Delirium and PTSD from the ICU Experience

Nightmares After the I.C.U. – NYTimes.com

Diaries Aid Mental Recovery – NYTimes.com

I just recently read the two New York Times articles above about delirium and Post-traumatic Stress Disorder (PTSD) in patients hospitalized in intensive care units (ICUs). They are compelling stories of people who may suffer what can be the terror of being in the ICU. The hallucinations and delusions of delirium can certainly be caused by the sedatives used to prevent them from tearing out their intravenous lines and breathing tubes, actions which could kill them.

How ironic that many patients who suffer from the horrific delusions and hallucinations caused by delirium believe that the very doctors and nurses who are working to keep them alive are trying to kill them. This is the reason why antipsychotics, such as haloperidol, may be recommended by consulting psychiatrists (see post, Ban Haldol? – The Practical Psychosomaticist).

However, there may be medical reasons why intensivists might not want to use antipsychotics. It’s even more sad and frustrating for families that the drugs used for pain control and sedation,  such as opioids and benzodiazepines, themselves cause delirium, and that’s over and above the catastrophic medical causes of delirium as well.

The usual recommendations by psychiatrists are to avoid psychotropic medications if at all possible, even psychiatric drugs that patients were taking prior to hospitalization. Delirium trumps all other psychiatric illness in that it’s impossible to diagnose other primary mental illnesses, including PTSD (which can’t be diagnosed until much later, often several weeks after the patient has been released from the hospital), in the setting of delirium. The brain in delirium is an organ that is acutely injured, just like any other bodily organ can be injured. It’s impossible to predict how someone will react to psychiatric medications in that context. Usually they can make it more challenging to create a safe treatment environment.

What nurses and critical care doctors can do in the ICU is offer hope and reassure families that they’re aware of what can happen to their loved ones in critical care environments, and let them know they’re working to protect them from both medical and psychological harm.

References:

Bienvenu, O. J., et al. (2013). “Post-traumatic stress disorder symptoms after acute lung injury: a 2-year prospective longitudinal study.” Psychol Med: 1-15.
BACKGROUND: Survivors of critical illnesses often have clinically significant post-traumatic stress disorder (PTSD) symptoms. This study describes the 2-year prevalence and duration of PTSD symptoms after acute lung injury (ALI), and examines patient baseline and critical illness/intensive care-related risk factors. Method This prospective, longitudinal cohort study recruited patients from 13 intensive care units (ICUs) in four hospitals, with follow-up 3, 6, 12 and 24 months after ALI onset. The outcome of interest was an Impact of Events Scale – Revised (IES-R) mean score 1.6 (‘PTSD symptoms’). RESULTS: During the 2-year follow-up, 66/186 patients (35%) had PTSD symptoms, with the greatest prevalence by the 3-month follow-up. Fifty-six patients with post-ALI PTSD symptoms survived to the 24-month follow-up, and 35 (62%) of these had PTSD symptoms at the 24-month follow-up; 50% had taken psychiatric medications and 40% had seen a psychiatrist since hospital discharge. Risk/protective factors for PTSD symptoms were pre-ALI depression [hazard odds ratio (OR) 1.96, 95% confidence interval (CI) 1.06-3.64], ICU length of stay (for a doubling of days, OR 1.39, 95% CI 1.06-1.83), proportion of ICU days with sepsis (per decile, OR 1.08, 95% CI 1.00-1.16), high ICU opiate doses (mean morphine equivalent 100 mg/day, OR 2.13, 95% CI 1.02-4.42) and proportion of ICU days on opiates (per decile, OR 0.83, 95% CI 0.74-0.94) or corticosteroids (per decile, OR 0.91, 95% CI 0.84-0.99). CONCLUSIONS: PTSD symptoms are common, long-lasting and associated with psychiatric treatment during the first 2 years after ALI. Risk factors include pre-ALI depression, durations of stay and sepsis in the ICU, and administration of high-dose opiates in the ICU. Protective factors include durations of opiate and corticosteroid administration in the ICU.

Davydow, D. S., et al. (2008). “Posttraumatic stress disorder in general intensive care unit survivors: a systematic review.” General Hospital Psychiatry 30(5): 421-434.
OBJECTIVE: Our objective was to summarize and critically review data on the prevalence of posttraumatic stress disorder (PTSD) in general intensive care unit (ICU) survivors, risk factors for post-ICU PTSD and the impact of post-ICU PTSD on health-related quality of life (HRQOL). METHODS: We conducted a systematic literature review using Medline, EMBASE, Cochrane Library, CINAHL, PsycINFO and a hand-search of 13 journals. RESULTS: Fifteen studies were eligible. The median point prevalence of questionnaire-ascertained “clinically significant” PTSD symptoms was 22% (n=1,104), and the median point prevalence of clinician-diagnosed PTSD was 19% (n=93). Consistent predictors of post-ICU PTSD included prior psychopathology, greater ICU benzodiazepine administration and post-ICU memories of in-ICU frightening and/or psychotic experiences. Female sex and younger age were less consistent predictors, and severity of critical illness was consistently not a predictor. Post-ICU PTSD was associated with substantially lower HRQOL. CONCLUSIONS: The prevalence of PTSD in ICU survivors is high and negatively impacts survivors’ HRQOL. Future studies should comprehensively address how patient-specific factors (e.g., pre-ICU psychopathology), ICU management factors (e.g., administration of sedatives) and ICU clinical factors (e.g., in-ICU delirium) relate to one another and to post-ICU PTSD. Clinicians caring for the growing population of ICU survivors should be aware of PTSD risk factors and monitor patients’ needs for early intervention.

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