%\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e5.6%\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e16.7%\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e6\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e5.6%\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e16.7%\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e8 (all sessions)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e38.9%\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD, Standard Deviation\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePre-post intervention change\u003c/div\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePre\u003c/div\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePost\u003c/div\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eCohen\u0026rsquo;s d\u003c/div\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePaired t-test\u003c/div\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003emean\u003c/span\u003e\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eSD\u003c/span\u003e\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003emean\u003c/span\u003e\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eSD\u003c/span\u003e\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003et\u003c/span\u003e\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003ep\u003c/span\u003e\u003c/div\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eIntention-to-treat analyses\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eDepression\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e13.33\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e6.15\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e11.12\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e4.55\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e-0.45\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e2.26\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.04\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eAnxiety\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e8.72\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e5.48\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e7.94\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e4.32\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e-0.19\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1.03\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.16\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eLoneliness\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e6.11\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1.78\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e6.29\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e2.08\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.03\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e-0.16\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.88\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSocial withdrawal\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e9.28\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e5.74\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e9.64\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e5.74\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.03\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e-0.34\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.74\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSelf-esteem\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e27.00\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e4.92\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e25.65\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e3.97\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e-0.25\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1.19\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.25\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePer-protocol analyses\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eDepression\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e14.6\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e5.96\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e11.73\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e4.5\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e-0.53\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e2.29\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.04\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eAnxiety\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e9.73\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e5.32\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e8.6\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e4.01\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e-0.23\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1.03\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.32\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eLoneliness\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e6.33\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1.59\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e6.33\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e2.09\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.00\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1.00\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSocial withdrawal\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e9.07\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e6.06\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e9.4\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e5.85\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.06\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e-0.61\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.55\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSelf-esteem\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e27.07\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e5.26\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e25.67\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e4.13\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e-0.29\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1.26\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e0.23\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD, Standard Deviation\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eThemes and statement examples regarding interactions while attending peer-support groups\u003c/div\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eThemes\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSubthemes\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eStatement example\u003c/div\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth colspan=\"3\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eInteractions while participating in peer-support groups\u003c/div\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eInteractions that convey having the same feelings\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eClaims of having the same experiences\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"When I think about it carefully, until around this March, for about a year after I got sick, I was in exactly the same condition as you.\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSupports for others\u0026rsquo; opinion\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"I also truly thought that maintaining my mental state was the most challenging part...\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eInteractions for dealing with their difficulties\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eProposals of coping strategies\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"If you have the environment to rest and adjust your physical condition, based on my experience, I think the risk of your condition worsening is reduced; that's what I thought after listening.\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eInformation exchanges\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"(In response to a question about the experience with self-E Epipharyngeal Abrasive Therapy, a self-care practice) I bought cotton swabs and tried it, but somehow I couldn't properly insert them into my nose, so I stopped.\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003epromoting alternative thinking\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"\u0026hellip;, so I think that maybe you should really acknowledge your own efforts, your perseverance, and give yourself some credit for that.\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eInteractions of showing empathy\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSympathy\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\" XXX-san, I think it must be frustrating not knowing the cause\u0026hellip; \"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eEncouragement\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"So, XXX-san, I don't think you should feel pathetic at all.\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePraise\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"Listening to XXX-san's story, I thought it was amazing how you've been inventive in dealing with various things...\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eInteractions that enhance the atmosphere\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eIdle talk\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"Your icon of the Java sparrow plushie is super cute.\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePresentation of a differing opinion\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"(In response to the opinion that it might be cured in 30 years) \u0026hellip;, leading to growing old and dying with a disabled body. \"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eInteractions adapting to suit health conditions\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"It becomes quite tough to look at the screen for a long time, so I often close my eyes. \"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eXXX-san, the names of the participants\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab5\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eThemes and statement examples regarding thoughts on participating in the peer-support groups\u003c/div\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eThemes\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSubthemes\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eStatement example\u003c/div\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eEmotional supports\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eFeeling relieved through talking\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"After I had a chance to speak, I felt a bit lighter.\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePleased by the empathy of others\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"I'm really grateful that you understand and empathize with me as if it were your own issue.\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eThe pleasure of finding out others have the same feelings\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"It was really good to have this kind of opportunity, as it's been difficult to meet people who are going through similar experiences.\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eBuilding a sense of bonding\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eThe group's existence as a support\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"I was especially looking forward to later sessions, \u0026hellip;, naturally, it feels like my mood has lifted a bit in anticipation of this day.\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eFeeling a sense of solidarity\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"For 2 months, I've felt a strong sense of camaraderie with XXX-san and XXX-san, as if we've been working together in tandem...\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eBeing able to speak honestly\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"Since I've been lying to everyone around me, it was a relief that I didn't have to tell any lies today.\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eGlad to encourage someone\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"Currently, I'm the one receiving a lot of encouragement, but the fact that I can encourage others is something that really makes me happy.\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eChange in perspective\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eGaining new insights\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"I've received a really good perspective, wondering if even now, there might be things I can do aimed at growth, personal growth.\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ebecoming more positive\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"At first, I was really down, like I couldn't see the goal, or I didn't know what to do, but now, I feel more like thinking about what I could try doing next or what to experiment with.\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eViewing oneself objectively\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"Through an objective lens, I've come to reaffirm, by listening to everyone's stories, that there indeed are times when I can't move much and that it's a phase where I'm unable to be active.\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eChange in behavior or new actions\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eBecoming a catalyst for taking new actions\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"Hearing about how everyone spends their time, I thought about creating moments to step away from social media and try different ways to spend my time.\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eGaining new information and strategies\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"I'm glad to have learned even a little about everyone's current symptoms and how they communicate to others.\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eFeelings of inadequate responses during sessions\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eStruggling with how to approach others\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"Because of that, I was a bit unsure about how to join in the conversation or at what point it would be okay to chime in.\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eWishing for more exchange of information\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"I did think it would have been better if we could have set something like this up sooner and had the opportunity to exchange various pieces of information earlier.\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eAdverse effects associated with participation\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eNegative feelings about the group ending\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"I'm definitely anxious about the future, feeling as if I'm losing allies around me; that's what I think.\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eFeelings of tension and fatigue during participation\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\"Actually, I might have been a bit nervous last week too, because I was extremely tired after the meeting ended, and, yes, I ended up feeling quite drained and had to rest for the rest of the afternoon.\"\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eXXX-san, the names of the participants\u003c/p\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[{"identity":"1ba6ff54-8bb6-454f-a8e7-8bdbdcbd9ce9","identifier":"10.13039/501100009438","name":"National Center of Neurology and Psychiatry","awardNumber":"4-3","order_by":0}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"National Center of Neurology and Psychiatry","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Post-acute sequelae of COVID-19, peer support, depression, pre-post intervention, mixed method, COVID-19","lastPublishedDoi":"10.21203/rs.3.rs-4249778/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4249778/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis pilot examined the effect of online peer support on mental health problems among individuals with post-acute sequelae of COVID-2019 (PASC).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA single-arm pre-post design of online peer support design consisting of eight sessions of 1 h per week with three to six participants and two facilitators per group was performed. Participants were recruited from online communities, social media, and medical clinics for the PASC between May and August 2023. The degrees of depression, anxiety, loneliness, social withdrawal, and self-esteem were measured pre- and post-intervention. Participants\u0026rsquo; statements during the sessions were analyzed using thematic analyses.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 18 participants, 3 dropped out of the interventions, and 17 (including 2 participants who dropped out) completed the pre- and post-intervention questionnaires. Depression severity significantly decreased in the paired t-test and linear mixed model. The following interactions were extracted: conveying the same feelings, dealing with difficulties, showing empathy, enhancing the atmosphere, and adapting to suit health conditions. Impressions extracted from participating in the interventions included feelings of emotional support, a sense of bonding, changes in perspective, changes in behaviors or new actions through participation, inadequacy during sessions, and adverse effects associated with participation.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOnline peer support may be helpful in treating depression in individuals with PASC.\u003c/p\u003e","manuscriptTitle":"Online peer support for mental health in individuals with post-acute sequelae of COVID-19: A pre-post pilot study with mixed methods","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-16 17:15:35","doi":"10.21203/rs.3.rs-4249778/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"98cf31e2-75e2-4837-a2e4-b2ce9131177f","owner":[],"postedDate":"April 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":30532590,"name":"Psychology"}],"tags":[],"updatedAt":"2024-04-16T17:15:35+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-16 17:15:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4249778","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4249778","identity":"rs-4249778","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}