Again, as with anxiety and depression, despite the high prevalence of PTSD related to critical illness and ICU stays, there have been limited studies of nonpharmacologic interventions, and there is no standard protocol for acute stress intervention in the setting of critical illness and ICU care.
Among the few studies conducted to date, Peris et al, compared psychological outcomes of 2 cohorts of patients surviving major trauma treated before or after the institution of an in-ICU clinical psychologist intervention.9 Patients in the interventional cohort had a significantly lower prevalence of PTSD symptoms (21.1% vs 57.0% at 12-month follow-up).
The intervention addressed the psycho-emotional needs of patients and their relative caregivers with a focus on stress management, which involved cognitive and emotional restructuring, while promoting family-centered decision making as a way of alleviating stress. The structure of the intervention highlights a transition from an independent model of care to an interdisciplinary plan of care that is collaborative and patient-centered.
ICU diaries have been used in Scandinavia since the 1990s and are now being implemented in hospitals around the world.13 ICU diaries help patients and family members understand and come to terms with their critical illness experiences and may positively affect long-term psychological and quality of life outcomes.
In outpatient settings, exposure therapy, or combinations of exposure and cognitive therapy, have the strongest evidence of benefit and are recommended as a first-line treatment for PTSD.14 These approaches have not yet been tested in the ICU or specifically with survivors of critical illness. However, some recent studies suggest that these strategies, as well as exposure techniques including brief prolonged exposure and virtual reality, may be beneficial for the treatment of early signs of PTSD and prevention of adverse outcomes.15 The most common PTSD symptom in critical illness survivors is avoidance and, therefore, cognitive behavioral techniques that include exposure therapy could be most beneficial.
Of note, none of the PTSD treatment guidelines advocate the routine use of early psychological debriefing to treat or prevent PTSD in individuals exposed to trauma, reflecting the fact that evidence does not generally support this practice.
Pulmonology Advisor: What would you recommend to clinicians who treat patients with critical illness?
Dr Jackson: All too often we hear from patients that they feel their concerns are minimized or dismissed by clinicians who are unfamiliar with the long-term sequelae often experienced after critical illness. I think one area where we can definitely do better is clinicians becoming more familiar with the notion that brain injuries, PTSD, and the like can and often do occur in ICU survivors at rates that often eclipse those seen in many other clinical populations.
Perhaps one day we will know better how to prevent or repair these difficulties, but many of the patients we hear from do not necessarily expect this right now. They just want to be heard and understood, and many of them wish they had been educated prior to discharge about the possible challenges that await them. This is one area where I think all of us can do a bit better.
Dr Mikkelsen: To prepare our patients and their families for life after critical illness, it is imperative that we begin to educate and empower our patients at the earliest opportunity, beginning in the ICU. As hard as we work to save the lives of our patients who are critically ill, it is equally important to deliver and support care pathways in the ICU and post-ICU that mitigate suffering and long-term impairments.
Dr Jutte: Although some hospitals have the luxury of having a psychologist on ICU staff, the vast majority do not. Having a psychologist with the knowledge, skills, and abilities to work with individuals who are critically ill and in the ICU can likely have multiple advantages including:
- Helping patients engage in recommended treatments such as early mobilization.
- Assisting critical care team members to communicate effectively with patients so that patients can derive the most benefit from treatment.
- Helping improve post-discharge and long-term outcomes.
- Possibly reducing readmission rates through coordination of care, enhanced patient engagement in treatment, and enhanced post-discharge planning, particularly if there are new or worsened mental health or cognitive difficulties.
We need more “champions” of early mobilization programs and of including a rehabilitation psychologist on staff in ICUs across the country. This can help increase psychology research programs so we can learn more about what effective prevention and treatment efforts may include with regard to optimal timing, duration, and effective elements; and improve patient engagement in treatment, thereby positively affecting long-term physical, cognitive, and psychological outcomes.
Pulmonology Advisor: What should be the next steps in this area in terms of research, education, or otherwise?
Dr Jackson: If you look at the number of ICU survivors who experience some combination of cognitive impairment, psychological distress, or physical debility, or the number of survivors who have just one of these issues, the number is astoundingly — almost shockingly — large. It really represents a massive public health problem, and yet it continues to be wildly underappreciated and overlooked. A key challenge in this regard is education and advocacy. Addressing this issue could perhaps take the form of initiatives like International Post-Intensive Care Syndrome Day, with all the trappings and awareness of International Delirium Day, for example.
Another challenge is to develop clinical programs that are available to larger groups of people. We have an ICU Recovery Center at Vanderbilt where we see patients locally and from around the country, and there are numerous similar resources at medical centers in North America, but they are mostly few and far between. This state of affairs stands in sharp contrast to the situation in oncology where, the last time I checked, there were more than 300 centers dedicated to survivorship.
We have a long way to go, but I am so happy to be partnering with passionate and committed colleagues and deeply dedicated patients as we tackle this challenge. I am confident that the next decade is going to herald major advances in understanding and treating PICS, particularly as we better understand the biologic mechanisms and the physiology that drives and sustains problems like memory deficits, depression, and other difficulties related to critical illness.
Dr Mikkelsen: There is a sense of urgency to identify which survivors are at greatest risk for long-term impairments and to provide clinicians with recommendations for how and when to screen for impairments postdischarge. An international state-of-the-art conference was recently held to address these fundamental questions, and the results of this work should be published within the next year.
In parallel, novel strategies are urgently needed to prevent and rehabilitate long-term impairments, now that we recognize the burden of the sequelae of critical illness.
Dr Jutte: More research efforts need to be directed toward randomized clinical trials of effective nonpharmacologic treatments of mental health difficulties such as anxiety, depressive symptoms, acute stress, and PTSD. Additional studies of in-ICU psychological interventions that evaluate variables thought to facilitate or hinder recovery from critical illness utilizing a patient-centered and collaborative team approach are imperative.
More psychology internship and residency programming could be directed toward providing educational and clinical experiences in the ICU working with patients who are critically ill. We need to determine which elements, factors, and personnel may be instrumental in enhancing long-term recovery from critical illnesses — for example, in outpatient post-hospitalization programs. We also need to better understand how to assist family members across the continuum of care.
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