Psychiatric-Medical ComorbidityPosttraumatic stress disorder in general intensive care unit survivors: a systematic review☆
Introduction
Millions of patients require intensive care unit (ICU) treatment annually [approximately 4.4 million in the United States [1] and over 130,000 in the United Kingdom (personal communication — Cathy Welch, statistical research assistant for the Intensive Care National Audit and Research Centre) alone], and with recent advances in critical care medicine, more patients are surviving ICU stays [2]. With this increase in survival, research in the field has begun to focus on longer-term outcomes of ICU-treated patients, including mental health, health-related quality of life (HRQOL) and cognitive outcomes [3], [4], [5].
Critical illnesses and their requisite ICU therapies expose patients to extreme stressors, including respiratory insufficiency, pain with endotracheal intubation and suctioning, release of inflammatory cytokines, strain on the hypothalamic-pituitary-adrenal axis, administration of exogenous catecholamines and delirium with associated psychotic experiences, all in the context of a limited ability to communicate and reduced autonomy. Critical illnesses are also, by definition, life-threatening, and many patients recall extremely frightening ICU experiences [6]. Thus, posttraumatic stress disorder (PTSD) is a potential concern, and a number of studies have appeared regarding post-ICU PTSD [7], [8]. In this report, we present results of a systematic review of (1) the prevalence of PTSD following general ICU treatment, (2) potential risk factors for post-ICU PTSD and (3) the relationship of post-ICU PTSD symptoms to HRQOL. As we have recently conducted a separate systematic review of psychopathology in acute lung injury/acute respiratory distress syndrome (ALI/ARDS) survivors [9], we chose not to include studies that focused exclusively on this patient group. Also, we chose not to include studies that focused exclusively on survivors from trauma, neurological, coronary or surgical ICUs, given the possibility of potentially confounding risk factors for PTSD (e.g., trauma, myocardial infarction or anesthesia/surgery). Our report differs from prior reviews on this topic [7], [8] in its exclusion of both ALI/ARDS-specific and specialty ICU-specific studies. A particularly important difference, however, is that we systematically review potential risk factors for post-ICU PTSD, whereas prior reviews focused on prevalence and methodological issues without systematically reviewing potential risk factors [7], [8].
Section snippets
Search strategy
We searched Medline (1966–2007), EMBASE (1974–2007), CINAHL (1982–2007), the Cochrane Library (2007, Issue 1) and PsycInfo (1967–2007) as of October 26, 2007. Our search strategy included the following terms mapped to the appropriate MeSH/EMTREE subject headings and “exploded”: (“mental disorders” OR “psychometrics”) AND (“respiratory distress syndrome, adult” OR “critical care” OR “critical illness” OR “intensive care units” OR “sepsis”). The following terms were also included as text words:
Search results and study characteristics
The authors reviewed 16,301 citations, 1908 abstracts and 193 full-text articles (Fig. 1). Fifteen articles were eligible for data abstraction [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24] (Table 1). The percent agreement (kappa statistic) for each stage of the study selection and data abstraction process was as follows: citation review, 91% (κ=0.54); abstract review, 98% (κ=0.84); full-text review, 99% (κ=0.89); and data abstraction, 98.7% (κ=0.98).
Discussion
This systematic review of PTSD in general ICU survivors highlights three important issues. First, the prevalence of substantial post-ICU PTSD symptoms is high, and symptoms appear to persist over time. Across studies, the median point prevalence of questionnaire-ascertained substantial PTSD symptoms was 22%, and the median point prevalence of clinician-diagnosed PTSD was 19%. These figures are quite a bit higher than the 3.5% one-year prevalence of PTSD in a recent study of US adults that
Acknowledgments
The authors thank Christina Jones, R.N., Ph.D., John P. Kress, M.D., Joan (Perrins) Maclean, R.N., Ph.D., Janice Rattray, R.N., Ph.D., Peter Scragg, Ph.D., and Kannika Sukantarat, Ph.D., for providing additional data from their studies included in this review.
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Dr. Needham is supported by a Clinician-Scientist Award from the Canadian Institutes of Health Research and by the National Institutes of Health (Acute Lung Injury SCCOR Grant # P050 HL73994). Dr. Bienvenu is supported by a Career Development Award from the National Institutes of Health (K23 MH64543).