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Treatment of Parental Post-Traumatic Stress Disorder After PICU Admission: Who, What, Where, When?

Unauthorized reproduction of this article is prohibited Pediatric Critical Care Medicine www.pccmjournal.org 877 It is now rare for a child to die during admission to a PICU (1). Although survival is clearly the desired outcome, it is becoming increasingly evident that there are far-reaching psychologic after-effects on the child and their family following PICU discharge, including post-traumatic stress disorder (PTSD), anxiety, and depression. A recent review reported PTSD prevalence rates of 10–21% in parents and 5–28% in children following acute critical illness (2). Furthermore, up to 84% of parents may have subclinical symptoms of PTSD, which may persist up to 12 months following discharge (2). Poor parental mental wellbeing has further implications, including inability to work, loss of earnings, dependence on benefits, and chronic ill-health. There are also well-described links between child and parental mental health, suggesting that successful interventions aimed at parental symptoms are likely to have additional beneficial effects on child psychologic symptoms (3). Early effective intervention could minimize development of psychologic sequelae in PICU survivors and their parents, but the nature of the appropriate intervention and who should be targeted is not clear. In this issue of Pediatr Crit Care Med, Dr. Samuel et al (4) aimed to establish whether the use of a screening instrument to define those parents at highest risk for PTSD, and providing parents with an appointment at a specific follow-up clinic, was associated with lower rates of psychologic symptoms in these parents in the longer term. Families containing a parent scoring at risk were randomized to receive either an appointment in a follow-up clinic at 2 months post discharge or treatment as usual (no followup). The decision to offer the intervention was informed by previous research on parental preferences, suggesting that the majority would appreciate such an intervention. It was anticipated that attendance rates at the clinic would be improved by targeting those parents at highest risk. The follow-up clinic was led by a clinical psychologist along with a PICU consultant and nurse. In this clinic, parents were given the opportunity to ask questions about their child’s PICU admission and to raise any concerns about their child’s current health. Clinic staff advised families regarding accessing further support services if specific psychologic issues were identified. All parents, including controls and those who had screened at low risk of PTSD, were sent questionnaires, which measured psychologic symptoms 6 months after discharge. This study included 209 parents, but only 37% of these were screened as at high risk for PTSD. Thirty-eight parents were randomized to the intervention, but only 14 opted to attend the clinic. No significant improvement was found in PTSD symptoms in the intervention group although there was evidence of a small beneficial effect on both anxiety and depression scores. We are aware of only two other published studies reporting on follow-up clinics designed to recognize and attend to parental and/or child psychologic problems. In the only other study that used a randomized controlled design, there was no impact from the clinic on parental distress overall, but a subgroup of parents who had been more acutely distressed at the time of their child’s admission were significantly more likely both to attend the clinic and to benefit from it in terms of self-report measures of post-traumatic stress and depression (5). In the other study, all parents who chose to attend similarly reported psychologic difficulties in parents and children (6). However, clinic attendance rates in both studies were low (25–33%). There are few published studies of interventions to reduce the risk of psychologic sequelae after PICU admission. A recently published Cochrane Review of the effects of writing diaries as a means of reducing the risk of future PTSD in patients and their families found no clear evidence to support their effectiveness in improving psychologic recovery after critical illness (7). The currently available data, along with UK national guidance on PTSD in adults (8), suggests that interventions should be directed only at those most likely to benefit. Screening parents to establish who are most at risk of poorer outcomes might be beneficial, both in terms of maximizing the effectiveness of any intervention and making the best use of available resources. The study by Samuel et al (4) has highlighted several important factors: Copyright © 2015 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000502 Simon Nadel, FRCP Paediatric Intensive Care Unit St Mary’s Hospital and Imperial College London London, United Kingdom