Psychological Trauma:

Theory, Research, Practice, and Policy

© 2020 American Psychological Association 2020, Vol. 12, No. S1, S100 –S104
ISSN: 1942-9681 http://dx.doi.org/10.1037/tra0000884

COVID-19: Understanding and Mitigating Trauma in ICU Survivors

Jamie L. Tingey Jacob A. Bentley
Seattle Pacific University Seattle Pacific University and Johns Hopkins University School
of Medicine

Megan M. Hosey
Johns Hopkins University School of Medicine

The spread of coronavirus disease 2019 (COVID-19) has placed many individuals in need of critical care,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

with a high proportion of hospitalized patients being admitted to intensive care units (ICU) to treat acute
This document is copyrighted by the American Psychological Association or one of its allied publishers.

outcomes of COVID-19 (e.g., respiratory failure via mechanical ventilation). The ICU is known to be a
setting where individuals are at a high risk of experiencing significant psychological difficulties, and
patients with COVID-19 are particularly susceptible to such experiences, which can impact their recovery
process (e.g., postintensive care syndrome). This article seeks to highlight the intersection between
critical care related to trauma and COVID-19 and point providers toward opportunities for anticipating
and managing secondary effects in effort to promote psychological adaptation.

Keywords: acute respiratory failure, coronavirus, critical care, postintensive care syndrome, posttrau-
matic stress disorder

Approximately 20% of individuals infected with severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) develop se-
vere illness that requires hospitalization (Huang et al., 2020; World
Health Organization, 2020). Although rates vary geographically,
approximately one quarter of hospitalized patients are expected to
require a stay on an intensive care unit (ICU; Ferguson et al.,
2020). Recent findings map onto this projection, with approxi-
mately 5% to 11.5% of the total infected population being admitted
to ICUs (Centers for Disease Control and Prevention, 2020a;
World Health Organization, 2020).
Patients with coronavirus disease 2019 (COVID-19) in the ICU
have acute respiratory failure (ARF; Grasselli et al., 2020; Wu et
al., 2020). Treating ARF often requires invasive mechanical ven-
tilation (MV) to assist with breathing and maintain biological
homeostasis and, prior to the COVID-19 pandemic, patients were
surviving ARF at higher rates (Bentley, 2017; Kahn et al., 2006).
Currently, approximately 88% of COVID-19 patients in the ICU
require MV (Grasselli et al., 2020).
Editor’s Note. This commentary received rapid review due to the time-
sensitive nature of the content. It was reviewed by the Journal Editor.—KKT
This article was published Online First June 25, 2020.
Jamie L. Tingey, Department of Clinical Psychology, Seattle Pacific
University; Jacob A. Bentley, Department of Clinical Psychology, Seattle
Pacific University, and Department of Physical Medicine and Rehabilita-
tion, Johns Hopkins University School of Medicine; Megan M. Hosey,
Department of Physical Medicine and Rehabilitation, Johns Hopkins Uni-
versity School of Medicine.
Correspondence concerning this article should be addressed to Megan
M. Hosey, Department of Physical Medicine and Rehabilitation, Johns
Hopkins University School of Medicine, 600 North Wolfe Street, Phipps
179, Baltimore, MD 21287. E-mail: mhosey@jhu.edu
Many COVID-19 survivors will face a long recovery following
their ICU stay, as they adjust to the physical and psychological
implications of their illness and hospital course. The very nature of
the ICU, being both medically critical and intense, can have
serious repercussions on individuals’ psychological well-being. In
the ICU, patient control over basic physical functions is low, and
the critical care environment can be stressful. These units can be
loud, with flashing and beeping machines, alarms, and staff mov-
ing in and out of rooms—noise alone often contributes to signif-
icant sleep and mood disturbances (Devlin & Weinhouse, 2016;
Tainter et al., 2016). Invasive medical procedures are frequently
necessary, oftentimes when patients are not fully aware of what is
happening as a result of medical sedation and/or altered mental
status (e.g., ICU delirium; Maldonado, 2017). The combination of
these factors can pose threats to one’s sense of safety and increase
susceptibility to having a traumatic experience (McGiffin,
Galatzer-Levy, & Bonanno, 2016).
The term postintensive care syndrome (PICS) is readily applied
in the literature to describe new or worsening health problems
following critical illness, including cognitive and psychological
impairment (McPeake & Mikkelsen, 2018; Needham et al., 2012).
In the case of COVID-19, individuals may be more susceptible to
PICS, given prolonged ICU stay. Patients with COVID-19 are
averaging a length of stay of 10.4 days in the ICU (Ferguson et al.,
2020), roughly tripling the average stay of 3.3 days (Hunter,
Johnson, & Coustasse, 2014). Thus, we can anticipate that the
impact and intensity of the ICU will be felt by many receiving
critical care services related to COVID-19.
Psychological Outcomes in Critical Illness
ICU survivors are at a heightened risk for experiencing psycho-
logical symptoms during and following their ICU stay (Bienvenu
et al., 2018; Neufeld et al., 2020). Approximately one third of ICU

S100
 COVID-19: TRAUMA IN ICU SURVIVORS S101

Table 1
Brief Self-Report Measures for Critical Care Survivors

Measure name Constructs measured Items and scaling Source

Patient Health Questionnaire 9 (PHQ-9)
Generalized Anxiety Disorder-7 (GAD-7)
Hospital Anxiety Depression Scale (HADS)a
Impact of Event Scale⫺6 (IES-6)a
Breathlessness Catastrophizing Scale (BCS)
Montreal Cognitive Assessment (MoCA)
a
Included in the National Heart Lung and Blood Institute’s Core Outcomes Measures for Survivors of Critical Illness (Needham et al., 2017)
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Symptoms of depression nine-item, 4-point scale Kroenke & Spitzer (2002)
Symptoms of anxiety seven-item, 4-point scale Spitzer, Kroenke, Williams, & Löwe
(2006)
States of depression and anxiety 14-item, 4-point scale Zigmond & Snaith (1983)
Symptoms of PTSD six-item, 5-point scale Hosey et al. (2019); Thoresen et al. (2010)
Catastrophic thinking related to breathlessness 13- Solomon et al. (2015)
item, 5-point scale
Cognitive impairment 30-item scale; points vary by Nasreddine et al. (2005)
cognitive domain

survivors experience anxiety and depression symptoms during the
first year of recovery (Bienvenu et al., 2018; Davydow, Gifford,
Desai, Bienvenu, & Needham, 2009; Nikayin et al., 2016; Rabiee
et al., 2016). Symptoms of posttraumatic stress disorder (PTSD)
are also prevalent, with approximately one fifth of survivors ex-
periencing clinically important symptoms in the first year (Jackson
et al., 2016; Parker et al., 2015; Wade, Hardy, Howell, & Mythen,
2013). These symptoms can have a profound and lasting influence
on individuals’ quality of life (Bienvenu et al., 2018; Herridge et
al., 2011). Given these associations, we can expect psychological
challenges among these survivors. To this end, health care provid-
ers play a critical role in promoting psychological adaptation in
this population.
Psychological Integration in Medical
Intensive Care Settings
Early intervention appears important for reducing psychological
distress among ICU survivors (Karnatovskaia et al., 2019; Roberts
et al., 2018). Although limited studies have examined nonpharma-
cological interventions, research suggests promising directions.
Limiting sedation and encouraging early rehabilitation appear to
improve functional outcomes for ICU survivors (Parker, Srich-
aroenchai, & Needham, 2013). The addition of self-management
and cognitive restructuring skills (Peris et al., 2011) has yielded
positive results for mitigating PTSD and anxiety symptoms. ICU
diaries may be particularly efficacious, as evidenced by attenuating
psychiatric symptoms and, consequently, improving psychological
recovery following intensive care (Aitken et al., 2013; McIlroy,
King, Garrouste-Orgeas, Tabah, & Ramanan, 2019). Typically
written by hospital staff and/or family, these diaries summarize
and narrate patient’s daily activities, often serving as a tool for
filling in the memory gaps of patients to assist with establishing a
sense of coherence and continuity to otherwise unanchored expe-
riences (Aitken et al., 2013). Social support from family and
friends has repeatedly been shown to reduce PTSD symptoms and
improve health-related quality of life among ICU patients (Chivu-
kula, Hariharan, Rana, Thomas, & Swain, 2014; Deja et al., 2006).
Amid this pandemic, policies have been implemented in an
effort to prevent the spread of COVID-19 (Centers for Disease
Control and Prevention, 2020b, 2020c), meanwhile indirectly cre-
ating barriers to traditional forms of patient-centered care, includ-
ing aforementioned practices. For example, visitation restrictions
prevent family and friends from being with patients, rendering
traditional social support inaccessible. Now, maybe more than
ever, society is imploring health care providers to achieve the
daunting task of delivering care that meets both the medical and
psychological needs of patients, as many battle this life-threatening
disease alone.
Intervening With Systems, Providers, and Patients
Practicable opportunities for anticipating and managing second-
ary effects of critical care exist, despite restrictive policies. In the
ICU, nonpharmacological methods can be conducted to manage
symptoms of distress (Chlan, 2002). These include encouraging
and facilitating communication (if clinically indicated) with pa-
tients’ social network, which can help bridge the gap from patient
to social support. Relaying information regarding patients’ daily
events and progress could also provide material for family mem-
bers to complete ICU diary entries remotely. This could support
patients’ psychological adaption, while simultaneously providing
families with a purposeful task that might also provide a form of
psychological support (Hart, Turnbull, Oppenheim, & Courtright,
2020). Recommendations and/or referrals for additional support
following ICU discharge will be important for COVID-19 survi-
vors.
Outpatient providers can implement brief and psychometrically
validated screening instruments that are readily available for as-
sessing distressing symptoms commonly experienced by ICU sur-
Table 2
Example Questions for Eliciting Survivor Experiences
Tell me about your experience in the ICU.
What, if anything, have you heard about ICU delirium?
Did you have difficulty distinguishing what was a dream and what was
real?
Did you have times where you thought nurses or doctors were trying to
harm you?
Did you ever see or hear things that others did not?
Did you notice yourself feeling more irritable than usual?
Was there a specific experience in the ICU that caused you to feel
particularly distressed?
Do you find yourself thinking about your hospital stay more than you
would like?
Is there anything else you might want to share about what you
experienced during or following your ICU stay?
Note. ICU ⫽ intensive care unit.
 S102 TINGEY, BENTLEY, AND HOSEY
Table 3
Select Resources for Critical Care Survivors
Organization/Group
Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center
Outcomes after Critical Illness and Surgery (OACIS) Group
Acute Respiratory Distress Syndrome (ARDS) Foundation
Trauma Survivors Network (TSN)
Society for Critical Care Medicine (SCCM)
ICUsteps
ICU Diary Network
Note. ICU ⫽ intensive care unit.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
vivors (see Table 1). Of note, the Impact of Event Scale ⫺6
(IES-6) has recently been shown to be a reliable and valid measure
for screening PTSD in ARF survivors (Hosey et al., 2019) and may
be particularly relevant for patients with COVID-19 after dis-
charge from the ICU. These screeners can be quickly administered
by providers of varied disciplines to produce data and inform
systematic decisions for treatment interventions. That is, providers
can discern who may benefit from psychological support and
respond accordingly. Additionally, providers engaging in trauma
treatment can consider asking COVID-19 survivors specific ques-
tions to normalize ICU experiences and elicit discussion (see Table
2).
Recent literature highlights the applicability of cognitive ther-
apy for PTSD in this affected population, which may be useful for
providers (Murray et al., 2020; https://oxcadatresources.com/).
Telephone-delivered interventions that focus on coping skills may
be one feasible treatment modality amid the current environment
of social distancing, because it has been shown to reduce psycho-
logical distress following ICU discharge (Cox et al., 2012). Uti-
lizing mobile applications that promote behavioral activation
and/or conduct breathing exercises and mindfulness may also
prove advantageous, because this appears to serve as a feasible
form of home-based care with individuals recovering from ARF
(Parker et al., 2020). Finally, various resources are available to
ICU survivors, families, and providers with substantial informa-
tion that can aid in promoting psychological adjustment among
ICU survivors (see Table 3).
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