Mental Health Care During and After the ICU

Critical illness is associated with high rates of significant, negative psychologic and psychiatric sequelae that are associated commonly with post-intensive care syndrome (PICS).¹ PICS refers to the cognitive, physical, and psychologic impairments that many patients experience after an ICU admission.¹ The primary mental health impairments that critical illness survivors experience are long-term cognitive impairments, depression (approximately 30% of survivors), anxiety (up to approximately 70%), and posttraumatic stress disorder (PTSD) (10%-50%).^{1 , 2} Delirium during critical illness, sometimes referred to as “ICU psychosis,” is also common and has been associated with PTSD.²

Despite these data, patients often do not receive mental health care during or after their ICU admission in our country. Few US hospitals have comprehensive psychologic or psychiatric care available either during or after an ICU admission. Europe seems to be doing better in terms of prioritizing the mental health needs of this population. They have pioneered research in reporting psychologic/psychiatric outcomes and treatments for ICU patients.^{1 , 2} We hear growing concerns about a potential mental health crisis due to coronavirus disease 2019 (COVID-19), which includes the fact that difficulties in coping with this illness and associated stressors (ie, isolation, financial stressors) could lead potentially to higher suicide rates, drug overdoses, trauma, and mood disorders. These concerns are likely to be more prominent in the ICU population, given both their more severe physical illness and the higher rate of mental health concerns already noted in this population,^{1 , 2} In response, we must be prepared for the possibility that patients and survivors who are admitted to the ICU because of COVID-19 may require intensified mental health care interventions to address PICS.

Even prior to the COVID-19 pandemic, our country had an unmet, yet important, need to improve our provision of mental health care for critically ill patients and ICU survivors. Filling this gap in mental health care could protect against some of the negative outcomes of critical illness. During this era of COVID-19, the need to address these negative psychologic outcomes will likely become increasingly important. We urge public health experts, hospital administrators, and clinicians to prioritize actions that are developed to address these mental health care needs both during and after critical illness.

To start, ICU clinicians regularly should screen for delirium. In pediatrics, for example, some hospitals have trained their bedside nurses to use a delirium screener each and every shift.³ Hospitals can devote resources to train staff, particularly nurses, to better recognize and manage delirium, including not only screening and assessment, but also implementation of nonpharmacologic interventions (eg, improving sleep/wake cycles and orienting patients). Early mobilization/rehabilitation is another initiative that more and more ICUs are implementing to improve the long-term outcomes for patients in the ICU and should be considered.⁴ Preventative measures to mitigate PICS increasingly are being implemented in ICUs. One such tool is the ABCDEF bundle,⁴ an evidence-based guide for multidisciplinary critical care coordination, put forth by the Society of Critical Care Medicine. Adjustments to the ABCDEF bundle due to COVID-19 restrictions and challenges (socially isolated patients) have been proposed recently to lessen the burden of delirium among patients with COVID-19.⁵

Hospital administrators should consider allocating resources to creating or increasing the use of consultation/liaison services for both psychiatric and psychologic care. Ideally, ICUs will have either part-time or embedded psychologists and psychiatrists for critical care patients, both during and after the ICU admissions. Likewise, there is a need to develop and implement systems to screen for anxiety, depression, PTSD/trauma, and cognitive disturbances surrounding ICU admission in an effort to both treat and prevent these outcomes.

Hospitals and clinicians must also consider post-ICU follow-up care. Hospitals can consider developing and creating post-ICU care clinics to better monitor and manage PICS.¹ Europe has led the way in establishing these clinics, but they are still scarce in the United States.¹ As a broader public health issue, we also need to train our mental health care workforce in these unique ICU issues and outcomes. Although a select few mental health care clinicians are specialized in rehabilitation psychology or critical illness, most are not. Amid this global pandemic we are facing and the unprecedented surge in ICU admissions, it is likely that mental health clinicians may be providing services to patients or families who have been impacted negatively by critical care during this era of COVID-19. As such, more mental health care clinicians should familiarize themselves with the psychologic outcomes of critical illness and receive additional training and education in this realm and/or mentorship.

The evidence is growing and convincing that critical care is associated with substantial mental health needs and cognitive impairments that negatively impact the overall quality of life of patients. Public health experts, hospitals, and clinicians need to prioritize mental health care both during and after ICU admissions. Now more than ever, mental health care for ICU patients and survivors is critical, particularly in light of the global pandemic that we are facing today. As a nation and global community, we have turned to public health experts for guidance in increasing the capacity for patients with COVID-19 by increasing the availability of ICU beds and associated medical needs. But we cannot forget about the equally important psychologic outcomes of our critical care patients. We have an obligation to also increase capacity to meet the mental health care needs of ICU survivors, to minimize issues related to PICS, and to consider the provision of mental health care and screening as a psychosocial standard of care for critically ill patients.