PTSD affects ICU patients under stress

One cringes upon even thinking about the gruesome battlefield memories that must haunt the minds of war veterans after witnessing such unimaginable, ruthless sights. It is not surprising to find that many of these soldiers have come back from war physically and emotionally injured by these experiences in the form of post-traumatic stress disorder (PTSD).

While PTSD is very commonly associated with war veterans, symptoms of PTSD have been observed in Intensive Care Unit (ICU) survivors as well. Both Dale Needham, M.D, PhD, a critical care specialist at Hopkins School of Medicine, and Joseph Bienvenu, M.D, PhD, associate professor of psychiatry and behavioral sciences at Hopkins, have collaborated and obtained striking findings about the state of these patients. A study of patients in the ICU with acute lung injury reveals the shocking evidence of the prevalence of such PTSD symptoms.

“We had a population of 186 patients that have acute lung injury and survived their stay. They were recruited from 13 ICUs and 4 hospitals. We found that 35% had important symptoms of PTSD over the 2 year follow-up. That is a very high rate, and is as high or higher than PTSD symptoms in people that have survived sexual assault or have been in combat in Afghanistan or Iraq. These symptoms were most common at the very first follow up assessment at 3 months. Most people still had symptoms at the 24 month follow-up,” Needham said.

Near death, patients with acute lung injury require the use of a mechanical ventilator. With failing organs, patients face pain and shortness of breath, which seems to have led to symptoms of PTSD. While this study only included patients with acute lung injury, there has also been evidence of PTSD in patients with other illnesses.

“We have looked at the prevalence of substantial PTSD symptoms in other critically ill patients and found that maybe 20 percent have substantial PTSD symptoms. Acute lung injury is a little worse. It is an archetypal critical illness where patients have to be in the ICU for a while,” Bienvenu said.

Furthermore, the incidence of PTSD was much higher in patients who were depressed before coming to the ICU as well as in patients who were given a high dose of opiates during their stay to ameliorate pain. Patients who suffered from sepsis, a bacterial infection in the bloodstream, leading to a drop in blood pressure and an increase in heart rate, also experienced severe PTSD symptoms.

“It is a balancing act between too much and too little. The reason that too much might be bad is that excessive sedation contributes to brain failure, so these patients often will remember things that did not even happen like that their nurses were trying to kill them,” Bienvenu said.

Researchers have been determining and experimenting with ways in which PTSD symptoms can be decreased. One possibility may by the use of ICU diaries, which showed promise in a European study. Kept by the patient’s family or nurse, an ICU diary is written details of what happened to the patient, which may also include photographs.

“After the ICU, if the patient is interested, the nurse would send the ICU diary and review it with the patient by phone. Patients have a lower rate of getting PTSD when this is done. It is likely helpful in filling in the blanks of what happened to them in the ICU and helping them piece their life together again with accurate memories rather than with either amnesia, the absence of memories or false memories,” Needham said.

Another method of possible treatment includes early interventional treatment with a rehab psychologist who could help guide the patient while they are in the ICU, hopefully eliminating delirium and PTSD symptoms. However, this issue with such treatments that the patient must be awake and somewhat conscious, which may be difficult for patients with acute lung injury.

Overall, this study displays what should be done in order to prevent and reduce cases of PTSD in patients.

“This study helps teach us that we also need to think of the psychological morbidity, not just the obvious physical morbidity. We cannot just focus on physical morbidity,” Needham said.