ICU Survivors Prone to Some Depression Symptoms
Medpage Today
Published: Apr 7, 2014 | Updated: Apr 8, 2014
Symptoms of depression, dominated by physical manifestations such as appetite loss, fatigue, and insomnia, were found in one-third of ICU survivors followed for a year after discharge, researchers said.
Scores on the Beck Depression Inventory II exceeding a cutoff of 13 (on the instrument's 63-point scale) were seen in 116 of 347 ICU survivors for whom 1-year follow-up was available, according to James C. Jackson, PsyD, of Vanderbilt University in Nashville, and colleagues.
Mean somatic symptom scores were markedly higher in these individuals than were affective and cognitive signs of depression -- "even though somatic items account for only 21 of 63 points" on the Beck scale, the researchers said in their report, appearing online in Lancet Respiratory Medicine.
They noted that, among the 116 patients meeting the study's criteria for depression at the 1-year evaluation, scores for 83 on the somatic items alone totaled more than 13, whereas only five patients exceeded the cutoff solely on the basis of affective-cognitive symptoms.
"This finding suggests that physical disability contributes predominantly to this depression, which has implications for the roles of physical rehabilitation versus antidepressant medications in the prevention and management of depression after ICU admission," Jackson and colleagues wrote.
Also noteworthy was a finding that depression, by these criteria, was five times as common among the ICU survivors in the study as was post-traumatic stress disorder (PTSD), which was assessed as "probable" at 1 year in 7% of the 361 survivors for whom data were available.
"Monitoring these outcomes is relevant for survivors of all ages, and that nonpharmacological interventions during the ICU stay (previously assumed to improve physical outcomes in ICU survivors) should be tested in terms of their ability to change mental health and functional outcomes," the researchers concluded.
For the study, Jackson and colleagues recruited patients who had been admitted to ICUs at two Nashville hospitals for respiratory failure, septic shock, or cardiogenic shock. Patients with recent previous ICU admissions or mechanical ventilation were excluded, as were those showing clinically significant cognitive impairment or who were judged likely to be hard to follow for 1 year for various reasons.
A total of 826 were enrolled during their ICU stays. Of these, 31% died within the next 3 months, and 96 survivors were lost to 3-month follow-up.
In addition to the Beck scale, patients were evaluated with the PTSD Checklist and three instruments for general evaluation of functioning and overall health and quality of life.
Notably, depression was not evaluated by DSM-IV (the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th edition), under which a patient must have experienced seriously depressed mood or loss of interest in normal daily activities in order to be diagnosed with clinical depression.
Instead, Jackson and colleagues assessed depression solely with the Beck scale -- commonly used in clinical studies to evaluate the severity of depression symptoms but not, strictly speaking, a diagnostic instrument. As Jackson and colleagues acknowledged, patients could have high Beck scores without showing significantly depressed mood, the canonical symptom of depression.
Nevertheless, Karen Weihs, MD, a professor of psychiatry at the University of Arizona in Tucson, who was not involved in the study, told MedPage Today that this approach did not seriously undermine the study results.
"I'm not so concerned about the fact that it may not indicate that these people all had DSM-diagnosable mood disorders, so much as I'm impressed that [the authors] are identifying significant levels of disability that go with a lot of somatic symptoms," said Weihs, who specializes in psychosomatic medicine.
She added that the study was important in highlighting symptoms such as fatigue and poor appetite in this population, which physicians and other providers often have a difficult time treating.
"In primary care, those are very, very common symptoms that may or may not be presented by people who say they're depressed," Weihs said. "What we may be seeing here is some people who are not so inclined or able to use words for feelings, but more express their symptoms [in] somatic [terms]."
Two critical care specialists at the University of Michigan in Ann Arbor made a similar point in a commentary appearing with the report in Lancet Respiratory Medicine.
"The predominance of physical over cognitive symptoms of depression ... raises the question of what exactly is being measured: mental or physical illness," wrote Hallie Prescott, MD, and Theodore Iwashyna, MD, PhD, noting that many of the symptoms seen in the study can result from lost muscle mass and/or comorbid illnesses.
"However, these somatic symptoms are themselves important and they need to be recognized, and efforts taken to ameliorate their burden."
Of the 347 patients with Beck scores available 1 year later, 67% had scores of 13 or below. Mild depression, defined as scores of 14 to 19, was seen in 12%; moderate depression (Beck score 20 to 28) in 14%; and severe depression (Beck score 29 or higher) in 7%.
Depression by these measures was more common among those with a patient-reported history of depression (49 of 115, 43%) versus those with no such history (62 of 217, 29%).
For functional outcomes, about one-quarter of 1-year survivors showed persistent disability. Some 27% showed at least partial disability according to scores on the Katz Activities of Daily Living Scale, and 23% were rated as disabled according to responses on the Functional Activities Questionnaire.
For 361 survivors who completed the 100-point Short Form-36 assessment of quality of life, the median score was 55 on the mental component (interquartile range 45 to 60) and 32 for the physical component (IQR 25 to 43).
Beck scores at 1 year were significantly higher among patients who had relatively long periods of delirium during their ICU stays and also as a function of increasing age. Delirium duration also predicted lower scores on the Short Form-36 mental component.
The study was funded by the NIH.
Medpage Today
Published: Apr 7, 2014 | Updated: Apr 8, 2014
Symptoms of depression, dominated by physical manifestations such as appetite loss, fatigue, and insomnia, were found in one-third of ICU survivors followed for a year after discharge, researchers said.
Scores on the Beck Depression Inventory II exceeding a cutoff of 13 (on the instrument's 63-point scale) were seen in 116 of 347 ICU survivors for whom 1-year follow-up was available, according to James C. Jackson, PsyD, of Vanderbilt University in Nashville, and colleagues.
Mean somatic symptom scores were markedly higher in these individuals than were affective and cognitive signs of depression -- "even though somatic items account for only 21 of 63 points" on the Beck scale, the researchers said in their report, appearing online in Lancet Respiratory Medicine.
They noted that, among the 116 patients meeting the study's criteria for depression at the 1-year evaluation, scores for 83 on the somatic items alone totaled more than 13, whereas only five patients exceeded the cutoff solely on the basis of affective-cognitive symptoms.
"This finding suggests that physical disability contributes predominantly to this depression, which has implications for the roles of physical rehabilitation versus antidepressant medications in the prevention and management of depression after ICU admission," Jackson and colleagues wrote.
Also noteworthy was a finding that depression, by these criteria, was five times as common among the ICU survivors in the study as was post-traumatic stress disorder (PTSD), which was assessed as "probable" at 1 year in 7% of the 361 survivors for whom data were available.
"Monitoring these outcomes is relevant for survivors of all ages, and that nonpharmacological interventions during the ICU stay (previously assumed to improve physical outcomes in ICU survivors) should be tested in terms of their ability to change mental health and functional outcomes," the researchers concluded.
For the study, Jackson and colleagues recruited patients who had been admitted to ICUs at two Nashville hospitals for respiratory failure, septic shock, or cardiogenic shock. Patients with recent previous ICU admissions or mechanical ventilation were excluded, as were those showing clinically significant cognitive impairment or who were judged likely to be hard to follow for 1 year for various reasons.
A total of 826 were enrolled during their ICU stays. Of these, 31% died within the next 3 months, and 96 survivors were lost to 3-month follow-up.
In addition to the Beck scale, patients were evaluated with the PTSD Checklist and three instruments for general evaluation of functioning and overall health and quality of life.
Notably, depression was not evaluated by DSM-IV (the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th edition), under which a patient must have experienced seriously depressed mood or loss of interest in normal daily activities in order to be diagnosed with clinical depression.
Instead, Jackson and colleagues assessed depression solely with the Beck scale -- commonly used in clinical studies to evaluate the severity of depression symptoms but not, strictly speaking, a diagnostic instrument. As Jackson and colleagues acknowledged, patients could have high Beck scores without showing significantly depressed mood, the canonical symptom of depression.
Nevertheless, Karen Weihs, MD, a professor of psychiatry at the University of Arizona in Tucson, who was not involved in the study, told MedPage Today that this approach did not seriously undermine the study results.
"I'm not so concerned about the fact that it may not indicate that these people all had DSM-diagnosable mood disorders, so much as I'm impressed that [the authors] are identifying significant levels of disability that go with a lot of somatic symptoms," said Weihs, who specializes in psychosomatic medicine.
She added that the study was important in highlighting symptoms such as fatigue and poor appetite in this population, which physicians and other providers often have a difficult time treating.
"In primary care, those are very, very common symptoms that may or may not be presented by people who say they're depressed," Weihs said. "What we may be seeing here is some people who are not so inclined or able to use words for feelings, but more express their symptoms [in] somatic [terms]."
Two critical care specialists at the University of Michigan in Ann Arbor made a similar point in a commentary appearing with the report in Lancet Respiratory Medicine.
"The predominance of physical over cognitive symptoms of depression ... raises the question of what exactly is being measured: mental or physical illness," wrote Hallie Prescott, MD, and Theodore Iwashyna, MD, PhD, noting that many of the symptoms seen in the study can result from lost muscle mass and/or comorbid illnesses.
"However, these somatic symptoms are themselves important and they need to be recognized, and efforts taken to ameliorate their burden."
Of the 347 patients with Beck scores available 1 year later, 67% had scores of 13 or below. Mild depression, defined as scores of 14 to 19, was seen in 12%; moderate depression (Beck score 20 to 28) in 14%; and severe depression (Beck score 29 or higher) in 7%.
Depression by these measures was more common among those with a patient-reported history of depression (49 of 115, 43%) versus those with no such history (62 of 217, 29%).
For functional outcomes, about one-quarter of 1-year survivors showed persistent disability. Some 27% showed at least partial disability according to scores on the Katz Activities of Daily Living Scale, and 23% were rated as disabled according to responses on the Functional Activities Questionnaire.
For 361 survivors who completed the 100-point Short Form-36 assessment of quality of life, the median score was 55 on the mental component (interquartile range 45 to 60) and 32 for the physical component (IQR 25 to 43).
Beck scores at 1 year were significantly higher among patients who had relatively long periods of delirium during their ICU stays and also as a function of increasing age. Delirium duration also predicted lower scores on the Short Form-36 mental component.
The study was funded by the NIH.
