PTSD post ICU
Dr Christina Jones
Nurse Consultant Critical Care Rehabilitation
& Honorary Lecturer
 
Intensive Care Resear...
Post Traumatic Stress Disorder
DSM IV-R American Psychiatric Association
– Exposure to a traumatic event/s in which the in...
Study Subgroup N Anxiety Depression PTSD
Jones et al Brit J Inten Care 1994;2:46-53 - 28 55.5% - -
Koshy et al Intens Care...
Post ICU PTSD
Suggested less symptoms in steroid treated
groups
ICU: Schelling et al Crit Care Med 1999; 27:2678-2683
Card...
PTSD post ICU
Drug usage in ICU (ARDS patients)
– PTSD correlated with days of sedation and paralysis
Nelson, Weinert, Bur...
Importance of memory for ICU
Adverse memories
Retrospective (10yr) of patient experiences
after ARDS
– 27% incidence of PTSD
– Patients recall of adver...
PTSD related symptoms & ICU memories
Delusions but
No recall of ICU
Delusions but
can recall ICU
No delusions
30 ICU patie...
Delusional memories
Large study (> 200) at 6 – 18 months post ICU
– 26% recalled delusional memories
» More likely for you...
RACHEL group study (2002-2005)
5 ICUs across Europe
– Ratio of PTSD and relationship to:-
» patient previous psychological...
Factors associated with PTSD
In ICU
Physical restraint (23% of restrained patients)
– Combined with no sedation
Deep sedat...
RACHEL study ICU diariesRACHEL study ICU diaries
In main studyIn main study
– 231 completing 3 month follow-up231 completi...
ICU Diaries
Idea originated in Sweden
– Nursing intervention
– Daily account of ICU stay in every day language
– Photograp...
PTSD-related symptom levels
71421 191728N =
Study centre
BergenNorrkopingWhiston
PTSS-14at3Months
75
70
65
60
55
50
45
40
...
Why diaries are important
Impact of diaries
Small RCT (n=36) showed reduction in those
receiving ICU diary
– Decrease in anxiety (p < 0.05)
– Decrea...
Impact on relatives
Small study to investigate whether a diary
was important to relatives following patients'
deaths in th...
RACHEL II Diary study
To examine the impact of a diary on development of
PTSD
Randomised controlled trial
Study units
– Wh...
Experimental plan
One month post ICU discharge
– Level of symptoms of PTSD using the PTSS-14
Twigg E, Humphris G, Jones C,...
Results
Fewer intervention patients, compared to
controls, were diagnosed as having new
onset PTSD at 3 months
– 8/162 (5%...
Change in PTSS-14 scores between 1 and 3
months by study group and high scores
*p = 0.04
* *
Psychological help
• Helping with traumatic memories
– Screening for level of psychological distress
» Watchful waiting
» ...
Further information
Christina.jones@sthk.nhs.uk
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PTSD post ICU Dr Christina Jones

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PTSD post ICU Dr Christina Jones

  1. 1. PTSD post ICU Dr Christina Jones Nurse Consultant Critical Care Rehabilitation & Honorary Lecturer   Intensive Care Research Group, Intensive Care Unit, Whiston Hospital & School of Clinical Science, University of Liverpool
  2. 2. Post Traumatic Stress Disorder DSM IV-R American Psychiatric Association – Exposure to a traumatic event/s in which the individual experienced/witnessed or was confronted with event/s involving actual or threatened death/serious injury or threat to the physical integrity of self/others AND responded with intense fear, helplessness or horror – 3 symptom groups » Intrusion (nightmares, flashbacks) » Avoidance (avoiding reminders) » Hyperarousal (not sleeping) – Symptoms are experienced for more than one month – Clinically significant distress/impairment in social, occupational or other areas of functioning
  3. 3. Study Subgroup N Anxiety Depression PTSD Jones et al Brit J Inten Care 1994;2:46-53 - 28 55.5% - - Koshy et al Intens Care Med 1997;23(S1):S160 - 50 - - 15% Schelling et al Crit Care Med 1998;26:651- 659 ARDS 80 - - 27.5% Nelson et al Crit Care Med 2000;28(11):3626-3630 ARDS 24 43.5% - 25% Schnyder et al Am J Psych 2001;158:594-599 Trauma 106 - - 14% Scragg et al Anaesth 2001;56:9-14 - 80 47% 47% 15% Jones et al Crit Care Med 2001;29(3):573-580 - 126 34% 25% 51% Cuthbertson et al Intens Care Med 2004;30:2004-2008 - 78 - - 5-15% Hopkins et al 2005Am J Resp Crit Care Med 2005;171:340-347 ARDS 62 24% 16% Jones et al Intens Care Med 2007 DOI 10.1007/s00134-007-0600-8 - 231 (5 ICUs) - - 3-15%* Girard et al Critical Care 2007 11:R28 - 43 14% Studies - psychological recovery
  4. 4. Post ICU PTSD Suggested less symptoms in steroid treated groups ICU: Schelling et al Crit Care Med 1999; 27:2678-2683 Cardiac Surg: Schelling et al Biol Psychiatry 2004; 55:627-633 5 -15% incidence after general ICU – Relationship to duration of ventilation – Previous psychological stress – Female Cuthbertson BH et al Int Care Med 2004, 30: 450-455
  5. 5. PTSD post ICU Drug usage in ICU (ARDS patients) – PTSD correlated with days of sedation and paralysis Nelson, Weinert, Bury, Marinelli Crit Care Med 2000;28(11):3626-3630 Small study (45 patients) showed relationship between the level of symptoms of PTSD – total dose of lorazepam – Younger patients – women Girard et al 2007 http://ccforum.com/content/11/1/R28
  6. 6. Importance of memory for ICU
  7. 7. Adverse memories Retrospective (10yr) of patient experiences after ARDS – 27% incidence of PTSD – Patients recall of adverse experiences » Nightmares (64%), Anxiety (42%), Pain (40%), Respiratory Distress (38%), None in (21%) Schelling et al Crit Care Med 1998; 26: 651-659
  8. 8. PTSD related symptoms & ICU memories Delusions but No recall of ICU Delusions but can recall ICU No delusions 30 ICU patients recall tested at 2 weeks & IES at 8 weeks post ICU Jones C, Griffiths RD, Humphris G, Skirrow PM. Critical Care Medicine 2001; 29:573-580 Impact of Events Scale at 8 weeks P=0.001 worse IES > 19
  9. 9. Delusional memories Large study (> 200) at 6 – 18 months post ICU – 26% recalled delusional memories » More likely for younger patients and to be bothered by them » More common > 3 days ICU stay » Temperature > 38ºC » more likely not to have returned to work at 1 year Ringdal M et al Intensive and Critical Care Nursing 2006;22(6):346-354 Large study (464 patients) at 6 months post ICU – 93% described ICU as friendly and calm – Unpleasant experiences » suction, nasogastric tube, family worries and pain – 51% recalled dreams and nightmares » 14% these memories disturbed daily life » Worse health related quality of life Granja C et al. Critical Care 2005, R:R96-R109 (DOI 10.1186/cc3026)
  10. 10. RACHEL group study (2002-2005) 5 ICUs across Europe – Ratio of PTSD and relationship to:- » patient previous psychological history » In ICU periods of delirium or withdrawal symptoms » patient care practice, e.g. sedation depth, opiate and sedation doses or physical restraint » Memories for ICU – Secondary aim impact of diaries
  11. 11. Factors associated with PTSD In ICU Physical restraint (23% of restrained patients) – Combined with no sedation Deep sedation/large sedative doses – Found to be related to delirium Recall of delusional memories Patient factors Recall of delusional memories for ICU – More common where history of previous psychological problems » Depression, anxiety, panic attacks, phobias – Deep sedation/large sedative doses Jones et al. Precipitants of post-traumatic stress disorder following intensive care: a hypothesis generating study of diversity in care. Intens Care Med 2007;33(6):978-985
  12. 12. RACHEL study ICU diariesRACHEL study ICU diaries In main studyIn main study – 231 completing 3 month follow-up231 completing 3 month follow-up In 3 study centres using diariesIn 3 study centres using diaries – 108 completing 3 month follow-up108 completing 3 month follow-up – 42 patients received an ICU diary42 patients received an ICU diary – Time of receiving diaryTime of receiving diary » 1 week – 1 month post ICU discharge1 week – 1 month post ICU discharge » Median 1 monthMedian 1 month (Jones C, Capuzzo M, Flaatten H, Backman C, Rylander C, Griffiths R D ICU diaries my reduce symptoms of posttraumatic stress disorder. Intensive Care Medicine 2006;32(Suppl 1):S144)
  13. 13. ICU Diaries Idea originated in Sweden – Nursing intervention – Daily account of ICU stay in every day language – Photograph of patient taken at start » Aim to fill in memory gaps and help patients understand their illness – Given to the patient after their discharge from ICU » At a time of the patients choosing » With staff support to go through the diary and photos Bäckman C, Walter SM. Intensive Care Medicine 2001;27:426-429
  14. 14. PTSD-related symptom levels 71421 191728N = Study centre BergenNorrkopingWhiston PTSS-14at3Months 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 DIARY No Yes 61410 61320N = Study centre BergenNorrkopingWhiston PTSS-143Months 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 DIARY No Yes All patients from diary study centres Patients recalling delusional memories Mann-Whitney U p = 0.043 Mann-Whitney U p = 0.028
  15. 15. Why diaries are important
  16. 16. Impact of diaries Small RCT (n=36) showed reduction in those receiving ICU diary – Decrease in anxiety (p < 0.05) – Decrease in depression (p = 0.005) Knowles & Tarrier (2009) Evaluation of the effect of prospective patient diaries on emotional well-being in intensive care unit survivors: A randomised control trial Critical Care Medicine 37:184-191
  17. 17. Impact on relatives Small study to investigate whether a diary was important to relatives following patients' deaths in the ICU – All the relatives except one said the diary:- » helped them to return and adjust to everyday life » made it easier to accept what had happened » help them to understand the seriousness of the patient's injury or disease Bergbom et al Patients' and relatives' opinions and feelings about diaries kept by nurses in an intensive care unit: pilot study. Intensive & Critical Care Nursing 1999;15(4):185-191
  18. 18. RACHEL II Diary study To examine the impact of a diary on development of PTSD Randomised controlled trial Study units – Whiston Hospital, UK – Ferrara University Hospital, Italy – Haukeland University Hospital, Bergen, Norway – Ullevål Hospital, Oslo, Norway – Vrinnevishuset, Norrköping, Sweden – Gotenburg, Sweden – Malmo, Sweden – Hospital Pedro Hispano, Matosinhos, Porto, Portugal – Hospital Geral de Santo António, Porto, Portugal – Hillerød, Copenhagen, Denmark coordinating three ICUs » Nordsjaelland, Odense, Skejby Hospitals
  19. 19. Experimental plan One month post ICU discharge – Level of symptoms of PTSD using the PTSS-14 Twigg E, Humphris G, Jones C, Bramwell R, Griffiths RD. Use of a screening questionnaire for post-traumatic stress disorder (PTSD) on a sample of UK ICU patients. Acta Anaesthesiol Scand 2008;52:202-208 – Randomised to study group – Intervention group » allowed to choose when they want their diary. – Control group » Given their diaries at the 3 month follow-up appointment after they have completed questionnaires Three months post ICU discharge – Patients had clinic appointment or telephoned to complete follow-up PDS for diagnosis of PTSD Foa EB et al. Psych Assess 1997;9:445-45
  20. 20. Results Fewer intervention patients, compared to controls, were diagnosed as having new onset PTSD at 3 months – 8/162 (5%) versus 21/160 (13.1%) (p = 0.02) Jones C et al ICU diaries reduce posttraumatic stress disorder after critical illness: a randomised controlled trial Intensive Care Medicine 2009;35(1):S115.
  21. 21. Change in PTSS-14 scores between 1 and 3 months by study group and high scores *p = 0.04 * *
  22. 22. Psychological help • Helping with traumatic memories – Screening for level of psychological distress » Watchful waiting » Refer for treatment if symptoms high » One off debriefing may make things worse – Normalising traumatic memories http://www.healthtalkonline.org/Intensive_care/Intensive_care_Patients_experiences – Cognitive behavioural therapy (CBT) aimed at trauma symptoms » Systematic desensitisation » Anxiety management – Eye Movement Desensitisation and Reprocessing (EMDR) » Processing traumatic memories Foa et al. Journal of Clinical Psychology 1999; 60(suppl. 16): 1-76. NICE guideline for treatment :-http://guidance.nice.org.uk/CG26/guidance/pdf
  23. 23. Further information Christina.jones@sthk.nhs.uk
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