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Patients recovering from COVID-19 may face a second battle -- coping with the disease's mental health ramifications.

This is particularly true for the sickest of the sick who required time in the ICU and intubation. These patients may experience "post-intensive care syndrome" (PICS) that could manifest as a combination of physical, cognitive, and mental health impairments following an ICU stay for a critical illness.

PICS can greatly impact the quality of life (QoL) in the short- and long-term, explained Sapna Kudchadkar, MD, PhD of Johns Hopkins Medicine in Baltimore.

PICS "impacts not only the patient but also their family and caregivers, and is also an issue for of critical illness," she told MedPage Today.

Adult patients may experience difficulties resuming the activities of daily life or struggle to return to work. Physically, patients may suffer from muscle weakness and chronic pain. Cognitively, these individuals may have trouble with concentration and memory, and cognitive issues may be particularly pronounced in people with a history of dementia. People suffering from PICS may experience anxiety, sleep difficulties, depression, or post-traumatic stress disorder (PTSD).

Even patients who were previously healthy prior to their ICU stay, for COVID-19 or other critical illnesses, are at risk for PICS after discharge, Kudchadkar noted.

'The Era of PPE and Isolation Rooms'

COVID-19 patients are likely at higher risk for PICS, according to the experts.

"For COVID survivors, we are already starting to observe many of these impairments, and the muscle weakness can be profound," Kudchadkar explained. "We have also observed a high incidence of persistent delirium, even in patients who were only mechanically ventilated or in the ICU for a few days."

"These issues are augmented due to visitor restrictions and a loss of human touch and familiar faces in the era of PPE and isolation rooms," she added.

Jessi Gold, MD, of the Washington University in St. Louis, agreed, telling MedPage Today that COVID-19 has drastically changed the landscape of the ICU.

"The ways in which we were normally trying to avoid [PICS], we don't have as much ability to do that [with COVID-19]," she said. For example, healthcare providers in "giant spacesuits" and geared up with personal protective equipment (PPE) -- leaving them near faceless -- may make patients afraid. To mitigate this, some providers have taped a picture of their face to their chest to put the patient at ease.

COVID-19 has stripped ICU patients of the usual factors that help them feel safe and grounded, Gold said.

"You don't have family at the bedside, reorienting you or making you feel like you belong in some capacity," she said. "You don't have family getting you up and walking, which happens if you're in the ICU and can move. You don't have a lot of staff coming in and checking on you as much -- there's a lot less in and out movements of people. And yet there's more codes and beeping and noise and worry and stress -- [the patient] might not understand what's going on."

But there is room for creative interventions. Gold suggested that healthcare providers learn more about the patient to make them feel more at ease. Also, FaceTime and other virtual methods of communication can be utilized to help connect the patient with their family. Even for intubated patients, hearing the voice of a loved one through a phone can be advantageous, she noted.

Delirium in the ICU

A systematic review and meta-analysis found delirium occurred in about 65% of patients with COVID-19 (26 of 40 ICU patients).

Agitation (69%, 40 of 58 ICU patients in one study) and altered consciousness (21%, 17 of 82 patients who subsequently died in another study) were common in COVID-10 patients in the ICU, according to Jonathan Rogers, MRCPsych, of University College London, and colleagues.

One study found 33% of patients with COVID-19 (15 of 45) had a upon discharge, they reported in the

Kudchadkar stressed that "the goal should always be to optimize pain control and utilize minimal, but effective, sedation in mechanically ventilated patients. We cannot assume that every patient requires heavy sedation -- a risk factor for delirium -- but instead titrate or prescribe sedation individualized to the patient's needs."

Other interventions to decrease the risk of delirium include ensuring patients receiving sufficient sunlight exposure and helping them maintain normal circadian rhythms, she stated.

Improving sleep hygiene for these patients can also bolster their ability to participate in early rehabilitation, Kudchadkar added. Early physical therapy, occupational, therapy, and speech-language therapy can increase a patient's chance of regaining a good QoL, she stated.

"We must do our best to humanize the ICU experience," she said. "Giving patients ways to communicate, asking them about their favorite things, engaging them as much as possible -- particularly given the visitor restrictions, gowns, masks, and loss of human touch -- these are all important ways to make a difference that isn't technology or pharmacologically based."

Post-ICU Mental Health

Gold noted the importance of looking beyond survival in the ICU, emphasizing that healthcare providers should take these potential mental health issues after discharge seriously. For instance, providers may want to counsel patients upon ICU discharge to look out for symptoms of PICS, or any mental health changes in the coming weeks and months.

Those recovering from a severe case of COVID-19 might experience nightmares, startle response, PTSD, trouble sleeping, emotional instability, depression, appetite changes, and loss of interest. ICU patients who were intubated may experience flashbacks of trauma, real or imagined. For example, a patient in the ICU may overhear a conversation between healthcare providers about another patient in the bed next to them, and incorporate that information into their own thoughts.

Kudchadkar added that patients who recover from a long COVID-19 fight, and are finally being discharged from the hospital, may have mixed feelings.

"It can be overwhelming to go home back to 'normal' after such a long and stressful road in the hospital, not just for the patient but the caregivers as well," she explained. "It's a happy time but can be a hard one as well. Acknowledging that is important, and providing resources [is] key."

"I've had patients and families tell me they are scared to go home; that they feel 'safer' in the hospital. That's a tough way to transition," Kudchadkar said.

In the review, Rogers and colleagues also looked at studies from SARS and MERS cases, and found that a many of those patients experienced some degree of confusion (27.9%, 36 of 129 patients), depressed mood (32.6%, 42 of 129), anxiety (35.7%, 46 of 129), impaired memory (34.1%, 44 of 129), and insomnia (41.9%, 54 of 129).

In the meta-analysis, they determined the point prevalence in the post-illness stage of these cases was 32.2% (95% CI 23.7-42.0%) for PTSD, 14.9% (12.1-18.2%) for depression, and 14.8% (11.1-19.4%) for anxiety. Among 580 patients from six studies, 76.9% (95% CI 68.1-84.6) returned to work at a mean follow-up time of 35.3 months.

In an in the journal, Iris Sommer, MD, PhD, of the University Medical Center Groningen, and P. Roberto Bakker, MD, PhD, of Maastricht University Medical Centre, both in the Netherlands, pointed out that COVID-19 patients will likely experience an even greater mental health burden during recovery.

Upon discharge, these patients are returning into a society "in deep economic crisis, with shortage of basic needs such as food in some countries and other countries still in lockdown and enforcing physical isolation," they stated. "These social adversities will keep stress levels after somatic recovery high, and further increase patients' risk for long-term psychiatric complications such as anxiety and depression."

PICS Screening

Fear and anxiety over getting sick again may linger especially because there is little evidence regarding risk of reinfection with the coronavirus that causes COVID-19.

Henk Stam, MD, PhD, of Erasmus University Medical Center in the Netherlands, and colleagues, cautioned that there may be an "unprecedented" amount of individuals suffering from PICS following the pandemic.

"The notion that patients surviving intensive care and mechanical ventilation for several weeks can be discharged home without further medical attention is a dangerous illusion," they stated in the . They added that "[PICS] and other severe conditions will require not only adequate screening but early rehabilitation and other interventions."

Stam and colleagues said screening for PICS among recovering patients can be done by an individual general practitioner, or by a multidisciplinary team via telemedicine.

For patients already experiencing PICS, inpatient and outpatient rehabilitation centers will be vital in helping them manage mental, cognitive, and physical impairments. "Many rehabilitation institutions are already involved in acute care for patients with Covid-19," Stam's group explained. "Some of them are equipped with ICU beds, and most of the rehabilitation institutions admit patients who have been discharged from ICU and are not yet ready to return home."

They stressed it "remains important for policymakers to prepare to allocate additional resources to facilitate in- and outpatients' interventions for ICU survivors."

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