Anxiety Predicts Early Outcome in Critically Ill Patients

Abstract

Background: Anxiety results from the anticipation of a future threat. Anxiety is associated with poor outcomes following acute myocardial infarction, surgery, or Guillain-Barre Syndrome. Objective: To assess anxiety in critically ill patients in association with organ dysfunction. Methods: Prospective multicenter cohort study of adult ICU patients who were spontaneously breathing and had normal mental status. Upon ICU admission, intensity of anxiety was assessed using the State-Trait Anxiety Inventory-State (STAI-State) instrument and a visual analogue scale (VAS). Causes of anxiety were investigated by asking patients whether they feared death, believed to be vulnerable and believed to be in a serious condition. Severity of illness was assessed using SAPS-II and SOFA scores. Patients were followed-up for seven days. Main outcome measures: Primary endpoint was a composite outcome of mortality, persistence or worsening of organ dysfunction, unplanned surgery, coronary-angiography or transfusion, or readmission to the ICU in the first week following discharge; secondary outcomes were the duration of mechanical ventilation, hospital and ICU length of stay and mortality. Findings: From April 2015 to December 2017, 391 patients (median age, 63yo [49-74]; 159 (40.7%) women; SAPS-II 28 [19-37]) were included. 203/391 (51.9%) patients reported moderate to severe anxiety (STAI-State ≥40), 262/391 (67.9%) patients believed to be in a severe condition, 209/391 (54.4%) reported feeling vulnerable, and 178/391 (46.4%) patients feared death. Out of 391, 175 (44.8%) patients met the primary endpoint. After adjustment to SAPS-II and SOFA, STAI-State ≥40 (OR, 2.49; 95%CI, [1.56-3.98], p=0.0001) and absence of fear of death (OR, 0.53; 95%CI, [0.33-0.85]; p=0.008) were associated with the primary endpoint, especially in patients without organ dysfunction at admission (OR, 3.80; 95%CI, [1.99-7.25] p<0.0001 and OR, 0.37; 95%CI, [0.19-0.70], p=0.002). Interpretation: Moderate to severe anxiety and absence of fear of death at ICU admission are predictors of seven days-outcomes in ICU patients who were upon admission spontaneously breathing and had normal mental status. Funding: This study was promoted without funding by APHP. Declaration of Interest: None of the authors have any commercial conflict of interest to be disclosed. Ethical Approval: The present study follows up on our previous study on anxiety in patients admitted to the ICU for a GBS and was approved by the ethical committee of St Germain en Laye. It was also approved by the Advisory Committee for Data Processing in Health Research (CCTIRS) with a waiver for written informed consent. According to the French regulation only oral and written information were required.