Are Peer Support Programs Effective in the Detection and Prevention of Mental Health Issues in Commercial Aviation?

ABSTRACT

Background

In the aftermath of the Germanwings crash in 2015, several regulations have been instituted around pilots’ mental health issues and flight safety. One of these (CAT.GEN.MPA.215) stipulates that European operators are to implement a Peer Support Program to encourage pilots’ self-referral of mental health issues and identify mental wellbeing issues as early as possible. However, knowledge is scarce regarding how effective these programs are on a range of outcomes.

Objective

This systematic review aimed to identify articles investigating peer support programs and their effectiveness in preventing and detecting mental health issues, in commercial aviation and other high-risk organizations.

Method

A systematic search was performed in three databases, following the structure of the PRISMA guidelines. All articles (2.123) were exported to Rayyan Citation, where the screening process was performed.

Results

Four articles met the final inclusion criteria. Overall, the search revealed little empirical evidence of the effectiveness of peer support in detecting and preventing mental health.

Conclusion

Although there is limited or no evidence in any direction, the peer support programs seem to be without evident harm and were generally appreciated. The insufficient empirical evidence is nonetheless concerning, with these programs being implemented throughout Europe in such a high-risk context as the aviation industry. The results highlight the importance of more research on peer support in aviation.

KEYWORDS:

• peer support
• mental health prevention
• aviation
• high-risk organizations
• systematic literature review

Introduction

Major depressive disorder (MDD), commonly referred to as depression, is the third-most important cause of ill health worldwide and affects an estimated 264 million people (World Health Organization Mathers et al., 2008; World Health Organization, 2017). The few studies that address depression among pilots indicate that mental ill health in this group is on a level comparable to that among the general population (Bor et al., 2002, Pasha & Stokes, 2018). In a systematic review of depression and suicide among commercial airline pilots, the prevalence of depression experienced by this group ranged from 1.9% to 12.6% (Pasha & Stokes, 2018). This large disparity in results is explained by the difference between anonymous and non-anonymous studies, and the pilots’ fear of negative impact on their careers if they report depression or other mental health issues.

The Germanwings crash in March of 2015 brought the sensitive subject of pilot mental health to the forefront in a tragic way, and in the aftermath of the crash there has been an increased awareness and concern about pilot mental health and aviation safety. As a result, several recommendations have been made to identify pilots with mental health disorders and enhance flight safety. For example, the European Union Aviation Safety Agency (EASA) advised improving medical examinations to detect those who are inappropriate for flight duty, and an enhanced initial psychiatric evaluation is now mandatory, as are psychological assessments of commercial pilots before line flying.

Despite these precautionary actions, depression and other mental ill health can be difficult to detect (Cepoiu et al., 2008), and studies indicate that there is likely an underreporting of psychological diagnoses, especially among pilots (Lollis et al., 2009; Parker et al., 2001). Additionally, even with medical and psychological screening, pilots are at risk of experiencing mental distress, which may impair their performance and jeopardize safety. Extensive international work health research has shown that working conditions and work organization play an important role in the occurrence of both physical and psychological stress-related ill health (see, e.g., Holmes, 2001; Michie, 2003; Sverke et al., 2016), and several known risk factors associated with mental health problems are common work conditions in commercial aviation. Experiencing occupational stressors, working long duty hours, and having high levels of reported fatigue, for example, are recognized to be associated with the development of mood disorders (Pasha & Stokes, 2018).

Following the French Civil Aviation Safety Investigation Authority’s final report on the safety investigation of the Germanwings accident (Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile), the European Union Aviation Safety Agency (EASA, 2015), in addition to the medical and psychological screening of pilots, also recommended the implementation of pilot support and reporting systems linked to the employer safety management system. The European Union subsequently published a legislation in 2018 (Regulation EU 2018/1042), which was followed by an EASA ED Decision (2018/012/R) stipulating that European operators, under the oversight of an EASA Member State, are to implement a Peer Support Program (regulation reference CAT.GEN.MPA.215). The purpose of the Peer Support Program (PSP) legislation is to encourage pilots to self-refer any mental wellbeing issues they may have, or to allow others to raise concerns about a pilot’s fitness to operate, in a safe and confidential environment and knowing that they will be appropriately supported.

Unlike the majority of other peer support programs in which the objective is to provide peer support after critical incidents and trauma, the purpose of implementing these support programs is pro-active and preventative, intending to offer a method for helping pilots maintain their optimal performance by identifying and supporting mental wellbeing issues as early as possible. The practice of peer support has rapidly developed within organizations whose employees are at high risk of exposure to potentially traumatic incidents, and features prominently in international mental health policy and practice related to recovery-oriented mental health service (Cyr et al., 2016; Penney, 2018). The rationale for providing peer support programs often includes the goal of reducing the negative effects of traumatic events on psychological wellbeing, especially in so-called high-risk organizations. Military and emergency services personnel such as police, firefighters, doctors, and other medical staff are among the most well-known psychologically high-risk professions (Mitchell & Leonhardt, 2010) in which peer models of post-trauma support systems are used. Three frequently used peer support models are Critical Incident Stress Management (CISM), Critical Incident Stress Debriefing (CISD), and Trauma Risk Management (TRiM). These models are comprehensive, integrated, and multi-component crisis intervention programs based on peer support, aiming to keep personnel functioning after traumatic events by enhancing the understanding and acceptance of stress reactions. TRiM, for example, differs from the Peer Support Program (CAT.GEN.MPA.215), not only in its focus on post-trauma support but also in that the clients themselves do not seek contact/support and the support sessions entail a predetermined structure and goals (Creamer et al., 2012).

The majority of literature studying peer support models in organizations concerns interventions post-stress and -trauma. However, the evidence is scarce. The previously mentioned TRiM stands out in the mix of such peer support programs by being one of few that, through a randomized trial, has tested its effectiveness. In that trial, no significant effects on psychological health or stigma were found (Greenberg et al., 2010). The authors asserted that one reason for this could be the low number of potentially traumatic events, the area in which the program aims to have an effect (Greenberg et al., 2010). To summarize, the evidence is scarce regarding how effective the peer models are on a range of outcomes, and there is little consensus on the basic concepts and procedures for peer support programs in general. There are few systematic reviews that investigate the topic of peer support, and even fewer in which the programs’ objectives are to prevent and identify mental health problems. Accordingly, it is currently unknown to what extent peer support programs can actually prevent and detect mental health problems in the airline pilot population.

Aim

The purpose of the legislated Peer Support Program (CAT.GEN.MPA.215) is to enable the prevention and early detection of mental health issues among commercial airline pilots, and to provide appropriate advice and support to the concerned pilot if needed. With the launching and running of the Peer Support Program, there is a need for a systematic review identifying and examining the scientific evidence of peer support models whose objective is to prevent and identify mental health problems. It is of utmost importance that the mental health support used in aviation be based on scientific evidence, or at least evidence-based practices. A systematic review of scientific literature would contribute to identifying best practice for the implementation of peer support programs in commercial aviation, and would also help identify knowledge gaps and direct future research.

Thus, this systematic review of literature aims to identify and summarize studies investigating peer support in organizational settings with a focus on the prevention and detection of mental health issues in commercial aviation and other high-risk organizations (i.e. those in which the personnel operate within a high-risk environment and are routinely exposed to potentially traumatic events). The main question this review addresses is whether peer support programs are effective in detecting and preventing mental health issues.

Method

A systematic search was performed in the databases PubMed, PsycInfo, and Web of Science, following the structure of the PRISMA guidelines (the Preferred Reporting Items for Systematic Reviews and Meta-Analyses). In Figure 1, a flow diagram of the systematic review is outlined.

Figure 1. PRISMA flow diagram of included studies.

In the first step, articles were included if they were published in peer-reviewed journals in English and had the main purpose of being directly related to peer support in aviation or other high-risk organizations. Articles focusing solely on post-trauma support were excluded. The search in all databases identified 2,568 articles. As peer support is a relatively scarcely researched field, a large number of keywords were included in the search. The search consisted of two search strings: one containing synonyms for peer support, and one containing terms related to high-risk organizations, aviation, and occupational health. In PubMed and PsycInfo, the search was limited to title and abstract. The search strings contained MeSH terms in PubMed and subject headings in PsycInfo. In Web of Science, the search was limited to topic: title, abstract, author keywords, and KeyWords Plus. The searches were conducted in June 2020, and the searches in the respective databases are shown in Figure 2.

Figure 2. Database search terms.

Screening and Eligibility

In the second step, the identified articles were screened. All articles that met the inclusion criteria in the first step were imported into EndNote to identify and remove duplicates. The remaining articles were exported to Rayyan Citation, where additional duplicates were removed. The remaining 2,123 articles were then categorized by one reviewer in accordance with the classifier function in Rayyan as “yes,” “maybe,” or “no” based on titles and abstracts. All articles categorized as “no” were excluded. After this first round of inclusion/exclusion, 119 articles remained. All articles categorized as “maybe” underwent a second screening process by two reviewers independently, now being categorized as “yes” or “no.” Once again, the articles categorized as “no” were excluded. After this second round of inclusion/exclusion, 16 articles remained. In the next step the articles were read through and screened, once again by two reviewers. In the final screening, only articles related to peer support in high-risk organizations/aviation and the detection and prevention of mental health problems were included. Additionally, citation lists of relevant studies were searched to check for any additional papers. After the references were examined, two additional searches were done (in PubMed) by one of the researchers to ensure that nothing of value was left out. The first search was done solely on peer support, limited to title and abstract, in combination with filters of article type: clinical trial, meta-analysis, randomized controlled trial, and systematic review. The second search was done on peer support and prevention, both limited to title and abstract. No relevant articles were found in the citation lists of relevant studies or in the additional searches.

Certainty of Evidence

The four articles that remained after the final screening were then assessed in terms of their quality of evidence, using the GRADE approach (Granholm et al., 2019). GRADE (Grading of Recommendations Assessment, Development and Evaluation) is a framework for assessing and ranking the relative strength of results obtained from scientific research in healthcare (e.g. in public health, health policy, and systems and coverage decisions). There are several factors that affect the quality of evidence in this framework, beginning with the study design (trials or observational studies) and then addressing reasons to possibly rate the quality of evidence up or down. According to the GRADE approach to quality of evidence, case reports and observational studies without special strengths or important limitations provide low-quality evidence, which was the case with two of the four articles (one qualitative interview study and one using a mixed-method approach with a quantitative survey pre- and post-implementation and a qualitative content analysis). As neither of them have sources of control group results, they would be graded as very low-quality evidence. Another article falls into the category of expert opinion (using the Delphi method to outline guidelines for peer support with the help of experts within the field), which is not a category of quality of evidence according to the GRADE approach. The last article is a database and literature review and, because it is not an original research article, should not actually be included in this systematic review. However, as the scientific literature on preventative peer support is so scarce, and as the article contributes to the aim of identifying best practice and knowledge gaps that can direct future research, its relevance was considered sufficiently high for inclusion.

Results

The search identified 2,123 articles, four of which met the final inclusion criteria. All included articles were related to peer support in high-risk organizations and aviation and the detection and prevention of mental health problems. Two of the four articles addressed peer support in aviation settings: one qualitative interview study exploring peer support and its role in addressing pilots’ emotional wellbeing (Santilhano et al., 2019); and one literature study based on the official incident and accident reports and a literature search aiming to study how peer support groups and Just Culture principles can be applied to pilot mental health problems and negative life events (Mulder & de Rooy, 2018). The third article (Creamer et al., 2012) aimed to outline guidelines for the design and implementation of peer support programs. Using the Delphi method, the study invited 92 experts on and practitioners of peer support to participate in order to generate key areas of consensus that could provide guidelines in the health field. The fourth article used a mixed-method approach (a quantitative survey pre- and post-implementation and qualitative content analysis) and examined a second victim peer support program in a healthcare setting (Dukhanin et al., 2018). Applying the GRADE approach to quality of evidence, all these articles would fall into the category of low or very low quality of evidence, based on their study design and different outcomes.

Are Peer Support Programs Effective in Detecting and Preventing Mental Health Issues?

Overall, the search revealed little empirical evidence of the effectiveness of peer support in detecting and preventing mental health. Both articles on peer support in aviation addressed the effects of peer support, but with different approaches and methods. The article aiming to study how peer support groups and Just Culture principles can be applied to pilot mental health problems and negative life events (Mulder & de Rooy, 2018) found no protective effect of peer support programs on mental health problems, although the programs were generally appreciated by those involved. The study included a literature review, and when the authors found no articles on the effects of pilot peer support in improving and/or preventing mental health issues in aviation, they looked at similar professions. Five articles were then found. In three of these articles, the authors were pleased with the programs and the effects but did not provide empirical evidence to support this (see Castellano, 2012; Greden et al., 2010 and Hochberg et al., 2013). The fourth article in Mulder and de Rooy’s (2018) literature review found peer support to be one of three effective coping mechanisms among a group of nurses (see Burnard et al. 2000). The fifth article in the review compared experiences of participants in mental health recovery groups, one held by a peer and one by a mental health professional (see Beehler et al. 2014). Participants reported both to be helpful.

The second article on peer support in an aviation setting was a qualitative phenomenological study conducted in the South African aviation context (Santilhano et al., 2019). The study aimed to explore the participants’ experiences and thoughts on peer support, and its findings were based on nine interviews with six airline pilots and three mental health professionals. Five core questions were posed, eliciting four key themes. The first theme involved the content and conceptualization of the term “peer support” and highlighted, for example, the importance of mutual understanding and trust as well as the sensitive nature of the peer role. The second theme concerned the importance of support and an emotionally safe workplace. The findings suggested that pilots may be uncomfortable seeking support from managers or the aviation system as they fear unintended consequences. The third theme involved the impact of wellbeing on fitness to fly, and found that there was too little emphasis on the emotional and psychological wellbeing of the pilots in the medical assessments and fitness to fly certification process. The fourth theme suggests that the benefit of peer support in aviation may extend beyond pilots’ wellbeing. The respondents stated, for example, that peer support adds to operational and organizational safety, and also contributes to the peers’ personal growth. The study concluded that pilot peer support may enhance the perception of support and safety in aviation, and highlighted the importance of integrating support for pilots’ mental health and wellbeing as a vital element and resource in aviation safety in general.

The aim of the third article, by Creamer et al. (2012), was to outline guidelines for the design and implementation of peer support programs in high-risk organizations, and by doing so, also lay a foundation for future research. The study invited 92 experts on and practitioners of peer support from 17 different countries to participate in a web-based Delphi process. The participants were presented with 77 statements related to peer support programs to rate according to importance. Three rounds of rating resulted in consensus on 62 of the statements which, when combined, formed eight main recommendations. The first recommendation concerns the goals of peer support programs, which are to provide low-level psychological interventions and a space in which people can confide. Additionally, they include identifying people at risk and, when appropriate, helping people get into contact with a professional. The second recommendation concerns what it takes to become a peer supporter. Apart from undergoing interviews, one should have significant working experience and the respect of one’s coworkers. Thirdly, before becoming a peer supporter one should be educated and tested in the skills necessary for being a peer supporter. These include listening, being able to conduct low-level psychological interventions, and knowing where to refer people for adequate help from professional services. After becoming a peer supporter, one should also take part in further/recurrent education. The fourth recommendation states that a mental health professional should be involved in this education and serve in the role of clinical director in the peer support program. The fifth recommendation states that peer supporters should provide both preventative and post-incident health services. However, there is not to be regular contact between a peer supporter and a user of the service. If a contact requires more attention, the peer should consult a specialist and provide referral options. Information shared with a peer supporter should be confidential (exceptions to this include when the peer needs to discuss a case with a professional involved in the program, or if the peer fears that someone could be in harm’s way). The sixth recommendation states that peer supporters should be offered as the first contact to coworkers who have experienced a work-related incident. Before meeting with a peer, one should be able to freely choose which peer one wants to see. The seventh recommendation concerns the health and wellbeing of peer supporters, stating that they are not to be accessible all hours of the day and that they should have experts close at hand in order to seek advice, related to both their work and their own health. The final recommendation, concerning program evaluation, states that before starting a PSP there should be well-defined and measurable outcome goals, both quantitative and qualitative, that can be used to evaluate the program. Evaluation should be done regularly and handled externally.

The fourth and last article examined a second victim peer support program in a healthcare setting (Dukhanin et al., 2018). A mixed-method approach was used, including a quantitative survey pre- and post-implementation and qualitative content analysis on participants’ experiences and feedback post-implementation. Although the main purpose of the peer support program was to support personnel after stressful experiences at work, it was also intended to increase resilience and support preventatively. The post-implementation survey was administered four years after the first survey, and results showed that the respondents at that time reported a greater awareness of the availability of support and were more likely to contact an organizational support structure. However, there was no difference between pre- and post-implementation in the inclination to seek organizational support after a serious incident, and results also showed that the respondents at the later time point were less inclined to seek support from a peer/colleague. Among the respondents who had been in contact with the peer support program (10%), directly or through someone they knew, 93% were likely to recommend the program to others. The quantitative content analysis of the participants’ thoughts about and experiences of the program in the follow-up survey identified both favorable factors and barriers. Favorable factors of the program included confidentiality, reliable follow-up, and having access to support all hours of the day. Favorable factors in the contact with a peer included the supporter being an active listener, having clinical expertise, being non-judgmental, and being willing to contribute by sharing their own experiences. Barriers to using the peer support program included overcoming blame culture, the need to promote the initiative, and the need for more staff time to handle adverse events. Perceived unfavorable factors in the peer support sessions included the peer supporter blaming or pitying the client, downplaying or not paying attention to potentially traumatic events, and being too focused on a problem-solving approach, which led to the peer supporter not taking notice of the client’s feelings and emotions. The content analysis also revealed varied preferences for the support format and specific support interventions, regarding, for example, group sessions vs. individual meetings, dialogue with a peer or senior, support programs run by the hospital or their respective hospital unit, support coming in a hotline format or a service for reporting errors, support held by a neutral party or not, etc. Most respondents described the peer support program as helpful. A few were more hesitant, with concerns related to the stigma of help-seeking, people’s awareness of the program, and the lack of time to use it.

Table 1. Summary of included studies on peer support in high-risk organizations and aviation and the detection and prevention of mental health problems is presented in Table 1.

Reference	Design/Method	Sample and Settings	Outcomes/Results
Santilhano et al. (2019).	Qualitative phenomenological design using semi-structured interviews.	9 participants of a South African PPSP: peers, mental health professionals and flight operations managers.	The results suggest that pilot peers enhance the perception of support and safety. However, it is concluded that peer support needs to become integrated as a resource to be truly effective, and that the working definitions of health and fitness to fly need to become clearer, more inclusive of holistic well-being
Mulder and de Rooy (2018).	Literature review and review of official incident and accident reports.	Professions comparable to pilots (using the International Standard Classification of Occupations (ISCO)).	No evidence was found on the effects of pilot peer support in improving and/or preventing mental health issues. Three of the five articles, with week or no empirical evidence as support, found that people participating in peer support programs tend to be pleased with the programs.
Creamer et al. (2012).	Web-based Delphi process.	92 experts and practitioners of peer-support.	The Delphi process resulted in consensus on 62 of 77 statements. These were used to create 8 main recommendations relevant to designing and implementing peer support programs in high-risk settings.
Dukhanin et al. (2018).	Mixed-method evaluation design. Surveys, pre and post implementation analyzed using quantitative and qualitative analysis.	Aproximately 200 health care workers.	Participants reported being more aware of the available support and more inclined to using it. At the follow up, 4 years after implementation, more participants reported having support available if needed and benefits of using the organizational support

Discussion

The aim of this systematic literature review was to identify studies on peer support addressing the prevention and detection of mental health issues in aviation and other high-risk organizations. Against the backdrop of the EU legislation and EASA rules on Peer Support Programs, the objective was to contribute a scientific knowledge base for the practical implementation of the Peer support programs, and by doing so, also identify knowledge gaps and direct future research. The main question addressed in this review was whether peer support programs are effective in detecting and preventing mental health issues. The short answer is that there is little empirical evidence of such effects. Although there is limited or no evidence in any direction, the programs seem to be without evident harm and are generally appreciated.

One reason for the lack of evidence is that peer support programs generally have a history of being independent of external mental health agents and agencies (Creamer et al., 2012). This has meant that anyone outside a program has not been able to study its collected data. Because of this, the field of peer support has stood out among many other research fields and it has been impossible for external parties to evaluate the programs. When programs claim to see effects of their interventions, there has been no way to confirm such findings.

The insufficient scientific knowledge and empirical evidence regarding the preventative effect of peer support is concerning, with its implementation throughout Europe in such a high-risk context as the aviation industry. There are several reasons for this. Firstly, the EASA legislation on Peer Support Programs (CAT.GEN.MPA.215) is both comprehensive and complex. It includes many sensitive issues concerning the relationship between formal safety management and reporting systems (both within the airline companies and to aviation authorities) and its relation to the key element of the peer support program, i.e. that it is based on trust and confidence and is fully independent of management, the pilot representative body, or authority influence in its daily operations. Upholding the trust and confidentiality of the program, while simultaneously meeting the obligations and constraints of the different stakeholders as well as the requirements of authority’s oversight, will most likely be an intricate and difficult balancing act. Despite the best of intentions, running the programs will likely face problems including, for example, gaps in (or overstepping) responsibility, perceived unjustified breaches of confidentiality, and the revocation of medical licenses/certificates or dismissal.

Implementing the Peer Support Programs throughout Europe without scientific evidence is also precarious as we do not know enough about the actual effects of peer support in aviation and are consequently relying on something that might not work. Will the Peer Support Programs contribute to identifying those in need, and will those who need it the most take contact with their peers? And what do we know about how to design the program for the best result? Research on post-trauma peer support systems (TRiM) emphasizes the importance of a distinct and predetermined structure for the program and well-defined manuals for the peer supporters (Whybrow et al., 2015), which is not the case with the legislated Peer Support Programs in aviation. Implementing support programs on a large scale in the aviation industry without sufficient scientific knowledge entails a risk that it will become a paper product, ensuring that the regulation is in place and is approved by oversight authorities but not engaging in the prevention of mental ill health in pilots. By “ticking the boxes”, the airlines might settle for having complied with the regulation, and/or may actually believe they have fulfilled all they have to in order to prevent pilots’ mental ill health. In turn, this might result in no effort being put into other important and well-documented measures and activities for promoting mental health, such as improving working conditions. Extensive international work health research has shown that employment and working conditions play an important role in the occurrence of both physical and psychological stress-related ill health (see, e.g., Levi et al., 2000; Holmes, 2001; Michie, 2003; Sverke et al., 2016); thus, this is an area where proactive interventions can truly have an impact.

In order to have the safest and most effective support programs possible, we need to quickly address potential ways to gain systematic and scientifically based knowledge about peer support in aviation. The current launching of Peer Support Programs throughout Europe offers an excellent opportunity to conduct scientifically and ecologically valid studies on peer support in aviation. Future research should monitor and evaluate the effects of the Peer Support Programs on pilot mental health, as well as studying the practical and legal challenges. Studying mental health is challenging but highly important, especially in such a high-risk context as the aviation industry. Work with flight safety must be predominantly proactive, and an important task for the airlines and authorities is to set the conditions for safe acts. In the wake of the COVID-19 pandemic, with airlines battling to recover and get back on the market, more pilots than ever will likely return to unsecure and perhaps worsened employment and working conditions, with inadequate contracts, roster adaptations, and longer working hours. In EASA’s review of aviation safety issues arising from the pandemic (Version 2 – April, 2021), reduced focus on human and organizational factors vital for safety, as well as decreased wellbeing of aviation professionals during shutdown and upon return to work, were identified to be among the highest risks to the aviation system. This makes it more important than ever to proactively mitigate mental health risks among pilots; and pilot peer support programs, based on scientific knowledge and properly implemented, could be one of a range of measures in this pursuit.

Study Limitations

Drawing on the results from the systematic search and screening process performed in this literature review, it is notable that there were few articles that addressed its preventative use and effect in organizational settings. From a methodological standpoint, the literature on peer support in general is predominantly comprised of studies using cross-sectional designs, often with small samples, or longitudinal designs without comparison groups. Because of the scarce number of articles, and widespread methods, settings, etc., it was difficult to determine in advance any strict and narrow inclusion and exclusion criteria. Another limitation of this systematic review is the number of databases used (three). If additional databases had been used, more articles may have been found. Also, the time between the systematic search (June 2020) and the submission of the text constitutes a limitation. New articles on the topic may have been published during this gap, naturally excluding them from this article.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Trafikverket [TRV 2018/125661].