Cooccurrence of and remission from general anxiety, depression, and posttraumatic stress disorder symptoms after acute lung injury: a 2-year longitudinal study

Abstract

Objective: To evaluate the cooccurrence, and predictors of remission, of general anxiety, depression, and posttraumatic stress disorder symptoms during 2-year follow-up in survivors of acute lung injury treated in an ICU.

Design: Prospective cohort study, with follow-up at 3, 6, 12, and 24 months post-acute lung injury.

Setting: Thirteen medical and surgical ICUs in four hospitals.

Patients: Survivors among 520 patients with acute lung injury.

Measurements and main results: The outcomes of interest were measured using the Hospital Anxiety and Depression Scale anxiety and depression subscales (scores ≥ 8 indicating substantial symptoms) and the Impact of Event Scale-Revised (scores ≥ 1.6 indicating substantial posttraumatic stress disorder symptoms). Of the 520 enrolled patients, 274 died before 3-month follow-up; 186 of 196 consenting survivors (95%) completed at least one Hospital Anxiety and Depression Scale and Impact of Event Scale-Revised assessment during 2-year follow-up, and most completed multiple assessments. Across follow-up time points, the prevalence of suprathreshold general anxiety, depression, and posttraumatic stress disorder symptoms ranged from 38% to 44%, 26% to 33%, and 22% to 24%, respectively; more than half of the patients had suprathreshold symptoms in at least one domain during 2-year follow-up. The majority of survivors (59%) with any suprathreshold symptoms were above threshold for two or more types of symptoms (i.e., general anxiety, depression, and/or posttraumatic stress disorder). In fact, the most common pattern involved simultaneous general anxiety, depression, and posttraumatic stress disorder symptoms. Most patients with general anxiety, depression, or posttraumatic stress disorder symptoms during 2-year follow-up had suprathreshold symptoms at 24-month (last) follow-up. Higher Short-Form-36 physical functioning domain scores at the prior visit were associated with a greater likelihood of remission from general anxiety and posttraumatic stress disorder symptoms during follow-up.

Conclusions: The majority of acute lung injury survivors had clinically significant general anxiety, depression, or posttraumatic stress disorder symptoms, and these symptoms tended to co-occur across domains. Better physical functioning during recovery predicted subsequent remission of general anxiety and posttraumatic stress disorder symptoms.

Figure 1. Flow diagram of study participants

^a Some patients had a follow-up visit but did not have complete Hospital Anxiety and Depression Scale (HADS) or Impact of Event Scale-Revised (IESR) data for the following reasons, respectively, physically incapable/cognitively incapable/other: At 3 months, 22 did not have complete HADS data (9/5/8), and 23 did not have complete IESR data (7/5/11). At 6 months, 12 did not have complete HADS data (4/2/6), and 13 did not have complete IESR data (5/2/6). At 12 months, 14 did not have complete HADS data (5/4/5), and 15 did not have complete IESR data (5/4/6). At 24 months, 10 did not have complete HADS data (0/6/4), and 11 did not have complete IESR data (1/5/5).

Figure 2. Prevalence of general anxiety symptoms (HADS anxiety scores ≥8), depression symptoms (HADS depression scores ≥8), and PTSD symptoms (IESR scores ≥1.6) in the first 2 years after ALI

HADS, Hospital Anxiety and Depression Scale; IESR, Impact of Event Scale-Revised; PTSD, posttraumatic stress disorder

Figure 3

Trajectories of Hospital Anxiety and Depression Scale (HADS) anxiety scores among ALI survivors whose general anxiety symptoms remained below threshold throughout 24-month follow-up (“No Symptoms”), those whose symptoms remained above threshold throughout (“Maintainers”), those whose symptoms remitted and did not recur (“Remitters”), and those with remissions and recurrences (“Recurrence”). Thin gray lines indicate individual trajectories, and thick black lines indicate mean trajectories. The horizontal dashed lines indicate the threshold for general anxiety symptoms (HADS anxiety score ≥8)

Figure 4

Trajectories of Hospital Anxiety and Depression (HADS) depression scores among ALI survivors whose depression symptoms remained below threshold throughout 24-month follow-up (“No Symptoms”), those whose symptoms remained above threshold throughout (“Maintainers”), those whose symptoms remitted and did not recur (“Remitters”), and those with remissions and recurrences (“Recurrence”). Thin gray lines indicate individual trajectories, and thick black lines indicate mean trajectories. The horizontal dashed lines indicate the threshold for depression symptoms (HADS depression score ≥8).

Figure 5

Trajectories of Impact of Event Scale-Revised (IESR) scores among ALI survivors whose posttraumatic stress disorder (PTSD) symptoms remained below threshold throughout 24-month follow-up (“No Symptoms”), those whose symptoms remained above threshold throughout (“Maintainers”), those whose symptoms remitted and did not recur (“Remitters”), and those with remissions and recurrences (“Recurrence”). Thin gray lines indicate individual trajectories, and thick black lines indicate mean trajectories. The horizontal dashed lines indicate the threshold for PTSD symptoms (IESR score ≥1.6).