Factors Predicting Poor MH Health Identified in ICU Caregivers

Individuals recovering from serious illness or injury—the kind that requires an extended stay in an intensive care unit (ICU)—face a long road back to health and depend heavily on the support of their family and friends.

But this support often comes with a price for the caregivers, and studies have linked caregiver assistance with outcomes including emotional distress, poor quality of life, and symptoms of posttraumatic stress disorder. These outcomes start a vicious cycle, said Babar Khan, M.D., an assistant professor of medicine at Indiana University School of Medicine, who specializes in both pulmonary and critical care medicine.

“Once caregivers begin experiencing distress, they can no longer provide all the support the patient needs, which hinders rehabilitation and makes the environment even more difficult for caregivers,” he said.

A study published May 12 in the New England Journal of Medicine illustrates some of the severe and lasting neuropsychological problems facing caregivers of critically ill patients and provides evidence of the risk factors affecting these outcomes, which can lead to strategies to mitigate or prevent them.

These findings come from a multi-center Canadian program called RECOVER that enrolled 280 caregivers of ICU survivors who had been on mechanical ventilation for at least seven days (one primary caregiver was recruited per patient). The caregiver/patient dyads were then assessed four times over the course of a year (at seven days and then three, six, and 12 months after hospital discharge) on a variety of physical and psychological measures.

The analysis found that depression was common and chronic among the caregivers: 67 percent reported depressive symptoms after a week of caregiving, while 43 percent were still depressed after one year.

The researchers, led by Jill Cameron, Ph.D., an associate professor in the Department of Occupational Science and Occupational Therapy at the University of Toronto, were also able to identify two types of trajectories for the caregivers. The depressive symptoms of 84 percent of the caregivers decreased over time but persisted in 16 percent of the caregivers at the same level for the whole year. Also, this group on average had higher clinical depression scores.

The researchers also noted that patient characteristics had no bearing on caregiver outcomes; rather, certain caregiver characteristics were more suggestive of who might be prone to worse outcomes.

Over the course of the year, caregivers fared psychologically better if they were older, had income higher than $39,000 U.S., were caring for a spouse, had lots of social support, felt a greater sense of control over the situation, and felt that caregiving had less impact on other life activities.

Cameron noted that the last three elements showed especially strong associations with caregivers’ mental health and also might be the factors that could identify those caregivers at risk of persistent depression.

She said that these findings show that ICU centers should not use the severity of injury as the primary driver in determining how closely to follow up with patients and caregivers once they are discharged.

“Caregivers are not a uniform body of individuals,” she pointed out, “and we need more family-centered models of care that can address the different and unique needs of every caregiving situation.”

Though he was not involved in the study, these findings are of great personal interest to Khan, who is the medical director of Indiana’s Eskenazi Health Critical Care Recovery Center (CCRC)—a model started in 2011 that espouses Cameron’s sentiments and focuses on both the physical and mental recovery of ICU survivors (Psychiatric News, June 5, 2015).

“As part of the CCRC model, we always include a family conference shortly after discharge in which the patient and the family meet all the therapists, physical and cognitive, and develop a care plan for both patient and caregivers,” he told Psychiatric News.

The planning goes beyond medical care, as the CCRC tries to assist with matters like financial planning and crisis management, he added. And information like this will enable them to create more individualized regimens that can minimize the tremendous burden facing ICU survivors.

The RECOVER analysis was supported by grants from the Canadian Institutes of Health Research, the Ontario Academic Health Science Center and Ministry of Health Education Fund, and the University of Toronto Department of Medicine Integration Challenge Fund. ■