Psychiatric symptoms after acute respiratory distress syndrome: a 5-year longitudinal study
EJRC Article Review
There is a paucity of data illustrating the long-term (>1-year) psychological and psychiatric morbidity in survivors of acute respiratory distress syndrome (ARDS). Bienvenu et al. investigated the occurrence of anxiety, depression and post-traumatic stress disorder (PTSD) over a 5-year period in a prospective cohort study of 196 patients.
Between 2004-2007, mechanically ventilated patients found to have “acute lung injury” as per the American-European Consensus Criteria (prior to the now widely adopted Berlin Criteria (2012)) were enrolled. Of note, patients with life-limiting disease (life expectancy <6 months) and those with primary neurological disease, head trauma and/or currently admitted to specialty neurological ICUs were excluded – conditions/environments that carry a higher prevalence of psychiatric illness.
The study adopted frequent follow-up points at 3, 6, 12, 24, 36, 48 and 60 months. Whilst the intervals between each would allow for analysis of symptoms over time there is certainly a possibility to miss the onset of relapsing/worsening symptoms should they occur between follow-up points.
From the cohort, most were male (56%) and <50 years old (53%). Seventy-five percent were active smokers. An association between education (years) and the risk of developing prolonged anxiety, depressive or PTSD symptoms was noted (odds ratio (OR) 2.0, 3.0 and 2.2 respectively). The majority of patients had a total education of less than 12 years (63%).
It was not surprising that the main cause for ARDS was sepsis (74%). Specific cause-of-death was not listed but the in-hospital mortality was 45%, roughly in-keeping with that observed in the ARDS population. Following consent, a further 38 (15%) died before the first follow-up period at 3-months. Within the follow-up period 65/196 (33%) died. The mortality risk factors were identified as increasing age and increasing organ dysfunction as reflected in the APACHE II (score>20, 70%) and SOFA (score>10, 31%) scores. There was 2-9% mortality between each follow-up period with the highest occurring between 12 and 24 months. The severity of psychiatric illness at the time of death was not given.
The study utilised validated scoring systems but in the absence of clinic interview to gauge anxiety, depression and post-traumatic stress disorder symptoms. The Hospital Anxiety and Depression Scale (HADS) was used and has demonstrated a sensitivity and specificity of >0.8.
The occurrence (prolonged or recurring) of anxiety, depression and PTSD in ARDS survivors was common (38%, 32% and 23% respectively). Patients found to have prolonged symptoms of all three was 13% and this was the most common pattern observed, and anxiety was common in most. Of note, the combination of anxiety and PTSD carried an odds ratio of 9.1 (4.1-20).
An interesting finding was that the median duration of symptoms was 33-39 months – which corresponds to 71-100% of the observed follow-up time, suggesting that majority of symptom onset are not delayed or transient. Furthermore, where the symptoms of anxiety, depression or PTSD were remitting, the median duration was 12 months. With regards to anxiety and depressive symptoms, remission was taken as a score of <8, and perhaps this may prevent those with new “milder” but persistent symptoms from being identified and intervention planned earlier and thus reducing the chance of relapse. The utilisation of a Reliable Change Index (RCI) however allowed for detection of statistically meaningful changes.
ICU/critical illness specific factors (LoS >14 days, proportion of ICU days with sepsis, delirium, daily equivalent doses of midazolam, morphine, prednisolone, were not related to risk of developing prolonged anxiety, depressive or PTSD symptoms. The study size is likely to be a limitation in this respect. History of depression prior to ARDS was independently associated with prolonged post ARDS psych morbidity (OR 2.4-2.9) and Short Form (SF) 36 physical function normed score <40 (OR 3.5-4.2).
The study design does not allow generalisability. An area of focus could be to investigate different rehabilitation strategies during critical illness i.e. early physiotherapy, early treatment initiation etc.
The occurrence of significant psychiatric illness and initiation of related treatment is linked to critical illness. This therefore supports the need for formal post-ICU follow-up to identify individuals at risk or currently displaying symptoms. Resources such as patient diaries are useful and evolving tools – one that was absent from this cohort.
Take Home Messages
Clinically significant, long-term symptoms of anxiety, depression, and PTSD are common in the first 5 years of ARDS. In-hospital screening of psychiatric history in critically ill patients may help predict and identify those that require frequent and/or structured specialist psychiatric input to improve quality of life after critical illness.
This article review was prepared and submitted by Sunil Patel on behalf of the ESICM Journal Review Club.
Bienvenu, O.J., Friedman, L.A., Colantuoni, E., Dinglas, V.D., Sepulveda, K.A., Mendez-Tellez, P., Shanholz, C., Pronovost, P.J. and Needham, D.M., 2017. Psychiatric symptoms after acute respiratory distress syndrome: a 5-year longitudinal study. Intensive Care Medicine, (2018) 44:38–47. https://doi.org/10.1007/s00134-017-5009-4