Elsevier

Critical Care Clinics

Volume 34, Issue 4, October 2018, Pages 599-608
Critical Care Clinics

Psychiatric Morbidity After Critical Illness

https://doi.org/10.1016/j.ccc.2018.06.006Get rights and content

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Key points

  • Critical illness survivors frequently have substantial psychiatric morbidity, including posttraumatic stress, 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 intensive care unit (ICU) experiences are risk factors for longer term psychiatric morbidity.

  • ICU diaries may be effective in decreasing psychiatric morbidity after critical illness,

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:

  • Clinically significant PTS symptoms occur in 1 out of 5 critical illness survivors at 1-year follow-up.24

  • Clinically significant depression symptoms occur in 1 out of 3 critical illness survivors through 1-year follow-up.25

  • 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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    Disclosure Statement: The authors have no conflicts of interest or financial ties to disclose.

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