Mental Health Rehabilitation in Critical Cases : Addressing the Psychological Impact of Critical Care

Introduction:

Intensive care unit admission is an unanticipated event for most families and patients. In addition, the distinct environment of the ICU and long-term treatment modalities cause psychological stress to the patients and their families. Critical illness profoundly impacts a person’s health, and addressing mental health needs is important in providing comprehensive care for critically ill patients. ICU-related mental disorders are extremely debilitating and may cause suicidal ideas in patients. Optimal psychological care and rehabilitation will positively affect a patient’s psychological recovery after a critical illness.

What Are the Mental Health Issues in Critical Care?

Some of the common mental health issues in critical care include the following:

• Anxiety.

• Depression.

• ICU-related delirium.

• Dreams, hallucinations, and nightmares.

• Post-traumatic stress disorder (PTSD).

• Irritability.

• Mood changes.

• Poor concentration.

• Relocation stress.

• Lower quality of life.

• Cognitive dysfunction.

• Sleeping difficulties.

Other problems associated with critical care stay include the following:

• Inability to cope.

• Increased medical costs.

• Slower return to work.

• Burden and stress on families.

What Are the Risk Factors Associated With the Psychological Impacts of Critical Illness?

The risk factors associated with psychological problems after critical illness include the following:

Psychological Risk Factors:

• Length of sedation.

• Disturbed memories.

• Use of vasopressors and Benzodiazepines.

• Premorbid psychiatric history.

Risk Factors for Delirium:

• Anticholinergic drugs.

• Benzodiazepines.

• Age.

• Visual or hearing impairments.

• Drug or alcohol withdrawal.

• Infections and pain.

• Hypertension.

• Metabolic derangements.

Risk Factors for Postoperative Cognitive Dysfunction:

• Length of anesthesia.

• Lower education level.

• Age.

• Second operation.

• Infection.

• Respiratory complications.

Risk Factors for Cognitive Dysfunction Following Critical Illness:

• Sepsis.

• Delirium.

• Dysglycemia.

• Hypoxemia.

What Is the Pathogenesis of Psychological Sequelae After Critical Illness?

The pathogenesis of cognitive dysfunction and psychological sequelae after critical illness is not fully understood. However, it is multifactorial, including the following.

• The major theories of pathogenesis include neurotoxic, neuromodulators, and neuroinflammatory mechanisms.

• Anesthetics are powerful modulators for the development and functions of neurons. Medications, hypoxia, dysglycemia, and sleep disturbances alter neurotransmitter synthesis and functions resulting in psychological sequelae after critical illness.

• Dysregulation of the immune system and inflammatory mediators has a role in cognitive dysfunction pathogenesis as they are important for memory formation.

• Increases in cytokines production and reactive oxygen species lead to synaptic and neuronal disruption in acute respiratory distress syndrome (ARDS) and sepsis.

What Are the Psychological Impacts of Critical Illness and Critical Care Admission?

Critical care admission has a severe psychological impact on the patients, such as stress, altered consciousness, post-traumatic stress disorder, and delirium. More than 50 % of critical care patients suffered psychological disorders after admission.

Patients are exposed to many stress factors in ICU, such as illness, pain, thirst, hunger, strange noise and light, sleep deprivation, nakedness, loss of dignity, fear of dying, inability to communicate, and interventions such as mechanical ventilation and invasive cardiovascular support monitoring. The psychological impacts and consequences of critical illness in detail include the following:

Anxiety and Depression:

• Critical illness can be a very stressful experience for patients leading to anxiety and depression.

• Patients worry about their medical condition, treatment outcomes, and the ability to resume their routine.

• Depression is caused by their condition's physical and emotional stress, isolation, and confinement in an ICU.

Delirium:

• Delirium is the decreased ability to focus, disturbances in consciousness, attention, and cognition changes.

• Undetected and untreated anxiety may result in delirium in critically ill patients.

• The manifestations of delirium include acute confusion, ICU psychosis, cognitive impairment, neurological impairment, and encephalopathy.

Post-Traumatic Stress Disorder (PTSD):

• Post-traumatic stress disorder develops in people who experienced a scary or dangerous event.

• Symptoms include severe anxiety, nightmares, and thoughts about the event.

Post-Intensive Care Syndrome (PICS):

• Post-intensive care syndrome is a collection of physical, cognitive, and psychological symptoms persisting for more than a few months or years after ICU discharge.

• PICS include fatigue, weakness, depression, anxiety, difficulty concentrating, and post-traumatic stress disorder (PTSD).

What Is the Psychologist’s Role in Mental Health and Rehabilitation in the ICU?

Psychologists play a vital role in critical care settings and follow-up care. They assess and reduce distress for patients, families, and staff to provide improved outcomes. They also maintain a healthy working environment by managing stress. In addition, they supervise cognitive and psychological assessments of patients and provide training to improve the psychological support of patients with delirium, agitation, and stress.

What Are the Mental Health Rehabilitation Strategies in Critical Care?

The mental health rehabilitation strategies after critical illness include the following:

Preventive Strategies:

• The preventive strategies focus on detecting, treating, and managing delirium.

• It includes conservative approaches for managing agitation and treating the causes.

• The pain, agitation, and delirium (PAD) guidelines recommend regular assessment of sedation, delirium, and treatment of pain and symptoms.

• Sedation guidelines include minimal sedation, a sedative interruption strategy (spontaneous awakening trial), or a targeted sedation strategy (a light level of sedation is given continuously).

• Non-Benzodiazepine drugs (Dexmedetomidine or Propofol) reduce the length of mechanical ventilation and ICU stay.

• Early and progressive mobilization, environmental control measures, and sleep hygiene can prevent delirium.

• ABCDE bundle (awakening, breathing, choice of sedatives, daily delirium monitoring, and early mobility exercise) and PAD guidelines are effective preventive strategies.

• Music therapy reduces anxiety and sedation levels in ICU. In addition, it provides a state of relaxation and improves temper and motivation.

Neurorehabilitative Strategies:

Neurorehabilitative strategies include activities for the patients to overcome their psychological trauma and regain independence. They focus on:

• Patient diaries - To help patients fill the memory gaps, reduce post-traumatic stress disorders and improve their quality of life.

• Patient follow-up ranged from before hospital discharge to twelve weeks post-discharge.

• Cognitive rehabilitation helps patients to improve cognitive function after critical illness. It includes activities to improve memory, attention, and decision-making skills.

• Mind-body therapies such as yoga and meditation manage health symptoms by reducing stress and improving mood and relaxation.

• Support groups help patients connect with others and provide a safe space to discuss psychological concerns.

• Lifestyle changes include healthy eating, avoiding drugs and alcohol, regular exercise, and managing anxiety and depression.

Conclusion:

Mental health management and rehabilitation are vital in reducing the psychological impacts of critical illness. Further research on minimizing the psychological consequences of surviving ICU treatment is needed. In addition, further work is needed to identify specific patients’ needs following hospital discharge.