Depressive and Anxiety Symptoms in Relatives of Intensive Care Unit Patients and the Perceived Need for Support

INTRODUCTION

Admission of a patient in the Intensive Care Unit (ICU) and the recovery process may be stressful for family members. Patients’ relatives have to deal with the unfamiliarity of the ICU environment and the treatment procedures and with the uncertainty of the patients’ outcome. Thus, family's psychological stress is one of the most important issues concerning the ICU admission of a patient, due to lack of appreciation of their health condition, in terms of diagnosis, prognosis, and treatment.[1] Family members may experience high levels of fear, denial, anger, and guilt when facing the possibility of loss of their loved one in the ICU environment.[2] Several studies have addressed the short- and medium-term impact of ICU stay on the lives of the patients’ caregivers, and it has been consistently suggested that family members of ICU patients display depressive symptoms,[3] posttraumatic stress and anxiety,[4] fatigue and poor quality of sleep,[5] and that the symptoms tend to persist for several months after the patients’ hospitalization. A previous review reported that a high proportion of family members present with symptoms of anxiety and depression (70% and 35%, respectively).[6]

In Greece, there are only a few studies addressing the experiences of families of ICU patients. Paparrigopoulos et al.[7] found high levels of anxiety and depressive symptoms as well as posttraumatic stress (97% and 81%, respectively) in family members on the 1^st week of admission. Those high rates of symptoms persisted 3 days before patients’ discharge to other wards (87% and 59%, respectively). More recently, a study on 223 Greek family members of ICU patients reported that a significant proportion of family members experienced high levels of cardiac anxiety on the 3^rd day of admission.[8]

The aim of the present study is to explore the families’ psychological symptoms and their evolution over the 1^st week of patients’ ICU stay. Additional study objectives are:

1. To explore the satisfaction of the ICU patients’ families during the 1^st week of ICU stay

2. To explore the families’ need for support

3. To report on the level of satisfaction regarding the information provided by ICU physicians

4. To search for the impact of the participation to the decision-making process on the psychological condition of family members.

METHODS

RESULTS

Most participants were female (61.1%) and middle-aged, as 58.3% were in the range of 40–64 years. Two-thirds were living in urban areas. Most (71.3%) had no previous experience of a relative's ICU stay, whereas almost 20% had a history of mental disorder. Table 1 depicts the participants’ characteristics.

Table 1 Participants’ characteristics

Table 2 shows the scores of the participants on the scales that measure the anxiety and depression levels (HAM-A and Beck II, respectively), at two different time points, that is, on patient's admission (day 1) and day 7 of ICU stay.

Table 2 Participants’ scores on depression and anxiety measures

Table 3 shows the levels of anxiety as recorded with the HAM-A scale. Anxiety levels are not significantly different among 2-time points that are day 1 and day 7 of ICU admission.

Table 3 Scores on Hamilton Anxiety Rating Scale on day 1 and 7 of admission

On the other hand, the percentage of relatives who scored ≥17 on Beck-II raised from 38% (day 1) to 58.3% (day 7) [Table 4]. With the use of the McNemar test, it was found that changes of the scores on the Beck-II scale were statistically significant.

Table 4 Scores on the Beck Depression Scale II on day 1 and 7 of admission

Regarding the factors that are associated with changes in the caregivers reported anxiety symptoms, we examined several demographic and clinical data (APACHE II score). Table 5 depicts all factors that have been correlated to changes in anxiety. Age, education, closeness of relationship, and APACHE II score were the statistical significant factors.

Table 5 Factors associated with score changing Hamilton Anxiety Rating Scale

On the contrary, although changes in depressive symptoms between the 2-time points were statistically significant, there was no correlation of changes with the aforementioned factors (data not presented in a table).

Participants’ views on the patients’ ICU stay were also sought for. Those questions involved their perspective about treatment decision-making procedures, the perceived need for information and support, and the conditions of visiting the patient and the waiting room [Table 6].

Table 6 Changes in the views of patients’ relatives between days 1 and 7

DISCUSSION

The primary objective of the present study was to explore the development of acute psychological symptoms in family members of patients admitted to the ICU. Over a week period, total anxiety levels of family members were not significantly changed and a relatively small number of participants experienced severe anxiety at the 2-time points (13.9% and 12%, respectively). On the other hand, families’ depression levels were significantly higher at day 7 of evaluation, compared to day 1, and as high as 58.3% of them had scores ≥17 on the Beck-II sale, compared to 38% at the initial evaluation (P = 0.000).

Various studies worldwide have yielded different results regarding the psychological manifestations of ICU patients’ relatives. In a study in Brazil on 471 participants, the rates of anxiety and depression were 34% and 17%, respectively.[11] Even higher rates of anxiety (52%) were revealed in the study of Bandari et al.[12] on 720 relatives of ICU patients, whereas Choi et al.[13] reported a rate of depressive symptoms as high as 90%. Our results, especially the relatively low levels of anxiety that have been recorded, are somewhat different from those of previous research. This may be explained by differences at the time point of assessment, the sample, and the research tools. For instance in a comparative study in two tertiary hospitals in India and the USA Kulkarni et al.[14] reported on the differences of the levels of anxiety and depression among relatives of ICU patients in these countries. Interviews were held within 48–72 h of admission. It was found that relatives in India displayed higher levels of anxiety than their American counterparts, although posttraumatic stress was almost the same in the two groups. Comorbid depressive and anxiety symptoms were present in 30% and 5% in relatives in India and the USA, respectively. The differences were attributed to differences in education and socioeconomic factors within different health systems. It was also found that the severity of the patients’ condition and being a spouse were predictors of the development of depressive symptoms. The results of the present study are somewhat different, as depressive symptoms were gradually evolved over a week, independently of the aforementioned factors.

Regarding anxiety levels our study shows no statistical difference in overall scores between days 1 and 7 of admission. However, in cases that there were changes in anxiety levels, factors such as age, education, closeness of relationship, and APACHE II score were found to correlate. Improvement was recorded in ages 16–40 years and worsening in ages >65 years. Higher education was also associated with improvement in anxiety rates at day 7. More specifically, anxiety in lower education participants was rated as “moderate to severe” in 40%, comparing with 26.7% in the highly educated participants at day 1, whereas at day 7, those rates were 61.5% and 15.4%, respectively. With regard to the kinship to the patient, among the participants with anxiety, spouses had severe anxiety at a rate of 40% at day 1 which raised significantly (53.8%) at day 7, whereas the percentage of children with severe anxiety was 20% and 23.1%, respectively. McAdam et al.[4] studied a sample of 74 family members of ICU patients who had poor prognosis and high possibility of death at day 4 of admission. More than half family members displayed symptoms of posttraumatic stress, whereas 80% had marginal anxiety symptoms and 70% marginal depressive symptoms. Other symptoms, such as fear, sorrow, and fatigue were present in 80% of the relatives. Younger age and female gender were associated with symptoms’ development. The results of the present study, as well as those of another Greek study,[7] are in line with the notion that women are prone to develop anxiety symptoms during a relative's ICU stay.[15]

It is interesting to note that while anxiety symptoms are subjected to changes associated with several demographic and clinical factors, depressive symptoms in our sample increase steadily over a week and are not related to any of these factors. This means that during the 1^st week of ICU admission, depressive symptoms are gradually evolving, while anxiety symptoms may fluctuate and they are affected by the severity of the patients’ condition, as measured with the APACHE II score.

With regard to the attitudes of family members toward the ICU stay of their relatives and the treatment procedure, the present study showed that families thought of having control over the care at a rate of 31.5%. A proportion of family members (30.5%) felt that they were members of the treatment decision-making process and even more (38.9%) preferred to be a part of this process. Importantly, 39.8% of family members felt that they had support from the ICU personnel and they had the time to express their concerns and to get answers to their queries regarding the treatment of their loved ones. Another study finding was that some family members (31.5%) wish to receive information about the ICU through brochure, as they thought it would be helpful and relieving to know about the ICU operation and about their rights and obligations. Even larger percentage of relatives (42.5%) opted for flexibility in the visiting hours and for the setup of a waiting room for them (48.2%). Much less relatives (almost 30%) had a positive attitude toward receiving support from associations and mental health specialists. It is interesting to note that during ICU stay of a patient the attitudes of their relatives gradually change. As Table 6 shows, there are significant differences in relatives’ views on participating in the decision-making procedure and on expressing their opinion and concerns regarding the treatment process. Importantly, over a week, they changed their attitudes about receiving support by the ICU personnel and even by mental health specialists, such as psychologists. This could be explained by the higher levels of depressive symptoms they developed which made them less reluctant to seeking help and support.

Several studies have addressed the issue of supporting families whose relative is admitted in the ICU. There is some evidence that several interventions, such as supportive groups[16] and the provision of material with information regarding the ICU treatment[17] may reduce relatives’ symptoms of depression and anxiety. In another study, the most effective way for relatives to deal with anxiety and depressive symptoms during the first days of ICU admission was acceptance and support seeking through counseling.[18] A previous Greek qualitative study highlighted the need of ICU patients’ families to receive information regarding the treatment process.[19] More recently, Chatzaki et al.[20] conducted a multicenter study on 230 patients’ relatives. They found that the provision of information and reassurance was most important for relatives. These results are in line with the findings of our study.

Regarding decision-making process, Heyland et al.[21] found that a quarter of relatives prefer treating physicians to make decisions and a further 15% did not wish to be part of this process. Almost 40% preferred share decision-making and 22% did so after physicians’ recommendations. The results of the present study are in line with previous research. It is worthy to note that according to Pochard et al.[22] more than two-thirds of relatives suffer anxiety or depressive symptoms, and this undermines their ability to act as the patient's surrogates. Conceivably, clinicians should bear in mind that relatives’ ability to participate in end-of-life decisions may be limited by their psychological manifestations.

Notably, it has been suggested that satisfaction of patients’ relatives regarding ICU stay is high.[21] Auerbach et al.[23] showed that the good interpersonal relationship with the medical and nursing staff may impact on the relatives’ satisfaction and their need for information. Thus, satisfaction with the ICU treatment may be mediated by good communication between the personnel and the relatives[24] and by support provision.

CONCLUSIONS

The findings of this study may be relevant for clinical practice. Given the high rates of depressive symptoms of patients’ relatives and their positive attitudes toward receiving support from specialists, efforts should be made to address these needs. For instance, ICU personnel should establish a close cooperation with the consultation-liaison psychiatric service of the hospital, so as to refer relatives promptly. Moreover, the ICU personnel should be trained to recognize as early as possible those relatives in need for support. For the relatives of patients whose clinical condition worsens during ICU stay, ICU personnel should be aware that they may be prone to develop anxiety symptoms and arrange appropriate consultation. Moreover, some training on basic supportive skills may be warranted for the ICU personnel. This could be relevant for relatives reluctant to receiving interventions from specialists, yet in need for psychological help.