Anxiety, Depression and Post Traumatic Stress Disorder after critical illness: a UK-wide prospective cohort study

doi:10.1186/s13054-018-2223-6

Multicenter Study

. 2018 Nov 23;22(1):310.

doi: 10.1186/s13054-018-2223-6.

Anxiety, Depression and Post Traumatic Stress Disorder after critical illness: a UK-wide prospective cohort study

Robert Hatch^{1

2}, Duncan Young^{3

2}, Vicki Barber⁴, John Griffiths⁵, David A Harrison⁶, Peter Watkinson^{7

8}

Affiliations

¹ NIHR Academic Clinical Fellow in Intensive Care Medicine, Oxford Deanery, Oxford, UK.
² Kadoorie Centre for Critical Care Research and Education, University of Oxford, Level 3, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.
³ Professor of Intensive Care Medicine, University of Oxford, Oxford, UK.
⁴ OCTRU Hub Manager, University of Oxford, Oxford, UK.
⁵ Consultant in Intensive Care Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
⁶ Head Statistician, Intensive Care National Audit & Research Centre (ICNARC), London, UK.
⁷ Associate Professor of Intensive Care Medicine, Oxford University Hospitals NHS Trust, Oxford, UK. peter.watkinson@ndcn.ox.ac.uk.
⁸ Kadoorie Centre for Critical Care Research and Education, University of Oxford, Level 3, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK. peter.watkinson@ndcn.ox.ac.uk.

PMID: 30466485
PMCID: PMC6251214
DOI: 10.1186/s13054-018-2223-6

Multicenter Study

Anxiety, Depression and Post Traumatic Stress Disorder after critical illness: a UK-wide prospective cohort study

Robert Hatch et al. Crit Care. 2018.

. 2018 Nov 23;22(1):310.

doi: 10.1186/s13054-018-2223-6.

Authors

Robert Hatch^{1

2}, Duncan Young^{3

2}, Vicki Barber⁴, John Griffiths⁵, David A Harrison⁶, Peter Watkinson^{7

8}

Affiliations

¹ NIHR Academic Clinical Fellow in Intensive Care Medicine, Oxford Deanery, Oxford, UK.
² Kadoorie Centre for Critical Care Research and Education, University of Oxford, Level 3, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.
³ Professor of Intensive Care Medicine, University of Oxford, Oxford, UK.
⁴ OCTRU Hub Manager, University of Oxford, Oxford, UK.
⁵ Consultant in Intensive Care Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
⁶ Head Statistician, Intensive Care National Audit & Research Centre (ICNARC), London, UK.
⁷ Associate Professor of Intensive Care Medicine, Oxford University Hospitals NHS Trust, Oxford, UK. peter.watkinson@ndcn.ox.ac.uk.
⁸ Kadoorie Centre for Critical Care Research and Education, University of Oxford, Level 3, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK. peter.watkinson@ndcn.ox.ac.uk.

PMID: 30466485
PMCID: PMC6251214
DOI: 10.1186/s13054-018-2223-6

Abstract

Background: Survivors of intensive care are known to be at increased risk of developing longer-term psychopathology issues. We present a large UK multicentre study assessing the anxiety, depression and post-traumatic stress disorder (PTSD) caseness in the first year following discharge from an intensive care unit (ICU).

Methods: Design: prospective multicentre follow-up study of survivors of ICU in the UK.

Setting: patients from 26 ICUs in the UK.

Inclusion criteria: patients who had received at least 24 h of level 3 ICU care and were 16 years of age or older.

Interventions: postal follow up: Hospital Anxiety and Depression Score (HADS) and the Post-Traumatic Stress Disorder (PTSD) Check List-Civilian (PCL-C) at 3 and 12 months following discharge from ICU.

Main outcome measure: caseness of anxiety, depression and PTSD, 2-year survival.

Results: In total, 21,633 patients admitted to ICU were included in the study. Postal questionnaires were sent to 13,155 survivors; of these 38% (4943/13155) responded and 55% (2731/4943) of respondents passed thresholds for one or more condition at 3 or 12 months following discharge. Caseness prevalence was 46%, 40% and 22% for anxiety, depression and PTSD respectively; 18% (870/4943 patients) met the caseness threshold for all three psychological conditions. Patients with symptoms of depression were 47% more likely to die during the first 2 years after discharge from ICU than those without (HR 1.47, CI 1.19-1.80).

Conclusions: Over half of those who respond to postal questionnaire following treatment on ICU in the UK reported significant symptoms of anxiety, depression or PTSD. When symptoms of one psychological disorder are present, there is a 65% chance they will co-occur with symptoms of one of the other two disorders. Depression following critical illness is associated with an increased mortality risk in the first 2 years following discharge from ICU.

Trial registration: ISRCTN Registry, ISRCTN69112866 . Registered on 2 May 2006.

Keywords: Anxiety; Critical care; Critical illness; Depression; Intensive care; Multicentre study; Outcome assessment; PCL-C; PICS; PTSD; Post-Intensive Care Syndrome; Post-traumatic stress disorder; Post-traumatic stress disorder civilian checklist; Postal; Questionnaire; Survivors.

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Conflict of interest statement

Ethics approval and consent to participate

This study was granted national ethics approval. Phases 1 and 2 - Oxford Research Ethics Committee B (REC 06/Q1605/17), phase 3 - South Central – Berkshire REC (11/SC/0172). Informed written consent to participate in the study was obtained from all patients who chose to respond to a questionnaire.

Consent for publication

Not applicable.

Competing interests

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

**Fig. 1**
Caseness distribution against time for the Hospital Anxiety and Depression Score (HADS) and Post-Traumatic Stress Disorder Check List - Civilian (PCL-C) at 3 and 12 months post ICU discharge

**Fig. 2**
Analysis of change in the Hospital Anxiety and Depression Score (HADS)/Post-Traumatic Stress Disorder Check List - Civilian (PCL-C) in responders between 3 and 12 months post ICU discharge

**Fig. 3**
Cross over in caseness - anxiety/depression and post-traumatic stress disorder (PTSD) caseness amongst responders

**Fig. 4**
Survival versus depression (2 years) - Kaplan-Meier curve of 2-year survival amongst responders grouped by depression caseness. HADS, Hospital Anxiety and Depression Score

**Fig. 5**
Hazard ratios showing the effect of known confounders (age, sex and illness severity), and anxiety, depression or post-traumatic stress disorder (PTSD) caseness on survival. APACHE, Acute Physiology and Chronic Health Evaluation; PCL-C, Post-Traumatic Stress Disorder Check List - Civilian

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References

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1. Nikayin S, Rabiee A, Hashem MD, et al. Anxiety symptoms in survivors of critical illness: a systematic review and meta-analysis. Gen Hosp Psychiatry. 2016;43:23–29. doi: 10.1016/j.genhosppsych.2016.08.005. - DOI - PMC - PubMed
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[1] Desai SV, Law TJ, Needham DM. Long-term complications of critical care. Crit Care Med. 2011;39:371–379. doi: 10.1097/CCM.0b013e3181fd66e5. - DOI - PubMed

[2] Desai SV, Law TJ, Needham DM. Long-term complications of critical care. Crit Care Med. 2011;39:371–379. doi: 10.1097/CCM.0b013e3181fd66e5. - DOI - PubMed

[3] Judy E. Davidson, RN, CNS, DNP, FCCM; Ramona O. Hopkins, PhD; Deborah Louis, RN, MSN; Theodore J. Iwashyna, MD P (2013) Post-intensive care syndrome. In: Soc Crit Care Med http://www.myicucare.org/Thrive/Pages/Post-intensive-Care-Syndrome.aspx. Accessed 12 Feb 2018.

[4] Judy E. Davidson, RN, CNS, DNP, FCCM; Ramona O. Hopkins, PhD; Deborah Louis, RN, MSN; Theodore J. Iwashyna, MD P (2013) Post-intensive care syndrome. In: Soc Crit Care Med http://www.myicucare.org/Thrive/Pages/Post-intensive-Care-Syndrome.aspx. Accessed 12 Feb 2018.

[5] Nikayin S, Rabiee A, Hashem MD, et al. Anxiety symptoms in survivors of critical illness: a systematic review and meta-analysis. Gen Hosp Psychiatry. 2016;43:23–29. doi: 10.1016/j.genhosppsych.2016.08.005. - DOI - PMC - PubMed

[6] Nikayin S, Rabiee A, Hashem MD, et al. Anxiety symptoms in survivors of critical illness: a systematic review and meta-analysis. Gen Hosp Psychiatry. 2016;43:23–29. doi: 10.1016/j.genhosppsych.2016.08.005. - DOI - PMC - PubMed

[7] Wade Dorothy M, Howell David C, Weinman John A, Hardy Rebecca J, Mythen Michael G, Brewin Chris R, Borja-Boluda Susana, Matejowsky Claire F, Raine Rosalind A. Investigating risk factors for psychological morbidity three months after intensive care: a prospective cohort study. Critical Care. 2012;16(5):R192. doi: 10.1186/cc11677. - DOI - PMC - PubMed

[8] Wade Dorothy M, Howell David C, Weinman John A, Hardy Rebecca J, Mythen Michael G, Brewin Chris R, Borja-Boluda Susana, Matejowsky Claire F, Raine Rosalind A. Investigating risk factors for psychological morbidity three months after intensive care: a prospective cohort study. Critical Care. 2012;16(5):R192. doi: 10.1186/cc11677. - DOI - PMC - PubMed

[9] Samuelson KAM, Lundberg D, Fridlund B. Stressful memories and psychological distress in adult mechanically ventilated intensive care patients - a 2-month follow-up study. Acta Anaesthesiol Scand. 2007;51:671–678. doi: 10.1111/j.1399-6576.2007.01292.x. - DOI - PubMed

[10] Samuelson KAM, Lundberg D, Fridlund B. Stressful memories and psychological distress in adult mechanically ventilated intensive care patients - a 2-month follow-up study. Acta Anaesthesiol Scand. 2007;51:671–678. doi: 10.1111/j.1399-6576.2007.01292.x. - DOI - PubMed

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