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

Study Description

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Brief Summary:

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.

Condition or disease	Intervention/treatment	Phase
Respiratory Insufficiency; Depression; Rehabilitation; Critical Care	Behavioral: Behavioral Activation - Rehabilitation	Not Applicable

Detailed Description:

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 are no randomized controlled trials (RCT), in ARF survivors, evaluating any intervention for depression. To improve mental and physical health outcomes in ARF survivors, the following gaps within existing patient-oriented research must be addressed: 1) interventions to improve depressive symptoms and associated physical functioning impairments, 2) evaluation of modifiable psychosocial risk factors for depressive symptoms, and 3) validation of screening instruments to assess depressive symptoms. This K23 application, by Ann Parker, MD, aims to address these gaps by designing and conducting a pilot RCT (Aim 1) of an intervention combining Behavioral Activation and physical rehabilitation (delivered via telephone and 2 home visits over 12-weeks) versus a "usual care" control group, and evaluating its feasibility (primary outcome) and efficacy to reduce depressive symptoms and improve physical functioning (secondary outcomes). Behavioral Activation, as proposed for this pilot RCT, is an evidence-based psychological treatment for depression, which increases adaptive behaviors to achieve patient-valued goals. Using the combined patient cohort from the intervention and control groups of the RCT, Dr. Parker also will evaluate modifiable psychosocial risk factors for depressive symptoms in ARF survivors and the association between the intervention and these modifiable factors (Aim 2), and the measurement properties of two commonly used depression screening instruments in ARF survivors versus a "gold standard" clinician diagnostic interview that she will be trained to perform (Aim 3).

Dr. Parker, an Instructor in Pulmonary and Critical Care Medicine at Johns Hopkins University, has the long-term career goal of becoming an independent, NIH-funded patient-oriented researcher in ARF, focused on the intersection of mental and physical health and multidisciplinary behavioral interventions, consistent with the most recent NHLBI Strategic Vision. This award will allow Dr. Parker to achieve the following training goals: 1) obtain practical experience designing and conducting a pilot RCT; 2) undertake didactic and mentored training in psychosocial research and related behavioral interventions; 3) establish local and national collaborations with experts in mental and physical outcomes of ARF survivors; and 4) obtain preliminary data and experience to submit a successful R-level grant. Via this award, Dr. Parker will expand on her prior coursework in biostatistics and epidemiology and expand her existing mentorship team to include additional national leaders with a strong track record of fostering successful academic careers, to allow her to establish independence in investigating the unique intersection of physical and mental health outcomes in ARF.

Study Design

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Study Type :	Interventional (Clinical Trial)
Estimated Enrollment :	54 participants
Allocation:	Randomized
Intervention Model:	Parallel Assignment
Masking:	Single (Outcomes Assessor)
Primary Purpose:	Treatment
Official Title:	A Pilot, Feasibility Randomized Controlled Trial of a Behavioral Activation And Rehabilitation Intervention To Improve Psychological And Physical Impairments In Acute Respiratory Failure Survivors
Actual Study Start Date :	March 2, 2018
Estimated Primary Completion Date :	June 2021
Estimated Study Completion Date :	June 2021

Arms and Interventions

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Arm	Intervention/treatment
Experimental: Behavioral Activation - Rehabilitation; Behavioral Activation - Rehabilitation	Behavioral: Behavioral Activation - Rehabilitation; 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.
No Intervention: Usual Care Control; Usual Care Control

Outcome Measures

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Primary Outcome Measures :

1. Feasibility measure per participant [ Time Frame: End of intervention (12 weeks) ]
   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.
2. Total feasibility measure [ Time Frame: End of intervention (12 weeks) ]
   Total number of intervention phone calls completed by all study participants as a proportion of total intervention phone calls expected in the study
3. Feasibility measure/Assess loss to follow-up [ Time Frame: End of intervention (12 weeks) ]
   Number of patients completing all study follow-up sessions as a proportion of the number of patients enrolled.
4. Feasibility measure [ Time Frame: End of intervention (12 weeks) ]
   Number of patients enrolled per month

Secondary Outcome Measures :

1. Hospital Anxiety and Depression Scale (HADS) [ Time Frame: End of intervention (12 weeks) ]
   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.
2. Personal Health Questionnaire - 8 item version (PHQ-8) [ Time Frame: End of intervention (12 weeks) ]
   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.
3. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (SCID-5) [ Time Frame: End of intervention (12 weeks) ]
   A clinical interview to assess depressive symptoms. This is a qualitative assessment.
4. Activity Measure for Post-Acute Care Computer Adaptive Test (AMPAC-CAT) [ Time Frame: Baseline, end of intervention (12 weeks) ]
   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.
5. EQ-5D-5L [ Time Frame: End of intervention (12 weeks) ]
   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).
6. Healthcare Utilization [ Time Frame: End of intervention (12 weeks) ]
   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
7. Brief Coping with Problems Experienced (Brief COPE) [ Time Frame: Baseline, end of intervention (12 weeks) ]
   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).
8. Behavioral Activation for Depression SCALE (BAS) [ Time Frame: Baseline, end of intervention (12 weeks) ]
   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.
9. Connor-Davidson Resilience Scale (CD RISC) [ Time Frame: Baseline, end of intervention (12 weeks) ]
   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.
10. Number of phone attempts needed by the OT to reach the participant for each session [ Time Frame: End of intervention (12 weeks) ]
    Measure of adherence
11. Proportion of sessions fully completed and partially completed [ Time Frame: End of intervention (12 weeks) ]
    Measure of adherence
12. Montreal Cognitive Assessment (MoCA) - BLIND [ Time Frame: End of intervention (12 weeks) ]
    Measure of cognitive impairment
13. Impact of Events Scale - Revised (IES-R) [ Time Frame: End of intervention (12 weeks) ]
    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).

Eligibility Criteria

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Ages Eligible for Study:	18 Years to 100 Years (Adult, Senior)
Sexes Eligible for Study:	All
Accepts Healthy Volunteers:	No

Criteria

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):

  1. Mechanical ventilation via an endotracheal tube or tracheostomy > 12hrs (and not ventilator-dependent before admission) OR
  2. Non-invasive ventilation (CPAP, BiPAP) > 4 hours in a 24 hour period provided for acute respiratory failure (not for OSA or other stable use) OR
  3. High flow nasal cannula with 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 IQ-CODE 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

Contacts and Locations

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Study Description Study Design Arms and Interventions Outcome Measures Eligibility Criteria Contacts and Locations More Information

Contacts

Contact: Albahi M Malik	4109558706	amalik37@jhmi.edu

Locations

United States, Maryland
Johns Hopkins University	Recruiting
Baltimore, Maryland, United States, 21205

Sponsors and Collaborators

Johns Hopkins University

National Heart, Lung, and Blood Institute (NHLBI)

Investigators

Principal Investigator:	Ann M Parker, MD	Johns Hopkins University

More Information

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Study Description Study Design Arms and Interventions Outcome Measures Eligibility Criteria Contacts and Locations More Information

Responsible Party:	Johns Hopkins University
ClinicalTrials.gov Identifier:	NCT03431493 History of Changes
Other Study ID Numbers:	IRB00143231; K23HL138206 ( U.S. NIH Grant/Contract )
First Posted:	February 13, 2018
Last Update Posted:	March 19, 2018
Last Verified:	March 2018
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD:	No

Studies a U.S. FDA-regulated Drug Product:		No
Studies a U.S. FDA-regulated Device Product:		No

Additional relevant MeSH terms:

Respiratory Insufficiency; Respiratory Distress Syndrome, Adult; Pulmonary Valve Insufficiency; Respiration Disorders; Respiratory Tract Diseases	Lung Diseases; Heart Valve Diseases; Heart Diseases; Cardiovascular Diseases