Delivering Cognitive Behavioral Therapy for Post–Intensive Care Syndrome–Family via a Mobile Health App

Amy Petrinec, PhD, RN; Cindy Wilk, MSN, RN; Joel W. Hughes, PhD; Melissa D. Zullo, PhD, MPH, MA; Yea-Jyh Chen, PhD, RN; Patrick A. Palmieri, PhD


Am J Crit Care. 2021;30(6):451-458. 

In This Article

Abstract and Introduction


Background: Family members of intensive care unit (ICU) patients are at risk for post–intensive care syndrome–family (PICS-F), including symptoms of anxiety, depression, and posttraumatic stress. Cognitive behavioral therapy is the first-line nonpharmacologic treatment for many psychological symptoms and has been successfully delivered by use of mobile technology for symptom self-management.

Objectives: To determine the feasibility of delivering cognitive behavioral therapy through a smartphone app to family members of critically ill patients.

Methods: This was a prospective longitudinal cohort study with a consecutive sample of patients admitted to 2 adult ICUs and their family members. The control group period was followed by the intervention group period. The intervention consisted of a mobile health app preloaded on a smartphone provided to family members. The study time points were enrollment (within 5 days of ICU admission), 30 days after admission, and 60 days after admission. Study measures included demographic data, app use, satisfaction with the app, mental health self-efficacy, and measures of PICS-F symptoms.

Results: The study sample consisted of 49 predominantly White (92%) and female (82%) family members (24 intervention, 25 control). Smartphone ownership was 88%. Completion rates for study measures were 92% in the control group and 79% in the intervention group. Family members logged in to the app a mean of 18.58 times (range 2–89) and spent a mean of 81.29 minutes (range 4.93–426.63 minutes) using the app.

Conclusions: The study results confirm the feasibility of implementing app-based delivery of cognitive behavioral therapy to family members of ICU patients.


Nearly 6 million patients are admitted to the intensive care unit (ICU) each year in the United States.[1] Although most patients leave after a brief stay, 20% to 39% require mechanical ventilation and a potentially prolonged stay.[2] Family members of these critically ill adult patients are at risk of developing clinically significant psychological distress now called post–intensive care syndrome–family (PICS-F), which includes symptoms of anxiety, depression, posttraumatic stress, and complicated grief.[3]

The prevalence of PICS-F symptoms can be as high as 69% within the first 6 months of ICU hospitalization and has been documented up to 4 years after the ICU illness.[4–14] Identification and treatment of PICS-F symptoms has been recognized by the Society of Critical Care Medicine, the leading critical care organization in the United States, and is addressed in their current clinical guidelines.[15,16] PICS-F reduces the quality of life of families of critically ill patients and may impede the patient's recovery.[9,10,17]

Cognitive behavioral therapy (CBT) is a form of therapy emphasizing cognitive and behavioral strategies directed at correcting unhelpful appraisals of stressful events and their influence on emotions and active coping behaviors for responding to distress.[18] This type of therapy has become a first-line nonpharmacologic treatment for symptoms of a growing list of mental health problems, including depression, anxiety, posttraumatic stress, substance misuse, and eating disorders.[19] Delivery of CBT programs through mobile health solutions has been shown to be efficacious, cost-effective, and well-accepted by individuals with mild-to-moderate symptoms of depression, anxiety, and posttraumatic stress.[20–23] With the development and rapid market growth of smartphone technology, mobile health apps delivering CBT have also demonstrated significant efficacy in treating a variety of symptoms, including anxiety, depression, and posttraumatic stress.[24–27] Similar to the effects of in-person CBT, the effectiveness of using a mobile health app for self-management of symptoms of anxiety and depression appears to be mediated by improvements in mental health self-efficacy,[28] which accords with Bandura's social learning theory.[29] Despite the effectiveness of mobile health delivery of CBT in various populations of individuals experiencing anxiety, depression, or posttraumatic stress, the effectiveness of this mode of delivery has not been examined in family members at risk for PICS-F symptoms.

We aimed to determine whether delivery of CBT via a mobile health app can be integrated into the support provided to family members of critically ill patients during and after the ICU hospitalization. Our study sought to answer the following questions: (1) What is the prevalence of smartphone ownership among family members of ICU patients? (2) How much would family members of ICU patients use the mobile health app during the course of the study? (3) How satisfied were family members with the mobile health app? and (4) What is the completion rate of follow-up measures of PICS-F among family members of ICU patients? The secondary outcomes we examined were changes in PICS-F symptoms, health-related quality of life (HRQOL), and mental health self-efficacy during the course of the study and differences between the intervention and control groups.