“Everyone is happy because I am already out of danger, but now I feel that I have a huge, steep stair in front of my… “.
Thanks to scientific and technological advances, ICU get higher and higher survival rates. However, from a holistic view of health and of the continuity of care, attention to emotional health in the ICU and the follow-up post-ICU is thinking as something entirely necessary.
Circumstances, severity and prognosis of critically ill patient in their emotional evolution are very different. During admission to ICU will be frequent reactions of fear, insecurity, anxiety and uncertainty. During states of semi-conscience (due to disease, sedation, etc.), the person receives external stimuli from different sources (environmental noises, fragments of conversations of staff and families…), and the brain performs a puzzle with the pieces to be able to make sense of. The resulting picture can be threatening or positive, depending on external (environmental context, treatment and employed techniques) and internal features (physical pain, prior psychological instability, personal history…).
It is important to understand these emotions as “normal” responses to a highly exceptional situation. They are not psychiatric disorders but adaptive responses of the organism, but this does not mean that we should not address them. Opposite, we have to hand, control, understanding, because not chronicity will be essential to prevent problems in the future, and they are a challenge for healthcare professionals who have to deal with them together with the rest of their clinical duties. When these adaptive attempts do not work or there are other circumstances that increase the emotional vulnerability of the person, the risk of Post Intensive Care Syndrome (PICS), and perhaps of of Post traumatic Stress Disorder (PTSD) becomes especially apparent.
To analyze these situations, in recent years a large number of investigations have been developed. In a meta-analysis by Parker et al. about 3,400 patients and 40 studies, the authors conclude that prevalence on symptomatology of PTSD ranging from 25% to 44% in the first 6 months post-ICU and 17% to 34% in the 7 to 12 months after ICU discharge.
Although, end cause is not yet completely consensual, the authors point out as a risk factor for PTSD symptomatology the use of benzodiazepines, as well as the existence of prior psychopathology, memories of traumatic experiences in ICU and poorer quality of care.
The meta-analysis reviewed a selection of preventive measures that can significantly reduce this problem. Among these, emphasizes the incorporation of “ICU Diaries” for relatives, with the help of staff, they can complete sequentially throughout the ICU stay to pick up situations, developments and decisions that occur, and thus facilitate the patient understanding, remembrance and subsequent sense of lived experiences. The delivery of a “Manual of self-help and rehabilitation”, seems to have adequate effect in the short term (2 months), although it loses preventive capacity beyond 6 months. Paradoxically, they point out that the continuity of care through a “nursing outpatient”, does not significantly reduce the symptoms of PTSD. From our perspective, this result must be analyzed taking into account that monitoring posed by the authors is intended to the early detection of problems (element that is carried out with great success from this type of nursing consultation), and not so much an specialized intervention in its reduction, for what is probably needed another format of external consultation with multidisciplinary lines of intervention.
The authors conclude that if we know that approximately 1 out of every 5 patients of ICU will develop symptoms of PTSD after a year of having been admitted to the unit, the interventions to reduce psychiatric morbidity in these people are something urgent.
From this perspective, the support and training to ICU staff in emotional skills for interaction with the patient (even in situations of apparent lack of awareness or sedation), in mental health and early detection of symptoms, the facilitation of the creation of “ICU Diaries”, the follow-up of patients during and after their ICU stay by follow-up PICS consultations, and the collaboration of psychologists and psychiatrists with the ICU team, raised as roads to follow in making “this stair less steer”.
Macarena Gálvez Herrer, PhD in Clinical Psychology. Member of the teaching and researching team of Proyecto HU-CI