PTSD symptoms common after an ICU stay
Patients who have survived a stay in the intensive care unit (ICU) have a greatly increased risk of developing symptoms of post-traumatic stress disorder (PTSD), according to a new study presented at the 2014 American Thoracic Society International Conference.
“An ICU stay can be traumatic for both patients and their families,” said Ann M. Parker, MD, a Pulmonary and Critical Care Medicine fellow at Johns Hopkins University in Baltimore, Maryland. “In our analysis of more than 3,400 ICU patients, we found that one quarter of ICU survivors exhibited symptoms of PTSD.” The systematic review of 28 studies involved a total of 3,428 adult ICU survivors. Evaluation included testing with validated PTSD instruments, most commonly the Impact of Events Scale (IES, score range 0-75), administered one month or more after the ICU stay.
In a subset of 429 patients assessed 1-6 months after their stay in the ICU, meta-analysis demonstrated the pooled prevalence of PTSD symptoms was 23% at an IES threshold of ≥35 and 42% at a threshold of ≥20. In 698 patients assessed at 7-12 months, corresponding pooled PTSD prevalence rates were 17% and 34%. Rates in other studies included in the analysis ranged from 5% to 62%.
Risk factors for the occurrence of PTSD symptoms included younger age, use of benzodiazepines and/or mechanical ventilation during the ICU stay, and post-ICU memories of frightening ICU experiences. In some studies of European ICU patients, keeping an ICU diary significantly reduced the occurrence of PTSD symptoms.
Importantly, 3 of 3 studies demonstrated that more PTSD symptoms were associated with worse health-related quality of life.
A potential limitation of this systematic review is the variability of patient populations and PTSD survey instruments studied, which makes direct comparison between studies difficult.
The Diagnostic and Statistical Manual, 4th Edition, Text Revision (DSM) published by the American Psychiatric Association provides the internationally accepted diagnostic criteria for PTSD. There are more than 20 signs and symptoms of PTSD, but the DSM groups them into six diagnostic criteria. All of the criteria must be met for a valid diagnosis. Usually, only the first four diagnostic criteria are in dispute in an insurance claim.
Criterion A is what distinguishes PTSD from other anxiety disorders. It requires that the claimant be exposed to a traumatic event in which both of the following are true: (1) There was actual or threatened death or serious injury to self or others; and (2) the claimant’s response involved intense fear, helplessness or horror. Although the development of PTSD can be delayed, an intense response must occur at the time of the trauma to satisfy DSM Criterion A(2).
Criterion B requires re-experiencing the traumatic event. Distressing recollections are common after any upsetting event, even a bad date, and are not sufficient to satisfy the criterion. For claimants with PTSD, these memories intrude upon their daily affairs and their dreams at night. They act or feel as if the event is recurring. They become overwhelmed by intense physical and mental symptoms when confronting reminders of the traumatic event.
Criterion C requires avoidance and numbing. When asked for a statement, affected claimants will try to avoid thinking or talking about the traumatic event or be unable to recall important aspects of it. Discussing other aspects of their lives with them will reveal that they’ve lost interest and stopped participating in previously valued activities. These claimants often present with a restricted range of emotional expression. They often detach from others (e.g., stop attending church or family events) and lose interest in the future.
Criterion D is evidenced as difficulty falling asleep, irritability with outbursts of anger, poor concentration, excessive watchfulness, and an exaggerated startle response. Sleep problems can be assessed by asking questions of the claimant’s spouse. Claims adjusters can note if a claimant is irritable or frequently loses track of his or her thoughts when answering questions or completing forms. These signs are most pronounced when encountering reminders of the traumatic event, an activity often required by the claims adjuster. Consider if the claimant strongly prefers to sit with his or her back to the wall or facing the door or window, or appears to startle at routine environmental noises (e.g., a door slamming down the hall).
“Our meta-analysis confirms that a large proportion of patients who survive an ICU stay will suffer PTSD symptoms, which are associated with worse health-related quality of life,” said Thiti Sricharoenchai, MD, Instructor in the Division of Pulmonary and Critical Care Medicine at Thammasat University, Thailand who conducted this study as a post-doctoral research fellow at Johns Hopkins University. “Further research should focus on PTSD screening, prevention, and treatment in this vulnerable patient population.”
Dr. Parker and her mentor, Dr. Dale Needham, Associate Professor of Pulmonary and Critical Care Medicine at Johns Hopkins University, are currently planning a study to evaluate an out-patient intervention to address PTSD symptoms in ICU survivors.
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* Please note that numbers in this release may differ slightly from those in the abstract. Many of these investigations are ongoing; the release represents the most up-to-date data available at press time.
Abstract 50802
A Meta-Analysis Of Post-Traumatic Stress Disorder (PTSD) Symptoms In Intensive Care Unit Survivors
Type: Scientific Abstract
Category: 04.07 - ICU Management/Outcome (CC)
Authors: T. Sricharoenchai1, A.M. Parker2, S. Raparla3, K. Schneck4, O.J. Bienvenu2, D.M. Needham2; 1Thammasat University - Pathum Thani/TH, 2Johns Hopkins University
School of Medicine - Baltimore, MD/US, 3Good Samaritan Hospital - Baltimore, MD/US, 4University of Delaware - Newark, DE/US; Outcomes After Critical Illness and Surgery
Abstract Body
Rationale: We systematically reviewed the literature on the prevalence, risk factors, and prevention/treatment strategies for post-traumatic stress disorder (PTSD) symptoms in intensive care unit (ICU) survivors.
Methods: We searched 5 databases (PubMed, Embase, CINAHL, Psyc INFO, and Cochrane Library) from inception through July 15, 2012 for studies meeting these criteria: (1) adult ICU survivors, (2) use of validated PTSD instruments ≥1 month post-ICU, (3) focus on general ICU populations, and (4) ≥10 patients with substantial PTSD symptoms. Two reviewers independently reviewed all titles/abstracts/full-text articles in duplicate and abstracted data. Random-effects meta-analysis was performed using STATA.
Results: The search identified 3,243 titles/abstracts, with 28 articles on 25 unique cohorts (2 of 25 from the United States), representing 3,437 patients. The Impact of Events Scale (IES) (score range 0-75; higher scores indicating greater symptoms), was the most common instrument (12 studies). In 429 patients, 1-6 months post-ICU, the pooled mean [95% CI] IES score was 19 [95% CI: 16-22], and the pooled prevalence of clinically important PTSD symptoms was 23% and 42% using an IES threshold ≥35 and ≥20, respectively. In 698 patients, 7-12 months post-ICU, the pooled mean IES score was 17 [9-24] and pooled prevalence of PTSD symptoms was 34% and 36%. In other studies, the point prevalence of PTSD symptoms ranged from 5 to 62%. Younger age was consistently associated with greater PTSD symptoms, which were cross-sectionally associated with worse quality of life in 2 of 3 studies. ICU risk factors for PTSD symptoms included benzodiazepine administration, mechanical ventilation, and post-ICU memories of frightening ICU experiences. ICU length of stay, severity of illness, and admission diagnosis were not consistently associated with PTSD symptoms. In exclusively European-based studies, an ICU diary was associated with a significant reduction in PTSD symptoms (RCT, n=352 and prospective controlled study, n=143); a self-help rehabilitation manual was associated with a significant reduction at 2 months, but not 6 months (RCT, n=126); and a nurse-led ICU follow-up clinic did not reduce PTSD symptoms (RCT, n=286).
Conclusions: PTSD symptoms occurred in 1/4 to 1/3 of ICU survivors over 1-year follow-up, especially in those who were young, received benzodiazepines, and had post-ICU memories of frightening ICU experiences. In European studies, ICU diaries reduced PTSD symptoms; the generalizability of these results should be evaluated in North America. Given the high PTSD point prevalence in ICU survivors, additional studies are needed evaluating systematic screening, prevention and/or treatment interventions.
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