Behavioral Activation-Rehabilitation to Improve Depressive Symptoms & Physical Function After Acute Respiratory Failure

Study Overview
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Brief Summary
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More and more people are surviving after receiving life support for respiratory failure in the intensive care unit, but these patients often experience problems with depression and physical functioning that lead to reduced quality of life. There is a lack of treatment for these patients, with past research suggesting that treatment may be more successful if mental and physical health are addressed at the same time. This research evaluates whether a therapy delivered via telephone and home visits, combining treatment for depression and physical rehabilitation, is feasible and might help patients recover.

Detailed Description
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A growing number of Acute Respiratory Failure (ARF) survivors are burdened by depressive symptoms and physical impairments that last for years after intensive care unit discharge. Notably, depressive symptoms are independently associated with subsequent development of new impairments in physical functioning. There is a lack of treatment options to address these impairments in ARF survivors, with past research suggesting combining treatment for mental and physical health might be more successful. Therefore, this study is designed to evaluate: The feasibility (primary outcome) of participant recruitment and retention in a pilot randomized controlled trial (RCT) of an intervention combining Behavioral Activation (an evidence-based psychological treatment for depression) and physical rehabilitation delivered via telephone and 2 home visits over 12-weeks versus a usual care control group. The efficacy (secondary outcome) of this Behavioral Activation-Rehabilitation intervention to reduce depressive symptoms and improve physical functioning. Modifiable psychosocial risk factors for depressive symptoms in ARF survivors and the association between the intervention and these modifiable factors.

Official Title
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A Pilot, Feasibility Randomized Controlled Trial of a Behavioral Activation And Rehabilitation Intervention To Improve Psychological And Physical Impairments In Acute Respiratory Failure Survivors

Conditions
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Respiratory Insufficiency, Depression, Rehabilitation, Critical Care

Intervention / Treatment
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* Behavioral: Behavioral Activation - Rehabilitation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: ≥18 years old Living at home before the current admission (not in a facility) Acute respiratory failure managed in the ICU > 24hrs (≥1 of the following): Mechanical ventilation via an endotracheal tube or tracheostomy > 12hrs (and not ventilator-dependent before admission) OR Non-invasive ventilation (CPAP, BiPAP) > 4 hours in a 24 hour period provided for acute respiratory failure (not for Obstructive Sleep Apnoea (OSA) or other stable use) OR High flow nasal cannula with Fraction of Inspired Oxygen (FiO2) ≥ 0.5 for ≥4 hours in a 24hr period At least mild depressive symptoms (score ≥2 on PHQ-2 scale) Exclusion Criteria: Pre-existing cognitive impairment (based on review of medical records, or proxy- administered Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) score >3.3) Declines informed consent or not capable of providing informed consent Non-English speaking Homelessness or living >50 miles away from study site Bedbound prior to the current admission Expected survival < 6 months according to ICU attending ICU Length Of Stay (LOS) > 30 days Not discharged home from the hospital Complex medical care expected soon after discharge (e.g. multiple planned surgeries, transplantation evaluation, extensive travel needs for hemodialysis, chemotherapy or radiation therapy, etc) Active substance abuse or psychosis Lack of access to telephone or inability to use telephone independently Pregnancy Suicidality Incarcerated

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 100 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Behavioral Activation - Rehabilitation<br>Behavioral Activation - Rehabilitation | Behavioral: Behavioral Activation - Rehabilitation<br>* Participants will first receive a home visit from a physical therapist (PT) who will evaluate home safety and establish/verify the participant's exercise prescription. Within 1 week, an occupational therapist (OT) will visit the home to: 1) explain the purpose of behavioral activation (BA); 2) help the participant identify long-term recovery goals regarding valued activities; and 3) then, using the principles of BA, identify short-term goals for the next week and an action plan. The OT will then call the participant weekly (weeks 2-5) to review the status of the prior week's goals and use BA to set new goals for the upcoming week. The PT and OT will repeat home visits at week 6 to assess the participant's progress, and the OT will conduct phone calls every 2 weeks for weeks 8-12.<br>|
| No Intervention: Usual Care Control<br>Usual Care Control | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Feasibility measure per participant | Total number of intervention phone calls completed per patient as a proportion of the number of intervention phone calls each patient is intended to complete. | End of intervention (12 weeks) | 
| Total feasibility measure | Total number of intervention phone calls completed by all study participants as a proportion of total intervention phone calls expected in the study | End of intervention (12 weeks) | 
| Feasibility measure/Assess loss to follow-up | Number of patients completing all study follow-up sessions as a proportion of the number of patients enrolled. | End of intervention (12 weeks) | 
| Feasibility measure | Number of patients enrolled per month | End of intervention (12 weeks) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hospital Anxiety and Depression Scale (HADS) | An instrument used to assess depressive and anxiety symptoms. Scores for each subscale range from 0 to 21. A HADS score ≥8 indicates clinically important symptoms on either subscale. | End of intervention (12 weeks) | 
| Personal Health Questionnaire - 8 item version (PHQ-8) | The PHQ-8 uses a 4-point Likert scale to assess depressive symptoms. The score range is 0 to 27. Scores 5-9 indicate mild symptoms, 10-14 moderate, and ≥20 severe depressive symptoms. | End of intervention (12 weeks) | 
| Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (SCID-5) | A clinical interview to assess depressive symptoms. This is a qualitative assessment. | End of intervention (12 weeks) | 
| Activity Measure for Post-Acute Care Computer Adaptive Test (AMPAC-CAT) | The AMPAC-CAT, a measure of physical function, has 269 items across three domains (basic mobility, daily activity and applied cognitive). The computer adaptive test requires a mean of 22 items from the item bank. Scores are norm-based. | Baseline, end of intervention (12 weeks) | 
| EQ-5D-5L | The EQ-5D-5L is an instrument developed by the EuroQol group to measure health status. The Eq-5D-5L has 5 dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has 5 levels, ranging from 1 (no problems) to 5 (extreme problems). The resulting health utility score ranges from -0.11 to 1.00. The EQ-5D-5L also records the respondent's self-rated health on a visual analog scale (0 to 100). | End of intervention (12 weeks) | 
| Healthcare Utilization | Patient interview to assess the following post-discharge variables: inpatient readmissions (hospitals, skilled nursing facilities, acute and sub-acute rehabilitation facilities) and outpatient mental health and physical rehabilitation services | End of intervention (12 weeks) | 
| Brief Coping with Problems Experienced (Brief COPE) | A 28-item measure of coping strategies with responses provided using a 4-point Likert scale. Scores are provided for the 14 subscales, each of which corresponds to a specific coping strategy (minimum score=2 to maximum score=8). | Baseline, end of intervention (12 weeks) | 
| Behavioral Activation for Depression SCALE (BAS) | This is a 25-item scale that measures changes in avoidance and activation over the course of Behavioral Activation treatment using a 7 point scale (0=not at all to 6=completely). The scale is grouped into 4 subscales (Activation, Avoidance/Rumination, Work/School Impairment, and Social Impairment). To calculate a total score, items on all subscales other than Activation are reverse-coded and then an unweighted sum is computed. | Baseline, end of intervention (12 weeks) | 
| Connor-Davidson Resilience Scale (CD RISC) | This is a 25-item scale with each item rated on a 5-point scale (higher scores indicating greater resilience). The total score ranges from 0 to 100. | Baseline, end of intervention (12 weeks) | 
| Number of phone attempts needed by the OT to reach the participant for each session | Measure of adherence | End of intervention (12 weeks) | 
| Proportion of sessions fully completed and partially completed | Measure of adherence | End of intervention (12 weeks) | 
| Montreal Cognitive Assessment (MoCA) - BLIND | Measure of cognitive impairment | End of intervention (12 weeks) | 
| Impact of Events Scale - Revised (IES-R) | This is a measure the subjective response to a specific traumatic event (in this case - critical illness and associated ICU experience). The IES-R consists of 22 items, each rated on a 5-point scale; item scores are averaged to generate a mean total score (range: 0-4). | End of intervention (12 weeks) |