Original article
Depression following critical illness: Analysis of incidence and risk factors
Journal of the Intensive Care Society 2015, Vol. 16(2) 105–108 ! The Intensive Care Society 2014 Reprints and permissions: sagepub.co.uk/ journalsPermissions.nav DOI: 10.1177/1751143714559904 jics.sagepub.com
Ceri Battle, Karen James and Paul Temblett
Abstract Purpose: Depression is common in ICU survivors and is known to negatively affect health-related quality of life. The reported risk factors for depression include increasing age, gender and hospital and ICU length of stay. The aim of this study was to investigate the risk factors for depression in survivors of critical illness. Materials and methods: Patients attending the ICU Follow-up Clinic completed the Hospital Anxiety and Depression Scale and data were also collected from their medical records. Risk factors investigated included age, gender, Apache II score, ICU length of stay and a diagnosis of sepsis during ICU admission. Results: A total of 63 patients participated, with 29 (46%) patients suffering with depression. On multivariable logistic regression, the only significant risk factor for depression was sepsis (p < 0.05, odds ratio: 6.8; 95% CI: 1.8–25.8). Age, gender and ICU length of stay were not found to be risk factors for depression. Conclusions: There are a number of potential causative factors as to why sepsis would cause long-term depression and this needs further investigation.
Keywords Depression, critical illness, incidence, risk factors, sepsis
Introduction Intensive care medicine involves the treatment of critically ill patients with acute physiological derangement and organ failure. Critical illness is now well recognised as being associated with a number of detrimental long-term sequelae that can affect healthrelated quality of life for up to five years following ICU discharge.1 These sequelae include cognitive impairment, depression, post-traumatic stress disorder and functional disabilities and are now collectively labelled ‘post-intensive care syndrome’.2 Depression is common in general ICU survivors and is known to negatively affect health related quality of life.2–5 A postal questionnaire study of patients who had previously been treated in a general adult intensive care unit (reported) stated that 38 (47%) of 80 patients who returned fully completed questionnaires reported clinically significant anxiety and depression as measured by the Hospital Anxiety and Depression Scale.6 In a recent study by Jackson et al., depression was reported to be five times more common than post-traumatic stress disorder after critical illness.7 It was also highlighted that the depression
was driven by somatic symptoms such as weakness, appetite change or fatigue, suggesting approaches targeting physical rather than cognitive causes could benefit patients leaving critical care.7 The reported risk factors for depression include levels of the personality trait optimism, surgery and depression early during intensive care admission.3,4 Rattray et al. highlighted that increasing age, gender and hospital and ICU length of stay (LOS) were related to negative emotional outcomes post discharge.5 In a recent study, APACHE II scores were reported to positively correlate with depression following critical illness.8 The same study found that adverse social and economic status is associated with higher rates of depression following ICU stay.8 Iwashyna et al.9 recently highlighted an increased prevalence of moderate to severe cognitive impairment after sepsis and critical illness. Cognitive
Ed Major Critical Care Unit, Morriston Hospital, Swansea, UK Corresponding author: Ceri Battle, Physiotherapy Dept, Morriston Hospital, Swansea, SA6 6NL, UK. Email: [email protected]
106
Journal of the Intensive Care Society 16(2)
impairment is associated with psychological morbidity including anxiety and depression.10 The aim of this study was to investigate the risk factors for depression in survivors of critical illness.
Methods The South West Wales Research Ethics Committee (REC) deemed this study to be service evaluation and, as such, REC approval was not needed; Health Board Caldicott Guardian approval was obtained for publication of the study findings. Patients who had been treated on the general ICU in Morriston Hospital for four days or more were invited to attend the multidisciplinary follow-up clinic. On attendance at the clinic, patients completed the Hospital Anxiety and Depression Scale (HADS).11 The HADS is commonly used in hospital settings as a screening instrument for anxiety and depression. It does not contain questions pertaining to somatic complaints and as a result it is less likely to be confounded by the direct effects of medical conditions.6 Both of the subscales (one for depression and one for anxiety) have threshold scores (>8) above which a clinical disorder is likely.11 For the purpose of this study, if a patient scored >8 on the depression subscale, they were considered to suffer with depression.
Only patients aged 18 years or more, who were at least three months post-ICU discharge, were included in the study in order to assess ‘longer term’ outcomes. Data including demographics, co-morbidity and primary diagnosis on ICU admission, need for mechanical ventilation and risk factors were also collected from their medical records during the clinic. Risk factors investigated were selected a priori, based on prior research findings and included age, Apache II score on ICU admission, ICU LOS and a diagnosis of sepsis during ICU admission. ICU LOS was defined as the number of whole days the patient was managed on ICU or the high dependency unit. The diagnosis of sepsis was given from the patients’ medical records using the definition provided by the ‘Surviving Sepsis Campaign’ (2008).12 Baseline characteristics were presented as median and 25th and 75th interquartile range (due to nonnormal distributions) for the continuous variables and numbers and percentages for categorical variables. Differences between the baseline characteristics were analysed using Mann–Whitney U test (continuous variables) and Fisher’s Exact test (categorical variables). Odds ratios and 95% confidence intervals were presented from the univariate analysis. All prognostic variables were included in final analysis. Multivariable logistic regression analysis was used to
Table 1. Patients’ demographics, risk factors and results of univariate analysis. Data are presented as number (%) or median (IQR).
Sex Male Pre-existing co-morbidity Respiratory Cardiovascular Neurological Renal Depression Other Primary diagnosis Respiratory Surgical Cardiac Trauma Other Mechanical ventilation Risk factors Age Sepsis APACHE II ICU LOS
Total patients (n ¼ 63)
No depression n ¼ 34 (54%)
Depression n ¼ 29 (46%)
p-value
35 (56%)
18 (53%)
17 (59%)
0.80
25 24 6 12 6 9
(40%) (38%) (9%) (20%) (10%) (14%)
15 14 3 8 1 4
(44%) (41%) (9%) (24%) (3%) (12%)
10 10 3 4 5 5
(34%) (34%) (10%) (14%) (17%) (17%)
0.45 0.61 1.00 0.36 0.08 0.72
20 19 8 7 9 50
(32%) (30%) (13%) (11%) (14%) (79%)
11 12 4 4 5 25
(33%) (35%) (12%) (12%) (15%) (73%)
9 8 4 3 4 25
(31%) (28%) (14%) (10%) (14%) (86%)
1.00 0.59 1.00 1.00 1.00 0.35
66 23 17 7
(49–76) (37%) (11–20) (4–19)
66 8 17 9
(49–75) (24%) (10–19) (4–21)
66 15 17 7
(53–79) (52%) (11–21) (5–9)
0.59 0.02 0.78 0.23
CI: confidence intervals; ICU LOS: intensive care unit length of stay; OR: odds ratio.
Unadjusted OR (95%CI)
1.0 3.5 1.0 1.0
(0.9–1.0) (1.2–10.2) (0.9–1.1) (0.9–1.1)
107 Table 2. Risk factors and their adjusted odds ratios for depression in survivors of critical illness. Risk factor
Adjusted OR (95%CI)
p-value
Age APACHE II score ICU LOS Sepsis
1.0 1.0 0.9 6.8
0.99 0.51 0.05 0.005
(0.9–1.0) (0.9–1.1) (0.9–1.0) (1.8–25.8)
CI: confidence intervals; ICU LOS: intensive care unit length of stay; OR: odds ratio.
identify significant predictors using the likelihood test statistic. For the categorical variables, the data were coded with a ‘1’ if the variable was present and a ‘0’ if absent. Age, APACHE II score and ICU LOS were analysed as continuous variables. Adjusted odds ratios and the 95% confidence intervals were calculated for each risk factor. Statistical significance for the identification of independent risk factors was set at p < 0.05. There was less than 1% missing data, therefore we used a simple imputation of the mean method to avoid exclusion of patients from the final analysis.13 Statistical analyses were performed using SPSS Version 20 (Chicago, Illinois, USA).
Results A total of 63 patients participated in this study. The median age of the patients was 66 years and 56% were male. No statistical difference was reported in the demographic data, including pre-existing comorbidity, primary reason for admission or whether the patient received mechanical ventilation during their stay. Depression was reported in 46% of all patients completing the HADS. On univariate analysis, the only significant risk factor for depression in survivors of critical illness was a diagnosis of sepsis during ICU admission. Table 1 highlights the demographic data and risk factors with their unadjusted odds ratios (95% confidence intervals). The results of the multivariable analysis are highlighted in Table 2. The only risk factor for depression in survivors of critical illness was sepsis.
Discussion The aim of the study was to investigate the incidence of depression and its risk factors in survivors of critical illness. The rate of depression in this study was 46% which is similar to that reported by Scragg et al.6 The results of the study highlighted that the only risk factor for depression in survivors of critical illness was a diagnosis of sepsis during the ICU admission. Age, APACHE II score and ICU LOS were not found to be significant risk factors in this study as reported in the study by Rattray et al.5
The reasons for sepsis causing depression in critical illness survivors are unclear and further research is needed in this field in order to fully understand the mechanisms responsible. Depression may occur as a consequence of the inflammation or neurotransmitter imbalances caused by sepsis. This inflammation may lead to a breakdown in the blood–brain barrier, which alters the impact on the brain of certain medications commonly prescribed on ICU such as opiates and sedatives. More recent research has suggested that long-term depression may be caused by more somatic symptoms such as fatigue and physical disability, rather than the previously thought cognitive symptoms.7 These somatic symptoms may be more appropriately addressed with interventions such as rehabilitation programmes, rather than the use of antidepressant medications commonly used in survivors of critical illness. Knowledge of the risk factors for long-term depression in critical illness survivors allows clinicians to target these patients in their ICU followup clinics. NICE83 Rehabilitation after Critical Illness guideline (2009) recommends that multidisciplinary rehabilitation was provided for all patients, from ICU admission through to post-hospital discharge.14 The guidelines specifically stated that at hospital discharge patients are referred to appropriate rehabilitation services if ongoing needs are identified. Following this at two to three months post-hospital discharge, a review and functional reassessment of the patient should be undertaken to determine the extent of recovery and identify and address any new physical and/or psychological morbidity.14 The results of this study suggest that sepsis patients should be targeted, or at least considered, for attendance at follow-up services. There are a number of limitations to this study which should be considered when interpreting the study findings. It is possible that the patients’ scores for depression were a reflection of their physical disability that is well recognised in survivors of critical illness. While the HADS is a validated screening tool for patients, a more specific tool for diagnosing depression would improve the strength of the study findings. In order to address these limitations, a further study could be conducted in which the patient is interviewed in order to gain more in-depth knowledge into the patients’ condition. Another limitation of this study is that there may have been other confounding variables that influenced the study’s results that were not included in the analysis.
Conclusions The results of this study demonstrate that sepsis is a potential risk factor for depression in survivors of critical illness at three months post-hospital discharge. Knowledge of the risk factors for poor psychological status in critical illness survivors assists the clinician in
108 deciding which patients should be targeted in ICU follow-up clinics. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References 1. Cuthbertson BH, Roughton S, Jenkinson D, et al. Quality of life in the five years after intensive care: a cohort study. Crit Care 2010; 14: R6. 2. Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference. Crit Care Med 2012; 40: 502–509. 3. Myhren H, Ekeberg O, Tøien K, et al. Posttraumatic stress, anxiety and depression symptoms in patients during the first year post intensive care unit discharge. Crit Care 2010; 14: R14. 4. Davydow DS, Gifford JM, Desai SV, et al. Depression in general intensive care unit survivors: a systematic review. Int Care Med 2009; 35: 796–809. 5. Rattray JE, Johnston M and Wildsmith JA. Predictors of emotional outcomes of intensive care. Anaesthesia 2005; 60: 1085–1092.
Journal of the Intensive Care Society 16(2) 6. Scragg P, Jones A and Fauvel N. Psychological problems following ICU treatment. Anaesthesia 2001; 56: 9–14. 7. Jackson JC, Pandharipande PP, Girard TD, et al. Depression, posttraumatic stress disorder, and functional disability in survivors of critical illness in the BRAIN-ICU study: a longitudinal cohort study. Lancet Respir Med 2015; 2: 369–379. 8. Kowalczyk M, Nestorowicz A, Fijalkowska A, et al. Emotional sequelae among survivors of critical illness: a long-term retrospective study. Eur J Anaesthesiol 2013; 30: 111–118. 9. Iwashyna TJ, Ely EW, Smith DM, et al. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 2010; 304: 1787–1794. 10. Wilcox ME, Brummel NE, Archer K, et al. Cognitive dysfunction in ICU patients: risk factors, predictors, and rehabilitation interventions. Crit Care Med 2013; 41: S81–98. 11. Zigmond AS and Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983; 67: 361–370. 12. Surviving Sepsis Campaign. Institute for Healthcare Improvement, http://www.survivingsepsis.org/About_ the_Campaign/Documents/sepsisdefinitionsihitool.pdf (2008, acccessed 16 June 2014). 13. Bouwmeester W, Zuithoff NPA, Mallett S, et al. Reporting and methods in clinical prediction research: a systematic review. PLoS Med 2012; 9: e1001221. 14. NICE. (2009). Rehabilitation after critical illness NICE Clinical Guideline 83. London, UK: National Institute for Health and Clinical Excellence, 2009.
Depression following critical illness: Analysis of incidence and risk factors
Journal of the Intensive Care Society 2015, Vol. 16(2) 105–108 ! The Intensive Care Society 2014 Reprints and permissions: sagepub.co.uk/ journalsPermissions.nav DOI: 10.1177/1751143714559904 jics.sagepub.com
Ceri Battle, Karen James and Paul Temblett
Abstract Purpose: Depression is common in ICU survivors and is known to negatively affect health-related quality of life. The reported risk factors for depression include increasing age, gender and hospital and ICU length of stay. The aim of this study was to investigate the risk factors for depression in survivors of critical illness. Materials and methods: Patients attending the ICU Follow-up Clinic completed the Hospital Anxiety and Depression Scale and data were also collected from their medical records. Risk factors investigated included age, gender, Apache II score, ICU length of stay and a diagnosis of sepsis during ICU admission. Results: A total of 63 patients participated, with 29 (46%) patients suffering with depression. On multivariable logistic regression, the only significant risk factor for depression was sepsis (p < 0.05, odds ratio: 6.8; 95% CI: 1.8–25.8). Age, gender and ICU length of stay were not found to be risk factors for depression. Conclusions: There are a number of potential causative factors as to why sepsis would cause long-term depression and this needs further investigation.
Keywords Depression, critical illness, incidence, risk factors, sepsis
Introduction Intensive care medicine involves the treatment of critically ill patients with acute physiological derangement and organ failure. Critical illness is now well recognised as being associated with a number of detrimental long-term sequelae that can affect healthrelated quality of life for up to five years following ICU discharge.1 These sequelae include cognitive impairment, depression, post-traumatic stress disorder and functional disabilities and are now collectively labelled ‘post-intensive care syndrome’.2 Depression is common in general ICU survivors and is known to negatively affect health related quality of life.2–5 A postal questionnaire study of patients who had previously been treated in a general adult intensive care unit (reported) stated that 38 (47%) of 80 patients who returned fully completed questionnaires reported clinically significant anxiety and depression as measured by the Hospital Anxiety and Depression Scale.6 In a recent study by Jackson et al., depression was reported to be five times more common than post-traumatic stress disorder after critical illness.7 It was also highlighted that the depression
was driven by somatic symptoms such as weakness, appetite change or fatigue, suggesting approaches targeting physical rather than cognitive causes could benefit patients leaving critical care.7 The reported risk factors for depression include levels of the personality trait optimism, surgery and depression early during intensive care admission.3,4 Rattray et al. highlighted that increasing age, gender and hospital and ICU length of stay (LOS) were related to negative emotional outcomes post discharge.5 In a recent study, APACHE II scores were reported to positively correlate with depression following critical illness.8 The same study found that adverse social and economic status is associated with higher rates of depression following ICU stay.8 Iwashyna et al.9 recently highlighted an increased prevalence of moderate to severe cognitive impairment after sepsis and critical illness. Cognitive
Ed Major Critical Care Unit, Morriston Hospital, Swansea, UK Corresponding author: Ceri Battle, Physiotherapy Dept, Morriston Hospital, Swansea, SA6 6NL, UK. Email: [email protected]
106
Journal of the Intensive Care Society 16(2)
impairment is associated with psychological morbidity including anxiety and depression.10 The aim of this study was to investigate the risk factors for depression in survivors of critical illness.
Methods The South West Wales Research Ethics Committee (REC) deemed this study to be service evaluation and, as such, REC approval was not needed; Health Board Caldicott Guardian approval was obtained for publication of the study findings. Patients who had been treated on the general ICU in Morriston Hospital for four days or more were invited to attend the multidisciplinary follow-up clinic. On attendance at the clinic, patients completed the Hospital Anxiety and Depression Scale (HADS).11 The HADS is commonly used in hospital settings as a screening instrument for anxiety and depression. It does not contain questions pertaining to somatic complaints and as a result it is less likely to be confounded by the direct effects of medical conditions.6 Both of the subscales (one for depression and one for anxiety) have threshold scores (>8) above which a clinical disorder is likely.11 For the purpose of this study, if a patient scored >8 on the depression subscale, they were considered to suffer with depression.
Only patients aged 18 years or more, who were at least three months post-ICU discharge, were included in the study in order to assess ‘longer term’ outcomes. Data including demographics, co-morbidity and primary diagnosis on ICU admission, need for mechanical ventilation and risk factors were also collected from their medical records during the clinic. Risk factors investigated were selected a priori, based on prior research findings and included age, Apache II score on ICU admission, ICU LOS and a diagnosis of sepsis during ICU admission. ICU LOS was defined as the number of whole days the patient was managed on ICU or the high dependency unit. The diagnosis of sepsis was given from the patients’ medical records using the definition provided by the ‘Surviving Sepsis Campaign’ (2008).12 Baseline characteristics were presented as median and 25th and 75th interquartile range (due to nonnormal distributions) for the continuous variables and numbers and percentages for categorical variables. Differences between the baseline characteristics were analysed using Mann–Whitney U test (continuous variables) and Fisher’s Exact test (categorical variables). Odds ratios and 95% confidence intervals were presented from the univariate analysis. All prognostic variables were included in final analysis. Multivariable logistic regression analysis was used to
Table 1. Patients’ demographics, risk factors and results of univariate analysis. Data are presented as number (%) or median (IQR).
Sex Male Pre-existing co-morbidity Respiratory Cardiovascular Neurological Renal Depression Other Primary diagnosis Respiratory Surgical Cardiac Trauma Other Mechanical ventilation Risk factors Age Sepsis APACHE II ICU LOS
Total patients (n ¼ 63)
No depression n ¼ 34 (54%)
Depression n ¼ 29 (46%)
p-value
35 (56%)
18 (53%)
17 (59%)
0.80
25 24 6 12 6 9
(40%) (38%) (9%) (20%) (10%) (14%)
15 14 3 8 1 4
(44%) (41%) (9%) (24%) (3%) (12%)
10 10 3 4 5 5
(34%) (34%) (10%) (14%) (17%) (17%)
0.45 0.61 1.00 0.36 0.08 0.72
20 19 8 7 9 50
(32%) (30%) (13%) (11%) (14%) (79%)
11 12 4 4 5 25
(33%) (35%) (12%) (12%) (15%) (73%)
9 8 4 3 4 25
(31%) (28%) (14%) (10%) (14%) (86%)
1.00 0.59 1.00 1.00 1.00 0.35
66 23 17 7
(49–76) (37%) (11–20) (4–19)
66 8 17 9
(49–75) (24%) (10–19) (4–21)
66 15 17 7
(53–79) (52%) (11–21) (5–9)
0.59 0.02 0.78 0.23
CI: confidence intervals; ICU LOS: intensive care unit length of stay; OR: odds ratio.
Unadjusted OR (95%CI)
1.0 3.5 1.0 1.0
(0.9–1.0) (1.2–10.2) (0.9–1.1) (0.9–1.1)
107 Table 2. Risk factors and their adjusted odds ratios for depression in survivors of critical illness. Risk factor
Adjusted OR (95%CI)
p-value
Age APACHE II score ICU LOS Sepsis
1.0 1.0 0.9 6.8
0.99 0.51 0.05 0.005
(0.9–1.0) (0.9–1.1) (0.9–1.0) (1.8–25.8)
CI: confidence intervals; ICU LOS: intensive care unit length of stay; OR: odds ratio.
identify significant predictors using the likelihood test statistic. For the categorical variables, the data were coded with a ‘1’ if the variable was present and a ‘0’ if absent. Age, APACHE II score and ICU LOS were analysed as continuous variables. Adjusted odds ratios and the 95% confidence intervals were calculated for each risk factor. Statistical significance for the identification of independent risk factors was set at p < 0.05. There was less than 1% missing data, therefore we used a simple imputation of the mean method to avoid exclusion of patients from the final analysis.13 Statistical analyses were performed using SPSS Version 20 (Chicago, Illinois, USA).
Results A total of 63 patients participated in this study. The median age of the patients was 66 years and 56% were male. No statistical difference was reported in the demographic data, including pre-existing comorbidity, primary reason for admission or whether the patient received mechanical ventilation during their stay. Depression was reported in 46% of all patients completing the HADS. On univariate analysis, the only significant risk factor for depression in survivors of critical illness was a diagnosis of sepsis during ICU admission. Table 1 highlights the demographic data and risk factors with their unadjusted odds ratios (95% confidence intervals). The results of the multivariable analysis are highlighted in Table 2. The only risk factor for depression in survivors of critical illness was sepsis.
Discussion The aim of the study was to investigate the incidence of depression and its risk factors in survivors of critical illness. The rate of depression in this study was 46% which is similar to that reported by Scragg et al.6 The results of the study highlighted that the only risk factor for depression in survivors of critical illness was a diagnosis of sepsis during the ICU admission. Age, APACHE II score and ICU LOS were not found to be significant risk factors in this study as reported in the study by Rattray et al.5
The reasons for sepsis causing depression in critical illness survivors are unclear and further research is needed in this field in order to fully understand the mechanisms responsible. Depression may occur as a consequence of the inflammation or neurotransmitter imbalances caused by sepsis. This inflammation may lead to a breakdown in the blood–brain barrier, which alters the impact on the brain of certain medications commonly prescribed on ICU such as opiates and sedatives. More recent research has suggested that long-term depression may be caused by more somatic symptoms such as fatigue and physical disability, rather than the previously thought cognitive symptoms.7 These somatic symptoms may be more appropriately addressed with interventions such as rehabilitation programmes, rather than the use of antidepressant medications commonly used in survivors of critical illness. Knowledge of the risk factors for long-term depression in critical illness survivors allows clinicians to target these patients in their ICU followup clinics. NICE83 Rehabilitation after Critical Illness guideline (2009) recommends that multidisciplinary rehabilitation was provided for all patients, from ICU admission through to post-hospital discharge.14 The guidelines specifically stated that at hospital discharge patients are referred to appropriate rehabilitation services if ongoing needs are identified. Following this at two to three months post-hospital discharge, a review and functional reassessment of the patient should be undertaken to determine the extent of recovery and identify and address any new physical and/or psychological morbidity.14 The results of this study suggest that sepsis patients should be targeted, or at least considered, for attendance at follow-up services. There are a number of limitations to this study which should be considered when interpreting the study findings. It is possible that the patients’ scores for depression were a reflection of their physical disability that is well recognised in survivors of critical illness. While the HADS is a validated screening tool for patients, a more specific tool for diagnosing depression would improve the strength of the study findings. In order to address these limitations, a further study could be conducted in which the patient is interviewed in order to gain more in-depth knowledge into the patients’ condition. Another limitation of this study is that there may have been other confounding variables that influenced the study’s results that were not included in the analysis.
Conclusions The results of this study demonstrate that sepsis is a potential risk factor for depression in survivors of critical illness at three months post-hospital discharge. Knowledge of the risk factors for poor psychological status in critical illness survivors assists the clinician in
108 deciding which patients should be targeted in ICU follow-up clinics. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References 1. Cuthbertson BH, Roughton S, Jenkinson D, et al. Quality of life in the five years after intensive care: a cohort study. Crit Care 2010; 14: R6. 2. Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference. Crit Care Med 2012; 40: 502–509. 3. Myhren H, Ekeberg O, Tøien K, et al. Posttraumatic stress, anxiety and depression symptoms in patients during the first year post intensive care unit discharge. Crit Care 2010; 14: R14. 4. Davydow DS, Gifford JM, Desai SV, et al. Depression in general intensive care unit survivors: a systematic review. Int Care Med 2009; 35: 796–809. 5. Rattray JE, Johnston M and Wildsmith JA. Predictors of emotional outcomes of intensive care. Anaesthesia 2005; 60: 1085–1092.
Journal of the Intensive Care Society 16(2) 6. Scragg P, Jones A and Fauvel N. Psychological problems following ICU treatment. Anaesthesia 2001; 56: 9–14. 7. Jackson JC, Pandharipande PP, Girard TD, et al. Depression, posttraumatic stress disorder, and functional disability in survivors of critical illness in the BRAIN-ICU study: a longitudinal cohort study. Lancet Respir Med 2015; 2: 369–379. 8. Kowalczyk M, Nestorowicz A, Fijalkowska A, et al. Emotional sequelae among survivors of critical illness: a long-term retrospective study. Eur J Anaesthesiol 2013; 30: 111–118. 9. Iwashyna TJ, Ely EW, Smith DM, et al. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 2010; 304: 1787–1794. 10. Wilcox ME, Brummel NE, Archer K, et al. Cognitive dysfunction in ICU patients: risk factors, predictors, and rehabilitation interventions. Crit Care Med 2013; 41: S81–98. 11. Zigmond AS and Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983; 67: 361–370. 12. Surviving Sepsis Campaign. Institute for Healthcare Improvement, http://www.survivingsepsis.org/About_ the_Campaign/Documents/sepsisdefinitionsihitool.pdf (2008, acccessed 16 June 2014). 13. Bouwmeester W, Zuithoff NPA, Mallett S, et al. Reporting and methods in clinical prediction research: a systematic review. PLoS Med 2012; 9: e1001221. 14. NICE. (2009). Rehabilitation after critical illness NICE Clinical Guideline 83. London, UK: National Institute for Health and Clinical Excellence, 2009.
