Post-Traumatic Stress Disorder after Intensive Care Unit Discharge: Prevalence and Impact on Quality of Life

Research Article

Austin Crit Care J. 2019; 6(1): 1029.

Post-Traumatic Stress Disorder after Intensive Care Unit Discharge: Prevalence and Impact on Quality of Life

Julie Fauroux, Yannis Bornemann, Isabelle Desmeulles, Désiré Samba, Gérald Viquesnel, Frédéric Ethuin, Jean-Luc Hanouz, Véronique Pottier*

Department of Anesthesia and Surgical Intensive Care, Caen University Hospital, France

*Corresponding author: Véronique Pottier, Department of Anesthesia and Surgical Intensive Care, Caen University Hospital, 14033 Caen Cedex, France

Received: October 30, 2019; Accepted: November 28, 2019; Published: December 05, 2019


Background: Hospitalization in ICU is a trauma leading to Post Traumatic Stress Disorder (PTSD). The objective is to determine the prevalence of PTSD and its impact on quality of life.

Methods: Survivors of a before and after prospective study assessing the impact of a nurse implemented sedation algorithm on the outcome after the ICU stay, were followed up with by a phone survey.

Results: A total of 1156 ventilated patients were admitted during the study period. Among the 145 included patients, 47 died and 35 were lost or declined follow-up. Only 62 patients accepted it at 3 months (42.8%), 55 at 6 months (37.9%) and 42 at one year (29%). The prevalence of PTSD was 12.9 % at 3 months, 10.9 % at 6 months and 16.7 % at one year. ICU stay had a moderate impact on quality of life at 3 months, 6 months and 1 year. Approximately 10 % of patients had a severe impact on their quality of life at ICU discharge, up to one year. PTSD at 3 months was significantly higher than in the « before » period. There was no difference at 6 months or 1 year, nor was there a significant difference in quality of life between these 2 periods.

Conclusions: Improving the quality of care in the ICU should also take into consideration the possible deleterious consequences of the ICU stay. Follow-up is paramount in patients at risk, and increased efforts at improving their quality of life after ICU discharge are needed.

Keywords: Post-Traumatic Stress disorder; Quality of life; Impact; Delirium


PTSD: Post-Traumatic Stress Disorder; ICU: Intensive Care Unit; RASS: Richmond Agitation-Sedation Scale; BPS: Behavior Pain Scale; PTSS-10: Post-Traumatic Stress Syndrome 10-Question Inventory; SAPS II: Simplified Acute Physiology Score II


Hospitalization in the ICU department implies the use of invasive therapeutics that can be perceived as aggressive by the patient and can constitute physical or psychological pain. There are multiple sources of discomfort: noise, light, lack of sleep, pain, and patient’s misunderstanding of the environment. All of these factors can lead to Post-Traumatic Stress Disorder (PTSD) [1].

PTSD arises after an aggression. Clinical findings include symptoms of intrusion (repetitive, intrusive memories), symptoms of avoidance (avoidance of the situation, relational disorder) and neurovegetative symptoms (anger, hypervigilance and insomnia).

The prevalence of PTSD prevalence is approximately 1.2% in men and 2.7% in women [2], and can be the consequence of ICU stay trauma [3,4]. The « expected » prevalence of PTSD months after ICU discharge is approximately 14 to 41% [4-9], and a quarter of patients suffer from psychological disorders one year after ICU discharge.10 PTSD can remain many years after the ICU stay [7-11].

Psychiatric history, particularly an anxious or depressive state, high benzodiazepine consumption, frightening or psychotic experiences during the ICU stay, and delirium are documented risks factors for PTSD.8 [12-14], Other debated factors include female sex, young age, duration of mechanical ventilation and length of stay as well as agitation, physical restraint, and opioid administration [12].

Since its definition by the World Health Organization in 1994, quality of life has become a major tool for the evaluation of therapeutic effects. Patients and physicians strive for not only a longer life, but a better life.

Our objective was to evaluate the prevalence of PTSD after ICU stay and its impact on quality of life at 3 months, 6 months, and one year after discharge.

Materials and Methods

We conducted a prospective, « Before-After » interventional study in the 26-bed surgical ICU of Caen University Hospital between November 2014 and April 2017. The study was approved by the local Ethical Committee (CPP Nord Ouest III, CHU de Caen, Caen, France) under the number A14-D65-VOL.23 on December 06, 2014. The committee considered it as part of routine practice, and patient approval was not required. However, written information was systematically given to each included patient or to their next of kin. The study is recorded in ClinicalTrials with the number NCT03186521.

Inclusion criteria

Patients were included in our before/after study, entitled « ALGOSEDA », which assessed the impact of a sedation-analgesia titration algorithm in a nursing-managed surgical ICU on the complications of critical illness and on the outcome after the ICU stay. Our work concerns the second part of the study, the complications after ICU discharge. In « ALGOSEDA », patients aged 18 years or older, admitted to the ICU, and anticipated to require more than 48 hours of sedation and analgesia were eligible and assessed for enrollment.

Non-inclusion criteria

Patients were not eligible if they were under guardianship or ‹ 18 years of age, pregnant, under palliative care, experiencing brain injury, presenting with an initial Glasgow Coma score ‹ 14, receiving neuromuscular blocking agents at the time of enrollment, under therapeutic sedation (acute respiratory distress syndrome, acute severe asthma, intracranial hypertension, etc.), or admitted following resuscitated cardiac arrest.

Exclusion criteria

Patients were excluded from the study if they were extubated or dead within 48 hours after inclusion.

Study protocol

« Before » Period: Sedation and analgesia was exclusively managed by the attending physician and guided by the Richmond Agitation-Sedation Scale (RASS) [15,16] and Behavior Pain Scale (BPS) [17] and recorded every 4 hours by nurses. The dosage and choice of hypnotic drug (Propofol® or Midazolam®) was at the discretion of the physician, and the only opioid used was Sufentanil®.

« After » Period: Following medical prescription, the patient’s sedation and analgesia was managed by the ICU nurses according to the protocol displayed in each bedroom.

Every patient included in ALGOSEDA whether in the « Before » period or « After » period were contacted by phone and asked to answer two surveys at 3 months, 6 months and one year after ICU discharge.

Data collection

Booklets dedicated to the « ALGOSEDA » study were edited and completed by the department’s internal or principal investigators of the study. The anonymized data were recorded on an eCRF platform based on OpenClinica® (Open Clinica, LLC, Waltham, Massachusetts, USA).

The parameters collected and calculated were:

1) New hospitalization since ICU discharge

2) Psychotropic drug use since ICU discharge

3) PTSD assessed by Post-Traumatic Stress Syndrom-10 (PTSS- 10) [18]

4) Quality of life assessed by the WHOQOL-BREF19

PTSD was diagnosed using the Post-Traumatic Stress Syndrome 10-Question Inventory (PTSS-10) [18]. It includes ten items assessing symptoms of intrusion, avoidance and neuro-vegetative behavior related to PTSD. Each item is scored from 1 (never) to 7 points (always) with a total score ranging from 10 to 70. PTSD is defined by a score ≥ 35 (Appendix 1). PTSS-10 has a good sensibility (77%) and good specificity (97.5%) and is valid for ICU patients.

The WHOQOL-BREF is a subjective self-assessed scale of quality of life. It has been tested considerably in the French population [19]. We used the short (26 items) and more recent (2004) version of the WHOQOL-100 (WHOQOL group 1998). The WHOQOL-BREF produces a quality of life profile.

The WHOQOL-BREF is therefore based on a four-domain structure.

-Physical health (7 items): Activities related to daily living, dependence on medicinal substances and medical aids, energy and fatigue, mobility, pain and discomfort, sleep and rest, and work capacity.

-Psychological health (6 items): Body image and appearance, negative feelings, positive feelings, self-esteem, spirituality, religion, personal beliefs, thinking, learning, memory and concentration.

-Social relationships (3 items): Personal relationships, social support, sexual activity.

-Environment (8 items): Financial resources, freedom, physical safety and security, health and social care: accessibility and quality, home environment, opportunities for acquiring new information and skills, participation in and opportunities for recreation, leisure activities, physical environment (pollution/noise/traffic/climate), transport.

There are also two items that are examined separately: question 1 asks about an individual’s overall perception of quality of life and question 2 asks about an individual’s overall perception of their health.

The quotation is made on a scale of 5 points, allowing an evaluation of the intensity (« not at all-extremely »), the capacity (« not at allcompletely »), the frequency (« never-always »), the evaluation (« very satisfied/unsatisfied; very good/bad »). The final score varies from 26 to 130 (Appendix 2).

The impact of PTSD on the quality of life is split into three categories according to the severity of the damage. A score between 26 and 61 is considered as a severe impact on the quality of life, the impact is considered moderate between 62 and 96, and the impact is considered minor between 97 and 130.

Statistical analysis

Quantitative data are expressed as the mean ± SD, or median with confidence intervals at 95 % [CI 95 %] according to the normality of their distribution and were compared using the Mann–Whitney nonparametric U test when data were not normally distributed, or Student’s t-test for normally distributed data. Qualitative data are expressed as percentages and were compared using the Fisher’s exact test when data were not normally distributed, or the Chi-squared test for normally distributed data.

The normality of the distribution was determined by the D’Agostino-Pearson test. The level of significance was set at p ‹ 0.05 between the two tested periods (before/after).

All statistical analyses were performed with software R 3.4.0: A Language and Environment for Statistical Computing (R Foundation for Statistical Computing ©, Vienna, Austria).


A flow chart of the study design is depicted in Figure 1. During the study period, 1156 intubated and mechanically ventilated patients were admitted to the surgical ICU of Caen University Hospital. Among the 145 eligible patients (12.5%), 47 patients died, and 36 patients were lost to follow-up before the 3rd month call or they refused to answer. Only 62 patients accepted the follow-up at 3 months, 55 patients accepted at 6 months and 42 patients accepted at one year.