ICU Stays Can Result in Long-Lasting Mental Health Problems

Almost 6 million patients a year are admitted to an intensive care unit (ICU) in the United States, according to the Society of Critical Care Medicine (SCCM). The majority of those survive to be discharged. But for many of them, though their initial illness or injury may have been resolved, a new challenge awaits—a cluster of health problems commonly referred to as post-intensive care syndrome (PICS).

PICS problems can be physical—such as ICU-acquired weakness—or mental—including cognitive dysfunction, anxiety, depression, and posttraumatic stress disorder (PTSD).

Thirty percent to 80 percent of patients who leave the ICU have difficulty with memory, problem solving, organization, and decision making. Some improve during their first year post-ICU; others never fully recover, which can affect their ability to return to work or perform such everyday tasks as balancing a checkbook.

Other patients who have experienced an ICU stay may develop sleep disturbances, such as insomnia or nightmares. They also may feel depressed and anxious and, in extreme cases, may develop symptoms of PTSD including flashbacks and “triggers” such as lights and noise.

A study published October 3, 2013, in the New England Journal of Medicine found that approximately one-third of 800 patients followed for 12 months after their ICU stay had RBANS (Repeatable Battery for the Assessment of Neuropsychological Status) scores that were almost as severe as those found in individuals with moderate traumatic brain injury; a quarter of those studied had scores that were similar to those of mild Alzheimer’s patients. These findings were observed across all age ranges, and even among those with no previous mental health problems. The researchers concluded that patients in medical and surgical ICUs are at high risk for long-term cognitive impairment.

“ICU survivorship is a growing concern and a growing field of treatment and research,” said Babar Khan, M.D., of the Regenstrief Institute and the Indiana University Center for Aging Research in an interview with Psychiatric News. Khan is a principal investigator of a five-year, $3.2 million NHLBI-funded study of a mobile Critical Care Recovery Program (m-CCRP) and a critical care medicine physician and implementation scientist at the Indiana University Center for Health Innovation and Implementation Science.

M-CCRP is based on Khan’s experience in developing the Eskenazi Health Critical Care Recovery Center, an outpatient clinic that was the first collaborative care concept in the United States focusing on the many cognitive, physical, and psychological recovery needs of intensive care unit survivors.

According to Megan Schabbing, M.D., a psychiatrist with OhioHealth, the symptoms of PICS can persist for months, sometimes even years. Those at highest risk for developing PICS, Schabbing told Psychiatric News, are females and patients who were in severe respiratory distress while in the ICU and required mechanical ventilation, were heavily sedated, and immobile. Pre-existing mental health problems compound the risk.

“To minimize the possibility of developing PICS, ICU specialists should wean patients off medication and get them up and moving as soon as possible, even while still on a ventilator,” said Schabbing.

SCCM suggests that family members may also be able to help minimize the risk of PICS by helping their critically ill family member stay “oriented” by talking about familiar things, people, and events; mentioning the day, date, and time; bringing in pictures and items from home; and reading aloud at the bedside.

Keeping a diary or journal that can be reviewed later with the family member can also help the patient understand what has happened, clear up memories and answer questions, and reduce stress.

Families of ICU patients and survivors are also prone to developing anxiety, depression, and traumatic stress, according to Giora Netzer, M.D., co-author of “Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU,” published in the January issue of Critical Care Medicine.

Netzer, an associate professor of medicine, epidemiology, and public health at the University of Maryland School of Medicine, hopes that the guidelines will help increase the focus on the entire family as it goes through the intensive care experience.

“It’s a new commitment among physicians and reflects the large number of family support interventions that may improve care,” added Netzer, who is also a pulmonologist and critical care specialist at the University of Maryland Medical Center.

The guidelines were developed by a 29-member international panel of critical care, nursing, and public health experts. Among the recommendations are the following:

• Family presence in the ICU.

• Family education and instruction on how to assist with care.

• Communication between medical staff and family members to promote trust and lower the risks of anxiety, depression, and posttraumatic stress symptoms.

• Consultations between ICU team members including psychologists, psychiatrists, social workers, family navigators, and spiritual advisors.

• Support of family-centered care, such as providing space for family members to sleep.

Psychiatrists are vital members of a care team for PICS survivors and their families, noted Netzer. “They have the necessary experience in addressing the cognitive and mental health issues associated with PICS.”

“Psychiatrists are uniquely positioned to be an integral part of the interdisciplinary approach required to tackle PICS,” agreed Khan. He added that psychiatrists can have an even greater impact by educating and consulting with other mental health professionals, medical-surgical subspecialties, and subspecialties such as palliative care.

As the issue of post-intensive care syndrome becomes more recognized, increasing numbers of hospitals are beginning to screen patients before they are discharged from the ICU so that a care plan—including cognitive therapy, medication, even online support groups—can be instituted whether the patient is being transferred to a rehabilitation facility or being discharged to home.

“Screening at the time of discharge improves the likelihood that PICS can be identified and treated early,” said Schabbing.

“The experience of being ill is profound,” added Netzer. “The ICU is the extreme of that. We’re still learning the best way to deal with post-intensive care syndrome for both survivors and their families. But we’ve made a start.” ■