Family Members’ Anxiety and Depression: Things we Still Haven’t Learned
Abstract & Commentary
Pouchard and Associates, for the French Famirea group, conducted this prospective multicenter study to determine the prevalence of and factors associated with symptoms of anxiety and depression in family members of ICU patients. The study was conducted in 43 ICUs in France (37 adult, 6 pediatric). Each unit included 15 patients admitted for longer than 2 days. Data were obtained from 920 family members of 637 patients. Family members were asked to complete a questionnaire that included the Hospital Anxiety and Depression Scale, a 14-item self-administered tool developed to allow evaluation of the prevalence and potential factors associated with symptoms of anxiety and depression.
Patients in this study had a median age of 59 years, were mostly men (65.6%) of French descent, had a chronic disease (65.5%), had a median SAPS II score of 38, a median ICU length of stay of 9 days, and a hospital mortality of 18.5%. Family members who completed the questionnaire were primarily men (66.4%) of French descent with a median age of 45 years. The relationship to the patient was: 23.5% spouse, 22.8% parent, 24.7% children, 9.1% sibling, 10.8% "other" family member, and 9.1% not a relative.
Anxiety was present in 69.1% of the family members. Depression was present in 35.4% of the family members. The prevalence of anxiety in spouses was higher than in other family members (81.1% vs 65.1%). The prevalence of depression was higher in spouses than in other family members (47.3% vs 31.4%). Factors associated with symptoms of anxiety and depression were evaluated using multivariate logistic regression models. Anxiety was independently associated with 2 caregiver-related characteristics (no regular nurse-physician meetings, no room used only for meetings with families). Factors associated with symptoms of depression included 2 caregiver factors (no ICU waiting room, contradictions in the information given). There were no reported differences in anxiety or depression between family members of pediatric and adult ICU patients. A number of other factors failed to correlate with anxiety or depression including: mortality rate, length of ICU stay, SAS II score, nurse:patient ratio, or the number of physicians involved in the care. (Pouchard F, et al. Crit Care Med. 2001;29:1893-1897).
Comment by Karen Johnson, PhD, RN
Shame on us! That’s what I have to say about the results of this study! After 4 decades of critical care science, we have investigators in 2001 claiming to be "the first prospective multicenter study establishing that symptoms of anxiety and depression are common in family members visiting ICU patients."
As critical care clinicians, we say we are aware of the importance of family support to patient recovery. Well, if the family is anxious and depressed, what effect does that have on the patient’s recovery? If the family is anxious and depressed, how can we expect them to make life-and-death decisions? It is time we stopped criticizing family members’ behaviors and decision-making processes and started understanding and appreciating the conditions under which we ask them to participate in decision making.
The statistical results of this study indicate that caregiver factors associated with symptoms of anxiety include: no regular nurse-physician meetings (P = 0.02) and no room dedicated for meetings with families (P = 0.01). Caregiver factors associated with symptoms of depression include no waiting room (P = 0.009) and perceived contradictions in information (P = 0.04). My interpretation of these statistically significant results is this: critical care clinicians (both nurses and physicians) induce anxiety and depression in family members by not meeting with family members on a regular basis. When they do meet with families, they do so in a public area and give them conflicting information. These are the conditions under which we ask them to trust us. These are the conditions under which we expect them to make some of the most important decisions of their lives.
Pouchard et al pose that perhaps clinicians overestimate the extent to which family members who are anxious and depressed can actually make choices, voice their preferences, understand and appreciate the significance of information relevant to treatment decisions, and make comparisons and weigh options based on that information. As critical care clinicians, we cannot change the nature of the decisions we ask family members to make. We can, however, change our behaviors and the conditions we create under which they are asked to make these decisions. We can at the very least, as Pouchard et al conclude, do the following: 1) hold regular nurse-physician meetings to discuss patient and family needs; 2) hold these meetings in a room used only for family meetings; 3) have a designated ICU waiting room; and 4) ensure that there are no contradictions in the information given to families.
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