Critical Care Psychiatry: The Value of Psychiatrists in the ICU

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CATEGORY 1 CME

Premiere Date: May 20, 2024

Expiration Date: November 20, 2025

This activity offers CE credits for:

1. Physicians (CME)

2. Other

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ACTIVITY GOAL

To describe the field of critical care psychiatry by comparing and contrasting it with general consultation-liaison psychiatry and providing examples of commonly encountered challenges in the psychiatric care of patients in the intensive care unit.

LEARNING OBJECTIVES

1. Describe common clinical conditions, consultation questions, and challenges in the field of critical care psychiatry.

2. List the components of the ABCDEF Bundle and describe how they inform a multidisciplinary treatment approach for critically ill patients.

TARGET AUDIENCE

This accredited continuing education (CE) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

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In the modern history of medicine, some of the most lifesaving advances have come from the field of critical care medicine. Current medical knowledge and technology have transformed it into a field capable of sustaining life despite widespread organ failure, facilitating patient survival through injuries and illnesses that were previously lethal. Given the high proportion of both preexisting and newly emergent psychopathology among critically ill patients, psychiatry has an essential role in the critical care setting. Accordingly, the practice of critical care psychiatry (CCP) continues to grow as patients experience increasingly complex medical illnesses, which commonly affect brain function and quality of life over both short- and long-term time spans.

Critical care psychiatrists routinely face specific challenges that general outpatient psychiatrists only rarely see. How do you evaluate a patient who is intubated and/or heavily sedated? What medications are safe for a patient in multi-organ failure who is already on multiple medications? How do you treat symptoms of anxiety or depression in someone who is actively dying? What are the best ways of managing the specific psychopathology of patients who have lived through a course of treatment in the intensive care unit (ICU)?

Considering that each of these is a daunting task, and none of the solutions are simple, we advocate for increasing the role of psychiatrists with expertise working in the critical care setting, and with patients who are survivors of critical illness, to help address these difficult clinical challenges. In this CME article, we describe the basic components and common challenges of CCP (Table 1) and dive deeper into a few of these specific clinical scenarios.

Table 1. Common Conditions and Challenges Encountered in Critical Care Psychiatry

CCP is practiced by psychiatrists working in consultation-liaison (C-L) roles. C-L psychiatrists care for patients with comorbid medical illness across a variety of settings, both inpatient and outpatient. Over time, specific areas of focus within C-L psychiatry have developed, including psycho-oncology, transplant psychiatry, HIV/AIDS psychiatry, and many others.

Using these examples of C-L “sub-subspecialities,” the common features include the following:

• A clearly defined and specific patient population with illnesses that are prevalent enough to validate and justify an esoteric clinical approach
• A clinical and research literature specific to this clinical population that is more “granular” and detailed than the general psychiatry literature and representative of a niche within the C-L literature
• Clinical interventions for the specific patient population that require separate education and clinical mastery
• A sufficiently large group of practicing physicians active in this area to represent “critical mass” in its formation

Although sub-subspecialties do not require formal fellowship training or board certification, per se, past the subspecialty level, they do represent a distinct group of physicians. Viewed in this light, we believe that CCP meets the requirements to be considered the latest C-L psychiatry sub-subspecialty. We hope that a more formal recognition of CCP can accelerate advances in education, research, and patient care in the area.

Critical Care Psychiatry

Preexisting psychiatric illnesses are present in nearly one-third of patients admitted to the ICU, and many psychiatric conditions require initial general medical stabilization in the ICU, such as suicide attempts, adverse medication reactions, and complex withdrawal states.^1,2 Patients with critically illness frequently experience delirium, agitation, anxiety, and demoralization, and survivors of critical illness are at risk for developing depressive disorders, acute stress disorder/posttraumatic stress disorder (PTSD), and neurocognitive disorders.

Despite the high prevalence of psychiatric disorders among critically ill patients, development of integrated models of psychiatric care for this population have lagged behind those seen in other care environments. A 2001 study of 56 C-L services across Europe revealed that only 3% of hospital-based psychiatric consultations originated in the ICU, with some health systems reporting as few as 0%.³

This lack of collaboration is likely 2-sided; intensivists have long managed these conditions independently, without the input of psychiatric consultants who may have limited familiarity with the ICU setting, and psychiatrists have not always embraced opportunities to care for critically ill patients. In fact, some psychiatric consultants may respond to requests to see critically ill patients by asking the team to defer until the patient is either extubated or more medically stable (eg, “medically cleared”). However, given the high degree of psychiatric comorbidity in ICU patients and the need for team-based care, practices are evolving with more psychiatrists now interested in caring for critically ill patients and more intensivists open to integration of psychiatric care.

The Society of Critical Care Medicine’s ICU Liberation Campaign has helped transform the field through the introduction of the ABCDEF (sometimes abbreviated as “A to F”) bundle, described in Table 2, which highlights the multifactorial components that can optimize outcomes in critically ill patients.⁴ In challenging old practices and introducing new strategies, the implementation of the ABCDEF bundle has been proved to significantly improve ICU survivorship and morbidity. From an educational perspective, it provides psychiatrists who are interested in working in the ICU with a clear roadmap for navigating the critical care’s foremost patient priorities and emphasizes using multimodal strategies to optimally manage conditions such as delirium and agitation.

Table 2. ABCDEF (“A to F”) Bundle for Integrated Symptom Management in Patients in the ICU

Another important finding to emerge from the critical care literature is identification and description of post–intensive care syndrome (PICS). PICS is defined as new or worsening multidimensional impairment in physical, cognitive, other psychiatric, and social domains after a course of ICU care.⁵ This definition acknowledges the wide range of sequelae patients may experience and informs the multidisciplinary approach needed to address them. Partnerships between intensivists and psychiatrists can help with screening for impairment and referral to psychiatric care, with the shared goal of minimizing the long-term consequences of critical illness and ICU interventions. This conceptualization also highlights the need for ICU survivors to access longitudinal, multidisciplinary follow-up care from teams that include internists, psychiatrists, physical therapists, and other relevant specialists.

Many of the problems psychiatrists can help address are not new to the field of critical care, but it is a fast-evolving field that thrives on team-based care. For some of these concerns, there is even a moderate evidence base. However, studies specifically evaluating the impact of collaboration and integration with psychiatric consultants are still minimal, so this is one knowledge gap that practitioners of CCP can work to address, to benefit patients and staff alike.

The Critical Care Psychiatrist

C-L psychiatrists working with ICU teams may fill a number of roles, largely depending on the structure and culture of their home institution. ICUs vary widely in size, complexity, configuration, staffing, and the types of conditions they treat. For many institutions, traditional reactive consultation remains the default means by which psychiatrists are integrated. However, there is increasing interest in more heavily involved roles for psychiatrists such as embedded, comanaged, and proactive models of care. Conversely, in some ICUs, the role of the psychiatrist may be more removed, providing curbside recommendations or deferring consultation until the patient has transferred out of the ICU. Considering this amount of heterogeneity, there may be benefits to including psychiatrists in the systems-level design and coordination of intensive care.

Regardless of the specific role, there are certain fundamental skills and knowledge that can help prepare a consultant for critically ill patients. The expertise of C-L psychiatrists lies at the intersection of general medicine and psychiatry, and nowhere is that expertise more necessary than in the complex, acute environment of an ICU. Nevertheless, some psychiatrists may experience a steep learning curve as they begin to participate in the care of critically ill patients, needing to reacquaint themselves with pathophysiology with which they may not be clinically current. Consultants will always do well to embody humility, curiosity, and flexibility in adapting to new environments and continually improving their knowledge. In fact, this approach often attracts psychiatrists to the field of critical care.

To function in any new environment, understanding the language is a must. In deciphering an intensivist’s progress note, the consultant will encounter myriad abbreviations such as TSB, CAM, RASS, ARDS, NGT, CRRT, and many more (respectively, these stand for trial of spontaneous breathing, the confusion assessment method, the Richmond Agitation-Sedation Scale, acute respiratory distress syndrome, nasogastric tube, and continuous renal replacement therapy).⁶ Basic knowledge of ICU-related pathophysiology and interventions is one way for psychiatrists to be fully prepared to assist in caring for these patients.

Respiratory failure and mechanical ventilation are core concepts to understand the care of ICU patients. Many patients require sedation to tolerate mechanical ventilation, so familiarity with common sedative agents (such as propofol, fentanyl, and dexmedetomidine) is another helpful piece of knowledge. Common systemic medical problems treated in the ICU include stroke, myocardial infarction (MI), respiratory failure, shock, trauma, and burns.

Many psychiatric consultations are similar to those encountered by C-L psychiatrists elsewhere in the hospital, such as evaluation of safety, agitation, delirium, insomnia, depression, anxiety, psychosis, addictive disorders, and decision-making capacity. However, critical care psychiatrists may be more likely to see pathology such as catatonia, neuroleptic malignant syndrome, serotonin syndrome, and complex withdrawal states. Whether or not the reason for consultation is similar to those seen elsewhere, the numerous challenges specific to critical care (Table 1) will often complicate the care of critically ill patients.

In the ICU, even common consultation questions may require a distinct approach to patient evaluation and management. Patients often cannot provide a full history. If they are comatose or noncommunicative, they may not be able to provide any history. Accordingly, the psychiatrist relies more heavily on information gathered from review of the medical records, discussion with the consulting physician and the patient’s nurse, and collateral history from the patient’s friends or family.

Similarly, the determination of the plan of care also relies on input from several members of the team through shared decision-making, at minimum with the ICU physician and the patient or surrogate decision-maker. However, the complete multidisciplinary team also includes nurses, pharmacists, respiratory therapists, physical and occupational therapists, speech/language pathologists, and other consulting physicians.

Critically ill patients frequently require mechanical ventilation and are thus unable to speak. For many psychiatrists, this negates most, if not all, of their normal approach to psychiatric evaluation. However, by using a systematic approach, the critical care psychiatrist can effectively perform a thorough mental status examination and possibly even gather historical information about the patient. For specific techniques to utilize, see Table 3.⁶

Table 3. Mental Status Exam of a Patient Who Is Intubated or Nonspeaking⁶

First, adequate consciousness must be established to ensure the patient can participate in the interview. Then, language comprehension can be confirmed with the use of basic commands and “yes/no” questions. Basic cognitive functions such as orientation and attention must be tested to assess if there are any cognitive impairments are present that could affect the rest of the evaluation. If basic cognition is established, then increasingly difficult questions or prompts may be used to understand cognitive function more thoroughly.

For a patient with reasonably intact cognition, the psychiatrist may then go on to gather further information about active psychiatric symptoms and other pertinent history. When questions are phrased appropriately, some patients in the ICU can report a surprising amount of history this way. If the patient is unable to reliably participate by nodding, the psychiatrist may attempt another simple proxy for communication, such as squeezing their hand.

Given these potential barriers to communication, skills in physical examination are also very important in the evaluation of critically ill patients. A focused neuropsychiatric examination can provide an abundance of diagnostic information. This examination will often evaluate for reflexes, clonus, muscle tone, extrapyramidal symptoms, and catatonia. Ultimately, deficits in cognition and communication need not prevent the psychiatrist from performing an adequate evaluation of a patient in the ICU.

Prescribing medications is a core part of the psychiatric consultant’s armamentarium, but working with patients who are critically ill introduces new levels of challenges in prescribing (Table 4). Considering all the unique physiology of this patient population, critical care psychiatrists are often operating with a limited or absent evidence base due to a lack of prospective, controlled studies in this setting to evaluate the safety and effectiveness of commonly used pharmacologic agents.

Table 4. Common Pharmacologic Considerations for the Patient Who Is Critically Ill

Many patients are in multi-organ failure, so hepatic and renal function must be accounted for. Cardiac function (especially the QTc interval) and abnormal vital signs may also need to be considered. Gastrointestinal function and access are also important factors because many patients can only take enteral medications when they are crushed and administered via a nasogastric tube, limiting the available options for certain pharmacologic agents. Furthermore, most ICU patients are already being prescribed numerous medications, so drug-drug interactions are another consideration that will affect the choice and dose of additional agents.

The liaison aspect of C-L psychiatry is also of paramount importance when working in ICUs, where lives often hang in the balance and each patient’s status can change suddenly and dramatically. This type of environment can be frustrating, frightening, and bewildering for new and seasoned staff alike, so the psychiatrist’s role in staff support and education can have a profound impact.

At the core of ICU care is a multidisciplinary team collaborating daily. Psychiatrists can help the team to think of patients as whole, awake, and autonomous individuals with interests and loved ones outside of the hospital walls, so that the patients can experience individualized, compassionate care. ICU staff also benefit from understanding the rationale behind psychiatrists’ recommendations, such as bedside education for nurses about finer details of mental status findings and how they relate to behavioral interventions and choices of medications. Finally, keeping staff engaged while supporting them through the inevitable difficulty of working in a high-stress environment is an important aspect of sustaining a healthy and resilient workforce that is less prone to burnout and attrition.

As evidenced by “F for family” in the ABCDEF Bundle, patients’ loved ones can also become integral contributors to the holistic care of critically ill patients. Having a loved one who is suffering from a critical illness can be frightening enough to family members, but the manifestations of delirium, including agitation, combativeness, hallucinations, confusion, and even unresponsiveness, can be especially terrifying.

Critical care psychiatrists can offer education to the family about the nature and course of delirium, what symptoms mean, and even how family members can assist the patient with environmental interventions such as reorientation, sleep-wake cycle management, cognitive engagement, exercise and mobility, and promotion of feeling safe and comfortable. Understanding and participating in the care of their loved one can help families feel empowered instead of helpless.

Beyond the ICU

As a sub-subspecialty, CCP is esoteric and generally confined to a single care setting. Accordingly, as patients heal and transfer out of the ICU or discharge from the hospital, their psychiatric care will need to be transitioned, often to a general outpatient psychiatrist. Given the medical and psychiatric complexity of these patients, it can be helpful to both the patient and the outpatient psychiatrist to appreciate and understand the short- and long-term impacts of critical illness.

For example, in recent research involving elderly patients, the resolution of cognitive symptoms from hospital-related delirium was estimated to be only 55% at the time of hospital discharge and 80% at 6 months.⁷ Given the general understanding of delirium as an acute condition lasting days to weeks, these persisting cognitive deficits are often underrecognized, complicating the evaluation and treatment of patients with both cognitive and other psychiatric symptoms.

The general psychiatrist can benefit from basic knowledge about how to approach patients who are survivors of critical care. Considering the many traumatic reasons that individuals end up in the ICU, acute stress disorder and PTSD are important differential diagnoses. Many critically ill patients also face premature confrontations with their mortality, which can induce symptoms of anxiety or depressive disorders. Depressive disorders, specifically in the wake of certain medical conditions (such as stroke or MI) are known to generally respond favorably to antidepressant medication, whereas other types of psychological and existential disruptions with associated depressive symptoms may be better suited for treatment with psychotherapy.

The process of evaluating post-ICU psychiatric conditions (either new onset or worsened) can be complex and it can be helpful to include the patient’s medical history and their reaction to their time in the ICU in a thorough biopsychosocial evaluation. This approach can also apply to the care of family members of critical illness survivors, who may often seek treatment related to the stress of having a critically ill loved one.

The Way Ahead

CCP is an emerging sub-subspecialty of C-L psychiatry with the potential to improve the psychiatric status of many patients. The practice of CCP requires knowledge of internal medicine and psychopharmacology, skills in neuropsychiatric evaluation, and a flexible, team-based approach to properly serve as a consultant in the high-acuity critical care setting. Physicians must understand and tolerate the inherent risks of caring for critically ill patients in a practice setting where there are significant limitations to the available evidence guiding psychiatric care.

For those wishing to learn more about CCP, the Academy of Consultation-Liaison Psychiatry website offers many educational materials, including those found on the CCP Special Interest Group page,⁸ such as previous presentations from experts in the field and a selected bibliography of relevant, high-yield publications. Other online resources, such as the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at icudelirium.org, also provide clinicians with helpful educational materials that can be used to build knowledge, inform practice, and educate colleagues, patients, and families.

The practice and growth of CCP has much to offer our patients, our colleagues, and our health systems. The field is ripe for scholarship to better inform the safety and efficacy of psychiatric interventions used during and after a patient’s course of critical care. Given the high personal, institutional, and societal costs of critical care, psychiatrists working in the ICU environment to address neuropsychiatric sequelae of critical illness play a fundamental role in improving the care and recovery of survivors of critical illness.

As this care environment represents a rapidly changing landscape of clinical innovation and continuous redesign, CCP is well positioned to prioritize care that focuses on patients’ cognitive and psychological recovery, paving the way for substantial short- and long-term benefits to patients, their support networks, and the entire health system.

Dr Dragonetti is on the faculty at Wake Forest University School of Medicine in Winston-Salem, North Carolina. Dr Bui is on the faculty at Virginia Commonwealth University in Richmond, Virginia. Dr Rueve is division chief of psychiatry inpatient and consultation-liaison services for The Christ Hospital Health Network in Cincinnati, Ohio. Dr Bourgeois is vice chair of hospital psychiatry services at the University of California, Davis Medical Center in Sacramento.

References

1. Abrams TE, Vaughan-Sarrazin M, Rosenthal GE. Preexisting comorbid psychiatric conditions and mortality in nonsurgical intensive care patients. Am J Crit Care. 2010;19(3):241-249.

2. Baldwin WA, Rosenfeld BA, Breslow MJ, et al. Substance abuse-related admissions to adult intensive care. Chest. 1993;103(1):21-25.

3. Huyse FJ, Herzog T, Lobo A, et al. Consultation-Liaison psychiatric service delivery: results from a European study. Gen Hosp Psychiatry. 2001;23(3):124-132.

4. Pun BT, Balas MC, Barnes-Daly MA, et al. Caring for critically ill patients with the ABCDEF Bundle: results of the ICU Liberation Collaborative in over 15,000 adults. Crit Care Med. 2019;47(1):3-14.

5. Yuan C, Timmins F, Thompson DR. Post-intensive care syndrome: a concept analysis. Int J Nurs Stud. 2021;114:103814.

6. Ely EW, Vanderbilt University. Confusion Assessment Method for the ICU (CAM-ICU): The Complete Training Manual. Vanderbilt University; 2016.

7. Cole MG, Ciampi A, Belzile E, Zhong L. Persistent delirium in older hospital patients: a systematic review of frequency and prognosis. Age Ageing. 2009;38(1):19-26.

8. Critical care psychiatry SIG. Academy of Consultation-Liaison Psychiatry. Accessed January 5, 2024. https://www.clpsychiatry.org/sigs/critical-care-psychiatry-sig/