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A majority of family members of Covid-19 patients treated in ICUs reported significant symptoms of post-traumatic stress disorder in the following months, according to a study published Monday that sheds new light on the impact of hospital visitation restrictions during the pandemic.

The prevalence of PTSD symptoms was roughly twice the rate typically seen after a family member’s ICU stay before the pandemic, which the authors said was likely explained by the lack of access to loved ones during their ICU stay. “Those with higher scores reported more distrust of practitioners,” according to the study, published in JAMA Internal Medicine, and PTSD symptoms were especially prevalent among women and Hispanic family members.

Earlier studies have shown that “active engagement of families at the bedside reduces stress-related symptoms,” especially those of PTSD, the researchers said, but early in the pandemic, most hospitals prohibited or strictly limited in-person visits by family members to contain the spread of the coronavirus.

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This meant that family members of patients had to blindly trust updates about their loved ones from health care personnel, Timothy Amass, one of the authors of the study and an assistant professor in the Division of Pulmonary Sciences and Critical Care Medicine at the University of Colorado, said in an interview, and that may have contributed to the increased level of distrust of practitioners and higher levels of stress. Family members would have no way of confirming what they were being told, he said, because they could not see how doctors and nurses were interacting with and taking care of their loved ones.

Amass and his colleagues surveyed 330 people who had a family member admitted to an ICU for Covid-19 at 12 hospitals in five states from February through July 2020. About three months after ICU admission, the participants were given a questionnaire widely used to screen for PTSD symptoms in patients and their families after an ICU stay.

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The study found that 63.6% of the participants recorded a score of 10 or higher on a scale of 24, a cutoff that’s associated with significant symptoms of PTSD. In comparison, previous research before the pandemic had found significant PTSD symptoms in roughly 30% of ICU patients’ family members.

Amass said this is the first study to find a higher prevalence of stress in Hispanic family members of ICU patients, who accounted for 30% of participants who reported their race or ethnicity. In the study, Hispanic family members were less likely to report “above-and-beyond acts of compassion” by health care providers. These can be described as small acts of kindness, Amass said, including asking family members about the favorite music of the admitted patients so they can play it for them, or offering to take a family photo to hang on the wall for the patients.

“Whether they received fewer acts of compassion or perceived fewer acts of compassion, we don’t know,” he said. “But they did report them less frequently” in comparison to all the other participants.

The authors noted in the paper that previous research has shown that Hispanic people “are more likely to use touch at the bedside and be involved in patient care and that bedside care rituals may help reduce psychological distress.”

Amass said family members may have been dealing with external circumstances that kept them from even being at the hospital, such as the burdens of work or childcare, which meant they would have to receive updates via phone or video call. They may also have struggled with developing a connection with the health care personnel providing updates about their loved ones, he said, adding, “You might have a health care provider who maybe doesn’t look like you or you might not be sure how to relate to” and this can add to the levels of distrust being experienced.

Studies that have looked at the long-term effects of stress-related disorders among ICU patients and their family members have shown they can last anywhere up to four years, Amass said.

Generally, he said there are three reasons why a person might develop PTSD from having a loved one in the ICU: the sudden change in the health status of a loved one; the need to make critical and stressful health care decisions for them, such as whether to put them on a ventilator or other life-sustaining therapies; and a loss of control due to the sudden handoff of care to unknown health care providers.

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