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Any ICU is a highly specialized environment designed to provide critical care for patients facing life-threatening illnesses or injuries.

While primary focus within the ICU is typically physiologic stabilization and medical interventions, the psychological and emotional well-being of patients can significantly affect their recovery trajectory and overall experience.

Behavioral health specialists, including mental health and psychological support personnel, play an increasingly recognized and crucial role in optimizing the ICU patient experience, emerging from the shadows of the unit’s treatment team to influence outcomes ranging from delirium prevention to long-term quality of life.

“I think the real challenge is that we haven’t created structures to provide the toolkits. We haven’t done skills training,” said Giora Netzer, MD, MSCE, vice president and chief experience officer, University of Maryland Medical System in Baltimore. “I think about how much time I got trained on how to put in a central venous catheter, but we can’t match, you know, what our empathetic skills look like.”.

Empathy is an idea, he said.

“We have to teach people behaviors.”

Netzer said his system is in the middle of a system-wide universal skills training program based on trauma-informed care, “which is really the cutting edge of thinking about things, right? And trauma informed care acknowledges that 70% of us in the United States have suffered some kind of trauma.”

The ICU environment itself is inherently stressful, both for patients and their families. Patients are often critically ill, disoriented by medications, sleep deprivation, and the constant presence of medical equipment and alarms. They may experience pain, fear, anxiety, and a profound sense of loss of control.

Family members, too, grapple with immense stress, uncertainty, and grief, often feeling helpless as they witness their loved ones in such vulnerable states. These stressors can contribute to a range of behavioral health challenges, including anxiety, depression, posttraumatic stress disorder (PTSD), and delirium, which can persist long after discharge.

The Psychology of an ICU Patient

One of the most immediate and pervasive behavioral health concerns in the ICU is delirium. Delirium, characterized by acute brain dysfunction, manifests as fluctuating attention, disorganized thinking, and altered consciousness. It is highly prevalent in critically ill patients, with reported incidences ranging from 30% to 80% depending on the patient population and diagnostic criteria.

Delirium is not merely a transient state; it is associated with increased mortality, longer ICU and hospital stays, higher healthcare costs, and long-term cognitive impairment. Behavioral health interventions are pivotal in both preventing and managing delirium.

Nonpharmacologic strategies, such as early mobilization, reorientation, sleep-wake cycle optimization, and sensory stimulation, are often spearheaded or supported by behavioral health specialists. Psychologists or psychiatric nurses can help identify at-risk patients, educate staff on delirium prevention protocols, and provide direct interventions to reduce agitation and confusion.

Beyond delirium, anxiety and depression are common psychological impacts of an ICU stay. Patients may experience intense fear related to their illness, the procedures they undergo, and the uncertainty of their prognosis. The loss of independence, privacy, and familiar routines can also contribute to feelings of helplessness and sadness.

These emotional states can hinder recovery by affecting sleep, appetite, and motivation for rehabilitation. Behavioral health professionals can offer crucial support through various ways. Psychologists can provide psychoeducation, teach coping strategies such as relaxation techniques and mindfulness, and facilitate communication between patients, families, and the medical team. Early identification and intervention for anxiety and depression can mitigate their severity and prevent them from becoming chronic conditions.

Post-intensive care syndrome (PICS) is another significant area where behavioral health plays a vital role. PICS refers to a constellation of new or worsening impairments in physical, cognitive, and mental health that arise after critical illness and persist beyond hospital discharge.

Mental health components of PICS include anxiety, depression, and PTSD, which can profoundly affect a patient’s ability to return to their previous level of functioning and quality of life. The traumatic nature of critical illness, including memories of pain, fear, and intrusive medical procedures, can contribute to PTSD symptoms.

Behavioral health specialists are essential in the continuum of care for PICS. They can conduct screenings for psychological distress during and after the ICU stay, provide individual or group therapy, and connect patients with community resources. Early psychological intervention can help patients process their traumatic experiences, develop adaptive coping mechanisms, and reduce the long-term burden of PICS.

If You Build It…

At Vanderbilt University in Nashville, Tennessee, the behavioral health impact of a stay in the ICU became such a clear control of the patient’s wellbeing that staff assembled its multidisciplinary resources to establish the ICU Recovery Center in 2012, the second of its kind in the country.

“We started the ICU Recovery Center after realizing that there were focused efforts to help other populations, for instance, survivors of cancer, but really no programs to support the complex cognitive and mental health needs of ICU survivors, whether from the medical ICU, the surgical ICU, the CV [cardiovascular]-ICU, or even the trauma-ICU,” said Jim Jackson, PsyD, director of behavioral health at Vanderbilt University.

When they first built the center, Jackson said they had no way of knowing what the response would be.

“Referencing (the movie) ‘Field of Dreams’ it was a bit of an, ‘If you build it, they will come’” phenomenon, and people literally started coming from all over the US — California, Florida, Texas, Maine — almost everywhere — with wide-ranging problems.

From PTSD after a cardiac arrest, cognitive impairment after sepsis, physical debility after spending months in the hospital, they saw it all, Jackson said.

“We tailor our care and try to individualize it but there is a strong psychological component, with a particular focus on mental health and neuropsychological challenges. Addressing these as early as we can is crucial because in the absence of early intervention, these problems threaten to morph into challenges that are even harder to handle than they otherwise would be.”

At the center, clinicians help patients recover from critical illness and minimize the effects of PICS. The staff includes intensive care nurse practitioners, neuropsychologists, intensive care pharmacists, and case managers. The center offers a wide range of services to support patients’ recovery journey including mental health treatment, cognitive rehabilitation, coordination and referrals for ongoing care, medication reconciliation, assistance with medical equipment, educational resources, behavioral health consultations, support for caregivers and family members, and referral to government assistance programs.

As seen in the Vanderbilt example, the role of behavioral health extends beyond direct patient care to encompass support for families. Family members of ICU patients often experience significant psychological distress including anxiety, depression, and complicated grief. They may feel overwhelmed by medical jargon, difficult decisions, and the emotional toll of witnessing their loved one’s suffering.

Behavioral health professionals can provide emotional support, facilitate family meetings, and help families understand the patient’s condition and prognosis, Jackson said. By supporting families, behavioral health indirectly contributes to a better patient experience, as family well-being can positively influence patient morale and participation in care.

Furthermore, behavioral health specialists can assist in end-of-life discussions, helping families navigate complex ethical dilemmas and cope with loss, he said.

Challenges to integrating behavioral health into the ICU include limited resources, lack of awareness among healthcare providers about the importance of psychological care, and the fast-paced, high-acuity nature of the ICU environment.

However, a growing body of evidence highlights the impact of behavioral health on patient outcomes and is driving a shift toward more holistic, patient-centered care models. Hospitals are increasingly recognizing the value of investing in behavioral health services within critical care settings.