By Vibhu Sharma, MD
Associate Professor of Medicine, University of Colorado, Denver
SYNOPSIS: This multicenter cohort study found a high incidence of post-traumatic stress disorder symptoms among family members of COVID-19 patients at three months after the index intensive care unit admission.
SOURCE: Amass T, Van Scoy LJ, Hua M, et al. Stress-related disorders of family members of patients admitted to the intensive care unit with COVID-19. JAMA Intern Med 2022;182:624-633.
The authors aimed to assess the symptoms of post-traumatic stress disorder (PTSD) on families of patients admitted to the intensive care unit (ICU) three months after index admission. PTSD was assessed using the Impact of Events Scale 6 (IES-6). IES-6 is a summed score (0-18), with higher scores indicating greater PTSD symptoms. A score of 10 or higher has been associated with significant PTSD symptoms while scores lower than 10 (while not diagnostic of PTSD) still may indicate clinically relevant symptoms.
A cohort of 330 family members were surveyed at approximately 90 days after admission of their family member. Participants in the survey had a mean (standard deviation) age of 51.2 (15.1) years. Overall, 228 (69.1%) were women, 150 (52.8%) self-identified as white, and 92 (29.8%) were of Hispanic ethnicity. Symptoms of anxiety and depression also were assessed in these family members using the Hospital Anxiety and Depression Scale (HADS). This scale has been validated for family members of patients admitted to the ICU and has seven items each for depression and anxiety subscales. A total subscale score of > 8 out of a possible 21 points implies significant anxiety or depression. A family satisfaction in the ICU (FS-ICU) questionnaire also was administered to assess satisfaction with ICU care and decision making. Family members with high scores on the PTSD questionnaire (IES-6) also were selected for qualitative interviews to assess their ICU experience given their experience of high stress in the ICU.
Statistical analyses included linear mixed models for each outcome (IES-6 score and the HADS score). Missing outcome data were analyzed using multiple imputation via chained equations, “which fill in missing values stochastically using models built on other observed variables (3.4% of data cells were imputed).” Qualitative analyses also were performed using quantitatively identified variables of interest.
The mean IES-6 score assessing PTSD symptoms at three months was 12; 64% of respondents scored 10 or higher. The mean HADS score at three months was 7.3. About half of respondents had a HADS-anxiety (HADS-a) subscale score of ≥ 8, and a third had a HADS-depression (HADS-d) subscale score of ≥ 8 at three months, implying a considerable burden of anxiety and depression. These proportions dropped to 34% and 25%, respectively, at six months. Women and individuals identifying as Hispanic had significantly higher IES-6 scores. Individuals with college degrees scored lower on the IES-6 scale than those identifying an education level of high school or equivalent. Similar results were seen for the HADS-depression scale. With respect to the qualitative analysis, higher IES-6 scores correlated with greater distrust with clinician-provided information; Hispanic participants described greater distrust.
COMMENTARY
A high rate of PTSD in family members of patients admitted to the ICU with COVID-19 has been described in a French cohort study.1 This study found PTSD at approximately twice the rate in family members of patients with COVID-19-related acute respiratory distress syndrome (ARDS) compared with non-COVID-19 ARDS at 90 days after hospital discharge. The current cohort by Amass et al was surveyed 90 days after ICU admission (not at discharge) and found higher rates of PTSD (64%) compared to the Azoulay cohort (35%), presumably related to the more proximate experience of critical illness by family members.
In the current study, higher PTSD symptom scores were found in those of Hispanic ethnicity as well as among women. The qualitative analysis that also was part of this study found higher distrust of ICU practitioners among those with higher PTSD scores. In aggregate, both these cohort studies highlight the substantial burden of psychological distress in family members of critically ill patients, but specifically in those admitted to the ICU with COVID-19-related ARDS. The COVID-19 pandemic has led to unprecedented levels of isolation of patients and restriction of visitation by family members. Prior to the pandemic, symptoms of PTSD, depression, and anxiety among family members of the critically ill ranged from 15% to 30%,2,3 with studies demonstrating active engagement of family members at the bedside reducing the prevalence of these symptoms.4,5 This study drives home the importance of family engagement in the setting of patients critically ill with COVID-19 pneumonia and also suggests that minority populations may have greater distrust of medical decision-making by critical care clinicians in this setting. Greater attentiveness to interventions that allow for family care rituals may help decrease the burden of psychological distress, with special focus on women and those of Hispanic descent.6 While this may be difficult given isolation precautions necessitated by the pandemic, further studies to assess the feasibility of remote interventions (larger screens for interaction, on-demand live video instead of caregiver-provided access, and virtual reality) are needed.
REFERENCES
1. Azoulay E, Resche-Rigon M, Megarbane B, et al. Association of COVID-19 acute respiratory distress syndrome with symptoms of posttraumatic stress disorder in family members after ICU discharge. JAMA 2022;327:1042-1050.
2. Davidson JE, Jones C, Bienvenu OJ. Family response to critical illness: Postintensive care syndrome-family. Crit Care Med 2012;40:618-624.
3. Kross EK, Engelberg RA, Gries CJ, et al. ICU care associated with symptoms of depression and posttraumatic stress disorder among family members of patients who die in the ICU. Chest 2011;139:795-801.
4. Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007;356:469-478.
5. Curtis JR, Treece PD, Nielsen EL, et al. Randomized trial of communication facilitators to reduce family distress and intensity of end-of-life care. Am J Respir Crit Care Med 2016;193:154-162.
6. Amass TH, Villa G, OMahony S, et al. Family care rituals in the ICU to reduce symptoms of post-traumatic stress disorder in family members-A multicenter, multinational, before-and-after intervention trial. Crit Care Med 2020;48:176-184.
This multicenter cohort study revealed a high incidence of PTSD symptoms among family members of COVID-19 patients at three months after the ICU admission.
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