Psychological Disturbances at ICU Discharge: Evaluation Using the Intensive Care Psychological Assessment Tool (IPAT) and Association with Clinical Features: An observational cross-sectional study

Technical Summary: Psychological Disturbances at ICU Discharge Evaluated via IPAT

Problem Statement
Anxiety, depression, and delirium are prevalent among patients in Intensive Care Units (ICUs) and can persist as Post-Intensive Care Syndrome (PICS), significantly impacting quality of life and increasing mortality risks. While tools like the Hospital Anxiety and Depression Scale (HADS) and PTSS-10 exist, there is a need for rapid screening instruments specifically validated for conscious, oriented ICU patients at the point of discharge. This study addresses the gap in understanding the frequency of acute psychological disorders at ICU discharge and their association with specific clinical characteristics and therapeutic interventions.

Methodology
This observational cross-sectional study was conducted at the University of Health Sciences, Ankara Atatürk Sanatorium Training and Research Hospital, involving four ICUs (three tertiary, one secondary).

• Participants: 392 Turkish-speaking, literate adults (≥18 years) with a Glasgow Coma Scale (GCS) score of 15, who were conscious, communicative, and discharged to inpatient wards after at least 48 hours of ICU monitoring. Patients with pre-existing severe neurological impairments, dementia, autism, bipolar disorder, schizophrenia, or substance addiction were excluded.
• Data Collection: Data were collected retrospectively from medical records and prospectively via the Intensive Care Psychological Assessment Tool (IPAT) administered at the time of discharge.
• Instrument: The IPAT is a 10-item tool where patients rate symptoms (e.g., difficulty communicating, sleep trouble, tension, sadness, panic, confusion, hallucinations) on a scale of 0 ("No") to 2 ("A lot"). Scores range from 0 to 20.
• Grouping: Patients were stratified into two groups: those with an IPAT score < 6 and those with a score ≥ 6.
• Statistical Analysis: Univariate and multivariate logistic regression analyses were performed to identify risk factors associated with higher IPAT scores. Receiver Operating Characteristic (ROC) curve analysis was utilized to determine the IPAT cut-off value for predicting delirium.

Key Results

• Prevalence: 181 patients (46.2%) had an IPAT score of 6 or higher, indicating significant acute psychological distress.
• Risk Factors: Multivariate logistic regression identified five independent factors significantly associated with an IPAT score ≥ 6:
  • Advanced Age: Each one-year increase in age increased the likelihood of a high score by a factor of 1.019 (OR: 1.019; 95% CI: 1.004–1.034; p=0.015).
  • Disease Severity: Higher Acute Physiology and Chronic Health Evaluation-II (APACHE-II) scores were associated with increased risk (OR: 1.052; 95% CI: 1.017–1.087; p=0.003).
  • Psychiatric History: A history of psychiatric disorders was the strongest predictor, increasing risk by 4.452-fold (OR: 4.452; 95% CI: 2.017–9.828; p<0.001).
  • Medication Use: The use of psychotropic/sedative medications during the ICU stay increased risk by 2.608-fold (OR: 2.608; 95% CI: 1.189–5.719; p=0.017).
  • Ventilation: The need for Non-Invasive Mechanical Ventilation (NIMV) increased risk by 2.165-fold (OR: 2.165; 95% CI: 1.336–3.511; p=0.002).
• Delirium Prediction: All patients diagnosed with delirium during their stay had IPAT scores ≥ 6. ROC analysis determined a cut-off value of 9.5 for predicting delirium, yielding an Area Under the Curve (AUC) of 0.925, with 92.6% sensitivity and 84.9% specificity.
• Comorbidities: Higher IPAT scores were significantly associated with comorbidities including depression, Parkinson's disease, renal failure, stroke history, and heart failure. Conversely, lower rates of coronary artery disease and extrapulmonary malignancies were observed in the high-score group.

Key Contributions

• Validation of IPAT Utility: The study reinforces the IPAT as a viable, rapid screening tool for detecting acute psychological distress in conscious ICU patients at the moment of discharge.
• Multidimensional Risk Profile: The research delineates that psychological disturbances in ICU survivors are not solely dependent on the ICU environment but are multifactorial, driven by a combination of patient demographics (age), pre-existing conditions (psychiatric history), disease severity (APACHE-II), and specific interventions (NIMV, sedation).
• Delirium Screening Threshold: The study provides a specific, data-driven cut-off value (9.5) for the IPAT score to identify patients at high risk for delirium, offering a potential early warning system for clinical teams.

Significance and Claims
The authors conclude that psychological disorders in ICU patients are a multidimensional condition linked to both individual characteristics and therapeutic interventions. They assert that the IPAT score serves as a supportive tool for the early identification of at-risk groups, facilitating multidisciplinary management and potentially mitigating the development of Post-Intensive Care Syndrome (PICS).

The paper maintains a modest stance regarding its findings:

• It acknowledges that while the IPAT is useful for screening, the study's ability to track long-term PICS development was limited by the lack of post-discharge follow-up.
• It notes that the small sample size of patients with delirium (n=27) limits the statistical power of the ROC analysis and multivariate regression regarding delirium, suggesting these findings should be considered exploratory and require validation in larger cohorts.
• It highlights selection biases (conscious, literate, Turkish-speaking patients) and the inability to assess prior negative ICU experiences as limitations.
• The authors emphasize that early identification and targeted intervention are essential but call for further longitudinal studies to confirm the tool's efficacy in preventing long-term psychological sequelae.