key: cord-277621-mvsdrxzf
authors: Canavera, Kristin; Elliott, Andrew
title: Mental Health Care During and After the ICU: A Call to Action
date: 2020-06-27
journal: Chest
DOI: 10.1016/j.chest.2020.06.028
sha: 
doc_id: 277621
cord_uid: mvsdrxzf

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Critical illness is associated with high rates of significant, negative psychological and psychiatric sequelae that are commonly associated with Post-Intensive Care Syndrome (PICS). 1 PICS refers to the cognitive, physical, and psychological impairments that many patients experience post-ICU. 1 The primary mental health impairments that critical illness survivors experience are long-term cognitive impairments, depression (approximately 30% of survivors), anxiety (up to approximately 70%), and post-traumatic stress disorder (PTSD; 10-50%). 1,2 Delirium during critical illness, sometimes referred to as "ICU psychosis," is also common and has been associated with PTSD. 2 Despite this data, patients often do not receive mental health care during or after their ICU admission in our country. Few U.S. hospitals have comprehensive psychological or psychiatric care available either during or after an ICU admission. Europe seems to be doing better in terms of prioritizing the mental health needs of this population. They have pioneered research in reporting psychological/psychiatric outcomes and treatments for ICU patients. 1, 2 We hear growing concerns about a potential mental health crisis due to COVID-19, including that difficulties in coping with this illness and associated stressors (i.e., isolation, financial stressors) could potentially lead to higher suicide rates, drug overdoses, trauma, and mood disorders. These concerns are likely to be more prominent in the ICU population given both their more severe physical illness and the higher rate of mental health concerns already noted in this population, 1,2

In response, we must be prepared for the possibility that COVID-19 ICU patients and survivors may require intensified mental health care interventions to address PICs.

Even prior to the COVID-19 pandemic, our country had an unmet yet important need to improve our provision of mental health care for critically ill patients and ICU survivors. Filling this gap in mental health care could protect against some of the negative outcomes of critical illness. During this era of COVID-19, the need to address these negative psychological outcomes will likely become increasingly important. We urge public health experts, hospital administrators, and clinicians to prioritize actions developed to address these mental health care needs both during and after critical illness.

To start, ICU clinicians should regularly screen for delirium. In pediatrics, for example, some hospitals have trained their bedside nurses to use a delirium screener each and every shift. 3 Hospitals can devote resources to train staff, particularly nurses, to better recognize and manage delirium, including not only screening and assessment, but also implementation of nonpharmacological interventions (e.g., improving sleep/wake cycles and orienting patients). Early mobilization/rehabilitation is another initiative that more and more ICUs are implementing to improve the long-term outcomes for ICU patients and should be considered. 4 Preventative measures to mitigate PICS are increasingly being implemented in ICUs. One such tool is the ABCDEF bundle, 4 an evidence-based guide for multidisciplinary critical care coordination.

Adjustments to the ABCDEF bundle due to COVID-19 restrictions and challenges (socially isolated patients) have recently been proposed to lessen the burden of delirium among COVID-19 patients. 5 Hospital administrators should consider allocating resources to creating or increasing use of consultation/liaison services for both psychiatric and psychological care. Ideally, ICUs will have either part-time or embedded psychologists and psychiatrists for critical care patients, both during and after the ICU admissions. Likewise, there is a need to develop and implement systems to screen for anxiety, depression, PTSD/trauma, and cognitive disturbances surrounding ICU admission efforts to both treat and prevent these outcomes.

Hospitals and clinicians must also consider post-ICU follow-up care. Hospitals can consider developing and creating post-ICU care clinics to better monitor and manage PICS. 1 Europe has led the way in establishing these clinics, but they are still scarce in the U.S. 1 As a broader public health issue, we also need to train our mental health care workforce in these unique ICU issues and outcomes. While a select few mental health care clinicians are specialized in rehabilitation psychology or critical illness, most are not. Amidst this global pandemic we are facing and the unprecedented surge in ICU admissions, it is likely that mental health clinicians may be providing services to patients or families negatively impacted by critical care during this era of COVID-19. As such, more mental health care clinicians should familiarize themselves with the psychological outcomes of critical illness and receive additional training and education in this realm and/or mentorship.

The evidence is growing and convincing -critical care is associated with substantial mental health needs and cognitive impairments negatively impacting the overall quality of life of patients. Public health experts, hospitals, and clinicians need to prioritize mental health care both during and after ICU admissions. Now more than ever, mental health care for ICU patients and survivors is critical, particularly in light of the global pandemic we are facing today. As a nation and global community, we have turned to public health experts for guidance in increasing the capacity for COVID-19 patients by increasing the availability of ICU beds and associated medical needs. But we cannot forget about the equally important psychological outcomes of our critical care patients. We have an obligation to also increase capacity to meet the mental health care needs of ICU survivors, minimize issues related to PICS, and consider the provision of mental health care and screening as a psychosocial standard of care for critically ill patients.

Post-intensive care syndrome: its pathophysiology, prevention, and future directions

Psychological impact of critical illness

Assessment of Pediatric Delirium: a valid, rapid, observational tool for screening delirium in the PICU*

The ABCDEF Bundle: Science and Philosophy of How ICU Liberation Serves Patients and Families

COVID-19: ICU delirium management during SARS-CoV-2 pandemic