Treating the trauma of intensive care

For the once active and healthy 39-year-old former patient, life was different after his stay in the hospital's intensive care unit. He found the fast pace of his grocery store job overwhelming. He could not concentrate on simple tasks like completing his child's application for school. He remembered hallucinations—"kids with animal heads"—that he'd experienced in the ICU. He was terrified that he might get sick again, and he wondered, "Am I ever gonna be back normal the way I was before?"

This man's symptoms—avoidance, intrusive memories, anxiety—match those of post-traumatic stress disorder. He's not alone. A recent study by Johns Hopkins researchers of ICU survivors with acute lung injury who had required use of a mechanical ventilator found that about one-third experienced PTSD symptoms for up to two years. Although the study was limited to acute lung injury survivors, the researchers believe their findings will apply to survivors of other critical illnesses.

The ICU can be frightening—time spent there can include painful procedures, difficult breathing, and limited ability to communicate. "Just like victims of sexual assault and soldiers coming back from Afghanistan or the Middle East, ICU survivors have experienced a life-threatening stress," says Dale Needham, a critical care specialist at the School of Medicine and senior author of the study, which was published online by Psychological Medicine. Critical illness survivors afflicted with PTSD can experience a frustratingly slow recovery and trouble resuming their pre-ICU lives. The researchers, including first author O. Joseph Bienvenu, an associate professor of psychiatry and behavioral sciences at Johns Hopkins, found that the onset of PTSD symptoms was most common within three months of patients leaving the ICU. At the two-year mark, 62 percent still had symptoms, 40 percent had sought psychological treatment, and 50 percent had taken psychiatric medicines. (Among study participants without PTSD symptoms, those figures are 17 percent and 25 percent, respectively.)

According to the study, risk factors for PTSD include a longer stay in the ICU; a longer duration of sepsis, a serious and common ailment among ICU patients; administration of high doses of opiates in the ICU; and a history of depression. Protective factors include longer durations of corticosteroid and opiate administration in the ICU. The research team had hypothesized that there was a connection between PTSD and the delirium some patients experience in the ICU—hallucinations like the one described by the aforementioned patient, who was featured in a video Needham posted online for educational purposes. However, they did not find that link.

The study is part of Needham and Bienvenu's research on long-term health of critical illness survivors. It involved 186 patients who survived stays in 13 ICUs at four Baltimore hospitals; they were recruited for the study between October 2004 and October 2007. Although other research on PTSD in post–critical care patients exists, Needham says this study is unique in that it is relatively large for the field and that it is longitudinal: Patients were interviewed at three, six, 12, and 24 months, and a separate study in the program will allow them to be followed for up to five years. Because ICU survivors are often wary of returning to the hospital, the researchers conducted interviews in other locations or occasionally by phone to reduce the dropout rate. "We would go to the patient's home or their health care facility to conduct the research if they were unable or too scared to come back into the hospital," Needham says.

Mitigating what has been dubbed post–intensive care syndrome starts with awareness, Needham and Bienvenu say. "It's really just to get people thinking about the fact that ICU survivors have a few different kinds of problems," Bienvenu says—physical, yes, but also mental and cognitive. Being in the ICU is not yet a widely recognized risk factor for PTSD, but with communication of this research to other critical care physicians, primary care doctors, psychiatrists—anyone who might be involved in the patient's recovery—that could change. One technique that has shown promise is an ICU diary, in which a nurse or family member records what happened to a patient on a daily basis. This can help the patient make sense of the experience and interpret frightening memories. It can also help the patient's family members, who can experience PTSD symptoms as well.