Improving Psychological Distress Among Critical Illness Survivors and Their Caregivers

Study Overview
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Brief Summary
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Patients who receive life support in intensive care units commonly suffer from persistent depression, anxiety, and post-traumatic stress disorder (PTSD) symptoms after discharge. We are trying to learn which is a better way to manage this distress: a telephone-based adaptive coping skills training program or an educational program.

Detailed Description
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Public Summary of Research Project Why is this important? Nearly 800,000 Americans receive mechanical ventilation for acute respiratory failure in the ICU each year. Afterward, over half of both patients and their family caregivers suffer from psychological distress (depression, anxiety, and post-traumatic stress [PTSD]) for over 1 year after discharge. Patients and families told us that they need help with their distress because it worsens their quality of life. More specifically, patients said that learning how to adapt (that is, how to cope) with the physical and emotional changes of critical illness would be helpful. In fact, most ICU survivors use coping skills infrequently, which worsens psychological distress. But patients also told us that they wanted more information about critical illness, recovery, and what to expect. A lack of information increases PTSD symptoms. However, there are few treatments for this distress that can overcome ICU survivors' physical disability, great distance from expert medical centers, and concerns about how much treatments would cost. Therefore, we developed two treatments to address coping and lack of information. What is the main goal? We aim to compare which of two treatments are more effective in reducing psychological distress and improving quality of life. One is a coping skills training (CST) program provided by telephone. The other is an education program about critical illness that is accessed primarily online. Also, we will determine if unique groups of people with special characteristics have especially good improvement-and if so, what personal factors explain this response. How will we know which treatment is better? We will determine which treatment is most helpful by comparing participants' levels of psychological distress and quality of life with surveys taken over 6 months. We'll also record patients' own descriptions of how the treatments impacted their daily lives. The study will take 3 years and would be performed at 5 medical centers across the US that treat patients with diverse backgrounds and illnesses. 200 ICU survivor-family member pairs will be randomly assigned (like a coin flip) to receive either the CST program or the education program. Treatments consist of 6 weekly telephone calls with a trained staff member, web-based modules, and handouts. How will this help others in the future? This research is important because it aims to improve long-term recovery for entire families by focusing on a devastating, common, yet inadequately addressed problem. These treatments were developed with the direct input of patients and families. These treatments represent a new direction in treating critical illness because they can be delivered inexpensively by phone, easily adapted to future technologies, overcome barriers to care common to ICU survivors, and shared easily by phone or computer with others in need across the world.

Official Title
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Improving Psychological Distress Among Critical Illness Survivors and Their Caregivers

Conditions
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Intensive Care Unit Survivors, Informal Caregivers (Family and Friends)

Intervention / Treatment
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* Behavioral: coping skills training
* Other: education program


Participation Criteria
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Eligibility Criteria
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Patient inclusion criteria: age >=18 and mechanical ventilation for more than 48 consecutive hours Patient exclusions (pre-consent): current significant cognitive impairment (>=3 errors on the Callahan scale) or lacks decisional capacity pre-existing significant cognitive impairment residence at location other than home before hospital admission need for a translator because of poor English fluency [many study instruments are not validated in other languages] expected survival <3 months discharged to hospice (outpatient or inpatient) not liberated from mechanical ventilation at discharge Additional patient exclusion criteria (present post-consent but pre-randomization): Patients will become ineligible if they become too ill to participate they develop significant cognitive disability, exhibit suicidality, they do not return home within 2 months after hospital discharge, or die. Informal caregiver inclusion criteria: age >=18 years person most likely to provide the most post-discharge care. Exclusions for caregivers are: history of significant cognitive impairment English fluency poor enough to require a medical translator Informal caregiver exclusion criteria present after consent but before randomization: no longer available become too ill to participate exhibit suicidality A total of 200 patient-caregiver dyads (total cohort = 400) are targeted

Ages Eligible for Study
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Minimum Age: 18 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: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Coping skills training<br>6 sessions of weekly telephone-based coping skills training delivered by trained interventionist | Behavioral: coping skills training<br>* 6-session coping skills training program delivered by telephone w/ web augmentation<br>|
| Active Comparator: education program<br>6 week access to a web-based, critical illness-specific education program | Other: education program<br>* web-based, ICU-specific education program<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hospital Anxiety and Depression Scale Score | Hospital Anxiety and Depression Scale (HADS) questionnaire: The HADS is a fourteen item scale. Seven of the items relate to anxiety and seven relate to depression. The anxiety and depression subscales each range from 0 to 21, with higher scores indicating higher anxiety/depression complains. Patients were defined as having anxiety or depression or both if the score was 8 or more in the corresponding subscale. The 3 month measure is primary outcome timing, though changes at 6 months will be tested as well | 3 & 6 months post-randomization | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Impact of Events Scale-revised (IES-R) Score | The IES-R evaluates subjective distress caused by traumatic events and assesses manifestations of post-traumatic stress disorder (PTSD) or acute stress disorder. It is not diagnostic but possesses excellent reliability and validity for manifestations of PTSD. The IES-R has three subscales (eight items on intrusion, eight items on avoidance, and six items on hyperarousal). Each item is scored on a four point scale: 0 = not at all, 1 = a little bit, 2 = moderately often, 3 = quite a bit, and 4 = extremely often. The total score of each subscale may be averaged and a cumulative score of 30 is indicative of the presence of PTSD. The maximum score for each subscale is 32 for intrusion, 32 for avoidance, and 24 for hyperarousal. The minimum cumulative score is 0 and the maximum cumulative score possible is 88.3 months post-randomization is main time point while The 3 month IES-R score will be the primary analysis, though 6 month changes will be tested as well. | 3 & 6 months post-randomization | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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coping, acute respiratory failure, critical illness, depression, anxiety, post-traumatic stress, intensive care unit