Elsevier

General Hospital Psychiatry

Volume 32, Issue 2, March–April 2010, Pages 147-155
General Hospital Psychiatry

Psychiatric–Medical Comorbidity
Risk factors for depression and anxiety in survivors of acute respiratory distress syndrome

https://doi.org/10.1016/j.genhosppsych.2009.11.003Get rights and content

Abstract

Objective

Depression and anxiety are common morbidities of critical illness. We assessed risk factors of depression and anxiety in Acute Respiratory Distress Syndrome (ARDS) survivors at 1 and 2 years post-hospital discharge.

Method

Risk factors for depression and anxiety at 1 and 2 years were assessed using stepwise multiple regression analyses, with and without 1-year outcomes.

Results

ARDS survivors had depression (16% and 23%) and anxiety (24% and 23%) at 1 and 2 years, respectively. Predictors of depression at 1 year were alcohol dependence, female gender and younger age (P=.006). Predictors of anxiety were ratio of arterial oxygen tension to inspired oxygen fraction and duration of mechanical ventilation (P<.005). Predictors of depression at 2 years were depression at 1 year and the presence of cognitive sequelae (P<.0001). Predictors of anxiety at 2 years was anxiety at 1 year (P<.0001).

Conclusions

Medical variables that predicted depression or anxiety at 1 year no longer predicted depression and anxiety at 2 years. Medical variables appear to have a short-term effect on psychiatric outcomes. At 2 years lifestyle behaviors including history of smoking along with cognitive sequelae, depression and anxiety at 1 year predict depression and anxiety.

Introduction

Acute respiratory distress syndrome (ARDS) is a common critical illness that has disabling long-term physical and neurologic consequences for some survivors. Each year, ARDS affects approximately 190,000 people per year in the United States and is associated with 74,000 deaths and 3.6 million hospital days [1]. Acute respiratory distress syndrome is characterized by acute lung injury with respiratory failure, arterial hypoxemia, reduced total thoracic compliance and diffuse bilateral infiltrates on chest radiographs [2], [3]. Acute respiratory distress syndrome occurs in response to a variety of insults including sepsis, trauma, pneumonia, massive transfusion and other medical/surgical conditions. Treatment of ARDS requires aggressive supportive care including positive pressure ventilation [4] and increased oxygen concentrations with the attendant risks of barotrauma, oxygen toxicity and nosocomial infection. Acute respiratory distress syndrome may result in multiple organ system dysfunction, including the central nervous system [5], [6].

Individuals with a critical illness are faced with disease or injury that is life threatening requires intensive care unit (ICU) hospitalization, and invasive medical treatment. The legacy of critical illness and ICU treatment, including long-term outcomes has been under recognized and studied. Over 100,000 ARDS survivors per year [1] are at risk for long-term morbidity [7], [8] including decreased physical function [8], decreased quality of life [9], [10], development of psychiatric disorders [7], [11], [12] and neurologic injury (i.e., polyneuropathy, encephalopathy, and cognitive sequelae) [7], [8]. Psychiatric morbidity such as depression and anxiety are common morbidities of critical illness [10], [12], [13], [14]. The combination of medications, traumatic stress, pain, inflammation, hypoxemia and brain injury may contribute to psychiatric disorders following critical illness and ICU treatment [13], [15], [16]. The prevalence and severity of psychiatric disorders in survivors of critical illness is heterogeneous [15], [16], [17], [18], [19], and the reported prevalence of these disorders range from 17–48% to 60 months after ICU discharge. Depression occurs in 25% [7] to more than 50% of survivors of critical illness [10].

There is growing interest in the psychological impact of critical illness and its treatment; yet, most studies of psychiatric outcomes following critical illness are cohort studies that assess the prevalence of psychiatric morbidity, with few studies assessing risk factors for such disorders. Little is known regarding which factors of the critical illness and/or ICU treatment contribute to development of depression and anxiety in these patients. Further, no studies have assessed the impact of cognitive sequelae and its relationship to development of psychiatric morbidity in ICU survivors. The purpose of this study was to evaluate risk factors for depression and anxiety at 1 and 2 years after hospital discharge in ARDS survivors.

Section snippets

Methods

Acute respiratory distress syndrome survivors from a single-center mechanical ventilation randomized clinical trial of higher vs. lower tidal volume target strategies conducted from February 1994 to December 1999 [20] were eligible for, and invited to join this outcome study by the first author (R.O.H.). The inclusion criteria were tracheal intubation, ratio of arterial oxygen tension to inspired oxygen fraction (PaO2/FiO2) ≤150 mmHg, pulmonary artery balloon occlusion pressure ≤18 mmHg (when

Results

Descriptive statistics and medical data are presented in Table 1. There were 41 females and 33 males, with a mean age of 46±16 years (range 16–81 years), median age of 46 years (interquartile range of 35–57 years) and mean education level of 13±2.3 years (range 9–22 years). Excluding patients who died, the follow-up rate was 93% at 1 year and 90% at 2 years. At 2 years, 34% (21 of 62) were working or full time students, 34% (21 of 62) were receiving disability payments started after hospital

Discussion

The prevalence of depression and anxiety in ICU survivors is high [7]. Twenty-three percent of our patients had moderate to severe symptoms of depression and anxiety 2 years after hospital discharge. A recent systematic review of the literature found the point prevalence for depression and anxiety was >20% of ICU survivors [37]. A study of 13 ICUs in four hospitals found 26% of patients had symptoms of depression 6-month post acute lung injury [38]. Similar rates of depression have been

References (72)

  • RothenhäuslerH.B. et al.

    The relationship between cognitive performance and employment and health status in long-term survivors of the acute respiratory distress syndrome: results of an exploratory study

    Gen Hosp Psychiatry

    (2001)
  • DavydowD.S. et al.

    Posttraumatic stress disorder in general intensive care unit survivors: a systematic review

    Gen Hosp Psychiatry

    (2008)
  • KabacoffR.I. et al.

    Psychometric properties and diagnostic utility of the Beck Anxiety Inventory and the State-Trait Anxiety Inventory with old adult psychiatric outpatients

    J Anxiety Disord

    (1997)
  • RubenfeldG.D. et al.

    Incidence and outcomes of acute lung injury

    N Engl J Med

    (2005)
  • BernardG.R. et al.

    Report of the American-European Consensus Conference on acute respiratory distress syndrome: definitions, mechanics, relevant outcomes, and clinical trial coordination

    Am J Respir Crit Care Med

    (1994)
  • The Acute Respiratory Distress Syndrome Network

    Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome

    N Engl J Med

    (2000)
  • BellR.C. et al.

    Multiple organ system failure and infection in adult respiratory distress syndrome

    Ann Intern Med

    (1983)
  • MontgomeryA.B. et al.

    Causes of mortality in patients with the adult respiratory distress syndrome

    Am Rev Respir Dis

    (1985)
  • HopkinsR.O. et al.

    Two-year cognitive, emotional, and quality-of-life outcomes in acute respiratory distress syndrome

    Am J Respir Crit Care Med

    (2005)
  • HerridgeM.S. et al.

    One-year outcomes in survivors of the acute respiratory distress syndrome

    N Engl J Med

    (2003)
  • DavidsonT.A. et al.

    Reduced quality of life in survivors of acute respiratory distress syndrome compared with critically ill control patients

    JAMA

    (1999)
  • AngusD.C. et al.

    Quality-adjusted survival in the first year after the acute respiratory distress syndrome

    Am J Respir Crit Care Med

    (2001)
  • SchellingG. et al.

    Health-related quality of life and posttraumatic stress disorder in survivors of the acute respiratory distress syndrome

    Crit Care Med

    (1998)
  • KapfhammerH.P. et al.

    Posttraumatic stress disorder and health-related quality of life in long-term survivors of acute respiratory distress syndrome

    Am J Psychiatry

    (2004)
  • SkodolA.E.

    Anxiety in the medically ill: nosology and principles of differential diagnosis

    Semin Clin Neuropsychiatry

    (1999)
  • MichaelsA.J. et al.

    PTSD in critical care

    J Trauma

    (2000)
  • MilisenK. et al.

    A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients

    J Am Geriatr Soc

    (2001)
  • OrmeJ.F. et al.

    Pulmonary function and health-related quality of life in survivors of acute respiratory distress syndrome

    Am J Respir Crit Care Med

    (2003)
  • KupermanG.J. et al.

    HELP: A Dynamic Hospital Information System

    (1991)
  • KnausW.A. et al.

    APACHE II: a severity of disease classification system

    Crit Care Med

    (1985)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders

    (1994)
  • BeckA.T.

    Beck Depression Inventory: manual

    (1987)
  • BeckA. et al.

    Beck Anxiety Inventory

    (1993)
  • WechslerD.
  • ReyA.

    L'examen clinique en psychologic

    (1958)
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