There is significant evidence that patients who survive critical illness experience morbidity after discharge from the ICU. This is commonly referred to as the post-intensive care syndrome (PICS). In addition to a negative impact on the physical health of ICU survivors, PICS also includes mental health morbidity.
Studies have shown that mechanically ventilated ICU survivors have a higher incidence of mood and anxiety disorders such as depression and post-traumatic stress disorder than non-ICU hospitalised patients. There is also a higher incidence of usage of psychotropic medications, particularly antidepressants and sedative-hypnotics among ICU survivors.
Similarly, other studies have demonstrated that ICU survivorship was associated with an increased incidence of new mental health diagnoses. There is also evidence that ICU survivors are at a greater risk of substance misuse. Findings show that among opioid naïve patients experiencing mechanical ventilation, 2.6% had persistent opioid use after discharge compared with 1.5% in non-ICU control patients. Recent evidence shows that ICU survivors have higher rates of deliberate self-harm and suicide compared to non-ICU hospitalised patients.
It is thus evident that, in addition to physical and cognitive sequelae, survivors of critical illness are at increased risk of new mental health diagnoses, psychotropic medication use, substance misuse, self-harm, and suicide.
Emerging data show that caregivers of ICU patients are also affected. The collective sequelae experienced by family members of ICU survivors are referred to as PICS-family (PICS-F). Over 50% of patients who receive prolonged mechanical ventilation require caregiver support up to a year after discharge. This can create an enormous burden on caregivers, especially when very few resources are available to support them.
Findings from the Canadian RECOVER cohort found that almost two-thirds of caregivers reported symptoms of depression at the time of patient discharge, and 43% at 1-year post-discharge. In addition, their scores on psychological well-being and overall mental health showed significant deterioration over time. In another study of spouses of critically ill patients with sepsis and septic shock, the incidence of new mental illness among spouses was 23.5%. More recent data from France shows that caregivers of patients with COVID-19-ARDS had a higher incidence of PTSD symptoms compared to the general public and caregivers of patients with ARDS from other causes.
Mental health morbidity is thus an important issue in these vulnerable populations. However, the underlying mechanisms remain unclear. Possible explanations could include the fact that critical care is traumatic and often involves invasive interventions and sedation. Delirium is also common among these patients and could be associated with PTSD. Some studies have also shown that the incidence of new mental health diagnoses is associated with invasive procedures such as mechanical ventilation. Invasive mechanical ventilation and renal replacement therapy were also associated with the risk of self-harm and suicide among ICU survivors. Critical illness can also exacerbate existing mental health morbidity. Finally, there is insufficient support for ICU survivors and caregivers. This lack of support and low income could be associated with self-harm and suicide among ICU survivors and mental health morbidity among caregivers.
Efforts should be made to address mental health morbidity among ICU survivors. Involving mental healthcare providers during ICU admission could be an important step and improve outcomes in PICS. There should also be a more organised follow-up of ICU survivors, which should ideally include early mental health involvement after discharge. The goal should be to provide greater support to ICU survivors and caregivers to minimise the risk of mental health deterioration, self-harm and suicide.
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