Psychiatric–Medical ComorbidityRisk factors for depression and anxiety in survivors of acute respiratory distress syndrome
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.
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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
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