Erin L. Hall, PsyD
Clinical Health Psychologist
Depts of Trauma Surgery & Critical Care
Geisinger Medical Center
Since the late 1990s, researchers and clinicians have become increasingly aware of the fact that the intensive care unit (ICU) is a virtual hotbed for the development of chronic and sometimes intractable cognitive and mental health difficulties. Delirium, while less pervasive than it once was due to paradigm shifts and the integration of patient centered care, continues be common. Traumatic experiences are encountered and often grounded in concerns about death and dying and made worse by hallucinations. Anxiety and depression frequently take hold as individuals and their families adjust to aversive life sustaining technologies and grapple with uncertainty. The medical treatment one receives in an ICU is critical and lifesaving, but it can also take a significant psychological toll on patients. Thus, the ICU is a place where psychologists are uniquely equipped to provide expertise, guidance, and support to patients and improve psychological outcomes.
A key reason that the integration of psychologists in the ICU is so important is because the psychological outcomes after critical illness are so very alarming and their active engagement and early intervention can play a significant role in optimizing comprehensive treatment outcomes. Experts also believe that treatment outcomes are similar to or will be eclipsed by the challenges experienced by COVID-19 survivors. Consider these stats:
- A third of ICU survivors have been found to experience both depression1,2 and anxiety,3,4 and one in five are found with symptoms consistent with a diagnosis of PTSD.1,3,5-7
- Long-term cognitive impairment has also been found to be common in ICU survivors,1,3 impacting between 30 and 80%.2,4-7
- 50% of individuals employed at the time of ICU admission are completely out of the workforce 1 year later.
At this point in time there are a multitude of studies that address psychological and neurocognitive outcomes in COVID-19 positive patients and survivors. For instance, a recent study of more than 135,000 COVID-19 survivors six months after infection found that 33.62% of patients had symptoms warranting psychiatric diagnoses including dementia, depression, anxiety, and psychosis.9 The incidence of psychiatric problems in patients treated in an ICU setting was higher (i.e., 46.42%).9 Multiple theories on the etiology and pathophysiology of symptoms and long-term sequelae have been formulated. However, there is a relative absence of articles that help to clearly understand what happens between the diagnosis of COVID-19 and hospital discharge. Without understanding the experiences of patients during the phase of acute treatment, the long-term psychological outcomes of COVID-19 patients exist without a context.
Psychologists who work in critical care venues can shed light on ways psychological intervention may be used during ICU admission to prevent the development of later distress. One study done suggested decreased risk for PTSD after inpatient psychological intervention.8 With the novel coronavirus, there are many unique factors that make this arguably more distressing, from a psychological perspective, than ICU admission for other health conditions: the isolation and lack of family at bedside, the long-term course of illness, use of heavily sedating medications and reliance on restraints for managing sedation and agitation. For many, fear-inducing media coverage of the devastation of the virus has increased the terror they feel to be diagnosed and hospitalized.
Consider the unique roles and function psychologists fill on the care team in a variety of capacities in COVID ICUs.
- Assist with prevention, identification, and management of delirium.
- Promote nonpharmacologic interventions to improve altered mental status and assist with the pharmacologic management of agitation.
- Provide education about the nature, symptoms, and causes of delirium especially as a means to provide comfort and understanding.
- Address the delusional beliefs or memories commonly associated with delirium by validating distress, helping patients to establish a sense of safety in the environment, and challenging beliefs associated with these memories.
In addition, psychologists provide evaluation and intervention to address new or underlying psychiatric problems (e.g., anxiety, psychosis) to enhance medical treatment in the ICU. For example, patients with severe respiratory problems due to COVID-19 commonly experience new panic or anxiety when being weaned from a ventilator. Psychologists can assist with relaxation strategies, addressing dysfunctional thoughts (e.g., “I’m going to die if I feel short of breath”), and assist with supporting patient autonomy during ICU admission. Psychologists have a unique perspective in their understanding of challenging patients, delirium, withdrawal, and patient distress.
For many psychologists working with critically ill patients during the COVID-19 pandemic, the focus has been on helping to fill in the gaps of a patients’ memory or understanding and decreasing fear, addressing loneliness and promoting even the smallest factors over which the patient felt any sense of control. For some patients with a tenuous oxygen status or inability to communicate by more than a head nod or a squeeze of the hand, the warm presence of a psychologist to provide re-orientation in an unhurried fashion, a sense of calm to clarify reality from the delusional experiences, or to validate fears of dying provided comfort. A psychologist may have been the only member of the care team with the time to help connect with loved ones via an iPad or a cell phone. For patients, and families at home, this contact with each other inspired hope and connection.
In the ICU, some patients stayed longer, with minimal improvement over long stretches of time. Some came in already intubated and sedated never knowing the ICU environment until they awoke on the other side, if they did. For some time, the majority of patients in the ICU were in prone position, heavily sedated. As a medical professional walking through the unit, new challenges were to be expected daily: the patient stories, the weary co-workers, the fear of who it would be next, the feelings of inadequacy, and the constant wondering which patients may survive. The persistence of this virus has lasted especially with new variants and the unvaccinated. Thus, in some ICUs, the situations are much more dire, bleaker, and steadfast. Some places are still overwhelmed.
The reality is that most hospitals do not have a psychologist donning scrubs for a day’s work with the critically ill. For many patients, the ICU was an even lonelier, more terrifying place than for those in the small minority of hospitals lucky enough to have an ICU psychologist. While the integration of psychologists in critical care contexts has historically been slow to unfold, one potential positive outcome of the novel coronavirus pandemic has been a nearly universal recognition of the potential value that psychology has in the management of critically ill patients and their families. Psychologists who were at the bedside in the ICU during this time gained much experience related to understanding the impact of this life-altering pandemic. Their voices must continue to be heard as they engage with other behavioral health practitioners and experts from other disciplines in thoughtfully treating and supporting Covid-19 “long haulers,” with hearts grounded in compassion and minds grounded in science.
- Jackson, J. C., Pandharipande, P. P., Girard, T. D., Brummel, N. E., Thompson, J. L., Hughes, C. G., Pun, B. T., Vasilevskis, E. E., Morandi, A., Shintani, A. K., Hopkins, R. O., Bernard, G. R., Dittus, R. S., Ely, E. W., & Bringing to light the Risk Factors And Incidence of Neuropsychological dysfunction in ICU survivors (BRAIN-ICU) study investigators (2014). Depression, post-traumatic stress disorder, and functional disability in survivors of critical illness in the BRAIN-ICU study: a longitudinal cohort study. The Lancet. Respiratory medicine, 2(5), 369–379. https://doi.org/10.1016/S2213-2600(14)70051-7
- Davydow, D. S., Gifford, J. M., Desai, S. V., Bienvenu, O. J., & Needham, D. M. (2009). Depression in general intensive care unit survivors: a systematic review. Intensive care medicine, 35(5), 796–809. https://doi.org/10.1007/s00134-009-1396-5
- Needham, D. M., Davidson, J., Cohen, H., Hopkins, R. O., Weinert, C., Wunsch, H., Zawistowski, C., Bemis-Dougherty, A., Berney, S. C., Bienvenu, O. J., Brady, S. L., Brodsky, M. B., Denehy, L., Elliott, D., Flatley, C., Harabin, A. L., Jones, C., Louis, D., Meltzer, W., Muldoon, S. R., … Harvey, M. A. (2012). Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference. Critical care medicine, 40(2), 502–509. https://doi.org/10.1097/CCM.0b013e318232da75
- Nikayin, S., Rabiee, A., Hashem, M. D., Huang, M., Bienvenu, O. J., Turnbull, A. E., & Needham, D. M. (2016). Anxiety symptoms in survivors of critical illness: a systematic review and meta-analysis. General hospital psychiatry, 43, 23–29. https://doi.org/10.1016/j.genhosppsych.2016.08.005
- Patel, M. B., Jackson, J. C., Morandi, A., Girard, T. D., Hughes, C. G., Thompson, J. L., Kiehl, A. L., Elstad, M. R., Wasserstein, M. L., Goodman, R. B., Beckham, J. C., Chandrasekhar, R., Dittus, R. S., Ely, E. W., & Pandharipande, P. P. (2016). Incidence and Risk Factors for Intensive Care Unit-related Post-traumatic Stress Disorder in Veterans and Civilians. American journal of respiratory and critical care medicine, 193(12), 1373–1381. https://doi.org/10.1164/rccm.201506-1158OC
- Davydow, D. S., Gifford, J. M., Desai, S. V., Needham, D. M., & Bienvenu, O. J. (2008). Posttraumatic stress disorder in general intensive care unit survivors: a systematic review. General hospital psychiatry, 30(5), 421–434. https://doi.org/10.1016/j.genhosppsych.2008.05.006
- Mikkelsen, M. E., Christie, J. D., Lanken, P. N., Biester, R. C., Thompson, B. T., Bellamy, S. L., Localio, A. R., Demissie, E., Hopkins, R. O., & Angus, D. C. (2012). The adult respiratory distress syndrome cognitive outcomes study: long-term neuropsychological function in survivors of acute lung injury. American journal of respiratory and critical care medicine, 185(12), 1307–1315. https://doi.org/10.1164/rccm.201111-2025OC
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- Taquet, M., Geddes, G. R., Husain, M., Luciano, S., & Harrison, P. J. (2021). 6-month neurological and psychiatric outcomes in 236379 survivors of COVID-19: A retrospective cohort study using electronic health records. Lancet Psychiatry (Oxford, England), 8, 416-427. https://doi.org/10.1016/ S2215-0366(21)00084-5