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 Table of Contents  
BRIEF RESEARCH ARTICLE
Year : 2019  |  Volume : 3  |  Issue : 1  |  Page : 50-54

A study of psychiatric morbidities in recovering intensive care unit patients


Department of Psychiatry and Deaddiction Centre of Excellence, Seth G S Medical College and KEMH, Mumbai, Maharashtra, India

Date of Web Publication24-May-2019

Correspondence Address:
Dr. Shilpa Amit Adarkar
Plot No. 61/62, New Akash Nagar, Manewada, Nagpur - 440 035, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_33_18

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  Abstract 


Background: Patients recovering from Intensive Care Unit (ICU) admission may develop cognitive and psychological symptoms. With the improvement in medical facilities, survival rate of these patients has increased. With increase in survival rate, cognizance of cognitive and psychological symptoms has increased. There is compelling evidence that psychiatric illnesses such as depression impair functional status in patients with chronic medical illnesses. Identification and treatment of these symptoms in an early stage will lead to enhanced recovery and hence improvement in quality of life. Aims: This study commits to sociodemographic profile and assessment of cognitive and psychological symptoms in recovering ICU patients. Materials and Methods: After Institutional Review Board permission, 50 patients recovering from ICU were enrolled to study cognitive symptoms using Mini-Mental Status Examination. Psychological symptoms were assessed using Hospital Anxiety Depression Scale. Sociodemographic profile of these patients was also studied. Results: Of 50 patients, 22% suffered from mild to severe cognitive impairment. 22% had borderline symptoms to symptoms amounting to cases of anxiety. 36% patients had borderline symptoms to symptoms amounting to cases of depression. Conclusions: In our study, we found that ICU stay can lead to cognitive impairment in patients. ICU stay can also lead to psychological symptoms such as anxiety and depression.

Keywords: Anxiety, cognitive symptoms, depression, Intensive Care Unit


How to cite this article:
Bhagat PN, Adarkar SA. A study of psychiatric morbidities in recovering intensive care unit patients. Ann Indian Psychiatry 2019;3:50-4

How to cite this URL:
Bhagat PN, Adarkar SA. A study of psychiatric morbidities in recovering intensive care unit patients. Ann Indian Psychiatry [serial online] 2019 [cited 2019 Oct 13];3:50-4. Available from: http://www.anip.co.in/text.asp?2019/3/1/50/259086




  Introduction Top


Patients admitted to Intensive Care Unit (ICU) generally have a debilitating disease. With the improvement in medical facilities, ICU patient's mortality is reduced leading to increase in surviving patients. While the patient is recovering, he/she may develop some psychological symptoms such as sadness of mood, anxiety, sleep disturbances, and irritability, which may develop into psychiatric illness. Psychological outcomes after intensive care include posttraumatic stress disorder. The disorder is characterized by three clusters of symptoms: Re-experiencing, avoidance, and hyperarousal that persist for more than a month and cause distress or impaired functioning. Another outcome of interest, depression, is characterized by low mood or loss of interest for more than 2 weeks, with a range of other symptoms. Anxiety is a normal emotion that may become persistent and inappropriate. Cognitive impairments in memory, attention, and executive function are also seen.[1] As a greater number of patients survive critical illness, there is increasing interest in accelerating patients' recovery after ICU discharge. There is compelling evidence that psychiatric illnesses such as depression impair functional status in patients with chronic medical illnesses. Therefore, psychiatric conditions that develop after critical illness are a logical target for treatment or prevention strategies to improve recovery after critical illness. Studying the sociodemographic profile of recovering ICU patients, along with psychological symptoms which develop during the long duration of hospital stay will help in the early identification of at-risk patients for psychiatric morbidities. This study will help in planning intervention and prevention of psychiatric illness. However, little Indian research has been done to confirm whether patients recovering from ICU are more prone for psychiatric morbidities, hence we planned to do this research to study the sociodemographic profile of patients recovering from ICU admission and assess their cognitive and psychological symptoms.


  Materials and Methods Top


Institutional Review Board permission was taken to conduct the study. During the data collection period of 2 months, 60 patients were screened in the intermediate care, of which 50 patients consented for the study and were interviewed. Only those patients who were stable and transferred to intermediate care unit for recovery without any preexisting psychiatric illness were included in the study.

On these patients, we administered semi-structured pro forma to collect the details regarding sociodemographic profile. Mini-Mental Status Examination (MMSE) was used to assess the cognition and Hospital Anxiety Depression Scale (HADS) was used to assess the psychological symptoms.

MMSE also known as Folstein test is a brief 30-point questionnaire test that is used to screen for cognitive impairment. It is also used to estimate the severity of cognitive impairment and to follow the course of cognitive changes in an individual. It offers a quick and simple way to quantify cognitive function and screen for cognitive loss. It tests the individual's orientation, attention, calculation, recall, language, and motor skills. Each section of the test involves a related series of questions or commands. The individual receives one point for each correct answer. To score, add the number of correct responses.[2] The individual can receive a maximum score of 30 points. Patients with MMSE score of >24 has no cognitive impairment, 18–23 has mild cognitive impairment and 0–17 score has a severe cognitive impairment.[3]

HADS was devised 30 years ago by Zigmond and Snaith to measure anxiety and depression in a general medical population of patients. The questionnaire comprises seven questions for anxiety and seven questions for depression, and takes 2–5 min to complete. Although the anxiety and depression questions are interspersed within the questionnaire, it is vital that these are scored separately. Cutoff scores are available for quantification, for example, a score of 8 or more for anxiety has a specificity of 0.78 and a sensitivity of 0.9, and for depression a specificity of 0.79 and a sensitivity of 0.83.[4] It is a 14 item self-assessment scale that has been developed and found to be a reliable instrument for detecting states of depression and anxiety in the hospital setting with seven questions each for anxiety and depression. Each item in the questionnaire is scored from 0 to 3, and this means that a person can score between 0 and 21 for either anxiety or depression. Score 0–7 = Normal, 8–10 = Borderline abnormal (borderline case), and 11–21 = Abnormal (case).[5] The HADS questionnaire has been validated in many languages, countries, and settings including general practice and community settings.[4]


  Results Top


Sociodemographic profile

Amongst the sample of 50 patients, 31 were male. Mean age was 26 years. Majority of the patients had completed primary or secondary education. Majority of males were self-employed or skilled workers while the majority of females were homemakers. Forty-one patients were married and majority resided in Mumbai. Majority (43) were Hindus [Table 1].
Table 1: Demographic profile (n=50)

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Cognitive impairment

On MMSE, six patients had mild cognitive impairment (score 18–23) and five patients had a severe cognitive impairment (score 0–17). 22% of patients suffered from mild to severe cognitive deficits during ICU stay [Table 2].
Table 2: Cognitive impairment as per mini-mental status examination score (n=50)

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Psychological symptoms

Anxiety

On HADS, four patients had borderline anxiety (score 8–10), while seven patients were found to be cases of anxiety (score 11–21). About 22% of patients had borderline symptoms to symptoms amounting to cases of anxiety.

Depression

Ten patients had borderline depressive features (score 8–10) while eight patients were cases of depression (score 11–21). About 36% of patients had borderline symptoms to symptoms amounting to cases of depression [Table 3].
Table 3: Symptoms of anxiety and depression as per hospital anxiety depression scale (n=50)

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Duration of stay in Intensive Care Unit and severity of cognitive and psychological symptoms

33 patients stayed in ICU for up to 10 days and 17 patients were admitted for more than 10 days [Table 4].
Table 4: Duration of stay in Intensive Care Unit and severity of cognitive and psychological symptoms (n=50)

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Cognitive impairment and duration of Intensive Care Unit stay

Patients with severe cognitive impairment (23%) had a longer duration of stay in the ICU (>10 days). No such trend was observed with mild cognitive impairment [Graph 1].



Anxiety and duration of Intensive Care Unit stay

Patients of anxiety (18%) and those with borderline anxiety symptoms (23%) had a longer duration of stay in the ICU (>10 days).

Depression and duration of Intensive Care Unit stay

35% of the patients with depression and and 24% having borderline depression had a longer duration of stay in the ICU [Graph 2].




  Discussion Top


The mean age of our study population was 26 years and 62% were males whereas Pandharipande et al. reported in their study the mean age as 61 years with 51% being males.[6] Hence, though gender distribution is not very different, significant differences in age distribution was seen. The same study also observed that at 3 months, 40% of the patients had global cognition scores that were 1.5 standard deviation (SD) below the population means (similar to scores for patients with moderate traumatic brain injury), and 26% had scores 2 SD below the population means (similar to scores for patients with mild Alzheimer's disease).[6] However, in our study, we found that 22% of patients suffered from mild to severe cognitive impairment. This discrepancy can be due to the difference in age distribution and can also be due to the long-term effect of the critical illness. However, this cannot be said conclusively as much of the data on the prevalence of long-term cognitive impairment after critical illness have largely come from small cohort studies restricted to single disease processes (e.g., the acute respiratory distress syndrome) rather than taking into consideration all general/medical ICU admissions.[6],[7],[8],[9]

A study by Jackson et al. found that 11 of 34 patients (32%) were neuropsychologically impaired. Impairment was generally diffuse but occurred primarily in areas of psychomotor speed, visual and working memory, verbal fluency, and visuoconstruction. Scores on the Geriatric Depression Scale-Short Form were significantly more abnormal in the neuropsychologically impaired group than in the nonimpaired group at hospital discharge (P = 0.04) and at 6-month follow-up (P = 0.02), and clinically significant depression was found in 27% of impaired patients at hospital discharge.[10] Davydow found the prevalence of “clinically significant” depressive symptoms to be 28% (total n = 1213) in their study. Neither sex nor age was consistent risk factors for post-ICU depression, and severity of illness at ICU admission was consistently not a risk factor.[11] This is quite similar to the findings in our study, where we found that 36% of patients had borderline symptoms to symptoms amounting to cases of depression.

In a prospective study by Wade et al., it was found that level three patients with mixed diagnoses suffer considerable psychological distress both during and following a general ICU admission. Three months after being discharged, 27% had probable posttraumatic stress disorder (PTSD) symptoms, 46% had probable depression, and 44% had anxiety.[1] This is higher than what our study has found. The discrepancy may again be due to 3 months' follow-up by the above study. Furthermore, Myhren et al. identified a subpopulation whose level of PTSD symptoms actually increased over a 1-year follow-up, a finding that highlights the need for ongoing follow-up of critical illness survivors.[12],[13]

In the current study, we divided patients depending on the duration of stay in ICU, that is, patients who stayed in the ICU for up to 10 days and who stayed for more than 10 days. Similar distribution was also seen in a study by Williams et al. They observed that out of 19,921 hospital survivors, the proportion of patients who stayed in the ICU for ≤10 days (94%) was much greater than the proportion of patients who stayed >10 days (6%). The median length of stay in the ICU for those who stayed >10 days was 17 days (interquartile range, 13–24), and these patients accounted for 31% of the total ICU days of the whole cohort. There was an over-representation of trauma and sepsis (P < 0.001) in patients who stayed in the ICU for >10 days.[14] Gaudino et al. defined prolonged stay being >10 days for patients admitted to ICU after cardiac surgery,[15] but Bashour et al. selected ≥10 days because mortality in patients who stay in the ICU after cardiac surgery increases rapidly during the 1st 10 intensive care days.[16]

Based on the duration of stay in the ICU, we found that maximum patients with severe cognitive impairment and majority of patients who were cases and had borderline symptoms of anxiety and depression had a longer duration of stay in ICU (>10 days). Chung, et al. observed trends suggesting that longer ICU length of stay was associated with post-ICU memory of severe anxiety or panic during the ICU stay (U = 66.00, P = 0.08) and longer duration of mechanical ventilation was associated with post-ICU memory of difficulty in breathing or feeling of suffocation during the ICU stay (U = 69.50, P = 0.09).[17]


  Conclusions Top


In our study, we found that ICU stay can lead to cognitive impairment in patients. ICU stay can also lead to psychological symptoms such as anxiety and depression. Patients with a longer duration of stay in ICU are more likely to have a significant cognitive impairment, anxiety, and depression.

Limitations

Sample size of the study was small. Other psychological symptoms were not taken into consideration. We did not elicit the family history of depression, anxiety, or dementia in our study, which may be a confounding factor while interpreting the findings.

Future research

Long-term follow-up study can give better insight into the problems of ICU recovered patients. Comparison with general population and statistical application will give more clarity.

Clinical implications

Early psychological and cognitive evaluation of recovering ICU patients will help to identify symptoms. Early treatment of these patients will prevent long-term complications. Early intervention will improve psychological and cognitive health of patients and lead to better prognosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wade DM, Howell DC, Weinman JA, Hardy RJ, Mythen MG, Brewin CR, et al. Investigating risk factors for psychological morbidity three months after intensive care: A prospective cohort study. Crit Care 2012;16:R192.  Back to cited text no. 1
    
2.
Mini Mental State Examination; September, 2011. Available from: http://www.tdh.org.nz/assets/ED/2011/Sept-2011/MiniMentalStatusExam.pdf. [Last accessed on 2018 May 10].  Back to cited text no. 2
    
3.
Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98.  Back to cited text no. 3
    
4.
Stern AF. The hospital anxiety and depression scale. Occup Med (Lond) 2014;64:393-4.  Back to cited text no. 4
    
5.
Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361-70.  Back to cited text no. 5
    
6.
Pandharipande PP, Girard TD, Jackson JC, Morandi A, Thompson JL, Pun BT, et al. Long-term cognitive impairment after critical illness. N Engl J Med 2013;369:1306-16.  Back to cited text no. 6
    
7.
Hopkins RO, Weaver LK, Pope D, Orme JF, Bigler ED, Larson-Lohr V, et al. Neuropsychological sequelae and impaired health status in survivors of severe acute respiratory distress syndrome. Am J Respir Crit Care Med 1999;160:50-6.  Back to cited text no. 7
    
8.
Hopkins RO, Weaver LK, Collingridge D, Parkinson RB, Chan KJ, Orme JF Jr., et al. Two-year cognitive, emotional, and quality-of-life outcomes in acute respiratory distress syndrome. Am J Respir Crit Care Med 2005;171:340-7.  Back to cited text no. 8
    
9.
Herridge MS, Tansey CM, Matté A, Tomlinson G, Diaz-Granados N, Cooper A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011;364:1293-304.  Back to cited text no. 9
    
10.
Jackson JC, Hart RP, Gordon SM, Shintani A, Truman B, May L, et al. Six-month neuropsychological outcome of medical Intensive Care Unit patients. Crit Care Med 2003;31:1226-34.  Back to cited text no. 10
    
11.
Davydow DS, Gifford JM, Desai SV, Bienvenu OJ, Needham DM. Depression in general Intensive Care Unit survivors: A systematic review. Intensive Care Med 2009;35:796-809.  Back to cited text no. 11
    
12.
Myhren H, Ekeberg O, Tøien K, Karlsson S, Stokland O. Posttraumatic stress, anxiety and depression symptoms in patients during the first year post Intensive Care Unit discharge. Crit Care 2010;14:R14.  Back to cited text no. 12
    
13.
Davydow DS. The burden of adverse mental health outcomes in critical illness survivors. Crit Care 2010;14:125.  Back to cited text no. 13
    
14.
Williams TA, Ho KM, Dobb GJ, Finn JC, Knuiman M, Webb SA, et al. Effect of length of stay in Intensive Care Unit on hospital and long-term mortality of critically ill adult patients. Br J Anaesth 2010;104:459-64.  Back to cited text no. 14
    
15.
Gaudino M, Girola F, Piscitelli M, Martinelli L, Anselmi A, Della Vella C, et al. Long-term survival and quality of life of patients with prolonged postoperative Intensive Care Unit stay: Unmasking an apparent success. J Thorac Cardiovasc Surg 2007;134:465-9.  Back to cited text no. 15
    
16.
Bashour CA, Yared JP, Ryan TA, Rady MY, Mascha E, Leventhal MJ, et al. Long-term survival and functional capacity in cardiac surgery patients after prolonged intensive care. Crit Care Med 2000;28:3847-53.  Back to cited text no. 16
    
17.
Chung CR, Yoo HJ, Park J, Ryu S. Cognitive impairment and psychological distress at discharge from Intensive Care Unit. Psychiatry Investig 2017;14:376-9.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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