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Critical illness survivors frequently have substantial psychiatric morbidity, including posttraumatic stress, depression, and anxiety symptoms.
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Prior psychiatric illness is a potent predictor of postcritical illness psychiatric morbidity.
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Early emotional distress and memories of frightening psychotic and nightmarish intensive care unit (ICU) experiences are risk factors for longer term psychiatric morbidity.
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ICU diaries may be effective in decreasing psychiatric morbidity after critical illness,
Psychiatric Morbidity After Critical Illness
Section snippets
Key points
What is meant by psychiatric morbidity?
It is useful to think of emotional distress–related psychiatric morbidity after critical illness in terms of syndromes with overlapping signs, symptoms, and risk factors, rather than wholly distinct entities (Fig. 1). Posttraumatic stress (PTS) symptoms include hyperarousal, intrusive recollections, and avoidance behaviors related to a traumatic exposure. Depression symptoms include low mood, anhedonia (loss of the capacity for pleasure), and feelings of guilt or worthlessness. Anxiety symptoms
How is psychiatric morbidity measured?
Traditionally, clinicians assess psychiatric symptoms and their clinical significance by interviewing a patient and his or her family and caregivers, reviewing records, and examining the patient’s mental state. Clinical diagnostic interviews are relatively uncommon in studies of critical illness survivors because such interviews are time-consuming, expensive, logistically difficult, and potentially burdensome to patients (especially if repeated frequently during recovery). Self-report
Why is psychiatric morbidity relevant to critical illness?
In medically ill populations, psychiatric symptoms are associated with worse outcomes, including an increased physical symptom burden, more functional impairment, greater health care costs, poorer adherence to treatment, and decreased quality of life.9 In patients who have diabetes, recent myocardial infarction, or exacerbations of chronic obstructive pulmonary disease, psychiatric symptoms are also associated with increased mortality.10, 11, 12, 13
Psychiatric illnesses also add risk for
How often do critical illness survivors develop psychiatric morbidity?
A series of systematic reviews and meta-analyses, including numerous observational studies, highlighted the substantial prevalence of psychiatric morbidity in critical illness survivors:
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Clinically significant PTS symptoms occur in 1 out of 5 critical illness survivors at 1-year follow-up.24
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Clinically significant depression symptoms occur in 1 out of 3 critical illness survivors through 1-year follow-up.25
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Clinically significant anxiety symptoms occur in 1 out of 3 critical illness survivors
Which patient factors are associated with psychiatric morbidity after critical illness?
Personality traits influence a person’s ability and approaches to coping with life stressors such as critical illness. Pessimism is associated with emotional distress and worse quality of life after critical illness,27 and trait anxiety is associated with symptoms of PTS, depression, and anxiety after ICU discharge.28, 29
Prior psychiatric illness is a potent predictor of postcritical illness psychiatric symptoms24, 25, 26, 30, 31 (Fig. 2). Interestingly, patients with a history of anxiety
What intensive care unit and early postintensive care unit factors are associated with later psychiatric morbidity?
Persecutory delusional interpretations of ICU experiences (eg, manipulation of a Foley catheter misinterpreted as rape), frightening hallucinations, and agitation are common in-ICU psychiatric symptoms that are associated with post-ICU psychiatric morbidity24, 25, 26 (see Fig. 2; Fig. 3). In the ICU, well-meaning clinicians often manage anxiety or agitation with benzodiazepines; however, these medications are associated with worse post-ICU PTS symptoms.24 Psychiatric morbidity early in the
Which interventions are effective in decreasing postcritical illness psychiatric morbidity?
One of the most promising interventions to reduce long-term emotional distress in critical illness survivors is the use of ICU diaries. ICU diaries differ from conventional diaries in that clinicians and family members write entries to the patient, who often does not fully comprehend what is happening at the time. The goal is to provide a coherent narrative description of events for patients who may have no memory or a distorted memory of what occurred. Studies suggest that diaries may reduce
What if patients have substantial psychiatric morbidity at follow-up visits?
It is important to recognize that, as in other settings, simply screening for symptoms is insufficient to improve patients’ mental health. Furthermore, a thorough evaluation is necessary to rule out persistent delirium as a cause of mood symptoms because, otherwise, clinicians might ignore the potential cause of the delirium. Furthermore, some somatic treatments for depression could exacerbate delirium55 and psychotherapy would presumably have little lasting effect.
Much like their symptoms,
Summary
Critical illness survivors frequently have substantial psychiatric morbidity, including PTS, depression, and anxiety symptoms. Prior psychiatric illness is a potent predictor of postcritical illness psychiatric morbidity. Early emotional distress and memories of frightening psychotic and nightmarish ICU experiences are risk factors for longer term psychiatric morbidity. ICU diaries may be effective in decreasing psychiatric morbidity after critical illness, though these and other interventions
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Cited by (26)
Depressive symptoms over time among survivors after critical illness: A systematic review and meta-analysis
2024, General Hospital PsychiatryImpact of frailty on physical performance and quality of life after ICU admission
2024, Medicina IntensivaPrevalence and risk factors of delirium in psychiatric patients with critical illness
2023, Psychiatry Research CommunicationsTrajectory and outcomes of psychiatric symptoms in first-wave COVID-19 survivors referred for telepsychotherapy
2023, General Hospital PsychiatryPsychiatric morbidity among survivors of in-hospital cardiopulmonary resuscitation: A nationwide cohort study in South Korea
2022, Journal of Affective DisordersCitation Excerpt :In South Korea, the survival-to-discharge rate following ICPR was 11.7% (Park et al., 2020), suggesting that approximately 10% of patients are discharged alive from the hospital as survivors of ICPR. Survivors of critical illness admitted to the intensive care unit (ICU) are known to suffer from psychiatric morbidity such as depression, post-traumatic stress disorder (PTSD), and anxiety disorders (Hatch et al., 2020; Myhren et al., 2010; Prince et al., 2018). Moreover, in survivors of critical illness who were admitted to the ICU, new psychiatric diagnoses and psychoactive medication use increase in the months after ICU discharge (Wunsch et al., 2014).
Risks of mental disorders among intensive care unit survivors: A nationwide cohort study in Taiwan
2022, General Hospital PsychiatryCitation Excerpt :Direct effects of ICU admissions include life-threatening illness, subsequent ICU complications, and traumatic interventions. Additionally, brain injury [36], inflammation [37], pain [38], presence of delirium, restraint use, and medication such as sedatives [39], steroids [38] and certain cardiac medications are known risk factors of mental disorders [39,40]. Indirect effects include the risk of mental disorders include disability, unemployment, financial stressors, family conflict, and caregiver burden [41–43].
Disclosure Statement: The authors have no conflicts of interest or financial ties to disclose.