Abstract
Background
Admission to a Neuroscience Intensive Care Unit (Neuro-ICU) is sudden and often traumatic for both patients and their informal caregivers. No prior studies have assessed prospectively risk and resiliency factors for chronic posttraumatic symptoms, as well as the potential interdependence between patients and caregivers symptoms over time.
Purpose
To analyze the impact of baseline resiliency factors on symptoms of posttraumatic stress (PTS) longitudinally in dyads of patients admitted to the Neuroscience Intensive Care Unit (Neuro-ICU) and their primary family caregivers.
Method
We recruited dyads (M=108) of patients admitted to the Neuro-ICU (total N = 102) and their family caregivers (total N = 103). Dyads completed self-report assessments of PTS, and resiliency factors (mindfulness and coping) at baseline in the Neuro-ICU. PTS was measured again at 3- and 6-month follow-up.
Results
Clinically significant PTS symptoms were high at baseline in both patients (20%) and caregivers (16%), and remained high through 6 months (25% in patients;14% in caregivers). Actor-partner interdependence modeling demonstrated that severity of PTS symptoms was predictive of PTS symptoms at subsequent time points (ps<0.001). High baseline mindfulness and coping predicted less severe PTS symptoms in patients and caregivers (ps<0.001) at all time points. Own degree of PTS symptoms at 3 months predicted worse PTS symptoms in one’s partner at 6 months, for both patients and caregivers (p=0.02).
Conclusions
Findings highlight the need to prioritize assessment and treatment of PTS in Neuro-ICU patients and their informal caregivers through a dyadic approach.
Keywords: Neuroscience ICU, posttraumatic stress, mindfulness, coping, actor-partner interdependence model, informal caregiver
Introduction
Admission to the Neuroscience Intensive Care Unit (Neuro-ICU) is usually sudden and almost always traumatic for both patients and their informal caregivers (family and friends who provide emotional and instrumental care; 1). Unsurprisingly, approximately 21% of patients and 17% of caregivers develop clinically significant symptoms of post-traumatic stress (PTS) during the patient’s hospitalization (2,3). Prospective studies have identified high rates of chronic PTS in medical-surgical ICU patients (13–44%; 4,5), and Neuro-ICU caregivers (16–22%; 3,6). PTS has a profound public health impact due to its persistent course (5), negative effects on patients’ physical recovery (7–9), and significant risk for morbidity and mortality in both patients and caregivers (9–11).
Resiliency, or successful adaptation in the face of adversity or trauma (12), has positive associations with health outcomes (13). Here, we conceptualize resiliency in terms of two modifiable factors, mindfulness and coping. Mindfulness, the ability to remain present and defer judgment in the face of adversity (14), has been associated with positive physical and mental health outcomes (15), including lower PTS symptoms in a cross-sectional dyadic study of patients admitted to the Neuro-ICU and their family caregivers (2). Coping, the arsenal of cognitive, behavioral or emotional skills that an individual can rely on to manage stress, is also associated with improved physical and mental health outcomes (16). In Neuro-ICU populations, poor coping has been cross-sectionally associated with higher emotional distress in patients and their caregivers (2), while greater use of problem-focused coping skills points to better adjustment and quality of life (17–20).
Prior research on emotional functioning among Neuro-ICU populations has been limited by cross-sectional design or a focus on just the caregiver. However, consistent with the dyadic framework (21,22), patient and caregiver psychosocial factors are interdependent and must be studied together longitudinally in order to fully understand the pattern of emotional distress in this population. One such dyadic prospective study has shown that among general ICU populations, PTS symptoms in one individual negatively impact their partner’s mental health-related quality of life (23). In Neuro-ICU populations, a dyadic cross-sectional study has shown that depressive symptoms during hospitalization are interdependent between patients and caregivers, and one dyad member’s mindfulness is associated with fewer depressive symptoms both within him/herself as well as in his/her partner (2). However, no prior studies have prospectively assessed the long-term trajectory of PTS symptoms, the potentially protective role of resiliency factors, and the role of the dyad in the psychosocial recovery of Neuro-ICU patients and their family caregivers.
We aim to explore the relationship between resiliency factors and PTS in dyads of patients admitted to the Neuro-ICU and their caregivers. First, we estimate rates of clinically significant PTS in dyads during hospitalization and at 3- and 6-month follow-up. Then, we examine the relationship of patients’ and caregivers’ resiliency factors of mindfulness and coping at baseline (i.e., during hospitalization) with their own and their partners’ PTS at baseline and at 3 and 6 months. We first hypothesize that for both patients and caregivers, one’s own baseline PTS symptoms and resilience will be associated with his/her own chronic PTS symptoms (i.e., symptoms at 3- and 6-months). Second, we hypothesize that for both patients and caregivers, one’s own PTS symptoms and resilience factors at baseline will be associated with own partner’s baseline and chronic PTS symptoms. Findings may inform the development of novel interventions to prevent chronic PTS in dyads of survivors and their caregivers who play a critical role in the recovery process.
Materials and Methods
Sample and Design
This longitudinal prospective cohort study took place at a large tertiary medical center from 2015 to 2016. All study procedures were approved by the local institutional review board. The full recruitment and enrollment protocol was described previously (2). Inclusion criteria for patients were: 1) age 18 years or older; 2) English fluency and literacy; and 3) hospitalization to the Neuro-ICU. Patients were excluded if they were cognitively unable to provide informed consent; displayed aphasia or cognitive impairment that prohibited completion of study measures; had permanent cognitive impairment or anticipated death; or did not have an informal caregiver. Patients with transient aphasia or mild confusion were considered appropriate to participate. All patients were cleared for participation by the medical team. Inclusion criteria for caregivers were: 1) age 18 years or older; 2) English fluency and literacy; 3) identification as a primary informal caregiver of an eligible patient. Informed consent was obtained from all individuals participating in the study.
Dyads who provided written consent completed self-report measures, including demographics and psychosocial questionnaires, at the time of enrollment. Dyads were contacted via email 3 and 6 months after discharge to complete assessments via the secure online data capture software REDCap (24).
Measurement
PTS
PTS symptoms were measured with the Posttraumatic Checklist-Specific Stressors (PCL-S; 25). Seventeen items are scored using a Likert scale ranging from 1 (“not at all”) to 5 (“extremely”). Total scores are calculated by summing all items (range 17–85). Higher scores indicate more severe PTS. We calculated clinically significant levels of PTS symptoms to serve as diagnostic estimates of PTSD using dichotomized PCL-S score, with scores ≥44 representing clinically significant symptoms (25). This cutoff was chosen based on recommendations from the National Center for PTSD (26), and has shown high sensitivity and specificity for the diagnosis of PTSD in psychometric studies (25). Cutoff scores were used instead of the full criteria from The Diagnostic and Statistical Manual-IV-TR (DSM; 26) due to limitations imposed by the multiple imputation method (see Statistical Analysis). Rates of clinically significant PTS using this cutoff are similar to those previously published using DSM criteria (2,3). PTS symptoms were reported at baseline, 3- and 6-month follow-ups.
Mindfulness
Cognitive Affective Mindfulness Scale-Revised (CAMS-R) measured the extent to which individuals apply general concepts of mindfulness (28). Twelve items are scored on a Likert scale ranging from 1 (“rarely/not at all”) to 4 (“almost always”). Total scores are calculated by summing the 12 items (range 12–48). Higher scores reflect greater levels of mindfulness. Mindfulness was reported at baseline.
Coping
Coping skills were measured using the Measure of Current Status - Part A (29). Thirteen items assess relaxation, assertiveness, coping confidence, and awareness of tension. Items are scored on a five-point Likert scale from 0 (“I cannot do this at all”) to 4 (“I can do this extremely well”). A total comprehensive coping score is the sum of all items (range 0–52). Higher scores suggest better coping skills. Coping was reported at baseline.
Statistical Analysis
Participant characteristics were summarized with relevant measures of central tendency (e.g., proportion, mean). Univariate relationships between patient and caregiver variables were tested using Pearson r, chi-square, and paired sample t tests, as appropriate. Two-tailed tests with an α-level of 0.05 were used to determine statistical significance. Effect size for bivariate correlations was categorized as small, medium, or large based on Pearson r values of 0.10, 0.30, and 0.50 (30).
In order to take the assumption interdependence between patients and caregivers in a dyad into account, we used Actor-Partner Interdependence Modeling (APIM, (31) to test our hypotheses (32,33). Interdependence is a term that refers to the inherent interrelatedness of variables in two people with some type of interpersonal relationship (in this case, patients and their family caregivers, who have some type of interpersonal history; (31). In analysis, this can be understood an non-independence between the two subjects – that is, due to a shared context, patients and caregivers scores are more related to each other than they are to scores of individuals in other dyads, and so they cannot be treated as two independent individuals (31). Standard regression analysis cannot account for this relatedness; APIM accounts for interdependence by treating the dyad rather than the individual as the unit of analysis. The result is description of the unique impact of an individual’s predictor variables on their own outcome (actor effects), and the cross-over effects of an individual’s predictor variables on their partner’s outcome, controlling for the contribution of the partner’s own factors.
APIM has been used to describe psychosocial factors in medical ICU populations (23) and cross-sectionally in Neuro-ICU populations (2). For this study, our multilevel model tests the impact of patients’ and caregivers’ PTS symptoms and resilience factors on their own future PTS symptoms (actor effects). Then, the impact of PTS symptoms and resilience factors on their partner’s PTS symptoms (partner effects) is tested while controlling for actor effects. We tested whether patient and caregiver actor effects significantly differed using a contrast test. Contrast tests with p>0.05 indicate that the actor effects are not significantly different for patients and caregivers, so a pooled effect is reported and interpreted. This process is repeated with partner effects.
In accordance with standards put forth by the Patient-Centered Outcomes Research Institute (33), we performed multiple imputations using fully conditional specification to account for uncompleted measures (34). All analyses, including the creation and analysis of 40 imputed datasets, were completed using SPSS Version 24 (35).
Results
Characteristics of patients and caregivers
114 patient-caregiver dyads were enrolled into our prospective cohort (Figure 1). Of these, 102 patients (89%) and 103 caregivers (90%) completed questionnaires and were included in analyses. This represents 96 complete patient-caregiver dyads, 6 patients without caregivers, and 7 caregivers without patients from a total of 108 different dyads. Of the patient partners of the 7 caregivers without patients, 2 did not complete measures due to patient death after enrollment but before baseline completion, 2 declined to participate after enrollment because of the length of the measures, 1 withdrew consent for participation, and 2 did not complete measures for unknown reasons. Of the caregiver partners of the 6 patients without caregivers, 3 withdrew from participation due to the length of the measures, and 3 did not complete measures for unknown reasons. All patients were enrolled within 2 weeks of Neuro-ICU admission, with the majority of patients enrolled within 1–2 days of admission. Across all participants, rates of completion of at least one measure were 94% at baseline, 77% at 3 months, and 71% at 6 months.
Figure 1.
Flow diagram describing enrollment and exclusions prior to analysis.
Demographic and medical characteristics are presented in Table 1. Overall, patients and caregivers were middle aged and predominantly white and highly educated. There was a higher proportion of females to males and married/cohabitating individuals among the sample of caregivers compared to patients (p<0.05). The most common neurological diagnoses were cerebrovascular diseases, including ischemic and hemorrhagic stroke, and intracranial tumors or other structural lesions. The majority of caregivers were the patient’s partner.
Table 1.
Demographic and medical characteristics of neurosciences intensive care unit patients and their informal caregivers.
| Patients (N=102) | Caregivers (N=103) | |
|---|---|---|
| Demographic/Medical Characteristic | n (%) | n (%) |
| Age (M[SD]) | 52 (17) | 53 (14) |
| Gender (female) | 48 (47)* | 65 (63)* |
| Race/ethnicity (non-Hispanic white) | 83 (81) | 92 (89) |
| Education (some college or more) | 76 (75) | 82 (80) |
| Marital status (married/cohabitating) | 70 (69)* | 86 (83)* |
| Employment (full-time) | 52 (51) | 60 (58) |
| Diagnosis, n (%) | ||
| Cerebrovascular | ||
| Stroke/Hemorrhage | 38 (35) | |
| Brain aneurysm (unruptured) | 3 (3) | |
| Other vascular | 2 (2) | |
| Structural | ||
| Tumor | 32 (30) | |
| Lesion/brain mass | 9 (8) | |
| Other | 5 (5) | |
| Traumatic brain injury | 4 (4) | |
| Seizure | 11 (10) | |
| Other />1 diagnosis | 4 (4) | |
| Not reported | ||
| Discharge status, n (%) | ||
| Discharge to home | 69 (64) | |
| Discharge to rehabilitation facility | 31 (29) | |
| Deceased at discharge | 1 (1) | |
| Not reported | 7 (6) | |
| Relationship to patient, n (%) | ||
| Spouse/partner | 71 (66) | |
| Parent | 14 (13) | |
| Child | 14 (13) | |
| Sibling | 5 (5) | |
| Not reported | 4 (4) | |
p<0.05
Psychological factors in patients and caregivers
We summarize patient and caregiver psychological factors in Table 2. Mindfulness and coping scores did not differ between dyad members (t(1377)=−0.79 and t(653)=−0.27, respectively, ps>0.43). At baseline, rates of clinically significant PTS were high (20% in patients, 16% in caregivers). Rates (χ2(1)=0.27, p=0.28) and mean symptom levels (t(1809)=1.71, p=0.09) were similar in patients and caregivers. Rates of clinically significant PTS symptoms remained high at 6 month, with 25% of patients and 14% of caregivers reporting clinically significant symptoms. Patients were more likely than caregivers to report clinically significant PTS symptoms at 3- (p=0.04) and 6-month (p<0.001) follow-up.
Table 2.
Psychological characteristics of neurosciences intensive care unit patients and their informal caregivers.
| Patients | Caregivers | ||||
|---|---|---|---|---|---|
| Variable | M | SD | M | SD | |
| Continuous scores | |||||
| Mindfulness | 36.09 | 7.37 | 36.81 | 7.43 | |
| Coping | 31.90 | 11.77 | 32.42 | 11.21 | |
| Posttraumatic stress symptoms | |||||
| Baseline | 31.23 | 14.95 | 28.22 | 12.74 | |
| 3 months | 30.91 | 16.61 | 29.28 | 12.94 | |
| 6 months | 30.86 | 16.33 | 28.11 | 12.75 | |
| % with clinically significant symptoms | n (%) | n (%) | |||
| Baseline | 21 (20) | 16 (16) | |||
| 3 months | 23 (23) | 17 (17)* | |||
| 6 months | 26 (25) | 14 (14)** | |||
p<0.05
p<0.001
Married/cohabitating individuals showed lower PTS symptom severity (M = 28.08) than non-married/cohabitating individuals (M = 35.9; t(6064) = 2.88, p = 0.004) at baseline. Those with at least some college education had lower PTS symptom severity (3mo M = 28.64; 6m M = 27.87) compared to those with no college education (3mo M = 34.83, t(1852) = 2.08, p = 0.04; 6m M = 35.02, t(1547) = 2.39, p = 0.02). PTS symptom severity did not differ by any other demographic characteristics, including sex, age, race (white vs non-white), ethnicity (Hispanic vs. non-Hispanic), and history of mental health diagnosis, or by medical diagnosis.
Effects of Own Psychological Factors on Own PTS Symptoms (Actor Effects)
Bivariate analysis
For both patients and caregivers, own PTS symptoms were positively correlated with symptoms at subsequent time points (ps<0.001); higher baseline mindfulness and coping were associated with lower PTS symptoms at all time points (ps<0.05). Effect sizes were medium to large in both patients and caregivers. (Table 3).
Table 3.
Bivariate correlations of psychological resilience factors and posttraumatic stress symptoms for neurosciences intensive care unit patients and their informal caregivers.
| Variable | Patient baseline PTS symptoms | Patient 3mo PTS symptoms | Patient 6mo PTS symptoms | Patient Mindfulness | Patient Coping | Caregiver baseline PTS symptoms | Caregiver 3mo PTS symptoms | Caregiver 6mo PTS symptoms | Caregiver Mindfulness | Caregiver Coping |
|---|---|---|---|---|---|---|---|---|---|---|
| Patient baseline PTS symptoms | 1 | |||||||||
| Patient 3mo PTS symptoms | .545** | 1 | ||||||||
| Patient 6mo PTS symptoms | .485** | .768** | 1 | |||||||
| Patient Mindfulness | −.387** | −.331* | −.246 | 1 | ||||||
| Patient Coping | −.620** | −.433** | −.409** | .625** | 1 | |||||
| Caregiver baseline PTS symptoms | .197 | .148 | .193 | −.038 | −.084 | 1 | ||||
| Caregiver 3mo PTS symptoms | .197 | .248 | .341** | −.043 | −.129 | .632** | 1 | |||
| Caregiver 6mo PTS symptoms |
.212 | .250 | .327** | −.033 | −.153 | .608** | .834** | 1 | ||
| Caregiver Mindfulness | −.113 | −.113 | −.154 | .100 | .135 | −.531** | −.374** | −.329** | 1 | |
| Caregiver Coping | −.158 | −.122 | −.151 | .091 | .106 | −.665** | −.449** | −.416** | .796** | 1 |
p<0.05
p<0.001
Dyadic analysis
For both patients and caregivers, higher baseline mindfulness and coping were associated with lower PTS symptoms at baseline and at 3- and 6-month follow up (ps<0.001; Table 4). Higher PTS symptoms significantly predicted higher PTS at subsequent time points (ps<0.001). Contrast estimates demonstrated that all actor effects were equivalent for patients and caregivers (contrast effect ps>0.05).
Table 4.
Actor-Partner Interdependence Models on effect of own psychological resilience factors and posttraumatic stress symptoms on own and partner’s symptoms.
| Actor effects | Partner effects | |||||
|---|---|---|---|---|---|---|
| β | 95% Cl | p | β | 95% Cl | p | |
| Prior PTS Symptoms | ||||||
| Baseline → 3-month | 0.575 | 0.462 – 0.688 | <0.001 | 0.052 | −0.068 – 0.171 | 0.34 |
| 3-month → 6-month | 0.768 | 0.683 – 0.842 | <0.001 | 0.119 | 0.026 – 0.212 | 0.02 |
| Mindfulness | ||||||
| Baseline PTS symptoms | −0.643 | −0.754 – −0.532 | <0.001 | −0.056 | −0.167 – 0.054 | 0.30 |
| 3-month PTS symptoms | −0.438 | −0.565 – −0.311 | <0.001 | −0.076 | −0.203 – 0.051 | 0.21 |
| 6-month PTS symptoms | −0.411 | −0.537 – −0.285 | <0.001 | −0.103 | −0.228 – 0.021 | 0.12 |
| Coping | ||||||
| Baseline PTS symptoms | −0.449 | −0.578 – −0.321 | <0.001 | −0.034 | −0.130 – −0.130 | 0.61 |
| 3-month PTS symptoms | −0.347 | −0.479 – −0.215 | <0.001 | −0.045 | −0.178 – 0.087 | 0.45 |
| 6-month PTS symptoms | −0.294 | −0.425 – −0.162 | <0.001 | −0.068 | −0.201 – 0.064 | 0.32 |
Effects of Own Psychological Factors on Partner’s PTS Symptoms (Partner Effects)
Bivariate analysis
Patient and caregiver symptoms were positively correlated only at 6-month follow-up with a small effect size (p<0.001). Baseline mindfulness and coping were not correlated with one’s partner’s PTS symptoms. (Table 3).
Dyadic analysis
For both patients and caregivers, higher PTS symptoms at 3 month significantly predicted their partner’s higher PTS symptoms at 6 month (p=0.02; Table 4). This partner effect was equivalent from patients’ PTS symptoms to caregivers’ symptoms and vice versa from caregivers’ PTS symptoms to patients’ symptoms. No other partner effects were significant. Contrast estimates demonstrated that all partner effects were equivalent for patients and caregivers (contrast effect ps>0.05).
Discussion
We found that 20% of patients hospitalized in the Neuro-ICU and 16% of their informal caregivers endorse clinically significant levels of PTS symptoms. This is consistent with recent work in critical care populations (2,3,36). However, ours is the first study to assess the rates and trajectory of PTS in both patients and caregivers (e.g., dyads) within one study. Long-term, 1 in 4 patients and 1 in 6 caregivers reported clinically significant PTS at 6-month follow-up. The stable trajectory of high rates of clinically significant PTS we observed is consistent with a prior study of caregivers in the Neuro-ICU (3).
Higher levels of PTS symptoms were associated with more severe PTS symptoms at the subsequent time point (i.e., baseline to 3 months, 3 months to 6 months) in both patients and caregivers. This is in line with previous work in this population (3), which showed that higher caregivers’ PTS symptoms at baseline predicted higher future symptoms. Since PTS is characterized by intrusive thoughts and memories, untreated symptoms are likely to continue propagating. Therefore, identifying at-risk dyads and addressing symptoms early may decrease the risk of chronic PTS in this population.
For both patients and caregivers, higher levels of mindfulness and coping were associated with less severe PTS symptoms at baseline and at follow-up. This is consistent with cross-sectional reports showing that higher mindfulness is associated with lower PTS symptom severity (2). However, we are the first to show these relationships prospectively. Mindfulness skills have the potential to allow the dyad to identify and disengage from the recurring thoughts that drive PTS (2). Similarly, it has been theorized that the use of avoidant coping may maintain the intrusive thought patterns of PTS, so adaptive coping strategies may protect against the perpetuation of symptoms (37).
Dyadic modeling looks beyond how an individual’s resilience or distress can impact their psychiatric symptoms and reveals the cross-over effects these factors can have on one’s partner. In this population, we found that having more PTS symptoms at 3 months is associated with a higher degree of symptoms in one’s partner at 6 months. While the relative size of this partner effect is smaller than the actor effect over the same 3 month to 6 month time period (partner effect β=0.117 vs actor effect β=0.756), it indicates that an individual’s PTS symptoms at 6 months are still associated with their partner’s PTS symptoms after controlling for the variance explained by own PTS symptoms at 3 months and is therefore clinically meaningful. This was the same size for patients and caregivers (i.e. distress in either dyad member may influence his/her partner to the same degree). Clinically, this finding underscores the fact that the psychiatric symptoms of both patients and caregivers may play a role in outcomes, and that ignoring the symptoms of one member of the dyad ignores factors associated with the development of long-term PTS symptoms. Indeed, these findings fit within the larger context of literature showing that in general ICU dyads, PTS symptoms can contribute negatively to partners’ quality of life (23), and that long-term distress symptoms tend to align between dyad members in cancer populations (38). However, this is the first study demonstrating partner effects of psychiatric symptoms on a partner’s mental health outcome in a critical care setting. Partner effects were not present at baseline and 3-month follow-up. This pattern may stem from a shift in how dyads process the trauma of ICU hospitalization. Dyad members’ initial response to an acute stressor may be more individual, driven by personal resilience profiles and focus on the unique challenges that face the patient (e.g., physical recovery) and caregiver (e.g., balancing work with visiting the hospital). Later, once the dyad begins to return to their typical relationship dynamics, one dyad member’s chronic PTS may reinforce his/her partner’s intrusive thoughts and recurring memories of the dyad’s shared trauma.
APIM also allows for the examination of how effect patterns are similar or different between patients and caregivers. We found that all effects were the same for patients and caregivers. This suggests that the psychiatric symptoms of either dyad member can contribute equally to the mental health of the dyad as a whole. From a symptom prevention standpoint, this means that interventions that benefit patients would also benefit caregivers, and vice versa.
Taken together, these findings have two important clinical implications. First, since the presence of acute PTS symptoms predicts future PTS symptoms, and higher in-hospital mindfulness and coping are associated with lower PTS symptoms, early interventions to improve resiliency skills provide an important opportunity to prevent chronic symptoms in both patients and caregivers, and to optimize the physical recovery of patients. Second, the interdependence between patient and caregiver factors along with the similar pattern of actor and partner effects in both dyad members strongly supports developing dyadic resiliency interventions (e.g., patient and caregivers together), especially for dyads at risk for difficulties long-term, when PTS partner effects come into play.
One primary strength of this study is its prospective, longitudinal design, which allows for a better characterization of the trajectory of psychiatric symptoms and can aid in informing the development of future interventions. Additionally, our study achieved high participation rates, even at 6 month follow-up. This success can be attributed to our close work with Neuro-ICU nursing staff to gain participant trust, clear communication about the rationale and importance of the study with participants, and careful coordination of contact with participants to remind them about follow up and offer assistance in accessing and completing measures, if necessary (e.g., inviting participants to complete measures with a volunteer over the phone if they were uncomfortable with using the Internet).
This study has several limitations. For one, it relies on self-report measures, which may be biased, but offer the advantage of being practical and less burdensome for the neurocritical care population. However, even with this limitation of reporting bias, all 17 PCL-S items have been shown to correlate with clinician-administered PTSD screenings (25), minimizing additional bias of self-report measures over clinician diagnoses. Further, patients enrolled in this study were required to be cognitively able to participate in assessment, thus excluding those with severe cognitive impairments and the most seriously ill patients in the Neuro-ICU. Evidence on the relationship between illness severity and PTSD is mixed, with some studies demonstrating that those with more severe TBI report fever PTSD symptoms (39), possibly due to amnesia of the head trauma (40), and others suggesting no known relationship between illness severity and PTS symptoms in ICU populations (5), future studies should explore the role of resiliency factors among caregivers of these most severe patients to understand whether similar resiliency factors are beneficial. Additionally, while our study focuses particularly on modifiable psychosocial factors that can be addressed through an intervention, it is important to note that it does not account for a number of other factors that can impact the presence of PTS symptoms, including prior history of trauma, a prior PTSD diagnosis, amnesia to the traumatic event, presence of delirium, psychiatric co-morbidities, disfigurement, psychotropic medications administered. While we sought to understand the trajectory of PTS symptoms regardless of contributing factors, future work should incorporate these covariates in order to build a robust predictive model of PTS risk in this population. Finally, our sample was predominantly white and college-educated; future research should seek to include a more diverse population.
Our findings suggest a need to develop psychosocial interventions for patients admitted to the Neuro-ICU and their caregivers, to prevent chronic PTS. Though recent trials looking at early implementation of CBT-based stress-reduction techniques to prevent PTSD in ICU patients did not demonstrate a significant benefit (41), the intervention was based on a limited range of distress tolerance skills and was not designed as a dyadic intervention, which may have contributed to its negative findings. Interventions that draw from a wider psychotherapeutic arsenal, specifically emphasize mindfulness and coping skills, and that are designed for both patients and caregivers together may prove more effective. Given the high prevalence of chronic PTS and its impact of both long term patient and caregiver outcomes, our group is currently conducting a randomized clinical trial of a dyadic resilience skills intervention versus psychoeducational control aim at preventing chronic PTSD in Neuro-ICU patients and their caregivers.
Conclusion
In summary, findings presented here reveal the trajectories of PTS symptoms in Neuro-ICU patients and their caregivers, and underscore that clinically significant PTS is common and persistent in this population. Furthermore, there is crossover in chronic PTS symptoms between patients and caregivers, with higher long-term symptoms in each dyad member equally predicting more chronic psychiatric symptoms in their partner. Mindfulness and coping skills are protective against PTS symptoms in patients and caregivers. Findings suggest that it is critical to assess PTS symptoms in both patients and caregivers during the hospitalization. When possible, patients and caregivers should be considered together as a unit. Future work should consider potential resilience skill interventions in order to prevent the development of chronic PTS symptoms in Neuro-ICU patients and their family caregivers.
Acknowledgements
We thank Tara Tehan, Mary Guanci, Danielle Salgueiro, and the dedicated team of Neuro-ICU nurses for their help with recruitment.
Funding
This work was supported by the National Institute of Nursing Research [grant 1R21NR017979] and support from the Henry and Allison McCance Center for Brain Health.
Footnotes
Disclosures
Dr. Rosand reports serving as a consultant for Boehringer Ingelheim, Pfizer and New Beta Innovation.
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