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Preventing Posttraumatic Stress in ICU Survivors

A Single-Center Pilot Randomized Controlled Trial of ICU Diaries and Psychoeducation*

Kredentser, Maia S., MSc1; Blouw, Marcus, MD, MHA, FRCPC2; Marten, Nicole, RN3; Sareen, Jitender, MD, FRCPC4; Bienvenu, O. Joseph, MD, PhD5; Ryu, Jennifer, MD6; Beatie, Brooke E., MA1; Logsetty, Sarvesh, MD, FRCSC, FACS4,7; Graff, Lesley A., PhD8; Eggertson, Shauna, RN, BN9; Sweatman, Sophia, MD10; Debroni, Braeden, MD11; Cianflone, Nina12; Arora, Rakesh C., MD, PhD, FRCSC7,13; Zarychanski, Ryan, MD, MSc, FRCPC2; Olafson, Kendiss, MD, MPH, FRCPC2

doi: 10.1097/CCM.0000000000003367
Clinical Investigations
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Objectives: Critical illness can have a significant psychological impact on patients and their families. To inform the design of a larger trial, we assessed feasibility of ICU diaries and psychoeducation to prevent posttraumatic stress disorder, depression, and anxiety following ICU stays.

Design: Four-arm pilot randomized controlled trial.

Setting: A 10-bed tertiary ICU in Winnipeg, MB, Canada.

Patients: Critically ill patients greater than 17 years old with predicted ICU stays greater than 72 hours and mechanical ventilation duration greater than 24 hours.

Interventions: Patients were randomized to usual care, ICU diary, psychoeducation, or both ICU diary and psychoeducation.

Measurements and Main Results: Our primary objective was to determine feasibility measured by enrollment/mo. Secondary outcomes included acceptability of the ICU diary intervention and psychological distress, including patients’ memories 1 week post ICU using the ICU Memory Tool, posttraumatic stress disorder (Impact of Events Scale-Revised), depression, and anxiety symptoms (Hospital Anxiety and Depression Scale) 30 and 90 days post ICU. Over 3.5 years, we enrolled 58 patients, an average of 1.9 participants/mo. Families and healthcare providers wrote a mean of 3.2 diary entries/d (SD, 2.9) and indicated positive attitudes and low perceived burden toward ICU diary participation. A majority of patients reported distressing memories of their ICU stay. Those who received the diary intervention had significantly lower median Hospital Anxiety and Depression Scale anxiety (3.0 [interquartile range, 2–6.25] vs 8.0 [interquartile range, 7–10]; p = 0.01) and depression (3.0 [interquartile range, 1.75–5.25] vs 5.0 [interquartile range, 4–9]; p = 0.04) symptom scores at 90 days than patients who did not receive a diary.

Conclusions: ICU diaries are a feasible intervention in a tertiary Canadian ICU context. Preliminary evidence supports the efficacy of ICU diaries to reduce psychological morbidity following discharge.

1Department of Psychology, University of Manitoba, Winnipeg, MB, Canada.

2Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.

3Department of Internal Medicine, Section of Critical Care, St Boniface General Hospital, Winnipeg, MB, Canada.

4Department of Psychiatry, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.

5Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD.

6Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.

7Department of Surgery, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.

8Department of Clinical Health Psychology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.

9Melanoma Clinical Research Unit, Duke Cancer Institute, Duke University School of Medicine, Durham, NC.

10Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.

11Department of Family Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.

12College of Dentistry, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.

13Cardiac Sciences Program, St. Boniface General Hospital, Winnipeg, MB, Canada.

*See also p. 2048.

Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Clinical Trials Registration: Registration Number NCT02067559.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Supported, in part, by a grant from the Manitoba Medical Service Foundation (grant number 8-2014-07) to Dr. Blouw. Supported, in part, by Canadian Institutes of Health Research Foundation grant number 333252 (to Dr. Sareen).

Ms. Kredentser has received doctoral research awards from the Canadian Institutes of Health Research and the University of Manitoba Centre on Aging and Wu Scholarship. Dr. Blouw, Ms. Kredentser, and Drs. Sareen, Bienvenu, Ryu, Logsetty, and Olafson received funding from Manitoba Medical Services Foundation. Drs. Blouw, Sareen, Graff, Logsetty, and Olafson received support for article research from the Canadian Institutes of Health Research. Dr. Sareen disclosed that he was a consultant for UpToDate and has previously held Johnson and Johnson stock. Ms. Beatie has received doctoral research awards from the Social Sciences and Humanities Research Council of Canada and the University of Manitoba Centre on Aging. Drs. Ryu, Sweatman, and Debroni received a research stipend from the University of Manitoba for completing the Med II Summer Research Program while working on this article. Dr. Arora has received an unrestricted educational grant from Pfizer Canada Inc and honoraria from Mallickrodt Pharmaceuticals for work unrelated to this article. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: umkreden@myumanitoba.ca

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