The ICU is Traumatic For Everyone

A review and argument

Usually, in The Frontier Psychiatrists, we address outpatient medicine. Sometimes, we take a tour of psychiatry's acute care settings. Those are found lacking, for new readers. Today, we venture into the heart of the most complex part of any hospital: the intensive care unit.

Miracles take place there, to be sure, according to a Palliative Care colleague at Hopkins:

We talked about that without the machines and interventions if patient were to survive that would truly be a miracle, but medical staff has intervened to support and sustain patient’s body. It is through our knowledge we can do this. The chaplain once told me that he had a hard time with people talking about miracles as if God were a magician.

Those miracles come at a cost:

A stay in the intensive care unit (ICU) can be traumatic. Patients are confronted with their own mortality. They are rolled in and hooked up to machines. Perhaps they are ventilated or catheterised. They might drift in and out of consciousness, seeing a different set of faces each time they wake. Confusion, sedation, and delirium make it difficult to communicate; intubation makes it impossible. Mysterious alarms ring at strange times. If the stay is long enough, there is likely to be a death, perhaps more than one, elsewhere in the ward. Hallucinations are common, some of which sound like a scene from a horror movie. “I have had patients talk about seeing blood dripping down the walls, or children with no faces.”¹

That is not published in some namby pamby narrative medicine newsletter—it's from The Lancet.

The best-named bookstore in the mission.

The prevalence is common, for example, in those with acute lung injury:

One in three people who survived stays in an intensive care unit (ICU) and required use of a mechanical ventilator showed substantial post-traumatic stress disorder (PTSD) symptoms that lasted for up to two years, according to a new Johns Hopkins study of patients with acute lung injury.²

In an even larger systematic review, the prevalence of PTSD symptoms among patients admitted to the ICU was found to be:

19.83% (95% confidence interval [CI], 16.72–23.13)³

Which works out to 1 in 5 adults who receive care in the intensive care setting.

It Is Not Just The Patients…

The ICU can be a nightmare you can’t unsee, even if you work there. Healthcare workers are also vulnerable to developing symptoms after exposure to an array of human suffering that is not common in the lives of most of us:

Among nurses working in the ICU, the rate of those with PCL-C (a civilian PTSD rating scale) scores in the clinical range (>38) was 22.38% in a sample of 150 ICU nurses.⁴ This trend accelerated with the pandemic. Before COVID-19, PTSD was highly prevalent in ICU workers:

studies conducted before the Covid period show the prevalence of PTSD in ICU professionals ranging from 3.3% to almost 24%⁵

After the nightmare of COVID-19, the rates skyrocketed among ICU workers:

the prevalence of PTSD has increased to 73.3% among intensive care professionals⁶

I did a podcast about this phenomenon during the pandemic:

It’s Worse than a Warzone?

To put those numbers among health professionals in context, the rate of PTSD among Vietnam Veterans was around 30%.⁷. Another high trauma groups are police officers. When using the VA-recommended cut-off on the PCL-C of 33 or above, the rates of PTSD among that cohort were found to be:

15.0% of men and 18.2% of women had PTSD.⁸

The Cost of Those Miracles is Trauma for Patients and Healers Alike

The ICU allows us to save lives that we’d lose otherwise. So, for that matter, can war. Neither should be entered into lightly. It makes sense to think about how we can prevent or treat the trauma that predictably occurs in high-risk populations. In healthcare, the ICU is ground zero.

I will highlight a few of the technologies that I see as plausibly useful on the horizon for healing the minds and hearts of individuals injured by trauma:

1. Magnesium-Ibogaine just had remarkable data published in nature medicine⁹. I senior authored a review on the topic for an audience of primary care colleagues (in preprint now.)

2. MDMA has been submitted to the FDA for PTSD by newly-rebranded Lykos Therapeutics. My co-authors and I have another review on that topic for primary care colleagues (in preprint now).

3. Psilocybin analog COMP360 has Phase IIb safety data announced—with more data coming—for PTSD.

4. The Nightware device is an FDA-cleared breakthrough treatment for nightmares, including those from PTSD.

5. The FDA-cleared breakthrough PRISM system from GreyMatters Health uses EEG Neurofeedback—trained on fMRI data— to relieve PTSD symptoms. This month, we launch this treatment at Fermata (my practice and CRO)!

6. EMDR therapy has data for PTSD— as discussed with

   @Psych Fox
   in this recent podcast:

7. The GammaCore device has been submitted for FDA-Breakthrough status for PTSD. It’s already FDA-cleared in headaches and is available at my practice now!

The options are increasing. We need them.

1. Post-traumatic stress in the intensive care unit, Burki, Talha Khan, The Lancet Respiratory Medicine, Volume 7, Issue 10, 843 - 844, https://doi.org/10.1016/S2213-2600(19)30203-6

2. https://www.hopkinsmedicine.org/news/media/releases/ptsd_symptoms_common_among_icu_survivors

3. Righy, C., Rosa, R. G., Kochhann, R., Migliavaca, C. B., Robinson, C. C., Teche, S. P., Teixeira, C., Bozza, F. A., & Falavigna, M. (2019). Prevalence of post-traumatic stress disorder symptoms in adult critical care survivors: A systematic review and meta-analysis. Critical Care, 23. https://doi.org/10.1186/s13054-019-2489-3

4. Li, P., Kuang, H., & Tan, H. (2021). The occurrence of post-traumatic stress disorder (PTSD), job burnout, and its influencing factors among ICU nurses. American Journal of Translational Research, 13(7), 8302-8308. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8340215/

5. Crowe S, Howard AF, Vanderspank-Wright B, Gillis P, McLeod F, Penner C, et al. The effect of COVID-19 pandemic on the mental health of Canadian critical care nurses providing patient care during the early phase pandemic: a mixed method study. Intensive Crit Care Nurs. 2021;63:102999.

6. McMeekin DE, Hickman RL, Douglas SL, Kelley CG. Stress and coping of critical care nurses after unsuccessful cardiopulmonary resuscitation. Am J Crit Care. 2017;26:128–35.

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1. U.S. Department of Veterans Affairs. VA research on Vietnam Veterans.

2. Marmar CR, Schlenger W, Henn-Haase C, et al. Course of Posttraumatic Stress Disorder 40 Years After the Vietnam War: Findings From the National Vietnam Veterans Longitudinal Study. JAMA Psychiatry. 2015;72(9):875–881. doi:10.1001/jamapsychiatry.2015.0803

8. Hartley, T. A., Sarkisian, K., Violanti, J. M., Andrew, M. E., & Burchfiel, C. M. (2013). PTSD Symptoms Among Police Officers: Associations With Frequency, Recency, And Types Of Traumatic Events. International Journal of Emergency Mental Health, 15(4), 241. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4734407/

9. Cherian, K. N., Keynan, J. N., Anker, L., Faerman, A., Brown, R. E., Shamma, A., Keynan, O., Coetzee, J. P., Batail, J., Phillips, A., Bassano, N. J., Sahlem, G. L., Inzunza, J., Millar, T., Dickinson, J., Rolle, C. E., Keller, J., Adamson, M., Kratter, I. H., . . . Williams, N. R. (2024). Magnesium–ibogaine therapy in veterans with traumatic brain injuries. Nature Medicine, 1-9. https://doi.org/10.1038/s41591-023-02705-w