Psychological Outcomes of Critical Illness Erin K. Kross, MD Senior Fellow Pulmonary & Critical Care Medicine February 23, 2008
Objectives • Highlight the patient experience of critical illness • Review psychological sequelae of critical illness • Post-traumatic stress disorder (PTSD) • What is PTSD? • Why does it happen after critical illness? • Discuss post-traumatic stress disorder among patients • How common is it? • What are the risk factors for it? • What can we do about it? • Discuss post-traumatic stress disorder among family members • How common is it? • What can we do about it?
Experiences of Critical Care • What happens in the ICU can have long-term consequences for patients and families • What we do for patients and their families in the ICU has long-term consequences
Psychological Outcomes of Critical Illness • Major Depressive Disorder • Generalized Anxiety Disorder • Panic Disorder • Post-traumatic Stress Disorder • For family members: • All of the above • Complicated Grief Disorder
Post-traumatic Stress Disorder (PTSD) • PTSD is common after traumatic events • General population – lifetime prevalence • 5-6% men • 10-14% women • War veterans (2-15%) • Rape or assault victims (14-80%) Yehuda. NEJM 2002;346(2):108-114. Jackson et al. Crit Care 2007;11(1):R27.
PTSD • Traumatic events provoke fear, helplessness or horror in response to an event that threatens one’s life or safety • Exposure to traumatic events increase risk of other psychological morbidity • Depression • Panic disorder • Generalized anxiety disorder • Substance abuse
Why Does PTSD Matter? • Burden of symptoms can be high • Psychological stress, interruption of daily life • Inability to work • Inability to return to prior levels of functioning • Increased cost to society, secondary to increased health care costs
Diagnostic Criteria • Exposure to a traumatic event • Perceived or actual threat to one’s life or physical integrity, or that of another • 3 domains • Symptoms of re-experiencing • Symptoms of avoidance and emotional numbing • Symptoms of increased arousal • 2 criteria • Significant impairment in social, occupational or other functional domains • Symptoms present for at least 1 month after event
PTSD in the ICU • ICU treatment for critical illness exposes patients and families to enormous stress • Experience of life-threatening illness • Need for intensive, often invasive medical procedures • Meets DSM-IV criteria for “traumatic event” • Both patients and family members
Three Groups at Risk for PTSD • Patients who survive critical illness and are discharged following ICU care • Family members of individuals who survive critical illness • Family members of individuals who die during or shortly after their ICU stay
Survivors of Critical Illness • About 20 studies currently in the literature • Variation in study population • Number of subjects in the studies ranged 20 to 143 patients • Rates of follow-up ranged 30-84% • Variation in study design • Prospective vs. retrospective • Survey instruments used vs. diagnostic tools • Live interview vs. phone interview Jackson et al. Crit Care 2007;11(1):R27.
Survivors of Critical Illness • Review article • Medical ICU patients only • Excluded surgical or trauma patients • Some restricted to acute lung injury or septic shock • Most excluded patients with prior psychiatric illness, neurologic trauma or disease Jackson et al. Crit Care 2007;11(1):R27.
Survivors of Critical Illness • Evaluated for symptoms at different time points • Some studies looked at patients over time • Range from 2 months to 8 years following discharge • Other studies only looked at one point in time • Range from 3 months to 13 years following discharge
PTSD Among Survivors • Prevalence rates ranged from as low as 5% to as high as 63% in survivors of critical illness • Prevalence seems to vary over time • Highest prevalence when assessed close to the time of discharge • Prevalence decreases over time • Stabilizes around 6 months following traumatic event
Risk Factors for PTSD • Things we can’t change: • Younger age • Female gender • Prior mental health history • Things we might be able to change: • Increased length of stay • Increased duration of mechanical ventilation • Things we certainly can change: • Greater levels of sedation and/or neuromuscular blockade • Greater perceived social support appears to be protective Jackson et al. Crit Care 2007;11(1):R27.
Sedation in the ICU • Sedative drug infusions • Prolonged periods of altered mental status • Delay in regaining consciousness once stopped • Patients report pain and anxiety • Does sedation help or hurt the long-term psychological effects of being in the ICU? • Helps blunt the experience • But causes prolonged periods of amnesia Girard et al. Crit Care 2007;11(1):R28. Kress et al. AJRCCM 2003;168(12):1457-61. Nelson et al. Crit Care Med 2000;28:3626-30.
Sedation “Vacations” • Daily sedative interruption • Often combined with spontaneous breathing trials • Known short-term benefits in patients requiring mechanical ventilation • Shorter durations of mechanical ventilation • Shorter ICU lengths of stay Kress et al. NEJM 2000;342:1471-7.
Sedation and PTSD • Daily sedation “vacations” vs. continuous sedation • Compared long-term psychological outcomes • Lower IES scores with sedation vacations • Trend towards lower PTSD (0% vs. 36%) with sedation vacations Kress et al. AJRCCM 2003;168(12):1457-61.
Social Support and PTSD • Long-term survivors of ARDS • Health-Related Quality of Life • PTSD • The more social support, the less PTSD • More PTSD among those with high anxiety and pain • More anxiety among those who remembered “difficulty breathing” and “nightmares” Deja et al. Crit Care 2006;10(5):R147.
Family Members • Critical illness affects not only the patient who is sick, but also their family and friends • ICU can be a traumatic environment for these individuals • Alarms, machines, monitors, invasive devices
Why are Families at Risk for PTSD? • Traumatic experience • DSM-IV criteria • Family members are often asked to assume the role of surrogate decision-maker • Participate in decision making in the ICU • ICU patients often not able to participate in decisions about withholding or withdrawing life support
PTSD among Family Members • Far fewer studies about how the ICU experience affects family members • Largest study from France • Conducted in 21 medical-surgical ICUs in 2003 • Family members eligible if came to visit within 48 hours of admission • Closest family member was identified • Phone interviews conducted 90 days after ICU discharge (or death) Azoulay et al. AJRCCM 2005;171:987-994.
PTSD among Family Members • 228 family members of patients who survived their critical illness participated • 28.9% screened positive for significant levels of PTSD symptoms • Risk factors identified: • Things we can’t change: • Female gender • Children of the ICU patient • Things we can change: • Feeling information is incomplete • Sharing decisions in the ICU Azoulay et al. AJRCCM 2005;171:987-994.
Smaller Studies of Family Members • Only a handful of other studies • PTSD as high as 49% • 6 months after discharge • “Acute” symptoms very common • Prevalence of “PTSD” of 81% • One week after admission to the ICU • Doesn’t meet criteria for PTSD • High burden of psychological symptoms
Family Members of Those Who Die • Death is a stressful event for families • Studies of PTSD following bereavement • Deaths outside the ICU • Interviews with spouses 2 months after death of their spouse • 10% met criteria for PTSD • No difference between types of death • Chronic illness vs. sudden, unexpected death • Did not discuss hospitalization or ICU admission
PTSD among Family Members • Primary study is from France • 56 family members of patients who died were interviewed 90 days after death • Prevalence of PTSD for this group was 50% Azoulay et al. AJRCCM 2005;171:987-994.
Some Families are at Higher Risk • Among all patients that died – 50% • Family members of patients who died in the ICU after end-of-life decisions (60%) • Family members who were involved in end-of-life decisions (80%)
How Do We Decrease PTSD? • French group followed up with an interventional study • Goal: Lessening the effects of bereavement among family members whose loved one dies in the ICU • Enrolled 126 family members of patients who died in the ICU Laurtrette et al. NEJM 2007;356:469-78.
Intervention to Decrease PTSD • Intervention: Structured end-of-life care family conference and a brochure for the family • Control: Usual care • Interviews conducted 90 days following the death Laurtrette et al. NEJM 2007;356:469-78.
Intervention to Decrease PTSD • Prevalence of PTSD: • Control group = 67% • Intervention group = 45% • Primary differences between the 2 groups was attributed to physician-family communication • Intervention group spent more time in family conferences • Spent more of the conference time talking than the control group
Are the U.S. and France the Same? • Differences in regional, racial, religious and cultural influences affect families’ preferences for care and clinicians’ delivery of care • Decision making is different in France • More than half of family members did not want to participate in end-of-life decision making • 39% of physicians preferred to involve family members in end-of-life decisions Laurtrette et al. NEJM 2007;356:469-78. Vincent et al. Crit Care Med 2001;29(2S):N52-5.
Are the U.S. and France the Same? • In North America, patient autonomy is key • Extended to family members • Physicians involve family members in decision making for end-of-life care 70-80% of the time • Family members more satisfied with care when they are involved in decision-making at the end-of-life • Participation in end-of-life decision-making may result in differing burdens of psychological disease Laurtrette et al. NEJM 2007;356:469-78. Vincent et al. Crit Care Med 2001;29(2S):N52-5.
Preliminary Data from U.S. • End-of-Life Care Research Program at HMC • Group at Yale • Both finding lower prevalence of PTSD and depression than in France • Still higher than the general population Gries et al. In preparation. Seigel et al. Crit Care Med, in press.
Challenges to Studying PTSD in the ICU • Diagnosis of PTSD requires symptoms of distress, and a precipitating traumatic event • Difficult to know other history • Significant co-morbidity with PTSD and other psychiatric illnesses • Difficult to decipher the cause of PTSD symptoms, as well as the relative contribution of PTSD to an individual’s overall level of distress
Challenges to Studying PTSD in the ICU • Difficult to separate the experience of the ICU from other aspects of health care and illness • Difficult to separate this experience from other traumatic events that may have been experienced in the past • Clearly this is an important problem for both patients and family members of critically ill patients
What Can We Do? • For patients: • Everything they experience in the ICU may have long-term consequences • Regardless of sedation, there may be memories of their ICU stay • Decrease sedation as much as possible • Daily interruption of sedation • Provide social support • COMMUNICATION
What Can We Do? • For families: • The ICU experience is traumatic for families too • Provide social support • Participation in decision-making • COMMUNICATION
Acknowledgements • Video courtesy of the IPACC study • Harborview End-of-Life Care Research Team • J. Randall Curtis • Ruth Engelberg • Patsy Treece • Elizabeth Nielsen • Many, many more