Acute Physiologic Stress and Subsequent Anxiety Among Family Members of ICU Patients

Objectives: The ICU is a complex and stressful environment and is associated with significant psychologic morbidity for patients and their families. We sought to determine whether salivary cortisol, a physiologic measure of acute stress, was associated with subsequent psychologic distress among family members of ICU patients. Design: This is a prospective, observational study of family members of adult ICU patients. Setting: Adult medical and surgical ICU in a tertiary care center. Subjects: Family members of ICU patients. Interventions: Participants provided five salivary cortisol samples over 24 hours at the time of the patient ICU admission. The primary measure of cortisol was the area under the curve from ground; the secondary measure was the cortisol awakening response. Outcomes were obtained during a 3-month follow-up telephone call. The primary outcome was anxiety, measured by the Hospital Anxiety and Depression Scale-Anxiety. Secondary outcomes included depression and posttraumatic stress disorder. Measurements and Main Results: Among 100 participants, 92 completed follow-up. Twenty-nine participants (32%) reported symptoms of anxiety at 3 months, 15 participants (16%) reported depression symptoms, and 14 participants (15%) reported posttraumatic stress symptoms. In our primary analysis, cortisol level as measured by area under the curve from ground was not significantly associated with anxiety (odds ratio, 0.94; p = 0.70). In our secondary analysis, however, cortisol awakening response was significantly associated with anxiety (odds ratio, 1.08; p = 0.02). Conclusions: Roughly one third of family members experience anxiety after an ICU admission for their loved one, and many family members also experience depression and posttraumatic stress. Cortisol awakening response is associated with anxiety in family members of ICU patients 3 months following the ICU admission. Physiologic measurements of stress among ICU family members may help identify individuals at particular risk of adverse psychologic outcomes. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/29S62lw). Drs. Hopkins, Kuttler, Orme, Brown, and Hirshberg contributed in conception; Drs. Beesley, Wilson, Kuttler, Brown, and Hirshberg contributed in data acquisition; Drs. Beesley, Hopkins, Holt-Lunstad, Wilson, Brown, and Hirshberg contributed in data analysis; Drs. Beesley, Hopkins, Brown, and Hirshberg contributed in writing article; and all authors contributed in revising article for important intellectual content and approval of final copy. Supported, in part, by the Intermountain Research and Medical Foundation. Dr. Hopkins' institution received funding from the National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute, and she received support for article research from the NIH. Dr. Butler disclosed government work. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: Samuel.brown@imail.org; ellie.hirshberg@imail.org Copyright © by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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