Increased risk for new mental health diagnoses found in ECMO survivors

Patients who survived after receiving extracorporeal membrane oxygenation were found to be at a higher risk for a new mental health diagnosis or social problem diagnosis than other ICU survivors, according to a study published in JAMA.

“We suspected ECMO survivors would be at greater risk of mental health impacts because they are sedated and ventilated for longer and often face a more challenging recovery,” Shannon M. Fernando, MD, MSc, critical care physician at Lakeridge Health and postdoctoral fellow at The Ottawa Hospital and the University of Ottawa, said in a press release from The Ottawa Hospital. “But we didn’t have clear data until now.”

In a population-based retrospective cohort study, Fernando and colleagues analyzed 642 adult ECMO survivors (mean age, 50.7 years; 40.7% women) who were matched 1:6 to 3,820 adult ICU survivors who did not receive ECMO (mean age, 51 years; 40% women) from health administrative databases in Ontario, Canada, between April 1, 2010, and March 31, 2020. Researchers used overlap propensity score-weighted cause-specific proportional hazard models to compare the rate of mental health diagnoses between the two groups following discharge.

Researchers primarily looked for one or more of the following mental health diagnoses: mood disorder/anxiety disorder/PTSD; schizophrenia/psychotic disorder; other mental health diagnoses; and social problems, such as economic problems, marital difficulties, family disruption or divorce, parent-child problems, problems with aged parents, educational problems, social maladjustment, occupational problems and legal problems.

Occurrences of substance misuse, deliberate self-harm found through a hospital visit, suicide and the individual components of the primary outcome were secondary outcomes of the study.

Median follow-up was 730 days for ECMO survivors and 1,390 days for ICU survivors, and within those time periods, 236 (36.8%) ECMO survivors and 1,565 (40.9%) ICU survivors had a new diagnosed mental health condition, according to the study.

Incidence of any mental health condition per 100 person-years was 22.1 cases (95% CI, 19.5-25.1) among ECMO survivors compared with 14.5 cases (95% CI, 13.8-15.2) among ICU survivors, for an incidence difference of 7.6 cases per 100 person-years (95% CI, 4.7-10.5).

From these findings, researchers found that ECMO survivors had a higher risk for a mental health diagnosis after applying propensity weighting, with a hazard ratio of 1.24 (95% CI, 1.01-1.52).

Researchers also reported a similar increased risk among ECMO survivors in a sensitivity analysis that did not factor in patients discharged from Jan. 1, 2020, and onward (n = 4,324; HR = 1.27; 95% CI, 1.03-1.57) and patients with a previous history of a mental health diagnosis (n = 2,412; HR = 1.43; 95% CI, 1.02-2).

The association persisted in a post-hoc analysis that did not include patients not using mechanical ventilation (n = 2140; HR = 1.28; 95% CI, 1.04-1.57).

In terms of secondary outcomes, substance misuse (absolute rate difference, 0.2 per 100 person-years, 95% CI, –0.4 to 0.8; HR = 0.86; 95% CI, 0.48-1.53), deliberate self-harm (absolute rate difference, 0.1 per 100 person-years, 95% CI, –0.2 to 0.4; HR = 0.68; 95% CI, 0.21-2.23) and suicide, with five total cases in the cohort, were not found to significantly differ between the groups, according to researchers.

“We really need more research and investment in the area of post-critical illness,” Fernando said in the release. “Patients will need help long after they leave the ICU.”

This study by Fernando and colleagues adds to the literature indicating that more studies need to be done on the value and long-term outcomes of ECMO, according to an accompanying editorial by Marieke Zegers, PhD, senior researcher in the department of intensive care medicine at Radboud Institute for Health Sciences, Mark van den Boogaard, RN, PhD, assistant professor in the department of intensive care at Radboud University Medical Center, and J. G. (Hans) van der Hoeven, MD, PhD, professor at Radboud Institute for Health Sciences.

“The cost of hospital treatment with ECMO is high, ranging from U.S. $22,305 to U.S. $334,608 among adults,” Zegers, van den Boogaard and van der Hoeven wrote. “Accordingly, the use of ECMO is a pressing question in times of scarce resources and personnel — should clinicians use everything available in health care and especially for critically ill patients in the ICU? Sustainability of health care is a top priority that forces clinicians to weigh the costs and benefits of expensive treatments such as ECMO and to avoid costly care with minimal or no added value for patients’ lives.

“The absolute difference in new mental health disorders between patients who received ECMO and those who did not was small but does not necessarily represent a reason to withhold ECMO treatment,” they added. “Mental problems are just one aspect of post-ICU sequelae besides physical and cognitive problems and patients’ quality of life.”

Reference:

ECMO survivors have higher rate of new mental health diagnoses than other ICU survivors. https://www.ohri.ca/newsroom/story/view/1523?l=en. Published Oct. 26, 2022. Accessed Nov. 15, 2022.

Zegers M, et al. JAMA. 2022; doi:10.1001/jama.2022.18621.