Depression as an independent risk factor for mortality in critically ill patients

The Effects of Mukbang Watching on Enteral Feeding Intolerance Among Critically Ill Patients: Study Protocol for a Randomized Controlled Trail

Purpose

With an estimated prevalence of 38%, enteral feeding intolerance (EFI) is common in critically ill patients receiving enteral nutrition (EN), and is associated with higher mortality and longer duration of mechanical ventilation. Various methods have been reported to decrease the incidence of EFI during EN, such as post-pyloric feeding, continuous EN delivery, abdominal massage, and probiotic supplementation. However, several studies reported conflicting results. Inappropriate interventions may cause gastrointestinal (GI) injury. This study aims to design a protocol based on Mukbang videos, which are widely watched online, to detect their effects on the incidence of EFI, nutritional status, incidence of infectious complications, and activities of daily living.

Patients and Methods

We will conduct a three-arm, parallel-design, randomized controlled trial that will be implemented in 273 patients from intensive care units. Participants will be randomized into one of the three intervention arms (1:1:1), which will be performed by a research assistant. Participants were allocated to three groups: (a) watching mukbang video, (b) watching a cooking show, and (c) watching a non-food content video. Prior to EN initiation, each participant will watch a ten-minute mukbang video, cookery show, or non-food content video.

Conclusion

Mukbang videos show food, expressions of mukbangers and eating sounds. If it effectively reduces the incidence of EFI, leads to greater nutritional status, lower incidence of infectious complications, and a higher level of independence among patients compared with watching cooking videos or non-food content videos, it has broad dissemination potential as a non-invasive, easily assessing, and using method.

Association Between Preexisting Mental Health Disorders and Adverse Outcomes in Adult Intensive Care Patients: A Data Linkage Study

OBJECTIVES

Mental illness is known to adversely affect the physical health of patients in primary and acute care settings; however, its impact on critically ill patients is less well studied. This study aimed to determine the prevalence, characteristics, and outcomes of patients admitted to the ICU with a preexisting mental health disorder.

DESIGN

A multicenter, retrospective cohort study using linked data from electronic ICU clinical progress notes and the Australia and New Zealand Intensive Care Society Adult Patient Database.

SETTING/PATIENTS

All patients admitted to eight Australian adult ICUs in the calendar year 2019. Readmissions within the same hospitalization were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Natural language processing techniques were used to classify preexisting mental health disorders in participants based on clinician documentation in electronic ICU clinical progress notes. Sixteen thousand two hundred twenty-eight patients (58% male) were included in the study, of which 5,044 (31.1%) had a documented preexisting mental health disorder. Affective disorders were the most common subtype occurring in 2,633 patients (16.2%), followed by anxiety disorders, occurring in 1,611 patients (9.9%). Mixed-effects regression modeling found patients with a preexisting mental health disorder stayed in ICU 13% longer than other patients (β-coefficient, 0.12; 95% CI, 0.10-0.15) and were more likely to experience invasive ventilation (odds ratio, 1.42; 95% CI, 1.30-1.56). Severity of illness and ICU mortality rates were similar in both groups.

CONCLUSIONS

Patients with preexisting mental health disorders form a significant subgroup within the ICU. The presence of a preexisting mental health disorder is associated with greater ICU length of stay and higher rates of invasive ventilation, suggesting these patients may have a different clinical trajectory to patients with no mental health history. Further research is needed to better understand the reasons for these adverse outcomes and to develop interventions to better support these patients during and after ICU admission.

Elderly Patients and Management in Intensive Care Units (ICU): Clinical Challenges

There is a growing population of older adults requiring admission to the intensive care unit (ICU). This population outpaces the ability of clinicians with geriatric training to assist in their management. Specific training and education for intensivists in the care of older patients is valuable to help understand and inform clinical care, as physiologic changes of aging affect each organ system. This review highlights some of these aging processes and discusses clinical implications in the vulnerable older population. Other considerations when caring for these older patients in the ICU include functional outcomes and morbidity, as opposed to merely a focus on mortality. An overall holistic approach incorporating physiology of aging, applying current evidence, and including the patient and their family in care should be used when caring for older adults in the ICU.

Potential Role of the Antidepressants Fluoxetine and Fluvoxamine in the Treatment of COVID-19

Mapping non-canonical cellular pathways affected by approved medications can accelerate drug repurposing efforts, which are crucial in situations with a global impact such as the COVID-19 pandemic. Fluoxetine and fluvoxamine are well-established and widely-used antidepressive agents that act as serotonin reuptake inhibitors (SSRI-s). Interestingly, these drugs have been reported earlier to act as lysosomotropic agents, inhibitors of acid sphingomyelinase in the lysosomes, and as ligands of sigma-1 receptors, mechanisms that might be used to fight severe outcomes of COVID-19. In certain cases, these drugs were administered for selected COVID-19 patients because of their antidepressive effects, while in other cases, clinical studies were performed to assess the effect of these drugs on treating COVID-19 patients. Clinical studies produced promising data that encourage the further investigation of fluoxetine and fluvoxamine regarding their use in COVID-19. In this review, we summarize experimental data and the results of the performed clinical studies. We also provide an overview of previous knowledge on the tissue distribution of these drugs and by integrating this information with the published experimental results, we highlight the real opportunity of using these drugs in our fight against COVID-19.

Prior benzodiazepine use and mortality among adult patients with sepsis: A retrospective population-based cohort study in South Korea

OBJECTIVES

This study investigated whether long-term benzodiazepine use is associated with increased 90-day mortality among patients with sepsis.

METHODS

A retrospective population-based cohort study based on health records obtained from the National Health Insurance Service database in South Korea was conducted. All adult patients (≥18 years) admitted to the hospital with a primary diagnosis of sepsis or septic shock during 2010-2018 were included in the study. Sepsis and septic shock were diagnosed based on the International Classification of Diseases (10th revision: A40, A41 and R65.2). Benzodiazepine users were defined as individuals who were prescribed regular benzodiazepine continuously for over 6 months before admission.

RESULTS

A total of 251 837 patients with sepsis were included in this study, 16 686 of which (6.6%) were benzodiazepine users, and 235 151 (93.4%) were non-users. After propensity score (PS) matching, 33 370 patients (16 685 in both groups) were ultimately included. Moreover, following PS matching, the 90-day mortality among benzodiazepine users and non-users was 60.9% (10 167) and 41.4% (6916), respectively. Cox regression analysis further revealed the hazard ratio (HR) for 90-day mortality in benzodiazepine users to be 1.75, compared with non-users [95% confidence interval (CI): 1.70-1.81; P < .001]. Sensitivity analyses showed that, compared with non-users, HRs for 90-day mortality in benzodiazepine users without and with other psychiatric illnesses were 1.43 (95% CI: 1.38-1.49; P < .001) and 1.89 (95% CI: 1.84-1.94; P < .001), respectively.

CONCLUSION

Long-term benzodiazepine use is associated with increased 90-day mortality among adult patients with sepsis compared with non-users. This association was more evident in benzodiazepine users with other psychiatric diseases, such as depression or anxiety disorder.

Physical, Mental, and Cognitive Health Status of ICU Survivors Before ICU Admission: A Cohort Study

OBJECTIVES

Although patient's health status before ICU admission is the most important predictor for long-term outcomes, it is often not taken into account, potentially overestimating the attributable effects of critical illness. Studies that did assess the pre-ICU health status often included specific patient groups or assessed one specific health domain. Our aim was to explore patient's physical, mental, and cognitive functioning, as well as their quality of life before ICU admission.

DESIGN

Baseline data were used from the longitudinal prospective MONITOR-IC cohort study.

SETTING

ICUs of four Dutch hospitals.

PATIENTS

Adult ICU survivors (n = 2,467) admitted between July 2016 and December 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients, or their proxy, rated their level of frailty (Clinical Frailty Scale), fatigue (Checklist Individual Strength-8), anxiety and depression (Hospital Anxiety and Depression Scale), cognitive functioning (Cognitive Failure Questionnaire-14), and quality of life (Short Form-36) before ICU admission. Unplanned patients rated their pre-ICU health status retrospectively after ICU admission. Before ICU admission, 13% of all patients was frail, 65% suffered from fatigue, 28% and 26% from symptoms of anxiety and depression, respectively, and 6% from cognitive problems. Unplanned patients were significantly more frail and depressed. Patients with a poor pre-ICU health status were more often likely to be female, older, lower educated, divorced or widowed, living in a healthcare facility, and suffering from a chronic condition.

CONCLUSIONS

In an era with increasing attention for health problems after ICU admission, the results of this study indicate that a part of the ICU survivors already experience serious impairments in their physical, mental, and cognitive functioning before ICU admission. Substantial differences were seen between patient subgroups. These findings underline the importance of accounting for pre-ICU health status when studying long-term outcomes.

Use of music to enhance sleep and psychological outcomes in critically ill patients: a protocol for a systematic review and meta-analysis

INTRODUCTION

Music listening is used as a non-pharmacological intervention in various populations with positive results; however, evidence for its effect on sleep and psychological outcomes in critically ill patients remains unclear. It is essential to understand the impact of music listening for critically ill patients to optimise care and minimise the risk for harm. We will assess whether music listening improves sleep and psychological outcomes in critically ill patients.

METHODS AND ANALYSIS

We will systematically search scientific databases for relevant studies, including PubMed, Embase, CINAHL, PsycINFO, Web of Science, Scopus, ProQuest, the Cochrane Central Register of Controlled Trials, China Biological Medicine Database, China National Knowledge Infrastructure Library, Wan fang databases, VIP Database for Chinese Technical Periodicals and the Chinese Clinical Trial Registry. Databases will be searched for articles published from inception to 10 June 2020. Music therapy journals and reference lists in some articles will be hand-searched. Grey literature will also be searched. We will include randomised and quasi-randomised controlled trials that used music listening to improve sleep and psychological outcomes in critically ill patients. The primary outcomes will be sleep-related outcomes, and secondary outcomes will be anxiety and depression scores and physiological outcomes. Two reviewers will independently verify study eligibility and methodological quality; disagreements will be resolved by a third reviewer or through discussion. The risk of bias will be independently determined using the Cochrane Risk of Bias Tool. The Consolidated Standards of Reporting Trials checklist will be used to examine the quality of included papers. Data will be extracted from eligible studies by two researchers. RevMan V.5.3 will be used for meta-analysis.

ETHICS AND DISSEMINATION

This work will review existing trial data and will not introduce new patient data or interventions; therefore, ethics committee approval is not required. We will disseminate this protocol in a related peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019147202.

Pre-existing mental health disorders in patients admitted to the intensive care unit: A systematic review and meta-analysis of prevalence

AIMS

To determine the reported prevalence rate of pre-existing mental health disorders in patients admitted to adult ICUs and identify the most commonly occurring types of these disorders.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Five electronic databases were searched from 1 January 2000 -15 April 2020. Google Scholar was used to perform forwards citation searching.

METHODS

This review was conducted in line with the PRISMA guidelines and protocol registered with PROSPERO CRD42020181818. Meta-analyses were performed using the quality effects model to calculate weighted pooled prevalence estimates and heterogeneity was tested using the I² statistic.

RESULTS

Seven articles were included in the final review and meta-analysis (143,179 participants). Identified prevalence rates varied considerably, ranging from 6.2-28.0%, reflecting variation in each study's clinical context, as well as different patient selection and identification methodologies. The pooled prevalence rate of all pre-existing mental health disorders was 19.4% (95% CI 8.9-32.6%). Depression was the most common subtype, accounting for an estimated 60.5% (95% CI 54.4-66.5%) of identified mental health disorders. All analyses showed significant heterogeneity with I²  > 95%.

CONCLUSION

Approximately 19% of adult ICU patients have a history of a mental health disorder, most commonly depression. Further research is needed to improve the accuracy of this estimate as well as determine the best identification method.

IMPACT

This study has demonstrated that patients with pre-existing mental health disorders, particularly depression, constitute a significant subgroup in ICU. Given that the presence of a pre-existing mental health disorder appears to confer an increased mortality risk following ICU discharge, clinicians need to be made aware of this group of patients to provide additional support. Further research is needed to more accurately quantify this vulnerable group and establish methods to enable clinicians to readily identify and refer these patients for appropriate follow-up treatment.

Determinants of Depressive Symptoms at 1 Year Following ICU Discharge in Survivors of ≥ 7 Days of Mechanical Ventilation: Results From the RECOVER Program, a Secondary Analysis of a Prospective Multicenter Cohort Study

BACKGROUND

Moderate to severe depressive symptoms occur in up to one-third of patients at 1 year following ICU discharge, negatively affecting patient outcomes. This study evaluated patient and caregiver factors associated with the development of these symptoms.

METHODS

This study used the Rehabilitation and Recovery in Patients after Critical Illness and Their Family Caregivers (RECOVER) Program (Phase 1) cohort of 391 patients from 10 medical/surgical university-affiliated ICUs across Canada. We determined the association between patient depressive symptoms (captured by using the Beck Depression Inventory II [BDI-II]), patient characteristics (age, sex, socioeconomic status, Charlson score, and ICU length of stay [LOS]), functional independence measure (FIM) motor subscale score, and caregiver characteristics (Caregiver Assistance Scale and Center for Epidemiologic Studies-Depression Scale) by using linear mixed models at time points 3, 6, and 12 months.

RESULTS

BDI-II data were available for 246 patients. Median age at ICU admission was 56 years (interquartile range, 45-65 years), 143 (58%) were male, and median ICU LOS was 19 days (interquartile range, 13-32 days). During the 12-month follow-up, 67 of 246 (27.2%) patients had a BDI-II score ≥ 20, indicating moderate to severe depressive symptoms. Mixed models showed worse depressive symptoms in patients with lower FIM motor subscale scores (1.1 BDI-II points per 10 FIM points), lower income status (by 3.7 BDI-II points; P = .007), and incomplete secondary education (by 3.8 BDI-II points; P = .009); a curvilinear relation with age (P = .001) was also reported, with highest BDI-II at ages 45 to 50 years. No associations were found between patient BDI-II and comorbidities (P = .92), sex (P = .25), ICU LOS (P = .51), or caregiver variables (Caregiver Assistance Scale [P = .28] and Center for Epidemiologic Studies Depression Scale [P = .74]).

CONCLUSIONS

Increased functional dependence, lower income, and lower education are associated with increased severity of post-ICU depressive symptoms, whereas age has a curvilinear relation with symptom severity. Knowledge of risk factors may inform surveillance and targeted mental health follow-up. Early mobilization and rehabilitation aiming to improve function may serve to modify mood disorders.

Depression as Measured by PHQ-9 Versus Clinical Diagnosis as an Independent Predictor of Long-Term Mortality in a Prospective Cohort of Medical Inpatients

BACKGROUND

Depression has been associated with higher rates of mortality in medical patients. The aim of the study was to evaluate the impact of depression in medical inpatients on the rate of mortality during a prolonged follow-up period.

METHOD

This is a prospective follow-up study of a cohort of medical inpatients assessed during 1997-1998 in medical and surgical units at a tertiary university hospital in Spain and followed-up for a period ranging between 16.5 and 18 years. Eight hundred three patients were included; 420 (52.3%) were male, and the mean (SD) age was 41.7 (13.8) years. Main outcome was death for any cause during follow-up. The original full Patient Health Questionnaire (PHQ) was administered at baseline as self-report from which the PHQ-9 was derived. Depressive disorders were assessed using PHQ-9 and a structured clinical interview (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition).

RESULTS

Depressive disorders as defined by PHQ-9 were detected in 206 patients (25.7%), 122 (15.2%) of them fulfilling criteria for major depression. During follow-up, 152 patients (18.9%) died. A PHQ score indicating the presence of major depressive disorder predicted increased mortality (hazard ratio [HR], 2.44; 95% CI, 1.39-4.29), even after adjusting for important demographic and clinical variables. Similarly, the PHQ-9 score as a continuous measure of depression severity predicted increased mortality (HR, 1.06; 95% CI, 1.02-1.10). Results were similar for clinical interview diagnoses of major depression (HR, 2.07; 95% CI, 1.04-4.09).

CONCLUSIONS

Medical inpatients with a PHQ depressive disorder had a nearly 2-fold higher risk of long-term mortality, even after adjustment for several confounders. Depression severity as represented by the PHQ-9 score was also a risk factor.

[Depressive, anxiety and posttraumatic stress disorders as long-term sequelae of intensive care treatment]

Modern intensive care medicine has led to increased survival rates even after severe life-threatening medical conditions. In self-critical and multidimensional outcome research, however, it must be considered that beyond survival rates treatment on intensive care units (ICU) can also be associated with high long-term rates of depressive, anxiety and posttraumatic stress disorders. Significant correlations with increased somatic morbidity and mortality, persisting cognitive impairments and significant deficits in health-related quality of life must also be taken into consideration. Empirical analysis of the risk factors reveals that a history of premorbid depression, sociodemographic and socioeconomic variables, age, female sex, personality traits, the underlying pathophysiological condition requiring ICU treatment, mode of sedation and analgesia, life support measures, such as mechanical ventilation, manifold traumatic experiences and memories during the stay in the ICU are all of particular pathogenetic importance. In order to reduce principally modifiable risk factors several strategies are illustrated, including well-reflected intensive care sedation and analgesia, special prophylactic medication regarding the major risk of traumatic memories and posttraumatic stress disorder (PTSD), psychological and psychotherapeutic interventions in states of increased acute stress symptoms and aids for personal memories and reorientation.

Feelings of Loneliness and Living Alone as Predictors of Mortality in the Elderly: The PAQUID Study

OBJECTIVE

The aim of this work was to determine the predictive value of 2 indicators of psychosocial isolation (living alone and feelings of loneliness) in elderly people.

METHODS

Twenty-two-year follow-up cohort study of 3,620 community-dwelling elderly people enrolled in the PAQUID study, a French prospective population-based study. Participants completed a battery of tests including the Centre for Epidemiological Studies Depression scale and a question regarding living conditions (living alone or living with another person). Feelings of loneliness were measured using the Item 14 ("I felt lonely") of the French version of the Centre for Epidemiological Studies Depression scale. Mortality rate was measured over a 22-year follow-up period after the baseline assessment visit. The risk of death was estimated using Cox proportional hazards models, adjusted for age, sex, and educational level.

RESULTS

At baseline, 1,535 participants (42.4%) were living alone, and a total of 498 persons (13.8%) reported frequent feelings of loneliness (FoL). The participants reporting FoL were more frequently women (82.7%), and the mean (SD) age was 76.5 (7.1) years. At the end of the follow-up, 3,116 deaths (86.6%) occurred. Living alone and FoL were both independent predictors of death after 22 years of follow-up (hazard ratio, 1.14; 95% confidence of interval, 1.05-1.23; p = .001) and (hazard ratio, 1.20; 95% confidence of interval, 1.08-1.33; p = .001), respectively. No significant interaction was found between feelings of loneliness and living alone, suggesting that a joint exposure has only an additive effect (β = 0.08; relative risk = (0.85; 1.40); p = .48). The associations of both measures persisted after adjusting for health status. Adjusting for depression attenuated the predictive value of FoL.

CONCLUSIONS

Living alone and FoL were independently associated with higher risk of mortality. These factors may be useful as readily available psychosocial measures to identify vulnerability in community-dwelling older adults.