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Prevalence, Detection and Treatment of Anxiety, Depression, and Delirium in the Adult Critical Care Unit

Received November 27, 2000; revised April 03, 2001; accepted April 18, 2001. From the Adult Critical Care Unit and the Psychiatry Section, Fundacion Valle del Lili Medical Center, Cali, Colombia. Dr. Unutzer is at UCLA NPI Center for Health Services Research, Los Angeles. Dr. Duran is at the University of Miami Health Psychology Division, Miami, FL. Address correspondence to Dr. Rincon, Jefe Seccion de Psiquiatria, Fundacion Clinica Valle del Lili, Cra. 98 # 18 - 49, Cali, Colombia. E-mail: hernanrincon{at}mail.com

ABSTRACT

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This study assesses the levels of depression, anxiety, and delirium during admission to three adult critical care units (CCU) and the performance of CCU staff with respect to detection and treatment. During a 1-month period, 96 consecutive patients were evaluated on the first day of admission by an independent rater, using the Hospital Anxiety Depression Scale and the Confusional Assessment Method. Frequency of alcohol use and demographic data were recorded. CCU teams rarely made diagnoses of anxiety, depression, or delirium. On at least one screening test, 29.2% of patients were positive. Delirium was present in 7.3%, depression in 13.7%, anxiety in 24%, and possible problem drinking in 37.9%. Although some form of psychiatric treatment was offered to 58%, there was low agreement between psychiatric diagnoses made by the independent rater and the diagnoses made and treatments used by CCU staff. This suggests that the CCU staff are using psychotropic medications without any clear documentation and perhaps clear understanding of the psychiatric diagnoses they are treating. In summary, we found high rates of psychiatric disorders in adult CCU patients but low rates of detection and only moderate rates of treatment by CCU staff.

Key Words: Alcohol • Depression • Mental Disorders • Delirium

INTRODUCTION

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The criteria for admission to an adult critical care unit (CCU) are based on serious medical or surgical disorders, but psychiatric syndromes such as depression, anxiety, and organic disorders specially delirium are also highly prevalent in this setting.¹ The critically ill medical or surgical patient admitted to a CCU is challenged by great physical and emotional stress.^2,3 Such stress can affect all aspects of immunity and induce inappropriate responses of some components of the immune/inflammatory pathway.^4,5 Morbidity, and in some studies mortality, rates have been found to be higher in medical-surgical critical care patients with delirium^2,6 and may be higher with other psychiatric disorders as well. The symptoms of delirium, depression, and anxiety in critically ill patients can be effectively treated through psychiatric interventions,² and some psychosocial interventions have been shown to help "master the medical crisis" of inpatients recovering from surgery and myocardial infarction.⁷ Therefore, systematic psychosocial evaluation and treatment of patients with high levels of stress and psychiatric disorders in CCUs may contribute to improved patient biopsychosocial outcomes.^8,9,10,11

In this prospective cohort study we evaluated psychiatric morbidity (depression, anxiety and delirium) during the early phase of admission to a CCU and the performance of CCU physicians with respect to detection and treatment of these disorders.

METHODS

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Sample and Procedures
Study participants were recruited from 163 consecutive admissions to the Fundación Clínica Valle del Lili (FVL) adult CCU in Cali, Colombia, during a period of 1-month (February 9 through March 8, 1999). The FVL is a 150-bed, private, university-affiliated hospital opened in 1994 and located in the southern Cali (population 2,000,000). The hospital provides tertiary care to the community of Cali and all southwest Colombia. There are three adult CCUs: medical (10 beds), surgical (10 beds), and coronary (7 beds). Patients admitted to FVL belong to all socioeconomic groups and have private insurance or government obligatory health plan coverage. The CCUs have gradually increased their capacity from four total beds available in 1994 to 40 in 1999. Approximately 1,300 patients have been admitted annually in the last 5 years, with a mean length of stay of 4.02 days and an in-hospital mortality rate of 8.9%.

Consultation-liaison (C-L) psychiatrists are available 24 hours a day and the CCU teams can request psychiatric consultation and treatment after detection of a psychiatric syndrome or a behavioral problem. The psychiatrist on call assesses the patient and gives specific treatment recommendations. A C-L psychiatry team (C-L psychiatrist and nurse) provides follow-up. The CCU teams are generally felt to be sensitive to the psychosocial needs of their patients. In 1997, an Intensive and Critical Care Fellowship program that requires a 1-month clerkship in C-L psychiatry was started at the hospital.

Exclusion criteria were structural cerebral damage or excessive sedation resulting in inability to verbally communicate with the interviewer. Of a total of 163 adult patients, 96 were eligible for the study, and all consented to participate. One patient expired before the initial assessment, and the remaining 95 patients were administered two screening tests on their first day of admission. The Hospital Anxiety Depression Scale (HADS)^12,13 was used to detect depression and anxiety symptoms. The HADS was adapted from the Spanish translation¹⁴ and used by one of the authors (HR) in earlier studies with Colombian medical patients.^15,16 The Confusional Assessment Method (CAM)¹⁷ was used to detect delirium. Demographic data and alcohol use history were collected. The use of three or more drinks with a frequency of every 1–8 days was considered positive for "possible problem drinking." In a previous analysis,¹⁸ a CAM score of 4 or more out of 9 possible items was considered positive for delirium. In the present analysis we used the criteria recommended by Inouye of 3 out of 4 specific items positive.¹⁷ A HADS-Depression or HADS-Anxiety score of 10 or more was considered positive for a depressive or anxiety syndrome, respectively.¹² An independent rater (co-author PE) conducted the assessments, and the CCU teams were blind to results.

A structured review of CCU records was used to identify diagnoses of mental disorders made by CCU staff, referrals to psychiatry, and the use of psychotropic medications. Patients who received specific psychiatric diagnoses (anxiety syndrome, depression syndrome or delirium) and treatment and patients for whom a psychiatric condition consultation was requested at the time of assessment were considered to have been detected and to have received psychiatric treatment by the CCU teams. The likelihood of agreement between the CCU teams and the independent rater with regard to the detection of psychiatric disorders was calculated. Medical information to estimate the severity of the patients' medical problems, including an APACHE score, was obtained from an independent database that contained all CCU patient medical information.

Data Analysis
Analyses were performed using SPSS version 8.0. Descriptive analyses were used to describe the frequency of mental disorders, referrals, and treatment provided. Associations and cross-comparisons among three groups were assessed: 1) a group with psychiatric diagnoses made by the independent rater; 2) a group with diagnoses made by the medical team; and 3) a group receiving psychopharmacological drugs prescribed by CCU teams. (Since most patients were receiving benzodiazepines, all patients prescribed with psychotropics were put in this group.) Chi-square tests were calculated to compare observed and expected counts in groups 1 vs. 2, and 1 vs. 3. To further assess the strength of relationships among these same groups, we calculated kappa statistics to examine the correlation between the two different types of raters and the correlation between independent diagnoses and the use of psychotropics. P values were two-tailed and an alpha of 0.05 or less was required for statistical significance of the associations tested.

RESULTS

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All 96 patients who were eligible enrolled in the study and agreed to be tested. Fifty-nine (61.5%) were men, and the mean age was 61 (SD-14.3, range=18–91). The median APACHE score was 7.0 (SD=5.01, range=0–23). Table 1 shows the frequencies of medical-surgical syndromes.

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TABLE 1. Frequencies of medical surgical syndromes in critical care unit patients (n=96)

Ninety-five patients completed the independent assessment, and 29.5% (28/95) were positive on at least one screening test (Table 2). Delirium was present in 7.3% (7/ 95) of patients, a clinically significant depressive syndrome (HADS-D10) was present in 13.7% (13/95), and an anxiety syndrome (HADS-A10) in 24% (23/95). Problem drinking was present in 37.9% (36/95), and 12.6% (12/95) used prescribed or nonprescribed psychoactive drugs, and 1% had a history of mental disorder (1/95).

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TABLE 2. Screening tests results for in critical care unit patients (n=95)

The medical team made specific psychiatric diagnoses in only 9.5% of subjects (9/95); a formal consultation to psychiatry was requested for these cases. Nevertheless, some psychotropic medication was used in 58% of the subjects (55/95). Benzodiazepines were prescribed for 53.6% (51/95) of all patients. The only antipsychotic used was haloperidol in approximately 3% (3/95) of patients. Antidepressants were used in one patient. About 5% (5/95) of patients were taking two psychotropics, and no patients were taking three or more.

Table 3 and Table 4 compare the diagnoses made by independent raters and CCU staff and show the association of diagnoses made by independent raters and the use of psychotropic medications by CCU staff.

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TABLE 3. Relationship between psychiatric diagnoses by independent rater and CCU diagnoses

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TABLE 4. Relationship between psychiatric diagnosis by independent rater and use of psychotropic medications by CCU team

The association between diagnoses made by the independent rater and the CCU staff was not statistically significant (²=3.254; df=1; Fisher's exact test P=0.118). The probability of agreement between the two raters as measured by kappa was not statistically significant (kappa=0.148; SE=0.095; T=1,804; P=0.071). The association between syndromes detected by the independent rater and psychotropic medications prescribed by the medical team was also not statistically significant (²=0.129; df=1; P=0.719; Fisher's exact test = 0.821; kappa=0.31; SE=0.086; T=0.360; P=0.719).

DISCUSSION

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We found a 29.5% combined prevalence of threshold symptoms for anxiety, depression, or delirium in our population. In interpreting these results, we considered that 1) both HADS and CAM are highly sensitive and specific to detect anxiety, depression, and delirium in medical-surgical patients^12,13,17 and 2) our cases of probable depression and anxiety disorders may include some false positives. Nevertheless, in support of our findings, our rates of psychiatric disorders were consistent with other international reports of prevalence of anxiety and depression in CCU patients.¹ The independent rater detected five out of nine patients detected by CCU teams for whom psychiatric referral was requested; it is possible that the other four patients had a treatment already established, thus becoming false negatives. In their study with coronary patients in Toronto, Legault et al.¹ did not report their combined prevalence, but the specific prevalences of anxiety and depression disorder were similar to ours. Both studies were done with critical care patients early after admission but unfortunately using different scales. For example, Legault and colleagues¹ measured cognitive impairment instead of delirium.

Although there was a high rate of mental disorders such as delirium, anxiety, and depressive syndromes in the CCU patients we studied, CCU staff rarely made a formal psychiatric diagnosis and only referred 9.5% of patients for formal psychiatric consultation. They did provide some form of psychiatric treatment in the form of psychotropic medications to 58% of all patients. Most times, however, the staff seemed unaware of specific psychiatric diagnoses, suggesting that they are using standardized protocols or treatment for symptoms without diagnoses as the basis for psychotropic use.

There was low agreement between the detection and treatment of psychiatric disorders by CCU physicians with the results of the screens for psychiatric disorders. Gater et al.¹⁹ reported in a recent study done with medical ward patients that "only 40% of the definite (psychiatric) cases had been noted by the medical staff before the screening procedure." It appears likely that our CCU teams (physicians and nurses) are not sufficiently sensitized to make diagnoses of anxiety, depression, and delirium.

Anxiety is a normal reaction to a stressor like admission to a CCU, and in this study it was the most prevalent diagnosis. However, if anxiety is high, undetected, and untreated, it can be detrimental to a patient's psychological and physical well-being. Anxiety can further contribute to the activation of the stress system in an already highly challenged organism and perhaps cause changes in immunocompetence,^4,5,8 delay in wound healing in surgical patients,^20–22 and increased susceptibility to infections. Legault et al.¹ found that in myocardial infarction patients, higher anxiety levels were associated with increased length of stay in the CCU and hospital. They also found that high anxiety levels in the CCU were associated with higher prevalence of anxiety after 3 months.¹ Because anxiety seems to be highly prevalent in other critical care populations as well, there is a need to study the benefit of using benzodiazepines for patients in this setting as is routinely done in our CCU.²³

Depression in critically ill coronary patients has been found to be associated with higher morbidity and mortality in long-term follow-up. In their study, Legault et al.¹ described that depressed myocardial infarction (MI) patients followed for 3 months reported more global psychosocial dysfunction, greater domestic impairment, and greater social impairment. Frasure-Smith and colleagues^24–27 have shown that "depression while in the hospital after an MI is a significant predictor of 6-, 12- and 18-month post-MI cardiac mortality." The impact of early detection and treatment of depression post-MI is currently being assessed in a multicenter randomized trial. In the mean time, it is important to highlight that depressive and anxiety disorders in general medical patients can contribute to increased health services utilization and decreased compliance with medical treatments.²⁸

Kishi and colleagues⁶ reported that delirium was most frequent on the first day of admission from the emergency room to a CCU in Japan. Like in most studies done with medical surgical patients, they found an association of delirium with an increased length of stay.^6,28,29 Fulop et al.³⁰ reported the importance of early detection of cognitive impairment in geriatric inpatients.

The 38% prevalence of "possible problem drinking" was higher than in reports in the international literature on medical-surgical patients,³¹ but the risk of admission to a hospital is higher in patients who use alcohol.³² Rates of alcohol use in Colombia are high: an estimated 85% of the population uses alcohol, and the prevalence of alcoholism is 12% with an additional 10% at high risk for problem drinking.³³ We did not observe any full alcohol withdrawal syndromes, but it is possible that subthreshold syndromes could have contributed to the presentation of the psychiatric disorders found and the use of benzodiazepines, the most commonly used type of psychotropic medications in this group. There is a need to address this possibility in future studies.

Detection and treatment of psychiatric syndromes such as depression, anxiety, delirium, and alcohol abuse or withdrawal in the CCU is important for psychological, medical, quality-of-life, and economic reasons. A number of studies have attempted to improve care for medical and surgical inpatients with behavioral problems with variable results.^19,34–37 There is consensus that we should detect and treat delirium and depressive symptoms in critical care settings, but to our knowledge there are no published intervention studies with CCU patients. We are currently planning to study a comprehensive treatment approach, which will attempt to prevent, detect, and treat psychiatric symptoms in CCU patients. This will include interventions at different levels: 1) patient and family education before admission (especially among patients receiving elective procedures or when a CCU admission is expected); 2) medical and surgical team training (primary medical-surgical team, anesthesiology team, and CCU team); and 3) early detection and intervention in high-psychosocial-risk patients.

Methodological Limitations
Due to funding constrains, we were limited in the amount of data we could collect. An important strength of this study, however, is that all eligible patients were included. We were not able to perform comprehensive psychiatric assessments to confirm diagnoses, and our screening instruments could have overestimated the prevalence of the syndromes we studied. We also do not have information on psychiatric treatments other than psychotropic medications that were employed by the CCU team or consulting psychiatrists. Due to study methodology, it is possible that patients had been on psychotropic medications up to 24 hours before the assessment done by the independent rater, thus producing a number of false negatives. We also did not measure clinical outcomes, and we do not know if low diagnosis and limited treatment rates were associated with adverse clinical outcomes.

CONCLUSIONS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
We found high rates of psychiatric disorders in adult CCU patients in Cali, Colombia, and only low rates of detection and moderate rates of treatment by CCU staff. Studies of systematic interventions to diagnose and treat such disorders are needed to see if these interventions can improve the care and outcomes of adult CCU patients at a reasonable cost.

ACKNOWLEDGMENTS

 
The authors thank Dr. Marianna Baum and the Fogarty International Training Center at University of Miami for the support, help, and guidance offered to the first author (HR) during the writing of this manuscript.

This work was presented at the Academy of Psychosomatic Medicine 46th annual meeting, New Orleans,LA, November 18–21, 1999.

REFERENCES

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