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CME

Relatives of ICU Patients May Experience Enduring Stress, Grief

  • Authors: News Author: Marlene Busko
    CME Author: Laurie Barclay, MD
  • CME Released: 9/25/2008
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 9/25/2009
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Target Audience and Goal Statement

This article is intended for psychiatrists, intensivists, social workers, and other specialists who manage mental health concerns in relatives of patients hospitalized in the intensive care unit.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Describe the frequency of symptoms of anxiety and depression with time in relatives of patients hospitalized in the intensive care unit and posttraumatic stress symptoms and complicated grief 6 months after enrollment.
  2. Describe the association of anxiety, depression, and decision-making role preference during a patient's stay in the intensive care unit with posttraumatic stress symptoms and complicated grief in relatives of these patients.


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Author(s)

  • Marlene Busko

    Marlene Busko is a staff journalist for Medscape Psychiatry. She can be contacted at [email protected]

    Disclosures

    Disclosure: Marlene Busko has disclosed no relevant financial relationships.

Editor(s)

  • Brande Nicole Martin

    Brande Nicole Martin is the News CME editor for Medscape Medical News.

    Disclosures

    Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

CME Author(s)

  • Laurie Barclay, MD

    Laurie Barclay, MD, is a freelance reviewer and writer for Medscape.

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.


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CME

Relatives of ICU Patients May Experience Enduring Stress, Grief

Authors: News Author: Marlene Busko CME Author: Laurie Barclay, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME Released: 9/25/2008

Valid for credit through: 9/25/2009

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September 25, 2008 — Six months after a close family member is hospitalized in the intensive care unit (ICU), individuals may be less likely to be anxious or depressed, but they commonly experience persistent stress or grief, a small study suggests.

"All family members of patients who have been in the ICU should be screened for posttraumatic stress and, if they are bereaved, should also be screened for complicated grief," lead author Wendy G. Anderson, MD, from the University of California, San Francisco, told Medscape Psychiatry.

Unlike normal grieving in which an individual mourns the loss of a loved one for a number of months and then functions normally, individuals with complicated grief disorder experience a prolonged grief that severely affects their physical and emotional functioning, she explained.

"If patients don't receive psychological counseling, in most cases these disorders do not resolve on their own," she added.

The study, by researchers at the University of Pittsburgh, Pennsylvania, and the University of California, San Francisco, is published in the September 9 Online First issue of the Journal of General Internal Medicine.

Transient Anxiety, Persistent Stress

Previous observational studies reported that during and after a relative's stay in the ICU, family members were at high risk for the development of mental health disorders.

The current longitudinal cohort study examined anxiety, depression, decision-making preference, posttraumatic stress, and complicated grief in close family members of patients hospitalized in the ICU.

The study included family members who were the closest relatives of, and acted as surrogate decision makers for, 50 patients from medical surgical, trauma, transplant, and other ICUs in a large university hospital in Pittsburgh.

At enrollment, participants completed a Hospital Anxiety and Depression Scale questionnaire to determine their level of anxiety and depression.

They also completed a questionnaire about their decision-making preferences with respect to their relative's care including choices about shared decision making in collaboration with the treating clinician, solo decision making, or leaving decisions up to the treating clinician.

One month later, study participants were contacted by telephone and reassessed for anxiety and depression.

Participants were followed up at 6 months and reassessed for anxiety, depression, and posttraumatic stress symptoms. If their relative had died, they were also assessed for complicated grief symptoms.

The 50 family members enrolled in the study had a mean age of 54 years, and 84% were women. They were the patient's spouse (36%), parent (26%), child (12%), or other relative or of unknown relationship (26%).

Follow-up data were available for 39 participants at 1 month and 34 participants at 6 months.

At enrollment, 42% of patients had anxiety. This decreased to 21% and 15% at 1 and 6 months, respectively. The prevalence of depression was 16% at enrollment and decreased to 8% and 16% at 1- and 6-month follow-up.

Despite the decline in symptoms of these 2 disorders to rates found in the general population, at 6 months, 35% of the participants had posttraumatic stress symptoms, and 46% of bereaved participants had complicated grief symptoms.

Anxiety, depression, and decision-making preferences were not related to the development of posttraumatic stress or complicated grief symptoms. Furthermore, posttraumatic stress was as common in nonbereaved as in bereaved relatives.

Given the small sample size, however, the study findings need to be interpreted with caution; furthermore, larger studies are needed, the authors write.

Nevertheless, "for now, our results suggest that family members of ICU patients should be assessed for posttraumatic stress and complicated grief even if they do not experience anxiety and depression during the patients' ICU stay," they write.

The study was funded by The Greenwall Foundation and the University of Pittsburgh Institute for Doctor-Patient Communication. The Open Society Institute and the Senator H. John Heinz III Fellowship in Palliative Medicine at the University of Pittsburgh's Institute to Enhance Palliative Care funded Dr. Anderson's salary.

J Gen Intern Med. Published online September 9, 2008.

Clinical Context

Family members of patients in ICUs are at risk for mental health issues both during and after a patient's ICU stay. Psychiatric morbidity may include anxiety, depression, posttraumatic stress, and complicated grief.

It is not clear whether family members with anxiety and depression in the ICU later develop posttraumatic stress and complicated grief. The role ascribed to family members' involvement in ICU decision making in later development of these syndromes is also poorly understood.

Study Highlights

  • This was a prospective, longitudinal cohort study of family members of patients hospitalized in the ICU.
  • The objectives of the study were to evaluate the frequency of symptoms of anxiety and depression in this cohort with time; describe the frequency of posttraumatic stress symptoms and complicated grief 6 months after enrollment; and determine whether anxiety, depression, and decision-making role preference during a patient's ICU stay are associated with posttraumatic stress symptoms and complicated grief.
  • At a large university hospital, 50 family members of patients hospitalized in ICUs were evaluated. Initial consent rate was 63%.
  • Mean age of the participants was 54 years; most were white, Christian, and women, and approximately one third had attended college.
  • The participants were the patient's spouse (36%); parent (26%); child (12%); sibling, niece, or nephew (6%); or of unknown relationship (20%).
  • Participants completed the Control Preferences Scale to determine their role preferences for surrogate decision making.
  • Other outcome measures were the Hospital Anxiety and Depression Scale, Impact of Event Scale, and Inventory of Complicated Grief to measure anxiety and depression (at enrollment, 1 month, and 6 months), posttraumatic stress at 6 months, and complicated grief at 6 months.
  • All participants were interviewed at enrollment, 39 (78%) at 1 month, and 34 (68%) at 6 months.
  • Anxiety was present in 42% of participants at enrollment (95% confidence interval [CI], 29% - 56%), in 21% at 1 month, (95% CI, 10% - 35%), and in 15% at 6 months (95% CI, 6% - 29%).
  • At these time points, depression was present in 16% (95% CI, 8% - 28%), 8% (95% CI, 2% - 19%), and 6% (95% CI, 1% - 18%), respectively.
  • Posttraumatic stress was present at 6 months in 35% of participants (95% CI, 21% - 52%).
  • Of the 38% of participants who were bereaved, 46% had complicated grief (95% CI, 22% - 71%).
  • Compared with nonbereaved participants, bereaved participants had a similar prevalence of posttraumatic stress.
  • Neither posttraumatic stress nor complicated grief was associated with decision-making role preference or with anxiety or depression during the patient's ICU stay.
  • The investigators concluded that symptoms of anxiety and depression decreased with time but that both bereaved and nonbereaved participants had a high prevalence of posttraumatic stress and complicated grief.
  • The investigators therefore recommend that family members be evaluated for posttraumatic stress and complicated grief.
  • Limitations of the study include inability to determine whether the lack of association between anxiety, depression, and decision-making role preference in the ICU and posttraumatic stress or complicated grief is authentic or is a result of the small sample size.
  • Other limitations include sample demographically homogeneous, data collection from family members of patients in different types of ICUs at different points in the patients' ICU stay, inclusion of both bereaved and nonbereaved family members, use of symptom scales to measure anxiety and depression, and possible bias introduced by enrollment practices or retention rates.

Pearls for Practice

  • Family members of patients in ICUs have a high prevalence of anxiety and depression that decrease with time. Both bereaved and nonbereaved family members have a high prevalence of posttraumatic stress and complicated grief 6 months after the relative's ICU stay.
  • In this study cohort, neither posttraumatic stress nor complicated grief was associated with decision-making role preference or with anxiety or depression in family members during the patient's ICU stay.

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