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Investigating risk factors for psychological morbidity three months after intensive care: a prospective cohort study

Dorothy M Wade12*, David C Howell2, John A Weinman3, Rebecca J Hardy4, Michael G Mythen5, Chris R Brewin6, Susana Borja-Boluda2, Claire F Matejowsky2 and Rosalind A Raine1

Author Affiliations

1 Department of Applied Health Research, University College London (UCL), 1-19 Torrington Place, London, WC1E 7HB, UK

2 Critical Care Unit, University College London Hospitals NHS Foundation Trust (UCLH), 235 Euston Rd, London, NW1 2BU, UK

3 Psychology Department, Institute of Psychiatry, Kings College London, Guy's Campus, St. Thomas St, London, SE1 9RT, UK

4 MRC Unit for Lifelong Health and Ageing, University College London, 33 Bedford Place, London, WC1B 5JU, UK

5 UCLH/UCL NIHR Biomedical Research Centre, Maple House, 149 Tottenham Court Rd, London W1T 7DN, UK

6 Psychology Department, University College London, Gower St, London, WC1E 6BT, UK

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Critical Care 2012, 16:R192  doi:10.1186/cc11677

Published: 15 October 2012

Abstract

Introduction

There is growing evidence of poor mental health and quality of life among survivors of intensive care. However, it is not yet clear to what extent the trauma of life-threatening illness, associated drugs and treatments, or patients' psychological reactions during intensive care contribute to poor psychosocial outcomes. Our aim was to investigate the relative contributions of a broader set of risk factors and outcomes than had previously been considered in a single study.

Methods

A prospective cohort study of 157 mixed-diagnosis highest acuity patients was conducted in a large general intensive care unit (ICU). Data on four groups of risk factors (clinical, acute psychological, socio-demographic and chronic health) were collected during ICU admissions. Post-traumatic stress disorder (PTSD), depression, anxiety and quality of life were assessed using validated questionnaires at three months (n =100). Multivariable analysis was used.

Results

At follow-up, 55% of patients had psychological morbidity: 27.1% (95% CI: 18.3%, 35.9%) had probable PTSD; 46.3% (95% CI: 36.5%, 56.1%) probable depression, and 44.4% (95% CI: 34.6%, 54.2%) anxiety. The strongest clinical risk factor for PTSD was longer duration of sedation (regression coefficient = 0.69 points (95% CI: 0.12, 1.27) per day, scale = 0 to 51). There was a strong association between depression at three months and receiving benzodiazepines in the ICU (mean difference between groups = 6.73 points (95% CI: 1.42, 12.06), scale = 0 to 60). Use of inotropes or vasopressors was correlated with anxiety, and corticosteroids with better physical quality of life.

The effects of these clinical risk factors on outcomes were mediated (partially explained) by acute psychological reactions in the ICU. In fully adjusted models, the strongest independent risk factors for PTSD were mood in ICU, intrusive memories in ICU and psychological history. ICU mood, psychological history and socio-economic position were the strongest risk factors for depression.

Conclusions

Strikingly high rates of psychological morbidity were found in this cohort of intensive care survivors. The study's key finding was that acute psychological reactions in the ICU were the strongest modifiable risk factors for developing mental illness in the future. The observation that use of different ICU drugs correlated with different psychological outcomes merits further investigation. These findings suggest that psychological interventions, along with pharmacological modifications, could help reduce poor outcomes, including PTSD, after intensive care.