covid: PTSD in family members

 A recent article found that family members of patients hospitalized with Covid-19 acute respiratory distress syndrome (ARDS), versus family members with non-Covid ARDS, had significantly more posttraumatic stress disorder (PTSD) related symptoms (see covid PTSD fam members jam2022 in dropbox, or doi:10.1001/jama.2022.2017)

 

Details:

-- 602 family members and 307 patients were prospectively enrolled from 23 ICUs in France, from January 2020 to June 2020, with final follow-up by October 2020

    -- 517 family members of 307 surviving patients, of whom 273 (89%) completed a 90-day assessment:

        -- 303 family members of Covid-19 patients (median of 112 days post discharge)

        -- 214 family members of non-Covid patients

-- comparing demographics of family members of Covid versus non-Covid ARDS patients: mean age 50 vs 55, 75% vs 68% women, 50% vs 47% spouses of the ICU patient, 9% vs 10% on anxiolytics, 35% vs 89% were allowed to be present in the ICU, 35% vs 42% had remote telephone interactions with patients, 51% vs 54% had none, 77% vs 54% of physicians and nurses used personal protective equipment, 20% vs 87% had information from the staff during the ICU visit

-- level of social support range from zero (extremely limited) to 10 (extremely effective), with families of Covid patients rating the social support at 10 and for the non-Covid patients at 9.

 

-- Primary outcome: family members having symptoms of

    -- PTSD at 90 days after ICU discharge, using the Events Scale-Revised instrument (score from zero [best] to 42 [worst])

    -- anxiety or depression symptoms defined by subscale scores at least 7 on the HADS symptom score (0-42, with higher score being worse, and a minimal clinically important difference of difference of 1.5) [HADS= Hospital Anxiety and Depression Scale]

 

Results:

-- similar proportions of patients died before the 90-day assessment for each of the ARDS groups

 

-- family members of patients with Covid-related ARDS versus non-Covid ARDS:

    -- prevalence of PTSD symptoms: 35% (103/293) versus 19% (40/211), difference 16% (8%-24%), p<0.001

    -- prevalence of anxiety symptoms: 41% (121/294) versus 34% (70/207), difference 8% (0%-16%), p=0.05

    -- prevalence of depression symptoms: 31% (91/291) versus 18% (37/209), difference 13% (6%-21%), p<0.001

 

-- symptoms in family members of patients who died from Covid versus non-Covid related ARDS:

    -- PTSD: 63% versus 39%, difference 24% (7%-40%), p=0.008

    -- anxiety: 55% versus 32%, difference 23% (7%-39%), p=0.009

    -- depression: 55% versus 20%, difference 35% (18%-49%), p<0.001

 

-- Multivariable model adjusting for age, sex, and level of social support: odds ratio of Covid-related ARDS was associated with an increased risk for PTSD-related symptoms in family members, OR 2.05 (1.30-3.23)

-- Factors independently associated with PTSD symptoms, comparing Covid versus non-Covid-related ARDS: males, older people, and those with higher levels of social support were less likely to have PTSD symptoms

 

-- For the ICU survivors themselves at 90 days post discharge, comparing non-Covid versus Covid-related ARDS:

    -- PTSD: 20% versus 15%, p=0.24, nonsignificant

    -- anxiety: 25% versus 35%, p=0.07, a statistically nonsignificant trend

    -- depression: 22% versus 24%, p=0.65, nonsignificant

 

Commentary:

-- PTSD, other anxiety states, and depression have potentially long-term severe consequences for family members, limiting their well-being and ability to function normally.

-- These symptoms are also associated with increased risk of major adverse cardiovascular events (see http://gmodestmedblogs.blogspot.com/2022/02/ptsd-increases-risk-of-cardiovascular.html)

-- higher levels of social supports tend to ameliorate the effect of stressors. In this study they did control for social supports, still finding that those with Covid-related ARDS did significantly less well than those with non-Covid ARDS

    -- it has been found in other studies as well as the one above that those with ARDS not related to Covid do have increased PTSD, anxiety, and depression. And, other studies have also suggested that family members of patients with Covid-related ARDS have more PTSD when patients died in the ICU.

-- There are several possible mechanisms leading to this difference:  

    -- family members were excluded more often from being in the ICU with the patients who had Covid, more so than the non-Covid patients with ARDS

    -- family members may have had to wear personal protective equipment if they were allowed to be with their family members, which might have created an awkward distancing, lack of effective communication with the patients, and a less satisfactory interaction

    -- family members did not appear to have had as effective contact with the care teams in the ICU because of the Covid diagnosis, as confirmed above, also leading to a less satisfactory interaction and feeling more isolated from the horrendous ICU process for Covid patients (prolonged stays, prolonged intubation, proning, etc).

        -- the ICU process for Covid patients tends to be much worse than for other ICU patients

        -- and, those whose family members died in the ICU from covid, having had much less interaction with patients and staff during the ICU process, did not have the ability to reach appropriate closure, which tends to worsen the grief reaction

    -- there may have been significant disabilities associated with Covid-related ARDS (chronic lung disease, chronic kidney disease, etc.) which may have been more present than in those with ARDS by itself

    -- at hospital discharge, family members may have had more pandemic-related issues of financial insecurity, social distancing, or risk of job loss

 

Limitations:

-- we only have the assessment at the 90-day mark, and symptoms may change significantly over time

-- all of the above was self-reported information, and much of it was not validated through accepted instruments. For example, decreased social supports correlate with increased anxiety, depression, and PTSD in many studies. Although the perceived social supports were really quite high in the above study for all participants, but it is not clear what this means. For example, did this feeling of being supported change during the course of the in hospital stay or subsequently at home? Did their assessment of support change over time because of their inability to be intimately involved in the ICU care of their family member and thereby feel less involvement and less validation during the ICU stay? were there differences in supports/help for family members at home just because the patient had Covid? Any changes may have been important correlates of ultimate psychological effects

-- the study was done approximately two years ago, and it is possible that more current assessments might have had different results. Perhaps family members overall have become more resilient at later time periods as Covid has become more "normalized"?

-- this study was done in France where ICU management, treatment of family members and patients, and social networks and supports might be very different from other places. In particular the authors do note that the ICU's in the study had a particularly strong focus on family care (meaning that conditions might've been considerably worse in other hospitals in France or in other areas of the world)

 

So, this brings up another issue of collateral damage from Covid. One issue has been in the press (and in many of my blogs) over the last 1 to 2 years has been the "long Covid", which extends the patients' morbidity beyond the acute infection. This study brings up another issue of increased family psychological distress, which also could have significant long-term consequences in terms of the family members themselves, their interactions with each other and with the patient, and their ability to function normally in society

 

geoff

 

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