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Martina M. Cartwright
Martina M. Cartwright Ph.D., R.D.

The High Incidence of Post Intensive Care Unit (ICU) Anxiety and Depression

The long lasting effects of ICU treatment on mental health

Many patients who are discharged from the Intensive Care Unit (ICU) frequently suffer health problems long after they've left the hospital. The patient and their loved ones are often puzzled as to why, having survived a critical illness, that the former ICU patient is unable to work, enjoy activities, gain weight, and/or regain happiness after leaving the hospital. In researching this topic, I was alarmed at the number of individuals who are plagued by a profound range of serious mental health issues coupled with prolonged physical weakness.

The purpose of this piece is to bring attention to the widespread incidence of post-ICU depression and mental health and to encourage education and networking of professionals interested in assisting post-ICU patients and their caregivers. Hopefully, information contained in the article will provide caregivers and loved ones of former ICU patients with practical suggestions on how to initiate a successful dialog with a variety of health care professionals and mental health providers to ensure that the post-ICU care received results in the best possible outcome.

More than five million Americans are admitted to hospital ICUs every year for treatment of critical illness, and admission rates are on the rise. ICU survivors often require prolonged and costly rehabilitation for several weeks following discharge, and about half of these survivors are unable to return to work one year after hospitalization because of depression and post traumatic stress disorder (PTSD). The prevalence of these and other post-ICU mental health challenges requiring therapy has increased substantially. Anxiety disorder occurs in 12 percent to 43 percent of former ICU patients, and levels of depression range from 10 percent to 30 percent. Most significantly, there is an astonishingly high rate of PTSD, as high as 64 percent in those who survive the ICU. Psychological symptoms frequently appear a short time after ICU stay and may decrease as time passes, however, some patients experience an escalation of depression, anxiety, and other mental health issues during rehabilitation. Symptoms may appear and extend months after discharge, and persistent, untreated post-ICU depression can impair recovery and quality of life.

Although post-ICU mental health conditions are becoming increasingly recognized by critical care practitioners, caregivers and/or mental health professionals often remain unaware of the profound effect ICU stays have on mental hygiene. Former ICU patients often experience personality changes, anger, sleep problems, and sadness. Frequently, these alterations are attributed to the patient's frustration with recovery, rehabilitation, and the progress towards getting "life back to normal." However, these changes are more commonly linked to the critical illness episode itself and the necessary care delivered during the ICU stay.

Pain, critical illness, infection, mechanical ventilation support for respiratory failure, medications, muscle wasting, and metabolic changes can contribute to post-ICU depression, PTSD, and anxiety. People with a prior history of mental health issues including depression, anxiety disorders, and PTSD may be more susceptible to developing psychiatric issues that require attention long after their ICU stay. A common culprit of post ICU PTSD and anxiety is the routine use of sedatives. Most critically ill patients receive sedatives and some, especially benzodiazepines, are more likely to cause disorientation, confusion, and even psychotic experiences. Often these sedative-induced hallucinations are perceived by the patient as real, and the recollection of these frightening and traumatic incidents can trigger extreme anxiety days or even months after leaving the ICU. Because the duration from ICU discharge to psychological symptom onset may be significant, patients, caregivers, and health care practitioners may not make the link between the ICU stay and mental health. This can result in a delay of treatment. Symptoms such as nightmares, sleep disturbances, avoidance, depression, and anxiety should be considered as possible signs of post-ICU emotional distress, and consultation with a qualified mental health practitioner is encouraged.

Psychological symptoms may occur in both the patient and family members who care for them. Caregivers, loved ones, and family members are not immune to post-ICU emotional hardship. Profound lifestyle disruption coupled with feelings of helplessness, stress, guilt, and depression are common emotions experienced by those caring for patients recovering from life-threatening infirmities. Interventions designed to help families cope with the burden of critical illness after they leave the hospital are being supported by many in the critical care community. ICU practitioners often encourage patients and their families to seek a consultation with a clinical psychiatrist or psychologist before ICU discharge and throughout the recovery and rehabilitation period. However, finding a licensed mental health professional that specializes in, or is familiar with, post-ICU depression can be challenging. Further, few, if any patient education materials exist to help guide the patient and their loved ones through the often stressful and emotional aspects of post-ICU care. A multidisciplinary approach to education and treatment, including cooperation between physicians, caregivers, mental health professionals, pharmacists, and dietitians, is paramount to improving mental health and physical status of former ICU patients and their families.

In addition to psychological symptoms, the post-ICU patient is often plagued by extreme muscle weakness that persists even a year after hospital discharge. Muscle wasting occurs despite adequate diet and the reasons are unknown. However, the long-term effects on quality of life are significant. Fatigue, lack of endurance, poor appetite, and depression often prevent the former ICU patient from being able to work or enjoy activities. Further, poor nutritional status can lead to other complications like impaired wound healing, falls and fractures, and other health issues that many times lead to re-admission to the hospital.

Recognition and treatment of post-ICU health issues remains limited at best. Many health care practitioners, former patients, and their loved ones are unaware of the long-term ramifications of surviving critical illness. Rehabilitation often addresses concerns of the physical body, but few post-ICU rehab programs address the mental health and nutritional aspects. If you recognize these symptoms in someone who has been in the ICU recently, contact your health care practitioner and discuss what can be done to improve their quality of life.

The author has worked in the critical field for more than 15 years and has first-hand experience with post-ICU patients suffering from depression and profound physical weakness.

Selected References:
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Griffiths J, Fortune G, Barber V, Young JD: The prevalence of post traumatic stress disorder in survivors of ICU treatment: a systematic review.
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Scragg P, Jones A, Fauvel N: Psychological problems following ICU treatment.
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Eddleston JM, White P, Guthrie E: Survival, morbidity, and quality of life after discharge from intensive care.
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Davydow DS, Gifford JM, Desai SV, Bienvenu OJ, Needham DM: Depression in general intensive care unit survivors: a systematic review.
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Ringdal M, Plos K, Lundberg D, Johansson L, Bergbom I: Outcome after injury: memories, health-related quality of life, anxiety, and symptoms of depression after intensive care. J Trauma 2009 , 66:1226-1233

Myhren H, Toien K, Ekeberg O, Karlsson S, Sandvik L, Stokland O: Patients' memory and psychological distress after ICU stay compared with expectations of the relatives.
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About the Author
Martina M. Cartwright

Martina M. Cartwright, Ph.D., R.D., is an adjunct professor of Nutritional Sciences at the University of Arizona and an independent biomedical consultant.

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