Effect of a Nurse-Led Preventive Psychological Intervention on Symptoms of Posttraumatic Stress Disorder Among Critically Ill Patients: A Randomized Clinical Trial.

Importance: A meta-analysis of outcomes during the 6 months after intensive care unit (ICU) discharge indicate a prevalence for clinically important posttraumatic stress disorder (PTSD) symptoms of 25%. Objective: To determine whether a nurse-led preventive, complex psychological intervention, initiated in the ICU, reduces patient-reported PTSD symptom severity at 6 months. Design, Setting, and Participants: A multicenter, parallel-group, cluster-randomized clinical trial with integrated economic and process evaluations conducted in 24 ICUs in the United Kingdom. Participants were critically ill patients who regained mental capacity following receipt of level 3 (intensive) care. A total of 2961 eligible patients were identified from September 2015 to January 2017. A total of 2048 were approached for participation in the ICU, of which 1458 provided informed consent. Follow-up was completed December 2017. Interventions: Twenty four ICUs were randomized 1:1 to the intervention or control group. Intervention ICUs (n = 12; 669 participants) delivered usual care during a baseline period followed by an intervention period. The preventive, complex psychological intervention comprised promotion of a therapeutic ICU environment plus 3 stress support sessions and a relaxation and recovery program delivered by trained ICU nurses to high-risk (acutely stressed) patients. Control ICUs (n = 12; 789 participants) delivered usual care in both baseline and intervention periods. Main Outcomes and Measures: The primary clinical outcome was PTSD symptom severity among survivors at 6 months measured using the PTSD Symptom Scale-Self-Report questionnaire (score range, 0-51, with higher scores indicating greater symptom severity; the minimal clinically important difference was considered to be 4.2 points). Results: Among 1458 enrolled patients (mean [SD] age, 58 [16] years; 599 women [41%]), 1353 (93%) completed the study and were included in the final analysis. At 6 months, the mean PTSD Symptom Scale-Self-Report questionnaire score in intervention ICUs was 11.8 (baseline period) compared with 11.5 (intervention period) (difference, -0.40 [95% CI, -2.46 to 1.67]) and in control ICUs, 10.1 (baseline period) compared with 10.2 (intervention period) (difference, 0.06 [95% CI, -1.74 to 1.85]) between periods. There was no significant difference in PTSD symptom severity at 6 months (treatment effect estimate [difference in differences] of -0.03 [95% CI, -2.58 to 2.52]; P = .98). Conclusions and Relevance: Among critically ill patients in the ICU, a nurse-led preventive, complex psychological intervention did not significantly reduce patient-reported PTSD symptom severity at 6 months. These findings do not support the use of this psychological intervention. Trial Registration: ISRCTN53448131.

Intrusive memories of hallucinations and delusions in traumatized intensive care patients: An interview study.

OBJECTIVE: Psychological morbidity, including post-traumatic stress disorder (PTSD), is common in survivors of intensive care. Intrusive memories of trauma are important symptoms of PTSD. Research has not established which aspects of intensive care are most traumatizing; invasive medical procedures, fear of dying from life-threatening illness or injury, or effects of psychoactive drugs, including hallucinations and delusions. Our study aimed to investigate the roots of post-intensive care trauma by interviewing survivors with symptoms of PTSD. Were their intrusive memories primarily of real events or hallucinations and delusions from intensive care? DESIGN: Interview study as part of a mixed-methods investigation of psychological outcomes post-intensive care. METHODS: We used purposive sampling to identify patients with intrusive memories of intensive care unit. Detailed interviews were conducted to investigate the nature and content of post-intensive care memories. Intrusive memories were categorized as factual, hallucinatory/delusional, or uncertain. RESULTS: Thematic saturation was achieved after 17 interviews. Approximately 70% (12/17) of patients had hallucinatory/delusional intrusive memories of intensive care, while 12% (2/17) had factual but no hallucinatory/delusional memories; 18% (3) were uncertain whether memories were factual or hallucinatory/delusional. Further analysis suggested that 88% of all patients had hallucinatory/delusional intrusive memories. The content of intrusive memories commonly merged realistic events (involving intensive care staff, environment, medical procedures and unpleasant physical experiences) with delusions and frightening hallucinations. CONCLUSIONS: We found that patients in this in-depth study were more traumatized by frightening hallucinations/delusions than real events, suggesting they may have post-psychosis PTSD, rather than classic PTSD. Interventions are needed to diagnose and treat intensive care hallucinations/delusions, or minimize effects, to prevent PTSD.

Detecting acute distress and risk of future psychological morbidity in critically ill patients: validation of the intensive care psychological assessment tool.

INTRODUCTION: The psychological impact of critical illness on a patient can be severe, and frequently results in acute distress as well as psychological morbidity after leaving hospital. A UK guideline states that patients should be assessed in critical care units, both for acute distress and risk of future psychological morbidity; but no suitable method for carrying out this assessment exists. The Intensive care psychological assessment tool (IPAT) was developed as a simple, quick screening tool to be used routinely to detect acute distress, and the risk of future psychological morbidity, in critical care units. METHODS: A validation study of IPAT was conducted in the critical care unit of a London hospital. Once un-sedated, orientated and alert, critical care patients were assessed with the IPAT and validated tools for distress, to determine the IPAT's concurrent validity. Fifty six patients took IPAT again to establish test-retest reliability. Finally, patients completed posttraumatic stress disorder (PTSD), depression and anxiety questionnaires at three months, to determine predictive validity of the IPAT. RESULTS: One hundred and sixty six patients completed the IPAT, and 106 completed follow-up questionnaires at 3 months. Scale analysis showed IPAT was a reliable 10-item measure of critical care-related psychological distress. Test-retest reliability was good (r =0.8). There was good concurrent validity with measures of anxiety and depression (r =0.7, P <0.01; r =0.6, P <0.01). With a cut-point of ≥7, the IPAT had 82% sensitivity and 65% specificity to detect concurrent anxiety; and 80% sensitivity and 66% specificity to detect concurrent low mood (area under the curve (AUC) =0.8 for both). Predictive validity for psychological morbidity was good (r =0.4, P <0.01; r =0.64, P <0.01 for PTSD with days 1 and 2 data). The IPAT had 69% specificity and 57% sensitivity to predict future psychological morbidity (AUC =0.7). CONCLUSIONS: The IPAT was found to have good reliability and validity. Sensitivity and specificity analysis suggest the IPAT could provide a way of allowing staff to assess psychological distress among critical care patients after further replication and validation. Further work is also needed to determine its utility in predicting future psychological morbidity.

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

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. 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.