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Communications to the Editor |

Caregiving and Long-term Mechanical Ventilation FREE TO VIEW

Sara L. Douglas, PhD, CRNP; Barbara J. Daly, PhD, RN
Author and Funding Information

Affiliations: Case Western Reserve University, Cleveland, OH,  University of Pittsburgh, Pittsburgh, PA

Correspondence to: Sara L. Douglas, PhD, CRNP, Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44104; e-mail: SLD4@po.cwru.edu



Chest. 2004;126(4):1387-1388. doi:10.1378/chest.126.4.1387
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Published online

To the Editor:

We read with interest the recent research article by Im and colleagues,1and were particularly interested to note that they reported that it was difficult to compare their results to other studies of critically ill patients surviving mechanical ventilatory support. While we agree that such studies are rare, the similarity between the work of Im and colleagues and ours2 is remarkable and warrants comparison.

While this study focused on caregivers, the eligibility criteria for patient subjects was different than in our study, and as a result the caregiving experiences most likely were different as well. Im and colleagues1 defined prolonged mechanical ventilation as ≥ 48 h, while we defined it as > 96 h of continuous mechanical ventilation. We selected our definition based on pilot work that identified a significant difference in morbidity and mortality between patients receiving ventilation for 48 h vs 96 h (B. Daly, PhD; unpublished analysis; December 1999). Thus, most likely the patients in the study by Im and colleagues1were healthier than the patients in our study,2 and the caregiving experiences and expectations were different as well. It is this difference in eligibility criteria that may explain the differences reported in the two studies.

Another difference between the studies is that Im and colleagues1observed caregivers for 2 months after eligibility into the study; we followed caregivers for 6 months after hospital discharge.2 Given the variability in hospital length of stay associated with this patient population, the data obtained 2 months after initiation of ventilation of the patient undoubtedly yielded varying postdischarge time points, and captured subjects at different points along the postdischarge continuum.

Like Im and colleagues,1 we used the Center for Epidemiologic Studies Depression Scale (CES-D)3 to assess depressive symptomatology and found similar average scores (6 months after discharge). We also obtained baseline CES-D scores at hospital discharge and tracked changes in depression over time, and found that 51.2% and 36.4% of caregivers had some depressive symptomatology (CES-D scores > 15) at discharge and 6 months respectively. We found that 12.2% and 15.6% of caregivers were classified as having symptoms consistent with severe depression at hospital discharge and 6 months, respectively. The findings of Im and colleagues1confirmed ours2 in showing that caregivers of patients residing in an institution had higher CES-D scores than did caregivers of patients residing at home. Unlike Im and colleagues,1we found those differences to be statistically significant (p = 0.039).2 Of note is that a greater percentage of caregivers in our study were employed than in the study by Im and colleagues,1 and that 70.1% of our caregivers received assistance in caregiving activities.

We agree with Im and colleagues1that little is known about caregiving needs and experiences after prolonged mechanical ventilation in the ICU. Caregivers of patients receiving prolonged mechanical ventilation are at risk for prolonged depression and poor health. Given the large percentage of caregivers who scored in the “severe” range of the CES-D, these families have needs for support and assistance, not only from family and friends, but from the health-care system as well. However, since patients receiving prolonged mechanical ventilation (and their caregivers) do not fall into any of the other well-studied groups (eg, cancer, Alzheimer disease), they remain unrecognized by the health-care system. In light of our work,2 and the work of Im and colleagues,1 it may be reasonable to consider assessment of these caregivers to identify those in need of referral for mental health services, and to design ways to provide additional support for their caregiving experience.

Im, K, Belle, SH, Schulz, R, et al (2004) Prevalence and outcomes of caregiving after prolonged (≥ 48 hours) mechanical ventilation in the ICU.Chest125,597-606. [CrossRef] [PubMed]
 
Douglas, SL, Daly, BJ Caregivers of long-term ventilator patients: physical and psychological outcomes.Chest2003;123,1073-1081. [CrossRef] [PubMed]
 
Roberts, RE, Vernon, SW The center for epidemiologic studies depression scale: its use in a community sample.Am J Psychiatry1983;140,41-46. [PubMed]
 
To the Editor:

We would like to thank Drs. Douglas and Daly for their commentary on our article,1which was submitted prior to their article.2 Although the two studies included slightly different caregiver populations due to different patient eligibility criteria and definition of long-term ventilation in the ICU, some of the results are very similar.

The mean levels of caregivers’ depression (Center for Epidemiology depression scale [CES-D]) are remarkably similar, with similar variability, in these two studies: 13.9 (SD 12.8) and 13.2 (SD 11.0) for Douglas and Daly2 and Im et al,1respectively. However, these results can not be compared directly because of the two distinctively different outcome time points, ie, 6 months after discharge from the hospital for the sample used by Douglas et al2 and 2 months following ventilation for the sample used by Im et al.1We did collect CES-D data at 6 months and 12 months following intubation, but have not published these data yet. Despite the difference, both studies show similar proportions of caregivers at risk of clinical depression, defined as CES-D score ≥ 16, ie, 36.4% at 6 months after hospital discharge in the study of Douglas and Daly2 and 33.9% at 2 months following intubation in our study.

Douglas and Daly2 showed that there was a significant relationship between patient location and caregiver’s CES-D, indicating that caregivers of patients who resided in an institution reported more depressive symptoms than did caregivers of patients who resided at home. In our study, we found a similar relationship, though the p value associated with the parameter for location was 0.07. We did, however, indicate our opinion that it was important to consider strategies to assist caregivers whose care recipients were institutionalized precisely because they may be at greater risk of depression. The findings by Douglas and Daly2 provide supporting evidence for our proposition.

Most importantly, both studies conclude that caregivers of patients receiving mechanical ventilation do indeed suffer from, or are at risk of, serious clinical depression, something that is not well recognized in the field of caregiving research. We really need to work on developing intervention strategies to help this population. On this issue, we concur with Douglas and Daly.2

References
Im, K, Belle, SH, Schulz, R, et al Prevalence and outcomes of caregiving after prolonged (≥ 48 hours) mechanical ventilation in the ICU.Chest2004;125,597-606. [CrossRef] [PubMed]
 
Douglas, SL, Daly, BJ Caregivers of long-term ventilator patients: physical and psychological outcomes.Chest2003;123,1073-1081. [CrossRef] [PubMed]
 

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References

Im, K, Belle, SH, Schulz, R, et al (2004) Prevalence and outcomes of caregiving after prolonged (≥ 48 hours) mechanical ventilation in the ICU.Chest125,597-606. [CrossRef] [PubMed]
 
Douglas, SL, Daly, BJ Caregivers of long-term ventilator patients: physical and psychological outcomes.Chest2003;123,1073-1081. [CrossRef] [PubMed]
 
Roberts, RE, Vernon, SW The center for epidemiologic studies depression scale: its use in a community sample.Am J Psychiatry1983;140,41-46. [PubMed]
 
Im, K, Belle, SH, Schulz, R, et al Prevalence and outcomes of caregiving after prolonged (≥ 48 hours) mechanical ventilation in the ICU.Chest2004;125,597-606. [CrossRef] [PubMed]
 
Douglas, SL, Daly, BJ Caregivers of long-term ventilator patients: physical and psychological outcomes.Chest2003;123,1073-1081. [CrossRef] [PubMed]
 
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