Main findings

The prevalence o f psychological distress amongst the sample

This study clearly demonstrated the existence o f high rates of psychological distress amongst a sample o f discharged intensive care patients as measured through two standard indices of general trauma symptomatology, the ‘Trauma Symptom Checklist-33’ (Briere & Runtz, 1989) and the ‘Impact of Events Scale-Revised’ (Weiss & Marmar, 1997) and a commonly used measure o f psychological distress amongst medical patients the ‘Hospital Anxiety and Depression Scale’ (Zigmond & Snaith, 1983).

The ‘Hospital Anxiety and Depression Scale’ as a general measure of psychological problems revealed considerably elevated rates of anxiety and depression when this sample is compared with other studies. For example, Ormel et al (1997) measuring psychological distress using the HADS in a large community based sample o f chronic medical patients (N=5078) found significant distress (HADS score 12 +) in 24.5 % of the subjects. Almost double the proportion (47.5%) of discharged I.C.U patients in this study were found to be suffering from significant levels o f psychological distress.

Post-traumatic symptomatology as measured by the ‘Trauma Symptom Checklist-33’ and the ‘Impact o f Events Scale-Revised’ was also found to be high. The available research literature examining prevalence of PTSD for a variety of medical conditions (cancer, myocardial infarction and other coronary disorders, ARDS (acute respiratory distress

syndrome) and major transplant surgery) have reported prevalence rates o f between 5% and 10% for full PTSD with rates for partial or “subsyndromal” PTSD being as high as 25% (Green et al, 1997; Andrykowski & Cordova; 1998, Dew et al, 1996; Kutz et al, 1994; Stoll et al, 1995; Saranditis et al, 1997). In this study, 15% (8 women and 4 men) reported severe psychological trauma symptoms likely to result in a formal diagnosis of PTSD. 6 o f this sub-group were under the age of 35 (4 female and 2 male), three were middle aged ( 2 male, 1 female) and three were over 65 (female). Furthermore, the same group o f patients scored above clinical cut-off scores for the ‘Hospital Anxiety and Depression Scale’.

More information citing the original reason for I.C.U admission was made available through diagnostic rubric codes held by the hospital information service. Unfortunately, this detailed information had not been provided at the outset. This post-hoc analysis, revealed that of the twelve patients identified as possible PTSD cases, 1 patient (female > 70) had suffered cardiac arrest, 6 patients (4 women and 2 men) had required longer than anticipated post-operative care as a result o f surgical complications and 3 had diagnosed respiratory disorders (2 female, 1 male). Finally, two patients did in fact enter I.C.U (1 male, 1 female) as a result o f psychotropic drug overdose. These two patients, who clearly had some psychiatric history, had not been identified in the recruitment phase of the study.

An important note to make concerns the confidence with which one can identify ‘likely diagnosis o f full PTSD’ from research based indices. Prior to the development o f the hyperarousal subscale of lES-R (Marmar & Weiss, 1997) the Impact o f Events Scale (Horowitz et al, 1979) made speculative inference o f PTSD based on the severity of scores from the two subscales of ‘intrusion’, and ‘avoidance’. The addition o f the ‘hyperarousal subscale’ provides it with the third dimensional method o f capturing the severity o f symptomatic distress. In short, conceptually it better fits current diagnostic criteria. Hyperarousal scores amongst the most distressed in this survey were found to be high.

This study, in keeping with the general PTSD research literature, suggests that only a minority of I.C.U survivors may meet formal criteria for a diagnosis of PTSD. However, it is clear from the data that other discharged I.C.U patients may experience sub­ syndromal levels o f PTSD symptoms or “partial PTSD” Carlier and Gersons (1995). While the majority o f the sample may report insufficient symptoms to be considered at risk for a diagnosis o f full PTSD, the general level o f psychological symptoms, especially the strikingly high levels of anxiety and depression can nevertheless impair quality of life, and for that matter could lead to alternative psychological diagnosis.

Is intensive care experience a potential peri-traumatic stressor

The second primary aim of this study was to evaluate the extent to which intensive care treatment itself is linked to the formation of post-traumatic symptoms. Correlational

analysis examined the relationship between the discharged patient’s level o f psychological trauma, as accessed through seven questions about their ‘Experience after Intensive Care Treatment’ (ETIC-Q), and scores on the standard measures o f general trauma symptomatology. Significant positive correlations were found between ETIC-Q and both the ‘Trauma Symptom Checklist-33’ and the ‘Impact of Events Scale-Revised (lES- R)’, in addition to a significant association existing between ‘Experience after Intensive Care Treatment’ and the ‘Hospital Anxiety and Depression Scale’. The relationship was strongest between ETIC-Q total score and the ‘Impact o f Events Scale-Revised’ total score. The ‘intrusion’ and ‘hyperarousal’ subscale scores of the ‘Impact o f Events Scale- Revised’ were also highly correlated with reported levels of trauma symptoms specifically linked to intensive care. ‘Experience after intensive care treatment’ as assessed with the 7 item ETIC-Q measure was identified as a potentially good predictor of general trauma symptomatology on the standard self report measures, the TSC-33 and the LES-R. Based on this evidence, intensive care experience appears to be a strong peri-traumatic stressor.

It had been envisaged that responses on the lES-R (see chapter two) would be influenced by subjects’ responses on the ETIC-Q. Whilst pointing out that the vast majority of subjects did not report trauma associated with their I.C.U experience, those that did also returned high trauma scores on the lES-R. One may conclude that those distressed by their experience of I.C.U had beeen primed to think about their trauma and therefore would continue to express trauma symptoms on the LES-R which followed. This was a design ploy which is frequently employed during the administration o f structured clinical

interviews to assess clients for PTSD. Furthermore, the brief but conceptual similarity of the ETIC-Q to the lES-R has highlighted the possible development of the ETIC-Q as a screening tool for post-traumatic symptomatology amongst discharged I.C.U patients.