Investigating risk factors for psychological morbidity three months after intensive care: a prospective cohort study

Abstract

IntroductionThere is growing evidence of poor mental health and quality of life among survivors of intensive care. However, it is not yet clear to what extent the trauma of life-threatening illness, associated drugs and treatments, or patients' psychological reactions during intensive care contribute to poor psychosocial outcomes. Our aim was to investigate the relative contributions of a broader set of risk factors and outcomes than had previously been considered in a single study.MethodsA prospective cohort study of 157 mixed-diagnosis highest acuity patients was conducted in a large general intensive care unit (ICU). Data on four groups of risk factors (clinical, acute psychological, socio-demographic and chronic health) were collected during ICU admissions. Post-traumatic stress disorder (PTSD), depression, anxiety and quality of life were assessed using validated questionnaires at three months (n =100). Multivariable analysis was used.ResultsAt follow-up, 55% of patients had psychological morbidity: 27.1% (95% CI: 18.3%, 35.9%) had probable PTSD; 46.3% (95% CI: 36.5%, 56.1%) probable depression, and 44.4% (95% CI: 34.6%, 54.2%) anxiety. The strongest clinical risk factor for PTSD was longer duration of sedation (regression coefficient = 0.69 points (95% CI: 0.12, 1.27) per day, scale = 0 to 51). There was a strong association between depression at three months and receiving benzodiazepines in the ICU (mean difference between groups = 6.73 points (95% CI: 1.42, 12.06), scale = 0 to 60). Use of inotropes or vasopressors was correlated with anxiety, and corticosteroids with better physical quality of life.The effects of these clinical risk factors on outcomes were mediated (partially explained) by acute psychological reactions in the ICU. In fully adjusted models, the strongest independent risk factors for PTSD were mood in ICU, intrusive memories in ICU and psychological history. ICU mood, psychological history and socio-economic position were the strongest risk factors for depression.ConclusionsStrikingly high rates of psychological morbidity were found in this cohort of intensive care survivors. The study's key finding was that acute psychological reactions in the ICU were the strongest modifiable risk factors for developing mental illness in the future. The observation that use of different ICU drugs correlated with different psychological outcomes merits further investigation. These findings suggest that psychological interventions, along with pharmacological modifications, could help reduce poor outcomes, including PTSD, after intensive care.

Depressive, Angst- und posttraumatische Belastungsstörungen als Konsequenzen intensivmedizinischer Behandlung

“…Sowohl auf einer Symptomals auch auf einer Störungsebene zeichnet sich für diese affektive Morbidität eine oft langwierige Persistenz ab. Diese wird in einigen prospektiven Longitudinalstudien mit sukzessiven Messzeitpunkten für die ersten Monate nach überstandener intensivpflichtiger Erkrankung [4,5] bis zu 1 und 2 Jahren im weiteren Verlauf [6][7][8], in einigen Follow-up-Studien auch über einen sehr viel längeren Zeitraum nachgewiesen [9,10].…”

“…B. eine zuweilen extrem erschwerte Interviewsituation, die unsichere Bewertung gerade der somatischvegetativen Symptome eines depressiven Syndroms im Hinblick auf die Schwere der somatischen Erkrankung und den speziellen Behandlungskontext, noch nicht erfüllte Zeitkriterien oder aber die oft nicht mögliche Abgrenzung gegenüber deliranten Syndromen. Trotzdem scheinen die Prävalenzraten depressiver Störungen auch schon zu diesem Zeitpunkt bedeutsam erhöht zu sein [4,12]. Sie können bei jenen Patienten mit [7,8,17].…”

“…In einer ebenfalls prospektiven Beobachtungsstudie prädizierte das Ausmaß der mit der PTSD-Checklist gemessenen akuten Belastungssymptome auch ausgeprägte kognitive Beeinträchtigungen im Follow-up [17]. Akute Belastungssymptome sind hoch prädiktiv für depressive Störungen und PTSD [4].…”

“…Überlebende Intensivpatienten haben zuweilen aber nur wenige reale Erinnerungen speziell an die Aufnahmesituation und die erste Zeit auf der Intensivstation [4,60]. Eine Amnesie an die frühen Abschnitte der intensivmedizinischen Behandlung gilt als ein Risikofaktor im Hinblick auf das spätere PTSD-Risiko [61].…”

Posttraumatic Stress Syndrome Associated With Stays in the Intensive Care Unit: Importance of Nurses’ Involvement

“…2,3 Critically ill patients in whom PTSD develops may have a more complicated recovery than do other patients because the disorder is associated with higher rates of coronary heart disease, chronic pain, gastrointestinal disorders, arthritis, and decreased quality of life. [4][5][6][7] In this literature review, we examine the phenomenon of PTSD and the risk factors and complications associated with ICU-related PTSD to help nurses recognize the factors that place critically ill patients at risk.…”