Canadian critical care experts warn that we are not prepared to treat COVID-19 survivors who suffer from post-traumatic stress disorder (PTSD), an emerging public health concern identified in an Italian study.
The preliminary cross-sectional study published in JAMA Psychiatry found that a third of the 381 patients who presented to a Rome hospital with acute COVID-19 consequently developed PTSD, sounding the alarm about the mental health needs of survivors of severe COVID-19.
“There’s just not a lot of appreciation of what these folks have been through,” Margaret Herridge, a critical care physician at Toronto General Hospital, says of the thousands hospitalized for severe COVID-19 in Ontario. “I don’t think Canadian public health is really aware – this is not on their radar.”
More than a year into the pandemic, Herridge and her Canadian COVID-19 Prospective Cohort Study (CANCOV) team have turned their attention to understanding the long-term physical and psychological effects of the illness, co-leading Canada’s largest multi-centre study of long-term outcomes for patients and their families.
According to the American Psychiatric Association, PTSD is a psychiatric disorder occurring in people who have experienced or witnessed a traumatic event. Symptoms can include intrusive thoughts or memories about the traumatic experience, changes in mood and reactivity or disruption of sleep.
COVID-19 survivors with the highest PTSD risk in the Italian sample included women, those with prior histories of psychiatric disorders and those who were agitated or delirious during their acute illness.
This is in line with established research on PTSD and Herridge’s own prior studies on long-term outcomes for survivors of serious illness requiring hospitalization and ICU admission.
Herridge’s CANCOV study is still recruiting and aims for about 2,000 COVID-19 survivors to participate in the research and treatment program. However, Herridge shared that anecdotally, she is seeing a similar level of functional decline in COVID-19 survivors as in other forms of acute respiratory distress syndromes (ARDS).
“They have a lot of ICU-acquired weakness,” Herridge says. “They’ve lost a lot of muscle mass. They have functional disability, and they have cognitive dysfunction and mental health issues … we’re seeing the same constellation of problems – anxiety, depressive symptoms and PTSD in the patients.”
Delirium is a major PTSD risk factor in serious illnesses requiring ICU care, including in ARDS. And there has been growing recognition of a high prevalence of delirium among COVID-19 patients – a large international multi-centre study whose results appeared this month in The Lancet found that delirium was highly prevalent and prolonged in critically ill patients with COVID-19. The study also identifies benzodiazepine use and the lack of family visitation in the ICU as modifiable risk factors for delirium.
Sedative medications and delirium
Herridge is similarly concerned about the medication being used for sedation – out of necessity, but also due to resource challenges. She has noticed that COVID-19 patients are hard to oxygenate, which leads to the use of deep sedation with narcotics and benzodiazepines to intubate and position patients.
“Patients with COVID are very sick. They’re being ‘proned’ a lot. And so they’re really in a deep coma from drugs,” says Herridge. “We really moved away from deep coma in the last, I would say, 15 years in the ICU, but now we’ve really slid way back to the late 1990s when people were just in a coma and it was very bad for their brains, bad for their bodies, and bad for all of these long-term outcomes, including mental health.”
Herridge also worries that staffing shortages and busy ICUs mean that more sedative medication is being used.
“I’m sorry to say that a lot of people increased their restraint use because they didn’t want patients to accidentally extubate themselves or pull out central lines, so they’re being tied down, which is a huge risk factor for PTSD.”
Restricted family support
The other main contributing factor to high rates of delirium and subsequent development of PTSD, she says, is the lack of family support that would traditionally be available to patients in the ICU.
Hospital visitor policies have changed due to infection prevention and control measures, limiting and sometimes entirely restricting family visits at the bedside. Herridge says that as a result, “We’re depriving them of interaction with family members who often will really help ameliorate delirium.”
Herridge is also tracking the outcomes for family members and worries about how their mental health is affected. She says that family members and caregivers of ICU patients are particularly at risk during this time. The CANCOV research project is unique in that it offers clinical follow-up for patients and their families. Herridge says that in her day-to-day clinical work, the top referrals she makes are for mental health care, neurology and for cognitive assessment.
She is worried Canada is not prepared to support this growing population of COVID-19 survivors – particularly in terms of mental health resources, which are already strained.
After COVID-19, “patients can be left with important disabilities that can be lifelong and, similarly, cognitive dysfunctions and very prevalent mood disorders. And the other piece of this is that the family also has been through a traumatic life event.”