Elsevier

General Hospital Psychiatry

Volume 43, November–December 2016, Pages 23-29
General Hospital Psychiatry

Review Article
Anxiety symptoms in survivors of critical illness: a systematic review and meta-analysis

https://doi.org/10.1016/j.genhosppsych.2016.08.005Get rights and content

Abstract

Objectives

To evaluate the epidemiology of and postintensive care unit (ICU) interventions for anxiety symptoms after critical illness.

Methods

We searched five databases (1970–2015) to identify studies assessing anxiety symptoms in adult ICU survivors. Data from studies using the most common assessment instrument were meta-analyzed.

Results

We identified 27 studies (2880 patients) among 27,334 citations. The Hospital Anxiety and Depression Scale-Anxiety (HADS-A) subscale was the most common instrument (81% of studies). We pooled data at 2–3, 6 and 12–14 month time-points, with anxiety symptom prevalences [HADS-A≥8, 95% confidence interval (CI)] of 32%(27–38%), 40%(33–46%) and 34%(25–42%), respectively. In a subset of studies with repeated assessments in the exact same patients, there was no significant change in anxiety score or prevalence over time. Age, gender, severity of illness, diagnosis and length of stay were not associated with anxiety symptoms. Psychiatric symptoms during admission and memories of in-ICU delusional experiences were potential risk factors. Physical rehabilitation and ICU diaries had potential benefit.

Conclusions

One third of ICU survivors experience anxiety symptoms that are persistent during their first year of recovery. Psychiatric symptoms during admission and memories of in-ICU delusional experiences were associated with post-ICU anxiety. Physical rehabilitation and ICU diaries merit further investigation as possible interventions.

Introduction

With recent medical advances, the number of survivors of critical illness is increasing [1]. There are a growing number of studies evaluating survivors' outcomes after hospital discharge [2]. Critical illness survivors frequently face complicated recovery processes, including long-term impairments in physical and cognitive function, and quality of life [3], [4]. Psychiatric symptoms in critical illness survivors are associated with decreased quality of life [5], [6], [7]. Recently, there has been increased interest in the mental health outcomes of critical illness survivors [5], [6], [7]. Recent systematic reviews have focused on different aspects of mental health in this population, such as posttraumatic stress disorder (PTSD) [5] and depression [7]. However, to our knowledge, no published systematic review has examined nonspecific anxiety symptoms in critical illness survivors. Hence, our objectives were to (a) examine the prevalence of anxiety symptoms in critical illness survivors; (b) evaluate the natural history and change in symptom severity during the first year after critical illness; (c) identify preintensive care unit (ICU), ICU and post-ICU risk factors; and (d) assess post-ICU interventions for prevention or treatment of anxiety symptoms following critical illness.

Section snippets

Search strategy

To identify eligible studies, we searched five electronic databases (PubMed, Cumulative Index of Nursing and Allied Health Literature, PsycINFO®, EMBASE and the Cochrane Controlled Trials Registry) from 1970 through March 2015. We searched for articles with any patient outcome assessment after hospital discharge in survivors of critical illness, since articles may measure anxiety symptoms as part of a battery of assessments of other outcomes. Our keywords for the database searches focused on

Description of search and study characteristics

We identified 27,334 citations, and after removing the duplicates, we reviewed 18,693 unique titles and abstracts and 1579 full-text articles. A total of 27 unique studies from 29 publications (Fig. 1) met our eligibility criteria. All studies were published on or after the year 2000. These studies included 8 RCTs [14], [15], [16], [17], [18], [19], [20], [21], 15 cohort studies [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36] and 4 cross-sectional

Discussion

Our systematic review and meta-analysis of 27 studies with 2880 general ICU survivors demonstrate a prevalence of anxiety symptoms of 32–40% over 1-year follow-up. Studies with longitudinal assessment of the same population of ICU survivors showed no significant change in HADS-A scores or prevalence during the first year after discharge.

The reported anxiety symptoms across different studies ranged from 5 to 73%. This variability may be due to differences in patient populations, anxiety

Conclusion

In this meta-analysis of 27 studies with 2880 general ICU survivors, we found that at least one third of ICU survivors experience anxiety symptoms that persist during the first year after critical illness. Many traditional ICU factors, such as severity of illness and LOS, were not associated with anxiety symptoms. Psychiatric symptoms in the hospital and memories of delusional experiences while critically ill were associated with anxiety at post-ICU follow-up. No post-ICU interventions had

Acknowledgments

We thank the following investigators who provided additional data from their research studies to permit this meta-analysis: Drs. Ceri Battle, Brian Cuthbertson, Maité Garrouste-Orgeas, Richard Griffiths, Christina Jones, David McWilliams, Hilde Myhren, Giles Peek, Janice Rattray, Anna Schandl, Kannika Sukantarat, Marike van der Schaaf and Timothy Walsh. We also thank the following people for their assistance in literature searches, screening titles and abstracts, data collection and management:

References (50)

  • AM Parker et al.

    Posttraumatic stress disorder in critical illness survivors: a metaanalysis*

    Crit Care Med

    (2015)
  • M. Huang et al.

    Hopkins RO, et al

    Psychiatric Symptoms in Acute Respiratory Distress Syndrome Survivors: A One-Year National Multi-Center Study. Crit Care Med

    (2016)
  • A Rabiee et al.

    Depressive symptoms after critical illness: a systematic review and meta-analysis

    Crit Care Med

    (2016)
  • JPT Higgins et al.

    The Cochrane Collaboration's tool for assessing risk of bias in randomised trials

    BMJ

    (2011)
  • G Wells et al.

    The Newcastle-Ottawa scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses

    (2000)
  • AS Zigmond et al.

    The hospital anxiety and depression scale

    Acta Psychiatr Scand

    (1983)
  • JPT Higgins

    Measuring inconsistency in meta-analyses

    BMJ

    (2003)
  • P Sedgwick

    Meta-analysis: testing for reporting bias

    BMJ

    (2015)
  • D Moher et al.

    Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

    PLoS Med

    (2009)
  • BH Cuthbertson et al.

    The PRaCTICaL study of nurse led, intensive care follow-up programmes for improving long term outcomes from critical illness: a pragmatic randomised controlled trial

    BMJ

    (2009)
  • T Strøm et al.

    Long-term psychological effects of a no-sedation protocol in critically ill patients

    Crit Care

    (2011)
  • C Jones et al.

    Rehabilitation after critical illness: a randomized, controlled trial

    Crit Care Med

    (2003)
  • MM Treggiari et al.

    Randomized trial of light versus deep sedation on mental health after critical illness*

    Crit Care Med

    (2009)
  • TS Walsh et al.

    Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial

    JAMA Intern Med

    (2015)
  • RE Knowles et al.

    Evaluation of the effect of prospective patient diaries on emotional well-being in intensive care unit survivors: a randomized controlled trial*

    Crit Care Med

    (2009)
  • Cited by (285)

    View all citing articles on Scopus

    Source of Funding: This research was supported by the National Heart, Lung and Blood Institute [R24HL111895].

    View full text