Patients and Their Family Members Endure Psychological Distress Post-ICU Care

Approximately 4 million Americans are admitted to the Intensive Care Unit (ICU) each year. While there have been numerous advances in ICU treatment, life for patients and their family members post-ICU care is seldom addressed. Two studies, one led by Dimitry S. Davydow, MD, of the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine in Seattle and the other led by Wendy G. Anderson, MD, MS, of the University of California in San Francisco, reviewed data on posttraumatic stress disorder (PTSD) in surviving ICU patients and examined family members’ risk of mental health morbidity, respectively.

Davydow and colleagues found 15 eligible studies for a systematic literature review using Medline, EMBASE, Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and a hand-search of 13 journals. The selected studies took place in multiple European countries as well as the United Kingdom and the United States. They collectively comprised a sample size of 1,745 ICU survivors. They found that questionnaire-discovered “clinically significant” PTSD symptoms had a median point prevalence of 22% (n=1,104) while clinician-diagnosed PTSD had a median point prevalence of 19% (n=93). Consistent predictors of post-ICU PTSD (ie, prior psychopathology, greater ICU benzodiazepine administration, and post-ICU memories of in-ICU traumatic experiences) were revealed. In contrast, less consistent predictors included gender, younger age, and severity of critical illness. Significantly lower health-related quality of life was related to post-ICU PTSD.

Though Davydow and colleagues’ review is based on studies using screening tools for PTSD assessment, results still indicate in-ICU trauma as a trigger for PTSD symptoms in survivors that is detrimental to a patient’s quality of life post-ICU care. The researchers suggested that future studies should note how patient-specific factors (eg, pre-ICU psychopathology), ICU management factors (eg, sedative administration), and ICU clinical factors (eg, in-ICU hallucinations) are associated with one another and with post-ICU PTSD. Further, monitoring of both PTSD risk factors in ICU survivors and their needs for early intervention is necessary.

Anderson and colleagues conducted a prospective, longitudinal cohort study on 50 family members of ICU patients. Participants were interviewed at time of enrollment (n=50), 1 month (n=39), and 6 months (n=34). Prevalence of and factors related to anxiety, depression, PTSD, and complicated grief were measured by the Hospital Anxiety and Depression scale, Impact of Event scale, and Inventory of Complicated Grief scale. Anxiety and depression presented at all time points but diminished over time. However, PTSD presented in 35% of all participants (95% Confidence Interval [CI] 21% to 52%) and complicated grief presented in 46% of 19 bereaved participants (95% CI 22% to 71%). Anderson and colleagues concluded that it is important to assess PTSD and complicated grief in family members after a loved one’s stay in the ICU, as both conditions remained over time.

Funding for Davydow and colleagues’ study was provided by the National Institutes of Health and Canadian Institutes of Health Research. Funding for Anderson and colleagues’ study was provided by the University of Pittsburgh’s Institute for Doctor-Patient Communication and the Greenwall Foundation. (Davydow DS. Gen Hosp Psychiatry. 2008;30(5):421-434; Anderson WG. J Gen Intern Med. 2008. Epub ahead of print.) –ML

Long-term Cancer Survivors at Increased Risk for Severe Psychosocial Distress Following Treatment

According to the Centers for Disease Control, improved screening methods and earlier and more frequent screening as well as more effective treatment modalities have caused a significant decline in death rates among patients with cancer, among other interventions. It is estimated that there are 12 million cancer survivors living in the United States, with approximately 66% of those survivors living for >5 years following treatment.

Studies have shown that patients who survive cancer are at an increased risk for receiving inadequate health care, which may be necessary due to possible recurrence and lingering effects of prior cancer treatment. In addition, cancer survivors are at an increased risk for experiencing severe psychosocial distress, potentially due to changes in social support, difficulty maintaining employment, or fear of cancer recurrence. However, few prior studies have investigated the prevalence of psychosocial distress and depression among this patient population.

Karen E. Hoffman, MD, of the Harvard Radiation Oncology Program at Harvard Medical School in Boston, and colleagues, studied prevalence rates of distress and depression among 4,712 long-term cancer survivors and 126,841 adults who had never been diagnosed with cancer. They sought to determine if long-term cancer survivors experience distress and depression at rates higher than the general population as well as what clinical factors may impact the development of distress and depression.

Data were utilized from the National Health Interview Survey, a continuous health survey of 40,000 households conducted by the National Center for Health Statistics of the CDC. In the survey, participants were asked if they were  ever informed of having cancer or a malignant disease by a health professional. Participants who had received a cancer diagnosis ≥5 years prior to the study beginning and who were ≥18 years of age were included in the study. Distress was measured using a K6 scale, which asked participants to evaluate aspects of their mood and affect in the past 30 days, including presence and frequency of sadness, anxiety, restlessness, and worthlessness.

Hoffman and colleagues found that psychosocial distress was identified in 5.6% of cancer survivors as opposed to 3% of participants without cancer, and this finding persisted after controlling for demographic factors. In addition, survivors who experience comorbid conditions related to cancer and/or treatment were more likely to experience severe distress as were younger survivors (45–65 years of age), when compared to older survivors (≥65 years of age). Being unmarried and having difficulty completing daily activities without assistance were also factors that contributed to increased psychosocial distress.
They concluded that distress often occurs for patients who survive cancer for >5 years, with symptoms being unrelated to initial diagnosis and treatment. Thus, primary care physicians and other health professionals should remain aware of risk factors for distress and focus on screening and patient education for affected patients. Study limitations included use of self-report data and lack of additional diagnostic information. (50th Annual Meeting of the American Society for Therapeutic Radiology and Oncology; September 24, 2008; Boston, Massachusetts) –CP

Telephone-administered versus Traditional Psychotherapy for Depression

Telephone-administered psychotherapy, although slow to catch on, has received far more attention within the past decade than ever before. As the need for mental health care grows, along with the concurring recognition of access issues and boundaries to treatment, clinical trials are beginning to recognize the utility of telepsychiatry in certain cases. David C. Mohr, PhD, at Northwestern University, and colleagues,  examined the literature on using telepsychiatry to treat depression, and compared the effectiveness of face-to-face psychotherapy to telephone-administered methods.

“In a survey of primary care physicians, we found that 75% of depressed patients identified one or more barriers that would make it impossible or extremely difficult to attend face to face psychotherapy,” Dr. Mohr said. “While cost was a common one, structural problems, such as time constraints (job, childcare, etc), transportation problems, physical symptoms, and availability of services were also common.”

Mohr and colleagues reviewed 51 studies for inclusion into their meta-analysis, of which only 12 met inclusion criteria. Ten of the accepted studies had control conditions, with a mean effect size of d=0.26 (CI, 0.14-0.39). All therapist-patient interaction in the accepted studies was conducted over the telephone with adult patients; ≥4 sessions per patient with a clear treatment plan were required; and reduction of depressive symptoms was a treatment outcome.

A significant reduction in depressive symptoms was associated with telephone-administered psychotherapy. In the studies with a control condition, telepsychiatry had a mean effect size of d=0.26, although a 1997 meta-analysis of face-to-face psychotherapy with no control condition had a mean effect size of d=0.42. However, the pretreatment to posttreatment effect size for telepsychiatry was d=0.82, comparable to the pre-post treatment effects of face-to-face therapy in the range of d=0.71–0.73.

Although Mohr and colleagues’ analysis demonstrated a reduction of depressive symptoms with telepsychiatry, its low attrition rate, compared to face-to-face therapies, is an important aspect of this analysis. The telepsychiatry attrition rate of 7.56% (CI, 4.23-10.90) compared favorably to the 46.9% attrition rate of a 1993 meta-analysis of face-to-face psychotherapy, although such rates can range from 13.9% to 64.4% in the literature.

Despite the favorable attrition rates in telepsychiatry, Dr. Mohr said it is not clear whether there are types of problems or patients who benefit more or less from it.

“My sense is that it is most beneficial for those people who have barriers that would make it difficult for them to attend face-to-face treatments,” he said. “It is also probably less appropriate for more severe disorders, such as psychotic disorders.”

Funding for this study was provided by the National Institute of Mental Health. (Clinical Psychology: Science and Practice. 2008;15(3):243–253.) –LS

Personality May Affect PCPs’ Assessment of Patients’ MDD

For the majority of patients experiencing symptoms of major depressive disorder (MDD) and related disorders, the first healthcare professional visited for diagnosis and treatment is the primary care physician (PCP). However, there are often obstacles to completing a thorough mental health assessment by PCPs, such as limited time to gather patient information. In addition, there may be possible hesitation on the part of the PCP to inquire into a patient’s history of MDD or suicidal ideation and behavior due to the PCP’s own discomfort. Recently, researchers at the University of Rochester Medical Center in New York studied the effect of PCP personality and temperament on the consistency of complete patient MDD assessments.

Paul R. Duberstein, PhD, and colleagues studied data from 86 standardized patient visits with 46 PCPs who specialized in internal and family medicine. Six female actors portrayed patients with MDD or an adjustment disorder with depressed mood, and each physician was evaluated after one unannounced visit by an actor portraying a patient with MDD and another visit by an actor portraying a patient with an adjustment disorder.

Visits were taped without the physician’s knowledge, and recordings along with reports from the actors on doctoring behaviors and medical records were assessed to determine rates of MDD or related diagnosis. PCP personality was then divided into three categories: dutifulness, vulnerability, and openness to feelings. Dutifulness was defined as conscientiousness and ability to follow through with plans; vulnerability was defined as the presence of anxiety, unease, and stress; and openness was defined as empathy.

Duberstein and colleagues found that PCPs who were more dutiful and vulnerable had higher rates of reporting depression, but they asked fewer questions concerning MDD symptoms. Personality style did not affect the likelihood of PCPs inquiring about suicide.

The authors concluded that a PCP’s personality can affect the likelihood of MDD diagnosis and alter how often patients are asked about mood symptoms. While the area of interest requires further study, interventions for PCPs could include use of a screening questionnaire or mental health specialist who can further assess for the presence of MDD and other mood disorders. Nevertheless, the authors added, there is no “correct” method of inquiring about mood symptoms but that PCPs should select a method that fits best with their personal preference.

Study limitations included use of a single geographic location, that the majority of PCPs in the study were white men, and that roles portrayed by actors may not reflect the experience of a typical patient. (J Gen Intern Med. 2008. In press.) –CP

Long-term Antidepressant Treatment is Non-beneficial in Bipolar Disorder

Long-term antidepressant therapy for depression in patients with bipolar disorder is common. However, its benefits and risks remain ambiguous. Meta-analyses of relevant research in the subject conducted by S. Nassir Ghaemi, MD, of the Tufts Medical Center in Boston, Massachusetts, and colleagues, further investigated this issue.

Ghaemi and colleagues searched databases such as Medline, EMBASE, and the Cochrane Library for randomized controlled trials of bipolar disorder patients who underwent ≥6 months of antidepressant therapy plus mood stabilizer versus placebo with or without mood stabilizer. Seven trials with 12 contrasts, collectively comprising of 350 bipolar disorder patients, qualified for further investigation. Meta-analyses were used to compare reported risks of new depression with those reported of mania. Results revealed that long-term treatments with antidepressants led to 27% lower risk of new depression compared to both mood stabilizer-only and no treatment (pooled relative risk [RR]=.73; 95% confidence interval [CI] .55–.97; number-needed-to-treat [NNT)=11). However, there was a 72% greater risk for new mania (RR=1.72; 95% CI 1.23–2.41; number-needed-to-harm [NNH]=7). In studies comparing mood stabilizer-alone to mood stabilizer plus antidepressant, the addition of an antidepressant yielded no major protection from depression (RR=.84; 95% CI .56–1.27; NNT=16) or significant increase in risk of mania (RR=1.37; 95% CI .81–2.33; NNH=16).

The data indicated that long-term adjunctive antidepressant treatment was not superior to mood stabilizer monotreatment in patients with bipolar disorder, suggesting that reliance on mood stabilizers lays the foundation for prophylaxis in type-I bipolar disorder. Clinicians should be cautious in long-term use of antidepressants aimed at mitigating recurrences of bipolar disorder. (Acta Psychiatr Scand. 2008;118(5):347-356.) –ML


Psychiatric dispatches is written by Michelisa Lanche, Carlos Perkins, Jr, and Lonnie Stoltzfoos.

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