BACKGROUND:The family response to critical illness includes development of adverse psychological outcomes such as anxiety, acute stress disorder, posttraumatic stress, depression, and complicated ...grief. This cluster of complications from exposure to critical care is now entitled postintensive care syndrome–family. Adverse psychological outcomes occur in parents of neonatal and pediatric patients and in family members of adult patients, and may be present for >4 yrs after intensive care unit discharge. Psychological repercussions of critical illness affect the family memberʼs ability to fully engage in necessary care-giving functions after hospitalization.
PREVENTION:It has been suggested that the manner in which healthcare workers communicate with family members and the way in which families are included in care and decision-making, may affect long-term outcomes. Preventive strategies for optimal communication and inclusion in care are reviewed.
ASSESSMENT:Many tools are available to assess the risk for and to diagnose postintensive care syndrome–family conditions during hospitalization and at intervals after discharge.
TREATMENT:Visits after discharge, support groups, and clinics have been proposed for assessing the need for professional referrals as well as for treating family members when psychological illness persists. Studies evaluating these measures are reviewed.
Abstract Objectives To evaluate the epidemiology of, and post-intensive care unit (ICU) interventions for anxiety symptoms after critical illness. Methods We searched 5 databases (1970–2015) to ...identify studies assessing anxiety symptoms in adult ICU survivors. Data from studies using the most common assessment instrument were meta-analyzed. Results We identified 27 studies (2880 patients) among 27,334 citations. The Hospital Anxiety and Depression Scale-Anxiety subscale (HADS-A) was the most common instrument (81% of studies). We pooled data at 2–3, 6, and 12–14 month time-points, with anxiety symptom prevalences (HADS-A≥8, 95%CI) of 32%(27–38%), 40%(33–46%), and 34%(25–42%), respectively. In a subset of studies with repeated assessments in the exact same patients, there was no significant change in anxiety score or prevalence over time. Age, gender, severity of illness, diagnosis, and length of stay were not associated with anxiety symptoms. Psychiatric symptoms during admission and memories of in-ICU delusional experiences were potential risk factors. Physical rehabilitation and ICU diaries had potential benefit. Conclusions One-third of ICU survivors experience anxiety symptoms that are persistent during their first year of recovery. Psychiatric symptoms during admission and memories of in–ICU delusional experiences were associated with post-ICU anxiety. Physical rehabilitation and ICU diaries merit further investigation as possible interventions.
The human serotonin transporter (SERT) gene polymorphism (5HTTLPR) has been associated with multiple psychiatric disorders, including major depression, anxiety disorders, and substance use disorders. ...This study investigated the association between 5HTTLPR and psychiatric morbidity and comorbidity in a psychiatrist-examined population sample.
628 participants, mean age 48.3 years old, were assessed by psychiatrists using the Schedules for Clinical Assessment in Neuropsychiatry. Associations between 5HTTLPR and the prevalence, comorbidity, and time-to-diagnoses for 16 psychiatric conditions were evaluated, using several analytical approaches.
The SERT S allele was significantly associated with an increased lifetime prevalence of panic disorder. There was a “protective” association between SERT gene S allele carrier status and the risk of obsessive-compulsive disorder (OCD) in time-to-event analysis. Carriers of the S allele had a significant increased risk of two specific comorbid disorder pairs: major depressive disorder (MDD) and social phobia, and MDD and agoraphobia. Overall, there was no increased risk of receiving an initial or an additional diagnosis for a mental disorder in the SERT S allele carriers
The findings suggest that the S allele carrier status is associated with an increased prevalence of panic disorder in a community sample. There was an increased risk for comorbidity in a more homogeneous subgroup of cases with MDD and social phobia, as well as or agoraphobia. Our findings suggest a specific effect of the SERT promoter gene polymorphism on a subgroup of individuals identifiable by their comorbidity.
•In a community sample, we found an association of the SERT S allele with an increased risk for panic disorder, and a decreased risk for OCD.•SERT S allele was associated with increased risk for PD, a decreased risk for OCD, and increased risk for comorbidity between MDD, PD, Agoraphobia.•The SERT S allele was not associated with an increased risk for psychopathology.
OBJECTIVE:To conduct a systematic review and metaanalysis of the prevalence, risk factors, and prevention/treatment strategies for posttraumatic stress disorder symptoms in critical illness ...survivors.
DATA SOURCES:PubMed, Embase, CINAHL, PsycINFO, and Cochrane Library from inception through March 5, 2014.
STUDY SELECTION:Eligible studies met the following criteria1) adult general/nonspecialty ICU, 2) validated posttraumatic stress disorder instrument greater than or equal to 1 month post-ICU, and 3) sample size greater than or equal to 10 patients.
DATA EXTRACTION:Duplicate independent review and data abstraction from all eligible titles/abstracts/full-text articles.
DATA SYNTHESIS:The search identified 2,817 titles/abstracts, with 40 eligible articles on 36 unique cohorts (n = 4,260 patients). The Impact of Event Scale was the most common posttraumatic stress disorder instrument. Between 1 and 6 months post-ICU (six studies; n = 456), the pooled mean (95% CI) Impact of Event Scale score was 20 (17–24), and the pooled prevalences of clinically important posttraumatic stress disorder symptoms (95% CI) were 25% (18–34%) and 44% (36–52%) using Impact of Event Scale thresholds greater than or equal to 35 and greater than or equal to 20, respectively. Between 7 and 12 months post-ICU (five studies; n = 698), the pooled mean Impact of Event Scale score was 17 (9–24), and pooled prevalences of posttraumatic stress disorder symptoms were 17% (10–26%) and 34% (22–50%), respectively. ICU risk factors for posttraumatic stress disorder symptoms included benzodiazepine administration and post-ICU memories of frightening ICU experiences. Posttraumatic stress disorder symptoms were associated with worse quality of life. In European-based studies1) an ICU diary was associated with a significant reduction in posttraumatic stress disorder symptoms, 2) a self-help rehabilitation manual was associated with significant posttraumatic stress disorder symptom reduction at 2 months, but not 6 months; and 3) a nurse-led ICU follow-up clinic did not reduce posttraumatic stress disorder symptoms.
CONCLUSIONS:Clinically important posttraumatic stress disorder symptoms occurred in one fifth of critical illness survivors at 1-year follow-up, with higher prevalence in those who had comorbid psychopathology, received benzodiazepines, and had early memories of frightening ICU experiences. In European studies, ICU diaries reduced posttraumatic stress disorder symptoms.
OBJECTIVES:To synthesize data on prevalence, natural history, risk factors, and post-ICU interventions for depressive symptoms in ICU survivors.
DATA SOURCES:PubMed, EMBASE, Cumulative Index of ...Nursing and Allied Health Literature, PsycINFO, and Cochrane Controlled Trials Registry (1970–2015).
STUDY SELECTION:Studies measuring depression after hospital discharge using a validated instrument in more than 20 adults from non-specialty ICUs.
DATA EXTRACTION:Duplicate independent review and data abstraction.
DATA SYNTHESIS:The search identified 27,334 titles, with 42 eligible articles on 38 unique studies (n = 4,113). The Hospital Anxiety and Depression Scale-Depression subscale was used most commonly (58%). The pooled Hospital Anxiety and Depression Scale-Depression subscale prevalence (95% CI) of depressive symptoms at a threshold score greater than or equal to 8 was 29% (22–36%) at 2–3 months (12 studies; n = 1,078), 34% (24–43%) at 6 months (seven studies; n = 760), and 29% (23–34%) at 12–14 months (six studies; n = 1,041). The prevalence of suprathreshold depressive symptoms (compatible with Hospital Anxiety and Depression Scale-Depression subscale, ≥ 8) across all studies, using all instruments, was between 29% and 30% at all three time points. The pooled change in prevalence (95% CI) from 2–3 to 6 months (four studies; n = 387) was 5% (–1% to +12%), and from 6 to 12 months (three studies; n = 412) was 1% (–6% to +7%). Risk factors included pre-ICU psychologic morbidity and presence of in-ICU psychologic distress symptoms. We did not identify any post-ICU intervention with strong evidence of improvement in depressive symptoms.
CONCLUSIONS:Clinically important depressive symptoms occurred in approximately one-third of ICU survivors and were persistent through 12-month follow-up. Greater research into treatment is needed for this common and persistent post-ICU morbidity.
Knowledge of the prevalence and correlates of personality disorders in the community is important for identifying treatment needs and for provision of psychiatric services.
To estimate the prevalence ...of personality disorders in a community sample and to identify demographic subgroups with especially high prevalence.
Clinical psychologists used the International Personality Disorder Examination to assess DSM-IV and ICD-10 personality disorders in a sample of 742 subjects, ages 34-94 years, residing in Baltimore, Maryland. Logistic regression was used to evaluate the association between demographic characteristics and DSM-IV personality disorder clusters.
The estimated overall prevalence of DSM-IV personality disorders was 9%. Cluster A disorders were most prevalent in men who had never married. Cluster B disorders were most prevalent in young men without a high school degree, and cluster C disorders in high school graduates who had never married.
Approximately 9% of this community sample has a DSM-IV personality disorder. Personality disorders are over-represented in certain demographic subgroups of the community.
OBJECTIVES:To determine if a quality improvement intervention improves sleep and delirium/cognition.
DESIGN:Observational, pre–post design.
SETTING:A tertiary academic hospital in the United States.
...PATIENTS:300 medical ICU patients.
INTERVENTIONS:This medical ICU-wide project involved a “usual care” baseline stage, followed by a quality improvement stage incorporating multifaceted sleep-promoting interventions implemented with the aid of daily reminder checklists for ICU staff.
MEASUREMENTS AND MAIN RESULTS:Primary ICU outcomes were perceived sleep quality and noise ratings (measured on a 0–100 scale using the valid and reliable Richards–Campbell Sleep Questionnaire) and delirium/coma-free days. Secondary outcomes included ICU and hospital length of stay and mortality. Post-ICU measures of cognition and perceived sleep quality were evaluated in an ICU patient subset. During the baseline and sleep quality improvement stages, there were 122 and 178 patients, respectively, with more than one night in the ICU, accounting for 634 and 826 patient-days. Within the groups, 78 (63.9%) and 83 (46.6%) patients received mechanical ventilation. Over the 826 patient-day quality improvement period, checklist item completion rates ranged from 86% to 94%. In multivariable regression analysis of the quality improvement vs. baseline stages, improvements in overall Richards-Campbell Sleep Questionnaire sleep quality ratings did not reach statistical significance, but there were significant improvements in daily noise ratings (mean ± SD65.9±26.6 vs. 60.5±26.3, p = 0.001), incidence of delirium/coma (odds ratio0.46; 95% confidence interval, 0.23–0.89; p = 0.02), and daily delirium/coma-free status (odds ratio1.64; 95% confidence interval, 1.04–2.58; p = 0.03). Improvements in secondary ICU outcomes and post-ICU outcomes did not reach statistical significance.
CONCLUSIONS:An ICU-wide quality improvement intervention to improve sleep and delirium is feasible and associated with significant improvements in perceived nighttime noise, incidence of delirium/coma, and daily delirium/coma-free status. Improvement in perceived sleep quality did not reach statistical significance.
BACKGROUND:Millions of patients are discharged from intensive care units annually. These intensive care survivors and their families frequently report a wide range of impairments in their health ...status which may last for months and years after hospital discharge.
OBJECTIVES:To report on a 2-day Society of Critical Care Medicine conference aimed at improving the long-term outcomes after critical illness for patients and their families.
PARTICIPANTS:Thirty-one invited stakeholders participated in the conference. Stakeholders represented key professional organizations and groups, predominantly from North America, which are involved in the care of intensive care survivors after hospital discharge.
DESIGN:Invited experts and Society of Critical Care Medicine members presented a summary of existing data regarding the potential long-term physical, cognitive and mental health problems after intensive care and the results from studies of postintensive care unit interventions to address these problems. Stakeholders provided reactions, perspectives, concerns and strategies aimed at improving care and mitigating these long-term health problems.
MEASUREMENTS AND MAIN RESULTS:Three major themes emerged from the conference regarding(1) raising awareness and education, (2) understanding and addressing barriers to practice, and (3) identifying research gaps and resources. Postintensive care syndrome was agreed upon as the recommended term to describe new or worsening problems in physical, cognitive, or mental health status arising after a critical illness and persisting beyond acute care hospitalization. The term could be applied to either a survivor or family member.
CONCLUSIONS:Improving care for intensive care survivors and their families requires collaboration between practitioners and researchers in both the inpatient and outpatient settings. Strategies were developed to address the major themes arising from the conference to improve outcomes for survivors and families.
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