The novel virus SARS-CoV-2, as it was initially identified, was believed to have originated in Wuhan, China, and the Chinese authorities reported it to the World Health Organization (WHO) in December 2019 (Scripps Research Institute, 2020). Its presence was detected after a cluster of patients presented with pneumonia. The disease caused by this organism was officially designated COVID-19 by the WHO on 11 February 2020. According to Guarner (2020), SARS-CoV-2 has infected more people than both its predecessors-SARS-CoV and MERS-CoV. The most recent data from the WHO (2020) show that there have been 28 million confirmed cases of COVID-19 worldwide (WHO, 2020), and it can be inferred that this disease will inevitable affect all humanity in some form.
In the first two decades of the 21st century alone, the world has witnessed three coronaviruses emerge and cause outbreaks. The first was severe acute respiratory syndrome (SARS), which originated in Guangdong, China, followed in 2014 by the Middle East respiratory syndrome coronavirus (MERS-CoV), originating in Jeddah, Saudi Arabia (Oboho et al, 2015). Guarner (2020) reported that SARS was primarily transmitted person to person through droplets, while symptoms of MERS-CoV were nonspecific, although many who contracted it experienced severe acute respiratory distress.
Since it is a challenge to find scientifically sound information on the future impact of the COVID-19 pandemic, health professionals need to build on the foundation of knowledge already at their disposal to predict and prepare for some of the long-term impacts of the disease on survivors, especially with regard to mental health. The increasing infection rates, death rates and daily changes to life on both micro and macro levels have overwhelmed public health, medical and research communities. Even now, as the pandemic continues, it has been suggested that planning for its aftermath is vital (Stam et al, 2020).
Aftershocks affecting the cohort of post-intensive care survivors can include a multitude of complications. This article will focus on the impact that COVID-19 has had on the mental health of these patients. It would be naïve to believe that a patient who has experienced ventilation, sedation and long intensive care unit (ICU) inpatient admissions would be discharged with no further implications on their wellbeing. It is, therefore, hoped that this article will stand as a guide for health professionals on how to best support and prepare vulnerable patients.
Post-intensive care syndrome and mental health
The number of survivors from ICU admissions is growing (Kondakci et al, 2018). Prescott and Girard (2020) found that 80% of patients hospitalised with COVID-19 and 60% who were admitted to ICU following a COVID-19 diagnosis survived. Although patients have survived ICU admissions worldwide, the nature of COVID-19 and its impact on normal life may amplify post-intensive care syndrome (PICS). The frequency of PICS is on the rise, and it is recognised as a public health burden, with over one-quarter of patients reported to suffer from this condition, although the exact statistics are unknown (Rawal et al, 2017). PICS can be defined as the disability that remains after a patient survives critical illness and compromises the physical and cognitive function and psychological health of ICU survivors (Needham et al, 2012).
A landmark longitudinal study by Herridge et al (2003) evaluated 109 survivors of the acute respiratory distress syndrome SARS. This was documented at 3-, 6- and 12-month intervals. There were many elements to the investigation, including physical examination and pulmonary function, but perhaps most significantly, quality of life (QoL). Through interviews, researchers found that the results for physical and pulmonary function improved dramatically, but QoL did not improve in parallel. A more recent study in Italy reported that 44.1% of patients observed reported a worsened QoL following an ICU admission with a COVID-19 diagnosis (Carfi et al, 2020). The prevalence of post-traumatic stress disorder (PTSD), anxiety and depression at 6 months after discharge following the SARS and MERS outbreaks was 39%, 30% and 33%, respectively (Ahmed et al, 2020). Therefore, historical evidence suggests that the impact of COVID-19 would be similar, if not worse given its pandemic status.
Gosselin et al (2018) found that patients who were intubated or mechanically ventilated had a 14–51% chance of developing PTSD. Furthermore, Rawal et al (2017) found that some survivors of ICU developed psychiatric disabilities after discharge, including depression, anxiety and PTSD. The risk of developing these ranged from 1% to 62%.
PTSD is a complex disorder that can affect the QoL of the patient, their families and even the community in which they live (Taheri et al, 2019). Modern practice suggests that, because of the high risk ICU survivors developing PTSD, these individuals should undergo an evaluation for the disorder (Rawal et al, 2016). Hosseini et al (2020) found that 13% of patients discharged from ICU experienced PTSD.
Pharmacologically induced problems
For several years now, sedation strategies within ICU have moved towards daily wake-up calls, less sedation and even no sedation, in some cases (Strøm et al, 2010). Strøm et al (2010) found that non-sedation of critically ill patients who are mechanically ventilated is associated with an increased number of days without ventilation. Tembo (2018) found that daily sedation interruption (DSI) was associated with better outcomes, such as decreased hospital length of stay (LOS) and reduced incidence of ventilator-acquired pneumonia. Because of the pandemic, routine ICU practices, such as prioritising sedation, early mobility and daily breathing trials, may no longer be followed. As a result, patients with severe COVID-19 may be given more sedation, have limited early mobility and have fewer daily breathing trials than patients with sepsis previously, all of which would result in poorer outcomes for the patients recovery (Prescott and Girard, 2020).
Perhaps most surprising is the use of chloroquine and hydroxychloroquine as treatment for COVID-19. Although this treatment remains in the early phases of research and human experiments continue, health professionals should be vigilant of the known side effects of these drugs, despite them being uncommon. These include a phenomenon called ‘psychosis after chloroquine’, a term first coined in the 1950s and well known among health professionals (Hamm and Rosenthal, 2020). This is particularly applicable for those patients with pre-existing mental health conditions, as interactions can occur between their routine medication and the chloroquines. Hallucinations, depression, confusion, suicidal ideation and psychosis are just some of the wide spectrum of neuropsychiatric manifestations known to be caused by chloroquine and hydroxychloroquine (Jurrlink, 2020). These can occur at any age, during acute or chronic use and with or without a history of mental illness (Kwak et al, 2015).
Mental health effects of lockdown and isolation
During the pandemic, governments worldwide have closed their borders and instigated a lockdown protocol (Carroll et al, 2020). Due to stringent no-visitation policies placed within ICU departments, many family members reported feelings of anxiety, guilt and frustration at not being able to see loved ones (Wang et al, 2020). Although these policies were essential in reducing the risk of infection between health professionals and family members, they were primarily instated for the safety of the ICU patients. During this time, staff became creative, using phone calls, video conferencing and voice messaging, all of which are worthy efforts but cannot replace human contact (Wakam et al, 2020).
It appears that COVID-19 may exacerbate the psychological dysfunction experienced by the family members of those who received ICU care, including PTSD (Montauk and Kuhl, 2020). Families are being denied the opportunity to witness care being provided to their loved ones, and this separation has a domino effect on the family and patient. These fears and worries also transfer to patients within ICU, with many worried about being alone in hospital (45.6%) and dying before saying farewell to family and friends (44.5%) (Schellekens and Van Der Lee, 2020). For many families, the lack of closure will be the most challenging part of the COVID-19 pandemic. Health professionals must aim to ensure open discussion regarding the trauma family members are facing and acknowledge the need for post-ICU services (Montauk and Kuhl, 2020).
Disturbing memories
As anxiety, depression, sleep disturbance and PTSD are prevalent amongst ICU survivors, there are several risk factors to be aware of (Train et al, 2019). These include, but are not limited to, episodes of pain, anxiety and dreams. ICU-acquired delirium occurs in up to 80% of patients admitted to ICU, and statistics show that this can be a risk factor for the development of delusional memories after critical illness (Girard et al, 2008). In a qualitative study, Lars et al (2006) interviewed critically ill patients 3 and 12 months following discharge from ICU. Patients recollections of factual and fictional events showed little variation between the first and final interviews, with reports of disturbed memory and cognitive disruption (Lars et al, 2006).
Limited evidence suggests a strong link between treatment in ICU and the memories following discharge. The development of delusional memories and amnesia following ICU admission is a combination of deep sedation and corticoids (Aitken et al, 2016). Frightening and traumatic memories occur in 25–35% of patients in the early post-discharge period, and this must be acknowledged in discharge planning and aftercare treatment (Train et al, 2019).
Many studies have documented delusional memories related to being an ICU inpatient, the impact of which should not be overlooked (Tembo et al, 2017). Although there is limited evidence for COVID-19 survivors specifically, evidence from survivors of SARS and MERS can be relied on for guidance; these individuals reported increased depression, anxiety and PTSD (Hamm and Rosenthal, 2020; Kaseda and Levine, 2020). With these historical facts and the ongoing global pandemic, it must be acknowledged that COVID-19 survivors may be more susceptible to these conditions.
Post-discharge trajectory
Physical recovery from COVID-19 may be protracted, and even the psychological ramifications of the disease be long term, and mental health recovery may need time. Patients and their families should be alerted to the potential psychological impact of critical illness and its treatment, both verbally and in writing at the point of discharge (Greenhalgh et al, 2020).
Comprehensive discharge management and support plans are crucial for patients with COVID-19 post-ICU treatment and are optimal when developed by the multidisciplinary team, the patient and their relatives. Plans should be detailed and follow a bio-psycho-pharmaco-social (BPPS) approach (Clark and Clarke, 2014; Hext et al, 2020) in order to take into account the impact of these domains on each other, the patient's environment and the overall impact of all aspects on the patient. Diagnostic overshadowing, whereby signs and symptoms are attributed to a primary diagnosis and are subsequently not further explored is a real danger in patients who have a combination of physical and mental health issues (Hext et al, 2018).
Patients may have difficulties with many daily activities following discharge, including personal care, domestic tasks and social activities, and all these challenges should be considered in the BPPS management plan. Such difficulties may well predispose the patient to mental health problems or exacerbate existing or ICU-acquired ones. Baker and Clark (2020) discussed the impact of social distancing and isolation during the pandemic, especially regarding the threat to the mental health of older adults, and where lower socio-economic status is also a factor. This needs to be considered especially where the post-discharge COVID-19 ICU patient is returning to a very different community experience, for example, if the person will be subject to shielding. The impact of enhanced infection control measures including personal protective equipment (PPE) must also be considered, as this could lead to further exacerbation of feelings of isolation and loneliness.
For patients who have pre-existing mental health problems and who are already under the care of secondary mental health services, their team should be involved in the discharge planning process (Greenhalgh et al, 2020). Continuity between primary care and mental health services is especially important in these cases, especially with regard to possible exacerbation of a pre-existing condition.
In instances where the patient's behaviour has altered to the point of it being considered challenging, a positive behavioural support plan is recommended (Department of Health and Social Care (DHSC), 2014; Care Quality Commission, 2017). Although behavioural support plans may be presented in a selection of formats, the DHSC (2014) stated that these must comprise primary, secondary and tertiary interventions for the management of challenging behaviour. Hext et al (2018) recommended that a BPPS approach to positive behavioural support be adopted in order to avoid diagnostic overshadowing and to highlight the importance of the person's environment and its impact on all aspects of health and behaviour. It has been recommended that, for the management of challenging behaviour in psychiatric inpatient units (Clark et al, 2017), all care plans adopt a BPPS approach and have a positive behavioural support element. Clark et al (2017) made a case for this in more complex patients irrespective of the environment, having found a reduction in challenging behaviours by over 50%.
Risk assessment
Risk assessment is not just from the perspective of violence, aggression or other challenging behaviours but it also needs to cover all domains of the patient from a BPPS perspective and examine the patient's environment (Clark and Clarke, 2014). Risk assessment and management are core ingredients of any advanced assessment process, including psychiatric formulation, which is the standard assessment process used by psychiatrists and advanced mental health practitioners.
In its basic form, risk assessment involves determining:
- The risks (to the patient, others, and the environment)
- The likelihood of occurrence
- What can ben done to minimise the risk
- What plans should be in place should an emergency situation arise.
Risk assessment should be robust and dynamic, it should examine the impact of risk factors from each of the BPPS domains within the given environment on each other (Clark and Cangy, 2016). This process may subsequently increase overall risk factors. Risk can be calculated as low, medium or high, and risk management plans are developed accordingly. Risk is not a static commodity and, as such, risk assessment and management should be re-calculated on a regular basis. Figure 1 (Clark and Clarke, 2014) shows aspects to consider when assessing risk in this patient group. Safeguarding, mental capacity and carer's assessments are also applicable in some cases.
Figure 1. Considerations when undertaking bio-psycho-pharmaco-social risk assessment after COVID-19 discharge
Mental health and psychological support groups
Historically, the WHO (2017) recommended that patients who had been diagnosed with sepsis required additional support after discharge. This led to the establishment of post-acute care facilities that focus on improving care and rehabilitation, including physical, speech and occupational (Prescott and Girard, 2020). Health professionals would encourage patients and family members to attend ICU survivor peer support groups, in the form of follow-up ICU clinics, psychologist-led sessions, peer support meetings and community-based groups. Through these groups,' patients are more likely to recognise the symptoms and onset of PICS and seek support earlier (McPeake et al, 2019). However, with multiple outbreaks of COVID-19, family members may be reluctant to attend a support group because these will not permit social distancing. Furthermore, these facilities may not be available due to growing infection rates. There are recommendations (Greenhalgh et al, 2020) that such group meetings be held virtually and be made specifically for post-ICU COVID-19 survivors.
The COVID-19 pandemic has led to an increased demand on mental health services in primary care, including local Improving Access to Psychological Therapies (IAPT) programmes. The British Psychological Society (2020) suggested a three-tier approach incorporating provision of information regarding psychological care, structured rehabilitation and self-management, and, if necessary, specialist services.
Conclusion
The COVID-19 pandemic has a multitude of sequelae and complications for post-ICU survivors. This article has focused on the impact that these can have on the mental health of some patients. Mental health issues cannot be viewed in isolation, but are a part of the bigger BPPS presentation of the patient, and other BPPS domains will also impact on mental health status. It would be naïve to believe that a patient who has experienced ventilation, sedation and long ICU inpatient admission can be discharged with no further implications on their wellbeing. Health professionals must understand how to best assess, support and prepare these vulnerable patients as they re-enter a very different community from the one they remember.
KEY POINTS
- The COVID-19 pandemic has placed immense pressure on already overstretched health systems worldwide
- Routine intensive care unit (ICU) practices may no longer be followed during the pandemic, therefore complicating and delaying recovery
- Patients who have had a COVID-19 ICU admission may experience various mental health issues
- A detailed post-discharge bio-psycho-pharmaco-social (BPPS) support plan should be in place and regularly reviewed by the primary care team and should always include a BPPS risk assessment
- The fact that patients are returning to very different communities should be considered and addressed
CPD REFLECTIVE QUESTIONS
- How would you reduce the impact of social distancing, isolation and shielding on the mental health of post-ICU discharge COVID-19 patients?
- How would you conduct a risk assessment regarding safeguarding if the post-ICU discharge patient exhibits challenging behaviour involving aggression and lives in a multi-generational household?
- What voluntary groups are active at this time in your local area which may be helpful in your management plan?