SCCM Resource Library-Parental Symptoms of Anxiety and Depression Upon PICU Discharge and at 30-Day Follow-Up

Video Transcription

Hello, my name is Lynn Rosenberg and I am a combined internal medicine pediatrics resident at the University of Colorado.  I was once told by a mentor that I should say my thank yous at the beginning of my presentation while people are still paying attention instead of at the end.  So thank you to Yucheng and Linda for their stats expertise and a giant thank you to my mentor Hani Traub who has taught me how to be a better researcher and physician.  When we are in the pediatric ICU, our main focus is on our patients, the children. However, a growing body of evidence suggests that we should also be thinking about the  parents of children admitted to the ICU. As PICU mortality rates decreased over the last two decades, attention turned to improving long-term post-PICU morbidity.  Research shows that a PICU stay affects not just the child survivor, but also the larger family unit with effects most pronounced on parents.  There is ample research on the effects of being in the ICU with adult ICU patients. This 2012 consensus from SCCM highlighted the need for more attention on the aftermath  of an ICU stay on the patient with the term post-intensive care syndrome or PICS. They also described the effects on family members and coined the term PICS family.  In 2018, noticing the same constellation of symptoms in children, the pediatric community coined the term PICS-P.  Most recently, there has been increasing evidence regarding PICS-F within the pediatric community, or what we like to call PICS-PF or post-ICU syndrome in pediatric families.  One might argue this concept is even more important in pediatric survivors because a parent who isn't doing well will trickle down to the child.  Of all of the concepts affecting pediatric outcomes, we opted to focus on parental mental health.  Unfortunately, there is not the same wealth of information about families of patients in the PICU.  In recent years, the literature has just begun exploring the effects that an ICU stay can have on the family of a pediatric patient.  In 2004, Belufi et al. described similar numbers to the adult population, citing 32% of parents  of children admitted to the ICU met symptom criteria for acute stress disorder, with 21% meeting symptom criteria for PTSD.  In 2007, Bronner et al. described symptoms of PTSD in more than three-quarters of their cohort, with 15% of mothers and 9.3% of fathers actually meeting full diagnostic criteria  for PTSD. A recent review of literature by Nelson suggests that up to 84% of parents may have subclinical symptoms of PTSD, and up to 28% of children may be affected.  In 2020, Logan et al. investigated the rates of one, mental health diagnoses, two, outpatient  mental health visits, and three, prescriptions for antidepressants and anxiolytics among parents six months before and six months after their child's PICU admission, using each  parent as their own control. The study found that of the greater than 95,000 parents identified, 9.5% received a  new mental health diagnosis in the six months after their child's PICU hospitalization, which represented a 110% increase from pre-PICU rates.  A smaller proportion of parents were given new prescriptions for antidepressants and anxiolytics in the six months after their child's PICU hospitalization.  Mothers were twice as likely to receive a new mental health diagnosis and be taking a new medication than fathers in the post-PICU period.  The parental diagnosis of acute stress disorder or post-traumatic stress disorder increased by 87% from the pre-PICU to the post-PICU period.  So we've learned a lot about struggling parents, but we're left with a knowledge gap. Who are these parents that aren't doing well? Who should we be targeting for interventions?  Are there predictors that may help us utilize our limited resources wisely? While the existing data is compelling, it is scarce and largely out of date.  In our study, we hoped to provide a more current representation of the scope of the problem and address some of the limitations raised by previous research.  We aimed to better understand predictors of anxiety, depression, and PTSD in parents after  PICU discharge, to quantify anxiety and depression on discharge, and to explore associations between characteristics of hospital stay and parental symptoms prior to discharge.  We hypothesized that severity of illness upon admission and experiencing delirium during hospital stay would be associated with increased rates of PICS family after discharge.  In addition, we believed that many parents would be exhibiting symptoms prior to discharge and that these parents would be the ones to fare worse one month after discharge.  Finally, we predicted that prior mental health diagnosis would have increased rates of PICS family.  This prospective observational study enrolled parents of PICU survivors. Within 48 hours prior to discharge, each parent completed the Hospital Anxiety and Depression  Scale, or HADS, a brief, validated questionnaire with 14 questions that indicates risk for depression and anxiety.  Of note, our minimum length of stay was greater than or equal to two nights. At 30 days after discharge, participants were contacted to complete the HADS again, in addition  to another brief questionnaire called the Impact of Events Scale, or IES. This is a brief, validated questionnaire consisting of 22 questions that indicate risk for PTSD.  We extracted medical information about the child's PICU stay from the electronic medical record, including but not limited to demographics, diagnosis, reason for admission, severity  of illness, laboratory values, length of stay, and delirium status. Our primary outcome was a positive screen for either anxiety, depression, or PTSD more  than 30 days after PICU stay. Our secondary outcome was predictors of a positive screen upon discharge.  Chi-square Fisher's exact tests were used to describe bivariate associations between predictors of interest and a positive psychological screen.  All variables that achieved a p-value of less than 0.1 were built into a multivariable model. 126 parents enrolled and completed both assessments.  These were their baseline demographics. Note that 77% of participants were mothers, and nearly 67% had a college degree or higher.  Our surveyed population was largely white and non-Hispanic. The majority, roughly 75%, were married. Notably, fewer than 13% had a prior mental health diagnosis.  The reason for PICU admission was primarily respiratory at 44%, followed by neurologic at 33%, and cardiac at 14%.  Prior to discharge, 50% screened positive for anxiety and or depression. This was independently associated with higher education and a pre-PICU diagnosis of a mental  health disorder. At follow-up post-discharge, 44% of parents screened positive for anxiety, 32%, depression, 13%, and or PTSD symptoms, 27%.  In multivariable analysis, the only independent predictor of mental health symptoms more than 30 days after PICU stay was a positive HADS prior to PICU discharge.  The adjusted odds ratio was 5.9, with a p-value of less than 0.001.  So, we believe we can predict who needs the most attention by using a simple screen. This tells us who to target with interventions after hospitalization, such as post-ICU clinics.  In addition, our prior-to-discharge analysis indicates 50% of parents are in distress while still with us. This begs the question, how can we make the ICU stay easier on them?  How can we improve care of parents? We have implemented parental support groups in the Cornell PICU, and this may allow us  to help social workers and chaplains prioritize their visits. Overall, this pilot study demonstrates that screening for anxiety and depression at PICU  discharge may be a way to identify parents at higher risk for longer-term psychiatric symptoms.  By targeting at-risk parents, future interventional studies can be designed to test the effectiveness  of early intervention programs at decreasing the burden of post-ICU syndrome on families after a PICU stay.  Thank you so much for taking the time to listen to my talk, and let me know if you have any questions!

Video Summary

In this video, Lynn Rosenberg, a combined internal medicine pediatrics resident, discusses the importance of considering the mental health of parents whose children are admitted to the pediatric ICU. The concept of Post-Intensive Care Syndrome (PICS) and Post-ICU Syndrome in Pediatric Families (PICS-PF) is introduced to highlight the impact that an ICU stay can have on both the child survivor and their parents. Previous studies have shown high rates of mental health issues such as anxiety, depression, and PTSD among parents of pediatric ICU patients. Rosenberg's study aims to explore predictors of these symptoms and suggests that screening for anxiety and depression at PICU discharge may help identify parents in need of support and intervention programs to reduce the burden of post-ICU syndrome on families.

Asset Subtitle

Administration, Behavioral Health and Well Being, 2022

Asset Caption

INTRODUCTION: As PICU mortality rates decreased over the last two decades, attention turned to improving long-term post-PICU morbidity. Research shows that a PICU stay affects not just the child-survivor, but also the larger family unit, with effects most pronounced on parents. We hypothesized that many parents would already exhibit symptoms of anxiety/depression prior to PICU discharge, and this would predict future mental health symptoms. METHODS: This prospective observational study enrolled parents of PICU survivors. Each parent completed the Hospital Anxiety and Depression Scale (HADS) as a screen for symptoms of anxiety and depression within 48-hours prior to the child’s discharge. At 30+day follow-up, parents completed an additional HADS, as well as an Impact of Events Scale (IES) to screen for symptoms of post-traumatic stress disorder (PTSD). Demographic data were collected from parents and clinical data extracted from the child’s medical record. Chi-square/Fisher’s exact tests were used to describe bivariate associations between predictors of interest and a positive psychological screen; all variables that achieved p < 0.1 were built into a multivariable model. Primary outcome was a positive screen for either anxiety, depression, or PTSD more than 30-days after PICU stay. RESULTS: 126 parents enrolled and completed both assessments. 50% screened positive for anxiety and/or depression upon discharge; this was independently associated with higher education (aOR 2.6, p=0.046 for parents with college degrees), and with a pre-PICU diagnosis of a mental health disorder (aOR 4.4, p=0.035). At follow-up, 56 parents (44%) screened positive for anxiety, depression, and/or PTSD symptoms (32% anxiety, 13% depression, 27% PTSD). In multivariable analysis, the only independent predictor of mental health symptoms more than 30 days after PICU stay was a positive HADS prior to PICU discharge (aOR 5.9, p < 0.001). CONCLUSIONS: This pilot study demonstrates that screening for anxiety and depression at PICU discharge may be a way to identify parents at higher risk for longer-term psychiatric symptoms. By targeting at-risk parents, future interventional studies can be designed to test the effectiveness of early intervention programs at decreasing the burden of post-intensive care syndrome on families after PICU stay.

Meta Tag

Content Type Presentation

Knowledge Area Administration

Knowledge Area Behavioral Health and Well Being

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Patient and Family Support

Tag Pediatric Intensive Care Unit PICU

Tag Depression

Year 2022

Keywords

pediatric ICU

mental health

PICS-PF

anxiety

depression

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