ICU Patients at High Risk for Depression, Anxiety, PTSD

Two-thirds of the patients who survived acute respiratory distress syndrome and spent time in the ICU self-reported symptoms of at least one of these psychiatric disorders. The disorders can dog patients months after they’ve left the hospital, research shows.

Intensive care patients who survive life threatening illnesses remain at high risk for persistent bouts of depression, anxiety and post-traumatic stress disorder months after leaving the hospital, especially if they’re young, female, and jobless, according to a recent study from Johns Hopkins University.

The multi-institutional, national study involving more than 40 hospitals, which appears in the May issue of Critical Care Medicine, examined nearly 700 ICU patients. Two-thirds of the patients who survived acute respiratory distress syndrome (ARDS) and spent time in the ICU self-reported symptoms of at least one of these psychiatric disorders, and one-third of those patients with at least one psychiatric symptom said they experienced all three at the same time.

The report shows that these psychiatric disorders can dog patients months after they’ve left the hospital. Based on their self-reporting at six months, 36% of participants showed signs of depression, 42% showed signs of anxiety and 24% showed signs of PTSD. At 12 months, prevalence of these symptoms was nearly the same: 36%, 42%, and 23%, respectively.

Of the patients who experienced symptoms of depression, anxiety, or PTSD at six months, more than one-half, 57% to 66%, still had the same symptoms at 12 months, indicating the persistence of the symptoms.

Of the patients at six months without substantial symptoms of depression, anxiety, or PTSD, less than 15% later developed symptoms by the one-year mark. Most important, the researchers say, the majority of survivors, 63%, with any psychiatric illness experienced two or more symptoms at the same time at both six and 12 months.

A total of 645 survivors underwent a phone-based assessment to collect data for this study at the six-month follow-up, and 606 had a similar follow-up at one year. A total of 613 completed at least one psychiatric measure at six months by using the Hospital Anxiety and Depression Scale and the Impact of Event Scale-Revised (IES-R) surveys. There were 316 female and 297 male participants with an average age of 49, 82% of whom were white. At the one-year follow-up, 576 participants completed at least one psychiatric self-assessment.

The younger age group was 16% and 23% more likely to experience anxiety or PTSD, respectively, than the next older age group. Female patients are at 26%, 43%, and 80% higher risk than male patients for depression, anxiety, and PTSD symptoms, respectively.

Study coauthors Dale Needham, MD, professor of medicine and Joseph Bienvenu, MD, associate professor of Psychiatry and Behavioral Sciences, traded emails with HealthLeaders Media about their findings.

HLM: What is it about the ICU experience that prompts such levels of psychiatric distress?

Authors: There are many different factors hypothesized to be associated with these psychiatric symptoms, including:

• Experiencing a life-threatening situation while in a highly vulnerable state without the ability to effectively communicate and access usual coping skills;
• Physiological issues such as widespread inflammation; with potential break down of the blood brain barrier
• Endogenous and exogenous hormonal effects like cathecholamines and corticosteroids.

HLM: Why does psychiatric distress disproportionately affect women?

Authors: These findings are consistent with psychiatric literature outside of the ICU setting as well. Our study indicates that greater symptoms in women may be due to a higher prevalence of pre-ICU psychiatric symptoms, which is consistent with the psychiatric epidemiology literature that demonstrates women (compared to men) have high prevalence of anxiety and depressive disorders, and low prevalence of substance use disorders.  Also there may be differences between men versus women in how psychiatric symptoms manifest and can be detected. 

HLM: Can you determine how many of these patients are in psychiatric distress before they enter the ICU?

Authors: Most ICU studies are unable to do this because these symptoms can’t be measured prior to the onset of critical illness given the unexpected onset of critical illness. There are a few unique studies that have followed large cohorts of patients over time with repeated measures of psychiatric symptoms.  For patients who were in the ICU, these studies have shown an increase in symptoms after the ICU compared to before ICU.

HLM: Is it the ICU experience that prompts this psychiatric distress?

Authors: These patient outcomes are likely a combination of pre-existing symptoms as well as the ICU experience. However, the ICU experience can’t be separated from the experience of being critically ill.  For instance, in addition to the frightening experiences patients have while delirious in the ICU, they are also on the verge of death and unable to interpret what clinicians are doing to keep them alive.

HLM: Why did you focus on ARDS?

Authors: ARDS is an archetypal critical illness. In focusing on ARDS, we reduce some of the heterogeneity in the many different types of patients in the ICU. Moreover, by studying ARDS, we select for patients who are more severely ill and have risk factors for worse outcomes due to issues such as hypoxia and inflammation.

HLM: What should hospitals do to alleviate this psychiatric distress?

Authors: The results of our research are helpful in identifying patients who may be at risk. Identification of early symptoms should prompt further investigation for psychiatric problems.  Investigation for psychiatric problems should be broad since patients may have more than one psychiatric condition simultaneously (for example, symptoms of depression and PTSD together).  Moreover, the focus should NOT be exclusively on older or sicker patients, or on those with longer length of stay, since ICU severity of illness measures are not associated with worse psychiatric symptoms.

HLM: Should a psychiatric evaluation be a routine part of discharge planning?

Authors: At this stage, it is too early to recommend a specific standardized method for screening all patients for psychiatric symptoms as part of discharge planning.  However, if such symptoms are apparent as part of clinical care, that should prompt further investigation.