The burden of mental health diseases in ICU survivors is substantial, a recent study has found, and can have lasting effects on well-being, and ability to return to their pre-illness level of functioning and health-related quality of life.
Six out of 10 patients experienced symptoms of anxiety, depression and PTSD, and more than half of those affected experienced co-occurrence of the conditions, said the researchers. A third of those affected developed these symptoms only beyond six weeks after hospital discharge.
A potentially modifiable association with psychological symptoms was frightening memories of the ICU stay, said the team, a collaboration between Nelson Mandela University, University of Pretoria, and Central University of Technology, Bloemfontein.
Because the post-ICU syndrome (PICS) – defined as a constellation of new or worsened impairments in physical, cognitive and/or mental health that persist beyond critical care and hospital discharge – are often more related to the patients’ ICU stay than the admission diagnosis, it can be unexpected.
In this single-centre prospective observational cohort study, published in the SA Medical Journal, consecutive patients admitted to the adult medical-surgical ICU at an urban tertiary hospital in the Eastern Cape were screened for eligibility.
At the time of ICU discharge, or shortly thereafter in the hospital ward, the following categories of patients were deemed eligible for recruitment: patients aged ≥18 years who required either >48 hours’ respiratory support (invasive or non-invasive mechanical ventilation, or high-flow nasal oxygen), or had an ICU stay >48 hours for shock and/or organ failure.
They were ineligible if they were prisoners, had a life expectancy that was gauged to be <6 months, lived >300 km from the enrolling centre, were unable to be interviewed in English or isiXhosa, had active or recent psychosis, were admitted for self-harm or with central neurological pathology, or had pre-existing cognitive impairment (as determined by the Short Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE).[7]
Data collected included demographic and clinical information, and the retrospective baseline HRQOL was determined by completing the RAND SF- 36 questionnaire (the SF-36).
Patients were followed up at six weeks and six months post hospital discharge. The interview included questions pertaining to the recollection of frightening memories, or being physically restrained, during the ICU admission. The Hospital Anxiety and Depression Score and the Impact of Events Scale – Revised (IES-R) were completed.
When completing the IES-R when screening for PTSD, patients were asked to answer in relation to their ICU stay and not to any traumatic events leading to ICU admission e.g, vehicle accident or interpersonal violence.
Enrolment and data collection took place from 1 August 2020 to 31 May 2022. The starting date was shortly after the peak of the first local pandemic wave, and the study period included the second and third waves of the pandemic.
A total of 107 of 150 enrolled patients completed the six-month follow-up visit and were included in the final analysis. There were no significant differences between the patients who were lost to follow-up due to non-attendance, and those who completed the six-month follow-up.
Overall, 63 (58.9%) of the 107 ICU survivors were affected by significant psychological symptoms at either one or both of the study visits. Overall, 59 (55%) were affected by significant symptoms of anxiety, 36 (33.6%) by symptoms of depression and 31 (30.0%) by symptoms of PTSD, at either one or both study visits.
At the six-week and six-month study visits, respectively, 26 (24.3%) and 25 (21.5%) of the patients experienced significant symptoms of at least two psychological conditions. Among those who had significant psychological symptoms at either study visit, the chances of also having significant symptoms of a second or third condition were 52.0% and 56.8%, respectively.
Forty-five patients were referred for psychological assessment, while the others declined referral. Although many patients with significant psychological symptoms at six weeks improved either spontaneously or with therapy, some experienced significant ongoing symptoms at the six-month study visit. In addition, there were also several new cases of significant symptoms of psychological conditions at the six-month follow-up.
The percentages of patients diagnosed with anxiety, depression and PTSD at six months were 30.5, 30.0 and 38.7, respectively.
Specifically, younger age was found to be a significant independent predictor of mental health symptoms, with the odds increasing by a factor of 1.05 per younger life year.
Other independent predictors were female sex, and admission diagnosis of physical trauma and frightening memories during their ICU admission. ICU length of stay was not an independent predictor of significant psychological symptoms. Although 52 (48.6%) patients had to be physically restrained at some stage during their ICU stage, memories of this were not associated with psychological impairment.
Only 28 patients received benzodiazepines for a median (IQR) of 2.5 (1 – 4) days. Although benzodiazepine use was not associated with psychological impairment, all five patients who had received it for longer than a week suffered from significant mental health symptoms on follow-up.
The study authors concluded that six out of every 10 ICU survivors were affected by significant symptoms of anxiety, depression and/or PTSD. The high incidence of psychological symptoms, as well as co-occurrence of symptoms, are in keeping with findings from studies from higher-income countries.
Symptoms of anxiety affected >5 out of every 10 patients at either, or both, the study visits.
ICU survivors and their families, as well as healthcare providers who follow up ICU survivors, should be made aware that new symptoms of depression, anxiety and PTSD may well appear only months after hospital discharge.
Being younger and female, an admission diagnosis of trauma and having frightening memories of the ICU stay were identified as risk factors for experiencing significant psychological symptoms at follow-up.
The association between psychological symptoms and a lower mental HRQOL underscores the burden of mental health disease among ICU survivors.
While definitive treatment for all components of PICS may not been established as yet, there certainly are proven therapeutic strategies for depression, anxiety and PTSD, found the study.
To improve their quality of life, it is imperative to screen ICU survivors for psychological symptoms, suggested the authors. Additionally, screening patients merely once at six weeks may be insufficient to identify those with later-onset symptoms.
Study details
Symptoms of anxiety, depression, and post-traumatic stress disorder 6 weeks and 6 months after ICU: Six out of 10 survivors affected
E van der Merwe, L Stroud, G Sharp, N van Vuuren, M Mosola, T Fodo, F Paruk.
Published in SA Medical Journal in July 2024
Background
Mental health conditions such as depression, anxiety and post-traumatic stress disorder (PTSD) are being increasingly recognised as common adverse outcomes for critical illness survivors. These conditions can have lasting consequences on their wellbeing, ability to return to their pre-illness level of functioning and health-related quality of life. There is a paucity of South African data in terms of the psychological aspects of the post-intensive care unit (ICU) syndrome.
Objective
To identify and characterise patients who suffered from significant symptoms of mental health disease and poor mental health-related quality of life after ICU admission and who may benefit from appropriate referral, further investigation and medical intervention.
Methods
Critically ill patients in a multidisciplinary tertiary ICU were prospectively enrolled upon ICU discharge. Survivors were screened for anxiety, depression and post-traumatic stress syndrome at 6 weeks and 6 months after hospital discharge. The Hospital Anxiety and Depression Score (HADS) and the Impact Of Events Scale – Revised (IES-R) were used as screening tools. The mental component summary score (MCS) of the RAND short form-36 was used to determine the effect of psychological symptoms on health-related quality of life (HRQOL).
Results
The median age of the 107 ICU survivors was 42 years, and half of them were admitted for complications of COVID-19. Six out of every 10 ICU survivors experienced significant symptoms of anxiety, depression and/or PTSD at follow-up. At the 6-month study visit, 4 out of every 10 patients were experiencing significant psychological symptoms. Those affected had a significantly lower mental HRQOL when compared with those who were unaffected. More than half of those affected had co-occurrence of psychological symptoms. Significant symptoms of anxiety were common, with 5 out of every 10 participants experiencing significant symptoms at either, or both, of the study visits. More than 3 out of 10 of affected patients’ symptoms only occurred after the 6-week visit. Associations for significant psychological symptoms comprised female sex, younger age, a diagnosis of trauma and frightening memories of the ICU admission.
Conclusion
The burden of mental health disease in ICU survivors is substantial, affecting their HRQOL. Six out of 10 patients experienced symptoms of anxiety, depression and PTSD, and more than half of those affected experienced co-occurrence of the conditions. A third of those affected developed these symptoms only beyond 6 weeks after hospital discharge. A potentially modifiable association with psychological symptoms was frightening memories of the ICU stay.
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Raised levels of PTSD in family of ICU Covid patients – US cohort study
Almost half of ICU staff battle mental health issues during pandemic — International study
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55% of former ICU patients report symptoms of psychological disorders