Caring for critically ill patients with a mental illness: A discursive paper providing an overview and case exploration of the delivery of intensive care to people with psychiatric comorbidity

Abstract

Aim

To address the need for additional education in the management of mental illness in the critical care setting by providing a broad overview of the interrelationship between critical illness and mental illness. The paper also offers practical advice to support critical care staff in managing patients with mental illness in critical care by discussing two hypothetical case scenarios involving aggressive and disorganised behaviour.

People living with mental illness are over‐represented among critically unwell patients and experience worse outcomes, contributing to a life expectancy up to 30 years shorter than their peers. Strategic documents call for these inequitable outcomes to be addressed. Staff working in intensive care units (ICUs) possess advanced knowledge and specialist skills in managing critical illness but have reported limited confidence in managing patients with comorbid mental illness.

Design & Methods

A discursive paper, drawing on clinical experience and research of the authors and current literature.

Results

Like all people, patients with mental illnesses draw on their cognitive, behavioural, social and spiritual resources to cope with their experiences during critical illness. However, they may have fewer resources available due to co‐morbid mental illness, a history of trauma and social disadvantage.

By identifying and sensitively addressing patients' underlying needs in a trauma‐informed way, demonstrating respect and maximising patient autonomy, staff can reduce distress and disruptive behaviours and promote recovery.

Caring for patients who are distressed and/or display challenging behaviours can evoke strong and unpleasant emotional responses. Self‐care is fundamental to maintaining a compassionate approach and effective clinical judgement. Staff should be enabled to accept and acknowledge emotional responses and access support—informally with peers and/or through formal mechanisms as needed. Organisational leadership and endorsement of the principles of equitable care are critical to creation of the environment needed to improve outcomes for staff and patients.

Relevance to clinical practice

ICU nurses hold an important role in the care of patients with critical illnesses and are ideally placed to empower, advocate for and comfort those patients also living with mental illness. To perform these tasks optimally and sustainably, health services have a responsibility to provide nursing staff with adequate education and training in the management of mental illnesses, and sufficient formal and informal support to maintain their own well‐being while providing this care.

Patient and public involvement

This paper is grounded in accounts of patients with mental illness and clinicians providing care to patients with mental illness in critical care settings but there was no direct patient or public contribution.

What does this paper contribute to the wider global clinical community?

• Whether premorbid or developing as a result of illness or injury, mental illness is a common comorbidity among people being treated for critical illness.

• Strategic international documents advocate for equitable access to quality health care. However, inequitable health outcomes are commonly experienced by people with mental illness. Critical care staff have reported a perceived gap in skillset and knowledge base in managing mental illness in the critical care setting, which can contribute to suboptimal patient care and staff distress.

• To address this gap, this paper provides pragmatic advice to support the conceptualisation and management of mental health presentations and challenging behaviours often seen in the critical care setting.

1. INTRODUCTION

The term mental illness encompasses a broad range of conditions resulting in disturbed cognition, perception, mood and behaviour. These disturbances may be transient, fluctuating or enduring. Mental illness may be complicated by cognitive/intellectual impairment, social challenges or medical comorbidities (Wade & Halligan, 2017). People with severe mental illnesses, including psychotic conditions, personality disorders and substance dependence are multiply disadvantaged.

Inequity in access to treatment and care contribute to overrepresentation of people with mental illness among people presenting with chronic and critical illnesses and an excess mortality (Pilowsky et al., 2021). Recognition of longstanding inequities and immense social and economic burden underpin calls internationally to improve healthcare for this population (Lawrence & Kisely, 2010; Mitchell et al., 2009). Strategic documents promote parity of esteem and delivery of whole person care (Firth et al., 2019; Mitchell et al., 2017; Royal College of Nursing, 2019). Traditionally, services have been designed to promote efficiency, and professional training has emphasised developing skills in either mental or physical health rather than skills in both fields (Cornwall, 2014), achieving parity requires a substantial adaptation from this approach.

Critical care is a domain in which caring for people with mental illness is particularly challenging (Giandinoto & Edward, 2014, 2015; Kahl & Correll, 2020; Lake & Turner, 2017; MacNeela et al., 2012). Critical care settings are designed to enable specialised clinicians to provide life‐saving care and organ support. Critical care staff seldom receive specific training in management of mental illness (Weare et al., 2019). They report limited knowledge about the specific needs of people with mental illness and lack confidence providing care when mental illness complicates a presentation (Patterson et al., 2022; Weare et al., 2019). Suboptimal management of mental health issues in a critically unwell patient can impede recovery, contribute to poorer outcomes and moral distress in staff (Choe et al., 2015; Fond et al., 2021; Patterson et al., 2022; Pilowsky et al., 2021; Weare et al., 2019).

Optimising patient care and outcomes and promoting staff wellbeing is dependent on staff understanding the complex interactions between specific mental illnesses and physical health conditions, ways in which mental illness may influence behaviour, the effect that behaviour may have and development of appropriate self‐care strategies. To this end, this paper provides a conceptual overview of the intersection between mental health and critical illness, aimed at empowering critical care staff to care for patients with mental illness in critical care settings.

Practical guidance is grounded in two hypothetical case scenarios depicting challenges clinicians may experience. The nature of these cases was chosen based on priorities reported from critical care staff and reflects two key (but not mutually exclusive) populations: patients with severe mental illness (such as schizophrenia) and patients with personality disorders. They were also chosen to cover important acute situations commonly experienced in the ICU setting, with one reflecting aggression, and the other reflecting disorganised/unpredictable behaviour.

2. CASE SCENARIOS

2.1. Case 1

Mr F is a 22‐year‐old homeless man admitted to the ICU after being found unconscious in a local park from a suspected drug overdose. This is Mr F's 3rd ICU admission in 3 months, each following an overdose of recreational drugs which he states are not intentional; notes describe episodes of verbal and physical aggression and emotional lability during previous admissions. Mr F is known to use methamphetamine and consume harmful quantities of alcohol. He has a diagnosis of antisocial personality disorder but is not engaged with mental health (MH) services.

In ICU he was initially sedated with propofol. As sedation was weaned, Mr F became agitated, grabbing at the endotracheal tube (ETT) and not following instructions. The first two attempts at extubation were abandoned as staff considered Mr F too agitated to continue safely. On reducing sedation for the third time, Mr F started thrashing around in bed, trying to kick the staff attempting to restrain him and pulled out his ETT. As the sedation continued to wear off, he frequently tried to climb out of bed, yelling that he wants to leave the hospital.

2.2. Case 2

Ms P is a 67‐year‐old woman admitted to ICU after being brought to hospital by ambulance and police. Police were called by a neighbour when Ms P entered her property at 2 am yelling incomprehensibly and behaving aggressively. Police officers were unable to engage Ms P in conversation, observed agitation and called an ambulance, suspecting she was unwell.

On arrival at ED, Ms P was highly agitated, yelling that people were ‘trying to kill her’, and attempted to flee. She was physically restrained by security staff before Droperidol was given for sedation. She was admitted to ICU following aspiration. On examination Ms P had a low‐grade fever and a purulent foot ulcer. In ICU, Ms P remained suspicious, wanting to know the contents of each syringe or tablet. She was heard mumbling to herself, stared intensely at attending nurses and was observed tampering with her IV lines.

When contacted, Ms P's son reported a history of schizoaffective disorder, and while well controlled with medication recently, Ms P required several long mental health admissions and electroconvulsive therapy (ECT) around 5 years ago. Medical history included diagnosis of vascular dementia 12 months ago, COPD and metabolic syndrome. She had recently started a course of corticosteroids. Lately, according to her son, Ms P had seemed distracted and irritable. She began to worry that her neighbour was drug trafficking and described seeing shadowy figures outside her windows at night.

3. MENTAL ILLNESS IN CRITICAL CARE SETTINGS—GENERAL PRINCIPLES

Critical illness and its treatment are physiologically and psychologically stressful. Physiological responses are activated by the underlying disease processes, and in response to pain, sleep disruption, medications and other interventions needed to support life (Chu et al., 2021). Psychological stressors include compromised autonomy, privacy and dignity (Beach et al., 2015). Patients can experience a range of emotions including fear and hope (Papathanassoglou, 2010) and commonly report distressing and unpleasant experiences while undergoing treatment (Selwyn et al., 2021).

To tolerate these stressors, all patients employ a range of cognitive, behavioural, social and spiritual mechanisms. The precise patterns adopted to manage the stressors are unique to the patient, based on their history, strengths and resilience, bolstered by their available social supports and resources. Patients may depend on family, friends and colleagues to support them practically and emotionally. The nature of the condition and concomitant disadvantage may constrain the resources available. For example, if Mr F has grown up in, or now lives in a socially isolated setting he may not know how to seek help or express emotions in a manner that is regarded as acceptable, or be unable to identify what his needs are. Patients with mental illness may automatically use coping strategies which have been helpful in other settings but are less effective and potentially counterproductive in ICU, such as expressing discomfort or fear through anger and intimidation. For example, Mr F may have been exposed to aggression in childhood and may continue to be exposed to violence on a regular basis. He may therefore assert himself verbally or physically out of a pattern of self‐protection.

There are three key area that we will explore in detail below, which can improve interactions between critically ill patients with comorbid mental illness and staff:

A Trauma Informed Approach promotes an environment of psychological safety for all patients and staff.

Managing Challenging Behaviour requires a proactive, clear and measured response, and can achieve a more positive outcome within a shorter timeframe, while containing risks to the patient, co‐patients and staff.

Supporting Staff Emotions and Wellbeing ensuring the complex emotions which can arise in these situations are acknowledged with an appropriate response both at an interpersonal and service level can help to provide a safe workplace and protect against burnout.

4. A TRAUMA INFORMED APPROACH

Early intervention within ICU focussed on preventing or reducing patient stress and distress is needed to reduce the impact on concurrent and developing mental illness. This early intervention is largely indistinguishable from good medical and nursing practice where the patient is listened to and cared for with compassion. Patients are given simple assistance that supports and encourages hope and coping. The value of this simple but good caring practice is that the whole patient experience is likely to be better, other medical outcomes are likely to be improved and the experience for staff providing the care is likely to be a more positive one that promotes confidence in care of mental health.

Many ICU patients have a history of psychological trauma. Traumatic experiences can occur at any life stage and can be a single event or a recurrent pattern. When occurring in early childhood or adolescence, neurological development can be affected, limiting the person's capacity to process information and regulate emotions. Identifying a trauma history or response can be challenging. Clinicians may have little time to ‘get to know the patient’ and patients may be unaware of the trauma or choose not to disclose it.

Because of previous interactions, patients with a history of trauma can be slow to trust, particularly strangers or perceived authority figures. Staff must be guided by the patient around disclosure, as discussing or thinking about traumatic experiences can be distressing. Staff can notice non‐verbal cues often seen in psychological trauma, such as intense touch‐response, avoiding eye contact and general hyperarousal.

Combined with the vulnerability their critical illness imposes, this can make ICU experiences very uncomfortable. A history of trauma can heighten the feelings of anxiety common to critically ill patients, and if exposed to trauma‐associated stimuli, patients may become distressed, agitated and/or aggressive, and either flee or dissociate. Stimuli that appear non‐threatening to staff such as cuffs, alarms or other features of the ICU can be unsettling. Patients with previous psychological trauma can be sensitive to pain, personal space, loud noises, loss of autonomy or perceived rejection/devaluation.

Any of these may contribute to Mr F's behaviour and can be perceived as disruptive or difficult behaviour by staff, but can be modified by a trauma‐informed approach. The ‘Trauma‐informed‐care’ (TIC) model has been shown to reduce the use of restraints and seclusion in the mental health setting (Muskett, 2014). TIC is underpinned by six core principles (Ashana et al., 2020) which are explored within the ICU setting in Table 1.

TABLE 1.

The six core principles of Trauma Informed Care.

Safety	Trustworthiness/transparency	Collaboration/mutuality	Peer support	Empowerment	Cultural/historical/sexual issues
Cultivating a sense of psychological safety in the environment There are many aspects of the ICU environment which may have an association with not being safe for the patient with a trauma history, including loud noises, restricted movement, and bright lights Mitigating this can involve minimising alarms, providing privacy and dignity, and reassuring the patient that they are safe	Proactively building trust with the patient through open and clear communication This can involve talking through what is happening and why (even if it is not clear if the patient can understand/hear), apologising for any errors or inconsistencies, and avoiding inconsistent messages between different staff A common area where staff interactions may feel inconsistent is when they advise a review/procedure will happen at a specific time, but this does not happen due to unforeseen circumstances. Early apology/explanation can mitigate the impact of these events	Bidirectional staff‐patient communication This may involve family meetings, jointly developed plans (involving treating teams familiar to the patients such as the MH team if applicable) or family involvement in appropriate areas of care, such as mouth care or mobilisation	Utilising the patient's larger support network in their care This may involve supportive input from cultural/religious groups during family meetings Some ICU staff may also have backgrounds that the patient can relate to, which can assist with rapport and trust	Maximising the autonomy of the patient in their own care Many patients have had several experiences where they have lost control of their own bodies, which can make the ICU experience more distressing Staff can maximise patient input into decisions wherever this is clinically possible. Even small choices, such as what music they would like to listen to, can help the patient feel more in control and make their ICU stay less traumatic	Actively considering systems biases or misunderstandings which may produce a barrier to the patient and/or their family being engaged in their care It is important not to make assumptions based on cultural, religious or ethnic factors, and to recognise how unfamiliar cultural practices may be misinterpreted either by the staff or the patient For example, understanding the role of family in illness within the patient's cultural context can facilitate a better engagement in family meetings

Identifying and validating the underlying emotion can be helpful for some patients. Rather than assume what they are feeling, check in with patients: ‘it sounds like you're feeling really frustrated’ and acknowledge the patient's description of their experience. Using phrases like ‘that must have been really hard for you’ or paraphrasing a patient's account with ‘so what you're saying is…’ not only helps the patient feel heard and empowered, but facilitates emotional reflection and builds trust in the relationship (Stanton & Low, 2012).

Open and clear communication, combined with emotional availability and taking extra time can minimise the inherent staff‐patient power imbalance, making them more comfortable. When invited, some can advise what unsettles them and suggest ways to make them more comfortable. It is helpful to maximise patients' control over their situation by asking consent to initiate and continue with procedures, investigations or basic cares with ongoing dialogue of what you are doing and why. Critically important investigations and/or procedures can be difficult to modify, but this can be mitigated by providing options around when they occur, or what they would like to do before/after.

Use of a ‘trauma informed’ approach to clinical care regardless of whether there is a known trauma history, promotes safety of all.

5. MANAGING CHALLENGING BEHAVIOUR

Even when a trauma informed approach is applied well, unanticipated and unavoidable behavioural challenges can emerge. The specific nature of these can vary widely, but two common behavioural patterns are highlighted in the cases above. Mr F is exhibiting aggression, and Ms P is demonstrating unpredictable and disorganised behaviour. It is important to note that while these behavioural patterns will be explored separately below, these behaviours are not mutually exclusive, and elements of the suggested responses can be employed together as required.

5.1. Aggression

Aggression, as exhibited by Mr F, is unfortunately very common in ICU with recent studies demonstrating that 85%–99% of ICU nurses have experienced violence (Pich & Roche, 2020; Yoo et al., 2018). While most people living with mental illness are not aggressive and are more likely to be victims than perpetrators of violence, some symptoms of mental illness can increase the risk of aggression (Ghiasi et al., 2022). Regardless of circumstances, aggression against staff is never acceptable and organisations have a responsibility to ensure a safe workplace (Morphet et al., 2018).

Risk factors for aggression include characteristics specific to (1) the aggressor (including previous aggressive behaviour, drug/alcohol use and being a victim of violence), (2) the worker (personal characteristics and previous exposure/experience involving workplace violence) and (3) the environment (including time of day, level of stimulus, presence of security cameras and single patient rooms; Gillespie et al., 2010). Many practices implemented in other clinical settings to keep staff safe (e.g. restraint, discharge from hospital and being removed from facility grounds by security staff) are not always suitable for ICU patients who are fully dependent on medical care.

Predictable patterns of aggressive behaviour have been well studied outside of ICU (Gillespie et al., 2010; National Collaborating Centre for Mental Health, 2015), but there is limited information around predicting aggression in the ICU. Violence‐related emergency calls has been over‐represented among patients admitted following drug overdoses, isolated head trauma and cardiac arrest (Pol et al., 2019). As a general recommendation, staff can utilise whatever is known about the patient's static and dynamic risk factors to mitigate risk. Structured risk assessment tools can assist staff with conducting an objective evaluation (Calow et al., 2016), though future research should prospectively validate these tools in the ICU setting. In some circumstances, a cyclical pattern of behaviour between staff and patient can emerge and perpetuate aggressive behaviour. This can be broken by recognising when a pattern has developed and deliberately changing the approach, or rotating staff.

Static risk factors for aggression in any hospital setting include a history of aggression, male gender, developmental exposure to violence/trauma, cognitive impairment (including head trauma), forensic history and substance misuse. Collateral information from people who know the patient well can assist ICU staff in formulating an approach tailored to the patient. This may include family members, colleagues (such as the psychology/psychiatry team or other specialists) or ICU staff members who have previously provided care for the patient.

Dynamic risk factors include an altered mental state (e.g. delirium, psychosis or sedation), acute pain and heightened emotions such as fear or anger. Also consider the circumstances leading to admission, what else is happening in the ICU, and behaviour that was observed in the emergency department.

Critical junctions in care (including extubation and leaving/returning to theatre), encroaching on personal space, cares involving sedation (including intubation, insertion/removal of lines and invasive procedures) and cares involving discomfort (including suctioning, dressing changes and repositioning) are associated with aggression in ICU (Patterson et al., 2022).

Mr F's risk factors include male gender, substance misuse, previous aggression, a likely altered mental state and a critical junction in care. These risks could be mitigated through some careful planning prior to extubation. Minimising sensory demands (e.g. noise and light), and having sufficient staff present (including staff with who have good rapport with the patient), having security in close vicinity (in case required) but out of sight can all help to mitigate Mr F's aggression. Clear and concise planning with established roles of participating staff, and sufficient equipment available could reduce staff anxiety and facilitate the required procedure in a controlled manner with minimal escalation of aggressive behaviour from Mr F.

Staff response to verbal and/or physical aggression will be shaped by many factors, including how the clinical situation and cause of aggression is interpreted. An initial response may include the staff member stepping away to ensure their own safety. However, staff may instinctively approach the patient to prevent dislodgement of the ETT. Unfortunately, this natural response of providing safety for the patient may put the staff member(s) at risk and potentially escalate aggression. An invasion of the patient's personal space, or subsequent pain or discomfort, can precipitate a defensive response; especially if the patient has an altered mental state or a history of PTSD or psychological trauma.

Training on how to anticipate, prevent and manage aggression in ICU may help staff manage aggressive behaviour without exacerbating the situation, keeping both patients and staff safe. Once aggressive behaviour has begun, it is important to ensure all staff and patients are safe and that there are sufficient staff available to manage the situation. This may require calling for staff trained in managing aggression.

Addressing aggression can be approached in the following ways:

1. Verbal de‐escalation

Verbal de‐escalation utilises conversation to reduce agitation and is the first line approach as it minimises the risk to staff and co‐patients, while also minimising the risk of exposing the patient to trauma. Video resources are freely available to assist clinical staff developing skills at verbal de‐escalation (Simpson et al., 2020), but some general principles are discussed below.

When the situation is safe, the patient can be engaged, ideally by a single staff member trained in verbal de‐escalation. Once engaged and attentive, the patient will begin to respond to both verbal and non‐verbal cues of the staff member. The goals of engagement are to keep everyone calm and safe while addressing the patient's concerns and needs.

Verbal de‐escalation can usually occur from a safe distance, demonstrating respect for patient boundaries. Language needs to be clear, concise and simple, as the patient is likely to be in a state of hyperarousal. The patient should be invited into a collaborative discussion where their needs and emotions are identified and validated ‘what can I do to help?’, while still maintaining firm limits and boundaries ‘unfortunately, that's the hospital policy’.

Allowing the patient time and space to express feelings promotes engagement: ‘Mr. F, this has all been really tough for you, tell me what's going on and I'll see if I can help’. Provocative or authoritarian language such as ‘stop it’ can escalate the patient, while ‘agreeing to disagree’ can allow the conversation to move beyond points of contention to a resolution. Staff should look for opportunities where they can meet the patient's needs within the established boundaries and identify areas where the patient can be offered choices ‘I think we will be able to help you with that Mr. F. Let me know what you think of these options’.

• 2 Chemical restraint

A range of medications are available to help reduce acute agitation where verbal de‐escalation alone is unable to resolve the situation. Clinicians need to consider the patient's clinical picture and potential medication interactions when selecting an appropriate anxiolytic, especially in the case of delirious patients. Wilson et al. provide a guide to chemical restraint based on underlying cause (Wilson et al., 2015). While this was developed for the emergency department setting, the principles generally apply to the ICU setting also. Figure 1 provides additional detail around management of aggression associated with ICU cares, which can often be managed proactively.

FIGURE 1.

Pharmacological approach to aggression in context of ICU processes.

Physical restraint should be reserved for situations where there is imminent risk of harm to patients, staff or co‐patients, and should be performed only by staff members with relevant training and expertise. Physical restraint may assist in preventing immediate injurious behaviours such as pulling out lines, punching, kicking or biting, but is unlikely to reduce, and may aggravate, the underlying agitation. Further, physical restraint exposes both the patient and participating staff to risk of mechanical injuries, blood or body‐fluid exposure. It is also more likely to be a traumatic experience for the patient, family members, staff and any other witnessing parties (Burry et al., 2018).

5.2. Disorganised behaviour

The behaviours of most patients are predictable because there is a logic relevant to the context that is easy to follow and anticipate based on previous personal and observed experiences with the situation. This is further facilitated by clear communication (verbal and non‐verbal) between staff and patient, which can identify needs and reassure and redirect the patient as needed. Many of these patterns become disrupted in the disorganised patient, making behaviours harder to foresee and anticipate (Trackman, 1978).

Disorganised behaviour as exhibited by Ms P is a complex phenomenon, and commonly multi‐factorial. Patient experience and presentations vary widely. Patients can experience auditory or visual hallucinations, misidentify people, places or situations; they can become paranoid, struggle to follow conversation or understand what is happening.

As is the priority in any care setting, the first task in managing a patient behaving unpredictably is ensuring safety for all people involved. Ensuring early assessment of safety and management of acute risks allows the time and space needed for further diagnosis, treatment and cares (Tesar & Stern, 1986).

Given Ms P's confusion, her behaviour is likely to be less predictable or logical, and communication more challenging, complicating staff efforts at reassurance and redirection. When disoriented, a patient can behave as if in a different context, such as believing she is in a train station. Thus, behaviour can appear illogical from the staff perspective, such as Ms. P trying to flee hospital, which may reflect a hallucination or a misinterpreted cue. Further, the patient may struggle to express their own thoughts or follow instructions due to confusion.

Non‐verbal cues can be lost due to affective blunting, where staff are unable to identify frustration, fear or anger when it is present (Mäkinen et al., 2008). Patients can also misinterpret non‐verbal cues of staff, such as perceiving a smile intended to be warm and kind, as being mocking or hostile. Their response is therefore unpredictable and can commonly be aggressive or defensive. As such, Ms P is at risk of both intentional and unintentional harm to herself and others and should be kept under close visual observations. One aspect not distorted by acute disorganisation is patient history, and static risk factors.

Disorganisation can be highly distressing for the patient and their loved ones, and for staff. The goal of any clinician is to ease discomfort, and this can commence before the underlying cause has been determined. In the case of Ms P, this involves reassuring her and developing rapport to improve trust (Hilgers, 2003). A common response is to reassure the patient that their concerns are not reality‐based, such as telling Ms P that people are not trying to kill her. While well intended, such a response can be perceived as dismissive, and efforts to ‘convince’ the patient depend on neurocognitive processes which are not functioning.

Acknowledging and validating Ms P's emotional reaction to the experience, while not affirming the reported experience itself, will be more reassuring for her. Reassurance can be grounded in the belief that while nobody is trying to kill Ms. P, it would be terrifying to believe they are. She is likely to be comforted knowing she is safe in an ICU that provides 24‐hour care and monitoring, and that the staff are doing everything they can to help her and keep her comfortable. All of this is true, helps to orient the patient to reality and does not require staff to affirm or argue against delusional beliefs, while addressing her subsequent emotional reaction.

When less acutely distressed, distraction is another effective technique. Asking Ms P about her son, work and hobbies helps to keep her attention away from distressing thoughts. This form of conversation is also familiar in an unfamiliar environment, which can further help her to settle and build rapport with staff. The more staff come to learn about Ms. P's personal history and situation, the easier it will be to reassure her.

Once Ms P's acute distress has been addressed and the situation is safe, it is important to establish the underlying cause(s) of the disorganisation. For Ms. P, there are many potential causes to consider, such as delirium secondary to infection or medications, a cerebrovascular event, an acute exacerbation of her schizoaffective disorder, a side‐effect to corticosteroids or a cognitive impairment. It is also possible for multiple causes to be present at the same time.

Establishing the correct diagnosis is essential, as the appropriate treatment for one condition (such as antipsychotics for schizoaffective disorder) can be ineffective, or even worsen, another condition (such as anticholinergics in delirium). Table 2 summarises some common features of various causes for a disorganised mental state in ICU, and a suggested initial approach to treatment.

TABLE 2.

Differentiating features of common causes of a disorganised mental state.

Feature	Dementia (Simpson, 2014)	Delirium (Meagher et al., 2014)	Psychosis (Heckers et al., 2013)	Catatonia (Tandon et al., 2013)	Dissociation (Spiegel et al., 2013)
Onset	Months to years	Hours to days	Onset over years but can relapse in days	Hours to days	Minutes
Course over the day	Stable or sundowning pattern	Fluctuating, sometimes with lucid periods	Stable or worsening	Fluctuating, sometimes with lucid periods	Can onset, resolve, onset again
Examination findings	Physical observations and examination often normal	Physical observations often deranged. Examination abnormalities can help identify underlying cause(s)	Physical observations and examination often normal	Often presents with abnormal neurological exam. Brisk reflexes, lead‐piping and cogwheeling can occur	Can present with decreased GCS but otherwise normal physical observations. Pupils can be dilated and can have repetitive and stereotyped movements
History of mental illness	Uncommon	Uncommon	Common	Uncommon	Common, especially history of trauma, PTSD or borderline personality
Behaviour	Can be normal, agitated or withdrawn	Can be agitated, disorganised or withdrawn	Can be agitated, disorganised or withdrawn	Can be agitated, disorganised or withdrawn	Can be withdrawn, childlike, agitated or fearful
Attention	Often impaired	Usually impaired, can appear distracted or hypervigilant	Can be intact or impaired, can appear distracted, hypervigilant or perplexed	Often impaired	Usually impaired, can appear distracted or hypervigilant
Orientation	Often impaired	Usually impaired	Occasionally impaired	Usually impaired	May not be oriented. Can be re‐experiencing past trauma
Speech	Can be coherent, slowed or have word finding difficulty	Often incoherent, can be rapid or slowed	Usually coherent, can lose prosody	Can be sparse or slowed	Can be normal, child‐like or distressed
Sleep	Usually normal	Can have day‐night reversal or disrupted sleep	Can be normal or unsettled	Can be disrupted	Usually normal, can have nightmares
Thoughts	Often impoverished, sometimes systematised delusions	Tend to be poorly organised, can be delusional	Can be organised or disorganised, with systematised or non‐systematised delusions	Tends to be disorganised or impoverished	Tends to be disorganised, often themes of perceived threats, which can be related to past traumas
Perceptions	Primarily visual hallucinations or misidentification	Hallucinations, can involve any of the senses	Primarily auditory hallucinations	Can experience visual or auditory hallucinations	Primarily visual and auditory hallucinations
Treatment	Primarily environmental and psychosocial, reassurance by staff. Can stabilise to baseline but seldom resolves	Primarily identifying and treating underlying cause(s), reassurance by staff. Tends to resolve Medications can worsen condition, especially anticholinergics	Antipsychotic medications, reassurance by staff. Can resolve or stabilise to baseline	Often responds rapidly to Benzodiazepines, e.g. Lorazepam 1 mg	Low stimulus environment, staff reassurance, sensory grounding techniques PRN medications to reduce anxiety, e.g. benzodiazepines, olanzapine or quetiapine

Often one or more causes cannot be definitively excluded before treatment needs to commence. Given the diversity of the differential causes, a systematic approach to diagnosis and management is advised (Douglas & Josephson, 2011), with collaborative input often involving general medicine, neurology and/or psychiatry as indicated by the presentation and salient differentials.

6. SUPPORTING STAFF EMOTIONS AND WELLBEING

Patients living with mental illness are subject to strong and often rapidly fluctuating emotions which they may struggle to control. The physiological changes and medications associated with critical illness can compound these difficulties. It is natural for staff to experience a strong response to another's expression of emotion, particularly when it seems incongruent with the circumstances. Frustration, anger, hopelessness, anxiety and fear are common responses when faced with an emotionally dysregulated patient.

Sometimes strong feelings, mirroring the patient's, arise through empathy, particularly when the patient has similar characteristics or experiences to the staff member or their loved ones. Emotions can also arise in response to the patient and may differ from the patient's feelings. Staff may judge the ways patients live their lives and experience disgust or anger. Such feelings can be complicated by guilt about having such negative thoughts and feelings about a patient, as it feels incongruent to their role and identity as a healthcare provider. This is particularly common in presentations like Mr F. Combined with myriad other stressors within the critical care workplace, these feelings can contribute to longstanding moral distress in individual staff members, and low morale across a team (Carnevale, 2020; Herschkopf, 2021).

While normal, emotional responses to patients need to be managed to maintain effective clinical judgement and wellbeing. On the individual level, staff can mitigate the impact of reactive emotions through several steps (Meier et al., 2001) such as recognising and naming the feelings, and accepting that such feelings are normal and common. Breathing or grounding exercises (Silvestro & Ellyn Vohnoutka, 2021; Kanchibhotla et al., 2021) can also be used. Then reflecting on the emotion, and how it arose. On an interpersonal and service level, promoting open communication among staff members about their emotions in both formal and informal settings can help both in terms of emotional validation, but also in treatment planning for the patient. While formal structured processes at a unit level can be established, often staff find it helpful to also have informal conversations with trusted colleagues.

Recognition of the burden involved in providing care in the context of frequent verbal and physical aggression, and potential for it to contribute to moral distress, burnout and staff absenteeism/turnover (Vincent‐Höper et al., 2020), is critical to best outcomes. The service should provide opportunities for formal debrief for staff exposed to aggression and enable access to psychological support as indicated.

Managing a patient experiencing cognitive disorganisation like Ms P can be challenging physically and emotionally for staff in a very different way to managing Mr F; some staff may be more interested or have greater aptitude than others in providing care to this cohort. This ‘natural selection’ can contribute to staff being allocated to (or not) to care for disorganised patients, potentially increasing the burden on some and disrupting morale.

Effective debrief involves a thorough review of the event and management strategies and providing a safe place for staff to share their feelings to ensure staff and organisation alike can optimise their approach. The service should also ensure that care where aggression is anticipated is shared judiciously among ICU staff and not made the sole responsibility of a small number of staff who have demonstrated a specific interest/ability in aggression management (Elpern et al., 2005).

7. CONCLUSION

Mental illness is common in society, and people with mental illness are at increased risk of admission to critical care settings. Critical illness is inherently stressful, and all patients use various strategies to cope. Many of the needs of those with mental illnesses are the same as other patients, though managed and expressed differently. The mental illness or trauma history is not always known. However, by attentively addressing patients' underlying needs in a trauma‐informed way that demonstrates respect and maximises autonomy, staff can reduce patients' distress and any disruptive behaviours while empowering them to focus on recovery.

The case scenarios and subsequent discussion presented in this paper aims to provide staff with pragmatic and applied guidance in managing critically ill patients with mental illness, and the challenging behaviours which can emerge in this setting. Several themes emerge across both scenarios, including the importance of anticipating and preparing for difficult situations. Being aware of what is not known, such as a history of trauma, and the importance of seeking collateral and guidance from people who know the patient well, helps to tailor management. Clear communication both among staff and between staff, patients and family can deescalate a wide range of situations. Staff awareness of their own emotional reactions can help both in terms of how this influences their approach to a given situation, and to support one another after providing care in a challenging situation.

While these cases and the subsequent discussion were developed in consultation with ICU staff, and is intended to emphasise areas identified as key priorities, these scenarios are not mutually exclusive, and are not a comprehensive representation of the interplay between mental illness and critical illness. Nor do they explore all the challenging behaviours which can emerge. As such, the advice provided in this paper cannot be applied uniformly. Rather, this paper is intended to provide an initial foundation that critical care staff can draw upon and develop further. Ultimately, these concepts and suggested responses will be drawn on as needed, as staff tailor their approach to the specific patient and their circumstances. We also suggest seeking support from your local psychiatric service when required.

8. RELEVANCE TO CLINICAL PRACTICE

This paper arose in response to a need identified by the authors during their respective clinical practices and while conducting research with people with mental illness and clinicians working in the critical care environment.

It was identified that a skills gap in the management of comorbid mental illness among patients enduring a critical illness was resulting in both suboptimal care for this patient population, and contributing to distress among critical care staff. This paper addresses this unmet need by providing practical advice to critical care clinicians about how to conceptualise and manage scenarios commonly seen in critical care settings in a way that is sustainable for their own wellbeing, and draws on the diverse perspectives of the authorship, including psychiatry, intensive care medicine, nursing and allied health.

The authors hope that the advice set forth in this paper will improve the quality of care and overall outcomes of patients living with mental illness who become critically unwell and supports staff in providing this care in a sustainable way.

AUTHOR CONTRIBUTIONS

All listed authors have contributed to the manuscript substantially, agreed to the order in which the author names appear and agreed to the final submitted version. Contributions are as follows. DF: Conceptualisation of design, review of literature, drafting and evaluation of manuscript. SP: Conceptualisation of design, review of literature, revising and evaluation of manuscript. TB: Conceptualisation of design, review of literature, drafting and evaluation of manuscript. KB: Conceptualisation of design, evaluation of manuscript. JK: Conceptualisation of design, review of literature, revising and evaluation of manuscript. DS: Conceptualisation of design, review of literature, drafting and evaluation of manuscript. OT: Conceptualisation of design, review of literature, drafting and evaluation of manuscript.

FUNDING INFORMATION

No dedicated funding was received for this study. DF is supported in part by a Clinician Research Fellowship awarded by Metro North Hospital and Health Service. OT's contribution was supported by ‘The Common Good’, The Prince Charles Hospital Foundation and The Queensland Technologies Futures Fund. The contributions of other authors was enabled by in kind support of their employing organisations.

CONFLICT OF INTEREST STATEMENT

The authors declare they have no conflicts of interest.

ETHICS STATEMENT

This paper was the result of desktop research only and therefore ethical review was not required.

Flaws, D. , Patterson, S. , Bagshaw, T. , Boon, K. , Kenardy, J. , Sellers, D. , & Tronstad, O. (2023). Caring for critically ill patients with a mental illness: A discursive paper providing an overview and case exploration of the delivery of intensive care to people with psychiatric comorbidity. Nursing Open, 10, 7106–7117. 10.1002/nop2.1935

DATA AVAILABILITY STATEMENT

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.