The Burden of Psychiatric Symptoms after Critical Illness: Risks, Screening and Prevention

BY Allison Rhodes, Kathryne Adams, Xuan (Susan) Han & Cristina Montalvo

Many patients survive the ICU but have new or worsening psychiatric symptoms after discharge

More than five million patients are admitted to intensive care units (ICUs) in the United States each year. Due to continuous advances, more and more patients survive. However, many survivors of critical illness do not fully return to their previous baseline function. Post-intensive care syndrome (PICS) refers to new or worsening changes in mental health, cognitive function, or physical function following critical illness. In terms of mental health, survivors of critical illness may display symptoms of post-traumatic stress disorder (PTSD), depression, or anxiety. Anywhere from 13% to 25% of ICU survivors demonstrate psychiatric symptoms after discharge. The impact of psychiatric symptoms after ICU discharge is significant. Patients experience social isolation, difficulty returning to work, and decreased quality of life. There is also significant impact on family and caregivers. Additionally, psychiatric symptoms have been shown to be difficult to treat and may be less responsive to targeted interventions than cognitive and physical symptoms. Given the high morbidity of these symptoms, it is essential that intensivists, primary care providers, family members, and patients familiarize themselves with the risk factors. Intensivists should also familiarize themselves with the intra-ICU interventions that can mitigate the risk.

Who is most at risk?

There are several known risk factors for the development of psychiatric symptoms after ICU discharge. Previous psychiatric history and lack of social support are strong risk factors for developing psychiatric symptoms after ICU discharge. Patients with poor baseline physical functioning are at higher risk of developing depression. More research is needed to determine the impact of other sociodemographic factors, including race and ethnicity, socioeconomic status, and level of education.

Several aspects of critical illness itself have been identified as risk factors for developing psychiatric symptoms after discharge. These include delirium, mechanical ventilation, physical restraint, and exposure to sedating medications. Patients who have traumatic memories of ICU experiences also have a higher risk of developing psychiatric symptoms after discharge, in particular PTSD.

So what can be done? Screening

While some patients have the opportunity to receive focused care after discharge in multidisciplinary programs, most continue to receive care from primary care providers. It is essential that providers screen for new or worsening psychiatric symptoms after ICU discharge. Primary care providers should pay particular attention to patients with previous psychiatric history. There is no consensus on when to start screening, but most studies and society guidelines recommend screening at least one month after discharge. There are many assessment tools that have been used to screen for psychiatric symptoms after ICU discharge, including the PTSS-14 and IES-6 for PTSD; the BDI-II and PHQ-9 for depression, and the BAI and HADS for anxiety.

So what can be done? Prevention

Intensivists have the opportunity to minimize modifiable risk factors that lead to increased risk of psychiatric symptoms after ICU discharge. When clinically appropriate, intensivists can aim to shorten the duration of mechanical ventilation, minimize exposure to sedating medications, and reduce the use of physical restraints. In particular, the sedative dexmedetomidine has been shown to have the lowest risk for delirium and has been associated with decreased psychiatric symptoms six months after discharge. More research should be done to look at the impact of other interventions including the ABCDEF bundle, ICU diaries, depth of sedation, and daily spontaneous awakening trials. Intensivists play a critical role in educating and supporting caregivers. Finally, intensivists can improve patients’ long-term post-ICU psychiatric outcomes by facilitating transitions of care to ambulatory providers.

Article details

“The Psychiatric Domain of Post-Intensive Care Syndrome: A Review for the Intensivist”
Allison Rhodes, MD, MPH, Christopher Wilson, MD, Dimitar Zelenkov, PharmD, Kathryne Adams, MD, Janelle O. Poyant, PharmD, BCCCP, Xuan Han, MD, MS, Anthony Faugno, MD & Cristina Montalvo, MD, MBS
First published online August 22, 2024
DOI: 10.1177/08850666241275582
Journal of Intensive Care Medicine

About the Authors

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Allison Rhodes, MD, MPH is a third-year psychiatry resident at Tufts Medical Center. She earned her Bachelor's degree from Washington University in St. Louis and her MD and MPH from Tufts University School of Medicine. She previously served on the boards of GLMA: Health Professionals Advancing LGBTQ Equality, and AGLP: The Association of LGBTQ+ Psychiatrists. She is interested in consultation-liaison psychiatry, outpatient psychiatry, and resident education, and serves on the ACLP Online Education Subcommittee.

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Kathryne Adams, MD is a fourth-year Adult Psychiatry resident at Tufts Medical Center. She is passionate about critical care psychiatry, hospital safety, and innovations in systems of care. She graduated medical school from Rush Medical College and is pursuing a fellowship in Consult-Liaison Psychiatry after completion of her residency.

Xuan (Susan) Han, MD, MS is a pulmonary critical care physician at Tufts Medical Center and Assistant Professor in the Division of Pulmonary, Critical Care, and Sleep Medicine at Tufts University School of Medicine. She completed her medical education at the University of Chicago Pritzker School of Medicine, where she remained for her internal medicine residency and pulmonary critical care fellowship. During fellowship, she received a Master of Science in Biomedical Informatics degree from the Graham School. She is the Associate Director of the Critical Care Outpatient Clinic at Tufts Medical Center, a multidisciplinary and collaborative clinic that supports the recovery of survivors of critical illness. With a significant background in clinical and electronic health record-based research, Dr. Han seeks to understand and improve critical care practices and long-term patient outcomes after critical illness.

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Cristina Montalvo, MD, MBA, MBS is a Consultation-Liaison psychiatrist who completed her medical training at UMDNJ New Jersey Medical School and psychiatry residency and Consultation-Liaison fellowship at Boston University/Boston Medical Center. She currently services as Chief of Consultation-Liaison Psychiatry and Emergency Services at Tufts Medical Center, Division Chief of Consultation-Liaison and Psychiatric Emergency Services at Tufts Medicine, and Chief of Psychiatry at Lowell General Hospital. Additionally, Dr. Montalvo is an Assistant Professor in the Department of Psychiatry at Tufts University School of Medicine, contributing to education and training in the field.

Dr. Montalvo has been recognized for her contributions to psychiatric education and practice and is actively involved in research, focusing on quality improvement in psychiatric care with a focus on critical care psychiatry, and has presented extensively at national and international conferences.

With a passion for integrating mental health into comprehensive medical care, she is proponent for advocacy for innovative approaches to psychiatric treatment, aiming to improve patient outcomes and support healthcare professionals in challenging environments.