Validity of a single PTSD checklist item to screen for insomnia in survivors of critical illness
Introduction
As more patient survive the intensive care unit (ICU),1 there is growing recognition of the physical, cognitive, emotional and socioeconomic sequelae commonly experienced by ICU survivors.2, 3 One aspect that has been understudied is insomnia. Insomnia, clinically defined as difficulty falling or staying asleep,4 affects 6–15% of the general population and is even more common among patients with chronic medical and psychiatric conditions.5
Insomnia among ICU survivors may reflect a variety of etiologies, including a pre-existing sleep disorder, maladaptive sleep behaviors, sleep-related breathing disorders, circadian dysregulation,6, 7 or post-ICU sequelae including pain,8 anxiety, depression, and PTSD.9, 10 Prior work demonstrates that insomnia symptoms are reported by 28% to 50% of ICU survivors, depending on the measure used.11, 12 Identifying and treating insomnia in ICU survivors carries public health importance. Patients with insomnia are at risk for quality of life impairment and accidents.13 Evidence-based insomnia treatment (cognitive behavioral therapy) has proven effective in a variety of populations to improve sleep quality, depression, pain, and cancer-related fatigue.14, 15, 16, 17, 18, 19
A brief screen to identify ICU patients with insomnia would be useful. Unfortunately no insomnia screen has been validated in the post-ICU population. Existing literature on sleep after ICU is limited by a lack of standardized or validated metrics.20, 21 The gold standard for diagnosis of insomnia is clinical interview by a trained mental health or sleep specialist, frequently infeasible in the research setting.22, 23 In clinical practice, the 7-item Insomnia Severity Index (ISI) is often used. Validated as a research measure of insomnia, the ISI is helpful to identify symptom burden at diagnosis and to follow changes with treatment.24, 25 While the ISI itself is fairly brief, ICU survivor evaluations typically involve lengthy surveys to assess multiple aspects of disability. Survey fatigue must be carefully considered when proposing yet another metric for evaluation. To facilitate more widespread screening of insomnia in ICU survivors, we sought to identify a single item that could easily be incorporated in the research or clinical setting.
In this analysis, we took advantage of an existing ICU cohort that examined psychiatric sequelae after critical illness. Based on previous work, we chose a single item on the Posttraumatic Stress Disorder (PTSD) Checklist-Civilian Version (PCL-C)26 as a simple, rapid screen for difficulty falling or staying asleep. We validated this single PCL-C against the 8-item Insomnia Severity Index (ISI). In subset analyses, we examined the validity of this screen in patients with significant depressive and/or PTSD symptoms.
Section snippets
Study population
Our study is a secondary analysis of data from a longitudinal investigation of health outcomes in 120 medical-surgical ICU survivors admitted to a single tertiary care hospital, Harborview Medical Center, between September 2010 and July 2011.27 Study inclusion and exclusion criteria have been previously described.27 Subjects completed a baseline interview at enrollment and a follow-up interview at 12 months post hospital discharge. Informed consent was obtained from all subjects at enrollment.
Patient characteristics
Of 150 patients enrolled, 10 subjects died, and 2 subjects withdrew from the study before 12-month follow-up (Figure 1). Of the remaining 138 subjects, 120 (87% eligible) completed 12-month evaluations and were included in our analysis (3 incarcerated, 15 lost to follow-up). Characteristics of the 120 subjects included in our analysis are presented in Table 1. Subjects were predominately white males; 37.5% had a prior substance abuse or mental health diagnosis. At 12-month follow-up, subjects
Discussion
A single-item insomnia screen performed well to identify clinically significant insomnia in a cohort of medical surgical ICU survivors. While this brief screen is not sufficient to make a clinical diagnosis of insomnia, it may prove useful to identify patients who merit further sleep evaluation.
Functional disability after ICU is a common problem that places a burden on the patient and the health care system.36 As yet there are no effective interventions; randomized trials of targeted physical
Conclusions
A single item on the PCL-C showed good sensitivity to identify clinically significant insomnia symptoms in a cohort of medical surgical ICU survivors. Insomnia is an under-recognized problem in ICU survivors that merits further study. A standardized, brief screen may improve identification of patients who merit further sleep evaluation.
Acknowledgements
The authors would like to thank Collin McFadden for his assistance with data collection and management. This work was supported by grants KL2 TR000421, NRSA-T32/MH20021-12, R03 AA020146-02, and K24 MH086814-03 from the National Institutes of Health and grant ADAI-1009-2 from the University of Washington Alcohol and Drug Abuse Institute. Dr. Parsons was supported by VA Puget Sound Health Services Research & Development. The views expressed here are those of the authors and do not reflect the
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Cited by (3)
Screening tools for post–intensive care syndrome and post-traumatic symptoms in intensive care unit survivors: A scoping review
2023, Australian Critical CareCitation Excerpt :Although the PTSS-14 was developed according to DSM-IV diagnostic criteria of PTSD, it performed well in making provisional PTSD diagnosis in reference to the most current Diagnostic Manual of Mental Disorders (DSM-5) compared to PTSS-10 and PCL-5. The PCL-C sleep item score correlated significantly with ISI score, suggesting criterion validity, and correlation with QOL indices indicated construct validity66. The CAESAR67 demonstrated good construct validity to assess the experience of relatives of patients who die in the ICU.
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Conflict of interests: None.