June Peer Council Pre-screener

We will contact you if the peer council seems to be a good fit for you.

Thank you for your interest in participating in DBSA's Peer Council on behalf of Relmada.

Our goal with this initiative is to assist Relmada in understanding peer concerns and how to better educate other peers on one of their therapeutic treatments and how to better engage with peers in research.

WHAT WILL I BE ASKED TO DO?
You’d be invited to participate in one 90-minute online video conference. The video conference will be recorded and transcribed. At the end of the session, you will receive a $75 Amazon gift card as thanks for your participation.

PARTICIPATION REQUIREMENTS?
18 years or older
Has access and ability to participate in an online video conference, such as Zoom or FaceTime.

Please complete this pre-screener to see whether this peer council is a good fit for you. The pre-screener may take about 5-10 minutes to complete.

Question Title

* 1. Please provide your name and email address.

Name

Email Address

Question Title

* 2. Do you have access and ability to participate in online video conference, such as Zoom, FaceTime, or Google Hangouts?

Yes

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* 3. Which of the following apply to you? Please select all that apply.

I am living with depression or have experienced it in the past.

I am living with bipolar or have experienced it in the past.

Feelings such as prolonged sadness, low mood and/or energy, irritability, anger, worthlessness, guilt, and/or indecision interfere (or have interfered) with my life and pursuit of interests, relationships, and/or goals.

Episodes when feelings such as heightened mood, exaggerated optimism, restlessness, racing thoughts an speech, impulsive behavior, excessive irritability and aggression, and/or decreased need for sleep without fatigue interfere (or have interfered) with my life and pursuit of interests, relationships, and/or goals.

I am interested in helping advance understanding of and treatments for depression and/or bipolar.

I have been prescribed at least one antidepressant treatment in my lifetime.

I have been prescribed ketamine or Spravato (esketamine) in my lifetime.

I have been prescribed 4 or more different antidepressant treatments in my lifetime.

I have experienced electroconvulsive therapy (ECT) in my lifetime.

I have experience vagal nerve stimulation (VNS) therapy in my lifetime.

I am CURRENTLY prescribed antipsychotic medication.

I am living with psychosis/schizophrenia or have experienced it in the past.

I am living with a personality disorder or have experienced it in
the past.

I am in a relationship with and/or am a family member of one or more individuals who experience depression, bipolar, and/or the feelings and behaviors described above.

None of the above

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* 4. If you indicated you are in a relationship with someone who experiences depression, what is your relationship to that person?

Parent

Child

Partner

Relative

Neighbor

Friend

Other (please specify)

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* 5. Please describe your gender.

Female

Male

Non-binary/ Third gender/ Other

Prefer not to self-describe

Prefer not to answer

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* 6. What is your current age range?

Under 18

18-25

26-35

36-45

46-55

56-65

66-75

76+

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* 7. In what state or U.S. territory do you live?

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* 8. Please describe your community.

Rural

Small town

Suburban

Urban

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* 9. Have you ever participated in a clinical research study or a clinical trial?

Yes

I don't know

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* 10. If possible, can you identify the number of discrete periods of time when symptoms of
depression or bipolar significantly impacted your life?

Once

2-10 times

More than 10 times

Cannot recall or estimate

Symptoms are persistent and constantly impact my life

Zero times

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* 11. How would you describe the impact of depression and/or bipolar (or the symptoms you related to in a previous question) on your ability to work or attend school, your diet, sleep, self-care, relationships, and interests?

	No impact	Minimal impact	Some impact	Significant impact
Over your lifetime	Over your lifetime No impact	Over your lifetime Minimal impact	Over your lifetime Some impact	Over your lifetime Significant impact
Over the past year	Over the past year No impact	Over the past year Minimal impact	Over the past year Some impact	Over the past year Significant impact
Over the past month	Over the past month No impact	Over the past month Minimal impact	Over the past month Some impact	Over the past month Significant impact
Today	Today No impact	Today Minimal impact	Today Some impact	Today Significant impact

Question Title

* 12. Thinking about your answer to the question above, how often would you predict that element
of wellness might change for you?

It might vary constantly -- several times an hour

It might vary frequently -- many times a day

It might vary from day to day

It might vary from week to week

It might vary from month to month

It would be pretty stable, with very little change over time

I predict it would vary in response to external events, more than to time

I don't think there would be any way to predict the frequency of change based on time alone

It's hard for me to say

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* 13. Do you have access to care? (For example, mental health services, community mental health centers, healthcare professionals, therapists etc)

Yes

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* 14. Do you currently have health insurance, or not?

Yes, I do

No, I do not

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* 15. Which of the following categories best describes your employment status?

Employed, working full-time

Employed, working part-time

Not employed, looking for work

Not employed, NOT looking for work

Student

Retired

Homemaker

Self-employed

Disabled, not able to work

Prefer not to answer

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* 16. What is the highest level of school you have completed? (If you're currently enrolled in school, please indicate the highest degree you have received)

Some high school

High school degree or equivalent (e.g., GED)

Some college

Associate degree

Bachelor degree

Graduate or Master's degree

Doctorate or other postgraduate degree

Prefer not to answer

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* 17. Please describe your racial or ethnic identity? (Select all that apply.)

African-American/Black

East Asian

Hispanic/Latinx

Middle Eastern

Native American/Alaskan Native

Pacific Islander

South Asian

Southeast Asian

White/Caucasian

Prefer not to self-describe

Prefer not to answer

None of the above, please specify...

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* 18. Please describe your sexual orientation.

Asexual

Bisexual

Gay or lesbian

Heterosexual or straight

Prefer not to self-describe

Prefer not to answer

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* 19. May we contact you with similar opportunities to share your experience?

Yes

Thank you so much for the time, energy, and emotion you dedicated to sharing your experience and opinions.

We will contact you if the peer council seems to be a good fit for you.

Question Title

* 1. Please provide your name and email address.

Question Title

* 2. Do you have access and ability to participate in online video conference, such as Zoom, FaceTime, or Google Hangouts?

Question Title

* 3. Which of the following apply to you? Please select all that apply.

Question Title

* 4. If you indicated you are in a relationship with someone who experiences depression, what is your relationship to that person?

Question Title

* 5. Please describe your gender.

Question Title

* 6. What is your current age range?

Question Title

* 7. In what state or U.S. territory do you live?

Question Title

* 8. Please describe your community.

Question Title

* 9. Have you ever participated in a clinical research study or a clinical trial?

Question Title

* 10. If possible, can you identify the number of discrete periods of time when symptoms ofdepression or bipolar significantly impacted your life?

Question Title

* 11. How would you describe the impact of depression and/or bipolar (or the symptoms you related to in a previous question) on your ability to work or attend school, your diet, sleep, self-care, relationships, and interests?

Question Title

* 12. Thinking about your answer to the question above, how often would you predict that elementof wellness might change for you?

Question Title

* 13. Do you have access to care? (For example, mental health services, community mental health centers, healthcare professionals, therapists etc)

Question Title

* 14. Do you currently have health insurance, or not?

Question Title

* 15. Which of the following categories best describes your employment status?

Question Title

* 16. What is the highest level of school you have completed? (If you're currently enrolled in school, please indicate the highest degree you have received)

Question Title

* 17. Please describe your racial or ethnic identity? (Select all that apply.)

Question Title

* 18. Please describe your sexual orientation.

Question Title

* 19. May we contact you with similar opportunities to share your experience?

* 10. If possible, can you identify the number of discrete periods of time when symptoms of
depression or bipolar significantly impacted your life?

* 12. Thinking about your answer to the question above, how often would you predict that element
of wellness might change for you?