Association of Extracorporeal Membrane Oxygenation With New Mental Health Diagnoses in Adult Survivors of Critical Illness

Abstract

ImportanceExtracorporeal membrane oxygenation (ECMO) is used as temporary cardiorespiratory support in critically ill patients, but little is known regarding long-term psychiatric sequelae among survivors after ECMO.ObjectiveTo investigate the association between ECMO survivorship and postdischarge mental health diagnoses among adult survivors of critical illness.Design, Setting, and ParticipantsPopulation-based retrospective cohort study in Ontario, Canada, from April 1, 2010, through March 31, 2020. Adult patients (N=4462; age ≥18 years) admitted to the intensive care unit (ICU), and surviving to hospital discharge were included.ExposuresReceipt of ECMO.Main Outcomes and MeasuresThe primary outcome was a new mental health diagnosis (a composite of mood disorders, anxiety disorders, posttraumatic stress disorder; schizophrenia, other psychotic disorders; other mental health disorders; and social problems) following discharge. There were 8 secondary outcomes including incidence of substance misuse, deliberate self-harm, death by suicide, and individual components of the composite primary outcome. Patients were compared with ICU survivors not receiving ECMO using overlap propensity score–weighted cause-specific proportional hazard models.ResultsAmong 642 survivors who received ECMO (mean age, 50.7 years; 40.7% female), median length of follow-up was 730 days; among 3820 matched ICU survivors who did not receive ECMO (mean age, 51.0 years; 40.0% female), median length of follow-up was 1390 days. Incidence of new mental health conditions among survivors who received ECMO was 22.1 per 100-person years (95% confidence interval [CI] 19.5-25.1), and 14.5 per 100-person years (95% CI, 13.8-15.2) among non-ECMO ICU survivors (absolute rate difference of 7.6 per 100-person years [95% CI, 4.7-10.5]). Following propensity weighting, ECMO survivorship was significantly associated with an increased risk of new mental health diagnosis (hazard ratio [HR] 1.24 [95% CI, 1.01-1.52]). There were no significant differences between survivors who received ECMO vs ICU survivors who did not receive ECMO in substance misuse (1.6 [95% CI, 1.1 to 2.4] per 100 person-years vs 1.4 [95% CI, 1.2 to 1.6] per 100 person-years; absolute rate difference, 0.2 per 100 person-years [95% CI, −0.4 to 0.8]; HR, 0.86 [95% CI, 0.48 to 1.53]) or deliberate self-harm (0.4 [95% CI, 0.2 to 0.9] per 100 person-years vs 0.3 [95% CI, 0.2 to 0.3] per 100 person-years; absolute rate difference, 0.1 per 100 person-years [95% CI, −0.2 to 0.4]; HR, 0.68 [95% CI, 0.21 to 2.23]). There were fewer than 5 total cases of death by suicide in the entire cohort.Conclusions and RelevanceAmong adult survivors of critical illness, receipt of ECMO, compared with ICU hospitalization without ECMO, was significantly associated with a modestly increased risk of new mental health diagnosis or social problem diagnosis after discharge. Further research is necessary to elucidate the potential mechanisms underlying this relationship.

Extracorporeal Membrane Oxygenation and New Mental Health Diagnoses in Adult Survivors of Critical Illness—Reply

“…In Reply Our study demonstrated a modest association between survivorship after ECMO and new mental health diagnoses. In their Letter, Drs Li and Li hypothesize that this association may have been mediated by differences in sedation among patients exposed to ECMO.…”

“…A recent study demonstrated that patients who survive after receiving ECMO support experience substantial physical disability in the 6 months after discharge, regardless of baseline level of function . Because physical function is so closely tied to mental health morbidity, it stands to reason that this may contribute to the potential causes for the association we have demonstrated in our study . Future research using more granular data is necessary to elucidate the potential mechanisms that underlie this association.…”

Extracorporeal Membrane Oxygenation and New Mental Health Diagnoses in Adult Survivors of Critical Illness

“…To the Editor A recent study found that extracorporeal membrane oxygenation (ECMO) was significantly associated with a modestly increased risk of new mental health diagnoses or social problems in adult survivors of critical illness in Canada. Although Cox regression analyses were performed to determine the independent factors associated with new mental health diagnoses or social problems, it is important to consider the role of sedation in patients treated with ECMO.…”

Mental Health Outcomes Following Extracorporeal Membrane Oxygenation in Survivors of Critical Illness

“…Surviving ECMO treatment was significantly associated with an increased risk of new mental problems. 7 As a result of the study design, it is only possible to hypothesize about the causal factors between ECMO and new mental health problems. The authors elaborate about biological mechanisms that may manifest in psychiatric morbidity.…”

“…The authors underscore that future studies should elucidate the potential mechanisms underlying these relationships. 7 In the study by Fernando et al, 7 only preexisting mental health diagnosis (HR, 2.39 [95% CI, 1.78-3.20]) and having had an outpatient psychiatry visit in the year prior to the index admission (HR, 1.82 [95% CI, 1.25-2.65]) were significantly associated with outcome of a new mental health diagnosis. This finding corroborates results of previous studies that showed pre-ICU health status was the most important prognostic factor for mental health outcomes after ICU care, and even suicide.…”