WEBB FELLOW: Expanding the Role of C-L Psychiatry in Treating Intensive Care Unit (ICU) Survivors

Background:
A growing body of research has demonstrated lasting neuropsychiatric harms after critical illness, termed Post-Intensive Care Syndrome (PICS)1, due to acute brain injury and delirium, and to the shock and fear experienced in the intensive care unit (ICU) leading to downstream post-traumatic stress, anxiety disorders, and depression in both patients and their family members.2 Post-ICU recovery programs and best practices for ameliorating the psychological consequences of critical illness remain under investigation. Consultation-liaison psychiatrists carry an emerging role within this multidisciplinary space of clinical medicine.



Methods:
We designed and opened a PICS clinic within a Veterans Affairs hospital led by dually trained internist-psychiatrists to provide follow-up care for ICU survivors. Our cohort initially consisted of 21 patients who survived COVID-19-related critical illness3, and now includes any high-risk ICU survivor interested in establishing aftercare. Patients receive the following broad categories of interventions: review of the critical care course, psychopharmacotherapy, psychotherapy, primary care, and subspecialty referrals. Psychological symptom screening for post-traumatic stress (PCL-5), depression (PHQ-9), and anxiety (GAD-7) is conducted every one-to-three months.



Results:
We present the basic clinic design, implementation, and barriers of our post-ICU model of care. This presentation will also discuss the incorporation of psychotherapeutic techniques, including psychodynamic approaches and Meaning-Centered Psychotherapy4, in treating individuals who experienced a life-threatening illness. Long-term, observational psychological outcomes (up to 9 months) will be presented from our clinic cohort.



Discussion:
Evidence-based interventions and clinical programs for ICU survivors remain limited, ever-evolving, and best studied in Europe.5 We identified a high-risk population of ICU survivors exhibiting distressing psychological symptoms warranting intervention in our clinic. Approaches for providers to engage with and treat near-death survivors of critical illness should be individualized and carefully-coordinated, as the transition into survivorship is unique for each patient.



Conclusions:
A PICS clinic functions as a feasible post-hospitalization model of care for critical illness survivors. Consultation-liaison psychiatrists may use their expertise to capture patients at highest-risk in the hospital setting and collaborate across disciplines in the aftercare space. Treatment approaches and interventions deserve ongoing investigation and further replication.



References:
1. Mikkelsen ME, Still M, Anderson BJ, et al. Society of Critical Care Medicine's International Consensus Conference on Prediction and Identification of Long-Term Impairments After Critical Illness. Crit Care Med, 2020;48:1670-9.
2. A. Rabiee, S. Nikayin, M.D. Hashem, et al. Depressive symptoms after critical illness: a systematic review and meta-analysis. Crit Care Med, 44 (2016), pp. 1744-1753.
3. Sayde GE, Stefanescu A, Hammer R. Interdisciplinary Treatment for Survivors of Critical Illness in the Era of COVID-19: Expanding the Post-Intensive Care Recovery Model and Impact on Psychiatric Outcomes. J Acad Consult Liaison Psychiatry. 2023 Jan 30:S2667-2960(23)00027-7.
4. Breitbart, W.S., Poppito, S.R. (2014). Individual Meaning-Centered Psychotherapy for Patients with Advanced Cancer: A Treatment Manual. New York: Oxford University Press.
5. Schofield-Robinson OJ, Lewis SR, Smith AF, et al. Follow-up services for improving long-term outcomes in intensive care unit (ICU) survivors. Cochrane Database Syst Rev 2018;11:Cd012701.