Chronic Obstructive Pulmonary Disease (COPD) is prevalent and debilitating chronic disease in Veterans. COPD is highly co-morbid with depression and anxiety conferring greater morbidity and mortality risk. Physical activity is a modifiable behavior that can improve COPD outcomes. However, to date, interventions targeting physical activity have not addressed the high comorbidity between COPD and depression and/or anxiety symptoms ("emotional distress") despite emotional distress predicting poorer response to physical activity interventions. This CDA-2 proposal will develop and test the acceptability and feasibility of an integrative physical activity and mental health intervention for Veterans with COPD, emotional distress, and low physical activity. The intervention will be delivered via VA Video Connect enabling access to care among Veterans with substantial barriers to hospital-based outpatient care.

The current study will develop and test Step-Cognitive Behavioral Therapy (CBT) (Step-CBT), an integrated intervention that draws from existing pedometer-based physical activity (PA) interventions and brief CBT to target low PA, emotional distress, and physical disability in Veterans with chronic obstructive pulmonary disease (COPD) delivered via VA Video Connection (VVC). This study has three components: In Aim 1, we will conduct a cross-sectional study with 50 Veterans with COPD, low PA, and clinically significant depression and/or anxiety symptoms. Self-report measures will be collected and provide information on mean level and magnitude of the relations between PA, emotional distress, and physical disability. Participants will wear an ActiGraphy device for 14 days following their in-person session to measure objective PA. Based on these data, we will create Step-CBT, an intervention that integrates, tailors, and adapts a pedometer-based PA intervention and brief CBT (existing transdiagnostic protocol), based on patient interviews and current literature. In Aim 2, we will examine the acceptability of Step-CBT, an 8-session intervention delivered via VVC, in Veterans (N=6) collecting recruitment, enrollment, completion data and measures of physical functioning and emotional distress. We will conduct expert panel review of the manualized intervention protocol and acceptability results. In Aim 3, we will assess the feasibility of Step-CBT in a proof-of -concept study design in Veterans (N=40 enrolled with target of 25 completers) with COPD, low physical activity, and clinically significant depression and/or anxiety symptoms. The current research has great potential to improve physical and psychological functioning in Veterans with COPD through the development of an integrated PA-mental health intervention. Step-CBT delivered to patient's homes, would offer a safe option to increase/maintain physical functioning and mental health in Veterans with COPD.

Inclusion Criteria:

• Any gender-identified, greater than or equal to 40 years of age
• Clinical diagnosis of COPD defined as the presence of emphysema on a CT scan and one piece of clinical evidence of COPD (defined as a ratio of FEV1 to forced vital capacity < 0.70, > 10 pack-year cigarette smoking history, overall assessment of COPD in their problem list or in Pulmonary/Primary Care notes, or on bronchodilators (specifically antimuscarinics such as Tiotropium or Ipratropium). If there is no evidence of emphysema, or no CT on scan in their medical chart, three pieces of clinical evidence of COPD will suffice for a clinical diagnosis of COPD.
• Ability to communicate
• Able to participate in in-person study appointment at the VA
• English speaking
• Competent to provide informed consent
• Emotional distress. Clinically significant depression and/or anxiety defined as PHQ-8 > 10 and/or Beck Anxiety Inventory > 13
• Wireless Internet connection and Bluetooth capability
• Participants with > 90% accuracy of device Fitbit to manual step counts
• Agreeable to audio record study session
• Agreeable to wearing an ActiGraphy device and Fitbit and downloading the Fitbit app
• Email user for VVC visits links
• Either owns a smartphone or iPad compatible with the Fitbit app and enabled with Bluetooth or agreeable to using a study-issued iPad with Wi-Fi and Bluetooth capabilities
• Medical clearance from healthcare provider to participate in a physical activity program

Exclusion Criteria:

• COPD exacerbation in the previous 1 month
• Inability to ambulate
• Regular use of a rollator, walker, or wheelchair for ambulation
• Inability to complete questionnaires
• Inability to collect at least 4 valid days of 7-day baseline step count data
• Positive screening on the Mini-Cog defined as < 3 indicating possible cognitive impairment or dementia or major neurocognitive disorder diagnosis in electronic medical chart or refusal to complete the assessment
• Currently enrolled in another interventional study targeting exercise, physical activity, or mental health
• Average baseline step counts of greater than or equal to 10,000 steps per week
• Suicide flag in chart
• Oxygen saturation after 6-Minute Walk Test documented to be <85%