Patients recovering from COVID-19 may face a second battle—coping with the disease’s mental health ramifications in the form of “post-intensive care syndrome” (PICS).
This is particularly true for the sickest of the sick who require time in the ICU and intubation. These patients may experience 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 pediatric survivors 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.
PICS Risk in 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 dysexecutive syndrome upon discharge, they reported in the Lancet Psychiatry
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.”
PICS and 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 PICS in the form of 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 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.
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 Journal of Rehabilitation Medicine. 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.”
Article by Kristen Monaco, MedPage Today staff writer. Published courtesy of MedPage Today.
average American child’s diet improved considerably from 1999 to
2016, with less soda and more fruits and vegetables, though unhealthy
diets remained the rule rather than the exception, researchers
of National Health and Nutrition Examination Survey (NHANES) data on
more than 30,000 young people over the 18-year span indicated that
the proportion with poor diets declined from 76.8% to 56.1%
according to Junxiu Liu, PhD, of Tufts University in Boston, and
shown in their study online in JAMA,
the proportion of youth with an intermediate dietary score increased
significantly during that time period, from 23.2% to 43.7% (P<0.001).
The percentage of young people with an ideal dietary score, however,
remained low, increasing from just 0.07% to 0.25% (P=0.03),
Liu’s team said.
of sugar-sweetened beverages decreased from a mean of two servings a
day to just one (difference -1.0, 95% CI -1.2 to -0.78), and added
sugar consumption decreased from 106 g to 71.4 g a day (difference
-34.4, 95% CI -40.8 to -28.1; P<0.001
consumption of whole grains significantly increased from 0.46 to 0.95
servings per day (difference +0.50, 95% CI 0.40-0.59), and
consumption of total fruits and vegetables increased from 1.62 to
1.81 daily servings (difference +0.19, 95% CI 0.06-0.32; P<0.001
for both), the study found.
1999 to 2016, overall dietary quality improved among U.S. youth,
associated with increased consumption of fruits and vegetables
(especially whole fruits) and whole grains, with additional increases
in total dairy, total protein foods, seafood, and plant proteins, and
decreased consumption of sugar-sweetened beverages and added sugar,”
Liu and colleagues wrote.
diets did not improve in one important area, however: sodium
consumption increased from a mean of 3,166 mg to 3,326 mg per day
far exceeding the 2019 National Academies of Sciences, Engineering,
and Medicine dietary reference intake of 2,300 mg per day.
increase “may relate to steadily increasing consumption of
processed foods and food prepared away from home,” the
researchers speculated. “These findings support the need for
reactivating the currently suspended long-term U.S. Food and Drug
Administration voluntary sodium targets and timelines for reducing
sodium in packaged foods and restaurant foods.”
Asked for her perspective, Lauri Wright, PhD, of the University of North Florida in Jacksonville, who was not involved with the study, said: “I believe this study is good news, showing improvements in youth’s dietary patterns. There might be many things at play here. One might be the impact of the changes in the school lunch program in 2012 (with many changes occurring prior). The reformed school lunches were much higher in fruit and vegetables, lean dairy, nuts, and whole grains, while lower in fat and sodium.”
addition, she told MedPage
email, there has been more education directed at kids and parents
about eating healthier. For example, she said, programs such as Let’s
improved the amount of positive nutrition messaging.
I feel there are many more ‘healthy’ products out there for kids and
parents to choose from,” Wright said. “Water and low-fat
dairy have become the norm over the once popular sugar-sweetened
beverages. Though the study shows we still have a ways to go in
improving youth’s eating patterns, it does show the impact policy and
education can have.”
the study, Liu and colleagues analyzed data across nine NHANES
cycles, from 1999-2000 through 2015-2016. The study included young
people ages 2 to 19 who had completed at least one valid 24-hour
dietary recall. A total of 31,420 youth were included. Their mean age
was 10.6, and 49% were female. Respondents reported all food and
beverages consumed during the past 24 hours, midnight to midnight.
For younger children, proxy-assisted interviews were conducted.
quality was determined by the 50-point American Heart Association
(AHA) 2020 continuous diet score. Poor diet was defined as a score of
less than 20, an intermediate diet was 20 to 39.9, and an ideal diet
was 40 or higher. The researchers also assessed youth diets with the
Eating Index 2015,
and the results were similar.
study findings included the following:
fruit intake increased from 0.46 to 0.68 daily servings, while 100%
fruit juice intake decreased from 0.63 to 0.46 servings (P<0.001
red meat consumption decreased from 0.35 to 0.31 daily servings
while processed meat consumption remained stable
consumption decreased from 55.4% to 51.9% of total energy intake
fat intake increased from 33.2% to 34.5% of energy, and dietary
cholesterol increased from 218 to 254 mg per day (P<0.001
intake increased from a mean of 12.4 mg to 15.6 mg per day (P<0.001)
diets tended to worsen as children got older, reflecting the greater
amount of unhealthy choices available to older children. as well as
the increased freedom to choose them, Liu and colleagues said. For
example, in 2016 the estimated proportion of children ages 2-5 having
a poor diet was 39.8%. That percentage rose to 52.5% for children
ages 6-11 and to 66.6% for those ages 12-19.
of the study, the researchers said, included the inaccuracies
associated with self-reported dietary recall, as well as the
cross-sectional nature of the analysis, which did not allow for
evaluating dietary changes among individuals, only of national
study was supported by the National Institutes of Health and the
American Heart Association.
reported no conflicts of interest; co-authors disclosed relationships
with the National Dairy Council, PepsiCo, General Mills, and other
companies and organizations.
reported no conflicts of interest.
J, et al “Trends in diet quality among youth in the United
States, 1999-2016” JAMA 2020; 323(12): 1161-1174.
By Jeff Minerd, contributing editor, MedPage Today
State child access prevention (CAP) laws were linked with a 13% relative
reduction in childhood firearm-related fatalities compared with states without
such laws in the years 1991-2017, according to an analysis of CDC data.
So-called “negligence laws,” in which caregivers are criminally
liable if a child accesses and uses a firearm, were associated with a 13%
reduction in all-intent firearm fatalities, a 15% reduction in firearm
homicides, a 12% reduction in firearm suicides, and a 13% reduction in
unintentional firearm fatalities among children ages 0 to 14 years, reported
Eric Fleegler, MD, MPH, of Boston Children’s Hospital, and colleagues.
The most stringent CAP laws, which hold parents responsible if a child has
the ability to access firearms (but does not access or use them), were
associated with a 28% relative reduction in all-intent firearm-related deaths,
they wrote in JAMA Pediatrics.
However, recklessness laws, which hold firearm owners liable for directly
providing guns to minors, were not associated with reductions in firearm
fatalities among children ages 0-14, they added.
“I would argue there is not much value to recklessness laws, and states
that pass them thinking they are making a difference in terms of protecting
children’s lives should think again,” Fleegler told MedPage Today.
“If you want to make the biggest difference … you should be aiming for
these laws that say, ‘If a child could access a gun, then that is a criminal
Twenty-seven U.S. states have CAP laws in place and 16 impose criminal liability for negligently storing firearms,
although the nature of these laws varies across states.
These findings would be even more meaningful if the authors measured how CAP
laws directly impact safe gun storage, particularly since prior research
suggested up to 70% of firearm-owning homes failed to store guns unloaded, with
a locking device, and separate from ammunition, wrote Megan Ranney, MD, MPH, of
Brown University in Providence, Rhode Island, and colleagues, in an accompanying editorial.
Notably, “confounding is likely at least partially responsible”
for the association, and the data may also be subject to selection bias since
states with stricter CAP laws are likely to have other strategies in place that
prevent pediatric injury and death, Ranney’s group noted.
“CAP laws may serve as a proxy for prioritization of a range of injury
prevention efforts and broader social determinants of health,” they wrote.
“This finding does not obviate the potential consequence of CAP laws, but
it highlights that laws do not exist in a cultural vacuum.”
Ranney and colleagues advocated for “coalition building” between
firearm owners and community groups to implement public health programs that
aim to promote safe gun storage and reduce youth access.
“While nationally representative scientific opinion polls have found
that most firearm-owning Americans support CAP laws, the passage of a law is
only one element in successful injury prevention,” they wrote.
“Firearm owners must be leading and trusted voices in all aspects of
firearm injury and mortality prevention, as illustrated in other studies.”
For this study, morality data was collected from the Web-Based
Injury Statistics Query and Reporting System (WISQARS) for years 1991-2007
and the CDC’s
Compressed Mortality File for years 2008-2016. The authors did not include
adolescents, ages 15-19 years, because not all CAP laws apply to older teens,
Although this was “methodologically appropriate,” future research
should focus on states where CAP laws cover older adolescents, because youth
from ages 15-19 are at the highest risk of firearm homicide and suicide, the
There were 13,697 firearm-related deaths to occur in the study period, of
which 56% were homicides, 22% were suicides, 19% were unintentional, and 3%
were related to legal intervention or undetermined intent. Trends in firearm
fatalities varied by states with a high of 7.1 per 100,000 children in Alaska
in 2015 to a low of zero deaths in Connecticut and Delaware across many years,
the authors reported.
If states without criminal liability for negligent gun storage were to apply
negligence laws, 1,230 pediatric deaths could have been prevented, the authors
calculated, adding that if these states were to apply the strictest negligence
“could access” laws, 3,929 deaths could have been prevented, they
The authors cautioned against assuming causality based on the ecologic nature of the study, which was a limitation. It remains unclear how aware constituents of these states are of the CAP laws as well, which could influence safe gun storage practices, they said. Finally, some mortality data may have been misclassified and data on the perpetrators of homicides and unintentional fatalities in children were not available, they noted.
By Elizabeth Hlavinka, MedPage Today
Article reposted courtesy of MedPage Today.
Amid growing concerns about the mental health impact of working the frontlines of the pandemic, clinical psychologist Stephanie Zerwas, PhD is finding a way to help.
Zerwas knew therapists in Chapel Hill, North Carolina, wanted to give back during the COVID-19 crisis. “It’s really hard to see what people are going through and not be able to do anything,” Zerwas told MedPage Today. “There were a lot of therapists who knew that they could sort of cushion the fall of this.”
It was evident that one community needed strong mental health support, and quickly: healthcare workers on the front lines.
Zerwas, who runs a private practice in Chapel Hill, began organizing local therapists to aid the University of North Carolina’s physician mental health program. But as the number of volunteers grew, Zerwas decided to create her own initiative to provide accessible mental healthcare to a wider scope of front-liners.
She named it Project Parachute, and what started as a local movement in North Carolina now has more than 500 volunteer therapists in 37 states, all offering pro bono therapy sessions to front-line health workers — including physicians, nurses, custodial staff, management, and others.
“We have this really intense cognitive load right now, where we’re trying to make the very best decisions we can with all the information that’s being thrown at us,” Zerwas said. She started Project Parachute “to give people the support that they need at the right time.”
Here’s how it works: on the program’s website, volunteer therapists can input their specialty, availability, and how many clients they can take on. When a healthcare worker browses the site, they can search for sessions based on time preference or a therapist’s specialty. They’re not locked in to typical, hour-long sessions. Zerwas said that the project aims to provide flexible support, whether it’s a 30-minute check-in or a text.
Because mental health providers are not licensed to practice across state lines, clients must choose a therapist within their state. The majority of available therapists are located in North Carolina, Zerwas noted.
Project Parachute partnered with Eleos Health, a mental health care technology startup that provided a digital platform to match therapists with healthcare workers at a national level. The firm’s chief clinical officer, Shiri Sadeh-Sharvit, PhD, said the organization is lucky to have the opportunity to make a positive impact. She added that she is proud of the generosity and adaptability of mental health providers.
“Since the outbreak of the pandemic of COVID, clinicians have needed to change the methods in which they practice very quickly,” Sadeh-Sharvit said. “People were able to do so because there was no alternative.”
She said that the company is prepared to provide long-term pro bono services. “There isn’t an end date at the moment,” she said.
Healthcare workers face new and significant challenges during the COVID-19 pandemic, spurring concerns about the long-term impact on their mental health. Jessica Gold, MD, a psychiatrist at Washington University in St. Louis, said that healthcare workers already experienced high amounts of stress before the crisis.
“At baseline, being a healthcare worker has emotional strain and burnout,” Gold said in an interview with MedPage Today. The healthcare worker population is already at risk of higher rates of depression, substance use, burnout, and suicide; a pandemic adds stressors like an increased risk of infection, lack of protective equipment, isolation from family and social support networks, and fear of death, she noted.
Early research has shown that the COVID-19 crisis has impacted mental health outcomes of medical workers. A study of more than 1,300 healthcare workers in China found that around half of the participants experienced symptoms of depression and anxiety.
Kaz Nelson, MD, a psychiatrist at the University of Minnesota in Minneapolis, said that while healthcare providers are among a very resilient workforce, this crisis deprives front-liners of basic needs according to Maslow’s hierarchy.
“We are being pulled into this state where our basic safety needs are threatened,” Nelson told MedPage Today in an interview. “We’re just not equipped to [deal] with that on a day-to-day basis.”
Nelson said that barriers to accessing mental healthcare, such as time and cost, can be removed by programs that are free, confidential, and focused on providing support and skill development.
Gold said that by offering free mental health support to frontliners during the crisis, Project Parachute intervenes at a time when long-term mental health impacts can be prevented.
“We often don’t know what we need when we need it,” Gold said. “If it’s offered, they’re more likely to take it. If they start now they’re more likely to continue.”
By Amanda D’Ambrosio, Staff Writer, MedPage Today
the nation battles COVID-19, the health policy world is quietly
observing a milestone: the 10th anniversary of the Affordable Care
he was signing the bill into law on March 23, 2010, then-President
“The bill I’m signing will set in motion reforms that
generations of Americans have fought for and marched for and hungered
to see.” He listed some of the bill’s provisions, including a
ban on insurer discrimination against enrollees with preexisting
conditions, a mandate to cover children up to age 26 on their
parents’ policies, and a requirement that all health insurance
policies cover 10 categories of “essential health benefits.”
The law also strongly encouraged states to expand their Medicaid programs to include able-bodied adults making up to 138% of the federal poverty level — failure to do so would result in a state losing its federal Medicaid match — and created health insurance marketplaces in which individuals and small businesses could shop for health insurance plans. (The Medicaid expansion provision was later changed as a result of a Supreme Court case and is now completely optional for states.)
One Thing’s for Sure…
looking back at the law all agree on one thing: it did increase the
insurance rolls — “primarily through Medicaid,” said Bob
Moffit, PhD, senior fellow in health policy studies at the Heritage
Foundation, a right-leaning think tank here. “Roughly 90% of new
coverage came out of Medicaid. And there’s no question it increased
access to healthcare, particular mental health benefits and services
for low-income people,” as well as reducing uncompensated care
the percentage of uninsured Americans stands at 9.1%, down from 16%
when the law was signed into effect, Rosemarie Day, CEO of Day Health
Strategies in Somerville, Massachusetts, and the author of Marching
Toward Coverage: How Women Can Lead the Fight for Universal Health
noted in a blog
post on Monday.
However, although the ACA made these gains possible, there are still
many uninsured and underinsured patients who likely would be afraid
to seek care if they thought they had COVID-19, because they might
not be able to pay for it, Day said in a phone interview.
don’t have a culture of universal healthcare; we have a culture of
‘Gotcha,'” she said. “You show up in the ER? Here’s a bill.
People are afraid of that if they don’t have the resources … Also
right now, immigrants are going to be very afraid because they’re
told they’re going to be deported if they use anything that’s
publicly funded,” such as Medicaid.
On the other hand, the ACA has done a lot to help people get care earlier for other types of illnesses, including preventive care, which is one of the ACA’s essential health benefit categories. “Many preventive services are free, so people are availing themselves and therefore getting tested earlier than they would, meaning that if perchance you have cancer, you’re getting screened earlier in the game,” Day said. “That whole flow prevents unnecessary deaths and it’s all about that access to healthcare.”
…But Problems Remain
the law still has a lot of problems, said Joe Antos, PhD, scholar in
healthcare and retirement policy at the American Enterprise
Institute, a right-leaning think tank here. “The most obvious
one is the Democrats’ overreach on Medicaid,” he said in a phone
interview. “They wanted to make it look like states would have a
choice about whether they expanded Medicaid or not. But the penalty
… goes beyond a simple penalty. They didn’t have to do that.”
the Obama administration “could have found some way to phase in
mandatory eligibility up to where they ended up,” said Antos.
“In retrospect, that was a really terrible mistake. What we have
now is 13 states — mostly Southern states — who did not expand
their Medicaid eligibility under the ACA and they’re in even greater
trouble now than they were before. So that’s a truly lost opportunity
with regard to this virus pandemic, because that would have been
resolved by now.”
Moffit sees a different flaw with the ACA. “The problem the ACA had is that the ACA did not control costs,” he said in a phone interview. “If you look back to 2010, and asked Americans what was the number one problem in the healthcare system, it was how to control healthcare costs. When President Obama was campaigning for the ACA, he made the argument that we’d see a $2,500 reduction in typical family health care costs” each year. But “that was total nonsense; it never happened,” Moffit said, adding that instead premiums jumped from an average of $244 per month in 2013 to $550 per month.
has his own solution to the ACA’s problems. “We ought to target
the funds a lot better than in the past,” he said. “I like
the idea of taking all the money we’re spending on the ACA — about
$1.6 trillion — and turning it into block grants for states, on two
conditions: that states offset the cost of health insurance for
people who are low-income; and that states offset the cost of
coverage for people with preexisting medical conditions.”
praised the ACA’s provision banning discrimination against patients
with preexisting conditions, adding that in order to improve the law,
the federal government could “allow states to address this in
different ways, whether through reinsurance pools, risk transfer
pools, or direct subsidies … there are a lot of different ways of
doing that.” Moffit’s home state of Maryland, where he is a
former member of the state’s Health Care Commission, is using a 1332
waiver to establish a reinsurance program for higher-cost patients.
The program “has been dramatically successful. There has been a
10% reduction in individual market premiums, so it’s working out
quite well,” he said.
Day prefers a different approach: universal coverage using a hybrid public/private system. One way to improve coverage would be to increase enrollment among people who are eligible for government health insurance — such as for the Children’s Health Insurance Program — but haven’t yet been enrolled. “We ought to have some form of auto-enrollment for kids,” she said. The federal government also should put more “guardrails” on the plans in the ACA’s health insurance exchanges, “regulating the plans to include essential health benefits and do the things the private market wouldn’t do on its own. That’s how other countries do it,” such as Germany, she said.
By Joyce Frieden, News Editor, MedPage Today