The document discusses a pilot randomized clinical trial of an intervention called "Recovering Together" that aimed to improve long-term psychological outcomes for intensive care unit (ICU) patients and their caregivers. The intervention involved six sessions with a clinical psychologist for patients and their main caregivers after being discharged from the ICU. While results were mixed, patients who received the intervention had stable PTSD scores over time compared to increased scores for controls. The intervention shows promise but would need to be tested in larger, more diverse populations and settings to determine effectiveness for reducing post-intensive care syndrome.

1. Invited Commentary | Psychiatry
Mitigating Postintensive Care Syndrome Among Patients And Caregivers
via a Dyadic Intervention
David Y. Hwang, MD
Over the last decade, increasing attention has been paid to physical, cognitive, and psychological
symptoms that persist among survivors of critical illness who were initially admitted to the intensive
care unit (ICU) with non-neurologic diagnoses.1
The psychological symptoms are collectively referred
to as postintensive care syndrome (PICS); studies of these symptoms have focused on the
manifestations of long-term anxiety, depression, and posttraumatic stress disorder (PTSD) and have
found a high prevalence of each manifestation after discharge from the ICU. Parallel to studies on
the psychological aspects of PICS, there has been increasing recognition that family members of
critically ill patients are also at high risk for adverse psychological outcomes (referred to as PICS-F)
owing to their roles as surrogate decision makers in the ICU and informal caregivers following
discharge.2
Interventions to improve the psychological outcomes of PICS and PICS-F have taken
different approaches, some of which have been focused on the patient’s time in the ICU and others
have been designed for the recovery period after ICU discharge. Most of these interventions have
targeted patients or their families; few have taken an approach grounded in the theory that the
patient and the main caregiver profoundly impact one another and are an integrated dyad.
Vranceanu et al3
have reported on the outcomes of a pilot randomized clinical trial for
Recovering Together, an ICU support program conducted at Massachusetts General Hospital (MGH)
that aimed to improve long-term psychological outcomes among patients and their main informal
caregivers. In contrast to the non-neurologic population in which the concept of PICS originated,1
Recovering Together was developed among patients in neuroscience ICUs. However, the program
was targeted to only those patients whose cognitive impairment was mild enough such that they
could still participate meaningfully in sessions with a clinical psychologist. The MGH team developed
the content of the support program through extensive preliminary work demonstrating that
emotional distress experienced by 1 partner in the dyad (ie, patient or caregiver) impacts the other’s
distress, and strategies promoting resilience (eg, mindfulness, coping) practiced by 1 partner can
positively impact both partners’ distress.4
With this background, the Recovering Together program
was developed as a series of six 20- to 30-minute sessions between a clinical psychologist and the
dyad members. During the first 2 in-person sessions, the patient and caregiver were taught resiliency
strategies for managing emotions such as stress, fear, and anger. The final 4 sessions were conducted
via video conferencing after hospital discharge. Sessions were tailored for each dyad from a list of
specific skills that focused on adjustment to life at home, including optimizing interpersonal
communication, managing household roles, and adhering to treatment.
For this feasibility trial, the team enrolled dyads, each of which had at least 1 partner who was
screened for clinically significant anxiety, depression, or PTSD. Following randomization, 29 dyads
participated in the Recovering Together program, and 29 dyads received generic education regarding
acute neurologic injury and the transition from acute hospitalization to home. Importantly,
participants were blinded as to which group was the true intervention vs control group. Not only did
the pilot surpass all of the prespecified feasibility and fidelity primary end points, the trial found
clinically meaningful between-group improvement in some secondary end points, including
depression, anxiety, and PTSD among patients and caregivers who completed the program. Of note,
patients in the intervention group had stable PTSD scores between the end of the program and at a
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2. later 3-month time point compared with those in the control group, whose PTSD scores increased
following the end of the generic education program.
Although this pilot trial did not demonstrate between-group differences in mindfulness and
positive coping skills, any pilot trial in this field of research that has potential for a positive impact
regarding psychological outcomes is worthy of attention. The world of ICU and post-ICU intervention
studies that are designed to impact psychological PICS outcomes and PICS-F is filled with pilot trials
with equivocal results. Geense et al5
recently published a systemic review and meta-analysis of
nonpharmacologic interventions aimed at mitigating PICS among ICU survivors. The interventions
targeted psychological outcomes but varied in approach, including exercise, ICU diaries, education
programs, and telephone- and web-based psychosocial training for resiliency skills. Among 36
studies reviewed, only pooled data from 2 small studies of ICU diaries seemed to suggest a benefit for
patients’ symptoms of anxiety and depression, with 1 of the studies rated as having a high risk of bias.
With regard to families and caregivers, Zante et al6
recently published a systemic review of 11
randomized trials with the aim of improving PICS-F. Of those trials, the only one to show impact on
family anxiety, depression, and PTSD focused on end-of-life care conferences and was not applicable
to families of ICU survivors. Family-authored ICU diaries have not yet been shown to impact PICS-F
outcomes.
In the context of these studies, the MGH Recovering Together program’s unique strengths—as
an intervention that spans both the ICU admission and after discharge, uses expert clinical
psychologists to teach resilience skills, and engages patients and their families—may serve it well in
what will hopefully be a future multicenter efficacy study. However, there may also be challenges
ahead as the program potentially expands and its generalizability is tested. The participants in the
pilot were primarily of White race and well educated, and it is unclear how other demographic groups
might perceive the program. The trial enrolled a very specific patient population, that is, patients
admitted to a neuroscience ICU who had good in-hospital cognitive outcomes. It is unclear how the
intervention might translate to survivors of non–neurologic intensive care units and their families, as
presumably some of the program modules have content specific to brain injury. Conversely, patients
with severe cognitive disability from brain injury and their families were excluded from this study
because they were not the target of the initial research on which the program is based. The families
of patients with severe disabilities are certainly at risk for adverse psychological outcomes (if not
more so). Any adaptation of the intervention that could support families in these difficult situations
would increase the program’s impact, even if a truly dyadic approach is not feasible in these
scenarios.
In addition, although Vranceanu et al3
were able to demonstrate the feasibility of the
intervention at their institution, the effort to run the pilot study involved a dedicated team of several
clinical psychology fellows. What is feasible at MGH may be challenging to replicate in many other
environments where such resources may not be as readily available. It is possible that even if a future
multicenter trial of Recovering Together yielded favorable results, the principles of the program
might subsequently need to be adapted for scalability to sites that do not have easy access to
in-person clinical psychologists. Despite the hard work and resources needed to develop a
psychosocial program that improves both PICS and PICS-F, clinicians and researchers owe it to
patients and their families to be resilient in carefully implementing and testing novel programs as the
MGH team has done. Programs with the best of intentions can make a measurable difference.
ARTICLE INFORMATION
Published: October 14, 2020. doi:10.1001/jamanetworkopen.2020.21014
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Hwang DY.
JAMA Network Open.
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3. Corresponding Author: David Y. Hwang, MD, Division of Neurocritical Care and Emergency Neurology,
Department of Neurology, Yale School of Medicine, P.O. Box 208018, New Haven, CT 06520 (david.hwang@
yale.edu).
Author Affiliation: Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale
School of Medicine, New Haven, Connecticut.
Conflict Of Interest Disclosures: Dr Hwang reports that one of the authors of the subject of this Invited
Commentary was listed as a formal consultant on a recent grant application by Dr Hwang.
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JAMA Network Open | Psychiatry Mitigating Postintensive Care Syndrome Among Patients And Caregivers via a Dyadic Intervention
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