The Coma Family Program (COMA-F): A Resilience Program for Caregivers of Patients With Severe Acute Brain Injury

• Coma Family Program 1 (Behavioral): This intervention provides skills training to manage distress, uncertainty, and long-term caregiving challenges.
• Coma Family Program 2 (Behavioral): This involves education (but no skills training) about managing caregiving distress, uncertainty, and long-term challenges.

Primary outcomes

• Hospital anxiety and depression scale [baseline, 6-weeks, and 3-month follow-up]: Measures anxiety and depression. Anxiety and depression sub scales each range from 0 (minimum) to 21 (maximum) with higher scores meaning worse outcome.

Secondary outcomes

• Posttraumatic stress disorder checklist-5 [baseline, 6-weeks, and 3-month follow-up]: measures posttraumatic stress symptoms. Scores range from 0 (minimum) to 80 (maximum) with higher scores indicating worse outcome.
• World Health Organization Quality of Life-Short Form [baseline, 6-weeks, and 3-month follow-up]: Measures quality of life across four domains, physical, psychological, social, and environmental. Scores on each sub scale range from 0 (minimum) to 100 (maximum) with higher scores indicating better outcome.

Other outcomes

• Cognitive and Affective Mindfulness Scale [baseline, 6-weeks, and 3-month follow-up]: measures dispositional mindfulness. Scores range from 12 (minimum) to 48 (maximum), with higher scores indicating better outcome (greater dispositional mindfulness).
• Applied Mindfulness Process Scale [baseline, 6-weeks, and 3-month follow-up]: measures applied mindfulness. Scores range from 0 (minimum) to 60 (maximum) with higher scores indicating better outcome (more frequent application of mindfulness skills in daily life).
• Measure of Current Status-A [baseline, 6-weeks, and 3-month follow-up]: measures adaptive coping. Scores range from 0 (minimum) to 4 (maximum) with higher scores indicating better outcome (better use of adaptive coping skills).
• Intolerance of Uncertainty Scale Short Form [baseline, 6-weeks, and 3-month follow-up]: Measures intolerance of uncertainty. Scores range from 12 (minimum) to 60 (maximum) with higher scores indicating worse outcome (greater intolerance of uncertainty).
• Zarit Burden Interview Short Form [baseline, 6-weeks, and 3-month follow-up]: Measures caregiver burden. Scores range from 0 (minimum) to 48 (maximum) with higher scores indicating worse outcome (greater caregiver burden).

Sex: All, ages: 18 Years to any

Inclusion Criteria:

1. 18 years or older - study population
2. English fluency and literacy - measures and intervention are in English
3. Screens positive for emotional distress on either depression or anxiety subscales (>7) of the Hospital Anxiety and Depression scale - study population (caregivers must be at-risk for chronic distress via heightened acute distress)
4. Confirmed by the clinical team as the primary caregiver of a patient who has been admitted to an intensive care unit (ICU) with a severe acute brain injury with the following characteristics:

   1. 18 years or older - study population
   2. Admitted with ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, traumatic brain injury, or hypoxic-ischemic encephalopathy - study population
   3. Glasgow Coma Scale score below 9 (in judgement of the clinical team) while not intubated or an inability to follow meaningful commands while intubated at any point during the hospitalization for > 24 consecutive hours due to the brain injury itself and not a confounding factor (e.g., sedation or seizures) - study population
   4. Still alive in ICU at the time the clinical team approaches the caregiver about possible recruitment - excludes caregivers of those that passed away as would require a different intervention (e.g., grieving intervention)
   5. Has been committed to or has already received long-term life-sustaining treatments including tracheostomy and/or percutaneous endoscopic or surgical gastrostomy tube placement (trach or PEG) - study population; at time of enrollment patients can be in various early stages of cognitive/functional recovery from initial coma, but all were severe enough to require trach and/or PEG
   6. Has a prognosis for survival of greater than 3 months and does not have a concurrent diagnosis of a terminal illness or injury as judged by the clinical team - as in "d"; such caregivers would require different intervention
   7. Is still in ICU or has been transferred to a lower level of care (e.g., stepdown) for <7 days at the time of consent - study population; we aim to begin the intervention when caregivers are acutely distressed in the context of the patient's ICU stay or shortly after the ICU stay (i.e., within 7 days of leaving)

Exclusion Criteria:

* 1\. Serious mental illness, substance misuse, or active suicidal intent or plan - requires higher level of care