Psychiatry's role in the prevention of post-intensive care mental health impairment: stakeholder survey

From the Intensive Care Unit to Recovery: Managing Post-intensive Care Syndrome in Critically Ill Patients

Post-intensive care syndrome (PICS) is the term used to describe the decline in the physical, cognitive, and/or mental condition of individuals who have been discharged from the intensive care unit (ICU). This complication could result in a significant reduction in quality of life, with some patients experiencing symptoms of prolonged weakness, depression, anxiety, and post-traumatic stress disorder (PTSD). Intensive care advancement over the years has resulted in an increase in ICU survival rates and a proportional increase in PICS, creating a need for more in-depth research into the prevention and management of the disease. Hence, this study aims to examine the present body of literature on PICS, encompassing its underlying physiological processes and elements that contribute to its development, methods for evaluating and diagnosing the condition, current treatment choices as well as potential new approaches, and the constraints in managing PICS and the necessity for further investigation. In this article, studies were compiled from several databases, including, but not limited to, Google Scholar, PubMed, and Cochrane Library. These studies were reviewed, and their data were used to highlight important aspects regarding the efficacy of current PICS screening tools, the optimization and limitations of both pharmacologic and non-pharmacologic treatment methods, and the feasibility and safety of emerging treatments and technologies. The major conclusions of this review were centered around the need for multidisciplinary management of PICS. From pharmacological management using analgesia to non-pharmacological management using early mobilization and exercise therapy, the effective treatment of PICS requires a multifaceted approach. Patient follow-up and its importance were touched upon, including strategies and policies to bolster proper follow-up, thereby increasing favorable outcomes. Lastly, the importance of family involvement and the increased need for research into this topic were highlighted.

Telepsychiatry readiness assessment at the Department of Psychiatry, Dr. Soeharto Heerdjan Hospital, Indonesia

Background: The Dr. Soeharto Heerdjan Hospital, Jakarta, Indonesia, has deployed telepsychiatry since May 2022 to ensure continuity of care for its psychiatric patients. This model of service has not functioned optimally, owing to obstacles, including the absence of a registration officer, no designated consultation room, scheduling issues and challenges for patients or their representatives in using the telepsychiatry application.

OBJECTIVE

This study aimed to assess telepsychiatry readiness at Dr. Soeharto Heerdjan Hospital.

METHOD

An observational survey was conducted in April-May 2022, with a sample of 40 members of the telepsychiatry workforce, using the Telehealth Readiness Assessment (TRA) tool. Five key domains of the TRA tool are associated with the successful implementation of telehealth, including core readiness, financial considerations, operations, staff engagement and patient readiness. This tool includes a questionnaire, scoring sheet, supporting guidance and additional resources. The overall readiness score is a weighted average of the concept scores included within each of the five domains.

RESULTS

Of 40 respondents, 72.5% were females and 42.5% were between 31 and 40 years. From the total of five domains of telepsychiatry readiness, the level of telepsychiatry readiness at Dr. Soeharto Heerdjan Hospital was 70.05% or a moderate level.

CONCLUSION

Aspects of readiness that need to be improved include providing a workforce for telepsychiatry patient registration; drug delivery; scheduling; designated consultation rooms; user-friendly telepsychiatry applications and electronic media for information on telepsychiatry services.

Suicide within 1 year of non-fatal overdose: Risk factors and risk reduction with medications for opioid use disorder

OBJECTIVE

Individuals with substance use disorders and overdoses have high risk of suicide death, but evidence is limited on the relationship between interventions following the initial overdose and subsequent suicide death.

METHODS

National Medicare data were used to identify Medicare disability beneficiaries (MDBs) with inpatient or emergency care for non-fatal opioid overdoses from 2008 to 2016. Data were linked with National Death Index (NDI) to obtain dates and causes of death for the sample. Cox proportional hazards models estimated the associations between exposure to interventions (mechanical ventilation, MOUD) and suicide death.

RESULTS

The sample (n = 81,654) had a suicide rate in the year following a non-fatal overdose of 566 per 100,000 person-years. Post-overdose MOUD was associated with an adjusted hazard ratio of 0.20 (95%CI: 0.05,0.85). Risk of suicide was elevated for those whose initial overdoses required mechanical ventilation as part of the treatment (aHR: 1.86, 95%CI:[1.48,2.34]).

CONCLUSIONS

The year following a non-fatal opioid overdose is a very high-risk period for suicide among MDBs. Those receiving MOUD had an 80% reduction in the hazards of suicide, while those whose overdose treatment involved mechanical ventilation had 86% higher hazards of death by suicide. Our findings highlight the importance of psychiatric intervention in this high-risk population. Efforts are needed to initiate and retain more patients in MOUD.

A randomised pilot feasibility study of eye movement desensitisation and reprocessing recent traumatic episode protocol, to improve psychological recovery following intensive care admission for COVID-19

Background

Approximately 50% of intensive care survivors experience persistent psychological symptoms. Eye-movement desensitisation and reprocessing (EMDR) is a widely recommended trauma-focussed psychological therapy, which has not been investigated systematically in a cohort of intensive care survivors: We therefore conducted a randomised pilot feasibility study of EMDR, using the Recent Traumatic Episode Protocol (R-TEP), to prevent psychological distress in intensive care survivors. Findings will determine whether it would be possible to conduct a fully-powered clinical effectiveness trial and inform trial design.

Method

We aimed to recruit 26 patients who had been admitted to intensive care for over 24 h with COVID-19 infection. Consenting participants were randomised (1:1) to receive either usual care plus remotely delivered EMDR R-TEP or usual care alone (controls). The primary outcome was feasibility. We also report factors related to safety and symptom changes in post-traumatic stress disorder, (PTSD) anxiety and depression.

Results

We approached 51 eligible patients, with 26 (51%) providing consent. Intervention adherence (sessions offered/sessions completed) was 83%, and 23/26 participants completed all study procedures. There were no attributable adverse events. Between baseline and 6-month follow-up, mean change in PTSD score was -8 (SD = 10.5) in the intervention group versus +0.75 (SD = 15.2) in controls (p = 0.126). There were no significant changes to anxiety or depression.

Conclusion

Remotely delivered EMDR R-TEP met pre-determined feasibility and safety objectives. Whilst we achieved group separation in PTSD symptom change, we have identified a number of protocol refinements that would improve the design of a fully powered, multi-centre randomised controlled trial, consistent with currently recommended rehabilitation clinical pathways.

Trial registration

ClinicalTrials.gov: NCT04455360.

Sepsis-Associated Delirium: A Narrative Review

Delirium is characterized by an acutely altered mental status accompanied by reductions in cognitive function and attention. Delirium in septic patients, termed sepsis-associated delirium (SAD), differs in several specific aspects from the other types of delirium that are typically encountered in intensive care units. Since sepsis and delirium are both closely associated with increased morbidity and mortality, it is important to not only prevent but also promptly diagnose and treat SAD. We herein reviewed the etiology, pathogenesis, risk factors, prevention, diagnosis, treatment, and prognosis of SAD, including coronavirus disease 2019 (COVID-19)-related delirium. Delirium by itself not only worsens long-term prognosis, but it is also regarded as an important factor affecting the outcome of post-intensive care syndrome. In COVID-19 patients, the difficulties associated with adequately implementing the ABCDEF bundle (Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials: Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; Family engagement/empowerment) and the need for social isolation are issues that require the development of conventional care for SAD.