We know that post-traumatic stress disorder (PTSD) occurs among war veterans. What we are just beginning to learn is that it can occur in patients who have survived stays in the intensive care unit (ICU) as well.
Recent studies suggest that as many as 35 percent of the five million patients who are admitted to ICUs in the U. S. exhibit some signs of PTSD. These patients may experience intrusive thoughts, mood swings, avoidance or reckless behaviors, or emotional numbness—all signs of psychological trauma that may linger for two years or more and involve flashbacks of delusions and hallucinations about events that didn’t actually happen. Feelings of fear may persist long after any physical danger has passed. These patients return home mentally shaken. In some cases, they are unable to return to work or perform activities of daily living, thus placing a burden on them and family members.
A Lasting Effect
According to a study conducted at Johns Hopkins University School of Medicine, one in three ventilated patients was found to have PTSD. Researchers studied a group of patients with acute lung injury (ALI), but they believe that PTSD is common among other ICU patients as well. The greatest onset of symptoms occurred by the three-month follow-up visit. Sixty-two percent of the patients who were experiencing PTSD had symptoms at their two-year visit.
The study concluded that patients who had experienced depression before they were hospitalized were twice as likely to develop PTSD. Those who remained in ICU the longest were also more likely to experience PTSD. Also among those most at risk: patients who had sepsis while in the ICU and those who received high doses of opiates. Other studies suggest that women, younger patients, and patients with a history of emotional problems are at greater risk.
Sedation as a Cause
Some researchers point to sedation—particularly benzodiazepines—as a prime culprit. Although sedation is necessary to manage pain and to help ICU patients who are receiving mechanical ventilation tolerate the endotracheal tubes, sedatives can contribute to delirium and hallucinations, increasing the likelihood of PTSD. Even after the sedation is discontinued, delirium can continue. In response, the Society of Critical Care Medicine issued new sedation guidelines, instructing doctors to treat pain first and then weigh the benefits of using benzodiazepines for anxiety while continuing to assess the patient for pain, alertness, and delirium. Higher doses and longer duration of sedative administration seem to increase risk. More study is needed, but early evidence suggests that lighter sedation results in improved cognitive and physical recovery with fewer incidences of hallucinations.
Diaries as an Intervention
Some ICU nurses have spearheaded efforts to mitigate the trauma of the ICU for both patients and their family members. In Britain, Germany, and some Scandinavian countries, these nurses are using diaries to record the care provided to a patient. Family members can contribute to the diary, too, if they wish. The patient receives the diary on discharge. The idea is that the diary will help ground the patient in reality and anchor him against any hallucinations or amnesia experienced as a result of the ICU experience. One European study that researched the use of these diaries found that they reduced PTSD symptoms. Although diaries have been commonly used in European hospitals for more than 10 years, this practice has not caught on in the U.S., presumably because hospitals fear the diaries might violate privacy laws.
In addition to patient diaries, some care providers are working to identify other interventions that may help. The researchers who conducted the Johns Hopkins study are looking at whether changing care in the ICU can reduce the incidence of PTSD. Some early studies suggest that physical rehabilitation for these patients might be effective. One thing is certain: Special attention needs to be paid to those patients with risk factors. Simply alerting them and their primary care doctors to the increased risk for PTSD could make a difference.